of the most common and expensive medical conditions. • RS occurs in a number of forms, the most common of which are either acute or chronic. • Initial treatment of RS is usually by a primary care physician (PCP) and if unsuccessful, the PCP should refer either to a surgeon or to an allergist for specialized care. • In the vast majority of cases, RS is controlled by proper medical management without the need for surgery. • Surgery should be considered only in those patients who are properly managed but in whom a number of medical treatment programs fail. • The Allergist, who is trained in allergy, immunology, microbiology, internal medicine and/or pediatrics combined with an expert knowledge of nasal and sinus anatomy and appropriate pharmacology, is best suited to manage RS. Introduction RS affects about 31 million subjects in the US per year and is about midway between rhinitis and asthma in frequency. The annual costs are about the same as for asthma, making RS one of the 10 most costly conditions. The underlying causes of RS are shown in Table 1. Allergic rhinitis and non-allergic rhinopathy are the most common underlying causes, but anatomical abnormalities, sensitivity to nonsteroidal anti-inflammatory drugs (NSAID’s) and immune deficiencies are also frequently found. INTRODUCTION AND EXECUTIVE SUMMARY CHAPTER 3 CHAPTER 1 CHAPTER 4 CHAPTER 6 CHAPTER 2 CHAPTER 5 MEMBER SOCIETY SURVEY REPORT 3 2 Pawankar, Canonica, Holgate and Lockey Copyright 2011 World Allergy Organization Table 4 — The Underlying Causes of Rhinosinusitis Common Conditions Allergic and non-allergic rhinitis Anatomic abnormality of the ostiomeatal complex: - Septal deviation - Concha bullosum - Paradoxical curvature of the middle turbinate - Haller cells Aspirin sensitivity Common variable immunoglobulin deficiency: - Specific antibody deficiency - IgA deficiency Rhinitis medicamentosa Less Common Conditions Ciliary dyskinesia Kartagener’s syndrome Young’s syndrome Acquired immunodeficiency syndrome Bronchiectasis Cocaine abuse Wegener’s granulomatosis Cystic fibrosis From: Kaliner MA: Medical Management of Rhinosinusitis. In: Current Review of Rhinitis, MA Kaliner, Editor, Current Medicine, Philadelphia, 2002, pp.101-112 Symptoms and Severity The most common symptoms of acute and chronic RS are shown in Table 5. Patients complaining about these symptoms who are found to have purulent drainage in the nasal cavities or pharynx should be considered as possibly having RS. In most cases, a good history and physical examination, possibly including a rhinoscopic examination, leads the discerning physician to consider RS and initiate empiric treatment. A Computerized Tomography (CT) scan of the sinuses is the “gold standard” for confirming the diagnosis of RS. Table 5 — The signs and symptoms of acute and chronic RS Acute: Symptoms present for less than 28 days Chronic: Symptoms present for 3 months or more Pre-requisite symptoms: - Persistent upper respiratory infection (>10 days) - Persistent muco-purulent nasal and/or posterior pharyngeal discharge - Throat clearing and cough Additional supportive symptoms: - Congestion - Facial pain/pressure - Post-nasal drip - Fever - Headache - Anosmia, hyposmia - Facial tenderness - Periorbital edema - Ear pain, pressure - Halitosis - Upper dental pain - Fatigue - Sore throat The evaluation of RS is quite similar to the approach taken for rhinitis: determining whether the symptoms are acute or chronic; whether the disease involves the nose alone or both the nose and sinuses; whether the patient is allergic or not; whether there is an active infection or an on-going immune inflammatory response; whether to treat empirically or to take cultures from the nose, perform rhinoscopy, order a CT scan, do an immune evaluation, or consult with a surgeon about the need for sinus surgery. These complex evaluations are standard for allergists/ immunologists and are the type of analytic decisions for which the allergist is specifically trained. Therapeutic Considerations If the conclusion is that the patient does have chronic or recurrent RS, the overwhelming majority of patients do very well with careful medical