Richard R. Orlandi

Clinical Practice Guideline (Update): Adult Sinusitis

Objective This update of a 2007 guideline from the American Academy of Otolaryngology—Head and Neck Surgery Foundation provides evidence-based recommendations to manage adult rhinosinusitis, defined as symptomatic inflammation of the paranasal sinuses and nasal cavity. Changes from the prior guideline include a consumer added to the update group, evidence from 42 new systematic reviews, enhanced information on patient education and counseling, a new algorithm to clarify action statement relationships, expanded opportunities for watchful waiting (without antibiotic therapy) as initial therapy of acute bacterial rhinosinusitis (ABRS), and 3 new recommendations for managing chronic rhinosinusitis (CRS). Purpose The purpose of this multidisciplinary guideline is to identify quality improvement opportunities in managing adult rhinosinusitis and to create explicit and actionable recommendations to implement these opportunities in clinical practice. Specifically, the goals are to improve diagnostic accuracy for adult rhinosinusitis, promote appropriate use of ancillary tests to confirm diagnosis and guide management, and promote judicious use of systemic and topical therapy, which includes radiography, nasal endoscopy, computed tomography, and testing for allergy and immune function. Emphasis was also placed on identifying multiple chronic conditions that would modify management of rhinosinusitis, including asthma, cystic fibrosis, immunocompromised state, and ciliary dyskinesia. Action statements The update group made strong recommendations that clinicians (1) should distinguish presumed ABRS from acute rhinosinusitis (ARS) caused by viral upper respiratory infections and noninfectious conditions and (2) should confirm a clinical diagnosis of CRS with objective documentation of sinonasal inflammation, which may be accomplished using anterior rhinoscopy, nasal endoscopy, or computed tomography. The update group made recommendations that clinicians (1) should either offer watchful waiting (without antibiotics) or prescribe initial antibiotic therapy for adults with uncomplicated ABRS; (2) should prescribe amoxicillin with or without clavulanate as first-line therapy for 5 to 10 days (if a decision is made to treat ABRS with an antibiotic); (3) should reassess the patient to confirm ABRS, exclude other causes of illness, and detect complications if the patient worsens or fails to improve with the initial management option by 7 days after diagnosis or worsens during the initial management; (4) should distinguish CRS and recurrent ARS from isolated episodes of ABRS and other causes of sinonasal symptoms; (5) should assess the patient with CRS or recurrent ARS for multiple chronic conditions that would modify management, such as asthma, cystic fibrosis, immunocompromised state, and ciliary dyskinesia; (6) should confirm the presence or absence of nasal polyps in a patient with CRS; and (7) should recommend saline nasal irrigation, topical intranasal corticosteroids, or both for symptom relief of CRS. The update group stated as options that clinicians may (1) recommend analgesics, topical intranasal steroids, and/or nasal saline irrigation for symptomatic relief of viral rhinosinusitis; (2) recommend analgesics, topical intranasal steroids, and/or nasal saline irrigation) for symptomatic relief of ABRS; and (3) obtain testing for allergy and immune function in evaluating a patient with CRS or recurrent ARS. The update group made recommendations that clinicians (1) should not obtain radiographic imaging for patients who meet diagnostic criteria for ARS, unless a complication or alternative diagnosis is suspected, and (2) should not prescribe topical or systemic antifungal therapy for patients with CRS.

Cost Burden of Chronic Rhinosinusitis A Claims-Based Study

Objective. To quantify the cost burden and utilization of health care for chronic rhinosinusitis (CRS). Study Design. Historical cohort study. Setting. Academic medical centers. Methods. Medical claims data from 2003 to 2008 were analyzed. Patients were defined as having chronic sinus disease if they had a minimum of 2 CRS-related diagnoses with either computed tomography scanning or endoscopy performed between diagnoses. The prevalence and costs of CRS from the payer perspective (reimbursements) were determined. Results. More than 4.4 million patients with an average of 3.1 years of eligibility and at least 1 diagnosis of acute rhinosinusitis (ARS) or CRS were studied. A total of 5.5% (95% confidence interval [CI], 5.4%-5.6%) of those with ARS were diagnosed with CRS in the subsequent 4 years. Among patients with chronic disease, after 12 months, 39% were still consuming care for CRS, and after 24 months, nearly 28% were still doing so. Of the CRS patients whose diagnosis was confirmed with endoscopy or radiology, 46.2% underwent endoscopic sinus surgery (ESS). In the year prior to ESS, patient care costs averaged

Nationwide incidence of major complications in endoscopic sinus surgery

2449 (

Is Nasal Packing Necessary Following Endoscopic Sinus Surgery

2341-

Cost of adult chronic rhinosinusitis: A systematic review

2556). The ESS procedure plus 45-day postprocedure debridement and medical therapy costs averaged

Early postoperative care following endoscopic sinus surgery: an evidence-based review with recommendations†

7726 (

Injectable synthetic extracellular matrices for tissue engineering and repair.

7554-

Clinical practice guideline (update): Adult sinusitis executive summary

7898). In the year following the 45-day postprocedure period, consumption dropped by

Image-guided surgery of the sinuses: current technology and applications

885 (P < .0001). In the second year following ESS, therapy costs dropped an additional

Diagnosis and management of chronic rhinosinusitis in adults.

446 (P < .0001). Conclusions. A significant proportion of CRS patients require ongoing treatment of their sinus disease for years. Sinus surgery appears to reduce consumption of rhinosinusitis-related health care, but costs related to the procedure are significant.