The etiology and pathogenesis of chronic rhinosinusitis (also known as chronic rhinosinusitis, CRS) are not well understood, and there are controversies in the definition of diagnosis, typing, and selection of treatment options. In recent years, scholars, mainly in Europe and the United States, have organized a series of guiding documents on the diagnosis and treatment of rhinosinusitis. The Haikou standards developed in 1997 have been useful for the development of nasal endoscopic surgery, evaluation of postoperative efficacy, and academic exchange in China. In order to learn as much as possible from foreign advanced experience and to be in line with international practice, it is necessary to formulate, revise and continuously improve the guidelines for the diagnosis and treatment of chronic rhinosinusitis that are suitable for national conditions.
During the drafting of the guidelines for the diagnosis and treatment of chronic rhinosinusitis in China, reference was made to existing international guidelines, and based on the characteristics of China’s national conditions, the principle of “simplicity is preferable to complexity, and coarseness is preferable to detail” was followed, while taking into account the current medical system and the actual situation of clinical operability in China. In order to make this guideline more scientific, reasonable and practical, the editorial team also organized experts to give lectures in some cities in China, and fully consulted with colleagues from all over the country to make it perfect. This guideline is applicable to chronic rhinosinusitis in adults.
Clinical definition
Chronic rhinosinusitis is defined as chronic inflammation of the mucosa of the nasal cavity and sinuses, with nasal symptoms persisting for more than 12 weeks without complete resolution or even worsening of symptoms.
Clinical classification
1. Chronic rhinosinusitis (without nasal polyps)
2. Chronic rhinosinusitis (with nasal polyps)
Note: The mechanism of occurrence of nasal polyps is still unclear, and studies have shown that nasal polyps have their own relatively independent characteristics. Therefore, the classification in this guideline does not imply a necessary causal relationship between chronic rhinosinusitis and nasal polyps in terms of stages of development.
Diagnosis
I. Symptoms
1.Main symptoms: nasal congestion, mucous, purulent nasal discharge.
2.Secondary symptoms: head and face swelling and pain, reduced or lost sense of smell.
The diagnosis is based on the above two or more related symptoms, among which nasal congestion, mucous and purulent nasal discharge must be one of the main symptoms.
Examination
1. Nasal examination: mucopurulent secretions from the middle nasal tract and olfactory fissure, congestion and edema of the mucosa of the middle nasal tract or the presence of nasal polyps.
2. Imaging examination: CT scan shows sinus-oral nasal tract complex or nasal tract mucosal lesions.
Determination of disease severity
According to the visual analogue scale (VAS), the condition is classified as mild 0~3, moderate 3~7 and severe 7~10.
Drug treatment
The following types of drugs are commonly used in clinical practice.
I. Anti-inflammatory drugs
1. Glucocorticoids.
① intranasal local glucocorticoids: with anti-inflammatory and anti-edema effects, the course of treatment is not less than 12 weeks.
The recommended dose is 0.5 mg/(kg?d), taken once a day in the morning on an empty stomach for 5-10 d, up to 14 d. The contraindications to the use of systemic glucocorticosteroids should be noted, and the possible adverse reactions should be closely observed in the course of drug administration. Systemic or intranasal injection of glucocorticoids is not recommended.
2. Macrolide (14-ring) drugs: they have anti-inflammatory effects and are recommended to be taken orally in small doses (1/2 of the conventional antibacterial dose) for a long period of time, with a course of at least 12 weeks.
Second, antibacterial drugs
Penicillin, cephalosporins, sulfonamides, macrolides, fluoroquinolones sensitive drugs for chronic rhinosinusitis
Acute exacerbations, regular doses, duration of treatment not exceeding 2 weeks. Topical antibiotics in the nasal sinuses are not recommended.
III. Decongestants
Not recommended. Short-term use (<7d) for severe nasal congestion.
Mucus promoter
Can dilute mucus and improve cilia activity, recommended.
V. Systemic antihistamines
For patients with symptoms of allergic reactions, second-generation or new antihistamines can be taken orally.
Chinese medicine
Some herbal medicines are effective in improving the symptoms of chronic rhinosinusitis and should be selected according to the principle of dialectical treatment.
VII. Saline or hypertonic saline (2%~3%)
Surgical treatment
I. Indications for surgery
Chronic rhinosinusitis can be treated surgically if one of the following conditions exists.
1.Significant anatomical abnormalities affecting the sinus-oral nasal tract complex or the drainage of each sinus.
2. Nasal polyps affecting the sinonasal complex or the drainage of the sinuses.
3.Insatisfactory improvement of symptoms by drug treatment.
4.The appearance of cranial and orbital complications.
II. Perioperative treatment
The perioperative treatment is centered on surgery, and in principle, it should include a series of medication from 1 week before surgery to 3-6 months after surgery
In principle, it should include a series of medication strategies and treatment principles from 1 week before surgery to 3-6 months after surgery. At present, there is no unified standard for perioperative management of nasal endoscopic surgery, so no rigid rules will be made for the time being. The recommended
The treatment plan is as follows.
1. Pre-surgical medication: routine application of antimicrobial drugs, intranasal local and/or systemic glucocorticoids, mucus promoters, etc.
2.Post-surgical local treatment time: regular post-operative cavity cleaning and follow-up treatment interval after 1 to 2 weeks according to the recovery of the operated cavity.
The interval of treatment should last for 3-6 months.
3. Post-operative drug treatment is based on the same principles as the above-mentioned drug treatment for chronic rhinosinusitis, with anti-inflammatory drugs used for at least 12 weeks.
Evaluation of efficacy
I. Assessment methods
1.Subjective assessment: VAS is recommended for quantitative assessment of symptoms.
2. Objective assessment: quantitative assessment of nasal endoscopy is based on the Lund-Kennedy scale; quantitative assessment of sinus CT scan results is based on the Lund-Mackay scale.
Scoring criteria.
①Sinus: 0 = no abnormality, 1 = partial turbidity, 2 = total turbidity.
(ii) Sinonasal tract complex: 0 = no obstruction, 1 = obstruction.
③0 to 12 per side, total score 0 to 24
3. If quality of life assessment is performed: the Chinese version of the sino-nasal outcome test-20 (SNOT-20), a special scale for sinusitis, is recommended [8]; if necessary, it can be combined with the universal scale, the -medical outcome study shortform 36items health survey (SF-36, applicable to clinical research).
Timing of assessment
1.The assessment time for the immediate efficacy of drug treatment is 3 months, and the assessment time for the long-term efficacy is 1 year.
2.The assessment time for the immediate efficacy of surgical treatment is 1 year, and the assessment time for the long-term efficacy is 3 years.
If the patient has recently suffered from acute upper respiratory tract infection, it is recommended to postpone the evaluation until 2 weeks after the symptoms have completely disappeared.