Reliability of EP3OS symptom criteria and nasal endoscopy in the assessment of chronic rhinosinusitis--a GA² LEN study

Association Between Dietary Factors and Chronic Sinusitis Among Korean Individuals: Insights From a Large Population-Based Study in Asia

Objective: Population-based studies on chronic sinusitis have predominantly focused on Europe and the Americas, but research on chronic sinusitis within large Asian populations remains scarce. This study aims to explore the link between dietary factors and chronic sinusitis among ethnic Koreans in Asia. Design: A cross-sectional study. Setting: Data were collected from the Korean National Health and Nutrition Examination Survey (KNHANES) in 2012. Participants: Participants in the study were included based on a doctor's diagnosis of chronic sinusitis, as determined through the ear, nose, and throat examination questionnaires. Results: Adolescents [adjusted P value (aP) < .001, adjusted odds ratio (aOR) = 1.881, 95% confidence interval (CI) = 1.380-2.564] and individuals with college and higher education (aP = .042, aOR = 1.298, 95% CI = 1.009-1.669) were more likely to develop chronic rhinosinusitis. In addition, levels of dietary fat [P = .001, interquartile range (IQR) = 34.085] and energy intake (P = .004, IQR = 981.106) were associated with an increased risk of chronic sinusitis. Moreover, high dietary inflammatory index (aP < .001, aOR = 0.547, 95% CI = 0.415-0.721), and high intake of fried pork chops (aP = .028, aOR = 1.335, 95% CI = 1.033-1.777), bread (aP = .024, aOR = 1.364, 95% CI = 1.042-1.786), and rice (aP = .021, aOR = 1.382, 95% CI = 1.051-1.818) were risk factors for chronic sinusitis, while cucumber consumption (aP < .001, aOR = 0.547, 95% CI = 0.415-0.721) was a protective factor for chronic sinusitis. Conclusion: This study revealed a significant correlation between diet and development of chronic sinusitis. These findings suggest that promoting an anti-inflammatory dietary pattern and providing guidance on healthy eating habits could help reduce the incidence of chronic sinusitis and enhance its management.

Nasal sprays: commonly used medications that are often misunderstood

Sinonasal inflammatory disease is very common and all clinicians who care for these patients should understand the topical treatment options available. This article reviews the utility and application of steroidal, saline, decongestant, antihistamine and anticholinergic preparations for the treatment of sinonasal disease, with a particular focus on evidence-based guidelines for use in both specialist and non-specialist healthcare settings.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

A novel inflammatory endotype diagnostic model based on cytokines in chronic rhinosinusitis with nasal polyps

Background

Type 2 CRSwNP is characterized by severe symptoms, multiple comorbidities, longer recovery course and high recurrence rate. A simple and cost-effective diagnostic model for CRSwNP endotype integrating clinical characteristics and histopathological features is urgently needed.

Objective

To establish a clinical diagnostic model of inflammatory endotype in CRSwNP based on the clinical characteristics, pathological characteristics, and cytokines profile in the polyp tissue of patients.

Methods

A total of 244 participants with CRSwNP were enrolled at 2 different centers in China and Belgium from 2018 to 2020. IL-5 level of nasal polyp tissue was used as gold standard. Clinical characteristics were used to establish diagnostic models. The area under the receiver operating curve (AUC) was used to evaluate the diagnostic performance. The study was approved by the ethics board of the First Affiliated Hospital of Sun Yat-sen University ([2020] 302), and written informed consent was obtained from all subjects before inclusion.

Results

In total, 134 patients from China (training set) and 110 patients from Belgium (validation set) were included. The logistic regression (LR) model in predicting inflammatory endotype of CRSwNP showed the AUC of 83%, which was better than the diagnostic performance of machine learning models (AUC of 61.14%-82.42%), and single clinical variables. We developed a simplified scoring system based on LR model which shows similar diagnostic performance to the LR model (P = 0.6633).

Conclusion

The LR model in this diagnostic study provided greater accuracy in prediction of inflammatory endotype of CRSwNP than those obtained from the machine learning model and single clinical variable. This indicates great potential for the use of diagnostic model to facilitate inflammatory endotype evaluation when tissue cytokines are unable to be measured.

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

OBJECTIVE

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

DATA SOURCES

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

REVIEW METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

OBJECTIVE

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

METHODOLOGY

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

RESULTS

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

CONCLUSIONS

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

The GA2LEN survey for chronic rhinosinusitis prevalence studies: Arabic translation, cultural adaptation, and validation

Background: Chronic rhinosinusitis (CRS) is a common disease that significantly impacts quality of life. Its prevalence varies between different geographical areas. This study aimed to validate the Arabic version of the EPOS criteria in the GA2LEN questionnaire to use it as a tool to estimate the prevalence of CRS in Arab countries. Methods: This is multicentric cross-sectional validation study. The original English EPOS criteria used in the GA2LEN survey (four main questions and two additional questions) were translated into Arabic. The study was conducted at King Abdulaziz University Hospital – Riyadh and Qatif Central Hospital – Qatif in the period between October 2020 and August 2021. Groups of CRS and non-CRS patients were selected randomly from databases of the hospital and asked to participate in the study through phone calls. Sensitivity, specificity, positive, and negative predictive values were calculated for the Arabic questionnaire. Results: Of 200 subjects contacted to complete the questionnaire, 128 agreed to participate and completed the survey. The Arabic version of the GA2LEN questionnaire was found to be reliable with high sensitivity and specificity. The reliability of the questionnaire increased when we added the question, “Has a doctor ever told you that you have chronic sinusitis?” to the main four questions. The sensitivity, specificity, and positive and negative predictive values were 93.9%, 59.6%, 71.25%, and 90.2%, respectively. Conclusions: The Arabic version of the EPOS criteria in the GA2LEN questionnaire is a valid and reliable tool for epidemiological studies to estimate the prevalence of CRS.

Epidemiology of Chronic Rhinosinusitis: Prevalence and Risk Factors

Knowledge of chronic rhinosinusitis (CRS) epidemiology may directly impact patient care: aiding patient identification and establishing accurate diagnosis as well as informing treatment decisions. The objective of this review is to summarize the current evidence on the epidemiology of CRS, with a focus on prevalence and risk factors. Although the presence of either symptoms or objective findings alone have yielded CRS prevalence estimates of over 10%, the presence of both-consistent with guideline-based diagnostic criteria for CRS-has suggested that the true prevalence of CRS is consistently less than 5%, with approximately one-third of patients with CRS having nasal polyps, in epidemiologic studies from around the world. In comparison, the prevalence of CRS endotypes-pathophysiologic subclassification of CRS most commonly as related to type 2 or non-type 2 inflammation-has been found to vary significantly by region. The epidemiology of CRS is modified and ultimately determined by risk factors: genetic/hereditary, demographic, environmental, and imparted by predictive pre-/comorbid disease. The understanding of these epidemiologic relationships may help the provider to optimally identify and understand each individual's CRS disease process, thereby improving both diagnosis and treatment.

Analysis of Prevalence and Risk Factors of Adult Self-Reported Allergic Rhinitis and Asthma in Plain Lands and Hilly Areas of Shenmu City, China

Objective: The main aim of this study was to investigate the prevalence and risk factors of adult self-reported allergic rhinitis and asthma in plain lands and hilly areas of Shenmu City in China, and analyze the differences between regions.

Methods: The multi-stage stratified random sampling was applied in a cross-sectional survey of adult residents in Shenmu City, from September to December 2019. The unconditional logistic regression analysis was used to screen the influence factors of allergic rhinitis and asthma.

Results: 4,706 adults participated in the survey, and 99% (4,655 in 4,706) completed the questionnaires. The prevalence of allergic rhinitis was 25.4%, and the prevalence of asthma was 9.4%. The prevalence of the allergic rhinitis without asthma, asthma without allergic rhinitis, and the combined allergic rhinitis with asthma were 18.9, 2.9, and 6.5%, respectively. The prevalence of allergic rhinitis and asthma existed regional differences. The prevalence of adult self-reported allergic rhinitis was 41.5% in plain lands areas and 22.1% in hilly areas. The prevalence of adult self-reported asthma was 12.8% in plain lands and 8.8% in hilly areas. The prevalence of allergic rhinitis and asthma existed seasonal differences, with the highest prevalence from July to September. The analysis of risk factors showed that higher education [middle and high school (OR 1.72, 95%CI 1.42–2.07); college and above (OR 2.67, 95%CI 1.99–3.59)], comorbidities of other allergic diseases (OR 3.90, 95%CI 3.23–4.70), family history of allergies (OR 2.89, 95%CI 2.36–3.53), and plain lands areas (OR 2.51, 95%CI 2.06–3.05) were the risk factors for the allergic rhinitis without asthma. Aging [40–49 years old (OR 4.29, 95%CI 1.02–18.13); 50–59 years old (OR 5.89, 95%CI 1.40–24.76); ≥60 years old: (OR 6.14, 95%CI 1.41–26.71)], never-smokers (OR 1.66, 95%CI 0.99–2.80), comorbidities of other allergic disorders (OR 2.17, 95%CI 1.42–3.32), and family history of allergies (OR 2.20, 95%CI 1.40–3.47) were the risk factors for the asthma without allergic rhinitis. Advanced age [30–39 years (OR 2.16, 95%CI 1.23–3.82); 40–49 years (OR 2.86, 95%CI 1.56 to 5.25); 50–59 years (OR 2.95, 95%CI 1.58–5.51); ≥60 years old (OR 2.27, 95%CI 1.09–4.72)], higher education [middle and high school (OR 2.23, 95%CI 1.62–3.07); college and above (OR 4.28, 95%CI 2.72–6.74)], non-agricultural workers (OR 1.70, 95%CI 1.18–2.43),never-smokers (OR 2.26, 95%CI 1.51–3.39), comorbidities of other allergic diseases (OR 4.45, 95%CI 3.37–5.88), family history of allergies (OR 5.27, 95%CI 3.98–6.97), and plain lands areas (OR 2.07, 95%CI 1.51–2.86) were the risk factors for the combined allergic rhinitis with asthma.

Conclusions: The prevalence of allergic rhinitis and asthma in Shenmu City was relatively high, with regional differences. Genetic and environmental factors were the important risk factors associated with allergic rhinitis and asthma. Our research would provide data support for preventing and controlling allergic rhinitis and asthma in this region in the future, and appropriate prevention and control programs should be formulated according to the characteristics of different regions.

Correlation of Clinical Symptoms With Nasal Endoscopy and Radiological Findings in the Diagnosis of Chronic Rhinosinusitis: A Prospective Observational Study

Introduction: In the diagnosis of chronic rhinosinusitis (CRS), computed tomography (CT) of the nose and paranasal sinuses (PNS) remains the gold standard investigation. Though the diagnostic nasal endoscopy (DNE) is an equally effective and easily available investigation for diagnosis of CRS, its reliability and clinical significance to that of patient’s symptoms have to be proven.

Objective: The purpose of this study is to determine the correlations between the symptom severity score, radiological score, and the endoscopic score in the diagnosis of CRS. 

Methods: This prospective observational study included 70 patients with CRS. It was conducted in a tertiary care institute from January 2019 to June 2020. All patients were subjected to DNE and CT nose and PNS. Symptom score was assessed using Visual Analogue Scale (VAS) score of 0-10. DNE and CT scores were calculated using the Lund-Kennedy endoscopic scoring system and the Lund-Mackay CT scoring system, respectively. The correlation between these scores were done using Pearson’s correlation coefficient (p-value).

Results: The mean and standard deviation of the symptom score by VAS was 7 ± 1.7; the Lund-Kennedy score was 7.6 ± 2.3, and the Lund-Mackay score was 14.3 ± 6.5, respectively. The symptom score had moderate correlation with the Lund-Kennedy Score (r = 0.643, p < 0.001) and high degree of correlation with the Lund-Mackay Score (r = 0.835, p < 0.001). The Lund-Kennedy score had a positive correlation with The Lund-Mackay score.

Conclusion: DNE can be utilized as an early diagnostic tool in the clinical evaluation of CRS and is equally effective as CT in diagnosing the same. At the same time, a CT scan can be done in patients with positive symptoms and can be reserved as a second-level investigation for those patients with negative endoscopic findings but who become symptomatic on follow-up.

Therapeutic Options for Chronic Rhinosinusitis in N-ERD Patients

Patients with non-steroidal anti-inflammatory drug (NSAID)-exacerbated respiratory disease (N-ERD) often suffer from chronic rhinosinusitis (CRS) with nasal polyps, a form of primary diffuse Type 2 CRS. Although this disease is also seen in NSAID-tolerant patients, CRS in N-ERD often is more severe and more treatment resistant; local nasal therapy (nasal corticosteroids) and endoscopic sinus surgery are employed like in NSAID-tolerant patients, but with limited and/or short-lived effects. This mini-review gives an overview of the current additional treatment options for CRS in N-ERD. As such diets, aspirin therapy after desensitization, antileukotriene therapy and biologicals are discussed based on the current body of literature. Selecting the right treatment strategy depends on shared-decision making, local availability and cooperation between ENT-surgeons, allergists, and pulmonologists.

A randomized, double-blind, placebo- -controlled study to investigate the use of bacteriophages in patients with chronic rhinosinusitis with nasal polyps

Background A randomized, double-blind placebo-controlled study investigated the use of bacteriophages in the treatment of chronic rhinosinusitis with nasal polyps. Materials and Methods 40 adult patients with сhronic rhinosinusitis with nasal polyps were examined. All patients underwent functional endoscopic sinus surgery. After the surgery, 20 patients got the intranasal gel with a bacteriophages mixture (Otofag, Micromir, Russia) twice a day for ten weeks, and 20 patients got a placebo. Results On the 10th day, IL-1β secretion diminished (63 mg/ml versus 440 mg/ml in control). There was a decrease in the total number of microorganisms and Enterobacteriaceae (5.7 x 106 CFU/ml versus 1.2 x 109 CFU/ml in control), and the absence of Streptococci (versus 2.1 x 109 CFU/ml in control) on the 30th day of the treatment in the group with the bacteriophages. On the 10th day, a decrease in the activity of secretory IL-1β and IL-8 strongly and very strongly correlated with a total number of microorganisms (r = 0.7; r = 0.9 respectively), as well as secretory IL-8 with Enterobacteriaceae (r = 0.72) and Staphylococci (r = 0.65) in the active group treated with the bacteriophages. On the 30th day, the decrease in serum IL-1β significantly correlated with the total number of microorganisms (r = 0.80) and enterobacteria (r = 0.90) in the active group. Conclusions The administration of bacteriophages restored the balance of microorganisms in the nasal cavity and decreased the inflammatory response in chronic rhinosinusitis with nasal polyps. These changes, such as an inflammation dampening, could theoretically reduce the recurrent growth of polyp tissue in the future.

Dupilumab for the treatment of chronic rhinosinusitis with nasal polyposis

Introduction: Chronic rhinosinusitis with nasal polyps (CRSwNP) affects 1-2.5% of the population and is associated with significant adverse effects on quality of life (QoL). CRSwNP is strongly correlated with (late onset) asthma with 30-70% of the CRSwNP patients having asthma. Health-care spending in rhinosinusitis is high, especially because of indirect costs.Areas covered: In the last years, the recognition of endotyping as an essential presumption to precision medicine has significantly changed the integrated care pathways in the treatment of chronic rhinosinusitis. Dupilumab is the first biological available for the treatment of CRswNP, since late 2019. Treatment with dupilumab results in a significant improvement of QoL (measured as SNOT-22), rhinosinusitis disease severity, symptoms of rhinosinusitis, and especially sense of smell, nasal polyp score, Lund-Mackay CT score, and asthma outcomes (ACQ5 and FEV1) compared to placebo.Expert opinion: At this moment, the high cost of the treatment requires careful patient selection and within the EUFOREA and EPOS2020 context, experts have tried to give guidance based on today's data. We now need trials evaluating which patients benefit most from treatment with biologicals and in which patients the treatment is cost-effective.

International consensus statement on allergy and rhinology: rhinosinusitis 2021

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.

Primary care management of allergic rhinitis: a cross-sectional study in four ASEAN countries

Background

In primary care, general practitioners (GPs) and pharmacists are tasked with the frontline responsibility of identifying and managing allergic rhinitis (AR) patients. There are currently no consolidated data on current treatment practices, patient compliance, and usage of guidelines within Southeast Asian Nations (ASEAN). Objective: To assess the attitudes and practices on AR of GPs and pharmacists in 4 ASEAN countries (Philippines, Indonesia, Thailand, and Malaysia).

Methods

A cross-sectional survey of 329 GPs and 548 pharmacists was conducted from May to November 2019. Participants answered a questionnaire focused on their i) current practice in the management of AR, ii) views on patient compliance, iii) understanding and usage of guidelines.

Results

Clinical history was the most preferred method to diagnose AR by 95.4% of GPs and 58.8% of pharmacists. Second-generation antihistamines were the most widely available treatment option in GP clinics and pharmacies (94.8% and 97.2%) and correspondingly the most preferred treatment for both mild (90.3%, 76.8%) to moderatesevere rhinitis (90.3%, 78.6%) by GPs and pharmacists, respectively. Loratadine was ranked as the most preferred 2^nd generation antihistamines (GP vs pharmacists: 55.3% vs 58.9%). More than 90% of GPs and pharmacists ranked length and efficacy of treatment as important factors that increase patient compliance. Awareness of the ARIA guidelines was high among GPs (80%) and lower among pharmacists (48.4%). However, only 63.3% of GPs and 48.2% of pharmacists knew how to identify AR patients.

Conclusions

The survey in the 4 ASEAN countries has identified a need to strengthen the awareness and use of ARIA guidelines among the primary care practitioners. Adherence to ARIA guidelines, choosing the appropriate treatment option and prioritizing factors that increases patient compliance may contribute to better management outcomes of AR at the primary care practice

Adult chronic rhinosinusitis

Chronic rhinosinusitis (CRS) occurs in >10% of the adult population in Europe and the USA and can be differentiated into CRS without nasal polyps and CRS with nasal polyps (CRSwNP). Both phenotypes are characterized by a high disease burden and an overlapping spectrum of symptoms, with facial pain and loss of smell being the most differentiating. Great progress has been made in the understanding of CRS pathophysiology: from the epithelium and epithelial-mesenchymal transition to innate and adaptive immunity pathways and, finally, on the role of eosinophils and Staphylococcus aureus in the persistence of disease. Although clinical manifestations and diagnostic tools (including nasal endoscopy and imaging) have undergone major changes over the past few years, management (including pharmacotherapy, surgery and biologics) has experienced enormous progress based on the growing knowledge of key mediators in severe CRSwNP. The introduction of endotyping has led to a differentiation of 'tailored' surgical approaches, focusing on the mucosal concept in those with severe CRSwNP and on the identification of patients eligible for extended surgery and possibly biologics in the future.

Responsiveness and Convergent Validity of a New Patient-Reported Outcome Measure for Chronic Rhinosinusitis (CRS-PRO)

BACKGROUND

The CRS-PRO is a new patient-reported outcome measure (PROM) for chronic rhinosinusitis (CRS) that was developed using extensive patient input per Food and Drug Administration guidance on PROMs acceptable for use as end points in clinical trials.

OBJECTIVE

To assess the responsiveness and convergent validity of the CRS-PRO following standard-of-care medical therapy.

METHODS

This was a prospective study of 51 patients (21 with nasal polyps and 30 without) with newly diagnosed CRS or having an acute CRS exacerbation who were initiated on appropriate medical therapy. At the baseline visit each patient completed the CRS-PRO questionnaire, the 22-item Sino-Nasal Outcome Test, the EuroQol 5-dimensional questionnaire, and 4 Patient-Reported Outcome Measure Information System short forms along with objective testing including endoscopic and radiographic scores, smell discrimination, and nasal inspiratory flow testing. This same battery of questionnaires and testing was administered at a follow-up visit 4 to 8 weeks later.

RESULTS

We verified that shortening the 21-item CRS-PRO to 12 items as previously described maintains its psychometric properties. The 12-item CRS-PRO was responsive with a large effect size (Cohen's d, 0.94) comparable to the longer 22-item Sino-Nasal Outcome Test (Cohen's d, 0.93). The instrument was slightly more responsive to medically treated patients with CRS without nasal polyps compared with patients with CRS with nasal polyps (Cohen's d, 1.1 vs 0.89, respectively). The change in 12-item CRS-PRO total score has moderate correlation with change in Lund-Mackay computed tomography scores.

CONCLUSIONS

The CRS-PRO is a 12-item rigorously developed, responsive, and valid PROM that was developed using extensive input from patients with current definitions of CRS, including its 2 major phenotypes.

Development and Preliminary Validation of a New Patient-Reported Outcome Measure for Chronic Rhinosinusitis (CRS-PRO)

BACKGROUND

Patient-reported outcome (PRO) measures developed and validated on patients with the currently defined phenotypes of chronic rhinosinusitis (CRS) are needed to support clinical trials in CRS.

OBJECTIVE

This study developed and examined the initial reliability and validity of the CRS-PRO, a new PRO measure of CRS.

METHODS

Instrument development was performed through structured interviews and focus groups with clinical experts and 45 patients with CRS meeting current definitions of disease, 21 patients with CRS without nasal polyps (CRSsNP), and 24 patients with CRS with nasal polyps (CRSwNP) to identify items important to patients. Then another 50 patients (32 with CRSsNP and 18 with CRSwNP) with stable CRS symptoms were enrolled to evaluate the reliability of the instrument. Each patient completed the CRS-PRO, Sinonasal Outcome Test-22 (SNOT-22), and 4 Patient-Reported Outcome Measurement Information System short forms at the baseline visit and then at least 7 days later.

RESULTS

After the development process, 21 items were identified from the conceptual domains of physical symptoms, sensory impairment, psychosocial effects, and life impact. Using the responses of the 50 patients with CRS, 21 draft items were further refined to 12 items by eliminating conceptually similar or highly correlated items or those with low mean symptom severity. The 12-item questionnaire was shown to have excellent internal consistency (Cronbach α, 0.86) and test-retest reliability with a high intraclass correlation coefficient (0.89) and Pearson's correlation (r = 0.82, P < .0001). The 12-item CRS-PRO correlated highly with the longer SNOT-22 (r = 0.83, P < .0001) demonstrating its concurrent validity. We also demonstrated validity and reliability in a separate analysis for patients with CRSsNP and CRSwNP.

CONCLUSION

The CRS-PRO is a concise, valid, and reliable measure that was developed with extensive input from patients with CRS with current disease definitions.

Pediatric Versus Adult Chronic Rhinosinusitis

PURPOSE OF REVIEW

Pediatric and adult chronic rhinosinusitis (CRS) have some similarities but a number of differences. This article reviews the similarities and differences between pediatric and adult CRS.

RECENT FINDINGS

Rhinosinusitis is an inflammatory disease of the nose and the paranasal sinuses. In adults, inflammation in CRS without polyps (CRSsNP) mainly manifests with T-helper 1 lymphocytes while in CRS with polyps (CRSwNP) manifests with T-helper 2 lymphocytes and eosinophilic inflammation. In children, CRS inflammation manifests with neutrophils, macrophages, and lymphocytes. The associations between the ostiomeatal complex occlusion and CRS are revealed in adults but are not so evident in children. Although the relationship between the CRS and allergic rhinitis is still controversial, recent findings have shown an association between allergen sensitization and a specific group of adults with rhinosinusitis. Intranasal corticosteroids and saline constitute the first-line of medical treatment for both pediatric and adult rhinosinusitis. Low-dose macrolides are used for immunomodulatory activities and beneficial effects to adult patients with CRSsNP were demonstrated by recent meta-analyses. For surgical treatment, adenoidectomy is a key strategy to eradicate mature biofilms in pediatric CRS and effective in treating children with CRS regardless of the adenoid size. Although endoscopic sinus surgery has been proven to improve quality of life outcomes in adult CRS, it should be only considered in the pediatric CRS after failure of adenoidectomy. Pediatric and adult CRS are different in many aspects, including immunopathogenesis and management. Investigations should be considered in specific cases. After failure of medical treatments, endoscopic sinus surgery is recommended for adults, while adenoidectomy is primarily considered for children.

EUFOREA consensus on biologics for CRSwNP with or without asthma

Novel therapies such as type 2 targeting biologics are emerging treatment options for patients with chronic inflammatory respiratory diseases, fulfilling the needs of severely uncontrolled patients. The majority of patients with chronic rhinosinusitis with nasal polyps (CRSwNP) and over half of patients with asthma show a type 2 inflammatory signature in sinonasal mucosa and/or lungs. Importantly, both chronic respiratory diseases are frequent comorbidities, ensuring alleviation of both upper and lower airway pathology by systemic biological therapy. Type 2-targeting biologics such as anti-IgE, anti-IL4Rα, anti-IL5, and anti-IL5Rα have entered the market for selected pheno/endotypes of asthma patients and may soon also become available for CRSwNP patients. Given the high prevalence of chronic respiratory diseases and the high cost associated with biologics, patient selection is crucial in order to implement such therapies into chronic respiratory disease care pathways. The European Forum for Research and Education in Allergy and Airway Diseases (EUFOREA) organized a multidisciplinary Expert Board Meeting to discuss the positioning of biologics into the care pathways for CRSwNP patients with and without comorbid asthma.

Managing comorbid conditions in severe asthma

Asthma care has increasingly focused on personalised management for severe asthma, and recognition of the role and importance of comorbid conditions has increased. Severe asthma can be crippling; associated comorbid conditions often play a key role in the significant disease morbidity and frequently contribute to a severe and difficult-to-treat asthma phenotype. Comorbid conditions can be broadly grouped as being either airway-related or airway-unrelated. Airway-related comorbid conditions with the greatest impact are allergic rhinitis, chronic rhinosinusitis, vocal cord dysfunction, lung fungal sensitisation and underlying structural lung disease. The most important airway-unrelated comorbid conditions are obesity, obstructive sleep apnoea, gastro-oesophageal reflux disease and anxiety and depression. A diagnostic and management algorithm for comorbid conditions in severe asthma is outlined. It concentrates initially on the group with common comorbid conditions that can be managed in primary care. If asthma remains troublesome, emphasis can shift to identifying uncommon and more complex factors. The algorithm allows for personalised diagnostic and management pathways to be implemented. Personalised diagnosis and management of comorbid conditions are essential to achieving effective and improved outcomes for patients with severe asthma.

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

BACKGROUND

The prevalence of chronic rhinosinusitis (CRS) measured in epidemiologic studies is 5% to 12%. This might be an overestimation because of overlap with other diseases, such as allergic rhinitis.

OBJECTIVE

We aimed to calculate the prevalence of CRS using a combination of epidemiologically based CRS according to the European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS) together with sinonasal opacification on imaging.

METHODS

Subjects who underwent a computed tomographic or magnetic resonance imaging scan of the head for any nonrhinologic indication were asked to fill in the Global Allergy and Asthma European Network survey containing EPOS symptom criteria. The scans were evaluated according to the Lund-Mackay (LM) scoring system. Epidemiologically based CRS is based on nasal symptoms according to EPOS; clinically based CRS also encompasses endoscopy and/or CT scanning.

RESULTS

Eight hundred thirty-four subjects were included. One hundred seven (12.8%) had epidemiologically based CRS according to EPOS. Of these subjects, 50% had an LM score of 0, 26% had an LM score of 1 to 3, and 23% had an LM score of 4 or greater. Twenty-five (3.0%) subjects had clinically based CRS (based on LM score ≥4), and 53 (6.4%) subjects had clinically based CRS (based on LM score >0). Allergic rhinitis was reported by 167 (20%) subjects. In subjects who did not report upper airway symptoms, 57% had an LM score of 0, 30% had an LM score of 1 to 3, and 12% had an LM score of 4 or greater.

CONCLUSION

We found a prevalence of 3.0% to 6.4% of clinically based CRS (depending on an LM cutoff point; ie, LM ≥ 4 or LM > 0, respectively) in a relatively randomly selected group of subjects.

Effect of Nigella sativa Nasal Spray on the Treatment of Chronic Rhinosinusitis Without a Nasal Polyp

Background

Chronic rhinosinusitis (CRS) is a common inflammatory disease of nasal and paranasal sinuses, with many treatment methods available for the management of this disease. Recently, herbal medicines have shown a significant impact on inflammatory diseases such as CRS, and one of these herbal medicines is Nigella sativa. Therefore, the current study aimed to evaluate the effectiveness of N. sativa in patients with CRS without nasal polyp (CRSsNP).

Methods

In this randomized clinical trial, 65 patients with mild to moderate CRSsNP were enrolled based on the inclusion criteria. Patients were divided randomly into 2 parallel groups: intervention and placebo groups. Patients in the intervention group received 2 puffs/day of N. sativa nasal spray (1 g/day of N. sativa) and in the placebo group received 2 puffs/day of sodium chloride spray 0.65%.

Results

Thirty-one patients (19 men and 12 women) in the intervention group and 34 in the placebo group (18 men and 16 women) were evaluated. Lund–McKay, Lund Kennedy, and Sino-Nasal Outcome Test-22 scores were assessed for both groups after 8 weeks of treatments. These scores decreased significantly in both groups. However, these scores were significantly lower in the intervention group compared with the placebo group (P < .0001, for all).

Conclusion

The use of N. sativa nasal spray has symptom reliever effect with no adverse effects in patients with CRSsNP.

Rhinosinusitis symptoms, smoking and COPD: Prevalence and associations

OBJECTIVE (S)

To estimate the prevalence and associations among rhinosinusitis symptoms, smoking and chronic obstructive pulmonary disease (COPD).

DESIGN

Cross-sectional study.

SETTING

Population-based.

PARTICIPANTS

All adults aged 40 years or more living in the selected households in the city of Florianópolis (Florianópolis, Santa Catarina, Brazil).

MAIN OUTCOME MEASURES

Assessment instruments comprised household interviews, anthropometric measurements and spirometry. Rhinosinusitis symptoms were based on the responses to the 22-item Sinonasal Outcome Test (SNOT-22) questionnaire; smoking status was defined by the criteria of the CDC, and the functional diagnosis of COPD was done by spirometry.

RESULTS

The prevalence (n = 1056) of rhinosinusitis symptoms, smoking and COPD was 14.7%, 17.9% and 8.7%, respectively. Multivariate analysis showed that, with the exception of COPD, all other clinical variables (smoking, previous diagnosis of rhinitis, previous diagnosis of gastritis/ulcer/gastroesophageal reflux, and symptoms of depression) remained associated with higher prevalence of rhinosinusitis symptoms.

CONCLUSIONS

Rhinosinusitis symptoms were common both in smokers and in patients with COPD. However, only tobacco was significantly associated with rhinosinusitis symptoms and can act as a cofounder in the association between COPD and rhinosinusitis symptoms.

Age-related prevalence of chronic rhinosinusitis and nasal polyps and their relationships with asthma onset

BACKGROUND

Chronic rhinosinusitis (CRS) is a major disease condition with high morbidity and can influence lower airway disease status in adults. However, its associations with adult asthma onset and activity have not been examined in detail in a general adult population.

OBJECTIVE

To investigate relationships between CRS with nasal polyps (CRSwNP) and asthma characteristics.

METHODS

A cross-sectional data set of 17,506 adult participants (≥18 years old) in the Korean National Health and Nutrition Examination Survey from 2010 through 2012 was analyzed. CRS was defined using structured questionnaires according to the international guideline, and presence of nasal polyps was objectively assessed using nasal endoscopy. Presence of asthma and its onset and current activity were assessed using structured questionnaires.

RESULTS

CRS was significantly related to asthma, but the relationships were distinct by CRS and asthma status. CRSwNP was significantly associated with adult-onset asthma (onset after 18 years of age) or late-onset asthma (onset after 40 years of age), whereas CRS without nasal polyps was related to childhood-onset asthma (onset before 18 years) or early-onset asthma (onset before 40 years) in adults. The 2 CRS subgroups showed significant associations with current asthma but not with past asthma. However, the comorbid asthma rate was lower than 10% among subjects with CRS.

CONCLUSION

This study found distinct age-related patterns of CRSwNP and asthma and demonstrated their significant associations in a general population. However, the low prevalence of asthma in CRSwNP is in sharp contrast to findings in Western populations, which warrants further investigation for ethnic or regional differences in relationships between CRSwNP and asthma.

Acute and chronic rhinosinusitis and allergic rhinitis in relation to comorbidity, ethnicity and environment

Background

This study was conducted to assess the effect of comorbidity, ethnicity, occupation, smoking and place of residence on allergic rhinitis (AR), acute rhinosinusitis (ARS) and chronic rhinosinusitis (CRS).

Methods

A GA²LEN (The Global Allergy and Asthma European Network) screening questionnaire was sent to a random sample of the Dutch population (n = 16700) in three different areas of the Netherlands.

Results

Fifty percent (8347) of the questionnaires sent were returned. A total of 29% respondents (27–31% in different areas) met the criteria for AR, 18% (17–21%) for ARS and 16% (13–18%) for CRS. Risk factors for AR were itchy rash, eczema, adverse response after taking a painkiller, asthma, CRS and ARS. Moreover, the risk of AR was twice as low for full-time housewives/househusbands than for people with jobs. The risk of ARS or CRS was significantly higher in respondents with a doctor’s diagnosis of CRS, AR, itchy rash or smoking. The risk of CRS was also significantly higher in respondents with an adverse response after taking painkillers, active smoking or asthma. Caucasians are generally less likely to have AR or CRS than Latin-Americans, Hindustani and African-Creoles, and more likely to have ARS than Asian, Hindustani, Mediterranean and African-Creoles.

Conclusions

This study found shared and distinct risk factors for AR, ARS and CRS and therefore provides support for the belief that they have shared symptoms but are different diseases with different aetiologies.

Dietary Intake of Flavonoids and Ventilatory Function in European Adults: A GA²LEN Study

BACKGROUND

Flavonoids exert anti-inflammatory properties and modulate oxidative stress in vitro, suggesting a protective effect on lung function, but epidemiological studies examining this association are scarce.

METHODS

A stratified random sample was drawn from the GA²LEN screening survey, in which 55,000 adults aged 15 to 75 answered a questionnaire on respiratory symptoms. Post-bronchodilator spirometry was obtained from 2850 subjects. Forced vital capacity (FVC), the ratio between the forced exhaled volume in 1 second (FEV₁) and FVC (FEV₁/FVC), FVC below lower limit of normal (FVC < LLN), and FEV₁/FVC < LLN were calculated. Intake of the six main subclasses of flavonoids was estimated using the GA²LEN Food Frequency Questionnaire. Adjusted associations between outcomes and each subclass of flavonoids were examined with multivariate regressions. Simes' procedure was used to test for multiple comparisons.

RESULTS

A total of 2599 subjects had valid lung function and dietary data. A lower prevalence of FVC < LLN (airway restriction) was observed in those with higher total flavonoid (adjusted odds ratio (aOR), higher vs. lowest quintile intake 0.58; 95% Confidence Interval (CI) 0.36, 0.94), and pro-anthocyanidin intakes (aOR 0.47; 95% CI 0.27, 0.81). A higher FEV₁/FVC was associated with higher intakes of total flavonoids and pro-anthocyanidins (adjusted correlation coefficient (a β-coeff 0.33; 0.10, 0.57 and a β-coeff 0.44; 95% CI 0.19, 0.69, respectively). After Simes' procedure, the statistical significance of each of these associations was attenuated but remained below 0.05, with the exception of total flavonoids and airway restriction.

CONCLUSIONS

This population-based study in European adults provides cross-sectional evidence of a positive association of total flavonoid intake and pro-anthocyanidins and ventilatory function, and a negative association with spirometric restriction in European adults.

Asthma onset pattern and patient outcomes in a chronic rhinosinusitis population

BACKGROUND

Chronic rhinosinusitis (CRS) is strongly associated with comorbid asthma. This study compares early-onset and late-onset asthma in a CRS population using patient-reported and clinical characteristics.

METHODS

At enrollment into a clinical registry, CRS patients completed the 22-item Sino-Nasal Outcome Test (SNOT-22), Asthma Control Test (ACT), mini-Asthma Quality of Life Questionnaire (miniAQLQ), the 29-item Patient-Reported Outcomes Measurement Information System (PROMIS-29), and medication use questionnaires. Patients also reported comorbid asthma and age at first asthma diagnosis. Early-onset (<18 years) and late-onset (>18 years) asthma groups were defined. Analysis of variance (ANOVA), chi-square, and Kruskal-Wallis tests were used to compare patient responses.

RESULTS

A total of 199 non-asthmatic (56.1%), 71 early-onset asthmatic (20.0%), and 85 late-onset asthmatic (23.9%) CRS patients completed the survey. Body mass index (BMI) was significantly higher in late-onset asthmatic (p = 0.046) while age, gender, race, and smoking history did not differ with time of asthma onset. SNOT-22, ACT, and miniAQLQ were not different between asthma groups, but late-onset asthmatics had significantly lower physical function than non-asthmatics (p = 0.008). Compared to non-asthmatics, late-onset asthmatics showed increased rates of nasal polyps (p < 0.001), higher Lund-Mackay scores (p = 0.005), and had received more oral steroid courses (p < 0.001) and endoscopic surgeries (p = 0.008) for CRS management. Late-onset asthmatics compared to early-onset asthmatics showed increased nasal polyposis (p = 0.011) and oral steroid courses for CRS (p = 0.003).

CONCLUSION

While CRS-specific and asthma-specific patient-reported outcome measures (PROMs) were not significantly different among groups, CRS patients with late-onset asthma had poorer physical function, more frequent nasal polyposis, and required increased treatment for CRS. Late-onset asthma may predict more severe disease in CRS.

Longitudinal Evaluation of Chronic Rhinosinusitis Symptoms in a Population-Based Sample

BACKGROUND

Chronic rhinosinusitis (CRS) is a prevalent and disabling condition of the nose and sinuses. The natural history of CRS symptoms in a general population sample has not been previously studied.

OBJECTIVE

In a general population-based sample from Pennsylvania, we used 2 questionnaires mailed 6 months apart to estimate the prevalence of, and identify predictors for, stability or change in symptoms over time.

METHODS

We mailed the baseline and 6-month follow-up questionnaires to 23,700 primary care patients and 7,801 baseline responders, respectively. We categorized nasal and sinus symptoms using European Position Paper on Rhinosinusitis (EPOS) epidemiologic criteria. We defined 6 symptom groups over time on the basis of the presence of CRS symptoms at baseline and follow-up. We performed multivariable survey logistic regression controlling for confounding variables comparing persistent versus nonpersistent, recurrent versus stable past, and incident versus never.

RESULTS

There were 4,966 responders at follow-up: 558 had persistent symptoms, 190 recurrent symptoms, and 83 new symptoms meeting EPOS criteria for CRS. The prevalence of persistent symptoms was 4.8% (95% CI, 3.8-5.8), whereas the annual cumulative incidence of new symptoms was 1.9% and of recurrent symptoms was 3.2%. More severe symptoms at baseline were associated with persistence, whereas minor symptoms, allergies, and multiple treatments were associated with the development of new symptoms.

CONCLUSIONS

Less than half with nasal and sinus symptoms meeting CRS EPOS criteria in our general, regional population had symptom persistence over time, with symptom profiles at baseline and age of onset being strongly associated with stability of symptoms.

Contemporary Pharmacotherapy for Allergic Rhinitis and Chronic Rhinosinusitis

Chronic rhinosinusitis (CRS) and allergic rhinitis (AR) are chronic conditions causing nasal inflammation. CRS is increasingly recognized as a chronic inflammatory process rather than a chronic infection. Although the primary initiating factors in CRS remain unclear, AR is driven by IgE-mediated hypersensitivity to environmental allergens. Understanding the underlying inflammatory pathways and disease endotypes are driving innovation toward novel pharmacotherapies targeting critical mediators implicated in CRS and AR, including IL-4, IL-13, IL-5, IgE, and epithelial initiators IL-33 and TSLP. Extensive investigations are needed to determine the role, timing, predictive prognostic factors and long-term safety and efficacy of these agents.

The impact of asthma on the cost effectiveness of surgery for chronic rhinosinusitis with nasal polyps

BACKGROUND

The objective of this work was to evaluate the impact of asthma on the cost-effectiveness profile of endoscopic sinus surgery (ESS) compared to medical therapy for patients with chronic rhinosinusitis with nasal polyps (CRSwNP).

METHODS

The study design consisted of a cohort-style Markov decision-tree cost utility analysis with a 35-year time horizon. Matched cohorts of CRSwNP patients with (n = 95) and without (n = 95) asthma who underwent ESS were compared with cohorts of patients from the national Medical Expenditures Survey Panel (MEPS) database who underwent medical management for chronic rhinosinusitis (CRS). Baseline, 1-year, and 2-year health utility values were calculated from responses to the EuroQol-5 Dimension (EQ-5D) instrument in both cohorts. The primary outcome measure was the incremental cost effectiveness ratio (ICER) for each cohort.

RESULTS

The reference cases for CRSwNP patients with and without asthma yielded ICERs for ESS vs medical therapy alone of $12,066 per quality-adjusted life year (QALY) and $7,369 per QALY, respectively. At a willingness-to-pay threshold of $50,000/QALY, the ICER scatter plots demonstrated 86% and 99% certainty that the ESS strategy was the most cost-effective option for CRSwNP patients with and without asthma, respectively. ESS was not significantly more cost effective for CRSwNP patients without asthma (p = 0.494).

CONCLUSION

ESS remains cost effective compared to medical therapy for patients both with and without asthma. While the comorbidity of asthma results in an inferior ICER result, it does not result in a statistically significant negative impact on the overall cost effectiveness of ESS.

The value of frontal sinusotomy for chronic rhinosinusitis with nasal polyps-A cost utility analysis

OBJECTIVES/HYPOTHESIS

The number of surgical procedures performed for frontal sinusitis and the associated costs have increased dramatically over the past decade. The purpose of this study was to evaluate the cost-effectiveness of endoscopic frontal sinusotomy (EFS) in patients with chronic rhinosinusitis with nasal polyposis (CRSwNP).

STUDY DESIGN

Cohort-style Markov decision-tree economic model with a 36-year time horizon.

METHODS

Matched cohorts of CRSwNP patients who underwent endoscopic sinus surgery (ESS) with (n = 139) and without (n = 49) EFS were compared to each other and to patients (n = 139) from the Medical Expenditures Survey Panel database who underwent medical management for chronic rhinosinusitis. Multi-year health utility values were calculated from responses to the EuroQol 5-Dimension instrument. The primary outcome measure was the incremental cost-effectiveness ratio (ICER).

RESULTS

Decision analysis showed that ESS without EFS proved more cost-effective than ESS with EFS or medical management. ESS without EFS compared to medical management yielded an ICER of $9,004/quality-adjusted life year (QALY). ESS with EFS compared to ESS without EFS yielded an ICER of $62,310/QALY. At a willingness-to-pay (WTP) threshold of $50,000/QALY, ESS without EFS was more cost-effective than ESS with EFS with 52.1% certainty. These results were robust to one-way analysis and probabilistic sensitivity analysis.

CONCLUSIONS

ESS remains a cost-effective intervention compared to medical therapy alone for patients with CRSwNP. In this study, the addition of frontal sinusotomy during ESS for patients with CRSwNP was not found to be cost-effective at a WTP threshold of $50,000/QALY, but may be cost effective at a higher threshold of $100,000/QALY.

LEVEL OF EVIDENCE

2c. Laryngoscope, 128:43-51, 2018.

Patient-reported signs of dampness at home may be a risk factor for chronic rhinosinusitis: A cross-sectional study

BACKGROUND

An association between dampness at home and respiratory conditions has been convincingly demonstrated in children. Fewer studies have been performed in adults, and data are lacking for chronic rhinosinusitis (CRS). With a prevalence of 10.9% in Europe, CRS imposes a significant burden on quality of life, as well as economy.

OBJECTIVE

Our aim was to study CRS and other respiratory conditions in relation to dampness at home in a representative sample of adults.

METHODS

The Swedish GA² LEN questionnaire was answered by 26 577 adults (16-75 years) and included questions on respiratory symptoms, smoking, education and environmental exposure. CRS was defined according to the EP³ OS criteria. Dampness was defined as reporting water damage, floor dampness or visible moulds in the home during the last 12 months. The dampness score was ranked from 0 to 3, counting the number of signs of dampness reported.

RESULTS

Dampness at home was reported by 11.3% and was independently related to respiratory conditions after adjustment for demographic and socio-economic factors and smoking: CRS odds ratio (OR) 1.71; allergic rhinitis OR 1.24; current asthma OR 1.21; wheeze OR 1.37; nocturnal dyspnoea OR 1.80; nocturnal coughing OR 1.34; and chronic bronchitis OR 1.64. The risk of CRS and most of the other respiratory conditions was further elevated in subjects reporting multiple signs of dampness.

CONCLUSIONS AND CLINICAL RELEVANCE

This study demonstrated an independent association between dampness at home and CRS in adults. The high burden of this and the other respiratory conditions studied is a strong argument in favour of countering indoor dampness by improving building standards.

The validity of nasal endoscopy in patients with chronic rhinosinusitis-An inter-rater agreement study

OBJECTIVES

Nasal endoscopy is a cornerstone in diagnosing sinonasal disease, but different raters might generate different results using the technique. Our study aims to evaluate the agreement between multiple raters to assess the validity of nasal endoscopy.

DESIGN/PARTICIPANTS

Three independent and blinded raters evaluated 28 patients (56 nasal cavities) diagnosed with chronic rhinosinusitis according to the European Position Paper on Rhinosinusitis and Nasal Polyps. The ratings were compared using unweighted Fleiss' kappa coefficients (K_f ) for each objective parameter.

SETTING

The department of Otorhinolaryngology, Odense University Hospital, Denmark.

MAIN OUTCOME MEASURES

The ratings were quantified in a modified Lund-Kennedy endoscopy score and focused on the objective parameters specified in the diagnostic criteria: polyps, oedema and discharge.

RESULTS

The raters agreed on the findings concerning polyps and discharge but not regarding oedema with the inter-rater agreement for the different parameters being: polyps K_f =.66 (SE .07, P<.001), oedema K_f =.05 (SE .07, P=.21), discharge K_f =.35 (SE .08, P<.001), oedema exclusively in middle meatus K_f =-.07 (SE .04, P=.8) and discharge exclusively in middle meatus K_f =.16 (SE .07, P=.01).

CONCLUSION

Using nasal endoscopy, the evaluation of polyps by multiple raters showed sufficient reliability indicating an acceptable objective evaluation. The evaluation of discharge achieved a fair level of agreement while the assessment of oedema could not achieve a sufficient reliability questioning the inclusion of oedema in the criteria for diagnosing sinonasal disease.

An investigation on the use of snus and its association with respiratory and sleep-related symptoms: a cross-sectional population study

INTRODUCTION

Studies of the health effects of moist oral tobacco, snus, have produced inconsistent results. The main objective of this study is to examine the health effects of snus use on asthma, respiratory symptoms and sleep-related problems, a field that has not been investigated before.

METHODS AND MATERIAL

This cross-sectional study was based on a postal questionnaire completed by 26 697 (59.3%) participants aged 16 to 75 years and living in Sweden. The questionnaire included questions on tobacco use, asthma, respiratory symptoms and sleeping problems. The association of snus use with asthma, respiratory symptoms and sleep-related symptoms was mainly tested in never-smokers (n=16 082).

RESULTS

The current use of snus in never-smokers was associated with an increased risk of asthma (OR 1.51 (95% CI 1.28 to 1.77)), asthmatic symptoms, chronic bronchitis and chronic rhinosinusitis. This association was not present among ex-snus users. Snoring was independently related to both the former and current use of snus ((OR 1.37 (95% CI 1.12 to 1.68)) and (OR 1.59 (95% CI 1.34 to 1.89), respectively)). A higher risk of difficulty inducing sleep was seen among snus users.

CONCLUSION

Snus use was associated with a higher prevalence of asthma, respiratory symptoms and snoring. Healthcare professionals should be aware of these possible adverse effects of snus use.

Upper airway and skin symptoms in allergic and non-allergic asthma: Results from the Swedish GA2LEN study

BACKGROUND

Allergic and non-allergic asthma are viewed as separate entities, despite sharing similarities. The aims of this study were to determine differences in symptoms from the upper airways and the skin in allergic and non-allergic asthma. The secondary aims were to identify childhood risk factors and to compare quality of life in the two asthma groups.

METHODS

This cohort (age 17-76 years) consisted of 575 subjects with allergic or non-allergic asthma and 219 controls. The participants participated in an interview, spirometry, FeNO, skin prick test, and responded to the Mini Asthma Quality of Life Questionnaire.

RESULTS

Self-reported allergic rhinitis was significantly more common in both allergic and non-allergic asthma (82.3 and 40.7%) groups compared with the controls. The prevalence of chronic rhinosinusitis (CRS) was similar in both asthma groups. Eczema was significantly more common in both asthmatic groups (72.3 and 59.8%) than controls (47.0%) (p < 0.001 and p = 0.012). Severe respiratory infection in childhood and parental allergy were risk factors for both allergic and non-allergic asthma groups. Quality of life was significantly lower in non-allergic than allergic asthma groups (p = 0.01).

CONCLUSION

Concomitant symptoms from the upper airways and the skin were significantly more common in both allergic and non-allergic asthma. This indicates that non-allergic asthma has a systemic component with similarities to what is found in allergic asthma. There were similarities in the childhood risk factor pattern between the two types of asthma but asthma-related quality of life was lower in the non-allergic asthma group.

Is fruit and vegetable intake associated with asthma or chronic rhino-sinusitis in European adults? Results from the Global Allergy and Asthma Network of Excellence (GA2LEN) Survey

Background

Fruits and vegetables are rich in compounds with proposed antioxidant, anti-allergic and anti-inflammatory properties, which could contribute to reduce the prevalence of asthma and allergic diseases.

Objective

We investigated the association between asthma, and chronic rhino-sinusitis (CRS) with intake of fruits and vegetables in European adults.

Methods

A stratified random sample was drawn from the Global Allergy and Asthma Network of Excellence (GA²LEN) screening survey, in which 55,000 adults aged 15–75 answered a questionnaire on respiratory symptoms. Asthma score (derived from self-reported asthma symptoms) and CRS were the outcomes of interest. Dietary intake of 22 subgroups of fruits and vegetables was ascertained using the internationally validated GA²LEN Food Frequency Questionnaire. Adjusted associations were examined with negative binomial and multiple regressions. Simes procedure was used to control for multiple testing.

Results

A total of 3206 individuals had valid data on asthma and dietary exposures of interest. 22.8% reported having at least 1 asthma symptom (asthma score ≥1), whilst 19.5% had CRS. After adjustment for potential confounders, asthma score was negatively associated with intake of dried fruits (β-coefficient −2.34; 95% confidence interval [CI] −4.09, −0.59), whilst CRS was statistically negatively associated with total intake of fruits (OR 0.73; 95% CI 0.55, 0.97). Conversely, a positive association was observed between asthma score and alliums vegetables (adjusted β-coefficient 0.23; 95% CI 0.06, 0.40). None of these associations remained statistically significant after controlling for multiple testing.

Conclusion and clinical relevance

There was no consistent evidence for an association of asthma or CRS with fruit and vegetable intake in this representative sample of European adults.

An increased prevalence of self-reported allergic rhinitis in major Chinese cities from 2005 to 2011

BACKGROUND

The prevalence of allergic rhinitis (AR) has increased worldwide in recent decades. This study was conducted to investigate the prevalence of self-reported AR and profiles of AR-related comorbidities in the adult population of China over time.

METHODS

This study surveyed residents of 18 major cities in mainland China. Telephone interviews were conducted with study participants after sampling target telephone numbers by random digit dialing. The questions asked during telephone interviews were based on those included in validated questionnaires and focused on topics regarding AR, nonallergic rhinitis (NAR), acute/chronic rhinosinusitis (ARS/CRS), asthma, and atopic dermatitis (AD).

RESULTS

During 2011, a total of 47 216 telephone interviews were conducted, and the overall response rate was 77.5%. When compared with the AR prevalence in 11 cities surveyed in 2005, there was a significant increase in self-reported adult AR in eight of those cities (P < 0.01). In 2011, the standardized prevalence of self-reported adult AR in the 18 cities was 17.6%. The concentration of SO2 was positively correlated with the prevalence of AR (r = 0.504, P = 0.033). A multiple regression model showed that the absolute change in household yearly income was significantly associated with the change in the prevalence of AR (R(2)  = 0.68), after adjusting for PM10 , SO2 , NO2, temperature, and humidity. The overall prevalences of NAR, ARS, CRS, asthma, and AD in the general population were 16.4%, 5.4%, 2.1%, 5.8%, and 14%, respectively.

CONCLUSION

During a 6-year period, there was a significant increase in the prevalence of self-reported AR in the general Chinese adult population. The incidence of AR being accompanied by rhinosinusitis, asthma, or AD was significantly higher among individuals having self-reported AR compared with the general population.

Cost utility analysis of endoscopic sinus surgery for chronic rhinosinusitis with and without nasal polyposis

OBJECTIVE

To evaluate the cost-effectiveness of endoscopic sinus surgery (ESS) compared to medical therapy for patients with chronic rhinosinusitis (CRS) with and without nasal polyposis (NP).

STUDY DESIGN

Cohort-style Markov decision-tree economic model with a 36-year time horizon.

METHODS

Two cohorts of 229 CRS patients with and without NP who underwent ESS were compared with a matched cohort of 229 CRS patients from the Medical Expenditures Survey Panel database (Agency for Healthcare Research and Quality, Rockville, MD) who underwent medical management. Utility scores were calculated from sequential patient responses to the EuroQol five-dimensions questionnaire. Decision-tree analysis and a 10-state Markov model utilized published event probabilities and primary data to calculate long-term costs and utility. The primary outcome was the incremental cost per quality-adjusted life year (QALY). Thorough sensitivity analyses were performed.

RESULTS

The reference case for CRS with NP yielded an incremental cost-effectiveness ratio (ICER) for ESS versus medical therapy of $5,687.41/QALY. The reference case for CRS without NP yielded an ICER of $5,405.44/QALY. The cost-effectiveness acceptability curve in both cases demonstrated 95% certainty that the ESS strategy was the most cost-effective option at a willingness-to-pay threshold of $20,000/QALY or higher. These results were robust to one-way and probabilistic sensitivity analysis.

CONCLUSION

This study demonstrates the cost-effectiveness of ESS compared to medical therapy alone for the management of CRS patients both with and without NP. The presence of nasal polyps was not found to affect the overall cost-effectiveness of ESS.

LEVEL OF EVIDENCE

2C. Laryngoscope, 127:29-37, 2017.

Important non-disease-related determinants of exhaled nitric oxide levels in mild asthma - results from the Swedish GA(2) LEN study

BACKGROUND

Fractional exhaled nitric oxide (FeNO) has a potential clinical role in asthma management. Constitutive factors such as age, height and gender, as well as individual characteristics, such as IgE sensitization and smoking, affect the levels of FeNO in population-based studies. However, their effect on FeNO in subjects with asthma has been scarcely studied.

OBJECTIVE

To study the effects on FeNO of these commonly regarded determinants, as demonstrated in healthy subjects, as well as menarche age and parental smoking, in a population of asthmatics.

MATERIAL AND METHODS

Fractional exhaled nitric oxide was measured in 557 subjects with asthma from the Swedish GA(2) LEN study. Allergic sensitization was assessed by skin prick tests to most common aeroallergens. Upper airway comorbidities, smoking habits, smoking exposure during childhood and hormonal status (for women) were questionnaire-assessed.

RESULTS

Male gender (P < 0.001), greater height (P < 0.001) and sensitization to both perennial allergens and pollen (P < 0.001) are related to higher FeNO levels. Current smoking (P < 0.001) and having both parents smoking during childhood, vs. having neither (P < 0.001) or only one parent smoking (P = 0.002), are related to lower FeNO. Women with menarche between 9 and 11 years of age had lower FeNO than those with menarche between 12 and 14 years of age (P = 0.03) or 15 and 17 years of age (P = 0.003).

CONCLUSIONS AND CLINICAL RELEVANCE

Interpreting FeNO levels in clinical practice is complex, and constitutional determinants, as well as smoking and IgE sensitisation, are of importance in asthmatic subjects and should be accounted for when interpreting FeNO levels. Furthermore, menarche age and parental smoking during childhood and their effects on lowering FeNO deserve further studies.

The Heterogeneity Hidden in Allergic Rhinitis and Its Impact on Co-Existing Asthma in Adults: A Population-Based Survey

BACKGROUND

It has been suggested that there is some overlap between allergic rhinitis (AR), sinusitis and polyposis, but this has not been fully documented. The present study aimed to evaluate the prevalence of these co-existing diseases and their impact on bronchial asthma in the general population of Italy.

METHODS

Within the frame of the multicentre Gene Environment Interactions in Respiratory Diseases (GEIRD) study, a postal screening questionnaire including questions about self-reported symptoms of asthma, AR, AR with sinusitis without nasal polyps (AR + SsNP) and AR with sinusitis with nasal polyps (AR + SwNP) was administered. Random samples of subjects aged between 20 and 44 years (n = 5,162) answered the postal questionnaire in 4 Italian centres (Pavia, Sassari, Turin, Verona). In AR subjects, the association among AR only, AR + SsNP, AR + SwNP and bronchial asthma was estimated by the relative risk ratio (RRR) using multinomial regression models.

RESULTS

The prevalence of AR in the sample was 25.4% (95% CI 24.2-26.6). A self-reported diagnosis of AR + SsNP and AR + SwNP was reported by 5.7% (95% CI 5.0-6.3) and by 1.2% (95% CI 0.9-1.5) of the subjects, respectively. Current asthma was reported by 17.5% of the AR subjects. In the adjusted multivariate analysis, the risk of having current asthma (RRR = 2.31, 95% CI 1.29-4.15), of having at least 1 asthma attack per year (RRR = 2.30, 95% CI 1.19-4.46) and of having had an emergency department admission for respiratory diseases (RRR = 5.61, 95% CI 1.81-23.92) was higher for subjects with AR + SwNP than subjects with AR only.

CONCLUSIONS

The diagnosis of AR in the epidemiological setting includes heterogeneous upper airway diseases that affect the clinical features of AR and its interactions with asthma.

Epidemiology of chronic rhinosinusitis, selected risk factors, comorbidities, and economic burden

Chronic rhinosinusitis (CRS) is a relevant and prevalent medical condition in Germany, Europe and the world. If analysed in detail, the prevalence of CRS shows regional and temporary variety. In this review, currently available data regarding the prevalence of CRS is therefore sorted by country and/or region, time point of data collection and the CRS-definition employed. Risk factors like smoking and gastroesophageal reflux are discussed regarding their influence on CRS prevalence. Moreover, comorbidities of CRS, like asthma, conditions of the cardiovascular system and depression are listed and their influence on CRS is discussed. Furthermore, data on CRS prevalence in special cohorts, like immunocompromised patients, are presented. To estimate the economic burden of CRS, current data e.g. from Germany and the USA are included in this review.

Pathophysiology of chronic rhinosinusitis, pharmaceutical therapy options

Research in immunology has brought great progress in knowledge of inflammatory processes in the last 2 decades, which also has an impact on the upper airways. Our understanding of the pathophysiology of chronic rhinosinusitis developed from a rather mechanistic point of view with a focus on narrow clefts and mucociliary clearance to the appreciation of a complex network of immunological pathways forming the basis of disease. We today differentiate various forms of inflammation, we start to understand complex immune-regulatory networks and the reasons for their failure, and have already developed innovative approaches for therapy for the most severely ill subjects. Due to this new knowledge in inflammation and remodeling processes within mucosal tissue, specifically on the key driving factors, new diagnostic tools and therapeutic approaches for chronic rhinosinusitis have developed; the differentiation of endotypes based on pathophysiological principles will be crucial for the use of innovative therapies, mostly humanized monoclonal antibodies. Several hundred of those antibodies are currently developed for various indications and will impact our specialty as well as pneumology to a great extent.

Correlation between symptoms and objective findings may improve the symptom-based diagnosis of chronic rhinosinusitis for primary care and epidemiological studies

BACKGROUND

In primary care and epidemiological studies of chronic rhinosinusitis (CRS), symptom-based diagnosis is common, yet limited, because endoscopic and radiological signs are not considered.

OBJECTIVES

To evaluate the correlation between symptoms and objective findings of CRS to improve its symptom-based diagnosis for primary care and epidemiological studies by using data from a large-scale nationwide epidemiological study, the Korean National Health and Nutrition Examination Survey (KNHANES).

DESIGN

Cross-sectional study.

SETTING

Data from 2008 to 2012 KNHANES.

PARTICIPANTS

29,225 Adults aged >19 years.

OUTCOME MEASURES

Questionnaires targeted two major (nasal blockage and anterior/posterior nasal drip) and two minor (facial pain/pressure and reduction or loss of smell) symptoms. Nasal polyps or mucopurulent discharge from the middle meatus was defined as positive endoscopic findings for diagnosing CRS.

RESULTS

Of the four symptoms, reduction or loss of smell was the symptom most significantly related to positive endoscopic findings in multivariable analysis (OR=1.936 (95% CI 1.604 to 2.337)). The combinations of symptoms showed higher ORs than individual symptoms and combinations of reduction or loss of smell with other symptoms were statistically more reliable for positive endoscopic findings than other combinations.

CONCLUSIONS

Our results show that reduction or loss of smell was the symptom most significantly related to positive nasal endoscopic findings. Therefore, symptom-based diagnosis of CRS can be improved by considering reduction or loss of smell as an important symptom for positive endoscopic findings of CRS.

Chronic rhinosinusitis identification in administrative databases and health surveys: A systematic review

OBJECTIVES/HYPOTHESIS

Much of the epidemiological data on chronic rhinosinusitis (CRS) are based on large administrative databases and health surveys. The accuracy of CRS identification with these methods is unknown.

METHODS

A systematic review was performed to identify studies that measured the accuracy of CRS diagnoses in large administrative databases or within health surveys. The Quality Assessment of Diagnostic Accuracy Studies 2 tool was used to assess study quality.

RESULTS

Of 512 abstracts initially identified, 122 were selected for full-text review; only three studies (2.5%) measured the accuracy of CRS patient identification. In a single, large administrative database study with a CRS prevalence of 54.8%, a single International Classification of Diseases-9th Revision diagnostic code for CRS had a positive predictive value (PPV) of only 34%. A diagnostic code algorithm identified CRS patients with a PPV of 91.3% (95% confidence interval [CI], 85.3-95.1); in a population with a CRS prevalence of 5%, this algorithm had a PPV of 31%. In health survey studies having an estimated CRS prevalence of 25% to 46%, self-reported symptom-based CRS diagnosis had a PPV of 62% (95% CI, 50.2-72.1) when nasal endoscopy was the gold standard for CRS diagnosis, and 70% (95% CI, 57.4-80.8) when otolaryngologist-based CRS diagnosis (after interview and nasal endoscopy) was the gold standard.

CONCLUSION

Most health administrative data and health surveys examining CRS did not consider the accuracy of case identification. For unselected populations, administrative data and health surveys using self-reported diagnoses inaccurately identify patients with CRS. Epidemiological results based on such data should be interpreted with these results in mind. Laryngoscope, 126:1303-1310, 2016.

Clinical and biological markers of difficult-to-treat severe chronic rhinosinusitis

Chronic rhinosinusitis (CRS) is a chronic inflammatory disease of the upper airways of which two major phenotypes exist, CRS without nasal polyps (CRSsNP) and CRS with nasal polyps (CRSwNP). Some patients with CRS have suboptimal response to current guideline treatments. These patients remain severe and uncontrolled by treatment and have a poor quality of life. It is highly important to identify both clinical and biological markers, so-called biomarkers, in this subset of patients. The presence of nasal polyps and comorbidity with asthma and with aspirin-exacerbated respiratory disease (AERD) are the most common clinical traits that have been associated to difficult-to-treat severe CRS. In addition to clinical traits, numerous biological markers, with known etiopathogenic roles in CRS, have been associated to difficult-to-treat or recalcitrant CRS. This review summarizes the existing knowledge of the clinical and biological markers associated to difficult-to-treat or uncontrolled severe CRS.

Rhinosinusitis in morbidity registrations in Dutch General Practice: a retro-spective case-control study

Background

There is only limited accurate data on the epidemiology of rhinosinusitis in primary care.

This study was conducted to assess the incidence of acute and chronic rhinosinusitis by analysing data from two Dutch general practice registration projects. Several patient characteristics and diseases are related to the diagnosis rhinosinusitis.

Methods

The Continuous Morbidity Registration (CMR) and the Transitionproject (TP) are used to analyse the data on rhinosinusitis in primary practice. Both registries use codes to register diagnoses.

Results

In the CMR 3244 patients are registered with rhinosinusitis and in the TP 5424 CMR: The absolute incidence of (acute) rhinosinusitis is 5191 (18.8 per 1000 patient years). Regarding an odds ratio of 5.58, having nasal polyps is strongest related to rhinosinusitis compared to the other evaluated comorbidities. A separate code for chronic rhinosinusitis exists, but is not in use.

TP: Acute and chronic rhinosinusitis are coded as one diagnosis. The incidence of rhinosinusitis is 5574 or 28.7 per 1000 patient years. Patients who visit their general practitioner with “symptoms/complaints of sinus”, allergic rhinitis and “other diseases of the respiratory system” have the highest chances to be diagnosed with rhinosinusitis. Medication is prescribed in 90.6 % of the cases.

Conclusions

Rhinosinusitis is a common diagnosis in primary practice. In the used registries no difference could be made between acute and chronic rhinosinusitis, but they give insight in comorbidity and interventions taken by the GP in case of rhinosinusitis.