CANADIAN GUIDELINES FOR RHINOSINUSITIS: Practical Tools for the Busy Clinician

Acute bacterial rhinosinusitis (ABRS) and chronic rhinosinusitis (CRS) frequently present in clinical practice. Guidelines for management of these conditions - published extensively in the past.
Presented guidelines are applicable internationally - single algorithms for diagnosis and management of ABRS and CRS

INTRODUCTION
Current Canadian guidelines mark the first time that comprehensive guidelines covering both ABRS and CRS appear. Rhinosinusitis - Denotes inflammation of the sinus and nasal passages often occur simultaneously due to their close location and shared respiratory epithelium

 Rhinosinusitis is common and increasing in prevalence worldwide Rhinosinusitis continues to affect more individuals - impact on patient lives and total costs continue to rise.

DISCUSSION
ABRS and CRS have different pathologies and thus management strategies. Critical that clinicians understand these differences so appropriate treatment can be started. Canadian guidelines - Easy-to-read
practical recommendations to assist clinicians facing
patients with rhinosinusitis symptoms in everyday practice.

ABRS Diagnosis
requires the duration of appropriate symptoms be greater than 7 days. P Pain/Pressure/fullness O Nasal Obstruction D Nasal Discharge S Smell disorder (hyposmia/anosmia) 2 symptoms, one of which must be O or D, for > 7 days without improvement.

ABRS treatment
guidelines base severity by the degree to which symptoms impair the patient. low severity - easily tolerated symptoms, moderate severity - steady symptoms that are tolerable, severe severity - symptoms are difficult to tolerate or interfere with sleep or daily activities.

 Mild to moderate intensity INCS (1st step) antibiotics are reserved for patients failing to respond to INCS after 3 days & symptoms continue for more than 7 days. Severe illness - INCS and antibiotics recommended in combination as a first step in treatment.

CRS diagnosis
C Facial Congestion P Facial Pain O Nasal Obstruction D Nasal Discharge S Smell dysfunction (hyposmia/anosmia) At least two symptoms present for 8 to 12 weeks, Documented inflammation of the nasal mucosa or paranasal sinuses. Duration of symptoms for diagnosis - 12 weeks. Minimum duration according to guidelines 8 weeks

 presence or absence of nasal polyps is used to further categorize disease. Bilateral polyps in the middle meatus characterizes CRS with nasal polyps (CRSwNP) Lack of polyps constitutes CRS without nasal polyps (CRSsNP).

CRS treatment
CRS - primarily inflammatory disease with unknown contributions from bacteria, cytokines, leukocytes, and tissue remodeling, treatment based upon use of INCS as monotherapy or as adjunct therapy with antibiotics.

 Before treatment - predisposing and contributing conditions identified and treated. Conditions contributing to CRS:
allergic rhinitis asthma Ciliary dysfunction immune dysfunction lost ostia patency aspirin-exacerbated respiratory disease Cystic fibrosis.

 Nasal or oral corticosteroids are used with or without antibiotics for initial treatment of CRSsNP. Antibiotics should be a second-line agent with broad-spectrum coverage. duration of therapy should be longer than for ABRS.

 CRSwNP - Course of topical INCS and short courses of oral steroids used. Antibiotics are not recommended for CRSwNP unless there are symptoms suggesting infection.

Role of antibiotics
guidelines discuss concerns of increasing rates of antibiotic resistance Antibiotic resistance rates increased between 1988 and 2005 some rates have stabilized in the 5-year period between 2000 and 2005 (ciprofloxacin, penicillin, and TMP/SMX resistance) Because of trends in resistance rates, guidelines advise judicious use of antibiotic therapy and awareness of related issues

Ancillary therapy, testing, and prevention

Saline irrigation Use of saline irrigation as adjunct therapy primarily based on reported symptomatic improvement allergy testing in cases of recurrent episodes of ABRS or for CRS potential contributing condition Prevention of illness - hand washing & health education.

Guideline rationale and method

designed to be valuable tool for first-line clinicians. Evidence based, make specific recommendations, and comprehensively address both ABRS and CRS Guidelines were constructed using an evidence based strategy and present an evidence strength rating

Conclusion
The knowledge base of ABRS and CRS pathology and management continues to grow and evolve provide a solid foundation for future developments User-friendly tool - quickly grasp appropriate methods of diagnosis and management of ABRS and CRS