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Gata A, Raduly L, Budișan L, Bajcsi A, Ursu TM, Chira C, Dioșan L, Berindan-Neagoe I, Albu S. Machine Learning Model Predicts Postoperative Outcomes in Chronic Rhinosinusitis With Nasal Polyps. Clin Otolaryngol 2024; 49:776-784. [PMID: 39109612 DOI: 10.1111/coa.14208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 05/28/2024] [Accepted: 07/20/2024] [Indexed: 10/05/2024]
Abstract
OBJECTIVE Evaluating the possibility of predicting chronic rhinosinusitis with nasal polyps (CRSwNP) disease course using Artificial Intelligence. METHODS We prospectively included patients undergoing first endoscopic sinus surgery (ESS) for nasal polyposis. Preoperative (demographic data, blood eosinophiles, endoscopy, Lund-Mackay, SNOT-22 and depression PHQ scores) and follow-up data was standardly collected. Outcome measures included SNOT-22, PHQ-9 and endoscopy perioperative sinus endoscopy (POSE) scores and two different microRNAs (miR-125b, miR-203a-3p) from polyp tissue. Based on POSE score, three labels were created (controlled: 0-7; partial control: 8-15; or relapse: 16-32). Patients were divided into train and test groups and using Random Forest, we developed algorithms for predicting ESS related outcomes. RESULTS Based on data collected from 85 patients, the proposed Machine Learning-approach predicted whether the patient would present control, partial control or relapse of nasal polyposis at 18 months following ESS. The algorithm predicted ESS outcomes with an accuracy between 69.23% (for non-invasive input parameters) and 84.62% (when microRNAs were also included). Additionally, miR-125b significantly improved the algorithm's accuracy and ranked as one of the most important algorithm variables. CONCLUSION We propose a Machine Learning algorithm which could change the prediction of disease course in CRSwNP.
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Affiliation(s)
- Anda Gata
- Department of Otorhinolaryngology, University of Medicine and Pharmacy "Iuliu Hatieganu", Cluj Napoca, Romania
| | - Lajos Raduly
- Research Center for Functional Genomics, Biomedicine and Translational Medicine, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Liviuța Budișan
- Research Center for Functional Genomics, Biomedicine and Translational Medicine, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Adél Bajcsi
- Faculty of Mathematics and Computer Science, Department of Computer Science, Babes-Bolyai University, Cluj-Napoca, Romania
| | - Teodora-Maria Ursu
- Faculty of Mathematics and Computer Science, Department of Computer Science, Babes-Bolyai University, Cluj-Napoca, Romania
| | - Camelia Chira
- Faculty of Mathematics and Computer Science, Department of Computer Science, Babes-Bolyai University, Cluj-Napoca, Romania
| | - Laura Dioșan
- Faculty of Mathematics and Computer Science, Department of Computer Science, Babes-Bolyai University, Cluj-Napoca, Romania
| | - Ioana Berindan-Neagoe
- Research Center for Functional Genomics, Biomedicine and Translational Medicine, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Silviu Albu
- Department of Otorhinolaryngology, University of Medicine and Pharmacy "Iuliu Hatieganu", Cluj Napoca, Romania
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Gata A, Leucuta DC, Budisan L, Raduly L, Trombitas VE, Berindan-Neagoe I, Albu S. MicroRNA-125b Is a Potential Predictor of Surgical Outcomes in Chronic Rhinosinusitis with Nasal Polyps. Am J Rhinol Allergy 2024; 38:92-101. [PMID: 38192070 DOI: 10.1177/19458924231224343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Abstract
BACKGROUND Despite advances in surgical techniques, recurrence rates after endoscopic sinus surgery (ESS) for chronic rhinosinusitis with nasal polyps (CRSwNP) remain high and difficult to predict. OBJECTIVE This study aimed to evaluate the potential role of microRNA 125b (miR-125b) in predicting disease evolution following ESS. METHODS We conducted a prospective study including patients undergoing first ESS for CRSwNP in our department between January 2020 and November 2021. We determined miR-125b levels from nasal polyps and pursued a standardized follow-up for at least 18 months for each patient. RESULTS A total of 86 patients were included in the study. Higher postoperative endoscopy scores were associated with more severe disease at presentation on computed tomography scan, presence of concomitant asthma, and higher values of miR-125b. Even after multivariate repeated measures analysis and adjustments for confounders, miR-125b remained statistically significant. Moreover, miR-125 was the most important factor in predicting disease evolution at 18 months. CONCLUSION A clear, robust relation between nasal polyp control evaluated through objective measures and miR-125b values was observed. This finding indicates the potential role of miR-125b in predicting the course of the disease following ESS.
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Affiliation(s)
- Anda Gata
- II-nd Department of Otorhinolaryngology, University of Medicine and Pharmacy "Iuliu Hatieganu", Cluj Napoca, Romania
| | - Daniel-Corneliu Leucuta
- Medical informatics and Biostatistics Department, University of Medicine and Pharmacy "Iuliu Hatieganu", Cluj Napoca, Romania
| | - Liviuta Budisan
- Research Center for Functional Genomics, Biomedicine and Translational Medicine, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Lajos Raduly
- Research Center for Functional Genomics, Biomedicine and Translational Medicine, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Veronica E Trombitas
- II-nd Department of Otorhinolaryngology, University of Medicine and Pharmacy "Iuliu Hatieganu", Cluj Napoca, Romania
| | - Ioana Berindan-Neagoe
- Research Center for Functional Genomics, Biomedicine and Translational Medicine, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Silviu Albu
- II-nd Department of Otorhinolaryngology, University of Medicine and Pharmacy "Iuliu Hatieganu", Cluj Napoca, Romania
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Krasilnikova SV, Kolesnik AS, Gorbunova KV, Eliseeva TI, Shakhov AV. [Peak nasal inspiratory flow in the assessment of nasal airway obstruction]. Vestn Otorinolaringol 2024; 89:47-53. [PMID: 39171877 DOI: 10.17116/otorino20248904147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/23/2024]
Abstract
RELEVANCE Nasal congestion is one of the most common complaints in otolaryngology practice and can significantly impact the quality of life for patients. Objective and subjective assessments provide different information, but objective assessment of nasal obstruction is crucial for accurate diagnosis and appropriate treatment. This review demonstrates that peak nasal inspiratory flow (PNIF) is a reproducible and reliable measure of objective nasal patency. It is inexpensive, easy to use, suitable for serial measurements, and can be applied to patients of different age groups. PNIF is recommended for use in every outpatient clinic that treats patients with nasal congestion. OBJECTIVE To summarize the data on the application of PNIF in diagnosing conditions of the nasal airways. MATERIAL AND METHODS Publications (articles and relevant abstracts) available in the PubMed and eLibrary databases were analyzed. CONCLUSION PNIF offers an objective and non-invasive assessment of nasal airflow, aiding in diagnosis, therapy monitoring, and preoperative planning. Further research, standardization, and establishment of normative data will enhance the informative value of peak nasal inspiratory flow in assessing nasal obstruction.
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Affiliation(s)
- S V Krasilnikova
- Privolzhsky Research Medical University, Nizhny Novgorod, Russia
| | | | - K V Gorbunova
- Privolzhsky Research Medical University, Nizhny Novgorod, Russia
| | - T I Eliseeva
- Privolzhsky Research Medical University, Nizhny Novgorod, Russia
| | - A V Shakhov
- Privolzhsky Research Medical University, Nizhny Novgorod, Russia
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Merma-Linares C, Martinez MD, Gonzalez M, Alobid I, Figuerola E, Mullol J. Management of Mechanical Nasal Obstruction Isolated or Associated to Upper Airway Inflammatory Diseases in Real Life: Use of both Subjective and Objective Criteria. Curr Allergy Asthma Rep 2023; 23:567-578. [PMID: 37561310 PMCID: PMC10506933 DOI: 10.1007/s11882-023-01104-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/11/2023] [Indexed: 08/11/2023]
Abstract
PURPOSE OF REVIEW Mechanical nasal obstruction (MNO) is a prevalent condition with a high impact on patient's quality-of-life (QoL) and socio-economic burden. The aim of this study was to determine the usefulness of both subjective and objective criteria in the appropriate management of MNO, either alone or associated to upper airway inflammatory diseases such as allergic rhinitis (AR) or chronic rhinosinusitis with nasal polyps (CRSwNP). RECENT FINDINGS A long debate persists about the usefulness of subjective and objective methods for making decisions on the management of patients with nasal obstruction. Establishing standards and ranges of symptom scales and questionnaires is essential to measure the success of an intervention and its impact on QoL. To our knowledge this is the first real-life study to describe the management of MNO using both subjective and objective criteria in MNO isolated or associated to upper airway inflammatory diseases (AR or CRSwNP). Medical treatment (intranasal corticosteroids) has a minor but significant improvement in MNO subjective outcomes (NO, NOSE, and CQ7) with no changes in loss of smell and objective outcomes. After surgery, all MNO patients reported a significant improvement in both subjective and objective outcomes, this improvement being higher in CRSwNP. We concluded that in daily clinical practice, the therapeutic recommendation for MNO should be based on both subjective and objective outcomes, nasal corrective surgery being the treatment of choice in MNO, either isolated or associated to upper airway inflammatory diseases, AR or CRSwNP.
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Affiliation(s)
- Carla Merma-Linares
- Department of Otorhinolaryngology- Head and Neck Surgery, Hospital Universitari de Tarragona Joan XXIII, Doctor Mallafre Guasch 4, 43005, Tarragona, Catalonia, Spain.
- Institut d'Investigació Sanitària Pere Virgili, Tarragona, Catalonia, Spain.
- Clinical & Experimental Respiratory Immunoallergy, Institute of Biomedical Research "August Pi i Sunyer" (IDIBAPS), CIBERES, Barcelona, Catalonia, Spain.
- Universitat Rovira i Virgili, Tarragona, Spain.
| | - M Dolores Martinez
- Department of Otorhinolaryngology- Head and Neck Surgery, Hospital Universitari de Tarragona Joan XXIII, Doctor Mallafre Guasch 4, 43005, Tarragona, Catalonia, Spain
- Institut d'Investigació Sanitària Pere Virgili, Tarragona, Catalonia, Spain
| | - Miriam Gonzalez
- Department of Otorhinolaryngology- Head and Neck Surgery, Hospital Universitari de Tarragona Joan XXIII, Doctor Mallafre Guasch 4, 43005, Tarragona, Catalonia, Spain
- Institut d'Investigació Sanitària Pere Virgili, Tarragona, Catalonia, Spain
| | - Isam Alobid
- Skull Base Unit, ENT department, Hospital Clinic of Barcelona, Barcelona, Spain
- Clinical & Experimental Respiratory Immunoallergy, Institute of Biomedical Research "August Pi i Sunyer" (IDIBAPS), CIBERES, Barcelona, Catalonia, Spain
| | - Enric Figuerola
- Department of Otorhinolaryngology- Head and Neck Surgery, Hospital Universitari de Tarragona Joan XXIII, Doctor Mallafre Guasch 4, 43005, Tarragona, Catalonia, Spain
- Institut d'Investigació Sanitària Pere Virgili, Tarragona, Catalonia, Spain
| | - Joaquim Mullol
- Department of Otorhinolaryngology, Rhinology Unit & Smell Clinic, ENT Department, Hospital Clínic of Barcelona, Barcelona, Catalonia, Spain.
- Clinical & Experimental Respiratory Immunoallergy, Institute of Biomedical Research "August Pi i Sunyer" (IDIBAPS), CIBERES, Barcelona, Catalonia, Spain.
- Universitat de Barcelona, Barcelona, Spain.
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Hernandez AK, Hummel T. Intranasal trigeminal function in chronic rhinosinusitis: a review. Expert Rev Clin Immunol 2023; 19:921-938. [PMID: 37379521 DOI: 10.1080/1744666x.2023.2231149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 06/22/2023] [Accepted: 06/26/2023] [Indexed: 06/30/2023]
Abstract
INTRODUCTION Chronic rhinosinusitis (CRS) affects 5-12% of the general population with significant effects on quality of life. Chronic inflammation also seems to affect intranasal trigeminal sensitivity. AREAS COVERED A systematic literature search was done in Scopus, Web of Science, and PubMed in February 2023. The review addressed intranasal trigeminal function in patients with CRS and summarized current knowledge on trigeminal function as it relates to the symptoms, assessment, and treatment of CRS. EXPERT OPINION Olfaction and trigeminal function are synergistic and this interaction may contribute to trigeminal dysfunction in CRS. Aside from anatomic blockage through polypoid mucosal changes, trigeminal dysfunction may affect the perception of nasal obstruction in CRS. Upregulated immune defense mechanisms leading to damage of nerve endings, changes in nerve growth factor release or other mechanisms may be responsible for trigeminal dysfunction in CRS. Since the pathophysiology of trigeminal dysfunction in CRS is poorly understood, current treatment recommendations are directed toward the therapy of CRS as an underlying cause, although the effect of surgery and corticosteroids on trigeminal function remains unclear. A standardized and validated trigeminal test that is accessible and easy to use in clinical settings would be beneficial for future studies.
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Affiliation(s)
- Anna Kristina Hernandez
- Smell and Taste Clinic, Department of Otorhinolaryngology, Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Department of Otolaryngology - Head and Neck Surgery, Philippine General Hospital, University of the Philippines, Manila, Philippines
- Department of Otolaryngology - Head and Neck Surgery, Asian Hospital and Medical Center, Muntinlupa, Philippines
| | - Thomas Hummel
- Smell and Taste Clinic, Department of Otorhinolaryngology, Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
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Popper C, Martin H, Shah R, Sicard R, Hodges K, Frank-Ito DO. Intranasal Spray Characteristics for Best Drug Delivery in Patients With Chronic Rhinosinusitis. Laryngoscope 2023; 133:1036-1043. [PMID: 35560998 PMCID: PMC9653517 DOI: 10.1002/lary.30155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 04/05/2022] [Accepted: 04/22/2022] [Indexed: 11/08/2022]
Abstract
OBJECTIVES To determine parameter combinations for effective drug delivery of intranasal spray steroids to the ostiomeatal complex (OMC) and maxillary sinus (MS) in patients with chronic rhinosinusitis (CRS). METHODS Each patient's sinonasal cavity was reconstructed from computed tomography scans. Intranasal airflow and drug particle transport were simulated using computational fluid dynamic modeling. Airflow simulations were performed at 15 Pascal inhalation pressure. Intranasal spray particles of 1-100 μm were simulated at release speeds of 1, 5, and 10 m/s from 6 release locations (Bottom, Center, Top, Lateral, Lateral-Bottom, and Lateral-Top) at a nozzle insertion depth of 15 mm. Drug delivery simulations were performed in the head tilted forward position. RESULTS Maximal OMC deposition was 0.78%-12.44%, while maximal MS deposition was 0.02%-1.03% across all simulations. In general, particles between 6 and 10 μm had the best OMC (at 1 m/s particle velocity) and MS (at 10 m/s particle velocity) deposition. Particles ranging from 21 to 30 μm also had superior OMC deposition. The lateral and lateral-top spray release locations produced maximum OMC deposition, but no one release location demonstrated an increase in MS deposition. CONCLUSION This preliminary study suggests that it is challenging to determine a common set of intranasal spray parameter combinations for effective drug delivery to the OMC and MSs. Although drug particle size and spray particle velocity seem to impact particle deposition patterns, spray release location appears to vary with anatomical differences between subjects, particularly when the MS is the target location for particle deposition. Laryngoscope, 133:1036-1043, 2023.
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Affiliation(s)
- Carson Popper
- Campbell University School of Osteopathic Medicine, Buies Creek, North Carolina, USA
- Department of Head and Neck Surgery and Communication Sciences, Duke University Medical Center, Durham, North Carolina, USA
| | - Hannah Martin
- Department of Head and Neck Surgery and Communication Sciences, Duke University Medical Center, Durham, North Carolina, USA
| | - Reanna Shah
- Department of Head and Neck Surgery and Communication Sciences, Duke University Medical Center, Durham, North Carolina, USA
| | - Ryan Sicard
- Department of Head and Neck Surgery and Communication Sciences, Duke University Medical Center, Durham, North Carolina, USA
| | - Katrina Hodges
- Department of Head and Neck Surgery and Communication Sciences, Duke University Medical Center, Durham, North Carolina, USA
- Pre-Health Post-Baccalaureate Program, Meredith College, Raleigh, North Carolina, USA
| | - Dennis Onyeka Frank-Ito
- Department of Head and Neck Surgery and Communication Sciences, Duke University Medical Center, Durham, North Carolina, USA
- Computational Biology and Bioinformatics PhD Program, Duke University, Durham, North Carolina, USA
- Department of Mechanical Engineering and Materials Science, Duke University, Durham, North Carolina, USA
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MicroRNAs: Potential Biomarkers of Disease Severity in Chronic Rhinosinusitis with Nasal Polyps. Medicina (B Aires) 2023; 59:medicina59030550. [PMID: 36984551 PMCID: PMC10051206 DOI: 10.3390/medicina59030550] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 03/03/2023] [Accepted: 03/09/2023] [Indexed: 03/14/2023] Open
Abstract
Background and Objectives: Chronic rhinosinusitis with nasal polyps (CRwNP) has multiple clinical presentations, and predictors of successful treatment are correlated to different parameters. Differentially expressed microRNAs in nasal polyps emerge as possible facilitators of precise endotyping in this disease. We aimed to evaluate the correlation between the clinical parameters of CRSwNP and two different microRNAs. Materials and Methods: The expression of miR-125b and miR-203a-3p in nasal polyps (n = 86) and normal nasal mucosa (n = 20) was determined through microarray analysis. Preoperative workup included CT scan, nasal endoscopy, blood tests, symptoms and depression questionnaires. Results: MiR-125b showed significant overexpression in NP compared to the normal nasal mucosa. miR-125b expression levels were positively and significantly correlated with blood eosinophilia (p = 0.018) and nasal endoscopy score (p = 0.021). Although high CT scores were related to miR-125b overexpression, the correlation did not reach statistical significance. miR-203a-3p was underexpressed in nasal polyps and was significantly underexpressed in CRSwNP patients with environmental allergies. Conclusions: Both miR-125b and miR-203a-3p are potential biomarkers in CRSwNP. miR-125b also correlates with the clinical picture, while miR-203a-3p could help identify an associated allergy.
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Real-Life Effectiveness of Mepolizumab in Refractory Chronic Rhinosinusitis with Nasal Polyps. Biomedicines 2023; 11:biomedicines11020485. [PMID: 36831021 PMCID: PMC9952964 DOI: 10.3390/biomedicines11020485] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 01/24/2023] [Accepted: 02/06/2023] [Indexed: 02/10/2023] Open
Abstract
The aim of this study was to evaluate the efficacy of mepolizumab in patients affected by chronic rhinosinusitis with nasal polyps (CRSwNP) in real-life. A single-center retrospective observational study was conducted on severe CRSwNP patients treated with mepolizumab. Nasal endoscopic polyp score (NPS), visual analogue scale (VAS) symptom score, sinonasal outcome test (SNOT-22), asthma control test (ACT) score, fractional exhaled nitric oxide (FeNO), eosinophils blood cells and prednisone intake were assessed at baseline and after 6 months. A total of 55 patients were included; 49 patients (89%) presented with asthma; aspirin exacerbated respiratory disease (AERD) in 28 patients (51%). A statistically significant decrease in the SNOT-22 score was observed (median difference -63; 95% CI: -68; -58; p < 0.001) with median t0 76 and IQR (61;90) to t6 10 (5;15). A reduction in NPS, median t0 NPS 4; (IQR:4;6), median t6 NPS 1; (IQR:0;1) p < 0.001, was greater in patients with AERD. The median baseline VAS score was 6 (IQR:6;7) and the differences between t0 and t6 were statistically significant p < 0.001. Significant changes in blood eosinophils cells, median t0 500 cell/mcl (IQR:340;830), median t6 97 cell/mcl (IQR:60;160) p < 0.001, were greater in patients with AERD. Mepolizumab treatment effects have been demonstrated with significantly reduced symptoms, polyp scores, blood eosinophils and systemic corticosteroid use, resulting in an increased health-related quality of life in patients with severe CRSwNP, regardless of the presence or absence of asthma or AERD.
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Ow RA, Soler ZM, Sindwani R, Leopold DA, Lee JT, Mahmoud RA, Han JK. Efficacy of the exhalation delivery system with fluticasone in patients with chronic rhinosinusitis with nasal polyps whose symptoms recur after sinus surgery. Int Forum Allergy Rhinol 2023; 13:31-41. [PMID: 35674488 PMCID: PMC10084243 DOI: 10.1002/alr.23043] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 06/03/2022] [Accepted: 06/03/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Sinus surgery removes inflamed tissue, restores airflow, and improves delivery of medication into surgically opened spaces. The exhalation delivery system with fluticasone (EDS-FLU; XHANCE® ) uses a novel delivery system to create closed-palate, positive-pressure, bidirectional mechanics that significantly alter the deposition of the topically acting anti-inflammatory medication. We ask whether EDS-FLU efficacy differs for patients with recurrent symptoms after sinus surgery versus patients without surgery. OBJECTIVE We aimed to compare EDS-FLU treatment responses in patients with recurrent symptoms after endoscopic sinus surgery (ESS) and patients who have never had sinus surgery. METHODS Data were pooled from two large, controlled trials (NAVIGATE I and II) for exploratory analyses. Chronic rhinosinusitis symptoms, polyp grade, and quality-of-life measures were compared between patients with prior ESS and those without prior ESS. RESULTS Patients with prior ESS (exhalation delivery system-placebo [n = 53], EDS-FLU 186 μg [n = 52], and EDS-FLU 372 μg [n = 49]) and unoperated patients (exhalation delivery system-placebo [n = 108], EDS-FLU 186 μg [n = 108], and EDS-FLU 372 μg [n = 111]) treated with EDS-FLU reported similar and substantial benefits as measured by multiple symptom and quality-of-life/functioning outcomes (congestion score, 22-Item Sinonasal Outcomes Test [SNOT-22], Rhinosinusitis Disability Index [RSDI], Patient Global Impression of Change) and by nasal polyp grade. In previously operated patients, unlike surgery-naive patients, multiple outcomes (SNOT-22, RSDI, polyp grade) consistently showed numerically but not statistically greater responses to the higher dose. CONCLUSIONS Patients with recurrent symptoms after sinus surgery who were treated with EDS-FLU demonstrated significant symptom and quality-of-life improvement. Unlike unoperated patients, patients with prior ESS had a numerically but not statistically greater response to the higher dose of EDS-FLU (two sprays per nostril twice a day).
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Affiliation(s)
- Randall A Ow
- Sacramento Ear Nose Throat, Roseville, California, USA
| | - Zachary M Soler
- Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Raj Sindwani
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Donald A Leopold
- Department of Surgery, College of Medicine, University of Vermont, Burlington, Vermont, USA
| | - Jivianne T Lee
- Department of Head and Neck Surgery, UCLA David Geffen School of Medicine, Los Angeles, California, USA
| | | | - Joseph K Han
- Department of Otolaryngology Head and Neck Surgery, Eastern Virginia Medical School, Norfolk, Virginia, USA
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Bognanni A, Chu DK, Rank MA, Bernstein J, Ellis AK, Golden D, Greenhawt M, Hagan JB, Horner CC, Ledford DK, Lieberman J, Luong AU, Marks LA, Orlandi RR, Samant SA, Shaker M, Soler ZM, Stevens WW, Stukus DR, Wang J, Peters AT. Topical corticosteroids for chronic rhinosinusitis with nasal polyposis: GRADE systematic review and network meta-analysis. J Allergy Clin Immunol 2022; 150:1447-1459. [PMID: 35970310 DOI: 10.1016/j.jaci.2022.07.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 07/07/2022] [Accepted: 07/15/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND Chronic rhinosinusitis with nasal polyposis (CRSwNP) is associated with a significant disease burden. The optimal use of and administration route for intranasal corticosteroids (INCS) when managing CRSwNP are unclear. OBJECTIVE We systematically synthesized the evidence addressing INCS for CRSwNP. METHODS We searched studies archived in Medline, Embase, and Central from database inception until September 1, 2021, for randomized controlled trials comparing INCS using any delivery method to placebo or other INCS administration types. Paired reviewers screened records, abstracted data, and rated risk of bias (CLARITY revision of Cochrane Risk of Bias version 1 tool) independently and in duplicate. We synthesized the evidence for each outcome using random effects network meta-analyses. We critically appraised the evidence following the GRADE (Grades of Recommendation Assessment, Development, and Evaluation) approach. RESULTS We analyzed 61 randomized controlled trials (7176 participants, 8 interventions). Sinusitis-related quality of life might improve with INCS rinse (mean difference [MD] -6.83, 95% confidence interval [CI] -11.94 to -1.71) and exhalation delivery system (EDS) (MD -7.86, 95% CI -14.64 to -1.08) compared to placebo (both low certainty evidence). Nasal obstruction symptoms are likely improved when receiving INCS via stent/dressing (MD -0.31, 95% CI -0.54 to -0.08), spray (MD -0.51, 95% CI -0.61 to -0.41), and EDS (MD -0.35, 95% CI -0.51 to -0.18) (all moderate to high certainty) compared to placebo. We found no important differences in adverse effects among interventions (moderate certainty for INCS spray, very low to low certainty for others). CONCLUSIONS Multiple delivery forms of INCS are viable therapeutic options for CRSwNP, resulting in improvement of patient-important outcomes. INCS via stent, spray, and EDS appear to be beneficial across the widest range of considered outcomes.
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Affiliation(s)
- Antonio Bognanni
- Evidence in Allergy Group, Department of Medicine and Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Derek K Chu
- Evidence in Allergy Group, Department of Medicine and Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Matthew A Rank
- Mayo Clinic in Arizona and Phoenix Children's Hospital, Scottsdale and Phoenix, Ariz.
| | | | - Anne K Ellis
- Department of Medicine, Division of Allergy & Immunology, Queen's University, Kingston, Canada
| | - David Golden
- Johns Hopkins University School of Medicine, Baltimore, Md
| | - Matthew Greenhawt
- Children's Hospital Colorado and the University of Colorado School of Medicine, Aurora, Colo
| | | | - Caroline C Horner
- Department of Pediatrics, Division of Allergy and Pulmonary Medicine, Washington University School of Medicine, St Louis, Mo
| | - Dennis K Ledford
- Morsani College of Medicine, University of South Florida, Tampa, Fla
| | - Jay Lieberman
- University of Tennessee Health Science Center and LeBonheur Children's Hospital, Memphis, Tenn
| | - Amber U Luong
- McGovern Medical School of the University of Texas Health Science Center at Houston, Houston, Tex
| | | | | | | | - Marcus Shaker
- Dartmouth Geisel School of Medicine and the Dartmouth Hitchcock Medical Center, Section of Allergy, Lebanon, NH.
| | | | - Whitney W Stevens
- Division of Allergy and Immunology, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - David R Stukus
- Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio
| | - Julie Wang
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - Anju T Peters
- Division of Allergy and Immunology, Northwestern University Feinberg School of Medicine, Chicago, Ill
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Wang C, Yu L, Chu X, Wang K, Li J, Lai Y, Meng C, Wen W, Zhu D, Zhang Y, Zhang L. Short-term postoperative efficacy of steroid-eluting stents for eosinophilic chronic rhinosinusitis with nasal polyps: a randomized clinical trial. Int Forum Allergy Rhinol 2022; 13:899-909. [PMID: 36086876 DOI: 10.1002/alr.23085] [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: 06/09/2022] [Revised: 09/02/2022] [Accepted: 09/06/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Eosinophilic chronic rhinosinusitis with nasal polyps (ECRSwNP) is a refractory clinical phenotype with high symptom burden and relapse rate. Steroid-eluting stents are safe and effective for reducing polyp size, symptom burden, and the need for revision sinus surgery. This study aimed to evaluate the efficacy and safety of steroid-eluting stent implantation on the surgical outcomes of patients with ECRSwNP. METHODS This prospective, multicenter, randomized, intrapatient-controlled trial recruited patients aged 18 to 65 years with ECRSwNP requiring surgery. Ninety-eight patients were enrolled and randomly implanted with absorbable steroid-eluting stents containing mometasone furoate in one sinus at the end of surgery. All patients received standard postoperative care and follow-up. The primary outcome was the Lund-Kennedy endoscopic score within 12 weeks post-surgery. Secondary outcomes included nasal symptoms scores, nasal resistance, acoustic rhinometry, nasal nitric oxide levels, 3-dimensional volumetric computed tomography scores, and eosinophil counts in the ethmoid mucosa. RESULTS Ninety-five patients completed the trial. At postoperative weeks 4, 8, and 12, the Lund-Kennedy scores were significantly lower on the treatment side than on the control side (all p<0.01). Compared with the treatment side, the control side exhibited higher tissue eosinophilia at week 4 and higher volumetric, nasal obstruction, and total nasal symptom scores at postoperative week 8 (p = 0.011, p = 0.011, p<0.01, and p = 0.001, respectively). No adrenal cortical suppression or serious side effects were observed. CONCLUSION Steroid-eluting stents reduce postoperative sinus mucosal edema and eosinophilic inflammation, with persistent effects after stent disintegration, and are a good supplementary post-surgical treatment in patients with ECRSwNP. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Chengshuo Wang
- Department of Otolaryngology, Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University.,Beijing Key Laboratory of Nasal Diseases, Beijing Institute of Otolaryngology
| | - Longgang Yu
- Department of Otolaryngology, Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University.,Department of Otolaryngology, Head and Neck Surgery, the Affiliated Hospital of Qingdao University
| | - Xiaohan Chu
- Department of Otolaryngology, Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University
| | - Kuiji Wang
- Department of Otolaryngology, Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University
| | - Jian Li
- Otorhinolaryngology Hospital, The First Affiliated Hospital, Sun Yat-sen University
| | - Yinyan Lai
- Otorhinolaryngology Hospital, The First Affiliated Hospital, Sun Yat-sen University
| | - Cuida Meng
- Department of Otolaryngology, Head and Neck Surgery, China-Japan Union Hospital of Jilin University
| | - Weiping Wen
- Otorhinolaryngology Hospital, The First Affiliated Hospital, Sun Yat-sen University
| | - Dongdong Zhu
- Department of Otolaryngology, Head and Neck Surgery, China-Japan Union Hospital of Jilin University
| | - Yuan Zhang
- Department of Otolaryngology, Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University.,Beijing Key Laboratory of Nasal Diseases, Beijing Institute of Otolaryngology.,Department of Allergy, Beijing Tongren Hospital, Capital Medical University
| | - Luo Zhang
- Department of Otolaryngology, Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University.,Beijing Key Laboratory of Nasal Diseases, Beijing Institute of Otolaryngology.,Department of Allergy, Beijing Tongren Hospital, Capital Medical University
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12
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Hopkins C, Lee SE, Klimek L, Soler ZM. Clinical Assessment of Chronic Rhinosinusitis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:1406-1416. [PMID: 35183784 DOI: 10.1016/j.jaip.2022.02.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 01/27/2022] [Accepted: 02/06/2022] [Indexed: 12/15/2022]
Abstract
Chronic rhinosinusitis (CRS) is a common disease that affects >10% of the adult population in Europe and the United States. It has been delineated phenotypically into CRS without nasal polyps and CRS with nasal polyps. Both have a high disease burden and an overlapping spectrum of symptoms such as nasal obstruction, olfactory dysfunction, facial pain, pressure, and nasal discharge. Primary assessment includes evaluation of patient symptoms and impact on quality of life, nasal endoscopic examination, and imaging. Significant progress has been made in the understanding of CRS pathophysiology. There is a move toward describing CRS in terms of the predominant endotype or inflammatory pattern pathomechanism rather than the traditional classification of patients with and without nasal polyps. An increased elucidation of the disease endotypes, as characterized by their inflammatory pathways and mediators, is leading to a tailored more personalized treatment approach to the different disease subtypes.
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Affiliation(s)
| | - Stella E Lee
- Division of Otolaryngology-Head & Neck Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Ludger Klimek
- Center for Rhinology and Allergology, Wiesbaden, Germany
| | - Zachary M Soler
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC
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13
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Jeong SS, Chen T, Nguyen SA, Edwards TS, Schlosser RJ. Correlation of polyp grading scales with patient symptom scores and olfaction in chronic rhinosinusitis: a systematic review and meta-analysis. Rhinology 2022; 0:2995. [PMID: 35438689 DOI: 10.4193/rhin22.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2024]
Abstract
BACKGROUND Various nasal polyp (NP) scoring systems have been proposed and used in the literature. However, no single system has been identified as superior. Correlations between NP scoring systems and patient symptoms, quality of life (QOL) or olfaction vary widely. METHODS A systematic search of PubMed, CINAHL, Scopus, and Cochrane Library was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guideline. Any study examining endoscopy scores and symptom, QOL or olfaction measures in cross sectional manner or after therapeutic intervention were included. RESULTS This review identified 55 studies for a pooled meta-analysis of Lund-Kennedy (LK-NP) polyp scores (N = 6), Meltzer scores (N = 6), Nasal polyp scores (NPS; N = 19), Total polyp score (TPS; N=8) Lilholdt scores (N = 8), Olfactory cleft endoscopy score (OCES; N =4), Discharge, inflammation, polyp/edema score (DIP; N = 2), and Perioperative sinus endoscopy score (POSE; N = 2). Meta-regression assessed correlations between NP grading systems and SNOT-22, nasal congestion scores, total nasal symptom scores (TNSS), and Smell Identification Test-40 (SIT40). None of the NP grading systems correlated significantly with any symptom, QOL or olfactory metric. In intervention studies of surgery or monoclonal antibody treatment, changes in NPS scores did not correlate with any patient reported outcome measure (PROM) or olfactory outcomes. CONCLUSION Current NP endoscopic scoring systems are not associated with PROMs such as SNOT-22, nasal congestion scores, and TNSS as well as objective measures of olfaction. NP grading systems with improved clinical utility are needed.
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Affiliation(s)
- S S Jeong
- 1 Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA and 2 Albert Einstein College of Medicine, Bronx, NY, USA
| | - T Chen
- Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - S A Nguyen
- Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - T S Edwards
- Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - R J Schlosser
- Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA
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14
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Ow RA, McGinnis JP, Sacks HJ, Mehle ME. The Effect of EDS-FLU on Objective and Patient-Reported Subjective Outcomes for Patients with Chronic Rhinosinusitis with Nasal Polyps. EAR, NOSE & THROAT JOURNAL 2022:1455613221088698. [PMID: 35437059 DOI: 10.1177/01455613221088698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Exhalation delivery system with fluticasone (EDS-FLU) delivers medication high and deep in the nasal passages and has been shown to reduce nasal polyp (NP) grade, an objective measure of efficacy, and to yield clinically meaningful improvements on subjective measures of symptoms in patients with chronic rhinosinusitis with nasal polyps (CRSwNP). OBJECTIVES To better characterize EDS-FLU treatment, we analyzed responder rates for four outcome measures used in the EDS-FLU pivotal trials, in the overall study population as well as in subgroups of patients with or without prior sinus surgery or prior use of a standard intranasal corticosteroid spray (INS). METHODS Data were pooled from two randomized, 24-week (16-week, double-blind + 8-week, open-label), placebo-controlled studies (NAVIGATE I and II). Results for patients receiving EDS-FLU (186 µg [n = 161] or 372 µg [n = 160]) or EDS-placebo (n = 161) twice daily during the double-blind phase are described. Responder criteria included NP grade reduction (≥1-point), 22-item Sino-Nasal Outcome Test (SNOT-22) reduction (>12-points), Patient Global Impression of Change (PGIC) (much/very much improved), and congestion score improvement (>0.5-points). RESULTS More patients in the EDS-FLU group responded to each of the four responder criteria compared with EDS-placebo. More patients receiving EDS-FLU responded to ≥ 1 criterion compared with EDS-placebo at week 4 (82.7% and 60.4%, respectively) and week 16 (95.7% and 80.3%, respectively). Patients responded similarly irrespective of prior sinus surgery or prior INS use. Patient-reported outcome measures showed earlier responses than NP scores. CONCLUSIONS Meaningful improvements were seen across multiple response criteria with EDS-FLU, suggesting that the broad treatment effect of EDS-FLU includes objective reduction in polyp grade and improvements in several patient-reported outcomes. TRIAL REGISTRATION ClinicalTrials.gov (NAVIGATE I: NCT01622569 and NAVIGATE II: NCT01624662).
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Affiliation(s)
- Randall A Ow
- Sacramento Ear Nose Throat Medical, Roseville, CA, USA
| | | | | | - Mark E Mehle
- 6969Northeast Ohio Medical University, Rootstown, OH, USA
- Southwest General Medical Group, ENT Associates, Middleburg Heights, OH, USA
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15
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Patel ZM, Holbrook EH, Turner JH, Adappa ND, Albers MW, Altundag A, Appenzeller S, Costanzo RM, Croy I, Davis GE, Dehgani-Mobaraki P, Doty RL, Duffy VB, Goldstein BJ, Gudis DA, Haehner A, Higgins TS, Hopkins C, Huart C, Hummel T, Jitaroon K, Kern RC, Khanwalkar AR, Kobayashi M, Kondo K, Lane AP, Lechner M, Leopold DA, Levy JM, Marmura MJ, Mclelland L, Miwa T, Moberg PJ, Mueller CA, Nigwekar SU, O'Brien EK, Paunescu TG, Pellegrino R, Philpott C, Pinto JM, Reiter ER, Roalf DR, Rowan NR, Schlosser RJ, Schwob J, Seiden AM, Smith TL, Soler ZM, Sowerby L, Tan BK, Thamboo A, Wrobel B, Yan CH. International consensus statement on allergy and rhinology: Olfaction. Int Forum Allergy Rhinol 2022; 12:327-680. [PMID: 35373533 DOI: 10.1002/alr.22929] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 01/01/2021] [Accepted: 11/19/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND The literature regarding clinical olfaction, olfactory loss, and olfactory dysfunction has expanded rapidly over the past two decades, with an exponential rise in the past year. There is substantial variability in the quality of this literature and a need to consolidate and critically review the evidence. It is with that aim that we have gathered experts from around the world to produce this International Consensus on Allergy and Rhinology: Olfaction (ICAR:O). METHODS Using previously described methodology, specific topics were developed relating to olfaction. Each topic was assigned a literature review, evidence-based review, or evidence-based review with recommendations format as dictated by available evidence and scope within the ICAR:O document. Following iterative reviews of each topic, the ICAR:O document was integrated and reviewed by all authors for final consensus. RESULTS The ICAR:O document reviews nearly 100 separate topics within the realm of olfaction, including diagnosis, epidemiology, disease burden, diagnosis, testing, etiology, treatment, and associated pathologies. CONCLUSION This critical review of the existing clinical olfaction literature provides much needed insight and clarity into the evaluation, diagnosis, and treatment of patients with olfactory dysfunction, while also clearly delineating gaps in our knowledge and evidence base that we should investigate further.
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Affiliation(s)
- Zara M Patel
- Otolaryngology, Stanford University School of Medicine, Stanford, California, USA
| | - Eric H Holbrook
- Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - Justin H Turner
- Otolaryngology, Vanderbilt School of Medicine, Nashville, Tennessee, USA
| | - Nithin D Adappa
- Otolaryngology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mark W Albers
- Neurology, Harvard Medical School, Boston, Massachusetts, USA
| | - Aytug Altundag
- Otolaryngology, Biruni University School of Medicine, İstanbul, Turkey
| | - Simone Appenzeller
- Rheumatology, School of Medical Sciences, University of Campinas, São Paulo, Brazil
| | - Richard M Costanzo
- Physiology and Biophysics and Otolaryngology, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Ilona Croy
- Psychology and Psychosomatic Medicine, TU Dresden, Dresden, Germany
| | - Greg E Davis
- Otolaryngology, Proliance Surgeons, Seattle and Puyallup, Washington, USA
| | - Puya Dehgani-Mobaraki
- Associazione Naso Sano, Umbria Regional Registry of Volunteer Activities, Corciano, Italy
| | - Richard L Doty
- Smell and Taste Center, Otolaryngology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Valerie B Duffy
- Allied Health Sciences, University of Connecticut, Storrs, Connecticut, USA
| | | | - David A Gudis
- Otolaryngology, Columbia University Irving Medical Center, New York, USA
| | - Antje Haehner
- Smell and Taste, Otolaryngology, TU Dresden, Dresden, Germany
| | - Thomas S Higgins
- Otolaryngology, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Claire Hopkins
- Otolaryngology, Guy's and St. Thomas' Hospitals, London Bridge Hospital, London, UK
| | - Caroline Huart
- Otorhinolaryngology, Cliniques universitaires Saint-Luc, Institute of Neuroscience, Université catholgique de Louvain, Brussels, Belgium
| | - Thomas Hummel
- Smell and Taste, Otolaryngology, TU Dresden, Dresden, Germany
| | | | - Robert C Kern
- Otolaryngology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Ashoke R Khanwalkar
- Otolaryngology, Stanford University School of Medicine, Stanford, California, USA
| | - Masayoshi Kobayashi
- Otorhinolaryngology-Head and Neck Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - Kenji Kondo
- Otolaryngology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Andrew P Lane
- Otolaryngology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Matt Lechner
- Otolaryngology, Barts Health and University College London, London, UK
| | - Donald A Leopold
- Otolaryngology, University of Vermont Medical Center, Burlington, Vermont, USA
| | - Joshua M Levy
- Otolaryngology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Michael J Marmura
- Neurology Thomas Jefferson University School of Medicine, Philadelphia, Pennsylvania, USA
| | - Lisha Mclelland
- Otolaryngology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Takaki Miwa
- Otolaryngology, Kanazawa Medical University, Ishikawa, Japan
| | - Paul J Moberg
- Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | | | - Sagar U Nigwekar
- Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Erin K O'Brien
- Otolaryngology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Teodor G Paunescu
- Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Carl Philpott
- Otolaryngology, University of East Anglia, Norwich, UK
| | - Jayant M Pinto
- Otolaryngology, University of Chicago, Chicago, Illinois, USA
| | - Evan R Reiter
- Otolaryngology, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - David R Roalf
- Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Nicholas R Rowan
- Otolaryngology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Rodney J Schlosser
- Otolaryngology, Medical University of South Carolina, Mt Pleasant, South Carolina, USA
| | - James Schwob
- Biomedical Sciences, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Allen M Seiden
- Otolaryngology, University of Cincinnati School of Medicine, Cincinnati, Ohio, USA
| | - Timothy L Smith
- Otolaryngology, Oregon Health and Sciences University, Portland, Oregon, USA
| | - Zachary M Soler
- Otolaryngology, Medical University of South Carolina, Mt Pleasant, South Carolina, USA
| | - Leigh Sowerby
- Otolaryngology, University of Western Ontario, London, Ontario, Canada
| | - Bruce K Tan
- Otolaryngology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Andrew Thamboo
- Otolaryngology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Bozena Wrobel
- Otolaryngology, Keck School of Medicine, USC, Los Angeles, California, USA
| | - Carol H Yan
- Otolaryngology, School of Medicine, UCSD, La Jolla, California, USA
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16
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Djupesland PG, Reitsma S, Hopkins C, Sedaghat AR, Peters A, Fokkens WJ. Endoscopic grading systems for nasal polyps: are we comparing apples to oranges? Rhinology 2022; 60:169-176. [PMID: 35403178 DOI: 10.4193/rhin21.401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Endoscopic grading of nasal polyps (NP) is typically a coprimary endpoint in clinical trials evaluating treatments for chronic rhinosinusitis with nasal polyps (CRSwNP). However, a consensus on the most effective way to grade nasal polyps has not been reached. Different scales have been used, hampering the interpretation of data across trials. This review compares the characteristics of NP grading systems used in registration trials for approved NP treatments. These fundamental differences in grading systems make quantitative comparison of outcomes between trials inaccurate and potentially misleading. In lieu of a universal grading system, reporting the baseline distribution of polyp grades (unilateral and/or summed/total grades), as well as changes from baseline over time by baseline grade may help improve interpretability of outcomes and reduce inaccuracy when attempting cross-trial comparisons and making therapeutic decisions.
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Affiliation(s)
| | - S Reitsma
- Department of Otorhinolaryngology, Amsterdam University Medical Centres, location AMC, Amsterdam, The Netherlands
| | - C Hopkins
- Department of Otorhinolaryngology, Guy's Hospital, London, UK
| | - A R Sedaghat
- Department of Otolaryngology, Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - A Peters
- Division of Allergy and Immunology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - W J Fokkens
- Department of Otorhinolaryngology, Amsterdam University Medical Centres, location AMC, Amsterdam, The Netherlands
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17
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Presurgical olfactory function as an indicator of the outcome of functional endoscopic sinus surgery in chronic rhinosinusitis with nasal polyps. Eur Arch Otorhinolaryngol 2022; 279:5727-5733. [PMID: 35748932 PMCID: PMC9649454 DOI: 10.1007/s00405-022-07496-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 06/07/2022] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Chronic rhinosinusitis with nasal polyps (CRSwNP) often leads to impaired olfactory function and reduced quality of life. When conservative treatments such as nasal irrigation and topical steroids fail, functional endoscopic sinus surgery (FESS) is often necessary, because it improves symptoms and enhances quality of life. MATERIALS AND METHODS A total of 88 patients was included in this prospective study. All subjects underwent an extensive examination both presurgically and 4 months after operations including nasal endoscopy and psychophysical olfactory testing (Sniffin' Sticks). Moreover, disease-specific quality of life was assessed and presurgical CT scans were rated regarding the opacification of the paranasal sinuses. RESULTS Presurgically psychophysical tests showed an overall olfactory dysfunction. Olfactory test results (TDI score) correlated with endoscopic (Lund-Kennedy and Lildtholdt score) and CT scores (Lund-Mackay and TOCS scores). Four months after surgery olfactory function was enhanced and quality of life significantly showed an overall improvement. However, the outcome was dependent on the extent of presurgical olfactory function: olfaction and quality of life improved most pronounced in anosmics compared to hyposmic and especially normosmic patients. CONCLUSIONS This study confirmed that FESS in CRSwNP leads to a significant improvement of both olfaction and disease-specific quality of life. Moreover, preoperative psychophysical assessment of the extent of olfactory dysfunction can help to objectively assess possible risks and expected benefits of the surgery in terms of olfaction and quality of life.
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18
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Talat R, Gengler I, Phillips KM, Caradonna DS, Gray ST, Sedaghat AR. Chronic Rhinosinusitis Outcomes of Patients With Aspirin-Exacerbated Respiratory Disease Treated With Budesonide Irrigations: A Case Series. Ann Otol Rhinol Laryngol 2021; 131:1130-1136. [PMID: 34775833 DOI: 10.1177/00034894211054948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Pathophysiology-targeting treatments exist for aspirin-exacerbated respiratory disease (AERD) through aspirin desensitization and biologics, such as dupilumab. With increasing attention paid to these treatments, which may be associated with significant side effects and/or cost, there is little description of chronic rhinosinusitis with nasal polyps (CRSwNP) response to treatment with intranasal corticosteroids and saline irrigations in AERD. OBJECTIVE To determine the effect of intranasal budesonide irrigations for the treatment of CRSwNP in AERD. METHODS This is an observational study of 14 AERD patients presenting to a rhinology clinic for CRS who were treated with twice daily high volume, low pressure irrigations with 240 mL of saline to which a 0.5 mg/2 mL respule of budesonide was added. All participants completed a 22-item Sinonasal Outcome Test (SNOT-22) at enrollment and at follow up 1 to 6 months later. Polyp scores were also calculated at each time point. RESULTS SNOT-22 scores ranged from 26 to 98 (median: 40.5) at enrollment and 3 to 85 (median: 38.5) at follow-up. Polyp scores ranged from 2 to 6 (median: 4) at enrollment at 0 to 6 (median: 2) at follow-up. Over the treatment period, change in SNOT-22 score ranged from -38 to 16 (median: -18) and change in polyp score ranged from -2 to 0 (median: -0.5). Approximately 57% of participants experienced at least 1 minimal clinically important difference in SNOT-22 score and 21% of participants had a SNOT-22 score <20 at follow-up. CONCLUSION Medical management with intranasal corticosteroids and saline irrigations alone leads to significant improvement in sinonasal symptomatology in a subset of AERD.
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Affiliation(s)
- Rehab Talat
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Isabelle Gengler
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Katie M Phillips
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - David S Caradonna
- Department of Otolaryngology, Harvard Medical School, Boston, MA, USA.,Division of Otolaryngology, Boston, MA, USA
| | - Stacey T Gray
- Department of Otolaryngology, Harvard Medical School, Boston, MA, USA.,Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, MA, USA
| | - Ahmad R Sedaghat
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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19
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Borish L, Baroody FM, Kim MS, Lieberman JA, Peters A, Stevens WW, Bernstein JA. Yardstick for the medical management of chronic rhinosinusitis. Ann Allergy Asthma Immunol 2021; 128:118-128. [PMID: 34687874 DOI: 10.1016/j.anai.2021.10.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 10/07/2021] [Accepted: 10/11/2021] [Indexed: 02/07/2023]
Abstract
Chronic rhinosinusitis (CRS) is an inflammatory condition of the paranasal sinuses defined by classic symptoms, imaging findings, or endoscopic findings. There are a growing number of emerging pharmacologic therapies being evaluated to treat patients with CRS, some of which have gained indication status in the United States. There have not been updated treatment guidelines published in the United States however since 2014. This document is meant to serve as an updated expert consensus document for the pharmacologic management of patients with CRS. We review available data focusing on prospective clinical trials on oral and intranasal corticosteroids, nasal irrigation, biologics, antibiotics, and allergy immunotherapy for CRS both with and without nasal polyposis, including specific therapies for aspirin-exacerbated respiratory disease-associated CRS and allergic fungal CRS. There are multiple options to treat CRS, and clinicians should be knowledgeable on the efficacy and risks of these available therapies. Allergists-immunologists now have various therapies available to treat patients with CRS.
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Affiliation(s)
- Larry Borish
- Department of Medicine, Asthma and Allergic Disease Center, The University of Virginia, Charlottesville, Virginia
| | - Fuad M Baroody
- Department of Surgery (Otolaryngology-Head and Neck Surgery) and Pediatrics, The University of Chicago Medicine and the Comer Children's Hospital, Chicago, Illinois
| | - Margaret S Kim
- Division of Allergy-Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jay A Lieberman
- Division of Pulmonology, Allergy, & Immunology, Department of Pediatrics, The University of Tennessee Health Science Center, Memphis, Tennessee
| | - Anju Peters
- Division of Allergy-Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Whitney W Stevens
- Division of Allergy-Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jonathan A Bernstein
- Division of Immunology-Allergy Section, Department of Internal Medicine, The University of Cincinnati College of Medicine, Cincinnati, Ohio.
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20
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Yu L, Jiang Y, Yan B, Fang G, Wang C, Zhang L. Predictive value of clinical characteristics in eosinophilic chronic rhinosinusitis with nasal polyps: A cross-sectional study in the Chinese population. Int Forum Allergy Rhinol 2021; 12:726-734. [PMID: 34569170 DOI: 10.1002/alr.22901] [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: 03/20/2021] [Revised: 08/16/2021] [Accepted: 08/23/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND Eosinophilic chronic rhinosinusitis with nasal polyps (ECRSwNP) is a refractory subtype of chronic rhinosinusitis with nasal polyps (CRSwNP), with clinical characteristics differing from those of non-ECRSwNP. We aimed to explore the predictive value of clinical characteristics, including medical history, symptoms, and signs, prior to ECRSwNP diagnosis, and to develop a nomogram for use in clinical practice. METHODS A total of 502 patients with CRSwNP were enrolled. Based on the degree of eosinophilic infiltration in nasal polyps (NPs), patients were classified as ECRSwNP or non-ECRSwNP group. Participants' demographic characteristics, asthma history, severity of nasal symptoms (nasal obstruction, rhinorrhea, hyposmia, and facial pain/headache) according to the visual analog scale, and nasal polyp scores based on polyp scoring system were recorded. Logistic regression analysis was performed to screen for independent risk factors, and a model nomogram was constructed. RESULTS The percentage of asthmatic patients and the hyposmia, rhinorrhea, and total nasal symptom scores were significantly higher in ECRSwNP patients than that in non-ECRSwNP patients. The nasal polyp score was lower in the eosinophilic group than that in the non-eosinophilic group. Logistic regression analysis revealed that asthma history and hyposmia, rhinorrhea and nasal polyp scores were independent predictors of ECRSwNP. A nomogram consisting of these four independent risk factors was constructed, and its C-index was 0.808 (95% CI, 0.771 to 0.846). CONCLUSIONS The nomogram based on asthma history and olfactory, rhinorrhea, and nasal polyp scores could help predict ECRSwNP, providing a simple, fast, and practical way to distinguish ECRSwNP from non-ECRSwNP cases in clinical practice.
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Affiliation(s)
- Longgang Yu
- Department of Otolaryngology, Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Nasal Diseases, Beijing Institute of Otolaryngology, Beijing, China.,Department of Otolaryngology, Head and Neck Surgery, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yan Jiang
- Department of Otolaryngology, Head and Neck Surgery, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Bing Yan
- Beijing Key Laboratory of Nasal Diseases, Beijing Institute of Otolaryngology, Beijing, China
| | - Gaoli Fang
- Department of Otolaryngology, Head and Neck Surgery, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Chengshuo Wang
- Department of Otolaryngology, Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Nasal Diseases, Beijing Institute of Otolaryngology, Beijing, China
| | - Luo Zhang
- Department of Otolaryngology, Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Nasal Diseases, Beijing Institute of Otolaryngology, Beijing, China.,Department of Allergy, Beijing Tongren Hospital, Capital Medical University, Beijing, China
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21
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Brown HJ, Batra PS, Eggerstedt M, Ganti A, Papagiannopoulos P, Tajudeen BA. The possibility of short-term hypothalamic-pituitary-adrenal axis suppression with high-volume, high-dose nasal mometasone irrigation in postsurgical patients with chronic rhinosinusitis. Int Forum Allergy Rhinol 2021; 12:249-256. [PMID: 34569177 DOI: 10.1002/alr.22894] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 08/07/2021] [Accepted: 08/10/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND Medically refractory chronic rhinosinusitis (CRS) is often treated with functional endoscopic sinus surgery (FESS) and high-volume steroid nasal irrigation. While budesonide is the most common steroid irrigation for this indication, mometasone has a superior pharmacokinetic profile, which may allow dose escalation. The safety and efficacy of mometasone at higher concentrations than previously used in treating CRS have not been explored. METHODS Patients were recruited from a tertiary level clinic between June 2018 and December 2019. Inclusion criteria included adults (>18 years); CRS diagnosis; previous FESS; pre-treatment morning cortisol within normal range; minimum of twice daily high-volume sinonasal mometasone irrigations (total dose of 4 mg) for 12 weeks; and post-treatment morning cortisol measured within 2 weeks following the study period. Patients with potential for endogenous or exogenous disruption of the HPA axis were excluded. RESULTS 14 patients were enrolled in this prospective cohort study. In all but one patient, pre- and post-treatment morning cortisol levels were not significantly different and were within normal limits (6.7-25.4 μg/dL). Following an uninterrupted 12-week treatment course, no evidence of HPA axis suppression was found (P = 0.915). The single patient who was found to have a low (1.3 μg/dL) post-treatment morning serum cortisol level reportedly received an intraarticular steroid shot several days prior to the blood draw. She remained asymptomatic and her rechecked serum cortisol was within normal limits at 12.3 μg/dL. CONCLUSIONS High-volume 2 mg twice daily sinonasal mometasone irrigations did not cause HPA axis suppression in a representative sample of patients with refractory CRS post-FESS with normal baseline cortisol levels.
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Affiliation(s)
- Hannah J Brown
- Rush Medical College, Rush University Medical Center, Chicago, Illinois, USA
| | - Pete S Batra
- Rush Sinus Program, Department of Otorhinolaryngology - Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Michael Eggerstedt
- Rush Sinus Program, Department of Otorhinolaryngology - Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Ashwin Ganti
- Department of Otolaryngology-Head and Neck Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Peter Papagiannopoulos
- Rush Sinus Program, Department of Otorhinolaryngology - Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Bobby A Tajudeen
- Rush Sinus Program, Department of Otorhinolaryngology - Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, USA
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22
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Lötsch J, Hintschich CA, Petridis P, Pade J, Hummel T. Machine-Learning Points at Endoscopic, Quality of Life, and Olfactory Parameters as Outcome Criteria for Endoscopic Paranasal Sinus Surgery in Chronic Rhinosinusitis. J Clin Med 2021; 10:4245. [PMID: 34575356 PMCID: PMC8465949 DOI: 10.3390/jcm10184245] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 09/09/2021] [Accepted: 09/15/2021] [Indexed: 12/26/2022] Open
Abstract
Chronic rhinosinusitis (CRS) is often treated by functional endoscopic paranasal sinus surgery, which improves endoscopic parameters and quality of life, while olfactory function was suggested as a further criterion of treatment success. In a prospective cohort study, 37 parameters from four categories were recorded from 60 men and 98 women before and four months after endoscopic sinus surgery, including endoscopic measures of nasal anatomy/pathology, assessments of olfactory function, quality of life, and socio-demographic or concomitant conditions. Parameters containing relevant information about changes associated with surgery were examined using unsupervised and supervised methods, including machine-learning techniques for feature selection. The analyzed cohort included 52 men and 38 women. Changes in the endoscopic Lildholdt score allowed separation of baseline from postoperative data with a cross-validated accuracy of 85%. Further relevant information included primary nasal symptoms from SNOT-20 assessments, and self-assessments of olfactory function. Overall improvement in these relevant parameters was observed in 95% of patients. A ranked list of criteria was developed as a proposal to assess the outcome of functional endoscopic sinus surgery in CRS patients with nasal polyposis. Three different facets were captured, including the Lildholdt score as an endoscopic measure and, in addition, disease-specific quality of life and subjectively perceived olfactory function.
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Affiliation(s)
- Jörn Lötsch
- Institute of Clinical Pharmacology, Goethe-University, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Theodor-Stern-Kai 7, 60596 Frankfurt am Main, Germany
| | - Constantin A. Hintschich
- Department of Otorhinolaryngology, University of Regensburg, Franz-Josef-Strauß-Allee 11, 93053 Regensburg, Germany;
- Smell & Taste Clinic, Department of Otorhinolaryngology, TU Dresden, Fetscherstrasse 74, 01307 Dresden, Germany;
| | - Petros Petridis
- Department of Otorhinolaryngology, St. Johannes Municipal Hospital, Johannesstraße 9-17, 44137 Dortmund, Germany; (P.P.); (J.P.)
| | - Jürgen Pade
- Department of Otorhinolaryngology, St. Johannes Municipal Hospital, Johannesstraße 9-17, 44137 Dortmund, Germany; (P.P.); (J.P.)
| | - Thomas Hummel
- Smell & Taste Clinic, Department of Otorhinolaryngology, TU Dresden, Fetscherstrasse 74, 01307 Dresden, Germany;
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23
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Haque R, White AA, Jackson DJ, Hopkins C. Clinical evaluation and diagnosis of aspirin-exacerbated respiratory disease. J Allergy Clin Immunol 2021; 148:283-291. [PMID: 34364538 DOI: 10.1016/j.jaci.2021.06.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/14/2021] [Accepted: 06/15/2021] [Indexed: 12/30/2022]
Abstract
Aspirin-exacerbated respiratory disease (AERD) is a condition composed of chronic rhinosinusitis with nasal polyposis and asthma that is defined by respiratory hypersensitivity reactions to the cyclooxygenase 1-inhibitory effects of nonsteroidal anti-inflammatory drugs. It is diagnosed in 5% to 15% of patients with asthma and is even more common in those with comorbid nasal polyposis. Diagnosis is confirmed after an aspirin challenge procedure, yet many patients present with all components and can reliably be diagnosed by history. Patients with AERD commonly experience severe uncontrolled nasal polyposis and require multispecialty evaluation to properly stage and treat this condition. The presence of nasal polyposis plays a large component in the diminished quality of life in patients with AERD. In the last decade, multiple new therapeutic areas have been approved for type 2 airway diseases, offering patients with AERD many more options for control. This makes an early and accurate diagnosis of AERD important in the care of the larger population of type 2 airway diseases.
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Affiliation(s)
- Rubaiyat Haque
- Department of Adult Allergy, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom.
| | - Andrew A White
- Division of Asthma, Allergy and Immunology, Scripps Clinic, San Diego, Calif
| | - David J Jackson
- Guy's Severe Asthma Service, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; School of Immunology & Microbial Sciences, King's College London, London, United Kingdom
| | - Claire Hopkins
- Ear, Nose and Throat Department, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
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24
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Mucus composition abnormalities in sinonasal mucosa of chronic rhinosinusitis with and without nasal polyps. Inflammation 2021; 44:1937-1948. [PMID: 33999330 DOI: 10.1007/s10753-021-01471-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 03/11/2021] [Accepted: 04/15/2021] [Indexed: 12/30/2022]
Abstract
Mucus secretion and its composition are vital in the maintenance of airway health, among which hypoxia-inducible factors (HIFs) are thought to be involved in the regulation of mucin synthesis and regulation. Nasal mucus composition difference between healthy individuals and chronic rhinosinusitis (CRS) patients may contribute to the pathology of chronic nasal diseases, but so far, their role has yet to be completely understood. Nasal biopsy specimens were obtained from 24 healthy subjects and 99 patients with CRS without (CRSsNP, n=36) or with (CRSwNP, n=63) nasal polyps. Immunohistochemical (IHC) and immunofluorescent (IF) staining, quantitative real-time PCR, and western blot were performed to compare the nasal mucus composition between the subjects. Areas of the serous gland and mucous gland were both significantly increased in CRSsNP patients. In CRSwNP patients, a decrease in submucosal gland density and a marked increase in goblet cells were observed. The major gel-forming mucins in the sinonasal mucosa of CRSsNP and CRSwNP are MUC5B and MUC5AC respectively. Mucous cells are found in a higher proportion in both CRSsNP and CRSwNP. The proportion of MUC5AC-positive goblet cells was increased in CRSwNP. The mRNA level of HIF-2α was significantly increased in CRS, and both HIF-1α and HIF-2α were expressed in serous cell but not mucous cell. Over secretion and altered composition of mucus are observed in sinonasal mucosa of CRS, which was mainly associated with glandular hyperplasia in CRSsNP and goblet cell hyperplasia in CRSwNP. Mucus abnormality compromised both non-specific and specific antimicrobial capabilities in the sinonasal mucosa. HIF expression may contribute to differences in mucin synthesis and serous gland regulation, which needs further investigation to understand the pathology of CRS.
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25
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Ta NH, Gao J, Philpott C. A systematic review to examine the relationship between objective and patient-reported outcome measures in sinonasal disorders: recommendations for use in research and clinical practice. Int Forum Allergy Rhinol 2021; 11:910-923. [PMID: 33417297 PMCID: PMC8248036 DOI: 10.1002/alr.22744] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 11/01/2020] [Accepted: 11/12/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND Common sinonasal disorders include chronic rhinosinusitis (CRS), allergic rhinitis (AR), and a deviated nasal septum (DNS), which often coexist with shared common symptoms including nasal obstruction, olfactory dysfunction, and rhinorrhea. Various objective outcome measures and patient-reported outcome measures (PROMs) are used to assess disease severity; however, there is limited evidence in the literature on the correlation between them. This systematic review aims to examine the relationship between them and provide recommendations. METHODS A search of MEDLINE and EMBASE identified studies quantifying correlations between objective outcome measures and PROMs for the sinonasal conditions using a narrative synthesis. RESULTS In total, 59 studies met inclusion criteria. For nasal obstruction, rhinomanometry shows a lack of correlation whereas peak nasal inspiratory flow (PNIF) shows the strongest correlation with PROMs (r > 0.5). The Sniffin' Stick test shows a stronger correlation with PROMs (r > 0.5) than the University of Pennsylvania Smell Identification Test (UPSIT) (r < 0.5). Computed tomography (CT) sinus scores show little evidence of correlation with PROMs and nasal endoscopic ratings (weak correlation, r < 0.5). CONCLUSION Overall, objective outcome measures and PROMs assessing sinonasal symptoms are poorly correlated, and we recommend that objective outcome measures be used with validated PROMs depending on the setting. PNIF should be used in routine clinical practice for nasal obstruction; rhinomanometry and acoustic rhinometry may be useful in research. The Sniffin' Sticks test is recommended for olfactory dysfunction with UPSIT as an alternative. CT scores should be excluded as a routine CRS outcome measure, and endoscopic scores should be used in combination with PROMs until further research is conducted.
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Affiliation(s)
- Ngan Hong Ta
- Norwich Medical SchoolUniversity of East AngliaNorwichUK
| | - Jack Gao
- ENT DepartmentEast Suffolk and North Essex NHS Foundation TrustColchesterUK
| | - Carl Philpott
- ENT DepartmentJames Paget University Hospital NHS Foundation TrustGreat YarmouthUK
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26
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Orlandi RR, Kingdom TT, Smith TL, Bleier B, DeConde A, Luong AU, Poetker DM, Soler Z, Welch KC, Wise SK, Adappa N, Alt JA, Anselmo-Lima WT, Bachert C, Baroody FM, Batra PS, Bernal-Sprekelsen M, Beswick D, Bhattacharyya N, Chandra RK, Chang EH, Chiu A, Chowdhury N, Citardi MJ, Cohen NA, Conley DB, DelGaudio J, Desrosiers M, Douglas R, Eloy JA, Fokkens WJ, Gray ST, Gudis DA, Hamilos DL, Han JK, Harvey R, Hellings P, Holbrook EH, Hopkins C, Hwang P, Javer AR, Jiang RS, Kennedy D, Kern R, Laidlaw T, Lal D, Lane A, Lee HM, Lee JT, Levy JM, Lin SY, Lund V, McMains KC, Metson R, Mullol J, Naclerio R, Oakley G, Otori N, Palmer JN, Parikh SR, Passali D, Patel Z, Peters A, Philpott C, Psaltis AJ, Ramakrishnan VR, Ramanathan M, Roh HJ, Rudmik L, Sacks R, Schlosser RJ, Sedaghat AR, Senior BA, Sindwani R, Smith K, Snidvongs K, Stewart M, Suh JD, Tan BK, Turner JH, van Drunen CM, Voegels R, Wang DY, Woodworth BA, Wormald PJ, Wright ED, Yan C, Zhang L, Zhou B. International consensus statement on allergy and rhinology: rhinosinusitis 2021. Int Forum Allergy Rhinol 2021; 11:213-739. [PMID: 33236525 DOI: 10.1002/alr.22741] [Citation(s) in RCA: 413] [Impact Index Per Article: 137.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 11/09/2020] [Indexed: 02/06/2023]
Abstract
I. EXECUTIVE SUMMARY BACKGROUND: The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR-RS-2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence-based findings of the document. METHODS ICAR-RS presents over 180 topics in the forms of evidence-based reviews with recommendations (EBRRs), evidence-based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary. RESULTS ICAR-RS-2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence-based management algorithm is provided. CONCLUSION This ICAR-RS-2021 executive summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS.
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Affiliation(s)
| | | | | | | | | | - Amber U Luong
- University of Texas Medical School at Houston, Houston, TX
| | | | - Zachary Soler
- Medical University of South Carolina, Charleston, SC
| | - Kevin C Welch
- Feinberg School of Medicine, Northwestern University, Chicago, IL
| | | | | | | | | | - Claus Bachert
- Ghent University, Ghent, Belgium.,Karolinska Institute, Stockholm, Sweden.,Sun Yatsen University, Gangzhou, China
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - David A Gudis
- Columbia University Irving Medical Center, New York, NY
| | - Daniel L Hamilos
- Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | | | - Richard Harvey
- University of New South Wales and Macquarie University, Sydney, New South Wales, Australia
| | | | | | | | | | - Amin R Javer
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | | | | | | | | | | | | | | | | | - Valerie Lund
- Royal National Throat Nose and Ear Hospital, UCLH, London, UK
| | - Kevin C McMains
- Uniformed Services University of Health Sciences, San Antonio, TX
| | | | - Joaquim Mullol
- IDIBAPS Hospital Clinic, University of Barcelona, Barcelona, Spain
| | | | | | | | | | | | | | | | | | | | - Alkis J Psaltis
- University of Adelaide, Adelaide, South Australia, Australia
| | | | | | | | - Luke Rudmik
- University of Calgary, Calgary, Alberta, Canada
| | - Raymond Sacks
- University of New South Wales, Sydney, New South Wales, Australia
| | | | | | | | | | | | | | | | | | | | | | | | | | - De Yun Wang
- National University of Singapore, Singapore, Singapore
| | | | | | | | - Carol Yan
- University of California San Diego, La Jolla, CA
| | - Luo Zhang
- Capital Medical University, Beijing, China
| | - Bing Zhou
- Capital Medical University, Beijing, China
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27
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Caminati M, Senna G. Biologic Therapy in a Patient with Asthma and Nasal Polyps. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 7:1700-1701. [PMID: 31076065 DOI: 10.1016/j.jaip.2018.11.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 11/05/2018] [Accepted: 11/05/2018] [Indexed: 11/19/2022]
Affiliation(s)
- Marco Caminati
- Asthma Center and Allergy Unit, Verona University Hospital, Piazzale Scuro, Verona, Italy.
| | - Gianenrico Senna
- Asthma Center and Allergy Unit, Verona University Hospital, Piazzale Scuro, Verona, Italy
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28
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Naclerio R, Baroody F, Bachert C, Bleier B, Borish L, Brittain E, Chupp G, Fisher A, Fokkens W, Gevaert P, Kennedy D, Kim J, Laidlaw TM, Lee JJ, Piccirillo JF, Pinto JM, Roland LT, Schleimer RP, Schlosser RJ, Schwaninger JM, Smith TL, Tan BK, Tan M, Toskala E, Wenzel S, Togias A. Clinical Research Needs for the Management of Chronic Rhinosinusitis with Nasal Polyps in the New Era of Biologics: A National Institute of Allergy and Infectious Diseases Workshop. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2020; 8:1532-1549.e1. [PMID: 32142964 PMCID: PMC8177483 DOI: 10.1016/j.jaip.2020.02.023] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 02/25/2020] [Accepted: 02/25/2020] [Indexed: 12/11/2022]
Abstract
The development of biologics targeting various aspects of type 2 inflammation for the treatment of chronic rhinosinusitis with nasal polyps (CRSwNP) will provide clinicians with powerful tools to help treat these patients. However, other therapies are also available, and positioning of biologics in a management algorithm will require comparative trials. In November 2019, the National Institute of Allergy and Infectious Diseases convened a workshop to consider potential future trial designs. Workshop participants represented a wide spectrum of clinical specialties, including otolaryngology, allergy, and pulmonary medicine, as well as expertise in CRSwNP pathophysiology and in trial methodology and statistics. The workshop discussed the current state of knowledge in CRSwNP and considered the advantages and disadvantages of various clinical trial or observational study designs and various clinical outcomes. The output from this workshop, which is presented in this report, will hopefully provide investigators with adequate information and ideas to design future studies and answer critical clinical questions. It will also help clinicians understand the current state of the management of CRSwNP and its gaps and be more able to interpret the new information to come.
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Affiliation(s)
| | | | | | - Benjamin Bleier
- Harvard Medical School, Massachusetts Eye and Ear, Department of Otolaryngology, Boston, Mass
| | | | - Erica Brittain
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | | | - Anat Fisher
- University of British Columbia, Vancouver, BC, Canada
| | | | | | | | - Jean Kim
- Johns Hopkins University, Baltimore, Md
| | - Tanya M Laidlaw
- Harvard Medical School, Brigham and Women's Hospital, Division of Allergy and Clinical Immunology, Boston, Mass
| | | | | | | | - Lauren T Roland
- University of California-San Francisco, San Francisco, Calif
| | | | | | - Julie M Schwaninger
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | | | | | - Ming Tan
- Georgetown University, Washington, DC
| | | | | | - Alkis Togias
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md.
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29
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Epperson MV, Phillips KM, Caradonna DS, Gray ST, Sedaghat AR. Predictors of efficacy for combination oral and topical corticosteroids to treat patients with chronic rhinosinusitis with nasal polyps. Int Forum Allergy Rhinol 2019; 9:1436-1442. [PMID: 31609091 DOI: 10.1002/alr.22431] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Revised: 08/05/2019] [Accepted: 08/26/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND A short-course oral corticosteroid taper and topical intranasal corticosteroids may be used to maximize the success of medical management for chronic rhinosinusitis with nasal polyps (CRSwNP). In this study, we sought to identify characteristics that would be predictive of efficacy for this combination regimen. METHODS Sixty-four patients with CRS, bilateral polyps, a polyp score of at least 3, and a 22-item Sino-Nasal Outcome Test (SNOT-22) score ≥20 were prospectively enrolled and uniformly treated with a 15-day prednisone taper and twice daily dilute budesonide irrigations. Participants were assessed at enrollment and at follow up, 2 to 5 months later. Clinical and demographic characteristics were assessed at enrollment. At both time points, CRS symptoms were assessed with SNOT-22, and polyp score (range, 0 to 6) was assessed endoscopically. Associations were determined with regression. RESULTS Pretreatment SNOT-22 score (adjusted β = -0.83; 95% CI, -1.08 to -0.58; p < 0.001) and comorbid asthma (adjusted β = 15.75; 95% CI, 4.74 to 26.75; p = 0.007) were associated with a change in SNOT-22 experienced over the study period. Achieving a greater-than-1 minimal clinically important difference (MCID) improvement in SNOT-22 score was also associated with pretreatment SNOT-22 score (adjusted OR = 1.09; 95% CI, 1.04 to 1.14; p < 0.001) and comorbid asthma (adjusted OR = 0.13; 95% CI, 0.03 to 0.72; p = 0.019). SNOT-22 score ≥47 had 81.5% sensitivity and 78.4% specificity to detect patients experiencing 1 MCID improvement. Pretreatment polyp score was not associated with any outcome metric. CONCLUSION In treatment of CRSwNP with prednisone and budesonide irrigations, pretreatment endoscopy was not informative of treatment response. Pretreatment SNOT-22 and comorbid asthma may be more predictive.
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Affiliation(s)
- Madison V Epperson
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Katie M Phillips
- Department of Otolaryngology-Head and Neck Surgery, Stanford University, Stanford, CA
| | - David S Caradonna
- Department of Otolaryngology, Harvard Medical School, Boston, MA.,Division of Otolaryngology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Stacey T Gray
- Department of Otolaryngology, Harvard Medical School, Boston, MA.,Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, MA
| | - Ahmad R Sedaghat
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
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30
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Akiyama K, Makihara S, Uraguchi K, Samukawa Y, Oka A, Hoshikawa H. Impact of Preoperative Systemic Corticosteroids on the Histology and Diagnosis of Eosinophilic Chronic Rhinosinusitis. Int Arch Allergy Immunol 2019; 179:81-88. [DOI: 10.1159/000496437] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Accepted: 12/20/2018] [Indexed: 11/19/2022] Open
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31
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Sindwani R, Han JK, Soteres DF, Messina JC, Carothers JL, Mahmoud RA, Djupesland PG. NAVIGATE I: Randomized, Placebo-Controlled, Double-Blind Trial of the Exhalation Delivery System With Fluticasone for Chronic Rhinosinusitis With Nasal Polyps. Am J Rhinol Allergy 2019; 33:69-82. [PMID: 30477309 PMCID: PMC6604249 DOI: 10.1177/1945892418810281] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Chronic rhinosinusitis is a common, high-morbidity chronic inflammatory disease, and patients often experience suboptimal outcomes with current medical treatment. The exhalation delivery system with fluticasone (EDS-FLU) may improve care by increasing superior/posterior intranasal corticosteroid deposition. OBJECTIVE To evaluate the efficacy and safety of EDS-FLU versus EDS-placebo in patients with nasal polyps (NP). Coprimary end points were change in nasal congestion and polyp grade. Key secondary end points were Sino-Nasal Outcome Test-22 (SNOT-22) and Medical Outcomes Study Sleep Scale-Revised (MOS Sleep-R). Other prespecified end points included all 4 cardinal symptoms of NP, 36-Item Short Form Health Survey (SF-36), Patient Global Impression of Change (PGIC), Rhinosinusitis Disability Index (RSDI), and key indicators for surgical intervention. DESIGN Randomized, double-blind, EDS-placebo-controlled, multicenter study. METHODS Three hundred twenty-three subjects with NP and moderate-severe congestion/obstruction, most with history of corticosteroid use (94.4%) and/or prior surgery (60.4%), were randomized to EDS-FLU 93 µg, 186 µg, or 372 µg or EDS-placebo twice daily (BID) for 24 weeks (16 double-blind + 8 single-arm extension with EDS-FLU 372 µg BID). RESULTS All EDS-FLU doses produced significant improvement in both coprimary end points ( P < .05) and in SNOT-22 total score ( P ≤ .005). EDS-FLU significantly improved all 4 cardinal symptoms of NP ( P < .05), including congestion/obstruction, facial pain/pressure, rhinorrhea/post-nasal drip, and hyposmia/anosmia. Approximately 80% of subjects reported improvement with EDS-FLU, with 65% reporting "much" or "very much" improvement by week 16. Adverse events were generally local in nature and similar to other intranasal steroids studied for similar durations in similar populations, with the most common being epistaxis. CONCLUSIONS In patients with chronic rhinosinusitis with NP (CRSwNP) who were symptomatic despite high rates of prior intranasal steroid use and/or surgery, EDS-FLU produced statistically significant and clinically meaningful improvements compared to EDS-placebo in multiple subjective and objective outcomes (symptoms, SNOT-22, RSDI, SF-36, PGIC, and NP grade), including all 4 cardinal symptoms of CRSwNP.
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Affiliation(s)
- Raj Sindwani
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio
| | - Joseph K. Han
- Department of Otolaryngology, Head & Neck Surgery, Eastern
Virginia Medical School, Norfolk, Virginia
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Daval M, Picard H, Bequignon E, Bedbeder P, Coste A, Ayache D, Escabasse V. Chronic otitis media with effusion in chronic sinusitis with polyps. EAR, NOSE & THROAT JOURNAL 2018; 97:E13-E18. [PMID: 30138520 DOI: 10.1177/014556131809700803] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The relationship between otitis media with effusion (OME) and chronic rhinosinusitis with nasal polyposis (CRSwNP) remains unclear. We conducted a cross-sectional study of 80 consecutively presenting patients-42 males and 38 females, aged 15 to 76 years (median: 48)-who were diagnosed with CRSwNP. Our aim was to ascertain the prevalence of OME in CRSwNP patients, to determine whether the severity of CRSwNP affected OME, and to identify risk factors for OME in CRSwNP patients. The severity of CRSwNP was assessed on the basis of nasal symptoms, endoscopic nasal examinations, and Lund-Mackay staging scores. In addition to demographic data, we obtained information on each patient's history of otitis, otoscopic findings, and the results of pure-tone audiometry and tympanometry. We then compared the data between CRSwNP patients with OME (n = 20) and those without (n = 60). In the OME group, a conductive hearing loss was present in 16 patients (80.0%); all patients in the control group had normal hearing. With regard to symptoms, only rhinorrhea appeared to be more common in patients with OME than in those without, although the difference was not statistically significant. We found no significant difference in nasal polyposis grades between the two groups. Also, we found no correlations between the risk of OME and previous surgical treatment, asthma, allergy, aspirin intolerance, aspirin and/or NSAID intolerance, aspirin and/or sulfite intolerance, and aspirin-exacerbated respiratory disease. Based on our findings, we conclude that OME occurs frequently during the evolution of CRSwNP, even when the nasal disease is well controlled. This finding suggests the possible presence, in OME and/or CRSwNP, of a global inflammatory process that involves the epithelium in both the middle ear and upper airway.
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Affiliation(s)
- Mary Daval
- Department of Otorhinolaryngology-Head and Neck Surgery, Hôpital Intercommunal de Créteil, Créteil, France
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Leopold DA, Elkayam D, Messina JC, Kosik-Gonzalez C, Djupesland PG, Mahmoud RA. NAVIGATE II: Randomized, double-blind trial of the exhalation delivery system with fluticasone for nasal polyposis. J Allergy Clin Immunol 2018; 143:126-134.e5. [PMID: 29928924 DOI: 10.1016/j.jaci.2018.06.010] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 05/23/2018] [Accepted: 06/01/2018] [Indexed: 12/26/2022]
Abstract
BACKGROUND Chronic rhinosinusitis is common and sometimes complicated by nasal polyps (NPs). Corticosteroid nasal sprays are often unsatisfactory because they are ineffective at delivering medication to high/deep sites of inflammation. OBJECTIVE We sought to assess whether an exhalation delivery system with fluticasone (EDS-FLU) capable of high/deep drug deposition improves outcomes. METHODS Patients (n = 323) 18 years and older with moderate-to-severe congestion and NPs were randomized to twice-daily EDS-FLU (93, 186, or 372 μg) or exhalation delivery system (EDS)-placebo for 24 weeks (16 double-blind plus 8 open-label when all received 372 μg). Coprimary end points were change in nasal congestion/obstruction at 4 weeks and summed bilateral polyp grade at 16 weeks. Secondary end points included symptoms, polyp elimination, and functioning. RESULTS EDS-FLU was superior on both coprimary end points (P < .001 vs EDS-placebo, all doses). Mean polyp grade improved continuously through week 24 (P < .009, all comparisons), with polyps eliminated on at least 1 side in approximately 25% of patients at week 24 versus 8.7% with EDS-placebo (P ≤ .014, all comparisons). Sino-Nasal Outcomes Test scores also improved significantly versus those in patients receiving EDS-placebo (-21.1 to -21.4 vs -11.7 at week 16, P < .05 all doses). At the end of the double-blind period, EDS-FLU (all doses) significantly improved all 4 defining disease symptoms. In most patients (68%), those receiving EDS-FLU reported "much" or "very much" improvement. The number of patients eligible for surgery decreased by 62%-67%. The safety profile was similar to that reported in prior trials evaluating conventional corticosteroid nasal sprays in comparable populations. CONCLUSION EDS-FLU produces clinically and statistically significant improvement in all 4 diagnostically defining disease symptoms, polyp grade, and quality of life in patients with chronic rhinosinusitis with NPs.
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Affiliation(s)
- Donald A Leopold
- Department of Surgery, College of Medicine, University of Vermont, Burlington, Vt.
| | - David Elkayam
- Bellingham Asthma, Allergy and Immunology Clinic, Bellingham, Wash
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Palmer JN, Jacobson KW, Messina JC, Kosik‐Gonzalez C, Djupesland PG, Mahmoud RA. EXHANCE-12: 1-year study of the exhalation delivery system with fluticasone (EDS-FLU) in chronic rhinosinusitis. Int Forum Allergy Rhinol 2018; 8:869-876. [PMID: 29856520 PMCID: PMC6099484 DOI: 10.1002/alr.22141] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2018] [Revised: 04/12/2018] [Accepted: 04/18/2018] [Indexed: 01/06/2023]
Abstract
BACKGROUND Inadequate efficacy of current intranasal steroids in chronic rhinosinusitis (CRS) is attributable to ineffective and/or inconsistent drug delivery to target anatomic sites. A new exhalation delivery system with fluticasone (EDS-FLU) may improve outcomes by significantly increasing superior/posterior corticosteroid delivery. A study was conducted to assess the long-term efficacy and safety outcomes of EDS-FLU in individuals with CRS. METHODS This was a 12-month, multicenter, single-arm study evaluating the safety and efficacy of EDS-FLU 372 μg twice daily in CRS patients (with [n = 34] or without [n = 189] nasal polyps [NP]). Efficacy assessments by serial nasal endoscopy and patient report included: 22-item Sino-Nasal Outcome Test (SNOT-22), NP grade, standardized surgical indicator assessment, Lund-Kennedy score, and Patient Global Impression of Change. Adverse event (AE) evaluations included nasal endoscopy. Additional safety and efficacy outcomes were assessed. RESULTS Of 223 patients who received EDS-FLU, 96% reported prior corticosteroid use and 29% prior sinus surgery. The EDS-FLU AE profile was similar to conventional intranasal steroids studied in similar populations. Most patients (87%) reported symptom improvement. Through 12 months, mean SNOT-22 scores improved by -21.5 and -21.1 for CRS with and without NP, respectively. Among patients with NP, 54.2% had polyp elimination in at least 1 nostril and 83.3% had ≥1-point improvement in polyp grade. CONCLUSION Over 1 year of treatment in CRS with and without NP, EDS-FLU 372 μg twice daily was well tolerated and produced improvements across a broad range of objective and subjective measures. EDS-FLU may be a desirable new option for patients with this condition.
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Affiliation(s)
- James N. Palmer
- Department of Otorhinolaryngology–Head and Neck SurgeryUniversity of Pennsylvania, Perelman School of MedicinePhiladelphiaPA
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Kirtsreesakul V, Atchariyasathian V. Nasal Polyposis: Role of Allergy on Therapeutic Response of Eosinophil- and Noneosinophil-Dominated Inflammation. ACTA ACUST UNITED AC 2018. [DOI: 10.1177/194589240602000118] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background It is considered that allergy, at least in some cases, is associated with nasal polyps and affects recurrence rate. Our purpose was to determine the effects of aeroallergen hypersensitization on therapeutic response of eosinophil- and noneosinophil-dominated inflammation. Methods Sixty-eight patients were enrolled. Histopathological investigation and a skin-prick test were done and categorized as eosinophil-dominated inflammation with positive (ESPT+) or negative skin test (ESPT-) and nonesoinophil-dominated inflammation with positive (NESPT+) or negative skin test (NESPT-). Patients were treated over 6 weeks with budesonide nasal spray, 400 μg/day. At 0, 3, and 6 weeks after treatment, nasal symptoms, polyp size, nasal and oral peak expiratory flow (PEF) index and overall assessment within and between groups were evaluated and compared. Results At 3 and 6 weeks after treatment, the ESPT- group showed the most, and the NESPT+ group showed the least therapeutic improvement. In comparing between the positive and negative skin tests in each histopathology, the positive skin tests tended to have less improvement than the negative skin tests in all variables. The differences increased over time and reached statistical significance at 6 weeks in the PEF index and overall assessment of eosinophil-dominated inflammation (p = 0.004 and 0.033, respectively) and in sneezing score, postnasal drip score, and overall assessment of noneosinophil-dominated inflammation (p = 0.019, 0.035, and 0.013, respectively). Conclusion Nonallergic eosinophilic polyps had the best and allergic noneosinophilic polyps had the worst therapeutic response. Within each histopathology, allergic nasal polyps had less therapeutic response than nonallergic nasal polyps. This augmented effect could be caused by concomitant allergic inflammation.
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Affiliation(s)
- Virat Kirtsreesakul
- Department of Otolaryngology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Viraporn Atchariyasathian
- Department of Otolaryngology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
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Muganurmath CS, Curry AL, Schindzielorz AH. Causality Assessment of Olfactory and Gustatory Dysfunction Associated with Intranasal Fluticasone Propionate: Application of the Bradford Hill Criteria. Adv Ther 2018; 35:173-190. [PMID: 29396682 PMCID: PMC5818548 DOI: 10.1007/s12325-018-0665-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Indexed: 12/18/2022]
Abstract
Causality assessment is crucial to post-marketing pharmacovigilance and helps optimize safe and appropriate use of medicines by patients in the real world. Self-reported olfactory and gustatory dysfunction are common in the general population as well as in patients with allergic rhinitis and nasal polyposis. Intranasal corticosteroids, including intranasal fluticasone propionate (INFP), are amongst the most effective drugs indicated in the treatment of allergic rhinitis and nasal polyposis. While intranasal corticosteroids are associated with olfactory and gustatory dysfunction and are currently labeled for these adverse events, causality assessment has not been performed to date. Although there is no single widely accepted method to assess causality in pharmacovigilance, the Bradford Hill criteria offer a robust and comprehensive approach because nine distinct aspects of an observed potential drug–event association are assessed. In this literature-based narrative review, Hill’s criteria were applied to determine causal inference between INFP and olfactory and gustatory dysfunction.
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Rotter N. Evidence and evidence gaps in therapies of nasal obstruction and rhinosinusitis. GMS CURRENT TOPICS IN OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY 2016; 15:Doc06. [PMID: 28025606 PMCID: PMC5169079 DOI: 10.3205/cto000133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Therapeutic decisions in otorhinolaryngology are based on clinical experience, surgical skills, and scientific evidence. Recently, evidence-based therapies have gained increased attention and importance due to their potential to improve the individual patient's treatment and their potential at the same time to reduce treatment costs. In clinical practice, it is almost impossible to stay ahead of the increasing mass of literature and on the other hand critically assess the presented data. A solid scientific and statistical knowledge as well as a significant amount of spare time are required to detect systematic bias and other errors in study designs, also with respect to assessing whether or not a study should be part of an individual therapeutic decision. Meta-analyses, reviews, and clinical guidelines are, therefore, of increasing importance for evidence-based therapy in clinical practice. This review is an update of the availability of external evidence for the treatment of nasal obstruction and rhinosinusitis. It becomes evident that both groups of diseases differ significantly in the availability of external evidence. Furthermore, it becomes obvious that surgical treatment options are normally based on evidence of significantly lower quality than medical treatment options.
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Affiliation(s)
- Nicole Rotter
- Department of Otolaryngology, Head and Neck Surgery, Ulm University Medical Centre, Ulm, Germany
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Alobid I, Benítez P, Valero A, Berenguer J, Bernal-Sprekelsen M, Picado C, Mullol J. The Impact of Atopy, Sinus Opacification, and Nasal Patency on Quality of Life in Patients with Severe Nasal Polyposis. Otolaryngol Head Neck Surg 2016; 134:609-12. [PMID: 16564382 DOI: 10.1016/j.otohns.2005.10.061] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2005] [Accepted: 10/18/2005] [Indexed: 10/24/2022]
Abstract
OBJECTIVES: Nasal polyposis has a great impact on the quality of life. The aim of this study was to evaluate the association between quality of life and atopy, sinus opacification, and nasal patency in severe nasal polyposis. METHODS: One hundred nine patients completed the Medical Outcome Study Short Form-36 (SF-36) survey. Symptoms, polyp size, atopy, nasal patency, and sinus opacification were also scored. RESULTS: Patients showed worse scores in all SF-36 domains, except for physical functioning, compared with Spanish population. Atopic patients had worse scores in role physical, body pain, vitality, and mental health than nonatopic patients. Atopic patients showed lower physical component summary (44.7 ± 1.1) and mental component summary (38.4 ± 1.0) than nonatopic patients (48.3 ± 1.6, 40.6 ± 1.3; P < 0.05), respectively. There were no correlations between quality of life and symptoms, polyp size, CT scan, nasal patency, and atopy. CONCLUSION: Nasal polyposis has a considerable impact on quality of life and atopy worsens this impact. EBM rating: C-4
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Affiliation(s)
- Isam Alobid
- Rhinology Unit, Department of Otorhinolaryngology (ICEMEQ), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, Barcelona, Spain.
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Chong LY, Head K, Hopkins C, Philpott C, Burton MJ, Schilder AGM. Different types of intranasal steroids for chronic rhinosinusitis. Cochrane Database Syst Rev 2016; 4:CD011993. [PMID: 27115215 PMCID: PMC8939045 DOI: 10.1002/14651858.cd011993.pub2] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND This review is one of six looking at the primary medical management options for patients with chronic rhinosinusitis.Chronic rhinosinusitis is common and is characterised by inflammation of the lining of the nose and paranasal sinuses leading to nasal blockage, nasal discharge, facial pressure/pain and loss of sense of smell. The condition can occur with or without nasal polyps. Topical (intranasal) corticosteroids are used with the aim of reducing inflammation in the sinonasal mucosa in order to improve patient symptoms. OBJECTIVES To assess the effects of different types of intranasal steroids in people with chronic rhinosinusitis. SEARCH METHODS The Cochrane ENT Information Specialist searched the ENT Trials Register; Central Register of Controlled Trials (CENTRAL 2015, Issue 7); MEDLINE; EMBASE; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 11 August 2015. SELECTION CRITERIA Randomised controlled trials (RCTs) with a follow-up period of at least three months comparing first-generation intranasal corticosteroids (e.g. beclomethasone dipropionate, triamcinolone acetonide, flunisolide, budesonide) with second-generation intranasal corticosteroids (e.g. ciclesonide, fluticasone furoate, fluticasone propionate, mometasone furoate, betamethasone sodium phosphate), or sprays versus drops, or low-dose versus high-dose intranasal corticosteroids. DATA COLLECTION AND ANALYSIS We used the standard methodological procedures expected by Cochrane. Our primary outcomes were disease-specific health-related quality of life (HRQL), patient-reported disease severity and the commonest adverse event - epistaxis (nosebleed). Secondary outcomes included general HRQL, endoscopic nasal polyp score, computerised tomography (CT) scan score and the adverse event of local irritation. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics. MAIN RESULTS We included nine RCTs (911 participants), including four different comparisons. None of the studies evaluated our first primary outcome measure, disease-specific HRQL. Fluticasone propionate versus beclomethasone dipropionate We identified two small studies (56 participants with polyps) that evaluated disease severity and looked at the primary adverse effect: epistaxis , but no other outcomes. We cannot report any numerical data but the study authors reported no difference between the two steroids. The evidence was of very low quality. Fluticasone propionate versus mometasone furoate We identified only one study (100 participants with polyps) that evaluated disease severity (nasal symptoms scores), which reported no difference (no numerical data available). The evidence was of very low quality. High-dose versus low-dose steroidsWe included five studies (663 participants with nasal polyps), three using mometasone furoate (400 µg versus 200 µg in adults and older children, 200 µg versus 100 µg in younger children) and two using fluticasone propionate drops (800 µg versus 400 µg). We found low quality evidence relating to disease severity and nasal polyps size, with results from the high-dose and low-dose groups being similar. Although all studies reported more improvement in polyp score in the high-dose group, the significance of this is unclear due to the small size of the improvements.The primary adverse effect, epistaxis , was more common when higher doses were used (risk ratio (RR) 2.06, 95% confidence interval (CI) 1.20 to 3.54, 637 participants, moderate quality evidence). Most of the studies that contributed data to this outcome used a broad definition of epistaxis, which ranged from frank bleeding to bloody nasal discharge to flecks of blood in the mucus. Aqueous nasal spray versus aerosol spray We identified only one poorly reported study (unclear number of participants for comparison of interest, 91 between three treatment arms), in which there were significant baseline differences between the participants in the two groups. We were unable to draw meaningful conclusions from the data. AUTHORS' CONCLUSIONS We found insufficient evidence to suggest that one type of intranasal steroid is more effective than another in patients with chronic rhinosinusitis, nor that the effectiveness of a spray differs from an aerosol. We identified no studies that compared drops with spray.It is unclear if higher doses result in better symptom improvements (low quality evidence), but there was moderate quality evidence of an increased risk of epistaxis as an adverse effect of treatment when higher doses were used. This included all levels of severity of epistaxis and it is likely that the proportion of events that required patients to discontinue usage is low due to the low numbers of withdrawals attributed to it. If epistaxis is limited to streaks of blood in the mucus it may be tolerated by the patient and it may be safe to continue treatment. However, it may be a factor that affects compliance.There is insufficient evidence to suggest that the different types of corticosteroid molecule or spray versus aerosol have different effects. Lower doses have similar effectiveness but fewer side effects.Clearly more research in this area is needed, with specific attention given to trial design, disease-specific health-related quality of life outcomes and evaluation of longer-term outcomes and adverse effects.
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Affiliation(s)
| | | | - Claire Hopkins
- Guy's HospitalENT DepartmentGerat Maze PondLondonUKSE1 9RT
| | - Carl Philpott
- Norwich Medical School, University of East AngliaDepartment of MedicineNorwichUKNR4 7TJ
| | | | - Anne GM Schilder
- Faculty of Brain Sciences, University College LondonevidENT, Ear Institute330 Grays Inn RoadLondonUKWC1X 8DA
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Chong LY, Head K, Hopkins C, Philpott C, Schilder AGM, Burton MJ. Intranasal steroids versus placebo or no intervention for chronic rhinosinusitis. Cochrane Database Syst Rev 2016; 4:CD011996. [PMID: 27115217 PMCID: PMC9393647 DOI: 10.1002/14651858.cd011996.pub2] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND This review is one of six looking at the primary medical management options for patients with chronic rhinosinusitis.Chronic rhinosinusitis is common and is characterised by inflammation of the lining of the nose and paranasal sinuses leading to nasal blockage, rhinorrhoea, facial pressure/pain and loss of sense of smell. The condition can occur with or without nasal polyps. The use of topical (intranasal) corticosteroids has been widely advocated for the treatment of chronic rhinosinusitis given the belief that inflammation is a major component of this condition. OBJECTIVES To assess the effects of intranasal corticosteroids in people with chronic rhinosinusitis. SEARCH METHODS The Cochrane ENT Information Specialist searched the Cochrane ENT Trials Register; Central Register of Controlled Trials (CENTRAL 2015, Issue 8); MEDLINE; EMBASE; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 11 August 2015. SELECTION CRITERIA Randomised controlled trials (RCTs) with a follow-up period of at least three months comparing intranasal corticosteroids (e.g. beclomethasone dipropionate, triamcinolone acetonide, flunisolide, budesonide) against placebo or no treatment in patients with chronic rhinosinusitis. DATA COLLECTION AND ANALYSIS We used the standard methodological procedures expected by Cochrane. Our primary outcomes were disease-specific health-related quality of life (HRQL), patient-reported disease severity and the commonest adverse event - epistaxis. Secondary outcomes included general HRQL, endoscopic nasal polyp score, computerised tomography (CT) scan score and the adverse events of local irritation or other systemic adverse events. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics. MAIN RESULTS We included 18 RCTs with a total of 2738 participants. Fourteen studies had participants with nasal polyps and four studies had participants without nasal polyps. Only one study was conducted in children. Intranasal corticosteroids versus placebo or no intervention Only one study (20 adult participants without polyps) measured our primary outcome disease-specific HRQL using the Rhinosinusitis Outcome Measures-31 (RSOM-31). They reported no significant difference (numerical data not available) (very low quality evidence).Our second primary outcome, disease severity , was measured using the Chronic Sinusitis Survey in a second study (134 participants without polyps), which found no important difference (mean difference (MD) 2.84, 95% confidence interval (CI) -5.02 to 10.70; scale 0 to 100). Another study (chronic rhinosinusitis with nasal polyps) reported an increased chance of improvement in the intranasal corticosteroids group (RR 2.78, 95% CI 1.76 to 4.40; 109 participants). The quality of the evidence was low.Six studies provided data on at least two of the individual symptoms used in the EPOS 2012 criteria to define chronic rhinosinusitis (nasal blockage, rhinorrhoea, loss of sense of smell and facial pain/pressure). When all four symptoms in the EPOS criteria were available on a scale of 0 to 3 (higher = more severe symptoms), the average MD in change from baseline was -0.26 (95% CI -0.37 to -0.15; 243 participants; two studies; low quality evidence). Although there were more studies and participants when only nasal blockage and rhinorrhoea were considered (MD -0.31, 95% CI -0.38 to -0.24; 1702 participants; six studies), the MD was almost identical to when loss of sense of smell was also considered (1345 participants, four studies; moderate quality evidence).When considering the results for the individual symptoms, benefit was shown in the intranasal corticosteroids group. The effect size was larger for nasal blockage (MD -0.40, 95% CI -0.52 to -0.29; 1702 participants; six studies) than for rhinorrhoea (MD -0.25, 95% CI -0.33 to -0.17; 1702 participants; six studies) or loss of sense of smell (MD -0.19, 95% CI -0.28 to -0.11; 1345 participants; four studies). There was heterogeneity in the analysis for facial pain/pressure (MD -0.27, 95% CI -0.56 to 0.02; 243 participants; two studies). The quality of the evidence was moderate for nasal blockage, rhinorrhoea and loss of sense of smell, but low for facial pain/pressure.There was an increased risk of epistaxis with intranasal corticosteroids (risk ratio (RR) 2.74, 95% CI 1.88 to 4.00; 2508 participants; 13 studies; high quality evidence).Considering our secondary outcome, general HRQL, one study (134 participants without polyps) measured this using the SF-36 and reported a statistically significant benefit only on the general health subscale. The quality of the evidence was very low.It is unclear whether there is a difference in the risk of local irritation (RR 0.94, 95% CI 0.53 to 1.64; 2124 participants; 11 studies) (low quality evidence).None of the studies treated or followed up patients long enough to provide meaningful data on the risk of osteoporosis or stunted growth (children). Other comparisons We identified no other studies that compared intranasal corticosteroids plus co-intervention A versus placebo plus co-intervention A. AUTHORS' CONCLUSIONS Most of the evidence available was from studies in patients with chronic rhinosinusitis with nasal polyps. There is little information about quality of life (very low quality evidence). For disease severity, there seems to be improvement for all symptoms (low quality evidence), a moderate-sized benefit for nasal blockage and a small benefit for rhinorrhoea (moderate quality evidence). The risk of epistaxis is increased (high quality evidence), but these data included all levels of severity; small streaks of blood may not be a major concern for patients. It is unclear whether there is a difference in the risk of local irritation (low quality evidence).
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Affiliation(s)
| | | | - Claire Hopkins
- Guy's HospitalENT DepartmentGerat Maze PondLondonUKSE1 9RT
| | - Carl Philpott
- Norwich Medical School, University of East AngliaDepartment of MedicineNorwichUKNR4 7TJ
| | - Anne GM Schilder
- Faculty of Brain Sciences, University College LondonevidENT, Ear Institute330 Grays Inn RoadLondonUKWC1X 8DA
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Kalish L, Snidvongs K, Sivasubramaniam R, Cope D, Harvey RJ. WITHDRAWN: Topical steroids for nasal polyps. Cochrane Database Syst Rev 2016; 4:CD006549. [PMID: 27111709 PMCID: PMC10653020 DOI: 10.1002/14651858.cd006549.pub3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Review withdrawn from Issue 4, 2016. Replaced by new reviews 'Intranasal steroids versus placebo or no intervention for chronic rhinosinusitis' (Chong 2016a) and 'Different types of intranasal steroids for chronic rhinosinusitis' (Chong 2016b). The editorial group responsible for this previously published document have withdrawn it from publication.
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Affiliation(s)
- Larry Kalish
- Sydney Sinus and Allergy CentreSuite 206203‐233 New South Head RoadEdgecliffNSWAustralia2027
- Concord HospitalENT DepartmentConcordAustralia
| | - Kornkiat Snidvongs
- Chulalongkorn UniversityDepartment of Otolaryngology, Faculty of MedicineBangkokThailand
| | | | - Daron Cope
- Concord HospitalENT DepartmentConcordAustralia
| | - Richard J Harvey
- Macquarie UniversityAustralian School of Advanced MedicineSydneyAustralia
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Mygind N, Lund V. Intranasal corticosteroids for nasal polyposis : biological rationale, efficacy, and safety. ACTA ACUST UNITED AC 2016; 5:93-102. [PMID: 16512690 DOI: 10.2165/00151829-200605020-00003] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Nasal polyposis, occurring in about 2% of the general population, is the ultimate form of inflammation of the upper airways. For unknown reasons, polyps develop preferentially in subtypes of inflammatory diseases and are associated with perennial non-allergic rhinitis, asthma, intolerance of aspirin (acetylsalicylic acid)/NSAIDs, allergic fungal rhinosinusitis, cystic fibrosis, and primary ciliary dyskinesia. In contrast to common beliefs, IgE-mediated allergy does not seem to play an etiological role in nasal polyposis.The polyps originate from the mucosa around the clefts of the lateral nasal wall, especially in the region of the ostiomeatal complex. The factors that determine the localization of the disease to a few square centimeters of the airways are not known.Polyps are edematous bags covered by respiratory epithelium and contain very few nerves, blood vessels, and glands that have undergone cystic degeneration. They contain degranulated mast cells, have a very high concentration of histamine, and are characteristically infiltrated by eosinophils. These cells accumulate due to the release of proinflammatory cytokines (in particular, interleukin-5).Nasal polyposis is preceded by a prolonged history of rhinitis accompanied by severe and persistent nasal blockage; typically, the sense of smell is seriously impaired when polyps develop. The diagnosis is based on anterior rhinoscopy or, preferably, endoscopy.Nasal polyposis is medically treatable. Surgical treatment is carried out when medication fails. Intranasal corticosteroids reduce rhinitis symptoms, improve nasal breathing, reduce the size of polyps, and prevent, in part, their recurrence, but this treatment has little effect on the sense of smell. Intranasal corticosteroids can, as basic long-term therapy, be used alone in mild cases or together with systemic corticosteroids and/or surgery in severe cases. Systemic corticosteroids administered for 2-3 weeks have a beneficial effect on all observed symptoms and pathology, including the sense of smell. When nasal blockage is a problem in spite of medical treatment, surgery is recommended. Simple polypectomy can be performed, but endoscopic surgery is recommended in more severe and persistent cases.
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Affiliation(s)
- Niels Mygind
- Department of Medicine, Vejle Hospital, Vejle, Denmark
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Chronic Rhinosinusitis-Related Smell Loss: Medical And Surgical Treatment Efficacy. CURRENT OTORHINOLARYNGOLOGY REPORTS 2016; 4:142-147. [PMID: 29623247 DOI: 10.1007/s40136-016-0114-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Chronic rhinosinusitis (CRS) is an inflammatory disorder of the nasal cavities and paranasal sinuses. Olfactory dysfunction is a common manifestation of CRS and one of its cardinal diagnostic features. A decreased sense of smell can have a profound impact on a CRS patient's quality of life and overall wellbeing. The treatment of CRS-associated olfactory dysfunction includes a wide range of medical interventions, including anti-inflammatory and antibiotic medications, and surgical interventions, including endoscopic sinus and nasal surgery. The evidence and treatment efficacy for these interventions is quite varied. This review provides a summary of the efficacy of the medical and surgical therapeutic options for CRS-associated olfactory dysfunction.
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Orlandi RR, Kingdom TT, Hwang PH, Smith TL, Alt JA, Baroody FM, Batra PS, Bernal-Sprekelsen M, Bhattacharyya N, Chandra RK, Chiu A, Citardi MJ, Cohen NA, DelGaudio J, Desrosiers M, Dhong HJ, Douglas R, Ferguson B, Fokkens WJ, Georgalas C, Goldberg A, Gosepath J, Hamilos DL, Han JK, Harvey R, Hellings P, Hopkins C, Jankowski R, Javer AR, Kern R, Kountakis S, Kowalski ML, Lane A, Lanza DC, Lebowitz R, Lee HM, Lin SY, Lund V, Luong A, Mann W, Marple BF, McMains KC, Metson R, Naclerio R, Nayak JV, Otori N, Palmer JN, Parikh SR, Passali D, Peters A, Piccirillo J, Poetker DM, Psaltis AJ, Ramadan HH, Ramakrishnan VR, Riechelmann H, Roh HJ, Rudmik L, Sacks R, Schlosser RJ, Senior BA, Sindwani R, Stankiewicz JA, Stewart M, Tan BK, Toskala E, Voegels R, Wang DY, Weitzel EK, Wise S, Woodworth BA, Wormald PJ, Wright ED, Zhou B, Kennedy DW. International Consensus Statement on Allergy and Rhinology: Rhinosinusitis. Int Forum Allergy Rhinol 2016; 6 Suppl 1:S22-209. [DOI: 10.1002/alr.21695] [Citation(s) in RCA: 333] [Impact Index Per Article: 41.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Revised: 11/13/2015] [Accepted: 11/16/2015] [Indexed: 02/06/2023]
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Valerie Lund
- Royal National Throat Nose and Ear Hospital; London UK
| | - Amber Luong
- University of Texas Medical School at Houston
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Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, Brook I, Ashok Kumar K, Kramper M, Orlandi RR, Palmer JN, Patel ZM, Peters A, Walsh SA, Corrigan MD. Clinical practice guideline (update): adult sinusitis. Otolaryngol Head Neck Surg 2015; 152:S1-S39. [PMID: 25832968 DOI: 10.1177/0194599815572097] [Citation(s) in RCA: 495] [Impact Index Per Article: 55.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE This update of a 2007 guideline from the American Academy of Otolaryngology--Head and Neck Surgery Foundation provides evidence-based recommendations to manage adult rhinosinusitis, defined as symptomatic inflammation of the paranasal sinuses and nasal cavity. Changes from the prior guideline include a consumer added to the update group, evidence from 42 new systematic reviews, enhanced information on patient education and counseling, a new algorithm to clarify action statement relationships, expanded opportunities for watchful waiting (without antibiotic therapy) as initial therapy of acute bacterial rhinosinusitis (ABRS), and 3 new recommendations for managing chronic rhinosinusitis (CRS). PURPOSE The purpose of this multidisciplinary guideline is to identify quality improvement opportunities in managing adult rhinosinusitis and to create explicit and actionable recommendations to implement these opportunities in clinical practice. Specifically, the goals are to improve diagnostic accuracy for adult rhinosinusitis, promote appropriate use of ancillary tests to confirm diagnosis and guide management, and promote judicious use of systemic and topical therapy, which includes radiography, nasal endoscopy, computed tomography, and testing for allergy and immune function. Emphasis was also placed on identifying multiple chronic conditions that would modify management of rhinosinusitis, including asthma, cystic fibrosis, immunocompromised state, and ciliary dyskinesia. ACTION STATEMENTS The update group made strong recommendations that clinicians (1) should distinguish presumed ABRS from acute rhinosinusitis (ARS) caused by viral upper respiratory infections and noninfectious conditions and (2) should confirm a clinical diagnosis of CRS with objective documentation of sinonasal inflammation, which may be accomplished using anterior rhinoscopy, nasal endoscopy, or computed tomography. The update group made recommendations that clinicians (1) should either offer watchful waiting (without antibiotics) or prescribe initial antibiotic therapy for adults with uncomplicated ABRS; (2) should prescribe amoxicillin with or without clavulanate as first-line therapy for 5 to 10 days (if a decision is made to treat ABRS with an antibiotic); (3) should reassess the patient to confirm ABRS, exclude other causes of illness, and detect complications if the patient worsens or fails to improve with the initial management option by 7 days after diagnosis or worsens during the initial management; (4) should distinguish CRS and recurrent ARS from isolated episodes of ABRS and other causes of sinonasal symptoms; (5) should assess the patient with CRS or recurrent ARS for multiple chronic conditions that would modify management, such as asthma, cystic fibrosis, immunocompromised state, and ciliary dyskinesia; (6) should confirm the presence or absence of nasal polyps in a patient with CRS; and (7) should recommend saline nasal irrigation, topical intranasal corticosteroids, or both for symptom relief of CRS. The update group stated as options that clinicians may (1) recommend analgesics, topical intranasal steroids, and/or nasal saline irrigation for symptomatic relief of viral rhinosinusitis; (2) recommend analgesics, topical intranasal steroids, and/or nasal saline irrigation) for symptomatic relief of ABRS; and (3) obtain testing for allergy and immune function in evaluating a patient with CRS or recurrent ARS. The update group made recommendations that clinicians (1) should not obtain radiographic imaging for patients who meet diagnostic criteria for ARS, unless a complication or alternative diagnosis is suspected, and (2) should not prescribe topical or systemic antifungal therapy for patients with CRS.
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Affiliation(s)
- Richard M Rosenfeld
- Department of Otolaryngology, SUNY Downstate Medical Center, Brooklyn, New York, USA
| | - Jay F Piccirillo
- Department of Otolaryngology-Head and Neck Surgery, Washington University in St Louis, School of Medicine, St Louis, Missouri, USA
| | | | - Itzhak Brook
- Department of Pediatrics, Georgetown University, Washington, DC, USA
| | - Kaparaboyna Ashok Kumar
- Department of Family Medicine, University of Texas Health Sciences Center at San Antonio, San Antonio, Texas, USA
| | - Maggie Kramper
- Department of Otolaryngology, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Richard R Orlandi
- Division of Otolaryngology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - James N Palmer
- Department Otolaryngology, University of Pennsylvania Hospital, Philadelphia, Pennsylvania, USA
| | - Zara M Patel
- Department of Otolaryngology Head & Neck Surgery, Emory University, Atlanta, Georgia, USA
| | - Anju Peters
- Department of Internal Medicine, Northwestern University Allergy Division, Chicago, Illinois, USA
| | - Sandra A Walsh
- Consumers United for Evidence-Based Healthcare, Davis, California, USA
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Rimmer J, Fokkens W, Chong LY, Hopkins C. Surgical versus medical interventions for chronic rhinosinusitis with nasal polyps. Cochrane Database Syst Rev 2014; 2014:CD006991. [PMID: 25437000 PMCID: PMC11193160 DOI: 10.1002/14651858.cd006991.pub2] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Nasal polyps cause nasal obstruction, discharge and reduction in or loss of sense of smell, but their aetiology is unknown. The management of chronic rhinosinusitis with nasal polyps, aimed at improving these symptoms, includes both surgical and medical treatments, but there is no universally accepted management protocol. OBJECTIVES To assess the effectiveness of endonasal/endoscopic surgery versus medical treatment in chronic rhinosinusitis with nasal polyps. SEARCH METHODS We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the search was 20 February 2014. SELECTION CRITERIA Randomised controlled trials of any surgical intervention (e.g. polypectomy, endoscopic sinus surgery) versus any medical treatment (e.g. intranasal and/or systemic steroids), including placebo, in adult patients with chronic rhinosinusitis with nasal polyps. DATA COLLECTION AND ANALYSIS We used the standard methodological procedures expected by The Cochrane Collaboration. Meta-analysis was not possible due to the heterogeneity of the studies and the selective (incomplete) outcome reporting by the studies. MAIN RESULTS Four studies (231 participants randomised) are included in the review. No studies were at low risk of bias. The studies compared different types of surgery versus various types and doses of systemic and topical steroids and antibiotics. There were three comparison pairs: (1) endoscopic sinus surgery (ESS) versus systemic steroids (one study, n = 109), (2) polypectomy versus systemic steroids (two studies, n = 87); (3) ESS plus topical steroid versus antibiotics plus high-dose topical steroid (one study, n = 35). All participants also received topical steroids but doses and types were the same between the treatment arms of each study, except for the study using antibiotics. In that study, the medical treatment arm had higher doses than the surgical arm. In two of the studies, the authors failed to report the outcomes of interest. Although there were important differences in the types of treatments and comparisons used in these studies, the results were similar. PRIMARY OUTCOMES symptom scores and quality of life scores There were no important differences between groups in either the patient-reported disease-specific symptom scores or the health-related quality of life scores. Two studies (one comparing ESS plus topical steroid versus antibiotics plus high-dose topical steroid, the other ESS versus systemic steroids) failed to find a difference in generic health-related quality of life scores. The quality of this evidence is low or very low. Endoscopic scores and other secondary outcomes Two studies reported endoscopic scores. One study (ESS versus systemic steroids) reported a large, significant effect size in the surgical group, with a mean difference (MD) in score of -1.5 (95% confidence interval (CI) -1.78 to -1.22, n = 95) on a scale of 0 to 3 (0 = no polyposis, 3 = severe polyposis). In the other study (ESS plus topical steroid versus antibiotics plus high-dose topical steroid) no difference was found between the groups (MD 2.3%, 95% CI -17.4% to 12.8%, n = 34). None of the included studies reported recurrence rates. No differences were found for any objective measurements or olfactory tests in those studies in which they were measured. Complications Complication rates were not reported in all studies, but rates of up to 21% for medical treatment and 14.3% for surgical treatment are described. Epistaxis was the most commonly reported complication with both medical and surgical treatments, with severe complications reported rarely. AUTHORS' CONCLUSIONS The evidence relating to the effectiveness of different types of surgery versus medical treatment for adults with chronic rhinosinusitis with nasal polyps is of very low quality. The evidence does not show that one treatment is better than another in terms of patient-reported symptom scores and quality of life measurements. The one positive finding from amongst the several studies examining a number of different comparisons must be treated with appropriate caution, in particular when the clinical significance of the measure is uncertain.As the overall evidence is of very low quality (serious methodological limitations, reporting bias, indirectness and imprecision) and insufficient to draw firm conclusions, further research to investigate this problem, which has significant implications for quality of life and healthcare service usage, is justified.
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Banglawala SM, Oyer SL, Lohia S, Psaltis AJ, Soler ZM, Schlosser RJ. Olfactory outcomes in chronic rhinosinusitis with nasal polyposis after medical treatments: a systematic review and meta-analysis. Int Forum Allergy Rhinol 2014; 4:986-94. [DOI: 10.1002/alr.21373] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Revised: 05/31/2014] [Accepted: 06/10/2014] [Indexed: 11/08/2022]
Affiliation(s)
- Sarfaraz M. Banglawala
- Division of Rhinology and Sinus Surgery; Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina; Charleston SC
| | - Samuel L. Oyer
- Division of Rhinology and Sinus Surgery; Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina; Charleston SC
| | - Shivangi Lohia
- Division of Rhinology and Sinus Surgery; Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina; Charleston SC
| | - Alkis J. Psaltis
- Department of Otolaryngology-Head and Neck Surgery; Adelaide University, Adelaide; South Australia Australia
| | - Zachary M. Soler
- Division of Rhinology and Sinus Surgery; Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina; Charleston SC
| | - Rodney J. Schlosser
- Division of Rhinology and Sinus Surgery; Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina; Charleston SC
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Aboud SK, Husain S, Gendeh BS. Evaluation on quality of life in patients with nasal polyposis managed with optimal medical therapy. ALLERGY & RHINOLOGY (PROVIDENCE, R.I.) 2014; 5:2-8. [PMID: 24612853 PMCID: PMC4019740 DOI: 10.2500/ar.2014.5.0075] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Nasal polyposis (NP) has a great impact on quality of life (QOL) and its management involves a combination of medical therapy and surgery. To the authors' knowledge, no publication has extensively examined NP after optimal medical treatment based on subjective evaluations. The aim of this prospective study was designed to evaluate the QOL in NP patients after (1) a short course of oral steroids, (2) initial 3-month course of macrolide, and (3) long-term treatment with intranasal steroids. A total of 55 patients with grades I and II NP were consecutively treated with oral prednisolone at 25 mg in a single dose for 2 weeks, macrolide at 250 mg daily for the first 3 months, and long-term intranasal steroids. Patients were followed up and evaluated at baseline and 3, 6, and 12 months for QOL measure. At baseline, patients with grade I and grade II NP showed significantly worse QOL scores on all Rhinosinusitis Disability Index domains, particularly for physical function (4.59 ± 1.41) and were significantly higher in social function (3.16 ± 1.17). At 3, 6, and 12 months of treatment, patients showed a significant improvement in all impaired QOL domains compared with baseline after optimal medical therapy (p < 0.05). These results suggest that the optimal medical treatment to improve QOL incorporates medical polypectomy with a short course of oral steroids in addition to macrolide and this can be maintained by long-term intranasal steroid therapy.
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Affiliation(s)
- Saleh Khaled Aboud
- From the Department of Otorhinolaryngology–Head and Neck Surgery, Malaysian Allied Health Sciences Academy University, Jalan Elmu off Jalan Universiti, Kuala Lumpur, Malaysia, and
| | - Salina Husain
- Department of Otorhinolaryngology, Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Cheras, Kuala Lumpur, Malaysia
| | - Balwant Singh Gendeh
- Department of Otorhinolaryngology, Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Cheras, Kuala Lumpur, Malaysia
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Snidvongs K, Kalish L, Sacks R, Sivasubramaniam R, Cope D, Harvey RJ. Sinus surgery and delivery method influence the effectiveness of topical corticosteroids for chronic rhinosinusitis: systematic review and meta-analysis. Am J Rhinol Allergy 2013; 27:221-33. [PMID: 23710959 DOI: 10.2500/ajra.2013.27.3880] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Published randomized controlled trials (RCTs) on the efficacy of intranasal corticosteroid (INCS) in chronic rhinosinusitis (CRS) use either nasal delivery (nasal drop or nasal spray) or sinus delivery (sinus catheter or sinus irrigation) in patients with or without sinus surgery. This influences topical drug delivery and distribution. The effect of these factors on the published results of RCTs is assessed. This systematic review explores the strength of evidence supporting the influence of sinus surgery and delivery methods on the effectiveness of topical steroids in studies for CRS with meta-analyses. METHODS A systematic review was conducted of RCTs comparing INCS with either placebo or no intervention for treating CRS. Data were extracted for meta-analysis and subgroup analyses by sinus surgery status and topical delivery methods. RESULTS Forty-eight studies (3961 patients) met the inclusion criteria. INCS improved overall symptoms (standardized mean difference [SMD], -0.49; p < 0.00001) and the proportion of responders (risk ratio [RR], 0.59; p < 0.00001) compared with placebo. It decreased nasal polyp size with a greater proportion of responders (RR, 0.48; p < 0.00001) and prevented polyp recurrence (RR, 0.59; p = 0.0004) compared with placebo. Reduction of polyp size was greater in patients with sinus surgery (RR, 0.31; 95% confidence interval [CI], 0.20, 0.48) than those without (RR, 0.61; 95% CI, 0.46, 0.81; p = 0.009). Greater symptom improvement occurred when sinus delivery methods (SMD, -1.32; 95% CI, -2.26, -0.38) were compared with nasal delivery methods (SMD, -0.38; 95% CI, -0.55, -0.22; p < 0.00001). CONCLUSION INCS is effective for CRS. Prior sinus surgery and direct sinus delivery enhance the effectiveness of INCS in CRS.
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Affiliation(s)
- Kornkiat Snidvongs
- Australian School of Advanced Medicine, Macquarie University, Sydney, Australia.
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