Diagnosis and Management of Chronic Rhinosinusitis in Adults

Abstract

Chronic rhinosinusitis (CRS) is characterized by mucosal inflammation affecting both the nasal cavity and paranasal sinuses; its causes are potentially numerous, disparate, and frequently overlapping. The more common conditions that are associated with CRS are perennial allergic and nonallergic rhinitis, nasal polyps, and anatomical mechanical obstruction (septum/turbinate issues). Other less common etiologies include inflammation (eg, from superantigens), fungal sinusitis or bacterial sinusitis with or without associated biofilm formation, gastroesophageal reflux, smoke and other environmental exposures, immune deficiencies, genetics, and aspirin-exacerbated respiratory disease. A diagnosis of CRS is strongly suggested by a history of symptoms (eg, congestion and/or fullness; nasal obstruction, blockage, discharge, and/or purulence; discolored postnasal discharge; hyposmia/anosmia; facial pain and/or pressure) and their duration for > 3 months. A definitive diagnosis requires physical evidence of mucosal swelling or discharge appreciated during physical examination coupled with CT imaging if inflammation does not involve the middle meatus or ethmoid bulla. Multivariant causation makes the diagnosis of CRS and selection of treatment complex. Furthermore, various types of health care providers including ear, nose, and throat (ENT) specialists, allergists, primary care physicians, and pulmonologists treat CRS, and each is likely to have a different approach. A structured approach to the diagnosis and management of CRS can help streamline and standardize care no matter where patients present for evaluation and treatment. A 2008 Working Group on CRS in Adults, supported by the American Academy of Otolaryngic Allergy (AAOA), developed a series of algorithms for the differential diagnosis and treatment of CRS in adults, based on the evolving understanding of CRS as an inflammatory disease. The algorithms presented in this paper address an approach for all CRS patients as well as approaches for those with nasal polyps, edema observed on nasal endoscopy, purulence observed on nasal endoscopy, an abnormal history and physical examination, and an abnormal history and normal physical examination.

Cost Burden of Chronic Rhinosinusitis

“…Likely, these diagnostic interventions were appropriately reserved for those who failed initial management, and these patients may, therefore, represent more severe cases. 14,15 The resulting steep slope of the Kaplan-Meier ESS curve (Figure 2) within the first year after CRS diagnosis may in part be skewed by these stringent diagnosis definitions. While we increased the likelihood that CRS was accurately diagnosed, this action may have resulted in a bias toward a sicker patient population that may not represent the disease burden of CRS in general.…”

“…CRS is difficult to diagnose by symptoms alone. 14,15 We therefore adopted stringent diagnostic criteria involving radiologic or endoscopic confirmation of CRS, resulting in a sample comprising 2.3% of the original starting population, rather than the 20% with any diagnosis of CRS during the study period. Many patients with CRS may never have the diagnosis confirmed by radiologic or endoscopic evaluation.…”

International Consensus Statement on Allergy and Rhinology: Rhinosinusitis

“…There are several guidelines where recommendations are made, and these demonstrate consistency with regard to inclusion of oral antibiotics, INCS, and selective use of oral corticosteroids (Table X-1). 7,1138,1139 A recent systematic review demonstrated that INCS, oral antibiotics, and oral corticosteroids were used in 91%, 88%, and 62% of all MMT protocols for a mean of 8 weeks, 23 days, and 18 days, respectively. 1140 While incorporating the best available evidence into a recommendation for AMT, including evidence from this ICAR:RS document, a few key points should be remembered.…”

Different imaging techniques in the head and neck: Assets and drawbacks

“…The advantage of CT is the possibility of three-dimensional reconstructions [20] . To verify chronic sinusitis, CT of the paranasal sinuses should be performed [21] . The images illustrate mucosal swelling, whereas acute sinusitis additionally shows air-fluid level [21] .…”