Acute Exacerbations in Recurrent Acute Rhinosinusitis: Differences in Quality of Life and Endoscopy

Abstract

Objectives/Hypothesis: Research surrounding outcome differences for patients with recurrent acute rhinosinusitis (RARS) is scarce. This investigation explored quality of life (QOL) and sinonasal attributes in patients during acute episodes (AEs) and in-between AEs of RARS. Study Design: Retrospective outcomes research. Methods: Data from patients with RARS were collected from two academic institutions between 2009 and 2017 using prospective and retrospective methodology. During clinical presentation, subjects were classified as with or without an AEs using guideline definitions of acute bacterial rhinosinusitis (ABRS). Between-group differences in 22-item Sino-Nasal Outcome Test (SNOT-22) survey and Lund-Kennedy (LK) endoscopy scores were assessed. Results: Four hundred twenty-three clinical visits from 202 patients were included. Visits during an AE (168/423, 40%) were associated with significantly worse SNOT-22 total scores compared to between AEs (255/423, 60%; median = 53.0 [interquartile range (IQR) = 24.0] vs. 34.0 [IQR = 29.5]) and all SNOT-22 subdomain scores (all P < .001). LK scores were available for 167 visits, with 56 (34%) completed during an AE. Compared to visits without an AE, endoscopy findings associated with an AE were less frequently normal (LK score = 0, 45% vs. 62%, P = .031) with worse median LK scores (2.0 [IQR = 4.0] vs. 0.0 [IQR = 2.0], P = .005). Conclusions: AEs are associated with significantly worse QOL and mildly worse endoscopic findings. Almost half of visits during AEs had negative endoscopy, identifying a disparity between patient symptoms and objective findings and calling into question alternative or concomitant diagnoses. Diagnostic criteria for ABRS or AEs in RARS do not require objective confirmation of inflammation, presenting a conundrum for clinicians. The potential for overdiagnosis of ABRS and AEs should be considered when determining the risk/benefit ratio of treatments for RARS.

International consensus statement on allergy and rhinology: rhinosinusitis 2021

“…There is growing concern surrounding the over or misdiagnosis of RARS. Acute exacerbations characterized by symptoms are not necessarily associated with objective (endoscopic or radiologic) evidence of sinonasal inflammation 204,205 . Surgical appropriateness criteria for RARS suggest a diagnosis should include at least 4 episodes per year as well as objective evidence (endoscopic or radiologic) of an acute exacerbation 206 .…”

“…However, this number is likely an underestimate, as patients treated with watchful waiting, surgery or those who never filled their prescriptions remained unaccounted for 206 . Recent evidence suggests that RARS patients have an impairment in their QoL during exacerbations but this does not always correlate well with positive findings on nasal endoscopy 204 …”

“…However, according to Bhattacharya et al only 2.4% of patients with RARS receive a nasal endoscopy at the end of 1 year 232 . RARS patients have significant impairment in their QoL scores during exacerbations, although this does not correlate well with positive findings on nasal endoscopy 204,208 . Endoscopy is recommended in this cohort of patients to visualize contributing factors, confirm the presence of mucopus in the middle meatus and for getting access to a culture specimen 88 …”

“…Recent research by Beswick et al calls into question alternative or concomitant diagnoses during diagnosis of RARS 204 . In patients meeting diagnostic criteria for RARS, one‐half had a negative endoscopy during an acute exacerbation, indicating they may have been suffering from a different condition.…”

Diagnostic Criteria of Recurrent Acute Rhinosinusitis: A Systematic Review

“…Of the titles/abstracts reviewed, 69 full texts were selected and examined, and 22 articles met inclusion criteria (Figure 1). The articles were predominantly level IV evidence, 5,8,[11][12][13][14][15][16][17][18][19][20][21][22][23] while five level III articles [24][25][26][27][28] were included, and two level II articles 29,30 were included. The studies included a total of 1279 patients with follow-up ranging from 1 month to 3 years (Tables 1 and 2).…”