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Keywords:

  • allergic rhinitis;
  • chronic sinusitis;
  • computed tomography;
  • nasal endoscopy;
  • symptom-based diagnosis

Abstract

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Conclusions
  7. References

Objective:  Currently, the diagnosis of chronic rhinosinusitis (CRS) is a symptom-based definition. This study aims to study, verify and evaluate the predictive value of the symptom-based definition of CRS and compare this with objective tests.

Methods:  Seven hundred and sixty-eight adults, who were referred from primary care centers as patients who met the definition of CRS, were enrolled in the study. The patients were divided into two groups according to their allergic status. The patients were subjected to nasal endoscopy and computed tomography (CT) on the same day.

Results:  The results showed 73.15% of the nonallergic patients with symptom-based diagnosed CRS and 65.34% of the allergic patients with symptom-based diagnosed CRS had no CT and endoscopic pathology (Endoscopic score 0 + CT score 0). Nasal discharge was the most common major symptom in all patients from both groups who had pathologic endoscopic and/or CT scan scores.

Conclusions:  It is well established that symptoms are very important in the diagnosis of CRS. However, two major symptoms are insufficient for diagnosis. Therefore, endoscopy and CT have important differential diagnostic roles. Our study showed that in patients with three major symptoms, CT pathology may be sufficient for definitive diagnosis. However, in patients with two major symptoms such as nasal discharge and/or low grade nasal polyposis, endoscopy becomes considerably more important due to inspective findings. If no endoscopic findings are found, the importance of the CT scans is increased.

Chronic rhinosinusitis (CRS) is a common prevalent disease in which many factors may contribute. Diagnosing CRS is based primarily on major symptoms and signs of the disease. In primary care centers, CRS is diagnosed primarily using major symptom scales. This symptom-based definition should also be supported by objective signs such as nasal endoscopy and computed tomography (CT) (1). However, there may be a discrepancy between the subjective information and the objective data from nasal endoscopy and CT scans results. The aim of this study was to investigate the diagnostic value of symptom scales (VAS) by examining patients diagnosed as having sinusitis in primary care centers. The association of allergic rhinitis and CRS is well-known. A nasal allergy may block the ostia and delay mucociliary clearance in several ways, thereby increasing CRS pathogenesis (2). We divided patients with CRS into two groups as either allergic or nonallergic and then enrolled them in this study. Patients with allergic rhinitis were included as CRS symptoms in these patients may become considerably more severe than in nonallergic patients. The results in these patients may therefore be more significant and meaningful.

In this study, we evaluated the validity of the symptom-based definition of CRS and compared this with objective data obtained from nasal endoscopy and CT. The need and place for nasal endoscopy and CT scanning in the diagnosis of CRS was evaluated. In addition, we evaluated the negative prognostic effect of nasal allergy on CRS.

Methods

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Conclusions
  7. References

A total of 1013 patients diagnosed as having chronic sinusitis according to major CRS symptom scales were referred to our clinic. Seven hundred and sixty eight adult patients, who met the criteria for the definition of CRS, were included in the study. Each patient with symptoms of sinonasal disease at presentation filled out a questionnaire, consisting of major symptoms defined for CRS. The patients described the severity of their symptoms on a visual analogue scale from 0 to 10 cm. A score of 0 represented no symptoms at all, whereas 10 indicated the most severe symptoms. To qualify for a CRS diagnosis, all patients were required to have (new definition of the EPOS revision [EAACI position paper on rhinosinusitis and nasal polyps]) two or more symptoms, one of which should be either nasal blockage/obstruction/congestion or discharge (anterior/posterior nasal drip): blockage/congestion, discharge (anterior/postnasal drip), facial pain/pressure, reduction or loss of smell, for at least 3 months before enrollment with a VAS grade of 6 or more for each symptom or sign. Patients with a surgical history or who were on any medication were excluded from the study. A nasal smear and skin prick test were performed on all patients for classification into the allergic or nonallergic groups. An Alk-Abello panel, which included 18 allergens, was used for the skin prick test. Patients were classified as allergic if they had (i) allergic complaints for ≥2 years, (ii) at least two allergic symptoms such as sneezing, runny nose, itchy nose, nasal crease, and signs at the physical examination like pale and swollen nasal mucosa, watery discharge, (iii) eosinophilia in the nasal smear (≥15%), (iv) positive skin test to any extracts equal or greater than their histamine reaction, and (v) a detection of level II and above of related specific IgE (0.7 kU/l and above), using the Pharmacia diagnostic Immuno Caps FEIA method. Patients with positive symptoms and signs, a positive skin-prick test and specific IgE were classified in the chronic allergic rhinosinusitis (A-CRS) group.

Patients with negative skin-prick tests and negative nasal eosinophilia, basophilia and goblet cells in three separate nasal smears were classified in the nonallergic CRS group (NA-CRS). Each patient underwent a physical examination, which included nasal endoscopy. Endoscopy was performed under local anesthesia using 0° and 30° rigid endoscopes by three of the authors who were blinded to results obtained by the other two investigators. The endoscopic findings for each patient were graded according to a 0–3 scoring system and were dependent on the involvement level of nasal polyposis, severity of nasal discharge and edema (3). Each patient was then sent on the same day for a CT scan that involved axial and coronal scans of the paranasal sinuses (3 mm cut) without contrast agent. The findings of the paranasal CT scans were graded solely by another author according to the Lund-Mackay scoring system, which relies on a score of 0–2 dependent upon the absence, partial or complete opacification of each sinus system and the ostiomeatal complex (4). The subjects’ informed consent and permission from the local ethics committee were obtained prior to participation in the study.

Statistical analysis

The Student t-test, Chi-square test and Kendall’s tau-b nonparametric correlation test were used for statistical analysis.

Results

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Conclusions
  7. References

Seven hundred and sixty eight adult patients with A-CRS or NA-CRS were enrolled in the study. The NA-CRS group included 564 patients (322 males and 242 females, mean age 36.4 years). The A-CRS group included 204 patients (117 males and 87 females, mean age 32.3 years). Tables 1 and 2 present the endoscopic and CT scan scores of both groups. When we reviewed the mean values of zero endoscopic scores and the CT scan score of 0 in patients from both the allergic and nonallergic groups, the results showed that 70.7% of the allergic patients with symptom-based diagnosed CRS and 75.25% of the nonallergic patients with symptom-based diagnosed CRS had no endoscopic pathology (Endoscopic score 0). Similarly, 68.91% of the allergic patients with symptom-based diagnosed CRS and 76.95% of the nonallergic patients with symptom-based diagnosed CRS had no CT pathology (CT score 0). These combined results showed that 69.34% of the allergic patients with symptom-based diagnosed CRS and 77.15% of the nonallergic patients with symptom-based diagnosed CRS had no CT and endoscopic pathology (Endoscopic score 0 and CT score 0).

Table 1.   CT scores of the patients in the two groups
CT scoresNonallergic group (n)Allergic group (n)
RightLeftRightLeft
012012012012
Maxillary sinus39113241389130451562820150945
Ant. ethmoids389154213721256715426211493718
Post. ethmoids4239645450912315321301571928
Sphenoid sinus5341614515193117682019248
Frontal sinus524192151540917317141751316
OMC (0 or 2)390 174388 176157 47153 51
Table 2.   Scores between 0 and 3 for endoscopic findings in the two groups
Endoscopic scoresNonallergic group (n)Allergic group (n)
RightLeftRightLeft
0123012301230123
Polyp5153415052228140173141251741776
Oedema5171730 4507143 1721418 1511439 
Discharge4894035 4993828 1552821 1464711 

Nasal polyposis with different graded endoscopic scores was found in 8.6% of the NA-CRS group and 15.2% of the A-CRS group. No patient had nasal polyposis completely obstructing the nose (grade 3) in the NA-CRS group, whereas 2.7% of the patients in the A-CRS group had grade 3 nasal polypoid degeneration. All patients with grade 3 polyposis had ≥3 major symptoms. Nasal polyposis was found significantly higher in the A-CRS group as compared to the NA-CRS group (P < 0.05). These differences could also be seen when we reviewed the other criteria for endoscopic and CT findings. The mean percentages of clear, thin discharge (score 1) for the NA-CRS group and the A-CRS group were 7.15% and 13.55%, respectively. In addition, the mean percentage of thick, purulent discharge (score 2) was 6.25% in the NA-CRS group and 10.6% in the A-CRS group. All tips of nasal discharges were found to be significantly higher in A-CRS group than in NA-CRS group (< 0.05).

We reviewed the VAS of the patients in both groups who had pathologic endoscopic and CT scan scores (nonzero score). We found that 11.6% of the NA-CRS group and 15.38% of the A-CRS group had two major symptoms, one of which should be either nasal blockage/obstruction/congestion or discharge (anterior/posterior nasal drip) symptoms. Nasal discharge was also found to be the most common major symptom in all these patients. Reduction or loss of smell was found to be the least major symptom in all patients. In addition, 5.15% of the NA-CRS group and 9.40% of the A-CRS group had three or more major symptoms. All four symptoms of CRS were found to be significantly higher in A-CRS group than in NA-CRS group (< 0.05).

We compared the mean CT scores and mean endoscopic scores of all patients. We divided them to three groups; subjects with two CRS symptoms, three CRS symptoms and finally two or three CRS symptoms with nasal endoscopic findings. When comparing the groups, the mean CT and mean endoscopic scores of the three CRS symptoms group and symptoms with nasal endoscopic findings group were significantly higher than the two CRS symptoms group mean scores (Fig. 1; < 0.05).

image

Figure 1.  Mean CT scores and mean endoscopic scores for all patients. Two-symptom group means are significantly less than the three-symptom and symptoms + endoscopic finding groups.

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There was no correlation between symptoms, signs, endoscopic examination findings and CT results in patients with two major symptoms, except nasal blockage and discharge. A very weak degree of correlation was found between symptoms and endoscopic findings in patients who had two major symptoms, one of which was either nasal blockage or discharge symptoms (r = 0.36, < 0.05) and also between symptoms and CT findings (r = 0.38, < 0.05). In subjects with three major symptoms, there was a moderate degree of correlation between symptoms and endoscopic findings (r = 0.72, < 0.01) and symptoms and CT findings (r = 0.76, P < 0.01). The correlation between symptoms and CT was very strong (r = 0.94, < 0.01) in patients with nasal discharge on endoscopic examination and two major symptoms (one of which was either nasal blockage or discharge) or three major symptoms.

Discussion

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Conclusions
  7. References

Chronic rhinosinusitis is an increasingly common disease. Eighty-five per cent of the first visits for diagnosis of rhinosinusitis were made by primary care physicians (5). Currently, the diagnosis of CRS is still based principally on signs and symptoms. A task force proposed some criteria considered to be the most significant for the accurate clinical diagnosis of all forms of adult rhinosinusitis (6). A strong history consistent with CRS includes the presence of two or more major symptoms, including facial pain or pressure, nasal obstruction, nasal discharge (rhinorrhea and/or postnasal discharge) and hyposmia or anosmia (6). It is recommended that patients meeting this symptom-based definition of CRS receive several weeks of antibiotics (7). The majority of primary care physicians use symptom-based diagnostic approaches for patients with CRS and nasal endoscopy and/or CT are not viewed as being necessary to corroborate this diagnosis. Although both objective methods have an important diagnostic role in the diagnosis of CRS (8), primary care physicians do not have the training or equipment to perform nasal endoscopy, and/or are uninformed about the efficacy, timing, patient selection and interpretation of paranasal CT scans (9). It is therefore important to validate whether or not the definition of CRS based on subjective information correlates with objective findings obtained with endoscopy and CT.

This study, however, clearly demonstrated that approximately 73% of symptom-based diagnosed NA-CRS patients actually had no supporting objective findings. Several recent studies have directly addressed the subject of CT scans, endoscopic findings and patient-based outcomes in patients with CRS. Stankiewicz et al. questioned the accuracy and cost-effectiveness of the symptom-based CRS definition and the antibiotic regimen of these patients in several articles (1, 10, 11). They reported that 78% of CRS patients who were initially diagnosed using a symptom-based criterion showed no evidence of disease on endoscopy tests and no evidence of disease or minimal disease on CT scans (1). This percentage is very similar to our results.

When we reviewed the visual analogue scores of the patients in both groups who had pathologic endoscopic and/or CT scan scores (nonzero scores), all patients in both groups with three major symptoms had pathological CT scans. Therefore, in addition to signs and symptoms, radiological evaluation alone may be sufficient to make a definite diagnosis. However, nasal discharge was a common feature of CRS patients in both groups with two or more major symptoms supported by objective methods. This is the most important major finding in the diagnosis of CRS. Stankiewicz et al. also revealed this point in their study by stating that a negative endoscopic result was a reasonably good predictor of CT results that were either normal or showed minimal disease (10). If endoscopic evaluation was not possible, careful anterior rhinoscopy or the observation of nasal discharge following blowing of the patient’s nose is mandatory for a diagnosis of CRS.

Thus, the role of allergy in contributing to CRS should not be overlooked. Allergic rhinitis is one of the main factors contributing to the development of CRS (6). Also, the major symptoms of allergy and CRS are very similar. Differentiation between these symptoms is important for the management of the main disease and therefore a symptom-based definition of patients with allergic rhinitis may not be reliable. Despite the symptoms and findings of CRS patients with allergic rhinitis being significantly more severe than in the nonallergic patients (< 0.05), 65% of the allergic patients with symptom-based diagnosed CRS had no CT and endoscopic pathology.

All patients with grade 3 polyposis with polyps completely obstructing the nose had fewer than three major symptoms and all had nasal allergy (2.7%). Corey found that mold and dust mite species are the most common allergens associated with CRS (12, 13). Emanuel and Shah conducted a study of 200 patients undergoing endoscopic sinus surgery for CRS and reported that more than 60% of their subjects were sensitive to house dust mites (14, 15). Therefore, we believe that endoscopic evaluation of patients with allergic rhinitis should be mandatory. The mean score of three-symptom group and two or three symptoms with endoscopic findings patients are significantly higher than the two-symptom group (P < 0.05). This indicated that we need more than two symptoms to diagnosis rhinosinusitis.

If we have two major symptoms (one of which was either nasal blockage or discharge), nasal endoscopic findings such as nasal discharge and/or low grade nasal polyposis is mandatory for CRS diagnosis. If three major symptoms are present and nasal endoscopy is not available, a CT scan will be sufficient for CRS diagnosis.

Conclusions

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Conclusions
  7. References

The findings of this study show that the current symptom-based definition of CRS may have major defects. Although it is well established that symptoms are very important for the diagnosis of CRS, two major symptoms are insufficient for CRS diagnosis. At some point, endoscopy and CT have important diagnostic roles, either together or individually. In patients with three major symptoms, a CT scan may be sufficient for definitive diagnosis. However, in patients with less than three major symptoms, if anterior rhinoscopy is not possible, endoscopy is considerably more important than findings such as nasal discharge and/or low grade nasal polyposis. The CT scan is more important if no endoscopic findings are discovered.

References

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Conclusions
  7. References
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    Stankiewicz JA, Chow JM. A diagnostic dilemma for chronic rhinosinusitis: definition accuracy and validity. Am J Rhinol 2002;16:199202.
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    Stankiewicz JA, Chow JM. Cost analysis in the diagnosis of chronic rhinosinusitis. Am J Rhinol 2003;17:139142.
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    Gutman M, Torres A, Keen KJ, Houser SM. Prevalence of allergy in patients with chronic rhinosinusitis. Otolaryngol Head Neck Surg 2004;130:545552.
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    Corey JP. Environmental control of allergens. Otolaryngol Head Neck Surg 1994;111:340347.
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    Emanuel IA, Shah SB. Chronic rhinosinusitis: allergy and sinus computed tomography relationships. Otolaryngol Head Neck Surg 2000;123:687691.
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    Krause HF. Allergy and chronic rhinosinusitis. Otolaryngol Head Neck Surg 2003;128:1416.