Published online: November 10, 2017
Chronic rhinosinusitis (CRS) is a prevalent and disabling inflammatory condition of the nose and sinuses. It is defined by the presence of two or more cardinal symptoms (obstruction, drainage [anterior or posterior], smell loss, and facial pain or pressure) for at least 12 weeks duration, confirmed by objective evidence using sinus CT scan or nasal endoscopy. In tertiary care populations, in order to improve symptoms and productivity, CRS is treated with surgery for up to 50% of patients who do not respond to medical management. The natural history of CRS symptoms in a general population sample in the US, however, is unknown.
The study by Sundaresan and colleagues, recently published in The Journal of Allergy and Clinical Immunology: In Practice, used two questionnaires mailed six months apart to estimate the prevalence of, and to identify predictors for, stability or change in symptoms over time, in a general population-based sample from Pennsylvania. Baseline and 6-month follow-up questionnaires were mailed to 23,700 primary care patients and 7801 baseline responders, respectively. Nasal and sinus symptoms were categorized as CRS using European Position Paper on Rhinosinusitis (EPOS) epidemiologic criteria, which was defined only by the presence of symptoms for 12 weeks, without the need for objective evidence. They defined six symptom groups over time based on the presence of CRS symptoms at baseline and follow-up: (1) persistent, current CRS at baseline and follow-up; (2) non-persistent, current CRS at baseline but not follow-up; (3) recurrent, past CRS at baseline and current at follow-up; (4) stable past, past CRS at baseline and not current at follow-up; (5) incident, never CRS at baseline and current at follow-up; and (6) never, never CRS at baseline and not current at follow-up. Weighted analysis was used to estimate prevalence of these groups in the source population.
There were 4966 responders at follow-up, of which 558 had persistent symptoms, 190 recurrent symptoms, and 83 new symptoms meeting EPOS criteria for CRS. In the source population, the prevalence of persistent symptoms was 4.8%, while the annual cumulative incidence of new symptoms was 1.9% and of recurrent symptoms was 3.2%. In this study, less than half with nasal and sinus symptoms meeting CRS EPOS criteria at baseline had symptom persistence six months later, with certain symptom profiles at baseline (e.g., with smell loss, migraine, or severe symptoms) and younger age of onset associated with CRS persistence. Asthma, hay fever, and surgical or medical treatment did not predict CRS persistence. Subjects who eventually met EPOS symptom criteria had extended periods of upper airway, lower airway, allergy, ear, and constitutional symptoms, as well as numerous medical treatments that preceded meeting criteria for EPOS current CRS.
Given that half the patients who met CRS criteria at baseline did not six months later, this study suggested that physicians should evaluate longer periods of persistence as well as specific patterns of symptoms and multiplicity of symptoms before surgical intervention. Patients with three months of nasal obstruction and drainage alone were not likely to persist; while subjects who had additional symptoms (e.g., smell loss) were more likely to persist.
The Journal of Allergy and Clinical Immunology: In Practice is an official journal of the AAAAI, focusing on practical information for the practicing clinician.