Clinical characteristics and genotype analysis of patients with cystic fibrosis and nasal polyposis requiring surgery

Impact of elexacaftor/tezacaftor/ivacaftor CFTR modulator therapy on rates of endoscopic sinus surgery in cystic fibrosis

BACKGROUND

Elexacaftor/tezacaftor/ivacaftor (ETI), a combination cystic fibrosis transmembrane receptor (CFTR) modulator, has demonstrated improved pulmonary outcomes in individuals with cystic fibrosis (CF). However, ETI's impact on functional endoscopic sinus surgery (FESS) remains unclear.

METHODS

The TriNetX Analytics Research Network, consisting of 120 million global de-identified electronic medical records, was queried from 2012 to 2023 for subjects with CF who underwent sinus surgery.1 Patients on ETI prior to FESS (n = 6,056) were propensity score matched to control individuals with CF not on CFTR modulators (n = 37,906) and those on other FDA-approved CFTR modulators (tezacaftor/ivacaftor, lumacaftor/ivacaftor, and ivacaftor) (n = 2437) based on relevant factors. The primary outcome was the absolute risk reduction (ARR) of undergoing FESS. Secondary outcomes included ARR of CF-related pulmonary exacerbations and hospital admission from 0 to 6, 6 to 12, and 12 to 24 months following FESS.

RESULTS

ETI use demonstrated a significant ARR for FESS when compared to CF patients not on CFTR modulators (2.12%; 95% confidence interval [CI] 1.5-2.75; p-value < 0.0001) and those on other CFTR modulators (4.7%; 95% CI 3.54-5.85; p-value < 0.0001). No significant differences occurred in secondary outcomes between ETI and non-CFTR modulator groups, except for reduced CF-related pulmonary exacerbations from 0 to 6 months post-FESS. Additionally, a significant reduction in pulmonary exacerbations was observed at all time points and hospital admissions within 6 months following FESS compared to those using other CFTR modulators.

CONCLUSIONS

In a large dataset, CF patients on ETI demonstrated significantly reduced risk of FESS, pulmonary exacerbations, and hospital admission compared to patients not on CFTR modulators or those on other CFTR modulators, suggesting improved sinonasal disease and overall health status in CF.

Quality of Life and Impact of Endoscopic Sinus Surgery in Adult Patients With Cystic Fibrosis

Background

Cystic fibrosis (CF) is the most common autosomal recessive disease in Caucasian population. Due to its pathological mechanism, chronic rhino sinusitis (CRS) associated or not with nasal polyposis usually occurs in adults and affects close to one-half of all CF patients. The goal of our work was to evaluate the impact of endoscopic sinus surgery (ESS) in the quality of life (QoL) of the CF patients and demonstrate an improvement of the functional outcomes in the patients undergoing the surgical procedure rather than in the not treated ones. Methodology: We studied 54 adult patients affected by CF. Lund–Kennedy, Lund–Mackay scores, and Sino-Nasal Outcome Test-22 (SNOT-22) were analyzed.

Results

Twenty-two (40.7%) of the 54 CF patients underwent ESS. This group presented more likely complaints consistent with CRS. Lund–Kennedy and Lund–Mackay scores appeared higher in the ESS group: 10 (range of 6–12) and 16 (range of 12–20), respectively. SNOT-22 showed median values for non-ESS and ESS group of 17.5 (range of 3–68) and 44 (range of 10–73), respectively.

Conclusions

ESS represents the best option to improve clinical QoL of CF patients who do not response to conventional medical therapy.

Allergic Rhinitis Augments the Response to a Bacterial Sinus Infection in Mice: A Review of an Animal Model

Background

Sinusitis is a poorly understood disease. Despite the significant morbidity and the enormous cost of treating sinusitis, little progress has been made at improving our understanding of its pathophysiology. One reason for restricted progress in understanding the disease is the lack of a satisfactory animal model that mimics sinusitis in man.

Objective

We review data establishing the development of sinusitis in mice after instillation of Streptococcus pneumoniae, the most common pathogen responsible for acute sinusitis in man. We also review data showing that allergic inflammation in mice worsens a subsequent bacterial sinusitis. We use this data to hypothesize how allergic inflammation worsens a bacterial sinus infection.

Methods

Different strains of mice were made allergic and/or infected.

Results

We show our ability to generate an allergic reaction in the nose after sensitization to ovalbumin. Our data further show that an ongoing allergic nasal reaction worsens acute sinusitis.

Conclusion

A mouse model has been created for a study of the interaction of allergic rhinitis and acute bacterial sinusitis.

Correlations between cystic fibrosis genotype and sinus disease severity in chronic rhinosinusitis

OBJECTIVE

Cystic fibrosis (CF) patients commonly develop chronic rhinosinusitis (CRS). The impact of the most common cystic fibrosis transmembrane conductance regulator (CFTR) mutation, F508del, on the severity of sinonasal disease remains inconclusive. The objective of this study is to evaluate the impact of CFTR genotype functional classification on sinonasal disease severity in patients with CRS.

METHODS

Retrospective chart review of patients with CF who underwent endoscopic sinus surgery for chronic rhinosinusitis from 1998 to 2015. Patients were divided into high- or low-risk genotypes based on standardized CFTR gene functional classification. The primary outcome was the 22-item Sino-Nasal Outcome Test (SNOT-22) score. Secondary outcomes included endoscopic scores, extent of surgery performed, presence of polyposis, number of revision surgeries, and Lund-MacKay computed tomography scores.

RESULTS

Thirty-eight patients harbored a high-risk CFTR genotype, and 11 had a low-risk genotype. On bivariate analysis, there was no association between CFTR genotype risk stratification and measures of preoperative disease severity or postoperative outcomes. There were no associations between genotype risk stratification and outcome variables on multivariate linear regression, adjusted for age and gender. There were significant improvements in several SNOT-22 subdomains before and after endoscopic sinus surgery (P < 0.05), but the magnitude of improvement was not significantly different on the basis of CFTR genotype risk stratification.

CONCLUSION

High-risk CFTR genotypes are not associated with worse sinonasal disease severity or postoperative symptom control than low-risk CFTR genotypes after adjusting for confounding factors.

LEVEL OF EVIDENCE

Level 4. Laryngoscope, 1752-1758, 2018.

Nasal polyposis in cystic fibrosis: follow-up of children and adolescents for a 3-year period

INTRODUCTION

Nasal polyposis is often found in patients with cystic fibrosis.

OBJECTIVE

To assess the incidence of nasal polyposis, the response to medical treatment, recurrence and the need for surgical intervention in children and adolescents with cystic fibrosis during a three-year follow-up.

METHODS

Clinical symptoms (pulmonary, pancreatic insufficiency, malnutrition, nasal obstruction), two positive sweat chloride tests, and genotype findings in 23 patients with cystic fibrosis were analyzed. All patients underwent nasal endoscopy every 12 months from January 2005 to December 2007, to assess the presence and grade of Nasal Polyps. Nasal polyposis, when present, were treated with topical corticosteroids for 6-12 months, with progress being evaluated within the 3 years of follow-up.

RESULTS

In the first evaluation, nasal polyposis was diagnosed in 30.43% of patients (3 bilateral and 4 unilateral), recurrent pneumonia in 82.6%, pancreatic insufficiency in 87%, and malnutrition in 74%. The presence of nasal polyposis was not associated with chloride values in the sweat, genotype, clinical signs of severity of cystic fibrosis, or nasal symptoms. In the three-year period of follow up, 13 patients (56.52%) had at least one event of polyposis, with the youngest being diagnosed at 32 months of age. Only one patient underwent surgery (polypectomy), and there was one diagnosis of nasopharyngeal carcinoma.

CONCLUSION

The study showed a high incidence of nasal polyposis. Monitoring through routine endoscopy in patients with cystic fibrosis, even in the absence of nasal symptoms, is highly recommended. The therapy with topical corticosteroids achieved good results. Thus, an interaction between pediatricians and otolaryngologists is necessary.

Epidemiology of chronic rhinosinusitis, selected risk factors, comorbidities, and economic burden

Chronic rhinosinusitis (CRS) is a relevant and prevalent medical condition in Germany, Europe and the world. If analysed in detail, the prevalence of CRS shows regional and temporary variety. In this review, currently available data regarding the prevalence of CRS is therefore sorted by country and/or region, time point of data collection and the CRS-definition employed. Risk factors like smoking and gastroesophageal reflux are discussed regarding their influence on CRS prevalence. Moreover, comorbidities of CRS, like asthma, conditions of the cardiovascular system and depression are listed and their influence on CRS is discussed. Furthermore, data on CRS prevalence in special cohorts, like immunocompromised patients, are presented. To estimate the economic burden of CRS, current data e.g. from Germany and the USA are included in this review.

Comparison of radiographic and clinical characteristics of low-risk and high-risk cystic fibrosis genotypes

BACKGROUND

Patients with cystic fibrosis (CF) exhibit a wide range of disease severity, and can be broadly stratified into high-risk and low-risk groups based on cystic fibrosis transmembrane conductance regulator (CFTR) mutation class. Patients with a low-risk genotype are often diagnosed as adults, with milder disease and lower sweat chloride values. The aim of the current study was to better understand radiographic and clinical characteristics of sinus disease in adult CF patients within this risk category.

METHODS

Adult CF patients were retrospectively compared to a control group of patients with chronic rhinosinusitis. CF diagnostic testing and pulmonary characteristics were compared between high-risk and low-risk CF groups, and sinus CT findings were compared among all 3 groups.

RESULTS

When comparing CF cohorts (n = 25 and 30, respectively), earlier age at diagnosis (p < 0.001), higher sweat chloride values (p < 0.001), lower forced expiratory volume in 1 second (FEV1 ) values (p < 0.001), and a higher prevalence of pulmonary infection with Pseudomonas aeruginosa (p = 0.001) were found in the high-risk genotype group. A significantly increased incidence of sinus hypoplasia/aplasia and bony sclerosis was seen when comparing both CF groups to the control cohort (n = 30), as well as when comparing the high-risk and low-risk CF genotype cohorts.

CONCLUSION

The current study describes clinicopathologic findings of sinus disease in adult CF patients in the context of genotype severity. Our data demonstrate that while patients within a low-risk genotype cohort have generally milder lung disease, they retain classic radiographic findings of CF sinus disease that can help raise the index of suspicion for undiagnosed CF.

Bacterial sinusitis can be a focus for initial lung colonisation and chronic lung infection in patients with cystic fibrosis

A major purpose of treating patients with cystic fibrosis (CF) is to prevent or delay chronic lung infections with CF-pathogenic Gram-negative bacteria. In the intermittent stage, bacteria can usually be eradicated from the lungs with antibiotics, but following eradication, the next lung colonisations often occur with bacteria of identical genotype. This may be due to re-colonisation from the patient's paranasal sinuses. In our study, we found that approximately two-thirds of CF patients having sinus surgery (FESS) had growth of CF-lung-pathogenic Gram-negative bacteria in their sinuses (Pseudomonas aeruginosa, Achromobacter xylosoxidans, Burkholderia cepacia complex). The environment in the sinuses is in many ways similar to that of the lower respiratory tract, e.g. low oxygen concentration in secretions. Sinus bacteria are more difficult to eradicate than in the lungs, thus, having good conditions for adapting to the environment in the lungs. In the presence of bacteria, the environment of the sinuses differs from that of the lower respiratory tract by having a higher immunoglobulin A (IgA): IgG ratio, and reduced inflammation. We found a significant correlation between the concentration of IgA against P. aeruginosa (standard antigen and alginate) in nasal secretions and saliva and CF patients' infection status (not lung colonised, intermittently colonised or chronically lung-infected with P. aeruginosa). This supports the hypothesis that infections often originate in the sinuses and can be a focus for initial lung colonisation or for maintaining lung infections in CF patients. We are confident that anti-P. aeruginosa IgA can be used as an early supplementary tool to diagnose P. aeruginosa colonisation; P. aeruginosa being the microorganism causing most morbidity and mortality in CF patients. This is important since urgent treatment reduces morbidity when CF patients are early colonised with P. aeruginosa, however, there is a lack of diagnostic tools for detecting the early colonisation in the lungs and in the sinuses. We initiated a treatment strategy for CF patients to prevent sino-nasal bacteria being seeded into the lower airways: we recommended extensive functional endoscopic FESS with creation of sufficient drainage from all involved sinuses with subsequent i.v. antibiotics and at least 6 months of twice daily nasal irrigation with saline and antibiotics. By this strategy, sinus bacteria could be eradicated in a large proportion of patients. Essentially, growth of CF-pathogenic bacteria from the lower respiratory tract was decreased following the treatment. Furthermore, a number of patients have been free from CF-pathogenic bacteria for more than one year after FESS, and thus re-classified as "not lung colonised". We also corroborated that CF patients obtain an improved quality of life and reduction in their symptoms of chronic rhinosinusitis after FESS. It is primarily intermittently lung colonised CF patients with CF-pathogenic bacteria in their sinuses that seem to benefit from the treatment strategy. This is in accordance with the fact that we did not see a significant increase in lung function and only a small decrease in specific antibodies after FESS; a high systemic immune and inflammatory response and a decreasing lung function is generally not present in patients who primarily have sinus CF-pathogenic bacteria. It is important that guidelines are created for how CF patients with CF-pathogenic bacteria in the sinuses are to be treated, including criteria for who may likely benefit from FESS, and who may be treated exclusively with conservative therapy, e.g. saline and antibiotic irrigations.

Chronic infection with Pseudomonas aeruginosa in cystic fibrosis: a risk factor for nasal polyposis after lung transplantation

BACKGROUND

Nasal polyposis (NP) is common in cystic fibrosis (CF) patients. The prevalence of the CF phenotype with NP after lung transplantation (LTx) is unknown. Risk factors for the development of NP after LTx are not well described.

METHODS

CF patients with LTx at our center between November 1992 and December 2009 were included. They were regularly investigated with nasal endoscopy and aspiration of sinus secretions with microbiological evaluation. Patients with and without development of NP were compared along the following parameters: gender, age, dF508, diabetes, acute rejection, NP at LTx, and microbiology of the sinuses before and after LTx. A multivariate Cox regression analysis was performed.

RESULTS

The study included 94 patients; 21 were excluded because of incomplete data. Thirty-five (48%) of the remaining 73 patients developed NP. Mean time to diagnosis of NP was 4.2 (2.9-5.6) years after LTx. Prevalence of NP was 11% after the first year and 18%, 33%, and 44% after the first 2, 5, and 10 years, respectively. Patients with posttransplantation NP were younger, had NP before LTx, and were chronically infected with Pseudomonas aeruginosa (PA) in the nose. Multivariate analysis demonstrated that chronic infection with PA was the only significant risk factor for the development of nasal polyps after LTx (hazards ratio, 7.2; 95% confidence interval, 2.1-24.2; P=0.001).

CONCLUSIONS

In contrast to pretransplantation patients, NP is more common after LTx. Development of NP occurs throughout the whole observation time. Chronic sinonasal PA infection seems to be the only significant risk factor for NP after LTx.

IP-10 is a potential biomarker of cystic fibrosis acute pulmonary exacerbations

Background

Cystic fibrosis (CF) is characterized by acute pulmonary exacerbations (APE). The CF nasal airway exhibits a similar ion transport defect as the lung, and colonization, infection, and inflammation within the nasal passages are common among CF patients. Nasal lavage fluid (NLF) is a minimally invasive means to collect upper airway samples.

Methods

We collected NLF at the onset and resolution of CF APE and compared a 27-plex cytokine profile to stable CF outpatients and normal controls. We also tested IP-10 levels in the bronchoalveolar lavage fluid (BALF) of CF patients. Well-differentiated murine sinonasal monolayers were exposed to bacterial stimulus, and IP-10 levels were measured to test epithelial secretion.

Results

Subjects hospitalized for APE had elevated IP-10 (2582 pg/mL [95% CL of mean: 818,8165], N=13) which significantly decreased (647 pg/mL [357,1174], P<0.05, N =13) following antimicrobial therapy. Stable CF outpatients exhibited intermediately elevated levels (680 pg/mL [281,1644], N=13) that were less than CF inpatients upon admission (P=0.056) but not significantly different than normal controls (342 pg/mL [110,1061]; P=0.3, N=10). IP-10 was significantly increased in CF BALF (2673 pg/mL [1306,5458], N=10) compared to healthy post-lung transplant patients (8.4 pg/mL [0.03,2172], N=5, P<0.001). IP-10 levels from well-differentiated CF murine nasal epithelial monolayers exposed to Pseudomonas PAO-1 bacteria-free prep or LPS (100 nM) apically for 24 hours were significantly elevated (1159 ± 147, P<0.001 for PAO-1; 1373 ± 191, P<0.001 for LPS vs. 305 ± 68 for vehicle controls). Human sino-nasal epithelial cells derived from CF patients had a similar response to LPS (34% increase, P<0.05, N=6).

Conclusions

IP-10 is elevated in the nasal lavage of CF patients with APE and responds to antimicrobial therapy. IP-10 is induced by airway epithelia following stimulation with bacterial pathogens in a murine model. Additional research regarding IP-10 as a potential biomarker is warranted.

Modified Lothrop procedure in cystic fibrosis patients: does it have a role?

BACKGROUND

The management of frontal sinus disease in cystic fibrosis patients represents a challenge for many surgeons. Procedures can vary from the minimally invasive to those involving extensive open surgery.

OBJECTIVE

This study describes the outcomes of the endoscopic modified Lothrop procedure, in terms of safety and morbidity, for cystic fibrosis patients with frontal sinus disease who did not improve following traditional functional endoscopic sinus surgery.

METHOD AND RESULTS

The study setting was a tertiary referral unit in a London teaching hospital, the largest national base for adult cystic fibrosis patients. Two patients diagnosed in childhood with cystic fibrosis presented with histories of recurrent, severe frontal sinusitis; both had previously undergone multiple endoscopic sinus surgical procedures. The modified Lothrop procedure was performed on both patients. The outcome measures were symptom resolution and post-operative complications.

CONCLUSION

The endoscopic modified Lothrop procedure was beneficial in the cystic fibrosis patients with frontal sinus disease who failed to respond to standard functional endoscopic sinus surgery procedures.

Pathogenesis and management of nasal polyposis in cystic fibrosis

Beginning in preschool age, during their lives, up to 50% of cystic fibrosis (CF) patients experience obstructing nasal polyposis (NP), which is rare in non-CF children. Pathogenetic factors of NP in general and especially in CF are still obscure. However, defective epithelial ion transport from mucosal glands plays a central role in CF, and viscous secretions impair mucociliary clearance, promoting chronic pathogen colonization and neutrophil-dominated chronic inflammation. Presently, CF-NP is not curable but can be clinically stabilized, though the large variety of proposed treatment modalities indicates a lack of standardization and of evidence of treatment efficacy. When conservative measures are exhausted, surgical intervention combining individually adapted endoscopic sinus surgery and supportive conservative treatment is performed. Topical steroids, approved as the gold standard for non-CF NP, may be beneficial, but they are discussed to be less effective in neutrophilic inflammation, and CF-specific antimicrobial and mucolytic therapy, as is true of all treatment modalities, urgently requires evaluation by controlled clinical trials within interdisciplinary networks.

Nasal polyposis in lung transplant recipients with cystic fibrosis

BACKGROUND

Chronic rhinosinusitis with nasal polyposis is common in patients with cystic fibrosis (CF). There are still many open questions regarding factors related to this condition. Furthermore, the prevalence of nasal polyposis and its implications for the outcomes in lung transplant recipients with cystic fibrosis are unknown.

METHODS

All CF patients who underwent lung transplantation at our centre between November 1992 and December 2009 were included. Nasal polyp status was determined endoscopically at time sinus surgery and its relationships to gender, age at lung transplantation, Liou raw score, body mass index, FEV1%predicted, diabetes mellitus, pre-transplant pseudomonas colonisation of the sinuses and the lungs, pre-transplant corticosteroid use and type of mutation of the CFTR gene were analysed. The post-transplant survival times and the incidence of bronchiolitis obliterans syndrome in patients with or without nasal polyposis were compared.

RESULTS

Nasal polyps were found in 19% (17 patients) of the 89 lung transplant recipients, whose data was available for statistical analysis. None of the factors analysed was related to the nasal polyp status. The post-transplant survival times and the incidence of bronchiolitis obliterans syndrome did not significantly differ between patients with or without nasal polyposis.

CONCLUSIONS

CF-related nasal polyposis occurs in a relevant fraction of lung transplant recipients. A specific effect of nasal polyposis on post-transplant outcome could not be confirmed. Nevertheless, there was a trend to NP recurrence in patients with post-transplant sinonasal pseudomonas colonisation and is a tendency of less chronic rejection in CF patients with nasal polyps.

Extensive surgical and comprehensive postoperative medical management for cystic fibrosis chronic rhinosinusitis

BACKGROUND

Chronic rhinosinusitis has a major impact on the quality of life of patients with cystic fibrosis (CF) and may contribute to progression of chronic lung disease. Despite multiple sinus surgeries, maxillary sinus involvement is a recurrent problem. The modified endoscopic medial maxillectomy (MEMM) permits debridement in the clinic, improves mucus clearance with nasal irrigations, and increases access for topical delivery of therapeutics. However, clinical outcomes of aggressive sinus surgery with regimented postoperative medical treatment have not been systematically evaluated.

METHODS

CF patients completed the 22-Item Sinonasal Outcome Test questionnaires before sinus surgery (and bilateral MEMM) and at sequential postoperative visits. Objective measures included Lund-Kennedy endoscopic score and pulmonary function tests (forced expiratory volume at 1 second percent [FEV(1)%] predicted). Culture-directed antibiotic therapy, prednisone, and topical irrigations were initiated postoperatively.

RESULTS

Twenty-two patients (mean age, 26.5 years; 4.9 prior sinus operations) underwent MEMM and sinus surgery. Symptom scores were significantly reduced at 60 days (primary outcome, 64.7 ± 18.4 presurgery versus 27.5 ± 15.3 postsurgery; p < 0.0001) and up to a year postoperatively (27.6 ± 12.6; p < 0.0001). Endoscopic scores were also reduced after surgery (10.4 ± 1.1 presurgery versus 5.7 ± 2.4 [30 days], 5.7 ± 1.4 [60 days], 5.8 ± 1.3 [120 days], and 6.0 ± 1.1 [1 year]; p < 0.0001)]. There were no differences in FEV(1)% predicted up to 1 year postoperatively, but hospital admissions secondary to pulmonary exacerbations significantly decreased (2.0 ± 1.4 versus 3.2 ± 2.4, respectively; p < 0.05).

CONCLUSION

Prospective evaluation indicates sinus surgery with MEMM is associated with marked improvement in sinus disease outcomes. Additional studies are necessary to confirm whether this treatment paradigm is associated with improved CF pulmonary disease.

Retrospective analysis of chronic rhinosinusitis in patients with cystic fibrosis

INTRODUCTION

Chronic rhinosinusitis is very common in patients with cystic fibrosis. This can be explained by the unified airway concept, where the same pathophysiological phenomenon that affects the lungs, affects the paranasal sinuses. The management of these cases is difficult.

OBJECTIVE

To describe the teamwork of otolaryngologists and bronchopulmonary specialists in patients with cystic fibrosis.

METHOD

We performed a descriptive, retrospective study over the last 17 years, which included 14 patients with chronic rhinosinusitis and cystic fibrosis attended at a private hospital.

RESULTS

Of the patients, 64% were male and the median age was 23 years. The most frequent mutations found were ΔF508, M470 and R553. All of the patients with ΔF508 mutation had nasal polyps. 100% of the patients had clinical findings of chronic rhinosinusitis. All the patients had had endoscopic nasal surgery. The median number of endoscopic surgeries was 2.

CONCLUSIONS

Given the high prevalence of chronic rhinosinusitis in patients with cystic fibrosis, everyone should have a computed tomography scan of the paranasal sinuses during the initial assessment, considering that sinus germs are the ones that colonise the lower airway. The otolaryngologist should be part of the cystic fibrosis team. Before receiving a lung transplant or in cases of chronic headache, endoscopic surgery should be performed in patients in whom medical treatment fails to clear the sinuses because this infection is the one that colonises the lower airway.

An overview of international literature from cystic fibrosis registries. Part 3. Disease incidence, genotype/phenotype correlation, microbiology, pregnancy, clinical complications, lung transplantation, and miscellanea

This is the third article related to a review of the literature based on data from national cystic fibrosis (CF) patient registries up to June 2008 and covering a total of 115 published studies. It focuses on several topics: CF incidence, genotype/phenotype correlation, microbiology, pregnancy/paternity, clinical complications, lung transplantation, and others. Seventy seven papers meeting the inclusion criteria were found to be related to the topics listed above. Another seven studies, already evaluated in previous papers of this series, were recalled for specific topics. Incidence is described by several studies, results being quite different from one country to another and quite inhomogeneous among regions within the same country. Studies on genetics address the genotype/phenotype correlation and look for a predictive value of CFTR mutations in terms of clinical outcome, with controversial results. Papers on microbiology describe the clinical relevance of different pathogens and their role in the progress of CF lung disease. A few articles give information on the features of CF women undergoing a pregnancy and try to identify the ones associated with a better outcome. Studies on clinical complications discuss prevalence and the role of haemoptysis, pneumothorax, CF related diabetes, ABPA and cancer. Papers on lung transplantation focus on models able to improve the selection criteria for transplantation candidates and the factors linked to post transplantation survival. Finally, several studies deal with a number of interesting topics related to CF epidemiology: clinical trial methodology, quality of care comparison among countries and centers, relationship between diagnosis and age/gender, and evaluation of pharmacological therapy. On the whole, CF Registries have already contributed to important advances in the knowledge of the natural history of CF, establishing the foundations for future improvement in CF research and care.

Rhinosinusitis in cystic fibrosis: not a simple story

OBJECTIVE

Chronic inflammation of sinuses and nasal mucosa is found in 74-100% patients suffering from cystic fibrosis, whereas nasal polyps in 6-44% patients. The aim of this paper is to assess rhinosinusitis types taking into account the forms of cystic fibrosis and the kind of CFTR gene mutation.

MATERIAL AND METHODS

The author presents material of 126 cystic fibrosis patients, 90 with typical clinical features and 36 with atypical phenotype. Genetic tests were carried out to determine the genotype of CFTR gene. The sample was divided into four groups according to the genotype effect on the chloride canal function. Cytological examination of nasal mucosa was carried out in all the patients.

RESULTS

In 71.5% of patients with cystic fibrosis, infectious chronic non-specific rhinosinusitis was found. Other types of rhinosinusitis--acute infectious, chronic allergic and non-allergic with eosinophilia were found in 21.4% of patients, whereas in 7.1% of patients no clinical symptoms of rhinosinusitis were found. Nasal polyps were found in 23 (18.3%) patients with cystic fibrosis: in 21 patients with a typical form and in 2 patients with an atypical form. Nasal polyps were more frequent in groups with the genotype consisting of both "strong" mutations than in the group with unknown or "mild" mutations.

CONCLUSION

Rhinosinusitis in cystic fibrosis patients is not homogenous pathology. Infectious chronic non-specific rhinosinusitis is found the most frequently, but other forms of rhinosinusitis appear quite often and they require proper treatment.

Incidência e evolução da polipose nasal em crianças e adolescentes com fibrose cística

A polipose nasal é manifestação clínica de alerta para investigação de fibrose cística (FC). OBJETIVO: Avaliar incidência de pólipos nasais em crianças e adolescentes com FC, sua associação com idade, sexo, sintomas clínicos, achados laboratoriais e genótipo, e sua evolução com corticoterapia tópica. CASUÍSTICA E MÉTODOS: Foram avaliados sintomas clínicos, níveis de cloro no suor e mutações genéticas de 23 pacientes com FC. A polipose nasal foi investigada por exame endoscópico e quando presente, o paciente recebeu 6 meses de tratamento com corticosteróide tópico e foi realizada nova endoscopia depois. Para análise estatística utilizou-se média, desvio padrão e Teste de Fisher. RESULTADOS: 39,1% dos pacientes apresentaram polipose nasal (cinco bilateral, quatro unilateral), todos com mais de seis anos, 82,6%, pneumonias recorrentes, 87%, insuficiência pancreática e 74%, desnutrição. Não houve associação entre polipose e nível de cloro no suor, genótipo, fenótipo clínico e sintomas nasais. Houve melhora da polipose com tratamento clínico em sete pacientes, com regressão completa em seis. CONCLUSÃO: O estudo mostrou elevada incidência de polipose em crianças com FC, sendo encontrada em todos os espectros de gravidade clínica, mesmo na ausência de sintomas nasais. O tratamento com corticosteróide tópico mostrou-se eficaz. A interação de pneumopediatra e do otorrinolaringologista é fundamental para diagnóstico e seguimento.

Incidence and evolution of nasal polyps in children and adolescents with cystic fibrosis

Nasal polyps are a clinical sign of alert for investigating Cystic Fibrosis (CF).

Aims

To study the incidence of nasal polyps in children and adolescents with cystic fibrosis, its possible association with age, gender, clinical manifestations, genotype and sweat chlorine level, and its evolution with topical steroid therapy.

Methods

Clinical symptoms, sweat chlorine level and genotype were studied in 23 cystic fibrosis patients. Nasal polyps were diagnosed by nasal endoscopy and treated with topical steroids during 6 months, followed by a second nasal endoscopy. Fisher test was used for statistical analysis.

Results

Nasal polyps were found in 39.1% of the patients (five bilateral, four unilateral), all older than six years, recurrent pneumonia in 82.6%, pancreatic insufficiency in 87% and malnutrition in 74%. No association was seen between nasal polyps and sweat chlorine level, genotype, clinical sings of severity and nasal symptoms. Seven patients improved in their nasal polyps with topical steroids, six showed complete resolution.

Conclusion

The study showed a high incidence of nasal polyps in older children, who span the entire range of clinical severity, even in the absence of clinical nasal symptoms. Topical steroid therapy showed good results. An interaction among pediatricians and otolaryngologists is necessary for diagnosis and follow-up.

Risk factors for recurrent sinus surgery in cystic fibrosis: review of a decade of experience

BACKGROUND

Patients with cystic fibrosis (CF) who undergo endoscopic sinus surgery often require multiple revision procedures. Our objective was to identify risk factors for revision sinus surgery in patients with CF, to better identify this subset of patients who might be better suited for alternative interventions at their initial procedure.

METHODS

Patients with CF who presented to our academic tertiary care sinus clinic between 1994 and 2003 were reviewed. Data were collected from CT scans using the Lund-Mackay scale. Data are collected on demographics, comorbidities, CF genotype, number and type of sinus surgeries, and pulmonary function tests.

RESULTS

Eighty-one patients met inclusion criteria. Fifty patients were <18 years old at presentation. Forty-one patients were A508 homozygotes, 32 patients were A508 heterozygotes, and 5 patients were non-A508 heterozygotes. Respiratory comorbidities were asthma alone (28%) and aspirin triad (5%). Eighteen (22%) patients either smoked or lived with smokers. The mean Lund-Mackay score before the initial surgery was 16. Twenty patients were treated with medication only; 35 patients underwent 1 surgery; 14 patients underwent 2 surgeries; 8 patients underwent 3 surgeries; 2 patients underwent 4 surgeries; and 2 patients underwent 5 surgeries. Patients with higher Lund-Mackay scores at their initial CT were more likely to undergo repeat surgeries (p < 0.05).

CONCLUSION

CF patients with high Lund-Mackay scores at their initial surgery are more likely to undergo several revision surgeries. These patients should be considered for more alternative initial management of their sinuses.

Management of recurrent sinus disease in children with cystic fibrosis: a combined approach

OBJECTIVE

To determine whether a combined approach (CA) consisting of functional endoscopic sinus surgery (FESS), Caldwell-Luc operation, and medial maxillectomy is beneficial for children with cystic fibrosis (CF) with refractory sinonasal disease previously treated with endoscopic procedures alone.

STUDY DESIGN

Retrospective review and comparison of outcomes of CA and FESS alone for each CF patient.

OUTCOMES MEASURED

sinonasal symptoms, endoscopic findings, number of hospitalizations, antibiotic courses, and forced expiratory volume in 1 second (FEV1).

SETTING

Referral hospital.

RESULTS

Fifteen children underwent CA between 1996 and 2000 (7 males, 8 females; 13.8 years mean age; 42 months average follow-up period). Significant decrease in number of hospitalizations and intravenous antibiotic courses, with increased mean FEV1 (from 70.2% preoperation to 89.3% postoperation, P < 0.0001) were found. Marked clinical improvement persisted for several years.

CONCLUSION

Applying the CA after multiple failed endoscopic procedures in CF patients reduced morbidity and resulted in successful management of sinonasal disease. CA is suggested after multiple failed endoscopic procedures. Further studies of CA as a first-line procedure for difficult sinus cases in children with CF is recommended.

EBM RATING

C-4.

Are lower airway or throat cultures predictive of sinus bacteriology in cystic fibrosis?

The choice of antibiotics for sinusitis in children with cystic fibrosis (CF) is empirical or based on lower airway cultures, because sinus cultures are difficult to obtain. The aim of this study was to identify the main organisms cultured from CF children with chronic sinusitis, and to evaluate the concordance of concomitant sinus, oropharyngeal swab (OP), and bronchoalveolar lavage fluid (BALF) cultures. OP and BALF cultures were done preoperatively, and sinus cultures were obtained during clinically indicated sinus surgery. The genetic identity of the bacteria was compared if the same organisms were present in upper and lower airway cultures. In total, 45 paired sinus-BALF cultures from 31 patients were included. Twenty-four of these had matched OP cultures. The mean age of patients was 9.5 +/- 4.3 years, and 19 patients were DeltaF508 homozygous. Bacterial sinus infection was present in 96%, caused by S. aureus (49%), P. aeruginosa (42%), and H. influenzae (22%). The diagnostic accuracy of BALF or OP cultures was low in predicting sinus infection, particularly at younger ages. Positive and negative predictive values (PPV and NPV) of BALF for P. aeruginosa infection were 65% and 67%, and for S. aureus, 76% and 63%, respectively. Predictive values for OP cultures were similar. Bacterial species were the same in sinus and OP or BALF samples of 12 patients of these bacteria 83% showed genetic identity. We conclude that S. aureus is an important pathogen in pediatric CF sinusitis, and that BALF or oropharyngeal cultures are poor predictors for organisms present in the sinuses.

Modifier genetics: cystic fibrosis

Cystic fibrosis (CF) is the most common lethal autosomal recessive disorder in the Caucasian population, affecting about 30,000 individuals in the United States. The gene responsible for CF, the CF transmembrane conductance regulator (CFTR), was identified 15 years ago. Substantial variation in the many aspects of the CF phenotype among individuals with the same CFTR genotype demonstrates that factors independent of CFTR exert considerable influence on outcome in CF. To date, the majority of published studies investigating the cause of disease variability in CF report associations between candidate genes and some aspect of the CF phenotype. However, a definitive modifier gene for CF remains to be identified. Despite the challenges posed by searches for modifier effects, studies of affected twins and siblings indicate that genetic factors play a substantial role in intestinal manifestations. Identifying the factors contributing to variation in pulmonary disease, the primary cause of mortality, remains a challenge for CF research.

Inhibition of p38 mitogen activated protein kinase controls airway inflammation in cystic fibrosis

BACKGROUND

Cystic fibrosis (CF) airways are characterised by chronic inflammation, increased interleukin (IL)-8 secretion, and neutrophil activation which are considered the principal factors of morbidity and mortality in CF patients. Optimising management of this chronic inflammatory response is therefore a key issue of basic and clinical CF research. Several reports have addressed ways to manage CF airways inflammation, and an attractive therapeutic strategy may be the inhibition of the p38-mitogen activated protein kinase (p38-MAP-k) pathway.

METHODS

A new ex vivo model was used to study the mucosal inflammatory response to environmental airways stimuli. Nasal biopsy tissues from CF patients and controls were cultured ex vivo for 20 minutes, 4 hours, and 24 hours in the presence of lipopolysaccharide (LPS) from Pseudomonas aeruginosa (PA) with and without the p38-MAP-k inhibitor SB203580. Quantitative mRNA assessment, immunohistochemistry, and Western blots were used to detect the expression and modulation of inflammatory markers.

RESULTS

PA-LPS challenge induced a time dependent mucosal inflammation indicated by rapid epithelial activation, IL-8 release, COX-2 upregulation, and neutrophil migration to the upper mucosal layers. Some of these LPS induced changes (IL-8 release and neutrophil migration) were specific to CF tissues. SB203580 significantly controlled all LPS induced mucosal changes in CF tissues.

CONCLUSION

These findings provide a rationale and proof of principle for the potential use of p38-MAP-k inhibitors to control inflammation in patients with CF.

Analysis of most common CFTR mutations in patients affected by nasal polyps

Nasal polyps, a chronic inflammatory disease occurring in the nose and para-nasal sinuses, result from several different causes, including cystic fibrosis (CF). Forty-four patients affected by nasal polyps were admitted to the Department of Otolaryngology, Lublin University School of Medicine, Lublin, Poland, and screened for the most-commonly identified CFTR mutations [DeltaF508, G542X, N1303 K, 1717-1 (G to A), W1282X, G551D, R553X and DeltaI507] by applying the INNO-LIPA CF2 test strips. None of the patients had symptoms that allowed for the diagnosis of CF, including the negative sweat test. We detected 5 of 44 (11.4%) carriers of the CFTR mutations. All patients positive for this test were heterozygous carriers of DeltaF508. In the control group, only 1 of 70 (1.4%) cases showed DeltaF508 heterozygosity. The frequency of DeltaF508 mutation herein reported was significantly higher than in the control group (P = 0.0312) and in the general Polish population as well (P = 0.0059). Our data suggest that a heterozygous manifestation of the DeltaF508 may exist in a selected group of patients affected by nasal polyps, who have no other clinical features of CF.

Contemporary management of nasal polyps

Nasal polyposis is a multifactorial disease process resulting in a common pathologic structure. Better understanding of the pathophysiology has resulted in improved protocols for treatment. Different causes of polyposis are discussed with attention to both medical and surgical therapy. Recent advances in aspirin desensitization are detailed.

Endoscopic Sinus Surgery in Cystic Fibrosis: Effects on Pulmonary Function and Ideal Body Weight

There is some question as to whether surgical treatment of sinus disease in patients with cystic fibrosis improves pulmonary function or helps patients achieve their ideal body weight. To investigate this matter, we retrospectively studied 17 children with cystic fibrosis who had undergone endoscopic sinus surgery at the University of Kentucky College of Medicine over a 15-year period. All patients had advanced sinus disease at the time of surgery. Although there was an overall increase in mean pulmonary function values, which peaked 1 month postoperatively, no statistically significant improvements were maintained at 6 and 12 months. Nor was there any significant change in these patients’ percentage of ideal body weight.

Clinical characteristics and genotype analysis of patients with cystic fibrosis and nasal polyposis

The prevalence of nasal polyps in a group of paediatric patients with cystic fibrosis was prospectively studied in comparison with a control group with cystic fibrosis but without polyps. Clinical variables, including pulmonary function tests, skin testing and mucociliary transport, were carried out in both groups, as well as genotype analysis. Endoscopic intranasal evaluation identified polyps in 29 of 89 patients (33%). Statistical analysis revealed that patients with nasal polyposis had better pulmonary function, a higher rate of Pseudomonas aeruginosa colonization, more hospitalizations, and more prevalence of allergy to Aspergillus fumigatus than did the comparison group. We found no statistically different genotype distribution between the polyposis and the control group. However, it can be emphasized that the prevalence of the compound heterozygous genotype is higher in the nasal polyposis group than in controls. Our observations suggest that other genetic and environmental factors could play an important role in the development of nasal polyposis.

Nasal polyps in cystic fibrosis: clinical endoscopic study with nasal lavage fluid analysis

STUDY OBJECTIVES

Nasal polyps frequently appear in patients with cystic fibrosis (CF). The aims of this study were to focus on what problems (symptoms, endoscopic findings, and laboratory correlates) nasal polyps cause the CF patient, and how these correlate to the total health situation of this patient group.

PATIENTS AND STUDY DESIGN

The clinical histories, endoscopic investigations of the nasal cavity, and analyses of nasal lavage fluid of 44 patients with CF complicated with nasal polyposis have been compared with those of 67 CF control subjects. The patients were examined at annual control examinations (with pulmonary tests, working capacity, liver tests, and bacterial and blood tests) from 1995 to 1996 at Stockholm Cystic Fibrosis Center, Huddinge University Hospital. All patients were > 2 years of age. The endoscopic findings were related to the actual pulmonary function, inflammatory blood parameters, colonizing pathogens, antibodies (Staphylococcus aureus and Pseudomonas aeruginosa), and genotype.

RESULTS

The patients with nasal polyps differed with respect to chronic colonization of P aeruginosa in sputum samples and had a higher occurrence of serum antibodies against the same species. The two groups did not differ in pulmonary functions, inflammatory parameters, or genotype. The polyps found were mainly small (within the meatus media) and gave no significant increase in ongoing clinical symptoms such as rhinorrhea, nasal obstruction, or hyposmia. Neither was any significantly marked finding concerning the nose (mucosal swellings, secretion, etc.) made in the polyp patients. The patients with CF scored slightly lower in a smell identification test in comparison with the healthy control group. The nasal lavage fluid was analyzed (in 93 of the 111 patients) for the occurrence of P aeruginosa (by polymerase-chain reaction [PCR]), interleukin [IL]-5, IL-8, and lysozyme. The lysozyme and IL-8 content was equal in the two CF groups but increased in comparison with the healthy control group. P aeruginosa was not detected with PCR in any nasal lavage fluid. No measurable levels of IL-5 in the nasal lavage were found.

CONCLUSIONS

There was a higher frequency of chronic colonization of P aeruginosa in the lower respiratory tract in patients with nasal polyps. Otherwise, nonsevere nasal polyposis was not an indicator of lower respiratory tract morbidity in CF patients.

Factors associated with poor pulmonary function: cross-sectional analysis of data from the ERCF. European Epidemiologic Registry of Cystic Fibrosis

The European Epidemiologic Registry of Cystic Fibrosis began collecting longitudinal data on European cystic fibrosis patients in 1994. A cross-sectional analysis was performed to identify the factors associated with low values of % predicted forced expiratory volume in one second (FEV1) upon patient enrollment. Data from 7,010 patients aged > or =6 yrs were included. Clinical conditions, microbiological isolates and medications reported at enrollment or within the following 180 days were analysed for age-specific associations. Factors associated with FEV1 that were lower by >10% of pred values were: lower weight for age percentiles, haemoptysis, pneumothorax, pulmonary symptoms at presentation, Pseudomonas aeruginosa, Burkholderia cepacia, oral corticosteroids, nonsteroid anti-inflammatory drugs, dornase alfa, oxygen and assisted ventilation and, in patients >12 yrs old only, use of airway clearance techniques, inhaled bronchodilators, oral nutritional supplements, pancreatic enzymes and insulin or oral hypoglycaemics. Slightly impaired lung function (5-10%) was associated with: diabetes (> or = 18-yrs-old), gastro-oesophageal reflux, allergic bronchopulmonary aspergillosis, asthma-like symptoms, portal hypertension, Aspergillus spp. and Candida spp. Sex, Haemophilus influenzae and Staphylococcus aureus were not associated with impaired pulmonary status. Regular exercise (especially in older patients) and nasal polyposis were associated with slightly better FEV1. The results confirm those of previous studies and suggest selective prescribing in sicker patients.

European Epidemiologic Registry of Cystic Fibrosis (ERCF): comparison of major disease manifestations between patients with different classes of mutations

SUMMARY. By August 1997, 11,749 patients with cystic fibrosis had been enrolled in the European Epidemiologic Registry of Cystic Fibrosis (ERCF). Genotype analysis had been performed on 8,963 (76%) of these patients, and the majority had one or two identifiable mutations. Patients with known mutations were classified according to the type of mutation (Classes I-V), and were grouped according to the class of mutation on both chromosomes. This resulted in six subgroups, including all patients homozygous for Class I (I/I, n = 72), for Class II (II/II, n = 5,020), and for Class III mutations, (III/III, n = 23). Since there were only 23 patients homozygous for Class III mutations, a fourth group was made up of patients who were compound heterozygous for a Class II and III mutation (II/III, n = 265). There were only five patients homozygous for Class IV mutations, and consequently a fifth group was made up of all patients carrying at least one Class IV mutation, regardless of the nature of the mutation on the other chromosome (IV/any, n = 187). None were homozygous for Class V mutations; consequently, a sixth group consisted of patients carrying at least one Class V mutation (V/any, n = 22). Mean age was highest in groups III/III, IV/any, and V/any (15.6, 16, and 17 years, respectively) as opposed to 12.4 years in group II/II and 13.4 in group II/III, but both group III/III and V/any were small, and the confidence interval of the mean was large. The percentage of patients receiving pancreatic enzymes was lower in groups IV/any and V/any than in any of the other groups, i.e., approximately 50% of patients 18 years or older in both groups as opposed to between 90-100% of all other patients regardless of age. The prevalence of diabetes mellitus increased with age from 2.6% in patients < 18 years to 22.1% in patients 18 years or older in the large group II/II, but was only 1.5% in patients 18 years or older in group IV/any. Disregarding the small group III/III, abnormally elevated liver enzymes and/or bilirubin (1.5 x upper normal limit) was much less frequent in group IV/any than in any of the other groups, both overall and in patients aged 18 years or more. The course of lung disease appeared to be less dependent on genotype than pancreatic function, with only minor differences between groups; however, the mean values of both FVC % and FEV(1) % were slightly higher in group IV/any than all other groups in both younger and older patients. The same was found for the prevalence of some major clinical signs of severe lung disease, such as clubbing, hyperinflation, and crepitations. Overall mean weight expressed as an age percentile was markedly higher in group IV/any than in any other group, which may be related to the finding of a much lower prevalence of chronic P. aeruginosa infection in patients 18 years or older belonging to group IV/any (and V/any) than in any other group. In conclusion, the presence of a class IV mutation appears to offer some degree of protection against pancreatic insufficiency, diabetes mellitus, and liver disease. We confirmed that lung disease follows a milder clinical course in patients with a class IV mutation and that the presence of a class IV mutation (and possibly class V) is associated with a delay in the onset of P. aeruginosa infection.

Endoscopic sinus surgery in patients with cystic fibrosis: an analysis of complications

The application of endoscopic sinus surgery (ESS) for the management of paranasal sinus disease in patients with cystic fibrosis (CF) has been well described. Due to underlying medical issues such as acquired coagulopathies and advanced pulmonary disease, perioperative morbidity is assumed to be higher in this group. The incidence and type of complications associated with CF patients undergoing ESS has not been previously described. We reviewed 52 consecutive endoscopic procedures in 41 patients with CF performed by a single surgeon over a 34-month period. This review focused on perioperative and postoperative complications. Additional clinical data gathered included estimated blood loss, length of procedure, coagulation laboratory studies, the presence of nasal polyposis, the use of nasal packing, pulmonary function status, and average hospitalization time. A total of six complications were identified--four immediate and two delayed. The perioperative or immediate complications included two cases of epistaxis, one case of periorbital ecchymosis, and one case of pulmonary hemorrhage. Delayed complications include one case of epistaxis and one case of intranasal scarring. In two of these six patients, length of hospitalization was prolonged for management of the associated complications. No study has specifically addressed complications of ESS in the CF patient. Our review demonstrates a complication rate of 11.5%, which compares favorably with the non-CF ESS complication rates of 0-17% reported in the literature. Critical to successful management of these patients is coordinated care delivered by the pediatrician or internist, the pulmonary specialist, the anesthesia team, and the otolaryngologist. In addition to a review of current literature, we discuss the overall management approach adopted at our institution and highlight elements thought to minimize morbidity.

Epidemiologic study of cystic fibrosis: design and implementation of a prospective, multicenter, observational study of patients with cystic fibrosis in the U.S. and Canada

Cystic fibrosis (CF) is a complex illness characterized by chronic lung infection leading to deterioration in function and respiratory failure in over 85% of patients. An understanding of the risk factors for that progression and the interaction of these factors with current therapeutic strategies should materially improve the prevention of this progressive lung disease. The Epidemiologic Study of Cystic Fibrosis (ESCF) was therefore designed as a multicenter, longitudinal, observational study to prospectively collect detailed clinical, therapeutic, microbiologic, and lung function data from a large number of CF treatment sites in the U.S. and Canada. The ESCF also serves an important role as a phase-IV study of dornase alfa. To be eligible for enrollment, subjects must have the diagnosis of CF and receive the majority of their care at an ESCF site. In this paper, the authors present the ESCF study design in detail. Further, enrollment data collected at 194 study sites in 18,411 subjects enrolled from December 1, 1993 to December 31, 1995 are presented in summary form. This comprehensive study is unique in the detail of clinical data collected regarding patient monitoring and therapeutic practices in CF care. Two companion articles present data regarding practice patterns in cystic fibrosis care, including data on resource utilization and prescribing practices.

Genotype-phenotype correlations for the paranasal sinuses in cystic fibrosis

Genotype-phenotype correlations in cystic fibrosis (CF) have been found for lung and pancreatic function, but not for paranasal sinus disease. Because such correlations may have pathophysiological and clinical implications, the correlation of mutations, in particular DeltaF508, with paranasal sinus disease was investigated in 113 CF patients with known genotype. The clinical importance of paranasal sinus disease was evaluated using three parameters: polyps, overall clinical severity of upper airway problems, and surgery. Polyps were evaluated by nasal endoscopy and graded on a five-point scale. Four severity groups were distinguished based on history, clinical records, and examination: no upper airway problems; more problems than in control subjects; severe, recurrent or chronic problems; and paranasal sinus surgery cases. DeltaF508 homozygosity correlated with clinical severity (p < 0.02) and with the presence of polyps on endoscopy (p < 0.05). The relative risk for paranasal sinus surgery in DeltaF508 homozygous CF patients was 2.33. In conclusion, there are genotype-phenotype correlations for paranasal sinus disease in CF. DeltaF508 homozygosity is a risk factor for paranasal sinus disease in CF.

Sensation of smell does not determine nutritional status in patients with cystic fibrosis

Poor nutritional status in patients with cystic fibrosis (CF) is associated with increased mortality. Patients with CF often have a decreased sensation of smell secondary to recurrent sinus infections or sinus surgery; in other CF populations, a decreased sensation of smell has been associated with poor nutritional status. We hypothesized that a decreased sensation of smell would be associated with worse nutritional status in patients with CF. We studied 50 (26 F and 24 M) of 58 consecutive patients with CF (86%) aged 14-53 years (28 +/- 8; mean +/- SD) who attended the University of Washington Medical Center from June 1994 to March 1995 and who agreed to participate. Demographic information was obtained, and nutritional status was assessed by ideal body weight, arm muscle area, arm fat area, pancreatic sufficiency, insulin-requiring diabetes, vitamins A and E levels, albumin, iron, iron binding capacity, ferritin, cholesterol, and zinc levels. Objective sensation of small was examined (Sensonics, Philadelphia, PA), a sinus compacted tomogram (CT) was performed, and a questionnaire for prior sinus symptoms, sinus surgery, medications, and subjective sensation of smell was administered. Twenty-seven of 49 subjects (55%) had an objective decrease in sensation of smell, 23/50 (46%) had had prior sinus surgery. 46/50 (92%) were pancreatic insufficient, and 8/50 (16%) were insulin-requiring diabetics. Weight for height ranged from the 38th to 157th percentile (100 +/- 18; mean +/- SD). Arm muscle area ranged from the < 5th to the 75th percentile (25 +/- 23; mean +/- SD). Arm fat area ranged from the < 5th to the 95th percentile (45 +/- 39; mean +/- SD). Sinus CT scans were abnormal in all patients (100%). Patients with anosmia were more likely to have had sinus surgery, but their nutritional status was no different from that of patients with a normal sensation of smell. We conclude that decreased sensation of smell is common in patients with CF, especially those with prior sinus surgery. Subjective sensation of smell and sinus CT scans were unreliable indicators of a decreased objective sensation of smell. In this pilot study, no association was found between sensation of smell and nutritional status.