1989). The airway remodeling, with basement membrane thickening and epithelial damage, is similar to that seen from the eosinophilic inflammatory process in asthma (Ponikau et al 2003). In contrast to allergic rhinitis, in which the eosinophils do not degranulate, they release only scant amounts of MBP and they do not target fungi. Meltzer and colleagues’ December 2004 definitions subcategorized patients into those with and those without polyps (Meltzer et al 2004). Meltzer and colleagues suggested that patients without polyps may be a subcategory of CRS in which the inflammatory cells in the mucin are mostly neutrophils. Cases with polyps, however, were noted to have eosinophilic inflammation. In contrast, Ponikau and colleagues noted that, regardless of the presence or absence of polyps, mucin from patients with CRS uniformly have substantially elevated levels of MBP, a well-accepted surrogate marker for eosinophilic migration and degranulation (Ponikau, Sherris, Kephart, et al 2005). One might postulate that, over time in CRS patients, this chronic and debilitating disease with accumulation of mucosa may result in polyps. The common histopathologic denominator in CRS with, and in some cases without, nasal polyposis, therefore, is the eosinophilic infiltration into the nasal mucosa. This is the histological hallmark of CRS in that the eosinophils are present independently from atopy and are nearly absent in healthy controls (Ponikau et al 1999). It is commonly accepted that the role of eosinophils in the immune system is the defense against large, nonphagocytosable pathogens such as helminthic parasites (Gleich et al 1993). Diagnosis It is important to recognize the signs and symptoms associated with the disease to be able to arrive at a diagnosis of CRS. Through a careful patient history, the clinician should be able to collect information on timing and severity of symptoms associated with CRS (Meltzer et al 2004). The RSTF developed a list of major and minor criteria (signs and symptoms) to aid in diagnosis of rhinosinusitis (Table 1). CRS is probable if the patient has two or more major factors or one major and two or more minor factors for more than 12 weeks; CRS should be considered in the differential diagnosis if the patient has one major factor or two or more minor factors for more than 12 weeks (Benninger et al 2003). It is also important to gauge the severity of the condition in the patient as well as the impact on the patient’s quality of life (QoL). A number of severity scoring systems and QoL questionnaires have been developed for assessment of Therapeutics and Clinical Risk Management 2007:3(2) Chronic rhinosinusitis CRS (Meltzer et al 2004). Quantifying the impact of CRS on a patient’s daily functioning aids in determining future patient outcomes with given treatments (Meltzer et al 2004). In addition to history, physical signs are important criteria in the diagnosis of CRS. Anterior rhinoscopy is a noninvasive means of viewing the nasal mucosa (Meltzer et al 2004). However, it is difficult to view beyond the anterior portion of the nasal passages, even after administration of topical decongestants. Nasal endoscopy, although more invasive, is a preferable method for obtaining a magnified view of the nasal mucosa, turbinates, and interior of the nasal airway in the preoperative and post- surgical patient. Endoscopy aids in assessing the integrity of the mucosa, as well as directly seeing mucosal changes, polyps, crusting, and/or discharge. Cultures can also be obtained endoscopically (Meltzer et al 2004). Discolored nasal discharge, polyps, or polypoid swelling seen with anterior rhinoscopy or endoscopy, and edema or erythema of the middle meatus or ethmoid bulla seen on endoscopy, are consistent with CRS (Benninger et al 2003). If edema, erythema, or granulation tissue do not extend to the middle meatus or ethmoid bulla, radiologic imaging is necessary to view the sinuses and to make or confirm the diagnosis of CRS (Benninger et al 2003). Imaging modalities are often necessary in CRS, especially in patients with refractory or recurrent disease. Plain film X-rays have not been proven to be useful in CRS. Computed tomography (CT) scanning is the imaging method of choice. Direct coronal CT affords an excellent view of the bony structures and mucosal lining. These coronal CT scans are indicated in patients with recurrent sinusitis or CRS in order to properly consider treatment options and sequence the steps in the evaluation. In surgical candidates, Table 1 Factors associated with diagnosis of rhinosinusitis (RSTF 1996) (Benninger et al 2003) Major factors Facial pain/pressure* Nasal obstruction/ blockage Nasal discharge/ purulence/ discolored postnasal drainage Hyposmia/ anosmia Purulence in nasal cavity on examination Fever (acute rhinosinusitis only)† Minor factors Headache Fever (all nonacute rhinosinusitis) Halitosis Fatigue Dental pain Cough Ear pain/ pressure/ fullness Note: *Facial pain/pressure alone does not constitute a suggestive history for rhinosinusitis in the absence of another major nasal symptom or sign; †Fever in acute sinusitis alone does not constitute a strongly suggestive history for rhinosinusitis in the absence of another major nasal symptom or sign. 321