Impact of gender on clinical presentation of chronic rhinosinusitis with and without polyposis

Effect of Hormone Replacement Therapy on Chronic Rhinosinusitis Management

OBJECTIVES

To investigate whether hormone replacement therapy (HRT) impacts health care resource utilization in the management of chronic rhinosinusitis (CRS) in older women.

METHODS

Using the TriNetX US health record database, women 55 years or older with a diagnosis of CRS were included and followed for 3 years. The cohort was stratified into two groups: women who received HRT at the beginning of the study were compared to women who did not receive HRT. The groups were matched by age, race, ethnicity, history of asthma, and history of nasal polyps. Outcomes included whether the patient underwent endoscopic sinus surgery (ESS) and frequency of antibiotic use. Measures of association, Kaplan-Meier analysis, and cohort descriptive statistics were calculated.

RESULTS

Of the 65,400 women included, the mean age was 66.9 years. 27.0% and 3.6% of patients had a history of asthma or nasal polyps, respectively. Overall, 2.0% of CRS patients underwent ESS, with the HRT group less likely to undergo ESS [OR: 0.28; 95% CI: (0.25-0.32)] compared to patients who did not receive HRT. When stratified by polyp status, HRT patients with nasal polyps had a greater decrease in ESS rates compared to control than HRT patients without nasal polyps. The HRT group had a higher mean number of antibiotic prescriptions compared to the non-HRT group.

CONCLUSION

HRT is associated with decreased utilization of ESS to treat CRS, with a greater effect size for ESS among CRSwNP patients. However, HRT was associated with higher antibiotic utilization.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:3921-3926, 2024.

Dupilumab improves outcomes in patients with chronic rhinosinusitis with nasal polyps irrespective of gender: results from the SINUS-52 trial

Objectives

This post hoc analysis assessed disease characteristics and response to dupilumab treatment in male and female patients with severe chronic rhinosinusitis with nasal polyps (CRSwNP) (SINUS-52 study; NCT02898454).

Methods

Patients received dupilumab 300 mg or placebo every 2 weeks for 52 weeks on background intranasal corticosteroids. Efficacy was assessed through Week 52 using nasal polyp score (NPS), nasal congestion/obstruction score, loss of smell score and University of Pennsylvania Smell Identification Test score. Disease-specific health-related quality of life (HRQoL) was assessed using the 22-item Sino-Nasal Outcome Test (SNOT-22).

Results

The analysis included 192 male and 111 female patients. Female patients had higher mean SNOT-22 total score (56.6 vs. 49.1, P < 0.01) and more coexisting asthma (78.4% vs. 46.4%, P < 0.0001) and non-steroidal anti-inflammatory drug-exacerbated respiratory disease (NSAID-ERD) (38.7% vs. 18.8%, P = 0.0001) than male patients, but other baseline characteristics were similar. Dupilumab significantly improved CRSwNP outcomes vs. placebo at Week 52, regardless of gender: least squares mean differences (95% confidence interval) for NPS were -2.33 (-2.80, -1.86) in male and -2.54 (-3.18, -1.90) in female patients (both P < 0.0001 vs. placebo), and for SNOT-22 were -19.2 (-24.1, -14.2) in male and -24.4 (-31.5, -17.3) in female patients (both P < 0.0001 vs. placebo). There were no significant efficacy-by-gender interactions.

Conclusion

Female patients had greater asthma, NSAID-ERD and HRQoL burden at baseline than male patients. Dupilumab treatment significantly improved objective and subjective outcomes compared with placebo, irrespective of gender.

Gender Differences in Adults With Chronic Rhinosinusitis: A Scoping Review

OBJECTIVE

Gender differences in chronic rhinosinusitis (CRS) have been demonstrated in many studies over the last 15 years. The purpose of this scoping review is to investigate the current knowledge on gender differences in CRS and to analyze the gaps in the literature.

DATA SOURCES

A systematic search of PubMed, Cochrane Library, and Embase databases was performed.

REVIEW METHODS

This scoping review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines. Studies that evaluated gender differences in CRS were included in the review.

RESULTS

Of the 523 abstracts reviewed, a total of 23 studies met the criteria for inclusion. Articles consisted of retrospective and prospective cohort studies. They were divided into 3 categories based on whether they evaluated gender differences in (1) presentation and baseline quality of life, (2) pathophysiology, and/or (3) outcomes of treatment. Eleven studies addressed differences in presentation, 5 addressed differences in pathophysiology, and 10 dealt with differences in outcomes after surgical or medical management. Most of the studies showed worse baseline QoL secondary to CRS in women, with outcome of treatment being similar in both genders.

CONCLUSION

The experience of CRS appears to vary between genders, with women experiencing a greater subjective burden of disease than men, though with similar outcomes after treatment. Further research is indicated, particularly involving the pathophysiology of CRS, to fully understand the underlying causes of these discrepancies.

Exploring the impact of inflammatory endotypes on olfactory function and quality of life in chronic rhinosinusitis patients

OBJECTIVES

The aim of this observational cross-sectional study was to determine the endotypic inflammatory pattern of a sample of patients with CRS in Brazil, correlate it with olfactory function, and evaluate the clinical severity of the disease.

METHODS

In this cross-sectional study, 73 CRS patients were recruited. Patients were classified into type 2 and non-type 2 endotypic patterns based on IgE and eosinophilia levels. All subjects performed the University of Pennsylvania Smell Identification Test (UPSIT®) and responded to the Sino-Nasal Outcome Test (SNOT-22).

RESULTS

The majority of patients had type 2 CRS (n=57, 78.1%). Patients with type 2 CRS compared to non-type 2 CRS had a higher prevalence of nasal polyps (93% vs. 12.5%), asthma (40.3% vs. 12.5%), and non-steroidal anti-inflammatory drug exacerbated respiratory disease (NERD, 17.5% vs. 0%). Type 2 patients also had significantly lower UPSIT® and higher SNOT-22, Lund-Kennedy, and Lund-Mackay scores.

CONCLUSION

Our study provides evidence that type 2 CRS is associated with a higher prevalence of nasal polyps, asthma, and NERD, as well as decreased olfactory function and worse quality of life scores. These data will contribute to the body of knowledge on CRS and the development of treatments for this disease in Brazil.

LEVEL OF EVIDENCE: 3

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

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

Biological sex as a modulator in rhinologic anatomy, physiology, and pathology: A scoping review

BACKGROUND

Biological sex is increasingly recognized as a critical variable in health care. The authors reviewed the current literature regarding sex-based differences in rhinology to summarize the data and identify critical knowledge gaps.

METHODS

A scoping review was conducted. Publications reporting sex-based differences in anatomy, physiology, and pathology focusing on disease prevalence, disease burden, and outcomes in rhinology were identified.

RESULTS

Seventy-five relevant manuscripts were identified. While paranasal sinuses are of similar size at birth, they become larger in males leading to differences in ostium location. Females outperform males in olfactory identification but only in the 18- to 50-year age group. Estrogen and progesterone administration can impact muscarinic and α1 -adrenergic nasal mucosa receptor density. Chronic rhinosinusitis (CRS) and CRS without nasal polyps are more prevalent in females while CRS with nasal polyps is more prevalent in males. CRS symptom burden is higher in females before and after endoscopic sinus surgery; however, no difference in endoscopic sinus surgery utilization was found based on sex. Allergic rhinitis is more common in males before puberty and in females after puberty. Epistaxis is more prevalent in males and postmenopausal females compared with premenopausal females, perhaps from differences in sex-hormonal and hypertension status. In nasopharyngeal carcinoma, the incidence of sinus abnormalities was higher in males than females.

CONCLUSIONS

Although many sex-based differences exist in rhinology, further research is necessary to offer evidence-based treatment guidelines. Gonadal hormones should be studied as a therapeutic in rhinologic pathology as baseline physiologic differences exist such as those found in nasal mucosa receptor density.

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

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

Supplementary Information

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

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.

Man flu is not a thing - Gender-specific secondary analysis of a prospective randomized-controlled trial for acute rhinosinusitis

BACKGROUND

'Man flu' is a popular term to describe hypersensitivity to acute rhinosinusitis (ARS) in men. While this pop-cultural description may influence the social perspective of ARS, so far, no prospective observational data on the gender-specific natural development of ARS is available.

METHODS

Secondary data analyses were performed from the placebo arm of a prospective, interventional phase IV clinical trial. Objective measurement of ARS symptoms were assessed with the Major Symptom Score (MSS), a clinician-rated assessment tool. The Sino-Nasal Outcome Test-22 (SNOT-22) was used for symptom self-report. Repeated measures analysis of variance (ANOVA) with gender as a group variable were used to investigate changes in MMS and SNOT-22 total score and subscales over time.

RESULTS

While MMS scores did not differ at baseline, women showed a significantly greater reduction than men with a medium effect size (p = .040) over time. In the patient-reported symptom score, women showed a significantly higher symptom load at baseline (p = .038), but also a significantly faster subjective improvement of symptoms than men during the course of time with a medium effect size (p = .020). However, when separately assessing the SNOT-22 subscales, a significant time*gender effect was only found for emotional symptoms (p = .047). No gender effect was found for neither nasal, otological, or sleep symptoms (all p > .05).

DISCUSSION

Although a certain gender difference was found both in the clinician- as well as patient-rated ARS symptoms, the hypothesis of a 'man flu' should be disregarded. Gender differences in ARS symptomatology should be carefully evaluated without stigmatizing symptom distress based on gender perceptions.

Clinical Outcomes of Endonasal Sphenopalatine Artery Cauterization in Endoscopic Sinus Surgery

Endoscopic sinus surgery (ESS) is one of the common ENT surgeries performed. Various techniques are available for reducing the blood loss during ESS. The efficacy of cauterization of the SPA in reducing the per-operative blood loss has not been explored in the literature. This study evaluates the efficacy of SPA cauterization prior to sinus surgery and its per-operative and post-operative outcomes. To study the outcomes of endonasal SPA cauterization in patients undergoing ESS. This is a prospective observational study conducted in a tertiary care centre from October 2018 to October 2020. 30 patients underwent ESS where SPA was cauterized by bipolar diathermy in one side of the nasal cavity and in the contralateral side, SPA was not cauterized. The results were tabulated and compared between the cauterized and non cauterized side. p value < 0.05 was considered as statistically significant. Mean blood loss (p value = 0.20), operating time (p value = 0.19), surgical field grade, post operative Lund Kennedy Score at 1st, 4th and 12th week were compared and the difference between cauterized and non cauterized was found to be statistically insignificant. In this study, endonasal SPA cauterization did not significantly reduce the intra operative bleeding and surgical field grade in patients undergoing ESS. SPA cauterization did not adversely affect the per operative and post operative outcome and hence authors highlight the fact that it can be safely performed in cases where severe intra operative bleeding is expected and its effectiveness can be studied better in such cases.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Sex Disparities in Pediatric Acute Rhinosinusitis: A National Perspective

OBJECTIVE

This study aims to provide an age-stratified analysis of associations with patient sex in pediatric inpatients with acute rhinosinusitis (ARS).

STUDY DESIGN

Retrospective cohort study.

SETTING

National administrative database.

METHODS

The 2016 Kids' Inpatient Database was queried for pediatric inpatients (<21 years old) with ARS (ICD-10 J01). Orbital and intracranial sequelae were selected via ICD-10 codes. Statistical associations by sex were determined via univariate and multivariable analyses. Weighted measures are reported to provide national estimates.

RESULTS

Of the 5882 patients identified with ARS, 2404 (40.9%) were female and 3478 (59.1%) were male. Male patients were younger than female patients (mean, 9.3 vs 9.9 years; P < .001). Multivariable analysis indicated that males and females had similar total charges ($71,094 vs $66,892, P = .464) and length of stay (5.8 vs 6.1 days, P = .263). However, male patients underwent more procedures (1.8 vs 1.5, P < .001). Mortality was similar between male and female patients (odds ratio [OR], 0.91; P = .664). Male patients also had increased odds for having orbital (OR, 1.58; P < .001) and intracranial (OR, 1.99; P < .001) complications. Differences in sex-dependent sequela risk were starkest in patients aged 14 to 20 years, with male patients being more likely to have orbital (OR, 2.91; P < .001) and intracranial (OR, 3.86; P < .001) complications.

CONCLUSION

In a cohort of pediatric inpatients with ARS, males have increased odds for orbital and intracranial sequelae and undergo more procedures than females. However, males and females have similar charges and length of stay. Our study highlights age-stratified differences in ARS across patient sex.

Sex Differences in Otolaryngology: Focus on the Emerging Role of Estrogens in Inflammatory and Pro-Resolving Responses

Otolaryngology (also known as ear, nose, and throat (ENT)) diseases can be significantly affected by the level of sex hormones, which indicates that sex differences affect the manifestation, pathophysiology, and outcomes of these diseases. Recently, increasing evidence has suggested that proinflammatory responses in ENT diseases are linked to the level of sex hormones. The sex hormone receptors are present on a wide variety of immune cells; therefore, it is evident that they play crucial roles in regulating the immune system and hence affect the disease progression of ENT diseases. In this review, we focus on how sex hormones, particularly estrogens, regulate ENT diseases, such as chronic rhinosinusitis, vocal fold polyps, thyroid cancer, Sjögren’s syndrome, and head and neck cancers, from the perspectives of inflammatory responses and specialized proresolving mediator-driven resolution. This paper aims to clarify why considering sex differences in the field of basic and medical research on otolaryngology is a key component to successful therapy for both males and females in the future.

Socioeconomic Determinants of Tertiary Rhinology Care Utilization

Objective

The objective of this study was to determine the impact of patient demographics and socioeconomic factors on the utilization of tertiary rhinology care services in an upper Midwestern academic medical center.

Study Design

Retrospective review of electronic health records.

Setting

Academic medical center.

Methods

The electronic health record of our academic center was interrogated for the demographics and diagnosis of chronic rhinosinusitis (CRS) among adult patients seen by fellowship-trained rhinologists from 2000 to 2019. Patient characteristics (age, sex, race, insurance status) and population-level data (median income and education level) were compared with utilization of tertiary rhinology services for CRS. Utilization rates were calculated for each regional zip code and correlated with census data for median income and education. The association between determinants of health and tertiary rhinology utilization was assessed by multivariate regression analyses.

Results

A total of 8325 patients diagnosed with CRS used tertiary rhinology services. Patients were older (median, 58.9 years) and more likely to be female (57.6%), White (85%), and privately insured (60%) when compared with patients seen across our hospital system (P < .001). Adjusted analyses showed median income, education level, and White race to be independently correlated with tertiary care utilization. Private insurance alone was not an independent contributing factor to access.

Conclusion

Utilization of tertiary rhinology services correlated with income, race, and education level. Private insurance was not an independent factor. These results highlight social differences in determinants of access to tertiary otolaryngologic care.

Reversibility of mucociliary clearance and olfaction impairment following endoscopic sinus surgery: a prospective observational study

OBJECTIVE

Chronic rhinosinusitis is associated with altered mucociliary clearance and olfaction. The study aimed to analyse the reversibility of impairment and endoscopic factors predicting changes in mucociliary clearance and olfactory parameters.

METHODS

This prospective study included patients undergoing functional endoscopic sinus surgery for medically refractory chronic rhinosinusitis. Pre- and post-operative measurements of mucociliary clearance, olfactory thresholds, and identification scores were recorded.

RESULTS

Of the 96 patients, 65.6 per cent had polyposis and 80.2 per cent underwent primary surgery. Improvements in mucociliary clearance and olfaction scores were seen in all patients, with greater reversibility of impairment in patients with polyposis and in those who underwent revision surgery. The presence of polyps correlated significantly with changes in mucociliary clearance and olfaction.

CONCLUSION

The study highlights improvements in mucociliary clearance, olfactory thresholds and identification scores after functional endoscopic sinus surgery in chronic rhinosinusitis with or without nasal polyposis, as well as for primary and revision surgeries. Adequate post-operative care and prevention of polyps recurrence help to improve mucociliary clearance and olfaction scores.

The Relationship Between Indicators of Nasal Respiratory Function and Spirometric Parameters in Children With Bronchial Asthma

Introduction: The relationship between objective indicators of nasal obstruction and airflow limitation in children with bronchial asthma (BA) and allergic rhinitis (AR) has not yet been studied. Objective: To study the relationship between objective parameters of nasal obstruction and airflow limitation, determined using the methods of anterior active rhinomanometry (AARM) and spirometry in children with BA and AR. Materials and Methods: Eighty eight children and adolescents with BA and AR, boys-65.9% (58/88), were examined. The median age was 11.09 [10.42; 11.76] years. To determine airflow limitation, the following spirometric parameters were evaluated: forced vital capacity of the lungs (FVC), forced expiratory volume in 1 s (FEV1), the ratio of FEV1/FVC, and maximum expiratory flow at the point 25% of the flow-volume loop (MEF25). Data were recorded both in absolute values and in relative units (% pred). Nasal respiratory function was determined by AARM based on the total nasal airflow (TNAF) in absolute (Pa/cm3/s) and relative units (RTNAF, % pred). Results: In the general cohort and in boys but not in girls, a statistically significant direct correlation was found between TNAF (Pa/cm3/s) and absolute spirometry parameters of bronchial patency-all had p < 0.01. Also, RTNAF and relative MEF25 values (% pred) in the general cohort were R = 0.22, p = 0.04, and in boys, R = 0.28, p = 0.03. In girls, there was no statistically significant correlation between nasal respiratory function and spirometric parameters, all p > 0.05. Additional analysis of literature was conducted to ascertain that the identified gender differences were not occasional. Conclusion: The significant positive correlation of absolute values of AARM and spirometric parameters in children with BA and AR was established, which apparently reflects the physical development of children. Of all the relative indicators of spirometry, only MEF25 (% pred), which indirectly reflects the patency of small bronchi, had a distinct direct correlation with RTNAF. These patterns are clearly expressed in boys with BA. In girls with this disease, however, the relationship between nasal respiratory function and spirometric indicators seems to be more complex and requires further study.

Differences in men and women suffering from CRSwNP and AERD in quality of life

PURPOSE

While the overall impact of chronic rhinosinusitis (CRS) on patients' health is diverse, many affected individuals have a substantially impaired quality of life (QoL). The aim of this study was to evaluate the impact of sex-associated differences specifically in the subgroups of CRS with nasal polyps (CRSwNP) and aspirin-exacerbated respiratory disease (AERD) by assessing QoL parameters in women and men separately.

METHODS

In a retrospective single-center study, 59 patients with CRSwNP (39 males and 20 females) and 46 patients with AERD (18 males and 28 females) were included. Patient-reported outcome measures (PROM) evaluating QoL via the Sino-Nasal Outcome Test-20 German Adapted Version (SNOT-20 GAV) as well as the total polyp score (TPS) were analysed.

RESULTS

There was no significant difference in TPS (p = 0.5550) and total SNOT-20 GAV scores (p = 0.0726) between male or female patients with CRSwNP or AERD. Furthermore, no significant sex differences were found within disease groups regarding the subcategories of the SNOT-20 GAV items.

CONCLUSION

Thus, quality of life is severely impaired in patients suffering from various forms of CRS regardless of their sex.

Headache and rhinosinusitis: A review

PURPOSE OF REVIEW

To explain our current understanding of headache attributed to rhinosinusitis, an often inappropriately diagnosed secondary headache.

RECENT FINDINGS

Recent studies have shown that headache attributed to rhinosinusitis is often over-diagnosed in patients who actually have primary headache disorders, most commonly migraine. Failure to recognize and treat rhinosinusitis, however, can have devastating consequences. Abnormalities of the sinuses may also be treatable by surgical means, which may provide headache relief in appropriately selected patients.

SUMMARY

It is important for the practicing physician to understand how rhinosinusitis fits into the differential diagnosis of headache, both to avoid overdiagnosis in patients with primary headache, and to avoid underdiagnosis in patients with serious sinus disease.

Somatization, Depression, and Anxiety Disorders in a Rhinology Practice

Background

Patients present to rhinology clinics with various complaints. Symptoms may be attributable to objective findings, some remain unexplained. The objective is to investigate the incidence of psychological disorders in a rhinologic practice and evaluate a correlation of these psychiatric diseases with rhinologic symptoms.

Methods

Patients presenting to a rhinology clinic were administered the Generalized Anxiety Disorder 7 (GAD 7), Patient Health Questionnaire 9 (PHQ 9), and PHQ 15, psychometric instruments that can screen for generalized anxiety, major depression, and somatization disorder, respectively. Patients’ symptoms, endoscopic findings, medication, and psychiatric history were recorded. Multivariable analysis was performed for patients showed moderate-to-severe anxiety, depression, and somatic symptoms via 3 logistic regressions where the outcome was a GAD 7, PHQ 9, or PHQ 15 above 10.

Results

One hundred ninety-six patients were included for this study. There were 109 females and 87 males with a mean age of 49 years. Overall, 9%, 14%, and 21% exhibited moderate-to-severe anxiety, depressive, and somatization symptoms, respectively. Nasal obstruction was the only statistically significant variable that increased the odds of having moderate-to-severe anxiety symptoms. Similarly, headache, nasal obstruction, and anosmia/hyposmia were associated with increased odds of having depressive symptoms, and female gender, headache, and nasal discharge increased the odds of somatic symptom disorder. Edema was the only objective endoscopic finding, which was associated with depression only.

Conclusions

Patients should be counseled about the pathophysiology and psychiatric comorbidities affecting their primary rhinologic complaints. The provider needs to set realistic treatment expectations in order to achieve the desired clinical outcomes.

Update on the diagnostic considerations for neurogenic nasal and sinus symptoms: A current review suggests adding a possible diagnosis of migraine

BACKGROUND

Treatment of rhinosinusitis (RS) is one of the leading reasons for prescriptions of antibiotics, although they often fail to provide symptomatic relief. Appropriately diagnosing and treating patients presenting with RS for whom antibiotic therapy has failed or who have normal CT findings is a controversial topic. One explanation is that what these patients are experiencing is misinformation from the trigeminal nerve and autonomic nervous system. Midfacial pain and pressure with rhinorrhea and nasal congestion do not represent an infectious, or even inflammatory, condition within the sinus or nasal cavities, but a mirage that is best treated as a migraine variant. Observations Although there is not enough research to definitively prove this alternate etiology, we are reaching a tipping point where the clinical implications, real-world experience, and evolving literature support this possible alternate etiology. Four key factors support a midfacial migraine that mimics RS: 1) Pathophysiology: current pathophysiology literature offers a model of how migraine attacks could replicate clinical presentations of RS; 2) Clinical presentation: patients with infectious RS and midfacial migraine have similar symptomatic presentation, similar demographics, but poorly correlated radiological information; 3) Diagnosis: clinical studies support the proposition that there are alternative diagnostic tools for distinguishing patients with midfacial migraine; and 4) Prognosis: Select RS patients show significant improvement with migraine treatment.

CONCLUSIONS

We encourage medical professionals to consider migraine disease as a form of sensory misinformation and as a possible etiology of RS complaints. Clinicians can ask validated questions to determine if possible migraine could be an underlying cause, and there are standard preventative treatments for migraine that could alleviate patient symptoms. Dysfunctional vasomotor activity may be the root of the disturbances, particularly when antibiotic therapy fails and CT findings are discordant with symptoms. Until there is a diagnostic test for migraine, clinicians need to question a patient's self-diagnosis of rhinosinusitis. More research is needed to definitively answer this important question.

Anatomical Variation in Maxillary Sinus Ostium Positioning: Implications for Nasal-Sinus Disease

Among humans, superiorly located maxillary sinus ostia (MSO) result in drainage complications and maxillary sinus (MS) disease. While previous studies investigate maxillary sinusitis frequency or MSO-position relative to specific nasal landmarks, few explore MSO-position to overall MS dimensions. This study investigates whether MSO-position relates to MS size/shape and if sex-based differences exist. Twenty-nine landmarks, placed on magnetic resonance images (MRIs) of 109 individuals (males = 57; females = 52), captured maximum dimensions of the cranium, MS, nasal cavity, and MSO-position relative to the MS floor (MSO_MSF) and nasal floor (MSO_NCF). Landmark coordinates were used to calculate centroid sizes and 13 linear distances; distances were size standardized by cranial centroid-size. Principal components analysis (PCA) on 3D-coordinates indicates that variation in MSO-position relates to superior-inferior MS positioning within the face (PC1 22% variance) and MS height (PC2 12% variance). Regression analyses indicate that MS size (r² = 0.502; P < 0.001) and height (r² = 0.589; P < 0.0001) strongly contribute to MSO_MSF: larger, taller MSs exhibit greater MSO_MSFs. Sex-based differences were not evident in PC shape-analyses nor among size-standardized dimensions. However, Mann-Whitney U-tests indicate females have absolutely smaller MSs (P = 0.001) and MSO_MSF distances (P = 0.001). Further, regressions indicate females exhibit lower MSO_MSFs for a similar MS height. Overall, MSOs superiorly placed relative to the MS floor correlate with larger, taller MSs and/or sinuses positioned inferiorly within the face. While craniofacial surgeons/clinicians should be aware of potential sex-based differences in MS size and MSO position, this study does not suggest that higher incidences of female-reported sinusitis relate to sex-based differences in MS anatomy. Anat Rec, 302:917-930, 2019. © 2018 Wiley Periodicals, Inc.

How often is sinus surgery performed for chronic rhinosinusitis with versus without nasal polyps?

BACKGROUND

There currently are no data on the relative frequency of endoscopic sinus surgeries (ESS) performed for chronic rhinosinusitis with nasal polyposis (CRSwNP) versus chronic rhinosinusitis without nasal polyposis (CRSsNP) in the United States.

OBJECTIVES

To compare the rate of surgical interventions for CRSwNP and CRSsNP.

METHODS

Cases identified by CPT codes were extracted from the 2009-2011 State Ambulatory Surgery Databases for California, Florida, Maryland, and New York. Patient demographics, extent of surgery, mean charges, and operating room (OR) time were compared.

RESULTS

A total of 97,228 ESS cases were performed in the four states; 29.3% of surgeries were for patients with CRSwNP, 66.0% of patients with CRSsNP, and 4.8% for other indications. The proportion of ESS for CRSwNP varied across states, with California having the highest percentage (34.6%) and Maryland having the lowest (26.4%) (p < 0.0001). Patients with Medicaid (33.8%) and Medicare (32.2%) had higher rates of surgery for CRSwNP compared with patients with private insurance (29.9%) (p < 0.001). Surgeons who performed a higher volume of sinus surgery compared to lower volume surgeons performed a lower percentage of surgery for CRSwNP (24.4 versus 33.5%; p < 0.001). ESS cases for CRSwNP were more extensive (relative risk of four sinus surgeries of 1.88; p < 0.0001), used image guidance more frequently (relative risk, 1.39; p < 0.0001), and were less likely to include a balloon procedure (relative risk, 0.69; p < 0.0001). Patients with CRSwNP had longer OR times (ESS that involved all four sinuses took 14 minutes longer) (p < 0.0001), but no difference in charges compared with patients with CRSsNP who underwent a similar extent of surgery.

CONCLUSION

Almost 30% of ESS were performed for CRSwNP, and these cases were, on average, more extensive, used more OR time, and more often used image guidance than surgeries for CRSsNP. The rate of surgery performed for CRSwNP varied based on geography, payer, and surgical volume, which indicted that patient selection impacted surgical management.

TNF-alpha G/A308 polymorphism association with nasal polyposis in North part of Iran

Nasal Polyposis (NP) is a complex multi-factorial disease; associated with several environmental, genetic and inflammatory factors. TNF-alpha is one of the major pro-inflammatory cytokines involved in NP pathogenesis. Some of the polymorphisms of this gene affect its expression. Therefore, the aim of this study was to evaluate the polymorphism of TNF-alpha G/A308 gene and its association with nasal polyposis in north part of Iran. In this case-control study, 60 patients with NP and 75 healthy individuals referred to Guilan University hospital were evaluated. After DNA extraction, RFLP-PCR was used to determine polymorphism. Chi-square test was used to compare the frequency distribution of genotype and alleles of TNF-alpha gene with NP. The frequency of genotype G/G, A/A and G/A in the NP group was 46.7, 10.0 and 43.3%, and in the control group was 65.3, 5.3 and 29.3%, respectively. There was a statistically significant difference between genotype G/G in two groups (P = 0.006, OR 2.58, CI 1.27-5.23). In addition, the frequency of allele A in patients and controls was 31.7 and 20%, respectively; and this difference was statistically significant (p = 0.02). The findings of this study demonstrated that polymorphism in TNF-alpha gene might be a risk factor for NP in north part of Iran and the minor frequency of G308A allele in the current study is slightly more than other major populations. However, more investigations with high number of population are necessary in future.

A stepwise protocol for neural network modeling of persistent postoperative facial pain in chronic rhinosinusitis

In the artificial neural network field, no universal algorithm of modeling ensures obtaining the best possible model for a given task. Researchers frequently regard artificial neural networks with suspicion caused by the lack of repeatability of single experiments. We propose a systematic approach that may increase the probability of finding the optimal network architecture. In the experiments, the average effectiveness in groups of networks rather than single networks should be compared. Such an approach facilitates the analysis of the results caused by changes in the network parameters, while the influence of chance effects becomes negligible. As an example of this protocol, we present optimization of a neural network applied for prediction of persistent facial pain in patients operated for chronic rhinosinusitis. In the stepwise approach, the percentage of correct predictions was gradually increased from 54% to 75% for the external validation set.

Commentary on gender differences in prevalence, treatment, and quality of life of patients with chronic rhinosinusitis

Objective:

To examine the existing evidence on gender differences in the prevalence, treatment, and quality of life of patients with chronic rhinosinusitis (CRS).

Methods:

Review of the literature and expert opinion.

Results:

From a sociologic standpoint, women have historically been considered more likely to report symptoms, seek medical care, and give poorer self-evaluation of health, which may bias data toward increased prevalence and a greater effect of CRS on quality of life in women. However, the influence of gender seems to be restricted primarily to the evaluation of general quality of life, whereas the disease-specific health-related quality of life is not different between genders. Furthermore, migraine headaches, which are more common among women, may be misdiagnosed as CRS, which contributes to gender differences in the prevalence of CRS. The degree to which reported differences in prevalence and health utilization represent biologic or physiologic differences between genders is not known; however, differences in anatomic size, tobacco susceptibility, and hormonal factors have been speculated to increase the overall susceptibility to CRS in women compared with men.

Conclusions:

Focused research that examines the effect of gender on the development, treatment, and outcomes of CRS is warranted.

Familial risk of chronic rhinosinusitis with and without nasal polyposis: genetics or environment

BACKGROUND

Chronic rhinosinusitis (CRS) is a highly prevalent inflammatory condition, with significant effects on morbidity and quality of life, yet little is known about its pathogenesis. Preliminary evidence suggests there is a heritable component to the multifactorial etiology of CRS; however, our understanding of this genetic susceptibility is limited.

METHODS

Using an extensive genealogical database linked to medical records, the risk of CRS with nasal polyps (CRSwNP) and without polyps (CRSsNP) was calculated for relatives and spouses of adult probands (1638 CRSwNP and 24,200 CRSsNP patients diagnosed between 1996 and 2011) and were compared to random population controls matched 5:1 on sex and birth year from Cox regression models.

RESULTS

First-degree relatives (1stDRs) of CRSwNP patients demonstrated a 4.1-fold increased risk (p < 10(-3) ) of carrying the same diagnosis, whereas second-degree relatives (2ndDRs) demonstrated a 3.3-fold increased risk (p < 0.004), compared to controls. In CRSsNP patients, 1stDRs were at 2.4-fold increased risk (p < 10(-15) ), whereas 2ndDRs were at 1.4-fold increased risk (p < 10(-15) ) of the same diagnosis. Third-degree relatives (3rdDRs) had a slight increased risk at 1.1-fold (p < 10(-7) ). Spouses of CRSsNP patients, who likely share environmental circumstances, exhibited a 2-fold increased risk (p < 10(-15) ). No increased risk was observed in spouses of CRSwNP patients.

CONCLUSION

In the largest population study to date, a significant familial risk is confirmed in CRSwNP and CRSsNP, which may have a shared genetic and environmental component. Further understanding of the genetic basis of CRS and its interplay with environment factors could clarify disease etiology and lead to more effective targeted treatments.

The sinus headache explained

The concept of a sinus headache is problematic from neurology, allergology, and rhinology perspectives. It may be considered the final neurological diagnosis of exclusion when criteria for other craniofacial pain syndromes are not met. The International Headache Society definition implicates the presence of acute sinusitis, but this requirement is often not met in practice or with a patient's perception of the term. Otorhinolaryngologists have a similar exasperation with this cephalgia but tend to attribute idiopathic, nonallergic rhinopathy as the cause. Allergists often see patients who claim to have a sinus headache but instead have perennial allergic rhinitis or nonallergic rhinitis. A fresh perspective is required to determine the characteristics, differential diagnosis, and veracity of the sinus headache. We recommend using the term with caution only if the clinical picture meets the criteria for acute sinusitis-induced headache.

Frequency of sinus disease in normal subjects and patients with benign paroxysmal positional vertigo

BACKGROUND/AIMS

To determine if patients with benign paroxysmal positional vertigo (BPPV) have a higher frequency of rhinosinusitis than people with normal vestibular function.

METHODS

The subjects were 52 patients with BPPV and 46 normal people. Every subject had a sinus CT scan, a blood draw for IgE and a rhinologic examination by an otolaryngologist.

RESULTS

The frequency of rhinosinusitis based on physician diagnosis was 49% and based on CT scan findings 59%. This difference approached significance (p = 0.08). The observed frequency of rhinosinusitis was higher than predicted by survey data about the southern US region. The data trended toward higher prevalence of rhinosinusitis (by physician diagnosis) in the BPPV patients versus controls (58 vs. 39%, p = 0.06).

CONCLUSION

BPPV patients have a higher frequency of sinus disease compared to people with normal vestibular systems, perhaps due to age differences, but physiologic factors may also be involved. The higher frequency of rhinosinusitis in this geographical area than reported rates based on survey data raises concerns about the usefulness of questionnaire data for estimating population prevalence.

Genetic polymorphisms in chronic hyperplastic sinusitis with nasal polyposis

OBJECTIVES/HYPOTHESIS

Although many proinflammatory cytokines have been identified in nasal polyp tissue, the initial trigger that causes this inflammation characterized by edema, lymphocytosis, and eosinophilia, is still unknown. The purpose of the present study is to identify the presence of genetic polymorphisms in proinflammatory, anti-inflammatory, and chemokine genes that might contribute to genetic susceptibility to chronic hyperplastic sinusitis with nasal polyposis (CHSwNP).

STUDY DESIGN

Case control study.

METHODS

Buccal swabs were taken from the left and right oral mucosal surfaces from 179 patients with CHSwNP and 153 nonpolyposis controls with the Purgene DNA purification protocol (Gentra). Genotyping assays for cytokine gene loci were performed on 14 cytokine genes using the iPlex Gold and the Mass Array Compact system (Sequenom, San Diego, CA). Tests of Hardy-Weinberg equilibrium proportions were performed separately in the cases and controls. Tests for evidence of association between alleles at each single-nucleotide polymorphism (SNP) and case-control status were performed using unconditional logistic regression.

RESULTS

The frequency of the A allele in a SNP located in tumor necrosis factor (TNF)-alpha (rs1800629) is significantly different in patients with nasal polyposis versus controls without nasal polyposis, 18.6% and 11.5%, respectively with an individuals' odds of susceptibility to nasal polyps increasing almost two-fold (odds ratio, 1.86; confidence interval, 1.4-3.09) given at least one copy of the A allele at this SNP. All other cytokine gene polymorphisms of both inflammatory, anti-inflammatory, and chemokine genes were not statistically different between the two groups.

CONCLUSIONS

TNF-alpha-308, a SNP in the promoter region of this cytokine gene is associated with increased odds of developing nasal polyposis. TNF-alpha is a potent immuno-mediator and proinflammatory cytokine that has been implicated in the pathogenesis of a large number of human diseases. The location of this gene on the short arm of chromosome 6, with the major histocompatibility complex genes and complement, has raised the probability that polymorphism within this locus may contribute to a genetic association of this region of the genome with a wide variety of infectious and autoimmune diseases.