Topography of polyp recurrence in eosinophilic chronic rhinosinusitis

Sinonasal Symptom Correlation With the Postoperative Polyp Scale (POPS)

BACKGROUND

Commonly used endoscopic nasal polyp grading scales have been shown to correlate poorly with symptom scores and quality of life metrics. The recently described Postoperative Polyp Scale (POPS) is a grading system that more accurately characterizes polyp recurrence in postoperative sinus cavities by describing incremental recurrence in relation to the surgically opened sinus cavities.

OBJECTIVE

The objective of this study was to determine if the POPS correlated with sinonasal symptoms.

METHODS

CRSwNP patients were prospectively administered SNOT-22 questionnaires and graded according to the POPS starting at their 1-month postoperative appointments. Total POPS scores (sum of each side) and Max POPS score (larger value of left and right) were correlated with SNOT-22 total scores and subdomains using Kendall correlation testing.

RESULTS

A total of 127 patients were enrolled in the study. Both Total POPS or Max POPS were significantly correlated to the SNOT-22 total score (P < .001, P < .001), Rhinologic (P < .001, P < .001), Extra-Nasal Rhinologic (P < .001, P < .001), Ear/Facial (P < .001, P < .001), and Psychologic (P = .028, P = .017) subdomains. Kendall's tau indicated strong correlation (≥0.3) with Rhinologic subdomain, moderate correlation (.21-.29) with Extra-Nasal Rhinologic and Ear/Facial subdomains, and weak correlation (.1-.19) with Psychologic subdomain.

CONCLUSION

Previous endoscopic nasal polyp grading scales poorly correlate with symptoms and patient reported outcome measures. The new POPS moderately correlates with the total SNOT-22 score and strongly correlates with the Rhinologic subdomain, indicating that it may have good potential as a tool to evaluate postoperative CRSwNP patients.

Diagnostic significance of peripheral blood indices for eosinophilic chronic rhinosinusitis in Chinese adults

OBJECTIVE

Eosinophilic chronic rhinosinusitis (eCRS) is a refractory subtype of CRS. This study aimed to compare the differences in clinical features and peripheral blood indices between eCRS and non-eCRS Chinese patients and identify the predictive factors for eCRS.

METHODS

In this study, a total of 1352 patients with CRS were enrolled and divided into eCRS and non-eCRS groups based on the degree of eosinophilic infiltration in histopathology, and their demographic and clinical characteristics, as well as peripheral blood indices, were compared. Logistic regression analysis was used to identify the factors associated with eCRS, and the optimal cut-off values of predictors were determined using subject working curves.

RESULTS

As compared to those in the non-eCRS group patients, the proportion of males, age, proportion of smokers, peripheral blood eosinophil count, and erythrocyte count were significantly higher, while the peripheral blood neutrophil count, platelet count, neutrophil/lymphocyte count ratio (NLR), platelet/lymphocyte count ratio (PLR), and neutrophil × platelet/lymphocyte count ratio (SII index) were significantly lower in the eCRS group patients. Logistic regression analysis showed that age, peripheral blood neutrophil count, eosinophil count, and platelet count were independent predictors of eCRS, and eosinophil count > 2.05 × 108/L could be used as a diagnostic marker for eCRS with a sensitivity and specificity of 87.1% and 78.3%, respectively.

CONCLUSIONS

There were significant differences in the clinical features of eCRS and non-eCRS patients. Peripheral blood eosinophil count could early and more accurately predict eCRS.

Heterogeneity in the definition of chronic rhinosinusitis disease control: a systematic review of the scientific literature

PURPOSE

Disease control is conceptually recognized to be an important outcome measure for chronic rhinosinusitis (CRS). However, inconsistent usage is a significant factor in disadoption of important concepts and it is presently unclear how consistently the construct of CRS 'control' is being defined/applied. The objective of this study was to determine the heterogeneity of CRS disease control definitions in the scientific literature.

METHODS

Systematic review of PubMed and Web of Science databases from inception through December 31, 2022. Included studies used CRS disease control as an explicitly stated outcome measure. The definitions of CRS disease control were collected.

RESULTS

Thirty-one studies were identified with more than half published in 2021 or later. Definitions of CRS control were variable, although 48.4% of studies used the EPOS (2012 or 2020) criteria to define control, 14 other unique definitions of CRS disease control were also implemented. Most studies included the burden CRS symptoms (80.6%), need for antibiotics or systemic corticosteroids (77.4%) or nasal endoscopy findings (61.3%) as criteria in their definitions of CRS disease control. However, the specific combination of these criteria and prior time periods over which they were assessed were highly variable.

CONCLUSION

CRS disease control is not consistently defined in the scientific literature. Although many studies conceptually treated 'control' as the goal of CRS treatment, 15 different criteria were used to define CRS disease control, representing significant heterogeneity. Scientific derivation of criteria and collaborative consensus building are needed for the development of a widely-accepted and -applied definition of CRS disease control.

Postoperative Polyp Scale (POPS): Development of a New Sinonasal Polyp Grading Scale

OBJECTIVE

Commonly used endoscopic grading scales, such as the nasal polyp scale, inadequately describe the degree of polyposis found postoperatively in the paranasal sinus cavities. The purpose of this study was to create a novel grading system that more accurately characterizes polyp recurrence in postoperative sinus cavities, the Postoperative Polyp Scale (POPS).

METHODS

A modified Delphi method was utilized to establish the POPS using consensus opinion among 13 general otolaryngologists, rhinologists, and allergists. Postoperative endoscopy videos from 50 patients with chronic rhinosinusitis with nasal polyps were reviewed by 7 fellowship-trained rhinologists and scored according to the POPS. Videos were rated again 1 month later by the same reviewers, and scores were assessed for test-retest and inter-rater reliability.

RESULTS

Overall inter-rater reliability for the first and second reviews of the 52 videos was Kf = 0.49 (95% CI 0.42-0.57) and Kf = 0.50 (95% CI 0.42-0.57) for the POPS. Intra-rater reliability showed near-perfect test-retest reliability for the POPS with Kf = 0.80 (95% CI 0.76-0.84).

CONCLUSION

The POPS is an easy-to-use, reliable, and novel objective endoscopic grading scale that more accurately describes polyp recurrence in the postoperative state which will be useful in the future for measuring the efficacy of various medical and surgical interventions.

LEVEL OF EVIDENCE

5 Laryngoscope, 133:2885-2890, 2023.

Radiopathologic predictors of 1- and 2-year frontal sinusotomy outcomes in a southeast Asian chronic rhinosinusitis population

BACKGROUND

The frontal sinus and its drainage pathway are difficult spaces to navigate surgically. The complexity of the frontal recess anatomy as well as inflammatory factors may influence outcomes of endoscopic frontal sinusotomy. It is not clear which factors are more important in determining post-operative frontal ostium patency.

OBJECTIVE

The objective is to investigate whether the distribution of fronto-ethmoidal cells, frontal recess dimensions and sinonasal inflammation predict frontal ostium patency at 1- and 2-years after endoscopic frontal sinusotomy.

METHODS

A retrospective review of 94 chronic rhinosinusitis patients (185 sides) who had undergone endoscopic frontal sinusotomies between 2015 and 2019 was conducted. Computed tomography was used to evaluate the type of fronto-ethmoidal cells present and determine the dimensions of the frontal recess. The International Classification of the Radiological Complexity of frontal recess and frontal sinus was used to grade the complexity of frontal recess anatomy. Mucosal inflammation was graded according to a structured histopathology report. Frontal ostium patency at 1- and 2-years post-operatively was recorded.

RESULTS

The frontal ostium patency rates were 80.9% and 73.4% at 1- and 2-years respectively. Eosinophilic predominance (adjusted OR 3.5, 95% CI 1.6-8.0, p = 0.003) and mucosal ulceration on histology (adjusted OR 4.5, 95% CI 1.1-17.9, p = 0.033) predicted ostial stenosis at 1 year. Smoking (adjusted OR 7.6, 95% CI 2.4-24.7, p = 0.001), aspirin exacerbated respiratory disease (AERD) (adjusted OR 7.6, 95% CI 1.9-30.1, p = 0.004) and histological findings of severe inflammation (adjusted OR 8.9, 95% CI 1.9-41.2, p = 0.005) were independent predictors of ostial stenosis at 2 years. Frontal cell patterns, frontal recess dimensions and frontal recess complexity did not predict frontal ostium stenosis at both 1- and 2-years post-operatively.

CONCLUSION

Post-operative control of sinonasal inflammation is important in maintaining frontal ostium patency, regardless of frontal cell patterns or frontal recess dimensions.

Chronic rhinosinusitis disease control: a review of the history and the evidence

INTRODUCTION

Control is an important concept and outcome measure for chronic incurable diseases, defined as the extent to which manifestations of a disease are within acceptable limits. Control reflects a global metric of disease status and serves as the goal of treatment. This review will encompass the history of the disease control concept applied to chronic rhinosinusitis (CRS) and the body of scientific literature that has focused on the definition of CRS disease control.

AREAS COVERED

A review of the scientific literature identified historical studies and guidelines that have developed definitions of CRS disease control, as well as recent studies identifying the most significant determinants of CRS control. A particular focus was made on studies that investigated patients' and physicians' perspectives of CRS control.

EXPERT OPINION

Patients and physicians have well-aligned perspectives about the definition, criteria, and application of CRS disease control, with a specific prioritization of patients' assessments of their own CRS control, as well as the symptoms of nasal obstruction and nasal drainage. The development of future guidelines for assessing CRS control must be based on criteria supported by evidence as essential to the assessment of CRS control but should also be the subject of broad international consensus.

Advances in Sinus Surgery for Nasal Polyps

BACKGROUND

Chronic rhinosinusitis with nasal polyps (CRSwNP) is comprised of a diverse group of endotypes that cause significant morbidity for afflicted patients. While endoscopic sinus surgery helps ameliorate the disease, polyps frequently recur. Newer strategies are intended to provide access for topical steroid irrigations in attempts to improve the disease process and quality of life, and decrease overall recurrence of polyps.

OBJECTIVE

To review the current literature examining the latest surgical approaches for CRSwNP.

METHODS

Review article.

RESULTS

In dealing with the recalcitrant nature of CRSwNP, surgical techniques have simultaneously become more nuanced and aggressive. Bony resection in anatomically unfavorable areas such as the frontal, maxillary, and sphenoid outflow regions, replacing diseased or denuded mucosa with healthy grafts or flaps at the neo-ostia, and introducing drug-eluting biomaterials to newly opened sinus outflow tracts are highlights in the recent advancements in sinus surgery for CRSwNP. The Draf 3 or modified endoscopic Lothrop procedure has become a standard technique and demonstrated to improve quality of life and decrease polyp recurrence. A number of mucosal grafting or mucosal flap techniques have been described that cover exposed bone of the neo-ostium and evidence shows that this improves healing and diameter of the Draf 3. Partial middle turbinectomy, while controversial, appears to help decrease polyp recurrence in long-term follow-up studies. Modified endoscopic medial maxillectomy improves access to the maxillary sinus mucosa, facilitates debridement and, particularly, in the cystic fibrosis nasal polyp patient, improves overall management of the disease. Sphenoid drill-out procedure provides wider access for topical steroid irrigations and also may improve management of CRSwNP.

CONCLUSION

Surgical intervention remains a mainstay of therapy for CRSwNP. Newer techniques revolve around improving access for topical steroid therapy.

The Functional Diversity of Nitric Oxide Synthase Isoforms in Human Nose and Paranasal Sinuses: Contrasting Pathophysiological Aspects in Nasal Allergy and Chronic Rhinosinusitis

The human paranasal sinuses are the major source of intrinsic nitric oxide (NO) production in the human airway. NO plays several roles in the maintenance of physiological homeostasis and the regulation of airway inflammation through the expression of three NO synthase (NOS) isoforms. Measuring NO levels can contribute to the diagnosis and assessment of allergic rhinitis (AR) and chronic rhinosinusitis (CRS). In symptomatic AR patients, pro-inflammatory cytokines upregulate the expression of inducible NOS (iNOS) in the inferior turbinate. Excessive amounts of NO cause oxidative damage to cellular components, leading to the deposition of cytotoxic substances. CRS phenotype and endotype classifications have provided insights into modern treatment strategies. Analyses of the production of sinus NO and its metabolites revealed pathobiological diversity that can be exploited for useful biomarkers. Measuring nasal NO based on different NOS activities is a potent tool for specific interventions targeting molecular pathways underlying CRS endotype-specific inflammation. We provide a comprehensive review of the functional diversity of NOS isoforms in the human sinonasal system in relation to these two major nasal disorders' pathologies. The regulatory mechanisms of NOS expression associated with the substrate bioavailability indicate the involvement of both type 1 and type 2 immune responses.

The Prevalence of Odontogenic Pathology in Patients With Bilateral Rhinosinusitis

OBJECTIVE

We investigated cases with opacification on maxillary sinus computed tomography (CT) among patients with rhinosinusitis with opacification in both paranasal sinuses (bilateral rhinosinusitis) to confirm the involvement of odontogenic infections.

METHODS

This study included 75 patients who were diagnosed with bilateral rhinosinusitis based on clinical examination and evident opacification on at least one side on maxillary sinus imaging with computed tomography CT. The definition of odontogenic sinusitis was determined by examining EPT and oral findings, in addition to the CT and orthopantomography (OP), by one oral surgeon and two otolaryngologists.

RESULTS

We found that 45.3% of patients had odontogenic infections, which were associated with multiple infected teeth in some cases. Odontogenic infection was observed in both sinuses in some patients. Sinusitis with polyps was frequently associated with dental infection, and some cases were also associated with mycosis. Almost no oral symptoms were observed.

CONCLUSIONS

The results suggest that clinicians should consider odontogenic infection in patients with bilateral rhinosinusitis with opacification, on at least one side on maxillary sinus imaging. This means that accurate diagnosis may be challenging for otolaryngologist or dentists alone, suggesting that a collaboration between the two would be suitable for this task.