When surgery, antibiotics, and steroids fail to resolve chronic rhinosinusitis

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.

Predicting Odontogenic Sinusitis in Unilateral Sinus Disease: A Prospective, Multivariate Analysis

BACKGROUND

Odontogenic sinusitis (ODS) is a common cause of unilateral sinus disease (USD), but can be challenging to diagnose due to nonspecific clinical presentations, potentially subtle to absent dental pathology on sinus computed tomography (CT), and underrepresentation in the sinusitis literature.

OBJECTIVE

Identify sinonasal clinical variables predictive of ODS in patients presenting with unilateral maxillary sinus opacification on sinus CT.

METHODS

A prospective cohort study was conducted on 131 consecutive patients with USD and at least partial or complete maxillary sinus opacification on sinus CT. Patients' demographics, sinonasal symptoms (anterior and posterior drainage, nasal obstruction, facial pressure, smell loss, and foul smell), 22-item sinonasal outcome test, nasal endoscopy findings, CT findings, and histopathology were collected. Patients' diagnoses included ODS, chronic rhinosinusitis with or without nasal polyps, and inverted papilloma. Demographic and clinical data were compared between patients with unilateral ODS and non-odontogenic disease using univariate and multivariate analyses.

RESULTS

Of the 131 USD patients, 65 had ODS and 66 had non-odontogenic disease. The following variables were significantly associated with unilateral ODS on multivariate analysis: middle meatal pus on endoscopy (OR= 17.67, 95% CI-5.69, 54.87; p = 0.001), foul smell (OR= 6.11, 95% CI-1.64, 22.82; p=.007), facial pressure (OR= 3.55, 95% CI-1.25, 10.12; p = 0.018), and any frontal opacification on CT (OR= 5.19, 95% CI-1.68, 16.06; p = 0.004). Any sphenoid opacification on CT was inversely related to ODS (OR = 0.14, 95% CI-0.03, 0.69; p = 0.016). The study was adequately powered.

CONCLUSION

With unilateral maxillary sinus disease, the following features were significantly associated with ODS: foul smell, ipsilateral facial pressure, middle meatal pus on endoscopy, and any frontal sinus opacification on sinus CT. Additionally, any sphenoid sinus opacification on CT was inversely related to ODS. Presence or absence of these clinical variables can be used to increase or decrease one's suspicion of an odontogenic source of sinusitis.

Endoscopic sinus surgery improves aspirin treatment response in aspirin-exacerbated respiratory disease patients

BACKGROUND

Aspirin desensitization and treatment benefits most patients with aspirin-exacerbated respiratory disease (AERD), although some patients fail therapy. Our objective was to assess whether recent endoscopic sinus surgery (ESS) improved aspirin treatment outcomes in AERD patients who initially failed aspirin therapy.

METHODS

Outcomes of aspirin desensitization and treatment in AERD patients prospectively enrolled were assessed preoperatively and at 4, 12, and 24 weeks after ESS by determining changes in Asthma Control Test (ACT) and Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) scores and respiratory function. Biomarkers, including fractional excretion of nitric oxide (FeNO), spirometry, nasal inspiratory peak flow (NPF), immunoglobulin E (IgE), and eosinophil count, were measured.

RESULTS

Nineteen patients who benefited (responders) and 21 patients who failed (nonresponders) preoperative aspirin treatment with a distant history of ESS (mean, 48 months) were identified. Nonresponders were more likely to be African American (71%, p < 0.01) and have higher baseline IgE levels (252 kU/L vs 87 kU/L in responders, p < 0.01). 24 of the 40 patients (nine responders and 15 non-responders) required subsequent ESS and underwent another aspirin desensitization 3-4 weeks after ESS. All 24 patients tolerated a second round of aspirin desensitization and treatment. The primary aspirin therapy was associated with a significant increase in IgE in nonresponders, but there was no significant increase in IgE after the second aspirin desensitization and treatment.

CONCLUSION

Antecedent ESS enhances aspirin treatment responses in AERD patients and may convert patients who failed aspirin treatment before surgery to a more responsive phenotype after ESS. Patients with higher baseline serum IgE levels may benefit from ESS performed shortly before aspirin desensitization and therapy.

Aspirin exacerbated respiratory disease: Current topics and trends

Aspirin-exacerbated respiratory disease is a chronic and treatment-resistant disease, characterized by the presence of eosinophilic rhinosinusitis, nasal polyposis, bronchial asthma, and nonsteroidal anti-inflammatory drugs hypersensitivity. Alterations in arachidonic acid metabolism may induce an imbalance between pro-inflammatory and anti-inflammatory substances, expressed as an overproduction of cysteinyl leukotrienes and an underproduction of prostaglandin E2. Although eosinophils play a key role, recent studies have shown the importance of other cells and molecules in the development of the disease like mast cells, basophils, lymphocytes, platelets, neutrophils, macrophages, epithelial respiratory cells, IL-33 and thymic stromal lymphopoietin, making each of them promissory diagnostic and treatment targets. In this review, we summarize the most important clinical aspects of the disease, including the current topics about diagnosis and treatment, like provocation challenges and aspirin desensitization. We also discuss recent findings in the pathogenesis of the disease, as well as future trends in diagnosis and treatment, including monoclonal antibodies and a low salicylate diet as a treatment option.

Biocompatibility and Pharmacokinetics of Fluticasone-Eluting Sinus Implant in a Rabbit Model

Background

A novel, bioabsorbable, fibrinogen-based implant has been developed as a mucosal dressing after endoscopic sinus surgery (ESS). This implant can be formulated with fluticasone propionate (TP) for local elution of corticosteroid to reduce postoperative inflammation and promote mucosal healing.

Objective

This study investigated the biocompatibility and pharmacokinetics of the implant in a rabbit model.

Methods

Implants with and without TP were placed on both intact and demucosalized maxillary sinuses of 33 New Zealand White rabbits. Sinuses with either intact or denuded bone without implants acted as controls. Histopathologic assessments were carried out at 5, 15, and 28 days. Concentrations of TP in the maxillary sinus mucosa, nasal cavity mucosa, and plasma were measured for up to 44 days.

Results

Implants placed on intact mucosa or denuded bone were grossly integrated within 15 days. Minimal foreign body reaction was seen with negligible differences for inflammation, fibrosis, or bone remodeling among controls, sinuses with the implant, or sinuses with the implant plus TP, at all time points. All samples also showed complete or near-complete percentage reepithelialization at 28 days, although the denuded bone controls demonstrated greater percentage reepithelialization at 5 days compared with denuded bone with the implant or implant plus TP (p <0.0001). The maxillary sinus mucosa demonstrated levels of TP of >140 ng/g up to 44 days. Plasma concentrations of TP were generally very low and were undetectable after day 7.

Conclusions

The implant and the implant plus TP seemed to be biocompatible in rabbits. The implant plus TP effectively eluted steroid locally over at least 44 days, with negligible plasma concentrations. Further studies are warranted regarding potential therapeutic applications in patients undergoing ESS for chronic rhinosinusitis.

Evaluation of a steroid releasing sinus implant for the treatment of patients undergoing frontal sinus surgery for chronic rhinosinusitis

INTRODUCTION

Management of the frontal sinus places great demands on the otolaryngologist. Given that the fronto-ethmoidal region is susceptible to recurrent inflammation, scarring, and stenosis, maintaining long-term patency of the frontal sinus is a difficult challenge. Oral and topical anti-inflammatory therapy, post-operative stenting, and 'home-brew' drug elution have been used for the treatment of the frontal sinus with mixed success. Recently an implant has been approved for post-operative placement into the frontal recess. This implant provides reliable and consistent steroid drug elution to address inflammation of the frontal recess secondary to chronic sinusitis. Areas covered: This review discusses the development and application of steroid eluting implants in the postoperative care of patients with chronic frontal sinusitis. All randomized controlled trials evaluating steroid eluting implants are discussed. Relevant supporting material discussing background, economics, safety are included. Expert commentary: Steroid eluting implants fulfill a unique niche in the treatment following frontal sinus surgery. They are shown to decrease the need for post-operative interventions and improve outcomes in patients with chronic sinusitis. There is significant potential for growth in the use of steroid eluting implants.

Position statement of the Brazilian Academy of Rhinology on the use of antihistamines, antileukotrienes, and oral corticosteroids in the treatment of inflammatory sinonasal diseases

Introduction

Inflammatory conditions of the nose and paranasal sinuses are very prevalent in the general population, resulting in marked loss of quality of life in affected patients, as well as significant work, leisure, and social activity losses. These patients require specific and specialized treatment. A wide range of oral medications are available.

Objective

The present document is aimed to clarify, for professionals treating patients with inflammatory sinonasal diseases, both specialists and general practitioners, specific oral therapies in noninfectious nasal inflammatory conditions.

Methods

The methodology used to create this article included the search for the key words: oral corticosteroids, antihistamines, antileukotrienes, rhinitis, rhinosinusitis in the MEDLINE and EMBASE databases in the last 5 years. Since no relevant article was found for the text on the subject of interest in the last 5 years, the search was extended for another 5 years, and so on, according to the authors’ needs.

Results

Relevant literature was found regarding the use of antihistamines, antileukotrienes and oral corticosteroids in these conditions. The Brazilian Academy of Rhinology emphasizes, after extensive discussion by the collegiate, key points in the treatment with these drugs.

Conclusion

There is support in the literature for the use of these drugs; however, final considerations about the role of each of them have been made.

Prevention of sinonasal inflammation by a synthetic glycosaminoglycan

BACKGROUND

Glycosaminoglycans (GAGs) are polysaccharides that are distributed on respiratory epithelial cells, endothelial cells, and submucosal glands. Uniquely positioned, certain GAGs exhibit anti-inflammatory properties in respiratory diseases and serve important roles in repairing mucosal surfaces and modulating mucociliary clearance. We hypothesized that topical administration of a synthetic GAG (GM-0111) would prevent sinonasal inflammation in a mouse model of rhinosinusitis (RS).

METHODS

To test our hypothesis, C57BL/6 mice were intranasally administered fluorescent GM-0111, and sinonasal tissues were examined for coating and penetration ability. To test therapeutic feasibility, mice (n = 6) were given GM-0111 or hyaluronic acid (HA; 800 μg dose) prior to inducing RS with inflammatory molecule LL-37 (115 μg dose). After 24 hours, sinonasal tissues were harvested for histological and biochemical analysis of inflammatory markers (inflammatory cell infiltration, lamina propria [LP] thickening, and neutrophil enzyme myeloperoxidase [MPO]) and cell death.

RESULTS

GM-0111 was observed within sinonasal tissues 1 hour and 24 hours after intranasal administration, indicating rapid and effective coating and penetration. GM-0111 prevented sinonasal tissues from developing inflammatory changes, with significant reductions in mast cell infiltration (p < 0.05), LP thickening (p < 0.001), and MPO levels (p < 0.01) when compared to tissues treated with LL-37 and those pretreated with HA. GM-0111 reduced cell death within sinonasal tissues in contrast to LL-37-treated tissues.

CONCLUSION

We report a new synthetic GAG (GM-0111) that uniformly coats and penetrates into the sinonasal mucosa to prevent sinonasal inflammation and cell death in a mouse model of RS.

The Role of Surgery in Management of Samter's Triad: A Systematic Review

OBJECTIVE

Aspirin-exacerbated respiratory disease (AERD) represents a severe form of chronic rhinosinusitis (CRS) characterized by nasal polyposis, bronchial asthma, and aspirin intolerance. This syndrome, known as Samter's triad, is more difficult to manage than routine CRS and poses a challenge to the treating clinician. We performed a systematic review of the literature to determine the role of endoscopic sinus surgery in patients with AERD who are on adjuvant medical therapies.

DATA SOURCES

PubMed, Embase, Web of Science, Cochrane Database of Systematic Reviews, Cochrane Database of Abstracts of Reviews of Effects, Cochrane Central Register of Controlled Trials, Cochrane Methodology Register, Cochrane Technology Assessments, Cochrane Economic Evaluations, Cochrane Groups, and Clinicaltrials.gov.

REVIEW METHODS

A systematic review of the literature was performed using the 2009 PRISMA guidelines. Studies with both preoperative and postoperative data for patients with AERD who underwent sinus surgery were considered appropriate for inclusion. Publications were written in English, included patients aged 18 years or older, and had a minimum follow-up of 3 months.

RESULTS

Eighteen studies met criteria for inclusion in our review. The primary outcome was change in symptom profile as measured by sinonasal and asthma symptom scores. Most studies demonstrated improvement in sinus- and asthma-related symptoms and quality-of-life measures after endoscopic sinus surgery.

CONCLUSION

This review, which did not exclude the use of concomitant medical therapy, suggests that surgery is beneficial in AERD management. Evidence demonstrates improvement in sinonasal and asthma symptom severity and frequency, radiographic and endoscopy scores, and quality of life after surgery.

Long-term sinonasal outcomes of aspirin desensitization in aspirin exacerbated respiratory disease

OBJECTIVE

This study aimed to assess sinonasal outcomes in patients with aspirin exacerbated respiratory disease (AERD) undergoing aspirin desensitization following endoscopic sinus surgery (ESS).

STUDY DESIGN

Case series with chart review.

SETTING

University hospital.

SUBJECTS AND METHODS

A retrospective review of sinonasal outcomes was conducted for 30 AERD patients undergoing aspirin desensitization and maintenance therapy following ESS. Sinonasal outcomes were prospectively assessed by the Sinonasal Outcomes Test-22 (SNOT-22) and endoscopic polyp grading system. Data were collected preoperatively, 1 and 4 weeks postsurgery (before desensitization), and 1, 6, 12, 18, 24, and 30 months after aspirin desensitization.

RESULTS

Twenty-eight of 30 patients (93.3%) successfully completed aspirin desensitization, whereas 2 of 30 (6.7%) were unable to complete desensitization due to respiratory intolerance. Of the 21 patients who successfully completed a minimum of 24 weeks of follow-up, 20 (95.2%) patients demonstrated sustained endoscopic and symptomatic improvement for a median follow-up period of 33 months. After surgical treatment but before desensitization, patients experienced significant reductions in SNOT-22 and polyp grade scores. In the first 6 months after aspirin desensitization, patients experienced further significant reductions in SNOT-22 scores, whereas polyp grade remained stable. The improvements in symptom endoscopic scores were preserved throughout the follow-up period after desensitization. No patients required additional sinus surgery. One patient had to discontinue aspirin therapy due to gastrointestinal side effects. No other adverse reactions to aspirin were noted.

CONCLUSION

Aspirin desensitization following ESS appears to be a well-tolerated and effective adjunctive therapy for long-term control of nasal polyposis in patients with AERD.

Drug-eluting nasal implants: formulation, characterization, clinical applications and challenges

Chronic inflammation and infection of the nasal sinuses, also referred to as Chronic Rhinosinusitis (CRS), severely affects patients’ quality of life. Adhesions, ostial stenosis, infection and inflammation relapses complicate chronic sinusitis treatment strategies. Drug-eluting stents, packings or implants have been suggested as reasonable alternatives for addressing these concerns. This article reviewed potential drug candidates for nasal implants, formulation methods/optimization and characterization methods. Clinical applications and important considerations were also addressed. Clinically-approved implants (Propel™ implant, the Relieva stratus™ MicroFlow spacer, and the Sinu-Foam™ spacer) for CRS treatment was an important focus. The advantages and limitations, as well as future considerations, challenges and the need for additional research in the field of nasal drug implant development, were discussed.

Effect of prednisone on nasal symptoms and peripheral blood T-cell function in chronic rhinosinusitis

BACKGROUND

Systemic corticosteroids are the most effective anti-inflammatory drugs used for controlling chronic rhinosinusitis (CRS) symptoms. The potential mechanisms for their beneficial effects include increasing the number and function of T regulatory cells (Tregs), as reported in the local tissue post-intranasal steroid treatment. We investigated the effect of systemic corticosteroids on peripheral blood (PB) Tregs in subjects with CRS.

METHODS

Twenty CRS subjects and 19 controls were recruited. PB mononuclear cells (PBMCs) were isolated from CRS subjects before and after systemic corticosteroid administration in the course of clinical treatment. Control subjects received no treatment and were studied at one visit. Nasal symptoms were recorded. CD4(+) CD25(+) Foxp3(+) cells (Tregs) were analyzed by flow cytometry. Messenger RNA (mRNA) levels for interferon γ (IFN-γ), interleukin 4 (IL-4), IL-10, IL-13, IL-17A, transforming growth factor β1 (TGF-β1), forkhead box P3 (FoxP3), and GATA-binding factor 3 (GATA-3) were measured in PBMCs using real-time polymerase chain reaction (PCR).

RESULTS

CRS subjects reported improved nasal symptoms (p = 0.005) and significantly reduced PB Tregs after treatment with corticosteroids (p = 0.042). The transcript levels of IL-4 and GATA-3 were significantly higher in the CRS subjects at their first visit when compared to controls (p = 0.019 and p = 0.05, respectively). Corticosteroid treatment lowered the transcript levels of immunoregulatory transcription factors [FoxP3 (p = 0.048) and GATA-3 (p = 0.012)] and IFN-γ (p = 0.036) in PB.

CONCLUSION

In contrast to prior work in local nasal tissue, our study reports reduced PB Tregs and decreased T helper 1 (T(H)1) and T(H)2 function after treatment with systemic corticosteroids. These data indicate that corticosteroid effects on Tregs in CRS are complex involving local signals in the tissue that are distinct from those in circulating cells.

Steroid-eluting sinus implant for in-office treatment of recurrent nasal polyposis: a prospective, multicenter study

BACKGROUND

Treatment options for chronic rhinosinusitis with recurrent polyposis (CRSwNP) after endoscopic sinus surgery (ESS) are limited, and include frequent use of systemic steroids and revision surgery. A bioabsorbable, steroid-eluting implant was studied for its ability to dilate sinuses obstructed by polyps and provide localized, controlled steroid delivery to reestablish sinus patency. This study assessed the initial feasibility, safety, and efficacy of steroid-eluting implants placed in the office setting in patients who were candidates for revision ESS.

METHODS

Prospective, multicenter study enrolling 12 patients who had prior ESS but experienced recurrent polyposis refractory to medical therapy. Implants were placed bilaterally under topical anesthesia in-office. Follow-up through 6 months included endoscopic grading, patient-reported outcomes (22-item Sino-Nasal Outcomes Test [SNOT-22]) and need for revision ESS.

RESULTS

Implants were successfully inserted in 21 of 24 (88%) ethmoid sinuses, resulting in 11 evaluable patients. No serious adverse events occurred. Within 1 month, mean bilateral polyp grade was reduced from 4.5 at baseline to 2.3 (p = 0.008) and sustained through 6 months (2.33; p = 0.008). Mean SNOT-22 score was significantly improved from 2.19 at baseline to 0.90 within 1 month (p = 0.001) and sustained to 6 months (1.03; p = 0.012). Sixty-four percent of patients were no longer revision ESS candidates at 6 months.

CONCLUSION

The study provided initial clinical evidence of the feasibility, safety, and efficacy of in-office steroid-eluting implant placement in CRS patients with recurrent polyposis after ESS. Although further studies are needed, the results suggest this therapy may provide a safe and effective, office-based option for the treatment of obstructive polyposis.

Confounding factors in rhinological research

PURPOSE OF REVIEW

Basic science studies directed at understanding the inflammatory mechanisms in chronic rhinosinusitis (CRS) are increasing, yet their relevance to the underlying disease process is often conflicting and confounded by the enrollment of a heterogeneous CRS population. This review is aimed at exploring the issues affecting the basic science mucosal studies of CRS patients, with special attention to the inclusion criteria for CRS and the control group, and the site from which the mucosal tissue sample is obtained.

RECENT FINDINGS

A common confounding factor is an inadequate documentation of selection criteria for patients, controls, and tissue sites examined. Inconsistent definitions for CRS and for maximum medical therapy, and a lack of histopathology confirmation of mucosal inflammation (eosinophilic or neutrophilic) can bias the disease population entering a given study. Further confounding factors include the influence of coexisting diseases, pollution and cigarette smoke, and a need for same-site tissue comparisons, meticulous selection of relevant controls, and consensus on 'nondiseased' mucosal inflammatory cell populations and microbiology.

SUMMARY

Documentation of well defined patient and control groups, standardized specimen collection methods, and detection assays are critical in minimizing the bias and conflicting findings among investigators. With standardized sampling of tissue sites and tight controls on subcategories of CRS patients enrolled, studies will more likely identify the findings that can increase our understanding of the disparate group of CRS patients and identify new therapeutic targets in the CRS subcategories.

Complementary and integrative treatments: rhinosinusitis

Rhinosinusitis is characterized by inflammation of the mucosa involving the paranasal sinuses and the nasal cavity and is one of the most common health care problems, with significant impairment of quality of life. There is a growing amount of interest in the use of complementary and integrative medicine for the treatment of rhinosinusitis. This article focuses on an integrative approach to rhinosinusitis.

Anti-IgE--emerging opportunities for Omalizumab

INTRODUCTION

Omalizumab is a recombinant DNA-derived humanized IgG1 monoclonal antibody that selectively binds to free and membrane-bound immunoglobulin E (IgE) antibodies. Omalizumab has been licensed for use in severe allergic asthma. A search on the website clinicaltrials.gov reveals there are currently 109 clinical trials with Omalizumab of which 46 are for conditions other than asthma.

AREAS COVERED

In addition to asthma, Omalizumab has been investigated in various other conditions including perennial and seasonal allergic rhinitis (AR), peanut allergy, latex allergy, atopic dermatitis, chronic urticaria (CU), idiopathic anaphylaxis, mastocytosis, eosinophilic gastroenteritis and nasal polyposis. This review aims to look at the various randomised and non-randomised clinical trials, case series and case reports for the role of Omalizumab in conditions other than asthma. Numerous clinical trials have shown a positive light on the role of Omalizumab in conditions other than asthma.

EXPERT OPINION

We feel that the future of Omalizumab would include a more diverse range of clinical conditions, and future trials should not only look into the clinical usefulness but also the economic impact of using this interesting molecule.

Sinonasal outcome under aspirin desensitization following functional endoscopic sinus surgery in patients with aspirin triad

Recalcitrant forms of recurrent nasal polyposis are problematic for patients as for rhinosurgeons. In aspirin-sensitive patients, aspirin desensitization is supposed to prevent recurrence by targeting the metabolism of arachidonic acid. Aspirin-sensitive patients (n = 65) following aspirin desensitization after functional endoscopic sinus surgery (FESS) for recurrent nasal polyposis under daily intake of 500-mg aspirin were compared to a post-FESS group (n = 81) of aspirin-sensitive individuals using exclusively topical mometasone. Quality of life (QoL) scores including sinonasal, pulmonal and general QoL items as well as endoscopic endonasal examination findings were evaluated during the postoperative follow-up period. After a follow-up period of minimum 18 months, a significant improvement in nasal obstruction, rhinorrhea, post nasal drip, sense of smell, facial pain, sleep quality and further general QoL items in desensitized patients was found compared to aspirin-sensitive controls. Improvement in sinonasal symptoms was evident, whereas the severity of asthmatic symptoms showed no significant changes. Although the pathophysiology of aspirin sensitivity is still not fully understood and the therapy is not sufficiently investigated, aspirin desensitization seems to have a positive effect on QoL scores concerning sinonasal symptoms and should be regarded as a possible postoperative treatment modality for recurrent nasal polyposis in aspirin-sensitive individuals.

Spontaneous eosinophilic nasal inflammation in a genetically-mutant mouse: comparative study with an allergic inflammation model

BACKGROUND

Eosinophilic inflammation is a hallmark of chronic rhinosinusitis with nasal polyps. To model this disease process experimentally, nasal sensitization of mice with ovalbumin or aspergillus has been described. Here, we describe a genetically mutant mouse that develops robust spontaneous nasal eosinophilic inflammation. These mice lack the enzyme SHP-1 that down-regulates the IL-4Rα/stat6 signaling pathway. We compared nasal inflammation and inflammatory mediators in SHP-1 deficient mice (mev) and an ovalbumin-induced nasal allergy model.

METHODS

A novel technique of trans-pharyngeal nasal lavage was developed to obtain samples of inflammatory cells from the nasal passages of allergic and mev mice. Total and differential cell counts were performed on cytospin preparations. Expression of tissue mRNA for IL-4, IL-13, and mouse beta-defensin-1 (MBD-1) was determined by quantitative PCR. Eotaxin in the lavage fluid was assessed by ELISA.

RESULTS

Allergic and mev mice had increased total cells and eosinophils compared with controls. Expression of IL-4 was similarly increased in both allergic and mev mice, but expression of IL-13 and eotaxin was significantly greater in the allergic mice than mev mice. Eotaxin was significantly up-regulated in both allergic rhinitis and mev mice. In both models of eosinophilic inflammation, down-regulation of the innate immune marker MBD-1 was observed.

CONCLUSIONS

The mev mice display spontaneous chronic nasal eosinophilic inflammation with potential utility for chronic rhinosinusitis with nasal polyps research. The eosinophilic infiltrate is more robust in the mev mice than allergic mice, but Th2 cytokine expression is not as pronounced. Decreased MBD-1 expression in both models supports the concept that Th2-cytokines down-regulate sinonasal innate immunity in humans, and suggests a role for mouse models in investigating the interaction between adaptive and innate immunity in the sinonasal mucosa.

Advance II

Objective. Endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) may be compromised by postoperative inflammation, polyposis, and adhesions, often requiring subsequent intervention. To address this issue, the authors investigated the safety and effectiveness of controlled delivery of mometasone furoate to the sinus mucosa via bioabsorbable implants deployed at the time of ESS.

Study Design. Prospective, multicenter, randomized, controlled, double-blind trial using an intrapatient control design.

Setting. Otolaryngology–head and neck surgery centers; both academic and private practices.

Subjects and Methods. The study enrolled 105 patients with CRS undergoing bilateral ethmoidectomy to compare the effect of drug-releasing to non-drug-releasing implants using an intrapatient control design. Postoperative interventions, polyposis, and adhesions were assessed postoperatively. Efficacy was determined through independent analysis of randomized video-endoscopies by 3 blinded sinus surgeons. Safety assessments included ocular examinations.

Results. Implants were successfully deployed in all 210 ethmoid sinuses. Compared with control sinuses with non-drug-releasing implants, the drug-releasing implant provided a 29.0% relative reduction in postoperative interventions ( P = .028) and a 52% ( P = .005) decrease in lysis of adhesions. The relative reduction in frank polyposis was 44.9% ( P = .002). Similar reductions were observed in real-time grading performed by the clinical investigators. No clinically significant changes from baseline in intraocular pressure or cataracts were observed.

Conclusion. This study provides a high level of evidence that use of steroid-releasing implants that apply a sustained release of corticosteroid improves surgical outcomes by reducing synechiae formation, polyposis, and the need for postoperative interventions, with no observable ocular safety risk.

Early postoperative care following endoscopic sinus surgery: an evidence-based review with recommendations

BACKGROUND

Early postoperative care following endoscopic sinus surgery (ESS) has been suggested to minimize avoidable complications and optimize long-term outcomes. Several postoperative care strategies have been proposed but a formal comprehensive evaluation of the evidence has never been performed. The purpose of this article is to provide an evidence-based approach to early postoperative care following ESS.

METHODS

A systematic review of the literature was performed and the Clinical Practice Guideline Manual, Conference on Guideline Standardization (COGS), and the Appraisal of Guidelines and Research Evaluation (AGREE) instrument recommendations were followed. Study inclusion criteria were: adult population >18 years old; chronic rhinosinusitis (CRS) based on published diagnostic criteria; ESS following failed medical therapy; primary study objective was to evaluate an ESS early postoperative care strategy; and clearly defined primary clinical end-point.

RESULTS

This review identified and evaluated the literature on 7 early postoperative care strategies following ESS: saline irrigations, sinus cavity debridements, systemic steroids, topical steroids, oral antibiotics, topical decongestants, and drug-eluting spacers/stents.

CONCLUSION

Based on the available evidence, use of nasal saline irrigation, sinus cavity debridement, and standard topical nasal steroid spray are recommended early postoperative care interventions. Postoperative antibiotic, systemic steroid, nonstandard topical nasal steroid solution, and/or drug-eluting spacers/stents are options in postoperative management. These evidence-based recommendations should not necessarily be applied to all postoperative patients and clinical judgment, in addition to evidence, is critical to determining the most appropriate care.

Role of aspirin desensitization in the management of chronic rhinosinusitis

PURPOSE OF REVIEW

This review is set to revisit the pathogenesis of aspirin-exacerbated respiratory disease (AERD), the diagnostic method used, and finally the real impact of aspirin desensitization on chronic sinusitis with nasal polyposis (CRSwNP) in aspirin intolerant patients.

RECENT FINDINGS

In AERD, increased baseline production of cysteinyl-leukotriene (Cys-LT) is associated with upregulation of Cys-LT receptors on nasal inflammatory cells. This is further aggravated by inhibition of cyclooxygenase-1 by aspirin and other NSAIDs. New-found genetic markers need further study. Oral aspirin challenge is still the gold standard of diagnosis and can be safely conducted in a specialized outpatient clinic. Oral and endonasal aspirin desensitization show positive impact on CRSwNP course with decreased polyp recurrence, decreased number of hospitalizations, and decreased need for corticosteroids. Modulation of arachidonic acid metabolism and inhibition of intracellular biochemical pathways in key inflammatory cells involving anti-inflammatory cytokines interleukin (IL)-4 and IL-13 explain the clinical outcomes.

SUMMARY

Future studies should focus on establishing the lowest possible dose to maintain disease under check, allowing more widespread use of this underutilized and underrecognized treatment modality.