Revision rates and time to revision following endoscopic sinus surgery: A large database analysis

Surgical management of headache and facial pain/pressure in chronic rhinosinusitis: A systematic review and meta-analysis

BACKGROUND

Headache and facial pain are common symptoms of chronic rhinosinusitis (CRS). However, given the numerous etiologies that can cause these symptoms, the impact of sinus surgery is not well characterized.

METHODS

A systematic review was performed by searching the literature from inception through June 6, 2023. English-language articles reporting outcomes for facial pain/pressure or headache following endoscopic sinus surgery were selected for inclusion. Meta-analyses were performed using random and fixed effect models on continuous measures (mean), mean difference (Δ), and proportions (%).

RESULTS

A total of 26 articles reporting on 2839 patients were selected for inclusion. The mean patient age was 44.0 ± 3.9 (range 16.0-84.0), with an average symptom duration of 5.3 ± 2.8 years. Among these patients, 56.5% (95% confidence interval [CI]: 52.3-60.6) were male and 77.0% (95% CI: 56.6-92.3) had nasal polyposis (NP). Patients with and without NP reported substantial reductions in both 22-item sino-nasal outcome test facial pain/pressure (with NP: -1.4 [95% CI: -1.6 to -1.2; relative reduction 59.1%]; without NP: -1.5 [95% CI: -1.9 to -1.1; relative reduction 60.9%]) and visual analogue scale (VAS) headache (with NP: -2.5 [95% CI: -2.8 to -2.1; relative reduction 67.2%]; without NP: -2.8 [95% CI: -4.7 to -1.0; relative reduction 42.7%]). Symptom reductions were greater in the without NP versus with NP group; VAS facial pain/pressure: Δ0.4 (95% CI: 0.2-0.6; p = 0.0006) and VAS headache: Δ0.4 (95% CI: 0.1-0.7; p = 0.02).

CONCLUSIONS

Our findings suggest that CRS patients, regardless of polyp status, benefit from significant reductions in facial pain/pressure and headache following surgical therapy.

Comparative Effectiveness of Dupilumab Versus Sinus Surgery for Chronic Rhinosinusitis With Polyps: Systematic Review and a Meta-Analysis

BACKGROUND

Current treatment paradigms recommend surgical intervention when conventional medical management proves ineffective in resolving chronic rhinosinusitis with nasal polyposis.

OBJECTIVES

To assess and compare the efficacy of dupilumab and functional endoscopic sinus surgery (FESS) for the treatment of chronic rhinosinusitis with nasal polyp (CRSwNP) over time.

METHODS

Studies comparing CRSwNP patients who received dupilumab with those who underwent FESS were included. Outcome measures included the nasal congestion score (NCS), Sino-nasal Outcome Test-22 (SNOT-22), University of Pennsylvania Smell Identification Test-40 (UPSIT-40), and nasal polyp score (NPS). The risk of bias was evaluated using the Newcastle-Ottawa Scale.

RESULTS

A total of 4 studies with 724 participants were included. The dupilumab group had a superior NCS, but an inferior NPS, compared to the FESS group during the follow-up period. The SNOT-22 score of the dupilumab group was inferior to that of the FESS group until 6 months posttreatment, but the scores were similar at around 1 year. A similar trend was observed for the UPSIT-40 score, but the score of the dupilumab group was higher at around 1 year.

CONCLUSION

Functional endoscopic sinus surgery was more effective than dupilumab for several months after treatment. However, at 1 year after treatment, the effects of the 2 treatments became similar, with greater olfactory improvement seen in the dupilumab group.

Patterns of Olfactory Impairment Among Patients with Uncontrolled Chronic Rhinosinusitis

OBJECTIVES

Self-reported olfactory dysfunction is an assessment component criterion for chronic rhinosinusitis (CRS) disease control of the European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS). No studies have objectively explored olfactory function across different psychophysical olfactory domains among patients with uncontrolled CRS. We aimed to investigate the patterns of olfactory impairment in patients with uncontrolled CRS with Sniffin' Sticks test.

METHODS

A total of 79 patients with CRS were prospectively recruited and assessed for disease control based on the EPOS criteria. Sniffin' Sticks test scores, olfactory cleft computed tomography (CT) scores, olfactory cleft endoscopy scale (OCES), questionnaire of olfactory disorders-negative statements (QOD-NS), and sinonasal outcome test-22 (SNOT-22) were obtained. Multiple logistic regression was applied to explore risk factors of uncontrolled CRS.

RESULTS

Twenty-six percent of patients with CRS presented with uncontrolled status. The odor threshold (OT) (p = 0.005), odor identification (OI) (p = 0.041), and thresholds-discrimination-identification (TDI) (p = 0.029) scores were significantly lower in patients with uncontrolled CRS when compared with patients with controlled CRS. Furthermore, patients with uncontrolled CRS presented with a significantly increased percentage of anosmia (p = 0.014), olfactory cleft CT score (p = 0.038), OCES (p = 0.016), QOD-NS(p = 0.008), and SNOT-22 (p < 0.001) scores than patients with controlled CRS. After adjusting for patient demographics, as for the subdomain of olfaction, only the OT score was an independent risk factor for uncontrolled CRS (odds ratio = 0.604; p = 0.030). The OT scores less than 5.950 were the best predictor of uncontrolled CRS.

CONCLUSION

Patients with uncontrolled CRS demonstrated distinct patterns of olfactory impairment, and a reduced olfactory threshold was highly associated with uncontrolled CRS.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:2341-2348, 2024.

Multivariate analysis of clinical and radiological risk factors for revision endoscopic sinus surgery in patients with chronic rhinosinusitis with nasal polyps: can phenotype predict recurrence?

OBJECTIVE

This study aimed to analyse clinical and radiological features (phenotypes) to predict revision risk after functional endoscopic sinus surgery in patients with chronic rhinosinusitis with nasal polyps.

METHOD

Phenotype characteristics of the patients with chronic rhinosinusitis with nasal polyps who underwent functional endoscopic sinus surgery were analysed retrospectively.

RESULTS

The rates of asthma, aspirin sensitivity, smoking and a positive prick test result were significantly higher in revision functional endoscopic sinus surgery cases (p < 0.001, 0.001, < 0.001 and < 0.001, respectively). Multivariate analysis demonstrated that only gender, pre-operative nasal steroid use, pre-operative systemic steroid use, intra-operative systemic steroid use and smoking were significant risk factors for revision functional endoscopic sinus surgery (p = 0.034, 0.001, 0.010, 0.007 and 0.001, respectively). In addition, only eosinophilia and aspirin sensitivity were significant risk factors for multiple revision functional endoscopic sinus surgery procedures (p = 0.043 and 0.005, odds ratio = 2.4 and 5.2).

CONCLUSION

Beyond the endotype of chronic rhinosinusitis with nasal polyps, defining clinical and radiological factors enables a valid prediction of patients at high risk of revision functional endoscopic sinus surgery.

Outcomes of Endoscopic Sinus Surgery for Chronic Rhinosinusitis With Nasal Polyposis and Risk Factors of Recurrence in a Tertiary Care Teaching Hospital

Background

Endoscopic sinus surgery (ESS) has become the gold standard for treating patients with chronic rhinosinusitis (CRS) refractory to medical therapy. It is considered a relatively safe and effective procedure in all age groups, with overall success rates ranging from 76% to 97.5%. However, failure of primary endoscopic sinus surgery (PESS) occurs at a rate ranging from 2% to 24%. Patients who are still symptomatic after PESS and optimal medical therapy are candidates for revision endoscopic sinus surgery (RESS).

Objectives

to study the outcomes of ESS and assess the risk factors of recurrence of nasal polyps, as well as to compare the outcomes of PESS and RESS at a tertiary care teaching hospital.

Design

A retrospective cross-sectional study.

Methods

This study is conducted on patients with CRS with nasal polyps (CRSwNP) who underwent ESS at King Saud University Medical City (KSUMC) between May 2015 and December 2021. During this period, ESS was performed 470 times for CRSwNP. The Sinonasal Outcome Test 22 (SNOT-22) questionnaire, the Lund-Kennedy (LK) score, the Lund-MacKay (LM) score, and the polyp grading system were used to evaluate subjective and objective outcomes. They were scored preoperatively and from 6 to 12 months postoperatively.

Results

Out of the 470 endoscopic sinus surgeries, 321 (68.3%) were PESS and 149 (31.7%) were RESS. Asthma, aspirin sensitivity, and Samter's triad were observed more in the RESS group. The LK and LM scores were significantly different between primary and revision sinus surgeries, revealing that PESS patients had better postoperative LK and LM scores. The RESS patients had significantly worse postoperative SNOT-22 scores compared to PESS patients.

Conclusion

Lund-MacKay, Lund-Kennedy, and SNOT-22 scores improved after ESS for both primary and revision ESS patients, with better outcomes observed after PESS compared to RESS. The presence of asthma, aspirin sensitivity, Samter's Triad, high-grade nasal polyps, and older age were identified as risk factors for CRSwNP recurrence, which may require RESS.

Reduction in healthcare resource use through 24 months following sinus surgery with steroid-eluting implants in chronic rhinosinusitis patients with and without nasal polyps: a real-world study

OBJECTIVE

To investigate the impact of steroid-eluting implants after endoscopic sinus surgery (ESS) on health care resource use (HCRU) in chronic rhinosinusitis patients with (CRSwNP) and without (CRSsNP) nasal polyps.

METHODS

This retrospective, observational cohort study using real-world evidence data included adult patients with CRS who underwent ESS in 2015-2019 with at least 24 months of data before and after ESS. Patients who received implants were matched to patients who did not based on a propensity score developed using baseline characteristics and NP status. HCRU was compared between cohorts within each CRSwNP and CRSsNP subgroup using chi-square tests (binary variables).

RESULTS

The implant cohort in the CRSwNP subgroup had fewer all-cause outpatient (90.0% vs. 93.9%, p < .001) and all-cause otolaryngology (64.3% vs. 76.4%, p < .001) visits as well as fewer endoscopy (40.5% vs. 47.4%, p = .005) and debridement (48.8% vs. 55.6%, p = .007) procedures than the non-implant cohort. The implant cohort in the CRSsNP subgroup had fewer all-cause outpatient (88.9% vs. 94.2%, p < .001) and all-cause otolaryngology (53.5% vs. 74.4%, p < .001) visits as well as fewer endoscopy (31.8% vs. 41.7%, p < .001) and debridement (36.7% vs. 53.4%, p <.001) procedures than the non-implant cohort. Revision sinus surgery was reduced in the implant cohort in both subgroups, and reached statistical significance in the CRSwNP subgroup (3.8% vs. 6.0%, p = .039) but not in the CRSsNP subgroup (3.6% vs. 4.2%, p = .539).

CONCLUSIONS

Overall, patients receiving implants had lower HCRU for 24 months after sinus surgery independent of nasal polyp status, and revision surgery was reduced in CRSwNP patients. These findings provide additional evidence that long-term reductions in HCRU may be achieved with steroid-eluting implant use during sinus surgery.What is known on this topicPatients with chronic rhinosinusitis with nasal polyps (CRSwNP) have a disproportionately higher burden of disease and consume greater healthcare resources than chronic rhinosinusitis patients without nasal polyps (CRSsNP).CRSwNP patients represent approximately 30% of CRS patients who undergo surgery, but their clinical course is disproportionally complicated by disease recurrence and revision surgery.Steroid-eluting sinus implants have been shown in clinical trials to improve short-term postoperative outcomes after endoscopic sinus surgery (ESS) in CRS patients in general.A recent real-world evidence study reported that steroid-eluting sinus implants following ESS were associated with a reduction in HCRU in CRS patients followed for 18 months, but the impact of implants on HCRU in CRSwNP and CRSsNP patients separately remains unknown. What this study addsIn this observational study, reduced HCRU was observed in CRSwNP and CRSsNP patients who receive steroid-eluting sinus implants.Use of implants in CRSwNP and CRSsNP patients was associated with a significant reduction in healthcare visits (all-cause outpatient, all-cause otolaryngology), and sinus procedures (endoscopy, debridement).Revision surgery was significantly reduced in the implant cohort of CRSwNP patients and trended lower in the implant cohort of CRSsNP patients.Use of implants had no significant impact on all-cause ER/urgent care visits or sinus-related imaging.

Ostial Patency Measurements After Endoscopic Sphenoidotomies and Frontal Sinusotomies

BACKGROUND

Sphenoid and frontal sinuses have narrow ostia and are prone to stenosis. However, their relative rates of patency are not well established, and descriptive rates of sphenoid stenosis have never been reported. The objective is to measure the patency of the sphenoid and frontal sinus ostia postoperatively.

METHODS

A prospective multi-institutional cohort study was performed. Ostial patency was measured at surgery and 3 and 6 months postoperatively. Pertinent clinical history such as the presence of nasal polyps and prior history of ESS as well as the use of steroid eluting stents were recorded. Overall stenosis rates were calculated for both the sphenoid and frontal sinuses, and Wilcoxon-Signed Rank Test was used to compare intraoperative and postoperative ostial areas. Factorial Analysis of Variance (ANOVA) was performed to determine effects of 5 clinical factors.

RESULTS

Fifty patients were included. The mean sphenoid sinus ostial area decreased 42.2% in size from baseline to 3 months postoperatively (T0 55.2 ± 28.7 mm vs T3 m 31.8 ± 25.5 mm, P < .001). The mean frontal sinus ostial area decreased 39.8% in size from baseline to 3 months postoperatively (T0 33.7 ± 17.2 mm vs T3 m 19.9 ± 15.1 mm, P < .001). Neither the sphenoid nor the frontal sinus ostial patency demonstrated statistically significant change from 3 to 6 months postoperatively.

CONCLUSION

Both sphenoid and frontal sinus ostia routinely narrow postoperatively, predominately from baseline to 3 months. These findings can serve as a reference for both clinical outcomes and future studies of these surgeries.

The Impact of Gender on Long-Term Quality of Life After Sinus Surgery for Chronic Rhinosinusitis

OBJECTIVE

To identify the impact of gender on the clinical outcomes of endoscopic sinus surgery (ESS) through the comparison of quality of life measures in female and male patients who undergo surgical treatment for chronic rhinosinusitis (CRS).

STUDY DESIGN

Prospective observational cohort study.

METHODS

Patients with CRS completed the 22-item Sino-Nasal Outcome Test (SNOT-22) and EuroQol 5-Dimension Survey (EQ-5D) preoperatively and annually for 5 years following ESS. Health utility values (HUV) were calculated from EQ-5D scores. Comparisons of cohort characteristics were performed with chi-square and t-tests. A multivariable linear mixed effects model evaluated changes in SNOT-22 and HUV over time by gender.

RESULTS

Among the 1268 patients (54% female) enrolled, 789 and 343 completed postoperative surveys at one and 5 years, respectively. Preoperatively, females experienced more severe symptoms: mean SNOT-22 score (51.1 ± 20.9 female vs. 44.7 ± 20.0 male, p < 0.001) and HUV (0.80 ± 0.14 female vs. 0.84 ± 0.11 male, p < 0.001). These gender differences were resolved by year one postoperatively (SNOT-22: p = 0.083; HUV: p = 0.465). Two years after surgery, however, females reported more severe symptoms (SNOT-22: 25.6 ± 20.7 female vs. 21.5 ± 17.4 male, p = 0.005; HUV: 0.88 ± 0.12 female vs. 0.90 ± 0.11 male, p = 0.018), a difference that persisted at year five. These gender-related differences remained after adjusting for age, race, ethnicity, nasal polyps, history of prior ESS, and smoking status (p < 0.001). Within-subject improvement was comparable between genders (SNOT-22: p = 0.869; HUV: p = 0.611).

CONCLUSION

Females with CRS reported more severe symptoms both before and 5 years after surgery compared to their male counterparts. Understanding the mechanism behind these gender-related differences is important for optimizing CRS treatment.

LEVEL OF EVIDENCE

2 Laryngoscope, 133:3319-3326, 2023.

Predictors and Time Interval of Chronic Rhinosinusitis Recurrence After Endoscopic Sinus Surgery

Objective

Chronic rhinosinusitis (CRS) is a common inflammatory disease that significantly impacts the quality of life. Endoscopic sinus surgery (ESS) is indicated for refractory CRS. This study aims to estimate the predictors of CRS recurrence, and the rates with time intervals of recurrent CRS and revision ESS.

Methods

A retrospective cohort study included 516 patients who underwent ESS for CRS at King Abdulaziz Medical City in Riyadh between January 2017 and May 2020. Patients were followed up for 12-48 months postoperatively. The study sample was divided into two groups based on the recurrence status and compared using the appropriate statistical tests. Significant variables were included in the logistic regression model to determine the predictors of CRS recurrence.

Results

The recurrence rate of CRS following ESS was 14.5%, with a time interval of 28.31 months, and standard deviation (SD) =18.76. On the other hand, the rate of revision ESS for recurrent CRS was 6.8%, with a time interval of 34.18 months, SD =16. In the multivariable logistic regression model, the significant predictors of recurrent CRS were a high Lund-Mackay (LM) score [odds ratio (OR): 1.055, p=0.04] and a high eosinophil count (OR: 3.619, p=0.03). Almost half of the patients who developed recurrent CRS underwent revision surgery (46.7%).

Conclusion

CRS has a considerable recurrence rate despite the high success rate of ESS, and nearly half of the recurrent CRS patients need revision surgery. A high LM score and eosinophilic count significantly increase the likelihood of CRS recurrence.

Revision Rates and Symptom Trends Following Endoscopic Sinus Surgery: Impact of Race on Outcomes

OBJECTIVE

The purpose of this study is to determine the impact of demographics and sinonasal comorbidities on the revision rate of functional endoscopic sinus surgery (FESS) for chronic rhinosinusitis (CRS).

BACKGROUND

Although endoscopic sinus surgery (ESS) is often successful in providing long-term relief for patients suffering from CRS, revision surgery can occur. There is conflicting literature on the impact of race on FESS outcomes.

METHODS

A single-center retrospective cohort study of patients that underwent FESS for CRS between January 1, 2015 and June 1, 2021 at a single tertiary care academic center.

RESULTS

A total of 682 patients between the ages of 18 and 89 underwent primary ESS between January 1, 2015 and June 1, 2021 and were included in this study. Of these patients, 388 (56.9%) were female, with an average age of 48.6 ± 16.7. Thirty-eight patients (5.6%) underwent revision sinus surgery during the study period. Patients that identified as White had significantly lower rates of revision sinus surgery (4.1%) than non-White patients (10.7%), including those identifying as Asian, Black, multiracial, or other. On multivariate analysis, non-White race (OR 4.933), polyposis (3.175), and high preoperative SNOT-22 scores (OR 1.029) were independently associated with revision sinus surgery. The mean preoperative SNOT-22 for all participants was 39.1 ± 22.0, whereas the mean postoperative SNOT-22 was 20.6 ± 17.5 (p < 0.001).

CONCLUSION

Race plays an important role in outcomes following revision sinus surgery that is independent of location and insurance status. More studies are required to assess the reason race plays an important role in outcomes following revision sinus surgery.

LEVEL OF EVIDENCE

Level 3 Laryngoscope, 133:2878-2884, 2023.

Biological sex as a modulator in rhinologic anatomy, physiology, and pathology: A scoping review

BACKGROUND

Biological sex is increasingly recognized as a critical variable in health care. The authors reviewed the current literature regarding sex-based differences in rhinology to summarize the data and identify critical knowledge gaps.

METHODS

A scoping review was conducted. Publications reporting sex-based differences in anatomy, physiology, and pathology focusing on disease prevalence, disease burden, and outcomes in rhinology were identified.

RESULTS

Seventy-five relevant manuscripts were identified. While paranasal sinuses are of similar size at birth, they become larger in males leading to differences in ostium location. Females outperform males in olfactory identification but only in the 18- to 50-year age group. Estrogen and progesterone administration can impact muscarinic and α1 -adrenergic nasal mucosa receptor density. Chronic rhinosinusitis (CRS) and CRS without nasal polyps are more prevalent in females while CRS with nasal polyps is more prevalent in males. CRS symptom burden is higher in females before and after endoscopic sinus surgery; however, no difference in endoscopic sinus surgery utilization was found based on sex. Allergic rhinitis is more common in males before puberty and in females after puberty. Epistaxis is more prevalent in males and postmenopausal females compared with premenopausal females, perhaps from differences in sex-hormonal and hypertension status. In nasopharyngeal carcinoma, the incidence of sinus abnormalities was higher in males than females.

CONCLUSIONS

Although many sex-based differences exist in rhinology, further research is necessary to offer evidence-based treatment guidelines. Gonadal hormones should be studied as a therapeutic in rhinologic pathology as baseline physiologic differences exist such as those found in nasal mucosa receptor density.

Endoscopic sinus surgery outcomes in patients with chronic rhinosinusitis and immunoglobulin deficiencies

BACKGROUND

Patients with chronic rhinosinusitis (CRS) and immunoglobulin deficiencies (ID) have more recalcitrant sinonasal disease and a subset of these patients undergo surgical management for their CRS. However, there is a paucity of literature on the surgical outcomes in this patient population and appropriate treatment algorithms for CRS in patients with ID. The objective of this study was to better elucidate the outcomes of endoscopic sinus surgery (ESS) in patients with ID in terms of disease-specific quality-of-life scores and the need for revision surgery.

METHODS

A case-control study was performed comparing adult patients with ID and healthy controls that had undergone ESS for CRS. Patients were matched based on age, sex, CRS phenotype, and preoperative Lund-Mackay score. The revision surgery rates, time to revision surgery, and changes in sinonasal outcome tests (SNOT-22) were evaluated.

RESULTS

Thirteen patients with CRS and ID were matched to 26 control patients with CRS. The revision surgery rate for cases and controls was 31% and 12%, respectively, but there was no statistical difference (p > 0.05). There was a clinically meaningful reduction in SNOT-22 scores in both groups from the preoperative to postoperative period [mean of 12 points in patients with ID (p = 0.323) and 25 points in controls (p < 0.001)], however, there was again no significant difference between cases and controls (p > 0.05).

CONCLUSION

Our data suggests that patients with ID have clinically meaningful improvement in SNOT-22 scores after ESS but may have higher revision rates than immunocompetent patients with CRS. ID are rare disease entities, thus most attempts at studying this cohort would be limited by sample size. Further homogenous data on immunoglobulin deficient patients is required for future meta-analysis to better understand the impact of ESS in patients with ID.

Revision of endoscopic sinus surgery in adults: A population-based study in Taiwan

OBJECTIVE

This study aimed to elucidate the revision rate, time to revision, and factors associated with revision of endoscopic sinus surgery (ESS) in Taiwan.

DESIGN

Retrospective study.

SETTING

Population-based analysis.

PARTICIPANT

We identified all in-hospital patients, aged >20 years, who underwent ESS between 2000 and 2008 from the Taiwan National Health Insurance Research Database, and followed up with them until 2018.

MAIN OUTCOME MEASURES

Factors associated with revision surgery were analyzed using multivariable Cox proportional hazard model.

RESULTS

Overall, 66 592 patients were identified (mean age, 46.3 years; 62% males). The revision rate was 14.5% (9644/66 592) and time to revision surgery was 5.9 years. Multivariable Cox proportional hazard model showed that young age, male gender (hazard ratio [HR] = 1.18; 95% confidence interval [CI], 1.13-1.23), having nasal polyposis (HR = 1.17; 95% CI, 1.12-1.22), having allergic rhinitis (HR = 1.08; 95% CI, 1.04-1.13), having asthma (HR = 1.26; 95% CI, 1.14-1.39), and surgical time of >4 h (HR = 1.11; 95% CI, 1.06-1.16) were associated with increased risk of revision surgery. Concurrent septal surgery (HR = 0.81; 95% CI, 0.76-0.87), turbinate surgery (HR = 0.91; 95% CI, 0.85-0.97), or septal and turbinate surgery (HR = 0.68; 95% CI, 0.64-0.73) were associated with decreased risks of revision surgery.

CONCLUSION

In Taiwan, risk factors for revision ESS are young age, male gender, having nasal polyposis, having allergic rhinitis, having asthma, and long surgical times. Concurrent septal or turbinate surgery decreases the risk of revision.

Image guided dilation of sinus ostium in revision sinus surgery

PURPOSE

Assess if a rigid, image-guided balloon could be used effectively and safely in revision sinus surgery.

MATERIALS AND METHODS

A prospective, non-randomized, single-arm, multicenter study to assess the safety and device performance of the NuVent™ EM Balloon Sinus Dilation System. Adults with CRS in need of revision sinus surgery were enrolled for balloon sinus dilation of a frontal, sphenoid, or maxillary sinus. The primary device performance endpoint was the ability of the device to (1) navigate to; and (2) dilate tissue in subjects with scarred, granulated, or previously surgically-altered tissue (revision). Safety outcomes included the assessment of any operative adverse events (AEs) directly attributable to the device or for which direct cause could not be determined. A follow-up endoscopy was conducted at 14 days post-treatment for assessment of any AEs. Performance outcomes included the surgeon's ability to reach the target sinus (es) and dilate the ostia. Endoscopic photos were captured for each treated sinus pre- and post-dilation.

RESULTS

At 6 US clinical sites, 51 subjects were enrolled; 1 subject withdrew before treatment due to a cardiac complication from anesthesia. 121 sinuses were treated in 50 subjects. The device performed as expected in 100 % of the 121 treated sinuses, with investigators able to navigate to the treatment area and dilate the sinus ostium without difficulty. Ten AEs were seen in 9 subjects, with 0 related to the device.

CONCLUSION

The targeted frontal, maxillary or sphenoid sinus ostium were safely dilated in every revision subject treated, with no AEs directly attributed to the device.

A Decade of Clinical Advances in Chronic Rhinosinusitis: 2012-2022

The field of chronic rhinosinusitis (CRS) is constantly evolving. In the past 10 years, key advancements in basic and translational research as well as clinical studies have improved our understanding and management of CRS. Notably, treatment options have expanded to include novel therapeutic drugs, devices, and surgical techniques. Assessments of patient symptoms and their impact on quality of life have become more standardized. Progress has also been made in both determining the true prevalence of CRS and recognizing comorbidities that can impact CRS severity. Practice guidelines have also shifted from expert opinion to more data-driven analyses. This review highlights major clinical advancements made in the field of CRS over the past 10 years as well as identifies current gaps in knowledge that can form the basis for new areas of study over the next decade.

Neutrophils Play an Important Role in the Recurrence of Chronic Rhinosinusitis with Nasal Polyps

Despite the heterogeneity of chronic rhinosinusitis (CRS), a clear link exists between type 2 immunity and the severity of CRS with nasal polyps (CRSwNP). However, recent studies have demonstrated that patients with severe type 2 CRSwNP also display abundant neutrophilic inflammation. Therefore, we investigated the factors associated with the recurrence of CRSwNP following sinus surgery using a machine-learning algorithm. We collected the demographics, clinical variables, and inflammatory profiles of 210 patients with CRSwNP who underwent sinus surgery. After one year, we evaluated whether each patient showed recurrence. Machine-learning methods, such as decision trees, random forests, and support vector machine models, have been used to predict the recurrence of CRSwNP. The results indicated that neutrophil inflammation, such as tissue and serum neutrophils, is an important factor affecting the recurrence of surgical CRSwNP. Specifically, the random forest model showed the highest accuracy in detecting recurrence among the three machine-learning methods, which revealed tissue neutrophilia to be the most important variable in determining surgical outcomes. Therefore, our machine-learning approach suggests that neutrophilic inflammation is increased in patients with difficult-to-treat CRSwNP, and the increased presence of neutrophils in subepithelial regions is closely related to poor surgical outcomes in patients with CRSwNP.

Subgroups in the treatment of nasal polyposis with dupilumab: A retrospective study

Dupilumab has been shown to be safe and effective in treating chronic rhinosinusitis with polyposis (CRSwNP). There is to this date no published data whether subgroups like patients with aspirin exacerbated respiratory disease (AERD), increased histologic eosinophilia or elevated blood eosinophil or IgE-levels benefit greater from dupilumab therapy. Moreover, there is no data comparing the efficacy of functional endoscopic sinus surgery (FESS) with dupilumab therapy. We conducted a retrospective chart review of all patients that were treated at a tertiary referral center for CRswNP with dupilumab. We also contacted the patients with a questionnaire to evaluate the efficacy of previous surgeries and dupilumab therapy by visual analogue scale (VAS) and the glasgow benefit inventory (GBI) as well as report on side effects. Overall, 75 patients were included in the study at hand that reported back 138 times. While dupilumab treatment was efficient, we found no systematic evidence of greater efficacy of dupilumab in patients with AERD, histologic eosinophilia or increased blood eosinophil or IgE-levels. All patients showed a considerable decrease in subjective burden of disease, objective smell tests and endoscopic findings. From the patients point of view, dupilumab therapy showed greater efficacy both in the VAS and the GBI overall and all subcategories but "social support." Dupilumab is efficient in treating CRSwNP; this effect is independent from disease characteristics like AERD, histologic eosinophilia, serum IgE-levels or eosinophil counts. There seems to be a group of patients that benefit greater from dupilumab therapy compared to FESS.

Utility of Preoperative Laboratory Testing for Ambulatory Endoscopic Sinonasal Surgery in Low-Risk Patients

Background

Preoperative laboratory tests (PLTs) are often obtained prior to outpatient surgical procedures. The objective of this study is to examine the current practice of routine PLT in low-risk patients undergoing ambulatory endoscopic sinonasal surgery (ESS) and to assess whether such testing impacts surgical outcomes.

Methods

Patients undergoing ambulatory ESS were identified from the 2011 to 2018 NSQIP database. Low-risk patients were defined as American Society of Anesthesiologist class 1 or 2. PLTs were grouped into hematologic, chemistry, coagulation, and liver function tests. Chi-square analyses and independent samples t-tests were conducted to compare categoric and continuous variables, respectively.

Results

A total of 664 cases met the inclusion criteria, of which 419 (62.1%) underwent at least one PLT. Of these, the most frequent PLT obtained was a complete blood cell count (92.4%). Major complications occurred in 1.5% of patients. There were no statistically significant differences in overall postoperative complications between those with and without PLT ( P = .264). Specifically, no significant difference was seen in the incidence of postoperative bleeding ( P = .184), urinary tract infection ( P = .444), pulmonary embolism ( P = .444), or wound infection ( P = .701). On multivariable analyses, PLT status was not significantly associated with any complication ( P = .097) or unplanned readmission ( P = .898).

Conclusions

Our analysis did not reveal an association between the use of PLT and postoperative morbidity or unplanned readmission in low-risk patients undergoing outpatient ESS.

Host and Surgical Factors Affecting the Frequency and Duration of Revision Endoscopic Sinus Surgery

Background

Endoscopic sinus surgery is accepted as an effective surgical approach in the management of chronic rhinosinusitis. Different clinical pictures can be observed in chronic rhinosinusitis with nasal polyps (CRSwNP). Unfortunately, the eradication of the disease is impossible in all cases even if it is performed by experienced surgeons. In a significant number of patients, the polyps may regenerate and symptoms may reappear more or less in different durations. Due to the complex pathophysiology of the disease, revision sinus surgery is accepted as a multifactorial problem. We investigated the possible host and surgical factors which are related to increased frequency and earlier revision surgeries in CRSwNP.

Methodology

Patients operated on two or more times between 2010 and 2020 were retrospectively identified. A total of 49 patients with CRSwNP (38 male, 11 female) were statistically analyzed. The effects of host and surgical factors on the frequency and duration of revision surgery in CRSwNP were assessed.

Results

Samter’s syndrome was noted to be a significant host factor affecting recurrence and revision surgeries. In addition, we observed significantly more frequent scarring and adhesions in patients with a higher number of operations.

Conclusions

Patients with Samter’s syndrome should be informed of possible revision surgeries. The soft and mucosa-preserving technique is important for less scarring and good postoperative results.

Anxiety and depression mood disorder in patients with nasal septal deviation: A systematic review and meta-analysis

BACKGROUND

Nasal septal deviation (NSD) is one of the most prevalent upper airway diseases causing airway obstruction, and it can negatively impact patients' quality of life (QoL).

OBJECTIVE

The aim of this study was to determine the risk of anxiety and depression mood disorders in patients with NSD.

METHODS

A systematic review and meta-analysis was performed according to the PRISMA statement. An electronic search was performed on PubMed/MEDLINE, Scopus and Google Scholar. Raw affect size data were pooled comparing standardized between group mean differences.

RESULTS

A total of 625 patients (males: 53 %, n = 280/525) with a mean age of 32.4 years (n = 375, 95 % CI: 25.3-39.4) were included. The pooled standardized mean differences (SMD) for the prevalence of the anxiety disorder was 1.17 (n = 625, 95 % CI: 0.34-2.0). The pooled SMD for the prevalence of the depression disorder was 0.30 (n = 490, 95 % CI: 0.12-0.48).

CONCLUSION

Prevalence of anxiety and depression mood disorders is higher in patients with NSD compared to controls. These diseases should be investigated and considered during the diagnostic and therapeutic process to improve the QoL of patients with NSD.

Using machine learning for the personalised prediction of revision endoscopic sinus surgery

BACKGROUND

Revision endoscopic sinus surgery (ESS) is often considered for chronic rhinosinusitis (CRS) if maximal conservative treatment and baseline ESS prove insufficient. Emerging research outlines the risk factors of revision ESS. However, accurately predicting revision ESS at the individual level remains uncertain. This study aims to examine the prediction accuracy of revision ESS and to identify the effects of risk factors at the individual level.

METHODS

We collected demographic and clinical variables from the electronic health records of 767 surgical CRS patients ≥16 years of age. Revision ESS was performed on 111 (14.5%) patients. The prediction accuracy of revision ESS was examined by training and validating different machine learning models, while the effects of variables were analysed using the Shapley values and partial dependence plots.

RESULTS

The logistic regression, gradient boosting and random forest classifiers performed similarly in predicting revision ESS. Area under the receiving operating characteristic curve (AUROC) values were 0.744, 0.741 and 0.730, respectively, using data collected from the baseline visit until six months after baseline ESS. The length of time during which data were collected improved the prediction performance. For data collection times of 0, 3, 6 and 12 months after baseline ESS, AUROC values for the logistic regression were 0.682, 0.715, 0.744 and 0.784, respectively. The number of visits before or after baseline ESS, the number of days from the baseline visit to the baseline ESS, patient age, CRS with nasal polyps (CRSwNP), asthma, non-steroidal anti-inflammatory drug exacerbated respiratory disease and immunodeficiency or suspicion of it all associated with revision ESS. Patient age and number of visits before baseline ESS carried non-linear effects for predictions.

CONCLUSIONS

Intelligent data analysis identified important predictors of revision ESS at the individual level, such as the frequency of clinical visits, patient age, Type 2 high diseases and immunodeficiency or a suspicion of it.

Clinical and biological markers in disease and biologics to treat chronic rhinosinusitis

PURPOSE OF REVIEW

Chronic rhinosinusitis (CRS) is a heterogeneous disorder with diverse responses to conventional anti-inflammatory medical and surgical treatments. Even for the newly developed mAbs targeting type 2 (T2) reaction, a considerable number of patients with CRS with nasal polyps (CRSwNP) exhibited unsatisfying response. Identifying patients with a tendency to poor prognosis is critical for selecting targeted therapies to improve the treatment outcome. This review focuses on clinical and biological markers associated with prognosis of CRS patients under conventional medical and surgical treatments and provides an update summary of potential markers for T2 biologics.

RECENT FINDINGS

Allergic rhinitis, asthma, prior sinus surgery, nasal polyps, tissue eosinophilia and neutrophilia, blood eosinophilia and high levels of Charcot-Leyden crystal, cystatin SN, chemokine (C-C motif) ligand 17, macrophage inflammatory protein-1β and interleukin (IL)-5 in nasal secretions have been associated with poor prognosis in CRS patients under conventional medical and surgical treatments. Blood eosinophil level might be a biomarker for anti-IL-5 (mepolizumab) and anti-IL-5R (benralizumab) biologic in patients with refractory CRSwNP.

SUMMARY

Several clinical and biological markers have been associated with poor response to conventional treatments in CRS patients; however, majority of them should be verified by large-scale multicentre studies. More efforts are needed to identify biomarkers for biologics.

Factors Associated with Revision Sinus Surgery in Patients with Chronic Rhinosinusitis

Endoscopic sinus surgery (ESS) is performed in patients diagnosed with Chronic Rhinosinusitis (CRS) refractory to primary medical therapy to achieve adequate disease control. This study aimed to assess which factors and phenotypes of CRS are associated with revision surgery in patients undergoing ESS. This retrospective, single-center study included 667 patients undergoing ESS between 2012 and 2015. We performed group comparisons to detect differences between CRS patients undergoing primary or revision surgery and computed binary logistic regression models. Logistic regression analysis revealed higher odds for revision surgery in CRS patients with older age (p-value < 0.001), male gender (p-value = 0.011), diagnosis of AERD (p-value = 0.005), and presence of asthma (p-value < 0.001) or allergies (p-value = 0.031). Confirming previous studies, we found that the factors of age, CRSwNP, AERD, allergies, and asthma are associated with revision ESS and identified surgical techniques that were predominantly used in revision cases.

A modest proposal for a new way forward for clinical research: involve insurance companies

Is it time for medical insurance companies to organize and fund clinical research that evaluates the role of new treatments (drugs or device‐based therapies) in the context of existing clinical paradigms for common diseases?

Short report: nasal obstruction recovery after septoplasty in patients with nasal septal deviation affected by anxiety and depression

This research was aimed to explore whether the recovery of subjective symptoms and objective examination in nasal septum deviation (NSD) patients after septoplasty were related to the degree of preoperative anxiety or depression, in the hope of providing new ideas for clinical treatment. A total of 150 NSD patients were included in this prospective research. Visual analogue scale (VAS) scores, Nasal Obstruction Symptom Evaluation (NOSE) scores, self-rating anxiety scale (SAS) scores, self-rating depression scale (SDS) scores, total inspiratory and expiratory nasal resistance were recorded before and 6 months after operation. The results showed preoperative anxiety or depression was not statistically different between groups in terms of age, gender and course, but positively correlated with nasal obstruction (VAS and NOSE). The recovery of nasal obstruction in patients with anxiety or depression was worse than that in normal NSD patients 6 months after surgery, and was decreased with the increase of anxiety or depression degree. And no significant difference showed in the reduction of total inspiratory and expiratory nasal resistance between groups. In conclusion, anxiety and depression affected the improvement of nasal obstruction feeling in NSD patients after septoplasty, and the improvement was negatively correlated with the degree of anxiety and depression. It is necessary to evaluate the anxiety and depression of NSD patients before septoplasty.

Creation of aNovel Preoperative Imaging Review Acronym to Aid in Revision Endoscopic Sinus Surgery

OBJECTIVES

(1) Identify anatomic contributions to chronic rhinosinusitis (CRS) necessitating revision endoscopic sinus surgery (RESS). (2) Create a clinical acronym to guide imaging review prior to RESS that addresses pertinent sites of disease and potential sites of surgical morbidity.

DATA SOURCES

Ovid MEDLINE, Embase and Medline via Embase.com, Web of Science Core Collection, Cochrane Central Register of Controlled Trials (CENTRAL), and Google Scholar.

REVIEW METHODS

Systematic search was performed using a combination of standardized terms and keywords. Studies were included if they investigated anatomic contributions to persistent CRS requiring RESS or the relationship between anatomic landmarks and surgical morbidity. Identified studies were screened by title/abstract, followed by full-text review. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were strictly followed.

RESULTS

In total, 599 articles met screening criteria, 89 were eligible for full-text review, and 27 studies were included in the final review. The identified anatomic sites of interests are broad; the most frequently cited anatomic region was retained anterior ethmoid cells (22/27 studies), followed by posterior ethmoid cells (14/27 studies). Using the consolidated information, a clinical acronym, REVISIONS, was created: Residual uncinate, Ethmoid cells (agger, Haller, supraorbital), Vessels (anterior and posterior ethmoid), Infundibulum, Septal deviation, I (eye) compartment, Onodi cell, Natural os, and Skull base slope and integrity.

CONCLUSIONS

The REVISIONS acronym was developed as a tool to distill the unique anatomic contributions of primary endoscopic sinus surgery failure into a format that can be easily incorporated in preoperative radiologic review and surgical planning to optimize outcomes and minimize complications.

Prevalence and Symptom Burden of Nasal Polyps in a Large Austrian Population

BACKGROUND

Although chronic rhinosinusitis with nasal polyps (CRSwNP) is a common inflammatory condition with significant morbidity and financial cost, information regarding prevalence and disease burden of this condition is scarce.

OBJECTIVE

In this study we determined nasal polyp prevalence, polyp grade, concomitant disease, and symptom burden in > 10,000 central European subjects.

METHODS

In this retrospective, cross-sectional study, 10,259 patients who had undergone routine examination of their nose by nasal endoscopy during a visit at a publicly accessible ENT outpatient facility in Vienna were included. Patient details including presenting complaint, nasal symptoms, polyp score, age, gender, treatment, asthma and allergic status were extracted retrospectively. A detailed questionnaire including history of nasal symptoms, SNOT-20 GAV, and VAS was available for 101 patients with nasal polyps.

RESULTS

Nasal polyps were detected in 189 (1.84%) of the 10,259 patients. The calculated prevalence of polyps in Austria, adjusted for age and gender, was 1.95%. The average TPS was 3.4, 72.5% had a TPS of ≤4, with males and asthmatics having significantly larger polyps. Questionnaire analysis revealed that 67% suffered from a low symptom burden of ≤36. According to current EPOS guidelines, 6% of polyp patients fulfilled and another 8% potentially fulfil the eligibility criteria for biological therapy.

CONCLUSION

Nasal polyp prevalence was calculated to be 1.95% of the Austrian population. Large polyps (TPS>4) were found in 25%, 33% suffered from a high nasal symptom burden, and between 6 to 14% of polyp patients would be eligible for biological therapy according to EPOS guidelines.

Canadian Rhinology Working Group consensus statement: biologic therapies for chronic rhinosinusitis

BACKGROUND

Recent evidence suggests that biologic therapy with targeted activity within the Type 2 inflammatory pathway can improve the clinical signs and symptoms of chronic rhinosinusitis with nasal polyposis (CRSwNP). There remains a population in CRSwNP that despite medical therapy and endoscopic sinus surgery have persistent signs and symptoms of disease. Therefore, biologics, monoclonal antibody agents, could be beneficial therapeutic treatments for these patients. There have been eight 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. However, there are no formal recommendations for the optimal use of biologics in managing Chronic Rhinosinusitis (CRS) within the Canadian health care environment.

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. 17 fellowship trained rhinologists across Canada evaluated the 28 original statements on a scale of 1-10 and provided comments. A rating within 1-3 indicated disagreement, 8-10 demonstrated agreement and 4-7 represented being neutral towards a statement. All ratings were quantitively reviewed by mean, median, mode, range and standard deviation. Consensus was defined by removing the highest and lowest of the scores and using the "3 point relaxed system".

RESULTS

After three rounds, a total of 11 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 CRS.

CONCLUSION

This white paper provides guidance to Canadian physicians on the use of biologic therapy for the management of patients with CRS, 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.

Factors affecting upper airway control of NSAID-exacerbated respiratory disease: A real-world study of 167 patients

BACKGROUND

Nonsteroidal anti-inflammatory drug (NSAID) exacerbated respiratory disease (N-ERD) is a triad with asthma, chronic rhinosinusitis with nasal polyps, and NSAID intolerance. Uncontrolled N-ERD forms a major public health problem due to frequent and difficult-to-treat exacerbations and/or requiring putatively frequent endoscopic sinus surgeries (ESS). Our aim was to study factors affecting control of N-ERD.

METHODS

Retrospective patient record data (patient characteristics, prior sinus surgeries, follow-up data in 2020) from 167 N-ERD patients undergoing consultation at three tertiary hospitals from 2001 to 2017 was used. Outcome measurements reflecting uncontrolled N-ERD were revision ESS, corticosteroids/biological therapy, and antibiotic courses during 2016-2020. Associations were analyzed by using nonparametric tests, Cox's proportional hazard, and binary logistic regression models.

RESULTS

Nasal polyp eosinophilia increased the risk of revision surgery during the follow-up (adjusted hazard ratio [aHR] 3.21, confidence interval 1.23-8.38). Also baseline oral corticosteroids (OCS; HR, 1.73, 1.04-2.89) and baseline surgery without total ethmoidectomy increased the risk of revision ESS (HR, 2.17, 1.07-4.42) in unadjusted models. In addition, both baseline OCS (adjusted odds ratio [aOR] 2.78, 1.23-6.26) and a history of ≥4 previous ESS (aOR, 2.15, 0.98-4.70) were associated with the use of OCS/biological therapy during the follow-up, but not with high number of antibiotics.

CONCLUSIONS

Nasal polyp eosinophilia, baseline OCS, and a history of recurrent ESS predict uncontrolled N-ERD. These factors might be clinically useful in risk-estimation of uncontrolled disease and for organizing follow-ups. Prospective cohort studies with larger sample size are needed to further study the factors affecting the upper airway control of N-ERD.

Asthma increases long-term revision rates of endoscopic sinus surgery in chronic rhinosinusitis with and without nasal polyposis

BACKGROUND

Chronic rhinosinusitis with asthma (CRS-A) has a significant impact on patient morbidity and quality of life. Nevertheless, little is known about the natural history of endoscopic sinus surgery (ESS) in this cohort. The objective of this study was to evaluate revision rates of ESS in CRS-A and identify risk factors associated with increased likelihood for revision surgery compared to those with CRS without asthma (CRS-alone).

METHODS

The Utah Population Database was queried for patients age >18 years with CRS who underwent at least 1 ESS between 1996 and 2018. Demographic information and history of ESS were collected and compared between CRS-A and CRS-alone using chi-square tests for categorical variables and t tests for continuous variables. Risk factors for revision surgery were analyzed using Cox proportional hazard models.

RESULTS

A total of 33,090 patients (7693 CRS-A and 25,397 CRS-alone) were included in the final analysis. Mean follow up was 9.8 years in CRS-A and 9.1 years in CRS-alone (p < 0.001). The revision rate among patients with CRS-A (21.5%) was twice that of CRS-alone (10.8%) (p < 0.001). Among patients with CRS, a history of allergy (p < 0.001), asthma (p < 0.001), and nasal polyposis (p < 0.001) was independently associated with increased risk of revision ESS. Patients with CRS-A and nasal polyposis were 6 times more likely to require revision surgery than those with CRS-alone (p < 0.010).

CONCLUSION

The rate of revision ESS in CRS-A was twice that of CRS-alone; patients with CRS-A and nasal polyposis were 6 times more likely to require revision than those with CRS-alone. ©2021 ARSAAOA, LLC.

Efficacy of Absorbable Steroid-Impregnated Nasal Packing in Functional Endoscopic Sinus Surgery for Chronic Rhinosinusitis: A Systematic Review

OBJECTIVE

To evaluate the efficacy of absorbable steroid-impregnated nasal packing on postoperative outcomes following functional endoscopic sinus surgery (FESS) for chronic rhinosinusitis (CRS).

METHODS

A systematic review of the literature was conducted as per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Twelve databases (including Journals@Ovid, Embase®, Medline®, EBM Reviews and Joanna Briggs Institute EBP Database) were searched using relevant keywords and expanded with corresponding MeSH/Emtree terms. Results were narrowed to English articles assessing the efficacy of absorbable packing impregnated with steroids post-production placed at time of surgery under general anesthetic, with hollow-lumen devices and devices inserted in-office excluded.

RESULTS

Eight studies met criteria and were included in this review. Five evaluated the efficacy of the intervention in only CRS with nasal polyposis (CRSwNP) patients, two included all subtypes of CRS, and one included only CRS without nasal polyposis (CRSsNP). Of the eight studies, four studied the efficacy of Nasopore®, three studied bioabsorbable gels, and one studied bioabsorbable calcium alginate. Four studies applied triamcinolone as the operative steroid, with the other studies utilizing betamethasone, budesonide, mometasone, and dexamethasone. Seven studies demonstrated statistically significant improvements in endoscopic outcomes using validated scoring scales, albeit at differing timepoints. The one study which included only CRSsNP patients failed to find a significant difference.

CONCLUSION

Steroid-impregnated nasal packing appears to have positive effects on postoperative endoscopic outcomes in CRSwNP patients undergoing FESS. Additional research is needed to evaluate the efficacy of these interventions in more recently defined subtypes of CRS, and whether these interventions differ in their efficacy in eosinophilic and non-eosinophilic CRS. Laryngoscope, 131:1704-1714, 2021.

Systematic literature review of humanistic and economic burdens of chronic rhinosinusitis with nasal polyposis

OBJECTIVES

We conducted a systematic literature review (SLR) of randomized controlled trials and real-world evidence (RWE) studies to determine the humanistic (e.g. health-related/disease-specific quality of life [QOL]) and economic (e.g. direct and indirect costs) burdens of chronic rhinosinusitis with nasal polyposis (CRSwNP).

METHODS

The SLR adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Embase, MEDLINE and Evidence-Based Medicine Reviews databases were searched using OVID. Relevant studies involving adult patients with CRSwNP published between 1 January 2008 and 16 February 2019 were included, with relevant conference abstracts from 1 January 2017, onward.

RESULTS

Sino-Nasal Outcomes Test (SNOT)-22 was the most frequently used disease-specific health-related QOL/patient-reported outcomes instrument for patients with CRSwNP. Baseline SNOT-22 scores ranged from 25 to 73 for surgical candidates and from 14 to 56 for medically managed patients with CRSwNP. Mean baseline EuroQol-5 Dimensions (EQ-5D) index for patients with CRSwNP ranged from 0.81 to 0.86, and mean baseline Short Form-6 Dimensions (SF-6D) ranged from 0.67 to 0.75. Three months (EQ-5D) and 5 years (SF-6D) post-endoscopic sinus surgery (ESS), rates increased from 0.81 to 0.89 and from 0.69 to 0.80, respectively. One year post-diagnosis, patients with CRSwNP had significantly more systemic prescriptions, underwent significantly more medical procedures, demonstrated greater health care resource utilization and had significantly greater mean health care costs compared with matched controls (all p < .001). Overall, for patients with initial ESS, CRSwNP was associated with higher disease-related expenditures compared with CRS without nasal polyposis (NP), even for patients who did not undergo revision surgery.

CONCLUSIONS

This SLR identified substantial humanistic burden among surgery candidates. RWE shows that surgeries were used to treat relatively more severe CRSwNP patients as recommended by guidelines. Patient QOL is improved significantly after surgery; however, there is a lack of evidence on patients with revision surgery. Surgery is also associated with higher costs, and the presence of NP was a predictor of revision surgery. Patients with CRSwNP demonstrate greater health care resource utilization and costs compared to those with CRS without NP. Costs associated with different severity of CRSwNP and revision surgery need to be assessed further.

Preoperative Pulmonary Function Testing to Predict Recurrence of Chronic Rhinosinusitis With Nasal Polyps

Background

Although the close relationship between the upper and lower airways has been highlighted previously, little is known about the association between lung function and the recurrence of chronic rhinosinusitis with nasal polyps (CRSwNP). This study aimed to evaluate the factors associated with pulmonary function that affect CRSwNP recurrence after surgery.

Methods

We performed a series of routine pulmonary function tests for general anesthesia prior to CRSwNP surgery. The values for each parameter were compared in the presence or absence of recurrence.

Results

Sixty-nine patients with CRSwNP were included. The percent predicted forced expiratory volume in one second (%FEV₁) in the recurrent group was significantly lower than that in the non-recurrent group (P = .005). A multivariable logistic regression model revealed that %FEV₁ was a positive predictor of recurrence (odds ratio: 0.96, 95% CI: 0.92-0.99, P = .023). There were no significant differences in the other pulmonary functions between the two groups.

Conclusions

We found that %FEV₁ may be a predictor of CRSwNP recurrence after surgery. As %FEV₁ is a pulmonary function test that is routinely performed before surgery, this parameter is readily applicable. Moreover, as %FEV₁ appears to have the potential to reveal concealed asthma, %FEV₁ might be a particularly useful tool for the prediction of CRSwNP recurrence after surgery.

The Effect of Triamcinolone-Soaked Gelfoam in Patients with Polypoid Mucosal Change after Endoscopic Sinus Surgery

Background and Objectives: Chronic rhinosinusitis with nasal polyps (CRSwNP) recurs frequently after endoscopic sinus surgery (ESS). The aim of study was to evaluate the efficacy of triamcinolone-soaked absorbable gelatin foam (gelfoam) as a treatment for recurred polypoid changes after ESS.Subjects and Method: A total of 35 patients and 57 nasal cavities was retrospectively reviewed. All patients underwent triamcinolone- infused gelfoam packing for 1 week under nasal endoscopic guidance. Endoscopic scores were evaluated at 1 week, 1 month, and 3 months. We analyzed clinical characteristics between success and failure groups.Results: Endoscopic scores were significantly improved after triamcinolone-soaked gelfoam packing, and the effects were maintained at 3-month follow-up (1.85±0.61 vs. 0.82±0.77, p＜0.001). Duration between surgery and gelfoam packing was shorter in the success group compared to the failure group (8.2±6.9 vs. 13.7±8.4 weeks, p=0.033). Serum eosinophil cationic protein and tissue eosinophil counts were significantly higher in the failure group (p=0.025 and p=0.010, respectively).Conclusion: Triamcinolone-soaked gelfoam packing is an effective and safe method for managing recurrent polypoid change in patients with CRSwNP after ESS. Early intervention contributed to a successful result, and eosinophilic inflammation was associated with poor outcomes.

The use of balloon dilation in revision sinus surgery

BACKGROUND

Recent studies have demonstrated a dramatic increase in the use of balloon sinus dilation (BSD) in the United States. However, the use of BSD specifically in revision sinus surgery has not been investigated. This study addresses the question of how BSD is utilized as a tool in revision sinus surgery.

METHODS

Data from MarketScan (Truven Health) over a 5-year period (2012-2016) were analyzed. Patients who underwent a sinus procedure with a minimum of 2 years of follow-up were included.

RESULTS

A total of 62,304 patients met inclusion criteria; 6847 (10.99%) underwent revision. Age >55 years, the South geographical region, and medical comorbidities increased the odds of revision on multivariate analysis. For patients undergoing revision, BSD was used 11%, 21%, and 13% of the time for revisions of the maxillary, frontal, and sphenoid sinuses, respectively. For a sinus that underwent revision after an initial BSD, a repeat BSD was done close to 40% of the time.

CONCLUSION

BSD is used frequently in the revision setting, especially for the frontal sinus and for patients who had already undergone an initial BSD. Our findings highlight the prevalent role of BSD in revision surgery and the need to evaluate such practices.

Effect of Functional Endoscopic Sinus Surgery on Outcomes in Chronic Rhinosinusitis​

PURPOSE OF REVIEW

Chronic rhinosinusitis (CRS) has a significant negative impact on quality of life (QoL). Surgical treatment of CRS is indicated when medical therapy fails to achieve adequate symptom control. This review summarizes the latest information on the outcomes after endoscopic sinus surgery (ESS) with relation to QoL, revision rates, olfaction, absenteeism, asthma control, use of systemic medications, quality of sleep and complications. We also provide an update regarding the factors that can impact outcomes.

RECENT FINDINGS

CRS has classically been divided into two phenotypes depending on the presence or absence of nasal polyps. However, this is an oversimplification as many factors impact disease burden and outcome after treatment. It has been demonstrated that in many cases, ESS fails to meet the expectations of the patients. Evidence based patient counselling is key to help surgeons guide their patients in the best possible way to make well-informed decisions. Repeatedly it has been demonstrated that ESS improves QoL, improves olfaction, leads to better asthma control and less use of systemic antibiotics. However, various patient characteristics including phenotype, disease burden, comorbidities, age, gender and surgical technique can influence the outcome after ESSIt is of paramount importance to include a follow-up period when discussing revision rates. Based on available data, the genuine revision rate is probably 15-20% after five to ten years of follow-up. The revision rate is also affected by various factors and comorbidities.

Clinical Research Needs for the Management of Chronic Rhinosinusitis with Nasal Polyps in the New Era of Biologics: A National Institute of Allergy and Infectious Diseases Workshop

The development of biologics targeting various aspects of type 2 inflammation for the treatment of chronic rhinosinusitis with nasal polyps (CRSwNP) will provide clinicians with powerful tools to help treat these patients. However, other therapies are also available, and positioning of biologics in a management algorithm will require comparative trials. In November 2019, the National Institute of Allergy and Infectious Diseases convened a workshop to consider potential future trial designs. Workshop participants represented a wide spectrum of clinical specialties, including otolaryngology, allergy, and pulmonary medicine, as well as expertise in CRSwNP pathophysiology and in trial methodology and statistics. The workshop discussed the current state of knowledge in CRSwNP and considered the advantages and disadvantages of various clinical trial or observational study designs and various clinical outcomes. The output from this workshop, which is presented in this report, will hopefully provide investigators with adequate information and ideas to design future studies and answer critical clinical questions. It will also help clinicians understand the current state of the management of CRSwNP and its gaps and be more able to interpret the new information to come.

Anxiety and depression in patients with nasal septal deviation

OBJECTIVE

Nasal septal deviation (NSD) has a significant impact on patients' quality of life; however, there have been limited studies examining the psychological status of NSD patients. In this study, symptoms of depression and anxiety were investigated between NSD patients and controls using a self-report questionnaire.

METHODS

A case-control study design was used to evaluate the psychological burden of NSD in patients who visited the general hospital. The control group comprised of ENT outpatients without a history of chronic nasal disease. The Zung Self-rating Anxiety/Depression Scale (SDS/SAS) was used to evaluate the prevalence and severity of anxiety and depression between the NSD and control group.

RESULTS

Seventy-six patients with NSD and 79 control patients were enrolled in the study. We found that depression and anxiety, as well as the co-morbidity of depression with anxiety, were more common in the NSD group in comparison to the control (39.5% vs 22.8%, p = 0.025; 38.2% vs 15.2%, p = 0.001; and 27.6% vs 11.4%, p = 0.011, respectively). The average SDS and SAS score was higher in NSD patients compared to controls (SDS: 49.7 ± 13.1 vs 45.2 ± 10.4, p = 0.019 and SAS: 48.1 ± 11.6 vs 41.3 ± 9.3, p < 0.001, respectively), and NSD patients were found to have more severe levels of anxiety and depression.

CONCLUSION

Depression and anxiety are more common and severe in patients with NSD. Therefore, psychological distress should be taken into consideration during the diagnostic and therapeutic process for patients with NSD.

Assessing Cut-off Points of Eosinophils, Nasal Polyp, and Lund-Mackay Scores to Predict Surgery in Nasal Polyposis: A Real-World Study

Background

Developing tools to identify chronic rhinosinusitis with nasal polyps (CRSwNP) patients requiring surgical treatment would help clinicians treat patients more effectively. The aim of this retrospective cross-sectional study was to identify cut-off values ​​for eosinophil percentage, nasal polyps (NP), and Lund-Mackay (LM) scores that may predict the need for surgical treatment in Finnish CRSwNP patients.

Methods

Data of CRSwNP patients (N = 378) undergoing consultation for ESS in 2001–19 were used. Data was collected from patient records and Lund-Mackay scores were determined from sinus computed tomography scans. The percentage of eosinophils was microscopically evaluated from the polyp samples available (n = 81). Associations were analyzed by Mann Whitney U test, and cut-off values by the area under the receiver operating characteristic curve (AUROC).

Results

ESS was performed to 293 (77.5%) of patients. Polyp eosinophilia was associated significantly with ESS (p = 0.001), whereas peripheral blood eosinophil count, LM- score and endoscopic NP- score were not (p > 0.05). AUROC values (95% CI) for detecting those needing ESS were for polyp eosinophilia 0.71 (0.60–0.83), p = 0.001, for LM score 0.59 (0.50–0.67), p = 0.054; for NP score 0.56 (0.48–0.64), p = 0.17, and for blood eosinophil count 0.68 (0.46–0.90), p = 0.08. With the threshold value of polyp eosinophilia (>25%), the sensitivity and specificity were optimal for detecting the group needing ESS from the group not undergoing ESS. The cut-off value of blood eosinophil count (>0.26 × 10⁹/L) had relatively good, yet statistically insignificant (underpowered), predictive potential. Moderate cut-off values were found for endoscopic LM score (≥14/24) and NP score (≥4/8).

Conclusions

Polyp eosinophilia (>25%) predicted ESS among Finnish hospital-level CRSwNP patients. A future challenge would be to find less invasive and cost-effective clinical factors predicting uncontrolled CRSwNP.

Revision surgery rates in chronic rhinosinusitis with nasal polyps: meta-analysis of risk factors

BACKGROUND

Wide variations in revision endoscopic sinus surgery (ESS) rates for chronic rhinosinusitis with nasal polyposis (CRSwNP) have been reported. It is important to understand expected revision rates and factors that impact the need for revision.

METHODS

A literature search was conducted on PubMed, Scopus, and the Cochrane Database of Systematic Reviews. Following PRISMA guidelines, a systematic review and meta-analysis was performed on studies that reported revision surgery data for CRSwNP patients.

RESULTS

Forty-five studies with 34,220 subjects were meta-analyzed, with an overall revision rate of 18.6% (95% confidence interval, 14.1%-23.6%). Studies with extractable follow-up data reported a mean revision rate of 16.2% over a weighted mean follow-up of 89.6 months. Factors associated with increased revision rates included allergic fungal rhinosinusitis (28.7%), aspirin-exacerbated respiratory disease (27.2%), asthma (22.6%), prior polypectomy (26.0%), and publication prior to 2008 (22.7%) (p < 0.05 for all).

CONCLUSION

Although polyps can recur after ESS, reported long-term ESS revision rates are approximately 14% to 24%. Identifying risk factors for revision surgery can help manage patient expectations and determine optimal personalized treatments.

Comparison of steroid-releasing stents vs nonabsorbable packing as middle meatal spacers

BACKGROUND

A randomized controlled trial was held to compare nonabsorbable packs to steroid-eluting absorbable stents as middle meatal spacers after endoscopic sinus surgery in patients with chronic rhinosinusitis (CRS).

METHODS

CRS patients were randomly assigned to receive either nonabsorbable Merocel packs wrapped in non-latex glove material (packing type A) or Propel steroid eluting stents (packing type B). Twenty-two-item Sino-Nasal Outcome Test (SNOT-22) scores were collected preoperatively and postoperatively during the initial 4 debridements up to 3 months. Recording of the nasal endoscopy was also collected during all postoperative visits. In addition, Lund-Kennedy scores and middle turbinate lateralization scores, using a new visual analogue scale, were compared between the 2 types of packing.

RESULTS

Forty CRS patients were prospectively enrolled in this institutional review board (IRB)-approved study. Patients with packing type A had significantly lower middle turbinate lateralization scores at their first (∼10 days) postoperative visit (p = 0.02 and p = 0.04, for left and right sides, respectively). This difference disappeared by later postoperative visits (from 20 days to 3 months). Overall, patients receiving packing type A had significant lower SNOT-22 scores at 20 days postsurgery (p = 0.05). This difference also disappeared at 1 and 3 months postoperation. There were no statistically significant differences in Lund-Kennedy scores.

CONCLUSION

In this study, nonabsorbable packing materials showed significant superior middle meatal spacing capacities as evidenced by greater middle turbinate medialization capability at the first postoperative visit. Additionally, patients with this type of packing saw improvements in their SNOT-22 scores at the 20-day postoperative visit. This study showed that there was no significant improvement in postoperative outcomes with drug-eluting stents when compared to nonabsorbable packing.

Asthma Is the Dominant Factor for Recurrence in Chronic Rhinosinusitis

BACKGROUND

Factors associated with recurrence of chronic rhinosinusitis (CRS) are still poorly recognized.

OBJECTIVE

To evaluate which risk factors could influence the risk of recurrence among patients undergoing endoscopic sinus surgery in long-term follow-up.

METHODS

Patients with CRS who underwent endoscopic sinus surgery were followed for an average period of 12 years in a nonconcurrent cohort. After surgery, patients were considered to an additional endoscopic sinus surgery if appropriate medical therapy failed during this period. The presence of nasal polyps, asthma, nonsteroidal anti-inflammatory drug-exacerbated respiratory disease, smoking habits, peripheral blood eosinophilia, and atopy were assessed. The recurrence-free interval between groups (with or without these risk factors) was analyzed by Kaplan-Meyer curves, and the indication for a revisional surgery was considered to be the unfavorable event.

RESULTS

A total of 201 patients were enrolled in this study. Patients with chronic rhinosinusitis with nasal polyps (CRSwNP) were more likely than patients with chronic rhinosinusitis without nasal polyps (CRSsNP) to need revisional surgery (adjusted hazard ratio, 2.02). Asthma was the only factor that was significantly related to recurrence both in patients with CRSsNP (hazard ratio, 5.54) and in patients with CRSwNP (hazard ratio, 3.27). Although eosinophilia itself was not related to a higher chance of recurrence, its presence influenced the outcome of CRSwNP compared with CRSsNP and the impact of asthma among patients with CRSwNP.

CONCLUSIONS

Prognosis in patients with CRSwNP was inferior to that in patients with CRSsNP. Asthma was the only factor that increased the chance of recurrence in patients with either CRSsNP or CRSwNP.

Contribution of Epithelial Cell Dysfunction to the Pathogenesis of Chronic Rhinosinusitis with Nasal Polyps

Background

In the past, the airway epithelium was thought to be primarily an inert physical barrier. We now know that the upper airway epithelium plays a critical role in both innate and adaptive immunity, and that epithelial dysfunction is strongly associated with inflammatory airway disease. The pathogenesis of chronic rhinosinusitis is poorly understood, but growing evidence supports a key role for the airway epithelium in the pathophysiology of the disease.

Objective

The purpose of this study is to explore our current understanding of how dysfunction in human sinonasal epithelial cells (HSNECs) contributes to the pathogenesis of chronic rhinosinusitis with nasal polyps (CRSwNP) and to examine how current and developing therapies affect epithelial cell functions.

Methods

A literature review of papers published in English pertaining to epithelial cell dysfunction in patients with CRSwNP was performed using the PubMed database. The search utilized combinations of the following key words: sinusitis, polyps, epithelium, pathophysiology, barrier function, dendritic cells, eosinophils, T cells, complement, mucociliary clearance, vitamin D, cytokines, chemokines, taste receptors, steroids, saline, and therapy.

Results

HSNEC mucociliary clearance, barrier function, secretion of cytokines, influence on dendritic cells, influence on T-cells, regulation of eosinophils, vitamin D metabolism, complement production, and taste receptor function are altered in patients with CRSwNP and contribute to the pathogenesis of the disease. Current therapies utilized to manage CRSwNP counteract the effects of HSNEC dysfunction and relieve key symptoms of the disease.

Conclusion

HSNECs are key players in both innate and adaptive immunity, and altered epithelial functions are closely intertwined with the pathogenesis of CRSwNP. Our review supports further investigation of altered HSNEC function in patients with CRSwNP and supports development of novel epithelial-targeted therapies for its management.

A call for cost-effectiveness analysis for biologic therapies in chronic rhinosinusitis with nasal polyps

OBJECTIVE

To identify the need for cost-effectiveness analysis of biologic therapies in the treatment of chronic rhinosinusitis (CRS).

DATA SOURCES

Clinical trials of monoclonal antibodies (omalizumab, benralizumab, mepolizumab and dupilumab) for nasal polyposis or chronic rhinosinusitis published on PubMed.

STUDY SELECTIONS

Clinical trials of biologic therapies in CRS and nasal polyposis.

RESULTS

No cost-effectiveness analyses of biologic therapies in CRS have been performed.

CONCLUSION

As more clinical trials of biologic therapies for CRS are conducted, there is a need for cost-effectiveness analysis. Future analyses should consider these therapies as part of medical therapeutic options compared with surgery. To increase generalizability, analyses should include samples from allergy and primary care clinics rather than only otolaryngology clinics.

Endoscopic Visualization of the True Maxillary Ostium Following Uncinectomy

OBJECTIVES

To examine the frequency in which angled endoscopes are necessary to visualize the true maxillary ostium (TMO) following uncinectomy and prior to maxillary antrostomy. Additionally, to identify preoperative computed tomography (CT) measures that predict need for an angled endoscope to visualize the TMO.

STUDY DESIGN

Retrospective study.

SETTING

Tertiary academic hospital.

PATIENTS AND METHODS

Patients who underwent endoscopic sinus surgery (ESS) between December of 2017 and August of 2018 were retrospectively identified. Cases were reviewed if they were primary ESS cases for chronic rhinosinusitis without polyposis and if they were at least 18 years of age.

RESULTS

Sixty-three maxillary antrostomies were reviewed (82.5% were from bilateral cases). Thirty-five cases (55.6%) required an angled endoscope in order to visualize the TMO. Of the preoperative CT measures examined, a smaller sphenoid keel-caudal septum-nasolacrimal duct (SK-CS-NL) angle was significantly associated with need for an angled endoscope intraoperatively to visualize the TMO (17.1° SD ± 3.2 vs 15.0° SD ± 2.9; P = .010).

CONCLUSION

Angled endoscopes are likely required in the majority of maxillary antrostomies to visualize the TMO. This is important to recognize in order to prevent iatrogenic recirculation. The SK-CS-NL angle may help to identify cases preoperatively which require an angled endoscope to identify the TMO during surgery.

Immunological Characteristics in Refractory Chronic Rhinosinusitis with Nasal Polyps Undergoing Revision Surgeries

Purpose

Despite medical and surgical treatments, some cases of nasal polyps (NP) exhibit recidivism. However, the endotype of refractory chronic rhinosinusitis with NP (CRSwNP) remains unclear. Therefore, the objective of this study was to characterize the immunological profile of refractory CRSwNP.

Methods

The control (n =23), primary NP group (pNP, n =70) and refractory NP group (rNP, n =86) were enrolled in this study. Patients who underwent revision surgeries due to failed maximal medical treatment after primary surgery were defined as the rNP group. A total of 18 inflammatory markers were investigated in nasal tissues using multiplex cytokine assay or enzyme-linked immunosorbent assay.

Results

The clinical characteristics of rNP included more extensive disease and worse clinical course after surgery. Additionally, rNP subjects showed higher infection rate (mucopurulence and culture-positive rate), more frequent use of antibiotics and suffered from symptomatic bacterial infection, increased asthma morbidity compared to pNP. Cytokine profile analysis showed that levels of Th17-associated mediators (myeloperoxidase, interleukin (IL)-8, IL-17A and IL-23), B-cell activating factor (BAFF) and Th1 cytokine (interferon-γ) were up-regulated in rNP compared to controls and pNP. Human neutrophil elastase-positive cells were also enhanced in rNP compared with pNP. Upregulation of Th17/Th1mediators and BAFF were observed in rNP, regardless of tissue eosinophilia or asthmatic comorbidity. Interestingly, eosinophilic markers, such as eosinophil cationic protein and C-C motif chemokine ligand 24, were up-regulated in asthmatic rNP compared to pNP and controls. Levels of anti-dsDNA immunoglobulin (Ig) G and IgA were up-regulated in rNP and highest in asthmatic eosinophilic rNP among subtypes of rNP.

Conclusions

Our results suggest that Th17/Th1-associated mediators and BAFF may play a role and be a potential therapeutic target in refractory CRSwNP. Additionally, eosinophilic markers and autoantibodies may contribute to refractoriness in asthmatic rNP.