European Position Paper on Rhinosinusitis and Nasal Polyps 2020

The European Position Paper on Rhinosinusitis and Nasal Polyps 2020 is the update of similar evidence based position papers published in 2005 and 2007 and 2012. The core objective of the EPOS2020 guideline is to provide revised, up-to-date and clear evidence-based recommendations and integrated care pathways in ARS and CRS. EPOS2020 provides an update on the literature published and studies undertaken in the eight years since the EPOS2012 position paper was published and addresses areas not extensively covered in EPOS2012 such as paediatric CRS and sinus surgery. EPOS2020 also involves new stakeholders, including pharmacists and patients, and addresses new target users who have become more involved in the management and treatment of rhinosinusitis since the publication of the last EPOS document, including pharmacists, nurses, specialised care givers and indeed patients themselves, who employ increasing self-management of their condition using over the counter treatments. The document provides suggestions for future research in this area and offers updated guidance for definitions and outcome measurements in research in different settings. EPOS2020 contains chapters on definitions and classification where we have defined a large number of terms and indicated preferred terms. A new classification of CRS into primary and secondary CRS and further division into localized and diffuse disease, based on anatomic distribution is proposed. There are extensive chapters on epidemiology and predisposing factors, inflammatory mechanisms, (differential) diagnosis of facial pain, allergic rhinitis, genetics, cystic fibrosis, aspirin exacerbated respiratory disease, immunodeficiencies, allergic fungal rhinosinusitis and the relationship between upper and lower airways. The chapters on paediatric acute and chronic rhinosinusitis are totally rewritten. All available evidence for the management of acute rhinosinusitis and chronic rhinosinusitis with or without nasal polyps in adults and children is systematically reviewed and integrated care pathways based on the evidence are proposed. Despite considerable increases in the amount of quality publications in recent years, a large number of practical clinical questions remain. It was agreed that the best way to address these was to conduct a Delphi exercise. The results have been integrated into the respective sections. Last but not least, advice for patients and pharmacists and a new list of research needs are included.Peer reviewe

Entopy and local IgE

Rhinitis is a disorder of the nasal mucosa commonly attributed to specific immunoglobulin E (spIgE) mediated inflammation towards allergens. Allergic rhinitis (AR) is diagnosed when serum spIgE or skin prick test (SPT) is positive and non-allergic rhinitis (NAR) defined when these tests are negative. However, these systemic tests determine spIgE at distant sites instead of the nose itself. Evidence has shown that spIgE may be locally synthesized by the nasal mucosa and escape systemic detection, a condition termed local allergic rhinitis or entopy. This can be diagnosed by the nasal allergen provocation test (NAPT) which is unpopular due to its lengthy procedure. There is a need for simple local nasal assessments to determine nasal allergy. This thesis assessed alternative local diagnostic methods in the nose. The pitfall of systemic testing to identify nasal allergy was assessed in two systematic reviews which identified IgE mediated nasal allergy confirmed by positive NAPT or presence of nasal spIgE among those diagnosed with NAR. Other diagnostic markers for allergy were also studied through nasal endoscopy and radiological assessment. Middle turbinate oedema (seen on nasal endoscopy) and central mucosal thickening with or without sinus involvement (seen on radiology) were highly specific features of AR but were poorly sensitive. Local nasal sampling was then assessed as an alternative diagnostic tool. Inferior turbinate biopsy, nasal brushing and serum samples were collected and SPT performed among 166 consecutive patients who underwent inferior turbinate surgery. In the first phase of the study, three minimally invasive nasal sampling methods were compared (cytology brush, dental brush and nasal curette). The cytology brush was found to be optimal for protein harvest and further studied. Turbinate tissue spIgE was found to be a highly sensitive local test to diagnose AR. Nasal brushing spIgE was found to be comparably sensitive to tissue spIgE. Finally, the clinical characteristics of those with NAR based on absent tissue spIgE were assessed. Determining AR among rhinitics requires complete assessment which does not end at conventional systemic tests. Additional local tests are needed in order to truly rule out spIgE mediated disease

Efficacy of Mometasone Furoate and Fluticasone Furoate on Persistent Allergic Rhinoconjunctivitis

Allergic rhinoconjunctivitis denotes both nasal and ocular manifestation of allergy, which may be solely treated with intranasal steroid. This study compares the efficacy of mometasone furoate nasal spray (NS) and fluticasone furoate NS in treatment of allergic rhinoconjunctivitis. The secondary objective is to study the severity of baseline ocular symptoms in allergic rhinoconjunctivitis. Seventy-eight patients with allergic rhinoconjunctivitis were assessed subjectively and objectively using twice-daily symptom scores for nasal (reflective total nasal symptom score [rTNSS] and instantaneous TNSS [iTNSS]) and ocular (reflective total ocular symptom score [rTOSS] and instantaneous TOSS [iTOSS]) symptoms, rhinoconjunctivitis quality-of-life questionnaires (RQOLQs), and acoustic rhinometry. All measurements were taken at baseline and at 4 and 8 weeks of treatment. Sixty-three patients who were randomized into the mometasone furoate group (n = 36) and the fluticasone furoate group (n = 27) completed the study. Seventy-six percent of patients had mild ocular symptoms, 20.5% had moderate symptoms, and only 2.6% had severe symptoms at baseline based on the iTOSS; 65.1% had mild nasal symptoms and 3% had severe nasal symptoms. There was significant reduction in the symptom scores after 1 week (p < 0.05). Both groups had significant improvement in RQOLQ scores after 1 month, which further improved at 2 months (p < 0.05). The nasal dimensions also improved in both groups (p < 0.05) but there was no statistically significant difference between groups. Both mometasone furoate and fluticasone furoate are effective as single-modality treatment of allergic rhinoconjunctivitis. The majority of patients manifest mild ocular symptoms that may be solely treated with intranasal steroids