Evidence based schemes for diagnostic and treatment
- 8.5.3.2. Treatment
- Table 8.5 Treatment evidence and recommendations for adults with chronic rhinosinusitis with nasal polyps
- Table 8.6 Treatment evidence and recommendations postoperative treatment in adults with chronic rhinosinusitis with nasal polyps
8.1. Introduction
The following schemes for diagnosis and treatment are the result a critical evaluation of the available evidence. The tables give the level of evidence for studies with a positive outcome and well powered studies with negative outcoume. For example Ib (-) in this tables means a well designed (Ib) study with a negative outcome. The grade of recommendation for the available therapy is given. Under relevance it is indicated whether the group of authors think this treatment to be of relevance in the indicated disease. Since the preparation of the EP3 OS2007 document an increasing amount of evidence on the pathophysiology, diagnosis and treatment has been published.
However, in compiling the tables on the various forms of therapy, it may be that despite well powered level Ib trials, no significant benefit has been demonstrated. Equally results may be equivocal or apparently positive results are undermined by the small number of trials conducted and/or the small number of participants in the trial(s). In these cases, after detailed discussion, the EPOS group decided in most cases, that there was no evidence at present to recommend use of the treatment in question. Alternatively for some treatments no trials have been conducted, even though the treatment is commonly used in which case a pragmatic approach has been adopted in the recommendations.
8.2. Evidence based management for adults with acute
rhinosinusitis
8.2.1. Definitions
8.2.1.1. 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.
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.
8.2.1.2. Common cold/acute viral rhinosinusits is defined as duration of symptoms for less than 10 days.
8.2.1.3. 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.
8.2.1.4. Acute bacterial rhinosinusitis (ABRS)
Acute bacterial rhinosinusitis is suggested by the presence of at least 3 symptoms/signs of (247).
8.2.1. Definitions
8.2.1.1. 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.
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.
8.2.1.2. Common cold/acute viral rhinosinusits is defined as duration of symptoms for less than 10 days.
8.2.1.3. 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.
8.2.1.4. Acute bacterial rhinosinusitis (ABRS)
Acute bacterial rhinosinusitis is suggested by the presence of at least 3 symptoms/signs of (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).
8.2.2. Evidence based management for adults with acute
rhinosinusitis for primary care
8.2.2.1. Diagnosis
Symptom based, no need for radiology.
Not recommended: plain x-ray.
Symptoms
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/loss of smell;
Signs (if applicable)
8.2.2.1. Treatment
For treatment evidence and recommendations for acute rhinosinusitis see Table 8.1 Initial treatment depending on the severity of the disease (See Figure 8.1):
8.2.2.1. Diagnosis
Symptom based, no need for radiology.
Not recommended: plain x-ray.
Symptoms
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/loss of smell;
Signs (if applicable)
- nasal examination (swelling, redness, pus);
- oral examination: posterior discharge;
8.2.2.1. Treatment
For treatment evidence and recommendations for acute rhinosinusitis see Table 8.1 Initial treatment depending on the severity of the disease (See Figure 8.1):
- Mild (viral, common cold): start with symptomatic relief (analgetics, saline irrigation, decongestants, herbal compounds);
- Moderate (postviral): additional topical steroids
- Severe (including bacterial): additional topical steroids, consider antibiotics
8.3 Evidence based management for children with acute
rhinosinusitis for primary care
8.3.1. Definitions
8.3.1.1 Acute rhinosinusitis in children
Acute rhinosinusitis in children is defined as:
sudden onset of two or more of the symptoms:
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 b
8.3.1.2. Common cold/ acute viral rhinosinusits is defined as: duration of symptoms for less than 10 days.
8.3.1.3. 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.
8.3.1.4. Acute bacterial rhinosinusitis (ABRS)
Acute bacterial rhinosinusitis is suggested by the presence of at least 3 symptoms/signs of (247).
8.3.1. Definitions
8.3.1.1 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)
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 b
8.3.1.2. Common cold/ acute viral rhinosinusits is defined as: duration of symptoms for less than 10 days.
8.3.1.3. 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.
8.3.1.4. Acute bacterial rhinosinusitis (ABRS)
Acute bacterial rhinosinusitis is suggested by the presence of at least 3 symptoms/signs of (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).
8.3.2. Evidence based management for children with acute
rhinosinusitis in primary care
8.3.2.1. Diagnosis
Symptoms
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;
± cough
Signs (if applicable)
Not recommended: plain x-ray.
CT-Scan is also not recommended unless additional problems such as:
8.3.2.2. Treatment
For treatment evidence and recommendations for children with acute rhinosinusitis see Table 8.2 Initial treatment depending on the severity of the disease: see Figure 8.2.
8.3.2.1. Diagnosis
Symptoms
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;
± cough
Signs (if applicable)
- nasal examination (swelling, redness, pus);
- oral examination: posterior discharge;
Not recommended: plain x-ray.
CT-Scan is also not recommended unless additional problems such as:
- very severe diseases,
- immunocompromised patients;
- signs of complications.
8.3.2.2. Treatment
For treatment evidence and recommendations for children with acute rhinosinusitis see Table 8.2 Initial treatment depending on the severity of the disease: see Figure 8.2.
8.4 Evidence based management for adults and children with
acute rhinosinusitis for ENT specialists
8.4.1. Diagnosis
Symptoms
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/loss of smell;
Signs
Not recommended: plain x-ray
CT-Scan is also not recommended unless additional problems such as:
8.4.2. Treatment
For Treatment evidence and recommendations for acute rhinosinusitis. See Table 8.1. and Table 8.2 Initial treatment depending on the severity of the disease: See Figure 8.3.
8.4.1. Diagnosis
Symptoms
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/loss of smell;
Signs
- nasal examination (swelling, redness, pus);
- oral examination: posterior discharge;
- exclude dental infection.
Not recommended: plain x-ray
CT-Scan is also not recommended unless additional problems such as:
- very severe diseases,
- immunocompromised patients;
- signs of complications.
8.4.2. Treatment
For Treatment evidence and recommendations for acute rhinosinusitis. See Table 8.1. and Table 8.2 Initial treatment depending on the severity of the disease: See Figure 8.3.
8.5 Evidence based management for adults with Chronic
Rhinosinusitis
8.5.1. Definitions
8.5.1.1. Chronic Rhinosinusitis (with or without NP) 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;
for ≥12 weeks;
with validation by telephone or interview.
Questions on allergic symptoms (i.e. sneezing, watery rhinorrhea, nasal itching, and itchy watery eyes) should be included.
Chronic Rhinosinusitis with nasal polyps (CRSwNP): Chronic rhinosinusitis as defined above and bilateral, endoscopically visualised polyps in middle meatus.
Chronic Rhinosinusitis without nasal polyps (CRSsNP): Chronic Rhinosinusitis as defined above and 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.
8.5.1. Definitions
8.5.1.1. Chronic Rhinosinusitis (with or without NP) 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;
for ≥12 weeks;
with validation by telephone or interview.
Questions on allergic symptoms (i.e. sneezing, watery rhinorrhea, nasal itching, and itchy watery eyes) should be included.
Chronic Rhinosinusitis with nasal polyps (CRSwNP): Chronic rhinosinusitis as defined above and bilateral, endoscopically visualised polyps in middle meatus.
Chronic Rhinosinusitis without nasal polyps (CRSsNP): Chronic Rhinosinusitis as defined above and 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.
8.5.2. Evidence based management for adults with CRS with or
without NP for primary care and non-ENT specialists
8.5.2.1. Diagnosis
Symptoms present equal or longer than 12 weeks 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;
Signs (if applicable)
Additional diagnostic information
Not recommended: plain x-ray or CT-scan
8.5.2.2. Treatment
For treatment evidence and recommendations for chronic rhinosinusitis see Table 8.3 and 8.5.
Initial treatment depending on the availability of an endoscope and severity of disease: See Figure 8.4.
Acute exacerbations of CRS should be treated like acute rhinosinusitis.
8.5.3. Evidence based management for adults with CRS without NP for ENT specialists
8.5.3.1. Diagnosis
Symptoms present longer than 12 weeks 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;
Signs
8.5.2.1. Diagnosis
Symptoms present equal or longer than 12 weeks 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;
Signs (if applicable)
- nasal examination
- oral examination: posterior discharge;
Additional diagnostic information
- questions on allergy should be added and, if positive, allergy testing should be performed.
Not recommended: plain x-ray or CT-scan
8.5.2.2. Treatment
For treatment evidence and recommendations for chronic rhinosinusitis see Table 8.3 and 8.5.
Initial treatment depending on the availability of an endoscope and severity of disease: See Figure 8.4.
Acute exacerbations of CRS should be treated like acute rhinosinusitis.
8.5.3. Evidence based management for adults with CRS without NP for ENT specialists
8.5.3.1. Diagnosis
Symptoms present longer than 12 weeks 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;
Signs
- ENT examination, endoscopy;
- review primary care physician's diagnosis and treatment;
- questionnaire for allergy and if positive, allergy testing if it has not already been done
8.5.3.2. Treatment
For treatment evidence and recommendations for CRSsNP see Table 8.3 and 8.4.
Treatment should be based on severity of symptoms
Acute exacerbations of CRS should be treated like acute rhinosinusitis.
8.5.4. Evidence based management for adults with CRS with NP for ENT specialists
8.5.4.1. Diagnosis
Symptoms present longer than 12 weeks
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;
Signs
8.5.4.2. Treatment
For treatment evidence and recommendations for CRSwNP see Table 8.5 and 8.6.
Treatment should be based on severity of symptoms
For treatment evidence and recommendations for CRSsNP see Table 8.3 and 8.4.
Treatment should be based on severity of symptoms
- Decide on severity of symptomatology using VAS and endoscope. See Figure 8.5.
Acute exacerbations of CRS should be treated like acute rhinosinusitis.
8.5.4. Evidence based management for adults with CRS with NP for ENT specialists
8.5.4.1. Diagnosis
Symptoms present longer than 12 weeks
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;
Signs
- ENT examination, endoscopy;
- review primary care physician's diagnosis and treatment;
- questionnaire for allergy and if positive, allergy testing if it has not already been done.
8.5.4.2. Treatment
For treatment evidence and recommendations for CRSwNP see Table 8.5 and 8.6.
Treatment should be based on severity of symptoms
- Decide on severity of symptomatology using VAS and endoscope. See Figure 8.6.
8.6. Evidence based management for children with Chronic
Rhinosinusitis
8.6.1. Definitions
8.6.1.1. Chronic Rhinosinusitis (with or without NP) 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;
for ≥12 weeks;
with validation by telephone or interview.
Questions on allergic symptoms (i.e. sneezing, watery rhinorrhea, nasal itching, and itchy watery eyes) should be included.
Chronic rhinosinusitis with nasal polyps (CRSwNP): Chronic rhinosinusitis as defined above and bilateral, endoscopically visualised polyps in middle meatus.
Chronic Rhinosinusitis without nasal polyps (CRSsNP): Chronic Rhinosinusitis as defined above and 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.
8.6.2. Evidence based management for children with Chronic Rhinosinusitis
8.6.2.1. Diagnosis
Symptoms present equal or longer than 12 weeks 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;
Additional diagnostic information
Not recommended: plain x-ray or CT-scan (unless surgery is considered)
8.6.2.2. Treatment
For treatment evidence and recommendations for Chronic Rhinosinusitis in children see Table 8.7.
This management scheme is for young children. Older children (in the age that adenoids are not considered important) can be treated as adults. See Figure 8.7.
Acute exacerbations of CRS should be treated like acute rhinosinusitis.
Treatment should be based on severity of symptoms.
8.6.1. Definitions
8.6.1.1. Chronic Rhinosinusitis (with or without NP) 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;
for ≥12 weeks;
with validation by telephone or interview.
Questions on allergic symptoms (i.e. sneezing, watery rhinorrhea, nasal itching, and itchy watery eyes) should be included.
Chronic rhinosinusitis with nasal polyps (CRSwNP): Chronic rhinosinusitis as defined above and bilateral, endoscopically visualised polyps in middle meatus.
Chronic Rhinosinusitis without nasal polyps (CRSsNP): Chronic Rhinosinusitis as defined above and 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.
8.6.2. Evidence based management for children with Chronic Rhinosinusitis
8.6.2.1. Diagnosis
Symptoms present equal or longer than 12 weeks 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;
Additional diagnostic information
- questions on allergy should be added and, if positive, allergy testing should be performed.
Not recommended: plain x-ray or CT-scan (unless surgery is considered)
8.6.2.2. Treatment
For treatment evidence and recommendations for Chronic Rhinosinusitis in children see Table 8.7.
This management scheme is for young children. Older children (in the age that adenoids are not considered important) can be treated as adults. See Figure 8.7.
Acute exacerbations of CRS should be treated like acute rhinosinusitis.
Treatment should be based on severity of symptoms.
