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EP3OS: review of 2007
MULLOL J.
Coordinator of the Rhinology Unit.
Hospital Clínic. Barcelona
New Horizons in the Non-Invasive Management of Sinonasal Disorders.
International ENT Medical Summit.
Barcelona, 19 September 2007.
Keywords of New Horizons in the Non-Invasive management of sinonasal disorders - PDF
INTRODUCTION
The EP3OS guidelines offer a series of basic recommendations for the diagnosis and treatment of both chronic and acute rhinosinusitis and nasal polyposis.
These diseases have a high prevalence in the Western world. In the United States, it is calculated that up to 14% of the population (about 40 million people) suffer from this chronic disease and, more importantly, its prevalence continues to increase. However, it is also a disorder associated with a high economic cost. Its impact on the quality of life is not insignificant either, as it has an adverse effect on the performance of daily tasks.
Europe currently suffers from a marked lack of epidemiological studies, which prevents a more realistic approach being taken to this problem. From the studies that have been performed, it is inferred that the milder forms of rhinosinusitis, such as the common cold, affect up to 100% of the European population, with an average of two infections a year per affected person. It is estimated that the prevalence of acute rhinosinusitis in the EU countries is 1-2%, while that of chronic rhinosinusitis is 10%.
Rhinosinusitis has a negative effect on the patient’s quality of life and, to a certain extent, on that of his family. Recent studies not only show that patients with chronic rhinosinusitis have a significantly worse quality of life (measured with the SF-36 test) than the general population, but also that their quality of life is below that of patients with high blood pressure, diabetes or even angina pectoris (Figure 1).
WHY A REVIEW NOW?
In 2005, Fokkens et al. (Rhinology 2005, suppl 18: 1-88; Allergy 2005, 60: 583-601, executive summary) published the EP3OS guidelines (European Position Paper on Nasal Polyposis and Rhinosinusitis). The medium/long-term goal was to combine this document with the GINA guidelines (for asthma) and the ARIA recommendations (for rhinitis) in a single guideline, endorsed by the World Health Organisation.
This year, the first EP3OS consensus (Figure 2) has been reviewed with the goal of correcting errors and consolidating certain basic ideas in the management of rhinosinusitis and nasal polyposis. With more than 120 pages, the new document will be translated into more than 30 languages. “The need to perform a review after so little time is basically because of the significant number of studies that have been performed on rhinosinusitis in recent years, which have led to substantial changes in the evidence available on the best treatments,” acknowledged Dr. Mullol.
The EP3OS 2007 guidelines pursue many goals: review the knowledge available on rhinosinusitis and nasal polyposis; update diagnostic methods on the basis of recent evidence; revise available treatments applying documented evidence; refine the treatment approach to the disease; and guide the definitions and diagnostic methods used in research.
The treatment of acute rhinosinusitis seeks to achieve three basic goals: symptom relief, speed up cure of the disease and prevent complications.
ACUTE RHINOSINUSITIS
The EP3OS 2007 provides a classification for rhinosinusitis based on symptom duration (acute: less than 12 weeks; chronic: symptoms continue for more than 12 weeks) and also on the symptoms’ severity; in this case, it is considered to be a mild disease when the score on the visual analogue scale (VAS) is 0-3, moderate if it is 3-7 and severe when it is 7-10. Acute rhinosinusitis may be viral, the common cold, or non-viral. The natural history of the two types of acute condition is appreciably different: in the common cold, the symptoms do not last for more than 10 days, while in non-viral rhinosinusitis, symptoms worsen after the fifth day or continue for more than 10 days but less than 12 weeks.
The most characteristic symptoms of acute rhinosinusitis are facial pain or pressure, diminished or lost sense of smell, nasal blockage or obstruction, and rhinorrhoea or abundant mucus secretion (both anterior and posterior).
The treatment of acute rhinosinusitis seeks to achieve three basic goals: symptom relief, speed up cure of the disease and prevent complications. The following are signs of a potential complication, indicating urgent referral to a specialist: red eyes, eyeball displacement, diplopia, impaired sight, neurological involvement or frontal pain. The EP3OS guidelines establish a series of basic diagnostic and treatment recommendations which vary depending on the health professional they address: Primary Care physicians or specialists.
Among the treatment recommendations for the GP, it is stressed that if the symptoms last for less than 10 days, treatment should seek symptom relief; however, if the symptoms last for longer, the possibility of a moderate or severe rhinosinusitis should be considered and, initially, topical corticoids should be indicated; lastly, in more severe cases, it is recommended to prescribe antibiotics and/or topical corticoids. When these first treatment options do not give the expected results, the patient should be referred to the specialist.
On the basis of the scientific evidence and the recommendation levels, the first-line drugs for treating moderate/severe acute rhinosinusitis are: oral antibiotics (Ia), antibiotics + intranasal corticoids (Ib), the corticoids in monotherapy (Ib), oral corticoids (Ib), and antihistamines (Ib) when there are allergies.
To date, there is no sufficiently consistent and solid evidence that confirms the efficacy of other treatment resources (such as mucolytics, phytotherapy or saline solutions).
The recommendations included in the EP3OS guidelines for otorhinolaryngologists for the diagnosis of acute rhinosinusitis are not substantially different from those given to GPs. The main characteristic symptoms of this disease are highlighted (nasal obstruction and rhinorrhoea); an examination of the nasal (endoscopic) and oral cavity is always recommended in the event of suspicion as it is necessary to rule out the possibility of an infection.
Plain X-rays of the sinuses are not recommended and CT scans are only indicated for very specific situations (seriously ill or immunodepressed patients,...).
These patients usually see the specialist because they have been referred from Primary Care. Consequently, in the vast majority of cases, these are people with moderate/severe disease. If the symptoms are of a moderately severe disease (no symptom improvement within 14 days after starting the first treatment), the diagnosis should be reconsidered, a more thorough examination should be made and treatment started with corticoids and/or antibiotics. In patients with severe disease (no improvement documented after 48 h of treatment with corticoids and/or antibiotics), the possibility of hospitalizing the patient and/or administering a more aggressive treatment (i.v. antibiotics, oral corticoids and even surgery) should be considered. If complications appear, the EP3OS consensus also suggests referring the patient to a hospital, where more exhaustive examinations will be performed (nasal endoscopy, cultures, imaging) and more powerful treatments will be given (i.v. antibiotics and/or surgery) (Figure 3). There are no major differences between adults and children in the diagnostic and therapeutic management of acute rhinosinusitis.
These recommendations are similar for children; there are no major differences from adults in the diagnostic and therapeutic management of acute rhinosinusitis. In short, as the speaker summarised, “in the common cold, treatment should be symptom-driven. However, in acute rhinosinusitis continuing for more than 7 days, it is advised to administer intranasal corticoids (with or without antibiotics).”
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