European Position Paper on Rhinosinusitis and Nasal Polyps 2020.

The European Position Paper on Rhinosinusitis and Nasal Polyps 2020 is the update of similar evidence based position papers published in 2005 and 2007 and 2012. The core objective of the EPOS2020 guideline is to provide revised, up-to-date and clear evidence-based recommendations and integrated care pathways in ARS and CRS. EPOS2020 provides an update on the literature published and studies undertaken in the eight years since the EPOS2012 position paper was published and addresses areas not extensively covered in EPOS2012 such as paediatric CRS and sinus surgery. EPOS2020 also involves new stakeholders, including pharmacists and patients, and addresses new target users who have become more involved in the management and treatment of rhinosinusitis since the publication of the last EPOS document, including pharmacists, nurses, specialised care givers and indeed patients themselves, who employ increasing self-management of their condition using over the counter treatments. The document provides suggestions for future research in this area and offers updated guidance for definitions and outcome measurements in research in different settings. EPOS2020 contains chapters on definitions and classification where we have defined a large number of terms and indicated preferred terms. A new classification of CRS into primary and secondary CRS and further division into localized and diffuse disease, based on anatomic distribution is proposed. There are extensive chapters on epidemiology and predisposing factors, inflammatory mechanisms, (differential) diagnosis of facial pain, allergic rhinitis, genetics, cystic fibrosis, aspirin exacerbated respiratory disease, immunodeficiencies, allergic fungal rhinosinusitis and the relationship between upper and lower airways. The chapters on paediatric acute and chronic rhinosinusitis are totally rewritten. All available evidence for the management of acute rhinosinusitis and chronic rhinosinusitis with or without nasal polyps in adults and children is systematically reviewed and integrated care pathways based on the evidence are proposed. Despite considerable increases in the amount of quality publications in recent years, a large number of practical clinical questions remain. It was agreed that the best way to address these was to conduct a Delphi exercise . The results have been integrated into the respective sections. Last but not least, advice for patients and pharmacists and a new list of research needs are included. The full document can be downloaded for free on the website of this journal: http://www.rhinologyjournal.com.

Is 'sinus' pain really sinusitis?

So-called 'sinus pain' is a common complaint in GP and ear, nose and throat clinics, and patients often receive treatment with antibiotics and decongestants. Recent evidence suggests that facial pain may not be related to the sinuses at all and that doctors may have to rethink their prescribing strategy.

Long-term follow-up of patients with facial pain in chronic rhinosinusitis--correlation with nasal endoscopy and CT.

AIMS: Commonly attributed to chronic rhinosinusitis (CRS), facial pain is a frequent present-ing complaint in otolaryngology clinics. This study aimed to investigate nasal endoscopy and CT in a cohort of CRS patients presenting primarily with facial pain and to report on their long-term follow-up. SETTING: The setting was a busy otolaryngological practice on a small Mediterranean island. A cohort of 305 consecutive patients with chronic rhinosinusitis refractory to maximal medical therapy was assessed clinically, by nasal endoscopy and coronal sinus CT. The primary presenting symptom in 154 of these individuals was facial pain and this paper studied this particular subgroup of CRS patients. Using the Lund-Mckay scoring system, a CT positive for sinusitis was set at 2 or higher. A score of 0 or I was considered negative for sinusitis. The findings in CT positive and CT negative patients were compared. RESULTS: The CT in 61 (40%) patients with facial pain scored positive while 93 (60%) patients had a negative CT. Patients with facial pain as the presenting symptom in rhinosinusitis were significantly less likely to score positive for sinusitis on CT (chi squared test, p<0.0001). CT positive patients were significantly more likely to have pus or nasal polyps (chi squared test, p<0.0001) on nasal endoscopy than CT negative patients. Only 36% of patients with facial pain and other sinusitis symptoms had chronic rhinosinusitis as confirmed by CT and presence of pus or polyps on nasal endoscopy. Patients with positive CT were significantly more likely to be treated surgically while those with a negative CT were significantly more likely to be treated by medication (chi squared test, p<0.0001). CONCLUSION: Patients were followed up for a mean of two years and their outcomes analysed. The outcome for conservative treatment in CT negative patients (68% good or improved) was not as good as the outcome for surgical treatment in CT positive patients (87% good or improved).

Chronic sinusitis in Malta--correlation between symptoms and CT scan.

INTRODUCTION: The diagnosis of chronic rhinosinusitis (CRS) is clinical as it is based on patient symptoms. Sinus CT has been used as an objective measure of CRS with varying degrees of success and correlation to patient symptoms. AIMS: This study aimed to investigate the relationship between patient symptoms, nasal endoscopic findings and CT in a small Mediterranean island community. A cohort of 305 consecutive patients with symptoms of CRS, that persisted despite maximal medical therapy, was evaluated by medical history, clinical examination and nasal endoscopy followed by sinus CT. Scans scoring 2 or higher on the Lund-Mckay scoring system were classified as positive for sinusitis while those scoring 0 or 1 were classified as negative for sinusitis. SETTING: The setting of this study was a busy otolaryngological practice on a small Mediterranean island using a computerised database. RESULTS: In total, 172 patients (56%) had positive and 133 (44%) had negative CT scans. Males with CRS were significantly more likely to have a positive CT (chi squared test, p=0.0005). Postnasal drip/rhinorrhoea, nasal obstruction and hyposmia as primary symptoms were significantly more likely to be associated with a positive CT (chi squared test p=0.0001). Patients presenting with facial pain as the primary symptom were significantly more likely to have a negative CT (chi squared test, p=0.0001). Middle meatal pus or nasal polyps on nasal endoscopy were significantly more likely to be associated with a subsequently positive CT (chi squared test, p<0.0001). Mucosal oedema of the middle meatus was a non-specific finding. CT positive patients were more likely to be treated surgically while CT negative patients were more likely to be treated with medication (chi squared test, p=0.0001). CONCLUSION: Patients were followed up for a mean of 2 years. Overall, there was a good or improved outcome in 81% of patients. Those with a positive CT did significantly well with surgical treatment.

The role of atopy in Maltese patients with chronic rhinitis.

The global prevalence of allergic rhinitis has been on the increase and recent clinical experience in Malta has shown a similar trend. The aim of this study was to investigate the role of atopy in 415 patients presenting with rhinitis of at least 3 months duration, and to identify the common allergens responsible. Presenting clinical features, past and family history of seasonal allergic symptoms, exposure to cigarette smoking, pet ownership and occupation were analysed. All patients were skin tested for common allergens. Fifty-five per cent of patients were atopic, the main allergens responsible being house dust mite, cat dander and grass pollen. Rhinorrhoea and sneezing were significantly more common in atopic patients, who were more likely to have a past history and family history of seasonal asthma, eczema or rhinoconjunctivitis. Skin test-negative patients with idiopathic rhinitis were mostly females and tended to present a decade later. Differentiation between atopic and idiopathic chronic rhinitis may be helpful in the clinical setting in order to help predict response to treatment.

Age, smoking and nasal ciliary beat frequency.

The nasal ciliary beat frequency of 120 individuals in a British urban population was determined from nasal brushings. These individuals formed part of a previous study which looked at nasal and middle ear ciliary beat frequency in 60 patients with middle ear disease and compared it to nasal ciliary beat frequency in 60 matched controls. The present study intended to investigate any changes in nasal ciliary beat frequency with age. Comparison was also made between patients who were habitually exposed to tobacco smoke and non-exposed individuals. Nasal brushings were taken from the inferior turbinate using a cytology brush and the beat frequency was determined using a computerized photometric technique. In the population studied ages ranged from 2 to 69 years (mean 10.9 +/- 19.7 years). The mean beat frequency of 120 individuals was 11.5 +/- 2.5 Hz (SD), range 5.5-19.2 Hz. There was no particular trend observed with regards to beat frequency and advancing age. Nasal ciliary beat frequency in tobacco smoke-exposed patients (whether active or passive smokers) was significantly less than that in non-smoke exposed controls (P = 0.02, Student's t-test).

The effects of in vitro cotitine on nasal ciliary beat frequency.

Cotitine is one of the main metabolites of nicotine. It is stable and in vivo has a relatively long circulating half life. Nasal ciliated cells from non-smoking individuals were exposed in vitro to solutions of cotitine corresponding to serum levels in active and passive smokers. Ciliary beat frequency was measured by a computerized photometric technique. There was a significant drop in ciliary beat frequency compared with control ciliated cells in phosphate buffered saline. It is concluded that cotitine in active or passive smoking has a marked effect on ciliary function. It may be a factor leading to diminished mucociliary clearance and persistent middle ear effusion.

Nasal and middle ear ciliary beat frequency in chronic suppurative otitis media.

The middle ear mucociliary system has been shown to have an important function in the clearance of effusions. Little is known, however, about its role in chronic suppurative otitis media (CSOM). The ciliary beat frequencies of middle ear mucosal biopsies and nasal brushings of 27 patients with CSOM were analysed using a computerized photometric technique. The ciliary beat frequency in the middle ear mucosa was significantly less than that in nasal mucosa. Frequency in ears of smoking patients was significantly lower compared with non-smoking patients. Nasal brushings were taken from 27 otherwise healthy age and sex-matched non-smoking controls and the ciliary beat frequency was very similar to nasal samples from patients with CSOM. Ear controls were obtained from otosclerotic patients undergoing tympanotomy and the beat frequency was significantly higher than in the ear of patients with CSOM. It is concluded that middle ear ciliary function is significantly reduced in CSOM, particularly in patients who smoke.

Smoking and middle ear ciliary beat frequency in otitis media with effusion.

The middle ear mucociliary system has been shown to play an important role in clearing middle ear effusions. There is conflicting epidemiological evidence, however, as to whether exposure to tobacco smoke plays a significant role in persistence of middle ear effusion in patients with otherwise normal mucociliary function. Samples of middle ear mucosa from 33 patients with persistent otitis media with effusion (OME) were taken at myringotomy, together with corresponding nasal brushings. The aim of this study was to observe the mean ear ciliary beat frequency (CBF) and to compare it with nasal ciliary activity. Nasal brushings were collected from 33 age and sex matched non-smoking controls with no history of nasal atopy or topical nasal treatment. Ear CBF in OME was significantly reduced in comparison to paired nasal samples (p < 0.001). Ear CBF in adult OME patients who smoked or in children who were passive smokers was significantly less than in patients who were not exposed to cigarette smoke (p < 0.01). This study indicates that impaired ciliary function due to tobacco smoke exposure is an aetiological factor in persistent OME.

Surface morphology of middle ear epithelium in chronic ear disease.

The ultrastructural details of normal middle ear mucosa have been reported in detail in the literature. This study was aimed at investigating the superficial structure of middle ear epithelium with the scanning electron microscope in patients with persistent otitis media with effusion (OME) and chronic suppurative otitis media (CSOM), especially in the light of the authors' recent findings regarding decreased ciliary beat frequency (CBF) in patients exposed to tobacco smoke. Mucosal biopsies were taken from the anterior mesotympanum in four patients with OME and another four patients with CSOM. There was no significant abnormality of cellular surface structure in patients with chronic middle ear disease. Furthermore, no significant difference was observed between smoke exposed and nonsmoke exposed patients. It is concluded that the effect of tobacco smoke on CBF is functional and not related to any anatomical abnormality observed by scanning electron microscopy (SEM).