Nasal polyps in asthma and rhinitis. A review of 6,037 patients

Effect of Dupilumab in CRSwNP Sinonasal Outcomes from Real Life Studies: A Systematic Review with Meta-analysis

PURPOSE OF REVIEW

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a debilitating inflammatory condition that significantly impacts quality of life. Despite treatment advances, recurrence is common, prompting the exploration of novel therapies such as monoclonal antibodies targeting the type 2 immune response, notably dupilumab. This research aims to evaluate the real-world evidence (RWE) of dupilumab in treating severe CRSwNP, comparing sinonasal outcomes to those observed in randomized clinical trials.

RECENT FINDINGS

Significant improvements were noted, with the average SNOT-22 score reduction being 37.2 points post-dupilumab treatment. The nasal polyp size (NPS) showed an average decrease of 3.6 points. The analysis highlighted the practical effectiveness of dupilumab, emphasizing its benefit over conventional therapies in reducing NPS and improving nasal symptoms. The findings advocate for the integration of dupilumab into standard treatment protocols for severe CRSwNP, providing a robust alternative that could potentially reduce the high recurrence rates associated with current management strategies. This study underscores the utility of RWE in assessing the effectiveness of new medical treatments, suggesting that dupilumab offers substantial real-world benefits for patients suffering from this challenging condition.

Clinicopathological Changes of the Maxillary Sinus in Patients With Ethmoidal Polyposis: A Prospective Observational Study

OBJECTIVE OF STUDY

To determine the clinical, radiological and histopathological changes in maxillary antrum compared to ethmoid sinuses in patients with chronic sinusitis with nasal polyposis.

STUDY DESIGN

This is a prospective observational study conducted in a tertiary care hospital.

MATERIALS AND METHODS

A total number of 30 primary cases of inflammatory nasal polypi, not responding to conservative measures, were evaluated clinically and radiologically. They underwent endoscopic sinus surgery, and all sinuses were cleared of diseases. Histopathological evaluation of both maxillary sinus and ethmoid sinuses was done and compared.

RESULTS

Among 30 patients with 60 nasal cavities studied, nearly all showed partial or complete opacity of their maxillary antrum and blocked osteomeatal complexes on radiology. But, only a few patients (16.67%) showed frank polypi in their antrum intra-operatively. On histopathology, antral mucosa showed rare involvement, and the submucosa showed variable grades of inflammation, but it was significantly less compared to ethmoids.

CONCLUSION

Although maxillary antrum gets involved clinically in nearly all polyposis cases, pathological involvement is unlikely compared to ethmoid sinuses. Thus, it indicates a secondary inflammatory change in maxillary sinuses rather than primary involvement.

When the Nose Meets the Lab: Histopathological Analysis in Chronic Rhinosinusitis with Nasal Polyps for Routine Clinical Practice

PURPOSE OF REVIEW

We aimed to review the latest evidence regarding the value of tissue histopathological analysis in chronic rhinosinusitis with nasal polyps (CRSwNP) and to facilitate tissue analysis by proposing a pragmatic checklist for clinical settings.

RECENT FINDINGS

CRSwNP is a chronic inflammatory disease that severely impairs the patient's quality of life. The severity of the disease can be correlated with nasal polyps enriched in eosinophils/IL-5 and, although ≥ 10 eosinophils per high power field are considered enough to determine an eosinophilic CRS, this cut-off value, the biopsy method, and the sampling location are still a matter of debate. Besides, tissue eosinophil values might also have some added value when combined with other cellular counts (e.g., eosinophil-to-lymphocyte ratio, Charcot-Leyden crystals). Structured histopathology analysis of sinonasal tissue-including, for instance, tissue remodelling biomarkers, fibrosis, and eosinophilic aggregates-has proven to be a valuable tool for healthcare professionals to identify different pheno-endotypes of CRSwNP and to improve the prioritisation of candidates to targeted therapies. Patients with CRSwNP are treated according to their severity with corticosteroids (intranasal and systemic), endoscopic sinus surgery, and/or biological therapy. A panel of expert ear, nose, and throat specialists and pathologists proposed a pragmatic checklist to improve the clinical practice around tissue analysis in CRSwNP, to facilitate communication between hospital-based healthcare professionals, and to standardize the evaluation of inflammatory biomarkers.

Targeting Epithelium Dysfunction and Impaired Nasal Biofilms to Treat Immunological, Functional, and Structural Abnormalities of Chronic Rhinosinusitis

Chronic rhinosinusitis (CRS) with (CRSwNP) or without (CRSsNP) nasal polyps is a prevalent and heterogeneous disorder existing as a spectrum of clinical conditions with complex underlying pathomechanisms. CRS comprises a broad syndrome characterized by multiple immunological features involving complex interactions between the genes, the microbiome, host- and microbiota-derived exosomes, the epithelial barrier, and environmental and micromilieu exposures. The main pathophysiological feature is an epithelial barrier disruption, accompanied by microbiome alterations and unpredictable and multifactorial immunologic overreactions. Extrinsic pathogens and irritants interact with multiple epithelial receptors, which show distinct expression patterns, activate numerous signaling pathways, and lead to diverse antipathogen responses. CRSsNP is mainly characterized by fibrosis and mild inflammation and is often associated with Th1 or Th17 immunological profiles. CRSwNP appears to be associated with moderate or severe type 2 (T2) or Th2 eosinophilic inflammation. The diagnosis is based on clinical, endoscopic, and imaging findings. Possible CRS biomarkers from the peripheral blood, nasal secretions, tissue biopsies, and nasally exhaled air are studied to subgroup different CRS endotypes. The primary goal of CRS management is to maintain clinical control by nasal douching with isotonic or hypertonic saline solutions, administration of nasal and systemic steroids, antibiotics, biologic agents, or, in persistent and more severe cases, appropriate surgical procedures.

Effectiveness of Dupilumab Treatment to Treat Chronic Rhinosinusitis With Nasal Polyposis: A Systematic Review and Meta-Analysis

Background and Objectives

Evidence bearing on the safety and efficacy of dupilumab treatment for chronic rhinosinusitis with nasal polyps (CRSwNP) has recently been presented by researchers from various institutions. Therefore, we compared the safety and efficacy of dupilumab treatment to those of endoscopic sinus surgery.

Methods

The PubMed, Scopus, Embase, Web of Science, and Cochrane databases were searched independently by two authors from the dates of their inception to December 2022. We retrieved the clinical results of CRSwNP patients after dupilumab administration, including changes in patient symptoms and the effects on the quality of life, and compared the results of dupilumab (treatment group) to those of endoscopic sinus surgery (control group).

Results

Eight articles (1,251 patients) were ultimately included. Dupilumab significantly improved nasal symptoms (nasal congestion) (mean difference [MD], -1.4433; 95% confidence interval [CI], -1.7233 to -1.1632; I2=94.2%), the visual analog sinusitis score (MD, -5.0506; 95% CI, -5.4744 to -4.6267; I2=84.0%), olfactory function (standardized MD, 1.2691; 95% CI, 1.1549 to 1.3833; I2=18.4%), the quality of life (SNOT-22 score) (MD, -34.4941; 95% CI, -39.4187 to -29.5695; I2=90.8%), the Lund-Mackay computed tomography score (MD, -7.2713; 95% CI, -8.9442 to -5.5984; I2=87.7%), and the nasal polyp score (MD, -3.1021; 95% CI, -3.7066 to -2.4977; I2=95.6%) at about 12 months after treatment compared to the pretreatment values. Compared to endoscopic sinus surgery, dupilumab similarly improved olfactory function (MD, 1.9849; 95% CI, -1.6190 to 5.5888; I2=0.0%) but was less effective in terms of reducing the SNOT-22 score (MD, 3.8472; 95% CI, 1.9872 to 5.7073; I2=96.7%) and reducing nasal congestion (MD, 0.6519; 95% CI, 0.5619 to 0.7420; I2=97.7%).

Conclusion

Dupilumab reduced subjective symptom scores and improved the quality of life and objective measures of progression compared to the preoperative values.

Diagnostic value of serum and tissue eosinophil in diagnosis of asthma among patients with chronic rhinosinusitis

BACKGROUND

Chronic rhinosinusitis (CRS) is one of the most common chronic inflammatory diseases of sinonasal mucosa. Asthma among CRS patients is often underdiagnosed which makes the management of CRS more challenging. Therefore, using serum and tissue eosinophil as an indicator and predictor of asthma in CRS patients is vital for further preventing recurrent and increasing the effectiveness of treatment for CRS.

OBJECTIVE

To determine the association and diagnostic ability of serum and tissue eosinophils in the diagnosis of asthma among CRS patients.

METHODS

A cross-sectional study was conducted involving 24 CRS patients with asthma and without asthma, respectively, from the Otorhinolaryngology clinic of two tertiary hospitals located on the East Coast of Peninsular Malaysia. Serum and tissue eosinophils (obtained from nasal polyp) levels between both groups were compared. Association between serum and tissue eosinophils with asthma was evaluated using logistic regression analysis, adjusting for important sociodemographic characteristics. The diagnostic ability of serum and tissue eosinophil was then evaluated by assessing the receiver operating characteristic curve.

RESULTS

A total of 48 CRS patients with a mean [SD] age of 47.50 [14.99] years were included. Patients with asthma had significantly higher serum [0.48 vs 0.35 × 109/L] and tissue eosinophil [100 vs 8.5 per HPF] levels. Tissue eosinophils were found to be an independent predictor of asthma with adjusted OR 1.05, p < 0.001, after adjusting for age and serum eosinophils. The area under the receiver operating characteristic curve for serum eosinophil was 69.0%. At optimal cut-off value (0.375 × 109/L), the sensitivity and specificity for serum eosinophil was 75.0% and 70.8%. The area under the receiver operating characteristic curve for tissue eosinophil was 93.4%. At the optimal cut-off value (58.0 per HPF), the sensitivity and specificity for tissue eosinophils were 79.2% and 91.7%, respectively.

CONCLUSION

This study indicates a significantly higher level of serum and tissue eosinophils in CRS with asthma. However, there was no correlation between serum and tissue eosinophils in both group. Based on this study, the CRS patient needs to be screened for asthma if the level of serum eosinophil is > 0.375 × 109/L and tissue eosinophil > 58 per HPF.

Therapeutic Strategies to Prevent the Recurrence of Nasal Polyps after Surgical Treatment: An Update and In Vitro Study on Growth Inhibition of Fibroblasts

Chronic rhinosinusitis with nasal polyps (CRSwNP) is the most bothersome phenotype of chronic rhinosinusitis, which is typically characterized by a Type 2 inflammatory reaction, comorbidities and high rates of nasal polyp recurrence, causing severe impact on quality of life. Nasal polyp recurrence rates, defined as the number of patients undergoing revision endoscopic sinus surgery, are 20% within a 5 year period after surgery. The cornerstone of CRSwNP management consists of anti-inflammatory treatment with local corticosteroids. We performed a literature review regarding the therapeutic strategies used to prevent nasal polyp recurrence after surgical treatment. Finally, we report an in vitro study evaluating the efficacy of lysine-acetylsalicylic acid and other non-steroidal anti-inflammatory drugs (ketoprofen and diclofenac) on the proliferation of fibroblasts, obtained from nasal polyp tissue samples. Our study demonstrates that diclofenac, even more so than lysine-acetylsalicylic acid, significantly inhibits fibroblast proliferation and could be considered a valid therapeutic strategy in preventing CRSwNP recurrence.

Clinical outcomes of dupilumab therapy in chronic rhinosinusitis with nasal polyps in a Canadian tertiary care rhinology practice

BACKGROUND

In 2020, dupilumab became the first monoclonal antibody therapy to be approved by Health Canada for the treatment of chronic rhinosinusitis with nasal polyps (CRSwNP). The primary aim of this study was to characterize the outcomes in an initial cohort of patients with CRSwNP who have undergone dupilumab therapy.

METHODS

A retrospective study was conducted of patients with CRSwNP who were treated with dupilumab. Demographic information, comorbidities, number of previous surgeries, and insurance information were collected. The primary outcome were changes in the sinonasal outcome test (SNOT-22) scores from baseline to timepoints after receiving dupilumab.

RESULTS

Forty-eight patients were considered for dupilumab therapy, and 27 (56%) received coverage or were able to fund the medication independently. Patients waited an average of 3.6 months to obtain access to the medication. The mean age of the patients was 43. Forty-one percent (11/27) of patients had aspirin exacerbated respiratory disease, and 96% (26/27) had a diagnosis of asthma. The mean length of time on dupilumab was 12.1 months. The baseline SNOT-22 score was 60.6. The mean decrease at 1 month, 3 months, 6 months, and 12 months after starting dupilumab was 8.8, 26.5, 42.8, and 33.8, respectively. There were no serious adverse events.

CONCLUSION

Patients treated with dupilumab in a Canadian tertiary care rhinology clinic demonstrated substantial clinical improvement as measured by disease-specific sinonasal outcomes. Further studies are needed to determine the longer-term effectiveness and adverse event profile of this novel therapy.

Real-Life Effectiveness of Mepolizumab in Refractory Chronic Rhinosinusitis with Nasal Polyps

The aim of this study was to evaluate the efficacy of mepolizumab in patients affected by chronic rhinosinusitis with nasal polyps (CRSwNP) in real-life. A single-center retrospective observational study was conducted on severe CRSwNP patients treated with mepolizumab. Nasal endoscopic polyp score (NPS), visual analogue scale (VAS) symptom score, sinonasal outcome test (SNOT-22), asthma control test (ACT) score, fractional exhaled nitric oxide (FeNO), eosinophils blood cells and prednisone intake were assessed at baseline and after 6 months. A total of 55 patients were included; 49 patients (89%) presented with asthma; aspirin exacerbated respiratory disease (AERD) in 28 patients (51%). A statistically significant decrease in the SNOT-22 score was observed (median difference -63; 95% CI: -68; -58; p < 0.001) with median t0 76 and IQR (61;90) to t6 10 (5;15). A reduction in NPS, median t0 NPS 4; (IQR:4;6), median t6 NPS 1; (IQR:0;1) p < 0.001, was greater in patients with AERD. The median baseline VAS score was 6 (IQR:6;7) and the differences between t0 and t6 were statistically significant p < 0.001. Significant changes in blood eosinophils cells, median t0 500 cell/mcl (IQR:340;830), median t6 97 cell/mcl (IQR:60;160) p < 0.001, were greater in patients with AERD. Mepolizumab treatment effects have been demonstrated with significantly reduced symptoms, polyp scores, blood eosinophils and systemic corticosteroid use, resulting in an increased health-related quality of life in patients with severe CRSwNP, regardless of the presence or absence of asthma or AERD.

Phenotypes of Chronic Rhinosinusitis and Peripheral Blood Leukocytes Parameters in Elderly Patients

Background and Objectives: Chronic rhinosinusitis (CRS) is a common disease that can be differentiated into two phenotypes, with or without polyps (CRSwNP) or CRSsNP), which may be unilateral (UNIL) or bilateral (BIL). CRS may have an impact on absolute neutrophils and lymphocytes count in peripheral blood. The aim of the study was to investigate whether the incidence of a specific CRS phenotype changes with age and to compare the values of neutrophils, lymphocytes and neutrophil-to-lymphocyte ratio in the peripheral blood between groups of patients below and above 65 years of age with different CRS phenotypes. Material and Methods: A total of 235 patients aged 65 and over were examined, including 140 (59.6%) males. The group of patients <65 years of age comprised 160 subjects, including 103 (64.4%) males. In both groups, the sequence of frequency of particular phenotypes was similar: the most common phenotype was bilateral CRSwNP followed by CRSsNP BIL, CRSsNP UNIL, and finally, CRSwNP UNIL. Direct comparisons between determined phenotype in both groups of different ages revealed that, in the group ≥65 years, CRSwNP BIL occurred significantly more often than in the group <65 years of age. In fact, in the <65 group, bilateral CRSsNP was more common. The absolute neutrophils and lymphocytes counts were significantly higher in the whole group of patients with CRS ≥65 years of age and absolute number of neutrophils was higher in ≥65 years of age group with bilateral CRSsNP. Conclusions: The higher number of neutrophils in the whole ≥65 years of age group and in older patients with bilateral CRSsNP may indicate that CRS, despite of phenotype, may be an important source of infection that requires surgical treatment in elderly patients as well.

Nasal cytology as a reliable non-invasive procedure to phenotype patients with type 2 chronic rhinosinusitis with nasal polyps

BACKGROUND

The identification of type-2 inflammation in patients with chronic rhinosinusitis with nasal polyps (CRSwNP) acquires a crucial role in the endotypization needed for selecting patients for biological drugs targeting type-2 inflammation: to date, the parameters used include systemic and histological biomarkers. The aim of this study was to investigate whether nasal cytology could identify type-2 inflammation in patients with CRSwNP.

METHODOLOGY

Thirty-three consecutive patients with CRSwNP underwent nasal cytology sampling at the level of the lower nasal turbinate, and of the polypoid tissue, and surgical polyp tissue sample was collected. The cellularity of the 3 collected samples were compared.

RESULTS

Mean nasal polyp tissue, nasal polyps cytology and inferior turbinate cytology eosinophils counts were 43.7 ± 39.6 cells/HPF, 32.8 ± 44.7 cells/HPF and 27.6 ± 58.0 cells/HPF respectively with inferior turbinate cytology eosinophils significantly lower than nasal polyp tissue count (p = 0.007). Both mean nasal polyps cytology eosinophils and mean inferior turbinate cytology eosinophils were significantly higher in patients with type-2 CRSwNP (52.5 ± 67.0 cells/HPF vs 12.2 ± 17.3 cells/HPF, p = 0.012, and 32.0 ± 62.1 cells/HPF vs 2.9 ± 2.9 cells/HPF, p = 0.020 respectively).

CONCLUSIONS

Nasal cytology is suitable tool for assessing local biomarkers of type-2 inflammation in CRSwNP.

Neutrophil Lymphocyte Ratio: A Predictor of Disease Severity in Nasal Polyposis and Allergic Fungal Rhinosinusitis

To evaluate Neutrophil Lymphocyte ratio (NLR) as a predictor of disease severity in Nasal Polyposis and Allergic Fungal Rhinosinusitis (AFRS). This was a prospective non-randomized interventional study. Disease severity was graded based on endoscopic and CT scoring. Patients were given pre-operative oral steroids for two weeks and taken up for surgery. The pre-treatment neutrophil lymphocyte ratios were calculated from the differential leucocyte counts and compared with the disease severity and post-operative values. In the interventional arms, the disease severity correlated with the NLR. The mean pre-treatment NLR showed a statistically significant change after the intervention at eight weeks. The NLR normalized in patients with nasal polyposis and continued to be higher in patients with AFRS. NLR correlated to the disease severity and showed a linear correlation with the extent of the disease. NLR could be a potential cost-effective marker for disease severity and prognostication. Level of Evidence: Individual Cohort Study (2b).

Ingrained Insight into Nasal Polyposis; Role of Human Papillomavirus: An Indian Study

Nasal polyposis (NP) are benign lesion of nasal cavity, affecting up to 1-4% of population. It is known to have up to 70% recurrence rate. The underlying pathophysiology is still undetermined. Recent literatures have thrown light on the viral aetiology for NP. To our knowledge this is the first Indian study done, that aims to evaluate the prevalence of Human papillomavirus (HPV) in NP. It was a prospective case control study done among 40 individuals with NP and 40 healthy controls in a tertiary care centre. All the patients were subjected to routine clinical evaluation, investigations prior to proposed surgeries. The mucosal samples after the surgery were subjected to HPV DNA analysis by RT-PCR. Among the cases, the male to female ratio was 1.3:1. The mean age of patients with NP was 39 ± 14.6. The mean serum IgE levels among the case were 154 IU/ml and was significantly higher as compared to controls. Other inflammatory markers such as absolute eosinophil count, erythrocyte sedimentation rate, and neutrophil to leukocyte ration were found to be not significant. There was no HPV DNA detected among both case as well as controls. There seems to be strong association of IgE and NP, suggesting an IgE mediated pathway for its Causation. There is no association of HPV in NP.

Local Immunoglobulin E in nasal polyps: Role and modulation

In the airway, IgE is traditionally regarded as a key mediator in allergic diseases, such as AR and allergic asthma. However, growing evidence demonstrates the importance of local IgE in airway inflammatory diseases, irrespective of the presence of allergy. In this review, we discuss the most recent evidence for IgE in chronic rhinosinusitis with nasal polyps(CRSwNP), including the local IgE’s characteristics, the modulation of its synthesis, and its function. The levels of local IgE are significantly elevated in polyps independently of IgE serum levels and atopic status. Local IgE, which is correlated with type 2 inflammation, is polyclonal and functional. IgE is produced by active B cells and is dependent on the class switch recombination(CSR). In NPs, this process is triggered by not only allergens but also microbial colonization, especially the superantigen- Staphylococcus aureus. The production of local IgE is modulated by lymphocytes(such as Tfh, ILC2s, iTreg), cytokines(such as IL-4, IL-13, IFN-γ, TGF-β, IL-2, IL-21), transcription factors, and B cell-intrinsic factor. Due to the central role of IgE in NPs, it is regarded as an ideal target for therapy and has been proved to be clinically successful. Based on this knowledge, we believe that exploring the trigger and regulatory factors for the activation of local B cells and CSR to IgE will provide more valuable information for us to recognize the pathological mechanisms of local IgE and offer the possible option for new therapeutic targets of nasal polyps.

Immunolocalization of CD1a expressing dendritic cells in sinonasal polyposis

Sinonasal polyps are benign projections of edematous nasal mucosa lined by respiratory epithelium. Langerhans cells (LCs) belonging to the dendritic cell family located in respiratory epithelium are involved in antigen presentation and maintenance of local immunological homeostasis. This study aims to elucidate the morphology and distribution of CD1a positive LCs in normal nasal mucosa and compare the same with polypoid nasal mucosa by immunohistochemistry. Normal nasal mucosa (n = 20) was obtained from patients who underwent septoplasty for deviated nasal septum. Polypoid nasal mucosa (n = 22) was obtained from patients with chronic rhinosinusitis (CRS) or allergic fungal rhinosinusitis who underwent excision of nasal polyps. The tissues obtained were processed for immunohistochemistry and stained with CD1a-EP80 Rabbit monoclonal antibody. In the tissues studied, CD1a positive LCs were observed in both the epithelium and lamina propria. Different morphological subtypes of LCs were noted in the epithelium. The cells were distributed adjacent to walls of subepithelial capillaries and cysts. The median number of CD1a positive LCs was significantly higher in polypoid category (13.5 per mm²) as compared with normal nasal mucosa (2.5per mm²) (p = .001). Presence of CD1a positive LCs in polypoid nasal mucosa hints at a critical immunological role in the etiopathogenesis of nasal polyps.

Benralizumab improves symptoms of patients with severe, eosinophilic asthma with a diagnosis of nasal polyposis

BACKGROUND

Clinically meaningful improvement in the Sino-Nasal Outcome Test-22 (SNOT-22) was observed in patients with severe, eosinophilic asthma, and nasal polyposis (NP) treated with benralizumab in the ANDHI trial. A post hoc assessment of the effects of benralizumab on SNOT-22 response and asthma efficacy measures in these patients was conducted for further characterization of the efficacy and safety of benralizumab for patients with severe asthma and NP.

METHODS

Adults with severe, eosinophilic asthma who had experienced ≥2 prior-year exacerbations despite high-dosage inhaled corticosteroid plus additional controller[s] were randomized to 24 weeks of benralizumab or placebo. Patients with physician-diagnosed chronic rhinosinusitis with NP of any severity ongoing at baseline who consented to participate were included in the current ANDHI NP substudy population. Effect on NP symptoms was assessed by the SNOT-22, with an improvement of at least 8.9 defined as clinically significant (responder). Effects on chronic asthma outcomes were assessed by means of annualized asthma exacerbation rate (AER), St. George's Respiratory Questionnaire (SGRQ) total score, forced expiratory volume in one second (FEV₁ ), and Asthma Control Questionnaire-6 (ACQ-6). All p-values were nominal.

RESULTS

Of the ANDHI population (n = 656), 23% (n = 153) participated in the NP substudy (n = 96 benralizumab; n = 57 placebo). Patients were 50% female, with mean age of 53 years, had prior-year AER = 3.3; mean pre-bronchodilator FEV₁  = 55% predicted; and median blood eosinophil count ​= 510 cells/µl. For patients with high baseline SNOT-22 scores (>30), benralizumab treatment improved symptoms of NP as measured by SNOT-22 from baseline to Week 24 compared with placebo (Week 24: -10.44 [p = .0176]). Percentage of responders to SNOT-22 was greater for benralizumab vs. placebo (71.3% vs. 45.5%; p = .0036), and effect was enhanced for patients with high baseline SNOT-22 scores (>30). A 69% reduction vs. placebo in annualized AER (0.77 vs. 2.47; p < .0001) and greater clinically meaningful improvements from baseline in SGRQ total score (-16.7), FEV₁ (+0.32 L), and ACQ-6 (-0.88) were observed (p < .0001). Benralizumab was well-tolerated. Frequency of adverse events (AEs) was similar for benralizumab (76.0%) and placebo (73.7%) groups. Most common AEs (frequency ≥5%) reported at a greater frequency in benralizumab vs. placebo included headache, sinusitis, pyrexia, and influenza.

CONCLUSIONS

These substudy data from ANDHI demonstrated the efficacy profile of benralizumab for patients with severe, eosinophilic asthma and NP, with improvement in SNOT-22 and asthma outcomes.

Economic Evaluation of Dupilumab versus Endoscopic Sinus Surgery for the Treatment of Chronic Rhinosinusitis with Nasal Polyps

BACKGROUND

Dupilumab is a novel monoclonal antibody that recently received FDA approval for the treatment of chronic rhinosinusitis with nasal polyps (CRSwNP). Endoscopic sinus surgery (ESS) has been the mainstay of treatment for patients refractory to initial medical therapy. Data comparing the cost-effectiveness of these treatments is scarce. The objective of this study is to compare the cost-effectiveness of dupilumab and ESS treatment for patients with CRSwNP refractory to medical therapy.

METHODS

A cohort-style Markov decision tree economic evaluation with 10-year time horizon was performed. The two comparative treatment strategies were dupilumab therapy or ESS followed by postoperative maintenance therapy. Patients with response to treatment continued with either maintenance or dupilumab therapy; patients with no response underwent ESS. The primary outcome measure was incremental cost per quality-adjusted life year (QALY) calculated from sino-nasal outcome test (SNOT-22) scores. Sensitivity analyses were performed including discounting scenarios and a probabilistic sensitivity analysis.

RESULTS

The dupilumab strategy cost $195,164 and produced 1.779 QALYs. The ESS strategy cost $20,549 and produced 1.526 QALYs. This implies an incremental cost of $691,691 for dupilumab for every one-unit increase in QALY compared with ESS. Probability sensitivity analysis indicated that ESS was more cost-effective than dupilumab in all iterations.

CONCLUSIONS

While dupilumab and ESS may demonstrate similar clinical effectiveness, ESS remains the most cost-effective treatment option and should remain standard of care for CRSwNP patients refractory to medical therapy. This article is protected by copyright. All rights reserved.

Nasal Polyps in Children: The Early Origins of a Challenging Adulthood Condition

Nasal polyps (NPs) are benign inflammatory masses causing chronic nasal obstruction, usually associated with underlying chronic rhinosinusitis (CRS), which are rarely reported in childhood. The interest in NPs has recently increased due to new therapeutic options, namely biological agents, such as dupilumab, and an update of the European position paper on this topic was released in 2020, providing a detailed classification for these lesions and also discussing diagnostic and therapeutic approaches also in children. In childhood, NPs usually represent red flags for systemic diseases, such as cystic fibrosis and immunodeficiencies. This review outlines the recent data on NPs in childhood, focusing on predisposing factors for CRS as well as on the potential endotypes in this particular age group, for which further studies are required in order to better clarify their pathogenesis and to identify molecular biomarkers that could help achieve more personalized treatments.

Nitric Oxide Is Locally Produced in the Human Middle Ear and Is Reduced by Acquired Cholesteatoma

OBJECTIVE

To find out if nitric oxide (NO) can be locally produced in the middle ear and if chronic otitis media (COM) and acquired cholesteatoma affect the production.

DESIGN

Case-control study.

SETTING

Two tertiary-referral hospitals.

PATIENTS

Gaseous NO from 11 patients with unilateral perforations or grommet openings was measured with chemiluminescence. Middle ear mucosa from 48 patients with COM and 26 patients with cholesteatoma was investigated.

MAIN OUTCOME MEASURES

Detection of NO. Expression of nitric oxide synthase (NOS) mRNA, in mucosa from COM, cholesteatoma and healthy controls, quantified using polymerase chain reaction.

RESULTS

The gaseous NO from ears with a unilateral tympanic membrane perforation or a grommet was higher (9 ± 3 ppb, n = 11) than among the controls (4 ± 1 ppb, n = 11, p = 0.04). Lower levels of eNOS (2.64 ± 0.86 mol/100,000 mol ACTB) were detected in the pooled samples from the COM group (n = 48), compared with the control group (140.48 ± 92 mol/100,000 mol ACTB, n = 45, p = 0.010). In the cholesteatoma group (n = 26), a lower expression of nNOS (5.78 × 10-6 ± 1.13 × 10-6 ΔCt) was found in comparison with the controls (1.23 × 10-4 ± 3.18 × 10-5 ΔCt, n = 15, p = 0.011).

CONCLUSIONS

NO is likely a natural and permanent part of the gas mixture in the human middle ear. The presence of NOS enzymes in the middle ear mucosa indicates an ongoing NO production and the reduction of NOS in ears with cholesteatoma, and pooled samples from ears with COM, suggest a role for locally produced NO in middle ear disease.

ARIA-ITALY multidisciplinary consensus on nasal polyposis and biological treatments

In the recent years, it was recognized that type-2 inflammation links many forms of nasal polyposis with severe asthma. Thus, some biological drugs developed for severe asthma appeared to exert an effect on nasal polyposis. So far, there are several trials supporting this concept; therefore, some monoclonal antibodies for severe asthma were assessed also in polyposis, with promising results. Since different specialists are involved in the management of nasal polyposis (eg, pulmonologists, ENT, allergists), it was felt that an educational and informative document was needed to better identify the indications of biologicals in nasal polyposis. We collected the main Italian Scientific Societies, and prepared (under the Allergic Rhinitis and its Impact on Asthma, ARIA) a document endorsed by all Societies, to provide a provisional statement for the future use of monoclonal antibodies as a medical treatment for polyposis. It is the first nationwide endorsed document on this aspect. The current pathogenic knowledge and the experimental evidence are herein reviewed, and some suggestions for a correct prescription and follow-up are provided.

Sinus Microbiota in Patients With Eosinophilic and Non-Eosinophilic Chronic Rhinosinusitis With Nasal Polyps

Chronic rhinosinusitis with nasal polyps (CRSwNP) is characterized by Th2-skewed inflammation and increased colonization by Staphylococcus aureus. CRSwNP can be distinguished as eosinophilic (ECRSwNP) and non-eosinophilic (NECRSwNP) by the infiltration of eosinophils. The local microbiota plays an important role in the persistent inflammation of CRSwNP. To evaluate the bacterial community composition on the distinct types of CRSwNP patients, we collected nasal swabs from 16 ECRSwNP patients, 18 NECRSwNP patients, and 39 healthy control subjects. The microbiome structure for all the samples were analyzed by high-throughput 16S rRNA gene sequencing. Concentration of S. aureus was determined using TaqMan quantitative polymerase chain reaction (qPCR) targeting the nuclease (nuc) gene. The result showed significant differences in the sinus microbiome among healthy control subjects and CRSwNP patients. Microbiota community diversity was significantly lower in NECRSwNP samples compared to that of healthy control subjects. Interestingly, the abundance of several pathogenic bacteria was diverse between ECRSwNP and NECRSwNP patients. Although Staphylococcus prevailed in all groups, the abundance of Staphylococcus was significantly higher in the healthy control group than the ECRSwNP group. More importantly, the abundance of S. aureus was much higher in NECRSwNP patients. This study highlights that microbiota composition may contribute to the different clinical types of CRSwNP, inspiring new therapeutic strategies to resolve this chronic inflammation process.

Prevalence and Symptom Burden of Nasal Polyps in a Large Austrian Population

BACKGROUND

Although chronic rhinosinusitis with nasal polyps (CRSwNP) is a common inflammatory condition with significant morbidity and financial cost, information regarding prevalence and disease burden of this condition is scarce.

OBJECTIVE

In this study we determined nasal polyp prevalence, polyp grade, concomitant disease, and symptom burden in > 10,000 central European subjects.

METHODS

In this retrospective, cross-sectional study, 10,259 patients who had undergone routine examination of their nose by nasal endoscopy during a visit at a publicly accessible ENT outpatient facility in Vienna were included. Patient details including presenting complaint, nasal symptoms, polyp score, age, gender, treatment, asthma and allergic status were extracted retrospectively. A detailed questionnaire including history of nasal symptoms, SNOT-20 GAV, and VAS was available for 101 patients with nasal polyps.

RESULTS

Nasal polyps were detected in 189 (1.84%) of the 10,259 patients. The calculated prevalence of polyps in Austria, adjusted for age and gender, was 1.95%. The average TPS was 3.4, 72.5% had a TPS of ≤4, with males and asthmatics having significantly larger polyps. Questionnaire analysis revealed that 67% suffered from a low symptom burden of ≤36. According to current EPOS guidelines, 6% of polyp patients fulfilled and another 8% potentially fulfil the eligibility criteria for biological therapy.

CONCLUSION

Nasal polyp prevalence was calculated to be 1.95% of the Austrian population. Large polyps (TPS>4) were found in 25%, 33% suffered from a high nasal symptom burden, and between 6 to 14% of polyp patients would be eligible for biological therapy according to EPOS guidelines.

Changes in Clinical and Histological Characteristics of Nasal Polyps in Northern China over the Past 2-3 Decades

INTRODUCTION

Recent studies have shown that inflammatory patterns of nasal polyps from patients with chronic rhinosinusitis (CRS) with nasal polyps (CRSwNP) in East Asia have changed over time. However, to date there is a marked lack of similar data for CRSwNP in Northern China. This study thus aimed to assess the changes in the clinical and histological characteristics of CRSwNP patients from Northern China over the past 2-3 decades.

METHODS

This was a retrospective study, which examined data from 2 groups of 150 CRSwNP patients each, who had undergone endoscopic sinus surgery in Beijing Tongren Hospital from 1993 to 1995 (group A) and from 2015 to 2019 (group B). All relevant data for demographic, clinical, and histological parameters were collected for each patient from the 2 groups and compared for overall changes between the 2 groups.

RESULTS

The comorbidity of CRSwNP and asthma increased over time and the cellular phenotype of CRSwNPchanged significantly; in particular, the proportion of eosinophil-dominant CRSwNP increased, lymphocyte-dominant and plasma-dominant CRSwNP decreased significantly, and the proportions of neutrophil-dominant and mixed CRSwNP were not altered. The rate of polyp recurrence increased in CRSwNP but did not in eosinophilic CRSwNP. Smoking and age did not significantly impact the inflammatory patterns of CRSwNP.

CONCLUSIONS

The inflammatory patterns of CRSwNP patients have changed and comorbidity of asthma significantly increased in CRSwNP patients in Northern China over the past 2-3 decades.

Efficacy of Tezepelumab in Patients with Severe, Uncontrolled Asthma with and without Nasal Polyposis: A Post Hoc Analysis of the Phase 2b PATHWAY Study

Background

Tezepelumab is a human monoclonal antibody that blocks thymic stromal lymphopoietin, an epithelial cytokine implicated in asthma pathogenesis, from binding to its heterodimeric receptor. In the phase 2b PATHWAY study, tezepelumab significantly reduced annualized asthma exacerbation rates (AAERs) versus placebo, irrespective of baseline disease characteristics, and improved lung function and symptom control, in adults with severe, uncontrolled asthma. This post hoc analysis assessed the efficacy of tezepelumab in adults with severe, uncontrolled asthma with and without nasal polyposis (NP).

Methods

In this post hoc analysis of the PATHWAY study (NCT02054130), participants (N=550) were randomized 1:1:1:1 to receive subcutaneous tezepelumab 70 mg every 4 weeks (Q4W), 210 mg Q4W or 280 mg every 2 weeks (Q2W), or placebo Q2W, for 52 weeks. The AAER over 52 weeks and the change from baseline to week 52 in blood eosinophil count, fractional exhaled nitric oxide (FeNO) levels and serum levels of interleukin (IL)-5 and IL-13 with tezepelumab 210 mg (the phase 3 dose) and placebo were analyzed in patients grouped by self-reported presence (NP+) or absence (NP-) of NP at screening.

Results

At baseline, NP+ patients had higher blood eosinophil counts, higher FeNO levels and higher serum IL-5 and IL-13 levels than NP- patients. Tezepelumab 210 mg reduced the AAER versus placebo to a similar extent in both NP+ and NP- patients (NP+, 75% [95% confidence interval (CI): 15, 93], n=23; NP-, 73% [95% CI: 47, 86], n=112). Patients treated with tezepelumab 210 mg demonstrated greater reductions in blood eosinophil count and levels of FeNO, IL-5 and IL-13 than placebo-treated patients, irrespective of NP status.

Discussion

Tezepelumab reduced exacerbations and reduced type 2 inflammatory biomarkers in patients with and those without NP, supporting its efficacy in a broad population of patients with severe asthma.

Onset of effect and impact on health-related quality of life, exacerbation rate, lung function, and nasal polyposis symptoms for patients with severe eosinophilic asthma treated with benralizumab (ANDHI): a randomised, controlled, phase 3b trial

BACKGROUND

ANDHI was done to assess the efficacy of benralizumab, including onset of effect and impact on health-related quality of life (HRQOL), exacerbation rate, lung function, and nasal polyposis symptoms.

METHODS

This phase 3b, randomised, double-blind, parallel-group, placebo-controlled ANDHI study was completed in adults (aged 18-75 years) with severe eosinophilic asthma with at least 2 exacerbations in the previous year, despite high-dose inhaled corticosteroid plus additional controllers, screening blood eosinophil counts of at least 150 cells per μL, and an Asthma Control Questionnaire 6 (ACQ-6) score of 1·5 or more. Patients who met eligibility criteria were randomly assigned (2:1; stratified by previous exacerbation count [two, or three or more], maintenance oral corticosteroid use, and region), using an integrated web-based response system, to receive benralizumab at 30 mg every 8 weeks (first three doses given 4 weeks apart) or matched placebo for 24 weeks. Primary efficacy measure was annualised asthma exacerbation rate, with rate ratio (RR) calculated over the approximate 24-week follow-up. Secondary efficacy measures included change from baseline to end of treatment (week 24) in St George's Respiratory Questionnaire (SGRQ) total score (key secondary endpoint), FEV₁, peak expiratory flow (PEF), ACQ-6, Predominant Symptom and Impairment Assessment (PSIA), Clinician Global Impression of Change (CGI-C), Patient Global Impression of Change (PGI-C), and Sino-Nasal Outcome Test-22 (SNOT-22). All efficacy analyses, except for SNOT-22, were summarised and analysed using the full analysis set on an intention-to-treat population (all randomly assigned patients receiving investigational product, regardless of protocol adherence or continued participation in the study). SNOT-22 was summarised for the subgroup of patients with physician-diagnosed nasal polyposis with informed consent. This study is registered with ClinicalTrials.gov, NCT03170271.

FINDINGS

Between July 7, 2017, and Sept 25, 2019, 656 patients received benralizumab (n=427) or placebo (n=229). Baseline characteristics were consistent with severe eosinophilic asthma. Benralizumab significantly reduced exacerbation risk by 49% compared with placebo (RR estimate 0·51, 95% CI 0·39-0·65; p<0·0001) over the 24-week treatment period and provided clinically meaningful and statistically significant improvement from baseline to week 24 in SGRQ total score versus placebo (least squares mean change from baseline -8·11 (95% CI -11·41 to -4·82; p<0·0001), with similar differences at earlier timepoints. Benralizumab improved FEV₁, PEF, ACQ-6, CGI-C, PGI-C, PSIA, and SNOT-22 at week 24 versus placebo, with differences observed early (within weeks 1 to 4). Adverse events were reported for 271 (63%) of 427 patients on benralizumab versus 143 (62%) of 229 patients on placebo. The most commonly reported adverse events for the 427 patients receiving benralizumab (frequency >5%) were nasopharyngitis (30 [7%]), headache (37 [9%]), sinusitis (28 [7%]), bronchitis (22 [5%]), and pyrexia (26 [6%]). Fewer serious adverse events were reported for benralizumab (23 [5%]) versus placebo (25 [11%]), and the only common serious adverse event (experienced by >1% of patients) was worsening of asthma, which was reported for nine (2%) patients in the benralizumab group and nine (4%) patients in the placebo group.

INTERPRETATION

Our results extend the efficacy profile of benralizumab for patients with severe eosinophilic asthma, showing early clinical benefits in patient-reported outcomes, HRQOL, lung function, and nasal polyposis symptoms.

FUNDING

AstraZeneca.

Chronic Rhinosinusitis with Nasal Polyps: Targeting IgE with Anti-IgE Omalizumab Therapy

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a complex, clinically heterogeneous and persistent inflammatory disorder of the upper airway. Detailed mechanistic insights into disease pathogenesis are lacking, but it is now accepted that local tissue IgE driven T2-high inflammatory pathways are critical to disease. The recent CRSwNP Phase 3 POLYP1 and POLYP2 replicate studies of blocking IgE with omalizumab confirmed rapid improvements in all clinical parameters of sinonasal disease, confirming a pivotal role for IgE driven inflammatory pathways in CRSwNP. This review summarises the biology of IgE in relation to CRSwNP. Insight into how IgE may drive CRSwNP is evaluated in the context of clinical improvements seen with omalizumab. The need for further studies using a broader patient and biomarker specific groups to aid more precise drug-patient selection alongside more detailed mechanistic studies of omalizumab in CRSwNP is highlighted.

Extended nitric oxide analysis in patients with chronic rhinosinusitis with nasal polyps, with or without associated asthma

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a complex inflammatory disease highly impacting patient's quality of life, and associated with lower airway inflammation often evolving into asthma. Exhaled nitric oxide (FE_NO) is a non-invasive tool to assess Type 2 airway inflammation and its extended analysis allows to differentiate between alveolar concentration (CalvNO) and bronchial output (JawNO). It is also possible to assess the sino-nasal production of nitric oxide (nNO). We studied extended nitric oxide production in patients with CRSwNP with or without associated asthma. Consecutive adult patients with CRSwNP, with or without asthma, and 15 healthy controls were enrolled. Exclusion criteria were: smoking, uncontrolled asthma, recent upper or lower airway infections and oral corticosteroid therapy in the 4 weeks preceding clinical evaluation. Patients' demographic and clinical data were collected; patients underwent pulmonary function tests and extended nitric oxide analysis including nasal nNO assessment. A total of 125 subjects were enrolled (15 healthy controls; 69 with CRSwNP and asthma, and 41 with CRSwNP only). FE_NO, JawNO and CalvNO values were higher, while nNO was lower, in all patients with CRSwNP compared to healthy controls; no difference was found in CalvNO between patients with concomitant asthma and non-asthmatic subjects; in asthmatic patients, FE_NO and JawNO were significantly higher, while nNO values was lower, compared to patients with CRSwNP only. These results suggest that CRSwNP could be the first manifestation of a more complex systemic inflammatory pathology driven by Type 2 inflammation. An 'inflammatory gradient' hypothesis could describe a pattern of inflammation in CRSwNP patients that starts distally in the alveoli. Finally, our study indirectly reinforces the concept that novel biological drugs could become valid therapeutic options for nasal polyposis.

Adult chronic rhinosinusitis

Chronic rhinosinusitis (CRS) occurs in >10% of the adult population in Europe and the USA and can be differentiated into CRS without nasal polyps and CRS with nasal polyps (CRSwNP). Both phenotypes are characterized by a high disease burden and an overlapping spectrum of symptoms, with facial pain and loss of smell being the most differentiating. Great progress has been made in the understanding of CRS pathophysiology: from the epithelium and epithelial-mesenchymal transition to innate and adaptive immunity pathways and, finally, on the role of eosinophils and Staphylococcus aureus in the persistence of disease. Although clinical manifestations and diagnostic tools (including nasal endoscopy and imaging) have undergone major changes over the past few years, management (including pharmacotherapy, surgery and biologics) has experienced enormous progress based on the growing knowledge of key mediators in severe CRSwNP. The introduction of endotyping has led to a differentiation of 'tailored' surgical approaches, focusing on the mucosal concept in those with severe CRSwNP and on the identification of patients eligible for extended surgery and possibly biologics in the future.

Persistence of Sinonasal Disease Despite Mepolizumab

The treatment paradigm for the management of chronic rhinosinusitis with nasal polyposis (CRSwNP) is currently undergoing a rapid evolution with the development of monoclonal antibody therapies targeted at type 2 inflammatory pathways. The use of these biologic therapies in asthmatic patients, and more recently, patients with CRSwNP has produced promising results, especially for patients with severe disease. Many questions regarding the appropriate timing of these medications, whether or not these new treatment strategies should be used as a monotherapy or in conjunction with traditional therapies such as sinus surgery, the role of appropriate phenotyping, and identification of biomarkers, remain unanswered. We herein present a case of a patient with severe eosinophilic asthma and comorbid CRSwNP who failed to achieve control of his respiratory symptomology and ultimately progressed to sinus surgery despite treatment with an anti-interleukin 5 monoclonal antibody therapy (mepolizumab). Consideration is given to the mechanistic underpinnings of the reported patient's failure. This case highlights the need for further understanding of the optimal usage of these novel therapeutics in the management of CRSwNP and in the need to better understand the pathophysiology of CRSwNP.

Dupilumab improves health-related quality of life in patients with chronic rhinosinusitis with nasal polyposis

BACKGROUND

Chronic rhinosinusitis with nasal polyposis (CRSwNP) negatively affects health-related quality of life (HRQoL). In a previously reported randomized clinical trial (NCT01920893), addition of dupilumab to mometasone furoate in patients with CRSwNP refractory to intranasal corticosteroids (INCS) significantly improved endoscopic, radiographic, and clinical endpoints and patient-reported outcomes. The objective of this analysis was to examine the impact of dupilumab treatment on HRQoL and productivity using secondary outcome data from this trial.

METHODS

Following a 4-week mometasone furoate nasal spray run-in, patients were randomized to commence subcutaneous dupilumab (600 mg loading dose, then 300 mg once weekly for 15 weeks [n = 30], or matched placebo [n = 30]). Outcomes included scores on the CRS disease severity visual analog scale (VAS), 22-item Sino-Nasal Outcome Test (SNOT-22), 5-dimension EuroQoL (EQ-5D) general health status VAS, and 36-item Short-Form Health Survey (SF-36) for HRQoL and nasal polyp-related healthcare resource use questionnaires.

RESULTS

Following 16 weeks of treatment, the proportion of patients with moderate-to-severe CRSwNP (VAS > 3-10) decreased from 86.2% to 21.4% with dupilumab and 88.0% to 84.2% with placebo. Dupilumab (vs placebo) resulted in significantly greater improvement in HRQoL, based on SNOT-22, SF-36, and EQ-5D VAS scores. The dupilumab group had a significantly lower adjusted annualized mean number of sick leave days (0.09, vs 4.18 with placebo, P = .015) and significantly greater improvement (vs placebo) in the SNOT-22 item "reduced productivity."

CONCLUSIONS

In adults with CRSwNP refractory to treatment with INCS alone, the addition of dupilumab reduced disease severity, significantly improved HRQoL, and improved productivity.

The Intriguing Role of Interleukin 13 in the Pathophysiology of Asthma

Approximately 5–10% of asthmatic patients worldwide suffer from severe asthma. Experimental and clinical studies have demonstrated that IL-13 is an important cytokine in chronic airways inflammation. IL-13 is involved in Th2 inflammation and has been identified as a possible therapeutic target in the treatment of asthma. Two different human monoclonal antibodies (mAbs) anti-IL-13 (tralokinumab and lebrikizumab) block binding and signaling of IL-13 to its receptors, IL-13Rα1 and IL-13Rα2. Several randomized, double-blind, placebo-controlled multicenter studies have evaluated the safety and efficacy of tralokinumab and lebrikizumab in the treatment of adult patients with severe asthma, but all have failed to meet their primary endpoints. No serious adverse events related to the treatment with these anti-IL-13 mAbs have been reported in these studies. These negative clinical results contrast with positive findings from blocking IL-13 signaling in experimental models of asthma, raising doubts about the transferrable value of some models. Interestingly, dupilumab, a mAb which blocks both IL-4 and IL-13 signaling reduces exacerbation rates and improves lung function in severe asthmatics. These results suggest that IL-4 and IL-13 share some, but not all functional activities in airway inflammation. Tralokinumab might show efficacy in a highly selected cohort of asthmatics characterized by overexpression of IL-13.

ICON: Diagnosis and management of allergic conjunctivitis

Ocular allergy (OA), interchangeably known as allergic conjunctivitis, is a common immunological hypersensitivity disorder affecting up to 40% of the population. Ocular allergy has been increasing in frequency, with symptoms of itching, redness, and swelling that significantly impacts an individual's quality of life (QOL). Ocular allergy is an often underdiagnosed and undertreated health problem, because only 10% of patients with OA symptoms seek medical attention, whereas most patients manage with over-the-counter medications and complementary nonpharmacological remedies. The clinical course, duration, severity, and co-morbidities are varied and depend, in part, on the specific ocular tissues that are affected and on immunologic mechanism(s) involved, both local and systemic. It is frequently associated with allergic rhinitis (commonly recognized as allergic rhino conjunctivitis), and with other allergic comorbidities. The predominance of self-management increases the risk of suboptimal therapy that leads to recurrent exacerbations and the potential for development of more chronic conditions that can lead to corneal complications and interference with the visual axis. Multiple, often co-existing causes are seen, and a broad differential diagnosis for OA, increasing the difficulty of arriving at the correct diagnosis(es). Ocular allergy commonly overlaps with other anterior ocular disease disorders, including infectious disorders and dry eye syndromes. Therefore, successful management includes overcoming the challenges of underdiagnosis and even misdiagnosis by a better understanding of the subtleties of an in-depth patient history, ophthalmologic examination techniques, and diagnostic procedures, which are of paramount importance in making an accurate diagnosis of OA. Appropriate cross-referral between specialists (allergists and eyecare specialists) would maximize patient care and outcomes. This would significantly improve OA management and overcome the unmet needs in global health.

Efficacy and safety of dupilumab in patients with severe chronic rhinosinusitis with nasal polyps (LIBERTY NP SINUS-24 and LIBERTY NP SINUS-52): results from two multicentre, randomised, double-blind, placebo-controlled, parallel-group phase 3 trials

BACKGROUND

Patients with chronic rhinosinusitis with nasal polyps (CRSwNP) generally have a high symptom burden and poor health-related quality of life, often requiring recurring systemic corticosteroid use and repeated sinus surgery. Dupilumab is a fully human monoclonal antibody that inhibits signalling of interleukin (IL)-4 and IL-13, key drivers of type 2 inflammation, and has been approved for use in atopic dermatitis and asthma. In these two studies, we aimed to assess efficacy and safety of dupilumab in patients with CRSwNP despite previous treatment with systemic corticosteroids, surgery, or both.

METHODS

LIBERTY NP SINUS-24 and LIBERTY NP SINUS-52 were two multinational, multicentre, randomised, double-blind, placebo-controlled, parallel-group studies assessing dupilumab added to standard of care in adults with severe CRSwNP. SINUS-24 was done in 67 centres in 13 countries, and SINUS-52 was done in 117 centres in 14 countries. Eligible patients were 18 years or older with bilateral CRSwNP and symptoms despite intranasal corticosteroid use, receiving systemic corticosteroids in the preceding 2 years, or having had sinonasal surgery. Patients in SINUS-24 were randomly assigned (1:1) to subcutaneous dupilumab 300 mg or placebo every 2 weeks for 24 weeks. Patients in SINUS-52 were randomly assigned (1:1:1) to dupilumab 300 mg every 2 weeks for 52 weeks, dupilumab every 2 weeks for 24 weeks and then every 4 weeks for the remaining 28 weeks, or placebo every 2 weeks for 52 weeks. All patients were randomly assigned centrally with a permuted block randomisation schedule. Randomisation was stratified by asthma or non-steroidal anti-inflammatory drug-exacerbated respiratory disease status at screening, previous surgery at screening, and country. Patients with or without comorbid asthma were included. Coprimary endpoints were changes from baseline to week 24 in nasal polyp score (NPS), nasal congestion or obstruction, and sinus Lund-Mackay CT scores (a coprimary endpoint in Japan), done in an intention-to-treat population. Safety was assessed in a pooled population of both dupilumab groups in SINUS-52 up to week 24 and the dupilumab group in SINUS-24 and the placebo groups in both studies until week 24. The trials are complete and registered at ClinicalTrials.gov, NCT02912468 and NCT02898454.

FINDINGS

Between Dec 5, 2016, and Aug 3, 2017, 276 patients were enrolled in SINUS-24, with 143 in the dupilumab group and 133 in the placebo group receiving at least one study drug dose. Between Nov 28, 2016, and Aug 28, 2017, 448 patients were enrolled in SINUS-52, with 150 receiving at least one dose of dupilumab every 2 weeks, 145 receiving at least one dose of dupilumab every 2 weeks for 24 weeks and every 4 weeks until week 52, and 153 receiving at least one dose of placebo. Dupilumab significantly improved the coprimary endpoints in both studies. At 24 weeks, least squares mean difference in NPS of dupilumab treatment versus placebo was -2·06 (95% CI -2·43 to -1·69; p<0·0001) in SINUS-24 and -1·80 (-2·10 to -1·51; p<0·0001) in SINUS-52; difference in nasal congestion or obstruction score was -0·89 (-1·07 to -0·71; p<0·0001) in SINUS-24 and -0·87 (-1·03 to -0·71; p<0·0001) in SINUS-52; and difference in Lund-Mackay CT scores was -7·44 (-8·35 to -6·53; p<0·0001) in SINUS-24 and -5·13 (-5·80 to -4·46; p<0·0001) in SINUS-52. The most common adverse events (nasopharyngitis, worsening of nasal polyps and asthma, headache, epistaxis, and injection-site erythema) were more frequent with placebo.

INTERPRETATION

In adult patients with severe CRSwNP, dupilumab reduced polyp size, sinus opacification, and severity of symptoms and was well tolerated. These results support the benefits of adding dupilumab to daily standard of care for patients with severe CRSwNP who otherwise have few therapeutic options.

FUNDING

Sanofi and Regeneron Pharmaceuticals.

Chronic Rhinosinusitis with Nasal Polyps in Older Adults: Clinical Presentation, Pathophysiology, and Comorbidity

PURPOSE OF REVIEW

Chronic rhinosinusitis and nasal polyps (CRSwNP) is a common condition that significantly affects patients' life. This work aims to provide an up-to-date overview of CRSwNP in older adults, focusing on its aging-related clinical presentations, pathophysiology, and comorbidity associations including asthma.

RECENT FINDINGS

Recent large population-based studies using nasal endoscopy have shown that CRSwNP is a mostly late-onset disease. Age-related changes in physiologic functions, including nasal epithelial barrier dysfunction, may underlie the incidence and different clinical presentations of CRSwNP in older adults. However, there is still a paucity of evidence on the effect of aging on phenotypes and endotypes of CRSwNP. Meanwhile, late-onset asthma is a major comorbid condition in patients with CRSwNP; they frequently present with type 2 inflammatory signatures that are refractory to conventional treatments when they are comorbid. However, as they are more commonly non-atopic, causative factors other than classical atopic sensitization, such as Staphylococcus aureus specific IgE sensitization, are suggested to drive the type 2 inflammation. There are additional comorbidity associations in older patients with CRSwNP, including those with chronic otitis media and head and neck malignancy. Age is a major determinant for the incidence and clinical presentations of CRSwNP. Given the heterogeneity in phenotypes and endotypes, longitudinal investigations are warranted to elucidate the effects of aging on CRSwNP.

Relationship between Olfactory Acuity and Peak Expiratory Flow during Postoperative Follow-up in Chronic Rhinosinusitis Associated with Asthma

Objectives

The link between nasal and bronchial disease has been studied extensively for chronic rhinosinusitis and asthma. The concept of “united airway allergy” has become widely accepted in the past decade. We evaluated the relationship between the upper and lower airways during follow-up after endoscopic sinus surgery by monitoring sinonasal and pulmonary functions.

Methods

Thirty-nine subjects with chronic rhinosinusitis associated with bronchial asthma were entered in this study. A self smell test using stick-type odorant materials was carried out daily to evaluate postoperative recurrence of sinonasal disease. Each patient was assessed for peak expiratory flow (PEF) 3 times daily.

Results

The average (±SD) scores of initial symptoms were 8.3 ± 2.2, which was significantly decreased to 1.5 ± 1.4 by 3 months after operation. During postoperative follow-up, 25 of 39 patients showed no decrease in PEF, whereas the other 14 patients had at least 1 episode of a significant decline in PEF. In the postoperative course, with respect to the self smell test, 24 patients showed no aggravation of smell, but 15 patients had episode(s) of decreased olfaction. Twelve patients demonstrated worsening on the smell test concomitant with a decreased PEF. A discrepancy between olfactory acuity and pulmonary function was recognized in 5 patients. There were 22 patients with a good prognosis of parameters of both the upper and lower airways.

Conclusions

Daily monitoring of both upper and lower respiratory tract functions clearly revealed dual relationships, indicating that worsening of sinusitis accompanies asthma exacerbation. Appropriate measures of the upper and lower airways following endoscopic sinus surgery can be used to predict patient outcome.

Chronic rhinosinusitis with nasal polyps: insights into mechanisms of disease from emerging biological therapies

Introduction: Chronic rhinosinusitis with nasal polyps (CRSwNP) is a complex disease of the upper airway, with long-term morbidity. With detailed mechanistic studies currently lacking, understanding of the immunopathogenesis is still limited. However, outcomes from CRSwNP clinical studies using biologics that block key mediators or cells may provide some insights into how immune signaling pathways potentially integrate and modulate each other and contribute to disease. Current treatments are often ineffective and there is an urgent unmet clinical need for effective therapeutic strategies. Emerging biologics hold promise. Areas covered: This review covers the biology of CRSwNP in terms of the clinical outcomes reported from blocking immune cascades with available biologics. Immune amplification mechanisms and how biologics can potentially modulate such 'master' cytokines and signaling proteins that drive inflammation and contribute to tissue remodeling in CRSwNP are discussed. Expert commentary: Biologics have the potential to transform CRSwNP treatment. The ability to predict clinical response in a complex disease as CRSwNP to a biologic cannot necessarily be predicted by measuring a single protein or cell as a biomarker of disease. Further studies with biologics must be carefully undertaken to fully evaluate wider biomarker associated pheno-endotype responses along with any associated asthma outcome measures.

Immunological mechanisms underlying chronic rhinosinusitis with nasal polyps

INTRODUCTION

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a common and quality-of-life impacting disorder, with an underlying immunological mechanism similar to other conditions such as eosinophilic asthma or atopic eczema. Areas covered: This review article summarizes the most recent evidence on the main immunological mechanisms involved in the pathogenesis and the perpetuation of CRSwNP, with a particular focus on the key role of epithelium-derived inflammation as a consequence of the interaction with the airborne environment. Expert commentary: The increase in knowledge of the immunology of CRSwNP leads to the development of therapeutical strategies based upon the use of biologic agents that, according to a personalized and precision medicine approach, will provide each single patient with the most suitable immunological treatment.

Polyps, asthma, and allergy: what's new

PURPOSE OF REVIEW

Although chronic rhinosinusitis with nasal polyps, asthma, and allergy share common inflammatory mechanisms, there is no evidence of cause-and-effect relationship. In this review, we present new studies investigating the complex immunology that links these diseases. Advances in new therapies as well as evidence regarding indication and timing of surgery, especially of more complex cases, are highlighted.

RECENT FINDINGS

New studies have endotyped patients in an effort to describe the exact inflammatory profile of each phenotype, whereas described cytokines seem to play a significant role in amplification of T2 inflammation, directly or via innate lymphoid cells. New mAbs that block specific cytokines of these pathways have been developed and seem to show reduced asthma severity as well as improved sinonasal outcomes. Moreover, it has been shown that operating early in the course of disease leads not only to bigger improvements in SNOT-22 outcomes but also to reduced asthma incidence postoperatively in refractory cases.

SUMMARY

Applying data from current studies in clinical practice, we could better manage refractory cases with asthma and polyps, both medically and surgically. Treatment has to be patient-centered, and this demands a multidisciplinary-team approach of the airway diseases.

DNA Methylation of Proximal PLAT Promoter in Chronic Rhinosinusitis With Nasal Polyps

Background

Nasal polyps (NP) are characterized by pseudocysts derived from stromal tissue edema and cause persistent infections in patients with chronic rhinosinusitis (CRS). A low level of tissue-type plasminogen activator (gene name PLAT) is considered a cause of stromal tissue edema because of insufficient plasmin activation in NP; however, the mechanism regulating PLAT gene expression levels is still unclear. The epigenetic mechanism regulating the PLAT gene expression has been studied in other tissues.

Objective

We aimed to investigate the methylation levels in the proximal PLAT promoter and their effects on gene expression in NP tissue.

Methods

We investigated the methylation levels at 3 CpG sites in the proximal PLAT promoter regions (−618, −121, and −105 with respect to the transcription initiation site) by bisulfite pyrosequencing and their effects on the gene expression by quantitative real-time polymerase chain reaction (qPCR) in 20 paired samples of NP and inferior turbinate tissue (IT) from patients with CRS.

Results

The DNA methylation levels at all CpG sites were higher ( P < .01), and the PLAT expression was lower ( P < .001) in NP compared with IT. The methylation changes at the −618 site showed a negative correlation with the gene expression changes between NP and IT ( r = −.65, P < .01).

Conclusions

Hypermethylation of PLAT promoter may downregulate the gene expression in NP, leading to excessive fibrin deposition by aberrant coagulation cascade. DNA methylation of proximal PLAT promoter may contribute to NP growth and have a potential as a new therapeutic target.

Polypoid change of middle turbinate is associated to an increased risk of polyp recurrence after surgery in patients with chronic rhinosinusitis with nasal polyps

BACKGROUND

Chronic rhinosinusitis with nasal polyps (CRSwNP) affects approximately 4% of general population. Patients with CRSwNP have greater burden of CRS symptoms and higher rate of relapse after either medical or surgical treatments. The aim of this study was to evaluate the association between polypoid change of anterior free border of middle turbinate and rate of relapse in patients with CRSwNP.

METHODS

A controlled prospective cohort study was performed. Seventy-seven adult patients with CRSwNP in whom their MT polypoid change was proved and 77 patients without MT polypoid change were recruited. Allergy, asthma, aspirin hypersensitivity, Lund Kennedy and Lund Mackay scores and eosinophilic scores of polyp and middle turbinate were recorded. Patient's health-related quality of life was assessed using the 22-item Sino-Nasal Outcome Test (SNOT-22) questionnaire. All patients were evaluated 12 months after ESS. Polyp relapse, Lund Kennedy scores and SNOT-22 scores were documented.

RESULTS

The relapse rate in patients with MT polypoid change was significantly higher than the control group (37.14 vs. 20.58, p value = 0.03). Eosinophil score of nasal polyps and MT specimens were significantly higher in patients with MT polypoid change than patients without polypoid change. The postoperative Lund Kennedy and SNOT-22 scores in patients with MT polypoid change were significantly higher than the control group.

CONCLUSION

This study showed a significant association between polypoid change of anterior free border of middle turbinate and nasal polyp relapse. This new and simple criterion of severity of CRSwNP could have clinical implications.

Blood Eosinophilia and Nasal Polyps

In a controlled prospective study, patients who had nasal polypectomy were compared with patients who required other nasal surgery. Patients with and without asthma were identified. Both polyposis and asthma were independently associated with increased blood absolute eosinophil counts. Absolute eosinophil counts were: neither disease 0.199 × 106 cell/mL ± 0.025, polyposis alone 0.249 × 106 cell/mL ± 0.017, asthma alone 0.318 × 106 cell/mL ± 0.092, and both 0.375 × 106 cell/mL ± 0.076. In contrast, we were unable to show a difference between polyp patients and the controls in the serum IgE concentration or allergy skin test reactivity. Atopy was not a predictive factor for asthma in polyp patients. We conclude that nasal polyposis, like asthma, is highly associated with eosinophilia.

Nasal Polyposis: Role of Allergy on Therapeutic Response of Eosinophil- and Noneosinophil-Dominated Inflammation

Background

It is considered that allergy, at least in some cases, is associated with nasal polyps and affects recurrence rate. Our purpose was to determine the effects of aeroallergen hypersensitization on therapeutic response of eosinophil- and noneosinophil-dominated inflammation.

Methods

Sixty-eight patients were enrolled. Histopathological investigation and a skin-prick test were done and categorized as eosinophil-dominated inflammation with positive (ESPT+) or negative skin test (ESPT-) and nonesoinophil-dominated inflammation with positive (NESPT+) or negative skin test (NESPT-). Patients were treated over 6 weeks with budesonide nasal spray, 400 μg/day. At 0, 3, and 6 weeks after treatment, nasal symptoms, polyp size, nasal and oral peak expiratory flow (PEF) index and overall assessment within and between groups were evaluated and compared.

Results

At 3 and 6 weeks after treatment, the ESPT- group showed the most, and the NESPT+ group showed the least therapeutic improvement. In comparing between the positive and negative skin tests in each histopathology, the positive skin tests tended to have less improvement than the negative skin tests in all variables. The differences increased over time and reached statistical significance at 6 weeks in the PEF index and overall assessment of eosinophil-dominated inflammation (p = 0.004 and 0.033, respectively) and in sneezing score, postnasal drip score, and overall assessment of noneosinophil-dominated inflammation (p = 0.019, 0.035, and 0.013, respectively).

Conclusion

Nonallergic eosinophilic polyps had the best and allergic noneosinophilic polyps had the worst therapeutic response. Within each histopathology, allergic nasal polyps had less therapeutic response than nonallergic nasal polyps. This augmented effect could be caused by concomitant allergic inflammation.

The Differentiation of Polyps and Their Mucosal Ultrastructure

This paper reported both ultrastructural and biochemical studies of nasal polyps from 32 patients: 5 with an aspirin-induced asthma; 14 allergic patients with rhinitis; and 13 nonallergic patients with negative skin tests against the major inhalant allergens. The results of the studies have clearly shown that there are two different types of nasal polyps, neutrophil-dominant polyps and eosinophil-dominant polyps, and both leukocytes play a major role as important effector cells in the formation of nasal polyps. Cytotoxic effector molecules from both leukocytes initiate the connective tissue damage of the capillary basement membrane, bringing about enormous tissue edema, with broad disruptions of the epithelial lamina, causing polyp formation.

Allergic and Nonallergic Rhinitis. Classification and Pathogenesis: Part II. Nonallergic Rhinitis

Part I of this review classified and defined the causes of chronic rhinitis, describing in detail the etiology and pathophysiology of allergic rhinitis. Part II focuses on the nonallergic (non-IgE) causes of chronic rhinitis, concentrating on their clinical presentations, differential characteristics, and known or speculative pathophysiology. A comprehensive understanding of the allergic and nonallergic conditions associated with symptomatic rhinitis should aid the clinician in the appropriate diagnosis and treatment of patients with chronic rhinitis.

Immunologic Evaluation of Nasal Polyps

Forty-seven patients undergoing nasal polypectomy and 27 adult tonsillectomy patients were studied regarding history of allergy, duration of symptoms, and previous polypectomies. At surgery, samples of serum, tissues, and nasal washes were obtained for evaluation of total and allergen-specific IgE.

Serum IgE levels were not significantly higher in polypectomy patients. The IgE/mg of protein was significantly greater in polyp than tonsil tissue. Allergen-specific IgE levels did not differ in polyp and tonsil patients, nor was bacterial specific IgE detected in polyp patients. Allergen-specific IgG4 levels and the ratios of specific IgG4 to specific IgE did not differ between the patient groups.

Long-Term Follow-Up of Cellular Proliferation as a Predictive Index for the Relapse of Nasal Polyposis

Background

The objective of this study was to identify a reproducible clinical parameter for predicting relapses of nasal polyposis after surgery.

Methods

Ninety-three patients who had undergone ethmoidectomy of bilateral nasal polyps were followed for 3 years. Nasal polyps were obtained from all patients, and cellular suspensions were analyzed individually using flow cytometry. Based on the percentage of cells in the S phase, we identified three groups of patients (high, medium, and low percentages).

Results

A relapse of nasal polyposis was observed in 15.00, 70.00, and 100.00% of patients from the low-, medium-, and high-percentage groups, respectively. Patients suffering relapses had a high percentage of cells in the S phase.

Conclusions

We identified two cutoff values for the percentage of cells in the S phase; above the first cutoff, some of the patients suffered relapses; above the second cut-off, all patients suffered relapses.

Nasal Polyps: Epidemiology, Pathology, Immunology, and Treatment

Nasal polyps frequently are associated with aspirin intolerance, intrinsic asthma. Young's syndrome, cystic fibrosis, and Kartagener's syndrome. Children 16 years or younger with nasal polyps should be evaluated for cystic fibrosis. Nasal polyps are frequently bilateral, multiple, freely movable, and pale-gray and arise from the middle meatus of the nose. Histologically, they classically have pseudostratified ciliated columnar epithelium, thickening of the epithelial basement membrane, high stromal eosinophil count, mucin with neutral pH, few glands, and essentially no nerve endings. Cells consist of a mixture of lymphocytes, plasma cells, and eosinophils. Polyps from patients with Young's syndrome, Kartagener's syndrome, and cystic fibrosis have predominately neutrophils with insignificant eosinophils. Chemical mediators found in nasal polyps are as follows: histamine, serotonin, leukotrienes [(SRS-A or LTC4, LTD4, LTE4), LTB4], ECF-A, norepinephrine, kinins, TAME-esterase, and possibly PGD2. There is more histamine in nasal polyps than in normal nasal mucosa, and norepinephrine is present in greater concentration in the base of nasal polyps than in normal mucosa. The concentrations of IgA and IgE and, in some cases, IgG and IgM are greater in polyp fluid than in serum. IgE-mediated disease is not the cause of nasal polyps, but when present, may contribute to episodes of exacerbation. Despite medical or surgical management, a significant number of nasal polyps are recurrent. For treatment, systemic corticosteroids should be tried before surgical polypectomy. Polypectomy does not increase the risk of developing asthma or making asthma worse. At the present time, the pathogenesis of polyp formation is unknown.