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The EPOS Consensus. What does it bring us?


MULLOL J.
Coordinator of the Rhinology Unit.
Hospital Clínic. Barcelona.

New Concepts and New Strategies in Rhinosinusitis and Postoperative Care.
57th National Congress of the Spanish Society of Otorhinolaryngology.
Granada, 1 October 2006.

Keywords of 57th National Congress of SPO in Granada - PDF


PAPERS

Chronic rhinosinusitis is currently a very prevalent disease and its incidence has been increasingly steadily in Spain in recent years. In the United States, it is estimated that 14% of the population, that is, more than 35 million people in that country, suffer from chronic rhinosinusitis.

In Europe, it is estimated that the prevalence of chronic rhinosinusitis is slightly less than 10% (more than 50 million people). Apart from the obvious social and health consequences of this disorder, the impact on health costs is dramatic, generating an estimated annual cost of about 6 billion dollars in the United States.

In the case of acute rhinosinusitis, the data available in the European Union indicate that the prevalence is about 2%, affecting more than 20 million Europeans. Extrapolating these figures to Spain, Dr. Joaquim Mullol said that “we could have about a million people with this condition each year. If we add this to the number of cases of chronic rhinosinusitis, this would give more than 4 million people in Spain with the disease.”

In addition, rhinosinusitis has a significant impact on the patients’ quality of life, which makes it a major public health concern. Compared with other reference diseases with a high social impact (and taking into account the results obtained in the quality of life test SF-36), it is concluded that the degree of quality of life impairment suffered by patients with rhinosinusitis is similar to that experienced by patients with angina pectoris or diabetes.

Another problem caused by rhinosinusitis is the high degree of comorbidity associated with it, that is, many cases are associated with the presence of other clinically relevant diseases. Thus, it is common for these patients to also report aspirin intolerance, asthma or bronchial hyperreactivity, allergy, or some kind of infection (purulent or mucopurulent rhinorrhoea).


A NECESSARY CONSENSUS

Until now, there had been no unified criteria on the diagnosis and treatment of rhinosinusitis. Hence the lack of consensus on the definition of this disease or on the treatments of choice. This gap has been filled by the EPOS consensus.

In the late 90’s, the GINA (Global Initiative for Asthma) guidelines were published. Their purpose was to provide basic recommendations for the diagnosis and treatment of asthma. Subsequently, following this example, the ARIA (The Allergic Rhinitis and its Impact on Asthma) guidelines were published, which synthesised current knowledge on allergic rhinitis and its influence on asthma. Now, as a continuation of this line of work, we have the EPOS consensus.
This is an initiative promoted by the Academy of Allergology and Clinical Immunology (EAACI) and the European Rhinology Society (ERS) which updates and pools the recommendations on the correct diagnosis and treatment of rhinosinusitis. To quote Dr. Mullol, the only Spanish expert who took part in drawing up the consensus document, “this European consensus on rhinosinusitis and nasal polyposis was absolutely necessary and indispensable for optimising our approach to these diseases”.

This consensus document, which was published more than a year ago and is currently being revised, is based on scientific evidence (Evidence-Based Medicine). This evidence has been used to establish a new classification of rhinosinusitis (that takes into account particularly how the disease affects the patient). It targets specifically general practitioners, ENT and other specialists who may see patients with this disease in their practice.

First of all, the EPOS consensus provides a definition and classification for rhinosinusitis, distinguishing acute rhinosinusitis from the common cold and viral rhinosinusitis (both of these diseases are characterised by the presence of symptoms for periods less than 10 days). Acute-intermittent rhinosinusitis is characterised by the acute onset of two or more of the following symptoms: nasal congestion/obstruction, impairment/loss of the sense of smell, facial pain/pressure, mucoid rhinorrhoea/posterior rhinorrhoea. However, it also has the distinctive feature that the symptoms persist for more than 10 days (and less than 12 weeks), with increased symptom severity after 5 days.

Chronic rhinosinusitis is defined as a nasal and paranasal inflammation persisting for more than 12 weeks and which is associated with the presence of at least two of the following symptoms: nasal congestion/obstruction, impairment/loss of the sense of smell, facial pain/pressure, mucoid rhinorrhoea. However, to diagnose this disorder, there must also be significant findings in the nasal endoscopy (nasal polyps, mucupurulent rhinorrhoea in the middle meatus, oedema/obstruction of the mucosa in the middle meatus) and/or in the computerised tomography (changes in the mucosa of the ostiomeatal or sinus complex). Applying these premises, we could diagnose this disease with a certainty of almost 100%.

It is important to note that the classification of the EPOS consensus takes into account both symptom duration and symptom severity. In acute/intermittent rhinosinusitis, the symptoms fully resolve in less than 12 weeks, while in chronic/persistent rhinosinusitis, the symptoms persist for more than 12 weeks and never disappear altogether. The EPOS consensus targets specifically general practitioners, ENT and other specialists who may see patients with this disease in their practice.

As regards severity, the consensus distinguishes between mild rhinosinusitis (with a score on the symptom severity assessment scale VAS ≤4) and moderate/severe rhinosinusitis (with a VAS >4).


IDEAS ABOUT TREATMENT

This new European consensus on rhinosinusitis also addresses practical issues concerning therapeutic management of the disease. The treatment of acute rhinosinusitis pursues a three-fold goal: improve the symptoms, quickly cure the disease and prevent complications. Urgent treatment will be required if complications appear such as eye or eyelid swelling, displacement of the eyeball, double vision, impaired vision, swelling affecting the forehead region, severe headache or signs of meningitis.

For the common cold or mild acute rhinosinusitis, it is recommended to concentrate treatment on symptom relief, using as drugs of choice analgesics, hypertonic saline solution, and nasal decongestants. Antibiotics should never be prescribed in such cases.

When the acute/intermittent rhinosinusitis is moderate or severe, it is recommended to prescribe treatment for symptom relief (with analgesics, saline solution or seawater, or decongestants) and, in this case, add an oral antibiotic therapy (taking into account local resistance) and intranasal corticoids. These recommendations are based on the detailed analysis of more than 2,000 studies published in the scientific literature and, in particular, on the evaluation of about 50 studies which met certain quality criteria. It is concluded from the analysis of these papers that oral antibiotics have a degree of evidence 1a and a degree of recommendation A for treating moderate/severe acute/intermittent rhinosinusitis, while the degree of evidence is Ib for antibiotics + nasal cortocoids (recommendation A) and for nasal corticoids as monotherapy (recommendation B).

There is no truly conclusive evidence for decongestants, and the degree of recommendation is D. There is no evidence of efficacy for other drugs that are sometimes used in such cases, such as oral corticoids, phytotherapy (although studies are being begun that will soon provide consistent evidence) or nasal irrigation (although its use is still being recommended).

In chronic rhinosinusitis, the recommendation of the EPOS consensus is still based on the so-called sandwich therapy, that is, starting with medical treatment, continuing with nasal endoscopic surgery and ending with medical treatment. In mild rhinosinusitis, it is recommended to use nasal corticoids and nasal irrigation; in moderate/severe rhinosinusitis, it is considered necessary to add the use of oral antibiotics to the above treatment. If the treatment fails after three months, the possibility of surgery should be considered and the need to continue with medical treatment after surgery is stressed.
When the existence of a concurrent allergy is documented, it will be necessary to design an allergen avoidance management strategy. As regards the level of evidence available on the efficacy of the various treatments, the authors of this consensus consider that, on the basis of reviews of the scientific literature, the highest level of evidence (Ib) corresponds to the nasal corticoids, with a degree of recommendation A. For their part, the oral antibiotics and nasal irrigations only have inconsistent evidence (III), with a degree of recommendation C.

For the common cold or mild acute rhinosinusitis, it is recommended to concentrate treatment on symptom relief. When the acute/intermittent rhinosinusitis is moderate or severe, it is recommended to prescribe treatment for symptom relief and add an oral antibiotic therapy and intranasal corticoids.

Finally, when managing nasal polyps, it is recommended to use nasal corticoids as first choice in mild and moderate cases (combined with an oral corticoid in the latter). Surgery should be used in severe cases, adding oral corticoid therapy.

In chronic rhinosinusitis, the recommendation of the EPOS consensus is still based on the so-called sandwich therapy, that is, starting with medical treatment, continuing with nasal endoscopic surgery and ending with medical treatment.


CONCLUSION

By way of final recommendation, the EPOS consensus states that all patients with chronic rhinosinusitis or nasal polyps should be assessed to rule out the coexistence of asthma, and vice-versa. As the speaker assured, “this will enable a unified treatment strategy to be established among the experts who work with this type of disease”.



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