Objective Outcome Measures and Staging Systems

In an effort to objectify the severity of chronic rhinosinusitis and the response to medical therapy, numerous staging systems have been proposed. Theoretically, a uniform reporting scheme and a uniformly accepted staging system would improve scientific and accurate communication between otolaryngologists. Such a staging system might also permit the subsequent re-staging of patients after therapeutic intervention and thus become a management tool. To date, however, such a staging system has remained elusive.

Early attempts to devise such objective staging systems incorporated measures of disease severity (e.g., localized vs diffuse disease) combined with the presence or absence of related factors (e.g., asthma, allergy, polyposis).13'14 Extensions and refinements of these techniques have been proposed more recently. The first significant step forward was made by Kennedy1 in 1992 and, more recently, the Lund-MacKay staging system was endorsed by the Rhinosinusitis Task Force for future outcomes research.3

Kennedy's close follow-up and data collection of a patient cohort was the first to emphasize the importance of objective endoscopic follow-up after surgery. Kennedy pointed out that early recurrent disease is often detectable objectively on nasal endoscopy before the development of subjective symptoms. This provided the opportunity to treat such recurrent disease, either medically or with surgical debridement, at an early stage, when it is more manageable.

With respect to outcome measures and prognostic factors, Kennedy's study identified extent of disease as the primary predictor. Other seemingly related and important factors such as asthma, allergies, and ASA sensitivity, when severity of disease was factored in, were not independently related to outcome and

TABLE 16-1

Staging for Chronic Rhinosinusitis (Kennedy)

TABLE 16-1




Anatomic abnormalities

All unilateral sinus disease

Bilateral disease limited to ethmoid sinuses


Bilateral ethmoid disease with involvement of one

dependent sinus


Bilateral ethmoid disease with involvement of two or

more dependent sinuses on each side


Diffuse sinonasal polyposis

SOURCE: Adapted from Kennedy DW. Prognostic factors, outcomes and staging in ethmoid sinus surgery. Laryngoscope 1992;102(suppl):1-18

SOURCE: Adapted from Kennedy DW. Prognostic factors, outcomes and staging in ethmoid sinus surgery. Laryngoscope 1992;102(suppl):1-18

prognosis. However, in stage IV disease (diffuse sinonasal polyposis), asthma did worsen the prognosis. The primary assessment of extent of disease was made using radiographic and intraoperative data, and similar evaluations were used when the initial staging system was proposed.

The staging system proposed by Kennedy stratified patients into 4 categories of increasing severity (Table 16-1). Based on the preliminary study performed by Kennedy, this staging system was demonstrated to have strong prognostic and predictive value. This permits patient comparisons independent of other miscellaneous factors.

A modified Lund-MacKay staging system has been recommended by the Rhinosinusitis Task Force for use in outcomes research. This system was originally based on a numeric score derived from computed tomography (CT) scan analysis. The Task Force recommended the addition of demographic data, description of the presence of anatomic variants, as well as a surgery score, a symptom score, and the endoscopic appearance (Tables 16-2 to 16-7). The endoscopic appearance, which appears to have significant postoperative prognostic importance, is not formally included in the staging system, but its recording is recommended.

It is becoming apparent that objective evaluations incorporating relevant comorbid conditions, extent of radiologic and operative disease, and the endoscopic response to therapeutic intervention are objective measurement parameters that have prognostic value. These prognostic indicators will likely be demonstrated in the future to impact on and influence the management of chronic rhinosinusitis, including the decision for additional medical or surgical intervention.

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