Adult rhinosinusitis-defined 1997-otolaryngology---head-and-neck-surgery

1. SUPPLEMENTTO
Otolaryngology-
Head and Neck Surgery
SEPTEMBER1997 VOLUME 117 NUMBER3 PART2
Adult rhinosinusitis defined
DONALD C. LANZA, MD,and DAVIDW. KENNEDY,MD,Philadelphia, Pennsylvania
Sinusitis is a leading health-care problem believed to
be increasing in both incidence and prevalence.
According to various sources, 1,2 the cost of this disease
appears to be staggering. However, the significance of
such reports and the importance of papers that have
reported successful treatments for sinusitis are some-
what diminished by the fact that sinusitis is variously
defined.
For effective communication among physicians and
the uniform reporting of disease, an acceFtable defini-
tion of sinusitis is needed. Once this definition has been
established, continued steps can be made toward
improving the scientific understanding of sinusitis,
including developing a staging system, determining the
efficacy of treatments, and standardizing care.
Due to the complex nature of sinusitis and the
presently limited understanding of the relationship of
this disease with all associated factors, it is impossible
to issue a finalized definition and classification system.
The goal of this document is to review the leading
issues that have thus far prevented the establishment of
a consensus opinion on the definition of sinusitis and
then to present working definitions for acute rhinosi-
From the Department of Otorhinolaryngology-Headand Neck
Surgery, University of Pennsylvania School of Medicine,
Philadelphia.
Reprint requests: Donald C. Lanza, MD, Department of
Otnrhinolaryngology-Head and Neck Surgery, University of
PennsylvaniaSchoolof Medicine, 3400 SpruceSt., Philadelphia,
PA19104.
OtolaryngolHeadNeckSurg 1997;117:S1-$7.
Copyright© 1997 by the AmericanAcademyof Ololaryngology-
Headand NeckSurgeryFoundation,Inc.
0194-5998/97/$5.00 + 0 23/0/83513
nusitis, subacute rhinosinusitis, recurrent acute rhinosi-
nusitis, chronic rhinosinusitis, and acute exacerbation
of chronic rhinosinusitis. These working definitions
were developed through the Task Force on
Rhinosinusitis sponsored by the American Academy of
Otolaryngology-Head and Neck Surgery (AAO-HNS).
The definitions will be subject to periodic review
(approximately every 3 to 5 years) and have been
designed so that all physicians whose patients manifest
signs and symptoms consistent with rhinosinusitis wilt
be able to make an appropriate diagnosis.
METHODOLOGY
On the basis of a computerized literature review and
the combined clinical and research experience of the
authors, a presentation was developed for review by the
Task Force on Rhinosinusitis. The literature review was
not restricted to the field of rhinology but specifically
included a review of otolaryngic experience with otitis
media and tonsillitis. At the conclusion of the presenta-
tion and after lengthy discussion on August 17, 1996,
the Task Force on Rhinosinusitis voted on a series of
questions that were addressed in formulating the rec-
ommendations for this consensus statement. The rec-
ommendations were subsequently presented to and
approved by the governing bodies of the AAO-HNS,
the American Academy of Otolaryngic Atlergy
(AAOA), and the American Rhinologic Society (ARS).
BACKGROUND
Broadly speaking, sinusitis may be clinically
defined as the condition manifested by an inflammato-
ry response involving the following: the mucous mem-
branes (possibly including the neuroepithelium) of the
nasal cavity and paranasal sinuses, fluids within these
$1

2. $2 LANZAand KENNEDY
Otolaryngology-
Head and Neck Surgery
September 1997
Table 1. Multifactorial causes of rhinosinusitis
Host factors
Genetic/congenital conditions
Cystic fibrosis
Immotile cilia syndrome
Allergic/immune conditions
Anatomic abnormalities
Systemic diseases
Endocrine
Metabolic
Neuromechanisms
Neoplasm
Environmentalfactors
Infectious/viral agents
Trauma
Noxious chemicals
latrogenic
Medications
Surgery
cavities, and/or underlying bone. The fluids within
these cavities are dynamic and are related to dynamic
pathologic changes in the bone and soft tissues of the
nose and paranasal sinuses. Symptoms associated with
sinusitis include nasal obstruction, nasal congestion,
nasal discharge, nasal purulence, postnasal drip, facial
pressure and pain, alteration in the sense of smell,
cough not due to asthma, fever, halitosis, fatigue, den-
tal pain, pharyngitis, otologic symptoms (e.g., ear full-
ness and clicking), and headache. Although most physi-
cians and researchers agree broadly on such a definition
for sinusitis, the precise basis for the clinical diagnosis
of sinusitis is more difficult to define.
The controversial issues associated with the difficul-
ty in reaching a consensus on the definition of sinusitis
can be expressed in these questions:
1.Which term is more descriptive of the actual con-
dition being defined: "sinusitis" or "rhinosinusi-
tis"?
2.Who diagnoses sinusitis?
3.What is the etiology, pathophysiology, and
histopathology of sinusitis?
4. What are the temporal aspects of the disease?
5. Is pediatric Sinusitis a different clinical entity than
adult sinusitis?
6. What is the microbiology of sinusitis?
7. What criteria must be fulfilled for the clinical diag-
nosis of sinusitis?
These questions provide the basis for the discussion
that follows.
Sinusitis Versus Rhinosinusitis
Although traditionally referred to as sinusitis, this
health-care problem is often preceded by rhinitis and
rarely occurs without concurrent rhinitis. 3 Nasal
obstruction, hyposmia, and nasal discharge are all
symptoms consistent with the diagnosis of sinusitis.
Histologically, the nasal passages and the sinus cavities
have many similarities. The mucous blanket of the
sinuses is in continuity with that of the nasal cavity.
Furthermore, a study performed with computed tomo-
graphic (CT) scanning demonstrated that the mucosal
linings of the nose and sinuses are simultaneously
involved in the common cold.4 Previously, the common
cold was widely thought to afflict only the nasal pas-
sages and not the sinuses. Thus the Task Force on
Rhinosinusitis believed that for the purposes of clarity,
accuracy, education, and definition, the name "sinusi-
tis" should be changed to "rhinosinusitis." In the
remainder of the this document, sinusitis will be
referred to as rhinosinusitis.
Rhinosinusitis and Those Who Diagnose It
Rhinosinusitis is a diagnosis that is commonly made
by physician extenders,5 primary care physicians,6 oto-
laryngologists, allergists, and pulmonologists. Thus for
a definition of rhinosinusitis to become widely accept-
ed, it must be one that can be used by a variety of
health-care providers. Furthermore, reimbursement
schedules depend on accurate reporting across special-
ties for the diagnosis of the same disease.
Etiology, Pothophysiology, and Histopathology
The development of rhinosinusitis depends on a
variety of environmental and host factors including, but
not limited to, those listed in Table 1. At present, the
multifactorial nature and multiple causes of rhinosi-
nusitis may make it impossible to define the precise
cause of this disease in a given patient. More specifi-
cally, the precise impact of any given variable or cause
leading to rhinosinusitis in a person is often very diffi-
cult to determine. Thus it currently is impractical to
define rhinosinusitis on the basis of its cause.
Stated another way, it is commonplace to have a
clinical setting in which rhinosinusitis coexists with
other conditions, such as allergic rhinitis, cystic fibro-
sis, and/or asthma. It could be argued that rhinosinusi-
tis should be referred to as a syndrome rather than a dis-
ease. Although it is sometimes stated that the scientific
use of the term "syndrome" should be restricted to the
description of only those conditions for which causes
are either unknown or diverse, this principle is widely
violated. Nevertheless, compared with "disease," the
term "syndrome" is more commonly applied to any
postulated morbid entity whose characteristics are not
well established.7
The postulated pathophysiology of rhinosinusitis has
been reviewed elsewhere in detail and is not repeated in
this document. 8 Like acute otitis media, rhinosinusitis

3. Otolaryngology-
Head and Neck Surgery
Volume 117 Number 3 Part 2 LANZA and KENNEDY S3
is often preceded by an acute viral illness. Subsequently,
acute rhinosinusitis has four basic clinical courses: res-
olution, the development of adverse sequelae, or the
development of either symptomatic or silent chronic rhi-
nosinusitis. Chronic rhinosinusitis also can have four
basic clinical courses: resolution, persistence, or the
development of adverse sequelae with or without possi-
ble progression to generalized airway reactivity.
Histopathologically, acute rhinosinusitis is predomi-
nantly viewed as an exudative process associated with
necrosis, hemorrhage, and/or ulceration, in which neu-
trophils predominate.9 Chronic rhinosinusitis is pre-
dominantly a proliferative process associated with
fibrosis of the lamina propria, in which lymphocytes,
plasma cells, and eosinophils predominate along with,
perhaps, changes in bone. Pathologic review may also
reveal a variety of findings that include, but are not lim-
ited to, varying degrees of eosinophils in tissues and
secretions as well as polyp formation and {he presence
of granulomas, bacteria, or fungi. The significance of
these findings and their correlation with su,-cessful out-
comes of given treatments remain to be determined.
Some investigators maintain that chronic rhinosi-
nusitis represents irreversible mucosal disease and that
successful treatment requires aggressive tissue
removal. I° Others believe that chronic rhinosinusitis is
predominately a medical condition in which surgery
plays a role in the relief of symptoms and, perhaps, the
reversal of disease. 1I Limited clinical study has sug-
gested that medical therapy alone is sufficient treatment
for inflammatory conditions of the sinuses. 1~
Temporal Aspects of Rhinosinusitis
The time line that should be used to define acute and
chronic rhinosinusitis has been the subject of much
debate, which has generated further related questions.
Temporally speaking, when does acute rhinosinusitis
begin? This question is particularly germar~e to the sit-
uation in which a viral upper respiratory tract infection
has preceded acute rhinosinusitis. Subsequently, when
does an episode of acute rhinosinusitis cease, and when
does the condition become chronic rhinosinusitis?
Should acute rhinosinusitis refer to the severity of the
process or to the temporal entity? Can a physician make
a diagnosis of acute or chronic rhinosinusitis indepen-
dent of the patient's previous medical treatment? Some
of these questions may be answered by the definitions
given later in this section.
For more than 20 years, similar issues concerning
otitis media have been heatedly debated. 13 Until rela-
tively recently, 13 the otitis media literature arbitrarily
defined acute otitis media as lasting 3 weeks, subacute
otitis media as lasting 3 to 12 weeks, and chronic otitis
media as lasting 12 or more weeks. I¢ Not surprisingly,
a literature review reveals remarkable similarities
between otitis media and rhinosinusitis. 15 Moreover,
some of the literature on rhinosinusitis already recog-
nizes an entity that is termed "subacute. ''16,17 When
polled, the physicians serving on the Task Force on
Rhinosinusitis indicated that they would treat rhinosi-
nusitis lasting <2 to 3 weeks differently than they
would rhinosinusitis lasting 6 or 12 weeks.
The Task Force discussed the possibility- of timing
rhinosinusitis to 3 to 4, 6, 8, or 12 weeks. Further dis-
cussion centered on the length of time condition could
be considered acute rhinosinusitis. Acute rhinosinusitis
lasting longer than 4 weeks was believed to be excessive
and probably not accurate with regard to the histopatho-
logic process. However, the Task Force and the litera-
ture review did not uncover any pathologic studies to
help delineate the temporal nature of the inflammatory
process in acute and chronic rhinosinusitis. The term
"subacute," although not applied to the sinuses in
pathology, is used in other pathologic conditions.
Currently, the United States Food and Drug
Administration (FDA) recognizes acute rhinosinusitis as
a condition lasting up to 4 weeks and chronic rhinosi-
nusitis as a condition diagnosed after rhinosinusitis has
been present for 3 months. The FDA has no formal def-
inition to describe the condition that lasts 4 to 12 weeks.
Given the desire to develop a widely acceptable, eas-
ily adaptable, and clinically accurate description of rhi-
nosinusitis, the similarities of rhinosinusitis and otitis
media (along with the wide acceptance of those defini-
tions), and the other supporting data discussed above,
the Task Force believed it appropriate to reintroduce the
term "subacute rhinosinusitis."
Pediatric Rhinosinusitis and Adult Rhinosinusitis
Special notation is made that the maturity of chiI-
dren's immune systems affects both their susceptibility
to rhinosinusitis and the microbiology of the disease.
For example, children appear to be more susceptible to
viral infections, and they are exposed to higher rates of
infection through child care facilities. 18Thus, when do
multiple exposures to viral illness become interpreted
as rhinosinusitis? Although the special issues in chil-
dren were deemed significant, the Task Force believed
that, although pathophysiologically the disease seen in
adults was similar to that seen in children, the focus of
this document would be to address issues for adults.
Therefore, the definitions of pediatric rhinosinusitis are
reviewed and presented in another section of the Task
Force's report.
Microbiology
Definitions of rhinosinusitis based on the microbiol-
ogy of the sinuses are problematic. Some investigators

4. $4 LANZAand KENNEDY
Otolaryngology-
Head and Neck Surgery
September 1997
Table 2. Factors associated with the diagnosis of
chronic rhinosinusitis
Major factors
Facial pain/pressure*
Facial congestion/fullness
Nasal obstruction/blockage
Nasal discharge/purulence/discoloredpostnasaldrainage
Hyposmia/anosmia
Purulence in nasal cavity on examination
Fever(acute rhinosinusitisonly)t
Minor factors
Headache
Fever(all nonacute)
Halitosis
Fatigue
Dental pain
Cough
Ear pain/pressure/fullness
*Facial pain/pressure aldne does not constitute a suggestive history
for rhinosinusitis in the absence of another major nasa] symptom or
sign.
tFever in acute sinusitis alone does not constitute a strongly sugges-
tive history for acute in the absence of another major nasal symptom
or sign.
maintain that under normal circumstances, the maxil-
lary sinuses are sterile and are only transiently contam-
inated,t9 Others believe that in their normal state the
maxillary sinuses have aerobic and anaerobic bacterial
colonization.2° These issues are further clouded by the
suggestion that the normal bacteriologic make-up of the
ethmoidal sinuses is different from that of the maxillary
sinuses.21 The bacteriologic nature of the disease state
has been described by many authors, t9'22 Gram-nega-
tive enteric organisms tend to be present in patients
with severe diseaseY
Criteria Necessary for the Clinical Diagnosis of
Rhinosinusitis
It has been previously argued that patient history and
routine physical examinations are insufficient for the
proper diagnosis of chronic rhinosinusitis.24 However,
87% of visits for the diagnosis and treatment of sinusi-
tis are to primary care physicians.25 Moreover, 33% to
50% of all visits to these physicians are related to upper
respiratory tract and/or head and neck infections.26The
majority of primary care physicians do not have the
training or the equipment to perform endoscopy. In
addition, the initial treatment for all forms of rhinosi-
nusitis appears to be more empiric at this time. As a sec-
ondary but related issue, primary care physicians have
very little access to formal training in this area.8
Consequently, two expensive technologies--radi-
ographic imaging of the paranasal sinuses and diagnos-
tic nasal endoscopy--could be overused until the effi-
cacy of such testing for the initial diagnosis and treat-
ment of rhinosinusitis has been delineated.
The Task Force believes that a patient history and
physical examination should suffice for the routine diag-
nosis of most forms of rhinosinusitis. The history should
document all relevant symptoms, their time course, and
their severity. The physical examination should encom-
pass the head and neck and should include otoscopy,
anterior rhinoscopy, and oropharyngeal and neck exam-
inations. Anterior rhinoscopy identifying nasal puru-
lence appears to be the most significant finding on
examination. When indicated, a chest and/or ophthal-
mologic evaluation should be included. Patients with
symptoms refractory to empiric treatment or patients
with evidence of an impending complication should be
referred to a specialist and for imaging studies. Many
have argued that radiographic evaluation24 and/or nasal
endoscopy27 should be required for the definitive diag-
nosis of rhinosinusitis. By now, however, most agree
that CT scanning is superior to radiography and that
plain radiographs are of limited value.28,29Nevertheless,
endoscopy and CT scans, which are not required for the
initial diagnosis of any form of rhinosinusitis, may be
very helpful in difficult or recalcitrant cases.
In 1993, a multidisciplinary panel convened by
Value Health Sciences Inc., in cooperation with the
AAO-HNS, examined surgical indications for sinusitis.
Groundwork for this study developed major and minor
clinical factors believed to be significant for the diagno-
sis of chronic rhinosinusitis. The patient's clinical histo-
ry for chronic rhinosinusitis was considered either to be
strong or suggestive on the basis of major and minor
symptoms. This experience has aided in the develop-
ment of the current recommendations for the clinical
diagnosis and classification of rhinosinusitis.
DEFINITIONS OF RHINOSINUSITIS IN ADULTS
Rhinosinusitis may be clinically defined as a condi-
tion manifested by an inflammatory response involving
the following: the mucous membranes (possibly includ-
ing the neuroepithelium) of the nasal cavity and
paranasal sinuses, fluids within these cavities, and/or
underlying bone. The fluids within these cavities are
dynamic and are related to dynamic pathologic changes
in the bone and soft tissues of the nasal cavity and
paranasal sinuses. Symptoms associated with rhinosi-
nusitis include nasal obstruction, nasal congestion,
nasal discharge, nasal purulence, postnasal drip, facial
pressure and pain, alteration in the sense of smell,
cough, fever, halitosis, fatigue, dental pain, pharyngitis,
otologic symptoms (e.g., ear fullness and clicking), and
headache.
The following definitions are, in part, based on an
amended list of the major and minor clinical symptoms

5. Otolaryngology-
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Table 3. Classification of adult rhinosinusifis*
Classification
Acute
Subacute
Recurrent acute
Chronic
Acute
exacerbations
of chronic
Duration
-<4 weeks
4-12 weeks
_>4episodes per
year, with each
episode lasting
>7 to 10 days
and absence of
intervening signs
and symptoms of
chronic rhinosinusitis
_>
12 weeks
Sudden worsening of
chronic rhinosinusitis,
with return to baseline
after treatment
Strong history
_>2major factors,
1 major factor and
2 minor factors, or
nasal purulence on
examination
Same as chronic
Same as acute
_>2major factors,
t major factor and
2 minor factors, or
nasal purulence on
examination
Include in differential
1 major factor or
_>2minor factors
Same as chronic
1 major factor or
_>2minor factors
Special notes
Fever or facial pain does not
constitute a suggestive
history in the absence of
other nasal signs or symptoms
Consider acute bacterial rhinosi-
nusitis if symptoms worsen
after 5 days, if symptoms per-
sist for >10 days, or in
presence of symptoms out of
proportion to those typically
associated with viral infection
Complete resolution after effec-
tive medical therapy
Facial pain does not constitute
a suggestive history in
the absence of other nasal
signs or symptoms
*Rhinosinusitismay be clinically defined as the conditign manifested by an inflammatory response involving the mucous membranes (possibly
including neuroepithelium) of nasal cavity and paranasal sinuses, fluids within these cavities, and/or underlying bone. Fluids within these cavities
are dynamic and are related to dynamic pathologic changes in bone and soft tissues of nasal cavity and paranasal sinuses. Symptoms associated
with rhinosinusJtisinclude nasal obstruction, nasal congestion, nasal discharge, nasal purulence, postnasal drip, facial pressure and pain, alter-
ation in sense of smell, cough, fever, halitosis, fatigue, dental pain, pharyngitis, etologic symptoms (e.g., ear fullness and clicking), and headache,
and signs believed to be most significant for the accu-
rate clinical diagnosis of all forms of adult rhinosinusi-
tis (Table 2). Anterior rhinoscopy performed in the
decongested nose reveals hyperemia, edema, crusting,
polyps and/or, most significantly, purulence in the nasal
cavity. Purulence seen along the posterior pharyngeal
wall from above is equally significant in the diagnosis
of rhinosinusitis. On palpation, facial tenderness may or
may not be present. Imaging studies are clearly useful,
but they are not required to make the clinical diagnosis
of rhinosinusitis (see the radiologic diagnosis section of
the Task Force's report).
Based on the preceding information, lengthy discus-
sion, and debate, the Task Force on Rhinosinusitis con-
cluded that there were five different classifications of
adult rhinosinusitis. The focus of each classification is
its temporal nature and the diagnostic criteria that sup-
port the clinical diagnosis of rhinosinusitis (Table 3).
For reasons given earlier, these definitions do not take
into account the cause of rhinosinusitis. It is expected
that physicians will use multiple diagnoses concurrent-
ly when related conditions are known to exist that
might help explain the cause of rhinosinusitis. For
example, a patient with chronic rhinosinusitis may also
have the diagnosis of inhalant allergy, cystic fibrosis, or
immunodeficiency.
Acute Adult Rhinosinusitis
Acute adult rhinosinusitis is sudden in onset and
lasts up to 4 weeks. The symptoms resolve completely,
and once the disease has been treated antibiotics are no
longer required. A strong history consistent with acute
rhinosinusitis includes two or more major factors or one
major and two minor factors (Table 2). However, the
finding of nasal purulence is a strong indicator of an
accurate diagnosis. A suggestive history for which
acute rhinosinusitis should be included in the differen-
tial diagnosis includes one major factor or two or more
minor factors. In the absence of other nasal factors,
fever or pain alone does not constitute a strong history,

6. S6 LANZAand KENNEDY
Otolaryngology-
Head and Neck Surgery
September 1997
Severe, prolonged, or worsening infections may be
associated with a nonviral element. Factors suggesting
acute bacterial rhinosinusitis are the worsening of
symptoms after 5 days, the persistence of symptoms for
more than 10 days, or the presence of symptoms out of
proportion to those typically associated with a viral
(upper respiratory) infection.
Subacute Adult Rhinosinusitis
Subacute adult rhinosinusitis represents a continuum
of the natural progression of acute rhinosinusitis that
has not resolved. This condition is diagnosed after a 4-
week duration of acute rhinosinusitis, and it lastsup to
12 weeks. The Task Force recognizes that subacute rhi-
nosinusitis is not known to represent a discrete
histopathologic entity but that it may warrant therapy
different from that for either acute rhinosinusitis or
chronic rhinosinusitis. Patients with subacute adult rhi-
nosinusitis may or may not have been treated for the
acute phase, and the symptoms are less severe than in
acute rhinosinusitis. Thus, unlike in acute rhinosinusi-
tis, fever would not be considered a major factor. The
clinical factors required for the diagnosis of subacute
adult rhinosinusitis are the same as those for chronic
rhinosinusitis. Subacute rhinosinusitis usually resolves
completely after an effective medical regimen.
Recurrent Acute Adult Rhinosinusitis
Recurrent acute adult rhinosinusitis is defined by
symptoms and physical findings consistent with acute
rhinosinusitis, with these symptoms and findings wors-
ening after 5 days or persisting >10 days. However,
each episode lasts 7 to 10 days or more and may last up
to 4 weeks. Furthermore, _>4episodes occur in 1 year.
Between episodes, symptoms are absent without con-
current antibiotic therapy. The diagnostic criteria for
recurrent acute rhinosinusitis are otherwise identical to
those for acute rhinosinusitis.
Chronic Adult Rhinosinusitis
Chronic adult rhinosinusitis is rhinosinusitis lasting
>12 weeks. The diagnosis is confirmed by the major
and minor clinical factors complex described previous-
ly (Table 2) with or without findings on the physical
examination. A strong history consistent with chronic
rhinosinusitis includes the presence of two or more
major factors or one major and two minor factors. A
history suggesting that chronic sinusitis should be con-
sidered in the differential diagnosis includes two or
more minor factors or one major factor. Facial pain
does not constitute a strong history in the absence of
other nasal factors. Cultures may be of particular value
in identifying resistant microbial flora.
Acute Exacerbation of Chronic Adult
Rhinosinusitis
Acute exacerbation of chronic adult rhinosinusitis
represents a sudden worsening of the baseline chronic
rhinosinusitis with either worsening or new symptoms.
Typically, the acute (not chronic) symptoms resolve
completely between occurrences. Due to the underlying
chronic nature of this condition, bacterial flora may
represent resistant or atypical strains. Thus, endoscopi-
cally guided culture may be particularly helpful in
directing antimicrobial therapy.
CONCLUSION
The goal of this document was to identify a common
ground for the purpose of defining various forms of rhi-
nosinusitis. Specifically, definitions were given for
acute adult rhinosinusitis (also acute bacterial rhinosi-
nusitis), subacute adult rhinosinusitis, recurrent acute
adult rhinosinusitis, chronic adult rhinosinusitis, and
acute exacerbation of chronic adult rhinosinusitis are
defined.
The Task Force has sought definitions that physi-
cians "can live with" and use until more precise defini-
tions can be developed. The definitions are predomi-
nantly based on temporal and clinical factors that help
identify the presence of rhinosinusitis. These defini-
tions are intended to be broad and accurate for the
majority of conditions that are compatible with the
diagnoses, and they are also intended to be widely
acceptable. They are endorsed by the AAO-HNS, the
AAOA, and the ARS. The proposed definitions are
intended to serve as a unifying starting point for further
research to improve the understanding of this pervasive
health problem, It is anticipated that these definitions
will change as rhinosinusitis comes to be better under-
stood. This is a first step.
Based on these definitions, staging systems will be
developed and research protocols initiated to study the
efficacy of both medical and surgical treatments for rhi-
nosinusitis. The staging system will be the battleground
for hammering out the details that will be used for fur-
ther research on rhinosinusitis.
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