EPOS/ARIA

• Inflammation nose & paranasal sinuses with 2+ symptoms incl
• nasal blockage or discharge
• +/- facial pain/pressure
• +/- loss of smell

AND

endoscopic signs or CT changes

• 2 +symptoms incl
• nasal blockage or nasal discharge
• +/- facial pain
• +/- cough

AND

endoscopic signs and/or CT changes

• MILD = VAS 0-3
• MODERATE = VAS >3-7
• SEVERE = VAS >7-10

• Acute <12 weeks
• Chronic >12 weeks

Persistent symptoms despite adequate medical/surgical treatment

• Acute viral rhinosinusitis - symptoms <10days
• Acute post viral rhinosinusitis - increase in symptoms after  days 5 days or lasting >10 days <3 months

• Acute bacterial rhinosinusitis - 3+ signs incl
• -Discoloured discharge (with unilateral predominance)
• -Severe local pain (with unilateral predominance)
• -Fever (>38ºC)
• - Elevated ESR/CRP
• - ‘Double sickening’ (i.e. a deterioration after an initialmilder phase of illness).

• 
• Doxycycline 200mg 1/7 then 100mg od for 19 days

• History
• Examination
• +/- CT scan
• Allergy questionnaire - if +ve test

• chronic cough = symptom
• ?higher incidental ct findings
• Diagnosis = 2+blockage and/or d/c +/- pain +/- cough

• Adults 3-5/year
• Children 7-10/year
• 2% complicated by bacterial infection

• Environmental
• Anatomical
• Allergy
• Immune related
• Mucosal
• Reflux
• Anxiety,depression
• Dental
• Vasculitis

• 2+ >1 hour most days
• watery rhinorrhea
• sneezing
• nasal obstruction
• nasal pruritis
• +/- conjunctivitis

• GP - multiallergen test
• ENT - SPT, RAST if -ve SPT & strong suspicion or SPT contraindicated

• Intermittent- <4 days/week or <4 consecutive weeks
• Persistent > 4 days/week and >4 consecutive weeks

• Mild - normal sleep, no impairement daily activities/work/school
• Moderate/severe - sleep disturbance, impairment daily activitie/school/work,troublesome

• Intermittent
• Mild - oral or oral antihistmaines, LTRA, decongestant
• Mod/severe also topical steroids 

• Persistent
• Same mod/severe intermittent
• Mod/severe - preferred order
• Intranasal CS
• Antihistamine or LRTA
• If no improvement
• r/v dx
• increase dose intranasal CS
• Ipratrprium bromide for rhinorrhea
• Short term decongestansts/oral steroids
• If no improvement refer surgery

• If conjunctivitis add oral/opthalmic antihistamine.
• Consider specific immunotherapy

• Wheezing attacks
• Troublesome cough, sep at night
• Cough/wheeze after exercise
• Chest feel tight

• Exclusive breast feeding 3/12
• No ag avoidance diet pregnancy
• Avoid tobacco smoke pregnancy/children
• Infants and preschool children, we suggest multifaceted interventions to reduce early life exposure to house dust mite
• adults and children with perennial/persistent allergic rhinitis, we suggest that clinicians do not administer and patients do not use intranasal H1-antihistamines until more data on their relative efficacy and safety is available
• We suggest new generation oral H1-antihistamines rather than intranasal H1-antihistamines in adults with seasonal allergic rhinitis (conditional recommendation | moderate quality evidence) and in adults with perennial/persistent allergic rhinitis (conditional recommendation | very low quality evidence).We suggest new generation oral H1-antihistamines rather than intranasal H1-antihistamines in adults with seasonal allergic rhinitis (conditional recommendation | moderate quality evidence) and in adults with perennial/persistent allergic rhinitis (conditional recommendation | very low quality evidence).
• We suggest oral leukotriene receptor antagonists in adults and children with seasonal allergic rhinitis (conditional recommendation | high quality evidence) and in preschool children with perennial allergic rhinitis (conditional recommendation | low quality evidence). In adults with perennial allergic rhinitis we suggest that clinicians do not administer and patients do not use oral leukotriene receptor antagonists (conditional recommendation | high quality evidence).
• We suggest oral H1-antihistamines over oral leukotriene receptor antagonists in patients with seasonal allergic rhinitis (conditional recommendation | moderate quality evidence) and in preschool children with perennial allergic rhinitis (conditional recommendation | low quality evidence).
• In patients with seasonal allergic rhinitis, we suggest intranasal glucocorticosteroids over oral H1-antihistamines in adults (conditional recommendation | low quality evidence) and in children
• We suggest subcutaneous allergen specific immunotherapy in adults with seasonal (conditional recommendation | moderate quality evidence) and perennial allergic rhinitis due to house dust mites (conditional recommendation | low quality evidence).
• In children with allergic rhinitis, we suggest subcutaneous specific immunotherapy (conditional recommendation | low quality evidence).
• sublingual allergen specific immunotherapy in adults with rhinitis due to pollen (conditional recommendation | moderate quality evidence) or house dust mites

deranged interaction between host genetic and immunological factors and environmental and infectious agents