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Staging protocols for sinusitis


Aim of staging rhinosinusitis:
1. To decide on the severity of disease process
2. To decide on the optimal treatment modality
3. To decide the prognosis of disease

Various attempts were made to evolve a viable and effective staging protocol for rhinosinusitis.

1. Princetown staging (1993): This staging protocol was evolved at the international conference on sinus disease at Princetown. In this staging protocol CT scan assessment was extensively resorted to. Plain radiographs of paranasal sinuses were excluded from the staging protocol.
Each sinus group (maxillary, anterior ethmoid, posterior ethmoid, sphenoid and frontal) is graded separately as 0 when there is no abnormality, 1 when there was evidence of partial opacification, and 2 when there is total opacification.
The osteomeatal complex is taken next for staging purposes. It is scored as 0 when there is no obstruction, and a score of 2 is awarded if there is osteomeatal block.
Anatomical variants if any are noted. They do not contribute to the overall score. These variants are important when surgery is being planned. The variants include concha bullosa, paradoxical middle turbinate, Haller's cell, everted uncinate process, agger nasi pneumatisation, and absence of frontal sinus.

Since CT images are extensively resorted to in this staging protocol, when it should be taken is a very important point. CT scan for staging purposes is best obtained after adequate medical management, and during a period when there is no acute infection (3-4 weeks after acute or subacute infection).

Patient symptom data has also been used in this protocol. The patient is asked to grade his symptoms in a grade scale ranging from 0 -10. The grading symptoms include nasal block, congestion, nasal pressure, head ache, olfactory disturbance and discharge.

Nasal endoscopic examination also contributes to the quantification of the staging process. It takes into consideration the presence of polyps, discharge, edema, scarring, adhesions and crusting. The scoring protocol is as follows:
0- Absence of polyp
1- Presence of polyp confined to the middle meatus
2- Presence of polyp beyond the middle meatus

0-No discharge
1-Clear and thin discharge
2-Thick and purulent discharge

Friedman and Katsantonis staging protocol: (1984)

Stage I: Single focus disease shown radiographically, either unilateral or bilateral.
Stage II: Discontiguous or patchy areas of disease either unilateral or bialteral.
Stage III: contiguous disease throughout the ethmoidal labyrinth, with or without sinus opacity with symptomatic response to medication
Stage IV: contiguous hyperplastic disease involving all the sinuses, with minimal or no symptomatic response to medications

Patients with stage I disease were treated medically. Most patients in stage II undergo surgical intervention. Almost all patients belonging to Stage III and Stage IV disease will have to be operated on to treat the condition.
Stage III and IV disease with asthma is more prone for recurrence following surgery.

Gliklich and Metson system:

Stage 0: Less than 2mm mucosal thickening on any sinus wall
Stage I: Include all unilateral disease or anatomical abnormalities
Stage II:Bilateral disease limited to the ethmoid or maxillary sinuses
Stage III: Bilateral disease with involvement of atleast one sphenoid or frontal sinus
Stage IV: Pan sinusitis

Lund and McKay system: Uses a scoring and localization system. Points are given for the degree of opacification.
0 points = No abnormality
1 point = Partial opacification
2 points = Total opacification

Sinuses are identified as:
Maxillary
Anterior ethmoid
Posterior ethmoid
Sphenoid
Frontal

Osteomeatal complex obstruction:
0 points = no obstruction
2 points = obstruction
Each side is scored separately
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