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EAACI European Position Paper on Rhinosinusitis and Nasal Polyps

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EAACI European Position Paper on Rhinosinusitis and Nasal Polyps EAACI European Position Paper on Rhinosinusitis and Nasal Polyps Participants: Wytske Fokkens, Chair Valerie Lund, Co-Chair Claus Bachert Peter Clement Peter Helllings Mats Holmstrom Nick Jones Livije Kalogjera, David Kennedy Marek Kowalski Henrik Malmberg Joaquim Mullol Desiderio Passali Heinz Stammberger Pontus Stierna 50302_bw 24-03-2005 08:25 Pagina 1 European Position Paper on Rhinosinusitis and Nasal Polyps CONTENTS 8-4 Endocranial complications 48 8-5 Cavernous sinus thrombosis 49 1 Introduction 3 8-6 Osseous complications 49 8-7 Unusual complications of rhinosinusitis 50 2 Definition of rhinosinusitis and nasal polyps 4 8-8 Complications of surgical treatment 50 2-1 Introduction 4 2-2 Clinical definition 4 9 Special considerations: Rhinosinusitis in children 53 2-3 Definition for epidemiology/General Practice 5 9-1 Introduction 53 2-4 Definition for research 5 9-2 Anatomy 53 9-3 Epidemiology and pathophysiology 53 3 Chronic rhinosinusitis and nasal polyps 6 9-4 Symptoms and signs 53 3-1 Anatomy and (patho)physiology 6 9-5 Examination 54 3-2 Rhinosinusitis 6 9-6 Systemic disease and chronic rhinosinusitis 54 3-3 Nasal polyps and chronic rhinosinusitis 6 9-7 Management 55 4 Epidemiology and predisposing factors 8 10 Socio-economic cost of chronic rhinosinusitis 4-1 Introduction 8 and nasal polyps 58 4-2 Acute bacterial rhinosinusitis 8 10-1 Direct Costs 58 4-3 Factors associated with acute rhinosinusitis 9 10-2 Indirect Costs 58 4-4 Chronic rhinosinusitis (CRS) 9 4-5 Factors associated with chronic rhinosinusitis (CRS) 9 11 Outcomes measurements in research 60 4-6 Nasal polyps 12 4-7 Factors associated with NP 13 12 Evidence based schemes for diagnostic 4-8 Epidemiology and predisposing factors for and treatment 61 rhinosinusitis in children 14 12-1 Introduction 61 4-9 Conclusion 15 12-2 Level of evidence and grade of recommendation 61 12-3 Evidence based diagnosis and management 5 Inflammatory mechanisms in acute and chronic scheme for GP’s 63 rhinosinusitis and nasal polyposis 16 12-4 Evidence based diagnosis and management 5-1 Introduction 16 scheme for Non-ENT specialist for adults 5-2 Acute rhinosinusitis 16 with CRS/NP 64 5-3 Chronic rhinosinusitis 16 12-5 Evidence based diagnosis and management 5-4 Nasal polyps 17 scheme for ENT specialists 65 5-5 Conclusion 19 12-6 Evidence based schemes for therapy in children 69 6 Diagnosis 20 13 Research needs and priorities 70 6-1 Assessment of rhinosinusitis symptoms 20 6-2 Examination 21 14 References 70 6-3 Quality of Life 24 15 Appendix 85 7 Management 27 15-1 Survey of published olfactory tests 85 7-1 Treatment of rhinosinusitis with corticosteroids 27 15-2 Source of some olfactory tests 87 7-2 Treatment of rhinosinusitis with antibiotics 32 7-3 Other medical management for rhinosinusitis 36 7-4 Evidence based surgery for rhinosinusitis 42 7-5 Surgical treatment vs. medical treatment in CRS /NP 45 8 Complications of rhinosinusitis and nasal polyps 47 8-1 Introduction 47 8-2 Epidemiology of complications 47 8-3 Orbital complications 47 50302_bw 24-03-2005 08:25 Pagina 3 European Position Paper on Rhinosinusitis and Nasal Polyps 3 1. Introduction Rhinosinusitis is a significant health problem which seems to The present document is intended to be state-of-the art for the mirror the increasing frequency of allergic rhinitis and which specialist as well as for the general practitioner: results in a large financial burden on society (1-3). The last • to update their knowledge of rhinosinusitis and nasal poly- decade has seen the development of a number of guidelines, posis; consensus documents and position papers on the epidemiolo- • to provide an evidence-based documented revision of the gy, diagnosis and treatment of rhinosinusitis and nasal polypo- diagnostic methods; sis (4-6). • to provide an evidence-based revision of the available treat- ments; Data on (chronic) rhinosinusitis is limited and the disease enti- • to propose a stepwise approach to the management of the ty is badly defined. Therefore, the available data is difficult to disease; interpret and extrapolate. Although of considerable assistance, • to propose guidance for definitions and outcome measure- the available consensus documents on chronic rhinosinusitis ments in research in different settings. and nasal polyps do not answer a number of relevant questions that would unify the information and current concepts that Table 1-1. Category of evidence (8). exist in epidemiology, diagnosis, treatment and research. To add to this, none of these documents are evidence based. Ia Evidence from meta-analysis of randomised controlled trials Ib Evidence from at least one randomised controlled trial IIa Evidence from at least one controlled study without There is considerable interest in guidelines as tools for imple- randomisation menting health care based on proof of effectiveness. IIb Evidence from at least one other type of quasi-experimental Guidelines should be informative, simple and easy to use and study in a form that can be widely disseminated within the medical III Evidence from non-experimental descriptive studies, such as community in order to improve patient care. comparative studies, correlation studies, and case-control studies Evidence-based medicine is an important method of preparing IV Evidence from expert committee reports or opinions or guidelines (7, 8). Moreover, the implementation of guidelines clinical experience of respected authorities, or both is equally important. Table 1-2. Strength of recommendation. The European Academy of Allergology and Clinical A Directly based on category I evidence Immunology (EAACI) has created a Taskforce to consider B Directly based on category II evidence or extrapolated what is known about rhinosinusitis and nasal polyps, to offer recommendation from category I evidence evidence based recommendations on diagnosis and treatment, C Directly based on category III evidence or extrapolated and to consider how we can make progress with research in recommendation from category I or II evidence this area. The EP3OS document is also approved by the D Directly based on category IV evidence or extrapolated European Rhinologic Society (ERS). recommendation from category I, II or III evidence 50302_bw 24-03-2005 15:16 Pagina 4 4 Supplement 18 2. Definition of rhinosinusitis and nasal polyps 2-1 Introduction Figure 2-1. Former classification of Rhinosinusitis (11). Rhinitis and sinusitis usually coexist and are concurrent in most individuals; thus, the correct terminology is now rhinosi- nusitis. The diagnosis of rhinosinusitis is made by a wide vari- ety of practitioners, including allergologists, otolaryngologists, pulmonologists, primary care physicians and many others. Therefore, an accurate, efficient, and accessible definition of rhinosinusitis is required. A number of groups have published reports on rhinosinusitis and its definition. In most of these reports definitions are based on symptomatology and duration of disease and one definition aims at all practitioners (4-6, 9). In 2001 the WHO put together a working group on rhinitis and its impact on asthma (ARIA)(10). In this group rhinitis was classified according to duration and severity. Due to the large differences in technical possibilities to diag- Table 2-1. Classification of allergic rhinitis (10). nose and treat rhinosinusitis/nasal polyps by various profes- sions, the need to differentiate between subgroups varies. On 1- “Intermittent” means that the symptoms are present: one hand the epidemiologist wants a workable definition that • Less than 4 days a week, does not impose too many restrictions to study larger popula- • And for less than 4 weeks. tions. On the other hand researchers in a clinical setting are in 2- “Persistent” means that the symptoms are present: • More than 4 days a week, need of a set of clearly defined items that describes their • Or for more than 4 weeks. (should it be “and”, not or?) patient population accurately and avoids the comparison of 3- “Mild” means that there are none of the following items: ‘apples and oranges’ in studies that relate to diagnosis and • No sleep disturbance, treatment. The taskforce tried to accommodate these different • No impairment of daily activities, leisure and/or sport, needs by giving definitions that can be applied in appropriate • No impairment of school or work, studies. In this way the taskforce hopes to improve the compa- • Symptoms are not troublesome. rability of studies and thus enhance the evidence based diag- 4- “Moderate-severe” means that there are one or more of the nosis and treatment of patients with rhinosinusitis and nasal following items: polyps. • Sleep disturbance, • Impairment of daily activities, leisure and/or sport, • Impairment of school or work, 2-2 Clinical definition • Troublesome are symptoms. 2-2-1 Clinical definition of rhinosinusitis/nasal polyps Rhinosinusitis (including nasal polyps) is defined as: • Inflammation of the nose and the paranasal sinuses charac- Until recently rhinosinusitis was usually classified based on the terised by two or more symptoms: duration into acute, subacute, chronic and acute on chronic - blockage/congestion; (see figure 1). Yet this division does not correlate with the clas- - discharge: anterior/post nasal drip; sification of rhinitis. Moreover it does not incorporate the - facial pain/pressure, severity of the disease. Also due to the long timeline of 12 - reduction or loss of smell; weeks in chronic rhinosinusitis it can be difficult to discrimi- and either nate between recurrent acute rhinosinusitis and chronic rhi- •Endoscopic signs: nosinusitis with or without exacerbations. - polyps; - mucopurulent discharge from middle meatus; - oedema/mucosal obstruction primarily in middle meatus, and/or • CT changes: - mucosal changes within ostiomeatal complex and/or sinuses. 50302_bw 24-03-2005 08:25 Pagina 5 European Position Paper on Rhinosinusitis and Nasal Polyps 5 2-2-2 Severity of the disease rhea, nasal itching and itchy watery eyes should be included. The disease can be divided into MILD and MODERATE/ Also include questions on intermittent disease (see definition SEVERE based on total severity visual analogue scale (VAS) above).
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