BSACI guidelines for the management of rhinosinusitis and nasal polyposis

February 8, 2008 11:09 am

Summary

This guidance for the management of patients with rhinosinusitis and nasal polyposis has been prepared by the Standards of Care Committee (SOCC) of the British Society for Allergy and Clinical Immunology (BSACI). The recommendations are based on evidence and expert opinion and are evidence graded. These guidelines are for the benefit of both adult physicians and paediatricians treating allergic conditions. Rhinosinusitis implies inflammation of the nose and sinuses which may or may not have an infective component and includes nasal polyposis. Acute rhinosinusitis lasts up to 12 weeks and resolves completely. Chronic rhinosinusitis persists over 12 weeks and may involve acute exacerbations. Rhinosinusitis is common, affecting around 15% of the population and causes significant reduction in quality of life. The diagnosis is based largely on symptoms with confirmation by nasendoscopy. Computerized tomography scans and magnetic resonance imaging are abnormal in approximately one third of the population so are not recommended for routine diagnosis but should be reserved for those with acute complications, diagnostic uncertainty or failed medical therapy. Underlying conditions such as immune deficiency, Wegener’s granulomatosis, Churg-Strauss syndrome, aspirin hypersensitivity and allergic fungal sinusitis may present as rhinosinusitis. There are few good quality trials in this area but the available evidence suggests that treatment is primarily medical, involving douching, corticosteroids, antibiotics, anti-leukotrienes, and anti-histamines. Endoscopic sinus surgery should be considered for complications, anatomical variations causing local obstruction, allergic fungal disease or patients who remain very symptomatic despite medical treatment. Further well conducted trials in clearly defined patient groups are needed to improve management.

Introduction

These guidelines for the management of patients with rhinosinusitis and nasal polyposis are intended for use by physicians practising in allergy. Evidence for the recommendations was obtained by employing electronic literature searches using the primary key words – sinusitis, rhinosinusitis, nasal polyps and fungal rhino sinusitis. Further searches were carried out by combining these search terms with asthma, antihistamine, anti-leukotriene, decongestant, child, surgery, magnetic resonance imaging (MRI) computerized tomography (CT), aspirin and Churg-Strauss. Each article was reviewed for suitability for inclusion in the guideline. The recommendations were evidence graded at the time of preparation of these guidelines.

The grades of recommendation and the levels of evidence are defined as in our previous guideline on urticaria [1]. During the development of these guidelines, a web-based system was employed to allow consultation with all British Society for Allergy and Clinical Immunology (BSACI) members. All comments and suggestions were carefully considered by the Standards of Care Committee (SOCC). Where evidence was lacking a consensus was reached among the experts on the committee. Conflicts of interests were recorded by the SOCC, none jeopardized unbiased guideline development.

Executive summary and recommendations

Rhinosinusitis

  • Rhinosinusitis implies inflammation of the nose and paranasal sinuses.
  • The diagnosis of rhinosinusitis is primarily clinical and made on the history and examination with only a limited role for radiology (see text box 1).
  • Sinus X-rays are rarely helpful and CT scans should be reserved for patients failing medical therapy or those with atypical or severe disease, i.e. unilateral symptoms, blood-stained discharge, displacement of the eye and severe pain.
  • In epidemiological studies rhinosinusitis affects between 2% and 16% of the population.
  • Acute rhino sinusitis lasts <12 weeks and usually follows a viral upper respiratory tract infection (UTRI).
  • For acute rhinosinusitis the use of topical nasal corticosteroids or an antihistamine together with antibiotics is associated with more rapid resolution of symptoms (grade of recommendation =A).
  • Chronic rhinosinusitis (CRS) lasts more than 12 weeks and usually responds incompletely to therapy, which may need to be continued long-term (grade of recommendation = B).
  • Patients who fail initial medical therapy can respond to more specialized pharmacotherapy, which is as successful as surgery (grade of recommendation = B).
  • Treating CRS, either medically or surgically, benefits accompanying asthma (grade of recommendation =A).
  • Sinus surgery in children is of limited value and the disease in this age group often resolves spontaneously.
  • Severe recurrent polypoid rhino sinusitis should prompt investigations for aspirin sensitivity, allergic fungal rhinosinusitis or Churg-Strauss syndrome.

Nasal polyps

  • Nasal polyps are not associated with allergy but can be associated with asthma, aspirin sensitivity, cystic fibrosis, allergic fungal sinusitis (AFS) and Churg-Strauss syndrome.
  • At initial presentation all patients with polyps should be examined by an ear, nose, throat (ENT) surgeon.
  • Unilateral polyps may be a sign of malignancy and should always be subject to ENT referral.
  • Children with nasal polyps should be referred for further testing for cystic fibrosis.
  • Aspirin sensitivity should be suspected in severely affected polyp patients, especially those with recurrent polyps and intrinsic asthma.
  • The diagnosis of aspirin sensitivity relies upon either a clear history of two (ormore) aspirin/non-steroidal anti-inflammatory drugs (NSAID)-induced reactions or by aspirin challenge, which can be nasal, inhaled, or oral.
  • Aspirin challenge must be carried out only by doctors with appropriate experience and with full resuscitation facilities readily available.
  • Patients with aspirin sensitivity should be warned to avoid all drugs with cyclooxygenase (COX) 1 inhibitory activity.
  • Selective COX2 inhibitors appear to be safe in patients with aspirin sensitivity, although it is recommended that the first dose is administered in hospital under direct observation with monitoring for 2 h and resuscitation facilities readily available.
  • Allergic fungal rhinosinusitis is rare in the United Kingdom, but more common in warmer climates such as the Southern USA and Australia.
  • Allergic fungal rhinosinusitis is treated by surgery to remove infected tissue followed by topical corticosteroids.
  • Chronic rhinosinusitis (CRS) accompanied by systemic symptoms and signs may indicate an underlying vasculitis or granulomatous disease.

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