A cost utility analysis for the management of acute exacerbations of chronic rhinosinusitis

BACKGROUND

The management of acute exacerbations of chronic rhinosinusitis (AECRS) is understudied and the most cost-effective management of AECRS has not been previously investigated. The aim of this study is to determine the most cost-effective strategy for the initial management of AECRS.

METHODS

The study design consisted of a decision-tree economic model comparing three different initial strategies for managing a patient perceived AECRS: observation, upfront rescue medications, or clinic visit with diagnostic nasal endoscopy (DNE). The primary study outcome was the disease burden of a single AECRS, which was determined by the health utility value and the duration of symptoms. Strategies with an incremental cost-effectiveness ratio < $50,000/quality-adjusted life year (QALY) or equivalently < $137/quality-adjusted life day (QALD) were considered cost-effective.

RESULTS

Observation was the most cost-effective strategy at a willingness to pay of $137 per QALD. One-way sensitivity analysis demonstrated that observation was more effective than upfront rescue medications when the probability of bacterial infection as the cause of AECRS was <24.0%. Upfront rescue medications wer more cost effective than observation when the probability of bacterial infection exceeded 49.0%. Clinic visit with DNE was the most effective strategy to manage an AECRS, but it was not considered cost-effective.

CONCLUSION

Observation is the most cost-effective strategy for the initial management of AECRS when there is a low likelihood of bacterial infection. When the probability of bacterial etiology of AECRS exceeds 49.0%, upfront rescue medications proved to be the most cost-effective strategy.

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.

Direct economic burden 1 year postoperation in Chinese adult patients with chronic rhinosinusitis with nasal polyps

BACKGROUND

Chronic rhinosinusitis with nasal polyps (CRSwNP) remains a common and challenging clinical entity, and its economic burden has not been well described in China thus far.

METHODS

A total of 101 CRSwNP patients who underwent endoscopic sinus surgery were included to investigate direct costs in the first year post-surgery. Costs for outpatient visits, medication use, and examination costs were obtained from the Hospital Information System, and differences were compared between subgroups. Multiple linear regression analysis was adopted to investigate the main influencing factors on annual total direct costs for CRSwNP patients.

RESULTS

Ninety-two subjects completed the study. The individual mean total direct cost for a CRSwNP patient 1 year post-surgery was $742.4. The largest contributors were pharmacy costs ($580.2), followed by examination costs ($108.1) and outpatient visits ($54.1). Total direct costs were higher in subgroups of patients with uncontrolled clinical status, asthma comorbidity, and eosinophilic CRSwNP compared to their counterparts. The main influencing factors were clinical control status (P = 0.016) and asthma comorbidity (P = 0.035).

CONCLUSIONS

The individual mean total direct cost of CRSwNP in 1-year post-surgery was $742.4. Clinical control status and asthma comorbidity influence these costs and are therefore important in guiding health resources allocation for CRSwNP management.

Association between Helicobacter pylori Infection and Nasal Polyps: A Systematic Review and Meta-Analysis

BACKGROUND

Helicobacter pylori (H. pylori) has definite or possible associations with multiple local and distant manifestations. H. pylori has been isolated from multiple sites throughout the body, including the nose. Clinical non-randomized studies with H. pylori report discrepant data regarding the association between H. pylori infection and nasal polyps. The aim of this first systematic review and meta-analysis was the assessment of the strength of the association between H. pylori infection and incidence of nasal polyps.

METHODS

We performed an electronic search in the three major medical databases, namely PubMed, EMBASE and Cochrane, to extract and analyze data as per PRISMA guidelines.

RESULTS

Out of 57 articles, 12 studies were graded as good quality for analysis. Male-to-female ratio was 2:1, and age ranged between 17-78 years. The cumulative pooled rate of H. pylori infection in the nasal polyp group was 32.3% (controls 17.8%). The comparison between the two groups revealed a more significant incidence of H. pylori infection among the nasal polyp group (OR 4.12), though with high heterogeneity I² = 66%. Subgroup analysis demonstrated that in European studies, the prevalence of H. pylori infection among the nasal polyp group was significantly higher than in controls, yielding null heterogeneity. Subgroup analysis based on immunohistochemistry resulted in null heterogeneity with preserving a statistically significant difference in H. pylori infection prevalence between the groups.

CONCLUSION

The present study revealed a positive association between H. pylori infection and nasal polyps.

Development and Validation of the Sinonasal Outcome Test-12

OBJECTIVES

Quality of life (QoL) questionnaires are widely used in clinical interviews to assess the impact of medical interventions or measure the outcomes of healthcare services. The main aim of such questionnaires is the subjective assessment of health status and its impact on QoL. This study aimed to develop an efficient, short sinonasal disease assessment instrument, the sinonasal outcomes test-12 (SNOT-12), and to compare it with the preexisting SNOT-22.

METHODS

This was a two-phase cross-sectional study. The study was performed between June 2019 and February 2020 using the electronic files of the ORL department outpatient clinics at King Fahd University Hospital, affiliated with Imam Abdulrahman Bin Faisal University. The study was performed in 2 phases: an item reduction phase, which resulted in an initial SNOT-12 scale, and a validation phase, using a comparative analysis of the initial SNOT-12 and the SNOT-22.

RESULTS

The developed short-form SNOT-12 maintained the 4 latent factors extracted in EFA (nasal, Sleep/extra nasal, psychological, ear/facial). It strongly correlated with SNOT-22 (r = 0.973). It had good construct reliability (0.705-0.901) and validity and a higher discrimination power than the SNOT-22.

CONCLUSIONS

The SNOT-12 is a short, valid, and reliable instrument that may prove useful for the initial screening and monitoring of patients with chronic rhinosinusitis.

Nasal microbiome in chronic rhinosinusitis

Chronic rhinosinusitis (CRS) is defined as an inflammatory disorder of the paranasal sinuses and of the nasal mucosa that lasts 12 weeks or longer. In CRS microbes contribute to the disease pathogenesis. Clinical microbiology is focused on finding single pathogens that causes the disease and the main goal is the use of antibiotics to kill bacteria. Efforts to achieve a better understanding of CRS include the study of the sinus microbiome, and to evaluate the ability of probiotics to augment homeostasis and modulate the immune response of the host mucosa. This review provides an update on the role of the microbiome in CRS. The study was conducted using two databases: PubMed and Science Direct. We searched for articles in English that matched the review topic. We first used the abstracts of articles to assess whether they met the inclusion criteria. We also reviewed the references of the selected articles and read those with titles that might be of interest. Several studies have shown that endogenous microbiome dysbiosis can impact mucosa health and disease severity. Some bacterial species presenting protective or pathogenic effect. Antimicrobial agents can create a similar disruption and impact the nasal microbiome balance. On the other hand, probiotics offers a promising avenue for developing systemic and topical therapies geared towards strategic manipulation of the biological host load, thereby augmenting immune homeostasis. A better comprehension of sinus-nasal microbiome in healthy and in CRS patients and the link with different CRS phenotype can help in developing new prognostics, diagnostics, and therapeutics strategies. Going forward, the use of probiotics can restore the native sinus ecology with significant therapeutic and preventive implications.

Biologicals and Endoscopic Sinus Surgery for Severe Uncontrolled Chronic Rhinosinusitis With Nasal Polyps: An Economic Perspective

Chronic rhinosinusitis (CRS) with nasal polyps (CRSwNP) is a chronic disease with a high prevalence and high disease burden, and the lack of a cure. The socioeconomic burden of the disease is substantial and has been disproportionally increasing over past decades. Treatment is aimed at attaining disease control. Traditionally, topical corticosteroids, endoscopic sinus surgery, and oral corticosteroids are used to treat CRSwNP. The advent of biologics has revolutionized CRSwNP treatment, but these drugs are expensive. From an economic standpoint, it is worth debating whether biologics should be employed in patients with severe uncontrolled CRSwNP who fail to attain disease control with current therapies. This clinical commentary review provides an overview of the socioeconomic burden of chronic rhinosinusitis and treatment modalities, compares endoscopic sinus surgery versus biologics for severe CRSwNP, discusses management recommendations, and highlights future needs in this field. New ways to reduce costs of biologic treatments need to be explored to attain cost-effectiveness and provide patients who have severe CRSwNP with adequate treatment.

Observational retrospective study calculating health service costs of patients receiving surgery for chronic rhinosinusitis in England, using linked patient-level primary and secondary care electronic data

OBJECTIVES

Chronic rhinosinusitis (CRS) symptoms are experienced by an estimated 11% of UK adults, and symptoms have major impacts on quality of life. Data from UK and elsewhere suggest high economic burden of CRS, but detailed cost information and economic analyses regarding surgical pathway are lacking. This paper estimates healthcare costs for patients receiving surgery for CRS in England.

DESIGN

Observational retrospective study examining cost of healthcare of patients receiving CRS surgery.

SETTING

Linked electronic health records from the Clinical Practice Research Datalink, Hospital Episode Statistics and Office for National Statistics databases in England.

PARTICIPANTS

A phenotyping algorithm using medical ontology terms identified 'definite' CRS cases who received CRS surgery. Patients were registered with a general practice in England. Data covered the period 1997-2016. A cohort of 13 462 patients had received surgery for CRS, with 9056 (67%) having confirmed nasal polyps.

OUTCOME MEASURES

Information was extracted on numbers and types of primary care prescriptions and consultations, and inpatient and outpatient hospital investigations and procedures. Resource use was costed using published sources.

RESULTS

Total National Health Service costs in CRS surgery patients were £2173 over 1 year including surgery. Total costs per person-quarter were £1983 in the quarter containing surgery, mostly comprising surgical inpatient care costs (£1902), and around £60 per person-quarter in the 2 years before and after surgery, of which half were outpatient costs. Outpatient and primary care costs were low compared with the peak in inpatient costs at surgery. The highest outpatient expenditure was on CT scans, peaking in the quarter preceding surgery.

CONCLUSIONS

We present the first study of costs to the English healthcare system for patients receiving surgery for CRS. The total aggregate costs provide a further impetus for trials to evaluate the relative benefit of surgical intervention.

Effect of Airborne Particulate Matter on the Immunologic Characteristics of Chronic Rhinosinusitis with Nasal Polyps

The inflammatory mechanisms of environmental pollutants in chronic rhinosinusitis (CRS) have recently been proposed. However, the mechanisms underlying the inflammatory effects of particulate matter (PM) on nasal polyp (NP) tissues remain unknown. Here we investigated the mechanism underlying the inflammatory effects of PM10 on human nasal polyp-derived fibroblasts (NPDFs). We isolated NPDFs from human NP tissues obtained from patients with CRS with NPs (CRSwNP). The NPDFs were exposed to PM10 in vitro. Immunologic characteristics were assessed using real-time polymerase chain reaction, enzyme-linked immunosorbent assay, Western blot, and flow cytometry. Additionally, we investigated the effect of NPDF-conditioned media (CM) on the expression of CD4⁺ T cell inflammatory mediators. PM10-treated NPDFs significantly upregulated interleukin (IL)-6, IL-4, and IL-33 expression and CXCL1 protein levels than PM10-treated normal tissues. MAP kinase, AP-1, and NF-kB were the primary cell signaling proteins. Immune cells in NPDF-CM had elevated IL-13, IL-17A, and IL-10 expression, but no significant difference in IFN-γ, TNF-α, and IL-4 expression. Moreover, under a Th2 inducing condition, NPDF-CM-treated CD4⁺ T cells had increased expression of IL-13, IL-10, and IL-17, which was reversed on ST2 inhibitor addition. Our study suggests that PM10 exposure could significantly increase the Th2 inflammatory pathway in NP tissues, specifically the IL-33/ST2 pathway-mediated immune response.

Evaluation of previous management against a developed clinical pathway for chronic rhinosinusitis with nasal polyposis in Universiti Kebangsaan Malaysia Medical Center

The study aims to evaluate previous management of CRSwNP patients in Universiti Kebangsaan Malaysia Medical Center (UKMMC) against a developed CP.Chronic rhinosinusitis with nasal polyposis (CRSwNP) has high economic burden and impacts patient's quality of life. Implementation of clinical pathway (CP) can standardize care while optimizing resources.Analytical cross-sectionalThis study utilized medical records of 103 CRSwNP patients at UKMMC otorhinolaryngology clinic from 2010 to 2015. Patients were divided into groups who underwent or did not undergo surgery. Information was obtained regarding sociodemographic, follow-ups, pharmaceutical regimes, and treatment cost. Cost analysis was done using top-down analysis and activity-based costing and CP was formulated. Cost was calculated using year 2020 rates to adjust for inflation. (United States Dollars [USD]1 = Ringgit Malaysia [RM] 4.2015)Study showed non-CP patients were undertreated compared to CP. This affects clinical outcomes as optimal treatment demanded by CP was not achieved. Total cost for non-CP, non-surgery patients were lower (USD660) compared to CP (USD780) due to under treatment and shorter follow-ups. Meanwhile, total cost for non-CP surgery patients were higher (USD3600) compared to CP (USD2706) due to longer visit durations and hospital stays. Non-CP surgery group underwent lengthy follow-up duration (20.7 months) prior to operation compared to 12 months expected in CP.Study showed non-CP patients were undertreated compared to CP. We identified aspects which resulted in resource wastage and unnecessary burden to our healthcare system. This study enables development of a written CP by fine-tuning various aspects of CP which could be applied to our future practice.

Impact of asthma on endoscopic sinus surgery outcomes for chronic rhinosinusitis with polyposis - A cohort study

INTRODUCTION

Chronic rhinosinusitis with polyposis (CRSwNP) is a multifactorial naso-sinusal inflammatory disease that affects 2-4% of the adult population. It highly affects the patient quality of life (QoL) in many levels making it a public health issue. The management of CRSwNP is based on a detailed clinical history, a complete endoscopic examination and a precise computed tomographic (CT) analysis. The aim of this study is to evaluate the prevalence and severity of the various CRS clinical manifestations as well as to highlight the potential relationship between symptom scores, asthma and ESS outcomes.

PATIENTS AND METHODS

A retrospective cohort study was performed in the 20 August hospital, between January 2017 and December 2018, on patients diagnosed with CRS according to guidelines recommendations, and were beforehand refractory to initial medical therapy and elected to FESS. The patients were divided into two groups, the first group (G1) of patients with asthma and the second (G2) without asthma in order to expose an eventual significant difference in the improvement of symptoms after surgery. The Sino Nasal Outcome Test-22 (SNOT-22) was used to evaluate QOL.

RESULTS

A total of 100 patients participated in the study with an average age of 44.53 years. The sex ratio was 1.04 (51% men). Asthma was present in 48% of patients while 20% of patients were intolerant to aspirin with a significant difference between the asthmatic and non-asthmatic group (p < 0.05). It appears that asthma was not objectively correlated with a higher Lund Mackay radiological score (p > 0.05). A higher significant improvement was observed between preoperative and postoperative SNOT-22 scores in group with asthma [42.7 ± 16.3 versus 11.8 ± 9.1] and in group without asthma [38.3 ± 15.1 versus 10.5 ± 14.2].

CONCLUSION

Asthma in CRS is an additional symptom in these patients, mainly reflected in the subset of nasal symptoms in SNOT-22. However, it did not significantly affect the quality of life of the CRSwNP population.

Adverse Events Associated With Corticosteroid-Eluting Sinus Stents: A MAUDE Database Analysis

OBJECTIVE

Corticosteroid-eluting stents (CESs) are increasingly used after endoscopic sinus surgery to reduce the need for revision surgery, but their use is not without risks. The objective of this study is to describe adverse events related to CESs.

STUDY DESIGN

Retrospective cross-sectional study.

SETTING

The US Food and Drug Administration's MAUDE database (2011-2020; Manufacturer and User Facility Device Experience).

METHODS

The MAUDE database was queried for reports of adverse events involving the use of CESs approved by the Food and Drug Administration, including Propel, Propel Mini, Propel Contour, and Sinuva (Intersect ENT).

RESULTS

There were 28 reported adverse events in total, with all events being related to the Propel family of stents and none related to Sinuva stents. Overall, 22 were categorized as patient-related adverse events and 6 as device-related events. The most common adverse event was related to postoperative infection, accounting for 39% (n = 11) of all complications. Four of these patients developed periorbital cellulitis, and 5 developed a fungal infection. The second-most common adverse event was migration of the stent, representing 21% of all complications (n = 6). Overall, 8 patients (29%) in our cohort required reintervention in the operating room, with subsequent removal of the CES.

CONCLUSION

The most commonly reported adverse events were postoperative infection, including multiple cases of fungal infection, followed by migration of the stent. An increased awareness of the complications associated with CESs can be used to better inform patients during the consenting process as well as surgeons in their surgical decision making.

International consensus statement on allergy and rhinology: rhinosinusitis 2021

I.

EXECUTIVE SUMMARY

BACKGROUND: The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR-RS-2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence-based findings of the document.

METHODS

ICAR-RS presents over 180 topics in the forms of evidence-based reviews with recommendations (EBRRs), evidence-based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary.

RESULTS

ICAR-RS-2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence-based management algorithm is provided.

CONCLUSION

This ICAR-RS-2021 executive summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS.

Comparison of Blood and Tissue Eosinophil Count and Blood IgE in Patients with Chronic Sinusitis and Nasal Polyps

Background

The inflammatory mucosa of the sinus cavities is called sinusitis and is divided into various types based on its appearance and sign. Chronic rhinosinusitis is an inflammatory-infectious disease that involves the frontal, sphenoid, ethmoid, and maxillary sinuses. Chronic sinusitis is a multifactorial disease and the range of causes varies from environmental factors to genetic factors. The purpose of this study was to compare blood and tissue eosinophils and serum IgE levels in patients with chronic sinusitis with nasal polyp in Vali-e-Asr hospital in 1397.

Methods

In this descriptive-analytical study, the population under study included those with chronic sinusitis referred to Birjand Valiasr Hospital in 1397.3 cc of blood samples were taken 1 day before surgery to evaluate eosinophil counts and serum IgE levels. Also, samples taken from patients during surgery were counted, and then, 100 cells were counted, and eosinophil counts and percentages were calculated. The data were entered into the SPSS software after data collection.

Results

This study was performed on 70 patients with chronic rhinosinusitis which included 43 men (61.4%) and 27 women (38.6%) with mean age of 39.11 ± 13 13.72 years. There was no significant difference between sex of patients and mean serum IgE level (P < 0.05). The mean percentage of eosinophils in blood samples and tissues of patients with chronic sinusitis was significantly increased with the increase in CT scan (P < 0.05).

Conclusions

Tissue or blood eosinophilia was not observed in patients with chronic rhinosinusitis. Also, the mean eosinophil percentage of blood and tissue increased significantly in patients with increased scanning computed tomography (P < 0.05).

Pain Catastrophizing and Quality of Life in Adults With Chronic Rhinosinusitis

OBJECTIVES/HYPOTHESIS

Psychological comorbidity is common in patients with chronic rhinosinusitis (CRS) and is correlated with decreased overall and disease-specific quality of life (QoL). Prior research reported that anxiety and depression, as measured by the hospital anxiety and depression scale (HADS), are associated with worse CRS-specific QoL, as assessed via the Rhinosinusitis Disability Index (RSDI). Furthermore, patients prone to anxiety/depression may display an exaggerated response to real or anticipated discomfort; the pain catastrophizing scale (PCS) is a validated instrument designed to measure this phenomenon. This study is intended to explore the role of pain catastrophizing in relation to anxiety, depression, and disease-specific QoL in patients with facial pain attributed to CRS.

STUDY DESIGN

Prospective cohort study.

METHODS

Diagnosis of presumed CRS was based upon current American Academy of Otolaryngology - Head & Neck Surgery (AAO-HNS) guidelines; all participants reported facial pain as a component of their CRS symptomatology. RSDI, HADS, and PCS questionnaires were administered upon presentation prior to intervention, and objective measurements of sinonasal inflammation were obtained via nasal endoscopy and computed tomography (CT).

RESULTS

Seventy-five patients were enrolled in the study. Significant positive correlations were found between PCS and HADS, total RSDI, and RSDI emotional sub-scores (P < .05). The incidence of objective evidence of disease, as measured via nasal endoscopy and CT, was not significantly different in catastrophizing patients.

CONCLUSIONS

Pain catastrophizing correlates with anxiety/depression and worse disease-specific QoL in patients meeting symptomatic criteria for CRS. Otolaryngologists should be aware that catastrophic thinking can intensify a patient's perception of sinonasal symptoms, and clinicians may consider management of psychological comorbidity to optimize rhinologic outcomes.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:1939-1945, 2021.

Symptoms and Clinical Findings in Primary Headache Syndrome Versus Chronic Rhinosinusitis

BACKGROUND

Primary headache syndrome (PHS) patients frequently present to otolaryngologists with sinonasal complaints and diagnosis of chronic rhinosinusitis (CRS) due to symptomatic overlap. In this study, we compare demographic, subjective, and objective clinical findings of patients with PHS versus CRS.

METHODS

We retrospectively reviewed a database of patients presenting to a single tertiary care Rhinology clinic from December 2011-July 2017. Sino-Nasal Outcome Test-22 (SNOT) scores and Lund-Kennedy endoscopy scores were obtained. Lund-MacKay CT scores were calculated, if available. Requirement of headache specialist management was compared between PHS and CRS groups. Patients with both CRS and PHS (CRScPHS) that required headache specialist management were compared to patients with CRS without PHS (CRSsPHS) and patients with PHS alone using Kruskal-Wallis analysis of variance. Receiver operating characteristic (ROC) analyses were carried out to determine significant diagnostic thresholds.

RESULTS

One-hundred four PHS patients and 130 CRS patients were included. PHS patients (72.1%) were more likely than CRS patients to require headache specialist management (6.9%, p<0.0001). CRSsPHS patients had significantly higher Nasal domain scores compared to PHS patients (p = 0.042) but not compared to CRScPHS patients (p>0.99). CRScPHS (p = 0.0003) and PHS (p<0.0001) subgroups of patients had significantly higher Aural/Facial domain scores compared to CRSsPHS patients. PHS patients also had significantly higher Sleep domains scores compared to CRSsPHS patients (p<0.0001). Both CRScPHS and CRSsPHS subgroups had significantly higher nasal endoscopy scores (p<0.0001) and CT scores (p = 0.04 & p<0.0001, respectively) compared to the PHS group. Aural/Facial domain score of 4, nasal endoscopy score of 4, and CT score of 2 were found to be reliable diagnostic thresholds for absence of CRS.

CONCLUSIONS

The SNOT-22 may be used to distinguish PHS from CRS based upon the Aural/Facial and Sleep domains. Patients with CRS have more severe Nasal domain scores and worse objective endoscopy and CT findings.

Clinical Research Needs for the Management of Chronic Rhinosinusitis with Nasal Polyps in the New Era of Biologics: A National Institute of Allergy and Infectious Diseases Workshop

The development of biologics targeting various aspects of type 2 inflammation for the treatment of chronic rhinosinusitis with nasal polyps (CRSwNP) will provide clinicians with powerful tools to help treat these patients. However, other therapies are also available, and positioning of biologics in a management algorithm will require comparative trials. In November 2019, the National Institute of Allergy and Infectious Diseases convened a workshop to consider potential future trial designs. Workshop participants represented a wide spectrum of clinical specialties, including otolaryngology, allergy, and pulmonary medicine, as well as expertise in CRSwNP pathophysiology and in trial methodology and statistics. The workshop discussed the current state of knowledge in CRSwNP and considered the advantages and disadvantages of various clinical trial or observational study designs and various clinical outcomes. The output from this workshop, which is presented in this report, will hopefully provide investigators with adequate information and ideas to design future studies and answer critical clinical questions. It will also help clinicians understand the current state of the management of CRSwNP and its gaps and be more able to interpret the new information to come.

Correlation of nasal endoscopy and computed tomography scan findings in adult patients with chronic rhinosinusitis

Background:

The diagnosis of chronic rhinosinusitis (CRS) is usually based on appropriate clinical features. However, confirmation is based on the evidence of features of inflammation on nasal endoscopy and/or computed tomography (CT) scan of the paranasal sinuses. Though CT scan is the gold standard, studies have found nasal endoscopy equally helpful and sometimes complementary to CT scan in the diagnosis of CRS.

Aims and Objectives:

The aim of this study is to assess and correlate the findings on nasal endoscopy and CT scan of adult patients with CRS.

Materials and Methods:

Consecutive adult patients clinically diagnosed with CRS were enrolled. Those who did both nasal endoscopy and CT scan of the paranasal sinuses within 3 months’ interval were studied. The findings were correlated.

Results:

The commonest symptoms were rhinorrhea and nasal obstruction seen in 95% and 92.5% of the patients. Purulent discharge in the middle meatus was the commonest finding on nasal endoscopy seen in 56.7% of the patients. There was pathology of at least one paranasal sinus in 71.7% of the patients on CT scan. Maxillary sinus was most commonly affected. Obstruction of the osteomeatal complex was present in 51.7% of the patients. The sensitivity, specificity, positive, and negative predictive values of nasal endoscopy were 73.3%, 85.3%, 92.7%, and 55.8%, respectively.

Conclusion:

The presence of cream-coloured discharge in the middle meatus on nasal endoscopy is a good predictive index in the diagnosis of CRS, whereas sinus intraluminal lesions are better elucidated by CT scan.

A 10-Year Follow-Up of a Randomized Prospective Study of 2 Treatments for Chronic Rhinosinusitis Without Nasal Polyps and Investigation of the Impact of Gastroeosophageal Reflux Disease in the Resistance to Treatment

OBJECTIVES

To compare the 2 long-term medical strategies in chronic rhinosinusitis without nasal polyps (CRSnNP) and to identify the role of gastroesophageal reflux disease (GERD) and Helicobacter pylori as factors of treatment failure.

MATERIAL AND METHODS

Fifty-seven patients with CRSnNP were randomized into 2 therapeutic groups. The first group was treated with 4 weeks of amoxicillin/clavulanate and a short course of oral steroids. The second group received 8 weeks of clarithromycin. Sinonasal Outcome Test-20 (SNOT-20) and Lund and Mackay scores were assessed at baseline and after treatment, and GERD Health-Related Quality of Life (GERD-HRQL) questionnaire was evaluated in all patients. Patients with a GERD-HRQL score >8 received esogastroscopy and H pylori detection. Patients were followed during a 10-year period for clinical course and GERD evolution. The 10-year evolution of patients was described in terms of recurrence, medical, and surgical treatments.

RESULTS

Thirty-seven patients completed the study; SNOT-20 and Lund and Mackay scores similarly improved in both groups. Amoxicillin/clavulanate group had significantly more adverse reactions than the clarithromycin group (P = .03). After the therapeutic course, 35% (amoxicillin/clavulanate) and 41% (clarithromycin) of patients needed functional endoscopic sinus surgery (FESS). During the long-term follow-up, 54% (amoxicillin/clavulanate) and 40% (clarithromycin) of patients had late CRSnNP recurrence; FESS was performed in less than 15% of cases of recurrence. Gastroesophageal reflux disease complaint's severity was associated with late recurrence of CRSnNP.

CONCLUSION

Amoxicillin/clavulanate and clarithromycin would be competitive treatments for CRSnNP. Gastroesophageal reflux disease seems to be a negative factor for treatment response and recurrence.

Workplace Indirect Cost Impacts of Nasal and Sinus Symptoms and Related Conditions

OBJECTIVE

Evaluate associations of nasal and sinus and related symptoms, as well as selected health conditions which produce those symptoms, with total lost productive time (LPT) at work in the past 2 weeks.

METHODS

We used a cross-sectional analysis of 2402 currently working subjects. Self-reported physician diagnoses, condition statuses measured with standardized instruments, and symptom-based factor scores from an exploratory factor analysis were used in survey weighted log-binomial regression.

RESULTS

Pain and pressure, nasal blockage and discharge, and asthma and constitutional symptom factor scores as well as self-reported allergic rhinitis were associated with higher total LPT. Individuals who met operationalized criteria for multiple health conditions, especially chronic rhinosinusitis, had the greatest total LPT.

CONCLUSIONS

Better management of these symptoms, and awareness of how they impact an individual's ability to perform job-functions in the workplace, could improve overall productivity.

Psychometric and Clinimetric Validity of the Modified 25-Item Sino-Nasal Outcome Test

Background

Productivity losses are a significant part of the disease burden associated with rhinosinusitis, but existing measures of disease-specific quality of life exclude explicit assessment of the impact of the disease on productivity.

Objective

The objective of this study was to evaluate the clinimetric and psychometric validity of the 25-item Sino-Nasal Outcome Test (SNOT-25), a modified version of the SNOT-22.

Methods

This was a prospective cohort study conducted at an academic medical center. Participants included adult patients with rhinosinusitis who presented for routine visits to the Washington University in St. Louis School of Medicine otolaryngology clinic between August 2016 and March 2017.

Results

The SNOT-25 was created with the addition of three productivity-specific items to the SNOT-22 instrument. A total of 120 rhinosinusitis patients completed all baseline measurements and 94 (78.3%) completed 3-month follow-up. The Cronbach’s α was 0.83, indicating high internal consistency. Rhinosinusitis patients had on average a 24-point higher baseline SNOT-25 score (95% confidence interval [CI]: 13–35) as compared to healthy controls indicating good discriminative validity. There was high correlation between SNOT-25 scores at 3 months and 3.5 months ( r = .81; 95% CI, 0.73–0.87) confirming strong test–retest reliability. SNOT-25 had a strong correlation with the overall score of the Nasal Obstruction Symptom Evaluation instrument ( r = .55; 95% CI, 0.42–0.65), and among Short Form-36 subscales, the strongest correlations existed between SNOT-25 and the fatigue scale ( r = −.522; 95% CI, −0.63 to −0.39). Exploratory factor analysis revealed that the 3 new questions of SNOT-25 loaded together with reduction in productivity and concentration items on a new “productivity” factor.

Conclusion

The SNOT-25 is a valid instrument that can be used to assess rhinosinusitis disease burden including the impact on productivity and may be a better predictor of treatment decisions and outcomes.

Association between Sleep Duration and Chronic Rhinosinusitis among the Korean General Adult Population: Korea National Health and Nutrition Examination Survey

An association between sleep duration and a wide spectrum of diseases has been reported, but little is known about its relationship with chronic rhinosinusitis (CRS). The present study aimed to investigate whether sleep duration was associated with CRS after adjusting for potential confounding factors in Korean adults. We analyzed data from the Korea National Health and Nutrition Examination Survey 2005–2009 and enrolled 24,658 participants aged ≥20 years. Data regarding sociodemographic characteristics, self-reported sleep duration, CRS, and other medical diseases were collected from questionnaires. Multiple logistic regression analyses were used to identify the relationship between sleep duration and CRS. The overall prevalence of CRS was 4.4%. Subjects with sleep duration ≤5 hours showed a highest prevalence for CRS (6.1%), compared to subjects with longer sleep duration (p = 0.02). After adjusting for covariates (age, sex, household income, residency, dwelling type, education, depression, alcohol, allergic rhinitis, chronic otitis media, angina or myocardial infarction, asthma, chronic obstructive pulmonary disease, bronchiectasis, and gastric ulcer), the sleep duration of ≤5 hours was significantly associated with CRS (OR = 1.502; 95% CI = 1.164–1.938). Only in older subgroup (≥50 years old), shorter sleep duration (≤5 hours) showed higher odds for CRS. These results suggested that sleep duration may be negatively associated with CRS in older Korean adults.

Clarithromycin and endoscopic sinus surgery for adults with chronic rhinosinusitis with and without nasal polyps: study protocol for the MACRO randomised controlled trial

Background

Chronic rhinosinusitis (CRS) is a common source of ill health; 11% of UK adults reported CRS symptoms in a worldwide population study. Guidelines are conflicting regarding whether antibiotics should be included in primary medical management, reflecting the lack of evidence in systematic reviews. Insufficient evidence to inform the role of surgery contributes to a fivefold variation in UK intervention rates. The objective of this trial is to establish the comparative effectiveness of endoscopic sinus surgery (ESS) or a prolonged course of antibiotics (clarithromycin) in adult patients with CRS in terms of symptomatic improvement and costs to the National Health Service compared with standard medical care (intranasal medication) at 6 months.

Methods/design

A three-arm parallel-group trial will be conducted with patients who remain symptomatic after receiving appropriate medical therapy (either in primary or secondary care). They will be randomised to receive: (1) intranasal medication plus ESS, (2) intranasal medication plus clarithromycin (250 mg) or (3) intranasal medication plus a placebo. Intranasal medication (current standard medical care) is defined as a spray or drops of intranasal corticosteroids and saline irrigations. The primary outcome measure is the SNOT-22 questionnaire, which assesses disease-specific health-related quality of life. The study sample size is 600. Principal analyses will be according to the randomised groups irrespective of compliance. The trial will be conducted in at least 16 secondary or tertiary care centres with an internal pilot at six sites for 6 months.

Discussion

The potential cardiovascular side effects of macrolide antibiotics have been recently highlighted. The effectiveness of antibiotics will be established through this trial, which may help to reduce unnecessary usage and potential morbidity. If ESS is shown to be clinically effective and cost-effective, the trial may encourage earlier intervention. In contrast, if it is shown to be ineffective, then there should be a significant reduction in surgery rates. The trial results will feed into the other components of the MACRO research programme to establish best practice for the management of adults with CRS and design the ideal patient pathway across primary and secondary care.

Trial registration

ISRCTN36962030. Registered on 17 October 2018.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3314-7) contains supplementary material, which is available to authorized users.

Safety and efficacy of a bacteriophage cocktail in an in vivo model of Pseudomonas aeruginosa sinusitis

Pseudomonas aeruginosa (PA) is a bacterial pathogen that frequently displays antibiotic resistance. Its presence within the sinuses of chronic rhinosinusitis sufferers is associated with poorer quality of life. Obligately lytic bacteriophages (phages) are viruses that infect, replicate within, and lyse bacteria, causing bacterial death. The aims of this study were to assess the safety and efficacy of a PA phage cocktail (CT-PA) in a sheep model of rhinosinusitis. The sheep rhinosinusitis model was adapted to simulate PA infection in sheep frontal sinuses. To assess efficacy, after a 7-day biofilm formation period, sheep received twice-daily frontal trephine flushes of CT-PA or saline for 1 week. Biofilm quantitation on frontal sinus mucosa was performed using LIVE/DEAD BacLight staining. To assess safety, sheep received twice-daily frontal trephine flushes of CT-PA or vehicle control for 3 weeks. Blood and fecal samples were collected throughout treatment. Histopathology of frontal sinus, lung, heart, liver, spleen, and kidney tissue was performed. Sinus cilia were visualized using scanning electron microscopy (SEM). The Efficacy arm showed a statistically significant reduction in biofilm biomass with all concentrations of CT-PA tested (P < 0.05). Phage presence in sinuses was maintained for at least 16hours after the final flush. All Safety arm sheep completed 3 weeks of treatment. Phage was detected consistently in feces and sporadically in blood and organ samples. Histology and SEM of tissues revealed no treatment-related damage. In conclusion, CT-PA was able to decrease sinus PA biofilm at concentrations of 10⁸-10¹⁰ PFU/mL. No safety concerns were noted.

Comparison of Subtyping Approaches and the Underlying Drivers of Microbial Signatures for Chronic Rhinosinusitis

Chronic rhinosinusitis (CRS) is a major human health problem that significantly reduces quality of life. While various microbes have been implicated, there is no clear understanding of the role they play in CRS pathogenesis. Another equally important observation made for CRS patients is that the epithelial barrier in the sinonasal cavity is defective. Finding a robust approach to subtype CRS patients would be the first step toward unravelling the pathogenesis of this heterogeneous condition. Previous work has explored stratification based on the clinical presentation of the disease (with or without polyps), inflammatory markers, pathology, or microbial composition. Comparisons between the different stratification approaches used in these studies have not been possible due to the different cohorts, analytical methods, or sample sites used. In this study, two approaches for subtyping CRS patients were compared, and the underlying drivers of the heterogeneity in CRS were also explored.

Chronic rhinosinusitis (CRS) is a heterogeneous condition characterized by persistent sinus inflammation and microbial dysbiosis. This study aimed to identify clinically relevant subgroups of CRS patients based on distinct microbial signatures, with a comparison to the commonly used phenotypic subgrouping approach. The underlying drivers of these distinct microbial clusters were also investigated, together with associations with epithelial barrier integrity. Sinus biopsy specimens were collected from CRS patients (n = 23) and disease controls (n = 8). The expression of 42 tight junction genes was evaluated using quantitative PCR together with microbiota analysis and immunohistochemistry for measuring mucosal integrity and inflammation. CRS patients clustered into two distinct microbial subgroups using probabilistic modelling Dirichlet (DC) multinomial mixtures. DC1 exhibited significantly reduced bacterial diversity and increased dispersion and was dominated by Pseudomonas, Haemophilus, and Achromobacter. DC2 had significantly elevated B cells and incidences of nasal polyps and higher numbers of Anaerococcus, Megasphaera, Prevotella, Atopobium, and Propionibacterium. In addition, each DC exhibited distinct tight junction gene and protein expression profiles compared with those of controls. Stratifying CRS patients based on clinical phenotypic subtypes (absence or presence of nasal polyps [CRSsNP or CRSwNP, respectively] or with cystic fibrosis [CRSwCF]) accounted for a larger proportion of the variation in the microbial data set than with DC groupings. However, no significant differences between CRSsNP and CRSwNP cohorts were observed for inflammatory markers, beta-dispersion, and alpha-diversity measures. In conclusion, both approaches used for stratifying CRS patients had benefits and pitfalls, but DC clustering provided greater resolution when studying tight junction impairment. Future studies in CRS should give careful consideration to the patient subtyping approach used.

IMPORTANCE Chronic rhinosinusitis (CRS) is a major human health problem that significantly reduces quality of life. While various microbes have been implicated, there is no clear understanding of the role they play in CRS pathogenesis. Another equally important observation made for CRS patients is that the epithelial barrier in the sinonasal cavity is defective. Finding a robust approach to subtype CRS patients would be the first step toward unravelling the pathogenesis of this heterogeneous condition. Previous work has explored stratification based on the clinical presentation of the disease (with or without polyps), inflammatory markers, pathology, or microbial composition. Comparisons between the different stratification approaches used in these studies have not been possible due to the different cohorts, analytical methods, or sample sites used. In this study, two approaches for subtyping CRS patients were compared, and the underlying drivers of the heterogeneity in CRS were also explored.

Cost burden and resource utilization in patients with chronic rhinosinusitis and nasal polyps

OBJECTIVES/HYPOTHESIS

Establish treatment patterns and economic burden in US patients with chronic rhinosinusitis with nasal polyposis (CRSwNP) versus without chronic rhinosinusitis (CRS). Determine comparative costs of subgroups with high clinical burden.

STUDY DESIGN

Observational, retrospective, case-control study.

METHODS

This study matched patients with CRSwNP to patients without CRS (1:1) using the Truven Health MarketScan US claims database. Categorical and continuous variables were compared using McNemar test and paired t test (normal distribution) or Wilcoxon signed rank tests (non-normal distribution). Within subgroups, χ² and Wilcoxon or t tests were used (normal distribution).

RESULTS

There were 10,841 patients with CRSwNP and 10,841 patients without CRS included. Mean age in the CRSwNP cohort was 45.8 years; 56.2% were male. During follow-up, patients with CRSwNP had an increased diagnosis of asthma versus patients without CRS (20.8% vs. 8.1%, respectively; P < .001). Annual incremental costs were $11,507 higher for patients with CRSwNP versus those without CRS. Costs were higher in subgroups of patients with CRSwNP undergoing functional endoscopy sinus surgery (FESS), with a comorbid diagnosis of asthma, receiving oral corticosteroids, or macrolides versus the overall CRSwNP group. Patients with CRSwNP undergoing FESS had the highest costs of the four subgroups ($26,724, $22,456, $20,695, and $20,990, respectively).

CONCLUSIONS

Annual incremental costs were higher among patients with CRSwNP versus without CRS. Patients with CRSwNP with high clinical burden had higher overall costs than CRSwNP patients without.

LEVEL OF EVIDENCE

NA Laryngoscope, 129:1969-1975, 2019.

EXHANCE-12: 1-year study of the exhalation delivery system with fluticasone (EDS-FLU) in chronic rhinosinusitis

BACKGROUND

Inadequate efficacy of current intranasal steroids in chronic rhinosinusitis (CRS) is attributable to ineffective and/or inconsistent drug delivery to target anatomic sites. A new exhalation delivery system with fluticasone (EDS-FLU) may improve outcomes by significantly increasing superior/posterior corticosteroid delivery. A study was conducted to assess the long-term efficacy and safety outcomes of EDS-FLU in individuals with CRS.

METHODS

This was a 12-month, multicenter, single-arm study evaluating the safety and efficacy of EDS-FLU 372 μg twice daily in CRS patients (with [n = 34] or without [n = 189] nasal polyps [NP]). Efficacy assessments by serial nasal endoscopy and patient report included: 22-item Sino-Nasal Outcome Test (SNOT-22), NP grade, standardized surgical indicator assessment, Lund-Kennedy score, and Patient Global Impression of Change. Adverse event (AE) evaluations included nasal endoscopy. Additional safety and efficacy outcomes were assessed.

RESULTS

Of 223 patients who received EDS-FLU, 96% reported prior corticosteroid use and 29% prior sinus surgery. The EDS-FLU AE profile was similar to conventional intranasal steroids studied in similar populations. Most patients (87%) reported symptom improvement. Through 12 months, mean SNOT-22 scores improved by -21.5 and -21.1 for CRS with and without NP, respectively. Among patients with NP, 54.2% had polyp elimination in at least 1 nostril and 83.3% had ≥1-point improvement in polyp grade.

CONCLUSION

Over 1 year of treatment in CRS with and without NP, EDS-FLU 372 μg twice daily was well tolerated and produced improvements across a broad range of objective and subjective measures. EDS-FLU may be a desirable new option for patients with this condition.

Prevalence of Potential Adult Chronic Rhinosinusitis Symptoms in the United States

Objective To determine the prevalence of chronic rhinosinusitis-related symptoms in the United States. Study Design Cross-sectional analysis of a national database. Setting Representative sampling of the US adult population. Subjects and Methods The National Health and Nutrition Examination Survey data set, taste and smell supplement 2013-2014 was analyzed for sinonasal question responses regarding discolored nasal mucus, nasal blockage, sinus pain, and dysosmia. The individual prevalences as well as the prevalence of 2 or more of these symptoms (which would be compatible with a diagnosis of chronic rhinosinusitis) were determined for the US population. Results After excluding adults with an intercurrent head cold, 113.5 million adults (mean age 58.2 years; 52.6% female) were analyzed. Individual symptom prevalences were dysosmia (9.17 million, 8.1%), nasal blockage (6.9 million, 6.0%), sinus pain (2.37 million, 2.1%), and discolored mucous (1.28 million, 1.1%). Overall, 14.8 million (13.0%) adults had exactly 1 sinonasal symptom, and 2.37 million adults (2.1%) responded with 2 or more cardinal symptoms for chronic rhinosinusitis. With respect to sex, 1.9% of males reported 2 or more symptoms compatible with chronic rhinosinusitis vs 2.2% of females ( P = .690), which is not statistically significant. Conclusion Of US adults, 2.1% meet symptom criteria for the potential diagnosis of chronic rhinosinusitis at any given time. Further objective corroboration with a physical exam and determination of duration of symptoms would be required to determine the true prevalence of chronic rhinosinusitis, but this point prevalence represents the potential population at risk for chronic rhinosinusitis in the United States.

The personal financial burden of chronic rhinosinusitis: A Canadian perspective

BACKGROUND

Previous studies describe the financial burden of chronic rhinosinusitis (CRS) from the perspective of third-party payers, but, to our knowledge, none analyze the costs borne by patients (i.e., out-of-pocket expenses [OOPE]). Furthermore, this burden has not been previously investigated in the context of a publicly funded health care system.

OBJECTIVE

The purpose of this study was to characterize the financial impact of CRS on patients, specifically by evaluating its associated OOPEs and the perceived financial burden. The secondary aim was to determine the factors predictive of OOPEs and perceived burden.

METHODS

Patients with CRS at a tertiary care sinus center completed a self-administered questionnaire that assessed their socioeconomic characteristics, disease-specific quality of life (22-item Sino-Nasal Outcome Test [SNOT-22]), workdays missed due to CRS, perceived financial burden, and direct medical and nonmedical OOPEs over a 12-month period. Total OOPEs were calculated from the sum of direct medical and nonmedical OOPEs. Regression analyses determined factors predictive of OOPEs and the perceived burden.

RESULTS

A total of 84 patients completed the questionnaires. After accounting for health insurance coverage and the median direct medical, direct nonmedical, and total OOPEs per patient over a 12-month period were Canadian dollars (CAD) $336.00 (2011) [U.S. $339.85], CAD $129.87 [U.S. $131.86], and CAD $607.10 [U.S. $614.06], respectively. CRS resulted in an average of 20.6 workdays missed over a 12-month period. Factors predictive of a higher financial burden included younger age, a greater number of previous sinus surgeries, <80% health insurance coverage, residing out of town, and higher SNOT-22 scores.

CONCLUSION

Total OOPEs incurred from the treatment of CRS may amount to CAD $607.10 [U.S. $614.06] per patient per year, within the context of a single-payer health care system. Managing clinicians should be aware of patient groups with a greater perceived financial burden and consider counseling them on strategies to offset expenses, including obtaining travel grants, using telemedicine for follow-up assessments, providing drug samples, and streamlining diagnostic testing with medical visits.

Chronic Rhinosinusitis Patients with Polyps or Polypoid Mucosa have a Greater Burden of Illness

Background

Recent studies suggest chronic rhinosinusitis without nasal polyposis (CRSsNP) and CRS with nasal polyposis (CRScNP) represent distinct pathological entities. The aim of this study was to determine whether patients with CRSsNP, CRScNP, and polypoid CRS could be distinguished by clinical features, radiologic extent of disease or use of medications.

Methods

New patients with CRS (n = 126) were enrolled in a prospective outcomes study. Rhinoscopic evaluation was used to classify patients. The relationship between disease phenotype and clinical parameters was examined.

Results

Facial pain/pressure/headache was more prevalent in CRSsNP than CRScNP (p = 0.01). Nasal obstruction and hyposmia/ anosmia were more prevalent in CRScNP than CRSsNP (p = 0.025 and 0.01, respectively). Intermediate symptom prevalence was found in polypoid CRS. Multivariate analysis confirmed that prior surgery, CT scan score, and male gender were independent predictors of polyp/polypoid phenotype. Allergic status was unrelated to CRS classification. Medication use was higher in CRScNP patients than in CRSsNP patients.

Conclusion

Compared with CRSsNP, patients with CRScNP have a greater burden of symptoms, more prior surgery, higher CT scan scores, and greater use of medications.

A Comparison of Symptom Scores and Radiographic Staging Systems in Chronic Rhinosinusitis

Background

The aim of this study was to determine if one of the popular computed tomography (CT) scan staging systems exhibits better correlation with sinonasal symptom severity in chronic rhinosinusitis (CRS).

Methods

Adult patients meeting diagnostic criteria for CRS were prospectively studied with the Rhinosinusitis Symptom Inventory and their paranasal sinus CT scan was staged according to the Kennedy, Harvard, and Lund staging systems. From the Rhinosinusitis Symptom Inventory, Likert symptom severity scores were obtained and the nasal, facial, oropharyngeal, systemic, and total symptom scores were computed. Correlation analysis was conducted between symptom scores and CT scan stage for each of the three staging systems.

Results

Two hundred patients met inclusion criteria (mean age, 41.1 years; 42% men). The mean Lund score for the entire cohort was 10.0 (SD, 5.3). The Kennedy stage distributions were 40, 42, 84, and 34 patients for stages 1–4, respectively. The Harvard stage distributions were 17, 53, 85, and 45 patients for stages 1–4, respectively. All three staging systems exhibited statistically significant Pearson correlation (all p < 0.001) for the nasal symptom domain (nasal obstruction, rhinorrhea, and hyposmia), although the magnitude of the correlation coefficient generally was small (range of Pearson's r, 0.242–0.345). The Kennedy and Harvard systems exhibited significant but negative correlation with the oropharyngeal symptom domain. All three staging systems failed to significantly correlate CT stage with facial symptoms, systemic symptoms, and total symptom scores.

Conclusion

The Lund staging system exhibited the best correlation between nasal symptom scores and CT stage in CRS, but the degree of correlation remained small. All three systems were lacking in staging value for nonnasal sinonasal symptoms.

Subjective Headache before and after Endoscopic Sinus Surgery

Background

The aim of this study was to show the effect of endoscopic sinus surgery on subjective headache scores in patients diagnosed with chronic rhinosinusitis (CRS) with or without nasal polyps.

Methods

We performed a retrospective analysis of prospectively collected data from 201 patients over a 2-year period. Headache and Sino-Nasal Outcomes Test (SNOT-20) mean scores were compared preoperatively and 2 years postoperatively on patients diagnosed with CRS with or without nasal polyps.

Results

Two hundred one patients underwent surgical management of CRS with or without nasal polyps over a 3-year period. One hundred four patients were men and 97 were women, with a mean age of 49 (range, 18–80 years) years. Polyps were present in 78 patients with CRS. The mean subjective headache score based on a 0–10 visual analog scale improved from 4.7 preoperatively to 0.8 2 years postoperatively (p < 0.0001). The mean headache score of 123 patients without polyps was larger compared with 78 patients with polyps (5.1 versus 4.1, respectively; p < 0.05). As previously reported, the mean overall preoperative and postoperative SNOT-20 scores were 28.7 and 6.7, respectively (p < 0.0001).

Conclusion

Headache is a common symptom with CRS, present in 73.6% of our patients undergoing functional endoscopic sinus surgery for CRS with or without nasal polyps. An overall decrease in mean headache scores was noted at 2-year follow-up.

The sinonasal microbiota, neural signaling, and depression in chronic rhinosinusitis

BACKGROUND

The complex relationships between the human microbiota, the immune system, and the brain play important roles in both health and disease, and have been of increasing interest in the study of chronic inflammatory mucosal conditions. We hypothesized that the sinonasal microbiota may act as a modifier of interkingdom neural signaling and, subsequently, mental health, in the upper respiratory inflammatory condition chronic rhinosinusitis (CRS). In this study we investigated associations between the sinonasal microbiota; local concentrations of the neurotransmitters serotonin, dopamine, and γ-aminobutyric acid (GABA); and depression severity in a cohort of 14 CRS patients and 12 healthy controls.

METHODS

Subject demographics, clinical severity scores, depression index scores, and sinonasal swab and mucus samples were collected at the time of surgery. Bacterial communities were characterized from swabs by 16S rRNA gene-targeted sequencing and quantified by quantitative polymerase chain reaction. Mucus concentrations of the neurotransmitters serotonin, dopamine, and GABA were quantified by enzyme-linked immunosorbent assay.

RESULTS

Several commonly "health-associated" sinonasal bacterial taxa were positively associated with higher neurotransmitter concentrations and negatively associated with depression severity. In contrast, several taxa commonly associated with an imbalanced sinonasal microbiota negatively associated with neurotransmitters and positively with depression severity. Few significant differences were identified when comparing between control and CRS subject groups, including neurotransmitter concentrations, depression scores, or sinonasal microbiota composition or abundance.

CONCLUSION

The findings obtained lend support to the potential for downstream effects of the sinonasal microbiota on neural signaling and, subsequently, brain function and behavior.

General illness and psychological factors in patients with chronic nasal symptoms

OBJECTIVES

Only a minority of patients referred to specialists with sinonasal symptoms have clear evidence of chronic rhinosinusitis (CRS). This study aims to estimate the prevalence of and associations between (i) general illness factors (fatigue, autonomic dysfunction) and (ii) psychological factors (anxiety, depression, somatisation, personality traits) in patients presenting with sinonasal symptoms.

DESIGN

The following validated questionnaires were administered to patients: the Sino-Nasal Outcome Test-22 (SNOT-22) identifying symptom burden, Composite Autonomic Symptom Score-31 (COMPASS-31) measuring autonomic function, Chalder Fatigue Questionnaire, Patient Health Questionnaire-15 (PHQ-15) addressing somatisation symptoms, Hospital Anxiety and Depression Scale (HADS), and the International Personality Item Pool-50 (IPIP-50). Comparisons were made with normative and general population data, and relationships were analysed using nonparametric correlation.

SETTING

Secondary care ENT outpatients.

PARTICIPANTS

Adults referred with chronic sinonasal symptoms.

MAIN OUTCOME MEASURES

SNOT-22, COMPASS-31, Chalder, PHQ-15, HADS, and IPIP-50 questionnaire scores.

RESULTS

Sixty-one patients were included. There was a high prevalence of all general and psychological factors assessed compared with controls. Total SNOT-22 scores showed significant correlation with Chalder fatigue scores, total autonomic dysfunction score, anxiety, depression, somatisation tendencies and the emotionally unstable personality trait. Emotional instability and psychological dysfunction correlated significantly with sleep and psychological subscales of SNOT-22 but not the rhinological or ear/facial subscales.

CONCLUSION

Patients with sinonasal symptoms demonstrate high prevalence and complex associations of general illness factors, psychological distress and certain personality traits. The SNOT-22 is a valuable tool, but its utility is limited by correlations with these confounding factors (eg psychological factors) that may exaggerate the total score. The use of the SNOT-22 component subscales is likely to provide more clinically meaningful and discriminant information.

Chronic Rhinosinusitis and the Evolving Understanding of Microbial Ecology in Chronic Inflammatory Mucosal Disease

Chronic rhinosinusitis (CRS) encompasses a heterogeneous group of debilitating chronic inflammatory sinonasal diseases. Despite considerable research, the etiology of CRS remains poorly understood, and debate on potential roles of microbial communities is unresolved. Modern culture-independent (molecular) techniques have vastly improved our understanding of the microbiology of the human body. Recent studies that better capture the full complexity of the microbial communities associated with CRS reintroduce the possible importance of the microbiota either as a direct driver of disease or as being potentially involved in its exacerbation. This review presents a comprehensive discussion of the current understanding of bacterial, fungal, and viral associations with CRS, with a specific focus on the transition to the new perspective offered in recent years by modern technology in microbiological research. Clinical implications of this new perspective, including the role of antimicrobials, are discussed in depth. While principally framed within the context of CRS, this discussion also provides an analogue for reframing our understanding of many similarly complex and poorly understood chronic inflammatory diseases for which roles of microbes have been suggested but specific mechanisms of disease remain unclear. Finally, further technological advancements on the horizon, and current pressing questions for CRS microbiological research, are considered.

Impact of sinonasal disease on depression, sleep duration, and productivity among adults in the United States

Objective

Examine the relationship between depression symptoms and sinonasal inflammatory diseases, and investigate health disparities associated with allergic rhinitis (AR) and sinusitis in the United States.

Study Design

Cross‐sectional analysis of 2014 National Health Interview Survey (NHIS) data.

Methods

Adult cases of AR and sinusitis were extracted from the 2014 NHIS in addition to demographic, socioeconomic, and related depressive symptom data. The dataset was analyzed with chi‐square, t‐tests, and multivariate regression.

Results

There were 19.1 ± 1.1 million adult AR cases and 29.4 ± 1.4 million adult sinusitis cases. Of these, 20.6% and 22.0% reported depression symptoms in the past 12 months for those with AR or sinusitis, respectively. Both diseases were also associated with significantly fewer mean hours of sleep a night (AR: 7.02 vs. 7.14, P < 0.01; Sinusitis: 6.98 vs. 7.14, P < 0.01) and greater mean days of work missed (AR: 4.60 vs. 3.62, P < 0.01; Sinusitis: 5.87 vs. 3.41; P < 0.01). On multivariate analysis, the prevalence of AR and sinusitis was significantly higher among men, Caucasians, older adults, the more educated, and adults with depression symptoms. Only the prevalence of sinusitis varied depending on income and geography.

Conclusion

Allergic rhinitis and sinusitis are associated with an increased likelihood of depressive symptoms, shorter sleep duration, and more workdays lost. The prevalence of both are influenced by age, sex, race/ethnicity, and education level. Targeted initiatives should be developed to address these health disparities and comorbidities associated with inflammatory sinonasal disease.

Level of Evidence

4.

The Triple Aim and its implications on the management of chronic rhinosinusitis

INTRODUCTION

Accountable care organizations (ACO) and alternative payment models are a sign of the change in reimbursement from fee-for-service to value-based reimbursement. The focus of health care under ACOs is represented by the Triple Aim: to improve the experience of health care, improve the health of populations, and reduce the per capita costs. Individuals with chronic rhinosinusitis (CRS) are heavy consumers of health care services. Results of recent studies have indicated that there is the potential for improved outcomes and cost savings from early surgical intervention. Adhering to the principles of the Triple Aim may signal a paradigm shift in regard to timing of intervention for CRS in certain patients.

METHODS

A scoping review was performed to analyze the current literature related to management of CRS and the impact on cost, population health outcomes, and the patient's experience of health care.

RESULTS

A growing body of literature indicates that, in appropriately selected patients, when compared with medical management, endoscopic sinus surgery has the potential to improve patient outcomes and reduce the long-term cost burden of CRS.

CONCLUSION

With the advent of ACOs, a paradigm shift in the treatment of CRS is inevitable to better conform to the goals of the Triple Aim. Future treatment algorithms will need to account for the heterogeneity within CRS and seek to identify appropriate timing and interventions for patients on an individual basis if the value of health care is to be improved.

Single nucleotide polymorphisms related to cystic fibrosis in chronic rhinositus-a pilot study

BACKGROUND

The clinical association between cystic fibrosis (CF) and chronic rhinosinusitis (CRS) is well known. Studies have identified several non-CF transmembrane conductance regulator single nucleotide polymorphisms (SNPs) associated with disease severity in CF patients. We hypothesized that prevalence of these SNPs would be different between CRS patients and age/gender-matched non-CRS controls.

METHODS

This is a targeted SNP study of 1231 CRS patients identified through a large university hospital database who were compared with 8796 age- and gender-matched controls without a history of rhinitis, sinusitis, allergies, or asthma. Prevalence of 5 relevant SNPs was compared between groups, with p < 0.05 considered significant. Stratification by race and gender was performed among groups when statistically appropriate.

RESULTS

CRS patients exhibited a statistically significant (p = 0.036) lower prevalence of rs12883884 (associated with an ion transporter) compared with controls. This association was lost when patients were stratified by race. CRS patients manifested a greater prevalence of rs1403543 (chromosome 23) in both Caucasian and African American subgroups (p = 0.036 and p = 0.026, respectively). Statistical significance disappeared among Caucasians when stratified by gender, but persisted among African American women (p = 0.047). rs12188164 and rs12793173 were both more prevalent in African Americans with CRS than controls (p = 0.042 and p = 0.020, respectively). A trend was also observed for decreased prevalence of rs12883884 in CRS patients compared with controls in the African American subgroup (p = 0.086).

CONCLUSION

The identified SNPs were differentially prevalent in CRS compared with control groups, with some variability as a function of race and gender. Further research is required to confirm these findings and elucidate clinical significance.

A systematic review of the sinonasal microbiome in chronic rhinosinusitis

BACKGROUND

The interaction between the host and microorganisms in chronic rhinosinusitis (CRS) is poorly understood and is a growing area of interest. More recently, methodologies have been developed to assess the microbiome without the use of culture by analyzing the bacterial 16S ribosomal RNA gene. We reviewed the microbiome literature to better understand the role of microbes in CRS.

METHODS

Systematic review of studies that used the 16S ribosomal RNA gene deep sequencing.

RESULTS

Nine publications met the search criteria. Eight studies evaluated the microbiome in controls (total, 83 subjects; range, 3-28 per study), whereas six of the studies included patients with CRS (total, 121 patients; range, 7-43 per study). Various sequencing techniques, primers, sample sites, and extraction methods were used. Of the articles that specified the number of taxa in controls, an average of 1587 taxa were identified (range, 911-2330). Significant heterogeneity was noted among the studies; however, Firmicutes, Actinobacteria, and Bacteroides phyla were identified in every sample of control patients and patients with CRS. Three of the studies showed enrichment to some degree of Staphylococcus aureus in patients with CRS. The total bacterial burden in CRS was similar to the controls. One study demonstrated a decrease in diversity, whereas other studies did not show any changes in CRS when compared with controls.

CONCLUSION

Although there are common phyla present in both control patients and patients with CRS, no consistent enrichment of any particular taxon was identified. Our findings indicated that there was no clear single causative microbe in CRS. More studies are needed to better understand the significance of the host interaction with the microbiome and the role it plays in CRS.

Bacterial community collapse: a meta-analysis of the sinonasal microbiota in chronic rhinosinusitis

Chronic rhinosinusitis (CRS) is a common, debilitating condition characterized by long-term inflammation of the nasal cavity and paranasal sinuses. The role of the sinonasal bacteria in CRS is unclear. We conducted a meta-analysis combining and reanalysing published bacterial 16S rRNA sequence data to explore differences in sinonasal bacterial community composition and predicted function between healthy and CRS affected subjects. The results identify the most abundant bacteria across all subjects as Staphylococcus, Propionibacterium, Corynebacterium, Streptococcus and an unclassified lineage of Actinobacteria. The meta-analysis results suggest that the bacterial community associated with CRS patients is dysbiotic and ecological networks fostering healthy communities are fragmented. Increased dispersion of bacterial communities, significantly lower bacterial diversity, and increased abundance of members of the genus Corynebacterium are associated with CRS. Increased relative abundance and diversity of other members belonging to the phylum Actinobacteria and members from the genera Propionibacterium differentiated healthy sinuses from those that were chronically inflamed. Removal of Burkholderia and Propionibacterium phylotypes from the healthy community dataset was correlated with a significant increase in network fragmentation. This meta-analysis highlights the potential importance of the genera Burkholderia and Propionibacterium as gatekeepers, whose presence may be important in maintaining a stable sinonasal bacterial community.

Olfaction in Chronic Rhinosinusitis

Olfactory dysfunction is a frequent complaint in chronic rhinosinusitis patients and has a significant impact on quality of life. Therefore, it is essential that clinicians are aware of the importance of olfactory dysfunction in chronic rhinosinusitis (CRS) patients and know how to deal with it. Notably, the evaluation of olfactory function (i.e., using psychophysical testing) and imagery of olfactory bulb play an important role in the evaluation of patients and give essential information about the "baseline" olfactory function. Because the high impact of olfactory function on quality of life and medical and/or surgical treatment should be proposed to patients. However, it remains difficult to predict the outcome of treatment as well as long-term efficacy. The first section of this review is dedicated to the assessment of olfactory function. Secondly, we will discuss the etiopathology of olfactory dysfunction in CRS with and without nasal polyps. Finally, we will review literature findings about the efficacy of different treatments on olfactory function.

Quality of Life and Economic Burden of Respiratory Disease in Asia-Pacific-Asia-Pacific Burden of Respiratory Diseases Study

OBJECTIVES

Asia-Pacific Burden of Respiratory Diseases is a cross-sectional, observational study examining the burden of disease in adults with respiratory diseases across six countries. The aim of this study was to describe health care resource use (HCRU), work impairment, cost burden, and health-related quality of life (HRQOL) associated with respiratory disease in the Asia-Pacific.

METHODS

Consecutive participants aged 18 years or older with a primary diagnosis of asthma, allergic rhinitis, chronic obstructive pulmonary disease, or rhinosinusitis were enrolled. Participants completed a survey detailing respiratory symptoms, HCRU, work productivity and activity impairment, and HRQOL. Locally sourced unit costs for each country were used in the calculation of total costs.

RESULTS

The study enrolled 5250 patients. Overall, the mean annual cost for patients with a respiratory disease was US $4191 (SGD 8489) per patient. For patients who reported impairment at work, the mean annual cost was US $7315 (SGD 10,244), with productivity loss being the highest cost component for all four diseases (US $6310 [SGD 9100]). On average, patients were impaired for one-third of their time at work and 5% of their work time missed because of respiratory disease, which resulted in a 36% reduction in productivity. Patients with a primary diagnosis of chronic obstructive pulmonary disease had the greatest impact on HRQOL.

CONCLUSIONS

In the Asia-Pacific, respiratory diseases have a significant impact on HCRU and associated costs, along with work productivity. Timely and effective management of these diseases has the potential to reduce disease burden and health care costs and improve work productivity and HRQOL.

MgNd2 alloy in contact with nasal mucosa: an in vivo and in vitro approach

Biodegradable and biocompatible magnesium alloys appear to be very promising not only for temporary clinical application but also for developing deformable and degradable medical implants. This study analyzes the in vivo degradation behavior and the impact on the paranasal sinuses of the highly ductile Mg-2 wt%Nd alloy (MgNd2) in order to provide a basis for a satisfying stent system for the therapy of a chronic sinusitis. Moreover, in vitro tests were carried out on primary porcine nasal epithelial cells (PNEC). For the in vivo tests, cylindrical MgNd2 specimens were implanted into the sinus' mucosa of minipigs. During and after a total period of 180 days the long-term biodegradation and biocompatibility properties after direct contact with the physiological tissue were analyzed. Biodegradation was investigated by measuring the mass and volume losses of the MgNd2 specimens as well as by performing element analyses to obtain information about the degradation layer. The influence on the surrounding tissue of paranasal sinuses was evaluated by endoscopic and histopathological examinations of the mucosa. Here, only a locally unspecific chronic infection was found. The degradation rate showed a maximum after 45 days postsurgery and was determined to decrease subsequently. In vitro experiments using PNEC showed adequate biocompatibility of MgNd2. This study demonstrates a good in vivo biocompatibility for MgNd2 in the system of paranasal sinuses and underlines the promising properties of alloy MgNd2 for biodegradable nasal stent applications.

Risk factors for sleep impairment in adult patients with chronic rhinosinusitis

OBJECTIVE

Although sleep impairment is reported by patients with chronic rhinosinusitis, the associated factors have not been well studied. Therefore, we determined the associated risk factors for sleep impairment in patients with chronic rhinosinusitis (CRS).

METHODS

This study was a prospective cohort study. A total of 572 adult patients (171 women, 401 men; mean age, 49.0 years; range, 18-64 years) who completed a questionnaire, had a clinical examination, and underwent endoscopic sinus surgery were analyzed using stepwise multiple linear regression.

RESULTS

With regard to subjective symptoms, nasal obstruction (beta coef., 0.27; p<0.001), anterior nasal drainage (beta coef., 0.13; p=0.004), facial pain/pressure (beta coef., 0.09; p=0.048), headache (beta coef., 0.10; p=0.010), and cough (beta coef., 0.14; p<0.001) were predictors of an increased risk of sleep impairment of CRS (adjusted R(2), 0.240; p=0.048). In the matter of background parameters, total polyp score (polyp grading system) (beta coef., 0.16; p<0.001) and allergic rhinitis (beta coef., 0.09; p=0.034) were predictors of an increased risk of sleep impairment of CRS (adjusted R(2), 0.029; p=0.034).

CONCLUSION

These results suggest that sleep impairment in these patients is caused by the various mechanisms associated with nasal symptoms themselves, CRS and allergic rhinitis. However, the specific pathophysiology has not been clarified yet; further studies are expected to elucidate that of sleep impairment in patients with CRS.

Impact of cigarette smoking on the middle meatus microbiome in health and chronic rhinosinusitis

BACKGROUND

Although cigarette smoking aggravates chronic rhinosinusitis (CRS), a detailed examination of the sinus microbiota in CRS and its clinical subtypes has yet to be performed in relation to history of smoking. Consequently, we examined associations between smoking history and sinonasal microbiome alterations in both CRS and non-CRS populations.

METHODS

Middle meatus swabs collected during endoscopic sinus surgery were analyzed by analysis of 16S ribosomal RNA (rRNA) sequences. Multiple analysis of variance tests were performed to determine whether microbiome composition varied with smoking history and other clinical/demographic covariates associated with CRS subtypes.

RESULTS

A total 70 CRS patients and 31 control subjects were analyzed. In a univariate analysis, smoking (p = 0.04), preoperative antibiotics (p = 0.03), and purulence (p = 0.0002) were significantly associated with the genus-level composition of the middle meatus microbiota. When included in a multivariable model, smoking was found to have significant interactions with CRS (p = 0.02), polyposis (p = 0.03), purulence (p = 0.0004), and use of saline rinses (p = 0.05). Diverse bacterial taxa differed significantly in abundance between never-smokers and current/former smokers, as well as between different CRS subtypes.

CONCLUSION

Substantial changes in sinus bacterial colonization were observed in smokers and nonsmokers. Although the microbiota of both CRS and non-CRS subjects were altered with smoking history, different bacterial taxa were affected by smoking in the 2 patient groups. Thus, the effects of smoking on the sinus microbiota are likely to be modified by physiological and immunological functions of the underlying sinus mucosa.