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W. J. Fokkens and S. Reitsma
for surveillance, clinical debridement, and application of topical medication. Surgery can be combined with systemic and local corticosteroid
treatment. There is limited evidence for efcacy of
allergen immunotherapy, to both fungal and nonfungal antigens in atopic individuals with AFRS to
improve symptoms and reduce revision surgery.
Oral and topical antifungals do not improve symptoms in AFRS but may reduce recurrences,
although data are very incomplete. The use of biologicals for the treatment of AFRS is in its infancy
[6], and larger studies are underway.
Primary Diuse Chronic
Rhinosinusitis
After appropriate medical treatment, check of
treatable traits and compliance (see Fig. 22.1),
the care pathways for management of diffuse (i.e.
bilateral), CRS depends on endotyping (see
Fig.22.2).
Primary Diuse Non-type 2 Chronic
Rhinosinusitis
Primary diffuse non-type 2 CRS is what we
would formerly call non-eosinophilic CRS.The
phenotype is usually without nasal polyps
although in Asia non-eosinophilic CRS with
nasal polyps occurs, but with decreasing
frequency.
When one considers the diagnosis of primary
diffuse non-type 2 CRS, EPOS2020 advises to do
an additional work-up including evaluation of
blood eosinophils and total serum IgE to exclude
type 2 inammation. After appropriate medical
treatment, consisting of nasal saline rinsing and
local corticosteroids, one can chose between (F)
ESS and long-term antibiotics. The evidence for
long-term antibiotics is still very limited [5].
Xylitol
A relatively new evidence-based treatment option
is rinsing with a xylitol solution. Xylitol is a ve-
Self-care
pharmacy
Care
Primary
Care
Secondary/Tertiary
EPOS 2020: Care pathways for CRS
Two CRS symptoms
Refer to Primary Care
Primary care follow-up
Refer to Secondary /Tertiary Care
Check treatable traits / comorbidities
History and full ENT exam
Nasal endoscopy
Diffuse / bilateral CRS
Localized / unilateral CRS
No (apparent) CRS
Self-care
–
6-12 weeks:
improvement?
6-12 weeks:
improvement?
–
Follow EPOS 2020 management scheme
on diffuse / bilateral CRS
Consider CT scan
+
+
CT scan
+
Diagnosis rejected
Diagnosis confirmed
Fig. 22.1 Care pathways for management of CRS, intranasal corticosteroid (INCS), over-the-counter (OTC) [5]
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Diffuse / bilateral CRS
Primary
diffuse CRS
Appropriate medical therapy (AMT)
Nasal steroid (drop / spray / rinses)
Saline rinses
Educate technique / compliance
Consider OCS
CT-scan, SPT, lab; reconsider treatable traits, compliance
Non-type 2
Main complaint often
discharge/facial pain
Less asthma
Less atopy
NE: purulence
Lab: normal lgE, no eosinophilia
AMT (± long term antibiotics)
Additional therapy
Consider:
Additional investigations
Consider:
or
FESS
Additional work-up:
6–12 weeks: improvement?
–
Presence of:
+
6–12 weeks:
improvement?
–
Type 2
Main complaint often smell loss
or blockage/congestion
N-ERD and/or asthma
Atopy
NE: polyps, eosinophilic mucin
Lab: elevated IgE, eosinophilia
AMT (+ OCS)
or
FESS
–
–
Additional therapy
Consider:
Secondary diffuse CRS
(e.g. vasculitis/ immune disorder)
AFRS
+
+
6–12 weeks:
improvements?
–
–
Young
Atopy
Warm humid climate
Asthma
SPT: positive for fungi
Consider:
Tailored (extended) surgery
to remove all debris
Histopathology
eosinophils, hyphase, CL crystals
Culture fungus
FESS
Saline rinses
INCS
OCS
Consider immunotherapy
Repeat imaging with
concern for recurrence
Fig. 22.2 Care pathways for management of diffuse bilateral CRS, oral corticosteroids (OCS), aspirin treatment after
desensitization (ATAD) [5]
carbon sugar alcohol that occurs naturally in
many fruits and vegetables and is used widely in
the food industry as a sweetener. It has gained
interest as a natural antibacterial agent. Xylitol
signicantly reduces biolm biomass, inhibits
biolm formation, and reduces growth of
planktonic bacteria. The use of xylitol in saline
lavages has been evaluated in four studies.
Weismann et al. evaluated in a prospective,
randomized, double-blinded, controlled crossover pilot study the efcacy of a xylitol 5% in
saline irrigation once-daily compared to saline
irrigation during 10days with a 3-day washout
irrigation rest period in 20 subjects with CRS [7].
There was a signicant reduction in SNOT-20
score during the xylitol phase of irrigation as
compared to the saline phase (difference 6.3
points). There was no difference in VAS scores.
Lin etal. evaluated in a prospective, randomized, double-blind, controlled study the efcacy
of xylitol 5% nasal irrigation compared to saline
nasal irrigation in 25 of 30 patients with CRS
who completed the 30-day study [8]. Standard
subjective assessment scores were reduced signicantly only in the xylitol group (SNOT-22
reduction of 12 points; VAS reduction of 1.1).
The concentrations of nasal nitric oxide (NO)
and inducible nitric oxide synthase (iNOS)
mRNA in the right maxillary sinus increased signicantly, but only in the xylitol group.
Rabago et al. evaluated [9] in a prospective,
randomized, three-arm controlled study for
26weeks the efcacy of xylitol 5% nasal irrigation compared to saline irrigation and standard
care in 40 patients with chronic rhinosinusitis
with Gulf War illness. Patients using xylitol rinsing reported improved SNOT-20 scores over the
full period, signicantly better than standard care
but not signicantly better than saline irrigation
(subgroups too small for statistical analysis).
Kim etal. [10] examined the effect of xylitol
nasal irrigation in a double-blinded randomized
controlled crossover study in 34 CRS patients. A
signicant improvement of SNOT-20 and VAS
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W. J. Fokkens and S. Reitsma
symptom scores for sneezing (p=0.003), headache (p= 0.02), and facial pain (p=0.037) was
found compared to saline rinsing.
In conclusion, addition of xylitol to saline
rinses resulted in a signicant reduction of SNOT
(all studies) and VAS (reported in two) scores in
four small studies in primary diffuse non-type 2
CRS patients. Larger studies are needed to evaluate the magnitude of the improvement.
Other biolm reducing agents like colloidal
silver and (Manuka) honey showed no effect in
invivo studies, and addition of sodium hyaluronate or xyloglucan to nasal saline irrigation may
have some positive effect [5].
Primary Diuse Type 2 Chronic
Rhinosinusitis
Typical examples of primary diffuse type 2 CRS
are CRS with nasal polyps (CRSwNP) or eosinophilic CRS (eCRS). The diffuse disease of the
sinuses in these patients is characterized by type
2 inammation symbolized by hyper- eosinophilia
in blood and/or tissue or increased IgE.
For years, the treatment of diffuse type 2
CRS consisted of a combination of appropriate
local medical treatment (nasal saline rinsing and
local corticosteroids), combined with surgery
and short courses of systemic corticosteroids.
The potential side effects of more than a few
weeks of systemic corticosteroids per year signicantly limited treatment possibilities. Hence,
a large part of the patients with primary diffuse
type 2 CRS remained uncontrolled most of the
time with repetitive ESS and courses of systemic corticosteroids as only options to reduce
the burden of disease. Some authors have suggested using a tapering dose of systemic corticosteroids to nd the lowest dose to attain
disease control (especially anosmia). Often
tapering to a dose of less than 5mg of prednisolone every other day is possible (personal experience of the authors). However, the potential
side effects of systemic corticosteroids remain a
signicant limitation [11].
Aspirin Treatment After Desensitization
(ATAD)
A subgroup of patients with diffuse type 2 CRS
suffer from non-steroidal anti-inammatory drug
(NSAID)-exacerbated respiratory disease
(N-ERD). In general, these patients have more
severe disease, and many have co-morbid asthma
[12]. N-ERD is a chronic eosinophilic, inammatory disorder of the respiratory tract occurring in
patients with asthma and/or CRSwNP, symptoms
of which are exacerbated by NSAIDs, including
aspirin.
The management options in patients with
N-ERD are essentially based on strict avoidance
of the culprit drug and cross-reactive drugs.
Patient education is important, since NSAIDs
respiratory symptoms are not limited to a specic
drug, but may appear after the intake of other
cyclooxygenase (COX)-1 inhibitors.
In N-ERD patients, aspirin may induce a
period lasting 24 to 72h, in which patients are
refractory to repeated aspirin challenges and
experience less symptoms. Based on this principle, N-ERD can be treated with aspirin. Aspirin
treatment after desensitization (ATAD) with oral
aspirin is effective in improving QOL and total
nasal symptom score in patients with
N-ERD. However, the effects seem to be less
than treatment with biologicals [13]. Some retrospective studies also reported clinical benet
from nasal lysine-aspirin treatment. However, in
a randomized, double-blind placebo-controlled
cross over trial, these positive ndings could not
be conrmed.
Drug-Eluting Stents andExhalation
Delivery Systems
Nasal corticosteroids are the mainstay of treatment of diffuse type 2 CRS.First used mainly as
nasal sprays, later forms of delivery such as nasal
drops and rinses have become popular.
Exhalation Delivery Systems (EDS)
The newest possibility is the use of an exhalation
delivery system that claims to deliver the medication higher and deeper into the nose [14].
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The exhalation delivery system features a
mouthpiece that the patient blows into and a
nosepiece that seals to one side of the nose. When
the patient blows into it, it elevates and seals the
soft palate, which isolates the nasal cavity from
the oral cavity. The dosage of uticasone dipropionate delivered by the device is higher than
standard nasal sprays. There are no comparative
studies with uticasone nasal spray but in a metaanalysis the effect seems larger [5].
Drug-Eluting Stents
A major issue for all treatment with nasal corticosteroids is compliance. There are a number of
studies showing the compliance to nasal corticosteroids is often poor. Drug-eluting stents, particularly in the ethmoid sinuses, offer a potential
solution to both the compliance and delivery
issues of nasal corticosteroids. Drug-eluting biodegradable nasal implants/stents provide a sustained release of nasal corticosteroids for several
months. They can be placed directly postoperatively to prevent recurrence of disease or
alternatively, can be placed in the ethmoid cavities during an in-ofce procedure. Steroidimpregnated nasal spacers have been shown to
reduce the rates of postoperative intervention,
recurrent polyposis, and mucosal inammation
in CRS patients undergoing ESS during the early
months after surgery [15]. Although potentially
of greater benet than steroid nasal sprays or
non-steroid eluting packs, recent studies did not
demonstrate a signicant difference compared to
steroid nasal sprays. However, a signicant difference in short-term polyp formation was found
compared to non-steroid eluting packs [16–18].
In conclusion, drug-eluting stents and exhalation delivery systems create potential benets in
the treatment of diffuse type 2 chronic rhinosinusitis but direct comparisons to nasal sprays are
missing (or small with a potential type II error).
Large studies comparing these new options to
nasal sprays are needed.
Biologicals
The understanding of different endotypes in CRS
has also led to tailored approaches to manage the
underlying inammation. Biologicals are mono-
clonal antibodies that directly target inammatory mediators involved in pathogenesis. In
CRSwNP biologicals, target one or more of the
important biomarkers of CRSwNP that drive the
inammation in the sinonasal mucosa (i.e. interleukin- 4, IL-13, IL-5, and IgE). Biologicals are
used in various type 2 inammatory diseases,
such as eosinophilic asthma, urticaria, and atopic
dermatitis. In general, biologicals seem to have
few side effects, none of which are serious. At the
time of writing (2023), three biologicals have
been approved for CRSwNP in the European
Union: dupilumab (anti-interleukin-4Rα), omalizumab (anti-IgE), and mepolizumab (anti-IL5).
Trials with other biologicals like benralizumab
(anti-IL5, tezepelumab (anti-thymic stromal lymphopoietin: anti-TSLP) and depemokimab, a
long-acting anti-IL5, are ongoing.
Dupilumab is a human monoclonal antibody
directed against IL-4Rα. By inhibiting IL-4R signalling of both IL-4 and IL-13, it effectively
downregulates the molecular pathways that drive
type 2 inammation (e.g. pro-inammatory cytokines, chemokines, IgE, and nitric oxide). In
2019, dupilumab was the rst biologic to be
approved for severe, uncontrolled CRSwNP in
the European Union and the US.Treatment with
dupilumab results in a signicant improvement
of QoL (measured as SNOT-22), rhinosinusitis
disease severity, symptoms of rhinosinusitis and
especially sense of smell, nasal polyp score,
Lund-Mackay CT score and asthma outcomes
(ACQ5 and FEV1) compared to placebo [19].
Omalizumab (anti-IgE) followed suit in 2020.
Treatment with omalizumab demonstrated signicant improvement of QoL (measured as
SNOT-22), rhinosinusitis disease severity, symptoms of rhinosinusitis including sense of smell,
nasal polyp score, Lund-Mackay CT score, and
asthma outcomes (AQLQ), compared to placebo
as well [20].
Treatment with mepolizumab demonstrated
signicant improvement of QoL (measured as
SNOT-22), rhinosinusitis disease severity, symptoms of rhinosinusitis including sense of smell,
nasal polyp score (NPS), Lund-Mackay CT
score, and asthma outcomes (AQLQ), compared
to placebo as well.
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W. J. Fokkens and S. Reitsma
Indications for biological treatment in CRSwNP
Presence of bilateral polyps in a patient who had ESS*
Criteria Cut-off points
Evidence of type 2 inflammation
Need for systemic corticosteroids or
contraindication to systemic steroids
Significantly impaired quality of life
Significant loss of smell
Diagnosis of comorbid asthma
Fig. 22.3 Indications for biologic treatment in primary diffuse type 2 chronic rhinosinusitis [5]
Tissue eos ≥ 10/hpf, OR blood eos ≥ 250, OR total
lgE ≥ 100
≥ 2 courses per yr, OR long term (> 3 months)
low-dose steroids
SNOT-22 ≥ 40
Anosmic on smell test (score depending on test)
Asthma needing regular inhaled corticosteroids
*exceptional circumstances excluded (e.g., not fit for surgery)
Benralizumab reduced the NPS, decreased
nasal blockage, and reduced difculty with sense
of smell compared to placebo in patients with
CRSwNP [21].
Phase 3 trials with tezepelumab (anti-TSLP)
and depemokimab (long-acting anti-IL-5Rα
monoclonal antibody) are underway.
Indication foraBiologic
At the moment, the annual costs of biologicals in
Europe are 10,000–20,000 Euros per patient per
year. The cost of biologicals compared to regular
treatment is high and in most health care systems,
one cannot ignore the consideration of cost.
In line with these new developments, several
bodies have issued guidelines for the positioning
of biologicals in the treatment of CRSwNP [22,
23]. Most guidelines position biologicals in the
treatment of CRSwNP after at least one endoscopic sinus surgical intervention unless the
patient is not t for surgery. Further criteria proposed by researchers include the existence of
type 2 inammation, the regular need for systemic corticosteroids, (severe) impairment of
quality of life, loss of smell, and the presence of
various comorbidities. The latest EPOS2020/
EUFOREA guidelines propose a set of three out
of ve criteria in patients with CRSwNP and at
least one (F)ESS (see Fig.22.3). Cut-off criteria
for the criteria are given (see Fig.22.3).
Choosing theCorrect Biologic
In the light of these new developments, a crucial
question is the choice of biologic. There are no
direct published comparisons performed
between biologicals for CRSwNP although
some are ongoing. However, a number of network meta- analyses have been performed all
pointing to a superiority of dupilumab over the
other biologicals and ATAD [13]. Until direct
comparisons are available, it is difcult to draw
strong conclusions. Future important discussions around the use of biologicals and their
evaluation in daily practice will include the
choice of biologic for individual patients; the
expansion of indications for specic patient
subgroups with CRSwNP; the indications for
surgery and extent of individual endoscopic
sinus operations.
At the moment, the current biomarkers that
are readily accessible to clinicians have limited
use in identifying response to biologicals and are
unhelpful in predicting which biologic to use in
specic cases.
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In conclusion, the development of biologicals
as treatment for diffuse type 2 chronic rhinosinusitis is a breakthrough. For now, the availability in some countries and the high cost of the
treatment are limitations for the use.
Real-Life Experience withBiologicals
In recent years, a number of registries have been
started to evaluate real-life experience with biologicals in CRSwNP [24, 25]. The registries are
mainly performed using dupilumab therapy.
Interestingly, one of the registries shows the potential to signicantly reduce the dose interval between
dupilumab treatments to once every 6–8weeks (or
even longer) without losing disease control [26].
Further evaluations are needed to determine
whether this is also true for other biologicals.
Secondary Chronic Rhinosinusitis
Secondary CRS can also be divided into localized and systemic disease.
Localized Secondary Chronic
Rhinosinusitis
Localized secondary CRS is induced by a local
problem like a tumour. The treatment is outside
the scope of this chapter.
Diuse Bilateral Secondary Chronic
Rhinosinusitis
Diffuse bilateral secondary CRS can have
mechanical, inammatory, or immunological
reasons.
Diuse Bilateral Secondary Chronic
Rhinosinusitis DuetoMechanical
Reasons
Typical examples of diffuse bilateral secondary CRS due to mechanical reasons are cystic
brosis (CF) and primary ciliary dyskinesia
(PCD). Developments in the treatment options
for CF in the past decade have been evolutionary. For patients with the Phe508del homozygosity, cystic brosis transmembrane
conductance regulator (CFTR) modulators
such as elexacaftor, tezacaftor, ivacaftor, and
combinations of these medications can give
signicant benet [27, 28]. At this moment,
several new treatments are being evaluated
through clinical trials, which aim to improve
lung function by directly interacting with
CFTR or by altering its downstream effects.
Gene manipulating techniques and new molecular targets are also being explored [29].
Diuse Bilateral Secondary Chronic
Rhinosinusitis DuetoInammatory
Reasons
Diffuse bilateral secondary CRS due to inammatory reasons is a large group of diseases often
caused by an underlying vasculitis or granulomatous disease. Patients often show ANCA positivity. A growing body of research is available on
novel treatment options for remission induction,
clarifying some uncertainties concerning the
optimal use of the available drugs. Efforts are
being made to reduce the toxicity associated with
high-dose, prolonged glucocorticoids regimens.
Intensied immunosuppressive strategies for
patients with life-threatening manifestations,
including the combination of rituximab (RTX)
with cyclophosphamide (CYC) have revealed
promising data [30, 31]. The management of
refractory or relapsing eosinophilic granulomatosis with polyangiitis (EGPA) has been improved
by the recent demonstration of efcacy and safety
of interleukin-5 inhibitors, such as mepolizumab
[32]. The treatment of diffuse bilateral secondary
CRS due to inammatory reasons is usually led
by immunology or rheumatology colleagues.
Close collaboration with the otorhinolaryngologist is relevant for early detection of relapse and
local treatment. Surgery, in general, is best
avoided.
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W. J. Fokkens and S. Reitsma
Diuse Bilateral Secondary Chronic
Rhinosinusitis DuetoImmunological
Reasons
In difcult to treat CRS, an immunological disorder has to be considered. Immunodeciency can
be primary or secondary to other diagnoses or to
immunosuppressive medication. There is some
evidence for treatment with long-term antibiotics. The decision to treat with intravenous immunoglobulin replacement and the supervision of
that treatment should ideally be made by a clinical immunologist.
Summary ofAreas ofControversy
or Uncertainty
A vast subject such as new innovations and treatment in CRS has many points of discussion.
Regional discrepancies in management, such as
the use of balloon technology and the place and
choice of biologicals, raise points of debate, as
previously addressed in this chapter. In these rapidly developing domains of disease management,
many issues remain unclear, and real-life experience, in combination with new trials, will help to
dene the optimal personalized therapy for each
individual patient.
Key Learning Points
• There is a new classication of CRS with sig-
nicant impact on treatment choices
• The management of CRS has signicantly
changed in the past decade
• The major development in the treatment of
primary diffuse type 2 chronic rhinosinusitis
is the development of biologicals (monoclonal
antibody therapy)
• The exact indication for biologicals in preci-
sion medicine has to be dened
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Clinical Assessment
https://t.me/medicina_free
andManagement ofAcute
Rhinosinusitis
StephenR.Ell andRichardWeiChernGan
23
Introduction
Acute rhinosinusitis (ARS) may be regarded as a
spectrum of disease, which may be mild with
minimal patient impact and requiring only supportive treatment, or, at the other extreme, it may
be associated with life-threatening complications
requiring specialist medical and surgical treatment. The challenge is to identify where, between
these extremes, the patient presents so that the
most appropriate treatment may be given. Correct
diagnosis is important since other conditions may
present with similar symptoms.
Denitions
ARS is symptomatic acute inammation of the
nose and one or more of the paranasal sinuses.
The use of the term ‘rhinosinusitis’ is more accurate than ‘sinusitis’ since inammation of the
nasal cavity and paranasal sinuses almost always
occur together.
The clinical denition of ARS in adults,
according to the European Position Paper on
Rhinosinusitis and Nasal Polyps (EPOS) 2020
S. R. Ell (*) · R. W. C. Gan
Hull University Teaching Hospitals NHS Trust,
Castle Hill Hospital, Cottingham, East Yorkshire, UK
e-mail: srell@doctors.org.uk;
stephen.ell@nhs.net
[1], is an acute onset of two or more symptoms, at
least one of which should be either nasal blockage, obstruction or congestion; anterior nasal discharge or post-nasal drip; with or without facial
pain or pressure, or a reduced sense of smell.
Since children are less likely to describe a loss of
sense of smell accurately, EPOS 2020 denes
ARS in children as being an acute onset of two or
more symptoms of nasal blockage, obstruction,
or congestion, or discoloured nasal discharge or
cough. A single episode lasting less than 12weeks
is dened as acute. Recurrent ARS is dened as
four or more episodes of ARS per year with
symptom-free intervals.
The American Academy of Otolaryngology—
Head and Neck Surgery Foundation (AAO-HNS)
Clinical Practice Guideline: Adult Sinusitis
(2015) [2] denes ARS as up to 4 weeks of purulent nasal discharge accompanied by nasal
obstruction or facial pain, pressure or fullness, or
both: stressing that purulent discharge is a cardinal symptom.
Both EPOS 2020 and AAO-HNS Clinical
Practice Guidelines subdivide and distinguish the
range of ARS conditions from the milder viral
form to the more severe bacterial forms of disease. This emphasises the spectrum of severity
requiring tailored management.
EPOS 2020 describes three subgroups:
1. Viral ARS, also known as the ‘common cold’,
is a mild, self-limiting episode of ARS lasting
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
A. C. Swift et al. (eds.), Contemporary Rhinology: Science and Practice,
https://doi.org/10.1007/978-3-031-28690-2_23
287
288
https://t.me/medicina_free
S. R. Ell and R. W. C. Gan
less than 10days. A viral cause is either presumed or conrmed by microbiology.
2. Post-viral ARS is an episode of acute rhinosinusitis with an increase in symptoms after
5days or persistence of symptoms for more
than 10days, but without the symptoms and
signs of ABRS.This encompasses the group
of patients with persistent symptoms, the
majority of which will not have acute bacterial infection, since acute bacterial infection
makes up only 0.5–2.5% of cases [3].
3. ABRS is an episode of ARS with at least three
additional symptoms or signs of discoloured
mucus, severe local facial pain (often unilateral), fever more than 38 °C, raised serum
C-reactive protein (CRP) or erythrocyte sedimentation rate (ESR) or ‘double sickening’ or
‘double worsening’, which is a deterioration
of symptoms after an initial milder phase of
acute rhinosinusitis.
The AAO-HNS Clinical Practice Guideline:
Adult Sinusitis [2] denes ABRS as symptoms
worsening within 10 days or lasting more than
10days, which is akin to the EPOS 2020 Postviral ARS, but given their emphasis on the cardinal symptom of purulent discharge, their
denition of ABRS may be appreciated.
It should be noted that although there are
minor variations in how other consensus groups
or clinical guidelines around the world dene the
disease, there are also many similarities especially in terms of dening cardinal signs and
symptoms [3]. In this chapter, the terms used will
be based on the denitions described in EPOS
2020.
Epidemiology andEconomic Impact
There are fewer published studies on the epidemiology of ARS than there are on allergic rhinitis
and chronic rhinosinusitis. In the pre-Covid era,
the incidence of acute viral rhinosinusitis was
very high, with most adults having around two to
ve episodes of viral ARS per year [1]; however,
the pandemic precautions of physical distancing,
wearing of facemasks and restrictions on large
gatherings are likely to be associated with a signicant reduction in the incidence of ARS.The
following paragraphs describe the pre-pandemic
incidence of ARS; all are likely to be reduced by
the precautions necessitated by the Covid
pandemic.
In Europe, the incidence of ARS is estimated
between 21 and 28 episodes per 1000 people per
year [4, 5], which makes up about 2% of visits to
general practice [4] and more commonly occurs
in the winter months [6]. In Norway, it is a signicant nancial burden, mostly due to sick leave [4].
In the United Kingdom, the prevalence and
incidence of ARS is unknown; however, the prevalence of all types of rhinosinusitis in the United
Kingdom is estimated at 24.9% [7]. Risk factors
include a history of smoking, chronic rhinosinusitis, allergic rhinitis and eczema [8]. ARS is more
common in Caucasian women [4, 8, 9].
In the United States, the prevalence of rhinosinusitis as a whole is 11.6% [10]. Recurrent ARS
is estimated to have a prevalence of 1 in 3000
patients per year in the United States, costing
$1000/patient/year [9].
In Asia, the prevalence of chronic rhinosinusitis has been published for various countries, but
less is known on the prevalence of ARS.
Aetiology andPathogenesis
Episodes of ARS are due to viruses in 80–90% of
cases. In a poorly ventilated room full of people,
it only takes one unrestrained sneeze from an
infected person to generate an aerosol of about
40,000 droplets, each droplet carrying up to
2 million virions. Trillions of viruses are suspended in the air waiting for someone to breathe
in, waiting to coat their respiratory mucosa with
hordes of viral invaders; invaders that drill into
healthy ciliated columnar cells and use the cell
machinery for their own replication. Of these
infections, up to 50% are incited by rhinoviruses
or coronaviruses. The other 50% are due to inuenza, parainuenza, adeno- and enteroviruses
and respiratory syncytial viruses. All these
viruses survive longer in damp conditions and are
highly contagious.
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