Prevalence of chronic rhinosinusitis in the general population based on sinus radiology and symptomatology

The Role of the Gut and Airway Microbiota in Chronic Rhinosinusitis with Nasal Polyps: A Systematic Review

In recent years, there has been growing interest in understanding the potential role of microbiota dysbiosis or alterations in the composition and function of human microbiota in the development of chronic rhinosinusitis with nasal polyposis (CRSwNP). This systematic review evaluated the literature on CRSwNP and host microbiota for the last ten years, including mainly nasal bacteria, viruses, and fungi, following the PRISMA guidelines and using the major scientific publication databases. Seventy original papers, mainly from Asia and Europe, met the inclusion criteria, providing a comprehensive overview of the microbiota composition in CRSwNP patients and its implications for inflammatory processes in nasal polyps. This review also explores the potential impact of microbiota-modulating therapies for the CRSwNP treatment. Despite variability in study populations and methodologies, findings suggest that fluctuations in specific taxa abundance and reduced bacterial diversity can be accepted as critical factors influencing the onset or severity of CRSwNP. These microbiota alterations appear to be implicated in triggering cell-mediated immune responses, cytokine cascade changes, and defects in the epithelial barrier. Although further human studies are required, microbiota-modulating strategies could become integral to future combined CRSwNP treatments, complementing current therapies that mainly target inflammatory mediators and potentially improving patient outcomes.

Side- and Sinus-Specific Relationships between Chronic Rhinosinusitis and Ischemic Stroke Using Imaging Analyses

Recent studies have reported chronic rhinosinusitis (CRS) as an independent risk factor for stroke. However, the association with stroke depending on the affected sinuses has not been explored. This study aimed to elucidate the side- and sinus-specific relationship between CRS and ischemic stroke through imaging analyses. We retrospectively reviewed the medical records of patients who were diagnosed with ischemic stroke at a tertiary center. CRS was defined as having a total score of greater than or equal to 4, according to the Lund-Mackay scoring system, through brain magnetic resonance imaging or computed tomography. We investigated the side- and sinus-specific correlation between CRS and ischemic stroke. Subgroup analyses were performed for different age groups. CRS prevalence in patients with ischemic stroke was 18.4%, which was higher than the previously reported prevalence in the general population. Overall, there was no correlation between the directions of the CRS and ischemic stroke (p > 0.05). When each sinus was analyzed, the frontal (Cramer's V = 0.479, p < 0.001), anterior (Cramer's V = 0.396, p < 0.001)/posterior (Cramer's V = 0.300, p = 0.008) ethmoid, and sphenoid (Cramer's V = 0.383, p = 0.005) sinuses showed a statistically significant correlation with the side of stroke, but the maxillary sinus (Cramer's V = 0.138, p = 0.208) did not. In subgroup analyses, a significant right-side correlation between the two diseases was observed in the older-age subgroup (≥65 years old, Cramer's V = 0.142, p = 0.040). Diabetes mellitus (odds ratio = 1.596, 95% confidence interval = 1.204-2.116) was identified as an independent risk factor for having CRS in patients with ischemic stroke. CRS of the frontal, anterior/posterior ethmoid, and sphenoid sinuses has a directional relationship with ischemic stroke. Our results on which sinuses correlate with stroke advocate for the active surveillance of CRS in patients at high risk of ischemic stroke.

Validation and reliability of the Italian version of the Self-reported Mini Olfactory Questionnaire (Self-MOQ)

Objective

Olfactory dysfunction (OD) represents a frequent complaint in general population and especially in patients with chronic sinonasal diseases. The aim of this study was the cross-cultural adaptation and validation of the Self-reported Mini Olfactory Questionnaire (Self-MOQ) into Italian.

Methods

One hundred fifty patients affected by chronic sinonasal diseases and reporting hyposmia were enrolled. Other 150 normosmic subjects without inflammatory or neoplastic sinonasal disorders were used as a control group. The Short-form 36 (SF-36) questionnaire was used for clinical validity.

Results

Cronbach's alpha coefficient was 0.825. The test-retest reliability was excellent. The good correlation between the Self-MOQ and the Visual Analogue Scale scores (p < 0.05) demonstrated the construct validity of the questionnaire. The Self-MOQ was able to distinguish between subjects with or without OD (p < 0.05). Higher Self-MOQ score was found in case of nasal obstruction and posterior rhinorrhoea (p < 0.05). Self-MOQ showed significant correlation with SF-36 general health, SF-36 role functioning/physical, and SF-36 pain (p < 0.05).

Conclusions

The Italian version of the Self-MOQ showed good internal consistency, test-retest reliability, construct, and clinical validity.

Increased prevalence of CFTR variants and susceptibility to CRS: A real-world study based on Chinese children

Background

Chronic Rhinosinusitis is a common disease in children. The main function of CFTR is to maintain the thickness of the mucous layer on the surface of the nasal mucosa. CFTR disease-causing variant can cause CFTR protein dysfunction and induce or aggravate chronic infection. However, the carrying status of the CFTR variants in the Chinese population is not clear.

Objective

To study the frequency and variants of CFTR in Chinese children with CRS and to analyze the CFTR variants and the clinical characteristics and susceptibility to CRS.

Methods

Whole Exome Sequencing was performed to analyze the CFTR genes in a total of 106 CRS children from the Chinese mainland area. The CFTR variants, frequency and clinical data were summarized and analyzed.

Results

A total of 31 CFTR variants were detected, of which the carrying rate of 7 sites was significantly higher than that of the population database. 88 patients carried more than 2 variants. 37 people carried variants (MAF < 0.05), of which 91.89% had a history of recurrent upper respiratory infections, 16 had nasal polyps, 5 had bronchiectasis, and 1 was diagnosed with CF-related disorders.

Conclusion

The carrying rate of CFTR variants in Chinese CRS children increased, and the highest rates of variants (MAF < 0.05) are p.I556V, p. E217G, c.1210-12[T]. Carrying multiple CFTR variants, especially p.E217G, p.I807 M, p.V920L and c.1210-12[T] may lead to increased susceptibility to CRS. There are CF-related disorders in patients with CRS.

Translation and Validation of the Sinus and Nasal Quality of Life Surgery Survey in Serbian

Objective

The aim of this study was to translate the Sinus and Nasal Quality of Life Surgery Survey into the Serbian language to evaluate the test-retest reliability and validity.

Study Design

The study included 49 consecutive patients between 12 and 18 years old with rhinologic symptoms. Patients were given a paper survey to complete along with a link to complete the online survey within the same day.

Setting

The study was conducted at the University Children's Hospital Clinic for Pulmonology and Allergology between January 2023 and March 2023.

Methods

Responses between the paper and online survey were compared and regression analysis was performed to evaluate the relationship. Internal reliability and test-retest reliability were assessed using Cronbach's α coefficient and intraclass correlation coefficient. All data were collected and analyzed using SPSS 29.0.

Results

Pearson correlation coefficient between the paper and online survey was very high and statistically significant (r = 0.999; P < .001). Each item had a high correlation (0.993-1.000), where the lowest correlation coefficient was obtained from question 2 (0.993). Average scores in each item differed slightly for only item 2 (mean difference = -0.041), but not to the level of statistical significance. Bland-Altman plot indicated no proportional bias between the 2 versions. Linear regression analysis suggested a high level of agreement between the 2 versions (slope = 1.00, R 2 = 0.999).

Conclusion

The survey is a useful questionnaire to evaluate the quality of life in patients with rhinologic symptoms. The high correlation between the paper and online survey shows the reliability of the questionnaire regardless of administration modality.

Development of a mobile app for the evaluation of patients with chronic rhinosinusitis

OBJECTIVE

To develop a mobile application with a standardized routine, to be used by general otolaryngologists for evaluating patients with chronic rhinosinusitis.

METHODS

A systematic review was made to identify outcomes, recommendations and what tests that would be used in the routine evaluation of patients with chronic rhinosinusitis; establish an expert consensus on items to be included in this routine evaluation of patients with chronic rhinosinusitis using the Delphi method; development of an application for use on a mobile device, with the routine evaluation of patients with chronic rhinosinusitis.

RESULTS

Based on the systematic review, the outcomes used in studies about chronic rhinosinusitis were identified, as well as guidelines recommendations, which showed discrepancies between them. These recommendations and outcomes were presented to specialists in chronic rhinosinusitis, until a consensus was reached. As a result of the Delphi method, the flowchart of the routine evaluation of patients with chronic rhinosinusitis was defined, and then was used for the development of the mobile application.

CONCLUSION

The creation of the mobile application for evaluating patients with chronic rhinosinusitis followed an adequate methodology of elaboration made by specialists in the field of chronic rhinosinusitis, standardizing the investigation of these patients.

LEVEL OF EVIDENCE

Level 5.

Chronic maxillary sinusitis in palaeopathology: A review of methods

OBJECTIVE

This study reviews the palaeopathological literature discussing maxillary sinusitis to examine current trends and issues within the study of this condition, and to make recommendations for future research in this area.

MATERIALS

Seventy-five studies were identified through a literature search of digital and physical sources.

METHODS

Information regarding study metadata, the populations investigated, sinusitis diagnostic criteria, and sinusitis prevalence was examined.

RESULTS

Populations from the UK and Europe were the most studied, reflecting both palaeopathology's systemic colonialism and academic legacies. Most studies used diagnostic criteria published in the mid-1990s, with some subsequent studies modifying these criteria.

CONCLUSIONS

The diagnostic criteria from 1995 are widely used but do not include all possible bone changes seen within sinusitis. There is also a need for researchers to engage in issues of data reductionism when using descriptive categories for archaeological sites and populations.

SIGNIFICANCE

This paper provides considerations as to how the 1995 diagnostic criteria may be revised by future researchers and synthesises much of the published sinusitis prevalence data to assist researchers interested in the palaeopathology of respiratory disease.

LIMITATIONS

More general osteological research, which includes palaeopathological information, was likely missed from this review due to the choice of key terms and languages used in the literature search.

SUGGESTIONS FOR FURTHER RESEARCH

Additional research into sinusitis in archaeological populations outside of Western Europe is required. Further work examining the ability to compare pathological data from macroscopic observation and medical imaging would be advantageous to palaeopathology as a whole.

sPLA2GIB Promotes PGD2 and IL-13 Production in Eosinophilic Chronic Rhinosinusitis with Nasal Polyps

OBJECTIVE

Secreted phospholipase A2 Group IB (sPLA2GIB) regulates the release of arachidonic acid, prostaglandins, and other inflammatory lipid mediators. Although it has been well involved in extensive inflammatory diseases, its specific mechanism in chronic rhinosinusitis with nasal polyps (CRSwNP) remains unclear. In this study, we investigated the role of sPLA2GIB in the pathophysiology of CRSwNP.

METHODS

Quantitative PCR, immunofluorescence staining, western blotting, and enzyme-linked immunosorbent assay (ELISA) were used to analyze the expression of sPLA2s, phospholipase A2 receptor (PLA2R), and prostaglandin D2 (PGD2) in nasal samples. Human nasal epithelial cells (HNECs) were cultured at an air-liquid interface (ALI) and stimulated with various cytokines. The human mast cell line HMC-1 was stimulated with sPLA2GIB, and the expression of PGD2 and cytokines in the culture supernatant was detected by ELISA.

RESULTS

The mRNA and protein levels of sPLA2GIB were significantly higher in eosinophilic CRSwNP than in control tissues. sPLA2GIB was predominantly expressed in the nasal epithelial cells. PLA2R mRNA and protein levels were upregulated in both eosinophilic and non-eosinophilic CRSwNP compared with the control groups. IL-4, IL-13, TNF-α, and IL-1β upregulated the expression of sPLA2GIB in ALI-cultured HNECs. sPLA2GIB induced PGD2 and IL-13 production in HMC-1 cells in a hydrolytic activity-independent manner. PGD2 protein expression was elevated in tissue homogenates of eosinophilic CRSwNP, and PGD2 upregulated the expression of IL-13 in HMC-1 cells.

CONCLUSION

Increased secretion of sPLA2GIB by epithelial cells may promote eosinophilic inflammation in CRSwNP by enhancing PGD2 and IL-13 production in mast cells via binding to PLA2R.

LEVEL OF EVIDENCE

N/A Laryngoscope, 134:1107-1117, 2024.

Use of nonsteroidal anti-inflammatory drugs and poor olfaction in women

BACKGROUND

It is unclear whether regular use of nonsteroidal anti-inflammatory drugs (NSAIDs) is associated with poor olfaction in older adults.

METHODS

We selected 4020 participants, aged 50 to 79 years in 2018, from 36,492 eligible participants in the National Institute of Environmental Health Sciences Sister Study, according to their self-reported olfaction status. Of these, 3406 women completed the 12-item Brief Smell Identification Test. We defined poor olfaction as a test score ≤9 in the primary analysis. We then estimated odds ratios (ORs) and 95% confidence intervals (CIs) from weighted logistic models, accounting for the study design, missing exposures/outcomes, and covariates.

RESULTS

Overall, NSAID use was not associated with poor olfaction. However, we found evidence for potential multiplicative interactions. Specifically, the OR comparing regular versus never use of aspirin was 1.8 (95% CI, 1.1-3.2) among women who had not regularly used nonaspirin NSAIDs, while the corresponding OR was 0.8 (95% CI, 0.5-1.2) among nonaspirin NSAID users (P for interaction = 0.016). Similar results were seen for ibuprofen alone versus ibuprofen with other NSAID use (P for interaction = 0.010). Among women using either drug alone, associations with poor olfaction increased with increasing duration and cumulative dose. Post hoc analyses showed that the interactions could not be readily explained by potential biases. Other NSAIDs were not associated with olfaction.

CONCLUSION

Long-term regular use of aspirin or ibuprofen was associated with poor olfaction among women who never regularly used other types of NSAIDs. These preliminary findings warrant independent confirmation.

Reduced Glycolysis and Cytotoxicity in Staphylococcus aureus Isolates from Chronic Rhinosinusitis as Strategies for Host Adaptation

Chronic rhinosinusitis (CRS) is a multifactorial infection of the nasal cavity and sinuses. In this study, nasal swabs from control donors (N = 128) and patients with CRS (N = 246) were analysed. Culture methods and metagenomics revealed no obvious differences in the composition of the bacterial communities between the two groups. However, at the functional level, several metabolic pathways were significantly enriched in the CRS group compared to the control group. Pathways such as carbohydrate transport metabolism, ATP synthesis, cofactors and vitamins, photosynthesis and transcription were highly enriched in CRS. In contrast, pathways related to lipid metabolism were more representative in the control microbiome. As S. aureus is one of the main species found in the nasal cavity, staphylococcal isolates from control and CRS samples were analysed by microarray and functional assays. Although no significant genetic differences were detected by microarray, S. aureus from CRS induced less cytotoxicity to lung cells and lower rates of glycolysis in host cells than control isolates. These results suggest the differential modulation of staphylococcal virulence by the environment created by other microorganisms and their interactions with host cells in control and CRS samples. These changes were reflected in the differential expression of cytokines and in the expression of Agr, the most important quorum-sensing regulator of virulence in S. aureus. In addition, the CRS isolates remained stable in their cytotoxicity, whereas the cytotoxic activity of S. aureus isolated from control subjects decreased over time during in vitro passage. These results suggest that host factors influence the virulence of S. aureus and promote its adaptation to the nasal environment during CRS.

Airways Type-2 Related Disorders: Multiorgan, Systemic or Syndemic Disease?

Chronic rhinosinusitis (CRS) has recently undergone a significant paradigm shift, moving from a phenotypical classification towards an "endotype-based" definition that places more emphasis on clinical and therapeutic aspects. Similar to other airway diseases, like asthma, most cases of CRS in developed countries exhibit a dysregulated type-2 immune response and related cytokines. Consequently, the traditional distinction between upper and lower airways has been replaced by a "united airway" perspective. Additionally, type-2 related disorders extend beyond respiratory boundaries, encompassing conditions beyond the airways, such as atopic dermatitis. This necessitates a multidisciplinary approach. Moreover, consideration of possible systemic implications is crucial, particularly in relation to sleep-related breathing diseases like Obstructive Sleep Apnoea Syndrome (OSAS) and the alteration of systemic inflammatory mediators such as nitric oxide. The trends in epidemiological, economic, and social burden are progressively increasing worldwide, indicating syndemic characteristics. In light of these insights, this narrative review aims to present the latest evidence on respiratory type-2 related disorders, with a specific focus on CRS while promoting a comprehensive perspective on the "united airways". It also introduces a novel concept: viewing these conditions as a multiorgan, systemic, and syndemic disease.

Clinical Characteristics of Rhinosinusitis in Children in a Tertiary Care Center

BACKGROUND

Rhinosinusitis (RS) is a term used in clinical practice to describe inflammation of the paranasal and nasal sinuses. This condition can be categorized based on the duration of symptoms into acute, subacute, and chronic RS. It is important to note that RS presents differently in pediatric patients compared to adults. In children, typical symptoms include cough, bad breath (halitosis), irritability, fatigue, and swelling around the eyes. This study aims to shed light on the prevalence and clinical characteristics of RS in the pediatric age group.

METHODS

This retrospective cohort study was conducted at King Abdullah Specialized Children's Hospital (KASCH) in Riyadh, Saudi Arabia, which is a tertiary care center under the authority of the Ministry of National Guard Health Affairs (MNGHA) in Saudi Arabia, using the medical records of all patients diagnosed with RS between 2019 and 2022.

RESULTS

In this study, 345 pediatric patients with RS were examined. A significant portion (n = 106, 30.7%) were older than 12 years, and males made up the majority (n = 210, 60.9%). Chronic RS without nasal polyps prevailed (n = 299, 86.7%), mainly affecting the maxillary sinus (n = 200, 58%). Notably, 29% (n = 100) were diagnosed after age 12. Key symptoms included nasal congestion (n = 233, 67.5%), nasal discharge (n = 202, 58.6%), and facial discomfort (n = 191, 55.4%). Most (n = 314, 91%) received medical treatment, resulting in improvement for 78.8% (n = 272). Of those not improving (n = 73, 21.2%), 47.9% (n = 35) received medical management, and the rest underwent surgery, primarily functional endoscopic sinus surgery (n = 38, 52.1%).

CONCLUSION

 RS is a common condition affecting children, with symptoms like nasal obstruction, discharge, and facial discomfort. Chronic RS, particularly in the maxillary sinus, is the most prevalent type. Medical treatment was the first choice and generally effective, but when needed, surgical intervention, mainly functional endoscopic sinus surgery, was pursued.

Type 2 Biomarkers for the Indication and Response to Biologics in CRSwNP

PURPOSE OF REVIEW

Three biologics targeting type 2 inflammation have been approved for the treatment of severe and uncontrolled chronic rhinosinusitis with nasal polyps (CRSwNP). Nevertheless, around 40-60% of patients do not respond well to these biological treatments. Selecting appropriate patients is crucial to improve treatment outcome of biologics. This review summarizes the literature data on type 2 biomarkers, with a specific focus on the indication to biologics for severe CRSwNP.

RECENT FINDINGS

No consensus has been reached on how to define mucosal type 2 inflammation in CRSwNP. Clinical markers (e.g., 22-item Sino-nasal Outcome Test (SNOT-22) score, Lund-Mackay CT score (LMS), ethmoid/maxillary sinus CT score, and CT-radiomics), nasal secretion biomarkers (e.g., eosinophil cationic protein and interleukin-5), blood and nasal cytology eosinophil counts, and nasal swab eosinophil peroxidase activity have been reported to be associated with type 2 inflammation in CRSwNP. The time duration since the last surgery, SNOT-22 score at 1 week of treatment, and baseline serum osteoprotegerin levels might indicate the response to dupilumab. LMS and asthma control test scores were found to have moderate predictive value for acceptable improvement after 24-week treatment of omalizumab. High blood eosinophil levels at baseline were associated with treatment response to mepolizumab and benralizumab. Although several clinical and biological markers might be associated with type 2 inflammation and response to biologics in patients with CRSwNP, their validity requires further investigation. Identifying clinically applicable biomarkers for biologic treatment holds significant promise for advancing personalized approaches to biologics and optimizing treatment outcomes for patients with CRSwNP.

Identification of potential agonist-like molecules for α2-adrenergic receptor by multi-layer virtual screening to combat sinusitis

Sinusitis is one of the most common respiratory inflammatory conditions and a significant health issue that affects millions of people worldwide with a global prevalence of 10-15%. The side effects of available drug regimens of sinus infection demand the urgent development of new drug candidates to combat sinusitis. With the aim of identifying new drug-like candidates to control sinus, we have conducted multifold comprehensive screening of drug-like molecules targeting α2-adrenergic receptor (α2-AR), which serve as the primary drug target in sinusitis. By structure-based virtual screening of in-house compound's database, ten molecules (CP1-CP10) with agonistic effects for α2-AR were selected, and their binding mechanism with critical residues of α2-AR and their physicochemical properties were studied. Moreover, the process of receptor activation by these compounds and the conformational changes in α2-AR caused by these molecules, were further explored by molecular dynamic simulation. The MM-PBSA estimated free energies of compounds are higher than that of reference agonist (ΔGTOTAL = -39.0 kcal/mol). Among all, CP2-CP3, CP7-CP8 and CP6 have the highest binding free energies of -78.9 kcal/mol, -77.3 kcal/mol, -75.60 kcal/mol, -64.8 kcal/mol, and -61.6 kcal/mol, respectively. While CP4 (-55.0 kcal/mol), CP5 (-49.2 kcal/mol), CP9 (-54.8 ± 0.07 kcal/mol), CP10 (-56.7 ± 0.10 kcal/mol) and CP1 (-46.0 ± 0.08 kcal/mol) also exhibited significant binding free energies. These energetically favorable binding energies indicate strong binding affinity of our compounds for α2-AR as compared to known partial agonist. Therefore, these molecules can serve as excellent drug-like candidates for sinusitis.

Predictors and Time Interval of Chronic Rhinosinusitis Recurrence After Endoscopic Sinus Surgery

Objective

Chronic rhinosinusitis (CRS) is a common inflammatory disease that significantly impacts the quality of life. Endoscopic sinus surgery (ESS) is indicated for refractory CRS. This study aims to estimate the predictors of CRS recurrence, and the rates with time intervals of recurrent CRS and revision ESS.

Methods

A retrospective cohort study included 516 patients who underwent ESS for CRS at King Abdulaziz Medical City in Riyadh between January 2017 and May 2020. Patients were followed up for 12-48 months postoperatively. The study sample was divided into two groups based on the recurrence status and compared using the appropriate statistical tests. Significant variables were included in the logistic regression model to determine the predictors of CRS recurrence.

Results

The recurrence rate of CRS following ESS was 14.5%, with a time interval of 28.31 months, and standard deviation (SD) =18.76. On the other hand, the rate of revision ESS for recurrent CRS was 6.8%, with a time interval of 34.18 months, SD =16. In the multivariable logistic regression model, the significant predictors of recurrent CRS were a high Lund-Mackay (LM) score [odds ratio (OR): 1.055, p=0.04] and a high eosinophil count (OR: 3.619, p=0.03). Almost half of the patients who developed recurrent CRS underwent revision surgery (46.7%).

Conclusion

CRS has a considerable recurrence rate despite the high success rate of ESS, and nearly half of the recurrent CRS patients need revision surgery. A high LM score and eosinophilic count significantly increase the likelihood of CRS recurrence.

Effect of Functional Endoscopic Sinus Surgery on Functional and Symptomatic Outcomes in Patients with Chronic Rhinosinusitis: A Cross Sectional Study

Chronic Rhinosinusitis (CRS) is a common condition causing significant symptoms to those affected, cause burden to the healthcare consumption and productivity loss (Fokkens et al. in Rhinol J 58:82-111, 2020). Chronic Rhinosinusitis is diagnosed clinically on the basis of characteristic symptoms with inflammation of the mucosa of the nose and paranasal sinuses of at least 12 consecutive weeks duration (Fokkens et al. in A summary for otorhinolaryngologists Rhinology 50:1-12, 2012). Functional Endoscopic Sinus Surgery is a minimally invasive procedure recommended for chronic Rhinosinusitis. Patients are not routinely assessed specifically for functional and symptomatic improvement after surgery. Previous studies assessed either subjective or objective outcome of surgery (Elwany et al. in Eur Arch Otorhinolaryngol 255:511-514, 1998; Sino-nasal Outcome Test (SNOT-22): A predictor of post-surgical improvement in patients with chronic sinusitis - PMC, 2022. The present study assessed pre and post operative comparison of nasal mucociliary clearance, nasal patency and Sino-nasal outcome score and evaluated both subjective and objective outcomes of functional endoscopic sinus surgery simultaneously. To assess the effect of functional and symptomatic outcomes after Functional Endoscopic Sinus Surgery in patients with Chronic Rhinosinusitis visiting a tertiary care centre in South India. The present study was a hospital based cross-sectional study conducted in the Department of Otorhinolaryngology, in a tertiary care centre in South India, between February 2021 and May 2022. After obtaining informed consent all the patients fulfilling inclusion and exclusion criteria in the given time period were selected as the study population via consecutive sampling method. Detailed history, clinical examination and Diagnostic nasal endoscopy, Computed Tomography (CT) paranasal sinuses were done in all cases. Pre operative Saccharine transit time (STT), Peak nasal inspiratory flow rate (PNIFR) and Sino nasal outcome test (SNOT) 22 score were measured. All cases underwent Functional Endoscopic Sinus Surgery (FESS). Patients were followed up at 1st, 3rd and 6th month for functional and symptomatic outcomes. Data were analysed statistically using Friedman's ANOVA test. A total of 40 patients between the age of 20 and 60 with Chronic Rhinosinusitis with /without nasal polyposis were analysed. Incidence was found to be more common in middle aged group (37.5%). Among the study group 52.5% were females and 47.5% were males 55% was diagnosed as Chronic Rhinosinusitis with nasal polyp (CRSwNP) type and 45% as without nasal polyp (CRSsNP) type. On comparing the variation of Saccharine transit time, Peak nasal inspiratory flow rate and SNOT 22 score with post operative results done at, 1st, 3rd and 6th months using Friedman's ANOVA test showed statistically significant results (P value < 0.05). According to our study there is significant improvement in functional and symptomatic outcomes after Functional Endoscopic sinus surgery and restoration of mucociliary function in Chronic Rhinosinusitis patients. Thus, FESS is an excellent choice for treatment of CRS.

Sinonasal symptoms in migraine without aura: results from the cross-sectional 'Migraine in Poland' study

Background

Migraine without aura (MwoA) is often mistaken for rhinosinusitis. The purpose of this study was to assess the prevalence of sinonasal symptoms, sinusitis-targeting medication use and burden of migraine in a large group of people with MwoA attacks accompanied by rhinologic symptoms.

Methods

Data was collected in a cross-sectional online survey based on an adapted population-based study questionnaire. The analysis included the prevalence of rhinorrhea, mucopurulent nasal discharge, nasal congestion, facial pressure and tenderness to palpation, hyposmia/anosmia and osmophobia.

Results

1,679 (52.73%) MwoA people were identified among 3,225 respondents (women n = 2,809, 87.10%) aged 13-80 years (median age 39; standard deviation 10.4). 1004/1679 (59.8%) migraine patients reported one or more rhinologic symptoms and 341/1679 (20.3%) MwoA respondents had symptoms that met rhinosinusitis clinical diagnostic criteria during their headache attacks. In migraine patients, osmophobia was associated with hyposmia [n = 141 (12.7%) vs. n = 41 (7.2%); p = 0.001] and a sensation of unpleasant smells [n = 216 (19.4%) vs. n = 45 (8.5%); p = 0.001], while facial tenderness to palpation was associated with facial allodynia [n = 532 (50.4%) vs. n = 211 (33.9%); p < 0.001]. People with migraine accompanied by rhinosinusitis-like symptoms experienced more disease burden and used 'sinus medications' more often.

Conclusion

MwoA patients with rhinosinusitis-like symptoms during migraine attacks require cautious assessment, especially that some symptoms seem to have little value in distinguishing between these disorders (i.e., facial tenderness, hyposmia), while many of these patients have a greater disease burden and therefore often choose medications targeting rhinologic instead of neurologic mechanisms.

The epithelial barrier: The gateway to allergic, autoimmune, and metabolic diseases and chronic neuropsychiatric conditions

Since the 1960 s, our health has been compromised by exposure to over 350,000 newly introduced toxic substances, contributing to the current pandemic in allergic, autoimmune and metabolic diseases. The "Epithelial Barrier Theory" postulates that these diseases are exacerbated by persistent periepithelial inflammation (epithelitis) triggered by exposure to a wide range of epithelial barrier-damaging substances as well as genetic susceptibility. The epithelial barrier serves as the body's primary physical, chemical, and immunological barrier against external stimuli. A leaky epithelial barrier facilitates the translocation of the microbiome from the surface of the afflicted tissues to interepithelial and even deeper subepithelial locations. In turn, opportunistic bacterial colonization, microbiota dysbiosis, local inflammation and impaired tissue regeneration and remodelling follow. Migration of inflammatory cells to susceptible tissues contributes to damage and inflammation, initiating and aggravating many chronic inflammatory diseases. The objective of this review is to highlight and evaluate recent studies on epithelial physiology and its role in the pathogenesis of chronic diseases in light of the epithelial barrier theory.

Two-year results of tapered dupilumab for CRSwNP demonstrates enduring efficacy established in the first 6 months

BACKGROUND

Dupilumab is an anti-T2-inflammatory biological registered for chronic rhinosinusitis (CRS) with nasal polyps (CRSwNP), indicated by integrated CRS-care pathways when optimal medico-surgical treatment yields insufficient CRS control. This study aims to evaluate long-term results with focus on established therapeutic efficacy while tapering dupilumab.

METHODS

Real-life, prospective observational cohort study in single tertiary referral center with add-on dupilumab as primary biological treatment in adult (≥18 years) biological-naïve CRSwNP patients per the European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS)2020-indication with a 2-year follow-up. Tapering (increasing interdose interval) applied every 24 weeks, conditional to sufficient treatment response and CRS control.

RESULTS

Mean scores (s.d.) of all co-primary outcomes improved significantly from baseline ( 228) to the 48 ( 214) and 96-weeks ( 99) timepoints: Nasal Polyp Score (0-8) improved from 5,3 (1,9) to 1,4 (1,8) and 1,3 (1,7); SinoNasal Outcome Test (SNOT)-22 (0-110) improved from 53,6 (19,6) to 20,2 (15,4) and 21,2 (15,6); Sniffin'Sticks-12 identification test (0-12; 0-6 anosmia, 7-10 hyposmia, 11-12 normosmia) improved from 3,7 (2,4) to 7,7 (2,9) and 7,3 (3,04); Asthma Control Test (5-25; >19 indicating well-controlled asthma) improved from 18,5 (4,8) to 21,8 (3,8) and 21,4 (3,9). Tapering was feasible in 79,5% of the patients at the 24-weeks timepoint, and in 93,7% and 95,8% at the 48- and 96-weeks timepoints, respectively. One-way repeated-measures ANOVA demonstrated no significant alterations of individual co-primary outcome mean-scores from 24 weeks onward.

CONCLUSION

This first long-term real-life prospective observational cohort study shows high therapeutic efficacy of dupilumab for severe CRswNP in the first 2 years. Therapeutic efficacy is principally established within 24 weeks and endures while tapering dupilumab conditional to treatment response and CRS control.

The application of enhanced recovery after surgery (ERAS) in chronic rhinosinusitis patients undergoing endoscopic sinus surgery: A systematic review and meta-analysis

OBJECTIVES

Enhanced recovery after surgery (ERAS) has become extensively practiced and has shown encouraging benefits. Within recent years, ERAS has also been increasingly performed in chronic rhinosinusitis (CRS) patients undergoing endoscopic sinus surgery (ESS). However, the actual efficacy of ERAS in CRS patients undergoing ESS is not completely clear, and the related evidence remains weak. This systematic review and meta-analysis aimed to evaluate the effectiveness and safety of ERAS in the perioperative management of CRS patients receiving ESS.

METHODS

We searched randomized controlled trials in PubMed, Web of Science, EMBASE, Cochrane CENTRAL, Ovid, China National Knowledge Infrastructure, Chinese BioMedical Literature Database, Wanfang, and VIP Database up to February 2023, to analyze the effectiveness and safety of ERAS in ESS perioperative management of CRS patients. We appraised the methodological quality in the included RCTs using the Cochrane Collaboration tool and assessed the quality of evidence with the Recommendations Assessment, Development and Evaluation (GRADE) tool. Meta-analysis, subgroup analysis, and sensitivity analysis were carried out with the the software Review Manager 5.3 and Stata 12.0. In addition, potential publication bias was detected by Begg's test, Egger's test, and funnel plot test.

RESULTS

Twenty-eight studies involving 2636 patients were included within this study. In comparison with the standard care (SC) group, the ERAS group had the advantages in the following aspects: length of stay (MD = -2.50, 95%CI: -3.04 to -1.97), pain scores (MD = -1.07, 95%CI: -1.46 to -0.67), anxiety score (SMD = -2.13, 95%CI: -2.83 to -1.44), depression score (SMD = -2.42, 95%CI: -3.13 to -1.71), hospitalization expenses, and quality of life. At the same time, the ERAS group presented a markedly lower incidence of adverse events in comparison to the SC group, such as overall complications (RR = 0.28, 95%CI:0.20 to 0.41), postoperative nausea and vomiting (RR = 0.33, 95%CI:0.21 to 0.50), facial edema (RR = 0.20, 95%CI:0.11 to 0.38), low back pain (RR = 0.28, 95%CI:0.16 to 0.49), urinary retention (RR = 0.12, 95%CI:0.05 to 0.30) and haemorrhage (RR = 0.19, 95%CI:0.07 to 0.55).

CONCLUSIONS

The results showed that the ERAS protocol is effective and safe in CRS patients who undergo ESS. However, Due to the limited overall methodological quality included studies, caution should be exercised in the interpretation of the results. More high-quality, multiple-centre, and large-sample studies are in demand in the future to further validate its clinical efficacy.

The Management of Chronic Rhinosinusitis With Nasal Polyps (CRSwNP) With Biologics

Chronic rhinosinusitis with nasal polyps affects a significant portion of the worldwide population. This illness is associated with several chronic conditions and has an important impact on patient quality of life, leading to a great societal economic burden. In recent years, biologic medications have been developed and found to be effective in the treatment of chronic rhinosinusitis with nasal polyps. This review focuses on these treatment options and their ability to improve patient outcomes, including quality of life. It also reviews available evidence with regards to patient selection, monitoring of patients after treatment initiation, and comparison of different biologics and with other treatment options such as sinus surgery.

Targeting Epithelium Dysfunction and Impaired Nasal Biofilms to Treat Immunological, Functional, and Structural Abnormalities of Chronic Rhinosinusitis

Chronic rhinosinusitis (CRS) with (CRSwNP) or without (CRSsNP) nasal polyps is a prevalent and heterogeneous disorder existing as a spectrum of clinical conditions with complex underlying pathomechanisms. CRS comprises a broad syndrome characterized by multiple immunological features involving complex interactions between the genes, the microbiome, host- and microbiota-derived exosomes, the epithelial barrier, and environmental and micromilieu exposures. The main pathophysiological feature is an epithelial barrier disruption, accompanied by microbiome alterations and unpredictable and multifactorial immunologic overreactions. Extrinsic pathogens and irritants interact with multiple epithelial receptors, which show distinct expression patterns, activate numerous signaling pathways, and lead to diverse antipathogen responses. CRSsNP is mainly characterized by fibrosis and mild inflammation and is often associated with Th1 or Th17 immunological profiles. CRSwNP appears to be associated with moderate or severe type 2 (T2) or Th2 eosinophilic inflammation. The diagnosis is based on clinical, endoscopic, and imaging findings. Possible CRS biomarkers from the peripheral blood, nasal secretions, tissue biopsies, and nasally exhaled air are studied to subgroup different CRS endotypes. The primary goal of CRS management is to maintain clinical control by nasal douching with isotonic or hypertonic saline solutions, administration of nasal and systemic steroids, antibiotics, biologic agents, or, in persistent and more severe cases, appropriate surgical procedures.

Non-tuberculous Mycobacterium Rhinosinusitis in an Immunocompetent Patient

Non-tuberculous mycobacteria (NTM) are slow-growing opportunistic pathogens that cause a variety of cutaneous, soft tissue, and pulmonary infections. On rare occasions, NTM causes chronic rhinosinusitis, with the majority of cases presenting in immunocompromised individuals. Other potential risk factors include the presence of foreign bodies, previous sinus surgery or chemoradiation, and use of contaminated water in sinus rinses. We report here a rare case of NTM rhinosinusitis in an otherwise immunocompetent 66-year-old female. The patient underwent functional endoscopic sinus surgery where intraoperative acid-fast bacteria cultures grew Mycobacterium abscessus. She received five weeks of broad-spectrum IV antibiotic therapy followed by three months of oral azithromycin, tigecycline, and linezolid. A one-year post-operative visit showed appropriate healing without crusting or visible infection. This case contributes to the small handful of documented presentations of NTM rhinosinusitis in immunocompetent patients. NTM should be considered when patients present with refractory rhinosinusitis as they may require extended courses of antibiotic treatment. Familiarity with risk factors can further expedite making a diagnosis, ensuring prompt initiation of treatment and relief of symptoms for patients.

Performance of panoramic radiography compared with computed tomography in the evaluation of pathological changes in the maxillary sinuses: a systematic review and meta-analysis

OBJECTIVE

A systematic review was performed to evaluate the performance of panoramic radiography (PR) vs CT or cone beam CT (CBCT) in the diagnosis of pathological maxillary sinuses.

METHODS

This review was registered in the PROSPERO database under the number CRD42020211766. Observational studies that compared PR with CT/CBCT were used to evaluate pathological changes in the maxillary sinuses. A complete search of seven primary databases and gray literature was carried out. The risk of bias was assessed according to the Newcastle-Ottawa tool, and the GRADE tool was used to assess the quality of evidence. A binary meta-analysis was performed to assess the effectiveness of evaluating pathological alterations in the maxillary sinuses in PR and CT/CBCT.

RESULTS

Seven studies were included in our study, out of which four were included in a quantitative analysis. All studies were classified as low risk of bias. Five studies compared PR with CBCT and two studies compared PR to CT. The most common pathological alteration in maxillary sinuses reported was mucosal thickening. CT/CBCT was seen to be the most effective method for assessing pathological changes in the maxillary sinus when compared to PR (RR = 0.19, 95% confidence interval [CI] = 0.05 to 0.70, p = 0.01).

CONCLUSION

CT/CBCT are the most appropriate imaging methods to evaluate pathological changes in the maxillary sinuses, while PR is still limited in the evaluation of these changes being considered only for initial diagnosis.

Olfactory dysfunction in chronic rhinosinusitis: insights into the underlying mechanisms and treatments

INTRODUCTION

Olfactory dysfunction (OD) is a typical symptom of chronic rhinosinusitis (CRS), which adversely affects the patient's quality of life and results in mood depression. Studies investigating the impairment of olfactory epithelium (OE) have indicated that inflammation-induced cell damage and dysfunction in OE plays a vital role in the development of OD. Consequently, glucocorticoids and biologics are beneficial in the management of OD in CRS patients. However, the mechanisms underlying OE impairment in CRS patients have not been fully elucidated.

AREAS COVERED

This review focuses on mechanisms underlying inflammation-induced cell impairment in OE of CRS patients. Additionally, the methods used for detection of olfaction and both currently available and potentially new clinical treatments for OD are reviewed.

EXPERT OPINION

Chronic inflammation in OE impairs not only olfactory sensory neurons but also non-neuronal cells that are responsible for regeneration and support for neurons. The current treatment for OD in CRS is mainly aimed at attenuating and preventing inflammation. Strategies for use of combinations of these therapies may achieve greater efficacy in restoration of the damaged OE and consequently better management of OD.

Modes of Action of 1,8-Cineol in Infections and Inflammation

The monoterpene 1,8-Cineol is a natural plant-based therapeutic agent that is commonly applied to treat different inflammatory diseases due to its mucolytic, anti-microbial and anti-inflammatory properties. It has become increasingly clear in the recent years that 1,8-Cineol spreads almost everywhere in the human body after its oral administration, from the gut to the blood to the brain. Its anti-microbial potential and even its anti-viral effects have been observed to include numerous bacteria and fungi species. Many recent studies help to better understand the cellular and molecular immunological consequences of 1,8-Cineol treatment in inflammatory diseases and further provide information concerning the mechanistic modes of action in the regulation of distinct inflammatory biosynthetic pathways. This review aims to present a holistic and understandable overview of the different aspects of 1,8-Cineol in infections and inflammation.

Factors Influencing Recurrence after Surgical Treatment of Odontogenic Maxillary Sinusitis: An Analysis from the Oral and Maxillofacial Surgery Point of View

The aim of the study was to determine the factors influencing the development of recurrence after the surgical treatment of odontogenic maxillary sinusitis in an oral and maxillofacial surgery clinic over a 7-year period. Demographic and anamnesis data, clinical and radiological findings, treatment and outcome were analyzed. A multivariable analysis was performed to find associations between patient age, causative focus, surgical access for sinus revision, multilayer closure with a buccal fat pad, inferior meatal antrostomy (IMA) for temporary sinus drainage and sinusitis recurrence. A total of 164 patients with a mean age of 51.7 years were included. Sinusitis recurrence was observed in nine patients (5.48%) within 6 months after primary surgery. No significant correlation was detected between patient age, causative focus, surgical access for sinus revision, multilayer closure with a buccal fat pad, IMA for sinus drainage and the development of recurrence (p > 0.05). Patients with a history of antiresorptive-related osteonecrosis of the jaw showed a significant tendency toward disease recurrence (p = 0.0375). In conclusion, except for antiresorptive administration, none of the investigated variables were related to a higher risk of sinusitis recurrence. We encourage a combined approach of intraoral removal of the infective focus and sinus drainage via FESS, as well as an individual treatment decision in a multidisciplinary setting with collaboration between dentistry, maxillofacial surgery and otorhinolaryngology to avoid sinusitis recurrence.

Patient Perspectives on Acute Exacerbations of Chronic Rhinosinusitis: A Qualitative Study

OBJECTIVE

Acute exacerbations of chronic rhinosinusitis (AECRS) are currently defined as a transient worsening of symptoms that return to baseline. This definition is narrow and can only be made retrospectively. The literature has studied this phenomenon from the physician perspective, yet a key stakeholder's-the patient's perspective is not well elucidated in the literature. To understand AECRS from the patient's perspective, we performed this study to further clarify this phenomenon.

STUDY DESIGN

Basic qualitative study via patient interviews using constant comparative methodology was conducted.

SETTING

Tertiary care academic center.

METHODS

Two of the authors served as coders, and via group discussion, a common codebook was created and used to identify recurrent themes. The themes were analyzed for meaning and conclusions were summarized.

RESULTS

Ten interviews were conducted with chronic rhinosinusitis (CRS) patients. Recurring themes included the following: (1) patients identify with the term flare or sinus infection more than exacerbation; (2) consistent with the current definition, patients identify AECRS by worsening sinonasal symptoms but also relate secondary symptoms, including poor sleep, fatigue, exacerbation of lower respiratory tract symptoms, and malaise to AECRS; and (3) patients are greatly affected by AECRS via decreased quality of life (QOL), worsening of general health, and decreasing productivity.

CONCLUSION

Beyond worsening of sinonasal symptoms, the concept of AECRS reflects a more complex construct to patients with associated extranasal symptoms and systemic manifestations. In addition, AECRS have a large impact on patients, and therefore, understanding this component of CRS is pivotal in improving disease control and QOL in this patient population.

A Clinical Study of Nasal Polyposis and Comparison of the Different Methods of its Management

This study was done to study incidence, age and sex distribution of chronic rhinosinusitis with nasal polyposis and to study number of patients who required medical management only and how many required both medical and surgical management. Complications of medical and surgical management was also studied. A prospective study was carried out for 18 months. Clinically and radiologically diagnosed cases of chronic rhinosinusitis with nasal polyposis were chosen for the study. Cases of chronic rhinosinusitis without nasal polyposis, with complication and revision cases were excluded. We used SNOTT-22 as a subjective tool and Lund-Mackay score as an objective tool to compare role of medical and surgical management in our study. Total of 45 patients were included in the study in age group 11-45 years, with 26 males and 19 females (male: female = 1.4:1).16 patients (35.6%) improved with medical management only but 29 patients (64.4%) needed surgical management after medical treatment for 6 weeks.6 patients had complication,1 after medical management and 5 in medical plus surgical management group. In our study both medical and surgical management was found equally effective in management of nasal polyposis, in terms of patient satisfaction. In CT scan lower scores were found in patients with surgical management but it did not reflect much on overall SNOTT-22 score. Thus, we should do proper clinical evaluation followed by appropriate medical therapy for patients of chronic rhinosinusitis with nasal polyposis.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-023-03583-x.

Treatment Strategy of Uncontrolled Chronic Rhinosinusitis with Nasal Polyps: A Review of Recent Evidence

Chronic rhinosinusitis (CRS) is recognized as a heterogeneous disease with a wide range of clinical features, resulting in significant morbidity and cost to the healthcare system. While the phenotypic classification is determined by the presence or absence of nasal polyps and comorbidities, the endotype classification has been established based on molecular biomarkers or specific mechanisms. Research on CRS has now developed based on information based on three major endotypes: types 1, 2, and 3. Recently, biological therapies targeting type 2 inflammation have been clinically expanded and may be applied to other inflammatory endotypes in the future. The purpose of this review is to discuss the treatment options according to the type of CRS and summarize recent studies on new therapeutic approaches for patients with uncontrolled CRS with nasal polyps.

Real‐world burden and treatment of chronic rhinosinusitis in Japan: A retrospective claims database analysis

Objectives

Chronic rhinosinusitis (CRS) is a heterogeneous disease, which can be subdivided into CRS with (CRSwNP) or without (CRSsNP) nasal polyps. An intractable form of CRSwNP that is associated with an eosinophil-dominant inflammatory cell infiltration (eosinophilic CRS) has become more prevalent in Japan. There is currently limited information on the burden of CRS in Japan and treatment approaches used in real-world practice.

Methods

This retrospective, observational, comparative cohort study used information from the Japanese JMDC insurance claims database (study period April 1, 2015, to March 31, 2020). A CRS cohort was identified and matched with a control group without CRS. The primary objective was to clarify disease burden and treatment approaches by comparing comorbidities, healthcare resource utilization (HRU), and drug prescriptions in the CRS and non-CRS groups.

Results

In total, 23,256 individuals with CRS (1762 with CRSwNP and 21,494 with CRSsNP) were matched with 23,256 controls. The mean age was 45 years and the majority of individuals were male (57%). Individuals with CRS had a higher disease burden than controls, with more frequent comorbidities (particularly, type 2 inflammatory disease [e.g., allergic rhinitis and asthma], and those caused by systemic corticosteroids [SCS]), and higher HRU (including outpatient visits, laboratory examinations and surgical procedures). Further, individuals with CRS were prescribed more medications, both for CRS (including SCS) and non-CRS conditions, than controls.

Conclusion

In Japan, CRS is associated with a high disease burden, and multiple treatment approaches are used in affected individuals, including long-term SCS, which is generally not recommended.

Level of Evidence

3.

Determination of orally administered 1,8-Cineol in nasal polyp tissues from chronic rhinosinusitis patients using gas chromatography: mass spectrometry

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a common inflammatory disease causing considerable disease burden. The anti-inflammatory monoterpene 1,8-Cineol is a natural plant-based therapeutic agent that is well established to treat chronic and acute airway diseases. Aim of this study was to investigate whether the herbal drug 1,8-Cineol reaches the nasal tissue via the gut and the blood stream upon its oral administration. A highly sensitive gas chromatography mass spectrometry-based method with stir bar sorptive extraction (SBSE) for sample preparation has been developed and validated for the extraction, detection and quantification of 1,8-Cineol in tissue samples of nasal polyps from 30 CRSwNP patients. Data revealed a highly sensitive detection of 1,8-Cineol in nasal tissue samples after 14 days of oral administration of 1,8-Cineol prior to surgical treatment. There was no significant correlation between the measured 1,8-Cineol concentrations and bodyweight or BMI values of the analyzed patients, respectively. Our data indicate a systemic distribution of 1,8-Cineol in the human body after its oral administration. Individual differences in terms of metabolic characteristics and have to be further investigated. The study increases our understanding of the systemic effects of 1,8-Cineol upon its therapeutic application and benefit in patients with CRSwNP.

PD-1 and PD-L1 Expression Levels as a Potential Biomarker of Chronic Rhinosinusitis and Head and Neck Cancers

Inflammation is an etiological factor of various chronic diseases contributing to more than 50% of worldwide deaths. In this study, we focus on the immunosuppressive role of the programmed death-1 (PD-1) receptor and its ligand (PD-L1) in inflammatory-related diseases, including chronic rhinosinusitis and head and neck cancers. The study included 304 participants. Of this number, 162 patients had chronic rhinosinusitis with nasal polyps (CRSwNP), 40 patients had head and neck cancer (HNC) and there were 102 healthy subjects. The expression level of the PD-1 and PD-L1 genes in the tissues of the study groups was measured by qPCR and Western blot methods. The associations between the age of the patients and the extent of disease and genes' expression were evaluated. The study showed a significantly higher mRNA expression of PD-1 and PD-L1 in the tissues of both the CRSwNP and HNC patient groups compared to the healthy group. The severity of CRSwNP significantly correlated with the mRNA expression of PD-1 and PD-L1. Similarly, the age of the NHC patients influenced PD-L1 expression. In addition, a significantly higher level of PD-L1 protein was noticed also for both the CRSwNP and HNC patient groups. The increased expression of PD-1 and PD-L1 may be a potential biomarker of inflammatory-related diseases, including chronic rhinosinusitis and head and neck cancers.

Trigeminal Sensitivity in Patients With Allergic Rhinitis and Chronic Rhinosinusitis

OBJECTIVE

Allergic rhinitis (AR) and chronic rhinosinusitis with nasal polyps (CRSwNP) are of high importance in otorhinolaryngology. Some of their symptoms are related to changes in the nasal trigeminal sensitivity. The aim of this study was to compare nasal trigeminal sensitivity in patients with AR, CRSwNP, and healthy controls (HC).

METHODS

A total of 75 individuals participated (age 19-78 years; 34 AR, 10 CRSwNP and 31 HC). Olfactory function was determined using the extended Sniffin' Sticks test battery. Trigeminal sensitivity was assessed with CO₂ detection thresholds. Trigeminal negative mucosal potentials (NMP) and EEG-derived event-related potentials (ERP) were recorded in response to selective olfactory (phenylethyl alcohol) and trigeminal (CO₂ ) stimuli using high-precision air-dilution olfactometry.

RESULTS

In comparison to HC, AR patients had lower CO₂ thresholds, also reflected in shorter peak latencies in NMP and trigeminal ERP measurements. CRSwNP patients had a decreased sensitivity for trigeminal stimuli, also reflected in prolonged trigeminal ERP latencies, and reduced olfactory function compared to HC.

CONCLUSION

AR patients seemed to be more sensitive to trigeminal stimuli than CRSwNP patients. Importantly, the differences could be shown on psychophysical and electrophysiological levels. The changes in trigeminal sensitivity appear to be present already at the level of the respiratory epithelium. The differences between the two groups may depend on the specific inflammatory changes accompanying each disorder, the degree of inflammatory activity, or duration of the inflammatory disorder. However, because the sample sizes are relatively small, these results need to be confirmed in the future studies with larger groups.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:654-660, 2023.

Biologics for Nasal Polyps: Synthesizing Current Recommendations into a Practical Clinical Algorithm

BACKGROUND

Chronic rhinosinusitis with nasal polyps (CRSwNP) has been traditionally managed with a combination of topical and systemic medical therapy as well as endoscopic sinus surgery. The emergence of biologic therapies that target specific aspects of the inflammatory cascade has ushered in a potentially new paradigm in the management options available for CRSwNP.

PURPOSE

To summarize the current literature and recommendations supporting the use of available biologic therapies for CRSwNP and to develop an algorithm to aid clinical decision-making regarding treatment selection.

METHODS

A review of available literature and studies that demonstrated the clinical efficacy of biologic agents for the treatment of CRSwNP informing current CRSwNP consensus algorithms.

RESULTS

Current biologic medications target immunoglobulin E, interleukins, or interleukin receptors implicated in the Th2 inflammatory cascade. Institution of biologic therapy is now an option for patients who have disease refractory to topical medical therapy and endoscopic sinus surgery, those who cannot tolerate surgery, or patients with other comorbid Th2 diseases. Response to treatment should be monitored at 4-6 months and 1 year after initiating therapy. Across multiple indirect comparisons, dupilumab appears to have the largest therapeutic benefit across multiple subjective and objective outcomes. The choice of therapeutic agent also depends on drug availability, patient tolerance, presence of comorbid illnesses, and cost.

CONCLUSIONS

Biologics are emerging as an important option in the management of patients with CRSwNP. While more data is required to fully inform indications, treatment selection, and health economics related to their use, biologics may offer robust symptom relief to patients who have failed other interventions.

Minimal Radiographic Mucosal Thickness or Opacification Criterion for Sinus-Specific Endoscopic Sinus Surgery for Chronic Rhinosinusitis

OBJECTIVE

Primary chronic rhinosinusitis (CRS) is typically a diffuse process and the extent of endoscopic sinus surgery (ESS) performed for medically recalcitrant CRS is impacted by many factors. However, some third-party payors have implemented policies to authorize coverage for ESS in a sinus-by-sinus manner based on a minimal measurement of millimeters of mucosal thickening or sinus opacification in the corresponding sinus that is being surgically addressed. Our objective was to determine whether such policies are based on scientific evidence that in patients with medically recalcitrant CRS, a minimum measurement of mucosal thickening or sinus opacification is a predictor of CRS in that sinus or improved outcomes after ESS on a sinus-by-sinus basis.

DATA SOURCES

Medline, Embase, Scopus, and Web of Science databases, from inception through May 2022.

REVIEW METHODS

A systematic review was performed. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were followed.

RESULTS

We identified 6070 abstracts which were screened and from which 112 studies ultimately underwent a full-text review. From these studies, we found that none investigated (or provided evidence of) whether any minimal degree of radiographic mucosal thickening or sinus opacification predicted CRS or better outcomes after ESS in a sinus-specific manner.

CONCLUSION

We were unable to find evidence supporting a minimum millimeter measurement of mucosal thickening or sinus opacification as predictors of CRS or better post-ESS outcomes in a sinus-specific manner in patients with medically recalcitrant CRS. The extent of ESS for CRS should be determined through personalized medical decision-making that considers all patient-specific factors.

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 Rhinosinusitis Outcome Registry (CHRINOSOR): Establishment of an International Outcome Registry Driven by mHealth Technology

BACKGROUND

Real-world evidence (RWE) is a valuable instrument to better understand the patient journey and effectiveness of therapies. RWE on the prevalence of uncontrolled chronic rhinosinusitis (CRS) and CRS natural course of disease across Europe is scarce. In addition, there is limited RWE that enables comparison of the effectiveness of marketed therapies including topical or systemic corticosteroids, sinus surgery, or biologics.

OBJECTIVE

To establish an international CHRonic rhINOSinusitis Outcome Registry (CHRINOSOR) based on real-world data collection enabled by mobile health technology.

METHODOLOGY

A digital platform, Galenus Health, supporting patients and physicians in the management of chronic respiratory diseases, is used to collect data on patient profile, disease history, patient outcomes, and a set of relevant clinical outcomes. Adult patients with a diagnosis of CRS are eligible for inclusion.

RESULTS

A collaborative scientific network of 17 university ear-nose-throat (ENT) clinics from 10 European countries has been established with the aim to collect real-world data in a longitudinal and standardized manner. The Galenus Health digital platform is currently being implemented in these ENT clinics taking into account legal, privacy, and data security aspects. Up to 300 patients have already been included.

CONCLUSIONS

CHRINOSOR is a collaborative effort that aims at improving our understanding of CRS, its comorbidities, and the effectiveness of its treatments. Ultimately, these insights will guide us as scientific community to develop future care pathways informed by RWE.

The link between allergic rhinitis and chronic rhinosinusitis

PURPOSE OF REVIEW

Allergic rhinitis and chronic rhinosinusitis (CRS) are common disorders affecting millions of people worldwide. Although allergic rhinitis and CRS are distinct clinical entities, certain CRS endotypes share similar pathological mechanisms as those seen in patients with allergic rhinitis. This review assesses the literature behind the similarities and differences seen in patients with CRS and allergic rhinitis, and the role atopy might play in the pathophysiology of CRS.

RECENT FINDINGS

In examining the associations between allergic rhinitis and CRS, most studies have focused primarily on CRS with nasal polyps and type 2 inflammation in CRS. Recent studies have demonstrated the similarities and differences in pathologic mechanisms behind allergic rhinitis and CRS, with an emphasis on patient endotypes, genetics, and the nasoepithelial immunologic barrier. Related immunopathology shared by allergic rhinitis and type 2 inflammation in CRS has allowed for therapeutic overlap with biologic treatments.

SUMMARY

Allergic rhinitis and CRS often present as comorbid conditions, and understanding the relationship between allergic rhinitis and CRS is important when considering treatment options. Advances in understanding the genetics and immunology, as well as biologic and immunotherapeutic treatments have improved outcomes in patients with CRS, especially in the setting of atopy.

Evaluation of Routine Ear, Nose, and Throat Screening in Heart Transplant Candidates: A Retrospective Cohort Study

BACKGROUND

Patients with end-stage heart failure refractory to medication can be treated with a heart transplant (HTx). These patients are subjected to a preoperative screening procedure according to International Society for Heart and Lung Transplantation guidelines. Additionally, in our hospital, a routine ear, nose, and throat (ENT) screening is performed, directed toward the identification of asymptomatic infections and head and neck neoplasms. There are no studies demonstrating that this screening has additional value in these patients.

METHODS

To investigate the yield of protocolled ENT screening in candidates for HTx, we retrospectively reviewed the medical records of patients who were subjected to the screening procedure between 2012 and 2020.

RESULTS

The study population consisted of 251 patients of whom 177 (70.5%) were male with a median age of 52 years (IQR, 45-59 years). Ten patients (4.0%) were diagnosed with an infection (sinus) or a neoplasm, resulting in a number needed to screen of 25. In all cases, ENT consultation or sinus radiography did not influence the decision to list patients for HTx. Furthermore, no major ENT infections or occurrence of de novo head and neck malignant neoplasm were observed during follow-up after HTx.

CONCLUSIONS

The clinically relevant yield of protocolled ENT screening in candidates for HTx is low. Based on these findings, we believe that only patients with abnormal findings on a routine sinus computed tomography scan and/or specific ENT complaints should be referred to an otorhinolaryngologist.

Climate change, the environment, and rhinologic disease

BACKGROUND

The escalating negative impact of climate change on our environment has the potential to result in significant morbidity of rhinologic diseases.

METHODS

Evidence based review of examples of rhinologic diseases including allergic and nonallergic rhinitis, chronic rhinosinusitis, and allergic fungal rhinosinusitis was performed.

RESULTS

The lower socioeconomic population, including historically oppressed groups, will be disproportionately affected.

CONCLUSIONS

We need a systematic approach to improve healthcare database infrastructure and funding to promote diverse scientific collaboration to address these healthcare needs.

Current and Emerging Treatment Options in Sinus and Nasal Diseases: A Promising Future in the Appropriate Therapies

Chronic rhinosinusitis (CRS) is an inflammatory condition of the nose and paranasal sinuses defined by clinical symptoms, including two or more symptoms, one of which should be either nasal blockage or nasal discharge with or without facial pain/pressure or reduction in/loss of sense of smell [...].

Elucidating the Real-World Burden of Chronic Rhinosinusitis With Nasal Polyps in Patients in the USA

Objective

To characterize healthcare burden, treatment patterns, and clinical characteristics associated with chronic rhinosinusitis with nasal polyps (CRSwNP).

Study Design

Retrospective cohort.

Setting

Real-world study using US health insurance claims database.

Methods

Adults with ≥1 CRSwNP diagnosis (index date: first claim for nasal polyps [NPs] between January 1, 2008, and March 31, 2019) and continuous health insurance coverage for ≥180 days preindex (baseline) and postindex were included. Follow-up spanned from index to the earliest of disenrollment, death, or data end. Assessments included patient demographics, comorbidities, and blood eosinophil count at baseline, healthcare resource utilization (HCRU), and costs during follow-up in the overall population and stratified by number of surgeries.

Results

Of the 119,357 patients who met the inclusion criteria, 33,748 (28%) had ≥1 surgery during follow-up, among whom 3262 (9.7%) had ≥2 surgeries. At baseline, patients with ≥1 vs no NP surgeries had a greater comorbidity burden; a higher proportion of patients had comorbid asthma (37.8% vs 21.8%) and blood eosinophil count ≥300 cells/µL (42.6% vs 38.1%). During follow-up, patients with NP surgeries had higher all-cause and CRSwNP-related HCRU and costs than patients without NP surgery. All-cause healthcare costs per person per year increased with the number of surgeries during follow-up (no surgery, $10,628; ≥1 surgery, $20,747; ≥2 surgeries, $26,969).

Conclusion

Patients with CRSwNP and surgery had a greater disease burden than those without surgery, with higher HCRU and costs, and were more likely to have comorbid conditions (most commonly asthma) and elevated blood eosinophil count, indicating a subset of patients with recalcitrant CRSwNP.

Validation of the Dutch version of the 22-item Sino-Nasal Outcome Test (SNOT-22)

Background: The 22-item Sino-Nasal Outcome Test (SNOT-22) is a widely used questionnaire to measure disease-specific health-related quality of life in patients with chronic rhinosinusitis (CRS). The Dutch version has not been validated yet. Methods: The SNOT-22 was translated through a forward-backward translation technique and validated by a test-retest protocol in CRS patients, a responsiveness analysis in CRS patients treated with dupilumab, while using healthy individuals as controls. Results: The Dutch SNOT-22 showed excellent test-retest properties, good responsiveness to treatment with dupilumab, and a clear distinction between outcomes of CRS patients and healthy controls. Conclusion: The Dutch version of the SNOT-22 is a valid outcome measure in CRS patients.

Prevalence of chronic rhinosinusitis and its relating factors in patients with bronchiectasis: findings from KMBARC registry

BACKGROUND/AIMS

Patients with bronchiectasis often present with respiratory symptoms caused by chronic rhinosinusitis (CRS). However, studies on the prevalence of CRS and its relationship with bronchiectasis are limited.

METHODS

The baseline characteristics of patients with bronchiectasis recruited from the Korean Multicenter Bronchiectasis Audit and Research Collaboration were analyzed. CRS diagnosis was determined by a physician, on the basis of medical records, upper airway symptoms, and/or radiologic abnormalities. Questionnaires for quality of life, fatigue, and depression were administered when patients were stable for a minimum of 4 weeks after the bronchiectasis exacerbation.

RESULTS

The prevalence of CRS was 7.1% (66/931). Patients with CRS were significantly younger than those without CRS (60.5 ± 10.7 years vs. 64.6 ± 9.3 years, p = 0.001). Idiopathic bronchiectasis was more common in patients with CRS compared to those without CRS (53.0% vs. 36.0%, p = 0.006). Lung function, inflammatory markers, exacerbations, bronchiectasis severity, and scores for quality of life, fatigue, and depression did not differ between the two groups. In a logistic regression analysis, CRS was associated with age of bronchiectasis diagnosis (odds ratio [OR], 0.96; 95% confidence interval [CI], 0.94 to 0.99; p = 0.003) and idiopathic bronchiectasis (OR, 1.95; 95% CI, 1.12 to 3.34; p = 0.018).

CONCLUSION

The prevalence of CRS was relatively low. CRS was not associated with the severity or clinical outcomes of bronchiectasis. Early diagnosis and idiopathic etiology were associated with CRS. Our findings reflect the low recognition of CRS in the clinical practice of bronchiectasis and highlight the need for awareness of CRS by adopting objective diagnostic criteria.

Acupuncture for the Treatment of Chronic Rhinosinusitis: A PRISMA-Compliant Systematic Review and Meta-Analysis

Background. Chronic rhinosinusitis (CRS) is a highly prevalent disease associated with poor quality of life. In this paper, we appraised the role of acupuncture in the treatment of CRS. Methods. Electronic databases were searched for randomized controlled clinical trials (RCTs) that examined the role of acupuncture in CRS. The primary outcome measures included posttreatment CRS severity, as measured by the Visual Analogue Scale (VAS) and Total Effective Rate (TER). The risk of bias and quality of evidence were evaluated according to the Cochrane Collaboration’s risk-of-bias tool and GRADE tool, respectively. Results. Evidence from the RCTs (n = 10) suggested that acupuncture as a monotherapy or adjunctive therapy to conventional treatment was associated with significant improvements in VAS, TER, and quality of life when compared with conventional treatments for CRS. However, there was a similar incidence of adverse events. The risk of bias was unclear and the quality of evidence for each finding was generally moderate to low. Conclusions. Acupuncture as a stand-alone or adjunctive treatment for CRS was associated with clinical symptom improvement and better quality of life, without any risk for serious adverse events. However, the high clinical heterogeneity of the included RCTs and overall moderate-to-low quality of evidence necessitates rigorous, well-designed trials to confirm these findings. Trial Registrations. This trial is registered with PROSPERO (no. CRD42021292135).

Herbal medicine for the treatment of chronic rhinosinusitis: A systematic review and meta-analysis

Objectives: Chronic rhinosinusitis (CRS) is a disease with a high prevalence and a high socioeconomic burden. This study aimed to conduct a comprehensive systematic review to update the evidence on the use of herbal medicine (HM) for CRS treatment.

Methods: A total of 14 electronic databases for randomized controlled trials (RCTs) evaluating the effects of HM on the treatment of CRS were searched for articles published before July 2021. The primary outcome was CRS severity post-treatment, measured with the Visual Analogue Scale (VAS) and Total Effective Rate (TER). The risk of bias of the included studies and the quality of evidence of the main findings were assessed using the Cochrane Collaboration’s risk of bias tool and the Grading of Recommendations, Assessment, Development, and Evaluations tool.

Results: A total of 80 RCTs were included. Compared to placebo, HM significantly improved CRS severity as measured by TER and VAS. When HM was compared with conventional treatment (CT) as monotherapy or adjuvant therapy, CRS severity measured by TER and VAS, quality of life, Lund-Kennedy endoscopy score, Lund-Mackay computed tomography score, and nasal mucociliary function were significantly improved in the HM group. No serious adverse events associated with HM were reported. The risk of bias was generally unclear, and the quality of evidence ranged from moderate to low.

Conclusion: This review found some limited clinical evidence that HM or HM combined with CT may be more effective and safer than CT alone in treating CRS. However, the methodological quality of the included studies was generally low, and the quality of the evidence needs to be improved.

Association of Laryngopharyngeal Reflux Disease and Refractory Chronic Rhinosinusitis

OBJECTIVE

The current study was conducted to explore the association between laryngopharyngeal reflux disease (LPRD) and refractory chronic rhinosinusitis (RCRS), and to reveal the potential role of LPRD in the development of RCRS.

METHODS

A total of 104 patients diagnosed as chronic rhinosinusitis (CRS) and hospitalized, as well as 50 healthy participants were enrolled into this study. Among patients enrolled, 53 were RCRS and 51 were CRS. All participants were assessed with reflux symptom index (RSI) and reflux finding score (RFS). Patients with RSI >13 and/or RFS >7 were diagnosed as LPRD. In addition, pepsin in the nasal secretions from the middle meatus tract complex at fasting in the morning was analyzed using ELISA. Patients with pepsin concentration of >75 ng/ml was considered as positive, and confirmed as LPRD.

RESULTS

There was no significant difference in age, sex, height, and weight among RCRS, CRS, and control groups. The positive rates of RSI and RFS scores were 39.6% in the RCRS and 52.9% in the CRS, respectively, which were significantly higher than that of the control group (14.0%, P < 0.05), respectively. Significantly higher positive rate of pepsin assay was also observed for RCRS(43.4%) and CRS(64.7%) when compared with the control group (18.0%, P < 0.05). The positive rate of pepsin assay was strongly associated with the positive rate of RSI or RFS (P < 0.001).

CONCLUSION

The present findings have important implications that RSI and RFS score was highly associated with pepsin assay result in the patients with RCRS or CRS. We confirmed the importance of RSI and RFS scoring system as well as pepsin test, which may offer insight for clinical screening for LPRD among CRS patients.