Novel scoring system and algorithm for classifying chronic rhinosinusitis: the JESREC Study

T Tokunaga, M Sakashita, T Haruna, D Asaka, S Takeno, H Ikeda, T Nakayama, N Seki, S Ito, J Murata, Y Sakuma, N Yoshida, T Terada, I Morikura, H Sakaida, K Kondo, K Teraguchi, M Okano, N Otori, M Yoshikawa, K Hirakawa, S Haruna, T Himi, K Ikeda, J Ishitoya, Y Iino, R Kawata, H Kawauchi, M Kobayashi, T Yamasoba, T Miwa, M Urashima, M Tamari, E Noguchi, T Ninomiya, Y Imoto, T Morikawa, K Tomita, T Takabayashi, S Fujieda, T Tokunaga, M Sakashita, T Haruna, D Asaka, S Takeno, H Ikeda, T Nakayama, N Seki, S Ito, J Murata, Y Sakuma, N Yoshida, T Terada, I Morikura, H Sakaida, K Kondo, K Teraguchi, M Okano, N Otori, M Yoshikawa, K Hirakawa, S Haruna, T Himi, K Ikeda, J Ishitoya, Y Iino, R Kawata, H Kawauchi, M Kobayashi, T Yamasoba, T Miwa, M Urashima, M Tamari, E Noguchi, T Ninomiya, Y Imoto, T Morikawa, K Tomita, T Takabayashi, S Fujieda

Abstract

Background: Chronic rhinosinusitis (CRS) can be classified into CRS with nasal polyps (CRSwNP) and CRS without nasal polyps (CRSsNP). CRSwNP displays more intense eosinophilic infiltration and the presence of Th2 cytokines. Mucosal eosinophilia is associated with more severe symptoms and often requires multiple surgeries because of recurrence; however, even in eosinophilic CRS (ECRS), clinical course is variable. In this study, we wanted to set objective clinical criteria for the diagnosis of refractory CRS.

Methods: This was a retrospective study conducted by 15 institutions participating in the Japanese Epidemiological Survey of Refractory Eosinophilic Chronic Rhinosinusitis (JESREC). We evaluated patients with CRS treated with endoscopic sinus surgery (ESS), and risk of recurrence was estimated using Cox proportional hazard models. Multiple logistic regression models and receiver operating characteristics curves were constructed to create the diagnostic criterion for ECRS.

Results: We analyzed 1716 patients treated with ESS. To diagnose ECRS, the JESREC scoring system assessed unilateral or bilateral disease, the presence of nasal polyps, blood eosinophilia, and dominant shadow of ethmoid sinuses in computed tomography (CT) scans. The cutoff value of the score was 11 points (sensitivity: 83%, specificity: 66%). Blood eosinophilia (>5%), ethmoid sinus disease detected by CT scan, bronchial asthma, aspirin, and nonsteroidal anti-inflammatory drugs intolerance were associated significantly with recurrence.

Conclusion: We subdivided CRSwNP in non-ECRS, mild, moderate, and severe ECRS according to our algorithm. This classification was significantly correlated with prognosis. It is notable that this algorithm may give useful information to clinicians in the refractoriness of CRS before ESS or biopsy.

Keywords: chronic rhinosinusitis severity; clinical diagnostic criterion; endoscopic sinus surgery; eosinophilic infiltration; refractory chronic rhinosinusitis.

© 2015 The Authors. Allergy Published by John Wiley & Sons Ltd.

Figures

Figure 1
Figure 1
Kaplan–Meier curves of the recurrence‐free rate according to the number of eosinophils in nasal polyps. (A) All patients were divided into quintile groups. Eosinophils/high‐power field (HPF) in 1st quintile is 0–3.3; 2nd, 3.3–19.0; 3rd, 19.0–66.2; 4th, 6.2–211.9; and 5th, >211.9. (B) When the cutoff value was set to 70/HPF, it was the most significant difference. (***P < 0.001).
Figure 2
Figure 2
Diagnostic algorithm of refractory even in chronic rhinosinusitis. Factor A is >5% of eosinophils in peripheral blood and ethmoid‐dominant shadow in computed tomography, while factor B is comorbid (bronchial asthma, aspirin intolerance, NSAIDs intolerance). *Factor A (+): all of two factors are applied, (−): at least one factor is not applied. **Factor B (+): at least one factor is applied, (−): all of three factors are not applied. Numbers under the figure show the proportion in the participant of this study.
Figure 3
Figure 3
Kaplan–Meier curves of the recurrence‐free rate according to the classified groups by the diagnostic algorithm. (Log& #x2010;rank test: P < 0.001).

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