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De Corso E, Settimi S, Penazzi D, D’Agostino G, Corbò M, Rigante M, Montuori C, Rizzuti A, Pacilli MC, Di Cesare T, Lo Verde S, Rizzi A, Chini R, Galli J. Dupilumab Improves Facial Pain and Reduces Rescue Treatments in Patients with CRSwNP and Recalcitrant Frontal Sinusitis. J Pers Med 2024; 14:735. [PMID: 39063989 PMCID: PMC11277593 DOI: 10.3390/jpm14070735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Revised: 06/30/2024] [Accepted: 07/05/2024] [Indexed: 07/28/2024] Open
Abstract
Recalcitrant frontal sinusitis in patients with chronic rhinosinusitis and nasal polyps (CRSwNP) has a negative impact on their quality of life due to frontal pain and a high risk of sinus occlusion, thus necessitating antibiotics, systemic corticosteroids, and multiple surgeries. The aim of this study was to assess the efficacy of dupilumab in reducing frontal pain and the need for rescue treatments for recalcitrant frontal sinusitis in patients with CRSwNP. We enrolled a cohort of 10 patients with severe uncontrolled CRSwNP and concomitant recurrent frontal sinusitis associated with severe facial pain measured by MIDAS score who were treated with dupilumab 300 mg every 2 weeks and followed for at least 12 months. The mean MIDAS score decreased from 45.6 ± 10.7 at baseline to 1.3 ± 2.3 at 6 months (p < 0.05). VAS craniofacial pain decreased from 7.3 ± 1.6 at baseline to 1.2 ± 1.5 at 6 months (p < 0.05). No patient needed oral corticosteroids during treatment with dupilumab (p < 0.05), and the use of analgesics decreased from 9.6 ± 3.1 NSAID pills/week in the last 2 months at baseline to 0.6 ± 1.3 at 1 year of follow-up (p < 0.05). Our results demonstrated that use of subcutaneous dupilumab can improve symptom control, including recurrent severe cranio-facial pain, and reduce the need for rescue medical treatments (systemic steroids and NSAID) in patients with severe uncontrolled CRSwNP and concomitant recurrent frontal sinusitis.
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Affiliation(s)
- Eugenio De Corso
- Unit of Otorhinolaryngology and Head-Neck Surgery, “A. Gemelli” University Hospital Foundation IRCCS, 00168 Rome, Italy; (E.D.C.); (M.R.); (T.D.C.); (J.G.)
| | - Stefano Settimi
- Unit of Otorhinolaryngology and Head-Neck Surgery, “A. Gemelli” University Hospital Foundation IRCCS, 00168 Rome, Italy; (E.D.C.); (M.R.); (T.D.C.); (J.G.)
- Department of Head-Neck and Sensory Organs, Catholic University of Sacred Heart, 00168 Rome, Italy; (D.P.); (G.D.); (M.C.); (C.M.); (A.R.); (M.C.P.); (S.L.V.)
| | - Daniele Penazzi
- Department of Head-Neck and Sensory Organs, Catholic University of Sacred Heart, 00168 Rome, Italy; (D.P.); (G.D.); (M.C.); (C.M.); (A.R.); (M.C.P.); (S.L.V.)
| | - Giuseppe D’Agostino
- Department of Head-Neck and Sensory Organs, Catholic University of Sacred Heart, 00168 Rome, Italy; (D.P.); (G.D.); (M.C.); (C.M.); (A.R.); (M.C.P.); (S.L.V.)
| | - Marco Corbò
- Department of Head-Neck and Sensory Organs, Catholic University of Sacred Heart, 00168 Rome, Italy; (D.P.); (G.D.); (M.C.); (C.M.); (A.R.); (M.C.P.); (S.L.V.)
| | - Mario Rigante
- Unit of Otorhinolaryngology and Head-Neck Surgery, “A. Gemelli” University Hospital Foundation IRCCS, 00168 Rome, Italy; (E.D.C.); (M.R.); (T.D.C.); (J.G.)
| | - Claudio Montuori
- Department of Head-Neck and Sensory Organs, Catholic University of Sacred Heart, 00168 Rome, Italy; (D.P.); (G.D.); (M.C.); (C.M.); (A.R.); (M.C.P.); (S.L.V.)
| | - Alberta Rizzuti
- Department of Head-Neck and Sensory Organs, Catholic University of Sacred Heart, 00168 Rome, Italy; (D.P.); (G.D.); (M.C.); (C.M.); (A.R.); (M.C.P.); (S.L.V.)
| | - Maria Clara Pacilli
- Department of Head-Neck and Sensory Organs, Catholic University of Sacred Heart, 00168 Rome, Italy; (D.P.); (G.D.); (M.C.); (C.M.); (A.R.); (M.C.P.); (S.L.V.)
| | - Tiziana Di Cesare
- Unit of Otorhinolaryngology and Head-Neck Surgery, “A. Gemelli” University Hospital Foundation IRCCS, 00168 Rome, Italy; (E.D.C.); (M.R.); (T.D.C.); (J.G.)
| | - Simone Lo Verde
- Department of Head-Neck and Sensory Organs, Catholic University of Sacred Heart, 00168 Rome, Italy; (D.P.); (G.D.); (M.C.); (C.M.); (A.R.); (M.C.P.); (S.L.V.)
| | - Angela Rizzi
- Unit of Allergology e Clinical Immunology, “A. Gemelli” Hospital Foundation IRCCS, 00168 Rome, Italy; (A.R.); (R.C.)
| | - Raffaella Chini
- Unit of Allergology e Clinical Immunology, “A. Gemelli” Hospital Foundation IRCCS, 00168 Rome, Italy; (A.R.); (R.C.)
| | - Jacopo Galli
- Unit of Otorhinolaryngology and Head-Neck Surgery, “A. Gemelli” University Hospital Foundation IRCCS, 00168 Rome, Italy; (E.D.C.); (M.R.); (T.D.C.); (J.G.)
- Department of Head-Neck and Sensory Organs, Catholic University of Sacred Heart, 00168 Rome, Italy; (D.P.); (G.D.); (M.C.); (C.M.); (A.R.); (M.C.P.); (S.L.V.)
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Eren E, İşlek A, Bakiş YB, Altay S. 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? J Laryngol Otol 2024; 138:527-534. [PMID: 37997646 DOI: 10.1017/s0022215123001962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2023]
Abstract
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.
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Affiliation(s)
- Erdem Eren
- Department of Otolaryngology - Head and Neck Surgery, İzmir Atatürk Research and Education Hospital, İzmir, Turkey and Izmir University of Economics, Faculty of Medicine, Medical Point Hospital, İzmir, Turkey
| | - Akif İşlek
- Otolaryngology - Head and Neck Surgery Clinic, Acıbadem Eskişehir Hospital, Eskişehir, Turkey
| | - Yaşar Batuhan Bakiş
- Department of Otolaryngology - Head and Neck Surgery, İzmir Atatürk Research and Education Hospital, İzmir, Turkey and Izmir University of Economics, Faculty of Medicine, Medical Point Hospital, İzmir, Turkey
| | - Sedat Altay
- Radiology Clinic, İzmir Atatürk Research and Education Hospital, İzmir, Turkey
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Hentati F, Kim J, Hoying D, D'Anza B, Rodriguez K. Revision Rates and Symptom Trends Following Endoscopic Sinus Surgery: Impact of Race on Outcomes. Laryngoscope 2023; 133:2878-2884. [PMID: 36971208 DOI: 10.1002/lary.30647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 02/13/2023] [Accepted: 02/28/2023] [Indexed: 10/19/2023]
Abstract
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.
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Affiliation(s)
- Firas Hentati
- Case Western Reserve University School of Medicine, Cleveland, Ohio, U.S.A
| | - Jaehee Kim
- Case Western Reserve University School of Medicine, Cleveland, Ohio, U.S.A
| | - David Hoying
- Case Western Reserve University School of Medicine, Cleveland, Ohio, U.S.A
| | - Brian D'Anza
- Case Western Reserve University School of Medicine, Cleveland, Ohio, U.S.A
- University Hospitals Cleveland Medical Center, Cleveland, Ohio, U.S.A
| | - Kenneth Rodriguez
- Case Western Reserve University School of Medicine, Cleveland, Ohio, U.S.A
- University Hospitals Cleveland Medical Center, Cleveland, Ohio, U.S.A
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Misirovs R, Chan R, Stewart K, Lipworth B. Phenotypic associations of medical polypectomy and revision surgery following endoscopic sinus surgery: a retrospective study of a single-centre experience in Scotland. J Laryngol Otol 2023; 137:1277-1284. [PMID: 37212124 PMCID: PMC10627783 DOI: 10.1017/s0022215123000853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 04/19/2023] [Accepted: 04/24/2023] [Indexed: 05/23/2023]
Abstract
BACKGROUND Some chronic rhinosinusitis with nasal polyps patients undergo revision surgery at some point following initial functional endoscopic sinus surgery. This review aimed to identify the predictive factors for recurrence of nasal polyps requiring oral corticosteroids or revision surgery in chronic rhinosinusitis with nasal polyps following functional endoscopic sinus surgery. METHOD A retrospective analysis of 221 patients who underwent functional endoscopic sinus surgery for chronic rhinosinusitis with nasal polyps in a tertiary rhinology centre, between January 2015 and December 2018, was undertaken. RESULTS Forty-four (21.6 per cent) patients underwent medical polypectomy, 19 (9 per cent) underwent revision surgery and 51 (24.3 per cent) underwent combined polypectomy during the mean follow-up time of 5.3 years. Patients aged less than 55 years of age, with a history of previous functional endoscopic sinus surgery, peripheral blood eosinophil counts of 300 cells/μl or higher, a Lund-Mackay score of more than 17 and concomitant aspirin-exacerbated respiratory disease had significantly increased odds for medical polypectomy, revision surgery and combined polypectomy. CONCLUSION Knowing these predictive factors, clinicians can better identify patients with an increased likelihood of severe polyp recurrence and therefore arrange closer follow-up to optimise therapy.
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Affiliation(s)
- Rasads Misirovs
- Tayside Rhinology Mega-Clinic and Scottish Centre for Respiratory Research, Ninewells Hospital and Medical School, University of Dundee, Scotland, UK
- Department of Doctoral Studies, Riga Stradins University, Riga, Latvia
| | - Rory Chan
- Tayside Rhinology Mega-Clinic and Scottish Centre for Respiratory Research, Ninewells Hospital and Medical School, University of Dundee, Scotland, UK
| | - Kirsten Stewart
- Tayside Rhinology Mega-Clinic and Scottish Centre for Respiratory Research, Ninewells Hospital and Medical School, University of Dundee, Scotland, UK
| | - Brian Lipworth
- Tayside Rhinology Mega-Clinic and Scottish Centre for Respiratory Research, Ninewells Hospital and Medical School, University of Dundee, Scotland, UK
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De Corso E, Settimi S, Montuori C, Cantiani A, Corbò M, Di Bella GA, Sovardi F, Pagella F, Rigante M, Passali GC, Paludetti G, Galli J. How to manage recurrences after surgery in CRSwNP patients in the biologic era: a narrative review. ACTA OTORHINOLARYNGOLOGICA ITALICA : ORGANO UFFICIALE DELLA SOCIETA ITALIANA DI OTORINOLARINGOLOGIA E CHIRURGIA CERVICO-FACCIALE 2023; 43:S3-S13. [PMID: 37698095 PMCID: PMC10159635 DOI: 10.14639/0392-100x-suppl.1-43-2023-01] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 01/30/2023] [Indexed: 09/13/2023]
Abstract
Objective This narrative review analyses factors affecting recurrence of Chronic rhinosinusitis with nasal polyps (CRSwNP) after surgery, such as type, extension and completeness of endoscopic sinus surgery (ESS). We also described new implications in the management of recurrences after the advent of biologics. Methods We identified four topics: definition of disease state; factors linked to recurrence of polyps; evaluation and management of recurrence in clinical practice. Results We analysed the differences between exacerbation and recurrence, as well as the concept of "controlled disease". We focused on potential predictors of recurrence after ESS, such as type 2 inflammation, asthma, aspirin-exacerbated respiratory disease, incomplete initial surgery and lack of adherence to long-term post-operative local corticosteroids. We discussed the new aspects of diagnosis and treatment of recurrences after surgery, summarising our suggestions in a detailed algorithm for practical management of patients with recurrent disease. Conclusions The results emphasised the importance of accurate evaluation of patients with CRSwNP recurrence, focusing on the reasons of failure and risk of disease progression, in order to guide personalised interventions. It is crucial to define the concept of appropriate surgery, which affects the choice between starting a biologic or repeating surgery.
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Affiliation(s)
- Eugenio De Corso
- Unit of Otorhinolaryngology, “A. Gemelli” University Hospital Foundation IRCCS, Rome, Italy
| | - Stefano Settimi
- Unit of Otorhinolaryngology, “A. Gemelli” University Hospital Foundation IRCCS, Rome, Italy
- Department of Head, Neck and Sensory Organs, Catholic University of Sacred Heart, Rome, Italy
| | - Claudio Montuori
- Department of Head, Neck and Sensory Organs, Catholic University of Sacred Heart, Rome, Italy
| | - Alessandro Cantiani
- Department of Head, Neck and Sensory Organs, Catholic University of Sacred Heart, Rome, Italy
| | - Marco Corbò
- Department of Head, Neck and Sensory Organs, Catholic University of Sacred Heart, Rome, Italy
| | | | - Fabio Sovardi
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Fabio Pagella
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Mario Rigante
- Unit of Otorhinolaryngology, “A. Gemelli” University Hospital Foundation IRCCS, Rome, Italy
| | - Giulio Cesare Passali
- Unit of Otorhinolaryngology, “A. Gemelli” University Hospital Foundation IRCCS, Rome, Italy
- Department of Head, Neck and Sensory Organs, Catholic University of Sacred Heart, Rome, Italy
| | - Gaetano Paludetti
- Unit of Otorhinolaryngology, “A. Gemelli” University Hospital Foundation IRCCS, Rome, Italy
| | - Jacopo Galli
- Unit of Otorhinolaryngology, “A. Gemelli” University Hospital Foundation IRCCS, Rome, Italy
- Department of Head, Neck and Sensory Organs, Catholic University of Sacred Heart, Rome, Italy
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The importance of follow-up examinations in chronic rhinosinusitis with nasal polyposis. Am J Otolaryngol 2023; 44:103672. [DOI: 10.1016/j.amjoto.2022.103672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 10/16/2022] [Indexed: 11/07/2022]
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Toppila‐Salmi S, Hällfors J, Aakko J, Mannerström B, Nieminen K, Telg G, Lehtimäki L. The burden of chronic rhinosinusitis with nasal polyps and its relation to asthma in Finland. Clin Transl Allergy 2022; 12:e12200. [PMID: 36246729 PMCID: PMC9549071 DOI: 10.1002/clt2.12200] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 08/17/2022] [Accepted: 08/26/2022] [Indexed: 11/30/2022] Open
Abstract
Background Chronic rhinosinusitis with nasal polyps (CRSwNP) is commonly associated with asthma. Treatment of CRSwNP includes intranasal and systemic corticosteroids, with non‐responsive patients commonly considered for endoscopic sinus surgery (ESS). This nationwide register‐based study evaluated the incidence, prevalence, and treatment burden of CRSwNP in Finland, and their association with the presence and severity of comorbid asthma. Methods Electronic health records of patients diagnosed with CRSwNP between 1.1.2012 and 31.12.2018 in Finnish specialty and primary care were included in the study. The patients were divided into subgroups based on presence, severity, and control of asthma: no asthma, mild to moderate asthma, severe controlled asthma, and severe uncontrolled asthma. A mean cumulative count of ESS was calculated over time per subgroup. Results The prevalence of CRSwNP increased from 602.2 to 856.7 patients per 100,000 population between years 2012 and 2019 (p < 0.001). A total of 18,563 patients (59.9% male) had incident CRSwNP between 2012 and 2019, with 27% having asthma, 6% having severe asthma, and 1.5% having severe uncontrolled asthma. In the no asthma, severe controlled asthma, and severe uncontrolled asthma subgroups, systemic corticosteroids were used by 54.1%, 94.9% and 99.3% (p < 0.001), respectively, while the ESS count 3 years post diagnosis was 0.49, 0.68 and 0.80, respectively. Conclusions The prevalence of CRSwNP showed a significant increase in the recent decade in Finland. Comorbid asthma, and in particular severe asthma, increased the probability of receiving systemic corticosteroids and undergoing ESS. Thus, improved management of CRSwNP in patients with comorbid asthma is urgently needed.
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Affiliation(s)
- Sanna Toppila‐Salmi
- Department of AllergologyDepartment of Pulmonary Medicine, Heart and Lung CenterSkin and Allergy HospitalHelsinki University Hospital and University of HelsinkiHelsinkiFinland
| | | | | | | | | | | | - Lauri Lehtimäki
- Faculty of Medicine and Health TechnologyTampere University Respiratory Research GroupTampere UniversityTampereFinland,Allergy CentreTampere University HospitalTampereFinland
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Nuutinen M, Haukka J, Virkkula P, Torkki P, Toppila-Salmi S. Using machine learning for the personalised prediction of revision endoscopic sinus surgery. PLoS One 2022; 17:e0267146. [PMID: 35486626 PMCID: PMC9053825 DOI: 10.1371/journal.pone.0267146] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 04/03/2022] [Indexed: 11/19/2022] Open
Abstract
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.
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Affiliation(s)
- Mikko Nuutinen
- Haartman Institute, University of Helsinki, Helsinki, Finland
- Nordic Healthcare Group, Helsinki, Finland
| | - Jari Haukka
- Department of Public Health, University of Helsinki, Helsinki, Finland
| | - Paula Virkkula
- Department of Otorhinolaryngology-Head and Neck Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Paulus Torkki
- Department of Public Health, University of Helsinki, Helsinki, Finland
| | - Sanna Toppila-Salmi
- Haartman Institute, University of Helsinki, Helsinki, Finland
- Skin and Allergy Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
- * E-mail:
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Arancibia C, Langdon C, Mullol J, Alobid I. Twelve-year long-term postoperative outcomes in patients with chronic rhinosinusitis with nasal polyps. Rhinology 2022; 60:109-117. [PMID: 35112673 DOI: 10.4193/rhin21.148] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Evidence regarding long-term postoperative follow-up of chronic rhinosinusitis with nasal polyps (CRSwNP) patients is scarce in the literature. The objective of the present study was to report long-term 12-year postoperative outcomes for CRSwNP patients. METHODS CRSwNP patients were prospectively followed after endoscopic sinus surgery. Sinonasal symptoms, nasal polyp score (NPS), Barcelona Smell Test 24 (BAST-24), Lund-Mackay Score (LMS), and Medical Outcome Study Short Form-36 (SF-36) questionnaire were assessed before and 12 years after surgery. RESULTS At long-term follow-up (median, 12 years), a strong improvement was noted for all patients (N=76) in nasal symptoms score, NPS, BAST-24, and LMS scores compared with baseline. No long-term improvement in SF-36 was found. CONCLUSION Patients with CRSwNP have a long-term 12-year postoperative improvement in nasal symptoms, polyp size, computed tomography, and olfaction.
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Affiliation(s)
- C Arancibia
- Rhinology and Skull Base Unit, Department of Otorhinolaryngology, Hospital Clinic, Universitat de Barcelona, Spain
| | - C Langdon
- Rhinology and Skull Base Unit, Department of Otorhinolaryngology, Hospital Clinic, Universitat de Barcelona, Spain; Institut dInvestigacions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigacion Biomedica en Red de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - J Mullol
- Rhinology and Skull Base Unit, Department of Otorhinolaryngology, Hospital Clinic, Universitat de Barcelona, Spain; Institut dInvestigacions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigacion Biomedica en Red de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - I Alobid
- Rhinology and Skull Base Unit, Department of Otorhinolaryngology, Hospital Clinic, Universitat de Barcelona, Spain; Institut dInvestigacions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigacion Biomedica en Red de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
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Lilja M, Koskinen A, Julkunen-Iivari A, Mäkitie A, Numminen J, Rautiainen M, Myller JP, Markkola A, Suvinen M, Mäkelä M, Renkonen R, Pekkanen J, Toppila-Salmi SK. Radiological score of computed tomography scans predicts revision surgery for chronic rhinosinusitis. ACTA OTORHINOLARYNGOLOGICA ITALICA 2022; 42:63-74. [PMID: 35292788 PMCID: PMC9058939 DOI: 10.14639/0392-100x-n1561] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 09/14/2021] [Indexed: 11/23/2022]
Abstract
Objective Methods Results Conclusion
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Factors Associated with Revision Sinus Surgery in Patients with Chronic Rhinosinusitis. J Pers Med 2022; 12:jpm12020167. [PMID: 35207656 PMCID: PMC8878652 DOI: 10.3390/jpm12020167] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 01/17/2022] [Accepted: 01/21/2022] [Indexed: 02/07/2023] Open
Abstract
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.
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Tsai T, Shih LC, Lee IT, Ng TY, Wang JY, Hsu CL, Bau DAT, Tai CJ. Older Age Is Associated With Better Compliance With Follow-up in Taiwan After Functional Endoscopic Sinus Surgery. In Vivo 2021; 34:2571-2576. [PMID: 32871786 DOI: 10.21873/invivo.12074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 06/25/2020] [Accepted: 06/27/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND/AIM Functional endoscopic sinus surgery (FESS) is frequently conducted for restoring sinus ventilation and function. Postoperative care is critical for success. However, loss to follow-up is disturbing. The specific aim of this study was to identify critical factors contributing to loss of patients to follow-up and how to improve it. PATIENTS AND METHODS A total of 221 patients with chronic rhinosinusitis undergoing FESS were enrolled. Patients were divided into three groups according to their follow-up after surgery: Less than 1 month (short-term), 1-3 months (medium-term) and more than 3 months (long-term). The gender, age, smoking status, comorbidities, laterality, Lund-Mackay score, 22-question Sinonasal Outcome Test, nasal obstruction Visual Analogue Scale and mucociliary clearance were evaluated for their contribution to better compliance in follow-up. RESULTS The results revealed that older patients had better compliance in follow-up compared with younger ones (p=0.0093). Other factors were not contributory (p>0.05). CONCLUSION In contrast to the US, older patients in Taiwan have better compliance in postoperative follow-up, while younger ones require more education on the importance of follow-up.
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Affiliation(s)
- Tammy Tsai
- Department of Otorhinolaryngology, China Medical University Hospital, Taichung, Taiwan, R.O.C
| | - Liang-Chun Shih
- Department of Otorhinolaryngology, China Medical University Hospital, Taichung, Taiwan, R.O.C.,Graduate Institute of Biomedical Sciences, China Medical University, Taichung, Taiwan, R.O.C
| | - Ivan T Lee
- Division of Allergy, Immunology, and Rheumatology, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, U.S.A
| | - Teik-Ying Ng
- Department of Otorhinolaryngology, China Medical University Hospital, Taichung, Taiwan, R.O.C.,School of Medicine, China Medical University, Taichung, Taiwan, R.O.C
| | - Jong-Yi Wang
- Department of Health Services Administration, China Medical University, Taichung, Taiwan, R.O.C
| | - Che-Lun Hsu
- Department of Otorhinolaryngology, China Medical University Hospital, Taichung, Taiwan, R.O.C
| | - DA-Tian Bau
- Graduate Institute of Biomedical Sciences, China Medical University, Taichung, Taiwan, R.O.C. .,Terry Fox Cancer Research Laboratory, Department of Medical Research, China Medical University Hospital, Taichung, Taiwan, R.O.C.,Department of Bioinformatics and Medical Engineering, Asia University, Taichung, Taiwan, R.O.C
| | - Chih-Jaan Tai
- Department of Otorhinolaryngology, China Medical University Hospital, Taichung, Taiwan, R.O.C. .,School of Medicine, China Medical University, Taichung, Taiwan, R.O.C.,Department of Health Services Administration, China Medical University, Taichung, Taiwan, R.O.C
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13
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Lilja MJ, Koskinen A, Virkkula P, Vento SI, Myller J, Hammarén-Malmi S, Laulajainen-Hongisto A, Hytönen M, Mäkitie A, Numminen J, Sillanpää S, Raitiola H, Rautiainen M, Toppila-Salmi SK. Factors Affecting the Control of Chronic Rhinosinusitis With Nasal Polyps: A Comparison in Patients With or Without NERD. ALLERGY & RHINOLOGY 2021; 12:21526567211003844. [PMID: 33996192 PMCID: PMC8082978 DOI: 10.1177/21526567211003844] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 02/19/2021] [Accepted: 02/26/2021] [Indexed: 11/16/2022]
Abstract
Objectives The aim was to compare the control of chronic rhinosinusitis with nasal polyps (CRSwNP) after endoscopic sinus surgery (ESS), in patients with/without nonsteroidal anti-inflammatory drug exacerbated respiratory disease (NERD). Study Desing: A retrospective hospital-based sample of CRSwNP patients with/without NERD with follow-up. Setting Tertiary rhinology centers. Methods Electronic patient record data from 116 CRSwNP patients (46 with NERD and 70 without NERD) undergoing ESS during 2001–17 were studied. Mean follow-up time was 9.9 years (range 1.1–15.3). Endpoints reflecting uncontrolled CRSwNP were revision ESS, and need for rescue/advanced therapy (e.g. antibiotics, oral corticosteroids and/or biological therapy) during follow-up. NERD was variable of interest and gender, age, asthma, allergic rhinitis (AR), smoking, Lund-Mackay (LM) score of sinus computed tomography scans previous ESS and baseline total ethmoidectomy were used as covariates. Results Twenty-one (49.7%) NERD patients and 18 (25.7%) non-NERD patients underwent revision ESS within a mean ± SD of 4.3 ± 2.8 and 3.7 ± 2.6 years, respectively (p = .013, by Logrank test). In Cox´s regression models, NERD, female gender, young age, asthma, AR, previous ESS, and lack of total ethmoidectomy were associated with revision-ESS. In adjusted model, only the total ethmoidectomy predicted revision-free survival. In adjusted logistic regression model, there was an insignificant trend that NERD and LM score were associated with the need for rescue/advanced therapy in the follow-up. Conclusions Patients with NERD had higher risk of uncontrolled CRSwNP than patient group without NERD, as measured by revision ESS and/or need for rescue/advanced therapy in the follow-up. In addition, baseline total ethmoidectomy was associated with revision-free survival.
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Affiliation(s)
- Markus Jukka Lilja
- Department of Otorhinolaryngology---Head and Neck Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.,Skin and Allergy Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Anni Koskinen
- Department of Otorhinolaryngology---Head and Neck Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.,Skin and Allergy Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Paula Virkkula
- Department of Otorhinolaryngology---Head and Neck Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.,Skin and Allergy Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Seija Inkeri Vento
- Department of Otorhinolaryngology---Head and Neck Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Jyri Myller
- Department of Otorhinolaryngology, Päijät-Häme Central Hospital, Lahti, Finland
| | - Sari Hammarén-Malmi
- Department of Otorhinolaryngology---Head and Neck Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Anu Laulajainen-Hongisto
- Department of Otorhinolaryngology---Head and Neck Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.,Skin and Allergy Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Maija Hytönen
- Department of Otorhinolaryngology---Head and Neck Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Antti Mäkitie
- Department of Otorhinolaryngology---Head and Neck Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Jura Numminen
- Department of Otorhinolaryngology, University of Tampere, Faculty of Medicine and Health Technology and Tampere University Hospital, Tampere, Finland
| | - Saara Sillanpää
- Department of Otorhinolaryngology, University of Tampere, Faculty of Medicine and Health Technology and Tampere University Hospital, Tampere, Finland
| | - Hannu Raitiola
- Department of Otorhinolaryngology, University of Tampere, Faculty of Medicine and Health Technology and Tampere University Hospital, Tampere, Finland
| | - Markus Rautiainen
- Department of Otorhinolaryngology, University of Tampere, Faculty of Medicine and Health Technology and Tampere University Hospital, Tampere, Finland
| | - Sanna Katriina Toppila-Salmi
- Skin and Allergy Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.,Haartman Institute, University of Helsinki, Helsinki, Finland
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14
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Lyly A, Laulajainen‐Hongisto A, Turpeinen H, Vento SI, Myller J, Numminen J, Sillanpää S, Sahlman J, Kauppi P, Toppila‐Salmi S. Factors affecting upper airway control of NSAID-exacerbated respiratory disease: A real-world study of 167 patients. Immun Inflamm Dis 2021; 9:80-89. [PMID: 33400396 PMCID: PMC7860608 DOI: 10.1002/iid3.347] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 08/14/2020] [Accepted: 08/24/2020] [Indexed: 12/11/2022] Open
Abstract
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.
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Affiliation(s)
- Annina Lyly
- Inflammation Center, Skin and Allergy HospitalUniversity of Helsinki and Helsinki University HospitalHelsinkiFinland
- Department of Otorhinolaryngology—Head and Neck SurgeryUniversity of Helsinki and Helsinki University HospitalHelsinkiFinland
| | - Anu Laulajainen‐Hongisto
- Inflammation Center, Skin and Allergy HospitalUniversity of Helsinki and Helsinki University HospitalHelsinkiFinland
- Department of Otorhinolaryngology—Head and Neck SurgeryUniversity of Helsinki and Helsinki University HospitalHelsinkiFinland
| | - Heikki Turpeinen
- Inflammation Center, Skin and Allergy HospitalUniversity of Helsinki and Helsinki University HospitalHelsinkiFinland
| | - Seija I. Vento
- Department of Otorhinolaryngology—Head and Neck SurgeryUniversity of Helsinki and Helsinki University HospitalHelsinkiFinland
| | - Jyri Myller
- Department of OtorhinolaryngologyPäijät‐Häme Central HospitalLahtiFinland
| | - Jura Numminen
- Department of OtorhinolaryngologyUniversity of Tampere, Faculty of Medicine and Life Sciences and Tampere University HospitalTampereFinland
| | - Saara Sillanpää
- Department of OtorhinolaryngologyUniversity of Tampere, Faculty of Medicine and Life Sciences and Tampere University HospitalTampereFinland
| | - Johanna Sahlman
- Department of OtorhinolaryngologyKuopio University HospitalKuopioFinland
| | - Paula Kauppi
- Inflammation Center, Skin and Allergy HospitalUniversity of Helsinki and Helsinki University HospitalHelsinkiFinland
| | - Sanna Toppila‐Salmi
- Inflammation Center, Skin and Allergy HospitalUniversity of Helsinki and Helsinki University HospitalHelsinkiFinland
- Medicum, Haartman InstituteUniversity of HelsinkiHelsinkiFinland
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15
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Cingi C, Bayar Muluk N, Mitsias DI, Papadopoulos NG, Klimek L, Laulajainen-Hongisto A, Hytönen M, Toppila-Salmi SK, Scadding GK. The Nose as a Route for Therapy: Part 1. Pharmacotherapy. FRONTIERS IN ALLERGY 2021; 2:638136. [PMID: 35387039 PMCID: PMC8974766 DOI: 10.3389/falgy.2021.638136] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Accepted: 01/08/2021] [Indexed: 12/30/2022] Open
Abstract
This article reviews nasal structure and function in the light of intranasal pharmacotherapy. The nose provides an accessible, fast route for local treatment of nose and sinus diseases, with lower doses than are necessary systemically and few adverse effects. It can also be used for other medications as it has sufficient surface area protected from local damage by mucociliary clearance, absence of digestive enzymes, responsive blood flow, and provides a rapid route to the central nervous system.
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Affiliation(s)
- Cemal Cingi
- Department of Otolaryngology, Eskişehir Osmangazi University, Eskişehir, Turkey
| | - Nuray Bayar Muluk
- Department of Otolaryngology, Kirikkale University, Kirikkale, Turkey
| | - Dimitrios I Mitsias
- Allergy Department, 2nd Pediatric Clinic, National and Kapodistrian University of Athens, Athens, Greece
| | - Nikolaos G Papadopoulos
- Allergy Department, 2nd Pediatric Clinic, National and Kapodistrian University of Athens, Athens, Greece.,Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - Ludger Klimek
- Centre for Rhinology and Allergology, Wiesbaden, Germany
| | - Anu Laulajainen-Hongisto
- Department of Otorhinolaryngology-Head and Neck Surgery, Helsinki University Hospital, Helsinki, Finland
| | - Maija Hytönen
- Department of Otorhinolaryngology-Head and Neck Surgery, Helsinki University Hospital, Helsinki, Finland
| | - Sanna Katriina Toppila-Salmi
- Skin and Allergy Hospital, Helsinki University Central Hospital, Helsinki, Finland.,Faculty of Medicine, The Haartman Institute, University of Helsinki, Helsinki, Finland
| | - Glenis Kathleen Scadding
- University College London Hospitals NHS Foundation Trust, London, United Kingdom.,Royal National Throat Nose and Ear Hospital, London, United Kingdom
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16
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High Discontinuation Rates of Peroral ASA Treatment for CRSwNP: A Real-World Multicenter Study of 171 N-ERD Patients. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:3565-3574. [PMID: 32693216 DOI: 10.1016/j.jaip.2020.06.063] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 06/23/2020] [Accepted: 06/29/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND Nonsteroidal anti-inflammatory drug (NSAID) exacerbated respiratory disease (N-ERD) consists of chronic rhinosinusitis with nasal polyposis (CRSwNP), asthma, and NSAID intolerance. Acetylsalicylic acid treatment after desensitization (ATAD) is a treatment option for uncontrolled N-ERD. OBJECTIVE To evaluate peroral ATAD's long-term effectiveness on CRSwNP disease control. METHODS The retrospective data (patient characteristics, sinus surgeries before ATAD, ATAD, follow-up data [2019]) were collected from patient records of 171 patients with N-ERD (102 ATAD patients, 69 controls with CRSwNP+N-ERD without ATAD) who underwent tertiary hospital consultation from 2001 to 2017. Outcome measurements were ATAD discontinuation, revision sinus surgery, and corticosteroid and antibiotic courses for airway infections during 2016-2019. Associations were analyzed by survival and nonparametric methods. RESULTS The ATAD group had more tissue eosinophilia, symptoms, and sinus surgeries before ATAD than others. The ATAD discontinuation rate was 63%, independent of ATAD dose or duration, usually due to side effects. Compared with the N-ERD group without ATAD, ATAD (mean duration, 2.9 years) did not affect the revision endoscopic sinus surgery rate (P = .21, by the log-rank test) or the number of peroral corticosteroid courses per year (P > .05, by the Mann-Whitney U-test) during the follow-up (mean, 7.6 years) despite the dose or duration of ATAD. CONCLUSIONS The discontinuation rate of ATAD was high (63%), and ATAD did not affect revision sinus surgery rate nor the need of peroral corticosteroids during follow-up. However, the remaining 37% of the ATAD group did continue the treatment, indicating that they may have benefited from ATAD.
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17
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Loftus CA, Soler ZM, Desiato VM, Koochakzadeh S, Yoo F, Storck KA, Schlosser RJ. Factors impacting revision surgery in patients with chronic rhinosinusitis with nasal polyposis. Int Forum Allergy Rhinol 2020; 10:289-302. [DOI: 10.1002/alr.22505] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 10/24/2019] [Accepted: 11/15/2019] [Indexed: 12/12/2022]
Affiliation(s)
- Catherine A. Loftus
- Department of Otolaryngology–Head and Neck SurgeryMedical University of South Carolina Charleston SC
| | - Zachary M. Soler
- Department of Otolaryngology–Head and Neck SurgeryMedical University of South Carolina Charleston SC
| | - Vincent M. Desiato
- Department of Otolaryngology–Head and Neck SurgeryMedical University of South Carolina Charleston SC
| | - Sina Koochakzadeh
- Department of Otolaryngology–Head and Neck SurgeryMedical University of South Carolina Charleston SC
| | - Frederick Yoo
- Department of Otolaryngology–Head and Neck SurgeryMedical University of South Carolina Charleston SC
| | - Kristina A. Storck
- Department of Otolaryngology–Head and Neck SurgeryMedical University of South Carolina Charleston SC
| | - Rodney J. Schlosser
- Department of Otolaryngology–Head and Neck SurgeryMedical University of South Carolina Charleston SC
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18
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Virkkula P, Penttilä E, Vento SI, Myller J, Koskinen A, Hammarén-Malmi S, Laulajainen-Hongisto A, Hytönen M, Lilja M, Numminen J, Sillanpää S, Sahlman J, Toppila-Salmi S. Assessing Cut-off Points of Eosinophils, Nasal Polyp, and Lund-Mackay Scores to Predict Surgery in Nasal Polyposis: A Real-World Study. ALLERGY & RHINOLOGY (PROVIDENCE, R.I.) 2020; 11:2152656720956596. [PMID: 35141001 PMCID: PMC8819805 DOI: 10.1177/2152656720956596] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
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.
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Affiliation(s)
- P Virkkula
- Department of Otorhinolaryngology-Head and Neck surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - E Penttilä
- Department of Otorhinolaryngology, University of Eastern Finland, Kuopio, Finland.,Department of Otorhinolaryngology, Kuopio University Hospital, Kuopio, Finland
| | - S I Vento
- Department of Otorhinolaryngology-Head and Neck surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - J Myller
- Department of Otorhinolaryngology, Päijät-Häme Central Hospital, Lahti, Finland
| | - A Koskinen
- Department of Otorhinolaryngology-Head and Neck surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - S Hammarén-Malmi
- Department of Otorhinolaryngology-Head and Neck surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - A Laulajainen-Hongisto
- Department of Otorhinolaryngology-Head and Neck surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - M Hytönen
- Department of Otorhinolaryngology-Head and Neck surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - M Lilja
- Department of Otorhinolaryngology-Head and Neck surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - J Numminen
- Department of Otorhinolaryngology, University of Tampere, Tampere, Finland.,Faculty of Medicine and Life Sciences and Tampere University Hospital, Tampere, Finland
| | - S Sillanpää
- Department of Otorhinolaryngology, University of Tampere, Tampere, Finland.,Faculty of Medicine and Life Sciences and Tampere University Hospital, Tampere, Finland
| | - J Sahlman
- Department of Otorhinolaryngology, Kuopio University Hospital, Kuopio, Finland
| | - S Toppila-Salmi
- Department of Allergy, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Haartman Institute, University of Helsinki, Helsinki, Finland
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19
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Loftus CA, Soler ZM, Koochakzadeh S, Desiato VM, Yoo F, Nguyen SA, Schlosser RJ. Revision surgery rates in chronic rhinosinusitis with nasal polyps: meta-analysis of risk factors. Int Forum Allergy Rhinol 2019; 10:199-207. [PMID: 31752051 DOI: 10.1002/alr.22487] [Citation(s) in RCA: 95] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 10/21/2019] [Accepted: 10/24/2019] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Catherine A Loftus
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC
| | - Zachary M Soler
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC
| | - Sina Koochakzadeh
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC
| | - Vincent M Desiato
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC
| | - Frederick Yoo
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC
| | - Shaun A Nguyen
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC
| | - Rodney J Schlosser
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC
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20
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Kumar H, Jain R. Review: The role of computational simulation in understanding the postoperative sinonasal environment. Clin Biomech (Bristol, Avon) 2019; 68:212-220. [PMID: 31325767 DOI: 10.1016/j.clinbiomech.2018.01.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 01/12/2018] [Accepted: 01/17/2018] [Indexed: 02/07/2023]
Abstract
Nasal surgery improves symptoms in a majority of patients for whom medical treatment has failed. In rhinosinusitis patients, endoscopic sinus surgery aims to alleviate obstruction and re-establish mucociliary clearance. Surgery alters the structure-function relationship within the nasal passage, which is difficult to assess clinically. Computational modelling has been used to investigate this relationship by simulating air flow and environmental variables inside realistic three-dimensional models of the human nasal airway but many questions remain unanswered and need further investigation. The application of computational models to improve pre-surgical planning and post-surgical treatment may not be currently possible due to the absence of knowledge correlating the model-predicted parameters to physiological variables. Links between these parameters to patient outcomes are yet to be established. This article reviews the recent application of computational modelling to understand the nasal structure-function relationship following surgery in patients with sinusitis and nasal obstruction.
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Affiliation(s)
- Haribalan Kumar
- Auckland Bioengineering Institute, The University of Auckland, New Zealand.
| | - Ravi Jain
- Department of surgery, The University of Auckland, New Zealand
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21
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Kumar H, Jain R. Review: The role of computational simulation in understanding the postoperative sinonasal environment. Clin Biomech (Bristol, Avon) 2019; 66:2-10. [PMID: 30195934 DOI: 10.1016/j.clinbiomech.2018.02.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 01/29/2018] [Accepted: 02/01/2018] [Indexed: 02/07/2023]
Abstract
Nasal surgery improves symptoms in a majority of patients for whom medical treatment has failed. In rhinosinusitis patients, endoscopic sinus surgery aims to alleviate obstruction and re-establish mucociliary clearance. Surgery alters the structure-function relationship within the nasal passage, which is difficult to assess clinically. Computational modelling has been used to investigate this relationship by simulating air flow and environmental variables inside realistic three-dimensional models of the human nasal airway but many questions remain unanswered and need further investigation. The application of computational models to improve pre-surgical planning and post-surgical treatment may not be currently possible due to the absence of knowledge correlating the model-predicted parameters to physiological variables. Links between these parameters to patient outcomes are yet to be established. This article reviews the recent application of computational modelling to understand the nasal structure-function relationship following surgery in patients with sinusitis and nasal obstruction.
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Affiliation(s)
- Haribalan Kumar
- Auckland Bioengineering Institute, The University of Auckland, New Zealand.
| | - Ravi Jain
- Department of surgery, The University of Auckland, New Zealand
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Ahmed OH, Lafer MP, Bandler I, Zan E, Wang B, Lebowitz RA, Lieberman SM. Endoscopic Visualization of the True Maxillary Ostium Following Uncinectomy. EAR, NOSE & THROAT JOURNAL 2019; 99:384-387. [PMID: 31124375 DOI: 10.1177/0145561319853260] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
- Omar H Ahmed
- Department of Otolaryngology-Head and Neck Surgery, New York University, New York, NY, USA
| | - Marissa P Lafer
- Department of Otolaryngology-Head and Neck Surgery, New York University, New York, NY, USA
| | - Ilana Bandler
- State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Elcin Zan
- Department of Radiology, New York University, New York, NY, USA
| | - Binhuan Wang
- Division of Biostatistics, Department of Population Health, New York University, New York, NY, USA
| | - Richard A Lebowitz
- Department of Otolaryngology-Head and Neck Surgery, New York University, New York, NY, USA
| | - Seth M Lieberman
- Department of Otolaryngology-Head and Neck Surgery, New York University, New York, NY, USA
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Fu T, Lee D, Yip J, Jamal A, Lee JM. Impact of Septal Deviation on Recurrent Chronic Rhinosinusitis after Primary Surgery: A Matched Case-Control Study. Otolaryngol Head Neck Surg 2018; 160:922-927. [PMID: 30481474 DOI: 10.1177/0194599818815106] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To evaluate the impact of untreated deviated nasal septum (DNS) on recalcitrant chronic rhinosinusitis (CRS) among patients undergoing revision endoscopic sinus surgery (ESS). STUDY DESIGN Case-control study. SETTING Tertiary academic center. SUBJECTS AND METHODS We performed a retrospective review of 489 patients undergoing revision ESS for CRS at a tertiary academic center. Patients undergoing septoplasty were matched to nonseptoplasty controls based on age and sex. Preoperative Lund-Mackay score (LMS) was compared between cohorts. Linear regression was used to identify predictors of LMS and ostiomeatal complex (OMC) obstruction. RESULTS Thirty-six matched pairs (72 patients) were selected for analysis: 36 undergoing septoplasty and revision ESS and 36 undergoing revision ESS alone. Compared with nonseptoplasty controls, the septoplasty group had a significantly higher average LMS (17.8 vs 14.6, P = .02) and a greater rate of OMC obstruction (89% vs 61%, P < .01). The septoplasty group also had significantly higher opacification scores in the maxillary (1.5 vs 1.2, P = .03) and posterior ethmoid (1.8 vs 1.4, P = .02) sinuses. On multivariable analysis, DNS was an independent predictor of LMS ( P = .02) and OMC obstruction ( P < .01). CONCLUSION Untreated DNS is associated with radiographic markers of CRS severity among patients undergoing revision ESS and may contribute to the multifactorial pathogenesis of persistent CRS.
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Affiliation(s)
- Terence Fu
- 1 Division of Rhinology, Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Daniel Lee
- 1 Division of Rhinology, Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Jonathan Yip
- 1 Division of Rhinology, Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Alisha Jamal
- 2 Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - John M Lee
- 1 Division of Rhinology, Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada
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24
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Hunter TD, DeConde AS, Manes RP. Disease-related expenditures and revision rates in chronic rhinosinusitis patients after endoscopic sinus surgery. J Med Econ 2018. [PMID: 29534616 DOI: 10.1080/13696998.2018.1452748] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
AIMS The objective of this study was to quantify the treatment costs and revision surgery rates in chronic rhinosinusitis (CRS) patients, with and without nasal polyposis (CRSwNP and CRSsNP), who require treatment with endoscopic sinus surgery (ESS). The additive contributions of nasal polyposis (NP) and revision surgery to 1-year costs were a primary focus. MATERIALS AND METHODS Adults (aged 18-64 years) undergoing ESS for CRS in 2012-2015 were identified within the Blue Health Intelligence database and used to estimate revision rates. Patients with ±1 year of enrollment around the index ESS were used to estimate 1-year healthcare expenditures. Revision ESS rates were evaluated via Kaplan-Meier and Cox regression models. Disease-related healthcare and pharmacy expenditures were modeled with generalized linear regression to assess the impact of baseline patient characteristics. RESULTS A total of 86,052 patients underwent ESS for CRS (43.5 ± 12.4 years; 49.3% male), and a sub-set of 23,542 patients were available for 1-year healthcare expenditure analysis (44.0 ± 12.1 years; 50.0% male). Revision ESS rates within 1 year were 3.5% in the CRSwNP cohort and 1.6% in the CRSsNP cohort. NP, deviated septum, gender, and region were statistically significant predictors of revision surgery. Mean 1-year treatment expenditures, including the index ESS, were $8,824 for CRSsNP and $11,166 for CRSwNP patients without revision ESS. CRSwNP doubled the risk of revision surgery in the first year after ESS compared with CRSsNP and cost 24% more in the absence of a second procedure. Revision ESS within the first year increased mean 1-year expenditures by $11,150 and $13,139 for CRSsNP and CRSwNP, respectively. LIMITATIONS The primary limitation was the limited length of follow-up available for estimating revision ESS rates. CONCLUSIONS In a large commercially insured US population, disease-related expenditures for patients having ESS for CRS are substantial, as are the additive impacts of NP and revision surgery.
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Affiliation(s)
- Tina D Hunter
- a CTI Clinical Trial and Consulting Services, Inc., Biostatistics & Health Outcomes Research , Covington , KY , USA
| | - Adam S DeConde
- b University of California-San Diego , San Diego , CA , USA
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Taylor RJ, Schlosser RJ, Soler ZM, Mattos JL, Mulligan JK. Glucocorticoid receptor isoform expression in peripheral blood mononuclear leukocytes of patients with chronic rhinosinusitis. Int Forum Allergy Rhinol 2018; 8:10.1002/alr.22120. [PMID: 29719127 PMCID: PMC6214788 DOI: 10.1002/alr.22120] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Revised: 02/22/2018] [Accepted: 03/01/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND In several inflammatory disorders, altered peripheral blood mononuclear leukocyte (PBML) glucocorticoid (GC) receptor isoform expression has been associated with GC resistance and disease severity. However, it is unclear if PBML GC receptor isoforms are expressed differentially and are associated with worsened disease severity in chronic rhinosinusitis (CRS). METHODS PBMLs were isolated from control (n = 8), CRS without nasal polyps (CRSsNP) (n = 8), atopic CRS with nasal polyps (CRSwNP) (n = 8), non-atopic CRSwNP (n = 8), and allergic fungal rhinosinusitis (AFRS) (n = 8) patients. Demographics, atopic status, asthmatic status, 22-item Sino-Nasal Outcome Test (SNOT-22) scores, Lund-Kennedy nasal endoscopy scores, Lund-Mackay sinus computed tomography (CT) scores, Kennedy Osteitis scores, and GC utilization 6 months postoperatively were collected. Intracellular immunostaining was then performed for functional GC receptor α (GCRα) and nonfunctional GC receptor β (GCRβ), followed by flow cytometry analysis of geometric mean fluorescent intensity (MFI) and the percentage of cells expressing each GC receptor isoform. RESULTS Compared to controls, each CRS subtype had decreased PBML GCRα and GCRα:GCRβ MFI expression, but no difference in GCRβ expression. Decreasing PBML GCRα in AFRS was associated with increasing Lund-Mackay sinus CT scores (r = -0.880, p =0.004). No significant associations were found between GC receptor isoform expression and other clinical measures. CONCLUSION CRS patients have reduced functional PBML GCRα expression and decreased GCRα:GCRβ compared to controls. Reductions in GCRα in AFRS are associated with worsening Lund-Mackay sinus CT scores. The clinical implications of decreased functional GC receptor expression merits further investigation.
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Affiliation(s)
- Robert J. Taylor
- Department of Otolaryngology–Head and Neck Surgery, Medical University of South Carolina, Charleston, SC
| | - Rodney J. Schlosser
- Department of Otolaryngology–Head and Neck Surgery, Medical University of South Carolina, Charleston, SC
- Ralph H. Johnson VA Medical Center, Charleston, SC
| | - Zachary M. Soler
- Department of Otolaryngology–Head and Neck Surgery, Medical University of South Carolina, Charleston, SC
| | - Jose L. Mattos
- Department of Otolaryngology–Head and Neck Surgery, Medical University of South Carolina, Charleston, SC
| | - Jennifer K. Mulligan
- Department of Otolaryngology–Head and Neck Surgery, Medical University of South Carolina, Charleston, SC
- Ralph H. Johnson VA Medical Center, Charleston, SC
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC
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26
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Stein NR, Jafari A, DeConde AS. Revision rates and time to revision following endoscopic sinus surgery: A large database analysis. Laryngoscope 2017; 128:31-36. [PMID: 28688189 DOI: 10.1002/lary.26741] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 05/16/2017] [Accepted: 05/22/2017] [Indexed: 01/13/2023]
Abstract
OBJECTIVES/HYPOTHESIS Endoscopic sinus surgery (ESS) is performed for patients with chronic rhinosinusitis (CRS) that have failed maximal medical therapy. This study seeks to determine the prevalence of revision surgery and factors predicting the need for revision after ESS using a large statewide surgery database. STUDY DESIGN Large retrospective cohort study using the State Ambulatory Surgery Database for the state of California between 2005 and 2011. METHODS We identified over 61,000 patients with CRS who underwent ESS, determined by Current Procedural Terminology code. We identified which patients underwent a repeat surgery, and performed multivariable modeling to determine which factors (nasal polyps, age, gender, insurance, hospital setting, ethnicity) predicted the need for revision. Adjusted odds ratios (AOR) and 95% confidence intervals are presented. RESULTS Of 61,339 patients who underwent ESS, 4,078 (6.65%) returned for revision ESS during the time period investigated. In a multivariable logistic regression model, positive predictors of revision were a diagnosis of nasal polyps (AOR: 1.20, 95% CI: 1.11-1.29, P < .001) and female gender (AOR: 1.20, 95% CI: 1.11-1.29, P < .001); public insurance was marginally predictive of increased reoperation (AOR: 1.10, 95% CI: 1.00-1.21, P = .048). Patients of Hispanic ethnicity were less likely to have revision surgery (AOR: 0.86, 95% CI: 0.77-0.97, P = .011). Age, income, and hospital setting were not significant predictors. CONCLUSIONS A minority of patients with CRS who undergo ESS will have a revision surgery. This likelihood is increased in female patients and those with nasal polyps, and decreased in patients of Hispanic ethnicity, even when controlling for income, insurance, and hospital setting. LEVEL OF EVIDENCE 4. Laryngoscope, 128:31-36, 2018.
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Affiliation(s)
- Nathan R Stein
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of California San Diego, San Diego, California, U.S.A
| | - Aria Jafari
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of California San Diego, San Diego, California, U.S.A
| | - Adam S DeConde
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of California San Diego, San Diego, California, U.S.A
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