Biologics for chronic rhinosinusitis

Switching of biological therapy to dupilumab in comorbid patients with severe asthma and CRSwNP

PURPOSE

Nowadays, several efficacious biologic drugs are used for severe asthma with or without chronic rhinosinusitis with nasal polyps (CRSwNP). However, it has been observed that not all comorbid patients (asthma/CRSwNP) receiving biologic treatment for asthma experience satisfactory control of both conditions equally.

METHODS

We selected 20 patients who had both severe asthma and comorbid CRSwNP under biological treatment with benralizumab, omalizumab or mepolizumab with adequate control of asthma but inadequate control of nasal symptoms. Patients were switched to dupilumab and outcomes were evaluated at baseline (T0), at 3 months (T1), at 6 months (T2), at 12 months (T3) and finally at 18 months (T4). Data were collected at each time point including blood tests measuring eosinophil levels and total IgE, SNOT22, ACT, NPS score, rhinomanometry, olfactory testing, and nasal cytology.

RESULTS

The results showed an overall improvement in all the outcomes. Peripheral eosinophilia was observed consistently with existing literature. All patients registered an improvement in sinonasal outcomes, while only one patient had a worsening of asthma. Three patients interrupted the therapy due to various causes: poor asthma control, onset of psoriasis and thrombocytopenia.

CONCLUSIONS

The response to a biologic treatment for CRSwNP control may be heterogenous and it seems that patients may benefit from switching improving control in equal measure in the upper and lower airway. Further studies to explore the endotype/phenotype which best fits with each biologic are mandatory to personalize the therapy.

Methotrexate for recurrent chronic rhinosinusitis with nasal polyps: A randomized, controlled, phase 2 clinical trial

OBJECTIVE

This randomized, controlled, open-label, phase 2 clinical trial aimed to assess the efficacy and safety of low-dose methotrexate as maintenance therapy for recurrent postoperative chronic rhinosinusitis with nasal polyps (CRSwNPs).

METHODS

Forty-one patients with CRSwNPs who experienced postoperative polyp recurrence(s) were randomly divided into three groups to receive one of the following treatments for 8 weeks: daily intranasal mometasone furoate monohydrate 200 mcg (control [intranasal corticosteroids (INCS)] arm, n = 13]); daily per oral methylprednisolone 8 mg (oral corticosteroids [OCS] arm, n = 14); and once weekly per oral 10 mg methotrexate (MTX arm, n = 14). All patients were assessed at three clinical visits according to the Lund-Kennedy endoscopic grading system (LKES), visual analog scale (VAS), Turkish version of the Sinonasal Outcome Test-22 (SNOT-22), peak nasal inspiratory flow (PNIF), butanol olfactory threshold test (BuOT), serum total IgE level, presence of peripheral eosinophilia, serum biochemical assays, and adverse events.

RESULTS

All efficacy outcome measures significantly improved in all three groups, except for the nonrecovery of peripheral eosinophilia in the INCS group. There was no significant difference among the groups in terms of LKES scores. Scores for the Turkish version of the SNOT-22, PNIF, BuOT, and serum IgE levels were also similar among the groups. However, total VAS scores recovered significantly better in the INCS group than in the MTX group. Serum biochemical assays remained normal in all groups. Adverse events were minor and observed only in the OCS group.

CONCLUSION

Low-dose MTX was a safe and effective maintenance therapy for patients with recurrent postoperative CRSwNPs.

Systematic review with meta-analysis: Efficacy and safety of biological treatment on salivary gland function in primary Sjögren's syndrome

Objective: The study aimed to assess the efficacy and safety of clinical trials of biologics in improving the salivary gland (SG) function in primary Sjögren's syndrome (pSS), which has not been analyzed critically and systematically. Methods: PubMed, Web of Science, ClinicalTrials.gov, the EU Clinical Trials Register, and the Cochrane Library were searched for clinical trials that reported effects of biological treatment on the SG function and safety in pSS patients. Inclusion criteria were defined following participants, interventions, comparisons, outcome, and study design (PICOS) recommendations. The objective index (the change of unstimulated whole saliva (UWS) flow) and the serious adverse event (SAE) were assessed as main outcome measures. A meta-analysis of the efficacy and safety of the treatment was conducted. Quality assessment, sensitivity analysis, and publication bias were assessed. The effect size together with a 95% confidence interval was used to estimate the efficacy and safety of biological treatment and was plotted as a forest plot. Results: The literature search yielded 6,678 studies, nine of which fulfilled the inclusion criteria, with seven randomized controlled trials (RCTs) and two non-RCT clinical studies. Generally, biologics do not significantly increase UWS from the baseline of pSS patients compared to the control group at a matched time point (p = 0.55; standard mean difference, SMD = 0.05; 95% confidence interval, CI: -0.11 and 0.21). However, pSS patients with shorter disease duration (≤3 years; SMD = 0.46; 95% CI: 0.06 and 0.85) were prone to have a better response to biological treatment by showing higher increased UWS than patients with longer disease duration (> 3 years; SMD = -0.03; 95% CI: -0.21 and 0.15) (p = 0.03). For the meta-analysis of the safety of biological treatment, the SAEs in the biologics group were significantly higher than those of the control group (p = 0.0021; log odds ratio, OR = 1.03; 95% CI: 0.37 and 1.69). Conclusion: Biological intervention during the early course of the disease may benefit pSS patients better than that during the late course. Significantly, more SAEs in the biologics group indicate that the safety of biologics needs to be addressed for future biological clinical trials and treatment.

Laser nasal surgery (Review)

Laser nasal surgery has been an elusive subject in the last 10 to 15 years It was considered as a potential surgical staple for nasal surgery in the 1980s; however, it did not become one due to technical difficulties. Laser therapy has reemerged as an alternative to classical endoscopic surgery, and otorhinolaryngology surgeons are considering the benefits that it can offer. The advantages of this procedure are shorter hospitalization time, lack of nasal packing, high procedural precision with tissue sparing, and the unique capability of reducing both bacterial and fungal colonization at the level of the paranasal sinus. Therefore, laser therapy appears to be an invaluable tool for clinical practice. Due to the absence of a guaranteed cure for reoccurring nasal polyposis, laser therapy is worth investigating. For this therapy to evolve, an improved understanding of laser types and the effects that they produce is required. By investing in further developments of the equipment, the technique may become more widely used. With the current accelerated rate of technological evolution and robotic capabilities, laser nasal surgery may become a gold standard in future years. The aim of the present review is to evaluate whether it is worth investing in nasal laser surgery as a future alternative to current treatment standards.

Comparing the severity of chronic rhinosinusitis symptoms before versus during the COVID-19 pandemic

Background

COVID-19 measures such as masking, social distancing, and staying indoors may mitigate chronic rhinosinusitis (CRS) symptoms. We evaluate whether these measures correlated with improved symptoms in patients with CRS.

Methods

This retrospective study compared SNOT-22 survey data from the Northwestern CRS Registry at the time of enrollment and at years 1-5 of follow-up. The final sample consisted of 1826 SNOT-22 surveys for 598 patients. April 10, 2020 to December 31, 2021 was considered "during the pandemic" and prior to March 11, 2020 was considered "pre-pandemic." Wilcoxon test was used to compare SNOT22 at enrollment pre-pandemic versus during pandemic. Separate linear mixed models were performed to estimate SNOT22 at 1 to 5 years after enrollment pre-pandemic versus during pandemic.

Results

Subjects enrolled during the pandemic had worse SNOT22 scores than those enrolled pre-pandemic (53 vs. 42, p = .0024). Total SNOT-22 scores were improved during the pandemic than before the pandemic at 1 year follow-up (18.17 vs. 12.22, p = .001). This effect persists when evaluating the nasal (7.33 vs. 5.13, p = .003), sleep (2.63 vs. 1.39, p = .008), function (1.40 vs. 0.72, p = .015), and emotion (0.77 vs. 0.17, p < .001) domains individually. There was no statistically significant difference in total SNOT-22 score at Years 2-5 of follow-up.

Conclusions

Patients with CRS experience a greater reduction in symptom severity in their first year of treatment during the pandemic than before the pandemic, plausibly from measures such as masking and staying indoors.

Level of Evidence

4.

Adverse effects of dupilumab in chronic rhinosinusitis with nasal polyps. Case report and narrative review

Herein we review the current literature on the adverse effects related to biological therapy with the monoclonal antibody dupilumab in patients with type 2 inflammation prevalent phenotype chronic rhinosinusitis with nasal polyps (CRSwNP). Our review shows that the side effects of dupilumab may be linked to the prevalent type 2 inflammation phenotype (asthma, dermatitis, CRSwNP). We also report the first case of cutaneous rash as a side effect of dupilumab in a patient with CRSwNP.

Developments and Emerging Trends in the Global Treatment of Chronic Rhinosinusitis From 2001 to 2020: A Systematic Bibliometric Analysis

Background

Research on the treatment of chronic rhinosinusitis (CRS) has increased in recent decades. We undertook a bibliometric and visualization analysis of studies on CRS treatment to track research trends and highlight current research “hotspots”.

Methods

Original publications related to CRS treatment were obtained from the Science Citation Index-Expanded (SCI-E) and Social Sciences Citation Index (SSCI) databases in the Web of Science Core Collection (WoSCC) of Clarivate Analytics between 2001 and 2020. The country/region, institution, author, journal, references, and keywords involved in this topic were extracted using CiteSpace and VOSviewer to identify and analyze the research focus and trends in this field.

Results

In the previous two decades (especially after 2015), the number of publications on CRS treatment has grown markedly. With regard to publications and access to collaborative networks, the leading country was the USA. High-frequency keywords were “CRS,” “endoscopic sinus surgery,” “sinusitis,” “nasal polyps,” “asthma,” “rhinosinusitis,” “management,” “diagnosis,” “outcomes,” and “quality of life.” Inspection of keyword bursts suggested that “clinical practice guideline,” “adult CRS,” “innate lymphoid cell,” “recurrence,” and “mepolizumab” are the emerging research hotspots. The timeline view of the cluster map revealed that biologic agents have become an up-and-coming “hot topic” in CRS treatment in recent years.

Conclusion

Academic understanding of CRS treatment has improved markedly over the past 20 years. We study analyzed the papers objectively, methodically, and comprehensively, and identified hotspots and prospective trends in the field of CRS treatment. These results will aid rhinologists in gaining greater insight into CRS treatment strategies and identifying the changing dynamics of CRS research.

Efficacy and safety of omalizumab in chronic rhinosinusitis with nasal polyps: a systematic review and meta-analysis of randomised controlled trials

OBJECTIVES

To assess the efficacy and safety of omalizumab for chronic rhinosinusitis with nasal polyps (CRSwNP) and to identify evidence gaps that will guide future research on omalizumab for CRSwNP.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

A comprehensive search was performed in PubMed, Embase, Web of Science and the Cochrane Library on 13 October 2020.

ELIGIBILITY CRITERIA

Randomised controlled trials (RCTs) comparing omalizumab with placebo, given for at least 16 weeks in adult patients with CRSwNP.

DATA EXTRACTION AND SYNTHESIS

Two independent authors screened search results, extracted data and assessed studies using the Cochrane risk of bias tool. Data were pooled using the inverse-variance method and expressed as mean differences (MDs) with 95% CIs. Heterogeneity was assessed by the χ² test and the I² statistic.

RESULTS

A total of four RCTs involving 303 participants were identified. When comparing omalizumab to placebo, there was a significant difference in Nasal Polyps Score (MD=-1.20; 95% CI -1.48 to -0.92), Nasal Congestion Score (MD=-0.67; 95% CI -0.86 to -0.48), Sino-Nasal Outcome Test-22 (MD=-15.62; 95% CI -19.79 to -11.45), Total Nasal Symptom Score (MD=-1.84; 95% CI -2.43 to -1.25) and reduced need for surgery (risk ratio (RR)=5.61; 95% CI 1.99 to 15.81). Furthermore, there was no difference in the risk of serious adverse events ((RR=1.40; 95% CI 0.29 to 6.80), adverse events (RR=0.83; 95% CI 0.60 to 1.15) and rescue systemic corticosteroid (RR=0.52; 95% CI 0.17 to 1.61).

CONCLUSIONS

This was the first meta-analysis that identified omalizumab significantly improved endoscopic, clinical and patient-reported outcomes in adults with moderate to severe CRSwNP and it was safe and well tolerated.

PROSPERO REGISTRATION NUMBER

CRD42020207639.

Safety review of current systemic treatments for severe chronic rhinosinusitis with nasal polyps and future directions

Introduction: Chronic rhinosinusitis is a common condition characterized by inflammation of the nasal and sinus linings, rhinorrhea, nasal blockage, facial pain, and loss of sense of smell for longer than 12 weeks. CRS can occur with or without nasal polyps.Areas covered: First-line treatment in chronic rhinosinusitis with nasal polyps is long-term intranasal corticosteroids, which have few adverse events associated with their use, as second-generation intranasal corticosteroids having a bioavailability of <0.5%. Systemic corticosteroids are used when intranasal steroids fail to achieve symptom control. However, the repeated use of oral corticosteroids is associated with numerous adverse events and the benefit from a course of oral corticosteroids is lost within three to six months.Expert opinion: Antibiotics are commonly prescribed in nasal polyposis although there is also very little evidence for their use outside of acute infection. Macrolide antibiotics are also associated with a transient increase in the risk of arrhythmias. Biologics offer a steroid-sparing alternative to the treatment of severe nasal polyposis. They have shown to be relatively well tolerated in studies to date; however, studies suggest that there is no disease modifying effect and that any benefit is lost within weeks of finishing treatment.

Syringe with Nasal Applicator versus Syringe Alone for Nasal Irrigation in Acute Rhinosinusitis: A Matched-Pair Randomized Controlled Trial

Background/Aims

Nasal saline irrigation is a common procedure to relieve nasal symptoms in upper respiratory tract diseases. There is no consensus on the recommended nasal saline delivery devices. The objectives of this study were to evaluate efficacy, satisfaction, adherence, and adverse effects in patients with acute upper respiratory tract diseases using a syringe with a nasal applicator for nasal irrigation.

Methods

Patients with acute nasopharyngitis, acute rhinitis, or acute rhinosinusitis were randomly allocated to use either (1) a syringe with a nasal applicator or (2) a syringe alone to irrigate one nostril. After the patients had completed irrigation with the allocated device in one nostril, they were instructed to perform nasal irrigation using the other device in the other nostril. All patients were instructed to use a syringe with a nasal applicator at home. The efficacy, satisfaction scores, adherence, and adverse effects were recorded.

Results

Sixty-four patients were enrolled. The mean age of the patients was 33.95 years (18-59 years). The mean duration of symptoms was 4.80 days. None of the enrolled patients regularly performed nasal irrigation. Forty-two had acute nasopharyngitis, 10 had acute rhinitis, and 12 had acute rhinosinusitis. At baseline, the mean overall efficacy score for the syringe with a nasal applicator was 8.17 ± 1.43, and that for the syringe alone was 5.95 ± 2.02 (MD 2.23, p < 0.001, 95% CI 1.75-2.70). At 1 week, the syringe with the nasal applicator had significantly higher scores in 3 of 4 domains, including symptom relief, ease of use, and patients' willingness to recommend the device to others, compared to baseline (p < 0.05). None of the enrolled patients had epistaxis, retained/dislodged the applicator during irrigation, or experienced an allergic reaction to the applicator after 1 week of nasal irrigation.

Conclusion

Use of a syringe with an applicator for nasal irrigation yielded high scores in overall efficacy.

Biologics for chronic rhinosinusitis

BACKGROUND

This living systematic review is one of several Cochrane Reviews evaluating the medical management of patients with chronic rhinosinusitis. Chronic rhinosinusitis is common. It is characterised by inflammation of the nasal and sinus linings, nasal blockage, rhinorrhoea, facial pressure/pain and loss of sense of smell. It occurs with or without nasal polyps.   'Biologics' are medicinal products produced by a biological process. Monoclonal antibodies are one type, already evaluated in other inflammatory conditions (e.g. asthma and atopic dermatitis).

OBJECTIVES

To assess the effects of biologics for the treatment of chronic rhinosinusitis.

SEARCH METHODS

The Cochrane ENT Information Specialist searched the Cochrane ENT Register; CENTRAL (2020, Issue 9); Ovid MEDLINE; Ovid Embase; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished studies. The date of the search was 28 September 2020.

SELECTION CRITERIA

Randomised controlled trials (RCTs) with at least three months follow-up comparing biologics (monoclonal antibodies) against placebo/no treatment in patients with chronic rhinosinusitis.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures. Our primary outcomes were disease-specific health-related quality of life (HRQL), disease severity and serious adverse events (SAEs). The secondary outcomes were avoidance of surgery, extent of disease (measured by endoscopic or computerised tomography (CT) score), generic HRQL and adverse effects (nasopharyngitis, including sore throat). We used GRADE to assess the certainty of the evidence for each outcome.

MAIN RESULTS

We included 10 studies. Of 1262 adult participants, 1260 had severe chronic rhinosinusitis with nasal polyps; 43% to 100% of participants also had asthma. Three biologics, with different targets, were evaluated: dupilumab, mepolizumab and omalizumab. All of the studies were sponsored or supported by industry. For this update (2021) we have included two new studies, including 265 participants, which reported data relating to omalizumab. Anti-IL-4Rα mAb (dupilumab) versus placebo/no treatment (all receiving intranasal steroids) Three studies (784 participants) evaluated dupilumab. Disease-specific HRQL was measured with the SNOT-22 (a 22-item questionnaire, with a score range of 0 to 110; minimal clinically important difference (MCID) 8.9 points). At 24 weeks, dupilumab results in a large reduction (improvement) in the SNOT-22 score (mean difference (MD) -19.61, 95% confidence interval (CI) -22.54 to -16.69; 3 studies; 784 participants; high certainty). At between 16 and 52 weeks of follow-up, dupilumab probably results in a large reduction in disease severity, as measured by a 0- to 10-point visual analogue scale (VAS) (MD -3.00, 95% CI -3.47 to -2.53; 3 studies; 784 participants; moderate certainty). This is a global symptom score, including all aspects of chronic rhinosinusitis symptoms. At between 16 and 52 weeks of follow-up, dupilumab may result in a reduction in serious adverse events compared to placebo (5.9% versus 12.5%, risk ratio (RR) 0.47, 95% CI 0.29 to 0.76; 3 studies, 782 participants; low certainty). Anti-IL-5 mAb (mepolizumab) versus placebo/no treatment (all receiving intranasal steroids) Two studies (137 participants) evaluated mepolizumab. Disease-specific HRQL was measured with the SNOT-22. At 25 weeks, the SNOT-22 score may be reduced (improved) in participants receiving mepolizumab (MD -13.26 points, 95% CI -22.08 to -4.44; 1 study; 105 participants; low certainty; MCID 8.9).  It is very uncertain whether there is a difference in disease severity at 25 weeks: on a 0- to 10-point VAS, disease severity was -2.03 lower in those receiving mepolizumab (95% CI -3.65 to -0.41; 1 study; 72 participants; very low certainty). It is very uncertain if there is a difference in the number of serious adverse events at between 25 and 40 weeks (1.4% versus 0%; RR 1.57, 95% CI 0.07 to 35.46; 2 studies; 135 participants, very low certainty). Anti-IgE mAb (omalizumab) versus placebo/no treatment (all receiving intranasal steroids) Five studies (329 participants) evaluated omalizumab. Disease-specific HRQL was measured with the SNOT-22. At 24 weeks omalizumab probably results in a large reduction in SNOT-22 score (MD -15.62, 95% CI -19.79 to -11.45; 2 studies; 265 participants; moderate certainty; MCID 8.9). We did not identify any evidence for overall disease severity. It is very uncertain whether omalizumab affects the number of serious adverse events, with follow-up between 20 and 26 weeks (0.8% versus 2.5%, RR 0.32, 95% CI 0.05 to 2.00; 5 studies; 329 participants; very low certainty).

AUTHORS' CONCLUSIONS

Almost all of the participants in the included studies had nasal polyps (99.8%) and all were using topical nasal steroids for their chronic rhinosinusitis symptoms. In these patients, dupilumab improves disease-specific HRQL compared to placebo. It probably also results in a reduction in disease severity, and may result in a reduction in the number of serious adverse events. Mepolizumab may improve disease-specific HRQL. It is very uncertain if there is a difference in disease severity or the number of serious adverse events. Omalizumab probably improves disease-specific HRQL compared to placebo. It is very uncertain if there is a difference in the number of serious adverse events. There was no evidence regarding the effect of omalizumab on disease severity (using global scores that address all symptoms of chronic rhinosinusitis).

Manifesto on united airways diseases (UAD): an Interasma (global asthma association - GAA) document

OBJECTIVE

The large amount of evidence and the renewed interest in upper and lower airways involvement in infectious and inflammatory diseases has led Interasma (Global Asthma Association) to take a position on United Airways Diseases (UAD).

METHODS

Starting from an extensive literature review, Interasma executive committee discussed and approved this Manifesto developed by Interasma scientific network (INES) members.

RESULTS

The manifesto describes the evidence gathered to date and defines, states, advocates, and proposes issues on UAD (rhinitis, rhinosinusitis and nasal polyposis), and concomitant/comorbid lower airways disorders (asthma, chronic obstructive pulmonary disease, bronchiectasis, cystic fibrosis, obstructive sleep apnoea) with the aim of challenging assumptions, fostering commitment, and bringing about change. UAD refers to clinical pictures characterized by the coexistence of upper and lower airways involvement, driven by a common pathophysiological mechanism, leading to a greater burden on patient's health status and requiring an integrated diagnostic and therapeutic plan. The high prevalence of UAD must be taken into account. Upper and lower airways diseases influence disease control and patient's quality of life.

CONCLUSIONS

Patients with UAD need to have a timely and adequate diagnosis, treatment, and, when recommended, referral for management in a specialized center. Diagnostic testing including skin prick or serum specific IgE, lung function, fractional exhaled nitric oxide (FeNO), polysomnography, allergen-specific immunotherapies, biological therapies and home based continuous positive airway pressure (CPAP) whenever these are recommended, should be part of the management plan for UAD. Education of medical students, physicians, health professionals, patients and caregivers on the UAD is needed.

Monoclonal Antibodies and Airway Diseases

Monoclonal antibodies, biologics, are a relatively new treatment option for severe chronic airway diseases, asthma, allergic rhinitis, and chronic rhinosinusitis (CRS). In this review, we focus on the physiological and pathomechanisms of monoclonal antibodies, and we present recent study results regarding their use as a therapeutic option against severe airway diseases. Airway mucosa acts as a relative barrier, modulating antigenic stimulation and responding to environmental pathogen exposure with a specific, self-limited response. In severe asthma and/or CRS, genome-environmental interactions lead to dysbiosis, aggravated inflammation, and disease. In healthy conditions, single or combined type 1, 2, and 3 immunological response pathways are invoked, generating cytokine, chemokine, innate cellular and T helper (Th) responses to eliminate viruses, helminths, and extracellular bacteria/fungi, correspondingly. Although the pathomechanisms are not fully known, the majority of severe airway diseases are related to type 2 high inflammation. Type 2 cytokines interleukins (IL) 4, 5, and 13, are orchestrated by innate lymphoid cell (ILC) and Th subsets leading to eosinophilia, immunoglobulin E (IgE) responses, and permanently impaired airway damage. Monoclonal antibodies can bind or block key parts of these inflammatory pathways, resulting in less inflammation and improved disease control.

A multicenter survey on the effectiveness of nasal irrigation devices in rhinosinusitis patients

BACKGROUND

Nasal irrigation is widely used as an adjunctive treatment for rhinosinusitis. However, there is little information available regarding the efficacy of the devices used in this procedure. The objective of this study was thus to evaluate the effectiveness of nasal irrigation devices based on the experiences of patients with rhinosinusitis.

METHODS

We conducted a multicenter survey study between November 2017 and December 2019. The questionnaire was developed based on the available literature and expert opinion and submitted to the otolaryngology residents and staff of each center as well as those in their networks.

RESULTS

Four hundred eighteen patients were enrolled in this study: 76 with acute viral rhinosinusitis (18%), 53 with acute bacterial rhinosinusitis (13%), 156 with chronic rhinosinusitis without nasal polyps (37%), and 133 with chronic rhinosinusitis with nasal polyps (32%). We found that high-volume devices were most effective in helping to clear secretion in patients with acute viral rhinosinusitis, chronic rhinosinusitis without nasal polyps, and acute bacterial rhinosinusitis (P = .017, .009, .002, respectively) and in reducing post-nasal drip in those with acute bacterial rhinosinusitis (P = .040). There were no statistically significant differences among devices in patients with chronic rhinosinusitis with nasal polyps.

CONCLUSIONS

Nasal irrigation with high-volume devices was an effective treatment for rhinosinusitis and was more effective at clearing nasal secretion and reducing post-nasal drip than that with other types of devices.

LEVEL OF EVIDENCE

2C.

Low-dose macrolides for treating pediatric rhinosinusitis: A retrospective study and literature review

The effects of low-dose macrolide (LDM) therapy on pediatric chronic rhinosinusitis (CRS) patients are unknown. This study aimed to assess the effectiveness of LDM for treating pediatric refractory CRS. A retrospective study was conducted by a medical chart review. Pediatric CRS patients (age <15 years) who received LDM after standard medical treatments failure between 2013 and 2019 were identified. The LDM treatments with any macrolide agents, doses, and regimens were included. Any co-interventions were allowed. Duration of the LDM therapy was ≥6 weeks. Outcomes were the total nasal symptoms by the visual analogue scale (TNS), presence of individual symptoms, physician-assessment nasal discharge and adverse events. Six patients (67% male, mean age 7±3.4 years) were assessed. All patients had failed to intranasal steroids and nasal saline irrigation but continued. The addition of LDM significantly improved TNS (mean difference ± standard deviation 5.83 ± 1.33; 95% confidence interval 4.44-7.23, p< 0.001). At the end of treatment, the numbers of patients with individual symptoms were decreased: nasal obstruction (100%-67%), rhinorrhea (83%-50%), hyposmia (50%-0%), cough (100%-33%), and physician-assessment thick mucoid discharge (33%-0%). No patients had facial pain. One patient reported mild tolerable nausea. Preliminary findings of this study showed some beneficial effects of LDM added to intranasal steroids and nasal saline irrigation in pediatric CRS after standard treatments failure. The beneficial effects included the improvements of the TNS and individual nasal symptoms and decrease in thick mucoid discharge.

Modern approaches to the treatment of chronic polypous rhinosinusitis

Introduction: Today, chronic polypous rhinosinusitis (CPR) occupies a special place among otolaryngological diseases, the incidence rate of which increases every year. To date, the main causes of chronic polypous rhinosinusitis are Staphylococcus aureus and anatomical abnormalities.

Diagnostics: Knowledge of a universal algorithm for the diagnosis of this disease, consisting of the collection of anamnesis, endoscopic examination of the nasal cavity, computed tomography of the paranasal sinuses, anterior active rhinomanometry and bacteriological determination of the microbial spectrum, allows diagnosing chronic polyposis rhinosinusitis in time, and, as a consequence, to prescribe a treatment.

Treatment: This review describes conservative therapies, including antibiotics and glucocorticosteroids. Today, the main task of doctors is to find the most effective method of administration of glucocorticosteroids to achieve the maximum effect. One of these methods is the introduction of the drug with the help of nebulizer, as in this case, the drug will remain in the perirhinal cavity for a long time and have the maximum effect due to the directed action only in the area of the pathological process.

Features of chronic polypous rhinosinusitis in childhood: It should be noted that children under 12 years of age due to the formation of the paranasal sinuses at different stages of ontogenesis will be characterized by different forms of chronic polyposis rhinosinusitis. That is why they should be known and taken into account when making a diagnosis and prescribing a treatment.

Conclusion: Today, the frequency of chronic rhinosinusitis increases exponentially, which makes the question of the modern approach to its treatment the most relevant. It is possible that additional research in this area will solve the issue of searching for both the optimal path of therapy and treatment of CPR in children.

Biologics for chronic rhinosinusitis

BACKGROUND

This living systematic review is one of several Cochrane Reviews evaluating the medical management of patients with chronic rhinosinusitis. Chronic rhinosinusitis is common. It is characterised by inflammation of the nasal and sinus linings, nasal blockage, rhinorrhoea, facial pressure/pain and loss of sense of smell. It occurs with or without nasal polyps.   'Biologics' are medicinal products produced by a biological process. Monoclonal antibodies are one type, already evaluated in related inflammatory conditions (e.g. asthma and atopic dermatitis).

OBJECTIVES

To assess the effects of biologics for the treatment of chronic rhinosinusitis.

SEARCH METHODS

The Cochrane ENT Information Specialist searched the Cochrane ENT Register; CENTRAL (2019, Issue 9); Ovid MEDLINE; Ovid Embase; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 16 September 2019.

SELECTION CRITERIA

Randomised controlled trials (RCTs) with at least three months follow-up comparing biologics (currently, monoclonal antibodies) against placebo/no treatment in patients with chronic rhinosinusitis.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures. Our primary outcomes were disease-specific health-related quality of life (HRQL), disease severity and serious adverse events (SAEs). The secondary outcomes were avoidance of surgery, extent of disease (measured by endoscopic or computerised tomography (CT) score), generic HRQL and adverse events (nasopharyngitis, including sore throat). We used GRADE to assess the certainty of the evidence for each outcome.

MAIN RESULTS

We included eight RCTs. Of 986 adult participants, 984 had severe chronic rhinosinusitis with nasal polyps; 43% to 100% of participants also had asthma. Three biologics, with different targets, were evaluated: dupilumab, mepolizumab and omalizumab. All the studies were sponsored or supported by industry. Anti-IL-4Rα mAb (dupilumab) versusplacebo/no treatment (all receiving intranasal steroids) Three studies (784 participants) evaluated dupilumab. Disease-specific HRQL was measured with the SNOT-22 (score 0 to 110; minimal clinically important difference (MCID) 8.9 points). At 24 weeks, the SNOT-22 score was 19.61 points lower (better) in participants receiving dupilumab (mean difference (MD) -19.61, 95% confidence interval (CI) -22.54 to -16.69; 3 studies; 784 participants; high certainty). Symptom severity measured on a 0- to 10-point visual analogue scale (VAS) was 3.00 lower in those receiving dupilumab (95% CI -3.47 to -2.53; 3 studies; 784 participants; moderate certainty). The risk of serious adverse events may be lower in the dupilumab group (risk ratio (RR) 0.45, 95% CI 0.28 to 0.75; 3 studies; 782 participants; low certainty).  The number of participants requiring nasal polyp surgery (actual or planned) during the treatment period is probably lower in those receiving dupilumab (RR 0.17, 95% CI 0.05 to 0.52; 2 studies; 725 participants; moderate certainty). Change in the extent of disease using the Lund Mackay computerised tomography (CT) score (0 to 24, higher = worse) was -7.00 (95% CI -9.61 to -4.39; 3 studies; 784 participants; high certainty), a large effect favouring the dupilumab group.  The EQ-5D visual analogue scale (0 to 100, higher = better; MCID 8 points) was used to measure change in generic quality of life. The mean difference favouring dupilumab was 8.59 (95% CI 5.31 to 11.86; 2 studies; 706 participants; moderate certainty). There may be little or no difference in the risk of nasopharyngitis (RR 0.95, 95% CI 0.72 to 1.25; 3 studies; 783 participants; low certainty). Anti-IL-5 mAb (mepolizumab) versusplacebo/no treatment (all receiving intranasal steroids) Two studies (137 participants) evaluated mepolizumab. Disease-specific HRQL measured with the SNOT-22 at 25 weeks was 13.26 points lower (better) in participants receiving mepolizumab (95% CI -22.08 to -4.44; 1 study; 105 participants; low certainty; MCID 8.9).  It is very uncertain whether there is a difference in s ymptom severity: on a 0- to 10-point VAS symptom severity was -2.03 lower in those receiving mepolizumab (95% CI -3.65 to -0.41; 1 study; 72 participants; very low certainty). It is very uncertain if there is difference in the risk of serious adverse events (RR 1.57, 95% CI 0.07 to 35.46; 2 studies; 135 participants, very low certainty). It is very uncertain whether or not the overall risk that patients still need surgery at trial end is lower in the mepolizumab group (RR 0.78, 95% CI 0.64 to 0.94; 2 studies; 135 participants; very low certainty). It is very uncertain whether mepolizumab reduces the extent of disease as measured by endoscopic nasal polyps score (scale range 0 to 8). The mean difference was 1.23 points lower in the mepolizumab group (MD -1.23, 95% -1.79 to -0.68; 2 studies; 137 participants; very low certainty). The difference in generic quality of life (EQ-5D) was 5.68 (95% CI -1.18 to 12.54; 1 study; 105 participants; low certainty), favouring the mepolizumab group. This difference is smaller than the MCID of 8 points. There may be little or no difference in the risk of nasopharyngitis (RR 0.73, 95% 0.36 to 1.47; 2 studies; 135 participants; low certainty). Anti-IgE mAb (omalizumab) versus placebo/no treatment (all receiving intranasal steroids) Three very small studies (65 participants) evaluated omalizumab. We are very uncertain about the effect of omalizumab on disease-specific HRQL, severe adverse events, extent of disease (CT scan scores), generic HRQL and adverse effects.

AUTHORS' CONCLUSIONS

In adults with severe chronic rhinosinusitis and nasal polyps, using regular topical nasal steroids, dupilumab improves disease-specific HRQL compared to placebo, and reduces the extent of the disease as measured on a CT scan. It probably also improves symptoms and generic HRQL and there is no evidence of an increased risk of serious adverse events. It may reduce the need for further surgery. There may be little or no difference in the risk of nasopharyngitis. In similar patients, mepolizumab may improve both disease-specific and generic HRQL. It is uncertain whether it reduces the need for surgery or improves nasal polyp scores. There may be little or no difference in the risk of nasopharyngitis. It is uncertain if there is a difference in symptom severity and the risk of serious adverse events. We are uncertain about the effects of omalizumab.