Research Needs section from Adult Sinusitis (Update) CPG
The guideline development group identified knowledge gaps based on existing practice patterns and the scope and quality of supporting literature. We present these gaps below to highlight areas for future research and investigation.
- Define the natural history and management of subacute rhinosinusitis.
- Determine the validity of diagnosing ABRS by patient history without confirmatory physical examination.
- Refine and validate diagnostic criteria for VRS and ABRS.
- Determine whether a 7- or 10-day symptom duration is more likely to be associated with ABRS.
- Assess the validity of diagnosing ABRS before 10 days based on persistent fever plus concurrent purulent nasal discharge.
- Determine whether a diagnostic algorithm tool would change physician behavior in terms of antibiotic prescription practices.
- Assess the impact of clinician beliefs about antibiotic prescribing for ABRS and how they might affect patient preferences and satisfaction.
- Assess the value of viral screening methods in the routine management of patients with suspected ABRS.
- Conduct randomized controlled trials (RCTs) to determine the efficacy of an “observation option” for nonsevere ABRS, by randomizing patients to immediate vs delayed antibiotics and assessing clinical outcomes.
- Standardize the definition of “severe” illness in patients diagnosed with ABRS and determine whether it is a valid and useful distinction for diagnosis in adults. Establish the proper terminology and management of sinusitis symptoms lasting between 4 and 12 weeks.
- Conduct RCTs with a superiority design that emphasize time to improvement/resolution, not just binary outcomes at fixed time points.
- Perform RCTs of antibiotics vs placebo using strict diagnostic criteria and stratify by clinical severity (ie, mild, moderate, or severe).
- Perform RCTs to assess the comparative efficacy of different antibiotics for initial management of uncomplicated ABRS.
- Evaluate the role of analgesic therapy in managing rhinosinusitis and the comparative efficacy of different drug classes.
- Assess the benefits of symptomatic therapy for VRS in properly conducted RCTs.
- Assess the benefits of various symptomatic therapies for ABRS in properly conducted RCTs.
- Determine optimum salinity, pH, and regimen for administering nasal saline irrigation.
- Devise strategies or treatment regiments to avoid the rebound effect of topical nasal decongestants.
- Determine the comparative clinical efficacy of antibiotics for culture-proven ABRS using RCTs with standardized, uniform definitions of clinical disease, severity, and clinical outcomes.
- Conduct RCTs to determine the efficacy of adjuvant therapy (nasal steroids, antihistamines, decongestants) in combination with antibiotics.
- Obtain greater evidence for which ABRS patients are most appropriate for short-course antibiotic regimens.
- Perform RCTs examining antibiotic efficacy among patient subpopulations and efficacy of fluoroquinolones relative to other antibiotics.
- Include quality-of-life and other patient-reported outcome measures as study outcomes in RCTs.
- Further assess the diagnosis of CRS and recurrent acute rhinosinusitis in primary care settings, rather than specialty clinic settings, because of biased disease prevalence.
- Conduct investigations to further characterize the role of fungi in the etiology of inflammation of the paranasal sinuses.
- Conduct investigations to determine the underlying causes of the inflammation that characterizes CRS and to determine the value of individualizing therapy based on this information.
- Determine the pathogenesis of CRS and the association of allergic rhinitis and CRS.
- Establish the benefit of testing for allergy and immune function in subgroups of patients with CRS.
- Perform RCTs to address outcomes of allergy management in patients with CRS or recurrent acute rhinosinusitis.
- Perform RCTs to address outcomes of detecting and managing immunodeficient states in patients with CRS or recurrent acute rhinosinusitis.
- Validate nasal endoscopy scoring systems.
- Assess the impact of intravenous immonoglobulin (IVIG) on CRS or recurrent acute rhinosinusitis in patients with humoral immune deficiency.
- Conduct longitudinal studies with comparable control groups to evaluate long-term benefits of adjunctive therapies in the secondary prevention of CRS and recurrent acute rhinosinusitis.
- Perform quantitative studies evaluating the impact of healthy lifestyle changes, such as smoking cessation, dietary modification, and exercise on CRS.
- Conduct RCTs of saline nasal irrigations as short-term vs long-term treatment for recurrent acute and CRS.
- Determine whether there is a difference in efficacy between isotonic and hypertonic concentrations for intranasal saline irrigations.
- Define what is maximal medical therapy, including the efficacy of certain medications over others and the amount of time required for treatment.
- Identify the natural history of CRS and determine whether it is curable.
- Determine if certain subtypes of CRS with nasal polyps may respond to antifungal therapy.
- Further assess the cost-effectiveness of management strategies for CRS and their impact on resource utilization and patient quality of life.
- Perform additional RCTs to clarify the impact of antibiotic therapy on CRS outcomes.
