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EP3OS Guideline. Consensus in the management of rhinosinusitis and nasal polyposis
ALOBID I.
Hospital Clínic.
Barcelona.
Current Vision of Rhinosinusitis
and recent progress in advanced sinonasal endoscopic surgery
Medical forum. Valencia, March 2007
Keywords of Current Vision of Rhinosinusitis 2007 - PDF
LECTURES
Rhinosinusitis is a common chronic disease that affects a large number of people (14% in USA) and its prevalence is increasing. In addition to its adverse impact on the patient’s quality of life, it also has a considerable social and health impact and is associated with a high cost (almost 6 billion dollars in USA). In Europe, its estimated prevalence ranges between 5 and 10%, depending on the country.
Less common, although also important, is nasal polyposis, which affects 2-4% of the general population. It is more common in patients with non-allergic rhinitis (prevalence 5%), asthmatic patients (7-14%) and, above all, in patients who have asthma and aspirin intolerance (more than 90%).
Using the SF-36 quality of life test, chronic rhinosinusitis has a detrimental effect on the normal performance of daily tasks by the patient to an extent that is at least similar (or even greater) to other chronic diseases, such as diabetes or angina pectoris.
Until now, other respiratory diseases that are as prevalent as rhinosinusitis and nasal polyposis had consensus documents that provided the keys for diagnosis and treatment. The GINA guideline, in the case of asthma, and, more recently, the ARIA document for rhinitis, had yet to be matched by an equivalent document for rhinosinusitis. An attempt has been made to make up for this shortcoming with the publication of the EP3OS consensus. As Dr. Isam Alobid explained in his lecture, “it is a European consensus on nasal polyposis and rhinosinusitis in which a number of leading international experts have taken part, including Dr. Joaquim Mullol from Spain.”
DEFINITIONS AND AETIOLOGY
This consensus document is evidence-based (a comprehensive review of the medical literature) and provides guidelines on the diagnosis and treatment of rhinosinusitis and nasal polyposis. It is intended for both general practitioners and specialists (both in otorhinolaryngology and in other areas).
From 1985 until 1998, the guidelines were based primarily on expert opinions (Opinion-Based Medicine). Since then and until today, the trend is to draw up guidelines based on evidence (Evidence-Based Medicine, EBM), applying them by means of clinical trials and suitable actions. In EBM, the level of evidence is classified in different groups:
Ia) evidence from meta-analyses of randomized, controlled trials;
Ib) evidence from at least one randomized, controlled trial;
IIa) evidence from a controlled, non-randomized trial;
IIb) evidence from at least another type of experimental study;
III) evidence from non-experimental descriptive studies, such as comparative, correlation and case-control studies;
IV) evidence from opinions or consensuses of expert committees or the clinical experience of recognised authorities, or both.
First of all, this consensus defines and classifies the main types of rhinosinusitis. On one hand, it distinguishes between the common cold/viral rhinosinusitis (the symptoms are present for less than 10 days) and acute intermittent rhinosinusitis; the latter disease has an acute onset with at least two characteristic symptoms (nasal congestion/obstruction, impairment/loss of the sense of smell, facial pain/pressure and/or mucoid/posterior rhinorrhoea), intensifying after five days or persisting for more than 10 days (but less than 12 weeks). Both disorders are diagnosed on the basis of the symptoms; no ORL examination and/or radiologic study is required.
Persistent chronic rhinosinusitis is defined clinically as a nasal and paranasal inflammation lasting for more than 12 weeks with nasal obstruction and one or more of the following symptoms: facial pain/pressure, impairment/loss of the sense of smell and mucoid rhinorrhoea. It is also characterised clinically by findings in the nasal endoscopy (nasal polyps, mucopurulent rhinorrhoea and/or mucosal oedema/obstruction) and/or findings in the computerised tomography (changes in the mucosa of the osteomeatal or sinus complex). In short, as the speaker summarised, “we would be dealing with a chronic persistent rhinosinusitis when nasal symptoms and findings in the nasal endoscopy and/or the computerised tomography are reported.”
In this consensus, rhinosinusitis is classified both by the duration of the symptoms and their severity (mild, with a VAS ≤4, moderate/severe with a VAS >4). In addition, the aetiology of the sinonasal inflammation is considered. Bacteria, viruses, fungi and/or allergens may be involved in the development of this condition.
THERAPEUTIC MEASURES
The treatment of acute intermittent rhinosinusitis pursues a three-fold goal: improve the symptoms, achieve a rapid cure of the disease, and prevent complications (swelling in the ocular or palpebral area; displacement of the eyeball, double vision, sight impairment, swelling in the forehead area, severe one-sided frontal headache, signs of meningitis or neurological focality). In patients with common colds or mild acute rhinosinusitis, it is recommended to treat the symptoms with analgesics, physiological saline/salt water, topical nasal decongestants or inhalations; antibiotic therapy is not indicated.
In patients with moderate or severe acute intermittent rhinosinusitis, in addition to symptom relief (analgesics, saline solution, …), oral antibiotics and nasal corticoids are advised. Upon reviewing the studies published in the literature, oral antibiotics and topical corticoids have the strongest evidence in favour and a higher level of recommendation (both alone and combined with nasal corticoids). To date, there are no scientific articles that support the efficacy of oral corticoids, antihistamines (in the absence of allergy) and nasal irrigations. In any case, Dr. Alobid added, “the prescription of antibiotic therapy should be rationalised, particularly considering that Spain is the European country with the second highest sales of antibiotics for outpatient use, with a marked increase in resistance to antibiotics. The treatment of acute intermittent rhinosinusitis pursues a three-fold goal: improve the symptoms, achieve a rapid cure of the disease, and prevent complications”.
The basic therapy for chronic persistent rhinosinusitis is the so-called “sandwich” therapy, i.e., start with the best possible medical treatment and, if it fails, perform endoscopic nasal surgery and then provide the best possible medical treatment. If the rhinosinusitis is mild, it is advised to use nasal corticoids and nasal irrigation (saline solution). In patients with moderate or severe rhinosinusitis, this standard treatment should be supplemented with oral antibiotics (administered over long periods). If treatment fails after three months, it should be studied whether surgery is indicated, followed by medical treatment. In patients with concurrent allergy, an allergen avoidance therapy should be used.
The nasal corticoids have the most consistent evidence of efficacy, with recommendation grade A; in contrast, the evidence in favour of oral antibiotics, nasal irrigation, nasal decongestion or allergen avoidance is weaker. To date, there is no evidence of efficacy for other therapies, such as short-course oral antibiotics, nasal antibiotics, oral corticoids or antihistamines.
In patients with chronic rhinosinusitis associated with nasal polyps, the treatment will depend on the severity of the polyposis. If the nasal polyposis is mild, the evidence supports the administration of nasal corticoids and nasal irrigation; however, if the nasal polyposis is moderate, nasal corticoids (high dose or drops) will be given and may be combined with oral corticoids (short course). If the treatment fails after three months (severe), the possibility of surgery should be considered, followed by drug therapy based on nasal corticoids.
As regards the management of postsurgical nasal polyposis, the EP3OS document indicates nasal corticoids as the drugs with strongest evidence in favour of their efficacy and a higher recommendation grade (A). There is no evidence for the efficacy of nasal decongestants or nasal antibiotics.
To conclude, symptom relief is recommended for the common cold, adding antibiotics and/or nasal corticoids in acute intermittent rhinosinusitis. In chronic persistent rhinosinusitis, the first line of therapy should be nasal irrigation and nasal corticoids in mild cases (adding antibiotic therapy if this fails after 3 months), and using nasal irrigation, nasal corticoids and antibiotics (Iong courses) in moderate-severe rhinosinusitis (leaving surgery as the second line of therapy). Finally, in patients with chronic rhinosinusitis and nasal polyposis, it is recommended to give a nasal corticoid in mild and moderate cases, leaving surgery for severe nasal polyposis (plus oral corticoids).
As a general recommendation, Dr. Alobid highlighted that “all patients with nasal polyps should be assessed by the pulmonologist or allergologist, while all asthmatic patients should be assessed by an otorhinolaryngologist. Diagnostic assessment and treatment strategy should be unified.” *
* ARTICLE REVIEWED AND AUTHORISED BY DR. J. MULLOL (EP3OS SCIENTIFIC COMMITTEE).
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