1
|
Levin M, Chan Y, Sommer DD, Thamboo A, Lee JM. Quantifying surgical completeness in patients with aspirin exacerbated respiratory disease. J Otolaryngol Head Neck Surg 2023; 52:83. [PMID: 38105254 PMCID: PMC10726574 DOI: 10.1186/s40463-023-00682-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 11/17/2023] [Indexed: 12/19/2023] Open
Abstract
BACKGROUND Aspirin exacerbated respiratory disease (AERD) in patients who have had sinus surgery remains a management challenge. Aspirin desensitization and biologics are additional treatment options. It remains unclear if patients require a more comprehensive surgery prior to implementing such additional therapies. The purpose of this study was to quantify prior surgery completeness in AERD patients at a tertiary rhinology practice. METHODS Paranasal sinus CT scans were reviewed by four academic rhinologists to assess surgery completeness. Using a published CT grading system, each sinus was graded on the completeness of surgery and middle turbinate reduction. A score out of 14 was calculated for each patient (7 per side). RESULTS Sixty-one patients with AERD out of 141 available were included. Mean inter-rater agreement across all sinuses was moderate (k = 0.42). The mean completeness score was 6.7/14. The following procedures were rated as complete (means): uncinectomy (L: 84%, R: 82%, k = 0.44), maxillary (L: 83%, R: 77%, k = 0.32), middle turbinate reduction (L: 45%, R: 46%, k = 0.31), anterior ethmoid (L: 35%, R: 39%, k = 0.51), sphenoid (L: 36%, R: 35%, k = 0.4), posterior ethmoid (L: 30%, R: 30%, k = 0.48), frontal (L: 22%, R: 21%, k = 0.46). CONCLUSION Prior surgery in AERD patients were mostly deemed incomplete. Uncinectomy and maxillary antrostomy are the most common procedures previously performed. It remains toe seen whether this would be considered 'adequate' surgery or more 'complete' surgery is required to achieve greater disease control.
Collapse
Affiliation(s)
- Marc Levin
- Division of Rhinology, Department of Otolaryngology - Head and Neck Surgery, St. Michael's Hospital, Unity Health Toronto, University of Toronto, 30 Bond Street, 8 Cardinal Carter, Toronto, ON, M5B 1WB, Canada
| | - Yvonne Chan
- Division of Rhinology, Department of Otolaryngology - Head and Neck Surgery, St. Michael's Hospital, Unity Health Toronto, University of Toronto, 30 Bond Street, 8 Cardinal Carter, Toronto, ON, M5B 1WB, Canada
| | - Doron D Sommer
- Department of Surgery - Division of Otolaryngology Head and Neck Surgery, McMaster University, Hamilton, ON, Canada
| | - Andrew Thamboo
- Department of Surgery - Division of Otolaryngology Head and Neck Surgery, University of British Columbia, Vancouver, BC, Canada
| | - John M Lee
- Division of Rhinology, Department of Otolaryngology - Head and Neck Surgery, St. Michael's Hospital, Unity Health Toronto, University of Toronto, 30 Bond Street, 8 Cardinal Carter, Toronto, ON, M5B 1WB, Canada.
| |
Collapse
|
3
|
Thamboo AV, Lee M, Bhutani M, Chan C, Chan Y, Chapman KR, Chin CJ, Connors L, Dorscheid D, Ellis AK, Gall RM, Godbout K, Janjua A, Javer A, Kilty S, Kim H, Kirkpatrick G, Lee JM, Leigh R, Lemiere C, Monteiro E, Neighbour H, Keith PK, Philteos G, Quirt J, Rotenberg B, Ruiz JC, Scott JR, Sommer DD, Sowerby L, Tewfik M, Waserman S, Witterick I, Wright ED, Yamashita C, Desrosiers M. Canadian multidisciplinary expert consensus on the use of biologics in upper airways: a Delphi study. J Otolaryngol Head Neck Surg 2023; 52:30. [PMID: 37095527 PMCID: PMC10127402 DOI: 10.1186/s40463-023-00626-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 02/23/2023] [Indexed: 04/26/2023] Open
Abstract
BACKGROUND Chronic rhinosinusitis with nasal polyposis (CRSwNP) often coexists with lower airway disease. With the overlap between upper and lower airway disease, optimal management of the upper airways is undertaken in conjunction with that of the lower airways. Biologic therapy with targeted activity within the Type 2 inflammatory pathway can improve the clinical signs and symptoms of both upper and lower airway diseases. Knowledge gaps nevertheless exist in how best to approach patient care as a whole. There have been sixteen randomized, double-blind, placebo-controlled trails performed for CRSwNP targeted components of the Type 2 inflammatory pathway, notably interleukin (IL)-4, IL-5 and IL-13, IL- 5R, IL-33, and immunoglobulin (Ig)E. This white paper considers the perspectives of experts in various disciplines such as rhinology, allergy, and respirology across Canada, all of whom have unique and valuable insights to contribute on how to best approach patients with upper airway disease from a multidisciplinary perspective. METHODS A Delphi Method process was utilized involving three rounds of questionnaires in which the first two were completed individually online and the third was discussed on a virtual platform with all the panelists. A national multidisciplinary expert panel of 34 certified specialists was created, composed of 16 rhinologists, 7 allergists, and 11 respirologists who evaluated the 20 original statements on a scale of 1-9 and provided comments. All ratings were quantitively reviewed by mean, median, mode, range, standard deviation and inter-rater reliability. Consensus was defined by relative interrater reliability measures-kappa coefficient ([Formula: see text]) value > 0.61. RESULTS After three rounds, a total of 22 statements achieved consensus. This white paper only contains the final agreed upon statements and clear rationale and support for the statements regarding the use of biologics in patients with upper airway disease. CONCLUSION This white paper provides guidance to Canadian physicians on the use of biologic therapy for the management of upper airway disease from a multidisciplinary perspective, but the medical and surgical regimen should ultimately be individualized to the patient. As more biologics become available and additional trials are published we will provide updated versions of this white paper every few years.
Collapse
Affiliation(s)
- Andrew V Thamboo
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, St. Paul Sinus Center, University of British Columbia, 2600-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
| | - Melissa Lee
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, St. Paul Sinus Center, University of British Columbia, 2600-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Mohit Bhutani
- Department of Respirology, University of Alberta, Edmonton, AB, Canada
| | - Charles Chan
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Yvonne Chan
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada
| | - Ken R Chapman
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Christopher J Chin
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, Dalhousie University, Halifax, NS, Canada
| | - Lori Connors
- Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Del Dorscheid
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Anne K Ellis
- Division of Allergy and Immunology, Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Richard M Gall
- Department of Otolaryngology-Head and Neck Surgery, University of Manitoba, Winnipeg, MB, Canada
| | | | - Arif Janjua
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, St. Paul Sinus Center, University of British Columbia, 2600-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Amin Javer
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, St. Paul Sinus Center, University of British Columbia, 2600-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Shaun Kilty
- Department of Otolaryngology-Head and Neck Surgery, The University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada
| | - Harold Kim
- Division of Clinical Immunology and Allergy, Department of Medicine, Western University, London, ON, Canada
- Division of Clinical Immunology and Allergy, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Gordon Kirkpatrick
- Division of Respiratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - John M Lee
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada
| | - Richard Leigh
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Catherine Lemiere
- Department of Medicine, CIUSS du Nord de l'île de Montreal, Université de Montreal, Montreal, QC, Canada
| | - Eric Monteiro
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Helen Neighbour
- Division of Clinical Immunology and Allergy, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Paul K Keith
- Division of Clinical Immunology and Allergy, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | | | - Jaclyn Quirt
- Division of Clinical Immunology and Allergy, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Brian Rotenberg
- Department of Otolaryngology-Head and Neck Surgery, Western University, London, ON, Canada
| | - Juan C Ruiz
- Division of Clinical Immunology and Allergy, University of Calgary, Calgary, AB, Canada
| | - John R Scott
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, Dalhousie University, Halifax, NS, Canada
| | - Doron D Sommer
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Leigh Sowerby
- Department of Otolaryngology-Head and Neck Surgery, Western University, London, ON, Canada
| | - Marc Tewfik
- Department of Otolaryngology-Head and Neck Surgery, McGill University, Montreal, QC, Canada
| | - Susan Waserman
- Division of Clinical Immunology and Allergy, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Ian Witterick
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada
| | - Erin D Wright
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Cory Yamashita
- Department of Medicine, Western University, London, ON, Canada
| | - Martin Desrosiers
- Division of Otolaryngology-Head and Neck Surgery, Centre Hospitalier de l'Université de Montreal, Montreal, QC, Canada
| |
Collapse
|
4
|
Grose E, Li AY, Lee JM. Clinical outcomes of dupilumab therapy in chronic rhinosinusitis with nasal polyps in a Canadian tertiary care rhinology practice. ALLERGY, ASTHMA, AND CLINICAL IMMUNOLOGY : OFFICIAL JOURNAL OF THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY 2023; 19:26. [PMID: 36998065 DOI: 10.1186/s13223-023-00782-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 02/27/2023] [Indexed: 04/01/2023]
Abstract
BACKGROUND In 2020, dupilumab became the first monoclonal antibody therapy to be approved by Health Canada for the treatment of chronic rhinosinusitis with nasal polyps (CRSwNP). The primary aim of this study was to characterize the outcomes in an initial cohort of patients with CRSwNP who have undergone dupilumab therapy. METHODS A retrospective study was conducted of patients with CRSwNP who were treated with dupilumab. Demographic information, comorbidities, number of previous surgeries, and insurance information were collected. The primary outcome were changes in the sinonasal outcome test (SNOT-22) scores from baseline to timepoints after receiving dupilumab. RESULTS Forty-eight patients were considered for dupilumab therapy, and 27 (56%) received coverage or were able to fund the medication independently. Patients waited an average of 3.6 months to obtain access to the medication. The mean age of the patients was 43. Forty-one percent (11/27) of patients had aspirin exacerbated respiratory disease, and 96% (26/27) had a diagnosis of asthma. The mean length of time on dupilumab was 12.1 months. The baseline SNOT-22 score was 60.6. The mean decrease at 1 month, 3 months, 6 months, and 12 months after starting dupilumab was 8.8, 26.5, 42.8, and 33.8, respectively. There were no serious adverse events. CONCLUSION Patients treated with dupilumab in a Canadian tertiary care rhinology clinic demonstrated substantial clinical improvement as measured by disease-specific sinonasal outcomes. Further studies are needed to determine the longer-term effectiveness and adverse event profile of this novel therapy.
Collapse
Affiliation(s)
- Elysia Grose
- Division of Rhinology, Department of Otolaryngology-Head and Neck Surgery, University of Toronto, 600 University Avenue, Toronto, ON, M5G 1X5, USA.
| | - Alyssa Y Li
- Division of Rhinology, Department of Otolaryngology-Head and Neck Surgery, University of Toronto, 600 University Avenue, Toronto, ON, M5G 1X5, USA
| | - John M Lee
- Division of Rhinology, Department of Otolaryngology-Head and Neck Surgery, University of Toronto, 600 University Avenue, Toronto, ON, M5G 1X5, USA.
| |
Collapse
|