Developed by a broad group of both primary care physicians and specialists to update the knowledge of acute and chronic rhinosinusitis and nasal polyposis, the EP3OS guidelines include a review of diagnostic methods and treatments, propose a step-wise approach to the management of the disease, explore new findings on how rhinosinusitis develops and consider how we can make progress with continued research in this area. The complete guidelines are published in a special supplement of this month's issue of the journal Rhinology.
The EP3OS position paper is important because it provides an evidence- based approach to best ensure that patients' symptoms are properly diagnosed and effectively treated. Because rhinosinusitis is diagnosed by a variety of physicians, it's important to have an accurate, efficient, and accessible definition of the disease that can be applied in numerous situations.
Among the updated information in the guidelines is a new definition of rhinosinusitis aimed at helping physicians better identify and diagnose the disease. EP3OS defines rhinosinusitis (including nasal polyps) as the inflammation of the nose and the paranasal sinuses characterised by two or more symptoms, one of which should be either nasal congestion or nasal discharge. Other symptoms of rhinosinusitis may include facial pain or pressure, reduction or loss of smell; and either endoscopic signs of nasal polyps or mucus and pus discharged primarily from the sinuses, or CT changes showing mucosal changes within the sinuses. Rhinosinusitis symptoms are diagnosed as mild, moderate or severe, depending on symptom severity; and acute or chronic, depending on symptom duration. Individuals with symptoms present less than 12 weeks, with complete symptom resolution, are classified as having acute rhinosinusitis (ARS). Patients with symptoms present more than 12 weeks, without complete resolution of symptoms and subject to symptom exacerbations, are classified as having chronic rhinosinusitis (CRS).
Another important component of the new guidelines is an updated treatment schematic for primary care physicians and non-ENT specialists that reflects the significant amount of clinical research done in this area in recent years. EP3OS supports a new step-wise management approach and recommends that primary care physicians and non-ENT specialists prescribe topical corticosteroids and oral antibiotics, for example, as first-line therapy for adults with ARS. For adults with CRS with or without nasal polyps, EP3OS recommends that primary care physicians and non-ENT specialists prescribe topical steroids and nasal douching as first-line therapy. The guidelines also provide recommendations on when primary care physicians and non-ENT specialists should refer their patients to an ENT specialist.
'We've taken a look at a multitude of treatments for the disease and highlighted the level of evidence to support their efficacy in treating rhinosinusitis and nasal polyps,' said Prof. Dr. Fokkens. 'Because there is a substantial amount of new evidence, there are considerable changes in the schemes for diagnosis and treatment.'
Updates for ENT specialists are also included in the new guidelines. For ENT specialists, diagnosis of ARS is recommended beyond presence of symptoms for ARS. EP3OS recommends a nasal examination (swelling, redness, pus), oral examination (posterior discharge) and nose and throat examination including nasal endoscopy. Diagnosis of CRS includes nasal endoscopy to determine whether there are visible nasal polyps, as well as a review of the primary care physician's diagnosis and treatment and allergy questionnaire. Appropriate medical treatment is as effective as surgery for the majority of CRS patients, so sinus surgery should be reserved for patients who do not satisfactorily respond to recommended medical treatment. In CRS without polyps additional long-term antibiotics may be of benefit whereas when polyps are present the use of topical steroid (sprays or drops) and oral steroids are stratified according to polyp size.
The new EP3OS report also includes an expanded section on the treatment of rhinosinusitis in children, stratifies the severity of disease based on a visual analogue score, and provides new information on the pathogenesis of rhinosinusitis and the relationship between the upper and lower respiratory tracts.
EP3OS was first initiated by EAACI and approved by the European Rhinologic Society (ERS) and is intended for the ENT and non-ENT specialists as well as for the general practitioners. It was instigated in 2002 under the chairmanship of Prof. WJ Fokkens and Prof. VJ Lund, culminating in the first report in 2005.