International consensus statement on allergy and rhinology: rhinosinusitis 2021

I.

EXECUTIVE SUMMARY

BACKGROUND: The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR-RS-2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence-based findings of the document.

METHODS

ICAR-RS presents over 180 topics in the forms of evidence-based reviews with recommendations (EBRRs), evidence-based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary.

RESULTS

ICAR-RS-2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence-based management algorithm is provided.

CONCLUSION

This ICAR-RS-2021 executive summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS.

Quality Indicators for the Diagnosis and Management of Acute Bacterial Rhinosinusitis

Background

Acute bacterial rhinosinusitis (ABRS) is a highly prevalent disease that is treated by a variety of specialties, including but not limited to, family physicians, emergency physicians, otolaryngology—head and neck surgeons, infectious disease specialists, and allergy and immunologists. Unfortunately, despite high-quality guidelines, variable and substandard care continues to be demonstrated in the treatment of ABRS.

Objective

This study aimed to develop ABRS-specific quality indicators (QIs) to evaluate the diagnosis and management that reduces symptoms, improves quality of life, and prevents complications.

Methods

A guideline-based approach, proposed by Kötter et al., was used to develop QIs for ABRS. Candidate indicators (CIs) were extracted from 4 guiding documents and evaluated using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool. Each CI and its supporting evidence was summarized and reviewed by an expert panel based on validity, reliability, and feasibility of measurement. Final QIs were selected from CIs utilizing the modified RAND/University of California at Los Angeles appropriateness methodology.

Results

Twenty-nine CIs were identified after literature review and evaluated by our panel. Of these, 5 CIs reached consensus as being appropriate QIs, with 1 requiring additional discussion. After a second round of evaluations, the panel selected 7 QIs as appropriate measures of high-quality care.

Conclusion

This study proposes 7 QIs for the diagnosis and management of patients with ABRS. These QIs can serve multiple purposes, including documenting the quality of care; comparing institutions and providers; prioritizing quality improvement initiatives; supporting accountability, regulation, and accreditation; and determining pay for performance initiatives.

Pilot Investigation: Prospective Needs Assessment of Knowledge, Attitude, and Insight About Mental Health Treatment Options in Patients With Chronic Rhinosinusitis

INTRODUCTION

Mood disorders frequently coexist with chronic rhinosinusitis (CRS), yet patient views of how mental health impacts their disease, and their willingness to engage in treatment is not well understood.

METHODS

Subjects with CRS were enrolled regardless of their mental health status and completed a needs questionnaire on mental health as it related to CRS. In addition, demographic and disease-specific data were collected.

RESULTS

We enrolled 55 subjects. In addition, 29.1% of them had polyps, with mean endoscopy/computed tomography (CT)/Sino-Nasal Outcome Test (SNOT-22) scores of 3.9/9.7/41.2, respectively and 45% thought depression was common in CRS patients. In total, 78.2% were open to taking a depression screener and would be comfortable discussing mental health with their Ear Nose and Throat provider, 76.4% of patients felt that treating mental health problems could improve sinus-related quality of life (QOL), and 87.3% were open to meeting with a mental health professional or participating in a course on managing stress/anxiety/mental health issues. The multivariate regression model of whether patients felt that treating the mind would improve sinus-related QOL as predicted by age, gender, SNOT-22, CT scores, and endoscopy scores was statistically significant (P = .027) and explained 42% of the variance in answers, but only age and gender approached statistical significance (P = .06 and .04).

CONCLUSIONS

CRS patients acknowledged the high prevalence of comorbid mood disorders and were willing to discuss and be treated for mental health issues. Many patients felt that treating their mental health would improve their disease-specific QOL. These findings warrant further study of how to incorporate the management of metal health into CRS treatment algorithms.

Aspirin-exacerbated respiratory disease: longitudinal assessment of a large cohort and implications of diagnostic delay

BACKGROUND

Aspirin-exacerbated respiratory disease (AERD) refers to the combination of asthma, chronic rhinosinusitis with nasal polyposis (CRSwNP), and acute respiratory tract reactions to ingestion of aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs). There have been no in the literature investigating diagnostic delay in AERD. We aimed to investigate whether delay of diagnosis of AERD is associated with poorer clinical outcomes as well as to characterize the role of specialty evaluation in diagnosis.

METHODS

We conducted a retrospective observational study of 254 subjects with incident AERD diagnoses between 2009 and 2016 among Kaiser Permanente Northern California (KPNC) members. Descriptive and bivariate statistics were employed to analyze clinical characteristics and outcomes of AERD subjects with and without delay in diagnosis (defined as 1 year or greater from symptom onset to diagnosis).

RESULTS

Of the 254 patients in the AERD cohort, 24.4% had a delayed diagnosis. Patients with allergies were significantly less likely to have a delay in diagnosis (p < 0.01). Patients with a delay in diagnosis were more likely to have 2 or more courses of systemic steroids (p = 0.04). Allergists, otolaryngologists, and primary care physicians diagnosed 56%, 36%, and 8% of patients, respectively. There was no association between provider specialty at time of diagnosis and delay in diagnosis (p = 0.22).

CONCLUSION

A substantial proportion of AERD patients have a diagnostic delay. Patients with allergies have a lower risk for this delay. This study is the first to describe diagnostic delay in AERD patients.

Quality indicators for the diagnosis and management of chronic rhinosinusitis

BACKGROUND

Chronic rhinosinusitis (CRS) has been identified as a high-priority disease category for quality improvement. To this end, this study aimed to develop CRS-specific quality indicators (QIs) to evaluate diagnosis and management that relieves patient discomfort, improves quality of life, and prevents complications.

METHODS

A guideline-based approach, proposed in 2012 by Kötter et al. was used to develop QIs for CRS. Candidate indicators (CIs) were extracted from 3 practice guidelines and 1 international consensus statement on the diagnosis and management of CRS. Guidelines were evaluated using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool. Each CI and its supporting evidence was summarized and reviewed by an expert panel based on validity, reliability, and feasibility of measurement. Final QIs were selected from CIs utilizing the modified RAND Corporation-University of California, Los Angeles (RAND/UCLA) appropriateness methodology.

RESULTS

Thirty-nine CIs were identified after literature review and evaluated by our panel. Of these, 9 CIs reached consensus as being appropriate QIs, with 4 requiring additional discussion. After a second round of evaluations, the panel selected 9 QIs as appropriate measures of high-quality care.

CONCLUSION

This study proposes 9 QIs for the diagnosis and management of patients with CRS. These QIs can serve multiple purposes, including documenting the quality of care; comparing institutions and providers; prioritizing quality improvement initiatives; supporting accountability, regulation, and accreditation; and determining pay-for-performance initiatives.

Cyclamen europaeum extract for acute sinusitis

BACKGROUND

Acute sinusitis is a common reason for primary care encounters. It causes significant symptoms including facial pain, congested nose, headache, thick nasal mucus, fever, and cough and often results in time off work or school. Sinusitis treatment focuses on eliminating causative factors and controlling the inflammatory and infectious components. The frozen, dried, natural fluid extract of the Cyclamen europaeum plant delivered intranasally is thought to have beneficial effects in relieving congestion by facilitating nasal drainage, and has an anti-inflammatory effect.

OBJECTIVES

To assess the effectiveness of topical intranasal Cyclamen europaeum extract on clinical response in adults and children with acute sinusitis.

SEARCH METHODS

We searched CENTRAL, which includes the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE, Embase, and trials registers (ClinicalTrials.gov; WHO ICTRP) in January 2018. We also searched the reference lists of included studies and review literature for further relevant studies and contacted trial authors for additional information.

SELECTION CRITERIA

Randomised controlled trials comparing Cyclamen europaeum extract administered intranasally to placebo, antibiotics, intranasal corticosteroids, or no treatment in adults or children, or both, with acute sinusitis. Acute sinusitis was defined by clinical diagnosis and confirmed by nasal endoscopy or by radiological evidence.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed trial quality. We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included two randomised controlled trials that involved a total of 147 adult outpatients with acute sinusitis confirmed by radiology or nasal endoscopy who were assigned to Cyclamen europaeum nasal spray or placebo study arms for up to 15 days. The risk of selection and detection bias was unclear, as allocation concealment and blinding of outcome assessors were not reported in either study. Attrition was high (60%) in one study, although dropouts were balanced between study arms.Neither study reported our two primary outcomes: proportion of participants whose symptoms resolved or improved at 14 days and 30 days. No serious adverse events or complications related to treatment were reported; however, more mild adverse events such as nasal and throat irritation, mild epistaxis, and sneezing occurred in Cyclamen europaeum group participants (50%) compared to placebo group participants (24%) (risk ratio 2.11, 95% confidence interval 1.35 to 3.29); moderate-quality evidence.

AUTHORS' CONCLUSIONS

The effectiveness of Cyclamen europaeum for people with acute sinusitis is unknown. Although no serious side effects were observed, 50% of participants who received Cyclamen europaeum reported adverse events compared with 24% of those who received placebo.

Sino-Nasal outcome test-22 outcomes after sinus surgery: A systematic review and meta-analysis

OBJECTIVES/HYPOTHESIS

The goal of the study was to perform a systematic review with meta-analysis to determine the mean change in the 22-item Sino-Nasal Outcome Test (SNOT-22) across patients who have had endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) in the literature.

METHODS

A literature search was performed to identify studies that assessed SNOT-22 scores before and after ESS in adult patients with CRS. A random effects model with inverse variance weighting was used to generate the mean change after surgery, along with the forest plot and 95% confidence interval (CI). The impact of patient-specific factors across studies was assessed using a mixed-effects meta-regression.

RESULTS

The final study list included 40 unique patient cohorts published from 2008 to 2016. All studies showed a statistically significant change in mean SNOT-22 scores between baseline and postoperative time points (P < .001), ranging from 12.7 to 44.8, at an average follow-up of 10.6 months. The summary change in mean SNOT-22 across all studies was 24.4 (95% CI: 22.0-26.8). After forward, step-wise multivariate modeling, studies with higher mean preoperative SNOT-22 score and higher asthma prevalence were associated with greater changes in SNOT-22 score after ESS, whereas studies with longer mean follow-up had smaller changes in SNOT-22 score.

CONCLUSIONS

Studies evaluating quality-of-life outcomes after sinus surgery using the SNOT-22 instrument universally show significant improvement after ESS. Across the published literature, the magnitude of change is quite variable and appears to be influenced by a number of factors including baseline SNOT-22 score, asthma prevalence, and length of follow-up. Laryngoscope, 128:581-592, 2018.