Clinical predictors of neo-osteogenesis in patients with chronic rhinosinusitis

Correlation of Eosinophils and Type 2 Inflammatory Mediators with Osteitis in Chronic Rhinosinusitis with Nasal Polyps

Objective

Osteitis is more prevalent in patients with chronic rhinosinusitis with nasal polyps (CRSwNP), making the disease refractory and prone to recurrence. However, the pathophysiologic mechanism of osteitis formation in CRS has not been fully elucidated, and this study aimed to further elucidate the association of eosinophils and type 2 inflammatory mediators with osteitis in patients with CRSwNP.

Methods

This retrospective study collected clinical data on 125 cases of CRSwNP. The participants were categorized into two groups based on the presence or absence of osteitis in their sinus CT scan. The groups were classified as the osteitis group and the non-osteitis group. The clinical baseline data, type 2 inflammatory mediators, and eosinophils were compared between the two groups. The correlation between these factors and the Global Osteitis score scale (GOSS) was also evaluated.

Results

There were 69 cases in the osteitis group and 56 cases in the non-osteitis group of CRSwNP patients. The prevalence of concomitant asthma (P=0.009), SNOT-22 score, LUND-MAKAY score, and LUND-KEDENY score were significantly higher in the osteitis group than in the non-osteitis group (All P values were < 0.001); the absolute values of IL-13 (P<0.001), periosteal proteins (P<0.001), and tissue eosinophils (P < 0.05) were significantly higher in the osteitis group as compared with the non-osteitis group. Logistic regression analysis showed that IL-13 and periosteal proteins were risk factors for CRSwNP osteitis (P<0.001). ROC curve analysis revealed that IL-13 had the highest predictive value (AUC=0.786) with a cut-off value of 5.8059 pg/mL, the sensitivity of 58.0%, and a specificity of 89.3% respectively.

Conclusion

Osteitis could indicate the more severe symptoms of chronic rhinosinusitis with nasal polyps (CRSwNP), and elevated IL-13, periosteal proteins, and tissue eosinophils are risk factors for osteitis formation in patients with CRSwNP.

Preliminary study on AI-assisted diagnosis of bone remodeling in chronic maxillary sinusitis

OBJECTIVE

To construct the deep learning convolution neural network (CNN) model and machine learning support vector machine (SVM) model of bone remodeling of chronic maxillary sinusitis (CMS) based on CT image data to improve the accuracy of image diagnosis.

METHODS

Maxillary sinus CT data of 1000 samples in 500 patients from January 2018 to December 2021 in our hospital was collected. The first part is the establishment and testing of chronic maxillary sinusitis detection model by 461 images. The second part is the establishment and testing of the detection model of chronic maxillary sinusitis with bone remodeling by 802 images. The sensitivity, specificity and accuracy and area under the curve (AUC) value of the test set were recorded, respectively.

RESULTS

Preliminary application results of CT based AI in the diagnosis of chronic maxillary sinusitis and bone remodeling. The sensitivity, specificity and accuracy of the test set of 93 samples of CMS, were 0.9796, 0.8636 and 0.9247, respectively. Simultaneously, the value of AUC was 0.94. And the sensitivity, specificity and accuracy of the test set of 161 samples of CMS with bone remodeling were 0.7353, 0.9685 and 0.9193, respectively. Simultaneously, the value of AUC was 0.89.

CONCLUSION

It is feasible to use artificial intelligence research methods such as deep learning and machine learning to automatically identify CMS and bone remodeling in MSCT images of paranasal sinuses, which is helpful to standardize imaging diagnosis and meet the needs of clinical application.

Correlation of Kennedy Osteitis Score with the Tissue and Peripheral Eosinophil Counts in Patients of Eosinophilic Chronic Rhinosinusitis

Background

The presence of osteoid bone in chronic rhinosinusitis especially the eosinophilic subtype is commonly associated with recalcitrant illness. In practice, the radiological features of osteitis sinus alterations are frequently described, but the clinical and histopathologic implications are not well understood.

Objective

This study was done to correlate the radiological and the clinico-histopathological aspects in patients of eosinophilic chronic rhinosinusitis.

Methods

A cross-sectional study was done on sixty patients of chronic rhinosinusitis with nasal polyposis (CRSwNP) patients especially the eosinophilic subtype undergoing sinus surgery. Radiologically, osteitis was graded using standards that had already been published in the literature. Analysis was done on the relationships between CT documented osteitis, histopathological, and peripheral eosinophilic counts in patients of eosinophilic chronic rhinosinusitis.

Results

The patients with higher tissue eosinophilia and higher peripheral eosinophils had higher osteitis score. Pearson's correlation coefficient between Tissue Eosinophils and KOS was highly significant with p-value <0.001 (0.891). R2 value for KOS versus Tissue Eosinophils was 79.44%,implying that 79.44% variations were explained by Tissue Eosinophils in KOS. And R2 value for KOS versus Peripheral Eosinophils was 74.26%, implying that 74.26% variations were explained by Peripheral Eosinophils in KOS. Thereby, showing a positive relationship between the variables that were studied.

Conclusion

Kennedy Osteitis Score, histopathological and peripheral eosinophilia can be used as a marker to predict the disease severity in eosinophilic chronic rhinosinusitis.

Comparison of Fungal and Non-Fungal Rhinosinusitis by Culture-Based Analysis

BACKGROUND

Incidence of fungal rhinosinusitis has increased in recent few years. We investigated the differences in microbiological findings between patients with fungal and non-fungal rhinosinusitis by growing microbiological cultures from samples obtained from sinus surgery.

METHODS

Using the Chang Gung Research Database, we enrolled all chronic rhinosinusitis (CRS) patients who had ever undergone sinus surgery from 2001 to 2019 and had microbiological culture during sinus surgery. Enrolled patients were divided into fungal and non-fungal groups, based on fungal culture and surgical pathology.

RESULTS

A total of 898 patients were diagnosed with fungal rhinosinusitis and 2884 with non-fungal rhinosinusitis. The fungal group had a higher age distribution (56.9 ± 13.1 vs. 47.0 ± 14.9), a larger proportion of females (62.4% vs. 37.0%), more unilateral lesions (80.4% vs. 41.6%), a lower incidence of the need for revision surgery (3.6% vs. 6.0%, p = 0.004), and a higher proportion of Pseudomonas aeruginosa in the culture (14.3% vs. 4.6%, p < 0.001).

CONCLUSIONS

This large-scale study showed that Pseudomonas aeruginosa are more commonly found in patients with fungal rhinosinusitis and in patients who needed revision surgery, suggesting that efforts aimed at eliminating Pseudomonas are needed in order to improve the disease outcomes of patients with fungal rhinosinusitis.

Mucosal flaps prevent neo-osteogenesis after frontal drill-out procedures: A computer-assisted study

Objective

Although several mucosal flap techniques have been reported to improve the outcomes in Draf IIb and Draf III procedures, there is scant knowledge on frontal ostium neo-osteogenesis after reconstruction with mucosa flap. This study evaluates the potential benefits of mucosa flaps on frontal ostium neo-osteogenesis after frontal sinus drill-out procedures.

Methods

Forty-three patients who underwent extended Draf IIb and Draf III were enrolled. Among them, 20 patients had frontal neo-ostium (FNO) reconstructed by mucosal flap (group A), and 23 patients did not have neo-ostium reconstruction (group B). The cross-sectional area of FNO, frontonasal bone, and the amount of frontal neo-osteogenesis (FNOG) were measured with OsiriX®. In addition, the Global Osteitis Scoring Scale (GOSS), Lund-Mackay score (LMS), and Lund-Kennedy score (LKS) were also evaluated.

Results

At one year postoperatively, the remaining neo-ostium area was significantly larger in group A (p = .001), and group A had significantly less FNOG (p < .05). The month 12 postoperative GOSS score was significantly decreased in group A. In contrast, it slightly increased in group B. Both the average LKS and LMS were significantly reduced in groups A and B at month 12 postoperatively. Still, the average LKS of group A significantly decreased than that of group B at month 12 postoperatively.

Conclusion

Coverage of the bare frontal bone with the mucosal flap could prevent excessive neo-osteogenesis and keep the neo-ostium open widely.

Level of Evidence

2b.

Clinical and immunologic implication of neo-osteogenesis in chronic rhinosinusitis

INTRODUCTION

Chronic rhinosinusitis (CRS) is a multifactorial disease characterized by long-term inflammation of the nasal and sinus passages. Neo-osteogenesis which is a major finding of recalcitrant CRS is clinically related to the disease severity and surgical outcomes of CRS.

AREAS COVERED

The immunological and molecular mechanisms underlying neo-osteogenesis of CRS remain unclear, and many recent studies have suggested the importance of inflammatory mediators secreted by immune cells. This paper provides a broader understanding of neo-osteogenesis in CRS by reviewing recent updates and evidence of the association between CRS pathophysiology and neo-osteogenesis.

EXPERT OPINION

Crosstalk between the bone and mucosa eventually results in refractory CRS. In addition, both eosinophilic and non-eosinophilic CRS cytokines can play a role in neo-osteogenesis and trigger an enhanced CRS-associated immune response. The significance of predicting neo-osteogenesis in advance or during postoperative care could be essential for effectively managing refractory CRS and enhancing the prognosis of CRS patients.

Minimal Radiographic Mucosal Thickness or Opacification Criterion for Sinus-Specific Endoscopic Sinus Surgery for Chronic Rhinosinusitis

OBJECTIVE

Primary chronic rhinosinusitis (CRS) is typically a diffuse process and the extent of endoscopic sinus surgery (ESS) performed for medically recalcitrant CRS is impacted by many factors. However, some third-party payors have implemented policies to authorize coverage for ESS in a sinus-by-sinus manner based on a minimal measurement of millimeters of mucosal thickening or sinus opacification in the corresponding sinus that is being surgically addressed. Our objective was to determine whether such policies are based on scientific evidence that in patients with medically recalcitrant CRS, a minimum measurement of mucosal thickening or sinus opacification is a predictor of CRS in that sinus or improved outcomes after ESS on a sinus-by-sinus basis.

DATA SOURCES

Medline, Embase, Scopus, and Web of Science databases, from inception through May 2022.

REVIEW METHODS

A systematic review was performed. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were followed.

RESULTS

We identified 6070 abstracts which were screened and from which 112 studies ultimately underwent a full-text review. From these studies, we found that none investigated (or provided evidence of) whether any minimal degree of radiographic mucosal thickening or sinus opacification predicted CRS or better outcomes after ESS in a sinus-specific manner.

CONCLUSION

We were unable to find evidence supporting a minimum millimeter measurement of mucosal thickening or sinus opacification as predictors of CRS or better post-ESS outcomes in a sinus-specific manner in patients with medically recalcitrant CRS. The extent of ESS for CRS should be determined through personalized medical decision-making that considers all patient-specific factors.

Osteitis in Eosinophilic Chronic Rhinosinusitis

OBJECTIVES

Eosinophilic chronic rhinosinusitis (ECRS) is an allergic inflammatory disease characterized by chronic inflammation of the sinus mucosa, and sometimes, osteitis. This study aimed to investigate the pattern of osteitis in ECRS and the relationship between bony thickening of the middle turbinate and recurrence of ECRS.

METHODS

A total of 246 patients with paranasal diseases were included in the study. The patients' data on bone thickening level, mucosal thickening, polyp score, clinical severity, and laboratory data were retrospectively evaluated.

RESULTS

In total, 38, 186, and 22 patients had ECRS, non-ECRS (NECRS), and odontogenic sinusitis, respectively. The Lund-Mackey (LM) score and Global Osteitis Scoring Scale (GOSS) scores in patients with ECRS were higher than those in patients with other paranasal diseases. There was a significant positive correlation between the GOSS score and ECRS clinical disease severity. Postoperative recurrence was significantly increased in patients with ECRS associated with bony thickening of the middle turbinate.

CONCLUSION

Both mucosal inflammation and osteitis were more severe in patients with ECRS than in patients with other diseases, and clinical disease severity was correlated with osteitis. Furthermore, the postoperative recurrence rate tended to increase in patients with ECRS who had bony thickening of the middle turbinate.

Osteitis in Diseases With Unilateral Opacification of Paranasal Sinuses

OBJECTIVES

Chronic rhinosinusitis (CRS) is a common disease with mucosal inflammation, and may sometimes be accompanied by bone thickening. The disease is usually bilateral; when it is unilateral, there may be a specific disease. This study aimed to investigate the association between unilateral sinus opacification and osteitis.

METHODS

In total, 104 patients with computed tomography revealing unilateral sinus opacification were included in this study. Patients were retrospectively evaluated using the Global Osteitis Scoring Scale (GOSS) score, Lund-Mackey (LM) score, polyp score, and blood tests.

RESULTS

In total, 47, 11, 9, 17, and 20 patients had CRS, paranasal sinus cyst, inverted papilloma, mycetoma, and odontogenic sinusitis, respectively. The GOSS score in patients with mycetoma was higher than that in patients with CRS. However, no significant differences in the GOSS scores between patients with mycetoma, inverted papilloma, and odontogenic sinusitis existed. 10 of the 104 patients had osteitis with extensive bone thickening and a GOSS score of 4 or higher. Patients with CRS and mycetoma tended to have a higher GOSS score for the maxillary sinus than for the other sinuses. There was a significant positive correlation between the GOSS score and LM score in patients with diseases other than paranasal sinus cyst.

CONCLUSIONS

Mycetoma is more likely to cause osteitis than CRS, and a unique mechanism of osteitis exacerbation is predicted. As there is a positive correlation between bone thickening and sinus inflammation, a close association between osteitis and mucosal inflammation is inferred in diseases involving unilateral sinus opacification.

Chronic Rhinosinusitis Disease Disparity in the South Florida Hispanic Population

OBJECTIVES/HYPOTHESIS

The role of social determinants of health in chronic rhinosinusitis (CRS) is poorly characterized. Limited research examining CRS health disparities indicates that minority status is associated with worse CRS. However, many of these studies are retrospective or performed in populations without substantial ethnic minorities. Rhinologists need to characterize existing CRS disease disparities to develop targeted strategies for improving care in these populations. This prospective study assesses preoperative CRS disease burden in South Florida (SFL) Hispanic and non-Hispanic patients and examines potential factors contributing CRS disease disparities.

STUDY DESIGN

Prospective cohort study.

METHODS

The prospective cohort study included consecutive patients having primary endoscopic sinus surgery (ESS) for CRS between September 2019 and February 2020 with complete preoperative data. Data were collected in clinic and surgery. Descriptive statistics compare Hispanic and non-Hispanic cohorts. Linear regression adjusts for confounders. Relative risk (RR) compared CRS severity markers.

RESULTS

Thirty-eight Hispanic and 56 non-Hispanic patients met inclusion criteria. Age, sex, CT scores, insurance payer, and comorbidities were similar between cohorts. Hispanics presented with worse 22-item Sinonasal Outcome Test (SNOT-22) (55; SD = 18) compared to non-Hispanics (37; SD = 22) (P < .001). Hispanics tended to have a higher risk of severe CRS markers, including nasal polyps RR = 2.5 (95% CI: 1.0-5.9), neo-osteogenesis RR = 1.6 (95% CI: 0.5-4.7), extended procedures (i.e., draft III) RR = 2.97 (95% CI: 1.0-9.1), and tissue eosinophilia RR = 1.46 (95% CI: 0.6-3.5). Hispanics reported longer sinonasal symptom duration.

CONCLUSIONS

SFL hispanic patients presenting for primary ESS have worse sinonasal disease burden. SFL Hispanics have markers of greater CRS severity and report longer delays before receiving CRS care. These factors may contribute to increased sinonasal disease burden in Hispanic patients.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:2659-2665, 2021.

Obliterative sinusitis: An underreported clinical entity

Obliterative paranasal sinusitis is a rare sequela and end stage of chronic rhinosinusitis, which is often overlooked on imaging. It is an exuberant form of neo-osteogenesis characterized by complete or partial obliteration of the sinus cavity by new bone formation. This article presents a series of cases of obliterative sinusitis involving the sphenoid and maxillary sinuses. It is important to comment on the presence of obliterative sinusitis in the radiology report and not confuse it for native bone, fibro-osseous lesion, or arrested pneumatization, as this may have clinical implications for patients being considered for surgery. Given its potential implications for severity of sinusitis as well as prognostic significance for outcomes following endoscopic sinus surgery, awareness and timely identification of this entity is important to guide referring clinicians.

Computed Tomography Evaluation of Unilateral Chronic Maxillary Sinusitis With Osteitis

BACKGROUND

Computed tomography (CT) is the preferred noninvasive method for the evaluation of osteitis in chronic sinusitis. Some scholars believe that the bone changes associated with chronic sinusitis always show high attenuation (high density) and are positively correlated with the severity of the disease. However, sinus bone remodeling is a complex process that may cause high or low attenuation. There have been few reports on the spread of osteitis. Therefore, additional research on sinus CT is necessary.

OBJECTIVE

To observe bony changes in chronic maxillary sinusitis (CMS) by CT and reveal the mechanism.

METHODS

A retrospective study was conducted in 45 patients with unilateral CMS with bony changes in the sinus walls. The patients' clinical data and CT results were analyzed and compared between the affected and normal sides. We propose the location, involvement, attenuation, and thickness method to evaluate CMS with osteitis.

RESULTS

Of the 45 patients, 40 (88.9%), 2, 12, and 7 had posterior external, medial, anterior, and superior lesions, respectively. The nasal region, sphenoid bone, palatine bone, and zygomatic arch were involved in 3, 12, 8, and 18 (40%) patients, respectively. Computed tomography indicated high attenuation in 30 (75.0%) and low attenuation in 10 (25.0%) patients; 6 (15.0%) showed new bone marrow cavities. The bone thickness was significantly different between the affected and normal sides in 40 patients (P < .001), including members of both the high- and low-attenuation groups (high-attenuation group: P < .001; low-attenuation group: P < .01). However, there was no significant difference in the thickness of the affected side between the high- and low-attenuation groups (P > .05).

CONCLUSIONS

Chronic rhinosinusitis with bony changes may occur in the maxillary sinus walls and spread to adjacent bones. Both increased and decreased attenuation may occur in these circumstances. Analyzing the CT features of bone changes in unilateral CMS can improve the accuracy of disease diagnosis.

International consensus statement on allergy and rhinology: rhinosinusitis 2021

I.

EXECUTIVE SUMMARY

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

METHODS

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

RESULTS

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

CONCLUSION

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

Advances in the Knowledge of the Underlying Airway Remodeling Mechanisms in Chronic Rhinosinusitis Based on the Endotypes: A Review

Chronic rhinosinusitis (CRS) is a chronic inflammatory condition of the nasal and paranasal sinus mucosa that affects up to 10% of the population worldwide. CRS is the most representative disease of the upper respiratory tract where airway remodeling occurs, including epithelial damage, thickening of the basement membrane, fibrosis, goblet cell hyperplasia, subepithelial edema, and osteitis. CRS is divided into two phenotypes according to the presence or absence of nasal polyps: CRS with nasal polyp (CRSwNP) and CRS without nasal polyps (CRSsNP). Based on the underlying pathophysiologic mechanism, CRS is also classified as eosinophilic CRS and non-eosinophilic CRS, owing to Type 2 T helper (Th2)-based inflammation and Type 1 T helper (Th1)/Type 17 T helper (Th17) skewed immune response, respectively. Differences in tissue remodeling in CRS are suggested to be based on the clinical phenotype and endotypes; this is because fibrosis is prominent in CRSsNP, whereas edematous changes occur in CRSwNP, especially in the eosinophilic type. This review aims to summarize the latest information on the different mechanisms of airway remodeling in CRS according to distinct endotypes.

Crosstalk Between Mucosal Inflammation and Bone Metabolism in Chronic Rhinosinusitis

Chronic rhinosinusitis (CRS) is a multifactorial and highly heterogeneous upper airway disease that affects approximately 12% of the general population. There is increasing evidence supporting the impact of osteitis on the pathophysiology of CRS. Osteitis is frequently observed in patients with CRS, and is associated with severe sinonasal inflammation and recalcitrant cases. The overlying inflammatory sinonasal mucosa plays a critical role in the initiation of osteitis; however, the underlying molecular mechanisms and functional significance remain unclear. Increasingly many studies have suggested that immune cells play a crucial role in the bone remodeling process in CRS. The purpose of this review is to summarize the current state of knowledge regarding the specific role of sinonasal inflammation in bone remodeling in CRS patients.

Impact of Paranasal Sinus Surgery in Granulomatosis With Polyangiitis: A Longitudinal Computed Tomography Study

OBJECTIVES/HYPOTHESIS

Severe chronic rhinosinusitis (CRS) in patients with granulomatosis with polyangiitis (GPA) failing medical therapies can be treated with paranasal sinus surgery. Whether this surgery protects from progressive sinonasal damage remains unknown. Here, we aimed to analyze time-dependent relations between sinus surgeries and computed tomography (CT) imaging features in the CRS of GPA.

STUDY DESIGN

Longitudinal observational study.

METHODS

We assessed CRS features including bone thickening by global osteitis scoring scale, bone erosions, and mucosal thickening by Lund-Mackay scores in serial paranasal sinus CT scans (742 CT scans in total) from a cohort of 127 well-characterized GPA patients. Data on sinonasal surgical procedures were from a mandatory national registry and from chart review. We defined the time from baseline CT to last CT as the study observation period in each patient. Datasets were analyzed by linear mixed models.

RESULTS

We found that 23/127 cohort patients had one or more paranasal sinus surgical procedures, and 96% of these (22/23) had osteitis by CT after surgery. In patients with nasal surgery alone or no surgery, we identified osteitis in 7/11 (64%) and 45/93 (48%), respectively. During the observation period of a median of 5 years, 38 patients had progression of their sinus osteitis, with the highest annual osteitis progression rates observed around the time of surgery.

CONCLUSIONS

In this cohort, paranasal sinus surgery was associated with prevalence, severity, and progression rate of sinus osteitis, indicating that sinus surgery does not reduce the bone damage development in the CRS of GPA.

LEVEL OF EVIDENCE

4 Laryngoscope, 130: E460-E468, 2020.

Risk factors for neo-osteogenesis in cystic fibrosis and non-cystic fibrosis chronic rhinosinusitis

BACKGROUND

The purpose of this retrospective review was to determine how patient-related factors and culture data affect neo-osteogenesis in patients with chronic rhinosinusitis (CRS) and patients with cystic fibrosis (CF) with CRS.

METHODS

Information from a database associated with a large tertiary medical center was used to assess adult patients with CF CRS and non-CF CRS (total, n = 102; CF CRS, n = 31; non-CF CRS, n = 71). Radiologic evidence of neo-osteogenesis was measured using the Global Osteitis Scoring Scale (GOSS), and mucosal disease was assessed using the Lund-Mackay score (LMS) by 2 independent reviewers who were blinded to the patient's disease state. Bacterial cultures were obtained endoscopically. Multiple logistic regression models were used to evaluate the effect of age, sex, number of previous surgeries, CF, and culture species on the odds of neo-osteogenesis.

RESULTS

Fifty-one of the 102 patients (50%) met radiologic criteria for neo-osteogenesis. Sixty-nine patients (67.6%) with CF CRS and non-CF CRS had culture data. In the multiple logistic regression model, male gender was significantly associated with neo-osteogenesis (odds ratio [OR], 5.2; 95% confidence interval [CI], 1.68-17.86; p = 0.006). Pseudomonas aeruginosa was not associated with neo-osteogenesis (OR, 3.12; 95% CI, 0.84-12.80; p = 0.097). Age, number of surgeries, CF, Staphylococcus aureus, and coagulase-negative Staphylococcus were not statistically significant.

CONCLUSION

To our knowledge, this is the first study to assess risk factors associated with neo-osteogenesis and patients with CF CRS. Interestingly, male gender was the only significant predictor of neo-osteogenesis.

Interleukin (IL)-13 and IL-17A contribute to neo-osteogenesis in chronic rhinosinusitis by inducing RUNX2

Background

There is increasing evidence supporting the impact of neoosteogenesis in the pathophysiology of chronic rhinosinusitis (CRS), especially in the recalcitrant group of patients. Runt-related transcription factor 2 (RUNX2), a member of the RUNX family, controls osteoblast differentiation and bone formation. However, the role and regulation of RUNX2 in CRS patients with neoosteogenesis remain unclear. The aim of the study is to determine the role of RUNX2 in neoosteogenesis of CRS patients.

Methods

Sinonasal bone and overlying mucosa samples were obtained from CRS patients with or without neoosteogenesis (n = 67) and healthy controls (n = 11). Double immunofluorescence, immunohistochemistry, and immunoblotting were used to evaluate RUNX2 expression in CRS patients with and without neoosteogenesis. In addition, the osteogenic activity of pro-inflammatory cytokines was examined by measuring alkaline phosphatase (ALP) activity and bone mineralisation in vitro.

Findings

RUNX2 was highly expressed in osteoblasts of CRS patients with neoosteogenesis compared with tissues from control subjects and those with CRS without neoosteogenesis. Mucosal extracts from CRS patients with neoosteogenesis showed increased RUNX2 expression and ALP activity in C2C12 cells, whereas those from patients without neoosteogenesis did not. Expression of interleukin (IL)-13 and IL-17A was upregulated in CRS patients with neoosteogenesis. ALP activity and Alizarin Red staining showed IL-13 and IL-17A dose-dependent osteoblast differentiation and mineralisation in vitro.

Interpretation

These findings suggested that IL-13- or IL-17A-induced RUNX2 contributed to new bone formation in CRS patients through its effect on the activity of osteoblasts. RUNX2 may be a novel target for preventing neoosteogenesis in CRS patients.

Osteitis in Chronic Rhinosinusitis

PURPOSE OF REVIEW

Osteitis is recognized as a common factor in recalcitrant chronic rhinosinusitis (CRS). There is evidence for the association of osteitis with revision surgeries and CRS severity, in terms of higher Lund-Mackay scores. This is a narrative review on the osteitis in CRS patients.

RECENT FINDINGS

Evidence to date is inconclusive with regard to the etiology and pathogenesis of this bony thickening. Histopathology of osteitis in primary CRS is likely a process of neo-osteogenesis and bone remodeling. For better understanding, various associating factors have been studied including an inflammatory pattern of rhinosinusitis. Recent studies have associated osteitis with nasal polyps and tissue eosinophilia with the increase in periostin expression and P-glycoprotein mucosal expression. There is no association of osteitis to symptoms or quality of life. Osteitis is an outcome of neo-osteogenesis rather than inflammatory processes in CRS patients without a prior history of surgery. While CT has become a staple in osteitis assessment, the standards for grading osteitic severity remain in an experimental stage. There is no association between the presence or severity of osteitis at the time of surgery and clinical outcomes at 1 year after surgery. This review provides a comprehensive overview of the pathogenesis, epidemiology, and correlation with clinical and biological factors of osteitis in CRS patients.

Clinical Predictors of Frontal Ostium Restenosis After Draf 3 Procedure for Refractory Chronic Rhinosinusitis

Background The Draf 3 procedure has been demonstrated to be effective in the treatment of refractory frontal sinus disease. A variety of clinical factors may contribute to the change of frontal neo-ostium (FNO) area after this procedure. Imaging plays a vital role in the evaluation and follow-up after surgery and provides useful prognostic information. Objectives (1) To investigate the influence of local anatomic factors on FNO after a Draf 3 procedure by radiological measurements on imaging software and (2) to explore other predictive factors of FNO restenosis. Methods Twenty-four patients with chronic rhinosinusitis who underwent a Draf 3 procedure and were followed up for more than 12 months (2012-2014) were enrolled in this study. Data on patient demographics, medical history, and computed tomography scans were collected. Anatomic dimensions were measured with OsiriX® (Pixmeo, Geneva, Switzerland). Stenotic ostium was defined as a loss of more than 50% of the original intraoperative area. Multivariate linear regression was used to assess independent factors linked to frontal neo-osteogenesis 1 year after the surgery. A receiver operating characteristic curve was built for the cutoff value of preoperative dimension to predict restenosis of FNO area. Results A significant association was demonstrated between the minimum anteroposterior diameter (FOAP_MIN) of the frontal ostium preoperatively and FNO area 1 year postoperatively. Multivariate linear regression showed that FOAP_MIN of the frontal ostium preoperatively and the percentage of serum eosinophils (EOSs) correlated with the contour area of the FNO 1 year postoperatively. FOAP_MIN ≤ 3.592 mm yielded a sensitivity of 95% and a specificity of 75% for the diagnosis of FNO restenosis. Conclusions Both FOAP_MIN and EOS are independent predictors of the contour area of the FNO 1 year postoperatively. Patients with a higher risk of developing frontal ostium restenosis can be identified preoperatively by measurements of the frontal sinus anatomic dimensions.

Maxillary sinus volume: new physiopathological data in fungal ball genesis? A retrospective study

OBJECTIVES

The goal of this study was to compare maxillary sinus (MS) volume in patients with, or without, maxillary fungal ball.

DESIGN

Monocentric retrospective study performed on 115 patient CT scans.

SETTINGS

We defined two groups of patients according to the absence (control group) or the presence (fungal ball group) of unilateral fungal ball in the MS. Sinus 3D reconstruction was created from CT scan.

PARTICIPANTS

Control group: 71 patients (36 women - 50.7%); mean age was 51 years. Fungal ball group: 44 patients (29 women - 65.9%); mean age was 54.5 years.

MAIN OUTCOME MEASURE

The univariate association between MS volume and sinus covariates was tested by anova. Multivariate analysis was made including all variables statistically significant in univariate analysis.

RESULTS

In the control group, mean MS volume was 14 766 mm³ . The volumes of the two MSs were not statistically different in the control group (P = 0.145). In the fungal ball group, mean MS volume was 15 982 mm³ . Fungal ball was found in the smallest MS in 41 of 44 cases. Univariate analysis showed a statistical difference between the pathological and the non-pathological MS volumes (P < 10^-4 ). Multivariate analysis confirmed the correlation between MS volume and the presence of a fungal ball (P < 10^-4 ).

CONCLUSIONS

This study suggests that maxillary fungal ball is associated with a smaller size of the affected MS.