Socioeconomic, comorbidity, lifestyle, and quality of life comparisons between chronic rhinosinusitis phenotypes

Definition of sinonasal and otological exacerbation in patients with primary ciliary dyskinesia: an expert consensus

Background

Recurrent infections of the nose, sinuses and ears are common problems for people with primary ciliary dyskinesia. While pulmonary exacerbations in primary ciliary dyskinesia are defined, there is no definition for ear-nose-throat exacerbations, a potential outcome for research and clinical trials.

Methods

We set up an expert panel of 24 ear-nose-throat specialists, respiratory physicians, other healthcare professionals and patients to develop consensus definitions of sinonasal and otological exacerbations in children and adults with primary ciliary dyskinesia for research settings. We reviewed the literature and used a modified Delphi approach with four electronic surveys.

Results

Definitions for both sinonasal and otological exacerbations are based on a combination of major and minor criteria, requiring three major or two major and at least two minor criteria each. Major criteria for a sinonasal exacerbation are 1) reported acute increase in nasal discharge or change in colour, 2) reported acute pain or sensitivity in the sinus regions and 3) mucopurulent discharge on examination. Minor criteria include reported symptoms, examination signs, doctor's decision to treat and improvement after at least 14 days. Major criteria for the otological exacerbation are 1) reported acute ear pain or sensitivity, 2) reported acute ear discharge, 3) ear discharge on examination and 4) signs of otitis media in otoscopy. Minor criteria are reported acute hearing problems, signs of acute complication, and doctor's decision to treat.

Conclusion

These definitions might offer a useful outcome measure for primary ciliary dyskinesia research in different settings. They should be validated in future studies and trials together with other potential outcomes, to assess their usability.

Effectiveness of the Posterior Nasal Nerve Cryoablation in Allergic and Non-Allergic Rhinitis

OBJECTIVES

This study assessed the impact of cryoablation of the posterior nasal nerve on symptoms of rhinitis in individuals with allergic rhinitis (AR) and non-allergic rhinitis (NAR).

DATA SOURCES

PubMed, SCOPUS, Embase, Web of Science, and Cochrane databases for studies published up to June 2023.

REVIEW METHODS

Studies that evaluated the quality of life and rhinitis-related symptom scores before and after cryotherapy treatment, as well as sham-controlled studies, were included.

RESULTS

In total, 368 patients from seven studies were analyzed. Patients who underwent cryoablation showed a significant improvement in rhinitis-related symptoms in both NAR and AR. In particular, the most significant improvement was observed in symptoms of rhinorrhea and congestion. Furthermore, cryoablation improved the disease-specific quality of life evaluated using the Rhinoconjunctivitis Quality of Life Questionnaire. The rate of clinical improvement in the total nasal symptom score (total nasal symptom score [TNSS]; >30% reduction from baseline) after cryotherapy was 74%. The change in TNSS score significantly increased over time in NAR patients (p = 0.0041). Therefore, changes in the TNSS score after 12 months of cryotherapy treatment were greater in the NAR group than in the AR group (p = 0.0020), indicating that cryoablation is effective for both types of rhinitis and has better long-term efficacy in NAR than in AR.

CONCLUSIONS

Subjective symptom scores related to rhinitis, particularly for rhinorrhea and congestion, decrease after cryoablation of the posterior nasal nerve. Furthermore, the symptom improvement was greater in NAR than AR. Laryngoscope, 134:2502-2512, 2024.

Characteristics of mucin hypersecretion in different inflammatory patterns based on endotypes of chronic rhinosinusitis

BACKGROUND

Chronic rhinosinusitis (CRS) is usually accompanied by mucin hypersecretion that can lead to mucus accumulation and impair nasal mucociliary clearance, thus exacerbating airway inflammation. Abnormal mucin hypersecretion is regulated by different T helper (Th) cytokines, which are associated with different endotype-driven inflammatory responses. Therefore, it is of great significance to understand how these factors regulate mucin hypersecretion to provide precise treatment strategies for different endotypes of CRS. BODY: Thus far, the most common endotypes of CRS are classified as type 1, type 2, or type 3 immune responses based on innate and adaptive cell-mediated effector immunity, and the representative Th cytokines in these immune responses, such as IFN-γ, TNF-α, IL-4, IL-5, IL-13, IL-10, IL-17, and IL-22, play an important regulatory role in mucin secretion. We reviewed all the related literature in the PubMed database to determine the expression of these Th cytokines in CRS and the role they play in the regulation of mucin secretion.

CONCLUSION

We believe that the main Th cytokines involved in specific endotypes of CRS play a key role in regulating abnormal mucin secretion, which contributes to better understanding of the pathogenesis of CRS and provides therapeutic targets for airway inflammatory diseases associated with mucin hypersecretion.

The Long-Term Implications of Rhinitis and Chronic Rhinosinusitis in Young Adults

BACKGROUND

The long-term impact of rhinitis and chronic rhinosinusitis (CRS) on general health and medical services utilization in young adults have been limitedly studied.

METHODS

A case-control study in the Israeli Defense Forces, between the years 2005 and 2019, of all individuals with either rhinitis or CRS and a matched cohort of healthy individuals with a minimum of 5 years of consecutive follow-up.

RESULTS

The study groups included 617 patients with rhinitis and 296 patients with CRS and 2739 healthy controls with an average age of 28 years. During a mean follow-up of 8 years, a significant fraction of patients in both study groups were diagnosed with asthma compared to the control group, (26.1% and 23.3% vs. 3.7%, respectively; CI 95%: 12.1%-14.9%, p < 0.0001). 7.6% of patients with rhinitis developed CRS. Significantly increased loss of productivity and medical system utilization were noted in the study groups compared to controls (p < 0.0001). Moreover, deterioration in general health, manifested as loss of physical fitness for combative service was observed in a third of patients during follow-up.

CONCLUSIONS

Rhinitis and CRS significantly impact productivity and medical service utilization in young adults, as well as general health associated with development of asthma and impairment of physical fitness. A minority of rhinitis patients develop CRS overtime, further affecting this patient group. These patients should be followed up and managed to improve disease control and associated outcomes.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:3299-3303, 2023.

Intranasal Anticholinergics for Treatment of Chronic Rhinitis: Systematic Review and Meta-Analysis

OBJECTIVE

Topical intranasal anticholinergics are commonly prescribed for the relief of chronic rhinitis and associated symptoms, warranting thorough assessment of the supporting evidence. The present study aimed to evaluate the safety and efficacy of anticholinergic nasal sprays in the management of allergic and non-allergic rhinitis symptom severity and duration.

METHODS

A search encompassing the Cochrane Library, PubMed/MEDLINE, and Scopus databases was conducted. Primary studies describing rhinorrhea, nasal congestion, and/or postnasal drip outcomes in rhinitis patients treated with an anticholinergic spray were included for review.

RESULTS

The search yielded 1,029 unique abstracts, of which 12 studies (n = 2,024) met inclusion criteria for qualitative synthesis and 9 (n = 1,920) for meta-analysis. Median follow-up was 4 weeks and ipratropium bromide was the most extensively trialed anticholinergic. Compared to placebo, anticholinergic treatment was demonstrated to significantly reduce rhinorrhea severity scores (standardized mean difference [95% CI] = -0.77 [-1.20, -0.35]; -0.43 [-0.72, -0.13]) and duration (-0.62 [-0.95, -0.30]; -0.29 [-0.47, -0.10]) in allergic and non-allergic rhinitis patients respectively. Benefit was less consistent for nasal congestion, postnasal drip, and sneezing symptoms. Reported adverse effects included nasal mucosa dryness or irritation, epistaxis, headaches, and pharyngitis, though comparison to placebo found significantly greater risk for epistaxis only (risk ratio [95% CI] = 2.19 [1.22, 3.93]).

CONCLUSION

Albeit treating other symptoms with less benefit, anticholinergic nasal sprays appear to be safe and efficacious in reducing rhinorrhea severity and duration in both rhinitis etiologies. This evidence supports their continued use in the treatment of rhinitis-associated rhinorrhea.

LEVEL OF EVIDENCE

1 Laryngoscope, 133:722-731, 2023.

Dupilumab Improves Outcomes in Patients with Chronic Rhinosinusitis with Nasal Polyps and Coexisting Asthma Irrespective of Baseline Asthma Characteristics

Purpose

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a predominantly type 2 inflammatory disease frequently coexisting with other type 2 conditions including asthma and non-steroidal anti-inflammatory drug-exacerbated respiratory disease (NSAID-ERD). Coexisting asthma leads to increased CRSwNP symptom burden. Dupilumab, a monoclonal antibody that blocks the shared receptor component for interleukin-4 and -13, demonstrated efficacy in adults with severe CRSwNP in the Phase 3 SINUS-24 (NCT02912468) and SINUS-52 (NCT02898454) studies, including in patients with coexisting asthma/NSAID-ERD. However, the impact of different asthma characteristics on dupilumab treatment in this population is unknown. We report CRSwNP and asthma outcomes with dupilumab in patients with CRSwNP and coexisting asthma according to baseline asthma characteristics.

Methods

Change from baseline at Week 24 (pooled studies) and Week 52 (SINUS-52) in CRSwNP outcomes (nasal polyp score, nasal congestion, 22-item Sino-Nasal Outcome Test [SNOT-22], loss of smell score, University of Pennsylvania Smell Identification Test) and asthma outcomes (5-item Asthma Control Questionnaire [ACQ-5], pre-bronchodilator forced expiratory volume in 1 second [FEV₁]) were analyzed post hoc for placebo and dupilumab 300 mg every 2 weeks according to baseline blood eosinophils ≥150/≥300 cells/µL, ACQ-5 scores <1.5/≥1.5, and FEV₁ <80%.

Results

In the pooled studies, 428/724 patients (59.1%) had coexisting asthma, of which 181/428 (42.3%) had coexisting NSAID-ERD. Dupilumab significantly improved all CRSwNP and asthma outcomes vs placebo at Week 24 (P < 0.001) regardless of baseline eosinophil or ACQ-5 category, or FEV₁ <80%. Similar magnitude of improvement was seen at Week 52 (SINUS-52) and in patients with NSAID-ERD (pooled studies, Week 24). By Week 24, improvements with dupilumab exceeded the minimum clinically important differences for ACQ-5 and SNOT-22 in 35.2% to 74.2% and 72.0% to 78.7% of patients, respectively.

Conclusion

Dupilumab improved CRSwNP outcomes in patients with CRSwNP and coexisting asthma, and improved asthma outcomes, regardless of differences in baseline asthma characteristics.

[Clinical and diagnostic features in the phenotyping of isolated sphenoiditis]

The relevance of the issues of diagnosis and treatment of isolated sphenoiditis (IS) is increasing, due to the widespread introduction into clinical practice of radiation diagnostic methods that allow the diagnosis, including latent forms of IS. Among the chronic forms of IS, polypous-cystic and fungal lesions of the sphenoid sinus (SS) predominate.

OBJECTIVE

To study the age, gender and radiological features of SS in patients with IS.

MATERIAL AND METHODS

A retrospective observational single-center non-randomized study was conducted - an analysis of the case histories of 56 patients aged 18 to 68 years who were on inpatient treatment at the Semashko Nizhny Novgorod Regional Clinical Hospital (Department of Ear, Throat and Nose Diseases of the Privolzhsky Research Medical University) in the period 2018-2020, by age, gender composition, clinical and radiological manifestations in various forms of IS.

RESULTS

The duration of the disease was 59±19 days. Latent forms were detected in 40% of patients. Statistically, the polypous-cystic form of IS was diagnosed more often than the fungal one (z=4.2; p=0.001). The median age of patients with polypous-cystic and fungal IS was 46.5 [35.0; 59.0] years. Evaluation of computed tomograms on the Lund-Mackay scale showed higher values in patients with polypous-cystic IS than in patients with fungal SS lesion (p=0.07). Obstruction of the anastomosis was detected in 38 out of 50 (69.5%) patients with polypous-cystic IS and in 13 out of 50 (92.9%) patients with fungal IS.

CONCLUSIONS

Against the background of a significant prevalence of rhinosinusitis, the absolute values of isolated sphenoiditis, even with a relative value of 5% of the total, are very significant. Determining the phenotype of isolated sphenoiditis and their features is very important for building a consistent treatment strategy. Age, gender, clinical and radiological manifestations should form the basis of phenotyping and further construction of a therapeutic and diagnostic algorithm.