ACAAI 2011: Guidelines for the Diagnosis and Management of Sinusitis/ Rhinosinusitis, Part 2

Diagnosis of Chronic Rhinosinusitis

The complexity of CRS is exemplified by lack of agreement as to its categorization. The most important differentiating features are the presence or absence of: nasal polyps; eosinophilic or other inflammatory features; or fungal hyphae in the sinus mucosa. Although categorizing chronic rhinosinusitis is complex, CRS with or without nasal polyps is one way to initially begin classification. Prolonged duration of RS symptoms (>8-12 weeks) is the primary reason to evaluate patients for CRS. Dr. Meltzer emphasized the need to differentiate CRS from recurrent episodes of ARS.

Individual symptoms of CRS are similar to those seen in ARS (anterior and/or posterior mucopurulent drainage, nasal obstruction, facial pain/pressure). A decreased sense of smell is an important CRS symptom, especially in patients with nasal polyps. Facial pain, pressure or fullness is relatively more common in CRS without NP, whereas a decreased sense of smell is more common in CRS with NP.

In contrast to ARS, diagnostic testing is often used in patients with CRS. Nasal airway examination is important. Nasal endoscopy is preferred over anterior rhinoscopy due to its better illumination/visualization, and also the ability to obtain endoscopic cultures. Like ARS, plain radiography not helpful in work-up of suspected CRS, but CT can be particularly valuable for confirming diagnosis when symptoms are vague or persist despite optimal medical treatment (although not as a first-line recommendation). Allergy/Immunology evaluation can also be helpful. As many as 60% of patients with CRS have allergic sensitivities. Medical management of allergies is especially recommended for patients who are being considered for sinus surgery. Immunologic testing is recommended by some guideline documents for patients with recurrent ARS or CRS when aggressive management has failed or for recurrent/persistent purulent infections.

Management of Chronic Rhinosinusitis

Dr. Meltzer pointed out that there is no overall consensus or simple algorithm for CRS treatment, due to disease heterogeneity, incomplete understanding of pathologies, lack of uniform definitions of subtypes, and a dearth of standardized clinical/laboratory end points to measure therapeutic responses. The guidelines suggest the following:

For CRS patients without nasal polyps:

Mild symptoms: Intranasal CS (1b/A) for several months, nasal saline lavage (1b/A; there are many types of applicators and tonicities).

Moderate-to-severe symptoms: obtain culture, continue intranasal CS, continue nasal saline lavage, and add long-term macrolide antibiotic x 3 month (1b/A). If patient is still not responsive, get CT and consider surgery.

For CRS patients with nasal polyps:

• Mild symptoms: Again, intranasal CS (1b/A) for several months. If beneficial, continue/review every 6 months. If no improvement, add short course (1 month) oral CS (1b/A). If beneficial after 1 month, continue intranasal CS (drops). If still no improvement after 1 month, CT and consider surgery.
• Moderate symptoms: Intranasal CS for 3 months. If beneficial, continue/review every 6 months. If no improvement, add short course (1 month) oral CS. If beneficial after 1 month, continue intranasal CS (drops). If still no improvement after 1 month, get CT and consider surgery.
• Severe symptoms: Intranasal CS plus short course (1 month) oral CS. If beneficial continue only intranasal CS. If no improvement, get CT and consider surgery.