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Staging systems and outcome results for head and neck neoplasms have long been important to the otolaryngologist in determining future treatment and advising the patient and family. Staging systems and statistical and outcome analysis for rhinosinusitis have greatly lagged behind that which exists for other disease entities. Most reports discuss surgical technique and relate to the author’s method of assessing and evaluating disease. Some staging systems use various aspects of patient symptoms, and others incorporate aspects of the physical examination. Most staging systems use some features of CT scan findings because CT scans provide information about volume and location of disease. Because there is no standardized or uniform method of reporting results, there is difficulty in comparing techniques and results from one author to another. Even the definition of the various types of rhinosinusitis has been debated. There have been discussions and agreement by the American Academy of Otolaryngology Head and Neck Surgery (AAO-HNS), Rhinology and Paranasal Sinus Committee about definitions of rhinosinusitis (acute, subacute, recurrent acute, chronic, and acute exacerbation of chronic).1

The desire to have outcome data and uniform definitions of disease and staging of disease is stimulated by the growing interest in the diagnosis and management of rhinosinusitis, the number one chronic disease in the United States. There is prognostic value in having any staging system and evaluating outcome. With a higher stage, there should be worsening of disease and therefore a greater and more intense level of management. It is not clear whether the ideal staging system, however, is best based on nasal endoscopic findings, patient history, CT abnormalities, or some combination of these.

Staging Systems

In 1993, the International Conference on Sinus Disease: Terminology, Staging, and Therapy, was held in Princeton, New Jersey.² The purpose of the conference was to bring together leading authorities in nasal and sinus disease representing otolaryngology, radiology, family medicine, internal medicine, and pediatrics from around the world to discuss anatomical nomenclature, sinus staging, and medical management of rhinosinusitis. The conference stressed the diagnostic categories of rhinosinusitis, symptom score, related systemic diagnoses, radiologic staging, surgical score, and endoscopic appearance score. This was an attempt to bring together several different patient symptoms and signs to create a staging system. (Demographic information presented in this chapter is based on the American Academy of Otolaryngology Head and Neck Surgery Rhinology and Paranasal Sinus Committee Classification of Rhinosinusitis, modified since the conference.¹)

Systemic diagnoses with disease are included in the discussion in this chapter. Diseases included are abnormalities of mucociliary clearance (primary ciliary dyskinesia and Young’s syndrome), asthma (with or without aspirin sensitivity and acetylsalicylic acid triad), bronchiectasis, diabetes mellitus, immune deficiency, multiple myeloma, sarcoidosis, and other conditions predisposing to infection. Underlying factors to be included are atopy and smoking.

Radiologic staging requires CT scan assessment. Plain radiographs have no role in the staging process. Each sinus group (maxillary, anterior ethmoid, posterior ethmoid, sphenoid, and frontal) is graded as 0 (no abnormality), 1 (partial opacification), or 2 (total opacification). The ostiomeatal complex is scored as either 0 (no occlusion) or 2 (total opacification). Anatomical variants are noted as absent (0) or present (1) but do not contribute to scan score. Variants include concha bullosa, paradoxical middle turbinate, infraorbital ethmoid cells (Haller’s cells), everted uncinate process, agger nasi pneumatization, and absence of frontal sinus. These variants have little impact on staging but are important for planning surgery. Anatomical variants with normal mucosa are probably inconsequential.

Other authors have looked at different aspects of CT scans as a staging tool. Friedman and Katsantonis,3 for example, have used a staging system since 1984 that is based on their experience in assessing and evaluating sinus disease and provides a statistical basis for sinus surgery:

Stage I: Single-focus disease radiographically, either unilaterally or bilaterally

Stage II: Discontiguous or patchy areas of disease radiofrequency, either unilateral or bilateral

Stage III: Contiguous disease throughout the ethmoid labyrinth, with or without other major sinus opacity, with symptomatic response to medication

Stage IV:

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