Rhinosinusitis: Establishing definitions for clinical research and patient care  Eli O. Meltzer, MD, Daniel L. Hamilos, MD, James A. Hadley, MD, Donald C. Lanza, MD, Bradley F. Marple, MD, Richard A. Nicklas, MD, Claus Bachert, MD, PhD, James Baraniuk, MD, Fuad M. Baroody, MD, Michael S. Benninger, MD, Itzhak Brook, MD, Badrul A. Chowdhury, MD, PhD, Howard M. Druce, MD, Stephen Durham, MD, Berrylin Ferguson, MD, Jack M. Gwaltney, MD, Michael Kaliner, MD, David W. Kennedy, MD, Valerie Lund, MD, Robert Naclerio, MD, Ruby Pawankar, MD, PhD, Jay F. Piccirillo, MD, Patricia Rohane, MD, Ronald Simon, MD, Raymond G. Slavin, MD, MS, Alkis Togias, MD, Ellen R. Wald, MD, S. James Zinreich, MD  Journal of Allergy and Clinical Immunology  Volume 114, Issue 6, Pages 155-212 (December 2004) DOI: 10.1016/j.jaci.2004.09.029 Copyright © 2004 American Academy of Allergy, Asthma and Immunology Terms and Conditions

Fig 1 Sinus CT scan of a patient with viral rhinosinusitis showing abnormalities of the maxillary and ethmoid sinuses. Reprinted with permission Arch Otolaryngol Head Neck Surg 1994;120:144. Copyrighted © 1994, American Medical Association. All Rights reserved. Journal of Allergy and Clinical Immunology 2004 114, 155-212DOI: (10.1016/j.jaci.2004.09.029) Copyright © 2004 American Academy of Allergy, Asthma and Immunology Terms and Conditions

Fig 2 Coronal CT scan of the maxillary sinus of an adult with a common cold. A, Fourth day of illness, showing multiple bubbles in the sinus cavity (white arrows), occlusion of the infundibulum (black arrowhead), and homogeneous abnormality along the medial wall and floor of the sinus cavity (black arrow). B, Seventh day of illness, showing occlusion of the infundibulum (black arrowhead) and homogenous abnormality of the lower two thirds of the sinus cavity (black arrow). Few bubbles are still present in this material, but most of those present earlier have burst (white arrow). Reprinted with permission from Gwaltney JM, Jr, Hendley JO, Phillips CD, et al. Nose blowing propels nasal fluid into the paranasal sinuses. Clin Infect Dis 2000;30(2):387-92. Published by The University of Chicago Press. © 2000 by the Infectious Diseases Society of America. Journal of Allergy and Clinical Immunology 2004 114, 155-212DOI: (10.1016/j.jaci.2004.09.029) Copyright © 2004 American Academy of Allergy, Asthma and Immunology Terms and Conditions

Fig 3 Intranasal pressure time histories for a representative nose blow, coughing bout, and sneeze shown on the same scale for comparison (dashed line, nose blow; solid line, coughing bout; dotted line, sneeze). Reprinted with permission from Gwaltney JM, Jr, Hendley JO, Phillips CD, et al. Nose blowing propels nasal fluid into the paranasal sinuses. Clin Infect Dis 2000;30(2):387-92. Published by The University of Chicago Press. © 2000 by the Infectious Diseases Society of America. Journal of Allergy and Clinical Immunology 2004 114, 155-212DOI: (10.1016/j.jaci.2004.09.029) Copyright © 2004 American Academy of Allergy, Asthma and Immunology Terms and Conditions

Fig 4 Sinus CT scan of an adult after instillation of contrast medium into the nasopharynx, followed by nose blowing. A, Contrast in an anterior ethmoid sinus cell (short arrow) and in the floor of the nasal cavities (long arrow). B, Contrast in the infundibulum bilaterally (short arrows) and in the maxillary sinus outlining a bubble (long arrows). C, Contrast in the posterior ethmoid sinus (arrow). D, Contrast in the sphenoid sinus outlining a bubble (arrow). Reprinted with permission from Gwaltney JM, Jr, Hendley JO, Phillips CD, et al. Nose blowing propels nasal fluid into the paranasal sinuses. Clin Infect Dis 2000;30(2):387-92. Published by The University of Chicago Press. © 2000 by the Infectious Diseases Society of America. Journal of Allergy and Clinical Immunology 2004 114, 155-212DOI: (10.1016/j.jaci.2004.09.029) Copyright © 2004 American Academy of Allergy, Asthma and Immunology Terms and Conditions

Fig 5 Soft tissue algorithm CT scan showing findings typical of AFRS. Note the heterogeneous appearance within involved paranasal sinuses. Journal of Allergy and Clinical Immunology 2004 114, 155-212DOI: (10.1016/j.jaci.2004.09.029) Copyright © 2004 American Academy of Allergy, Asthma and Immunology Terms and Conditions

Fig 6 Sinus pressure thresholds (mean ± 95% CI) decreased from the healthy control (non–chronic fatigue syndrome/no rhinosinusitis) to chronic fatigue syndrome/CRS group. Significant differences were found from non–chronic fatigue syndrome/no rhinosinusitis (∗P < .05, ∗∗P < .001, ∗∗∗P < .00001, and ∗∗∗∗P < .0000001), chronic fatigue syndrome/CRS (#P < .01, ##P < .0001), and chronic fatigue syndrome/no rhinosinusitis (@.07 < P < .05, @@P < .02). Sinus thresholds were significantly reduced in both subjects with chronic fatigue syndrome and subjects without chronic fatigue syndrome with acute rhinosinusitis and CRS compared with the non–chronic fatigue syndrome/no rhinosinusitis control group. CFS, Chronic fatigue syndrome; sinusitis, rhinosinusitis. Journal of Allergy and Clinical Immunology 2004 114, 155-212DOI: (10.1016/j.jaci.2004.09.029) Copyright © 2004 American Academy of Allergy, Asthma and Immunology Terms and Conditions

Fig 7 Two distinct histologic subsets of CRS. Glandular hypertrophy-hyperplasia is noted in May class III, with an increase in the percentage of the mucosal area occupied by mucous glands. In contrast, visually observed and histologic polypoid degeneration occurs in an exclusive and nonoverlapping group. Massive polyposis is found in pansinusitis (May class IV). Journal of Allergy and Clinical Immunology 2004 114, 155-212DOI: (10.1016/j.jaci.2004.09.029) Copyright © 2004 American Academy of Allergy, Asthma and Immunology Terms and Conditions

Fig 8 Proposed subclassification of CRS. Journal of Allergy and Clinical Immunology 2004 114, 155-212DOI: (10.1016/j.jaci.2004.09.029) Copyright © 2004 American Academy of Allergy, Asthma and Immunology Terms and Conditions

Table XII Individual rhinosinusitis symptoms: severity scoring assessment Journal of Allergy and Clinical Immunology 2004 114, 155-212DOI: (10.1016/j.jaci.2004.09.029) Copyright © 2004 American Academy of Allergy, Asthma and Immunology Terms and Conditions

Table XIII Global assessment of rhinosinusitis symptom severity Journal of Allergy and Clinical Immunology 2004 114, 155-212DOI: (10.1016/j.jaci.2004.09.029) Copyright © 2004 American Academy of Allergy, Asthma and Immunology Terms and Conditions

Table XIV Quality of life assessment for rhinosinusitis severity Journal of Allergy and Clinical Immunology 2004 114, 155-212DOI: (10.1016/j.jaci.2004.09.029) Copyright © 2004 American Academy of Allergy, Asthma and Immunology Terms and Conditions

Table XV Effect of current and past treatment assessments Journal of Allergy and Clinical Immunology 2004 114, 155-212DOI: (10.1016/j.jaci.2004.09.029) Copyright © 2004 American Academy of Allergy, Asthma and Immunology Terms and Conditions