The European Position Paper on Rhinosinusitis and Nasal Polyps 2012 is the update of similar evidence based position papers published in 2005 and 2007. The document contains chapters on definitions and classification, we now also propose definitions for 'difficult to treat' rhinosinusitis, control of disease and better definitions for rhinosinusitis in children. More emphasis is placed on the diagnosis and treatment of acute rhinosinusitis. Throughout the document the terms chronic rhinosinusitis without nasal polyps (CRSsNP) and chronic rhinosinusitis with nasal polyps (CRSwNP) are used to further point out differences in pathophysiology and treatment of these two entities. There are extensive chapters on epidemiology and predisposing factors, inflammatory mechanisms, (differential) diagnosis of facial pain, genetics, cystic fibrosis, aspirin exacerbated respiratory disease, immunodeficiencies, allergic fungal rhinosinusitis and the relationship between the upper and lower airways. The chapters on paediatric acute and chronic rhinosinusitis are totally rewritten. Last but not least all available evidence for management of acute rhinosinusitis and chronic rhinosinusitis with or without nasal polyps in adults and children is analyzed and presented and management schemes based on the evidence are proposed. This executive summary for otorhinolaryngologists focuses on the most important changes and issues for otorhinolaryngologists.

Contributing Authors: Isam Alobid, MD, PhD¹, Nithin D. Adappa, MD², Henry P. Barham, MD³, Thiago Bezerra, MD⁴, Nadieska Caballero, MD⁵, Eugene G. Chang, MD⁶, Gaurav Chawdhary, MD⁷, Philip Chen, MD⁸, John P. Dahl, MD, PhD⁹, Anthony Del Signore, MD¹⁰, Carrie Flanagan, MD¹¹, Daniel N. Frank, PhD¹², Kai Fruth, MD, PhD¹³, Anne Getz, MD¹⁴, Samuel Greig, MD¹⁵, Elisa A. Illing, MD¹⁶, David W. Jang, MD¹⁷, Yong Gi Jung, MD¹⁸, Sammy Khalili, MD, MSc¹⁹, Cristobal Langdon, MD²⁰, Kent Lam, MD²¹, Stella Lee, MD²², Seth Lieberman, MD²³, Patricia Loftus, MD²⁴, Luis Macias‐Valle, MD²⁵, R. Peter Manes, MD²⁶, Jill Mazza, MD²⁷, Leandra Mfuna, MD²⁸, David Morrissey, MD²⁹, Sue Jean Mun, MD³⁰, Jonathan B. Overdevest, MD, PhD³¹, Jayant M. Pinto, MD³², Jain Ravi, MD³³, Douglas Reh, MD³⁴, Peta L. Sacks, MD³⁵, Michael H. Saste, MD³⁶, John Schneider, MD, MA³⁷, Ahmad R. Sedaghat, MD, PhD³⁸, Zachary M. Soler, MD³⁹, Neville Teo, MD⁴⁰, Kota Wada, MD⁴¹, Kevin Welch, MD⁴², Troy D. Woodard, MD⁴³, Alan Workman⁴⁴, Yi Chen Zhao, MD⁴⁵, David Zopf, MD⁴⁶Contributing Author Affiliations: ¹Universidad de Barcelona; ²University of Pennsylvania; ³Louisiana State University Health Sciences Center; ⁴Universidade de São Paulo; ⁵ENT Specialists of Illinois; ⁶University of Arizona; ⁷University of Oxford; ⁸University of Texas; ⁹University of Indiana; ¹⁰Mount Sinai Beth Israel; ¹¹Emory University; ¹²University of Colorado; ¹³Wiesbaden, Germany; ¹⁴University of Colorado; ¹⁵University of Alberta; ¹⁶University of Alabama at Birmingham; ¹⁷Duke University; ¹⁸Sungkyunkwan University; ¹⁹University of Pennsylvania; ²⁰Universidad de Barcelona; ²¹Northwestern University; ²²University of Pittsburgh; ²³New York University; ²⁴Emory University; ²⁵University of British Columbia; ²⁶Yale University School of Medicine; ²⁷Private Practice; ²⁸Department of Otolaryngology, Hôtel‐Dieu Hospital, Centre de Recherche du Centre Hospitalier de l'Université de Montréal; ²⁹University of Adelaide; ³⁰Pusan National University; ³¹University of California, San Francisco; ³²University of Chicago; ³³University of Auckland; ³⁴Johns Hopkins University; ³⁵University of New South Wales, Australia; ³⁶Stanford University; ³⁷Washington University; ³⁸Harvard Medical School; ³⁹Medical University of South Carolina; ⁴⁰Singapore General Hospital; ⁴¹Taho University; ⁴²Northwestern University; ⁴³Cleveland Clinic Foundation; ⁴⁴University of Pennsylvania; ⁴⁵University of Adelaide; ⁴⁶University of Michigan

Multilevel anatomic obstruction is often present in snoring and obstructive sleep apnoea (OSA). As the nose is the first anatomical boundary of the upper airway, nasal obstruction may contribute to sleep-disordered breathing (SDB). A number of pathophysiological mechanisms can potentially explain the role of nasal pathology in SDB. These include the Starling resistor model, the unstable oral airway, the nasal ventilatory reflex and the role of nitric oxide (NO). Clinically, a number of case–control studies have shown that nasal obstruction is associated with snoring and mild SDB. However, there is not a linear correlation between the degree of nasal obstruction and the severity of SDB, while nasal obstruction is not the main contributing factor in the majority of patients with moderate to severe OSA. Randomised controlled studies have shown that in patients with allergic rhinitis or non-allergic rhinitis and sleep disturbance, nasal steroids could improve the subjective quality of sleep, and may be useful for patients with mild OSA, however, they are not by themselves an adequate treatment for most OSA patients. Similarly, nasal surgery may improve quality of life and snoring in a subgroup of patients with mild SDB and septal deviation, but it is not an effective treatment for OSA as such. On the other hand, in patients who do not tolerate continuous positive airway pressure (CPAP) well, if upper airway evaluation demonstrates an obstructive nasal passage, nasal airway surgery can improve CPAP compliance and adherence.

There is no standard definition for thyroid glands extending below the thoracic inlet, and there are no clear guidelines for pre-operatively identifying those patients that may require an intrathoracic approach. We therefore reviewed the current literature in order to establish the current practices regarding the management of retrosternal goitres (RSGs), and propose a classification system to aid pre-operative planning for this important group of patients. A PubMed Medline search was conducted using the search terms 'retrosternal', 'substernal', 'intrathoracic', 'mediastinal', 'goitre' and 'goiter', resulting in 626 hits. Exclusion criteria reduced the number of papers to the 34 used for this review. A total of 34 papers totaling 2426 patients were included. Eighty-four percent of patients operated on for RSG were achieved via a cervical approach, with the remainder also requiring manubriotomy (3.1%), full sternotomy (6.6%) or thoracotomy (4%). Tracheomalacia occurred in 1% of patients and Superior Vena Cava syndrome (SVC) in 3.2%. There was a clear and highly significant association between the extent and definition of RSG and reported complications, as well as the approach used, with the incidence of tracheomalacia, SVC and need for intrathoracic approach increasing more than 10-fold in cases of RSG reaching the aortic arch. There is a clear need to establish a common standard in the definition and description of the extent of RSG. Using our findings, we propose a new, simple, 3-grade classification system of RSGs, based on their relation with the aortic arch and the right atrium.