Interaction of eosinophilic and neutrophilic inflammation in patients with chronic rhinosinusitis

PURPOSE OF REVIEW

In the past year, the endotype of chronic rhinosinusitis (CRS) has been studied from a new perspective. Eosinophilic and neutrophilic inflammation are not independent processes in the pathogenesis of CRS. In this review, we will focus on recent research on mixed eosinophilic-neutrophilic inflammation in CRS and discuss the mechanism and potential treatments.

RECENT FINDINGS

Traditionally, patients with eosinophilic CRS (ECRS) present with severe clinical manifestations, comorbidities, and a higher recurrence rate. Recent studies have found that approximately 40% of patients with ECRS present with neutrophilic infiltration, while patients with predominantly eosinophilic infiltration along with neutrophilic inflammation present with more complex inflammation, clinical manifestations and exhibit refractory characteristics.

SUMMARY

The complex inflammatory profile and refractory clinical characteristics of mixed eosinophilic-neutrophilic inflammation in CRS are current challenges for clinicians. We summarize the features of eosinophilic and neutrophilic inflammation and current studies on the mechanisms of mixed eosinophilic-neutrophilic inflammation and suggest potentially effective therapeutic methods. We hope that this review will help with determining precise treatment options for patients.

Investigating the prevalence of halitosis and its associated factors amongst the general population of Karachi, Pakistan

Objective

To assess the prevalence of halitosis among the general population of Karachi, and to identify factors contributing to its occurrence.

METHODS

The cross-sectional study was conducted from March to July 2022 in Karachi after approval from the ethics review board of Dow University of Health Sciences, Karachi, and comprised the adult population of Karachi. Data was collected online using a questionnaire that was piloted before its link was distributed through social media platforms. The questionnaire evaluated the association of demographic features with self-perceived halitosis on the basis of which factors predictive of halitosis were determined. Data was analysed using SPSS 26.

RESULTS

Of a total of 342 subjects, 182(53%) were females and 160(47%) were males. There were 141(41$) subjects aged 18-25 years, and 166(48%) were graduates. Overall, 240(70%) subjects reported to have self-perceived halitosis. Age, monthly household income, niswar and tea consumption, irregular use of dental floss and tongue cleaning were associated with higher incidence of halitosis (p<0.05). Carrying water bottle while outside was associated with decreased halitosis (p=0.007). Symptoms of gastroesophageal reflux disease, sinusitis, asthma, diabetes, hypertension and mental stress were associated with halitosis (p<0.05). Higher monthly household income and daily use of dental floss predicted lower odds of halitosis (p<0.05).

Conclusion

Maintaining good oral hygiene and hydration reduced, while comorbid conditions increased the probability of halitosis.

Gender Differences in Quality of Life of Adolescent Patients With Chronic Rhinosinusitis

OBJECTIVES

To identify the differences in the impact of chronic rhinosinusitis (CRS) between female and male adolescent patients at presentation.

STUDY DESIGN

Cross sectional study.

METHODS

Adolescent patients, age 12 to 18 years old, presenting to our Otolaryngology clinic between August 2020 and April 2023 for CRS were asked to fill both the SNOT-22 and the SN5 forms. Female and male cohorts were compared regarding their demographics, comorbidities, subjective and objective disease measurements, and choice of treatment.

RESULTS

Sixty-six patients were included, 30 female and 36 male patients. There were no differences in age, allergic rhinitis, asthma, obstructive sleep apnea, presence of nasal septal deviation, and objective disease severity (P > .05 for all). At presentation, mean overall SNOT-22, ear/facial, sleep, and psychological domains were all higher in female patients (43vs 30.9, P = .02; 9.1vs 6, P = .03; 11.8vs 8.3, P = .07; 14.1vs 8.8, P = .02 respectively). SN5 scores and overall QoL visual analog scale were similar in females and males.

CONCLUSION

Female patients with CRS show higher subjective disease burden. Incorporating data on gender-specific differences may be important to personalize treatment decision making.

Determinants of the microbiome spatial variability in chronic rhinosinusitis

BACKGROUND

The sinus microbiome in patients with chronic rhinosinusitis (CRS) is considered homogenous across the sinonasal cavity. The middle nasal meatus is the recommended sampling site for 16S rRNA sequencing. However, individuals with unusually high between-site variability between the middle meatus and the sinuses were identified in previous studies. This study aimed to identify which factors determine increased microbial heterogeneity between sampling sites in the sinuses.

METHODOLOGY

In this cross-sectional study samples for 16S rRNA sequencing were obtained from the middle meatus, the maxillary and the frontal sinus in 50 patients with CRS. The microbiome diversity between sampling sites was analysed in relation to the size of the sinus ostia and clinical metadata.

RESULTS

In approximately 15% of study participants, the differences between sampling sites within one patient were greater than between the patient and other individuals. Contrary to a popular hypothesis, obstruction of the sinus ostium resulted in decreased dissimilarity between the sinus and the middle meatus. The dissimilarity between the sampling sites was patient-specific: greater between-sinus differences were associated with greater meatus-sinus differences, regardless of the drainage pathway patency. Decreased spatial variability was observed in patients with nasal polyps and extensive mucosal changes in the sinuses.

CONCLUSIONS

Sampling from the middle meatus is not universally representative of the sinus microbiome. The differences between sites cannot be predicted from the patency of communication pathways between them.

Nasal Packing Materials and Placement Duration on Wound Healing in Nasal Mucosa: An Animal Study

OBJECTIVE

The histological findings of wound healing depending on different nasal packing materials and replacement periods were lacking.

METHODS

Mucosal defects were created in the nasal septum of rabbits and covered with Spongel®, Algoderm®, or Nasopore®, which were cleaned on Day 14. To investigate the effect of replacement durations, Spongel® was removed on Days 3 and 7. All nasal septal specimens were collected on Day 28. Samples without packing material were prepared as controls. Depending on residual packing materials in the regenerated tissue, specimens were classified into the remnant and non-remnant groups, and morphology was compared using epithelium grade score and subepithelial thickness.

RESULTS

The epithelium grade score in the Spongel-14d group was lower than that in the other groups (p < 0.05). Subepithelial thickness was higher in the Algoderm-14d and Spongel-14d groups (p < 0.05). Epithelium grade scores were higher and subepithelial thicknesses were lower in the Spongel-3d and -7d groups than in the Spongel-14d group. Epithelium grade score was lower and subepithelial thickness was higher in the remnant group (n = 10) than in the non-remnant group (n = 15; p < 0.05).

CONCLUSIONS

Differences in packing materials and placement durations affected wound healing of nasal mucosa. The selection of appropriate packing materials and replacement duration was considered essential for ideal wound healing.

LEVEL OF EVIDENCE

NA Laryngoscope, 134:562-568, 2024.

The effects of priming on rhinologic patient reported outcome measures: a randomized controlled trial

BACKGROUND

Patient-reported outcome measures (PROMs) are questionnaires designed to assess a patient's perception of their medical condition. The 22-item Sino-Nasal Outcomes Test (SNOT-22), the Rhinosinusitis Disability Index (RSDI) and the mini-Rhinoconjunctivitis Quality of Life Questionnaire (MiniRQLQ) are validated PROMs commonly used to assess rhinologic conditions. The objective of this study is to determine if responses on these PROMs may be influenced by priming respondents with positive or negative health-related questionnaires.

METHODS

Nine hundred patients were prospectively randomized to one of nine groups. Groups A, D and G were positively primed prior to completing the SNOT-22, the RSDI and MiniRQLQ, respectively. Groups B, E, and H were negatively primed. Groups C, F, and I served as control groups, completing the PROMs without priming. Priming was performed by administering a survey designed to make patients think about their health-related quality of life in a positive or negative way.

RESULTS

Patients who were primed negatively had statistically significantly worse scores on the SNOT-22, RSDI and MiniRQLQ when compared to patients who were primed positively. When compared to the control group, patients who were primed negatively had statistically worse scores on the SNOT-22 and RSDI. There was no significant difference in scores between the positive priming and the control groups for any PROM.

CONCLUSIONS

Priming subjects regarding their health-related quality of life impacts their responses on rhinologic PROMs. Further study is required to understand the clinical and research implications of this novel finding and to clarify the optimal manner for administering and interpreting PROMs.

Dental implant as a potential risk factor for maxillary sinus fungus ball

Fungus ball is the most common form of non-invasive fungal sinusitis, and maxillary sinus is the most commonly involved site. Maxillary sinus fungus ball (MFB) accounts for a considerable proportion of unilateral maxillary sinusitis. The prevalence of MFB has recently increased; however, its contributing factors are unclear. This study analyzed the association between MFB and dental implants. One hundred one patients who underwent unilateral maxillary sinus surgery were divided into two groups based on surgical biopsy results: unilateral bacterial sinusitis (UBS, n = 45) and MFB (n = 56). Stratified random sampling of 30 patients from each group was performed to adjust for age. The number of dental implants on maxillary teeth and degree of penetration into the maxillary sinus was radiologically evaluated. The number of patients with dental implants was greater (P = 0.085) and the number of implants was significantly higher (P = 0.031) in the MFB group. Dental implant can be a potential risk factor for MFB development. Therefore, dental implant surgeons should take caution in penetrating the maxillary sinus floor during implant insertion and otolaryngologists should consider the possibility of fungus ball when assessing patients with sinusitis who have dental implants.

Paranasal sinus occupancy assessed from magnetic resonance images-associations with clinical indicators in patients with systemic lupus erythematosus

OBJECTIVES

Nasal, paranasal sinus and mucosal disorders are common symptoms in autoimmune rheumatic diseases. Soft tissue changes and fluid accumulation in the osteomeatal complexes and paranasal sinuses manifest as opaqueness on radiological images which can be assessed using visual scoring and computational methods on CT scans, but their results do not always correlate. Using MRI, we investigate the applicability of different image analysis methods in SLE.

METHODS

We assessed paranasal sinus opaqueness on MRI from 51 SLE patients, using three visual scoring systems and expert-delineated computational volumes, and examined their association with markers of disease activity, inflammation, endothelial dysfunction and common small vessel disease (SVD) indicators, adjusting for age and sex-at-birth.

RESULTS

The average paranasal sinus volume occupation was 4.55 (6.47%) [median (interquartile range) = 0.67 (0.25-2.65) ml], mainly in the maxillary and ethmoid sinuses. It was highly correlated with Lund-Mackay (LM) scores modified at 50% opaqueness cut-off (Spearman's ρ: 0.71 maxillary and 0.618 ethmoids, P < 0.001 in all), and with more granular variations of the LM system. The modified LM scores were associated with SVD scores (0: B = 5.078, s.e. = 1.69, P = 0.0026; 2: B = -0.066, s.e. = 0.023, P = 0.0045) and disease activity (anti-dsDNA: B = 4.59, s.e. = 2.22, P = 0.045; SLEDAI 3-7: 2.86 < B < 4.30; 1.38 < s.e. < 1.63; 0.0083 ≤ P ≤ 0.0375). Computationally derived percent opaqueness yielded similar results.

CONCLUSION

In patients with SLE, MRI computational assessment of sinuses opaqueness and LM scores modified at a 50% cut-off may be useful tools in understanding the relationships among paranasal sinus occupancy, disease activity and SVD markers.

Not just snot: Local inflammatory profiles in patients with aspirin-exacerbated respiratory disease differ from patients with aspirin-tolerant chronic rhinosinusitis

KEY POINTS

IL-5, CCL2, and CXCL8 in sinus mucous are higher in patients with AERD relative to aspirin-tolerant patients with CRS These mediators are pleiotropic, leading to widescale inflammatory processes contributing to AERD AERD is not only a T2 disease but heterogeneous: this may explain the refractory nature of AERD.

The role of semaphorins in allergic diseases

Semaphorins were originally identified as guidance molecules in neural development. However, accumulating evidence indicates that 'immune semaphorins' are critically involved in regulating immune cell activation, differentiation, mobility and migration. Semaphorins are also intimately associated with the pathogenesis of allergic diseases including asthma, allergic rhinitis, atopic dermatitis, allergic conjunctivitis, and eosinophilic chronic rhinosinusitis. Interestingly, reflecting their function in positive or negative regulation of immune cells, levels of some semaphorins are increased while others are decreased in patients with allergic diseases. This review presents the pathogenic functions of immune semaphorins in allergic inflammation and discusses the potential use of these molecules as therapeutic targets for allergic diseases.

Management of oculo-orbital complications of odontogenic sinusitis in adults

Introduction: Odontogenic maxillary sinusitis (OMS) is an infectious inflammatory pathology caused by a dental condition. Considering the anatomical relations with the orbit, maxillary sinus infection can easily spread, evolving into severe oculo-orbital complications that can sometimes be life-threatening. Material and methods: We performed a retrospective study of over 2 years, examining the data of 18 patients diagnosed with OMS with oculo-orbital complications. The patients were evaluated regarding their dental history, symptoms, clinical and endoscopic findings, ophthalmologic evaluation, bacteriologic tests, computed tomography (CT) imaging, medical and surgical treatment, and outcomes. Results: The age of the patients was between 24 and 65 years old with an almost equal gender distribution: 10 female and 8 male patients. From the total, 7 patients had type II diabetes, 2 of whom were insulin-dependent, 1 patient had thrombophilia and 2 patients had renal failure with peritoneal dialysis. Regarding the type of oculo-orbital complications, 10 patients were diagnosed with preseptal cellulitis and 8 with orbital cellulitis. Just 5 patients with orbital cellulitis required surgical treatment and orbitotomy was performed, followed by endonasal endoscopic drainage. The evolution after surgical treatment was favorable for all operated patients. Discussions: Oculo-orbital complications of OMS are typically more severe than those of rhinogenic sinusitis because anaerobic bacteria are involved. Immunosuppression represents a favorable environment for the development of OMS and its complications, diabetes being the most common risk factor. A negative prognostic feature is the appearance of ophthalmological symptoms in both eyes, so visual function may be reduced. The treatment of oculo-orbital complications of OMS is urgent and depends on a broad-spectrum antibiotic therapy associated or not with surgical intervention. Conclusions: The diagnosis of oculo-orbital complications of OMS is complex and requires clinical experience as well as extensive medical knowledge to treat both the cause and the consequences of the conditions quickly and effectively. The proper management of oculo-orbital complications is based on a multidisciplinary team: ophthalmology, ENT, dentistry, imaging, and laboratory. Abbreviations: OMS = odontogenic maxillary sinusitis, CT = computed tomography, ENT = ear-nose-throat, MRI = magnetic resonance imaging, HNS = head and neck surgery.

Expression of HORMAD1 in Chronic Rhinosinusitis and Its Correlation with Inflammatory Factors

OBJECTIVE

To explore the abnormal expression of HORMA domain containing protein 1 (HORMAD1) in chronic rhinosinusitis (CRS) patients and its correlation with the expression of inflammatory factors.

STUDY DESIGN

Observational study. Place and Duration of the Study: Department of Otolaryngology Head and Neck Surgery, the Affiliated Huai'an No.1 People's Hospital of Nanjing Medical University, China, from August 2021 to October 2022.

METHODOLOGY

Eighty CRS patients and 80 healthy volunteers participated in this study according to the inclusion and exclusion criteria. The plasma samples of the patients were collected and the level of HORMAD1 was determined by RT-qPCR methods. Commercially available ELISA kits were used for the detection of the levels of cytokines, and the correlation between HORMAD1 expression and the level of cytokines was analysed.

RESULTS

HORMAD1 expression was significantly increased in CRS patients as compared to the healthy subjects. Moreover, the results of ROC curve suggested AUC for HORMAD1 was 0.9442, 95% confidence interval, 0.9057 to 0.9827. IL-1β, TNF-α, IL-6 as well as IFN-γ were all markedly elevated in the CRS group. Positive correlations were found between HORMAD1 expression and the cytokines.

CONCLUSION

HORMAD1 may trigger an inflammatory response in CRS patients. The results of the current study could be beneficial for improving the therapeutic efficacy of CRS patients.

KEY WORDS

HORMAD1, Chronic rhinosinusitis, Expression, Inflammatory factors, DNA damage, Cytokines.

Early increase in eosinophil count may predict long-term hypereosinophilia during dupilumab treatment: a 2-year observational study

KEY POINTS

In a limited subset of patients, dupilumab-induced hypereosinophilia is persistent. Two-month follow-up eosinophil count may predict long-lasting hypereosinophilia.

An Emerging Role of Extracellular Traps in Chronic Rhinosinusitis

PURPOSE OF REVIEW

Chronic rhinosinusitis (CRS) is a complicated, heterogeneous disease likely caused by inflammatory and infectious factors. There is clear evidence that innate immune cells, including neutrophils and eosinophils, play a significant role in CRS. Multiple immune cells, including neutrophils and eosinophils, have been shown to release chromatin and granular proteins into the extracellular space in response to triggering extracellular traps (ETs). The formation of ETs remains controversial due to their critical function during pathogen clearance while being associated with harmful inflammatory illnesses. This article summarizes recent research on neutrophil extracellular traps (NETs) and eosinophil extracellular traps (EETs) and their possible significance in the pathophysiology of CRS.

RECENT FINDINGS

A novel type of programmed cell death called ETosis, which releases ETs, has been proposed by recent study. Significantly more NETs are presented in nasal polyps, and its granule proteins LL-37 induce NETs production in CRS with nasal polyps (CRSwNP) patients. Similar to NETs, developed in the tissue of nasal polyps, primarily in subepithelial regions with epithelial barrier defects, and are associated with linked to elevated tissue levels of IL-5 and S. aureus colonization. This article provides a comprehensive overview of NETs and EETs, as well as an in-depth understanding of the functions of these ETs in CRS.

The potential roles and mechanisms of Chitinase-3-like-1 in the pathogenesis of type 2-biased airway diseases

The immune modulation in the epithelium is a protective feature of the epithelial function in the mucosal airways. Dysfunction of the epithelium can lead to chronic allergic airway inflammatory diseases, such as chronic rhinosinusitis with nasal polyps (CRSwNP), allergic rhinitis (AR), and allergic asthma. Chitinase-3-like-1 (CHI3L1) is a key modulator in the epithelium against irritants, pathogens, and allergens and is involved in cancers, autoimmune diseases, neurological disorders, and other chronic diseases. Induction of epithelial cell-derived CHI3L1 is also confirmed to be implicated in the pathogenesis of Th2-related airway diseases like CRSwNP, AR, and allergic asthma, triggering a cascade of subsequent inflammatory reactions leading to the disease development. The techniques that block the biological function of CHI3L1 include small interfering RNA, neutralizing antibodies, and microRNAs and these methods proved to be successful in preclinical and clinical investigation in cancers, autoimmune diseases, asthma, and chronic obstructive pulmonary disease. Therefore, treatment with CHI3L1-blocking methods could open up therapeutic options for allergic airway diseases. This review article discusses the role of epithelial cell-derived CHI3L1 in the development of CRSwNP, AR, and allergic asthma and examines the use of CHI3L1 as a potential therapeutic agent for allergic airway diseases.

Readability and quality analysis of patient education materials in aspirin-exacerbated respiratory disease

KEY POINTS

Patients are increasingly turning to online education materials to aid with disease management. Patient education materials on aspirin-exacerbated respiratory disease are of poor readability with significant room for improvement.

Hypoxia-inducible factor 1α activates the NLRP3 inflammasome to regulate epithelial differentiation in chronic rhinosinusitis

BACKGROUND

Chronic rhinosinusitis (CRS) is an upper airway inflammation disease associated with hypoxia-mediated inflammation. The effect of hypoxia-inducible factor 1α (HIF-1α) on NOD-like receptor family pyrin domain containing 3 (NLRP3) inflammasome activation in the pathogenesis of sinonasal mucosa is unclear.

OBJECTIVE

We investigated the effect and mechanism of HIF-1α on NLRP3 inflammasome activation in the primary human nasal epithelial cells (hNECs).

METHODS

We measured the expression levels of HIF-1α and the NLRP3 inflammasome in nasal biopsy samples and hNECs derived from negative controls (healthy) and patients with CRS with and without nasal polyps, then further analyzed the specific mechanism of HIF-1α regulation of the NLRP3 inflammasome and its effect on hNEC differentiation.

RESULTS

Increased mRNA and protein expression levels of HIF-1α and the NLRP3 inflammasome were found in all CRS biopsy samples. HIF-1α enhanced expression of phosphorylated NLRP3 (S295) in both HEK293T cells and hNECs; it also promoted recruitment of caspase-1 and apoptotic speck-like protein containing caspase recruitment domain (aka ASC) by NLRP3. HIF-1α also improved NLRP3's stability by preventing NLRP3 degradation caused by hypoxia-mediated inflammation. In addition, HIF-1α could also increase expression of Mucin5AC and decrease expression of α-tubulin by promoting activation of the NLRP3 inflammasome in hNECs. In addition, HIF-1α could also directly promote P63 expression in hNECs.

CONCLUSION

HIF-1α could potentially induce cilia loss and enhance the proliferation of goblet cells, possibly mediated by the regulation of NLRP3 phosphorylation in CRS inflammation.

Orbital cellulitis with panophthalmitis and scleral necrosis - a case report

BACKGROUND

Orbital cellulitis is common in young children and is often secondary to coexisting sinus disease. Coexisting orbital cellulitis and panophthalmitis is a rare clinical event and usually occurs secondary to trauma or from an endogenous source.

CASE PRESENTATION

A febrile 2-year-old male presented with periorbital inflammation and exudative retinal detachment. Imaging showed acute sinusitis and extensive orbital cellulitis. Because of progressive scleral thinning, the patient underwent enucleation.

CONCLUSION

We present a case of concurrent orbital cellulitis, panophthalmitis, and scleral necrosis in an immunocompetent pediatric patient. Timely intervention is important to prevent life threatening complications with the rare occurrence of coexistent orbital cellulitis and panophthalmitis.

[The expression and significance of Piezo1 in chronic rhinosinusitis with nasal polyps]

Objective:To explore the expression and importance of Piezo1, E-cadherin, and Vimentin in nasal polyps patients. Methods:Thirty-five patients undergoing endoscopic sinus surgery under general anesthesia were streamed into 20 cases of nasal polyps（NP group） and 15 cases of simple septoplasty without any sinus disease（Control group）. Immunofluorescence staining and Western Blot were applied to detect the protein level of Piezo1, E-cadherin, and Vimentin in NP tissues and nasal polyp-derived primary human nasal epithelial cells（pHNECs）. Also, BEAS-2B cell lines were treated with human TGF-β1 protein to establish epithelial mesenchymal transition（EMT） model in vitro and quantitative real-time polymerase chain reaction were used to calculate Piezo1 and above biomarkers in the model. Results:Compared with control group, Piezo1 and Vimentin showed higher level while E-cadherin was lower in NP tissues and pHNECs.In EMT model in vitro, Piezo1 and Vimentin were demonstrated higher expression with decreased level of E-cadherin. Conclusion:The tendency of Piezo1 is consistent with the mesenchymal-related biomarker Vimentin, going against with epithelial-related biomarker E-cadherin, implying its involvement with EMT process in nasal polyps.

A 28-Year-Old Woman With Nail Discoloration, Recurrent Bronchitis, and Left-Sided Facial Swelling

CASE PRESENTATION

A 28-year-old woman with a history of congenital hip dysplasia was referred for evaluation of recurrent bronchitis. She had undergone left hip replacement with titanium implants 11 years prior to presentation. The patient reported frequent bouts of bronchitis, sinusitis, and left-sided nontender facial swelling that started after the hip replacement surgery. She also reported nail discoloration of her left first toenail 1 year after this procedure, and nail discoloration of her right first toenail 3 years after the procedure. She was treated for onychomycosis without improvement. Review of symptoms was positive for chronic dry cough and facial tenderness but was negative for dyspnea, wheezing, or chest tightness. She previously had been diagnosed with common variable immunodeficiency based on low immunoglobulin levels, and the condition was maintained with monthly IV immunoglobulins but without any improvement or change in the frequency of sinusitis, bronchitis, or facial swelling. She did not use tobacco, and her family history was unremarkable.