xRead - Nasal Obstruction (September 2024) Full Articles

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findings workup and any potential complications related to further diagnostic or therapeutic interventions, are more difficult to measure and will generally be excluded from this analysis. The following recommendations focus on diagnostic algorithms within the context of the cost and availability of modalities in the US, based on existing evidence. IX.B.3.a. CRS Diagnosis Using “Symptoms Alone” The symptom-based component for CRS diagnosis cur rently emphasizes the 4 cardinal symptoms of nasal obstruction, nasal discharge, facial pain or pressure, and reduction or loss of smell. Of note, component symp toms no longer utilize the “minor” symptoms (headache, fever, halitosis, fatigue, dental pain, cough, and ear symp toms) advanced by prior guidelines due to their fre quent absence in CRS and overlap with other medi cal conditions. 13,514,515,549 Nonetheless, the cardinal symp toms, even when used in the combinations recommended by consensus statements, are common in the general population with between 10% and 13% of US and Euro pean adults meeting current CRS symptom-combination and duration definitions. 13,515 Of the cardinal symptoms, prior studies consistently demonstrate discolored nasal discharge and smell loss—individually and especially in combination—enhance positive predictive value of symp tom criteria for CRS diagnosis. 514,516,548,550 Nasal obstruc tion is almost universal and has the highest average severity among patients with CRS, but its absence in the presence of other cardinal symptoms may be indica tive of a non-CRS etiology. 516,525,546,551 Other studies sug gest that facial pain (but not pressure) is not univer sal and its presence may also decrease the likelihood of a CRS diagnosis. 548,550 It has been shown that CRS diagnosis particularly in primary care and emergency room settings is limited in accuracy due, in part, to poor adherence to guidelines regarding objective inflamma tion documentation. 552 Prior studies comparing symptoms against a CT gold standard have suggested the specificity of symptoms in the range of 2% to 12% and positive predic tive values ranging between 35% and 54%. 31,480,513 Together, these studies indicate a low diagnostic efficacy for the symptom-only based approach. Given the cost of resource utilization related to a diagnosis of CRS; the use of a poor diagnostic approach, although much less expensive to use, would likely result in unneeded healthcare uti lization especially in the form of unnecessary antibiotic prescriptions. It should be noted that RS currently is the single most common indication for ambulatory antibiotic prescription. 553

Using Symptoms Alone to Diagnose CRS Aggregate Grade of Evidence: C (Level 3: 8 studies; level 4: 2 studies; Table IX-2). Benefit: A “symptoms alone” strategy is a patient centered and widely available means for establish ing possible diagnosis of CRS. Harm: High rate of false-positive diagnoses may prevent or delay the establishment of correct underlying diagnoses and potential for inappro priate interventions resulting in direct and indi rect healthcare costs (eg, time lost from work and potential adverse effects from treatments). Cost: Low—performed at all specialist and non specialist visits. Benefits-Harm Assessment: Harm over benefit, if used as the sole clinical method for CRS diagnosis, as there is a significant risk of misdiagnosis. Value Judgments: Assessing patient reported symptoms is an important component of the patient encounter, but is too inaccurate to be the IX.B.3.b. CRS Diagnosis with Nasal Endoscopy The diagnostic utility of nasal airway examination to eval uate for CRS is well established in the literature. 548,554–556 While anterior rhinoscopy may reveal mucopurulent drainage or severe nasal polyposis in some patients, this examination technique does not consistently provide suf ficient illumination and visualization of structures beyond the inferior turbinate. Nasal endoscopy provides a more thorough examination of sinus drainage pathways and allows for determination of the presence of mucosal edema, nasal polyposis, and purulent drainage. Given the growing implications the presence of nasal polyps has on therapeutic choices, definitive phenotyping of CRS patients is becoming particularly important to ensure patients are prescribed indicated therapy. Additionally, nasal endoscopy can assist with obtaining cultures or biop sies of targeted sinonasal locations and establishing alter native pathologies that may be symptomatically similar to CRS, such as intranasal tumors, adenoid hypertrophy, or posterior septal deviation. In post-surgical patients, the surgical alterations of the anatomy also facilitate a thor ough examination of the sinuses using nasal endoscopy only means used to diagnose CRS. Policy Level: Recommend against. Intervention: Recommendation against using a “symptoms-alone” strategy to make the diagnosis ofCRS.