Chronic rhinosinusitis increased the risk of stroke: a 5-year follow-up study

Side- and Sinus-Specific Relationships between Chronic Rhinosinusitis and Ischemic Stroke Using Imaging Analyses

Recent studies have reported chronic rhinosinusitis (CRS) as an independent risk factor for stroke. However, the association with stroke depending on the affected sinuses has not been explored. This study aimed to elucidate the side- and sinus-specific relationship between CRS and ischemic stroke through imaging analyses. We retrospectively reviewed the medical records of patients who were diagnosed with ischemic stroke at a tertiary center. CRS was defined as having a total score of greater than or equal to 4, according to the Lund-Mackay scoring system, through brain magnetic resonance imaging or computed tomography. We investigated the side- and sinus-specific correlation between CRS and ischemic stroke. Subgroup analyses were performed for different age groups. CRS prevalence in patients with ischemic stroke was 18.4%, which was higher than the previously reported prevalence in the general population. Overall, there was no correlation between the directions of the CRS and ischemic stroke (p > 0.05). When each sinus was analyzed, the frontal (Cramer's V = 0.479, p < 0.001), anterior (Cramer's V = 0.396, p < 0.001)/posterior (Cramer's V = 0.300, p = 0.008) ethmoid, and sphenoid (Cramer's V = 0.383, p = 0.005) sinuses showed a statistically significant correlation with the side of stroke, but the maxillary sinus (Cramer's V = 0.138, p = 0.208) did not. In subgroup analyses, a significant right-side correlation between the two diseases was observed in the older-age subgroup (≥65 years old, Cramer's V = 0.142, p = 0.040). Diabetes mellitus (odds ratio = 1.596, 95% confidence interval = 1.204-2.116) was identified as an independent risk factor for having CRS in patients with ischemic stroke. CRS of the frontal, anterior/posterior ethmoid, and sphenoid sinuses has a directional relationship with ischemic stroke. Our results on which sinuses correlate with stroke advocate for the active surveillance of CRS in patients at high risk of ischemic stroke.

Genetically predicted chronic rhinosinusitis and the risk of stroke: a two-sample Mendelian randomization study

Objective

The causal association between chronic rhinosinusitis (CRS) and stroke remains uncertain due to the susceptibility of observational studies to confounding and the possibility of reverse causality. This study aims to examine the potential causal relationship between CRS and the risk of stroke, encompassing various subtypes.

Methods

In this research, we utilized genome-wide association study (GWAS) data for CRS from FinnGen. We identified significant single-nucleotide polymorphisms (SNPs) associated with CRS and used them as instrumental variables (IVs). GWAS data for any ischemic stroke (AIS), ischemic stroke (IS), large-artery atherosclerotic stroke (LAS), small-vessel strokes (SVS), cardioembolic strokes (CES), intracerebral hemorrhage (ICH), lobar ICH, and non-lobar ICH came from multi-ancestry GWAS datasets. We conducted two-sample Mendelian randomization (MR) analyses using inverse variance weighting (IVW), weighted median, and MR-Egger regression methods to investigate potential causal relationships between CRS and stroke. Both heterogeneity and pleiotropy were evaluated by sensitivity analyses.

Result

The IVW analysis revealed no significant associations between CRS and AIS (OR = 0.99, 95% CI [0.93-1.05], p = 0.73), IS (OR = 0.97, 95% CI [0.81-1.17], p = 0.09), SVS (OR = 0.96, 95% CI [0.82-1.12], p = 0.58), LAS (OR = 0.91, 95% CI [0.77-1.08], p = 0.09), CES (OR = 0.97, 95% CI [0.81-1.17], p = 0.79), ICH (OR = 1.28, 95% CI [0.74-2.22], p = 0.28), lobar ICH (OR = 1.22, 95% CI [0.60-2.50], p = 0.28), and non-lobar ICH (OR = 1.25, 95% CI [0.65-2.40], p = 0.79). Sensitivity analysis found no evidence of horizontal pleiotropy.

Conclusion

According to genetic evidence, this Mendelian randomization (MR) study does not indicate a causal relationship between CRS and stroke in European populations. However, further studies are necessary to comprehensively evaluate the potential association between CRS and stroke.

Paranasal sinus occupancy assessed from magnetic resonance images-associations with clinical indicators in patients with systemic lupus erythematosus

OBJECTIVES

Nasal, paranasal sinus and mucosal disorders are common symptoms in autoimmune rheumatic diseases. Soft tissue changes and fluid accumulation in the osteomeatal complexes and paranasal sinuses manifest as opaqueness on radiological images which can be assessed using visual scoring and computational methods on CT scans, but their results do not always correlate. Using MRI, we investigate the applicability of different image analysis methods in SLE.

METHODS

We assessed paranasal sinus opaqueness on MRI from 51 SLE patients, using three visual scoring systems and expert-delineated computational volumes, and examined their association with markers of disease activity, inflammation, endothelial dysfunction and common small vessel disease (SVD) indicators, adjusting for age and sex-at-birth.

RESULTS

The average paranasal sinus volume occupation was 4.55 (6.47%) [median (interquartile range) = 0.67 (0.25-2.65) ml], mainly in the maxillary and ethmoid sinuses. It was highly correlated with Lund-Mackay (LM) scores modified at 50% opaqueness cut-off (Spearman's ρ: 0.71 maxillary and 0.618 ethmoids, P < 0.001 in all), and with more granular variations of the LM system. The modified LM scores were associated with SVD scores (0: B = 5.078, s.e. = 1.69, P = 0.0026; 2: B = -0.066, s.e. = 0.023, P = 0.0045) and disease activity (anti-dsDNA: B = 4.59, s.e. = 2.22, P = 0.045; SLEDAI 3-7: 2.86 < B < 4.30; 1.38 < s.e. < 1.63; 0.0083 ≤ P ≤ 0.0375). Computationally derived percent opaqueness yielded similar results.

CONCLUSION

In patients with SLE, MRI computational assessment of sinuses opaqueness and LM scores modified at a 50% cut-off may be useful tools in understanding the relationships among paranasal sinus occupancy, disease activity and SVD markers.

Is There a Correlation between Endoscopic Sinus Surgery and Improvement in Erectile Dysfunction?

BACKGROUND

In recent years, the focus on respiratory disorders has increased, notably on chronic rhinosinusitis (CRS), an inflammatory condition of the upper airway that can significantly impact one's quality of life. Interestingly, CRS has emerged as a potential comorbidity in erectile dysfunction (ED). This study aims to assess the impact of endoscopic sinus surgery for CRS on sexual function.

MATERIALS AND METHODS

The authors conducted a prospective study of patients who visited their clinics for chronic rhinosinusitis between June 2018 and June 2022. The study involved 53 patients aged between 40 and 70 years who were treated for CRS with nasal polyps (CRSwNP) and CRS without nasal polyps (CRSsNP). Preoperative and postoperative assessments were performed using the Nasal Obstruction Symptoms Evaluation Score (NOSE score) and the 5th International Index of Erectile Function Score (IIEF-5 score) to evaluate potential improvements in sexual function following endoscopic sinus surgery.

RESULTS

Before surgery, the average NOSE score was 72.6, which decreased to 24.9 postoperatively. The average preoperative IIEF-5 score was 16.35, while the postoperative average increased to 19.52. Statistical analysis revealed a significant improvement in erectile function for penetration (p-value = 0.024) and overall satisfaction after intercourse (p-value < 0.001) regarding the degree of nasal obstruction.

CONCLUSION

This study underscores the potential benefits of treating chronic obstructive upper airway diseases such as sinusitis in improving the sexual outcomes of patients clinically diagnosed with erectile dysfunction.

Chronic rhinosinusitis is not associated with increased incidence of acute myocardial infarction: A national population-based study

BACKGROUND & AIMS

Chronic rhinosinusitis (CRS) is one of the most prevalent upper respiratory tract diseases. However, little is known the effect of CRS on the cardiovascular aspects of patients. This study aimed to investigate the incidence of acute myocardial infarction (AMI) in patients with CRS compared with that in the general population.

METHODS

This retrospective cohort study was performed using the Korean National Health Insurance Service (NHIS) database. To minimize confounding, age, sex, and cardiovascular risk profiles were adjusted. The primary endpoint was newly diagnosed AMI in patients between January 2005 and December 2018. The relative risk of AMI in patients with CRS was compared with that in controls. Kaplan-Meier survival curves and Cox proportional regression tests were used for statistical analyses.

RESULTS

Among 5,179,981 patients from the NHIS database, 996,679 patients with CRS were selected. The control group was 10 times (n = 9,966,790) the number of individuals in the CRS group. The CRS group had better cardiovascular profiles than those of the control group and had an adjusted hazard ratio of 0.99 (95% confidence interval, 0.97-1.02) for AMI.

CONCLUSION

There was no significant association between the two groups regardless of the presence of nasal polyps. This is the first study adjusting cardiovascular risk profiles and analyzing the relationship between CRS and AMI. CRS was not associated with a high incidence of AMI after adjusting for cardiovascular risk factors.

Paranasal sinuses opacification on magnetic resonance imaging in relation to brain health in sporadic small vessel disease - Systematic review and pilot analysis

BACKGROUND

The paranasal sinus mucosal thickening, visible in magnetic resonance imaging (MRI), maybe a source of inflammation in microvessels, but its relationship with small vessel disease (SVD) is unclear. We reviewed the literature and analysed a sample of patients with sporadic SVD to identify any association between paranasal sinus opacification severity and SVD neuroimaging markers.

METHODS

We systematically reviewed MEDLINE and EMBASE databases up to April 2020 for studies on paranasal sinus mucosal changes in patients with SVD, cerebrovascular disease (CVD), and age-related neurodegenerative diseases. We analysed clinical and MRI data from 100 participants in a prospective study, the Mild Stroke Study 3 (ISRCTN 12113543) at 1-3, 6 and 12 months following a minor stroke to test key outcomes from the literature review. We used multivariate linear regression to explore associations between modified Lund-Mackay (LM) scores and brain, white matter hyperintensities (WMH), enlarged perivascular spaces (PVS) volumes at each time point, adjusted for baseline age, sex, diabetes, hypercholesterolaemia, hypertension and smoking.

RESULTS

The literature review, after screening 3652 publications, yielded 11 primary studies, for qualitative synthesis with contradictory results, as positive associations/higher risk from 5/7 CVD studies were contradicted by the two studies with largest samples, and data from dementia studies was equally split in their outcome. From the pilot sample of patients analysed (female N = 33, mean age 67.42 (9.70) years), total LM scores had a borderline negative association with PVS in the centrum semiovale at baseline and 6 months (B = -0.25, SE = 0.14, p = 0.06) but were not associated with average brain tissue, WMH or normal-appearing white matter volumes.

CONCLUSION

The inconclusive results from the literature review and empirical study justify larger studies between PVS volume and paranasal sinuses opacification in patients with sporadic SVD.

Rhinosinusitis and Stroke: A Systematic Review

Rhinosinusitis is one of the most common inflammatory diseases. It has been recognized that intracranial vessels are involved and there might be an association with stroke occurrence. The aim of this study was to evaluate the association between rhinosinusitis and cardiovascular diseases, especially stroke, through a literature review. The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. We performed on PubMed a literature search from February 2000 to February 2022, using the search terms 'rhinosinusitis' OR 'chronic rhinosinusitis' AND 'stroke' OR 'ischemic stroke'. Fourteen studies were eligible and included in the analysis. Overall, the studies encompassed a total of 1,006,338 patients included in this review. All studies concluded that there is a statistically significant correlation between clinical or radiological sinus inflammation and the risk of stroke, which is independent of traditional stroke risk factors. In conclusion, rhinosinusitis is associated with an increased incidence of stroke.

Phenotypes of Chronic Rhinosinusitis and Peripheral Blood Leukocytes Parameters in Elderly Patients

Background and Objectives: Chronic rhinosinusitis (CRS) is a common disease that can be differentiated into two phenotypes, with or without polyps (CRSwNP) or CRSsNP), which may be unilateral (UNIL) or bilateral (BIL). CRS may have an impact on absolute neutrophils and lymphocytes count in peripheral blood. The aim of the study was to investigate whether the incidence of a specific CRS phenotype changes with age and to compare the values of neutrophils, lymphocytes and neutrophil-to-lymphocyte ratio in the peripheral blood between groups of patients below and above 65 years of age with different CRS phenotypes. Material and Methods: A total of 235 patients aged 65 and over were examined, including 140 (59.6%) males. The group of patients <65 years of age comprised 160 subjects, including 103 (64.4%) males. In both groups, the sequence of frequency of particular phenotypes was similar: the most common phenotype was bilateral CRSwNP followed by CRSsNP BIL, CRSsNP UNIL, and finally, CRSwNP UNIL. Direct comparisons between determined phenotype in both groups of different ages revealed that, in the group ≥65 years, CRSwNP BIL occurred significantly more often than in the group <65 years of age. In fact, in the <65 group, bilateral CRSsNP was more common. The absolute neutrophils and lymphocytes counts were significantly higher in the whole group of patients with CRS ≥65 years of age and absolute number of neutrophils was higher in ≥65 years of age group with bilateral CRSsNP. Conclusions: The higher number of neutrophils in the whole ≥65 years of age group and in older patients with bilateral CRSsNP may indicate that CRS, despite of phenotype, may be an important source of infection that requires surgical treatment in elderly patients as well.

Chronic Rhinosinusitis and the Increased Incidence of Atopic Dermatitis

BACKGROUND

Chronic rhinosinusitis (CRS) is often associated with other comorbidities due to chronic inflammation. However, no population-based, longitudinal study has investigated the relationship between CRS and chronic skin inflammation.

OBJECTIVE

To investigate the potential relationship between CRS and chronic skin inflammatory diseases, such as atopic dermatitis (AD), vitiligo, and psoriasis.

METHODS

A total of 5638 patients with CRS and 11 276 without CRS as a comparison group, were included from the Korean National Health Insurance Service database from 2002-2013. A propensity score matching (1:2) was performed using the nearest neighbor matching method, sociodemographic factors, and enrollment year. The Cox proportional hazards model was used to analyze the hazard ratio of CRS for AD, vitiligo, and psoriasis.

RESULTS

Results from this study showed that patients with CRS had no significant risk of the subsequent development of vitiligo or psoriasis compared to patients without CRS. However, we found a significantly higher incidence of AD in CRS patients than in those without CRS. The incidence of AD was 63.59 per 1000 person-years in the CRS group and 45.38 per 1000 person-years in the comparison group. Additionally, young and middle-aged CRS patients were independently associated with a higher incidence of subsequent AD events, but we could not find a significantly higher incidence of AD events in the elderly group.

CONCLUSIONS

Our findings suggest there are no significant differences in the overall risk of vitiligo and psoriasis events in patients with CRS; however, we detected a higher risk of AD in young and middle-aged CRS patients. Therefore, clinicians should consider the risk of developing AD in specific patients who are newly diagnosed with CRS.

Prognostic Role of Chronic Rhinosinusitis in Acute Ischemic Stroke Patients Undergoing Mechanical Thrombectomy

Background: The aim of the study was to assess the relevance of chronic rhinosinusitis (CRS) CT features to the efficacy of mechanical thrombectomy (MT) in patients with acute ischemic stroke. Methods: This study included 311 patients qualified for MT in whom the CRS features were assessed based on a CT scan, according to the Lund-Mackay (L-M) score. Clinical, inflammatory parameters, patients neurological (NIHSS) and functional status (mRS), and recanalisation efficacy (TICI) were compared between patients with mild lesions (L-M score 0–3 points)-group 1, and patients with more severe lesions (L–M score 4–24)-group 2. Results: There was a significant difference in the NIHSS on day seven after stroke onset-10 points in group 1 and 14 points in group 2, p = 0.02. NIHSS ≤ 6 points on day seven was found in 41.9% of patients in group 1, and in 27.5% in group 2, p = 0.042. There were no significant differences in mRS score and in the TICI score. L-M score, lipid abnormalities and CRP were factors associated with NIHSS ≥ 7 points on day 7. Conclusions: The CT features of CRS may be used as a prognostic tool for early prognosis assessment in stroke patients.

Chronic rhinosinusitis and progression of cognitive impairment in dementia

AIM

The relationship between chronic inflammatory disease and cognitive decline is still unclear, but there is increasing evidence to support the role of systemic inflammation. The aim of this study was to investigate if chronic rhinosinusitis (CRS) in dementia or mild cognitive impairment (MCI) is associated with the progression of cognitive decline.

MATERIAL AND METHODS

We retrospectively reviewed the data of patients who complained of memory impairment, and underwent brain magnetic resonance imaging (MRI) from January 2006 to April 2019. According to the Mini-Mental State Examination (MMSE) score, subjects (n=661) were divided into three groups: dementia (≤17), MCI (18-23), and normal (≥24). CRS was defined as a total score of greater than or equal to 4 according to the Lund-Mackay scoring system using brain MRI. Multiple logistic regression analyses estimated adjusted odds ratio (aOR) for the association between CRS and dementia or MCI. Among the subjects with follow-up MMSE (n=286), a repeated-measures ANOVA was used to assess the difference of changes in MMSE scores between the groups with and without CRS.

RESULTS

According to the initial MMSE score, there were 221 subjects with dementia, 195 with MCI, and 245 with normal results. CRS was not significantly associated with dementia (aOR=1.519, CI=0.909-2.538, P=0.111), while being suggestively associated with MCI (aOR=1.740, CI=1.041-2.906, P=0.034). The MMSE scores at follow-up decreased further in subjects with CRS than in those without CRS (P=0.009). Especially, in the initial dementia group, there was a significant between-group difference in the MMSE score from baseline to follow-up (13.6±4.3 to 11.1±6.3 in CRS group vs. 13.5±3.3 to 14.4±5.4 in no CRS group, P=0.002).

CONCLUSION

The result of the present study implies a potential association between CRS and progression of cognitive decline. Physicians should be aware of this possibility in patients with clinically diagnosed CRS.

Chronic bronchitis without airflow obstruction, asthma and rhinitis are differently associated with cardiovascular risk factors and diseases

BACKGROUND AND OBJECTIVES

Cardiovascular and respiratory diseases can frequently coexist. Understanding their link may improve disease management. We aimed at assessing the associations of chronic bronchitis (CB), asthma and rhinitis with cardiovascular diseases and risk factors in the general population.

METHODS

We used data collected in the Gene Environment Interactions in Respiratory Diseases study, an Italian multicentre, multicase-control study. Among 2463 participants (age 21-86, female 50%) who underwent standardized interviews, skin prick and lung function tests, we identified 254 cases of CB without airflow obstruction, 418 cases of asthma without CB, 959 cases of rhinitis alone, and 832 controls. The associations of respiratory diseases with reported cardiovascular risk factors (lifestyles, hypertension, dyslipidaemia), heart disorders (myocardial infarction, coronary thrombosis, angina, aorta or heart surgery) and intermittent claudication were estimated through relative risk ratios (RRR) by multinomial logistic regression models.

RESULTS

Compared to controls, CB cases were more likely to be heavy smokers, alcohol consumers, physically inactive, and to suffer from hypertension or dyslipidaemia; rhinitis cases were less obese but more likely to have hypertension. Asthma was significantly associated with current smoking. After adjusting for cardiovascular risk factors, heart disorders were associated with CB (RRR[95%CI]: 1.58[1.12-2.22]) and rhinitis (1.35[0.98-1.85]) and intermittent claudication was associated with CB (3.43[2.52-4.67]), asthma (1.51[1.04-2.21]) and rhinitis (2.03[1.34-3.07]).

CONCLUSIONS

CB, asthma and rhinitis were associated with cardiovascular risk factors and diseases. In particular, CB shared with cardiovascular diseases almost all risk factors and was strongly associated with a higher risk of heart disorders and intermittent claudication.

Relationship of Chronic Rhinosinusitis with Asthma, Myocardial Infarction, Stroke, Anxiety, and Depression

BACKGROUND

Chronic rhinosinusitis (CRS) is a common chronic inflammatory disease of the nose and paranasal sinuses. It often has a high burden and is difficult to treat because of comorbidities. However, no population-based, long-term longitudinal study has investigated the relationship between CRS and its comorbidities.

OBJECTIVE

To investigate the potential relationship between CRS and its comorbidities-asthma, acute myocardial infarction (AMI), stroke, anxiety disorder, and depression-using a representative sample.

METHODS

Data for a total of 1,025,340 patients from the Korean National Health Insurance Service database from 2002 to 2013, including 14,762 patients with CRS and 29,524 patients without CRS, were used for this study. A 1:2 propensity score matching was performed using the nearest-neighbor matching method and sociodemographic factors and enrollment year. Cox proportional hazards model was used to analyze the hazard ratio (HR) of CRS for asthma, AMI, stroke, anxiety disorder, and depression.

RESULTS

The incidence rates of asthma, AMI, and stroke were 71.1, 3.1, and 7.7 per 1000 person-years in patients with CRS, respectively. The adjusted HRs of asthma, AMI, and stroke were 2.06 (95% CI, 2.00-2.13), 1.29 (95% CI, 1.15-1.44), and 1.16 (95% CI, 1.08-1.24), respectively, in patients with CRS versus patients without CRS. The incidence rates of anxiety disorder and depression in patients with CRS were 42.1 and 24.2 per 1000 person-years, respectively. The adjusted HRs of anxiety disorder (HR, 1.54; 95% CI, 1.49-1.60) and depression (HR, 1.50; 95% CI, 1.44-1.57) were significantly greater in patients with CRS versus patients without CRS.

CONCLUSIONS

CRS is associated with an increased incidence of asthma, AMI, stroke, anxiety disorder, and depression. Therefore, we suggest that clinicians should monitor patients with CRS carefully, and optimize management as a means to potentially decrease these other associated comorbid conditions.

Increased risk of psoriasis in patients with chronic rhinosinusitis without nasal polyps: a longitudinal follow-up study using Korean national sample cohort

PURPOSE

Focal chronic inflammation or infection is thought to be one of the causes of psoriasis. Few reports on the association between chronic rhinosinusitis (CRS) and psoriasis exist, thus it is poorly defined. This study seeks to investigate the incidence of psoriasis in patients with CRS with reference to a matched control group.

METHODS

This national cohort study relies on data from Korean Health Insurance Review and Assessment Service-National Sample Cohort (HIRA-NSC), which were entered from 2002 to 2013. A total of 34,219 patients with CRS without nasal polyps was matched with 136,976 controls. The Cox proportional hazard model was used to analyze the crude (simple) and adjusted hazard ratios (HRs) of psoriasis. For subgroup analysis, participants were grouped by age and sex.

RESULTS

The risk of psoriasis was higher in the CRS group than in the control group (adjusted HR 1.28, 95% CI 1.12-1.47, P < 0.001). Children, adolescents below 19 years regardless of sex, and old adult men above 60 years are at significantly higher risk for subsequent psoriasis after CRS diagnosis.

CONCLUSION

CRS may increase the risk of psoriasis.

Mucociliary transport as a link between chronic rhinosinusitis and trace element dysbalance

Chronis rhinosinusitis is considered as a widespread public health issue with a prevalence of 10%. The disease significantly reduces quality of life and increases the risk of cardiovascular diseases as well as certain forms of cancer. Alteration of mucociliary clearance frequently observed in the patients and plays a significant role in disease pathogenesis. Certain studies have demonstrated that patients with chronic rhinosinusitis are characterized by significant reduction of essential trace elements and toxic metal overload. However, the particular mechanisms of the role of trace element dysbalance in chronic rhinosinusitis are unclear. We hypothesize that exposure to toxic trace elements (arsenic, nickel, cadmium) damages ciliary mucosal epithelium thus affecting mucociliary transport. In turn, altered mucociliary transport results in reduced removal of the inhaled metal-containing particles from nasal mucosa leading to their absorption and further aggravation of toxicity. Essential trace elements (zinc, selenium) play a significant role in regulation of mucociliary transport and immunity, thus their deficiency (either dietary or due to antagonism with toxic metals) may be associated with impaired functions and increased toxic metal toxicity. Therefore, a vicious circle involving metal accumulation and toxicity, essential element deficiency, impairment of mucociliary transport and metal particle removal, resulting in further accumulation of metals and aggravation of toxic effects is formed. The present hypothesis is supported by the findings on the impact of trace elements especially zinc and arsenic on mucociliary clearance, the role of mucociliary transport in heavy metal particles elimination from the airways, trace element dysbalance in chronic rhinosinusitis, as well as toxic and essential metal antagonism. The data from hypothesis testing and its verification may be used for development of therapeutic approach for management of chronic rhinosinusitis. Particularly, the use of essential elements (zinc, selenium) may reduce toxic metal toxicity thus destroying the vicious circle of heavy metal exposure, toxicity, alteration of mucociliary clearance, and aggravation of chronic rhinosinusitis. Essential element supplementation may be considered as a tool for management of chronic refractory rhinosinusitis. In addition, analysis of essential and toxic trace element status may provide an additional diagnostic approach to risk assessment of chronic rhinosinusitis in highly polluted environments.

Risk of Stroke among Patients with Chronic Rhinosinusitis: A Systematic Review and Meta-analysis

BACKGROUND

Recent studies have suggested that patients with chronic rhinosinusitis (CRS) may have a higher risk of stroke although the data are still limited. The current systematic review and meta-analysis was conducted with the aims to identify all studies that investigated this relationship and summarize their results together to better characterize the risk of stroke among patients with CRS.

METHODS

A comprehensive literature review was conducted by searching for published articles in MEDLINE and EMBASE databases from inception to October 2018 to identify all observational studies that compared the risk of stroke among patients with CRS to individuals without CRS. Pooled risk ratio (RR) and 95% confidence interval (CI) were calculated using random-effect, generic inverse variance method of DerSimonian and Laird.

RESULTS

A total of 5 studies with 447,065 participants met the eligibility criteria and were included into the meta-analysis. The risk of stroke among patients with CRS was significantly higher than individuals without CRS with the pooled RR of 1.79 (95% CI, 1.34-2.40, I² = 84%).

CONCLUSIONS

The current study found that CRS is associated with higher risk stroke. Whether this relationship is causal and how it should be addressed in clinical practice require further investigations.

Chronic rhinosinusitis increases the risk of hemorrhagic and ischemic stroke: A longitudinal follow-up study using a national sample cohort

BACKGROUND

Several studies have reported that chronic rhinosinusitis (CRS) increases the risk of stroke. The aim of this study is to elucidate the putative association between CRS and stroke (ischemic or hemorrhagic) using large population-based national health insurance data.

METHODS

Using the national cohort study from the Korean Health Insurance Review and Assessment Service, CRS patients (n = 22,959) and control participants (n = 91,836) were selected and matched at a rate of 1:4 (age, sex, income, region, hypertension, diabetes, and dyslipidemia). A Cox-proportional hazard model was used to analyze the hazard ratio (HR) of CRS for hemorrhagic stroke and ischemic stroke. We divided the participants according to age and gender for the subgroup analysis.

RESULTS

The HR for hemorrhagic and ischemic stroke was significantly increased in the CRS patients compared to that in the controls (adjusted HR = 2.43, 95% confidence interval [CI] = 2.10-2.80 for hemorrhagic stroke; adjusted HR = 1.76, 95% CI = 1.61-1.92 for ischemic stroke) after adjusting for age, sex, income, region of residence, hypertension, diabetes, dyslipidemia, ischemic heart disease, migraine, chronic kidney disease, depression, sleep disorder, and chronic obstructive pulmonary disorder. In the subgroup analysis, the HR of hemorrhagic stroke was significantly increased in the CRS group regardless of age and gender. The HR of ischemic stroke was also significantly increased in all subgroups of the CRS group.

CONCLUSION

CRS consistently increased the risk of ischemic and hemorrhagic stroke regardless of age and gender.

Mortality risk in patients with chronic rhinosinusitis and its association to asthma

BACKGROUND

Chronic rhinosinusitis (CRS) is a highly prevalent inflammatory condition, with significant effects on morbidity and quality of life. Given that other chronic inflammatory conditions have been associated with increased mortality risk, we sought to evaluate the relationship between mortality and CRS including the influence of asthma. Our objective was to determine if CRS, with or without asthma, is associated with altered risk of mortality.

METHODS

Using a statewide population database, we retrospectively identified 27,005 patients diagnosed with CRS between 1996 and 2012, and 134,440 unaffected controls matched 5:1 on birth year and sex. Risk of mortality was determined from Cox models and Kaplan-Meier curves were used to compare survival.

RESULTS

A significant interaction between CRS and asthma status was observed in which CRS appeared to confer a protective effect in asthma patients. Asthma, when present, increased mortality in CRS-negative controls (p-interaction < 0.0001). Independent of asthma status, CRS patients exhibited a decreased mortality risk (hazard ratio [HR] = 0.80; 95% confidence interval [CI], 0.74 to 0.85) compared to controls. However, in patients diagnosed at or before the median age of CRS onset (42 years) independent of asthma status, survival was not improved (HR = 0.98; 95% CI, 0.81 to 1.18). Risk of mortality was greater in CRS with nasal polyps (n = 1643) compared to 25,362 polyp-negative CRS patients (HR = 1.38; 95% CI, 1.09 to 1.77).

CONCLUSION

CRS was associated with lower risk of mortality compared to controls, and appeared to mitigate increased mortality from asthma. We posit that better survival conferred by CRS may be secondary to treatment. However, the etiology of this relationship and the effect of CRS treatment on mortality are unknown.

Chronic Rhinosinusitis Associated with Erectile Dysfunction: A Population-Based Study

Few studies have investigated the relationship between chronic rhinosinusitis (CRS) and erectile dysfunction (ED). This case-control study aimed to investigate the association between CRS and the risk of ED in a large national sample. Tapping Taiwan's National Health Insurance Research Database, we identified people 30 years or older with a new primary diagnosis of CRS between 1996 and 2007. The cases were compared with sex- and age-matched controls. We identified 14 039 cases and recruited 140 387 matched controls. Both groups were followed up in the same database until the end of 2007 for instances of ED. Of those with CRS, 294 (2.1%) developed ED during a mean (SD) follow-up of 3.20 (2.33) years, while 1 661 (1.2%) of the matched controls developed ED, mean follow up 2.97 (2.39) years. Cox regression analyses were performed adjusting for sex, age, insurance premium, residence, hypertension, hyperlipidemia, diabetes, obesity, coronary heart disease, chronic kidney disease, chronic obstructive pulmonary disease, asthma, allergic rhinitis, arrhythmia, ischemic stroke, intracerebral hemorrhage, and medications. CRS was revealed to be an independent predictor of ED in the fully adjusted model (HR = 1.51; 95% CI = 1.33-1.73; P < 0.0001).

Incidental paranasal sinusitis on routine brain magnetic resonance scans: association with atherosclerosis

BACKGROUND

Incidental paranasal sinusitis (IPS) is common on imaging for non-sinusitis disorders, usually without symptoms or obstructive features, and possibly arising from periodontitis (PD). PD associations with atherosclerosis have been widely reported. We test if IPS may also be associated with atherosclerosis.

METHODS

IPS was scored retrospectively in a random sample of 180 magnetic resonance (MR) brain scans and compared with chart review for atherosclerosis (all subtypes), rhinosinusitis, and related factors (smoking, asthma, and relevant surgery). IPS was scored out of 30, from all sinuses, with maxillary sinuses weighted double volumetrically. Significant IPS (Sig IPS) was designated as 6 or more out of 30. Bivariate logistic regression was used to test for associations of Sig IPS to the clinical data, with multivariate analysis then testing for potential confounders.

RESULTS

A total of 173 subjects were analyzed (7 exclusions). MR indications included suspected acute/prior stroke (22.0%). Sig IPS found in 20 (11.6%). Positive histories for atherosclerosis were cerebral, 57 (32.9%); coronary, 48 (27.7%); and peripheral arterial disease, 14 (8.1%). IPS ≥6 was strongly associated with cerebrovascular disease (odds ratio [OR] 6.0, p < 0.001), and less robustly to smoking (OR 2.9, p = 0.07) and rhinosinusitis (OR 2.4, p = 0.09). No associations with coronary or peripheral artery diseases were found. After controlling for smoking and rhinosinusitis, yielding significant subclinical sinusitis, the link of Sig IPS to cerebrovascular disease persisted (modified OR 5.2, p = 0.002).

CONCLUSION

Significant incidental sinusitis, which is mostly subclinical sinusitis, is associated with cerebrovascular disease but not other atheroscleroses. This suggests possible common causation of both by PD.

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

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

Five-year risk of incident disease following a diagnosis of chronic rhinosinusitis

BACKGROUND

Chronic rhinosinusitis (CRS) has a broad range of comorbidities. Due to a lack of longitudinal studies, it is not known whether these comorbidities cause CRS, are promoted by CRS, or share a systemic disease process with CRS.

OBJECTIVE

The objective of this study was to determine the risk of incident disease within 5 years after a new diagnosis of CRS with nasal polyps (CRSwNP) and without nasal polyps (CRSsNP).

METHODS

We conducted a case-control study nested within the longitudinal cohort of primary care patients in the Geisinger Clinic using electronic health record data. We evaluated incident disease over 5 years in newly diagnosed CRSwNP and CRSsNP cases compared to controls using multivariable Cox regression models.

RESULTS

CRSsNP (n = 3612) cases were at greater risk (HR, 95% confidence interval) than controls for incidence of: upper airway diseases, including adenotonsillitis (3.29, 2.41-4.50); lower aerodigestive tract diseases, including asthma (2.69, 2.14-3.38); epithelial conditions, including atopic dermatitis (2.75, 1.23-6.16); and hypertension (1.38, 1.19-1.61). CRSwNP (n = 241) cases were at greater risk for obesity than controls (1.74, 1.08-2.80), but CRSwNP was not associated with other diseases.

CONCLUSION

The risk of other diseases associated with CRS adds to the burden of an already highly burdensome condition, and suggests either that CRS promotes onset of other diseases or is an indicator of systemic disease processes. Different patterns of association with diseases by CRS phenotype may be due to CRSwNP sample size limitations or reflect a different pattern of disease onset by phenotype. These findings have implications for screening guidelines and care of CRS patients.

Disparities in grant funding for Chronic rhinosinusitis

OBJECTIVES/HYPOTHESIS

The objective of this study was to identify the level of grant funding for chronic rhinosinusitis (CRS) with the purpose of elucidating if disparities exist compared to other common chronic diseases.

STUDY DESIGN

Review of four major health research grant agencies from the United States (National Institutes of Health), Canada (Canadian Institute of Health Research), and United Kingdom (National Institute of Health Research and Medical Research Council).

METHODS

Research operating grants awarded in the fields of CRS, asthma, diabetes, and dementia were identified using database-specific search strategies. Searches were limited to the previous 10 years (2004-2014). Comparator chronic diseases were chosen to have similar prevalence rates and low mortality risk. Research efficiency was calculated as the monetary value of grants awarded per paper published.

RESULTS

There is a large disparity in the number of grants awarded for research in CRS (n = 196; $74,774,384), asthma (n = 13,226; $8,358,861,941), diabetes (n = 54,902; $47,282,739,735), and dementia (n = 34,569; $16,709,900,125). In terms of research efficiency, CRS researchers received eight to 12 times less financial support per paper published compared to those in our comparator conditions.

CONCLUSIONS

This study has demonstrated that over the last 10 years, CRS is disproportionately underfunded (∼$75 million) compared to other similarly prevalent chronic diseases such as asthma (∼$8.3 billion), diabetes (∼$47.2 billion), and dementia (∼$16.7 billion). We feel this justifies further research into identifying and reducing barriers to obtaining grant support for CRS.

LEVEL OF EVIDENCE

NA.

Case Definitions for Chronic Rhinosinusitis in Administrative Data: A Systematic Review

Background

The use of administrative data for pharmacoepidemiology research on chronic rhinosinusitis (CRS) has become increasingly popular. Although large sample sizes and ease of accessibility have made electronic health data an attractive data option, the risk of inaccurate cohort identification can lead to biased outcomes.

Objectives

The objectives of this systematic review were to (1) report current case definitions for CRS used in administrative data base research, and (2) define the various administrative data bases used for CRS research.

Methods

Medical literature data bases were searched from the date of their inception to February 1, 2015. Included studies were publications that obtained CRS-specific data from a health records data base. Studies were excluded if they evaluated a non-CRS cohort, failed to use or report an international classification of disease (ICD) code in the case definition, or published in a non-peer-reviewed journal.

Results

Of the 27 studies that met inclusion criteria, 8 different CRS case definitions were identified and 13 administrative data bases were evaluated. Of the 8 different CRS case definitions identified, only one was validated. The most commonly used CRS case definition was the ICD-9 473.x code alone.

Conclusion

To optimize the accuracy of pharmacoepidemiologic research for CRS that used administrative data, it is important to apply appropriate case definitions for CRS. Various nonvalidated CRS case definitions are currently being used in administrative data base research. There is a need to develop a generalizable and validated ICD-based CRS case definition to increase the accuracy of future pharmacoepidemiologic research.

Basilar artery territory stroke secondary to invasive fungal sphenoid sinusitis: a case report and review of the literature

Background

Mucormycosis is a fungal infection with the following 5 classic forms: cutaneous, pulmonary, gastrointestinal, disseminated, and rhinocerebral. The rhinocerebral form can be rapidly progressive and invasive with a high mortality rate. We present a case of a 38-year-old man with invasive mucormycosis that led to a basilar artery territory stroke. Rhinocerebral mucormycosis is an unusual cause of stroke.

Case Report

A 38-year-old man with a past medical history of diabetes mellitus presented with altered mental status. A lumbar puncture revealed eosinophilic pleocytosis with a mildly elevated total protein and borderline low glucose level. CT revealed a left medullary and cerebellar infarct confirmed by MRI. MRI also displayed a diffuse marrow signal abnormality in the clivus with contiguous sinus disease. Endoscopic sinus surgery confirmed that the fungal sinusitis was mucormycosis of the Rhizopus genus, which had affected the left sphenoid sinus, invaded through the skull base, and involved the basilar artery. He was given liposomal amphotericin (500 mg i.v.) with posaconazole (400 mg i.v. twice daily). Due to the severity of the invasion and poor prognosis, the patient was discharged with comfort care measures.

Discussion

Clinicians should be aware of invasive sinusitis as a rare cause of stroke in diabetics. Once the subarachnoid space and basal arteries of the brain have been invaded, the prognosis is very poor. The key to improvement of outcomes is early recognition and treatment, and examination of the sinuses on neuroimaging in all cases of stroke is vital.

Dementia is Associated with Chronic Rhinosinusitis: A Population-Based Case-Controlled Study

Background

Cardiovascular diseases are reported to be associated with both chronic rhinosinusitis (CRS) and dementia. Nevertheless, whether dementia is associated with CRS is still unknown. In the present study, we explored the association between dementia with prior CRS using a population-based data set.

Methods

This study used the Taiwan Longitudinal Health Insurance Database 2000 as the source of data for a case-control study. We included 8768 subjects with dementia as cases and 8768 age- and sex-matched subjects as controls. We identified cases who had received a diagnosis of CRS before having received a diagnosis of dementia. Conditional logistic regression analyses were performed to examine the association of dementia with previously diagnosed CRS.

Results

Results showed that of all sampled subjects, 875 (5.0%) had been previously diagnosed with CRS. A chi-squared test showed that there was a significant difference in the prevalences of prior CRS between cases and controls (6.0% versus 4.0%; p < 0.001). The adjusted odds ratio (OR) of prior CRS for subjects with dementia was 1.44 (95% CI, 1.25—1.66) compared with controls. Furthermore, compared with controls, the OR of prior CRS was similar for subjects with dementia for both sexes (the OR for male subjects was 1.48 and OR for female subjects was 1.41).

Conclusion

We concluded that subjects with dementia had a higher odds of having had prior CRS than controls. This study implies a potential association between CRS and dementia.

The association of premorbid diseases with chronic rhinosinusitis with and without polyps

PURPOSE OF REVIEW

To review the recent insights regarding the epidemiology of adult chronic rhinosinusitis (CRS), with particular attention to its association with other premorbid conditions. Identifying premorbid disease associations establishes potential risk factors for developing CRS and helps corroborate current postulates of the various pathophysiologic mechanisms involved with the development and persistence of paranasal sinus inflammation.

RECENT FINDINGS

Recent findings demonstrate that the diagnosis of CRS is associated with a higher premorbid prevalence of upper airway diseases, lower airway diseases, gastroesophageal reflux disease, diseases of epithelial tissues, autoimmune disorders, and psychiatric conditions. Although some of these conditions have long been associated with CRS, improvements in study design and future studies in the general population will more accurately estimate the relative strengths of associations, clinical relevance, and temporal relationship of these various conditions in relation to the development of CRS.

SUMMARY

The predisposing patterns of premorbid illnesses may provide valuable information regarding the underlying causes of CRS and allow for both therapeutic and preventive interventions. There remains conflicting evidence within the literature regarding the association of CRS with some medical conditions, signifying the need for continued research on the subject. Limitations of the current studies include small sample sizes, lack of prospective longitudinal or interventional studies that help establish causality, and variable criteria for diagnosis of CRS in the outpatient setting.

Association between ischemic stroke and iron-deficiency anemia: a population-based study

Background

Very little is known about the relationship between non-sickle cell anemia and stroke. The purpose of this study is to evaluate the association of iron-deficiency anemia (IDA) with stroke based on a nationwide coverage database in Taiwan.

Methods

The case-control study subjects were obtained from the Taiwanese Longitudinal Health Insurance Database 2000. We included 51,093 subjects with stroke as cases and randomly selected 153,279 controls (3 controls per case) in this study.Separate conditional logistic regression analyses were used to calculate the odds ratio (OR) for having been previously diagnosed with IDA between cases and controls.We further analyzed the association between stroke and IDA by stroke subtype.

Results

Results showed that 3,685 study subjects (1.81%) had been diagnosed with IDA prior to the index date; of those subjects, 1,268 (2.48%) were cases and 2,417 (1.58%) were controls (p<0.001). Conditional logistic regression shows that the OR of having previously received an IDA diagnosis among cases was 1.49 (95% CI: 1.39~1.60; p < 0.01) that of controls after adjusting for monthly income, geographic region, hypertension, diabetes, coronary heart disease, atrial fibrillation, heart failure, hyperlipidemia, tobacco use disorder, and alcohol abuse/alcohol dependency syndrome. Furthermore, the adjusted OR of prior IDA for cases with ischemic stroke was found to be 1.45 (95% CI: 1.34~1.58) compared to controls. However, we did not find any significant relationship between IDA and subarachnoid/intracerebral hemorrhage even adjusting for other confounding factors (OR=1.17, 95% CI=0.97~1.40).

Conclusion

There is a significant association between prior IDA and ischemic stroke.