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Ríos-Deidán C, Reyes MS, Acosta-Castillo T, Escalante-Fiallos E, Villacrés-Silva D. Histological Characteristics of Chronic Allergic Rhinitis Versus Non-allergy: Is There a Difference in the Remodeling? Indian J Otolaryngol Head Neck Surg 2023; 75:3364-3372. [PMID: 37974791 PMCID: PMC10645690 DOI: 10.1007/s12070-023-03922-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 05/29/2023] [Indexed: 11/19/2023] Open
Abstract
Demonstrate the histological remodeling changes in the turbinates, identify the frequency of the two forms of rhinitis in the samples studied and determine the remodeling differences found in the two variants. Patients attended an otolaryngology service at the Social Security Hospital of city Sangolqui-Ecuador from February 2016 to June 2017. The allergic variant was determined when eosinophils were found by higher magnification field and non-allergic when they were not found in the submucosal segment. Epithelial, inflammatory, and stromal markers were analyzed. One hundred twenty histopathological samples were analyzed, 75% presented allergic rhinitis, the age averaged 36.2 years. When we compared between the allergic and non-allergic variants: epithelial and stromal markers we had significant differences, as well as between each of its components; except fibrosis. In relation to the inflammatory pattern, there were significant differences between the number of mast cells and stromal markers with eosinophils > 10 by field. The allergic type corresponded to 75% of patients with persistent severe rhinitis who underwent turbinectomy. Regarding remodeling, there was a statistically significant difference in favor of the allergic variant. Eosinophilia greater than 10 was directly related to mastocytosis and subepithelial edema.
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Affiliation(s)
- Carlos Ríos-Deidán
- Otorhinolaryngology Department of Medical Sciences Faculty, Central University of Ecuador, 170527 Quito, Ecuador
| | - Maria-Soledad Reyes
- Pathology Unit, Ecuadorian Institute of Social Security Sangolquí, Sangolquí, Ecuador
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Cui Y, Wang K, Shi J, Sun Y. Endotyping Difficult-to-Treat Chronic Rhinosinusitis with Nasal Polyps by Structured Histopathology. Int Arch Allergy Immunol 2023; 184:1036-1046. [PMID: 37331342 DOI: 10.1159/000530864] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 04/13/2023] [Indexed: 06/20/2023] Open
Abstract
INTRODUCTION This study aimed to identify the histopathologic characteristics associated with difficult-to-treat chronic rhinosinusitis with nasal polyps (CRSwNPs), enabling physicians to predict the risk of poor outcome after endoscopic sinus surgery (ESS). METHODS A prospective cohort study performed at the First Affiliated Hospital of Sun Yat-sen University between January 2015 and December 2018 with CRSwNP patients who underwent ESS. Polyp specimens were collected during surgery and were subjected to structured histopathological evaluation. Difficult-to-treat CRSwNPs were determined at 12-15 months post-operation according to the European Position Paper. Multiple logistic regression model was used to assess the association between histopathological parameters and the difficult-to-treat CRSwNP. RESULTS Among 174 subjects included in the analysis, 49 (28.2%) were classified with difficult-to-treat CRSwNP, which had higher numbers of total inflammatory cells, tissue eosinophils, and percentages of eosinophil aggregates and Charcot-Leyden crystals (CLC) formation but a lower number of interstitial glands than the nondifficult-to-treat CRSwNP. Inflammatory cell infiltration (adjusted OR: 1.017), tissue eosinophilia (adjusted OR: 1.005), eosinophil aggregation (adjusted OR: 3.536), and CLC formation (adjusted OR: 6.972) were independently associated with the difficult-to-treat outcome. Furthermore, patients with tissue eosinophil aggregation and CLC formation had an increasingly higher likelihood of uncontrolled disease versus those with tissue eosinophilia. CONCLUSION The difficult-to-treat CRSwNP appears to be characterized by increased total inflammatory infiltrates, tissue eosinophilia, eosinophil aggregation, and CLC formation in structured histopathology.
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Affiliation(s)
- Yueming Cui
- Department of Otolaryngology, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Kanghua Wang
- Department of Otolaryngology, the Seventh Affiliated Hospital of Sun Yat-sen University, Shenzhen, China
| | - Jianbo Shi
- Department of Otolaryngology, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yueqi Sun
- Department of Otolaryngology, the Seventh Affiliated Hospital of Sun Yat-sen University, Shenzhen, China
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Molecular and Clinical Predictors of Quality of Life in Chronic Rhinosinusitis with Nasal Polyps. J Clin Med 2023; 12:jcm12041391. [PMID: 36835929 PMCID: PMC9965377 DOI: 10.3390/jcm12041391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 12/19/2022] [Accepted: 01/31/2023] [Indexed: 02/12/2023] Open
Abstract
(1) Background: Factors influencing the quality of life (QoL) of patients with chronic rhinosinusitis with nasal polyposis (CRSwNP) are poorly understood. We set out to determine the predictive factors on patients' QoL using the Sino-Nasal Outcome Test-22 (SNOT-22); (2) Methods: An ambispective analysis of data from patients diagnosed with CRSwNP in our institution. All the patients underwent a nasal polyp biopsy and completed the SNOT-22 questionnaire. Demographic and molecular data as well as the SNOT-22 scores were collected. Patients were classified in six subgroups considering the presence of asthma, non-steroidal drugs (NSAID) intolerance and corticosteroid resistance; (3) Results: The mean SNOT-22 score was 39. Considering the clinical parameters, the SNOT-22 value was significantly associated with NSAID intolerance (p = 0.04) and the endoscopic polyp score (p = 0.04). A high SNOT-22 value was also correlated with high tissue eosinophilia (p = 0.01) and high IL-8 expression; (4) Conclusions: Eosinophilia, IL-8 expression and NSAID intolerance can be used as predictors of worse QoL in patients with CRSwNP.
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Sharbel D, Li M, Unsal AA, Tadros SY, Lee J, Biddinger P, Holmes T, Kountakis SE. Use of mucosal eosinophil count as a guide in the management of chronic rhinosinusitis. Int Forum Allergy Rhinol 2020; 10:474-480. [DOI: 10.1002/alr.22517] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 11/13/2019] [Accepted: 12/10/2019] [Indexed: 11/08/2022]
Affiliation(s)
- Daniel Sharbel
- Department of Otolaryngology–Head and Neck SurgeryMedical College of Georgia at Augusta University Augusta GA
| | - Mingsi Li
- Department of Otolaryngology–Head and Neck SurgeryMedical College of Georgia at Augusta University Augusta GA
| | - Aykut A. Unsal
- Department of Otolaryngology–Head and Neck SurgeryDrexel University College of Medicine Philadelphia PA
| | - Sandra Y. Tadros
- Department of Otolaryngology–Head and Neck SurgeryNew York University Langone Health New York City NY
| | - Jason Lee
- Department of Otolaryngology–Head and Neck SurgeryUniversity of Kansas Medical Center Kansas City KS
| | - Paul Biddinger
- Department of PathologyMedical College of Georgia at Augusta University Augusta GA
| | - Thomas Holmes
- Department of Otolaryngology–Head and Neck SurgeryMedical College of Georgia at Augusta University Augusta GA
| | - Stilianos E. Kountakis
- Department of Otolaryngology–Head and Neck SurgeryMedical College of Georgia at Augusta University Augusta GA
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Song Y, Yin J, Chang H, Zhou Q, Peng H, Ji W, Song Q. Comparison of four staining methods for detecting eosinophils in nasal polyps. Sci Rep 2018; 8:17718. [PMID: 30531899 PMCID: PMC6286356 DOI: 10.1038/s41598-018-36102-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 11/14/2018] [Indexed: 12/17/2022] Open
Abstract
The study aimed to find a more appropriate method to detect eosinophils in formalin- fixed nasal polyps, since there is no consensus on the standard counting method of eosinophils now. Four 5 μm serial sections were obtained from each 10% neutral formalin-fixed paraffin block and were stained with Chromotrope 2R, Congo red, MBPmAb immunohistochemistry, and conventional hematoxylin and eosin stain respectively. Each section was scanned by the Aperio digital section scanner. The same selected areas were procured for assessment in the serial sections. Chromotrope 2R and MBPmAb immunohistochemistry were specific in detecting eosinophils, which had the lower background staining compared with Congo red and conventional hematoxylin and eosin stain. There were significant differences among the four methods in terms of the eosinophil counting data (p < 0.05), while no significant difference between Chromotrope 2R and Congo red (P = 0.1413). The eosinophil counts in nasal polyps could be more accurately assessed by Chromotrope 2R and Congo red compared with MBPmAb immunohistochemistry and conventional hematoxylin and eosin stain. The popularization of Chromotrope 2R and Congo red may help to unify the eosinophil count in the definition of eosinophilic CRSwNP.
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Affiliation(s)
- Yu Song
- Peking University Ninth School of Clinical Medicine, Beijing, 100038, China
| | - Jinshu Yin
- Peking University Ninth School of Clinical Medicine, Beijing, 100038, China.
- Department of Otorhinolaryngology-Head and Neck Surgery, Beijing Shijitan Hospital of Capital Medical University, Beijing, 100038, China.
| | - Hong Chang
- Department of Pathology, Beijing Shijitan Hospital of Capital Medical University, Beijing, 100038, China
| | - Quan Zhou
- Department of Pathology, Beijing Shijitan Hospital of Capital Medical University, Beijing, 100038, China
| | - Hong Peng
- Department of Otorhinolaryngology-Head and Neck Surgery, Beijing Shijitan Hospital of Capital Medical University, Beijing, 100038, China
| | - Wei Ji
- Department of Otorhinolaryngology-Head and Neck Surgery, Beijing Shijitan Hospital of Capital Medical University, Beijing, 100038, China
| | - Qingkun Song
- Department of science and technology, Beijing Shijitan Hospital of Capital Medical University, Beijing, 100038, China
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Anzić S, Turkalj M, Župan A, Labor M, Plavec D, Baudoin T. Eight weeks of omeprazole 20 mg significantly reduces both laryngopharyngeal reflux and comorbid chronic rhinosinusitis signs and symptoms: Randomised, double-blind, placebo-controlled trial. Clin Otolaryngol 2017; 43:496-501. [DOI: 10.1111/coa.13005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2017] [Indexed: 12/13/2022]
Affiliation(s)
- S.A. Anzić
- ENT Department; Children's Hospital Srebrnjak; Zagreb Croatia
| | - M. Turkalj
- Department for Allergy and Pulmonology; Children's Hospital Srebrnjak; Zagreb Croatia
- Faculty of Medicine; J.J. Strossmayer University of Osijek; Osijek Croatia
| | - A. Župan
- Department for Allergy and Pulmonology; Children's Hospital Srebrnjak; Zagreb Croatia
| | - M. Labor
- Faculty of Medicine; J.J. Strossmayer University of Osijek; Osijek Croatia
- Department of Medicine; University Hospital Center Osijek; Osijek Croatia
| | - D. Plavec
- Faculty of Medicine; J.J. Strossmayer University of Osijek; Osijek Croatia
- Research Department; Children's Hospital Srebrnjak; Zagreb Croatia
| | - T. Baudoin
- ENT Department; University Hospital Center Sisters of Charity; Zagreb Croatia
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Weber RK, Hosemann W. Comprehensive review on endonasal endoscopic sinus surgery. GMS CURRENT TOPICS IN OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY 2015; 14:Doc08. [PMID: 26770282 PMCID: PMC4702057 DOI: 10.3205/cto000123] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Endonasal endoscopic sinus surgery is the standard procedure for surgery of most paranasal sinus diseases. Appropriate frame conditions provided, the respective procedures are safe and successful. These prerequisites encompass appropriate technical equipment, anatomical oriented surgical technique, proper patient selection, and individually adapted extent of surgery. The range of endonasal sinus operations has dramatically increased during the last 20 years and reaches from partial uncinectomy to pansinus surgery with extended surgery of the frontal (Draf type III), maxillary (grade 3-4, medial maxillectomy, prelacrimal approach) and sphenoid sinus. In addition there are operations outside and beyond the paranasal sinuses. The development of surgical technique is still constantly evolving. This article gives a comprehensive review on the most recent state of the art in endoscopic sinus surgery according to the literature with the following aspects: principles and fundamentals, surgical techniques, indications, outcome, postoperative care, nasal packing and stents, technical equipment.
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Affiliation(s)
- Rainer K. Weber
- Division of Paranasal Sinus and Skull Base Surgery, Traumatology, Department of Otorhinolaryngology, Municipal Hospital of Karlsruhe, Germany
- I-Sinus International Sinus Institute, Karlsruhe, Germany
| | - Werner Hosemann
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Greifswald, Germany
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Grgić MV, Ćupić H, Kalogjera L, Baudoin T. Surgical treatment for nasal polyposis: predictors of outcome. Eur Arch Otorhinolaryngol 2015; 272:3735-43. [PMID: 25634061 DOI: 10.1007/s00405-015-3519-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Accepted: 01/19/2015] [Indexed: 10/24/2022]
Abstract
Nasal polyps recur in approximately one-third of patients after surgical treatment. It would be beneficial to be able to predict the patients in whom we might expect recurrence and to predict the clinical outcome after surgery. The study included 30 patients operated for nasal polyps. Removed polyps were analyzed by immunohistochemical analysis for IL-5, IgE, vascular endothelial growth factor and eosinophilic infiltration. These parameters together with preoperative CT score were used as independent variables, and subjective score improvement after 2 years was used as a dependent variable in multiple linear regression analysis. Furthermore, the patients were divided into two groups: low and high polyp tissue immunoreactivity. The Chi-squared test was used to determine whether polyp immunoreactivity influences polyp recurrence and subjective score. Preoperative CT score had a slightly positive correlation with subjective score after 2 years. High eosinophil infiltration significantly predicted a higher risk for polyp recurrence. High IL-5 positivity was related to greater risk for polyp recurrence than low IL-5 reactivity but not significantly. IgE and VEGF reactivity in polyp specimens did not have any effect on polyp recurrence. High eosinophilic infiltration in polyps can predict worse outcome after surgical treatment of chronic rhinosinusitis with nasal polyposis. IgE and VEGF do not have prognostic significance to polyp recurrence after surgery. The preoperative extent of disease measured by CT score had a slightly positive correlation with worse outcome after surgery.
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Affiliation(s)
- Marko Velimir Grgić
- Department of ENT and Head and Neck Surgery, 'Sisters of Mercy' University Medical Center, Zagreb University School of Medicine, Vinogradska 29, Zagreb, Croatia.
| | - Hrvoje Ćupić
- Department of Pathology, University Hospital 'Sisters of Mercy' University Medical Center, Zagreb University School of Dentistry, Vinogradska 29, Zagreb, Croatia
| | - Livije Kalogjera
- Department of ENT and Head and Neck Surgery, 'Sisters of Mercy' University Medical Center, Zagreb University School of Medicine, Vinogradska 29, Zagreb, Croatia
| | - Tomislav Baudoin
- Department of ENT and Head and Neck Surgery, 'Sisters of Mercy' University Medical Center, Zagreb University School of Medicine, Vinogradska 29, Zagreb, Croatia
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Adnane C, Adouly T, Zouak A, Mahtar M. Quality of life outcomes after functional endoscopic sinus surgery for nasal polyposis. Am J Otolaryngol 2015; 36:47-51. [PMID: 25456510 DOI: 10.1016/j.amjoto.2014.09.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Revised: 09/28/2014] [Accepted: 09/30/2014] [Indexed: 11/30/2022]
Abstract
PURPOSE The objective of this study is to determine the results of functional endoscopic sinus surgeries (FESS) for chronic rhinosinusitis with polyps and assess the association between surgery and specific quality of life outcomes. MATERIALS AND METHODS A prospective study was performed in a tertiary referral center. Fifty-eight patients affected by chronic rhinosinusitis with nasal polyposis underwent endoscopic sinus surgery from January 2011 to April 2013 and followed for 1 year. The rhinosinusitis disability index (RSDI), a validated disease-specific instrument, was used to quantify the patient's symptoms before and 12 months after surgery. RESULTS A strongly statistically significant reduction was seen between the mean scores on RSDI before and after FESS [86.43 (IQR=16.10) versus 51.16 (IQR=18.95), Wilcoxon signed-rank test, p<0.0001]. In multiple regression model, only four preoperative characteristics predicted the outcomes. The high mucosal eosinophilia density was the most important preoperative predictor. CONCLUSIONS There is evidence which supports the efficacy of FESS to improve long-term QOL outcomes in patients with CRS. The mucosal eosinophilia density and prior sinus surgery appeared to be the most predictive factors of surgical outcomes.
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Affiliation(s)
- C Adnane
- Department of ENT, 20 août hospital, Ibn Rochd University Hospital, Casablanca, Morocco.
| | - T Adouly
- Department of ENT, 20 août hospital, Ibn Rochd University Hospital, Casablanca, Morocco
| | - A Zouak
- Department of ENT, 20 août hospital, Ibn Rochd University Hospital, Casablanca, Morocco
| | - M Mahtar
- Department of ENT, 20 août hospital, Ibn Rochd University Hospital, Casablanca, Morocco
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Wang ET, Zheng Y, Liu PF, Guo LJ. Eosinophilic chronic rhinosinusitis in East Asians. World J Clin Cases 2014; 2:873-882. [PMID: 25516863 PMCID: PMC4266836 DOI: 10.12998/wjcc.v2.i12.873] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Revised: 08/28/2014] [Accepted: 09/17/2014] [Indexed: 02/05/2023] Open
Abstract
Chronic rhinosinusitis (CRS) is a common disease worldwide, with a prevalence rate of 5%-15% in the general population. CRS is currently classified into two types: CRS with and without nasal polyps. CRS may also be divided into eosinophilic CRS (ECRS) and non-ECRS subtypes based on the presence of tissue eosinophilic infiltration or not. There are significant geographic and ethnic differences in the tissue eosinophilic infiltration, which is predominant in Western white patients and less common in East Asians, despite an increasing tendency for its prevalence in East Asia countries. ECRS differs significantly from non-ECRS in clinical characteristics, treatment outcomes and strategies, and underlying pathogenic mechanisms. ECRS commonly demonstrates more severe symptoms, polyp diseases with a higher incidence of bilateral polyps and sinonasal diseases on computed tomography, and the increase in blood eosinophils. ECRS is considered a special and recalcitrant subtype of CRS, commonly with poor treatment outcomes compared to non-ECRS. The differentiation of specific subtypes and clinical features of CRS will be important for developing novel treatment strategies and improving treatment outcomes for individual phenotypes of CRS. This review discusses clinical features, diagnosis, treatment and prognosis of ECRS in East Asians.
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Jiang N, Kern RC, Altman KW. Histopathological evaluation of chronic rhinosinusitis: a critical review. Am J Rhinol Allergy 2014; 27:396-402. [PMID: 24119603 DOI: 10.2500/ajra.2013.27.3916] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Chronic rhinosinusitis (CRS) consists of a constellation of symptoms, including facial pressure/pain, hyposmia, rhinorrhea, and nasal congestion. On histopathological evaluation, the disease can be divided into pathophysiologically distinct subgroups. This study systematically reviews the literature regarding the unique histopathological findings of the various subtypes of CRS to determine the potential diagnostic value of performing tissue analysis of CRS specimens beyond routine hematoxylin and eosin (H&E) staining. METHODS A PubMed search was untaken to identify articles that evaluated the histopathological features of CRS. Six hundred fifty-four relevant articles were identified and after application of specific exclusion criteria, 71 articles were further reviewed in detail. RESULTS All articles included analysis of tissue samples from in-office biopsies or intraoperative specimens of patients who underwent sinus surgery. CRS was often further divided into subgroups and compared with each other and with a control group. The subgroups included CRS with and without nasal polyps, asthmatic and nonasthmatic patients, and with and without eosinophilia. Distinct inflammatory mediators were found for the different subgroups. Twenty-eight articles evaluated these inflammatory markers for their potential value as prognostic indicators. CONCLUSION CRS is a heterogeneous disease based on its histopathological findings. Information that is obtainable from light microscopy, but typically goes unreported, can serve as valuable prognostic indictors. However, routine H&E staining is suboptimal in distinguishing among the various subgroups of CRS. Assessment of specific inflammatory mediators in sinus mucosa specimens may help provide prognostic information and guide more tailored treatment for the individual patient.
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Affiliation(s)
- Nancy Jiang
- Department of Otolaryngology, Mount Sinai School of Medicine, New York, New York, USA
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Histopathologic Relationship Between Ethmoid Sinus and Ipsilateral Middle Turbinate in Non-Polypose Chronic Sinusitis by FESS. Indian J Otolaryngol Head Neck Surg 2014; 65:324-8. [PMID: 24427670 DOI: 10.1007/s12070-012-0483-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2011] [Accepted: 01/16/2012] [Indexed: 10/14/2022] Open
Abstract
Chronic rhinosinusitis (CRS) is a common disease with significant effects on the quality of life. Infection was previously a common cause of rhino sinusitis, while nowadays its main cause is inflammation. Non-polyposis CRS patients who were resistant to medical treatment and underwent endoscopic sinus surgery in Ghaem and Imam Reza hospitals were studied from December 2008 to November 2009. There were 11 males and four females ranging in age from 14 to 57 years with the average age of 32.2. First, samples were taken from the ethmoid sinus and the ipsilateral middle turbinate. Then, histopathologic research on grade of inflammation, mucosal thickness, inflammatory cell count, metaplasia type, and hypersecretion was performed. Fifteen patients were studied. There were positive statistical correlations between inflammation grade, eosinophil counts and plasma cell counts in ethmoid and turbinate; but such a correlation was not found in lymphocyte and neutrophil in two sites. The prominent inflammatory cell in both areas was the same for 11 patients; whereas in other four cases, it was insignificantly different. Positive statistical correlation between the inflammation grades in two sites shows the coexistence of rhinitis and sinusitis; therefore, this proves the correct combination usage of rhinosinusitis. Prominent cells of the samples which were obtained from two places were similar for most patients, so this similarity is a sign of inflammatory process presence in both places. The prominent cells were mostly lymphocytes.There were more lymphocytes than eosinophils in non-allergic patients.
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Tang J, Liu S, Zhang L, Chen W, Shi S, Yu Q, Tang C, Wang Y. Correlation analysis of prognostic and pathological features of patients with chronic sinusitis and nasal polyps following endoscopic surgery. Exp Ther Med 2013; 6:167-171. [PMID: 23935740 PMCID: PMC3735513 DOI: 10.3892/etm.2013.1072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2013] [Accepted: 04/04/2013] [Indexed: 01/21/2023] Open
Abstract
The aim of this study was to evaluate the therapeutic value of pathological indicators to predict the efficacy of endoscopic sinus surgery (ESS) in patients with chronic rhinosinusitis (CRS) with nasal polyps. A total of 53 patients with CRS with nasal polyps, who had undergone endoscopic surgery at least one year before, were surveyed for their clinical symptoms. Surgical specimen biopsies were consulted and related pathological indicators were measured. The association between the main symptoms of CRS with nasal polyps following ESS and pathological indicators were statistically analyzed. The main symptoms of patients with CRS with nasal polyps following ESS were nasal congestion, thick nasal discharge, rhinorrhea or sneezing. Goblet cells are associated with the symptoms of sneezing and thick nasal discharge, pathological gland formation is associated with dizziness, and the degree of tissue edema is associated with post-nasal discharge (P<0.05). Pathological indicators aid the prediction of the efficacy of nasal ESS in patients with CRS with nasal polyps.
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Affiliation(s)
- Jun Tang
- Department of Otolaryngology - Head and Neck Surgery, The First People's Hospital of Foshan, Foshan, Guangdong 528000
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Soy FK, Pinar E, Imre A, Calli C, Calli A, Oncel S. Histopathologic parameters in chronic rhinosinusitis with nasal polyposis: impact on quality of life outcomes. Int Forum Allergy Rhinol 2013; 3:828-33. [DOI: 10.1002/alr.21183] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Revised: 04/11/2013] [Accepted: 04/24/2013] [Indexed: 11/09/2022]
Affiliation(s)
- Fatih Kemal Soy
- Otorhinolaryngology Department; Katip Celebi University Ataturk Training and Research Hospital; Izmir Turkey
| | - Ercan Pinar
- Otorhinolaryngology Department; Katip Celebi University Ataturk Training and Research Hospital; Izmir Turkey
| | - Abdulkadir Imre
- Otorhinolaryngology Department; Katip Celebi University Ataturk Training and Research Hospital; Izmir Turkey
| | - Caglar Calli
- Otorhinolaryngology Department; Katip Celebi University Ataturk Training and Research Hospital; Izmir Turkey
| | - Aylin Calli
- Pathology Department; Katip Celebi University Ataturk Training and Research Hospital; Izmir Turkey
| | - Semih Oncel
- Vocational School of Health Services; Dokuz Eylul University; Izmir Turkey
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Ikeda K, Shiozawa A, Ono N, Kusunoki T, Hirotsu M, Homma H, Saitoh T, Murata J. Subclassification of chronic rhinosinusitis with nasal polyp based on eosinophil and neutrophil. Laryngoscope 2013; 123:E1-9. [DOI: 10.1002/lary.24154] [Citation(s) in RCA: 125] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2012] [Revised: 03/25/2013] [Accepted: 03/25/2013] [Indexed: 12/31/2022]
Affiliation(s)
- Katsuhisa Ikeda
- Department of Otorhinolaryngology; Juntendo University Faculty of Medicine; Tokyo Japan
| | - Akihito Shiozawa
- Department of Otorhinolaryngology; Juntendo University Faculty of Medicine; Tokyo Japan
| | - Noritsugu Ono
- Department of Otorhinolaryngology; Juntendo University Faculty of Medicine; Tokyo Japan
| | - Takeshi Kusunoki
- Department of Otorhinolaryngology; Juntendo University Faculty of Medicine; Tokyo Japan
| | - Mikio Hirotsu
- Department of Otorhinolaryngology; Juntendo University Faculty of Medicine; Tokyo Japan
| | - Hirotomo Homma
- Department of Otorhinolaryngology; Juntendo University Faculty of Medicine; Tokyo Japan
| | - Tatsuya Saitoh
- Department of Otorhinolaryngology; Juntendo University Faculty of Medicine; Tokyo Japan
| | - Junko Murata
- Department of Otorhinolaryngology; Juntendo University Faculty of Medicine; Tokyo Japan
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Cleland EJ, Bassiouni A, Wormald PJ. The bacteriology of chronic rhinosinusitis and the pre-eminence of Staphylococcus aureus in revision patients. Int Forum Allergy Rhinol 2013; 3:642-6. [PMID: 23468020 DOI: 10.1002/alr.21159] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2012] [Revised: 11/15/2012] [Accepted: 12/14/2012] [Indexed: 12/19/2022]
Abstract
BACKGROUND The role of bacteria in the etiopathogenesis of chronic rhinosinusitis (CRS) remains an area of interest. The impact of surgery and factors such as the presence of polyps, asthma, and aspirin sensitivity on the bacterial state are poorly understood. To determine the effect of these factors, this study examines the culture results from a large cohort of CRS patients. METHODS This retrospective study used the culture results from 513 CRS patients, which were analyzed for species growth and compared to factors such as previous surgery, presence of polyps, aspirin sensitivity, and asthma. Univariate and multivariate logistic regression models were used for statistical analysis. RESULTS Eighty-three percent (83%) of patients had a positive culture result. The average number of isolates detected per patient was 0.95. S. aureus was the most frequently cultured organism (35%), followed by P. aeruginosa (9%), Haemophilus spp. (7%), and S. pneumonia (5%). Revision patients were more likely to grow S. aureus (p = 0.001), P. aeruginosa (p = 0.044) and have a positive culture (p = 0.001). Asthma was correlated with a positive culture (p = 0.039). No difference was determined between polyp and nonpolyp patients for any of the bacterial outcomes. CONCLUSION This study highlights important factors in the bacteriology of CRS patients. S. aureus was the most prevalent species identified in our cohort, followed by P. aeruginosa. S. aureus rates of isolation were also significantly higher in patients undergoing revision surgery. No association was found between the presence of nasal polyposis and culture rates.
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Affiliation(s)
- Edward John Cleland
- Department of Surgery-Otorhinolaryngology, Head and Neck Surgery, University of Adelaide, Adelaide, Australia
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Snidvongs K, Lam M, Sacks R, Earls P, Kalish L, Phillips PS, Pratt E, Harvey RJ. Structured histopathology profiling of chronic rhinosinusitis in routine practice. Int Forum Allergy Rhinol 2012; 2:376-85. [PMID: 22419386 DOI: 10.1002/alr.21032] [Citation(s) in RCA: 153] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2011] [Revised: 10/06/2011] [Accepted: 01/05/2012] [Indexed: 12/16/2022]
Abstract
BACKGROUND Tissue eosinophilia in chronic rhinosinusitis (CRS) is a marker of inflammatory disorders recalcitrant to surgical intervention. Eosinophilic chronic rhinosinusitis (ECRS) is traditionally associated with asthma, polyps, aspirin sensitivity, high serum eosinophilia, and elevated immunoglobulin E (IgE). However, patients with ECRS may not present with these associations and there is a need to establish other surrogate markers. The objective of the study was to determine the associations between the histopathology, serology, and clinical characteristics in CRS patients. METHODS A cross-sectional study was undertaken of CRS patients undergoing surgery. Tissue eosinophilia and other pathological features were compared to traditional surrogate features of ECRS, as well as to symptoms, and to radiologic and endoscopic scores. RESULTS A total of 51 patients were assessed (47% female, mean age 46.6 ± 4.1 years). High tissue eosinophilia (>10 per high-power field [HPF]) was more prominent in polyps (84%) (χ(2) = 25.76; p < 0.01) but was also seen in nonpolyp patients (19%). Asthma was not associated with high tissue eosinophilia (p = 0.60), with 43% of nonasthmatics demonstrating high tissue eosinophilia. Serum eosinophilia predicted high tissue eosinophilia at >0.30 × 10(9)/L or 4.4% of leukocytes (sensitivity 52%, specificity 87%, receiver operating characteristic [ROC] p = 0.001), with low negative predictive value. Serum IgE was nonpredictive (p = 0.08). CONCLUSION The diagnosis of ECRS has unique prognostic implications. Traditional features of the ECRS phenotype are not necessarily reliable markers for the presence of tissue eosinophilia. Serum eosinophilia may be a good surrogate marker of tissue eosinophilia but of limited use. The routine use of structured histopathology reporting in CRS is suggested, to allow for the diagnosis of ECRS and to identify other prognostic markers.
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Affiliation(s)
- Kornkiat Snidvongs
- Australian School of Advanced Medicine, Macquarie University, Sydney, Australia.
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Prognostic value of Helicobacter pylori sinonasal colonization for efficacy of endoscopic sinus surgery. Eur Arch Otorhinolaryngol 2012; 269:2197-202. [DOI: 10.1007/s00405-012-1923-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2011] [Accepted: 01/03/2012] [Indexed: 12/11/2022]
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Ikeda K, Yokoi H, Kusunoki T, Saitoh T, Yao T, Kase K, Minekawa A, Inoshita A, Kawano K. Bacteriology of recurrent exacerbation of postoperative course in chronic rhinosinusitis in relation to asthma. Auris Nasus Larynx 2011; 38:469-73. [PMID: 21216117 DOI: 10.1016/j.anl.2010.10.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2010] [Revised: 10/06/2010] [Accepted: 10/06/2010] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Co-mobidity of asthma is known to result in a poor prognosis of post-endoscopic sinus surgery (post-ESS). Bacterial infection may play a key role in recurrent pathophysiology of sinusitis in post-ESS. METHODS Forty-two patients with CRS associated with asthma undergoing ESS were enrolled. Bacterial culture was performed from the sinus cavity at the time of acute infectious episodes. Recurrence of sinonasal disease was analyzed in terms of steroid responsiveness and peak expiratory flow (PEF). RESULTS Totally 75 aspirates were obtained during post-ESS; 2 repeat aspirates from 10 patients, 3 from 5 patients, and 4 from 2 patients. Only 6 specimens (8.0%) obtained from 5 patients (11.9%) showed no growth whereas 83 isolates were recovered from 69 specimens. Sixteen patients had at least one episode of a significant decline of PEF. All except one patient complained of symptoms and signs of upper respiratory infections prior to a depression of PEF. Positive culture was obtained in 10 out of 11 patients examined at the time of acute exacerbation of CRS. CONCLUSION Bacterial infection may play a critical role of recurrent polyps and refractory symptoms during post-ESS follow-up. Moreover, worsening of sinusitis accompanies asthma exacerbation.
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Affiliation(s)
- Katsuhisa Ikeda
- Department of Otorhinolaryngology, Juntendo University Faculty of Medicine, Bunkyo-ku, Tokyo, Japan.
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Jeong WJ, Lee CH, Cho SH, Rhee CS. Eosinophilic allergic polyp: a clinically oriented concept of nasal polyp. Otolaryngol Head Neck Surg 2010; 144:241-6. [PMID: 21493424 DOI: 10.1177/0194599810391738] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Tissue eosinophilia is a hallmark of nasal polyposis. However, there is no universally accepted definition for eosinophilic nasal polyp. The aims of this study were to histologically analyze the inflammatory cell population in the nasal polyp and propose the concept of eosinophilic allergic polyp (EAP), a simple and objective concept that would be clinically and practically valuable. STUDY DESIGN A cohort study with histological analysis of tissue sections and chart review. SETTING A tertiary university hospital. SUBJECTS AND METHODS Nasal polyp tissues were harvested during routine endoscopic sinus surgery from a cohort of 118 patients. Total number of inflammatory cells, including eosinophils, was counted. The presence of allergy and asthma was assessed, which was then correlated with the histologic findings. To determine a criterion for EAP, a receiver operating characteristic curve was used to identify the best cutoff point, which was further validated by comparing the eosinophil proportion in each group with reference to the clinical parameters. RESULTS Eosinophil accounted for an average of 18.7% of all inflammatory cells. The proportion of nasal polyps with at least 1 or more eosinophil infiltration accounted for 90.7% of all nasal polyps. When the concept of EAP was applied, a tissue eosinophil count of 11% was found to be significant and clinically most useful. Using this criterion, the proportion of EAP among nasal polyps was 62.7%. CONCLUSION The authors suggest a tissue eosinophil proportion of more than 11% as a criterion for EAP, a clinically useful concept of nasal polyp that bears good correlation with asthma and allergy.
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Affiliation(s)
- Woo-Jin Jeong
- Department of Otorhinolaryngology, Seoul National University College of Medicine, Seoul, Korea
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Relationship between clinical measures and histopathologic findings in chronic rhinosinusitis. Otolaryngol Head Neck Surg 2009; 141:454-61. [PMID: 19786212 DOI: 10.1016/j.otohns.2009.06.085] [Citation(s) in RCA: 140] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2009] [Revised: 06/02/2009] [Accepted: 06/16/2009] [Indexed: 01/02/2023]
Abstract
OBJECTIVE Describe detailed histopathologic findings from a cohort of patients with chronic rhinosinusitis and evaluate whether histologic measures correlate with baseline clinical factors. STUDY DESIGN Cross-sectional study with planned data collection. SETTING Tertiary medical center. SUBJECTS AND METHODS Adult patients with chronic rhinosinusitis were prospectively enrolled and demographic data and medical comorbidities recorded. Disease severity was measured by computed tomography (CT), endoscopy, Smell Identification Test (SIT), the Chronic Sinusitis Survey, Rhinosinusitis Disability Index, and SF-36 General Health Survey. Mucosal specimens were assessed for the presence of mucosal inflammation, including cellular (eosinophils, neutrophils, lymphocytes, mast cells, plasma cells, macrophages), epithelial (squamous metaplasia, basement membrane thickening, goblet cells), and stromal markers (subepithelial edema, fibrosis). Histopathologic findings were correlated to baseline clinical factors. RESULTS A total of 147 subjects were enrolled with histologic samples available for review. Presence of inflammatory markers was diverse, with lymphocytes present in 100 percent of subjects, eosinophils in 49.7 percent, and neutrophils found in 0.7 percent. Total eosinophil counts correlated with the presence of nasal polyposis (r = -0.367; P < 0.001), asthma (r = 0.264; P = 0.001), and aspirin intolerance (r = 0.279; P = 0.001). Mucosal eosinophilia correlated with worse disease severity on CT (r = 0.414; P < 0.001), endoscopy (r = 0.376; P < 0.001), and SIT (r = -0.253; P = 0.002), with the highest correlations seen in subgroups without nasal polyps. Histopathologic findings did not significantly correlate with any quality-of-life measure. CONCLUSION Mucosal eosinophilia correlates with objective disease severity as defined by CT, endoscopy, and SIT scores. Although other histologic markers of inflammation are present, none show similar correlations. The presence of mucosal eosinophils does not correlate with quality-of-life scores.
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Myller JP, Toppila-Salmi SK, Toppila EM, Torkkeli TVM, Numminen JEA, Renkonen RLO, Rautiainen MEP. Mucosal eosinophils and l-selectin ligands are associated with invasive and noninvasive sinus surgery outcomes. Am J Rhinol Allergy 2009; 23:21-7. [PMID: 19379607 DOI: 10.2500/ajra.2009.23.3250] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Chronic rhinosinusitis (CRS) is characterized by persistent inflammation of the nasal and paranasal mucosa with numerous emigrated leukocytes. L-Selectin on leukocytes and its endothelial glycosylated ligands initiate leukocyte infiltration into inflamed tissues. Endoscopic sinus surgery (ESS) is the major approach for restoring sinus physiology after failure of conservative therapy; however, the effect of enlarging the maxillary sinus ostium is still unknown. Here, we compared two histological markers of local inflammation, the number of mucosal eosinophils, and the expression of endothelial L-selectin ligands, with clinical outcomes after enlarging or saving the maxillary sinus ostium. METHODS Twenty-three patients with CRS underwent uncinectomy on one side and additional middle meatal antrostomy on the other side. Maxillary sinus mucosa biopsy specimens from these patients and nine healthy subjects were taken for immunohistochemical evaluations of the number of mucosal eosinophils and endothelial L-Selectin ligands. Also, symptoms and mucociliary clearance were measured. RESULTS The postoperative reduction of the endothelial L-Selectin ligands was independent of the operation technique. There was a correlation between postoperative number of mucosal eosinophils and symptom score, which was also independent of the surgical technique. The postoperative decrease of mucosal eosinophils, as well as the correlation of the intraoperative eosinophils with the postoperative symptom score, was found only on antrostomy side. CONCLUSION ESS decreases the expression of endothelial L-Selectin ligands, which might lead to decreased eosinophil traffic into maxillary sinus mucosa, putatively more when enlarging the maxillary sinus ostium. Both intra- and postoperative low number of eosinophils seem to be indicators of good subjective recovery.
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Affiliation(s)
- Jyri P Myller
- Department of Clinical Medicine University of Tampere, Tampere, Finland
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Ardehali MM, Amali A, Bakhshaee M, Madani Z, Amiri M. The comparison of histopathological characteristics of polyps in asthmatic and nonasthmatic patients. Otolaryngol Head Neck Surg 2009; 140:748-51. [PMID: 19393423 DOI: 10.1016/j.otohns.2009.01.027] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2008] [Revised: 01/13/2009] [Accepted: 01/15/2009] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Considering the different clinical aspects of polyps in asthmatic and nonasthmatic patients, we aimed to explore their histopathological characteristics. MATERIAL AND METHODS Twenty-five asthmatic patients and 25 nonasthmatic patients with polypoid chronic rhinosinusitis (29 male, 21 female; mean age 41.3 +/- 13.27; range 15-78 years) were enrolled in the study to be compared on the basis of histopathological characteristics. They were compared according to the following seven light microscopic findings: basement membrane thickness, goblet cell hyperplasia, subepithelial edema, submucous gland formation, eosinophilic infiltration, lymphocytic infiltration, and polymorphonuclear infiltration. RESULTS Basement membrane thickening, goblet cell hyperplasia, and eosinophilic and lymphocytic infiltration were more prominent in the asthmatic compared with the nonasthmatic group (P < 0.05), whereas polymorphonuclear infiltration was more prominent in nonasthmatics (P < 0.05). No statistically significant differences were found between the two groups with regard to submucosal gland hyperplasia or subepithelial edema. CONCLUSION Asthmatic patients present histopathological characteristics of a marked chronic inflammatory reaction, which might explain the negative effect on chronic rhinosinusitis outcome and the severity of the disease in this group.
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Baudoin T, Kalogjera L, Geber G, Grgić M, Cupić H, Tiljak MK. Correlation of histopathology and symptoms in allergic and non-allergic patients with chronic rhinosinusitis. Eur Arch Otorhinolaryngol 2008; 265:657-61. [PMID: 18004580 DOI: 10.1007/s00405-007-0530-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2006] [Accepted: 10/30/2007] [Indexed: 10/22/2022]
Abstract
The aim of this study was to estimate and compare some histopathologic predictors of efficacy of endoscopic sinus surgery (ESS) in allergic and non-allergic patients with chronic rhinosinusitis (CRS). Symptomatology was rated in 50 allergic and 50 non-allergic patients prior to as well as 12 and 24 months after surgery. Specimens taken during the procedure were scored for goblet cells, subepithelial thickening, mast cells and eosinophils. The correlation between histopathology and symptoms was evaluated. Goblet cells and subepithelial thickening were the best predictors in both groups of patients. These parameters are significant global outcome predictors for allergic, but not for non-allergic patients. It is concluded that certain histopathologic parameters in CRS correlate with certain symptoms. Certain histopathologic changes are predictable for persistence of some bothersome symptoms after ESS. Pathologic evaluation might give prediction of response to ESS in allergic and non-allegic patients with CRS.
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Affiliation(s)
- Tomislav Baudoin
- Department of Otolaryngology-Head and Neck Surgery, Sestre Milosrdnice University Hospital, Zagreb, Croatia.
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Dejima K, Adachi N, Oshima A, Nishimura Y, Uchida M, Ushijima C, Hama T, Hisa Y. [Outcomes of endoscopic sinus surgery in chronic sinusitis cases complicated/ not complicated by bronchial asthma and eosinophilic infiltration of the sinus mucosa]. ACTA ACUST UNITED AC 2008; 111:58-64. [PMID: 18326341 DOI: 10.3950/jibiinkoka.111.58] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Intractable sinusitis is, in most cases, complicated by bronchial asthma and severe eosinophilic infiltration of the sinus mucosa. Our aim here was to study the postoperative outcomes of chronic sinusitis complicated/not complicated by bronchial asthma and of cases with eosinophilic sinusitis/non-eosinophilic sinusitis. METHODS We conducted a prospective analysis of the outcome of 180 patients with or without bronchial asthma and eosinophilic infiltration who underwent endoscopic sinus surgery (ESS) for chronic sinusitis. The patients were divided into four groups by the presence/absence of asthma and presence/absence of eosinophilic infiltration of the sinus mucosa. One surgeon performed the ESS, and all the groups received the same postoperative treatment. RESULTS The outcomes of ESS were significantly worse in the cases complicated by eosinophilic sinusitis and asthma, especially in relation to the incidence of smell disturbances and the endonasal findings. Patients suffering from chronic sinusitis without asthma showed good improvement following ESS. There was no significant differences in the outcome after ESS between cases of eosinophilic sinusitis and those with non-eosinophilic sinusitis among the patients without asthma. CONCLUSIONS We contend that eosinophilic sinusitis without asthma may not represent intractable sinusitis. We wish to emphasize that complication by
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Affiliation(s)
- Kenji Dejima
- Department of Otorhinolaryngology, Kyoto Second Red Cross Hospital, Kyoto
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Bibliography. Current world literature. Nose and paranasal sinuses. Curr Opin Otolaryngol Head Neck Surg 2007; 15:48-55. [PMID: 17211184 DOI: 10.1097/moo.0b013e32802e6d9b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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