Investigation of sinonasal anatomy via low-dose multidetector CT examination in chronic rhinosinusitis patients with higher risk for perioperative complications

ACR Appropriateness Criteria® Sinonasal Disease: 2021 Update

This article presents guidelines for initial imaging utilization in patients presenting with sinonasal disease, including acute rhinosinusitis without and with suspected orbital and intracranial complications, chronic rhinosinusitis, suspected invasive fungal sinusitis, suspected sinonasal mass, and suspected cerebrospinal fluid leak. CT and MRI are the primary imaging modalities used to evaluate patients with sinonasal disease. Given its detailed depiction of bony anatomy, CT can accurately demonstrate the presence of sinonasal disease, bony erosions, and anatomic variants, and is essential for surgical planning. Given its superior soft tissue contrast, MRI can accurately identify clinically suspected intracranial and intraorbital complications, delineate soft tissue extension of tumor and distinguish mass from obstructed secretions.The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

The classification, diagnosis, and treatment of rhinosinusitis

Background: Rhinosinusitis, one of the most common conditions encountered by clinicians, affects quality of life and reduces work productivity. Despite its high prevalence and economic burden, there are considerable differences in practice regarding the management of rhinosinusitis. Based on many studies, including the updated guidelines, classifications have been subdivided, and new treatments have been added.Current Concepts: Rhinosinusitis can be classified as acute rhinosinusitis (ARS) or chronic rhinosinusitis (CRS) with a cut-off duration of 12 weeks. It is diagnosed based on subjective symptoms and objective findings on computed tomography or endoscopy. Viral infections account for the majority of the causes of ARS, with watchful waiting without antibiotics as its important initial management. Meanwhile, CRS is divided into primary and secondary CRS, which is further subdivided by anatomic distribution and endotype. Particularly, the Type 2 endotype is characterized by a high recurrence rate and high resistance to current therapies. Biologics using monoclonal antibodies could therefore be used as new therapeutic options for the treatment of primary type 2 CRS. Furthermore, given the chronicity of CRS, it is important to recognize that endoscopic sinus surgery and continuous postoperative medical treatment are important for its management.Discussion and Conclusion: Accurate diagnoses based on diagnostic criteria and subdivided classifications are necessary to determine the treatment plan and prognosis. In particular, it is important to differentiate the endotype of CRS and provide appropriate treatments to improve the patient’s symptoms and quality of life.

Manifesto on united airways diseases (UAD): an Interasma (global asthma association - GAA) document

OBJECTIVE

The large amount of evidence and the renewed interest in upper and lower airways involvement in infectious and inflammatory diseases has led Interasma (Global Asthma Association) to take a position on United Airways Diseases (UAD).

METHODS

Starting from an extensive literature review, Interasma executive committee discussed and approved this Manifesto developed by Interasma scientific network (INES) members.

RESULTS

The manifesto describes the evidence gathered to date and defines, states, advocates, and proposes issues on UAD (rhinitis, rhinosinusitis and nasal polyposis), and concomitant/comorbid lower airways disorders (asthma, chronic obstructive pulmonary disease, bronchiectasis, cystic fibrosis, obstructive sleep apnoea) with the aim of challenging assumptions, fostering commitment, and bringing about change. UAD refers to clinical pictures characterized by the coexistence of upper and lower airways involvement, driven by a common pathophysiological mechanism, leading to a greater burden on patient's health status and requiring an integrated diagnostic and therapeutic plan. The high prevalence of UAD must be taken into account. Upper and lower airways diseases influence disease control and patient's quality of life.

CONCLUSIONS

Patients with UAD need to have a timely and adequate diagnosis, treatment, and, when recommended, referral for management in a specialized center. Diagnostic testing including skin prick or serum specific IgE, lung function, fractional exhaled nitric oxide (FeNO), polysomnography, allergen-specific immunotherapies, biological therapies and home based continuous positive airway pressure (CPAP) whenever these are recommended, should be part of the management plan for UAD. Education of medical students, physicians, health professionals, patients and caregivers on the UAD is needed.

Expression of Bitter Taste Receptors and Solitary Chemosensory Cell Markers in the Human Sinonasal Cavity

Some bitter taste receptors (TAS2R gene products) are expressed in the human sinonasal cavity and may function to detect airborne irritants. The expression of all 25 human bitter taste receptors and their location within the upper airway is not yet clear. The aim of this study is to characterize the presence and distribution of TAS2R transcripts and solitary chemosensory cells (SCCs) in different locations of the human sinonasal cavity. Biopsies were obtained from human subjects at up to 4 different sinonasal anatomic sites. PCR, microarray, and qRT-PCR were used to examine gene transcript expression. The 25 human bitter taste receptors as well as the sweet/umami receptor subunit, TAS1R3, and canonical taste signaling effectors are expressed in sinonasal tissue. All 25 human bitter taste receptors are expressed in the human upper airway, and expression of these gene products was higher in the ethmoid sinus than nasal cavity locations. Fluorescent in situ hybridization demonstrates that epithelial TRPM5 and TAS2R38 are expressed in a rare cell population compared with multiciliated cells, and at times, consistent with SCC morphology. Secondary analysis of published human sinus single-cell RNAseq data did not uncover TAS2R or canonical taste transduction transcripts in multiciliated cells. These findings indicate that the sinus has higher expression of SCC markers than the nasal cavity in chronic rhinosinusitis patients, comprising a rare cell type. Biopsies obtained from the ethmoid sinus may serve as the best location for study of human upper airway taste receptors and SCCs.

Standard-dose versus low-dose multidetector computed tomography examinations in patients with uncontrolled chronic rhinosinusitis: A randomized, controlled trial

BACKGROUND

Multidetector computed tomography (MDCT) images for rhinosinusitis may have a risk of radiation hazards. Reduction in radiation dose may lead to a compromise in quality of MDCT images and have chances of postoperative complications.

OBJECTIVE

The aim of the study was to test the applicability of low-dose MDCT protocols for decision-making of sinus surgeries of patients with uncontrolled chronic rhinosinusitis.

DESIGN

Randomized, double-blind (patients and evaluators blind), controlled, trial.

SETTING

People's Hospital of Guanghan, China.

PATIENTS

A total of 288 patients with clinically confirmed uncontrolled chronic rhinosinusitis were subjected to randomization (1:1 ratio).

INTERVENTIONS

Patients were subjected to low-dose preoperative protocols of MDCT (n = 144; ldMDCT group) or standard-dose preoperative protocols of MDCT (n = 144; sdMDCT group).

OUTCOME MEASURES

Image analysis was performed by the workstation. Lund-Mackay score, modified Lund-Mackay score, estimated radiation exposure, and surgical complications were evaluated for each patient. The χ independent test or 2-tailed paired t test were performed for statistical analysis.

RESULTS

The preoperative MDCT images for standard-dose protocol had better quality than low-dose protocol (P < .001, q = 4.57). The area of images that give confidence for sinus surgery at one time was higher for standard-dose MDCT protocol technique than low-dose MDCT protocol method. Patients of ldMDCT group with large growth of nasal polyps (P = .03, q = 5.35) and complete opacification of sinuses (P = .03, q = 7.94) had complications after sinus surgeries. Either low-dose or standard-dose MDCT protocol was performed, the experience of otolaryngologist had decreased complication after surgeries.

CONCLUSION

Preoperative low-dose MDCT should be used for diagnosis of uncontrolled chronic rhinosinusitis for decision making of sinus surgeries.

LEVEL OF EVIDENCE

III.

TRIAL REGISTRATION

researchregistry4264 dated 1 March 2016 (www.researchregistry.com).