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Background Chronic rhinosinusitis (CRS) can be classified into CRS with nasal polyps (CRSwNP) and CRS without nasal polyps (CRSsNP). CRSwNP displays more intense eosinophilic infiltration and the presence of Th2 cytokines. Mucosal eosinophilia is associated with more severe symptoms and often requires multiple surgeries because of recurrence; however, even in eosinophilic CRS (ECRS), clinical course is variable. In this study, we wanted to set objective clinical criteria for the diagnosis of refractory CRS. Methods This was a retrospective study conducted by 15 institutions participating in the Japanese Epidemiological Survey of Refractory Eosinophilic Chronic Rhinosinusitis (JESREC). We evaluated patients with CRS treated with endoscopic sinus surgery (ESS), and risk of recurrence was estimated using Cox proportional hazard models. Multiple logistic regression models and receiver operating characteristics curves were constructed to create the diagnostic criterion for ECRS. Results We analyzed 1716 patients treated with ESS. To diagnose ECRS, the JESREC scoring system assessed unilateral or bilateral disease, the presence of nasal polyps, blood eosinophilia, and dominant shadow of ethmoid sinuses in computed tomography (CT) scans. The cutoff value of the score was 11 points (sensitivity: 83%, specificity: 66%). Blood eosinophilia (>5%), ethmoid sinus disease detected by CT scan, bronchial asthma, aspirin, and nonsteroidal anti-inflammatory drugs intolerance were associated significantly with recurrence. Conclusion We subdivided CRSwNP in non-ECRS, mild, moderate, and severe ECRS according to our algorithm. This classification was significantly correlated with prognosis. It is notable that this algorithm may give useful information to clinicians in the refractoriness of CRS before ESS or biopsy.

A 46-year-old Japanese woman pr esented with vesicles on her nose and the dosal aspect of her hands since 3 months. Physical examination revealed tense blisters and atrophic erythematous plaques on her arms and the dosal side of her hands (Fig. 1a). Erosions were also scattered on the face (Fig. 1b). She also had hypertrichosis on her face. The patient was first diagnosed as having systemic lupus erythematosus (SLE) in 1997 at the age of 41 years, when she presented with alopecia, fever, arthralgia, Raynaud’s phenomenon, hemolytic anemia and lymphadenopathy. Liver transamirase levels were slightly elevated. She had no sign of hepatitis including autoimmune hepatitis, drug-rela ted hepatotoxity, al coholic hepatitis, or viral infection. Systemic lupus eryhtematosus was well-controlled with a daily 5-mg dose of prednisolone (PSL). At age of 43 years she developed erythematous plaques with scaling on the back of her hands. Clinically the skin erupution at that time appeared to be discoid lupus erythematodes. She was treated with a steroid ointment and her eruptions gradually improved, but new skin lesions repeatedly appeared on her hands. Laboratory investigations at age 46 years while taking PSL 5mg disclosed the following results: white cell count 3.9 ×10