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22 Allergic and Non-allergic Rhinitis

251

41. Auge J, Vent J, Agache I, Airaksinen L, Campo Mozo P, Chaker A, etal. EAACI position paper on the standardization of nasal allergen challenges. Allergy. 2018;73(8):1597–608.

42. Gosepath J, Amedee RG, Mann WJ.Nasal provocation testing as an international standard for evaluation of allergic and nonallergic rhinitis. Laryngoscope. 2005;115(3):512–6.

43. San Nicolo M, Braun T, Eder K, Berghaus A, Groger M. Clinical relevance of IgE to prolin and/or polcalcin in pollen-sensitized patients. Int Arch Allergy Immunol. 2016;169(2):101–7.

44. Ha EK, Na MS, Lee S, Baek H, Lee SJ, Sheen YH, et al. Prevalence and clinical characteristics of local allergic rhinitis in children sensitized to house dust mites. Int Arch Allergy Immunol. 2017;174(3–4):183–9.

45. Al Ahmad M, Arifhodzic N, Nurkic J, Jusufovic E, Hanoun AL, Rodriguez T.Role of nasal challenge and local eosinophilia in indirect exposure to cat in allergic rhinitis patients. Eur Ann Allergy Clin Immunol. 2018;50(3):125–31.

46. Al-Ahmad M, Jusufovic E, Arifhodzic N, Nurkic J, Hanoun AL. Sensitization to cat: when is nasal challenge needed? Int Arch Allergy Immunol. 2019;179(2):108–13.

47. Blanca-Lopez N, Campo P, Salas M, Garcia Rodriguez C, Palomares F, Blanca M, etal. Seasonal local allergic rhinitis in areas with high concentrations of grass pollen. J Investig Allergol Clin Immunol. 2016;26(2):83–91.

48. Krajewska-Wojtys A, Jarzab J, Gawlik R, Bozek A. Local allergic rhinitis to pollens is underdiagnosed in young patients. Am J Rhinol Allergy. 2016;30(6):198–201.

49. Hamizan AW, Rimmer J, Alvarado R, Sewell WA, Kalish L, Sacks R, etal. Positive allergen reaction in allergic and nonallergic rhinitis: a systematic review. Int Forum Allergy Rhinol. 2017;7(9):868–77.

50. Comite P, Minale P, Ferrero F, Mussap M, Ciprandi G. Der p 1 IgE measurement for distinguishing between sensitization and allergy. Immunol Lett. 2015;166(2):145–6.

51. Demoly P, Passalacqua G, Pfaar O, Sastre J, Wahn U. Management of the polyallergic patient with allergy immunotherapy: a practice-based approach. Allergy Asthma Clin Immunol. 2016;12:2.

52. Klimek L, Hammerbacher AS, Hellings PW, Fokkens WJ, Hoffmann HJ, Muraro A, et al. The inuence of European legislation on the use of diagnostic test allergens for nasal allergen provocation in routine care of patients with allergic rhinitis. Rhinology. 2015;53(3):260–9.

53. Matricardi PM, Dramburg S, Potapova E, Skevaki C, Renz H. Molecular diagnosis for allergen immunotherapy. J Allergy Clin Immunol. 2019;143(3):831–43.

54. Canonica GW, Ansotegui IJ, Pawankar R, SchmidGrendelmeier P, van Hage M, Baena-Cagnani CE, et al. A WAO-ARIA-GA(2)LEN consensus docu-

ment on molecular-based allergy diagnostics. World Allergy Organ J. 2013;6(1):17.

55. Matricardi PM, Kleine-Tebbe J, Hoffmann HJ, Valenta R, Hilger C, Hofmaier S, et al. EAACI molecular allergology user’s guide. Pediatr Allergy Immunol. 2016;27(Suppl 23):1–250.

56. Stringari G, Tripodi S, Caffarelli C, Dondi A, Asero R, Di Rienzo Businco A, etal. The effect of componentresolved diagnosis on specic immunotherapy prescription in children with hay fever. J Allergy Clin Immunol. 2014;134(1):75–81.

57. Moreno C, Justicia JL, Quiralte J, Moreno-Ancillo A, Iglesias-Cadarso A, Torrecillas M, et al. Olive, grass or both? Molecular diagnosis for the allergen immunotherapy selection in polysensitized pollinic patients. Allergy. 2014;69(10):1357–63.

58. Hatzler L, Panetta V, Lau S, Wagner P, Bergmann RL, Illi S, etal. Molecular spreading and predictive value of preclinical IgE response to Phleum pratense in children with hay fever. J Allergy Clin Immunol. 2012;130(4):894–901.

59. Posa D, Perna S, Resch Y, Lupinek C, Panetta V, Hofmaier S, etal. Evolution and predictive value of IgE responses toward a comprehensive panel of house dust mite allergens during the rst 2 decades of life. J Allergy Clin Immunol. 2017;139(2):541–9.

60. Knol EF.Requirements for effective IgE cross- linking on mast cells and basophils. Mol Nutr Food Res. 2006;50(7):620–4.

61. Gomez E, Campo P, Rondon C, Barrionuevo E, Blanca-Lopez N, Torres MJ, et al. Role of the basophil activation test in the diagnosis of local allergic rhinitis. J Allergy Clin Immunol. 2013;132(4):975–6. e1–5.

62. WHO position paper. Allergen immunotherapy: therapeutic vaccines for allergic diseases. Arerugi. 1998;47(7):698–704.

63. Bousquet J, Pfaar O, Togias A, Schunemann HJ, Ansotegui I, Papadopoulos NG, et al. ARIA Care pathways for allergen immunotherapy. Allergy. 2019;74(11):2087–102.

64. Calderon MA, Cox L, Casale TB, Moingeon P, Demoly P. Multiple-allergen and single-allergen immunotherapy strategies in polysensitized patients: looking at the published evidence. J Allergy Clin Immunol. 2012;129(4):929–34.

65. Bachert C, van Cauwenberge P, Olbrecht J, van Schoor J.Prevalence, classication and perception of allergic and non-allergic rhinitis in Belgium. Allergy. 2006;61(6):693–8.

66. Corriveau MN, Claus B. Allergic and nonallergic rhinitis. In: Kennedy DW, Hwang PH, editors. Rhinology: diseases of nose, sinuses, and skull base. New York: Thieme Medical Publishers, Inc.; 2012. p.82–91.

67. Fokkens W, Saleh H, Georgalas C.Nonallergic rhinitis: denition, classication, and management. In: Georgalas C, Fokkens W, editors. Rhinology and skull base surgery. NewYork: Thieme Medical Publishers, Inc.; 2013. p.229–45.

252

Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/

M. Al-Ahmad et al.

68. Fokkens WJ. Thoughts on the pathophysiology of non-allergic rhinitis. Curr Allergy Asthma Rep. 2002;2(3):203–9.

69. Van Rijswijk JB, Blom HM, Fokkens WJ. Idiopathic rhinitis, the ongoing quest. Allergy. 2005;60(12):1471–81.

70. Blom HM, Godthelp T, Fokkens WJ, KleinJan A, Mulder PG, Rijntjes E. The effect of nasal steroid aqueous spray on nasal complaint scores and cellular inltrates in the nasal mucosa of patients with nonallergic, noninfectious perennial rhinitis. J Allergy Clin Immunol. 1997;100(6 Pt 1):739–47.

71. Dolovich J, Kennedy L, Vickerson F, Kazim F.Control of the hypersecretion of vasomotor rhinitis by topical ipratropium bromide. J Allergy Clin Immunol. 1987;80(3 Pt 1):274–8.

72. Van Rijswijk JB, Boeke EL, Keizer JM, Mulder PG, Blom HM, Fokkens WJ.Intranasal capsaicin reduces nasal hyperreactivity in idiopathic rhinitis: a doubleblind randomized application regimen study. Allergy. 2003;58(8):754–61.

73. Graf P. Rhinitis medicamentosa: a review of causes and treatment. Treat Respir Med. 2005;4(1):21–9.

74. Slavin RG. Occupational rhinitis. Ann Allergy Asthma Immunol. 1999;83(6 Pt 2):597–601.

75. Ellegård EK, Karlsson NG, Ellegård LH.Rhinitis in the menstrual cycle, pregnancy, and some endocrine disorders. Clin Allergy Immunol. 2007;19:305–21.

76. Jacobs RL, Freedman PM, Boswell RN.Non-allergic rhinitis with eosinophilia (NARES syndrome): clinical and immunologic presentation. J Allergy Clin Immunol. 1981;67(4):253–62.

77. Rondon C, Fernandez J, Canto G, Blanca M. Local allergic rhinitis: concept, clinical manifestations, and diagnostic approach. J Investig Allergol Clin Immunol. 2010;20(5):364–71.

78. Moneret-Vautrin DA, Hsieh V, Wayoff M, Guyot JL, Mouton C, Maria Y.Nonallergic rhinitis with eosinophilia syndrome a precursor of the triad: nasal polyposis, intrinsic asthma, and intolerance to aspirin. Ann Allergy. 1990;64(6):513–8.

79. Malmberg H, Grahne B, Holopainen E, Binder E.Ipratropium (Atrovent) in the treatment of vasomotor rhinitis of elderly patients. Clin Otolaryngol Allied Sci. 1983;8(4):273–6.

80. Sapci T, Yazici S, Evcimik MF, et al. Investigation of the effects of intranasal botulinum toxin type A and ipratropium bromidenasal spray on nasal hypersecretion in idiopathic rhinitis without eosinophilia. Rhinology. 2008;46(1):45–51.

81. Robinson SR, Wormald PJ. Endoscopic vidian neurectomy. Am J Rhinol. 2006;20(2):197–202.

82. Georgalas C, Jovancevic L. Gustory rhinitis. Curr Opin Otolaryngol Head Neck Surg. 2012;20(1):9–14.

AL GRAWANY

Acute Sinusitis andIts Complications

MatthewKim, AaronPearlman, AshutoshKacker, andMichaelG.Stewart

Key Points

• AVRS accounts for most cases of ARS.

• AVRS and AR can predispose for development of ABRS.

• Diagnosis of ARS (including AVRS and ABRS) is primarily clinical.

• Initial management of ARS consists of supportive therapy.

• Antibiotics should be considered after 7 days of symptoms or double-worsening.

• Further evaluation, including imaging, should be considered in patients with treatment failure or suspected complications.

• Management of orbital complications usually entails parenteral antibiotics and multidisciplinary evaluation, with surgery typically reserved for Chandler grades III-V.

• Management of intracranial complications entails parenteral antibiotics, surgery, and multidisciplinary evaluation.

M. Kim · A. Pearlman · A. Kacker · M. G. Stewart (*) Department of Otolaryngology—Head and Neck Surgery, Weill Cornell Medical College and NewYork-Presbyterian Hospital, New York, NY, USA e-mail: mk3183@cumc.columbia.edu;

anp2022@med.cornell.edu; ask9001@med.cornell.edu; mgs2002@med.cornell.edu

• Episodes of RARS are managed similarly to ABRS, with surgery reserved for patients with frequent infections.

• Immunologic testing and imaging (to evaluate for anatomic factors and rule out CRS) may be helpful in RARS.

23.1 Introduction

Rhinosinusitis is one of the most commonly diagnosed and treated disease entities within otorhinolaryngology. Contemporary understanding of rhinosinusitis as more than simply an anatomic or infectious pathologic process has led to a more sophisticated nosology in the realm of rhinosinusitis, including distinctions based on chronicity and etiology, with even more specic classications based on pathophysiologic mechanisms now coming to fruition. While this paradigm shift is best evidenced by current concepts surrounding the diagnosis and management of chronic rhinosinusitis, there has been a similar evolution in philosophy with regard to diagnosis of acute rhinosinusitis and the role and timing of antibiotic therapy. This chapter reviews the evaluation and treatment of acute viral rhinosinusitis, acute bacterial rhinosinusitis, and recurrent acute rhinosinusitis. Orbital and intracranial complicates of acute bacterial rhinosinusitis and their management are also reviewed.

https://doi.org/10.1007/978-3-030-54088-3_23

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23.1.1 Classication

• Acute rhinosinusitis (ARS) refers to inammation of the nasal cavity and paranasal sinuses lasting up to 4weeks. The term “rhinosinusitis” is preferred over sinusitis because there is almost always a component of rhinitis with sinusitis

– 4–12weeks: subacute rhinosinusitis – >12weeks: chronic rhinosinusitis (CRS)

• Acute bacterial rhinosinusitis (ABRS) refers to secondary bacterial infection of the paranasal sinuses

• Acute invasive fungal sinusitis refers to a lifethreatening, fulminant fungal infection seen in immunocompromised individuals (see chapter on fungal sinusitis)

23.1.2 Epidemiology

• One of the most common health complaints prompting medical evaluation and antibiotic prescription

– Global prevalence 6–15%

• Associated with signicant healthcare expenditures and decreased productivity

• Majority of cases occur in association with viral upper respiratory tract infection

– Allergic rhinitis is also common predispos-

ing factor.

• Other risk factors include:

– Age (<15 or >45years) – Smoking history – Anatomic variants (deviated nasal septum,

concha bullosa, nasal polyposis)

– Nasal foreign bodies (including nasal can-

nula, nasogastric tube)

23.1.3 Pathophysiology

• Most frequently caused by viral infection

– Symptom onset within 24h of infection – Most common pathogens: rhinovirus >

inuenza>parainuenza >adenovirus

Table 23.1 Causes of ARS (descending frequency)

Acute rhinosinusitis Viral Rhinovirus Inuenza Parainuenza Adenovirus Bacterial Streptococcus pneumoniae Haemophilus inuenzae Moraxella catarrhalis Staphylococcus aureus Fungal Aspergillus spp. Zygomycetes (Rhizopus, Rhizomucor, Mucor,

Absidia)

• Progression to ABRS in 0.5–2% – Mucosal edema → ↓mucociliary clear-

ance → mucus stasis → bacterial superinfection

– Most common pathogens: Streptococcus

pneumoniae > Haemophilus inuenzae > Moraxella catarrhalis > Staphylococ- cus aureus (Table23.1)

23.1.4 Clinical Presentation

• Acute viral rhinosinusitis (AVRS) and ABRS

present with similar symptoms

• Nasal symptoms – Congestion/obstruction – Purulent rhinorrhea/postnasal drip – Facial pain/pressure – Decreased olfaction

• Extranasal symptoms – Fever – Fatigue – Cough – Ear pressure/fullness – Throat pain – Dental pain – Halitosis – Headache

• Features suggestive of ABRS – Lack of improvement after 7–10days – “Double sickening or worsening” (worsen-

ing after a period of improvement)

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23 Acute Sinusitis andIts Complications

255

23.1.5 Diagnostic Evaluation

• Exam ndings – Facial exam: edema/erythema, tenderness – Anterior rhinoscopy: mucosal edema, tur-

binate hypertrophy, copious clear or purulent rhinorrhea

– Oral exam: postnasal drainage, pharyngeal

erythema

• Nasal endoscopy helpful in certain cases – Severe symptoms – Unilateral disease – Failure to respond to treatment – Suspected mass – Recent surgery – Immunocompromised patient – Suspected complicated infection

• Diagnosis based primarily on history and

exam

– Routine imaging NOT indicated – Imaging indicated under special

circumstances

Suspected orbital or intracranial complication Suspected recurrent acute rhinosinusitis

– Comparison of imaging modalities

Ultrasonography: not recommended Plain lm radiography (X-ray): historically used, not recommended Computed tomography (CT): excellent bony resolution, radiation exposure Magnetic resonance imaging (MRI): excellent soft tissue resolution, no radiation exposure, sensitive for intracranial and orbital infection

• Cultures – Not required for diagnosis, but can have

treatment implications

– Middle meatal cultures correlate well with

maxillary sinus aspiration

– Nasal or nasopharyngeal swab cultures not

clinically useful

23.1.6 Treatment

• Symptomatic relief – Indicated for both AVRS and ABRS

– Systemic agents: analgesics/antipyretics,

decongestants, mucolytics

– Topical agents (sprays): steroids, saline,

decongestants (limit use to 3–5days)

• Antimicrobial therapy for ABRS – Watchful waiting appropriate up to 7days

after diagnosis

– Antibiotics typically started for clinical

worsening or persistent symptoms after 7days

– First-line antibiotic choice is amoxicillin or

amoxicillin/clavulanate

Alternatives in Penicillin-allergic patients: third-generation cephalosporin ± clindamycin, doxycycline, uoroquinolone

• Macrolides and trimethoprimsulfamethoxazole no longer recommended for initial therapy due to increasing prevalence of resistance

– Duration of treatment 5–10days – Risk of antibiotic therapy

Allergic reactions GI upset Development of bacterial resistance

• Treatment failure: worsening or failure to improve after 7days of initial treatment

– Consider alternate diagnoses

Facial pain and headache syndromes Rhinitis Nasal airway obstruction

– Evaluate for possible complications of

ABRS (see below) – Middle meatal cultures – Change antibiotic

High-dose amoxicillin/clavulanate Respiratory uoroquinolone

– Failure of multiple antibiotic courses

Imaging to evaluate for anatomic abnormality or complicated ABRS

Middle meatal culture – Relapse after treatment

Mild → longer course of same antibiotic Moderate to severe→ consider change in antibiotic and/or imaging

• Oral steroids not recommended for routine use – Not helpful as monotherapy

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<10d

Nasal obstruction Purulent rhinorrhea Facial pain/pressure

Exam findings

≥10d

M. Kim et al.

Immune workup

Imaging

Other medical workup

“Double worsening”

AVRS

“Watchful waiting”

NSAIDs/analgesics

Topical decongestant

Saline irrigation

Oral decongestants

(up to 7d)

Lack of resolution

Shared

decision-

making

5-10d course of ABX

Topical steroids

Treatment failure

Middle meatal culture

Change ABX

imaging

Fig. 23.1 ARS treatment algorithm

– May shorten time to symptom resolution

when used in conjunction with antibiotics

Risk of adverse effects

• Oral antihistamines not recommended for ABRS

– May be helpful in allergic patients for

AVRS – Can lead to nasal dryness – Can cause drowsiness and xerostomia

(Fig.23.1)

23.1.7 Complications

• Suspect in patients with atypical signs and symptoms:

– Persistent high fever – Periorbital edema/erythema, proptosis,

diplopia/extraocular motility impairment, vision changes

– Cranial nerve palsy

ABRS

RARS

Return to baseline

Recurrent infection

Suspected complication

Imaging

Admision and IV ABX

Multidisciplinary consultation

– Headache, meningeal signs – Altered mental signs

• Predisposing factors – Winter months (increased incidence of

AVRS)

– Age

Infant: highest risk of meningitis 3–6 years: highest rate of hospitalization for complication of ABRS 10–29 years: highest risk of intracranial complication

• Teenage males likely to have simultaneous orbital and intracranial complications

• Orbital complications – Most common complication of acute

rhinosinusitis

Due to two-way communication between ethmoid and ophthalmic venous plexuses

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23 Acute Sinusitis andIts Complications

257

• Valveless ophthalmic veins communicate anteriorly with facial veins and posteriorly with cavernous sinus

Periorbita is the only soft tissue barrier between orbit and sinonasal cavity

• Fuses anteriorly with tarsal plates to form orbital septum

Usually polymicrobial

• Viridans streptococci and staphylocci are most common organisms

– Chandler classication system of orbital

complications

I: Preseptal orbital cellulitis

• Periorbital edema/erythema

• No chemosis or ocular symptoms

• Can occur in absence of sinusitis

– Infection of eyelid and orbital

adnexa – Trauma – Foreign body

II: Postseptal orbital cellulitis

• Proptosis, chemosis, ophthalmoplegia

• Can have decreased visual acuity later in disease course

III: Orbital subperiosteal abscess

• Symptoms similar to group II

• Usually normal vision unless abscess very large

IV: Orbital abscess

• Symptoms similar to group III

• Usually complete ophthalmoplegia and decrease in vision

V: Cavernous sinus thrombosis

• Symptoms similar to group IV

• Additional involvement of V1 and V2

• Bilateral eye symptoms

• Can have associated meningismus, frank meningitis, or sepsis

– Orbital apex syndrome

• Frontal bone osteomyelitis with subperiosteal Presents similar to cavernous sinus thrombosis with frank optic nerve involvement Trigeminal involvement would be limited to V1 branches

– Superior orbital ssure (Rochon–

Duvigneaud) syndrome

Similar to orbital apex syndrome but spares optic nerve

– Evaluation

Comprehensive ophthalmologic exam Imaging

• CT is the gold standard – IV contrast useful if concern for

abscess or cavernous sinus thrombosis

• MRI is better for cavernous sinus

thrombosis

– Management

Medical therapy—oral agents—is usually sufcient (Chandler I–II) Intravenous antibiotics (Chandler II–V)

• High-dose penicillin/beta-lacta-

mase inhibitor (e.g., ampicillin/sulbactam) or third-generation cephalosporin

• Adjunct medications: systemic/topi-

cal steroids and decongestants, saline irrigations, mucolytics

Surgery (Chandler IV–V)

• Subperiosteal abscess (III): size

>2cm and age >9 years more likely to require surgical intervention

• Lack of improvement over 48–72h

on medical therapy alone also indication for surgery

• Lateral and superior abscesses likely

require external orbitotomy Anticoagulation for cavernous sinus thrombosis is controversial

• Thought to stop progression of

thrombosis, decrease clot propaga-

tion, and allow better antibiotic

penetration

• Risk includes systemic or intracra-

nial hemorrhage and septic

embolization

abscess (“Pott’s puffy tumor”)

– Suppurative infection of diploic veins – Causes bone demineralization and

necrosis

– Requires medical and surgical therapy

Prolonged IV antibiotics for osteomyelitis

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M. Kim et al.

• Intracranial complications – More common in males and children >7

years

– CRS thought to increase risk due to chronic

mucosal/bony changes that decrease mucociliary clearance and hinder antibiotic penetration

Initial symptoms may not be characteristic of ARS

• Persistent headache and fever are typical presenting complaints

– Mechanism: septic thrombophlebitis or

direct bony extension (neurovascular foramina, congenital dehiscence, traumatic fracture)

– Microbiology

Meningitis mostly due to Streptococcus

pneumoniae

Abscess often polymicrobial, including anaerobes

– May be asymptomatic until late in course

due to involvement of non-eloquent frontal lobe

Seizures, focal neurologic decits are late ndings and portend poor prognosis Can present synchronously and in conjunction with orbital complications

– MRI with contrast is radiographic study of

choice

CT often also obtained for bony anatomy and surgical planning

– Epidural abscess

Most common intracranial complication Generally associated with frontal sinusitis

• Headache, fever, orbital pain, frontal pain

Favorable prognosis

– Subdural abscess

Also usually a sequela of frontal sinusitis Usually unilateral Tendency to spread over cerebral cortex and into interhemispheric region Higher morbidity and mortality

• Can have rapid progression

– Headaches, fever, letharg→coma

• Meningismus and focal neurologic decits

– Intracerebral abscess

Less common Typically involves frontal and parietal lobes

• Frontal sinusitis>sphenoid/ethmoid sinusitis

Fever, headache, lethargy, vomiting

• Seizures, focal decits are late ndings

Can also have mood swings and

• behavioral changes

Lumbar puncture contraindicated before imaging obtained

• Risk of brain herniation

– Venous sinus thrombosis

Sagittal sinus thrombosis can occur secondary to frontal sinusitis Meningeal signs and signicant neurologic complications Often in conjunction with other intracranial complications

– Meningitis

Typically secondary to ethmoiditis or sphenoiditis Headache, neck stiffness, fever Can present with sepsis or cranial neuropathy Often in conjunction with other intracranial complications

– Management

Broad-spectrum intravenous antibiotics with good intracranial penetration

• Often 4–8week course of antibiotics

Systemic steroids and anticonvulsants Neurosurgical drainage usually indicated Sinus surgery to address culprit sinuses

• Frontal sinus trephination can be useful adjunct to endoscopic techniques

Repeat imaging critical to monitor treatment response and prior to discharge to ensure continued resolution without treatment escalation

AL GRAWANY

23 Acute Sinusitis andIts Complications

23.1.8 Recurrent Acute Rhinosinusitis

• Predisposing factors – Viral ARS – Allergic rhinitis – Immunodeciency – Anatomy (e.g., deviated nasal septum, con-

cha bullosa)

• Conrming true ABRS episodes is important – Endoscopy reveals purulence during acute

episode

– Imaging between episodes can conrm

complete resolution and reveal anatomic anomalies

• Management – Immunologic testing

Immunoglobulin deciencies

• Combined variable immunodeciency (CVID)

• IgA deciency

• Specic antibody deciency

– Role of antibiotics and topical steroids lim-

ited to use during ARS episodes

– Surgery may be benecial in select patients

Appropriateness criteria

• ≥4 episodes per year

• ARS conrmed by endoscopy or imaging

• Shared decision-making

• Failed trial of nasal steroid or loss of productivity

Extent of surgery unclear

• Addressing anatomic variants predisposing to recurrent infection can be helpful

– Balloon sinuplasty may also be benecial

Less evidence than for ESS, for this indication

259

Take Home Messages

• ARS can be characterized by causative pathogen (virus, bacteria, fungus).

• Diagnosis is chiey clinical.

• Treatment depends on etiology and symptom duration.

• Complications of ABRS warrant special attention.