Classification and Definitions
2.1. Introduction
Rhinitis and sinusitis usually coexist and are concurrent in most individuals; thus, the correct terminology is now rhinosinusitis. Most guidelines and expert panel documents now have adopted the term rhinosinusitis instead of sinusitis (1, 2, 6, 28, 29).. The diagnosis of rhinosinusitis is made by a wide variety of practitioners, including allergologists, otolaryngologists, pulmonologists, primary care physicians, paediatricians, and many others. Therefore, an accurate, efficient, and accessible definition of rhinosinusitis is required.
Due to the large differences in technical possibilities to diagnose and treat rhinosinusitis with or withouw nasal polyps by various disciplines, the need to differentiate between subgroups varies. On the one hand the epidemiologist wants a workable definition that does not impose too many restrictions to study larger populations. On the other hand researchers in a clinical setting are in need of a set of clearly defined items that describes their patient population (phenotypes) accurately and avoids the comparison of 'apples and oranges' in studies that relate to diagnosis and treatment. The taskforce tried to accommodate these different needs by offering definitions that can be applied in different circumstances. In this way the taskforce hopes to improve the comparability of studies, thereby enhancing the evidence based diagnosis and treatment of patients with rhinosinusitis and nasal polyps.
2.2. Clinical definition of rhinosinusitis
2.2.1. Clinical definition of rhinosinusitis in adults Rhinosinusitis in adults is defined as:
- mucopurulent discharge primarily from middle meatus and/or
- oedema/mucosal obstruction primarily in middle meatus
and/or
2.2.2. Clinical definition of rhinosinusitis in children
Paediatric rhinosinusitis is defined as: inflammation of the nose and the paranasal sinuses characterised by two or more symptoms one of which should be either nasal blockage/obstruction/congestion or nasal discharge (anterior/ posterior nasal drip):
- mucopurulent discharge primarily from middle meatus and/or
- oedema/mucosal obstruction primarily in middle meatus
and/or
Rhinitis and sinusitis usually coexist and are concurrent in most individuals; thus, the correct terminology is now rhinosinusitis. Most guidelines and expert panel documents now have adopted the term rhinosinusitis instead of sinusitis (1, 2, 6, 28, 29).. The diagnosis of rhinosinusitis is made by a wide variety of practitioners, including allergologists, otolaryngologists, pulmonologists, primary care physicians, paediatricians, and many others. Therefore, an accurate, efficient, and accessible definition of rhinosinusitis is required.
Due to the large differences in technical possibilities to diagnose and treat rhinosinusitis with or withouw nasal polyps by various disciplines, the need to differentiate between subgroups varies. On the one hand the epidemiologist wants a workable definition that does not impose too many restrictions to study larger populations. On the other hand researchers in a clinical setting are in need of a set of clearly defined items that describes their patient population (phenotypes) accurately and avoids the comparison of 'apples and oranges' in studies that relate to diagnosis and treatment. The taskforce tried to accommodate these different needs by offering definitions that can be applied in different circumstances. In this way the taskforce hopes to improve the comparability of studies, thereby enhancing the evidence based diagnosis and treatment of patients with rhinosinusitis and nasal polyps.
2.2. Clinical definition of rhinosinusitis
2.2.1. Clinical definition of rhinosinusitis in adults Rhinosinusitis in adults is defined as:
- inflammation of the nose and the paranasal sinuses characterised by two or more symptoms, one of which should be either nasal blockage/obstruction/congestion or nasal discharge (anterior/posterior nasal drip): ± facial pain/pressure; ± reduction or loss of smell
- endoscopic signs of:
- mucopurulent discharge primarily from middle meatus and/or
- oedema/mucosal obstruction primarily in middle meatus
and/or
- CT changes:
2.2.2. Clinical definition of rhinosinusitis in children
Paediatric rhinosinusitis is defined as: inflammation of the nose and the paranasal sinuses characterised by two or more symptoms one of which should be either nasal blockage/obstruction/congestion or nasal discharge (anterior/ posterior nasal drip):
- ± facial pain/pressure
-
± cough
- endoscopic signs of:
- mucopurulent discharge primarily from middle meatus and/or
- oedema/mucosal obstruction primarily in middle meatus
and/or
- CT changes:
2.2.3. Severity of the disease in adult and children*
The disease can be divided into MILD, MODERATE and SEVERE based on total severity visual analogue scale (VAS) score (0 10 cm):
- MILD = VAS 0-3
- MODERATE = VAS >3-7
- SEVERE = VAS >7-10
To evaluate the total severity, the patient is asked to indicate on a VAS the answer to the question:
A VAS > 5 affects the patient QOL
The disease can be divided into MILD, MODERATE and SEVERE based on total severity visual analogue scale (VAS) score (0 10 cm):
- MILD = VAS 0-3
- MODERATE = VAS >3-7
- SEVERE = VAS >7-10
To evaluate the total severity, the patient is asked to indicate on a VAS the answer to the question:
A VAS > 5 affects the patient QOL
- only validated in adult CRS to date
2.2.4. Duration of the disease in adults and children
Acute:
< 12
weeks complete resolution of symptoms.
Chronic: ≥12
weeks symptoms without complete resolution of symptoms.
Chronic rhinosinusitis may also be subject to exacerbations
2.2.5. Control of disease
The goal of CRS treatment is to achieve and maintain clinical control. Control is defined as a disease state in which the patients do not have symptoms or the symptoms are not bothersome, if possible combined with a healthy or almost healthy mucosa and only the need for local medication. We do not know what percentage of patients with CRS actually can achieve control of disease and further studies are necessary. We here propose an assessment of current clinical control of CRS (see Table 2.1.). Further validation of this table is necessary.
Acute:
< 12
weeks complete resolution of symptoms.
Chronic: ≥12
weeks symptoms without complete resolution of symptoms.
Chronic rhinosinusitis may also be subject to exacerbations
2.2.5. Control of disease
The goal of CRS treatment is to achieve and maintain clinical control. Control is defined as a disease state in which the patients do not have symptoms or the symptoms are not bothersome, if possible combined with a healthy or almost healthy mucosa and only the need for local medication. We do not know what percentage of patients with CRS actually can achieve control of disease and further studies are necessary. We here propose an assessment of current clinical control of CRS (see Table 2.1.). Further validation of this table is necessary.
2.2.6. Definition of difficult-to-treat
rhinosinusitis
Patients who have persistent symptoms of rhinosinusitis despite appropriate treatment (recommended medication and surgery). Although the majority of CRS patients can obtain control, some patients will not do so even with the maximal medical therapy and surgery.
Patients who do not reach an acceptable level of control despite adequate surgery, intranasal corticosteroid treatment and up to 2 short courses of antibiotics or systemic corticosteroids in the last year can be considered to have difficult-to-treat rhinosinusitis.
2.3. Definition for use in epidemiology studies/General Practice
For epidemiological studies the definition is based on symptomatology without ENT examination or radiology
2.3.1. Definition of acute rhinosinusitis
2.3.1.1. Acute rhinosinusitis (ARS) in adults
Acute rhinosinusitis in adults is defined as:
sudden onset of two or more symptoms, one of which should be either nasal blockage/obstruction/congestion or nasal discharge (anterior/posterior nasal drip):
- ± facial pain/pressure,
- ± reduction or loss of smell for <12 weeks;
with symptom free intervals if the problem is recurrent, with validation by telephone or interview.
2.3.1.2. Acute rhinosinusitis in children
Acute rhinosinusitis in children is defined as: sudden onset of two or more of the symptoms:
- nasal blockage/obstruction/congestion
- or discoloured nasal discharge
- or cough (daytime and night-time)
for < 12 weeks;
with symptom free intervals if the problem is recurrent;
with validation by telephone or interview.
Questions on allergic symptoms (i.e. sneezing, watery rhinorrhea, nasal itching, and itchy watery eyes) should be included. ARS can occur once or more than once in a defined time period. This is usually expressed as episodes/year but there must be complete resolution of symptoms between episodes for it to constitute genuine recurrent ARS.
We recognise that in general acute rhinosinusitis will usually last a maximum of a few weeks. In the literature a number of different classifications have been proposed. In the past the term 'subacute' was sometimes used to fill the gap between acute and chronic rhinosinusitis. However the EPOS group felt that a separate term to describe patients with prolonged acute rhinosinusitis was not necessary because the number of patients who have such a prolonged course is small and there are very little data on which to offer evidence based recommendations on how to manage these patients. Also in the literature the term 'acute on chronic' can be found. The EPOS group felt that the term 'exacerbation of CRS' was more appropriate and also consistent with the term used in other respiratory diseases such as asthma.
Patients who have persistent symptoms of rhinosinusitis despite appropriate treatment (recommended medication and surgery). Although the majority of CRS patients can obtain control, some patients will not do so even with the maximal medical therapy and surgery.
Patients who do not reach an acceptable level of control despite adequate surgery, intranasal corticosteroid treatment and up to 2 short courses of antibiotics or systemic corticosteroids in the last year can be considered to have difficult-to-treat rhinosinusitis.
2.3. Definition for use in epidemiology studies/General Practice
For epidemiological studies the definition is based on symptomatology without ENT examination or radiology
2.3.1. Definition of acute rhinosinusitis
2.3.1.1. Acute rhinosinusitis (ARS) in adults
Acute rhinosinusitis in adults is defined as:
sudden onset of two or more symptoms, one of which should be either nasal blockage/obstruction/congestion or nasal discharge (anterior/posterior nasal drip):
- ± facial pain/pressure,
- ± reduction or loss of smell for <12 weeks;
with symptom free intervals if the problem is recurrent, with validation by telephone or interview.
2.3.1.2. Acute rhinosinusitis in children
Acute rhinosinusitis in children is defined as: sudden onset of two or more of the symptoms:
- nasal blockage/obstruction/congestion
- or discoloured nasal discharge
- or cough (daytime and night-time)
for < 12 weeks;
with symptom free intervals if the problem is recurrent;
with validation by telephone or interview.
Questions on allergic symptoms (i.e. sneezing, watery rhinorrhea, nasal itching, and itchy watery eyes) should be included. ARS can occur once or more than once in a defined time period. This is usually expressed as episodes/year but there must be complete resolution of symptoms between episodes for it to constitute genuine recurrent ARS.
We recognise that in general acute rhinosinusitis will usually last a maximum of a few weeks. In the literature a number of different classifications have been proposed. In the past the term 'subacute' was sometimes used to fill the gap between acute and chronic rhinosinusitis. However the EPOS group felt that a separate term to describe patients with prolonged acute rhinosinusitis was not necessary because the number of patients who have such a prolonged course is small and there are very little data on which to offer evidence based recommendations on how to manage these patients. Also in the literature the term 'acute on chronic' can be found. The EPOS group felt that the term 'exacerbation of CRS' was more appropriate and also consistent with the term used in other respiratory diseases such as asthma.
2.3.1.3. Classification of ARS in adults and children
ARS comprises of viral ARS (common cold) and post-viral ARS. In the EPOS 2007 the term non-viral ARS was chosen to indicate that most cases of ARS are not bacterial. However this term apparently led to confusion and for that reason we have decided to choose the term post-viral ARS to express the same phenomenon. A small percentage of the patients with postviral ARS will have bacterial ARS.
Common cold/ acute viral rhinosinusits is defined as: duration of symptoms for less than 10 days.
Acute post-viral rhinosinusitis is defined as: increase of symptoms after 5 days or persistent symptoms after 10 days with less than 12 weeks duration.
Acute bacterial rhinosinusitis (ABRS) Acute bacterial rhinosinusitis is suggested by the presence of at least 3 symptoms/signs of (236, 247):
- Discoloured discharge (with unilateral predominance) and purulent secretion in cavum nasi,
- Severe local pain (with unilateral predominance)
- Fever (>38ºC) - Elevated ESR/CRP
- 'Double sickening' (i.e. a deterioration after an initial milder phase of illness). (for more details see chapter 3.3.2.1.5)
ARS comprises of viral ARS (common cold) and post-viral ARS. In the EPOS 2007 the term non-viral ARS was chosen to indicate that most cases of ARS are not bacterial. However this term apparently led to confusion and for that reason we have decided to choose the term post-viral ARS to express the same phenomenon. A small percentage of the patients with postviral ARS will have bacterial ARS.
Common cold/ acute viral rhinosinusits is defined as: duration of symptoms for less than 10 days.
Acute post-viral rhinosinusitis is defined as: increase of symptoms after 5 days or persistent symptoms after 10 days with less than 12 weeks duration.
Acute bacterial rhinosinusitis (ABRS) Acute bacterial rhinosinusitis is suggested by the presence of at least 3 symptoms/signs of (236, 247):
- Discoloured discharge (with unilateral predominance) and purulent secretion in cavum nasi,
- Severe local pain (with unilateral predominance)
- Fever (>38ºC) - Elevated ESR/CRP
- 'Double sickening' (i.e. a deterioration after an initial milder phase of illness). (for more details see chapter 3.3.2.1.5)
2.3.2. Definition of Chronic rhinosinusitis
2.3.2.1. Definition of Chronic rhinosinusitis in adults
Chronic rhinosinusitis (with or without nasal polyps) in adults is defined as:
presence of two or more symptoms one of which should be either nasal blockage/obstruction/congestion or nasal discharge (anterior/posterior nasal drip):
with validation by telephone or interview.
Questions on allergic symptoms (i.e. sneezing, watery rhinorrhea, nasal itching, and itchy watery eyes) should be included (see Figure 2.2).
2.3.2.1. Definition of Chronic rhinosinusitis in adults
Chronic rhinosinusitis (with or without nasal polyps) in adults is defined as:
presence of two or more symptoms one of which should be either nasal blockage/obstruction/congestion or nasal discharge (anterior/posterior nasal drip):
- ± facial pain/pressure;
-
± reduction or loss of smell;
with validation by telephone or interview.
Questions on allergic symptoms (i.e. sneezing, watery rhinorrhea, nasal itching, and itchy watery eyes) should be included (see Figure 2.2).
2.3.2.2. Definition of Chronic rhinosinusitis in
children
Chronic rhinosinusitis (with or without nasal polyps) in children is defined as:
presence of two or more symptoms one of which should be either nasal blockage/obstruction/congestion or nasal discharge (anterior/posterior nasal drip):
2.4. Definition for research
For research purposes acute rhinosinusitis is defined as above. Bacteriology (antral tap, middle meatal culture) and/or radiology (X-ray, CT) are advised, but not obligatory. For research purposes chronic rhinosinusitis (CRS) is defined as per the clinical definition. For the purpose of a study, the differentiation between CRSsNP and CRSwNP must be based on endoscopy.
2.4.1. Definition of chronic rhinosinusitis when no earlier sinus surgery has been performed
Chronic rhinosinusitis with nasal polyps (CRSwNP): bilateral, endoscopically visualised in middle meatus. Chronic rhinosinusitis without nasal polyps (CRSsNP): no visible polyps in middle meatus, if necessary following decongestant.
This definition accepts that there is a spectrum of disease in CRS which includes polypoid change in the sinuses and/ or middle meatus but excludes those with polypoid disease presenting in the nasal cavity to avoid overlap.
2.4.2. Definition of chronic rhinosinusitis when sinus surgery has been performed
Once surgery has altered the anatomy of the lateral wall, the presence of polyps is defined as bilateral pedunculated lesions as opposed to cobblestoned mucosa > 6 months after surgery on endoscopic examination. Any mucosal disease without overt polyps should be regarded as CRS.
2.4.3. Conditions for sub-analysis
The following conditions should be considered for sub-analysis:
2.4.4. Exclusion from general studies
Patients with the following diseases should be excluded from general studies, but may be the subject of a specific study on chronic rhinosinusitis with or without nasal polyps:
1. cystic fibrosis based on positive sweat test or DNA alleles;
2. gross immunodeficiency (congenital or acquired);
3. congenital mucociliary problems (eg. primary ciliary dyskinesia (PCD));
4. non-invasive fungal balls and invasive fungal disease;
5. systemic vasculitis and granulomatous diseases;
6. cocaine abuse;
7. neoplasia.
Chronic rhinosinusitis (with or without nasal polyps) in children is defined as:
presence of two or more symptoms one of which should be either nasal blockage/obstruction/congestion or nasal discharge (anterior/posterior nasal drip):
- ± facial pain/pressure;
-
± cough;
2.4. Definition for research
For research purposes acute rhinosinusitis is defined as above. Bacteriology (antral tap, middle meatal culture) and/or radiology (X-ray, CT) are advised, but not obligatory. For research purposes chronic rhinosinusitis (CRS) is defined as per the clinical definition. For the purpose of a study, the differentiation between CRSsNP and CRSwNP must be based on endoscopy.
2.4.1. Definition of chronic rhinosinusitis when no earlier sinus surgery has been performed
Chronic rhinosinusitis with nasal polyps (CRSwNP): bilateral, endoscopically visualised in middle meatus. Chronic rhinosinusitis without nasal polyps (CRSsNP): no visible polyps in middle meatus, if necessary following decongestant.
This definition accepts that there is a spectrum of disease in CRS which includes polypoid change in the sinuses and/ or middle meatus but excludes those with polypoid disease presenting in the nasal cavity to avoid overlap.
2.4.2. Definition of chronic rhinosinusitis when sinus surgery has been performed
Once surgery has altered the anatomy of the lateral wall, the presence of polyps is defined as bilateral pedunculated lesions as opposed to cobblestoned mucosa > 6 months after surgery on endoscopic examination. Any mucosal disease without overt polyps should be regarded as CRS.
2.4.3. Conditions for sub-analysis
The following conditions should be considered for sub-analysis:
- aspirin sensitivity based on positive oral, bronchial, or nasal provocation or an obvious history;
-
asthma / bronchial hyper-reactivity / COPD / bronchiectasies
based on symptoms, respiratory function tests;
-
allergy based on specific serum specific IgE or Skin
Prick Test (SPT).
-
total IgE in serum (treatment effects may be influenced
by IgE level)
2.4.4. Exclusion from general studies
Patients with the following diseases should be excluded from general studies, but may be the subject of a specific study on chronic rhinosinusitis with or without nasal polyps:
1. cystic fibrosis based on positive sweat test or DNA alleles;
2. gross immunodeficiency (congenital or acquired);
3. congenital mucociliary problems (eg. primary ciliary dyskinesia (PCD));
4. non-invasive fungal balls and invasive fungal disease;
5. systemic vasculitis and granulomatous diseases;
6. cocaine abuse;
7. neoplasia.