Nasal polyposis pathophysiology: Endotype and phenotype open issues

Meta-analysis of the Relationship Between Neutrophil to Lymphocyte Ratio and Nasal Polyps

Our study aimed to enhance understanding of nasal polyp pathophysiology by reviewing the data for variations of NLR values between patients with nasal polyp and healthy controls. We searched Web of Science, PubMed, ProQuest, and Scopus up to 2 April 2023. The search strategy was not limited to any specific language. Twelve studies were included in our study. Of them, ten studies, involving 898 nasal polyp patients and 590 control patients, were included in the meta-analysis. The NLR levels in nasal polyp patients were statistically greater than in the control group (SMD = 0.56; 95%CI 0.04-1.08, P = 0.036). Subgroup analysis based on study design yielded that patients with nasal polyp exhibited significantly higher NLR levels than healthy controls in retrospective studies (SMD = 0.83; 95%CI 0.30-1.35, P = 0.002) but not in prospective studies (SMD = 0.10; 95%CI = -1.03 to 1.23, P = 0.85). Also, we found that the NLR levels in nasal polyp patients were significantly higher than healthy controls in high-quality studies (SMD = 1.00; 95%CI 0.38-1.62, P = 0.002) but not in low-quality studies (SMD = 0.11; 95%CI = -0.69 to 0.91, P = 0.79). A total of 312 patients with recurrence and 550 patients without recurrence were included in the study. The combined results revealed that NLR levels in nasal polyp recurrence patients were significantly higher than those of the nasal polyp without recurrence group (SMD = 0.06, 95% CI 0.39-0.81, P = 0.000). These results showed the relationship between the NLR in nasal polyps and can help medical doctors to predict the recurrence of the disease in such patients.

Biologics versus functional endoscopic sinus surgery for the treatment of chronic rhinosinusitis with nasal polyps: a literature review

OBJECTIVE

To review the literature comparing functional endoscopic sinus surgery to dupilumab for the treatment of chronic rhinosinusitis with nasal polyps, in terms of symptom control, cost-effectiveness and complications.

METHOD

A literature review was conducted using PubMed, ScienceDirect and Cochrane databases. Data were extracted manually.

RESULTS

A total of six papers relevant to the main objective were found.

CONCLUSION

Chronic rhinosinusitis with nasal polyps has a significant impact on patients' quality of life. Both functional endoscopic sinus surgery and dupilumab achieve comparable disease control and result in good symptom relief. Dupilumab is far more expensive than functional endoscopic sinus surgery and is not considered cost-effective for the time being. This is expected to change after 10 years when the drug patent expires. More research is needed to compare the complications of both treatment modalities.

A Decade of Pathogenesis Advances in Non-Type 2 Inflammatory Endotypes in Chronic Rhinosinusitis: 2012-2022

Chronic rhinosinusitis (CRS) is a heterogeneous disease characterized by localized inflammation of the upper airways. CRS includes two main phenotypes, namely, CRS with nasal polyps and CRS without nasal polyps. The phenotype-based classification method cannot reflect the pathological mechanism. The endotype-based classification method has been paid more and more attention by researchers. It is mainly divided into type 2 and non-type 2 endotypes. The mechanism driving the pathogenesis of non-type 2 inflammation is currently unknown. In this review, the PubMed and Web of Science databases were searched to conduct a critical analysis of representative literature works on the pathogenesis of non-type 2 inflammation in CRS published in the past decade. This review summarizes the latest evidence that may lead to the pathogenesis of non-type 2 inflammation. It is the main method that analyzing the pathogenesis from the perspective of immunology. Genomics and proteomics technique provide new approaches to the study of the pathogenesis. Due to differences in race, environment, geography, and living habits, there are differences in the occurrence of non-type 2 inflammation, which increase the difficulty of understanding the pathogenesis of non-type 2 inflammation in CRS. Studies have confirmed that non-type 2 endotype is more common in Asian patients. The emergence of overlap and unclassified endotypes has promoted the study of heterogeneity in CRS. In addition, as the source of inflammatory cells and the initiation site of the inflammatory response, microvessels and microlymphatic vessels in the nasal mucosal subepithelial tissue participate in the inflammatory response and tissue remodeling. It is uncertain whether CRS patients affect the risk of infection with SARS-CoV-2. In addition, the pathophysiological mechanism of non-type 2 CRS combined with COVID-19 remains to be further studied, and it is worth considering how to select the befitting biologics for CRS patients with non-type 2 inflammation.

Canadian multidisciplinary expert consensus on the use of biologics in upper airways: a Delphi study

BACKGROUND

Chronic rhinosinusitis with nasal polyposis (CRSwNP) often coexists with lower airway disease. With the overlap between upper and lower airway disease, optimal management of the upper airways is undertaken in conjunction with that of the lower airways. Biologic therapy with targeted activity within the Type 2 inflammatory pathway can improve the clinical signs and symptoms of both upper and lower airway diseases. Knowledge gaps nevertheless exist in how best to approach patient care as a whole. There have been sixteen randomized, double-blind, placebo-controlled trails performed for CRSwNP targeted components of the Type 2 inflammatory pathway, notably interleukin (IL)-4, IL-5 and IL-13, IL- 5R, IL-33, and immunoglobulin (Ig)E. This white paper considers the perspectives of experts in various disciplines such as rhinology, allergy, and respirology across Canada, all of whom have unique and valuable insights to contribute on how to best approach patients with upper airway disease from a multidisciplinary perspective.

METHODS

A Delphi Method process was utilized involving three rounds of questionnaires in which the first two were completed individually online and the third was discussed on a virtual platform with all the panelists. A national multidisciplinary expert panel of 34 certified specialists was created, composed of 16 rhinologists, 7 allergists, and 11 respirologists who evaluated the 20 original statements on a scale of 1-9 and provided comments. All ratings were quantitively reviewed by mean, median, mode, range, standard deviation and inter-rater reliability. Consensus was defined by relative interrater reliability measures-kappa coefficient ([Formula: see text]) value > 0.61.

RESULTS

After three rounds, a total of 22 statements achieved consensus. This white paper only contains the final agreed upon statements and clear rationale and support for the statements regarding the use of biologics in patients with upper airway disease.

CONCLUSION

This white paper provides guidance to Canadian physicians on the use of biologic therapy for the management of upper airway disease from a multidisciplinary perspective, but the medical and surgical regimen should ultimately be individualized to the patient. As more biologics become available and additional trials are published we will provide updated versions of this white paper every few years.

Therapeutic Strategies to Prevent the Recurrence of Nasal Polyps after Surgical Treatment: An Update and In Vitro Study on Growth Inhibition of Fibroblasts

Chronic rhinosinusitis with nasal polyps (CRSwNP) is the most bothersome phenotype of chronic rhinosinusitis, which is typically characterized by a Type 2 inflammatory reaction, comorbidities and high rates of nasal polyp recurrence, causing severe impact on quality of life. Nasal polyp recurrence rates, defined as the number of patients undergoing revision endoscopic sinus surgery, are 20% within a 5 year period after surgery. The cornerstone of CRSwNP management consists of anti-inflammatory treatment with local corticosteroids. We performed a literature review regarding the therapeutic strategies used to prevent nasal polyp recurrence after surgical treatment. Finally, we report an in vitro study evaluating the efficacy of lysine-acetylsalicylic acid and other non-steroidal anti-inflammatory drugs (ketoprofen and diclofenac) on the proliferation of fibroblasts, obtained from nasal polyp tissue samples. Our study demonstrates that diclofenac, even more so than lysine-acetylsalicylic acid, significantly inhibits fibroblast proliferation and could be considered a valid therapeutic strategy in preventing CRSwNP recurrence.

Role of Nasal Fibroblasts in Airway Remodeling of Chronic Rhinosinusitis: The Modulating Functions Reexamined

Chronic rhinosinusitis (CRS) is a multifactorial inflammatory disease of the nose and sinuses that affects more than 10% of the adult population worldwide. Currently, CRS is classified into endotypes according to the inflammatory response (Th1, Th2, and Th17) or the distribution of immune cells in the mucosa (eosinophilic and non-eosinophilic). CRS induces mucosal tissue remodeling. Extracellular matrix (ECM) accumulation, fibrin deposition, edema, immune cell infiltration, and angiogenesis are observed in the stromal region. Conversely, epithelial-to-mesenchymal transition (EMT), goblet cell hyperplasia, and increased epithelial permeability, hyperplasia, and metaplasia are found in the epithelium. Fibroblasts synthesize collagen and ECM, which create a structural skeleton of tissue and play an important role in the wound-healing process. This review discusses recent knowledge regarding the modulation of tissue remodeling by nasal fibroblasts in CRS.

Chronic Otitis Media in Patients with Chronic Rhinosinusitis: A Systematic Review

Introduction: Chronic otitis media (COM) and chronic rhinosinusitis (CRS) are two of the most common otolaryngological disorders. CRS and COM share pathophysiological mechanisms such as bacterial infection, biofilm, and the persistence of the obstruction state of ventilation routes. The purpose of this systematic review was to evaluate all available information on the association between COM and CRS. Methods: The protocol of this investigation was registered on PROSPERO in November 2022. Pubmed, Scopus, Web of Science, and Cochrane databases were systematically searched according to the PRISMA statement. Results: After the application of inclusion-exclusion criteria, four manuscripts with adequate relevance to this topic were included in the review. The study population consisted of 20,867 patients with a diagnosis of CRS, of whom 991 were also diagnosed with COM (4.75%). Conclusions: The included studies have shown that CRS has become significantly associated with COMas: a global inflammatory process that involves the epithelium in both the middle ear and upper airway. The identification of a relationship between CRS and COM may contribute to preventing chronic inflammatory conditions through the early management of the associated disease. Further, carefully designed studies are necessary to demonstrate the relationship between COM and CRS.

Exploration of Predictive Biomarkers for Postoperative Recurrence in Chronic Rhinosinusitis with Nasal Polyps Based on Serum Multiple-Cytokine Profiling

Background

Functional nasal endoscopic surgery (FESS) is an effective treatment approach for chronic rhinosinusitis with nasal polyps (CRSwNP) patients, but some patients still suffer from postoperative recurrence. This study is aimed at investigating the expression of multiple cytokines in CRSwNP and revealing their relationships with postoperative recurrence.

Methods

A total of 72 patients with CRSwNP, including 36 primary and 36 recurrent patients, were enrolled. Serum samples were obtained, 30 cytokine levels were measured by multiplex analysis, and the association between cytokine levels and recurrence was assessed. The most potential cytokines were further validated in another independent cohort with 60 primary and 60 recurrent CRSwNP patients.

Results

The results of multiple cytokine profiling exhibited that the levels of eotaxin, G-CSF, IFN-α, IL-13, IL-17A, IL-5, MCP-1, and RANTES were vastly changed in the recurrent group in comparison with the primary group. Receiver-operating characteristic (ROC) curves highlighted that serum levels of eotaxin, IL-17A, and RANTES were strongly predictive of postoperative recurrence (area under the curve (AUC) > 0.7, P < 0.05). Further validation results showed that elevated serum eotaxin, IL-17A, and RANTES levels were enhanced in the recurrent group. The ROC curve showed that serum eotaxin (AUC = 0.729, P < 0.001) and RANTES (AUC = 0.776, P < 0.001) exhibited stronger ability than serum IL-17A (AUC = 0.617, P = 0.027) in predicting CRSwNP recurrence.

Conclusion

Our data suggested that serum multiple cytokine profiling was associated with postoperative recurrence of CRSwNP, and eotaxin and RANTES might serve as potential biomarkers for predicting postoperative recurrence. These results might contribute to the understanding of the underlying mechanisms of recurrence and provide novel clues for precision therapy in CRSwNP.

Sex and age-related differences in chronic rhinosinusitis with nasal polyps electing ESS

PURPOSE

Sex and age of patients are variables affecting across the board all chronic rhinosinusitis with nasal polyps (CRSwNP) endotypes. The main aim of this investigation was to compare the clinical, laboratory, pathological and prognostic characteristics of CRSwNP in male vs female patients stratified according to age (young-adult [20 years ≤ age ≤ 40 years], and elderly [age ≥ 65 years]). This is the first study that analyzed the association of the above-mentioned features with age and sex combination in CRSwNP electing endoscopic sinus surgery (ESS).

MATERIALS AND METHODS

One hundred and five consecutive young-adult patients (62 males and 43 females) and 67 elderly patients (44 males and 23 females) with CRSwNP who had undergone ESS were enrolled.

RESULTS

The recurrence rate resulted associated with the age and sex combination (p = 0.0165). Young-adult males' recurrence rate (29.0%) was higher than young-adult females (11.6%) and elderly males (4.5%). Allergy resulted associated with age and sex combination (p = 0.0158). Young-adult males' allergy rate (50.0%) was higher than elderly males' (29.5%) and elderly females' (13%). Moreover, allergy rate was higher in young-adult females (41.9%) than in elderly females.

CONCLUSION

Our data suggest the possibility of an interaction between sex and age in the recurrence of nasal polyposis after ESS. More studies are needed to understand the role of sex hormones in pathogenesis and prognosis of CRSwNP.

STAT1 mediates the PI3K/AKT pathway through promoting microRNA-18a in nasal polyps

BACKGROUND

Epithelial to mesenchymal transition (EMT) is linked to the pathophysiology of chronic rhinosinusitis with nasal polyps (CRSwNP). The involvement of STAT1 has been reported in CRSwNP. However, its specific role in regulating EMT in CRSwNP is not clear. We sought to evaluate the role of STAT1 in EMT in CRSwNP using clinical samples and a murine model.

METHODS

Comprehensive analysis of differentially expressed genes was performed in nasal polyps from the CRSwNP patients, followed by pathway enrichment analysis. After bioinformatics prediction, the relationships between microRNA-18a (miR-18a) and PTEN or STAT1 were examined using dual-luciferase and RIP assays, respectively. The expression of STAT1, PTEN, and miR-18a in nasal tissues was detected using RT-qPCR, immunohistochemistry, and in situ hybridization. After the alteration of gene expression in mice with CRSwNP, western blot, RT-qPCR, and HE staining were conducted to detect EMT-related proteins, inflammatory factor secretion, inflammatory cell infiltration, and the PI3K/AKT pathway activity in nasal tissues.

RESULTS

STAT1 and miR-18a were highly expressed, and PTEN was poorly expressed in the nasal polyp. STAT1 promoted transcription of miR-18a, which targeted PTEN. Downregulation of STAT1 and miR-18a inhibited the EMT and inflammatory cell infiltration, while depletion of PTEN promoted the EMT and inflammatory cell infiltration in the nasal polyp. The PI3K/AKT pathway was activated in the nasal polyp and regulated by the STAT1/miR-18a/PTEN axis.

CONCLUSIONS

STAT1 acts as a transcription factor to promote transcription of miR-18a, and miR-18a targets PTEN to exacerbate the inflammatory response and EMT in CRSwNP.

Preoperative Sinonasal Computed Tomography Score in Chronic Rhinosinusitis with Nasal Polyps

This study investigated the relationship between sinonasal inflammatory involvement according to the computed tomography (CT) staging system (Lund–Mackay score) with clinical, laboratory, histopathological and prognostic features of chronic rhinosinusitis with nasal polyps (CRSwNP). Seventy-eight patients with CRSwNP who had undergone surgery were enrolled. Total (p = 0.0062), ethmoid (p = 0.0496), sphenoid (p = 0.0335), ostiomeatal complex (OMC) (p = 0.0235) and frontal (p = 0.0164) CT scores were predictive of non-steroidal anti-inflammatory drugs-exacerbated respiratory disease (NERD) in the univariate analysis. Total (p = 0.0022), ethmoid (p = 0.0290), sphenoid (p = 0.0370), frontal (p = 0.0116), maxillary (p = 0.0357) and OMC (p = 0.0058) CT scores were predictve of asthma at the univariate analysis. No significant differences were found between patients with vs. without allergy in terms of total and partial CT scores. High blood eosinophil counts (>0.24 vs. ≤0.24 cells × 109/L) resulted in being associated with total (p = 0.0213), maxillary (p = 0.0227) and ethmoid (p = 0.0491) CT scores in the univariate analysis. Higher ethmoid (p = 0.0006) and total sinonasal (p = 0.0027) CT scores were found to predict histopathologically eosinophil CRSwNPs in the univariate analysis. CT scores did not result as predictive of NSAID-exacerbated respiratory disease, asthma, or blood eosinophil count at the multivariate analysis. Risk of relapse was related to the presence of NERD (p = 0.0207, HR [95% CI] 3.914 [1.232–12.435]), higher preoperative total (HR = 1.098 95%CI: 1.001–1.204, p = 0.0486) and frontal sinus CT scores (HR = 1.555 95%CI: 1.006–1.886, p = 0.0218), but these results were not confirmed by the multivariable analysis. Sinonasal CT scores showed significant differences in this heterogeneous inflammatory condition. Identifying CRSwNP characteristics is necessary to avoid generic treatments with poor outcomes.

Sulfurous-arsenical-ferruginous thermal water nasal inhalation and irrigation in children with recurrent upper respiratory tract infections: Clinical outcomes and predictive factors

PURPOSE

Recurrent upper respiratory disorders (RURD) are among the most common problems diagnosed in pediatric otolaryngology practice. Although several preliminary studies have demonstrated beneficial effects of thermal water inhalations for RURD, inhalation of thermal water has not been included among validated management protocols. The effects of sulfurous-arsenical-ferruginous thermal water nasal irrigations have been confirmed also in prospective, randomized studies. The main aim of this explorative, retrospective, observational study has been to compare the clinical outcome in pediatric patients with RURD treated with sulfurous-arsenical-ferruginous thermal water inhalation versus combined inhalation and nasal irrigation.

METHODS

Two hundred and fifty-three pediatric patients with RURD were considered; 231 underwent thermal water inhalations (inhalation of hot humid air and aerosol) only, while 22 underwent nasal irrigations combined with inhalations. Subjective overall efficacy perception and treatment tolerability were scored as categorical variables (from 0 = no efficacy/worst tolerability to 3 = maximal efficacy/best tolerability).

RESULTS

Nasal obstruction, sneezing, serous, mucous, and purulent rhinorrhea, cough, and snoring improved respectively in 80.2%, 72.9%, 79.0%, 93.8%, 92.3%, 64.8%, and 60.4% of patients referring these symptoms at presentation, respectively. No statistically significant differences between inhalations alone and combined inhalations and irrigations emerged. The median overall efficacy perception score was 2 while the median treatment tolerability score was 3.

CONCLUSIONS

This investigation found that sulfurous-arsenical-ferruginous water treatment was a well-tolerated therapeutic option for selected pediatric patients with RURD. These promising preliminary results should be confirmed in prospective, randomized, double-blind settings, also using minimally invasive but objective and quantitative evaluation methods.

The SWI/SNF complex in eosinophilic and non eosinophilic chronic rhinosinusitis

Introduction

Chronic rhinosinusitis (CRS) can be classified as eosinophilic (eCRS) or non-eosinophilic (neCRS) based on infiltration type. The SWI/SNF complex may be involved in the pathophysiology of CRS.

Aim

To assess the expression of the SWI/SNF complex in both CRS groups; to correlate blood eosinophil count (BEC), and histopathology eosinophil count (HPEC) with the SWI/SNF expression level in eCRS and neCRS.

Materials and methods

The study population consisted of 96 patients (68 eCRS, 28 neCRS). Immunohistochemical staining was performed on sinonasal mucosa for assessment of SWI/SNF protein expression. Type of tissue infiltration was assessed in samples obtained from examined groups (HPEC). The diagnostic value of eCRS was 10 cells/HPF (high power field). Complete blood count was analysed in order to calculate BEC.

Results

BEC and HPEC correlated negatively with all the SWI/SNF subunits. HPEC and BEC correlated positively with clinical findings (L-M and SNOT-22), while SWI/SNF correlated negatively with clinical findings (L-M and SNOT-22).

Conclusions

The SWI/SNF was observed in both eCRS and neCRS, with lower expression in former. The meaning of its negative correlation with BEC, HPEC and clinical findings in eCRS group remains to be understood.

Middle turbinate handling during ESS. Our experience

PURPOSE

The treatment of middle turbinate (MT) during endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) remains a controversial issue. Several authors recommended preservation of MT to avoid complications, but MT resection is sometimes necessary. In the last years, our group has applied an original surgical technique to preserve MT, stabilize its head and ensure patency of the ostiomeatal complex (OMC) in ESS. We herein described this approach to the MT and reported its preliminary results in terms of post-operative endoscopic features and complications.

METHODS

The study retrospectively considered 34 consecutive adult patients suffering from CRS and treated with primary or revision ESS. Medialization of the MT and its stabilization to achieve post-operative patency of the OMC was obtained by means of: (i) creation of a surgically controlled synechia between the MT head and nasal septum; (ii) positioning of a silicone plate in the OMC. The silicone splints kept the MT head in an obliged position to contact the septum.

RESULTS

At 12-month follow-up control, we found: (i) stabilized MT medialization in all treated cases, (ii) only one case of lateral synechia without recurrent CRS, and (iii) a polypoid recurrence rate of 13%.

CONCLUSIONS

The MT handling technique during ESS herein preliminarily described seems to be an effective approach to medialize and stabilize the MT. This technique could be particularly appropriate for unstable MT after removing massive inflammatory lesions of the mucosa.

CD133, a Progenitor Cell Marker, is Reduced in Nasal Polyposis and Showed Significant Correlations with TGF-β1 and IL-8

Introduction  Combination of chronic inflammation and an altered tissue remodeling process are involved in the development of Chronic Rhinosinusitis with Nasal Polyps (CRSwNP). Studies demonstrated that mesenchymal stem cells expressing the progenitor gene CD133 were involved in a significant reduction of the chronic inflammatory process in the polypoid tissue.

Objective  To evaluate the levels of CD133 (Prominin-1) in nasal polypoid tissue and its correlation with interleukin-8 (IL-8) and transforming growth factor β1 (TGF-β1).

Methods  A total of 74 subjects were divided in the following groups: control group ( n  = 35); chronic rhinosinusitis with nasal polyps nonpresenting comorbid asthma and aspirin intolerance (CRSwNPnonAI) group ( n  = 27); and chronic rhinosinusitis with nasal polyps presenting comorbid asthma and aspirin intolerance (CRSwNPAI) group ( n  = 12). Histologic analysis and also evaluation of the concentration of CD133, IL-8, and TGF-β1 by enzyme-linked immunosorbent assay (ELISA) kits were performed in nasal tissue obtained from nasal polypectomy or from middle turbinate tissue.

Results  Higher eosinophilic infiltration was found in both CRSwNP groups by histologic analysis. Lower levels of TGF-β1 and IL-8 were observed in both CRSwNP groups when compared with the control group, whereas the CD133 levels were significantly reduced only in the CRSwNPnonAI group compared with the control group.

Conclusion  It was demonstrated that the nasal mucosa presenting polyposis showed a significant reduction of CD133 levels, and also that this reduction was significantly correlated with the reduction of TGF-β1 levels, but not with IL-8 levels. Therefore, these findings may be involved in the altered inflammatory and remodeling processes observed in the nasal polyposis.

Understanding Systemic and Local Inflammation Induced by Nasal Polyposis: Role of the Allergic Phenotype

Chronic rhinosinusitis with nasal polyps (CRSwNP) is characterized by persistent symptoms associated to the development of nasal polyps. To this day, the molecular mechanisms involved are still not well defined. However, it has been suggested that a sustained inflammation as allergy is involved in its onset. In this exploratory study, the aim was to investigate the effect of the allergic status in the development of CRSwNP. To achieve this, we recruited 22 patients with CRSwNP and classified them in non-allergic and allergic using ImmunoCAP ISAC molecular diagnosis. Plasma samples were analyzed using liquid chromatography coupled to mass spectrometry (LC-MS). Subsequently, significant metabolites from plasma that were commercially available were then analyzed by targeted analysis in some nasal polyps. Additionally, nasal polyp and nasal mucosa samples were examined for eosinophils, neutrophils, CD3⁺ and CD11c⁺ cells, as well as collagen deposition and goblet cell hyperplasia. We found that 9 out of the 22 patients were sensitized to some aeroallergens (named as allergic CRSwNP). The other 13 patients had no sensitizations (non-allergic CRSwNP). Regarding metabolomics, bilirubin, cortisol, lysophosphatidylcholines (LPCs) 16:0, 18:0 and 20:4 and lysophosphatidylinositol (LPI) 20:4, which are usually related to a sustained allergic inflammation, were unexpectedly increased in plasma of non-allergic CRSwNP compared to allergic CRSwNP. LPC 16:0, LPC 18:0 and LPI 20:4 followed the same trend in nasal polyp as they did in plasma. Comparison of nasal polyps with nasal mucosa showed a significant increase in eosinophils (p < 0.001) and neutrophils (p < 0.01) in allergic CRSwNP. There were more eosinophils in polyps of non-allergic CRSwNP than in their nasal mucosa (p < 0.01). Polyps from non-allergic CRSwNP had less eosinophils than the polyps of allergic CRSwNP (p < 0.05) and reduced amounts of collagen compared to their nasal mucosa (p < 0.001). Our data suggests that there is a systemic inflammatory response associated to CRSwNP in the absence of allergy, which could be accountable for the nasal polyp development. Allergic CRSwNP presented a higher number of eosinophils in nasal polyps, suggesting that eosinophilia might be connected to the development of nasal polyps in this phenotype.

Evaluation of nasal symptoms to distinguish eosinophilic from noneosinophilic nasal polyps based on peripheral blood

Background: Patients with eosinophilic chronic rhinosinusitis with nasal polyps (eCRSwNP) have poorer outcomes after endoscopic sinus surgery and a higher recurrence rate. Objective: This study aimed to investigate the profile of clinical symptoms of eCRSwNP and the related risk factors. Methods: We prospectively enrolled 298 inpatients with CRSwNP from February 2019 to December 2019. The patients were divided into eCRSwNP and non-eCRSwNP groups based on the percentage of blood eosinophils; the cutoff value was set at 3.05%. Clinical data on questionnaires, visual analog scale (VAS) scores, and laboratory tests were collected. The differences in clinical symptoms, including nasal congestion, rhinorrhea, olfactory disorders, and head and/or facial pain, between the two groups were analyzed to identify the influential factors. Logistic analysis and receiver operating characteristic curves were used to determine the diagnostic benefit for the specific symptom in the patients in the eCRSwNP group. Results: Nasal congestion and olfactory disorders were significantly different between the eCRSwNP and non-eCRSwNP groups. The patients in the eCRSwNP group more frequently had concerns about olfactory disorders (p = 0.002), whereas patients in the non-eCRSwNP group mostly had nasal congestion (p = 0.001). The logistic analysis showed that the primary risk factors for olfactory disorders of eCRSwNP were disease duration (p = 0.014) and alcohol intake (p = 0.012). Olfactory disorders were not associated with the disease course of the eCRSwNP group but were correlated with the disease duration of non-eCRSwNP (p = 0.008). A VAS score for the olfactory disorders of >5.75 could be used to predict the diagnosis of eCRSwNP (area under the curve, 0.674 [95% confidence intervals, 0.559-0.689]; P < 0.001). Conclusion: Olfactory disorder might be the major nasal symptom that could be used to distinguish a peripheral eosinophilia-based definition of eCRSwNP and non-eCRSwNP. The disease duration was a limiting factor for using olfactory to distinguish two subgroups of nasal polyp. The investigation with regard to the accurate time boundary should be further addressed.

Artificial intelligence for cellular phenotyping diagnosis of nasal polyps by whole-slide imaging

Background

artificial intelligence (AI) for cellular phenotyping diagnosis of nasal polyps by whole-slide imaging (WSI) is lacking. We aim to establish an AI chronic rhinosinusitis evaluation platform 2.0 (AICEP 2.0) to obtain the proportion of inflammatory cells for cellular phenotyping diagnosis of nasal polyps and to explore the clinical significance of different phenotypes of nasal polyps on the WSI.

Methods

a total of 453 patients were enrolled in our study. For the development of AICEP 2.0, 179 patients (WSIs) were obtained from the Third Affiliated Hospital of Sun Yat-Sen University (3HSYSU) from January 2008 to December 2018. A total of 24,625 patches were automatically extracted from the regions of interest under a 400× HPF by Openslide and the number of inflammatory cells in these patches was counted by two pathologists. For the application of AICEP 2.0 in a prospective cohort, 158 patients aged 14–70 years old with chronic rhinosinusitis with nasal polyps (CRSwNP) who had undergone endoscopic sinus surgery at 3HSYSU from June 2020 to December 2020 were included for preoperative demographic characteristics. For the application of AICEP 2.0 in a retrospective cohort, 116 patients with CRSwNP who had undergone endoscopic sinus surgery from May 2016 to June 2017 were enrolled for the recurrence rate. The proportion of inflammatory cells of these patients on WSI was calculated by our AICEP 2.0.

Findings

for AICEP 2.0, the mean absolute errors of the ratios of eosinophils, lymphocytes, neutrophils, and plasma cells were 1.64%, 2.13%, 1.06%, and 1.22%, respectively. The four phenotypes of nasal polyps were significantly different in clinical characteristics (including asthma, itching, sneezing, total IgE, peripheral eosinophils%, tissue eosinophils%, tissue neutrophils%, tissue lymphocytes%, tissue plasma cells%, and recurrence rate; P <0.05), but there were no significant differences in age distribution, onset time, total VAS score, Lund-Kennedy score, or Lund-Mackay score. The percentage of peripheral eosinophils was positively correlated with the percentage of tissue eosinophils (r = 0.560, P <0.001) and negatively correlated with tissue lymphocytes% (r = -0.489, P <0.001), tissue neutrophils% (r = -0.225, P = 0.005), and tissue plasma cells% (r = -0.266, P = 0.001) in WSIs.

High chemokine ligand 11 levels in nasal lavage fluid: A potential predictor of and therapeutic target for murine eosinophilic chronic rhinosinusitis

AIM

We aimed to discover whether group 2 innate lymphoid cells (ILC2s) and cytokines in nasal lavage fluid could be used to predict eosinophilic infiltration in mice with eosinophilic chronic rhinosinusitis (ECRS).

METHODS

Ten mice were divided into two groups. The ECRS group received an intranasal challenge of Aspergillus oryzae protease (AP) and ovalbumin (OVA) to establish disease. A control group received intranasal phosphate-buffered saline. Histopathology of nasal cavities and paranasal sinuses, and cytokine and ILC2s levels in nasal lavage fluid were analyzed and compared between the ECRS and control mouse groups.

KEY FINDINGS

ILC2s numbers were not significantly higher in the nasal lavage fluid of the ECRS group mice compared with those of the control group. Eotaxin/chemokine (CC motif) ligand 11 (CCL11) levels were significantly higher in the nasal lavage fluid of mice in the ECRS group compared with those in the control group. However, no statistical differences were seen in the classic proinflammatory cytokines, IL-33, IL-25, and thymic stromal thymopoietin (TSLP), or the classic type 2 cytokines, IL-4, IL-5, and IL-13 between groups.

SIGNIFICANCE

Eotaxin/CCL11 levels in nasal lavage fluid rather than that of ILC2s and classic proinflammatory and type 2 cytokines were significantly higher in ECRS mice compared with control ones. Eotaxin/CCL11 showed diagnostic and therapeutic value; however, more studies are needed to test and verify its value.

Advances in the Knowledge of the Underlying Airway Remodeling Mechanisms in Chronic Rhinosinusitis Based on the Endotypes: A Review

Chronic rhinosinusitis (CRS) is a chronic inflammatory condition of the nasal and paranasal sinus mucosa that affects up to 10% of the population worldwide. CRS is the most representative disease of the upper respiratory tract where airway remodeling occurs, including epithelial damage, thickening of the basement membrane, fibrosis, goblet cell hyperplasia, subepithelial edema, and osteitis. CRS is divided into two phenotypes according to the presence or absence of nasal polyps: CRS with nasal polyp (CRSwNP) and CRS without nasal polyps (CRSsNP). Based on the underlying pathophysiologic mechanism, CRS is also classified as eosinophilic CRS and non-eosinophilic CRS, owing to Type 2 T helper (Th2)-based inflammation and Type 1 T helper (Th1)/Type 17 T helper (Th17) skewed immune response, respectively. Differences in tissue remodeling in CRS are suggested to be based on the clinical phenotype and endotypes; this is because fibrosis is prominent in CRSsNP, whereas edematous changes occur in CRSwNP, especially in the eosinophilic type. This review aims to summarize the latest information on the different mechanisms of airway remodeling in CRS according to distinct endotypes.

Measurement of some serum cytokines in nasal polyp and evaluation of its correlation with disease severity

PURPOSE

Nasal polyp is originating from the nasal mucosa or paranasal sinus mucosa. In our study, it was aimed to investigate the possible effects of inflammatory cytokines Interleukin-13 (IL-13), IL-25, IL-33 and Syndecan-1 (SDC-1) in the pathogenesis process of nasal polyp and relationship between these parameters and disease severity.

METHODS

Our study was designed as a prospective case-control study. Patients diagnosed with nasal polyp were included in the patient group. The control group comprised volunteers with age and gender compatibility who does not have the disease. IL-13, IL-25, IL-33 and SDC-1 levels were detected in serum samples using enzyme-linked immunosorbent assay method. Nasal polyp disease severity was evaluated by means of "Sino-Nasal Outcome Test-22", "Lund-Mackay Score" and "Lund-Kennedy Score".

RESULTS

In this study, 35 patients, 29 controls, a total of 64 participants were included. Our evaluation revealed that all cytokine levels in the patient group were statistically significantly higher than the control group (p < 0.05). However, there was no correlation found between scoring methods and cytokine levels (p > 0.05).

CONCLUSION

The increase in cytokine levels in the patient group suggested that cytokine-mediated inflammation processes may be effective in nasal polyp pathogenesis.

Structured histopathology for endotyping and planning rational treatment in chronic rhinosinusitis

In chronic rhinosinusitis (CRS), endotyping, being based on the pathogenic mechanism, provides a precise picture appropriate for use in clinical practice. Structured histopathological examination of CRS is considered a necessary step in efforts to establish its pathogenesis and improve our endotyping capabilities. Herein we discuss the associations between histopathology and clinical characteristics of CRS patients to assist medical and surgical treatment choices.

Nasal polyps in eosinophilic granulomatosis with polyangiitis: Structured histopathology and CD105 expression

PURPOSE

Distinguishing the prodromal nasal polyposis of eosinophilic granulomatosis with polyangiitis (EGPA) from chronic rhinosinusitis with nasal polyps (CRSwNP) is a challenge for rhinologists and rheumatologists. It has recently been reported that angiogenesis and CD105 expressed on vascular endothelial cells could have a role in the pathogenesis and development of nasal polyps. This exploratory study examined the structured histopathology of nasal polyps in patients with EGPA and CRSwNP, comparing CD105 expression in their nasal tissue with that of a control group with no chronic sinonasal inflammation.

METHODS

A structured histopathological study was performed on surgical specimens of nasal tissue from 32 adults (13 with EGPA, 14 with CRSwNP, 5 controls), considering CD105 as a marker to determine microvessel density (MVD).

RESULTS

The mean eosinophil count was higher in EGPA patients with tissue inflammation (p = .002), and in CRSwNP patients with sub-epithelial edema (p = .009). Neutrophil infiltration was significantly associated with severe tissue inflammation in EGPA patients (p = .04), but with the absence of fibrosis in CRSwNP patients (p = .04). In the EGPA group, CD105-MVD correlated with tissue eosinophil count (p = .05). Mean CD105-MVD was significantly higher in EGPA patients with mucosal ulceration (p = .004). In the CRSwNP group, a CD105-MVD correlated positively and significantly with tissue eosinophil count (p = .01).

CONCLUSION

Alongside the known abundance of eosinophils, other cells might contribute to inflammatory processes. Neutrophils may amplify inflammation, eosinophil recruitment and tissue damage. CD105 expression in CRSwNP and EGPA nasal polyps supports the hypothesized involvement of angiogenesis in the pathogenesis and development of nasal polyps.

Neutrophil infiltrates and eosinophil aggregates in chronic rhinosinusitis with nasal polyps and EGPA

INTRODUCTION/OBJECTIVES

The histopathological study of inflammatory cells and their tendency to form aggregates in chronic rhinosinusitis with nasal polyps (CRSwNP) has shown promising results in determining the pathogenesis and predicting clinical outcome. Bilateral nasal polyps also occur in over 70% of patients with eosinophilic granulomatosis with polyangiitis (EGPA). The study aim was to investigate neutrophil infiltrates and eosinophil aggregates in CRSwNP and EGPA tissues of Caucasian patients.

METHOD

A histopathological study was performed on surgical specimens of nasal polyps from 144 adults (15 with allergic fungal rhinosinusitis; 19 with nonsteroidal anti-inflammatory drugs-exacerbated respiratory disease (NERD); 16 with intrinsic asthma; 21 with extrinsic asthma; 21 with allergy; 22 with eosinophil CRSwNP (ECRSwNP); 17 with non-ECRSwNP; 13 with EGPA).

RESULTS

Focusing on the presence of tissue eosinophil aggregates, NERD and ECRSwNP were the sub-cohorts with the highest rate. Neutrophil infiltrate rate was significantly higher in EGPA sub-cohort than in all CRSwNP sub-cohorts apart from non-ECRSwNP.

CONCLUSIONS

Structured histopathology is increasingly identifying the different histotypes of CRSwNP. This analysis can be used to better understand CRSwNP endotypes and develop targeted therapies. The response to therapy and therefore control of CRSwNP relapses definitely depends on our ability to act on the underlying inflammatory pattern. Key points • Systematic analysis of how neutrophil infiltrates and eosinophilic aggregates are distributed in the different phenotypes of CRSwNP and EGPA. • Neutrophil infiltrates and eosinophil aggregates are strong risk factors for nasal polyps' refractoriness. • NERD and ECRSwNP are the sub-cohorts of CRSwNP with the highest rate of tissue eosinophil aggregates. • Neutrophil infiltrates are significantly higher in EGPA.

The roles of nasal nitric oxide in diagnosis and endotypes of chronic rhinosinusitis with nasal polyps

Background

Chronic rhinosinusitis with polyps (CRSwNP) is a global health concern. Nasal nitric oxide (nNO), a clinical biomarker, have been studied to assess the presence of airway mucosal inflammation. This study aimed to clarify the roles of nNO in diagnosis and endotypes of CRSwNP.

Methods

Eighty-two CRSwNP patients and thirty healthy volunteers were recruited for this study. The patients were classified into eosinophilic CRSwNP (Eos CRSwNP) and non⁃eosinophilic CRSwNP (Non-Eos CRSwNP) endotypes by tissue eosinophil percentage. nNO levels were measured with an electrochemical sensor-based device. nNO levels and clinical factors were compared among the groups. Receiver-operating characteristic (ROC) curve and logistic regression analyses were performed to evaluate the predictive ability of the nNO for diagnosis and endotypes of CRSwNP.

Results

Eos CRSwNP patients(143.9 ± 106.2, ppb) had lower nNO levels than Non-Eos CRSwNP(228.3 ± 109.2, ppb, p = 0.013) and healthy subjects(366.5 ± 88, ppb, p < 0.0001). Patients with atopy exhibited significantly higher levers of nNO compared with patients without atopy (p < 0.05). For Eos CRSwNP diagnosis, nNO had high predictive value for Eos CRSwNP (AUC: 0.939; sensitivity: 76.74%; specificity: 96.67%; cut-off value: 231 ppb, p < 0.001). Furthermore, nNO levels were associated with CRSwNP endotypes (odds ratio: 1.010; 95% confidence interval: 1.003, 1.016%; p = 0.002). When the nNO concentration was 158 ppb, we could discriminate Eos CRSwNP from Non-Eos CRSwNP (AUC = 0.710, sensitivity: 76.92%; specificity, 60.47%, P = 0.001). After it was combinated by nNO, peripheral blood eosinophil count (PEAC) and VAS score, the AUC was increased to 0.894 (95%CI = 0.807 to 0.951, p < 0.0001, sensitivity:76.74%, specificity: 89.74%).

Conclusions

nNO may have potential for non-invasive diagnosis and endotype of CRSwNP. nNO combined with PEAC and VAS score may be a good diagnostic tool for endotyps of Eos CRSwNP. However, the atopic status of the patients influenced the levels of nNO.

Nasal Polyposis: Insights in Epithelial-Mesenchymal Transition and Differentiation of Polyp Mesenchymal Stem Cells

Chronic rhinosinusitis is a common inflammatory disease of paranasal sinuses, which causes rhinorrhea, nasal congestion, and hyposmia. The genetic predisposition or the exposure to irritants can sustain the inflammatory response and the development of nasal polyposis. Nasal polyps are benign and teardrop-shaped growths that project in the nasal cavities, and originate from the ethmoid sinuses. This inflammatory process is associated with high expression of IL-4, IL-5 and IL-13 and IgE. Antibodies targeting these cytokines or receptors represent a therapeutic strategy in the treatment of nasal polyposis in combination with corticosteroids. The molecular pathogenesis of nasal polyps in chronic rhinosinusitis (CRS) patients is associated with remodeling transition, a process in which epithelial cells lose their typical phenotype, acquiring a mesenchymal-like aspect. TGFβ/SMAD, ERK, and Wnt/β-catenin pathways are altered during the nasal tissue remodeling. miRNA and inhibitor molecules targeting these signaling pathways are able to interfere with the process; which could lead to alternative therapies. Nasal polyps are an alternative source of mesenchymal stem cells, which can be isolated from surgical biopsies. A molecular understanding of the biology of PO-MSCs will contribute to the delineating inflammatory process underlying the development of nasal polyps.

Crosstalk Between Mucosal Inflammation and Bone Metabolism in Chronic Rhinosinusitis

Chronic rhinosinusitis (CRS) is a multifactorial and highly heterogeneous upper airway disease that affects approximately 12% of the general population. There is increasing evidence supporting the impact of osteitis on the pathophysiology of CRS. Osteitis is frequently observed in patients with CRS, and is associated with severe sinonasal inflammation and recalcitrant cases. The overlying inflammatory sinonasal mucosa plays a critical role in the initiation of osteitis; however, the underlying molecular mechanisms and functional significance remain unclear. Increasingly many studies have suggested that immune cells play a crucial role in the bone remodeling process in CRS. The purpose of this review is to summarize the current state of knowledge regarding the specific role of sinonasal inflammation in bone remodeling in CRS patients.

Efficacy of buffered hypertonic seawater in different phenotypes of chronic rhinosinusitis with nasal polyps after endoscopic sinus surgery: a randomized double-blind study

PURPOSE

Nasal douching is commonly used as a postoperative management strategy for chronic rhinosinusitis with nasal polyps (CRSwNP). Few studies to date have compared the effectiveness of nasal douching in CRSwNP phenotypes after endoscopic sinus surgery (ESS). We evaluated the efficacy of seawater types in eosinophilic CRSwNP (ECRSwNP) and noneosinophilic CRSwNP (nonECRSwNP) after ESS.

METHODS

Patients with bilateral CRSwNP who had undergone ESS were blindly randomized to receive buffered hypertonic seawater (BHS) (n = 48) or physiological seawater (PS) (n = 45). CRSwNP patients were stratified by phenotypes (ECRSwNP and nonECRSwNP) retrospectively according to whether tissue eosinophils exceeded 10%. Follow-up evaluations were conducted at 2, 8, 16, and 24 weeks after surgery. Evaluations included the 22-item Sino-Nasal Outcome Test (SNOT-22), visual analog scale (VAS), Lund-Kennedy endoscopic score (LKES), saccharine clearance time (SCT), and adverse events.

RESULTS

All of the patients experienced significant improvements in SNOT-22 scores, VAS scores, and LKES over time. BHS resulted in better improvement of LEKS and SCT relative to PS at 8 weeks postoperatively. Mucosal edema formation was significantly reduced with less crusting among HBS recipients at 8 weeks. After stratification, only patients in the nonECRSwNP + BHS subgroup showed a significant improvement in LEKS and SCT at 8 weeks postoperatively. Side effect profiles were not significantly different among the groups.

CONCLUSIONS

BHS has a better inhibitory effect on mucosal edema and crusting during the early postoperative care period of CRSwNP. Among all of the patients, nonECRSwNP patients showed a significant improvement in LEKS and SCT at 8 weeks.

Blood Eosinophilic and Basophilic Trends in Recurring and Non-Recurring Eosinophilic Rhinosinusitis With Nasal Polyps

BACKGROUND

Very few studies have compared blood eosinophil and basophil levels before and after surgery in patients with eosinophilic CRSwNP (eCRSwNP). No investigations seem to have repeatedly measured them pre- and postoperatively in eCRSwNP patients with recurring versus non-recurring disease to examine how their levels evolved.

OBJECTIVE

Hence this study to analyze blood eosinophil and basophil levels in patients with eCRSwNP immediately before surgery and afterwards, at 4 months, 1 year, and then yearly up to 5 years.

METHODS

Fifty-one eCRSwNP patients were enrolled, who all had preoperative laboratory data and the results of at least 4 of the 6 scheduled postoperative follow-up tests.

RESULTS

Seventeen patients had recurrent disease. Blood eosinophil counts (p = 0.005) and percentages (p = 0.002) were both higher in these patients than in those whose eCRSwNPs did not recur after surgery. Blood basophil counts (p = 0.04) and percentages (p < 0.05) were also significantly higher in patients whose eCRSwNPs relapsed. The time by relapse interaction was not significant for either counts or percentages, though an effect of time was detected for basophil counts (p = 0.01).

CONCLUSIONS

In eCRSwNP, the statistical analysis of repeated quantitative laboratory data can shed light on the evolution of a patient's systemic inflammatory picture in response to previous treatments, and above all to long-term therapies. Long-term monitoring of blood eosinophil and basophil levels could be of significant value when monoclonal antibodies that inhibit IL signaling will widely enter in clinical practice for eCRSwNP treatment to follow the effectiveness of therapy over time.

Distinct Clinical Pathology and Microbiota in Chronic Rhinosinusitis With Nasal Polyps Endotypes

OBJECTIVES/HYPOTHESIS

Eosinophilic and noneosinophilic chronic rhinosinusitis with nasal polyps (ECRSwNP and NECRSwNP) show distinguished clinical pathology, but their underlying mechanism remains unclear. We aimed to investigate the clinical, hematological, and histopathological changes in chronic rhinosinusitis with nasal polyps (CRSwNP) endotypes and its association with microbiota.

STUDY DESIGN

A comparative cross-sectional study.

METHODS

A comparative study of 46 patients with CRSwNP (34.69 ± 16.39 years old) who underwent endoscopic sinus surgery were recruited and subdivided into ECRSwNP and NECRSwNP groups based on eosinophilic tissue inflammation; 12 healthy controls were also included. A structured histopathological analysis was conducted, and complete blood count was determined in patients. Endoscopic-guided middle meatus swabs and fecal samples were collected from the patients and controls and subsequently subjected to 16S rRNA gene sequencing on Illumina MiSeq.

RESULTS

Compared to NECRSwNP, ECRSwNP showed a statistically significant increase in the computed tomography score, endoscopic score, blood eosinophil percentage, tissue eosinophil count, inflammation degree, subepithelial edema, and eosinophil aggregation. Airway microbiota communities differed among the three groups. The abundance of Moraxella and Parvimonas was significantly higher in the ECRSwNP group. Distinct microbiota dysbiosis in CRSwNP endotypes was found to be correlated with different clinical pathologies. Moreover, the gut microbiota in ECRSwNP and NECRSwNP showed dysbiosis, that is, significant decrease in the abundance of Actinobacteria in the former and significant increase in the abundance of Enterobacterales and several genera in NECRSwNP.

CONCLUSIONS

Significant clinical pathology and microbiota changes were evident in patients with ECRSwNP and NECRSwNP. Distinct microbiota dysbiosis was correlated with different clinical pathologies. Understanding these differences may improve the prognosis and treatment of chronic rhinosinusitis.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E34-E44, 2021.

Can the systemic immune inflammation index preoperatively predict nasal polyp subtypes?

PURPOSE

Chronic rhinosinusitis with nasal polyps can be classified as eosinophilic or neutrophilic based on the major inflammatory cell type in the tissue. There is a need for predictive parameters to enable rhinologists to identify the type of nasal polyp in a patient without surgery. The aim of the present study was to test the predictive value of the markers of inflammation to estimate eosinophilic nasal polyps.

METHODS

The study analyzed 299 patients who underwent sinus surgery for nasal polyps from 2012 to 2019. Patients were divided into two groups according to pathology results (eosinophilic polyps = group 1, neutrophilic polyps = group 2). The values of preoperative complete blood count, systemic immune inflammation index, neutrophil-to-lymphocyte ratio, and platelet-to-lymphocyte ratio were compared.

RESULTS

In our series, results of ROC analyses for both mean eosinophil count and systemic immune inflammation index were statistically significant. For the eosinophil count (AUC = 0.681, p < 0.001) and systemic immune inflammation index (AUC = 0.621, p = 0.001). Patients with an eosinophil cut-off value of 0.25 cells × 10⁹/L had ORs of 49.27 (95% CI 11.68-207.81) and sensitivity: 0.69, specificity: 0.64. Patients with a systemic immune inflammation index cut-off value of 332.39 had ORs of 1.003 (95% CI 1.002-1.004) and sensitivity: 0.84, specificity: 0.39.

CONCLUSION

The systemic immune inflammation index and absolute blood eosinophil count could be used to predict nasal polyp subtypes before surgery. We believe that systemic immune inflammation index should also be studied to estimate postoperative recurrence.

Comparison of olfactory and taste functions between eosinophilic and non-eosinophilic chronic rhinosinusitis

OBJECTIVE

Most patients with chronic rhinosinusitis (CRS) complain of olfactory and/or taste dysfunctions. However, olfactory and taste dysfunctions depending on the subtype of CRS, classified as eosinophilic CRS (ECRS) and non-eosinophilic CRS (NCRS), have not been clearly reported. Therefore, the purpose of this study was to investigate the clinical features in olfactory and taste functions according to the subtype classified as ECRS and NCRS.

METHODS

We retrospectively analyzed the electronic medical records of patients who underwent endoscopic sinus surgery and were diagnosed with CRS. The patients were divided into ECRS and NCRS groups, according to their Japanese Epidemiological Survey of Refractory Eosinophilic Chronic Rhinosinusitis (JESREC) scores. We analyzed demographic characteristics, Sino-Nasal Outcome Test findings, Lund-Mackay score, and the results of previously-validated tests, including the Korean Version of Sniffin' Stick test and chemical gustatory function test.

RESULTS

Patients with ECRS and NCRS had decreased olfactory and taste functions compared to the control group. In particular, the olfactory score of ECRS patients was lower than that of NCRS patients (18.1 ± 9.5 vs 23.7 ± 8.5, respectively, p <0.001). On the other hand, taste scores of ECRS patients were not statistically different compared to NCRS patients (19.1 ± 4.7 vs. 18.3 ± 4.7, respectively, p = 0.166). Olfactory score decreased with increase in JESREC score (r=-0.203, p = 0.002), but it had no correlation with taste score (r = 0.072, p = 0.276).

CONCLUSION

We found a difference in olfactory function but no difference in taste function between patients in ECRS and NCRS groups. These results may provide valuable clinical features in terms of olfactory and taste functions according to the subtypes of CRS.

Pathogenesis of chronic rhinosinusitis with nasal polyps: role of IL-6 in airway epithelial cell dysfunction

Background

Chronic rhinosinusitis with nasal polyps (CRSwNP) is characterized by an alteration in airway epithelial cell functions including barrier function, wound repair mechanisms, mucociliary clearance. The mechanisms leading to epithelial cell dysfunction in nasal polyps (NPs) remain poorly understood. Our hypothesis was that among the inflammatory cytokines involved in NPs, IL-6 could alter epithelial repair mechanisms and mucociliary clearance. The aim of this study was to evaluate the in vitro effects of IL-6 on epithelial repair mechanisms in a wound repair model and on ciliary beating in primary cultures of Human Nasal Epithelial Cells (HNEC).

Methods

Primary cultures of HNEC taken from 38 patients during surgical procedures for CRSwNP were used in an in vitro model of wound healing. Effects of increasing concentrations of IL-6 (1 ng/mL, 10 ng/mL, and 100 ng/mL) and other ILs (IL-5, IL-9, IL-10) on wound closure kinetics were compared to cultures without IL-modulation. After wound closure, the differentiation process was characterized under basal conditions and after IL supplementation using cytokeratin-14, MUC5AC, and β_IV tubulin as immunomarkers of basal, mucus, and ciliated cells, respectively. The ciliated edges of primary cultures were analyzed on IL-6 modulation by digital high-speed video-microscopy to measure: ciliary beating frequency (CBF), ciliary length, relative ciliary density, metachronal wavelength and the ciliary beating efficiency index.

Results

Our results showed that: (i) IL-6 accelerated airway wound repair in vitro, with a dose–response effect whereas no effect was observed after other ILs-stimulation. After 24 h, 79% of wounded wells with IL6-100 were fully repaired, vs 46% in the IL6-10 group, 28% in the IL6-1 group and 15% in the control group; (ii) specific migration analyses of closed wound at late repair stage (Day 12) showed IL-6 had the highest migration compared with other ILs (iii) The study of the IL-6 effect on ciliary function showed that CBF and metachronal wave increased but without significant modifications of ciliary density, length of cilia and efficiency index.

Conclusion

The up-regulated epithelial cell proliferation observed in polyps could be induced by IL-6 in the case of prior epithelial damage. IL-6 could be a major cytokine in NP physiopathology.

Prognostic role of blood eosinophil and basophil levels in allergic fungal rhinosinusitis (AFRS)

PURPOSE

Allergic fungal rhinosinusitis (AFRS) forms a subset of chronic rhinosinusitis with nasal polyps (CRSwNP) that is mainly characterized by eosinophilic nasal polyps, allergic mucin detected in the sinuses at surgery, and specific features on computerized tomography. Which biological markers predict disease recurrence in AFRS is still not clear, and the role of blood inflammatory cells in predicting recurrent polyps after surgery has yet to be investigated. The aim of this study was to newly investigate the prognostic role (in terms of recurrence rate) of preoperative blood eosinophil and basophil levels in AFRS.

MATERIALS AND METHODS

A consecutive series of 17 adult patients who underwent endoscopic sinus surgery for AFRS was retrospectively assessed.

RESULTS

Sinonasal polyps recurred in 7 of 17 patients. Considering the whole cohort, a significant positive correlation emerged between blood eosinophil and basophil counts, but not between blood and tissue eosinophil counts. Statistical analysis found significantly higher blood eosinophil and basophil levels in AFRS patients who relapsed than in those who did not.

CONCLUSIONS

Considering the current difficulty of identifying more effective, personalized approaches to postoperative disease management in AFRS, our preliminary data support the impression that blood eosinophil and basophil levels warrant testing in further prospective and larger (preferably multi-institutional) investigations as part of the preoperative work-up for patients with AFRS in order to administer dedicated postoperative medical treatments for patients at higher risk of relapse.

Identification and Characterization of Nasal Polyposis and Mycoplasma Superinfection by Scanning Electron Microscopy and Nasal Cytology with Optical Microscopy: A Case Report

Nasal polyposis is characterized by benign, non-cancerous and painless growths originating in the tissue of the nasal cavities and paranasal sinuses. Polyps arise from chronic inflammation due to asthma, recurrent infections, allergies, drug sensitivity or immune disorders. They can obstruct the nasal cavities and thus cause respiratory problems, a reduction in the sense of smell and susceptibility to infections. Furthermore, nasal polyps can recur. Hence the importance of using valid diagnostic methods. In this work, the diagnostic investigation carried out by scanning electron microscopy (SEM) and nasal cytology led, for the first time, to the identification of a mycoplasma superinfection on nasal polyposis.

A classification of chronic rhinosinusitis with nasal polyps based on structured histopathology

AIMS

In chronic rhinosinusitis with nasal polyps (CRSwNP), tools based on objective evidence, such as histopathology, are needed to assist clinical decision-making. The main aim of this exploratory investigation was to determine whether structured histopathology could be used to classify CRSwNP in homogeneous histological clusters.

METHODS AND RESULTS

A cohort of 135 CRSwNP patients was assessed, on the basis of clinicopathological features: allergic fungal rhinosinusitis (17 patients); non-steroidal anti-inflammatory drug-exacerbated respiratory disease (19 patients); intrinsic asthma (18 patients); extrinsic asthma (21 patients); allergy (21 patients); histologically eosinophilic (22 patients); and histologically non-eosinophilic (17 patients). For structured histopathology, we considered: the degree of inflammation; eosinophil count; eosinophil aggregates; neutrophil infiltration; goblet cell hyperplasia; basement membrane thickening; fibrosis; hyperplastic/papillary changes; squamous metaplasia; mucosal ulceration; and subepithelial oedema. Cluster analysis identified four distinct sets of cases. On discriminant analysis, the global error rate was 1.48%, and the stratified error rates were 4.34%, 0%, 0%, and 0% for clusters 1, 2, 3 and 4, respectively. Cluster 1 was characterised by infrequent fibrosis (<4.5% of cases). Cluster 2 mainly featured neutrophil infiltration in 100% of cases, hyperplastic/papillary changes in 70% of cases, and fibrosis in 65% of cases. Cluster 3 showed fibrosis in 100% of cases. Cluster 4 showed hyperplastic/papillary changes in 100% of cases, and fibrosis in 92% of cases.

CONCLUSIONS

This study shows that cluster analysis can identify different histotypes among CRSwNP patients. The next step will be to investigate, in a larger series, the clinical (e.g. prognostic) implications of identifying such homogeneous clusters of patients with CRSwNP on the basis of their structured histopathology.

The spectrum of therapeutic activity of mepolizumab

Introduction: The basis of the development of the anti-interleukin-5 monoclonal antibody mepolizumab was the acknowledgment of the crucial importance of this cytokine in promoting eosinophils production, activation, and survival, which is associated with the eosinophilic asthma phenotype, as well as with other disorders characterized by high levels of eosinophils. Areas covered: All the available literature on the outcomes treatment with mepolizumab in eosinophilic disorders are reviewed, including asthma, chronic rhinosinusitis, esophagitis, granulomatosis with polyangiitis, eosinophilic chronic obstructive pulmonary disease, hypereosinophilic syndrome, and allergic bronchopulmonary aspergillosis. Expert opinion: The efficacy of mepolizumab in eosinophilic asthma is clearly demonstrated by a number of controlled trials and by meta-analyses. Among other eosinophilic disorders, controlled trials are available for chronic rhinosinusitis with nasal polyps, eosinophilic esophagitis, hypereosinophilic syndrome, eosinophilic granulomatosis with polyangiitis, and eosinophilic chronic obstructive pulmonary disease. Allergic bronchopulmonary aspergillosis, as well as other minor eosinophilic disorders, are backed only by case reports and are waiting controlled trials to verify the therapeutic role of mepolizumab.

Increased TSLP, IL-33, IL-25, IL-19, IL 21 and amphiregulin (AREG) levels in chronic rhinosinusitis with nasal polyp

OBJECTIVE

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a chronic inflammatory disease. The surrogate indicating biomarkers in patients with CRSwNP need further evaluation. The aim of this study was to investigate the association of thymic stromal lymphopoietin (TSLP) and amphiregulin (AREG) cytokines in patients with CRSwNP.

METHODS

Sinonasal tissue samples were collected from 33 patients with CRSwNP and 29 controls. Levels of AREG, IL-19, IL-21, IL-25, IL-33 and TSLP in nasal polyp and control sinonasal tissues were determined following the enzyme-linked immunosorbent assay method.

RESULTS

We found that AREG, IL-19, IL-21, IL-25, IL-33 and TSLP levels were significantly higher in the CRSwNP group compared to the control group (p < 0.000; p < 0.000; p < 0.000; p < 0.000; p < 0.003; p < 0.021, respectively).

CONCLUSIONS

Our findings indicated that AREG, IL-19, IL-21, IL-25, IL-33 and TSLP were significantly increased in tissue samples of CRSwNP patients and may be considered as molecular indicators and targets for therapeutic developments for patients with CRSwNP.

Identification of key genes and pathways in chronic rhinosinusitis with nasal polyps using bioinformatics analysis

PURPOSE

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a prevalent inflammatory disease of yet unknown etiology. The purpose of this study was to uncover key genes and pathways related to the pathogenesis of CRSwNP via bioinformatics approaches.

MATERIALS AND METHODS

The gene expression profile of GSE36830 extracted from Gene Expression Omnibus database was used to screen differentially expressed genes (DEGs) between nasal polyp samples and control samples. Furthermore, functional and pathway enrichment analysis was performed using the clusterProfiler package in R language. In addition, protein-protein interaction (PPI) network was constructed by STRING database and functional modules were detected using Molecular Complex Detection algorithm.

RESULTS

A total of 538 DEGs (326 up-regulated and 212 down-regulated) were identified. The most significantly enriched pathways for up-regulated and down-regulated genes were hematopoietic cell lineage and salivary secretion, respectively. Moreover, twenty hub genes with high connectivity degrees were selected from the PPI network, such as TYRO protein tyrosine kinase binding protein (TYROBP), G protein subunit gamma 2 (GNG2), CCR7, and CCR3. Besides, six important modules were obtained, which were highly associated with chemokine signaling pathway, Th1 and Th2 cell differentiation, complement and coagulation cascades, cell cycle, systemic lupus erythematosus, and Staphylococcus aureus infection.

CONCLUSIONS

The results of this study may provide new insights into potential molecular mechanisms of CRSwNP. Nevertheless, further experiments are needed to confirm these findings.

Role of blood inflammatory cells in chronic rhinosinusitis with nasal polyps

BACKGROUND/OBJECTIVE

The pathophysiological and prognostic role of blood inflammatory cells in chronic rhinosinusitis with nasal polyps (CRSwNP) emerging from recent studies was investigated.

MATERIAL AND METHODS

The main available evidence and largely-recent publications were critically analyzed.

RESULTS

Several authors reported a direct association between blood eosinophilia and CRSwNP recurrence rates. In some large series, a direct association between recurrent CRSwNP and blood basophil values emerged too. CRSwNP patients' blood eosinophil and basophil values were strongly related. It was also found that preoperative neutrophil-to-lymphocyte, eosinophil-to-lymphocyte, and basophil-to-lymphocyte ratios were significantly higher in patients who experienced a disease relapse than in those who did not. In histologically-confirmed eosinophilic-type CRSwNP treated with endoscopic sinus surgery, mean blood eosinophil values dropped significantly from before to after the surgical procedure.

CONCLUSIONS/SIGNIFICANCE

CRSwNP endotypes have different inflammatory profiles reflected in the relative proportions of different types of blood cells. The available data support the theory that blood eosinophil and basophil levels should be included in the routine preoperative work-up of CRSwNP patients in order to give patients accurate prognostic information, adopt rational follow-up protocols after surgery, and provide dedicated postoperative medical treatments.

Differential effects of postoperative oral corticosteroid on eosinophilic vs. non-eosinophilic CRSwNP subtypes

PURPOSE

The efficacy of postoperative oral corticosteroids on surgical outcomes in chronic rhinosinusitis with nasal polyps (CRSwNP) patients following endoscopic sinus surgery (ESS) remains controversial. This study evaluated the potential benefits of postoperative oral corticosteroids on surgical outcomes in CRSwNP patients and investigated the differential effects on eosinophilic CRSwNP (ECRSwNP) and noneosinophilic CRSwNP (NECRSwNP).

MATERIALS AND METHODS

Patients with bilateral CRSwNP who underwent ESS were enrolled and randomized to receive either oral prednisolone (30 mg/day) or placebo for 2 weeks after surgery. Visual analog scale (VAS) and Sino-Nasal Outcome Test 22 (SNOT-22) scores were chosen as the subjective outcomes, evaluated at preoperative baseline and 1, 3, and 6 months postoperatively. Lund-Kennedy Endoscopic Scores (LKESs) were used as the objective outcome, evaluated at preoperative baseline and at 2 weeks and 2, 3, and 6 months postoperatively.

RESULTS

In total, 100 patients with bilateral CRSwNP were enrolled, of whom only 82 completed the 6-month follow-up. The subjective outcomes showed no significant difference at each follow-up points. Of the objective outcomes, the corticosteroid group reporting a trend of improvement in LKESs at 6 months postoperatively (p = 0.05). After stratification by tissue eosinophils, only patients with NECRSwNP (<10 eosinophils/HPF) demonstrated a significant improvement in LKESs at 3 months postoperatively (p = 0.03).

CONCLUSIONS

Postoperative oral corticosteroids did not provide additional improvements in VAS and SNOT-22 scores; nevertheless, a trend of LKES improvement was noted at 6 months postoperatively. After stratification by tissue eosinophils, this effect was significant only among NECRSwNP patients at 3 months follow-up.

Agonist of PPAR-γ Reduced Epithelial-Mesenchymal Transition in Eosinophilic Chronic Rhinosinusitis with Nasal Polyps via Inhibition of High Mobility Group Box1

Epithelial-mesenchymal transition (EMT) has been reported to occur in eosinophilic chronic rhinosinusitis with nasal polyps (ECRSwNP). Among the cytokines that cause EMT, high mobility group box 1 (HMGB1) has been shown to give rise to EMT in airway epithelial cells. However, the mechanism of HMGB1-induced EMT in ECRSwNP is unknown. We explored the mechanism and possible inhibitor. Immunohistochemistry (IHC), immunofluorescence (IF), and western blot assay were used to detect the expression and location of HMGB1, peroxisome proliferator-activated receptor-γ (PPAR-γ), and EMT markers in eighteen ECRSwNP and twelve normal nasal mucosa tissues. Epithelial cells isolated from ECRSwNP were cultured with various doses of recombinant human HMGB1 (rhHMGB1) to study the expression of PPAR-γ, and EMT markers. Additionally, the ligand of PPAR-γ was incubated with epithelial cells to interfere with the effects of lipopolysaccharide (LPS) or rhHMGB1 to explore the effect on expression of HMGB1 and EMT markers. These results suggest that HMGB1 was highly expressed in ECRSwNP compared with its expression in control tissues, and EMT was also found highly in ECRSwNP compared with control tissues. Moreover, the cytoplasmic accumulation of HMGB1 in ECRSwNP was obvious compared with normal tissues. We also found dose-dependent induction by rhHMGB1 of up-regulation of N-cadherin and vimentin and down-regulation of ZO-1 and E-cadherin in epithelial cells isolated from ECRSwNP. The agonist of PPAR-γ not only reduced release of HMGB1 induced by LPS, but also reversed the EMT. The protective role of PPAR-γ also appeared in cells that had been incubated with rhHMGB1. In the current study, we discovered that the agonist of PPAR-γ has a potential role in inhibited HMGB1-induced EMT in ECRSwNP. The agonist of PPAR-γ may contribute to inhabit epithelial cells to become mesenchymal-like cells which play an important role in the pathogenesis of ECRSwNP.

Non-Eosinophilic Chronic Rhinosinusitis With Nasal Polyps: Eosinophil, Basophil, and Neutrophil Blood Counts Before and After Surgery

OBJECTIVES

Research selectively investigating non-eosinophilic chronic rhinosinusitis with nasal polyps (CRSwNP) is lacking. The inflammatory patterns seen in non-eosinophilic CRSwNP are still poorly understood. The present study is the first to compare blood eosinophil, basophil, and neutrophil counts before/after surgery in patients with non-eosinophilic CRSwNP stratified by their clinical features.

METHODS

The study concerned 107 consecutive patients with histologically confirmed non-eosinophilic CRSwNP who underwent endoscopic sinus surgery (ESS).

RESULTS

Statistical analysis ruled out any significant change in mean blood eosinophil, basophil, and neutrophil counts after ESS. A significant positive correlation emerged between blood eosinophil and basophil counts in both pre- and post-ESS laboratory tests. In the subcohort of allergic patients, a significant negative correlation was found after ESS between eosinophil and neutrophil levels and between basophil and neutrophil levels.

CONCLUSIONS

In eosinophilic CRSwNP, ESS can clear polyps, remove inflammatory tissue, and reduce the inflammatory cytokines it generates, with a consequent reduction in blood eosinophil levels. The different results in non-eosinophilic CRSwNP support the conviction that the 2 types of CRSwNP are entities with distinct inflammatory response patterns.

Mometasone furoate sinus implant - a new targeted approach to treating recurrent nasal polyp disease

Introduction: Chronic rhinosinusitis (CRS) is a broad heterogeneous inflammatory disorder of the nose and paranasal sinuses, resulting from the dysfunctional interplay between host immunity, defective epithelial barrier, and environmental factors. CRS with nasal polyps (CRSwNP) is considered a more severe clinical phenotype with greater burden of symptoms and higher relapse rate, especially with comorbid asthma or aspirin sensitivity. Available treatment options after endoscopic sinus surgery (ESS) - systemic corticosteroids or revision surgery - have significant risks and limitations. Areas covered: Bioabsorbable, steroid-eluting implants have been studied extensively for the ability to dilate and re-establish sinus patency by the localized, controlled delivery of topical corticosteroids to diseased sinonasal lining and nasal polyps. This review provides a comprehensive, up to date analysis of the literature regarding a novel, office-based, mometasone furoate (MF) sinus implant that may treat patients with recurrent CRSwNP after ESS. Expert commentary: Clinical evidence has demonstrated the safety and efficacy of steroid-eluting implant in the reduction of polyp size, symptom burden, and the need for revision sinus surgery. MF sinus implants may play an important role in the management of patients with recurrent polyposis after sinus surgery.

Chronic Rhinosinusitis-Could Phenotyping or Endotyping Aid Therapy?

OBJECTIVES

We reviewed the phenotyping and endotyping of chronic rhinosinusitis (CRS) and treatment options.

METHODS

We searched PubMed, Google, Google Scholar, and the Proquest Central Database of the Kırıkkale University Library.

RESULTS

Phenotypes are observable properties of an organism produced by the environment acting upon the genotype, that is, patients with a particular disorder are subgrouped according to common characteristics. Currently, CRS is usually phenotyped as being with (CRSwNP) or without (CRSsNP) nasal polyps. However, this is not immutable as some individuals progress from nonpolyp to polypoid CRS over time. Phenotypes of CRS are also based on inflammatory patterns, generally CRSwNP is eosinophilic, CRSsNP neutrophilic; but there is a spectrum, rather than a clear-cut division into 2 types. An endotype is a subtype of a condition defined by a distinct functional or pathobiological mechanism. Endotypes of CRS can be (1) nontype Th2, (2) moderate type Th2, and (3) severe type Th2 immune reactions, based on cytokines and mediators such as IL4, 5, 13. CRS endotyping can also include a (1) type 2 cytokine-based approach, (2) eosinophil-mediated approach, (3) immunoglobulin E-based approach, and (4) cysteinyl leukotriene-based approach. Subdivisions of CRSwNP can be made into nonsteroidal anti-inflammatory drug-exacerbated respiratory disease, allergic fungal sinusitis, and eosinophil pauci-granulomatous arteritis by testing. General treatment for all CRS is nasal douching. The place of surgery needs careful reconsideration. Endotype-directed therapies include glucocorticosteroids, antibiotics, aspirin, antifungals, anticytokines, and immunoglobulin replacement. The recognition of united airways and the co-occurrence of CRSwNPs and severe asthma should lead to common endotyping of both upper and lower airways in order to better direct therapy.

CONCLUSION

Endotyping can allow for the identification of groups of patients with CRS with a high likelihood of successful treatment, such as patients with a moderate type 2 immune reaction or those with acquired immune deficiency.