EPOS Primary Care Guidelines: European Position Paper on the Primary Care Diagnosis and Management of Rhinosinusitis and Nasal Polyps 2007 — a summary

Abstract

This paper is a summary of the 2007 European Position Paper on Rhinosinusitis and Nasal Polyps (EP3OS)1 which was published in Rhinology in 2007. In order to widen dissemination of the EP3OS paper, the editors of Rhinology and the Primary Care Respiratory Journal (PCRJ) have agreed to publish this summary - which is focussed on the needs of general practitioners and community-based non-specialist clinicians - in the PCRJ. In the EP3OS process, an evidence-based methodology was used to identify evidence and to grade recommendations for clinical practice for the management of rhinosinusitis. The EP3OS Taskforce was commissioned by the European Academy of Allergology and Clinical Immunology (EAACI) with the aims of: * Presenting specialist and generalist clinicians with an updated summary of knowledge of rhinosinusitis and nasal polyposis * Providing clinicans with an evidence-based summary of diagnostic methods appropriate for specialist and generalist settings * Providing evidence-based recommendations for management in specialist and generalist settings * Proposing guidance for definitions and outcome measurements in clinical practice and in research in different settings. The current document aims to distil the information presented in the full EP3OS document1 into a shorter and more concise format suitable for use in primary care generalist settings. The summary recommendations for generalists are that clinicians should be aware that rhinitis and sinusitis usually co-exist, and that management strategies should encompass this. Acute rhinosinusitis is an inflammatory condition that may be diagnosed on the basis of acute symptoms of nasal blockage, obstruction, congestion with or without facial pain or reduced smell; many episodes are self-limiting, but where symptoms persist or increase after five days, topical nasal steroids may be considered, with addition of antibiotics in patients with more severe or increasing symptoms. Non-resolution in 14 days, or the presence of atypical symptoms, should prompt consideration of referral to specialist care. Chronic rhinosinusitis occurs when symptoms have been present for >12 weeks, and anterior rhinoscopy or more detailed endoscopy should be performed to identify polyps. Topical nasal corticosteroids, nasal douching, and use of antihistamines in allergic patients, may be used in patients without, or with less symptomatic, polyps; referral to specialist care is needed for patients whose symptoms do not respond or who have large polyps.

High costs and burden of illness in acute rhinosinusitis: real-life treatment patterns and outcomes in Swedish primary care

“…The finding of the surprisingly high use of intranasal steroids is an indication of a change in the clinical treatment of acute rhinosinusitis in primary care, consistent with the EP 3 OS evidence-based guidelines. 4,5 The slight decrease in the number of patients using nasal corticosteroids and the corresponding increase in patients using antibiotics during the 15 days of study remains to be explained. One theory could be that some patients did not respond to initial nasal steroid treatment and were switched to antibiotics.…”

“…4,5 The inclusion criteria were based on data from an earlier clinical study, 10 international guidelines 4,5 and Swedish clinical practice. This approach tried to exclude 'common colds' by excluding patients with a symptom duration shorter than 7 days and an MSS <5, as well as excluding severe acute rhinosinusitis by not including patients with MSS >12 and by applying the exclusion criteria.…”

“…2,3 According to current European guidelines, the recommended treatment for mild acute rhinosinusitis is symptomatic, with nasal steroids advised in moderate cases. 4,5 Antibiotics should only be added if severe symptoms are present (e.g. fever >38°C, severe pain).…”

“…The evidence for the efficacy of decongestants in the treatment of acute rhinosinusitis in adults is poor, and decongestants only have a grade D recommendation. 4,5 According to recent estimates, bacterial infection is present in <50% of patients with symptoms of acute rhinosinusitis 6,7 and may be as low as 0.5-2%. 8 Several studies have shown that antibiotics commonly used in Sweden are of limited value in the management of patients with mild to moderate acute rhinosinusitis.…”

Rhinosinusitis, laryngopharyngeal reflux and cough: An ENT viewpoint

“…The latter is the main, however, is considered the most common pathology associated with PND. 11 There has been some dispute as to whether the PND syndrome is indeed a syndrome, and whether this can cause chronic cough. 12 The relationship between PND and cough is often disputed.…”