Rhinosinusitis Diagnosis and Management for the Clinician: A Synopsis of Recent Consensus Guidelines
2011; Elsevier BV; Volume: 86; Issue: 5 Linguagem: Inglês
10.4065/mcp.2010.0392
ISSN1942-5546
AutoresEli O. Meltzer, Daniel L. Hamilos,
Tópico(s)Otolaryngology and Infectious Diseases
ResumoRhinosinusitis (RS) affects approximately 1 in 7 adults in the United States, and its effect on quality of life, productivity, and finances is substantial. During the past 10 years, several expert panels from authoritative bodies have published evidence-based guidelines for the diagnosis and management of RS and its subtypes, including acute viral RS, acute bacterial RS, chronic RS (CRS) without nasal polyposis, CRS with nasal polyposis, and allergic fungal RS. This review examines and compares the recommendations of the Rhinosinusitis Initiative, the Joint Task Force on Practice Parameters, the Clinical Practice Guideline: Adult Sinusitis, the European Position Paper on Rhinosinusitis and Nasal Polyps 2007, and the British Society for Allergy and Clinical Immunology. Points of consensus and divergent opinions expressed in these guidelines regarding classification, diagnosis, and management of adults with acute RS (ARS) and CRS and their various subtypes are highlighted for the practicing clinician. Key points of agreement regarding therapy in the guidelines for ARS include the efficacy of symptomatic treatment, such as intranasal corticosteroids, and the importance of reducing the unnecessary use of antibiotics in ARS; however, guidelines do not agree precisely regarding when antibiotics should be considered as a reasonable treatment strategy. Although the guidelines diverge markedly on the management of CRS, the diagnostic utility of nasal airway examination is acknowledged by all. Important and relevant data from MEDLINE-indexed articles published since the most recent guidelines were issued are also considered, and needs for future research are discussed. Rhinosinusitis (RS) affects approximately 1 in 7 adults in the United States, and its effect on quality of life, productivity, and finances is substantial. During the past 10 years, several expert panels from authoritative bodies have published evidence-based guidelines for the diagnosis and management of RS and its subtypes, including acute viral RS, acute bacterial RS, chronic RS (CRS) without nasal polyposis, CRS with nasal polyposis, and allergic fungal RS. This review examines and compares the recommendations of the Rhinosinusitis Initiative, the Joint Task Force on Practice Parameters, the Clinical Practice Guideline: Adult Sinusitis, the European Position Paper on Rhinosinusitis and Nasal Polyps 2007, and the British Society for Allergy and Clinical Immunology. Points of consensus and divergent opinions expressed in these guidelines regarding classification, diagnosis, and management of adults with acute RS (ARS) and CRS and their various subtypes are highlighted for the practicing clinician. Key points of agreement regarding therapy in the guidelines for ARS include the efficacy of symptomatic treatment, such as intranasal corticosteroids, and the importance of reducing the unnecessary use of antibiotics in ARS; however, guidelines do not agree precisely regarding when antibiotics should be considered as a reasonable treatment strategy. Although the guidelines diverge markedly on the management of CRS, the diagnostic utility of nasal airway examination is acknowledged by all. Important and relevant data from MEDLINE-indexed articles published since the most recent guidelines were issued are also considered, and needs for future research are discussed. Rhinosinusitis (RS) poses a major health problem, substantially affecting quality of life, productivity, and finances. According to a recent analysis of US National Health Interview Survey data, RS affects approximately 1 in 7 adults.1Pleis JR Lucas JW Ward BW Summary health statistics for U.S. adults: National Health Interview Survey, 2008. National Center for Health Statistics.Vital Health Stat. 2009; 10 (Accessed February 16, 2011.): 1-157www.cdc.gov/nchs/data/series/sr_10/sr10_242.pdfGoogle Scholar The number of workdays missed annually because of RS was similar to that reported for acute asthma (5.67 days vs 5.79 days, respectively), and patients with RS were more likely to spend greater than $500 per year on health care than were people with chronic bronchitis, ulcer disease, asthma, and hay fever (all, P<.001).2Bhattacharyya N Contemporary assessment of the disease burden of sinusitis.Am J Rhinol Allergy. 2009; 23: 392-395Crossref PubMed Scopus (33) Google Scholar Other data suggest that chronic RS (CRS) affects certain general health domains (social functioning, bodily pain) more than angina, chronic heart failure, chronic obstructive pulmonary disease, or chronic back pain.3Gliklich RE Metson R The health impact of chronic sinusitis in patients seeking otolaryngologic care.Otolaryngol Head Neck Surg. 1995; 113: 104-109Crossref PubMed Scopus (258) Google Scholar Although a common illness, RS presents a number of diagnostic and management challenges to the practicing clinician. Rhinosinusitis is the broad umbrella term covering multiple disease entities, including acute RS (ARS), CRS, and nasal polyposis (NP).4Fokkens W Lund V Mullol J European Position Paper on Rhinosinusitis and Nasal Polyps Group European position paper on rhinosinusitis and nasal polyps 2007.Rhinology. 2007; 45 (Accessed February 16, 2011.): 1-139http://www.ep3os.org/EPOS2007.pdfPubMed Google Scholar However, RS has numerous subtypes and distinct etiologies, wide variations in severity and clinical presentation, and overlapping symptomatology and/or pathology with other medical conditions. Simple and accurate office-based testing methods for its detection are lacking. During the past decade, a number of expert panels have put forth evidence-based guidelines for the diagnosis and management of RS, including its subtypes.4Fokkens W Lund V Mullol J European Position Paper on Rhinosinusitis and Nasal Polyps Group European position paper on rhinosinusitis and nasal polyps 2007.Rhinology. 2007; 45 (Accessed February 16, 2011.): 1-139http://www.ep3os.org/EPOS2007.pdfPubMed Google Scholar, 5Meltzer EO Hamilos DL Hadley JA American Academy of Allergy, Asthma and Immunology (AAAAI) the American Academy of Otolaryngic Allergy (AAOA) the American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) the American College of Allergy, Asthma and Immunology (ACAAI) the American Rhinologic Society (ARS) et al.Rhinosinusitis: establishing definitions for clinical research and patient care.J Allergy Clin Immunol. 2004; 114: S155-S212Abstract Full Text Full Text PDF PubMed Scopus (297) Google Scholar, 6Slavin RG Spector SL Bernstein IL American Academy of Allergy, Asthma and Immunology the American College of Allergy, Asthma and Immunology the Joint Council of Allergy, Asthma and Immunology et al.The diagnosis and management of sinusitis: a practice parameter update.J Allergy Clin Immunol. 2005; 116: S13-S47Abstract Full Text Full Text PDF PubMed Scopus (134) Google Scholar, 7Rosenfeld RM Andes D Bhattacharyya N et al.Clinical practice guideline: adult sinusitis.Otolaryngol Head Neck Surg. 2007; 137: S1-S31Crossref PubMed Google Scholar Table 1 lists the organizations contributing to each of the projects: the European Position Paper on Rhinosinusitis and Nasal Polyps 2007 (EP3OS),4Fokkens W Lund V Mullol J European Position Paper on Rhinosinusitis and Nasal Polyps Group European position paper on rhinosinusitis and nasal polyps 2007.Rhinology. 2007; 45 (Accessed February 16, 2011.): 1-139http://www.ep3os.org/EPOS2007.pdfPubMed Google Scholar the Rhinosinusitis Initiative (RI),5Meltzer EO Hamilos DL Hadley JA American Academy of Allergy, Asthma and Immunology (AAAAI) the American Academy of Otolaryngic Allergy (AAOA) the American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) the American College of Allergy, Asthma and Immunology (ACAAI) the American Rhinologic Society (ARS) et al.Rhinosinusitis: establishing definitions for clinical research and patient care.J Allergy Clin Immunol. 2004; 114: S155-S212Abstract Full Text Full Text PDF PubMed Scopus (297) Google Scholar, 9Meltzer EO Hamilos DL Hadley JA Rhinosinusitis Initiative et al.Rhinosinusitis: developing guidance for clinical trials.J Allergy Clin Immunol. 2006; 118: S17-S61Abstract Full Text Full Text PDF PubMed Scopus (77) Google Scholar the Joint Task Force on Practice Parameters (JTFPP),6Slavin RG Spector SL Bernstein IL American Academy of Allergy, Asthma and Immunology the American College of Allergy, Asthma and Immunology the Joint Council of Allergy, Asthma and Immunology et al.The diagnosis and management of sinusitis: a practice parameter update.J Allergy Clin Immunol. 2005; 116: S13-S47Abstract Full Text Full Text PDF PubMed Scopus (134) Google Scholar and the Clinical Practice Guideline: Adult Sinusitis (CPG:AS).7Rosenfeld RM Andes D Bhattacharyya N et al.Clinical practice guideline: adult sinusitis.Otolaryngol Head Neck Surg. 2007; 137: S1-S31Crossref PubMed Google Scholar Another, comparatively brief, guideline has been released by the British Society for Allergy and Clinical Immunology (BSACI)8Scadding GK Durham SR Mirakian R British Society for Allergy and Clinical Immunology et al.BSACI guidelines for the management of rhinosinusitis and nasal polyposis.Clin Exp Allergy. 2008; 38: 260-275Crossref PubMed Scopus (68) Google Scholar; its recommendations frequently correspond with those of the EP3OS. These guidelines draw from the evidence base of the published literature and reflect as well the viewpoints of many leading experts in the fields of allergy, immunology, and otolaryngology. Intended to benefit the practicing clinician, this review compares the recommendations made for the diagnosis and management of RS in these 5 guidelines and evaluates the sometimes limited and contradictory evidence that underpins them and the variable quality of the studies that produced that evidence. Significant, relevant data published in MEDLINE-indexed articles since the most recent guidelines were issued are also reviewed. Key recommendations for diagnosis and treatment are indicated throughout the article in italics. As it is beyond the scope of this review to address the entire contents of these guidelines, the reader is encouraged to refer to the original documents.TABLE 1Recent Evidence-Based Guidelines for the Diagnosis and Treatment of RhinosinusitisReferenceGuideline designationRepresentation of contributorsFokkens et al,4Fokkens W Lund V Mullol J European Position Paper on Rhinosinusitis and Nasal Polyps Group European position paper on rhinosinusitis and nasal polyps 2007.Rhinology. 2007; 45 (Accessed February 16, 2011.): 1-139http://www.ep3os.org/EPOS2007.pdfPubMed Google Scholar 2007EP3OSTask force commissioned by the EAACIMeltzer et al,5Meltzer EO Hamilos DL Hadley JA American Academy of Allergy, Asthma and Immunology (AAAAI) the American Academy of Otolaryngic Allergy (AAOA) the American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) the American College of Allergy, Asthma and Immunology (ACAAI) the American Rhinologic Society (ARS) et al.Rhinosinusitis: establishing definitions for clinical research and patient care.J Allergy Clin Immunol. 2004; 114: S155-S212Abstract Full Text Full Text PDF PubMed Scopus (297) Google Scholar 2004RIJoint consensus of the major US allergy/ENT associations: AAAAI, AAOA, AAO-HNS. ACAAI, and ARSSlavin et al,6Slavin RG Spector SL Bernstein IL American Academy of Allergy, Asthma and Immunology the American College of Allergy, Asthma and Immunology the Joint Council of Allergy, Asthma and Immunology et al.The diagnosis and management of sinusitis: a practice parameter update.J Allergy Clin Immunol. 2005; 116: S13-S47Abstract Full Text Full Text PDF PubMed Scopus (134) Google Scholar 2005JTFPPAAAAI, ACAAI, and the Joint Council of Allergy, Asthma and ImmunologyRosenfeld et al,7Rosenfeld RM Andes D Bhattacharyya N et al.Clinical practice guideline: adult sinusitis.Otolaryngol Head Neck Surg. 2007; 137: S1-S31Crossref PubMed Google Scholar 2007CPG:ASPanel selected by the AAO-HNS FoundationScadding et al,8Scadding GK Durham SR Mirakian R British Society for Allergy and Clinical Immunology et al.BSACI guidelines for the management of rhinosinusitis and nasal polyposis.Clin Exp Allergy. 2008; 38: 260-275Crossref PubMed Scopus (68) Google Scholar 2008BSACIStandards of Care Committee of the BSACIAAAAI = American Academy of Allergy, Asthma and Immunology; AAOA = American Academy of Otolaryngic Allergy; AAO-HNS = American Academy of Otolaryngology–Head and Neck Surgery; ACAAI = American College of Allergy, Asthma and Immunology; ARS = American Rhinologic Society; BSACI = British Society for Allergy and Clinical Immunology; CPG:AS = Clinical Practice Guideline: Adult Sinusitis; EAACI = European Academy of Allergy (formerly Allergology) and Clinical Immunology; ENT = ear, nose, and throat; EP3OS = European Position Paper on Rhinosinusitis and Nasal Polyps 2007; JTFPP = Joint Task Force on Practice Parameters; RI = Rhinosinusitis Initiative. Open table in a new tab AAAAI = American Academy of Allergy, Asthma and Immunology; AAOA = American Academy of Otolaryngic Allergy; AAO-HNS = American Academy of Otolaryngology–Head and Neck Surgery; ACAAI = American College of Allergy, Asthma and Immunology; ARS = American Rhinologic Society; BSACI = British Society for Allergy and Clinical Immunology; CPG:AS = Clinical Practice Guideline: Adult Sinusitis; EAACI = European Academy of Allergy (formerly Allergology) and Clinical Immunology; ENT = ear, nose, and throat; EP3OS = European Position Paper on Rhinosinusitis and Nasal Polyps 2007; JTFPP = Joint Task Force on Practice Parameters; RI = Rhinosinusitis Initiative. Article Highlights •Guidelines promulgated by 5 major groups regarding acute rhinosinusitis (ARS) and chronic rhinosinusitis (CRS) are not in complete agreement regarding best practices•Clinicians continue to overprescribe antibiotics for ARS. Antibiotics are appropriate in cases of severe ARS, although standards of severity vary. The value of antibiotics for treatment of CRS is still unproven•The efficacy of intranasal corticosteroids has been well established by clinical trial data, and guidelines advise their use in ARS and CRS•Although some groups have proposed management plans for CRS, a lack of adequate clinical trial data makes it difficult to ensure that treatment recommendations are based on rigorous evidence•There has been a push for clinical trials examining CRS with nasal polyposis, CRS without nasal polyposis, and allergic fungal rhinosinusitis as distinct entities; however, few such trials have been conducted to date, and more data are needed to help clinicians treat these conditions appropriately •Guidelines promulgated by 5 major groups regarding acute rhinosinusitis (ARS) and chronic rhinosinusitis (CRS) are not in complete agreement regarding best practices•Clinicians continue to overprescribe antibiotics for ARS. Antibiotics are appropriate in cases of severe ARS, although standards of severity vary. The value of antibiotics for treatment of CRS is still unproven•The efficacy of intranasal corticosteroids has been well established by clinical trial data, and guidelines advise their use in ARS and CRS•Although some groups have proposed management plans for CRS, a lack of adequate clinical trial data makes it difficult to ensure that treatment recommendations are based on rigorous evidence•There has been a push for clinical trials examining CRS with nasal polyposis, CRS without nasal polyposis, and allergic fungal rhinosinusitis as distinct entities; however, few such trials have been conducted to date, and more data are needed to help clinicians treat these conditions appropriately Of the 5 guidelines and expert panel documents, 4 (EP3OS, RI, CPG:AS, and BSACI)4Fokkens W Lund V Mullol J European Position Paper on Rhinosinusitis and Nasal Polyps Group European position paper on rhinosinusitis and nasal polyps 2007.Rhinology. 2007; 45 (Accessed February 16, 2011.): 1-139http://www.ep3os.org/EPOS2007.pdfPubMed Google Scholar, 5Meltzer EO Hamilos DL Hadley JA American Academy of Allergy, Asthma and Immunology (AAAAI) the American Academy of Otolaryngic Allergy (AAOA) the American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) the American College of Allergy, Asthma and Immunology (ACAAI) the American Rhinologic Society (ARS) et al.Rhinosinusitis: establishing definitions for clinical research and patient care.J Allergy Clin Immunol. 2004; 114: S155-S212Abstract Full Text Full Text PDF PubMed Scopus (297) Google Scholar, 7Rosenfeld RM Andes D Bhattacharyya N et al.Clinical practice guideline: adult sinusitis.Otolaryngol Head Neck Surg. 2007; 137: S1-S31Crossref PubMed Google Scholar, 8Scadding GK Durham SR Mirakian R British Society for Allergy and Clinical Immunology et al.BSACI guidelines for the management of rhinosinusitis and nasal polyposis.Clin Exp Allergy. 2008; 38: 260-275Crossref PubMed Scopus (68) Google Scholar have adopted the term rhinosinusitis in place of sinusitis, the exception being the JTFPP.6Slavin RG Spector SL Bernstein IL American Academy of Allergy, Asthma and Immunology the American College of Allergy, Asthma and Immunology the Joint Council of Allergy, Asthma and Immunology et al.The diagnosis and management of sinusitis: a practice parameter update.J Allergy Clin Immunol. 2005; 116: S13-S47Abstract Full Text Full Text PDF PubMed Scopus (134) Google Scholar 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 the contiguous nasal mucosa.7Rosenfeld RM Andes D Bhattacharyya N et al.Clinical practice guideline: adult sinusitis.Otolaryngol Head Neck Surg. 2007; 137: S1-S31Crossref PubMed Google Scholar Regardless, the expert panels that adopted rhinosinusitis acknowledged that the terms rhinosinusitis and sinusitis should be used interchangeably, especially because the term rhinosinusitis has only come into common use during the past decade. Of the various subclassifications of RS, the simplest differentiation is based on duration of symptoms. Acute RS is defined by 3 of the guidelines (RI, JTFPP, and CPG:AS) as symptom duration of 4 weeks or less.5Meltzer EO Hamilos DL Hadley JA American Academy of Allergy, Asthma and Immunology (AAAAI) the American Academy of Otolaryngic Allergy (AAOA) the American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) the American College of Allergy, Asthma and Immunology (ACAAI) the American Rhinologic Society (ARS) et al.Rhinosinusitis: establishing definitions for clinical research and patient care.J Allergy Clin Immunol. 2004; 114: S155-S212Abstract Full Text Full Text PDF PubMed Scopus (297) Google Scholar, 6Slavin RG Spector SL Bernstein IL American Academy of Allergy, Asthma and Immunology the American College of Allergy, Asthma and Immunology the Joint Council of Allergy, Asthma and Immunology et al.The diagnosis and management of sinusitis: a practice parameter update.J Allergy Clin Immunol. 2005; 116: S13-S47Abstract Full Text Full Text PDF PubMed Scopus (134) Google Scholar, 7Rosenfeld RM Andes D Bhattacharyya N et al.Clinical practice guideline: adult sinusitis.Otolaryngol Head Neck Surg. 2007; 137: S1-S31Crossref PubMed Google Scholar The EP3OS4Fokkens W Lund V Mullol J European Position Paper on Rhinosinusitis and Nasal Polyps Group European position paper on rhinosinusitis and nasal polyps 2007.Rhinology. 2007; 45 (Accessed February 16, 2011.): 1-139http://www.ep3os.org/EPOS2007.pdfPubMed Google Scholar and BSACI8Scadding GK Durham SR Mirakian R British Society for Allergy and Clinical Immunology et al.BSACI guidelines for the management of rhinosinusitis and nasal polyposis.Clin Exp Allergy. 2008; 38: 260-275Crossref PubMed Scopus (68) Google Scholar guidelines qualify ARS as lasting less than 12 weeks, with complete resolution of symptoms. The CPG:AS includes a category of subacute RS, defined as symptom duration between 4 and 12 weeks,7Rosenfeld RM Andes D Bhattacharyya N et al.Clinical practice guideline: adult sinusitis.Otolaryngol Head Neck Surg. 2007; 137: S1-S31Crossref PubMed Google Scholar whereas the JTFPP6Slavin RG Spector SL Bernstein IL American Academy of Allergy, Asthma and Immunology the American College of Allergy, Asthma and Immunology the Joint Council of Allergy, Asthma and Immunology et al.The diagnosis and management of sinusitis: a practice parameter update.J Allergy Clin Immunol. 2005; 116: S13-S47Abstract Full Text Full Text PDF PubMed Scopus (134) Google Scholar definition specifies 4 to 8 weeks. Recurrent ARS is classified by the CPG:AS guidelines as 4 or more episodes of ARS within 1 year, without persistent symptoms between episodes.7Rosenfeld RM Andes D Bhattacharyya N et al.Clinical practice guideline: adult sinusitis.Otolaryngol Head Neck Surg. 2007; 137: S1-S31Crossref PubMed Google Scholar The JTFPP defines recurrent RS as 3 or more episodes per year.6Slavin RG Spector SL Bernstein IL American Academy of Allergy, Asthma and Immunology the American College of Allergy, Asthma and Immunology the Joint Council of Allergy, Asthma and Immunology et al.The diagnosis and management of sinusitis: a practice parameter update.J Allergy Clin Immunol. 2005; 116: S13-S47Abstract Full Text Full Text PDF PubMed Scopus (134) Google Scholar Four of the 5 guidelines (EP3OS,4Fokkens W Lund V Mullol J European Position Paper on Rhinosinusitis and Nasal Polyps Group European position paper on rhinosinusitis and nasal polyps 2007.Rhinology. 2007; 45 (Accessed February 16, 2011.): 1-139http://www.ep3os.org/EPOS2007.pdfPubMed Google Scholar RI,5Meltzer EO Hamilos DL Hadley JA American Academy of Allergy, Asthma and Immunology (AAAAI) the American Academy of Otolaryngic Allergy (AAOA) the American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) the American College of Allergy, Asthma and Immunology (ACAAI) the American Rhinologic Society (ARS) et al.Rhinosinusitis: establishing definitions for clinical research and patient care.J Allergy Clin Immunol. 2004; 114: S155-S212Abstract Full Text Full Text PDF PubMed Scopus (297) Google Scholar CPG:AS,7Rosenfeld RM Andes D Bhattacharyya N et al.Clinical practice guideline: adult sinusitis.Otolaryngol Head Neck Surg. 2007; 137: S1-S31Crossref PubMed Google Scholar and BSACI8Scadding GK Durham SR Mirakian R British Society for Allergy and Clinical Immunology et al.BSACI guidelines for the management of rhinosinusitis and nasal polyposis.Clin Exp Allergy. 2008; 38: 260-275Crossref PubMed Scopus (68) Google Scholar) designate CRS as symptoms persisting 12 weeks or longer, whereas the JTFPP6Slavin RG Spector SL Bernstein IL American Academy of Allergy, Asthma and Immunology the American College of Allergy, Asthma and Immunology the Joint Council of Allergy, Asthma and Immunology et al.The diagnosis and management of sinusitis: a practice parameter update.J Allergy Clin Immunol. 2005; 116: S13-S47Abstract Full Text Full Text PDF PubMed Scopus (134) Google Scholar indicates 8 weeks. All 5 guidelines recognize that an assessment of symptom severity is important to define the magnitude of disease and assist with treatment selection. For clinical purposes, the EP3OS and BSACI guidelines categorize disease severity on the basis of a 10-cm visual analog scale (VAS) that has been statistically validated for use in patients with RS. Patients responding to the question "How troublesome are your symptoms of rhinosinusitis?" provide a rating, with the scale ranging from 0 ("not troublesome") to 10 ("worst thinkable troublesome"). Scores are categorized as follows, between 0 and 3, mild disease; greater than 3 to 7, moderate disease;and greater than 7 to 10, severe disease.4Fokkens W Lund V Mullol J European Position Paper on Rhinosinusitis and Nasal Polyps Group European position paper on rhinosinusitis and nasal polyps 2007.Rhinology. 2007; 45 (Accessed February 16, 2011.): 1-139http://www.ep3os.org/EPOS2007.pdfPubMed Google Scholar Scores greater than 5 have been correlated with quality of life detriments.10Lim M Lew-Gor S Darby Y Brookes N Scadding G Lund VJ The relationship between subjective assessment instruments in chronic rhinosinusitis.Rhinology. 2007; 45: 144-147PubMed Google Scholar 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 2.4Fokkens W Lund V Mullol J European Position Paper on Rhinosinusitis and Nasal Polyps Group European position paper on rhinosinusitis and nasal polyps 2007.Rhinology. 2007; 45 (Accessed February 16, 2011.): 1-139http://www.ep3os.org/EPOS2007.pdfPubMed Google Scholar, 5Meltzer EO Hamilos DL Hadley JA American Academy of Allergy, Asthma and Immunology (AAAAI) the American Academy of Otolaryngic Allergy (AAOA) the American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) the American College of Allergy, Asthma and Immunology (ACAAI) the American Rhinologic Society (ARS) et al.Rhinosinusitis: establishing definitions for clinical research and patient care.J Allergy Clin Immunol. 2004; 114: S155-S212Abstract Full Text Full Text PDF PubMed Scopus (297) Google Scholar, 6Slavin RG Spector SL Bernstein IL American Academy of Allergy, Asthma and Immunology the American College of Allergy, Asthma and Immunology the Joint Council of Allergy, Asthma and Immunology et al.The diagnosis and management of sinusitis: a practice parameter update.J Allergy Clin Immunol. 2005; 116: S13-S47Abstract Full Text Full Text PDF PubMed Scopus (134) Google Scholar, 7Rosenfeld RM Andes D Bhattacharyya N et al.Clinical practice guideline: adult sinusitis.Otolaryngol Head Neck Surg. 2007; 137: S1-S31Crossref PubMed Google Scholar 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 (EP3OS4Fokkens W Lund V Mullol J European Position Paper on Rhinosinusitis and Nasal Polyps Group European position paper on rhinosinusitis and nasal polyps 2007.Rhinology. 2007; 45 (Accessed February 16, 2011.): 1-139http://www.ep3os.org/EPOS2007.pdfPubMed Google Scholar and BSACI8Scadding GK Durham SR Mirakian R British Society for Allergy and Clinical Immunology et al.BSACI guidelines for the management of rhinosinusitis and nasal polyposis.Clin Exp Allergy. 2008; 38: 260-275Crossref PubMed Scopus (68) Google Scholar do not specify "purulent"); and facial pain or pressure. The RI guidelines5Meltzer EO Hamilos DL Hadley JA American Academy of Allergy, Asthma and Immunology (AAAAI) the American Academy of Otolaryngic Allergy (AAOA) the American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) the American College of Allergy, Asthma and Immunology (ACAAI) the American Rhinologic Society (ARS) et al.Rhinosinusitis: establishing definitions for clinical research and patient care.J Allergy Clin Immunol. 2004; 114: S155-S212Abstract Full Text Full Text PDF PubMed Scopus (297) Google Scholar state that a diagnosis of ARS is probable if 2 or more of these major symptomsare present (the 3 already cited, as well as hyposmia-anosmia and fever), or 1 major symptom along with 2 or more minor symptoms (listed in Table 2). The JTFPP guidelines6Slavin RG Spector SL Bernstein IL American Academy of Allergy, Asthma and Immunology the American College of Allergy, Asthma and Immunology the Joint Council of Allergy, Asthma and Immunology et al.The diagnosis and management of sinusitis: a practice parameter update.J Allergy Clin Immunol. 2005; 116: S13-S47Abstract Full Text Full Text PDF PubMed Scopus (134) Google Scholar include these 4 symptoms along with headache and cough as being indicative of ARS. The CPG:AS guidelines7Rosenfeld RM Andes D Bhattacharyya N et al.Clinical practice guideline: adult sinusitis.Otolaryngol Head Neck Surg. 2007; 137: S1-S31Crossref PubMed Google Scholar require evidence of purulent nasal discharge for an ARS diagnosis, which must be accompanied by nasal obstruction, facial pain or pressure, or both. The EP3OS guidelines4Fokkens W Lund V Mullol J European Position Paper on Rhinosinusitis and Nasal Polyps Group European position paper on rhinosinusitis and nasal polyps 2007.Rhinology. 2007; 45 (Accessed February 16, 2011.): 1-139http://www.ep3os.org/EPOS2007.pdfPubMed Google Scholar require the presence of 2 or more major symptoms, 1 of which must be either nasal discharge or nasal blockage, congestion, or obstruction; other symptoms can include facial pain or pressure or reduction or loss of smell. The BSACI guidelines8Scadding GK Durham SR Mirakian R British Society for Allergy and Clinical Immunology et al.BSACI guidelines for the management of rhinosinusitis and nasal polyposis.Clin Exp Allergy. 2008; 38: 260-275Crossref PubMed Scopus (68) Google Scholar have these requirements plus characteristic signs on either endoscopy or computed tomography (CT). It should be noted that fever is cited as a possible diagnostic indicator only in the RI guidelines.5Meltzer EO Hamilos DL Hadley JA American Academy of Allergy, Asthma and Immunology (AAAAI) the American Academy of Otolaryngic Allergy (AAOA) the American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) the American College of Allergy, Asthma and Immunology (ACAAI) the American Rhinologic Society (ARS) et al.Rhinosinusitis: establishing definitions for clinical research and patient care.J Allergy Clin Immunol. 2004; 114: S155-S212Abstract Full Text Full Text PDF PubMed Scopus (297) Google ScholarTABLE 2Summary of Recent Evidence-Based Guidelines for the Diagnosis of ARS (Suspected AVRS or ABRS)a,ABRS = ac
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