REVIEWRhinosinusitis Diagnosis and Management for the Clinician: A Synopsis of Recent Consensus Guidelines
Section snippets
Rhinosinusitis vs Sinusitis
Of the 5 guidelines and expert panel documents, 4 (EP3OS, RI, CPG:AS, and BSACI)4, 5, 7, 8 have adopted the term rhinosinusitis in place of sinusitis, the exception being the JTFPP.6 The term rhinosinusitis may be more appropriate given that the nasal middle turbinate extends directly into the ethmoid sinuses, and effects on the middle turbinate may be seen in the anterior ethmoid sinuses as well. Clinically, sinus inflammation (ie, sinusitis) rarely occurs without concomitant inflammation of
Cardinal Signs or Symptoms
The expert guidelines demonstrate close agreement in their identification of the hallmark signs or symptoms of ARS; however, specific algorithms differ somewhat, as detailed in Table 2.4, 5, 6, 7 Three major signs or symptoms are consistently cited across all the guidelines as being primary diagnostic indicators for ARS: nasal congestion, obstruction, or blockage; anterior and/or posterior purulent rhinorrhea (EP3OS4 and BSACI8 do not specify “purulent”); and facial pain or pressure. The RI
MANAGEMENT OF ARS
The fundamental issue in determining appropriate treatment is identifying which ARS cases warrant antibiotics. Survey data confirm a remarkable overuse of antibiotics for ARS that is most likely viral rather than bacterial. Only an estimated 0.5% to 2.0% of ARS episodes have a bacterial etiology. In addition, the recent consensus documents discussed herein have reconsidered the appropriateness of antibiotic use for mild cases of presumed ABRS. Clinical studies have confirmed that roughly 60% of
DIAGNOSIS OF CRS
Despite a good deal of overlap between ARS and CRS with regard to individual symptoms, CRS is much more heterogeneous. The greater complexity of CRS is exemplified by a lack of agreement among leading authorities as to the categorization of the disease. Of the 5 consensus guidelines, the RI group has proposed the most detailed subclassification scheme to date (Figure 2).5 In this scheme, the most important differentiating features are the presence or absence of the following: (1) NP, (2)
MANAGEMENT OF CRS
The lack of an overall consensus or a succinct algorithm for the treatment of CRS is due in large part to the paucity of controlled studies for this indication. The design and interpretation of CRS clinical trials have been hindered by the inherent heterogeneity of the disease, a lack of uniform definitions for the various subtypes, an incomplete understanding of the underlying pathologies, and a lack of useful and standardized clinical and laboratory end points to measure response to therapy.83
CONTINUING RESEARCH
Many issues remain to be addressed in the field of RS management, particularly CRS. An encouraging upsurge in the number of CRS-oriented investigational studies has occurred since publication of the most recent RS guidelines. Promising areas of investigation in CRS include studies of the role of bacterial biofilms, immune hyperresponsiveness to colonizing fungi, and defects in innate immunity in the initiation or persistence of CRS.
Many recent studies have been conducted in patients with CRS.165
CONCLUSION
Current consensus and evidence-based guidelines are in agreement with regard to the diagnosis and treatment of ARS. The efficacy of intranasal corticosteroids has been well established by clinical trial data, and all 4 guidelines with evidence-based treatment recommendations (EP3OS, JTFPP, CPG:AS, and BSACI) advise their use in ARS; these 4 guidelines also recommend antibiotics for patients presenting with severe ARS symptoms. An issue of great concern in ARS, in which most cases by far are
Acknowledgments
We thank Karl Torbey, MD, and Rob Coover, MPH, of AdelphiEden Health Communications for editorial assistance. This assistance was funded by Schering Corp, now Merck & Co.
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Dr Meltzer has received grant/research support from Alcon, Alexza Pharmaceuticals, Amgen, Antigen Labs, Apotex, Astellas, AstraZeneca, Boehringer Ingelheim, Forest, GlaxoSmithKline, Johnson & Johnson, MAP, MEDA, Medimmune, Merck, Novartis, Proctor & Gamble, Schering-Plough, Sepracor, Teva, and UCB. He has served as a consultant/speaker for Alcon, Alexza Pharmaceuticals, Amgen, AstraZeneca, Boehringer Ingelheim, Capnia, Dainippon Sumitomo, Dey, GlaxoSmithKline, ISTA, Johnson & Johnson, Kalypsys, MAP, Meda, Merck, Sandoz, sanofi-aventis, Schering-Plough, Sepracor, SRxA, Stallergenes, Teva, VentiRx, Wockhardt, and Wyeth. Dr. Hamilos has received book royalties from UpToDate and Informa. Editorial assistance for the submitted manuscript was funded by Schering Corp, now Merck & Co.
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