Identifying clinical symptoms for improving the symptomatic diagnosis of chronic rhinosinusitis

Abstract

BACKGROUND Current symptom criteria for identifying patients with chronic rhinosinusitis (CRS) has poor specificity. OBJECTIVE To test the hypothesis that symptoms drawn from the task force on rhinosinusitis (RSTF) criteria and the International Headache Society (IHS) criteria for primary headaches can differentiate CRS patients from those with CRS-symptoms but no evidence for inflammation (non-CRS). METHODS A retrospective cohort study from a total of 140 charts of patients who received a diagnostic CT scan for CRS symptoms in a tertiary care clinic. The study was conducted in two phases: 1) using a retrospective review of otolaryngologist-documented symptoms (ODS) in the medical record and 2) using patient-reported symptoms (PRS) on a prospectively collected customized review of systems form from a separate cohort. A radiographic gold standard differentiated CRS from non-CRS patients. RESULTS Subjects in the CRS and non-CRS group were matched for age and race and almost universally met symptomatic criteria as defined by the RSTF in both study phases. In both study phases, facial pain, but not facial pressure, was negatively predictive for CRS (p<0.05). Similarly, hyposmia was positively predictive, while facial pain of a pulsating quality and photophobia were negatively predictive (p<0.05) although analysis of PRS was significant only when symptom frequency was considered. Nonetheless, significant overlap exists between the prevalence and frequency of symptoms in both groups. CONCLUSION The symptom-based diagnosis of CRS is challenging but symptoms of hyposmia are positively predictive while facial pain, a throbbing quality, headaches and photophobia are negatively predictive and show promise for improving the specificity of CRS diagnosis. Further validation studies are needed.

International Consensus Statement on Allergy and Rhinology: Rhinosinusitis

“…656,660,676,677 Nasal obstruction 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 indicative of a non-CRS etiology. 660,675,678,679 Other studies suggest that facial pain (but not pressure) is not universal and its presence may also decrease the likelihood of a CRS diagnosis. [676][677][678] Together, these studies suggest that refining symptom wording and increasing the emphasis of specific symptoms (eg, smell loss) can change the probability of CRS diagnosis.…”

Risk factors for chronic rhinosinusitis

“…[6**, 47*, 73, 74] Another condition strongly associated with CRS includes headache disorders like migraine potentially due to the overlapping symptoms and symptom vocabulary of chronic migraine and CRS. [47*, 75] In both the LHID2000 study and the GHS study, the strength of co/pre-morbid associations between CRS and headache diagnoses was moderate with aOR between 2.0 and 2.3. However, other lines of research suggest that while migraine affects CRS risk, it does not affect symptomatic improvement following treatment for CRS.…”

Cost-Efficient Workup and Management of Patients with Chronic Rhinosinusitis: Challenges and Unmet Needs

“…Further analysis of these criteria by Bhattacharyya [6], Stankiewicz and Chow [19], Benninger [20] and others have demonstrated the poor specificity of the symptom-only diagnosis compared to findings of inflammatory changes. Other studies have highlighted the relative importance of certain symptoms including anosmia, nasal obstruction, and discharge [4, 21]. Contemporary guidelines have steered away from the minor symptoms described by Lanza and Kennedy due to their overlap with many non-CRS conditions and refined the major symptoms to include nasal blockage, obstruction, congestion, discharge, facial pain, pressure, or loss of smell over 12 or more weeks [8].…”

“…A recent comprehensive literature review by Wuister et al favors the use of endoscopy in the diagnosis of CRS, and notes that the inability of the CT gold standard to differentiate between opacification due to CRS or other disease conditions may in fact create an underestimation of the added value of endoscopy to diagnosis [25]. Endoscopy does, however, suffer from a 21%-35% false negative rate for patients with positive symptoms [4, 10, 21, 24] and limited inter rater reliability [28]. Given these issues, nasal endoscopy may be best suited as a first line diagnostic test to “rule in” CRS in patients with a high pre-test probability for CRS, especially CRS with nasal polyposis (CRSwNP) and may be less well suited for patients with a history or findings with low CRS risk.…”