International consensus statement on allergy and rhinology: rhinosinusitis 2021

Abstract

I. Executive Summary Background The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR‐RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR‐RS‐2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence‐based findings of the document. Methods ICAR‐RS presents over 180 topics in the forms of evidence‐based reviews with recommendations (EBRRs), evidence‐based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary. Results ICAR‐RS‐2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence‐based management algorithm is provided. Conclusion This ICAR‐RS‐2021 executive summary provides a compilation of the evidence‐based recommendations for medical and surgical treatment of the most common forms of RS.

The Functional Diversity of Nitric Oxide Synthase Isoforms in Human Nose and Paranasal Sinuses: Contrasting Pathophysiological Aspects in Nasal Allergy and Chronic Rhinosinusitis

“…Chronic rhinosinusitis (CRS) is persistent inflammation of the nasal and sinus mucosa lasting ≥12 weeks, accompanied by two or more nose-related symptoms such as nasal blockage and nasal discharge [ 100 , 101 ]. As with many other chronic diseases, the clinical entity of CRS is considered a disease with heterogeneity.…”

“…The highest level of ARG2 expression was observed in the nonasthmatic and non-AR CRSsNP patients. The pathology of CRSsNP features cellular infiltrations of neutrophils, macrophages, and lymphocytes dominated by type 1 inflammatory cytokines [ 100 , 101 , 105 ]. It is speculated that moderate expression levels of ARG2 partially inhibit the production of NO so that it can no longer maintain its protective roles but allow an accumulation of NO in a range that is sufficient to promote type 2 inflammatory responses [ 141 ].…”

Management of Chronic Rhinosinusitis with Nasal Polyposis in the Era of Biologics

“…Diagnosis is made based on chronology of symptomatology and objective evidence on endoscopy or computed tomography imaging demonstrating evidence of polyposis. 3 CRSwNP is known to cause a significant burden to quality of life, 4 result in significant health care expenditures, 1 and more recently has been demonstrated to have an impact on cognitive function. [5][6][7][8] While the exact pathophysiologic mechanisms are yet to be elucidated, evidence evaluating Caucasian populations suggest an predominately type 2 inflammatory reaction and aberrant eosinophilic activation.…”

Challenging our assumptions: oral corticosteroids and chronic rhinosinusitis without nasal polyposis

“…The 2021 International Consensus on Allergy and Rhinology Statement on Rhinosinusitis considered OCSs as a therapeutic option in CRSsNP, but the document also cited a notable lack of high-level studies assessing their efficacy. 2 A 2011 systematic review of 33 articles on OCS use in CRSsNP found that nearly all studies were level 4 or 5 evidence, affording only weak recommendations for use. 3 In a subsequent 2013 review of OCS use in the perioperative period for surgery for CRSsNP, the authors were unable to make any evidence-based recommendations, citing the absence of high-level studies on the subject.…”

“…Although level 1 evidence supports the use of OCSs in the treatment of CRSwNP, the evidence for the use of OCSs in CRSsNP is far less substantive both in quantity and quality. The 2021 International Consensus on Allergy and Rhinology Statement on Rhinosinusitis considered OCSs as a therapeutic option in CRSsNP, but the document also cited a notable lack of high‐level studies assessing their efficacy 2 . A 2011 systematic review of 33 articles on OCS use in CRSsNP found that nearly all studies were level 4 or 5 evidence, affording only weak recommendations for use 3 .…”