European Position Paper on Rhinosinusitis and Nasal … · Rhinosinusitis: Clinical Definition...

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European Position Paper on Rhinosinusitis and Nasal Polyps 2012 www.rhinologyjournal.com

Transcript of European Position Paper on Rhinosinusitis and Nasal … · Rhinosinusitis: Clinical Definition...

Page 1: European Position Paper on Rhinosinusitis and Nasal … · Rhinosinusitis: Clinical Definition Rhinosinusitis is defined as Inflammation of the nose and the paranasal sinuses characterised

European Position Paper on Rhinosinusitis

and Nasal Polyps 2012

www.rhinologyjournal.com

Page 2: European Position Paper on Rhinosinusitis and Nasal … · Rhinosinusitis: Clinical Definition Rhinosinusitis is defined as Inflammation of the nose and the paranasal sinuses characterised
Page 3: European Position Paper on Rhinosinusitis and Nasal … · Rhinosinusitis: Clinical Definition Rhinosinusitis is defined as Inflammation of the nose and the paranasal sinuses characterised
Page 4: European Position Paper on Rhinosinusitis and Nasal … · Rhinosinusitis: Clinical Definition Rhinosinusitis is defined as Inflammation of the nose and the paranasal sinuses characterised

October 2012 - Amsterdam

Page 5: European Position Paper on Rhinosinusitis and Nasal … · Rhinosinusitis: Clinical Definition Rhinosinusitis is defined as Inflammation of the nose and the paranasal sinuses characterised

EP3OS 2012Authors

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Page 6: European Position Paper on Rhinosinusitis and Nasal … · Rhinosinusitis: Clinical Definition Rhinosinusitis is defined as Inflammation of the nose and the paranasal sinuses characterised

Objectives and Aims

◆ State-of-the-art review for specialists and GPs – Updated knowledge of rhinosinusitis and nasal

polyposis – Evidence-based documented review of the

diagnostic methods – Evidence-based review of the available treatments – Stepwise approach to the management of the

disease – Guidance for definitions and outcome measurements

in research in different settings

Page 7: European Position Paper on Rhinosinusitis and Nasal … · Rhinosinusitis: Clinical Definition Rhinosinusitis is defined as Inflammation of the nose and the paranasal sinuses characterised

Rhinosinusitis: Clinical Definition

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; – ± Reduction or loss of smell

AND either ENDOSCOPIC SIGNS of

– Polyps and/or – Mucopurulent discharge primarily from middle meatus and/or – Oedema/mucosal obstruction primarily in middle meatus

AND/OR CT CHANGES

– Mucosal changes within ostiomeatal complex and/or sinuses

European Position Paper on Rhinosinusitis and Nasal Polyps 2012. Fokkens WJ, Lund VJ, Mullol J, Bachert C, Alobid I, Baroody F, Cohen N, Cervin A, Douglas R, Gevaert P, Georgalas C, Goossens H, Harvey R, Hellings P, Hopkins C, Jones N, Joos G, Kalogjera L, Kern B, Kowalski M, Price D, Riechelmann H, Schlosser R, Senior B, Thomas M, Toskala E, Voegels R, Wang de Y, Wormald PJ. Rhinol Suppl. 2012 Mar;(23):3 1-298.

Page 8: European Position Paper on Rhinosinusitis and Nasal … · Rhinosinusitis: Clinical Definition Rhinosinusitis is defined as Inflammation of the nose and the paranasal sinuses characterised

Rhinosinusitis Symptoms

Reduction/loss of smell

Facial pain/ pressure

Nasal discharge (anterior/ posterior nasal drip)

Blockage/obstruction/congestion

Page 9: European Position Paper on Rhinosinusitis and Nasal … · Rhinosinusitis: Clinical Definition Rhinosinusitis is defined as Inflammation of the nose and the paranasal sinuses characterised

Rhinosinusitis: Severity and Duration

Severity

◆ Mild = VAS 0-3 ◆ Moderate = VAS >3-7 ◆ Severe = VAS >7-10

Duration

◆ Acute – <12 weeks – Complete resolution of

symptoms

◆ Chronic – >12 weeks – Without complete resolution

of symptoms – May be subject to

exacerbationsNot

troublesomeWorst

thinkable troublesome

10 cm

How Troublesome are YourSymptoms of Rhinosinusitis?

VAS = visual analogue scale.

Page 10: European Position Paper on Rhinosinusitis and Nasal … · Rhinosinusitis: Clinical Definition Rhinosinusitis is defined as Inflammation of the nose and the paranasal sinuses characterised

Difficult to control CRS

European Position Paper on Rhinosinusitis and Nasal Polyps 2012. Fokkens WJ, Lund VJ, Mullol J, Bachert C, Alobid I, Baroody F, Cohen N, Cervin A, Douglas R, Gevaert P, Georgalas C, Goossens H, Harvey R, Hellings P, Hopkins C, Jones N, Joos G, Kalogjera L, Kern B, Kowalski M, Price D, Riechelmann H, Schlosser R, Senior B, Thomas M, Toskala E, Voegels R, Wang de Y, Wormald PJ. Rhinol Suppl. 2012 Mar;(23):3 1-298.

Page 11: European Position Paper on Rhinosinusitis and Nasal … · Rhinosinusitis: Clinical Definition Rhinosinusitis is defined as Inflammation of the nose and the paranasal sinuses characterised

Category of Evidence

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 randomisation

IIb Evidence from at least one other type of quasi-experimental study

IIIEvidence from non-experimental descriptive studies, such as comparative studies, correlation studies, and case-control studies

IV Evidence from expert committee reports or opinions or clinical experience of respected authorities, or both

Page 12: European Position Paper on Rhinosinusitis and Nasal … · Rhinosinusitis: Clinical Definition Rhinosinusitis is defined as Inflammation of the nose and the paranasal sinuses characterised

Strength of Recommendation

A Directly based on Category I evidence

B Directly based on Category II evidence or extrapolated recommendation from Category I evidence

C Directly based on Category III evidence or extrapolated recommendation from Category I or II evidence

D Directly based on Category IV evidence or extrapolated recommendation from Category I, II or III evidence

Page 13: European Position Paper on Rhinosinusitis and Nasal … · Rhinosinusitis: Clinical Definition Rhinosinusitis is defined as Inflammation of the nose and the paranasal sinuses characterised

Definitions of Acute Viral and Non-Viral Rhinosinusitis

Defined As:Common cold/acute viral rhinosinusitis: Duration of symptoms for <10 days

Acute non-viral rhinosinusitis: Increase of symptoms after 5 days or persistent symptoms after 10 days with <12 weeks duration

European Position Paper on Rhinosinusitis and Nasal Polyps 2012. Fokkens WJ, Lund VJ, Mullol J, Bachert C, Alobid I, Baroody F, Cohen N, Cervin A, Douglas R, Gevaert P, Georgalas C, Goossens H, Harvey R, Hellings P, Hopkins C, Jones N, Joos G, Kalogjera L, Kern B, Kowalski M, Price D, Riechelmann H, Schlosser R, Senior B, Thomas M, Toskala E, Voegels R, Wang de Y, Wormald PJ. Rhinol Suppl. 2012 Mar;(23):3 1-298.

Page 14: European Position Paper on Rhinosinusitis and Nasal … · Rhinosinusitis: Clinical Definition Rhinosinusitis is defined as Inflammation of the nose and the paranasal sinuses characterised

European Position Paper on Rhinosinusitis and Nasal Polyps 2012. Fokkens WJ, Lund VJ, Mullol J, Bachert C, Alobid I, Baroody F, Cohen N, Cervin A, Douglas R, Gevaert P, Georgalas C, Goossens H, Harvey R, Hellings P, Hopkins C, Jones N, Joos G, Kalogjera L, Kern B, Kowalski M, Price D, Riechelmann H, Schlosser R, Senior B, Thomas M, Toskala E, Voegels R, Wang de Y, Wormald PJ. Rhinol Suppl. 2012 Mar;(23):3 1-298.

Page 15: European Position Paper on Rhinosinusitis and Nasal … · Rhinosinusitis: Clinical Definition Rhinosinusitis is defined as Inflammation of the nose and the paranasal sinuses characterised
Page 16: European Position Paper on Rhinosinusitis and Nasal … · Rhinosinusitis: Clinical Definition Rhinosinusitis is defined as Inflammation of the nose and the paranasal sinuses characterised

Diagnosis of Adults With Acute Rhinosinusitis for ENT Specialists

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

Examination – Nasal examination (swelling, redness, puss) – Oral examination: posterior discharge – Exclude dental infection

Imaging – (Plain x-ray not recommended) – CT scan is also not recommended unless additional problems are present, such as:

• very severe disease • immunocompromised patients • signs of complications

Page 17: European Position Paper on Rhinosinusitis and Nasal … · Rhinosinusitis: Clinical Definition Rhinosinusitis is defined as Inflammation of the nose and the paranasal sinuses characterised

Diagnosis of Adults With Acute Rhinosinusitis for Primary Care and Non-ENT Specialists

◆ Symptom-based, no need for imaging (plain x-ray not recommended)

◆ Symptoms for less than 12 weeks – 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

– With symptom-free intervals if the problem is recurrent – With validation by telephone or interview asking questions on allergy

symptoms, ie, sneezing, watery rhinorrhea, nasal itching and itchy watery eyes

European Position Paper on Rhinosinusitis and Nasal Polyps 2012. Fokkens WJ, Lund VJ, Mullol J, Bachert C, Alobid I, Baroody F, Cohen N, Cervin A, Douglas R, Gevaert P, Georgalas C, Goossens H, Harvey R, Hellings P, Hopkins C, Jones N, Joos G, Kalogjera L, Kern B, Kowalski M, Price D, Riechelmann H, Schlosser R, Senior B, Thomas M, Toskala E, Voegels R, Wang de Y, Wormald PJ. Rhinol Suppl. 2012 Mar;(23):3 1-298.

Page 18: European Position Paper on Rhinosinusitis and Nasal … · Rhinosinusitis: Clinical Definition Rhinosinusitis is defined as Inflammation of the nose and the paranasal sinuses characterised

Treatment Scheme for Primary Care and Non-ENT Specialists for Adults With Acute Rhinosinusitis

* Fever >38°C, severe pain.

Page 19: European Position Paper on Rhinosinusitis and Nasal … · Rhinosinusitis: Clinical Definition Rhinosinusitis is defined as Inflammation of the nose and the paranasal sinuses characterised

Evidence and Recommendations for Adults With Chronic Rhinosinusitis Without Nasal Polyps*

Page 20: European Position Paper on Rhinosinusitis and Nasal … · Rhinosinusitis: Clinical Definition Rhinosinusitis is defined as Inflammation of the nose and the paranasal sinuses characterised

Diagnosis of Adults With CRS With or Without NP for Primary Care and Non-ENT Specialists

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/loss of smell

– With validation by telephone or interview asking questions on allergy symptoms, ie, sneezing, watery rhinorrhea, nasal itching and itchy watery eyes

– If positive, allergy testing should be performed(Plain x-ray or CT scan not recommended)

European Position Paper on Rhinosinusitis and Nasal Polyps 2012. Fokkens WJ, Lund VJ, Mullol J, Bachert C, Alobid I, Baroody F, Cohen N, Cervin A, Douglas R, Gevaert P, Georgalas C, Goossens H, Harvey R, Hellings P, Hopkins C, Jones N, Joos G, Kalogjera L, Kern B, Kowalski M, Price D, Riechelmann H, Schlosser R, Senior B, Thomas M, Toskala E, Voegels R, Wang de Y, Wormald PJ. Rhinol Suppl. 2012 Mar;(23):3 1-298.

Page 21: European Position Paper on Rhinosinusitis and Nasal … · Rhinosinusitis: Clinical Definition Rhinosinusitis is defined as Inflammation of the nose and the paranasal sinuses characterised

Treatment Scheme for CRS With or Without Nasal Polyposis for Primary Care and Non-ENT Specialists

Acute exacerbations of CRS should be treated like acute rhinosinusitis.

Page 22: European Position Paper on Rhinosinusitis and Nasal … · Rhinosinusitis: Clinical Definition Rhinosinusitis is defined as Inflammation of the nose and the paranasal sinuses characterised

Evidence-Based Surgery for Rhinosinusitis

Surgery is indicated in selected patients who are not sufficiently responsive to medical treatment 1.In acute rhinosinusitis, surgery is reserved for the most

serious cases and their associated complications 2.More than a hundred reviewed case series (level IV) with

highly consistent results suggest that patients with CRS with and without nasal polyps benefit from sinus surgery

3.Major complications occur in less than 1%, and revision surgery is performed in approximately 10% within 3 years

Page 23: European Position Paper on Rhinosinusitis and Nasal … · Rhinosinusitis: Clinical Definition Rhinosinusitis is defined as Inflammation of the nose and the paranasal sinuses characterised

Evidence-Based Surgery for Rhinosinusitis (cont’d)

4. In the majority of CRS patients, appropriate medical therapy is as effective as surgery, so sinus surgery should be reserved for patients who do not satisfactorily respond to medical treatment (level 1b)

5. Functional endoscopic surgery is superior to minimal conventional procedures including polypectomy and antral irrigations (level Ib), but superiority to inferior meatal antrostomy or conventional sphenoethmoidectomy is not yet proven

Page 24: European Position Paper on Rhinosinusitis and Nasal … · Rhinosinusitis: Clinical Definition Rhinosinusitis is defined as Inflammation of the nose and the paranasal sinuses characterised

Diagnosis of Adults With CRS Without Nasal Polyposis for ENT Specialists

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/loss of smell

Examination – No visible polyps in middle meatus, if necessary following decongestant*

• Review primary care physician’s diagnosis and treatment • Questionnaire for allergy and if positive, allergy testing if it has not already been

performed Treatment should be based on severity of symptoms

– Decide on severity of symptomatology by using VAS

* 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.

Page 25: European Position Paper on Rhinosinusitis and Nasal … · Rhinosinusitis: Clinical Definition Rhinosinusitis is defined as Inflammation of the nose and the paranasal sinuses characterised

Treatment Scheme for Adults With CRS Without Nasal Polyposis for ENT Specialists

Page 26: European Position Paper on Rhinosinusitis and Nasal … · Rhinosinusitis: Clinical Definition Rhinosinusitis is defined as Inflammation of the nose and the paranasal sinuses characterised

Evidence and Recommendations for Adults With Chronic Rhinosinusitis With Nasal Polyps*

* Some of the studies included patients with CRS without nasal polyps. Acute exacerbations of CRS should be treated like acute rhinosinusitis.

Page 27: European Position Paper on Rhinosinusitis and Nasal … · Rhinosinusitis: Clinical Definition Rhinosinusitis is defined as Inflammation of the nose and the paranasal sinuses characterised

Diagnosis of Adults With CRS With Nasal Polyposis for ENT Specialists

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/loss of smell

Examination – Nasal endoscopy – polyps bilateral, endoscopically visualized in middle

meatus • Review primary care physician’s diagnosis and treatment • Questionnaire for allergy and if positive, allergy testing if it has not already been

performed Severity of the symptoms

– Mild/moderate/severe (VAS scale)

Page 28: European Position Paper on Rhinosinusitis and Nasal … · Rhinosinusitis: Clinical Definition Rhinosinusitis is defined as Inflammation of the nose and the paranasal sinuses characterised

Treatment Scheme for Adults With CRS With Nasal Polyposis for ENT Specialists

Page 29: European Position Paper on Rhinosinusitis and Nasal … · Rhinosinusitis: Clinical Definition Rhinosinusitis is defined as Inflammation of the nose and the paranasal sinuses characterised

Diagnosis of Children With Chronic Rhinosinusitis

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/loss of smell

Additional diagnostic information – Questions on allergy should be added and, if positive,

allergy testing should be performed – Other predisposing factors should be considered:

immune deficiency (innate, acquired, gastro-oesophageal reflux disease

Imaging – Plain x-ray not recommended – CT scan is also not recommended unless additional

problems (very severe disease, immunocompromised patients, signs of complications) are present

Treatment should be based on severity of symptoms

Examination (if applicable) – Nasal: swelling redness, puss – Oral: posterior discharge – Exclude dental infection – ENT examination should include

nasal endoscopy

Page 30: European Position Paper on Rhinosinusitis and Nasal … · Rhinosinusitis: Clinical Definition Rhinosinusitis is defined as Inflammation of the nose and the paranasal sinuses characterised

Treatment Scheme for Children With Acute Rhinosinusitis

* Fever >38°C, severe pain.

Page 31: European Position Paper on Rhinosinusitis and Nasal … · Rhinosinusitis: Clinical Definition Rhinosinusitis is defined as Inflammation of the nose and the paranasal sinuses characterised

Evidence and Recommendations for Children With Chronic Rhinosinusitis

Page 32: European Position Paper on Rhinosinusitis and Nasal … · Rhinosinusitis: Clinical Definition Rhinosinusitis is defined as Inflammation of the nose and the paranasal sinuses characterised

“However, there have been a number of studies showing good outcomes with iv antibiotics in small children with subperiosteal abscesses39 58 21: In such cases, and provided there is a. Clear clinical improvement within 24-48 hours b. no decrease in visual acuity c. small (<0.5-1 ml in volume) medially located subperiosteal abscess d. no significant systemic involvement e. age less than 2-4 years , there can be an argument for withholding surgical drainage43

“However, there have been a number of studies showing good outcomes with iv antibiotics in small children with subperiosteal abscesses39 58 21: In such cases, and provided there is a. Clear clinical improvement within 24-48 hours b. no decrease