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


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

  1. 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. $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. 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. $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. 5. Otolaryngology- Head and Neck Surgery Volume 117 Number 3 Part 2 LANZA and KENNEDY $5 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. 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. REFERENCES 1. Nationaldiseaseandtherapeuticindex.PlymouthMeeting,Pa.: IMSInc.;1992.p. 969-70.(gradeB) 2. Nationaldiseaseandtherapeuticindex.PlymouthMeeting,Pa.: IMSInc.;1994.p. 963-967.(gradeB) 3. LundVJ, KennedyDW.Quantificationforstagingsinusitis.The staging and therapygroup.Ann OtolRhinolLaryngolSuppl 1995;167:17-21.(gradeC) 4. GwaltneyJMJr,PhillipsCD,MillerRD,et al.Computedtomo- graphicstudyofthe commoncold.N EnglJ Med 1994;330:25- 30. (gradeA) 5. LewisCM. Protocolfor acuteand chronicsinusitis. J AmColl Health 1994;42:237-9.(gradeC)
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