Guidelines for Sinusitis Agreed to by Allergists, Otolaryngologist – Head and Neck Surgeons

Rhinosinusitis, the inflammation of the mucous membrane of the nose and sinuses, has increased in both prevalence and incidence. Health officials believe that this disorder, also known as sinusitis, causes significant physical symptoms, negatively affects quality of life, and can substantially impair daily functions. It is now estimated that rhinosinusitis affects approximately 31 million Americans each year.

Recognizing a need for evidence-based rhinosinusitis guidelines, five national societies,The American Academy of Allergy, Asthma and Immunology (AAAAI); The American Academy of Otolaryngic Allergy; The American Academy of Otolaryngology — Head and Neck Surgery (AAO-HNS); The American College of Allergy, Asthma and Immunology; and the American Rhinologic Society convened a panel of 30 physicians from a wide range of disciplines to develop definitions of rhinosinusitis for clinical research, and suggest clinical trial designs for studies that would allow for more appropriate use of pharmacologic, immunologic, and surgical interventions.

For the clinician, existing definitions of the disease fail to describe all manifestations of rhinosinusitis. This is due, in part, to the numerous causes of rhinosinusitis, which can be viral, bacterial, fungal, allergic, and for some patients, of unknown origin. Rhinosinusitis can be acute or chronic (the latter defined by the Sinus and Allergy Health Partnership as “a group of disorders characterized by inflammation of the mucosa of the nose and paranasal sinuses of at least 12 weeks’ duration.” (Otolaryngology Head and Neck Surgery, September 2003)). Other classes i.e., subacute, recurrent acute, acute exacerbation of chronic, community acquired bacterial, and nosocomial, have been used in medical literature.

“We believed that the lack of a consensus definition for chronic rhinosinusitis hampered efforts to conduct research studies or to attempt studies of medical treatment,” agreed Eli O. Meltzer, MD, a member of the AAAAI’s Sinusitis Committee and James Hadley, MD, Past President of both the AAOA and ARS.

Their findings are provided in a supplement, “Rhinosinusitis: Establishing Definitions for Clinical Research and Patient Care,” published concurrently in the December 2004 editions of the Journal of Allergy & Clinical Immunology (JACI) http://www.mosby.com/jaci/ and Otolaryngology – Head and Neck Surgery (OTO-HNS) http://www.mosby.com/oto/. The corresponding author is Eli O. Meltzer, MD, Co-Director, Allergy and Asthma Medical Group and Research Center, San Diego, CA.

Findings: After two days of meeting, this panel was able to reach consensus (more than 80 percent of committee members) on definitions and clinical research strategies for acute (bacterial) rhinosinusitis, chronic rhinosinusitis without polyps, chronic rhinosinusitis with polyps, and allergic fungal rhinosinusitis. Other conclusions reached were:

* No one etiologic factor fully explains or adequately accounts for the pathologic manifestations and clinical differences found in rhinosinusitis. The inflammatory component of these disorders manifests as a mixed mononuclear inflammatory cell infiltrate with neutrophils predominating in acute disease and eosinophils predominating in most chronic disease.

* Chronic rhinosinusitis has a significant inflammatory component that may be caused simultaneously or independently by various factors. These include but are not restricted to the possible roles of: persistent infection as a factor in chronic rhinosinusitis including biofilms and “osteitis” (inflammation of the bone); allergy and other disorders of immunity; intrinsic factors of the upper airway; super antigens from Staphylococcus aureus in chronic rhinosinusitis with nasal polyps; colonizing fungi that induce and sustain eosinophilic inflammation; and metabolic perturbations such as aspirin sensitivity.

The panel agreed on consensus definitions for rhinosinusitis as applied to (1) acute presumed bacterial rhinosinusitis; (2) chronic rhinosinusitis without polyps; (3) chronic rhinosinusitis with polyps; and (4) classic allergic fungal rhinosinusitis. Additionally, initial proposals were made for clinical trial designs, including an outline of suggested subjective and objective assessments applicable to these studies.

Conclusions: The definitions and guidelines outlined in “Rhinosinusitis: Establishing Definitions for Clinical Research and Patient Care,” will be invaluable to physicians who diagnose and treat sinusitis and the clinicians and researchers responsible for developing and implementing appropriate clinical studies.

The work of this important consensus panel will serve as a catalyst for further research of this debilitating disorder. But the participants in this effort agree that 1) promoting more research on both acute and chronic rhinosinusitis is essential; 2) a better understanding of the cause of these diseases is needed; 3) study designs for the evaluation of potential therapeutic modalities for rhinosinusitis, as well as appropriate outcome studies must be carefully considered.

The AAAAI is the largest professional medical specialty organization in the United States representing allergists, asthma specialists, clinical immunologists, allied health professionals and others with a special interest in the research and treatment of allergic disease. Allergy/immunology specialists are pediatric or internal medicine physicians who have elected an additional two years of training to become specialized in the treatment of asthma, allergy and immunologic disease. Established in 1943, the AAAAI has nearly 6,000 members in the United States, Canada and 60 other countries. The AAAAI serves as an advocate to the public by providing educational information through its Web site at http://www.aaaai.org.

The American Academy of Otolaryngology – Head and Neck Surgery http://www.entnet.org, one of the oldest medical associations in the nation, represents more than 10,000 physicians and allied health professionals who specialize in the diagnosis and treatment of disorders of the ears, nose, throat, and related structures of the head and neck. The Academy serves its members by facilitating the advancement of the science and art of medicine related to otolaryngology and by representing the specialty in governmental and socioeconomic issues. The organization’s mission is: “Working for the Best Ear, Nose, and Throat Care.”