Classification and Definition of Rhinosinusitis

8/16/2019 Classification and Definition of Rhinosinusitis

1/13

Classification and Definition Of Rhinosinusitis

2.1. IntroductionRhinitis 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 .The diagnosis of rhinosinusitis is made y a wide variety of practitioners,including allergologists, otolaryngologists, pulmonologists, primary care

physicians, paediatricians, and many others. Therefore, an accurate, efficient,and accessi le definition of rhinosinusitis is re!uired.Due to the large differences in technical possi ilities to diagnose and treatrhinosinusitis with or withouw nasal polyps y various disciplines, the need todifferentiate etween su groups varies. On the one hand the epidemiologistwants a wor"a le definition that does not impose too many restrictions to studylarger populations. On the other hand researchers in a clinical setting are in needof a set of clearly defined items that descri es their patient population#phenotypes$ accurately and avoids the comparison of %apples and oranges& instudies that relate to diagnosis and treatment. The tas"force tried toaccommodate these different needs y offering definitions that can e appliedin different circumstances. 'n this way the tas"force hopes to improve thecompara ility of studies, there y enhancing the evidence ased diagnosis and

treatment of patients with rhinosinusitis and nasal polyps.

2.2. Clinical definition of rhinosinusitis2.2.1. Clinical definition of rhinosinusitis in adultsRhinosinusitis in adults is defined as() inflammation of the nose and the paranasal sinuses characterised y two or more symptoms, one of which should e either nasal

loc"age*o struction*congestion or nasal discharge #anterior*posterior nasaldrip$(

± facial pain*pressure± reduction or loss of smelland either ) endoscopic signs of(- nasal polyps, and*or - mucopurulent discharge primarily from middle meatus and*or - oedema*mucosal o struction primarily in middle meatus and*or

) CT changes(- mucosal changes within the ostiomeatal complex and* or sinuses

2.2.3. Severity of the disease in adult and children +


2/13

The disease can e divided into M' D, MOD-R T- and /-0-R- ased on total severity visual analogue scale #0 /$ score #1 21cm$(- M' D 3 0 / 145

- MOD-R T- 3 0 / 6547- /-0-R- 3 0 / 67421To evaluate the total severity, the patient is as"ed to indicate on a 0 / theanswer to the !uestion(

0 / 6 8 affects the patient 9O) only validated in adult CR/ to date:ow trou lesome are your symptoms of rhinosinusitis

21 cm


3/13

anti iotics or systemic corticosteroids in the last year can e considered to havedifficult4to4treat rhinosinusitis.

2.3. Definition for use in epide iolo!y

studies"#eneral $racticeBor epidemiological studies the definition is ased on symptomatology without-


4/13

R/ comprises of viral R/ #common cold$ and post4viral R/. 'n the - O/?117 the term non4viral R/ was chosen to indicate that most cases of R/ arenot acterial. :owever this term apparently led to confusion and for that reasonwe have decided to choose the term post4viral R/ to express the same

phenomenon. small percentage of the patients with postviral R/ will have acterial R/.Common cold* acute viral rhinosinusits is defined as( duration of symptoms for less than 21 days.

cute post4viral rhinosinusitis is defined as( increase of symptoms after 8 daysor persistent symptoms after 21 days with less than 2? wee"s duration.

cute acterial rhinosinusitis # FR/$cute acterial rhinosinusitis is suggested y the presence of at least 5

symptoms*signs of #?5G, ?H7$(

-4 Discoloured discharge #with unilateral predominance$and purulent secretion in cavum nasi,-4 /evere local pain #with unilateral predominance$-4 Bever #65IoC$-4 -levated -/R*CR-4 %Dou le sic"ening& #i.e. a deterioration after an initialmilder phase of illness$. #for more details see chapter 5.5.?.2.8$

3.2. $athophysiolo!y of %'SSu ary

cute rhinosinusitis is a common disorder and it could e divided into acuteviral rhinosinusitis and acute acterial rhinosinusitis and is often preceded y aviral rhinitis or common cold. This study reviews the inflammatory mechanismsunderlying viral rhinitis, acute viral rhinosinusitis and acute acterialrhinosinusitis. Birst of all, the host needs to recogniEe the presence ofmicroorganisms through %pattern recognition&, initiating the host defensemechanisms through activation of multiple signal pathways. :ost defensemechanisms consist of oth cellular immune responses and release of solu lechemical factors, which operate in the ody through a complex interaction withcyto"ines and other mediators.3.2.1. )iral %'S &co on cold(* post-viral %'S*and +acterial %'S, a continuu

R/ could e divided theoretically into viral #common cold$, post4viral and acterial R/ # FR/$ and they usually appear inthis consecutive order. :owever, viral, post4viral, and acterial

R/ show a considera le overlap oth in their inflammatorymechanism as in their clinical presentation. 0iral infection of the

nose and sinuses induces multiple changes, including post4viralinflammation, which increase the ris" of acterial superinfection.


5/13

These changes include epithelial damage and mechanical,humoral, and cellular defences.

3.2.2. icro+iolo!y of viral &co on cold(* postviral*

and +acterial %'S) 0iruses.The most common viruses isolated in adult viral rhinitis and rhinosinusitis, arerhinoviruses and coronaviruses. Rhinovirusesare thought to account for approximately 81J of all colds.Other viruses isolated in the common cold are influenEa viruses,

parainfluenEa viruses, adenovirus, respiratory syncytial virus#R/0$, and enterovirus #22H$.) Facteria.

The most common acteria in FR/ are those elonging tothe %infernal trio& #S. pneumoniae, :aemophilus influenEa, and M. catarrhalis $ and S. aureus . lso other streptococcal speciesand anaero ic acteria are seen in FR/ #2284227$. ayne andFenninger performed a meta4analysis of ?8 studies concerningthe micro iology of FR/, analysing the prevalence of the mostcommon acteria in the middle nasal meatus and the maxillarysinus. The maxillary sinuses contained ?GJ S. pneumoniae ,?IJ H. influenza , GJ M. catarrhalis , and IJ S. aureus . Thesefindings correlated with those in the middle meatus, eingrespectively 5HJ, ?KJ, 22J and 2HJ #228$. 'n a study comparingnasopharyngeal cultures from children pre and post theintroduction of the neumococcal conAugate vaccine, Froo" and Lo er #21I$ reported a reduction in the incidence of S.

pneumoniae from HHJ to ?7J, and an increase in the incidenceof H. influenzae from 57J to HHJ, S. pyrogenes from 7J to 2?J,and S. aureus from HJ to IJ with no change in M. catarrhalis#from 25J to 2HJ$.

3.3. Diagnosis and Diferential Diagnosis o ARSSummaryARS is a common condition that is often self-managed bypatients without medical care being sought, and will usuallyimprove spontaneously or with treatment. When patients doconsult, this is usually to generalist primary care clinicians. Thediagnosis is clinical and relies on the presence and duration of typical symptoms, particularly nasal blockage, discharge, facialpain or pressure and reduction in smell. ARS usually occurs as acomplication of a viral acute upper respiratory tract infection,with persistence of symptoms beyond ! days or worseningof symptoms after " days. #ersistence of symptoms beyond

$ weeks signi%es chronic rather than acute rhinosinusitis.&i'erentiation from other conditions such as viral (RT),allergic rhinitis, oro-dental disease and facial pain syndromes


6/13

should be possible in most cases on clinical grounds, althoughinvestigations may be needed when diagnostic doubt remains.Septic complications are rare but serious, and all primarycare clinicians should be aware of *red +ag symptoms such asperiorbital oedema and visual symptoms, which re uire urgentspecialist assessment. Although antibiotics are commonlyprescribed in community practice, ARS the symptoms of ARS often relate more to in+ammation and disruption of sinus drainage mechanisms, and in most cases antibiotics isnot re uired. )maging, haematological and microbiologicalinvestigations and endoscopy are not routinely re uired in thediagnosis of ARS, but may be needed in particular settings, suchas research studies or in high-risk patients.3.3.1. IntroductionPost-viral ARS is a common condition in thecommunity, usually following viral URTI.ARS is a common condition, and is usually self-limiting. anypatients will self-manage or use over the counter remedies, sowill not seek medical care or have a formal diagnosis made.When medical care is sought, most patients will consult with

a primary care physician, although in some health systemsmay directly access specialist services. Although educationale'orts have been made to familiari/e 0eneral #ractitioners10#s2 with the concepts of rhinosinusitis and the diagnosticcriteria for the diagnosis of ARS 1$$32 , *sinusitis is commonly usedas a diagnostic label, and as this is fre uently considered by0#s an acute bacterial rather than in+ammatory condition 1$$42 ,antibiotics are e5tensively prescribed 1$$", $$62 . The disseminationof the 7# 38S 192 and other recent guidelines 1$, $$:2 emphasi/ingthe in+ammatory nature of ARS and providing standardi/ationof diagnostic criteria and use of investigations has lead to more

1$$;, $3!2 settings. )n addition to misunderstandings concerning thein+ammatory nature of ARS 1$$;2 , concern over the risk of septic

complications from untreated bacterial disease may be a factorin the ongoing high use of antibiotics in ARS. 8bservationalevidence indicates, however, that complications are rare 1$3 , $3$2usually manifest early in the course of the illness with severesymptoms 1$33, $342 , and that antibiotic treatment of ARS in generalpractice does not prevent complications 1"$, $3$2 . 0uidelinesagree that in uncomplicated cases, ARS is diagnosed on clinicalcriteria and supplementary investigations are not re uired 1$2. )nparticular patient groups and in those with severe or atypicalsymptoms, additional diagnostic procedures may be needed,as discussed below. ARS is fre uently an isolated clinical eventand a self-limiting condition, although may be recurrent in somecases. There may be an association with dental disease in some16 2.

3.3.2. Clinical Diagnosis in Primary Care ARS is diagnosed by the acute onset of ty icalsym toms that include nasal bloc!age, discharge,facial ain or ressure and reduction in smell.)n primary care setting 1and for epidemiological research2, ARS isde%ned by symptomatology without detailed 7


7/13

"ost acute viral URTI infections are self-limiting,and ost-viral ARS should not diagnosed before #$days duration of sym toms unless there is a clear worsening of sym toms after % days.3.3.2.1.1. Symptoms o ARS

The sub=ective assessment of ARS is based on the presence andseverity of symptoms.> @acial pain or pressure, headache, and> Reduction loss of smell

Besides these local symptoms, distant and systemic symptomsmay occur.&istant symptoms are pharyngeal, laryngeal, and trachealirritation causing sore throat, dysphonia, and cough, andgeneral symptoms including drowsiness, malaise, and fever.

There is little reliable evidence of the relative fre uency of di'erent symptoms in ARS in community practice. )ndividualvariations of these general symptom patterns are many 1$3"-$3;2 .8nly a small proportion of patients with purulent rhinosinusitis,without coe5isting chest disease, complain of cough 1$362 . )npatients with a suspicion of infection, facial or dental pain1especially if unilateral2 have been found to be predictors of acute ma5illary sinusitis, when validated by ma5illary antralaspiration 1$362 or paranasal sinus radiographs 1$3:2. .The symptomsof ARS occur abruptly without a history of recent nasal orsinus symptoms. A history of sudden worsening of pree5istingsymptoms suggests an acute e5acerbation of chronicrhinosinusitis, which should be diagnosed by similar criteria andtreated in a similar way to ARS.3.3.2.1.2. Sub ecti!e assessment o symptoms" se!eritySub=ective assessment should address the severity and theduration of symptoms. The recommended method of assessingseverity of symptoms is with the use of a visual analogue scale1CAS2 recorded by the patient on a !cm line giving a score ona measurable continuum of to ! 1see chapter $.$.3.2. &iseasespeci%c

uestionnaires measuring uality of life impairment areavailable 1$4!, $4 2 but not commonly used in clinical practiceD agood clinician will, however, informally assess the impact of ARSon their patient as part of a full clinical assessment. The CAS canbe used to assess overall symptom severity and the severity of individual symptoms 1see below2. Asking patients to rate theirsymptoms as absent, mild, moderate or severe, may also assesssymptom severity.3.3.2.1.3. Sub ecti!e assessment o symptoms" duration

The sudden onset of symptoms of nasal blockage, obstruction,congestion and discharge is usually due to a self limiting viralinfection, and ARS should not be considered in patients whohave e5perience symptoms for less than " days unless they areunusually severe. #ost-viral ARS should not be diagnosed inpatients with symptoms for less than ! days unless a markedworsening of symptoms occurs after " days, and features of severe pain and a pyre5ia of E39FG are present. Symptomsoccurring for longer than $ weeks indicate the presence of chronic rhinosinusitis.3.3.2.1.#. Assessment o speci$c indi!idual symptoms&.&.'.#.(.#. Individual sym toms


8/13

absent, mild, moderate or severe.&.&.'.#.(.'. Individual sym toms) *asal discharge

The presence and severity of nasal discharge 1anterior orposterior nasal drip2 is assessed by sub=ective report, and gradedby CAS score or by patient sub=ective assessment as absent,mild, moderate or severe. #atient reported purulence of nasaldischarge has been recommended as a diagnostic criterion foracute bacterial rhinosinusitis 1$$:2 , and is prioriti/ed by 0#s asa feature indicating the need for antibiotics 1$$62 , with limitedevidence to support this. #urulent nasal secretions have beenreported to increase the likelihood ratio of radiological sinusopacity 1$3:2 , and of obtaining a positive bacterial culture 1$4$2 ,although purulent rhinorrhoea with a unilateral predominancehas a positive predictive value 1##C2 of only "!H, and pus in thenasal cavity a ##C of only :H, in the prediction of a positivebacterial culture of an aspirate of the ma5illary sinus 1$362 , socannot be relied upon to accurately identify bacterial infection.&.&.'.#.(.&. Individual sym toms) Smell abnormalitiesReduction of smell can be rated by patient sub=ective report asa CAS score or assessed as absent, mild, moderate, or severe.Sub=ective report of olfaction correlates well with ob=ective tests1$43-$4"2 and loss of olfaction is commonly associated with ARS.&.&.'.#.(.(. Individual sym toms) +acial ain and ressure@acial pain and pressure commonly occur in ARS, although mayalso occur transiently in self-limiting viral upper respiratorytract infection 1(RT)2. @acial or dental pain, especially whenunilateral, has been found to be a predictor of acute ma5illarysinusitis with +uid retention in patients with suspected bacterialinfection when con%rmed by ma5illary antral aspiration 1$362or paranasal sinus radiographs 1$3:2 . #ain on bending forwardsand ma5illary toothache, particularly when unilateral, are ofteninterpreted by 0#s as indicative of more severe disease andthe need for antibiotics 1$$62 , with limited supportive evidence.

a5illary toothache is reported to increase the likelihood ratioof radiological sinus opacity to $." 1$3:2 , although the ##C of local

unilateral pain for bacterial infection was only 4 H in anotherstudy 1$362 . A further study reported that ma5illary toothachewas signi%cantly associated with the presence of a positivebacteriological culture, predominantly of S. neumoniae or

. in uen ae , obtained by sinus aspiration or lavage 1$462 . Theseverity of pain can be rated sub=ectively by patients as a CASscore or as absent, mild, moderate, or severe.

/acterial infection may occur in ARS, but inmost cases antibiotics have little e0ect onthe course of the illness.3.3.2.1.%. Clinical rules or t&e prediction o bacterial diseaseA number of studies have attempted to provide clinicians with

combinations of symptoms and signs predicting more severedisease, particularly in the prediction of a bacterial infection andthe likelihood of a response to antibiotics. )n a study of primarycare patients aged " years or older with a clinical diagnosisof ARS which assessed the likelihood of speci%c symptomsand tests in predicting a +uid level or total opacity of any sinuson GT 1as a gold standard of sinusitis2, Iindbaek 1$4:2 reportedfour factors having a high likelihood ratio and independentlyassociated with ARS. These were purulent rhinorrhoea, purulentsecretion in cavum nasi, a raised 7SR 1E !2, and *doublesickening 1i.e. a deterioration after an initial milder phase of illness2. A combination of at least three of these four symptomsand signs gave a speci%city of !.9 and a sensitivity of !.66 forARS.

Berg 1$362 reported that $ or more positive %ndings 1frompurulent rhinorrhoea with unilateral predominance, localpain with unilateral predominance, pus in the nasal cavity


9/13

and bilateral purulent rhinorrhoea2 provided ;"H sensitivityand ::H speci%city for ABRS. Williams 1$3:2 reported that fewerthan $ symptoms 1from ma5illary toothache, poor responseto antihistamines or decongestants, purulent nasal secretions,abnormal transillumination and coloured nasal discharge2 ruledout ABRS with a positive predictive value 1##C2 of J4!H, and 4or more symptoms ruled in ABRS 1##C, 9 H2.3.3.2.2. Clinical e'amination3.3.2.2.1. Anterior r&inoscopyAlthough anterior rhinoscopy alone is a very limitedinvestigation, it should be performed in primary care settingas part of the clinical assessment of suspected ARS. )t mayreveal supportive %ndings such as nasal in+ammation, mucosaloedema and purulent nasal discharge, and can sometimesreveal previously unsuspected %ndings such as polyps oranatomical abnormalities.3.3.2.2.2. (emperature

The presence of a fever of E39FG indicates the presence of a more severe illness and the possible need for more activetreatment, particularly in con=unction with more severesymptoms. A fever of E39FG is signi%cantly associated with thepresence of a positive bacteriologic culture, predominantlyS. neumoniae and . in uen ae , obtained by sinus aspiration orlavage 1$462 .

3.3.2.2.3. Inspection and palpation o sinuses)nspection and palpation of the ma5illofacial area can revealswelling and tenderness, which are commonly interpreted asindicating more severe disease 1$$62 and the need for antibiotics,although the sensitivity and speci%city of this symptom in theidenti%cation of ABRS is not established.3.3.2.2.#. )asal endoscopy


10/13

3.3.2.3.#. Procalcitonin#rocalcitonin has also been advocated as a potentialhaematological biomarker indicating more severe bacterialinfection, and investigated as a tool for guiding antibioticprescribing in respiratory tract infections in the community 1$"3

3.#. anagement o ARSSummary

The introduction of evidence-based management of ARShas a ma=or impact on the physician s management of ARSpatients. )t has been proven clearly in many clinical studiesthat ARS resolves without antibiotic treatment in most cases.Symptomatic treatment and reassurance is the preferredinitial management strategy for patients with mild symptoms.)ntranasal corticosteroids in monotherapy or in ad=uvanttherapy to oral antibiotics are proven to be e'ectiveD however,in patients with severe ARS, oral corticosteroids can be usedfor short-term relief of headache, facial pain and other acutesymptoms. Antibiotic therapy should be reserved for patientswith high fever or severe 1unilateral2 facial pain. @or initialtreatment, the most narrow-spectrum agent active againstthe likely pathogens should be used. Kerbal compounds havebeen commonly used in treatment of ARS, but only a few &B#Grandomi/ed studies have shown their e?cacy. Kence, thebene%t of herbal compounds in treatment of ARS need to becon%rmed by more well designed and randomi/ed clinical trialsin future.3.#.1. IntroductionARS is a common disease that is managed in both primarycare and speciali/ed clinics, and by general practitioners 10#s2,otolaryngologists and paediatricians. Therefore, consensus inthe management of ARS amongst 0#s and di'erent specialistswho commonly treat ARS is very important. Kowever, it needs tobe noticed that when analysing studies for scienti%c evidencesin the treatment of ARS 1no matter of the investigated drug2several of them present a mi5ture of patients with common coldand either post-viral or bacterial ARS 1i.e. corticosteroids andantibiotics in ARS, Williamson )0 $!!: 13 $22.

ARS resolves without antibiotic treatment inmost cases. Sym tomatic treatment and reassuranceis the referred initial management strategy for atients with mild sym toms.)t has been stated clearly in position papers and various metaanalysesthat ARS resolves without antibiotic treatment in mostcases 19, $;3-$;"2 . Symptomatic treatment and reassurance is thepreferred initial management strategy for patients with mildsymptoms. Antibiotic therapy should be reserved for patientswith high fever or severe 1unilateral2 facial pain. @or initialtreatment, the most narrow-spectrum agent active against thelikely pathogens 1Streptococcus pneumoniae and Kaemophilusin+uen/ae2 should be used, rather than a general broadspectrumagent 1$;32 .3.#.2. (reatment o ARS /it& antibioticsAccording to data from a


11/13

paediatricians 1;2 .A recent Gochrane study was performed to compare antibioticsagainst placebo, or between antibiotics from di'erent classes inthe treatment of acute ma5illary sinusitis in adults 1$;:2 . A total of "; studies were included in this reviewD si5 placebo-controlledstudies and "3 studies comparing di'erent classes of antibioticsor comparing di'erent dosing regimens of the same antibiotic.Among them, " studies involving 63 patients provided data forcomparison of antibiotics to placebo, where clinical failure wasde%ned as a lack of cure or improvement at : to " days followup. These studies found a slight statistical di'erence in favour of antibiotics, compared to placebo, with a pooled risk factor 1RR2of !.66 1;"H con%dence interval 1G)2 !.44 to !.;92. Kowever, theclinical signi%cance of the result is e uivocal, also consideringthat cure or improvement rate was high in both the placebogroup 19!H2 and the antibiotic group 1;!H2.Based on si5 studies, where clinical failure was de%ned as alack of total cure, there was signi%cant di'erence in favour of antibiotics compared to placebo with a pooled RR of !.:4 1;"HG) !.6" to !.942 at : to " days follow up.


12/13

atients with severe ARS, es ecially with the resence of high fever or severe 1unilateral2 facial ain. 3linicians should weigh the moderatebene4ts of antibiotic treatment against the

otential for adverse e0ects.Gomparison between various antibiotics in term of theirdose and duration, e?cacy and side-e'ect of treatments aresummari/ed in three tables, where a total of 4$ prospective,randomi/ed, double-blind, placebo controlled 1nM;, Table3.4.$2, or comparisons between antibiotics 1nM$", Table 3.4.32,or comparisons of di'erent dosages 1nM"2 or durations 1nM32of treatment 1Table 3.4.42 are listed. )n general, a short-coursetreatment, particularly for patients without severe disease andcomplicating factors, might lead to fewer adverse events, betterpatient compliance, lower rate of resistance development andfewer costs 1$;92 .Antibiotics overuse has been reported in some 7uropeancountries 13!!, 3! 2 to have directly resulted in an increasedprevalence of antimicrobial resistance in 7urope 13!$, 3!32 .

Although such data is still unavailable in Asia, a recent surveystudy showed that, even for mild ARS 1common cold2, medicaltreatments were still recommended by 9:H of 0#s, 93.;Hof otolaryngologists, and :!H of paediatricians 1;2 . The topthree %rst-line treatments prescribed were antihistamines13;.$H2, nasal decongestants 133.6H2, and antibiotics 1$;."H2.Antibiotics usage was much more often used as the %rst linetreatment of moderate 14".;H2 and severe 16!.3H2 ARS. 7venmore alarmingly, 3.6H of the participants used a combinationof more than two antibiotics classes for treatment of even mildARS.

The global threat posed by resistant microorganisms hasbecome an international health issue, a product of carelessantibiotics abuse. Therefore, for initial treatment, the most

narrow-spectrum agent active against the likely pathogens1Streptococcus pneumoniae and Kaemophilus in+uen/ae2should be used 1$;32 .3.#.3. (reatment /it& intranasal corticosteroids3.#.3.1. (reatment /it& intranasal corticosteroids)n the 7# 38S $!!: document, intranasal corticosteroids wererecommended for the treatment of ARS, both in moderate1monotherapy2 and severe 1with oral antibiotics2 disease.Intranasal corticosteroids are recommended for the treatment of ARS, both in moderate 1monothera y2and severe 1with oral antibiotics2 disease.

ost studies on corticosteroids in ARS have determined thee'ect of topical corticosteroids when used as ad=unct therapy to

antibiotics 1Table 3.4."2 13!4-3!;2 . Recently a double-blind, double-dummy, placebo-controlled study was published in whichtopical corticosteroid treatment was used as monotherapy andcompared to antibiotics 13 !2 . )n this study mometasone furoate1 @2 was used and compared to both amo5icillin and placebo inARS. @ $!! Ng twice daily was significantly superior to placeboand amo5icillin in improving the symptom score. (sed oncedaily @ was also superior to placebo but not to amo5icillin. Thisis the %rst study to show that topical corticosteroids when usedtwice daily are e'ective in treating ARS as monotherapy and ismore e'ective than amo5icillin when used twice daily. &ata of this study are also supported by two other studies with a similardesign 1Table 3.4."2 13 , 36:2 . Kowever, in another study, neitherantibiotics nor topical corticosteroids alone or in combination

were e'ective in altering the symptom severity or the durationof bacterial ARS 13 $2. Kowever, this study has included patientswith 4 days of symptoms, which only satisfy the inclusion criteria


13/13

of common cold but not ARS.)n a recent Gochrane analysis, the results of four &B#G studieswith a total of ;4" patients support the use of intranasalcorticosteroids as a monotherapy or as an ad=uvant therapy toantibiotics 1evidence level )a2 13 32 . Kigher doses of intranasalcorticosteroids had a stronger e'ect on improvement orcomplete relief of symptomsD for mometasone furoate 4!! Ngversus $!! Ng, 1RR . !D ;"H G) .!$ to . 9 versus RR .!4D ;"HG) !.;9 to . 2.

Classification and Definition of Rhinosinusitis

Documents

Transcript of Classification and Definition of Rhinosinusitis