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International consensus statement on rhinosinusitis

involved mucoceles encroaching the orbit. Of these 3, 2 developed blindness as a result of optic nerve ischemia. A control group of aspirin-tolerant patients did not have any orbital complications. 1743 Overall, mucocele formation in CRSwNP is rare, but prior surgery and aspirin-sensitivity may be risk factors. Rhinosinusitis (AECRS) XI.A AECRS: Incidence and Prevalence Acute exacerbations of CRS (AECRS) are described as a worsening of sinonasal symptom intensity with a return to baseline symptoms often after intervention with cor ticosteroids and/or antibiotics. 1,26–29,1748 The frequency of these CRS-related systemic medication treatments is a valid metric of QoL in CRS 1749 and may be considered as an exacerbation-defining event. 1748,1750 CRS patient-identified “flares” or sinus infections, which may also be considered exacerbation-defining events, have previously been asso ciated with decreased QoL 27 and changes in inflamma tory mediators detected in nasal mucus. 1010,1751 Yamasaki et al. have previously shown that CRS patients frequently report the use of antibiotics and oral corticosteroids in the previous 3 months (34.4% and 17.8%, respectively) and 12 months (54.8% and 27.4%). 28 In a subsequent study, Phillips et al. considered patients reporting greater than 3 episodes of oral corticosteroids or antibiotics in the previ ous 12 months to represent the exacerbation prone pheno type of CRS, 1748 which constituted 17.8% of CRS patients in Yamasaki et al. 28 The prevalence of AECRS may vary with the patient cohort being studied, season, and how the exacerbation was defined. These estimates for AECRS incidence are inherently limited as indirect measures of AECRS, as they may not be inclusive of all AECRS or may simply reflect poor disease control rather than a discrete AECRS. XI.B Pathophysiology of AECRS Although there are many contributing factors, CRS is characterized by a dysfunctional host-environment interaction. 31 AECRS pathophysiology is still early in its characterization, and challenging to study given hetero geneous definitions, but early investigations hypothesized mechanisms underlying CRS and ARS. Substantial study has focused on the identification of risk factors lead ing to an AECRS with rare emphasis on the pathophys iology of the development of AECRS. Associations of risk factors with AECRS, despite differing definitions of XI Acute Exaccerbation of Chronic

TABLE X-32 Evidence for AFRS management with Immunotherapy Study Year LOE Study Design Study Groups Clinical Endpoint Conclusions Gan 1736 2014 3 SR of level 3 and 4 studies AFRS patients N/A IT may reduce mucosal inflammation; harm is similar to other IT treatments; cost is high