Practice Guidelines

Sinus and Allergy Health Partnership Releases Report on Adult Chronic Rhinosinusitis

Am Fam Physician. 2004 May 1;69(9):2248-2249.

The Sinus and Allergy Health Partnership convened a multidisciplinary task force (the Chronic Rhinosinusitis Task Force) in January 2002 to update the definitions developed in 1996 for chronic rhinosinusitis to help physicians diagnose this disease more accurately. This new report, “Adult Chronic Rhinosinusitis: Definitions, Diagnosis, Epidemiology, and Pathophysiology,” includes guidance on how to measure a patient’s response to treatment, a summary of diagnostic techniques, and theories and controversies in the pathogenesis of chronic rhinosinusitis. The panel defines the disease in its simplest form to create a consistent baseline for clinical care and research. The full report is available in the September 2003 supplement of Otolaryngology–Head and Neck Surgery.

The definitions of chronic rhinosinusitis presented in the report have been endorsed by the American Academy of Otolaryngology–Head and Neck Surgery, the American Academy of Otolaryngic Allergy, the American Rhinologic Society, and the Sinus and Allergy Health Partnership.

Sinusitis is one of the most common health care problems in the United States, and there is evidence that it is increasing in prevalence and incidence. Estimates suggest that sinusitis is more widespread than arthritis or hypertension, and it affects approximately 31 million Americans annually.

Definition

Chronic rhinosinusitis is a group of disorders characterized by inflammation of the mucosa of the nose and paranasal sinuses lasting for at least 12 consecutive weeks. According to the task force, the definition was agreed on through multiple consensus meetings and supported by the expertise of the members on the panel and the relevant literature.

Factors associated with chronic rhinosinusitis include systemic (i.e., allergic, immunodeficiency, genetic/congenital, mucociliary dysfunction, endocrine, neuromechanism), local (i.e., anatomic, neoplastic, acquired mucociliary dysfunction), and environmental (i.e., microorganisms [viral, bacterial, fungal], noxious chemicals, pollutants, smoke, medications, trauma, surgery).

Diagnosis

According to the task force, a diagnosis of chronic rhinosinusitis may be suggested by symptoms and duration of illness, but it should be confirmed by physical evidence of mucosal swelling or discharge. Purulent drainage, polyps, and polypoid changes are consistent with inflammation, usually can be identified with anterior rhinoscopy, and are sufficient to support the diagnosis if the 12-week duration is met.

Clinical criteria for diagnosing chronic rhinosinusitis include:

  • Duration of disease is qualified by continuous symptoms for more than 12 consecutive weeks or more than 12 weeks of physical findings.

  • One sign of inflammation (i.e., discolored nasal drainage, edema or erythema of the middle meatus or ethmoid bulla, generalized or localized erythema, edema, or granulation tissue, or confirmation from a computed tomography scan or plain sinus radiograph) must be present and identified in association with ongoing symptoms of chronic rhinosinusitis.

The task force recommends that all patients who meet the clinical criteria for rhinosinusitis have a computed tomographic scan or quality photoendoscopy performed to confirm the diagnosis.

Treatment Results

Patients can suffer for decades with chronic rhinosinusitis because of the limitations of treatment and comorbid conditions, such as asthma, allergy, or aspirin sensitivity. Long-term follow-up and an understanding of any comorbid conditions are essential for evaluating treatment options. The effects of medical and surgical treatments may diminish over time. This decrease in response is moderately correlated with factors that predispose the patients to rhinosinusitis, such as inhalant sensitivities, inhaled irritants (tobacco smoke), nasal polyps, the aspirin triad, immune deficiencies, and infections.

Nasal endoscopy is the best objective indicator of early recurrence of sinus disease. This procedure allows for targeted culturing, quantification of microbial levels, and harvesting of inflammatory mediators or eosinophils. Most patients will show signs of recurrence within two years after surgery. There is no gold standard for the best means of quantifying the results of treatments for rhino-sinusitis. The panel recommends using at least one subjective and one objective measure to follow-up. The length of follow-up usually depends on which treatment intervention is being used.

Summary

The report states that chronic rhinosinusitis is an evolving area of study and new information is being assessed on an ongoing basis. Debate continues about potential etiologies and associated conditions, pathophysiology, common inflammatory mediators, and whether or not most cases of chronic rhinosinusitis are associated with infection. Evidence in the most recent literature supports the significant role that microbes (i.e., bacteria, fungi) play in the inflammatory process.

The report discusses classification schemes, the role of potential bacterial, allergic, and fungal etiologies, and the controversies about these areas of study.


Copyright © 2004 by the American Academy of Family Physicians.
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