Current Understanding of the Acute Exacerbation of Chronic Rhinosinusitis

Abstract

Background: Acute exacerbations of chronic rhinosinusitis (CRS) have been increasingly recognized as an important disease entity with a significant impact on the quality of life. There is a growing amount of research on the etiopathogenesis and management of acute exacerbations of CRS. This review aims to summarize the current literature and provide an overall understanding of acute CRS exacerbations.Methods: A related literature review with the key terms of “chronic rhinosinusitis” and “exacerbation” was performed using PubMed.Results: There is no consensus definition of the acute exacerbation of CRS. Impaired mucociliary clearance, atrophic rhinitis, and immunologic changes are important predisposing factors for acute CRS exacerbations. Current evidence supports the role of the transient viral infection as the initial inflammatory stimulus in the pathogenesis of acute CRS exacerbations. Secondary bacterial infection or microbial community dysbiosis within the sinonasal cavity is the main event during the acute exacerbation of CRS. Distinct changes in local and systemic immune responses during exacerbation provide new insights into the pathophysiology of CRS exacerbation. Although current guidelines suggest the use of short-term antibiotics in patients with acute CRS exacerbation for symptomatic relief, evidence-based treatment recommendations for acute CRS exacerbation are still lacking, and large-high-quality RCTs are required.Conclusion: There have been significant advances in understanding the etiology and immunological feathers of acute CRS exacerbation. Nevertheless, consensus definition, diagnostic criterion, biomarkers to differentiate acute CRS exacerbation from CRS, assessment of disease severity, and evidence-based treatment options for acute CRS exacerbation are still lacking.

International consensus statement on allergy and rhinology: rhinosinusitis 2021

“…Since these criteria were introduced, there has been limited work on AECRS. There have been 3 studies utilizing the suggested definition from the 2016 ICAR document, including 1 literature review and 2 cohort studies which used but did not assess the definition 29,210,211 …”

“…Consensus guidelines and expert opinion recommend short‐term antibiotics for AECRS, in the setting of a positive culture to provide symptomatic relief 1,31 . The treatment for ARS with the implementation of antibiotics has been extrapolated and applied to AECRS, despite AECRS being recognized as a distinct entity from ARS 210,1760 Antibiotics and treatment of the preexisting CRS are often implemented.…”

Bacterial Biofilm and its Role in the Pathogenesis of Disease

“…The host immune response to a viral infection consists of non-specific and specific components, which will eventually eliminate the invading agent, but also generate dead epithelial and immune cells, creating an environment opportune for secondary bacterial infections. During viral infection in chronic RS, a similar inflammatory process can occur as in acute RS [152,153].…”

Socioeconomic, comorbidity, lifestyle, and quality of life comparisons between chronic rhinosinusitis phenotypes

“…In terms of the differences in reporting URTIs, Wu et al elucidated the difficulties in defining acute exacerbations of CRS 27 and highlighted that others had used various metrics to measure this including the number of patientreported "sinus infections," CRS-related antibiotic courses, and CRS-related oral corticosteroid courses. [28][29][30] These are of course subjective metrics on the part of the patient and clinician, and in practice, it will be difficult to separate viral URTIs from bacterial episodes.…”