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New Definitions of Rhinosinusitis Are Circulated Through Two Journals Simultaneously

Donald C. Lanza, MD
St. Petersburg, FL

Our scientific understanding of rhinosinusitis that affects millions of lives continues to be hampered by lack of consensus on how to define the various forms of this disorder. In the December supplements of Otolaryngology-Head & Neck Surgery and the Journal of Allergy & Clinical Immunology, yet new definitions of rhinosinusitis are advanced.

Recognizing continued need for improvements on existing definitions for differing forms of rhinosisnusitis five national societies, The American Academy of Allergy, Asthma and Immunology (AAAAI); The American Academy of Otolaryngic Allergy (AAOA); The American Academy of Otolaryngology Head and Neck Surgery (AAO-HNS); The American College of Allergy, Asthma and Immunology (ACAAI); and the American Rhinologic Society (ARS) formed a multidisciplinary international committee comprised of 30 physicians from allergy/immunology, otolaryngology, infectious disease, and radiology. This panel worked to develop definitions of rhinosinusitis for clinical research, and to suggest clinical trial designs for studies that would allow for more appropriate use of pharmacologic, immunologic and surgical interventions. The committee was able to reach consensus on definitions and clinical research strategies for:
  1. acute (bacterial) rhinosinusitis,
  2. chronic rhinosinusitis without polyps,
  3. chronic rhinosinusitis with polyps, and
  4. allergic fungal rhinosinusitis.

At this panel there was general agreement that no one etiologic factor fully explains or adequately accounts for the pathologic manifestations and clinical heterogeneity of rhinosinusitis. Histopathologically speaking, the inflammatory component of these disorders manifests as a mixed mononuclear inflammatory cell infiltrate with neutrophils predominating in acute disease and eosinophils predominating in most chronic disease. Additionally, there has been an evolution of thought moving away from the notion that all of chronic rhinosinusitis can be explained on the basis of sinus ostial obstruction and persistent bacterial infection to an appreciation that chronic rhinosinusitis has a significant inflammatory component that may be caused simultaneously or independently by various factors. Evidences for the varying potential sources of this condition are discussed. These include but are not restricted to the possible roles of:
  1. Persistent infection as a factor in chronic rhinosinusitis including biofilms and "osteitis"
  2. Allergy and other disorders of immunity.
  3. Intrinsic factors of the upper airway.
  4. Superantigens from Staphylococcus aureus in chronic rhinosinusitis with nasal polyps.
  5. Colonizing fungi that induce and sustain eosinophilic inflammation.
  6. Genetic perturbations such as aspirin sensitivity.

This document reviews various etiologic factors in rhinosinusitis and highlights areas where their roles in rhinosinusitis are controversial and where new information is emerging. Varying contributors authored individual sections to serve as background information on the controversies and definitions presented later in this manuscript. The document presents a classification scheme for chronic rhinosinusitis based on current knowledge and consensus opinion, and discusses the subjective and objective measures used in the diagnosis and evaluation of rhinosinusitis.

Important factors in the design of clinical trials are then discussed. Ultimately, consensus definitions for rhinosinusitis are put forth for:
  1. Acute presumed bacterial rhinosinusitis
  2. Chronic rhinosinusitis without polyps
  3. Chronic rhinosinusitis with polyps
  4. Classic allergic fungal rhinosinusitis
For details, see:
Meltzer EO, Hamilos DL, Hadley JA, Lanza DC, Marple BF, Nicklas RA, Bachert C, Baraniuk J, Baroody FM, Benninger MS, Brook I, Chowdhury BA, Druce HM, Durham S, Ferguson B, Gwaltney JM, Kaliner M, Kennedy DW, Lund V, Naclerio R, Pawankar R, Piccirillo JF, Rohane P, Simon R, Slavin RG, Togias A, Wald ER, Zinreich SJ. Rhinosinusitis: establishing definitions for clinical research and patient care.
Simultaneously published at:
Otolaryngol Head Neck Surg. 2004 Dec;131(6 Suppl):S1-S62
J Allergy Clin Immunol. 2004 Dec;114(6 Suppl):155-212.



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