Clinical Characteristics of Patients with Chronic Rhinosinusitis without Nasal Polyps in an Academic Setting

Serum and Tissue Periostin Expression in Rhinosinusitis With Nasal Polyps

BackgroundThere is increasing evidence of the contribution of periostin in the pathogenesis of chronic rhinosinusitis with nasal polyps (CRSwNP).ObjectiveThis study aims to investigate the expression of periostin in nasal polyp tissue along with serum periostin and its potential function as a biomarker.MethodsThe study included 36 CRSwNP patients and 12 controls. Nasal polyp tissue from CRSwNP patients and inferior turbinate mucosa samples from controls were intraoperatively collected. POSTN gene mRNA expression from nasal polyp tissue was assessed with polymerase chain reaction and periostin levels on tissue samples were measured with ELISA and Western Blot. ELISA was performed to evaluate serum periostin on blood samples collected from patients undergoing functional endoscopic sinus surgery for CRSwNP (n = 36) and results were compared with assays performed on control subjects (n = 12).ResultsTissue periostin gene expression in terms of mRNA levels was significantly elevated in patients with CRSwNP than in healthy control subjects (P-value <.05). Τissue periostin values in CRSwNP patients were also significantly higher in CRSwNP compared to controls. A positive correlation between periostin levels and the presence of asthma and smoking was observed in the patient group. Serum periostin did not present a statistically significant difference between the 2 groups.ConclusionsOur data suggest that periostin expression is upregulated in nasal polyps and might determine a crucial role in the occurrence and evolution of the disease. Periostin appears to be a promising therapeutic target candidate in CRSwNP.

Multi-omics integration and machine learning identify and validate neutrophil extracellular trap-associated gene signatures in chronic rhinosinusitis with nasal polyps

This study aimed to explore the molecular characteristics of neutrophil extracellular traps (NETs) in chronic rhinosinusitis with nasal polyps (CRSwNP). Differentially expressed gene analysis, weighted gene co-expression network analysis, and machine learning algorithms identified three core NETs-associated genes: CXCR4, CYBB, and PTAFR, which were significantly upregulated in CRSwNP patients. The diagnostic performance of these genes was evaluated using receiver operating characteristic (ROC) curves, and their clinical relevance was validated using multicenter data. Immune infiltration analysis showed strong correlations between these genes and neutrophil and immune cell infiltration. Single-cell RNA sequencing demonstrated that these genes were predominantly expressed in myeloid and immune cells and exhibited dynamic changes during disease progression. These genes may contribute to CRSwNP pathogenesis through IL-17 signaling and metabolism-related pathways. This study identifies novel biomarkers and therapeutic targets for precise diagnosis and personalized treatment of CRSwNP.

Effects of Different Types of Medications on Olfactory Dysfunction in CRSwNP: A Systematic Review and Network Meta-Analysis

OBJECTIVE

To evaluate the efficacy of various pharmacological treatments for olfactory disorders in patients with chronic rhinosinusitis with nasal polyps (CRSwNP).

DATA SOURCES

PubMed, Embase, Cochrane Library, and Web of Science.

METHODS

We searched the related literature in PubMed, Embase, Cochrane Library, and Web of Science up to Aug 2024 to appraise the effects of pharmacotherapy on olfactory sensation. After that, two reviewers independently screened the retrieved articles, extracted the pertinent data, and assessed the risk of bias in the included studies. Then we used Stata 14.2 to perform a network meta-analysis.

RESULTS

Ninteen randomized controlled trials (RCTs) and 2354 participants were included. Compared with placebo, biologics demonstrated the most significant improvement in subjective olfactory dysfunction (OD) [standardized mean difference (SMD) = -0.75, 95% confidence intervals (CI) (-1.08, -0.41)]. In terms of objective olfactory function improvement, biologics also exhibited the greatest effect (SMD = 0.93, 95% CI [0.56, 1.31]). Among various biologics, dupilumab was the most effective in alleviating both subjective OD (SMD = -1.30, 95% CI [-1.51, -1.09]) and objective OD (mean difference [MD] = 11.13, 95% CI [9.91, 12.35]).

CONCLUSIONS

Our research results indicated that biologics might show better performance in terms of improving the olfactory sensation of patients with CRSwNP, particularly dupilumab. However, given the limitations of this study, future research should employ more standardized olfactory assessment methods and conduct more large-scale RCTs, ultimately guiding clinicians and patients in making informed and optimal treatment choices.

LEVEL OF EVIDENCE

NA.

Clinical efficacy and mechanisms of biologics for chronic rhinosinusitis with nasal polyps

The management of chronic rhinosinusitis with nasal polyps (CRSwNP) can be challenging, particularly when standard treatments including intranasal corticosteroids and endoscopic sinus surgery do not result in adequate symptom control. CRSwNP is frequently characterized by a type 2 immune signature, and many patients have other comorbid type 2 conditions, including asthma. There are currently 3 biologic therapies approved for the treatment of CRSwNP-omalizumab, mepolizumab, and dupilumab-and there are promising therapies in development. Biologic therapies allow for improved patient quality of life in CRSwNP, reduction in need for systemic corticosteroid treatment and endoscopic sinus surgery, and improvement in treatment of comorbidities. Translational studies assessing how biologic therapies can modify inflammation in CRSwNP have allowed for a greater understanding of CRSwNP pathogenesis. We review CRSwNP clinical trial and real-world data on the effectiveness and safety of biologics, discuss their therapeutic mechanisms, assess outcomes of biologic therapy versus endoscopic sinus surgery, and discuss therapies in development and future directions.

Impact of FESS on symptomatology and quality of life of patients with CRSsNP

PURPOSE

Chronic rhinosinusitis (CRS) has an impact on health related quality of life (HRQOL). The objective of this study was to examine generic and disease specific HRQOL and symptoms in CRS patients before and 6 months after sinus surgery.

METHODS

This prospective, observational study consisted of 30 patients with chronic sinusitis. Generic and disease specific HRQOL were measured using the Short Form Health Survey (SF 36) and Sino Nasal Outcome Test (SNOT 22).

RESULTS

The results revealed that chronic sinusitis has a significant impact on a person's quality of life reflected in the vitality, mental health, social activities, physical pain and perceived health status of patients also a positive correlation emerged between functional endoscopic sinus surgery (FESS) and improvement not only in symptomatology but also overall quality of life.

CONCLUSIONS

FESS turns out to be a useful and necessary intervention for the improvement of symptomatology related to chronic sinusitis but also for the improvement of the quality of life of individuals who appear to be severely affected by the condition.

New insights into the endotypes of chronic rhinosinusitis in the biologic era

Chronic rhinosinusitis (CRS) exhibits significant heterogeneity and has been generally classified as type 1 (T1), T2, and T3 endotypes according to the histopathologic and inflammatory features of the nasal mucosa. T2 inflammation has been regarded as the predominant endotype of CRS linked to disease severity and refractory conditions. The development of biological agents that specifically target key molecules involved in T2 inflammation offers a highly effective and promising therapeutic approach for CRS. Recent findings have expanded the understanding of CRS endotypes by incorporating a range of disease-related molecules for classification, with progress made on the endotyping of CRS without nasal polyps. In addition, there has been an increasing emphasis on the study of mixed inflammatory endotypes. This review examines recent findings on CRS endotyping and the related noninvasive biomarkers, as well as novel mechanisms governing endotype formation, and addresses the efficacy of biologics in targeting T2 inflammation. Further research is warranted to understand if newly identified CRS endotypes show clinical significance for precision medicine and the management and treatment of refractory CRS in the era of biologics.

Sex and gender in rhinosinusitis: a review

Rhinosinusitis is a highly prevalent, inflammatory condition affecting the nose and paranasal sinuses, impacting an individual's quality of life with significant health care burden. Sinusitis is more frequent in females, and they typically present with more severe symptoms and worse quality of life scores. Males are more likely to present with nasal polyps and have higher objective scores on imaging studies. Differences in sinus microbiota by sex may play a role in understanding differences in clinical presentations between them, but additional research is required. An improved understanding of sex and gender-based differences in pathophysiology and clinical presentations will help to decrease inequities in accessing healthcare and optimizing long-term personalized patient outcomes.

Relationship between serum ECP and TIgE levels and the risk of postoperative recurrence in patients with chronic rhinosinusitis with nasal polyps

Objective

This study was undertaken to assess the association between the likelihood of surgical recurrence and serum ECP and TIgE levels in chronic rhinosinusitis with nasal polyps (CRSwNP).

Methodology

Clinical information was gathered retrospectively from 166 cases of surgically treated CRSwNP as well as 60 cases of chronic rhinosinusitis without nasal polyps (CRSsNP). A comparative analysis on serum levels of total immunoglobulin E (TIgE) and eosinophil cationic protein (ECP) was carried out between the two groups. The CRSwNP patients were assigned into recurrence and non-recurrence groups based on the absence/presence of disease recurrence after a 2-year follow-up. An analysis was conducted on the correlation between the patients' clinical data and their serum ECP and TIgE levels. Receiver operating characteristic (ROC) curves were utilized to assess the clinical utility of these two biomarkers.

Results

The CRSwNP participants had higher serum levels of ECP and TIgE (4.28 ± 0.81 > 3.58 ± 0.77 ng/L, P < 0.001; 52.99 ± 8.62 > 15.65 ± 3.25 KU/L, P < 0.001) compared to CRSsNP participants. Univariate analysis indicated that neutrophil ratio, lymphocyte ratio, Lund-Kennedy score, Lund-Mackay score, SNOT-22 score, olfactory function score, and postoperative recurrence were significantly correlated with serum ECP and TIgE levels. Higher serum levels of TIgE and ECP (4.89 ± 0.79 < 4.11 ± 0.72, P < 0.001; 58.74 ± 8.27 < 51.40 ± 8.04, P < 0.001) were detected in the recurrence groups vs. the non-recurrence group. Multivariate analysis showed that serum ECP and TIgE were independent risk factors for recurrence of CRSwNP. Serum ECP and TIgE levels were found to be predictive of postoperative recurrence risk in CRSwNP patients (AUC: 0.77, 0.74, 0.84; P < 0.05) according to ROC curve analysis. Significant differences were not observed in any general clinical data.

Conclusion

The findings suggest that elevated serum ECP and TIgE levels in patients with CRSwNP can be as good predictors for the risk of recurrence after endoscopic sinus surgery.

Expression of Proliferating Cell Nuclear Antigen (PCNA) in Nasal Polyp: A Systematic Review and Meta-analysis

Nasal polyp (NP) is a pathological benign mass that affects the nasal cavity and paranasal sinuses. This lesion is occasionally associated with chronic rhinosinusitis (CRS), which is named chronic rhinosinusitis with nasal polyps (CRSwNP). Proliferating cell nuclear antigen (PCNA) indicates abnormal cell proliferation which may help assess the nasopharyngeal lesions and upper airway cancers. This study aimed to examine the PCNA expression in NP tissue. This study was conducted under the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. A thorough search using relevant keywords was performed on the electronic database to identify studies examining the PCNA expression in NP. Meta-analysis on pooled single group proportion and means of PCNA expression was conducted by the metamean and metaprop functions in R software (version 4.4.0). Quality assessment was done according to the Joanna Briggs Institute (JBI) checklist. Ten articles were included in this study. The PCNA expression in NP was higher than in normal nasal mucosa (NNM), while its expression in NP was lower than in inverted papilloma (IP). The mean percentage of PCNA expression in NP was 15.73% (95%-CI[2.87-28.58]) with considerable heterogeneity (I 2  = 97%[96-98%],p-value < 0.01). Based on a cutoff staining (> 5%), 64% of NP samples were PCNA-positive (95%-CI[42-81%]) with high heterogeneity (I 2  = 76%[47-89%], p-value < 0.01). NP tissue has a relatively high expression of the PCNA oncoprotein based on the immunohistochemistry (IHC) staining. Although more than half of NP samples were positive for PCNA, still the mean expression of this marker in NP was lower than in IP tissue.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s12070-024-05172-y.

Anti-IgE therapy in chronic rhinosinusitis with nasal polyps

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a chronic inflammatory condition characterized by type 2 (T2) immune responses with significant impacts on quality of life and health care costs. Local IgE production in nasal polyp tissue plays a key role in the T2 inflammatory cascade. Omalizumab, an anti-IgE monoclonal antibody, is an effective treatment for some patients with CRSwNP regardless of the patient's allergic status. Clinical trials, including the pivotal POLYP 1 and POLYP 2 studies, demonstrated omalizumab's efficacy in reducing nasal polyp size, improving symptom scores, and enhancing quality of life, particularly in patients with comorbid asthma and aspirin-exacerbated respiratory disease. As we summarize in this review, omalizumab's effect appears to involve the reduction in local IgE and T2 inflammation; however, this remains poorly understood. Notably, omalizumab's effectiveness appears to be partially sustained after long-term therapy, though symptoms and inflammation begin to return at discontinuation. Ongoing research is needed to determine the optimal duration of therapy and potential for biologics to modify the disease course. Additionally, further studies are needed to identify biomarkers to predict treatment response and to compare omalizumab with other biologics such as dupilumab in head-to-head trials. Omalizumab is one of the key T2-targeted therapeutic options for CRSwNP, with sustained effectiveness and strong safety profile.

Upper airway comorbidities of asthma

Asthma, characterized as a chronic heterogeneous airway disease, often presents with common comorbid conditions. The concept of "one airway, one disease" was coined more than 20 years ago, emphasizing the connection between asthma and upper airway comorbidities (UACs) such as allergic or nonallergic rhinitis, chronic rhinosinusitis with or without nasal polyps, and aspirin/nonsteroidal anti-inflammatory drug-exacerbated respiratory disease. Since then, numerous studies have demonstrated that UACs are closely related and affect asthma phenotypes. Recognizing these UACs and managing them are crucial aspects of comprehensive asthma care. Addressing these conditions as part of asthma treatment can lead to better control of symptoms, improved lung function, and better quality of life. Moreover, it is important to explore the field of respiratory biologics, which represents the latest advancements in medical treatment options for patients with asthma and UACs.

Monoclonal Antibody Switching in Biologic Treatment of Chronic Rhinosinusitis with Nasal Polyps

Objectives: to evaluate our real-world data on the efficacy and safety of switching between two monoclonal antibodies in biologic treatment of uncontrolled chronic rhinosinusitis with nasal polyps (CRSwNP). Methods: All patients receiving biologic treatment for uncontrolled CRSwNP between April 2020 and March 2024 at a tertiary referral center who needed transitioning between biologic agents were retrospectively analyzed. The following parameters were investigated: patient's clinical characteristics, wash-out periods, treatment outcome, and switching-related side effects. Results: Out of 91 CRSwNP patients who received biologic treatment, 4 patients (4.4%) necessitated switching to an alternative biologic agent. Three patients were switched to a different antibody because of insufficient symptom control with the initially prescribed biologic, while the other patient required switching to an alternative agent due to a side effect. Switching resulted in all four patients achieving a significant improvement in all outcome parameters. There were no switching-related side effects, and the switching procedure was performed in three cases without a wash-out period. Conclusion: CRSwNP patients under biologic therapy with an insufficient response or medication-related side effect may benefit from switching to an alternative biologic agent. Larger, prospective multicenter studies are warranted to further validate the effectiveness and safety of switching agents in the biologic treatment of CRSwNP.

Consultation for Chronic Rhinosinusitis With Nasal Polyps and Asthma: Clinical Presentation, Diagnostic Workup, and Treatment Options

Chronic rhinosinusitis (CRS) is characterized by chronic inflammation of the sinonasal mucosa, affects over 12% of the US population, and costs over $20 billion annually. CRS can be divided into 2 major phenotypes based on whether nasal polyps are present (chronic rhinosinusitis with nasal polyps [CRSwNP]) or absent (chronic rhinosinusitis without nasal polyps). This grand rounds review will discuss the clinical approach to patients with CRSwNP, including typical presentations, workup, and currently available treatment options. Tools that physicians can use to assess subjective sinonasal symptoms, as well as objective measures of disease, will be reviewed. Additional focus will be on recognizing clinical comorbidities commonly associated with CRSwNP, including asthma, bronchiectasis, allergic rhinitis, and nonsteroidal anti-inflammatory drug-exacerbated respiratory disease. Clinical outcomes can be improved by providing a comprehensive approach to evaluating (and managing) patients with CRSwNP.

IL-1β-induced epithelial cell and fibroblast transdifferentiation promotes neutrophil recruitment in chronic rhinosinusitis with nasal polyps

Neutrophilic inflammation contributes to multiple chronic inflammatory airway diseases, including asthma and chronic rhinosinusitis with nasal polyps (CRSwNP), and is associated with an unfavorable prognosis. Here, using single-cell RNA sequencing (scRNA-seq) to profile human nasal mucosa obtained from the inferior turbinates, middle turbinates, and nasal polyps of CRSwNP patients, we identify two IL-1 signaling-induced cell subsets-LY6D+ club cells and IDO1+ fibroblasts-that promote neutrophil recruitment by respectively releasing S100A8/A9 and CXCL1/2/3/5/6/8 into inflammatory regions. IL-1β, a pro-inflammatory cytokine involved in IL-1 signaling, induces the transdifferentiation of LY6D+ club cells and IDO1+ fibroblasts from primary epithelial cells and fibroblasts, respectively. In an LPS-induced neutrophilic CRSwNP mouse model, blocking IL-1β activity with a receptor antagonist significantly reduces the numbers of LY6D+ club cells and IDO1+ fibroblasts and mitigates nasal inflammation. This study implicates the function of two cell subsets in neutrophil recruitment and demonstrates an IL-1-based intervention for mitigating neutrophilic inflammation in CRSwNP.

TFE3 and TP53 were novel diagnostic biomarkers related to mitochondrial autophagy in chronic rhinosinusitis with nasal polyps

Background

Chronic rhinosinusitis with nasal polyps (CRSwNP) belongs to a subtype of Chronic rhinosinusitis which is a heterogeneous inflammatory condition. It has been reported that mitophagy may provide a new therapeutic option for CRSwNP.

Methods

The GSE136825 (training dataset) and GSE179265 (validation dataset) were scoured from the Gene Expression Omnibus database. The candidate genes related to mitophagy were identified by differential expression analysis. Subsequently, the biomarkers were selected from the machine learning, Receiver Operating Characteristic curves, and expression level verification. A backpropagation (BP) neural network was generated to evaluate the diagnostic ability of biomarkers. In addition, the infiltration abundance of immune cells, potential drugs, and related ear-nose-throat (ENT) diseases were analyzed based on the biomarkers. Finally, qPCR analysis was performed to verify these biomarkers.

Results

A total of 8 candidate genes were identified by overlapping 3,400 differentially expressed genes (DEGs) and 72 mitophagy-related genes Subsequently, TFE3 and TP53 were identified as biomarkers of CRSwNP, and the area under the curves (AUC) of the BP neural network was 0.74, which indicated that the biomarkers had excellent abilities. TFE3 and TP53 were co-enriched in the cancer pathway, cell cycle, endocytosis, etc. What's more, Macrophage and Immature dendritic cells had significant correlations with biomarkers. The drugs (Doxorubicin, Tetrachlorodibenzodioxin, etc.) and the ear-nose-throat diseases (hearing loss, sensorineural, tinnitus, etc.) related to biomarkers were predicted. Ultimately, qPCR results showed that the expression levels of TFE3 and TP53 in polyp tissue of CRSwNP were increased.

Conclusion

Overall, TFE3 and TP53 could be used as biomarkers or potential therapeutic targets to diagnose and treat CRSwNP.

Mupirocin Ointment Effect on Polyposis Recurrence After Sinus Surgery

Introduction

Staphylococcus aureus is an identified pathogen involved in the recurrence of symptoms in patients with chronic rhinosinusitis with nasal polyps. We investigated the effectiveness of a topical ointment of mupirocin applied in the nasal vestibule in lessening symptom recurrence and improving the efficiency of functional endoscopic sinus surgery.

Materials and Methods

Patients with chronic rhinosinusitis, nasal polyps, and a positive nostril culture for Staphylococcus aureus were included in a clinical trial. The right nostril was determined as the intervention group (applying mupirocin ointment) and the left as the control group (applying vitamin A ointment). Lund-Mackay radiological scores and Lund-Kennedy endoscopic scores were examined at the time of diagnosis and six months later.

Results

Among 60 patients with chronic rhinosinusitis with nasal polyps, 91.6% were positive for nostril Staphylococcus aureus. Comparing the average of the diagnostic radiological and endoscopic scores with the follow-up values in both groups indicated a significant improvement after surgery (P-value=0.001, 0.001). However, there was no significant difference in the radiological and endoscopic score improvements between the study and control groups (P-value > 0.56, 0.74).

Conclusion

Nasal mupirocin administration following endoscopic sinus surgery cannot significantly prevent symptom recurrence in chronic rhinosinusitis with nasal polyps.

Association of Obesity and Severe Asthma in Adults

The incidence of obesity and asthma continues to enhance, significantly impacting global public health. Adipose tissue is an organ that secretes hormones and cytokines, causes meta-inflammation, and contributes to the intensification of bronchial hyperreactivity, oxidative stress, and consequently affects the different phenotypes of asthma in obese people. As body weight increases, the risk of severe asthma increases, as well as more frequent exacerbations requiring the use of glucocorticoids and hospitalization, which consequently leads to a deterioration of the quality of life. This review discusses the relationship between obesity and severe asthma, the underlying molecular mechanisms, changes in respiratory function tests in obese people, its impact on the occurrence of comorbidities, and consequently, a different response to conventional asthma treatment. The article also reviews research on possible future therapies for severe asthma. The manuscript is a narrative review of clinical trials in severe asthma and comorbid obesity. The articles were found in the PubMed database using the keywords asthma and obesity. Studies on severe asthma were then selected for inclusion in the article. The sections: 'The classification connected with asthma and obesity', 'Obesity-related changes in pulmonary functional tests', and 'Obesity and inflammation', include studies on subjects without asthma or non-severe asthma, which, according to the authors, familiarize the reader with the pathophysiology of obesity-related asthma.

Assessment of chronic rhinosinusitis with nasal polyps: Development of the Nasal Polyp Patient Assessment Scoring Sheet tool

Background

Chronic rhinosinusitis (CRS) is a heterogeneous disorder with a wide range of validated subjective and objective assessment tools to assess disease severity. However, a comprehensive and easy-to-use tool that integrates these measures for determining disease severity and response to treatment is still obscure. The objective of this study was to develop a standardized assessment tool that facilitates diagnosis, uniform patient monitoring, and comparison of treatment outcomes between different centers both in routine clinical practice and in research.

Methods

To develop this tool, published literature on assessment tools was searched on various databases. A panel of 12 steering committee members conducted an advisory board meeting to review the findings. Specific outcome measures to be included in a comprehensive assessment tool and follow-up sheet were then collated following consensus approval from the panel. The tool was further validated for content and revised with expert recommendations to arrive at the finalized Nasal Polyp Patient Assessment Scoring Sheet (N-PASS) tool.

Results

The N-PASS tool was developed by integrating the subjective and objective measures for CRS assessment. Based on expert opinions, N-PASS was revised to be used as an easy-to-use guidance tool that captures patient-reported and physician-assessed components for comprehensively assessing disease status and response to treatment.

Conclusion

The N-PASS tool can be used to aid in the diagnosis and management of CRS cases with nasal polyps. The tool would also aid in improved monitoring of patients and pave the way for an international disease registry.

Level of evidence

Oxford Level 3.

Comparison of cytokine expression and disease severity between plasma cell-dominant and eosinophil-dominant patients in chronic rhinosinusitis with nasal polyps

PURPOSE

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a heterogeneous disease characterized by inflammation of the nasal and sinus mucosa. The inflammatory patterns may differ among patients, leading to different subtypes based on the dominant inflammatory cell type. This study aimed to compare the differences in cytokine expression and disease severity between plasma cell-dominant and eosinophil-dominant subtypes in patients with CRSwNP.

METHODS

This study included 53 CRSwNP patients and 19 control subjects who did not have asthma or a history of cigarette smoking. The expression of cytokines and inflammatory cells was assessed via enzyme-linked immunosorbent assay (ELISA) and immunohistochemistry, respectively.

RESULTS

Among the cytokines analyzed, only IL-6 was significantly different between the two subtypes. A greater proportion of mast cells and IgE cells was present in plasma cell-dominant CRSwNP patients than in eosinophil-dominant group. For the three disease severity scores (LMK-CT, TPS and SNOT-22), objective scores (LMK-CT and TPS) were greater in the eosinophil-dominant CRSwNP group, while the opposite result was shown for the subjective score (SNOT-22). Additionally, the percentage of plasma cell-dominant cells was significantly positively correlated with disease severity according to the TPS and SNOT-22 scores.

CONCLUSIONS

Our data revealed that plasma cell-dominant inflammation, a subtype of type 2 CRS, was significantly correlated with subjective disease severity. The study also highlights the role of IL-6, IgE and mast cells as distinguishing factors between eosinophil-dominant and plasma cell-dominant CRSwNP. This information could be useful for clinical diagnosis and personalized treatment.

Updated epithelial barrier dysfunction in chronic rhinosinusitis: Targeting pathophysiology and treatment response of tight junctions

Tight junction (TJ) proteins establish a physical barrier between epithelial cells, playing a crucial role in maintaining tissue homeostasis by safeguarding host tissues against pathogens, allergens, antigens, irritants, etc. Recently, an increasing number of studies have demonstrated that abnormal expression of TJs plays an essential role in the development and progression of inflammatory airway diseases, including chronic obstructive pulmonary disease, asthma, allergic rhinitis, and chronic rhinosinusitis (CRS) with or without nasal polyps. Among them, CRS with nasal polyps is a prevalent chronic inflammatory disease that affects the nasal cavity and paranasal sinuses, leading to a poor prognosis and significantly impacting patients' quality of life. Its pathogenesis primarily involves dysfunction of the nasal epithelial barrier, impaired mucociliary clearance, disordered immune response, and excessive tissue remodeling. Numerous studies have elucidated the pivotal role of TJs in both the pathogenesis and response to traditional therapies in CRS. We therefore to review and discuss potential factors contributing to impair and repair of TJs in the nasal epithelium based on their structure, function, and formation process.

Upper and lower airway interactions in children

PURPOSE OF REVIEW

The aim of the present review was to highlight the interactions between rhinitis, rhinosinusitis and asthma in children and to discuss the most relevant scientific progresses in the pathophysiology and treatment of these combined conditions.

RECENT FINDINGS

Advances in understanding the mechanisms underlying the relationship between upper and lower airways have provided valuable insights into the role of eosinophils in the pathophysiology of inflammatory events and have further delineated the concept of united airway disease. Studies addressed to evaluate the burden of sinonasal system on asthma outcomes showed a parallel severity of upper and lower airway diseases. Histopathology of sinonasal tissue in patients with chronic rhinosinusitis is different in adults and children. Targeted administration of biological agents represents an effective treatment in patients with severe uncontrolled asthma, but specific trials are awaited in children with chronic sinonasal disease.

SUMMARY

Allergic rhinitis and rhinosinusitis are important comorbidities in patients with asthma. Improved knowledge of pathogenic mechanisms of inflammation and remodelling in the sinonasal system and the lung has led to new therapeutic approaches in patients with united airway disease and opened interesting perspectives for personalized drug therapies.

[Features of inflammatory endotypes and phenotypes in chronic rhinosinusitis]

Recently, significant progress has been made in identifying the cellular and molecular mechanisms responsible for the pathogenesis of chronic rhinosinusitis (CRS). Cohort studies of CRS have led to advances in the clinical understanding of this disease. New therapeutic agents have been approved or are undergoing clinical trials to expand treatment options for this disease. One of the promising areas in medicine is the provision of personalized clinical care. From this perspective, CRS can be divided into three different endotypes depending on the type of underlying inflammatory response. In the United States, CRS with and without nasal polyps is predominantly characterized as the second inflammatory endotype. CRS with nasal polyps (about 17%) and without nasal polyps (up to 20%) belongs to the 1st and 3rd inflammatory endotypes, respectively. And if for the second inflammatory endotype the effectiveness of targeted biological therapy is beyond doubt, then for the first and third inflammatory endotypes the principles of such conservative therapy are under active development. Moreover, large validated studies to confirm associations between CRS phenotypes and endotypes, as well as to find effective biological markers of inflammatory endotypes, remain to be performed.

[Acute and chronic rhinosinusitis age characteristics]

Children's and adults' rhinosinusitis are two diseases that have both similarities and differences in anatomy, epidemiology, causes, pathogenesis, diagnosis and treatment. At the same rhinosinusitis is one of the most common in otorhinolaryngology's practice, both in children and adults. The of adults paranasal sinuses (PNS) anatomy differs from children's PNS anatomy. Although ostiomeatal complex occlusion is recognized as a major cause of poor ventilation and drainage of the adult paranasal sinuses, it does not have a strong effect on pediatric rhinosinusitis, but adenoids play a key role. Adenoids are bacteria and biofilms reservoirs that cause chronic refractory rhinosinusitis regardless of pharyngeal tonsil size. The prevalence of chronic rhinosinusitis (CRS) is lower in children than in adults. Diagnosis of children's rhinosinusitis is more difficult because nasal cavity endoscopic examination is performed rarely due to the occasional need of general anesthesia during the procedure. Moreover, it's necessary to take into account prevailing etiological role of viruses in ARS at children's age and chronic adenoiditis often accompanies pediatric CRS, which requires attention prescribing medical therapy as the basis of rhinosinusitis treatment. The DysheLORz based on Pelargonium sidoides roots is highly effective and safe for children's and adults ARS and CRS treatment, both as monotherapy and in combination with topical steroids and antibiotics. This herbal medicine immunomodulatory effect is mediated mainly by stimulating the production of TNF-α, IL-1, IL-12 and IFN-γ. It activates macrophages and improves their phagocytic activity. IL-12, together with TNF-α, enhances NK and cytotoxic CD8+ lymphocytes' activity against infected cells. IL-12 effect on Th1 lymphocytes maturation provides a link between innate and adaptive immunity. This is also increasing MCP-1, IP-10 and MIP-1β chemokines synthesis and decreasing MIP-1α, ENA-78, GROα and IL-8 production in PNS and nasal mucosa. This leads to decrease of neutrophils chemotaxis to the inflammation site, and decline of serine proteases concentration (neutrophils main enzymes), that increases mucous membrane epithelial barrier permeability, reducing bacterial infections risk. Additionally, Pelargonium sidoides increases epithelial cells beating cilia frequency and inhibits hemagglutinin and neuraminidase present on influenza virus surface. The drug increases antimicrobial peptides production as defensins, human neutrophil peptides (HNP) and bactericidal permeability-increasing protein (BPI), which is also important for rapid inflammation regression in rhinosinusitis. It causes bacterial adhesion to epithelial cells inhibition, phagocytosis stimulation, nitric oxide (NO) release and oxidative burst. The medicine had a direct effect on Streptococcus pneumoniae, Staphylococcus aureus, Neisseria, Moraxella catarrhalis and Haemophilus influenza. Based on these data, it is possible to explain the high effectiveness and safety of the drugs based on Pelargonium sidoides in ENT organs inflammation treatment, for both adults and children over 1 year old.

Evaluation of Improvement in Chronic Rhinosinusitis After Endoscopic Sinus Surgery Using Sino-Nasal Outcome Test-22 (SNOT22) Symptom Score

Sino-Nasal Outcome Test (SNOT-22) symptom score is the most widely used questionnaire due to its easy interpretation with respect to quality of life (QOL) in patients with chronic rhinosinusitis (CRS). It helps in deciding further treatment plan in patients with refractory CRS despite maximal medical therapy (MMT). Endoscopic sinus surgery (ESS) is suggested in patients not responding to medical treatment. The preoperative and post-operative QOL for patients with CRS is assessed using SNOT-22. To assess SNOT-22 score change in CRS resistant to MMT. This is a longitudinal study conducted from April 2021-September 2022 included patients diagnosed to have CRS, satisfying the inclusion criteria. SNOT-22 for symptom severity assessed at the first visit, 1 week and 12 weeks and after MMT. Patients who failed MMT, posted for ESS. Post-operatively SNOT-22 symptom score re-assessed at 15 days, 1 month, 2 months and 3 months. 56 patients (male-51% and female-49%) who failed to respond to MMT included in the study. The five major troublesome symptoms nasal blockage (92.86%), need to blow nose (75%), facial pressure/pain (53.57%), post nasal discharge (51.79%), and sneezing (42.86%). The mean SNOT-22 symptom score when compared with pre-operatively (69.54 ± 8.973) and after FESS (2.09 ± 1.881) had improved significantly (p < 0.001). CRS is more frequently seen in males aged between 21 and 30 years. The patient-based outcome measures, like SNOT-22 helps to foresee the extent of post- operative improvement. The effective management of CRS is by surgical intervention.

Biologics in severe uncontrolled chronic rhinosinusitis with nasal polyps: A bicentric experience

BACKGROUND AND AIM

The introduction of biologics in the management of chronic rhinosinusitis with nasal polyposis (CRSwNP) has allowed new therapeutic options and Dupilumab represents the first approved biological agent. Aim of this paper is to provide a multicentric study in a real-life setting of treatment with Dupilumab for severe uncontrolled CRSwNP in Italy.

METHODS

A retrospective data collection was performed from the departments of Otolaryngology of two major health institutions in Rome: San Camillo Forlanini Hospital and Tor Vergata University. Both centres contributed to the study providing information about patients affected by severe uncontrolled CRSwNP and treated with Dupilumab.

RESULTS

A total of 83 patients were included in the study (43 males; 40 females; mean age: 55.8 years). Monitoring our patients, we observed improvement in reduction of nasal polyposis and nasal obstruction, respectively measured through NPS and PNIF. Concerning the CRSwNP symptoms and their impact on quality of life, we found an improvement in the olfaction, as measured respectively by SSIT-16 and SNOT-22.

CONCLUSIONS

Dupilumab has demonstrated broad efficacy in CRSwNP management. Further studies are needed to confirm our results and to establish biomarkers to identify endotypes and predict response to biologics treatment in CRSwNP.

The Association Between Eosinophils and the Disease Process in Destructive Non-invasive Fungal Rhinosinusitis

OBJECTIVE

This study aims to investigate the significance of eosinophils in the progression and prognosis of destructive non-invasive fungal rhinosinusitis.

METHODS

This was a retrospective study of 126 patients who were operated on for a nasal sinus disease between 2010 and 2017; of these, 56 met the inclusion criteria. These were divided into two groups: (i) Group 1, with only the destructive non-invasive sinus polyposis type, and (ii) Group 2, with all types of nasal polyposis other than the destructive non-invasive sinus fungal polyposis type. Data including demographic data, paranasal sinuses (PNS) CT scans, pre- and post-operative eosinophils count, histopathology of polyps, and fungal cultures were collected from medical records from King Abdulaziz University Hospital, Jeddah, Saudi Arabia. A nonparametric Wilcoxon signed-rank test was used to determine a significant difference of p< 0.05. We performed multivariate analysis using repeated measure analysis of covariance (ANCOVA) and adjusted for confounders such as age, sex, pre- and post-operative IgE, fungal culture, and histopathology of the disease. Interaction between age, sex, IgE, and proportion of eosinophils was assessed at a p-value of 0.05.

RESULTS

A significant difference was found between pre-and post-operative blood eosinophils levels in Group 1 (p= 0.01) after adjusting for confounders such as age, sex, fungal culture, pre and post IgE, and histopathology of the disease. However, no significant difference was found in Group 2 (p= 0.663) even after adjusting for age, sex, fungal culture, pre and post IgE, and histopathology of the disease. We did not find any significant interaction (P>0.05) between pre- and post-operative levels of eosinophils with age, sex, and fungal culture among Group 1 and Group 2.

CONCLUSIONS

There is a statistically significant difference in blood eosinophils between pre- and post-operative levels in studied cases of destructive non-invasive fungal polyposis, a difference is not seen in nasal sinus polyp cases other than destructive non-invasive fungal polyposis types. High pre-operative eosinophils levels in destructive non-invasive fungal sinus polyposis types demonstrated the importance of eosinophils in the pathogenesis of this disease. The blood eosinophils can therefore be considered an important factor in the disease process and an indicator of the disease prognosis and destructive behavior.

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.

Management paradigms for chronic rhinosinusitis in individuals with asthma: An evidence-based review with recommendations

BACKGROUND

Despite the significant morbidity associated with chronic rhinosinusitis (CRS) in individuals with asthma (CRSwA), there is a paucity of codified, evidence-based management strategies for CRS in this population.

METHODS

Using PubMed, Embase, and Cochrane Review Databases, a systematic review was performed covering management strategies for CRSwA. A total of 5903 articles were screened, and 70 were included for full-text analysis. After application of exclusion criteria, 53 articles comprised the qualitative synthesis. The level of evidence was graded and benefit-harm assessments, as well as value judgment and recommendations, were provided RESULTS: Strong evidence confirms the benefit of oral and topical medications on sinonasal-specific outcomes in individuals with CRSwA; there is low-grade evidence demonstrating that these agents improve lung function and/or asthma control. Moderate to strong evidence suggests that endoscopic sinus surgery (ESS) improves both sinonasal- and asthma-specific quality of life. Although there is insufficient to low evidence to indicate that ESS improves pulmonary function in this population, data indicate a positive impact of this intervention on asthma control. Biologic medications strongly improve both subjective and objective sinonasal- and asthma-specific outcomes.

CONCLUSION

Evidence supports managing CRS in individuals with CRSwA in a stepwise fashion, starting with traditional nonbiologic oral and topical medication, and escalating to second-line treatments, such as ESS and biologics. Optimal treatment of individuals who have CRSwA often requires concurrent, directed management of asthma, as not all CRS interventions impact asthma status.

Current evidence of biofilms in chronic rhinosinusitis- a microbiological perspective

INTRODUCTION

Chronic rhinosinusitis (CRS) is characterized by inflammation of the paranasal sinus mucosa persisting for more than 12 weeks. This condition is associated with reduced quality-of-life and causes a high direct and indirect economic burden. Several pathogenic factors have been attributed to CRS, including bacterial and fungal biofilms on the sinonasal mucosa. Biofilms are well-established contributors to recalcitrance to treatment in other chronic inflammatory mucosal conditions such as cystic fibrosis and otitis media.

AREAS COVERED

This review will present an overview of the role of biofilms in CRS, including the evidence for biofilms being present on the sinonasal mucosa and their implications for disease severity. Furthermore, the interactions between biofilms and host-mediated immune factors are explored.

EXPERT OPINION

The eradication of biofilms has been a focus of research shortly after their recognition as a cause of disease. The currently available methodologies for identifying biofilms on mucosal surfaces are not sufficiently well-developed to be used in a clinical setting. A more accurate, cheaper, faster approach for biofilm detection is necessary, and molecular techniques may provide the possibility for this.

Novel insights into central compartment atopic disease - a literature review

INTRODUCTION

Central compartment atopic disease (CCAD) is a newly recognized variant subtype of chronic rhinosinusitis (CRS). Although CCAD has been reported to be correlated with allergy, there is still a considerable gap in our knowledge regarding CCAD.

AREAS COVERED

We have conducted a thorough analysis of the literature on CCAD. This review provides current understanding and therapeutic strategies of CCAD. In this article, we will review the clinical presentations and parameters, allergy-related etiology, endotypes, and recommended management of CCAD.

EXPERT OPINION

CCAD is considered as an aeroallergen-driven type 2/eosinophilic inflammatory pattern. Although CCAD can be diagnosed by endoscopy and radiology, as well as allergen test, pathogenesis and management strategies leave much to be desired, and further studies are needed.

The functional role and the clinical application of periostin in chronic rhinosinusitis

INTRODUCTION

Chronic rhinosinusitis (CRS) comprises several heterogenous groups, now classified based on endotype more often than on phenotype. A number of studies aimed at finding a useful biomarker for type 2 CRS suggest that periostin is a promising surrogate.

AREAS COVERED

A comprehensive overview of the clinical significance of tissue periostin expression and serum periostin in CRS patients is provided. The effects of comorbid asthma on serum periostin and samples other than serum in which periostin can be detected in CRS patients are also discussed. Moreover, the functional roles of periostin in CRS pathogenesis are summarized.

EXPERT OPINION

The position of periostin as a signature biomarker of type 2 CRS has been well established, enabling us to classify CRS patients by endotyping. Serum periostin is useful not only for endotyping CRS patients, but also for estimating disease severity, comorbidity, prognosis, and response to treatment, and in particular, predicting recurrence after surgery. However, it remains to be addressed how we apply serum periostin to using biologics for CRS patients. Further studies aimed at showing periostin to be a therapeutic target for CRS are awaited.

LRIG1 Levels in Chronic Rhinosinusitis With Nasal Polyps

Purpose: Nasal polyps (NPs), usually occurring together with chronic rhinosinusitis (CRS), are benign masses of mucosal origin arising from inflammation. The transmembrane protein known as leucine-rich repeats and immunoglobulin-like domains 1 (Lrig1) is a member of the Lrig family. Lrig1 is frequently expressed in the respiratory tract and epithelial tissues and can inhibit several signaling pathways involved in cell proliferation. The aim of this study was to determine Lrig1 levels in NP tissues of patients with CRS. Material and Methods: This study included 36 patients with CRS and NPs and 15 patients who underwent rhinoplasty as the control group. The Lrig1 levels of all participants were measured by the ELISA method. Results: This study revealed that Lrig1 levels were significantly lower in NP tissues than in tissues of the control group. The mean level of Lrig1 of the NP tissues was 22.2 ng/ml, while the mean level of the control group was 28.5 ng/ml. According to the results of ROC analysis, Lrig1 levels have the power to distinguish polyp tissues from control tissues (AUC=0.794). Lrig1 levels were higher in tissues with scores of 4-8 than in tissues with scores of 16-20 based on the results of computed tomography scoring. According to endoscopic evaluations, Lrig1 levels of tissues with scores of 5-8 or 9-11 were relatively lower than those of tissues with scores of 2-4. Conclusion: Lrig1 levels were found to be decreased in NP tissues. Thus, Lrig1 may be used to confirm the presence of NPs. Lrig1 may also be helpful in NP grading. Increasing the Lrig1 levels in cases of NPs has the potential to become a targetable treatment modality.

Biologicals in the treatment of chronic rhinosinusitis with nasal polyps – position of the Polish Society of Otorhinolaryngologists –Head and Neck Surgeons and the Polish Society of Allergology experts

Chronic rhinosinusitis with nasal polyps (CRSwNP) has a significant impact on the well-being and social functions of the patient. The generalized inflammatory process with the formation of nasal polyps and excess eosinophils in the mucosa of the paranasal sinuses is called type 2 inflammation, which is mediated by Th2 lymphocytes – cells of the immune system responsible for chronic inflammatory processes. Today, we also know the key pro-inflammatory mediators against which new drugs have been developed, the so-called biological drugs, are produced in cell lines. In this document, we present currently available biologicals approved for the treatment of patients with T2-related chronic rhinosinusitis.

B Lineage Cells and IgE in Allergic Rhinitis and CRSwNP and the Role of Omalizumab Treatment

BACKGROUND

Allergic rhinitis (AR) and chronic rhinosinusitis (CRS) are two prevalent nasal diseases where both type 2 inflammation and immunoglobulin E (IgE) may play important roles. Although they can exist independently or comorbidly, subtle but important differences exist in immunopathogenesis.

OBJECTIVE

To summarize current knowledge of pathophysiological roles of B lineage cells and IgE in AR and CRS with nasal polyps (CRSwNP).

METHODS

Searched PubMed database, reviewed AR and CRSwNP-related literature, and discussed disease diagnosis, comorbidity, epidemiology, pathophysiology, and treatment. Similarities and differences in B-cell biology and IgE are compared in the 2 conditions.

RESULTS

Both AR and CRSwNP have evidence for pathological type 2 inflammation, B-cell activation and differentiation, and IgE production. However, distinctions exist in the clinical and serological profiles at diagnosis, as well as treatments utilized. B-cell activation in AR may more frequently be regulated in the germinal center of lymphoid follicles, whereas CRSwNP may occur via extrafollicular pathways although controversies remain in these initial activating events. Oligoclonal and antigen-specific IgE maybe predominate in AR, but polyclonal and antigen-nonspecific IgE may predominate in CRSwNP. Omalizumab has been shown efficacious in treating both AR and CRSwNP in multiple clinical trials but is the only Food and Drug Administration-approved anti-IgE biologic to treat CRSwNP or allergic asthma. Staphylococcus aureus frequently colonizes the nasal airway and has the ability to activate type two responses including B-cell responses although the extent to which it modulates AR and CRSwNP disease severity is being investigated.

CONCLUSION

This review highlights current knowledge of the roles of B cells and IgE in the pathogenesis of AR and CRSwNP and a small comparison between the 2 diseases. More systemic studies should be done to elevate the understanding of these diseases and their treatment.

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.

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.

Multidisciplinary approaches to identifying and managing global airways disease: Expert recommendations based on qualitative discussions

Background

Chronic rhinosinusitis with nasal polyps (CRSwNP) and asthma frequently co-exist and share pathologic features. Taking a "global" treatment approach benefits diagnosis and treatment of both, but care is often siloed by specialty: joined-up clinics are uncommon. Our objectives were to explore expert opinion to give practical suggestions to identify adults needing global airways care; enhance cross-specialty working; and widen knowledge to support diagnosis and management, integrate with existing care pathways, and supplement existing guidelines.

Methods

Sixteen practicing physicians from northern Europe were invited for their national and/or international standing in treating asthma and/or chronic rhinosinusitis. Appreciative Inquiry techniques were used to guide their discussions.

Results

Key themes arising were screening and referral, collaboration on management, awareness and education, and research. Provided are screening criteria and suggestions for specialist referrals, and pointers for physicians to optimize their knowledge of global airways disease. Collaborative working is underscored, and practical suggestions are given for multidisciplinary teamworking within global airways clinics. Research gaps are identified.

Conclusion

This initiative provides practical suggestions for optimizing the care of adults with CRSwNP and asthma. Discussion of the role of allergy and drug exacerbations on these conditions, and care for patients with other global airways diseases were beyond scope; however, we expect some principles of our discussion will likely benefit patients with related conditions. The suggestions bridge asthma and CRSwNP management guidelines, envisioning interdisciplinary, global airway clinics relevant to various clinical settings. They highlight the value of joint screening for early recognition and referral of patients.

Geriatric otorhinolaryngology: reasons for outpatient referrals from generalists to ENT specialists

PURPOSE

To determine the main symptoms leading to referral of geriatric patients from primary care to otorhinolaryngology.

METHODS

 Retrospective, observational study performed on patients aged 65 and older, referred from Primary Care to the Otorhinolaryngology and Head and Neck Surgery department of a tertiary centre during 2019 and 2020. Symptoms leading to otorhinolaryngological referral were categorized as "Oto-neurological symptoms", "Nasal symptoms", "Pharyngolaryngeal symptoms", "Other Head and Neck symptoms" and "Other Reasons". Data regarding age, gender and whether patients maintain follow-up or have been discharged was also collected.

RESULTS

 The study population included a total of 1304 patients (697 female; 607 male). Oto-neurological symptoms were found to be the most prevalent symptoms, with 65% of patients reporting oto-neurological symptoms as at least one of the reasons for referral. Hearing loss was the most commonly reported symptom, with an association found between this symptom and age (p < 0.001). Results also showed an association between the female gender and vertigo/dizziness (p < 0.001) and tinnitus (p = 0.007). An association between the male gender and nasal symptoms was also found (p = 0.018), particularly nasal obstruction (p = 0.003) and epistaxis (p = 0.028). No statistically significant associations were found among the pharyngolaryngeal group.

CONCLUSIONS

 This retrospective observational study allowed for a better understanding of the type of otorhinolaryngological symptoms affecting elderly patients and driving otorhinolaryngology evaluation, cementing hearing loss as one of the major complaints among older adults and allowing for a better preparation by otorhinolaryngologists for the changing needs of this subset of the population.

A Decade of Clinical Advances in Chronic Rhinosinusitis: 2012-2022

The field of chronic rhinosinusitis (CRS) is constantly evolving. In the past 10 years, key advancements in basic and translational research as well as clinical studies have improved our understanding and management of CRS. Notably, treatment options have expanded to include novel therapeutic drugs, devices, and surgical techniques. Assessments of patient symptoms and their impact on quality of life have become more standardized. Progress has also been made in both determining the true prevalence of CRS and recognizing comorbidities that can impact CRS severity. Practice guidelines have also shifted from expert opinion to more data-driven analyses. This review highlights major clinical advancements made in the field of CRS over the past 10 years as well as identifies current gaps in knowledge that can form the basis for new areas of study over the next decade.

Current evaluation and management of patients with chronic rhinosinusitis and nasal polyps

INTRODUCTION

A clear understanding of the pathophysiology of chronic rhinosinusitis with nasal polyps (CRSwNP) and its close association with other airway pathologies, especially asthma, helps to comprehend the concept of the united airway and the importance of a multidisciplinary approach and the actual roll of biologic therapy.

AREAS COVERED

This expert review is the synthesis of a working group on the current state of the art of the evaluation and management of CRSwNP. A thorough analysis of the literature has been conducted for the latest studies and results, specially the European (EPOS 2020) and American (ICAR-RS 2021) guidelines.

EXPERT OPINION

The roles of optimal medical treatment and indications for surgery are becoming clearer, but much research is still needed regarding the extent and radicality when surgery is indicated. The main objectives of this review were to provide a clear and updated description of treatments, their indication, follow-up, and response criteria. These steps are considering the broad spectrum of inflammation endophenotypes and the biologic therapy available. Understanding the role and limitations of each specialty is key for providing greatest benefit to the patient.

White blood cells and chronic rhinosinusitis: a Mendelian randomization study

BACKGROUND

Risk factors for the pathogenesis of chronic rhinosinusitis (CRS) remain largely undetermined, which is likely due to the heterogeneity of the disease. White blood cell counts have been largely unexplored as a risk factor for CRS even though different types of white blood cells are involved in the inflammatory process of CRS.

OBJECTIVE

To investigate causal associations between different types of white blood cells on risk of CRS utilizing a Mendelian randomization (MR) analysis.

METHODS

A two-sample MR analysis was performed using respective GWAS summary statistics for the exposure traits (neutrophil count, eosinophil count, basophil count, lymphocyte count, and monocyte count) and outcome trait (CRS). For the exposure traits, the European Bioinformatics Institute database of complete GWAS summary data was used. For the outcome trait, summary statistics for CRS GWAS were obtained from FinnGen. Primary analysis for MR was performed using inverse-variance weighted two-sample MR. Sensitivity analyses included weighted median, MR-Egger, and MR-PRESSO (raw and outlier-corrected).

RESULTS

Eosinophils were associated with CRS (OR = 1.55 [95% CI 1.38, 1.73]; p = 4.3E-14). Eosinophil results were similar across additional MR methods. MR results did not demonstrate significant causal relationships between neutrophils, lymphocytes, monocytes, or basophils with CRS. No significant pleiotropic bias was observed.

CONCLUSIONS

In a two-sample MR analysis, a potential causal link between blood eosinophil counts and CRS has been demonstrated. In addition, causal relationships between blood counts among other white blood cell types and CRS were not found. Further studies involving genetic variation in CRS are needed to corroborate genetic causal effects for CRS.

The role of hypoxia in the pathophysiology of chronic rhinosinusitis

Chronic rhinosinusitis (CRS) is a chronic inflammatory disease of the nasal cavity characterized by excessive nasal mucus secretion and nasal congestion. The development of CRS is related to pathological mechanisms induced by hypoxia. Under hypoxic conditions, the stable expression of both Hypoxia inducible factor-1 (HIF-1) α and HIF-2α are involved in the immune response and inflammatory pathways of CRS. The imbalance in the composition of nasal microbiota may affect the hypoxic state of CRS and perpetuate existing inflammation. Hypoxia affects the differentiation of nasal epithelial cells such as ciliated cells and goblet cells, induces fibroblast proliferation, and leads to epithelial-mesenchymal transition (EMT) and tissue remodeling. Hypoxia also affects the proliferation and differentiation of macrophages, eosinophils, basophils, and mast cells in sinonasal mucosa, and thus influences the inflammatory state of CRS by regulating T cells and B cells. Given the multifactorial nature in which HIF is linked to CRS, this study aims to elucidate the effect of hypoxia on the pathogenic mechanisms of CRS.

An Integrated Analysis of Inflammatory Endotypes and Clinical Characteristics in Chronic Rhinosinusitis with Nasal Polyps

Objective

Chronic rhinosinusitis with nasal polyps (CRSwNP) is mainly characterised by type 1 (T1), type 2 (T2) and type 3 (T3) inflammatory endotypes. However, correlations between inflammatory endotypes and clinical features in CRSwNP have not been demonstrated sufficiently. This study aimed to determine the endotype-phenotype associations in CRSwNP.

Methods

Clinical data of 31 control subjects and 106 CRSwNP patients were analysed. Interferon (IFN)-γ (T1), Charcot-Leyden crystal galectin (CLC) (T2) and Interleukin (IL)-17A (T3) were used as biomarkers to identify the inflammatory endotypes.

Results

The mRNA expression level of IFN-γ was positively correlated with IL-17A (r = 0.817; P < 0.0001). Headache/facial pain (P = 0.039) was associated with T1 endotype. Smell loss (P = 0.025) was associated with T2 endotype. Purulent rhinorrhea (P = 0.001) was associated with T3 endotype. Atopy (P = 0.030), asthma (P = 0.005) and recurrence (P = 0.022) were more frequent in T2 endotype. Total Symptom Scores (TSS) of T2 (P < 0.001) and T3 (P = 0.009) endotype were higher than non-T2 and non-T3, respectively. Sino Nasal Outcome Test-22 (SNOT-22) total scores of T3 (P = 0.054) endotype were higher than non-T3.

Conclusion

Identifications of endotype-phenotype associations are useful in clinical diagnoses and targeted therapies for patients with CRSwNP.

Clinical and economic burden of chronic rhinosinusitis with nasal polyposis: A U.S. administrative claims analysis

Background: Limited data exist on the clinical and economic burden of chronic rhinosinusitis with nasal polyposis (CRSwNP). Objective: To describe patient characteristics, health-care resource utilization (HCRU), and health-care costs among patients with CRSwNP with and without comorbid asthma (primary analysis) and with surgical management of nasal polyps (secondary analysis). Methods: This was a retrospective study of patients diagnosed with CRSwNP conducted using administrative claims data from January 1, 2013, through March 31, 2019. Study outcomes were assessed over a 2-year follow-up. Results were stratified by baseline asthma status (primary analysis) and presented separately for patients with surgically managed CRSwNP (secondary analysis). Results: The primary analysis included 10,999 patients with CRSwNP (2649 with asthma, 8350 without asthma). Patients with versus without asthma had higher medication use, HCRU, and all-cause medical costs (mean ± standard deviation $34,667 ± $42,234 versus $27,122 ± $45,573; p < 0.001) across the full follow-up period. CRSwNP-related medical costs were significantly higher for patients with versus without asthma in year 2 of follow-up. In the surgical management analysis (n = 4943), most categories of medication use and CRSwNP-related HCRU declined from baseline levels during follow-up, and CRSwNP-related pharmacy costs in year 2 were less than half of baseline levels. Conclusion: Patients diagnosed with CRSwNP and asthma had a greater burden of illness than those without asthma. Higher CRSwNP-related medical costs in year 2 of follow-up for patients with asthma may indicate worsening symptoms over time. Among patients with surgically managed CRSwNP, HCRU and costs increased in year 1 of follow-up but decreased below baseline levels in year 2, potentially reflecting improved symptom severity.

XBP1 Regulates the Transcription of HIF-1a in BALB/c Mice with Chronic Rhinosinusitis without Polyps

X-box binding protein 1 (XBP1) is a transcription factor that recognizes the CRE-like element in enhancers of human T-cell leukemia virus and MHC class II gene and induces their transcription. This study was performed to characterize the function of XBP1, which was identified to be a differentially expressed gene via GEO database, in chronic rhinosinusitis (CRS) without nasal polyps (CRSsNP). XBP1 expression was significantly elevated in both CRSsNP patients and mice who were accompanied with mucosal thickening, goblet cell hyperplasia and chemosis, glandular hyperplasia, and dense infiltration of inflammatory cells. Silencing of XBP1 suppressed the development of CRSsNP in mice. Mechanistically, knockdown of XBP1 downregulated the expression of hypoxia-inducible factor 1-alpha (HIF-1a), and overexpression of XBP1 led to the opposite result. Silencing of HIF-1a inhibited β-catenin expression and impaired the Wnt/β-catenin pathway. Further overexpression of HIF-1a in XBP1-silenced CRSsNP mice exacerbated pathological changes in mouse nasal mucosal tissues, promoted inflammation, and activated the Wnt/β-catenin pathway. Taken together, overexpression of XBP1 may be associated with increased expression of HIF-1a and possibly contribute to the Wnt/β-catenin pathway activation and the development of CRSsNP.

Efficacy of an oral CRTH2 antagonist (AZD1981) in the treatment of chronic rhinosinusitis with nasal polyps in adults: A randomized controlled clinical trial

BACKGROUND

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a type 2 inflammatory disease of the upper airways. AZD1981 is a selective antagonist of chemoattractant receptor-homologous molecule expressed on T helper type 2 and other type 2 cells, including innate lymphoid cells type 2, eosinophils, and basophils.

OBJECTIVE

To evaluate the efficacy of AZD1981 in reducing nasal polyp size when added to intranasal corticosteroids in adult patients with CRSwNP.

METHODS

Eighty-one subjects (18-70 years of age) with CRSwNP were recruited and screened for trial eligibility from allergy and otolaryngology clinics from a single tertiary care site between June 2016 and August 2019. Eligible patients were randomized in a double-blind fashion to receive either AZD1981 (n = 22) or placebo (n = 21) orally three times a day for 12 weeks, added to intranasal corticosteroids. The primary endpoint was a change in nasal polyp score (NPS) at 12 weeks. Secondary endpoints included improvement in sinus computed tomography using Lund Mackay scoring, symptoms using visual analog scale, quality of life using Sino Nasal Outcome Test-22, and the Brief Smell Identification Test.

RESULTS

Forty-three patients met the inclusion criteria and were enrolled. At 12 weeks, there was no difference in NPS change in the AZD1981 arm (mean 0, standard error 0.34, n = 15) compared with placebo (mean 0.20, standard error 0.36, n = 17); mean difference -0.20 (95% confidence interval: -1.21, 0.81; p = .69). No significant differences were observed for Lund Mackay score, symptoms, quality of life, or smell test. AZD1981 was well tolerated except for one case of hypersensitivity reaction.

CONCLUSION

In patients with CRSwNP, the addition of AZD1981 to intranasal corticosteroids did not change nasal polyp size, radiographic scores, symptoms, or disease-specific quality of life.

Chronic Rhinosinusitis With Nasal Polyps: Quality of Life in the Biologics Era

Chronic rhinosinusitis (CRS) affects up to 12% of the general population and is traditionally divided into two main phenotypic subsets, based on the presence of nasal polyps (CRSwNP) or their absence. It is well-established that many patients with CRSwNP report poor quality of life (QoL), which is further compromised by comorbidities (eg, asthma, bronchiectasis, aspirin-exacerbated respiratory disease). Chronic rhinosinusitis CRS with nasal polyps is managed with a combination of medical therapy and surgical interventions, and biologics are emerging as a promising new treatment option for patients with inadequate response to the standard of care. A range of patient-reported outcome measures have been used to assess QoL for patients with CRSwNP in clinical trials, including disease-specific questionnaires (eg, Sino-Nasal Outcome Test-22) and generic ones (eg, Short Form-36). Significantly impaired QoL has been identified as a criterion for the indication to use biologics in patients with CRSwNP. This review summarizes clinical evidence (2010-2021) on QoL outcomes with currently available treatments for CRSwNP and assesses the improvement in QoL after biologic treatments, especially for patients with comorbidities reported in interventional studies (randomized controlled trials and real-world experience).