Diagnosis and Classification of Rhinosinusitis

3. Fatigue

4. Dental pain

5. Cough

6. Ear pain/pressure/fullness

• Diagnosis requires two major symptoms, or one major and two minor symptoms; secondary criteria only “count” if accompanied by another major criterion.

• Purulent nasal secretions on exam confirms the diagnosis.

Clinical Practice Guidelines on Adult Rhinosinusitis (2015)

• Revised to simplify diagnosis

• Symptoms for 4 weeks or less

• Purulent nasal drainage (anterior, posterior, or both) accompanied by nasal obstruction, facial pain-pressure-fullness, or both

• Viral rhinosinusitis: symptoms/signs of ARS fewer than 10 days; symptoms not worsening

• Acute bacterial rhinosinusitis (ABRS): symptom/signs of ARS for 10 days or more, or double worsening (worsen within 10 days after initial improvement)

• Purulent nasal secretions on exam

• Transillumination not useful

• Diagnosis is clinical

• Imaging not indicated unless complication suspected

Canadian Rhinosinusitis Guidelines (2011)

• Table 10–1 contains the guidelines.

Diagnosis of Chronic Rhinosinusitis

Task Force on Rhinosinusitis of AAO-HNS (1997)

• Symptoms for 3 months or longer

• Two of the following major criteria are required:

1. Nasal obstruction/congestion

2. Thick rhinorrhea or post-nasal purulent discharge

3. Facial pain/pressure

4. Decreased sense of smell (hyposmia)

• Seven minor criteria:

1. Headache

2. Halitosis

3. Fever

TABLE 10–1. ABRS Diagnosis Requires the Presence of At Least Two Major Symptoms*

* For diagnosis of ABRS, patient must have: (1) nasal obstruction OR nasal purulence/discolored postnasal discharge, AND (2) at least one other PODS symptom.

4. Fatigue

5. Dental pain

6. Cough

7. Ear pain/pressure/fullness

• Diagnosis requires two major symptoms, or one major and two minor symptoms

• Also requires one finding that confirms inflammation: mucosal thickening on CT scan; nasal polyps on rhinoscopy; or polyps, purulence, or edema on nasal endoscopy

Clinical Practice Guidelines on Adult Rhinosinusitis (2015)

• Revised to simplify diagnosis

• Twelve weeks or longer of two or more signs/symptoms:

1. Mucopurulent drainage (anterior, posterior, or both)

2. Nasal obstruction/congestion

3. Facial pain-pressure-fullness

4. Decreased sense of smell

• AND inflammation is documented by one or more findings:

1. Purulent (not clear) mucus or edema in middle meatus or anterior ethmoid region

2. Polyps in nasal cavity or middle meatus

3. Radiographic imaging showing sinus inflammation

• Need to confirm presence or absence of polyps

European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS 2012)

• Defined as inflammation in the nose and paranasal sinuses

Definition in Adults

• Two or more symptoms, one being either nasal blockage/congestion or nasal discharge (anterior/posterior), +/− facial pain or pressure, +/− reduction or loss of smell

• And either:

1. Endoscopic signs of nasal polyps, mucopurulent discharge primarily from middle meatus, or edema/mucosal obstruction primarily in middle meatus

2. CT showing mucosal changes within the OMC and/or sinuses

• Subdivided into CRS with polyps (CRSwNP) and without polyps (CRSsNP)

• CRSwNP: bilateral endoscopically visualized polyps in middle meatus

• CRSsNP: no visible polyps in middle meatus (if necessary following decongestant)

Definition in Children

• Substitutes +/− cough instead of +/− reduction or loss of smell

• Otherwise criteria are the same

Canadian Rhinosinusitis Guidelines (2011)

• Table 10–2 shows the guidelines.

Classification of Rhinosinusitis

Chronic Rhinosinusitis

• Multiple proposals

Phenotype Based on Asthma and Atopy Status

(Han JK, Laryngoscope. 2013;Mar;123 Suppl2:S15–27)

• Non-asthmatic CRS w/o allergy: purulence, low CT score, no polyps, Th1 profile, PMNs, IL-6, IL-8

• Non-asthmatic CRS with allergy: small polyps, less purulence, moderate CT score, eosinophils/mast cells, interferon-gamma

• Asthmatic CRS with allergy: large polyps, no purulence, high CT score, severe atopy, Th2 profile, IL-5, eos; “unified airway disease”

• Asthmatic CRS w/o allergy: large polyps, no purulence, high CT score, adult-onset asthma, minimal atopy, Th2 profile, eos; possible AERD precursor

• Aspirin-exacerbated respiratory disease (AERD): abundant polyps, no purulence, high CT score, adult-onset asthma, NSAID-induced bronchospasm, IL-4, eos, urine LTE4

• Allergic fungal sinusitis (AFS): may be unilateral, large polyps, some purulence, allergic mucin, high CT score, IL-5, IgE

Emerging Classification Schemes

• Phenotyping by other clinical data: age, lost productivity, patient-reported symptom scores

• Endotyping according to cellular and molecular biomarkers

• Microbiome composition, diversity, growth patterns

• Genotyping of receptors, factors of innate immunity

Table 10–2. CRS Diagnosis Requires the Presence of At Least Two Major Symptoms*