Chronic Rhinosinusitis in Children: Pathophysiology, Evaluation, and Medical Management

Pädiatrische Rhinologie

The following review article highlights key topics in pediatric rhinology that are currently the focus in research and at conferences as well as in the interdisciplinary discussion between otorhinolaryngologists and pediatricians. In particular, congenital malformations such as choanal atresia or nasal dermoid cysts are discussed, followed by statements on the current procedures for sinogenic orbital complications as well as on the diagnosis and therapy of chronic rhinosinusitis in children. Furthermore, updates on the role of the ENT specialist in the care for children with cystic fibrosis and primary ciliary dyskinesia are provided.

Pediatric chronic rhinosinusitis

PURPOSE

An up-to-date overview of diagnosis, differential diagnosis, comorbidities, and current medical and surgical management of pediatric chronic rhinosinusitis (PCRS).

METHODS

Review of current evidence-based literature on PCRS.

RESULTS

Diagnosis of PCRS seems to be improving based on recent evidence using nasal endoscopy as well as computed tomography scanning. Recent literature supports the fact that chronic adenoiditis can be an independent etiology of symptoms of chronic sinusitis, that are very similar to chronic adenoiditis. Allergic rhinitis and immune deficiency play important roles in the management of PCRS. Surgery for PCRS has evolved significantly in the last 15-20 years to include adenoidectomy as well as endoscopic sinus surgery.

CONCLUSIONS

PCRS is very common in children causing poor QOL for these children. Medical management remains the main stay of treatment with attention to management of co-morbidities that may contribute to the disease severity. Making the correct diagnosis will help with the choice of surgical intervention if medical management fails.

Fifteen-minute consultation: Child with persistent runny nose

A child with persistent runny nose may cause significant parental anxiety and healthcare utilisation. While the most common diagnoses are recurrent acute viral upper respiratory tract infections and allergic rhinitis, a careful history and examination is necessary to exclude other causes and to identify comorbidities. Treatment can then be tailored to the underlying cause. The aim of this article is to provide a systematic approach to such patients.

The Influence of Nonaerated Paranasal Sinuses on DTI Parameters of the Brain in 6- to 9-Year-Old Children

BACKGROUND AND PURPOSE

DTI is prone to susceptibility artifacts. Air in the paranasal sinuses can cause field inhomogeneity, thus affecting measurements. Children often have mucus in their sinuses or no pneumatization of them. This study investigated the influence of lack of air in the paranasal sinuses on measurements of WM diffusion characteristics.

MATERIALS AND METHODS

The study was embedded in the Generation R Study, a prospective population-based birth cohort in Rotterdam (the Netherlands). Brain MR imaging studies (1070 children, 6-9 years of age) were evaluated for mucosal thickening of the paranasal sinuses. Nonaeration of the paranasal sinuses (modified Lund-Mackay score) was compared with that in a randomly selected control group. The relationship between nonaerated paranasal sinuses and fractional anisotropy and mean diffusivity in the DTI fiber tracts was evaluated using ANCOVA and independent t tests.

RESULTS

The prevalence of mucosal thickening was 10.2% (109/1070). The mean modified Lund-Mackay score was 6.87 (SD, 3.76). In 52.3% (57/109), ≥ 1 paranasal sinus was not pneumatized. The results are reported in effect sizes (Cohen's d). Lower mean fractional anisotropy values were found in the uncinate fasciculus (right uncinate fasciculus/right frontal sinus, d = -0.60), superior longitudinal fasciculus (right superior longitudinal fasciculus/right ethmoid sinus, d = -0.56; right superior longitudinal fasciculus/right sphenoid sinus, d = -2.09), and cingulate bundle (right cingulum bundle/right sphenoid sinus, d = -1.28; left cingulum bundle/left sphenoid sinus, d = -1.49). Higher mean diffusivity values were found in the forceps major/right and left sphenoid sinuses, d = 0.78.

CONCLUSIONS

Nonaeration of the paranasal sinuses is a common incidental finding on pediatric MR imaging brain scans. The amount of air in the paranasal sinuses can influence fractional anisotropy and, to a lesser degree, mean diffusivity values of WM tracts and should be considered in DTI studies in pediatric populations.

Allergic Fungal Rhinosinusitis in a 12-Year-Old Male Resulting in the Remodeling of Cribriform Plate With Protrusion Into the Anterior Cranial Fossa: A Case Report

Allergic fungal rhinosinusitis (AFRS) in the pediatric population is a rare pathologic entity, and it is characterized by a type I hypersensitivity reaction to sinus fungi promoting the development of eosinophilic inflammation and thickened mucin. In the United States, a higher prevalence of AFRS is found among younger populations, African Americans, in counties characterized by elevated poverty rates, and patients without insurance or those reliant on Medicaid. Early clinical suspicion is essential for the timely diagnosis of this condition and to prevent the dissemination of the disease, thereby achieving a favorable prognosis. We report a case of a 12-year-old African American male who presented with the gradual onset of asymptomatic proptosis and seasonal allergy symptoms resulting in unilateral relative afferent pupillary defect and was ultimately diagnosed with AFRS.

Clinical Characteristics of Eosinophilic Chronic Rhinosinusitis with Nasal Polyps in Adolescents

Introduction

Eosinophilic chronic rhinosinusitis with nasal polyps (CRSwNP) is frequently associated with greater inflammation, poorer prognosis, and a high recurrence rate after sinus surgery.

Objective

This study evaluated the clinical and imaging characteristics of eosinophilic CRSwNP in patients aged 12-17.

Methods

We retrospectively enrolled 139 patients aged 12-17 with bilateral CRSwNP. Clinical characteristics, computed tomography (CT) features, tissue eosinophil counts, and eosinophil activity were evaluated.

Results

Twenty-three (16.5%) patients had recurrent nasal polyps that required revision surgery. Patients requiring revision surgery had higher tissue eosinophil infiltration in the sinus mucosa than those not requiring revision surgery. The optimal cut-off value to distinguish the need for revision surgery was a tissue eosinophil count > 21.5/high-power field determined by the receiver operating characteristic curve. The Lund-Mackay and olfactory cleft opacification scores on CT images were significant predictors of tissue eosinophil count in the univariate analysis, and only olfactory opacification scores remained statistically significant in the multivariate analysis.

Conclusion

This study revealed that the CT feature of the olfactory cleft opacification score could be a significant characteristic of eosinophilic CRSwNP in adolescents.

The analysis of etiology and treatment of chronic rhinosinusitis in our own material

<b>Introduction and aim:</b> The aim of the study was the analysis of etiology and treatment of chronic rhinosinusitis in our own material.</br></br> <b>Material and methods:</b> The study was performed on 520 women aged 18-87 and 789 men aged 19-85, diagnosed and treated for chronic rhinosinusitis between 2016 and 2020. The analysis was based on the medical records, taking into account: gender; age; type of symptoms; allergy tests; probable cause of inflammation; type of anatomical anomalies; assessment of the stage based on the Lund-Mackay score for CT scans; number of operations; pathology report; postoperative complications.</br></br> <b>Results:</b> The study showed that the hospitalized patients were most often aged 41-50, 51-60, and 31-40 for women and 51-60, 41-50, and 31-40 for men, respectively. The results of allergy tests in chronic rhinosinusitis patients showed that women were most often allergic to Pyralgin + Ketonal + paracetamol + ibuprofen in 4.50%, to penicillins in 1.07%, and to house dust mites in 0.92%, while in men positive reactions were found in 3.36% for Pyralgin + Ketonal + paracetamol + ibuprofen, 0.99% for house dust mites and 0.92% for cat and dog hair, respectively. Absence of anatomical anomalies was found in 20.75% of women and 26.36% of men, but most often they occurred in the form of deviated nasal septum and enlarged middle nasal concha. The pathology reports revealed the following: chronic rhinosinusitis, chronic polypoid rhinosinusitis, chronic cystic rhinosinusitis, and chronic allergic rhinosinusitis.</br></br> <b>Conclusions:</b> The main symptoms in patients with chronic rhinosinusitis included: nasal congestion + rhinorrhea, nasal congestion + nasal discharge + olfactory impairment, and nasal congestion + nasal discharge + headache. The most common probable causes of chronic rhinosinusitis in the studied patients included: anatomical anomalies, allergies, and irritants including tobacco smoke. Depending on the assessment of the stage based on the Lund-Mackay score for CT scans, it appears that moderate to severe inflammation prevailed in the studied patients.

Nasal polyposis in pediatric patients with Cornelia de Lange syndrome: endoscopic diagnosis, treatment and follow up in two case reports

BACKGROUND

Cornelia de Lange syndrome is a rare genetic disease with otolaryngological involvement. The classic phenotype is characterized by distinctive facial features, intellectual disability, growth delay, hirsutism, and upper-limb reduction. Nasal polyposis was previously reported in association with chronic rhinosinusitis, however data about prevalence, diagnosis, treatment and prognosis are lacking for this cohort of patients, affected by rare disease.

CASE PRESENTATION

We describe the whole diagnostic and therapeutic workflow of nasal polyps in two pediatric patients with Cornelia de Lange, successfully diagnosed and treated by nasal endoscopy.

CONCLUSION

Our report confirm that nasal endoscopy is a safe and useful tool in the diagnosis, treatment and follow-up of nasal polyps, even in Cornelia de Lange syndrome pediatric patients. We want to increase the alert for the detection of nasal polyps in patients with Cornelia de Lange syndrome since pediatric age. We recommend endoscopy in all patients with Cornelia de Lange syndrome and symptoms of chronic nasal obstruction and/or OSAS. Multidisciplinary team and sedation service could be useful in the management of Cornelia de Lange syndrome patients with airway obstruction symptoms and sleep disturbance when severe intellectual disability, autism or psychiatric findings are present.

New insights into the pathophysiology and therapeutic targets of asthma and comorbid chronic rhinosinusitis with or without nasal polyposis

Asthma and chronic rhinosinusitis with nasal polyps (CRSwNP) or without (CRSsNP) are chronic respiratory diseases. These two disorders often co-exist based on common anatomical, immunological, histopathological, and pathophysiological basis. Usually, asthma with comorbid CRSwNP is driven by type 2 (T2) inflammation which predisposes to more severe, often intractable, disease. In the past two decades, innovative technologies and detection techniques in combination with newly introduced targeted therapies helped shape our understanding of the immunological pathways underlying inflammatory airway diseases and to further identify several distinct clinical and inflammatory subsets to enhance the development of more effective personalized treatments. Presently, a number of targeted biologics has shown clinical efficacy in patients with refractory T2 airway inflammation, including anti-IgE (omalizumab), anti-IL-5 (mepolizumab, reslizumab)/anti-IL5R (benralizumab), anti-IL-4R-α (anti-IL-4/IL-13, dupilumab), and anti-TSLP (tezepelumab). In non-type-2 endotypes, no targeted biologics have consistently shown clinical efficacy so far. Presently, multiple therapeutical targets are being explored including cytokines, membrane molecules and intracellular signalling pathways to further expand current treatment options for severe asthma with and without comorbid CRSwNP. In this review, we discuss existing biologics, those under development and share some views on new horizons.

Endotypes of Nasal Polyps in Children: A Multidisciplinary Approach

Nasal polyps (NPs) are rarely reported in childhood and usually represent red flags for systemic diseases, such as cystic fibrosis (CF), primary ciliary dyskinesia (PCD) and immunodeficiencies. The European Position Paper released in 2020 (EPOS 2020) provided a detailed classification and defined the correct diagnostic and therapeutic approaches. We report a one-year experience of a multidisciplinary team, made up of otorhinolaryngologists, allergists, pediatricians, pneumologists and geneticists, with the aim of ensuring a personalized diagnostic and therapeutic management of the pathology. In 16 months of activity, 53 patients were admitted (25 children with chronic rhinosinusitis with polyposis and 28 with antro-choanal polyp). All patients underwent phenotypic and endo-typic assessment, using proper classification tools for nasal pathology (both endoscopic and radiological), as well as adequate cytological definition. An immuno-allergic evaluation was carried out. Pneumologists evaluated any lower airway respiratory disease. Genetic investigations concluded the diagnostic investigation. Our experience enhanced the complexity of children's NPs. A multidisciplinary assessment is mandatory for a targeted diagnostic and therapeutic pathway.

A Supplement with Ribes Nigrum, Boswellia Serrata, Bromelain and Vitamin D to Stop Local Inflammation in Chronic Sinusitis: A Case-Control Study

Although chronic sinusitis widely affects the adult population, the treatments currently used did not always satisfactorily solve the symptoms. Traditional therapy with steroids and antibiotics presents risks and benefits and the new drugs, i.e., monoclonal antibody, are valid solutions despite being quite expensive. Natural molecules could be a valid treatment that combines good efficacy and low price. We conducted a case -control study to evaluate the benefit of an oral supplement with Ribes nigrum, Boswellia serrata, Bromelain and Vitamin D on chronic sinusitis symptoms. 60 patients were randomly assigned to one of the three groups: control using nasal steroids only, treatment 1 using nasal steroid and 1 dose of the oral supplement for 30 days and treatment 2 in which patients used nasal steroid and two oral supplement doses daily for 15 days. Conditions of the nasal mucosa and a blood sample (WBC, IgE and CRP) were analyzed at T0, T1 (15 days after treatment) and T2 (30 days after treatment. Patients treated with the supplement improved their nasal findings (hyperemia of mucosa and rhinorrhea) with statistically significant differences from the control. Our preliminary data suggest that the addition of supplement containing Ribes nigrum, Boswellia serrata, Vitamin D and Bromelain to the traditional local therapy (nasal spray with cortisone) can be a supporting therapy to modulate the local inflammation in the nose in patients affected by chronic sinusitis.

Potential of Lactoferrin in the Treatment of Lung Diseases

Lactoferrin (LF) is a multifunctional iron-binding glycoprotein that exhibits a variety of properties, such as immunomodulatory, anti-inflammatory, antimicrobial, and anticancer, that can be used to treat numerous diseases. Lung diseases continue to be the leading cause of death and disability worldwide. Many of the therapies currently used to treat these diseases have limited efficacy or are associated with side effects. Therefore, there is a constant pursuit for new drugs and therapies, and LF is frequently considered a therapeutic agent and/or adjunct to drug-based therapies for the treatment of lung diseases. This article focuses on a review of the existing and most up-to-date literature on the contribution of the beneficial effects of LF on the treatment of lung diseases, including asthma, viral infections, cystic fibrosis, or lung cancer, among others. Although in vitro and in vivo studies indicate significant potency of LF in the treatment of the listed diseases, only in the case of respiratory tract infections do human studies seem to confirm them by demonstrating the effectiveness of LF in reducing episodes of illness and shortening the recovery period. For lung cancer, COVID-19 and sepsis, the reports are conflicting, and for other diseases, there is a paucity of human studies conclusively confirming the beneficial effects of LF.

Histopathologic differences between adult and pediatric patients with chronic rhinosinusitis

BACKGROUND

Adult and pediatric patients with chronic rhinosinusitis (CRS) may have differing philosophies in therapeutic management. Few studies have examined sinonasal tissue-level comparisons of these groups. This study examines histopathologic differences between children and adults with CRS, with the goal of understanding disease pathogenesis and optimizing medical management for both populations.

METHODS

In a retrospective cohort of CRS patients who underwent functional endoscopic sinus surgery (FESS), demographic factors, pertinent comorbidities, and a structured histopathologic report of 13 variables were compared across pediatric and adult CRS patients with and without nasal polyps (pCRSwNP, pCRSsNP, aCRSwNP, aCRSsNP, respectively).

RESULTS

A total of 378 adult (181 aCRSsNP, 197 aCRSwNP) and 50 pediatric (28 pCRSsNP, 22 pCRSwNP) patients were analyzed. Significantly more children compared with adults had a comorbid asthma diagnosis (64.5% vs. 37.2%, p = 0.003). Adults with CRS exhibited significantly more tissue neutrophilia (28.9% vs. 12.0%, p = 0.006), basement membrane thickening (70.3% vs. 44.0%, p < 0.001), subepithelial edema (61% vs. 30.0%, p < 0.001), squamous metaplasia (22.0% vs. 4.0%, p < 0.001), and eosinophil aggregates (22.8% vs. 4.0%, p < 0.001) than children with CRS. The majority (66.5%) of adult CRS patients exhibited a lymphoplasmacytic-predominant inflammatory background, whereas the majority (57.8%) of children with CRS exhibited a lymphocyte-predominant inflammatory background.

CONCLUSIONS

Sinonasal tissue of adult and pediatric CRS patients demonstrates clear histopathologic differences. Our findings provide insight into differing pathophysiology, which may enable optimization of targeted therapies for patients in each of these unique clinical groups.

Nasal Mycology of Chronic Rhinosinusitis Revealed by Nanopore Sequencing

Background: Nanopore sequencing (NS) is a third-generation sequencing technology capable of generating reads of long sequences. In this study, we used NS to investigate nasal mycology in patients with chronic rhinosinusitis (CRS). Methods: Nasal cavities of 13 CRS patients were individually irrigated with 20 mL of distilled water. The irrigant was forcefully blown by the patient into a basin. The collected fluid was placed into a centrifuge tube and processed using the method of Ponikau et al. The collected specimens were used for traditional fungal culture and sequenced for total DNA using NS. Results: Traditional fungal culture successfully grew fungi in the specimens of 11 (84.6%) patients. Aspergillus sp. and Penicillium sp. were found in four (30.8%) patients, Cladosporium sp. in three (23.1%) patients, and Candida albicans, Mucor sp. and Chaetomium sp. in one patient. NS revealed fungi abundance ranged from 81 to 2226, with the Shannon species diversity ranging from 1.094 to 1.683 at the genus level. Malassezia sp. was sequenced in 13 patients, Aspergillus sp. in 12 (92.3%) patients, Candida albicans in 11 (84.6%) patients, and Penicillium sp. in 10 (76.9%) patients. Conclusion: Our results showed that NS was sensitive and fast in detecting nasal fungi in CRS patients.

COVID-19 Co-Infection May Promote Development of Sinusitis Complication in Children

BACKGROUND

The olfactory dysfunction that occurs during a COVID-19 infection has sparked much debate about its similarity to sinusitis. Up to 65% of COVID-19 pediatric patients may be asymptomatic; however, when symptoms are observed, fever and cough are the most common. Nasal congestion and discharge as well as headaches can also be seen, which makes both entities, i.e., COVID-19 and sinusitis, similar to each other.

METHODS

In this review, we present the clinical case of a teenager with a history of acute sinusitis and COVID-19 co-infection followed by purulent meningoencephalitis. We aim to summarize available findings on the association between COVID-19, sinusitis, and possible common complications of both diseases.

RESULTS

Differentiating between COVID-19 and sinusitis can be confusing because presented symptoms may overlap or mimic each other. Increased risk of complications, especially in patients with bacterial sinusitis co-infected with SARS-CoV-2, should prompt physicians to monitor young patients and inform parents about disturbing symptoms and possible complications.

CONCLUSIONS

Acute sinusitis and COVID-19 co-infection may lead to numerous complications and should be included among the factors predisposing to worse prognosis. It is especially related to patients with high risk factors and even more important in children as they often pass the infection asymptomatically and its complications can lead to loss of health or life.

Nasal microbiome in chronic rhinosinusitis

Chronic rhinosinusitis (CRS) is defined as an inflammatory disorder of the paranasal sinuses and of the nasal mucosa that lasts 12 weeks or longer. In CRS microbes contribute to the disease pathogenesis. Clinical microbiology is focused on finding single pathogens that causes the disease and the main goal is the use of antibiotics to kill bacteria. Efforts to achieve a better understanding of CRS include the study of the sinus microbiome, and to evaluate the ability of probiotics to augment homeostasis and modulate the immune response of the host mucosa. This review provides an update on the role of the microbiome in CRS. The study was conducted using two databases: PubMed and Science Direct. We searched for articles in English that matched the review topic. We first used the abstracts of articles to assess whether they met the inclusion criteria. We also reviewed the references of the selected articles and read those with titles that might be of interest. Several studies have shown that endogenous microbiome dysbiosis can impact mucosa health and disease severity. Some bacterial species presenting protective or pathogenic effect. Antimicrobial agents can create a similar disruption and impact the nasal microbiome balance. On the other hand, probiotics offers a promising avenue for developing systemic and topical therapies geared towards strategic manipulation of the biological host load, thereby augmenting immune homeostasis. A better comprehension of sinus-nasal microbiome in healthy and in CRS patients and the link with different CRS phenotype can help in developing new prognostics, diagnostics, and therapeutics strategies. Going forward, the use of probiotics can restore the native sinus ecology with significant therapeutic and preventive implications.

Chronic and Recurrent Sinusitis in Children, as Manifestation of Immune Dysfunction and Atopic Background

Rhinosinusitis in children, as in adults, can be classified by duration (acute, recurrent, and chronic) and by cause (viral, bacterial, and inflammatory) and needs to be treated accordingly after careful investigation which include through clinical history, laboratory tests, and, if necessary, nasal endoscopy and imaging studies.

Efficacy and safety of traditional Chinese medicine nasal irrigation on chronic rhinosinusitis recovery after endoscopic sinus surgery: A protocol for a systematic review and meta-analysis

Background

Continuous comprehensive treatment is still needed after endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) to promote the recovery of sinus mucosal morphology and function. Traditional Chinese medicine (TCM) nasal irrigation is a promising external treatment of TCM, but at present, the application of TCM nasal irrigation after ESS for CRS has not been recommended by the guidelines. Therefore, this article aims to develop a systematic overview and meta-analysis protocol to assess the effectiveness and safety of Chinese herbal nasal rinse for CRS recovery after ESS.

Methods

Seven databases shall be retrieved from their inception until December 2021. Eligible randomized controlled trials will be covered in the study. The outcome indicators of the survey will consist of efficacy, visual analogue scale score, Lund-Kennedy score for nasal endoscopy, Lund-Mackay score for sinus computed tomography and other secondary outcome indicators. The selection of literature, extraction of data, and methodological quality evaluation of literature shall be conducted by two researchers separately. If there is any dispute, it can be discussed and solved by a third researcher. Review Manager 5.3 software will be applied to data analysis.

Results

The article will make a detailed research programme to explore the efficacy and safety of TCM nasal irrigation on CRS recovery after ESS.

Conclusion

This protocol is suitable for evaluating the effectiveness and safety of TCM nasal rinse for CRS recovery after ESS, and can provide corresponding evidence-based medical evidence.

Systematic review registration

Open Science Framework Registration DOI: 10.17605/OSF.IO/ZV73Q.

Immunopathologic characteristics of Chinese pediatric patients with chronic rhinosinusitis

Background

The histopathology of pediatric chronic rhinosinusitis with nasal polyps (CRSwNP) and without nasal polyps (CRSsNP) is rarely reported due to low prevalence or the unavailability of tissue samples. Hence, we aimed to characterize and compare the histologic features and protein expression of Th1/Th2/Th17-related cytokines in pediatric CRSsNP and CRSwNP.

Methods

The histologic characteristics of 15 children with CRSsNP, 52 children with CRSwNP, and 12 control participants were analyzed using hematoxylin and eosin staining. The expression of Th1/Th2/Th17-related cytokines were examined using immunohistochemistry and the enzyme-linked immunosorbent assay.

Results

Pediatric subjects with CRSwNP had more intact epithelium and less submucosal mucous glands compared to those with CRSsNP. Tissue eosinophils were more prevalent in the younger CRSwNP group compared to the older CRSwNP or the CRSsNP groups. The protein concentrations of Th2 cytokines were significantly higher in the CRSwNP group than the CRSsNP group or the control group. Moreover, the protein concentrations of Th17 cytokines were significantly higher in the younger CRSwNP group than the older CRSwNP group or the CRSsNP and control groups. The protein concentrations of Th1 and Th17 cytokines were also significantly higher in the CRSsNP group than the control group. Compared with non-eosinophilic CRSwNP, eosinophilic CRSwNP presented with elevated protein concentrations of Th1 and Th17 cytokines.

Conclusion

For the first time, we showed that pediatric CRSwNP presents as eosinophilic with Th2/Th17 inflammation, whereas CRSsNP presents as Th1/Th17 inflammation. Our study may provide a theoretical basis for the precise treatment of pediatric CRS in the future.

Quercetin attenuates lipopolysaccharide-mediated inflammatory injury in human nasal epithelial cells via regulating miR-21/DMBT1/NF-κB axis

BACKGROUND

Quercetin (Qu) belongs to a flavonoid polyphenolic compound present in fruits and vegetables which has been confirmed to exert anti-inflammatory properties. Our study aimed to explore the impacts of quercetin on lipopolysaccharide (LPS)-induced inflammatory injury and signal transduction of miR-21/DMBT1/NF-κB axis in human nasal epithelial cells (HNEpC).

METHODS

HNEpCs were cultured and treated with 1 μg/mL of LPS and a gradient concentration (10, 100, and 200 μM) of quercetin for 24 h. Cell viability, apoptosis, and cytokines were detected to assess the inflammatory injury in LPS-exposed HNEpCs. The expressions of miR-21, DMBT1, and NF-κB mRNA were detected by quantitative real-time polymerase chain reaction (qRT-PCR). The levels of DMBT1 and NF-κB protein were measured by western blotting.

RESULTS

LPS treatment reduced cell viability, promoted cell apoptosis and inflammatory response, down-regulated miR-21 expression and up-regulated DMBT1, and NF-κB in HNEpC cells. Quercetin exerted the opposite effects to attenuate LPS-induced inflammatory injury in HNEpC cells at a concentration-dependent way. Additionally, miR-21 directly targeted DMBT1 to reduce its expression and further inducing cell viability via inhibiting cell apoptosis and inflammatory response. MiR-21 inhibition or DMBT1 over-expression weakened the protective effects of quercetin against LPS-induced inflammatory injury in HNEpC cells.

CONCLUSIONS

Quercetin could protect HNEpC cells against LPS-induced inflammatory injury via inducing miR-21/DMBT1/NF-κB axis. Therefore, quercetin could be utilized as a potential compound to treat for allergic rhinitis.

Barrier Impairment and Type 2 Inflammation in Allergic Diseases: The Pediatric Perspective

Allergic diseases represent a global burden. Although the patho-physiological mechanisms are still poorly understood, epithelial barrier dysfunction and Th2 inflammatory response play a pivotal role. Barrier dysfunction, characterized by a loss of differentiation, reduced junctional integrity, and altered innate defence, underpins the pathogenesis of allergic diseases. Epithelial barrier impairment may be a potential therapeutic target for new treatment strategies Up now, monoclonal antibodies and new molecules targeting specific pathways of the immune response have been developed, and others are under investigation, both for adult and paediatric populations, which are affected by atopic dermatitis (AD), asthma, allergic rhinitis (AR), chronic rhinosinusitis with nasal polyps (CRSwNP), or eosinophilic esophagitis (EoE). In children affected by severe asthma biologics targeting IgE, IL-5 and against IL-4 and IL-13 receptors are already available, and they have also been applied in CRSwNP. In severe AD Dupilumab, a biologic which inhibits both IL-4 and IL-13, the most important cytokines involved in inflammation response, has been approved for treatment of patients over 12 years. While a biological approach has already shown great efficacy on the treatment of severe atopic conditions, early intervention to restore epithelial barrier integrity, and function may prevent the inflammatory response and the development of the atopic march.

Pediatric allergic fungal rhinosinusitis: optimizing outcomes

PURPOSE OF REVIEW

Allergic fungal rhinosinusitis (AFRS) is a debilitating condition for children. Despite there being several reviews on this topic in the adult population, there is a paucity of reviews of AFRS in the pediatric literature. This article reviews the recent evidence of pediatric AFRS with the aim to optimize outcomes of pediatric patients with this condition.

RECENT FINDINGS

AFRS is clinically characterized by nasal polyposis, a type I hypersensitivity to fungal epitopes, very thick eosinophilic mucin, and peripheral eosinophilia. Pediatric AFRS has similar clinical characteristics to that in adults but is thought to have a more aggressive nature, with higher serum immunoglobulin E and more frequently bone erosion and malformation of facial bones. Diagnosis of pediatric AFRS is made by using the Bent and Kuhn's criteria developed for adult AFRS. The mainstay of treatment is surgery followed by postoperative corticosteroids. Adjunctive therapies, including topical/oral antifungal agents, allergen immunotherapy and biologics may improve outcomes in pediatric AFRS, but to date the current evidence is limited.

SUMMARY

To optimize the outcome of pediatric AFRS, adequate and early diagnosis and treatment are essential. Appropriate and comprehensive endoscopic sinus surgery to open the sinuses, remove the fungal burden of disease and improve access of the sinuses to postoperative topical corticosteroid remains the standard of care.

Nasal Polyps in Children: The Early Origins of a Challenging Adulthood Condition

Nasal polyps (NPs) are benign inflammatory masses causing chronic nasal obstruction, usually associated with underlying chronic rhinosinusitis (CRS), which are rarely reported in childhood. The interest in NPs has recently increased due to new therapeutic options, namely biological agents, such as dupilumab, and an update of the European position paper on this topic was released in 2020, providing a detailed classification for these lesions and also discussing diagnostic and therapeutic approaches also in children. In childhood, NPs usually represent red flags for systemic diseases, such as cystic fibrosis and immunodeficiencies. This review outlines the recent data on NPs in childhood, focusing on predisposing factors for CRS as well as on the potential endotypes in this particular age group, for which further studies are required in order to better clarify their pathogenesis and to identify molecular biomarkers that could help achieve more personalized treatments.

Ciliary function and sinonasal mucosal cytology in pediatric patients with chronic rhinosinusitis during a year after functional endoscopic sinus surgery

BACKGROUND

The objective of the study is evaluation of ciliary function and mucosal cytology after endoscopic sinus surgery in children with chronic rhinosinusitis (CRS).

METHODOLOGY

A total of 132 children with CRS who underwent endoscopic sinus surgery, as well as 15 healthy controls were involved in the study. In this follow-up study patients were examined preoperatively, as well as 3, 6, 9, and 12 months after endoscopic sinus surgery. Assessment of ciliary function and sinonasal mucosal cytology was performed using high-speed videomicroscopy. Lund-Kennedy, Lund-Mackay, and sinonasal outcome test 20 (SNOT20) scores were also evaluated.

RESULTS

Total SNOT-20, Lund-Mackay, and Lund-Kennedy values significantly decreased after sinus surgery. In contrast, ciliary function and mucosal cytology only tended to improve after 6 months. 9 months after surgery the number of ciliated cells, ciliary beat frequency, cell viability, and ciliary length were significantly higher than preoperatively. The most significant improvement of ciliary function and cell height was observed 12 months after operation, whereas epithelial dystrophy and neutrophil infiltration were significantly reduced.

CONCLUSIONS

Substantial improvement was observed only in a year after surgery, whereas 0 to 3 months after the surgery ciliary function was severely impaired thus predisposing to recurrent sinusitis or other complications.

Serum, Whole Blood, Hair, and Mucosal Essential Trace Element and Mineral Levels in Children with Verified Chronic Rhinosinusitis Undergoing Functional Endoscopic Sinus Surgery

The objective of the present study was to assess hair, serum, whole blood, and excised tissue essential element content in children with chronic rhinosinusitis (CRS). Eighty-eight children with chronic rhinosinusitis and 66 healthy controls were enrolled in the present study. Evaluation of endoscopic Lund-Kennedy and computed tomography Lund-Mackay scores, as well as tissue sampling, was performed only in children with chronic rhinosinusitis. Assessment of Sino-Nasal Outcome Test-20 (SNOT-20) scores was performed in both cases and controls. Hair, whole blood, blood serum, and excised mucosal tissue (only in patients) analysis was performed using inductively coupled argon plasma mass-spectrometry. The obtained data demonstrate that whole blood Ca, Mg, Se, and Zn, as well as hair Ca, Cu, Mg, and Zn levels in the examined patients were significantly lower as compared with the control values. Only serum Zn concentration in children with CRS exceeded the respective control values, whereas serum Cu levels only tended to decrease in CRS. In turn, hair Fe content in children with CRS exceeded that in healthy controls. Regression analysis demonstrate that hair Ca levels, as well as whole blood Ca, Se, and Zn concentrations, were considered as negative predictors, whereas increased hair iron level was significantly directly associated with CRS. Significant associations between hair, serum, whole blood, and tissue element levels and Lund-Kennedy and Lund-Mackay scores were also revealed. Generally, the obtained data demonstrate that chronic rhinosinusitis is associated with impaired essential metal levels in pediatric patients with chronic rhinosinusitis. The observed alterations may contribute to CRS pathogenesis through modulation of mucociliary clearance, immunity, inflammatory response, and redox environment.

International consensus statement on allergy and rhinology: rhinosinusitis 2021

I.

EXECUTIVE SUMMARY

BACKGROUND: The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR-RS-2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence-based findings of the document.

METHODS

ICAR-RS presents over 180 topics in the forms of evidence-based reviews with recommendations (EBRRs), evidence-based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary.

RESULTS

ICAR-RS-2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence-based management algorithm is provided.

CONCLUSION

This ICAR-RS-2021 executive summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS.

Comparative Analysis of Mucociliary Clearance and Mucosal Morphology Using High-Speed Videomicroscopy in Children With Acute and Chronic Rhinosinusitis

OBJECTIVE

evaluation of mucociliary clearance and mucosal morphology using high-speed videomicroscopy, and their association with markers of disease severity in children with acute (ARS) and chronic rhinosinusitis (CRS).

METHODS

A total of 67 children aged from 6 to 17 years including 15 healthy children, 20 pediatric patients with acute rhinosinusitis, and 32 cases with chronic rhinosinusitis were enrolled in the present study. SNOT20, Lund-Kennedy, and Lund-Mackay scores were also evaluated.

RESULTS

Children with rhinosinusitis were characterized by significantly lower number of cells with motile cilia, ciliary beat frequency, cilia length, and cell viability, as well as ciliary beat asynchrony, epithelia dystrophy and reduced epithelial cell height, being more severe in ARS group. Neutrophil infiltration of sinonasal mucosa was more profound in children with ARS, whereas the number of lymphocytes was significantly reduced. Markers of ciliary function were characterized by a significant correlation with epithelia dystrophia and neutrophil infiltration. Discriminant analysis demonstrated significant group separation based on the parameters of mucociliary clearance and mucosal morphology. In regression models mucociliary function was also associated with SNOT20, Lund-Kennedy, and Lund-Mackay scores.

CONCLUSION

The results of the present study demonstrate significant alteration of mucociliary clearance and mucosal morphology and its association with sinonasal inflammation and disease severity in patients with rhinosinusitis. Given a tight association between altered mucociliary clearance and severity of the disease, modulation of inflammation and ciliary function both in acute and chronic rhinosinusitis may be considered as the potential tool in therapeutic and surgical management of the disease.

Factors Associated with Refractory Nasal Congestion Following Adenoidectomy

OBJECTIVE

The objective of this study was to better characterize factors associated with refractory rhinitis in pediatric patients who underwent adenoidectomy compared to those who had symptom resolution.

METHODS

The authors conducted a case series of patients younger than 18 years old who underwent adenoidectomy at Boston Medical Center from October 2012 to December 2018. Patients who underwent tonsillectomy and adenoidectomy or who underwent adenoidectomy for indications other than rhinitis were excluded. Patients who had refractory rhinitis symptoms postoperatively were compared to those who had resolution of their symptoms using Chi-square analysis and t-tests.

RESULTS

One hundred three patients who had refractory symptoms following adenoidectomy were compared to 139 patients who had resolution of symptoms. Patients who had refractory symptoms had significantly higher proportion of use (89.3%, P = .0011) and higher mean number of preoperative (1.50, P = .0226) and postoperative (1.10, P < .0001) medications, including nasal saline, intranasal steroids, antihistamines, and/or antibiotics. They were more likely to receive postoperative allergy evaluations (50%, P = .0068) and repeat surgery (30.1%, P < .0001), and had a higher proportion of reported history of allergies (24.3%, P = .0089).

CONCLUSION

Use and number of preoperative medications, reported history of allergies, and postoperative allergy evaluation were significantly higher in patients with refractory chronic rhinitis following adenoidectomy. This study identified differences in patients who developed refractory symptoms that may help clinical decision making for surgical management.

Pediatric Chronic Rhinosinusitis: Unmet Needs

Pediatric chronic rhinosinusitis (CRS) remains an elusive diagnostic medical condition, largely based on imperfect diagnostic criteria, lack of controlled studies of therapy, lack of measure for resolution, and lack of information of pediatric sinus microbiome dysbiosis. The true prevalence of pediatric CRS is unknown, and symptoms often over-lap with other diagnoses. We review the unmet needs in pediatric CRS, to highlight potential research opportunities to improve understanding and therapy of the disease process.

Pediatric Versus Adult Chronic Rhinosinusitis

PURPOSE OF REVIEW

Pediatric and adult chronic rhinosinusitis (CRS) have some similarities but a number of differences. This article reviews the similarities and differences between pediatric and adult CRS.

RECENT FINDINGS

Rhinosinusitis is an inflammatory disease of the nose and the paranasal sinuses. In adults, inflammation in CRS without polyps (CRSsNP) mainly manifests with T-helper 1 lymphocytes while in CRS with polyps (CRSwNP) manifests with T-helper 2 lymphocytes and eosinophilic inflammation. In children, CRS inflammation manifests with neutrophils, macrophages, and lymphocytes. The associations between the ostiomeatal complex occlusion and CRS are revealed in adults but are not so evident in children. Although the relationship between the CRS and allergic rhinitis is still controversial, recent findings have shown an association between allergen sensitization and a specific group of adults with rhinosinusitis. Intranasal corticosteroids and saline constitute the first-line of medical treatment for both pediatric and adult rhinosinusitis. Low-dose macrolides are used for immunomodulatory activities and beneficial effects to adult patients with CRSsNP were demonstrated by recent meta-analyses. For surgical treatment, adenoidectomy is a key strategy to eradicate mature biofilms in pediatric CRS and effective in treating children with CRS regardless of the adenoid size. Although endoscopic sinus surgery has been proven to improve quality of life outcomes in adult CRS, it should be only considered in the pediatric CRS after failure of adenoidectomy. Pediatric and adult CRS are different in many aspects, including immunopathogenesis and management. Investigations should be considered in specific cases. After failure of medical treatments, endoscopic sinus surgery is recommended for adults, while adenoidectomy is primarily considered for children.

A Child who has Nasal Polyposis Combined with Bronchiectasis

Nasal polyps are inflammatory lesions of sinonasal tissue that are associated with chronic rhinosinusitis, allergic reaction, and other diseases. Although it is the most common cause of nasal polyps, chronic inflammation of the nasal cavity is not common in children. When nasal polyps are found in childhood, it is important to investigate the cause, such as immunodeficiency disease, cystic fibrosis, primary ciliary dyskinesia, and other syndromes such as Woakes’ syndrome. We report a child who presented with nasal polyps combined with bronchiectasis with a review of related literature.

Differential IL-17A response to S. pneumoniae in adenoid tissue of children with sleep disordered breathing and otitis media with effusion

Streptococcus pneumonia, one of the major colonizers in nasopharyngeal adenoids, has been the predominant pathogen causing acute otitis media (AOM) in children. Recent evidence suggests an association between IL-17A-mediated immune response and the clearance of pneumococcal colonization in nasopharyngeal adenoids. Here, we evaluated the expressions of IL-17A and associated genes in hypertrophic adenoid tissues of children with sleep-disordered breathing (SDB) and otitis media with effusion (OME) and their association with pneumococcal carriage. Sixty-six pediatric patients with adenoid hypertrophy were enrolled. During adenoidectomy, nasopharyngeal swab and adenoid tissues were used to determine pneumococcal carriage and IL-17A expression. Our results revealed significantly higher levels of IL-17A and IL-17A:IL-10 mRNA in the SDB patients positive for nasopharyngeal pneumococcal carriage than those negative. However, these differences were not significant in the OME group. These results suggested, in OME patients, prolonged or chronic pneumococcal carriage may occur because of insufficient IL-17A-mediated mucosal clearance, and could further lead to AOM and OME development.

Anatomical variation of the sphenoid sinus in paediatric patients and its association with age and chronic rhinosinusitis

OBJECTIVE

To report the prevalence of different anatomical variations of the sphenoid sinus and its related structures among paediatric patients with or without chronic rhinosinusitis.

METHODS

Computed tomography scans of 50 paediatric patients with chronic rhinosinusitis were reviewed and compared to 50 scans of paediatric patients without chronic rhinosinusitis. The type of sphenoid sinus pneumatisation and the surrounding structures were thoroughly analysed. The patients were divided into three groups according to age.

RESULTS

Mean age was 10.9 years (range, 4-16 years). The sellar configuration was the commonest in all groups, while the conchal type was the least common. There were significant differences between paediatric patients with or without sinusitis in: sphenoid sinus pneumatisation type, vidian canal type and Onodi cell presence. In addition, there were significant differences between age groups in: sphenoid sinus pneumatisation type, single sinus septum and multiple septa presence, and internal carotid artery bulging.

CONCLUSION

Age and sinusitis have a significant impact on sphenoid pneumatisation type and surrounding structure variation. Recognition of these variations can be useful for mapping this region, and enables a safer and more efficient endoscopic surgical procedure.

The Role of the Adenoids in Pediatric Chronic Rhinosinusitis

There are several mechanisms by which the adenoids contribute to pediatric chronic rhinosinusitis (PCRS), particularly with children aged 12 years and younger. Understanding the role that the adenoids play in PCRS is crucial when attempting to treat these patients. A literature review was performed to address this problem and provide information surrounding this topic. This review will provide a better understanding of how adenoids contribute to PCRS, and also of the medical and surgical treatment options.