Chronic rhinosinusitis: the unrecognized epidemic

The Correlation Between Vitamin D Deficiency and Chronic Rhinosinusitis: A Systematic Review

Chronic rhinosinusitis (CRS) is marked by inflammation of the paranasal sinuses and mucosal lining of the nose. CRS can be classified as CRS with nasal polyps or CRS without polyps. In recent years, there has been increased attention on the immunological role of vitamin D in treating CRS, coupled with the observation of vitamin D deficiency among CRS patients. Vitamin D is acknowledged for its immunomodulatory properties, especially in allergic conditions. Recent studies suggest that individuals with CRS, especially those with CRS with nasal polyps, frequently demonstrate lower than normal levels of vitamin D. We conducted searches across various databases, including PubMed, Web of Science, ScienceDirect, and the Cochrane Library, both electronically and manually, to identify pertinent studies. Studies from 2003 to 2023 were included. Deficiency of vitamin D was considered with levels of vitamin D less than 30 ng/mL, and only original studies were included. Studies including patients taking vitamin D supplementation previously and patients with chronic kidney and liver diseases were excluded. We included nine studies that recruited 1,042 patients in total. More than half of the studies reported the presence of nasal polyps in CRS, and participants from four studies had CRS without nasal polyps. All of the included studies reported a negative correlation between levels of vitamin D and CRS. The majority of the studies depicted quite low levels of vitamin D among CRS patients. The degree of CRS severity as measured by endoscopic and radiological scores is moderately inversely correlated with vitamin D intake. Therefore, it is recommended that the relationship between various serum vitamin D concentrations and the severity of CRS be investigated in detail, along with an understanding of the cellular effects of vitamin D levels on the nasal mucosa.

Tissue-resident memory T cells exhibit phenotypically and functionally heterogeneous in human physiological and pathological nasal mucosa

Pathogens commonly enter mucosal barrier tissues and tissue-resident memory T cells (TRM) are essential for preventing mucosal lesions. However, the immunological properties of TRM cells in nasal mucosa are poorly known. In comparison with control tissues, decreasing CD103+ TRM cells were observed in Chronic rhinosinusitis with nasal polyps (CRSwNPs) and sinonasal inverted papilloma (SNIP), which presented high capability to produce effector cytokines. In CRSwNPs, we found that CD103+ TRM cells with higher cytokine and Granzyme B coexpressed high PD-1, CD103- TRM cells expressed higher IL-10. Homogenates isolated from CRSwNPs induced CD103 expression on peripheral T cells which could be inhibited by blocking TGF-β. The frequencies of CD103+ TRM cells in CRSwNPs were extremely negatively correlated with neutrophil infiltration. CD103+ TRM cells from Staphylococcus aureus positive CRSwNPs had a stronger response to SEB. Taken together, two phenotypically and functionally distinct subsets of TRM cells exist in nasal tissues and play critical roles in the progress of CRSwNPs and SNIPs.

The Impact of Sinonasal Symptoms in Relation to Potentially Life-Threatening Comorbidities

OBJECTIVE

While general health may be influenced by sinonasal symptoms, their effects may be overshadowed by comorbid states which may be more serious. To assess the validity of this postulate, we measured the extent to which sinonasal symptoms and concurrent conditions influenced general health.

STUDY DESIGN

Observational outcomes study.

SETTING

Academic medical center, community care sites.

METHODS

Adults with sinonasal symptoms completed the 22-item Sinonasal Outcome Test, along with the Patient-Reported Outcomes Measurement Information System global health short form. Comorbidities were categorized with the Deyo modification of the Charlson comorbidity index. Multivariate regression analyses were utilized to determine the relative impact of sinonasal symptoms and concurrent comorbid conditions on general health.

RESULTS

Data from 219 consecutive patients demonstrated that sinonasal symptoms were associated with significantly diminished general physical (β = -1.431, p < .001), mental (β = -1.000, p < .001), overall (β = -1.026, p < .001), and social health (β = -0.872, p = .003), regardless of the presence of potentially life-threatening comorbid conditions. Comorbid conditions included cardiovascular disease, chronic obstructive pulmonary disease, connective tissue disease, peptic ulcer, diabetes mellitus, and hepatic disease. The effect of sinonasal symptoms was neither subsumed nor overshadowed by the effects of comorbid states. Nasal, ear, sleep, and psychological domain scores were also associated with general physical, mental, and global health while adjusting for the impact of comorbidities.

CONCLUSION

Sinonasal symptoms have a substantial effect on general health which is not subsumed by the presence of potentially life-threatening concurrent comorbidities. These data may help support the importance of funding and resource allocation for conditions causing sinonasal symptoms.

Risk of new-onset and prevalent disease in chronic rhinosinusitis: A prospective cohort study

BACKGROUND

Chronic rhinosinusitis (CRS) is accompanied by burdensome comorbid conditions. Understanding the relative timing of the onset of these conditions could inform disease prevention, detection, and management.

OBJECTIVE

To evaluate the association between CRS and new-onset and prevalent asthma, noncystic fibrosis bronchiectasis (NCFBE), chronic obstructive pulmonary disease (COPD), gastroesophageal reflux disease (GERD), and obstructive sleep apnea (OSA).

METHODS

We conducted a prospective cohort study among primary care patients using a detailed medical and symptom questionnaire in 2014 and again in 2020. We used questionnaire and electronic health record (EHR) data to determine CRS status: CRSSE (moderate to severe symptoms with EHR evidence), CRSE (limited symptoms with EHR evidence), CRSS (moderate to severe symptoms without EHR evidence), CRSneg (limited symptoms and no EHR evidence; reference). We evaluated the association between CRS status and new-onset and prevalent disease using logistic regression to estimate odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

There were 7847 and 4445 respondents to the 2014 and 2020 questionnaires, respectively. CRSSE (vs CRSneg ) was associated with increased odds of new-onset asthma (OR, 1.74 [CI, 1.09-2.77), NCFBE (OR, 1.87 [CI, 1.12-3.13]), COPD (OR, 1.73 [CI, 1.14-2.68]), GERD (OR, 1.95 [CI, 1.61-2.35]), and OSA (OR, 1.91 [CI, 1.39-2.62]). Similarly, increased odds were observed for associations with the prevalence of these conditions.

CONCLUSION

The findings from the study support further exploration of CRS as a target for the prevention and detection of asthma, NCFBE, COPD, GERD, and OSA.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

The link between allergic rhinitis and chronic rhinosinusitis

PURPOSE OF REVIEW

Allergic rhinitis and chronic rhinosinusitis (CRS) are common disorders affecting millions of people worldwide. Although allergic rhinitis and CRS are distinct clinical entities, certain CRS endotypes share similar pathological mechanisms as those seen in patients with allergic rhinitis. This review assesses the literature behind the similarities and differences seen in patients with CRS and allergic rhinitis, and the role atopy might play in the pathophysiology of CRS.

RECENT FINDINGS

In examining the associations between allergic rhinitis and CRS, most studies have focused primarily on CRS with nasal polyps and type 2 inflammation in CRS. Recent studies have demonstrated the similarities and differences in pathologic mechanisms behind allergic rhinitis and CRS, with an emphasis on patient endotypes, genetics, and the nasoepithelial immunologic barrier. Related immunopathology shared by allergic rhinitis and type 2 inflammation in CRS has allowed for therapeutic overlap with biologic treatments.

SUMMARY

Allergic rhinitis and CRS often present as comorbid conditions, and understanding the relationship between allergic rhinitis and CRS is important when considering treatment options. Advances in understanding the genetics and immunology, as well as biologic and immunotherapeutic treatments have improved outcomes in patients with CRS, especially in the setting of atopy.

Epidemiology, Sociodemographic Factors and Comorbidity for Allergic Rhinitis, Asthma, and Rhinosinusitis Among 15 to 65-year-Old Iranian Patients

Background: It is well established that upper and lower airways are often clumped together when diagnosing and treating a disease. This study was designed to determine the prevalence of upper and lower airway diseases and to assess the effect of sociodemographic factors on the prevalence and the comorbidity of these disorders. Methods: This cross-sectional population-based study included patients with ages ranging between 15 to 65 years, who were referred to allergy outpatient clinics in various provinces of Iran from April to September 2020. A modified global Allergy and Asthma European Network (GA2LEN) screening questionnaire was filled out by local allergists of the 12 selected provinces in Iran. Information about the patients and sociodemographic factors was also recorded. Statistical analysis was done by univariate statistical analyses and multiple logistic regressions in SPSS software Version 26. Results: Out of 4988 recruited patients, 1078 (21.6%) had the symptoms of allergic rhinitis (AR) and 285 (5.7%) met the criteria of asthma. The prevalence of acute rhinosinusitis (ARS) and chronic rhinosinusitis (CRS) was 21.6 % and 22%, respectively. The highest prevalence of AR and ARS was in Tehran with the arateof of 33.9% each. Asthma was more prevalent in Khuzestan (14.2%) and CRS in Baluchestan (57.5%). Our analysis showed that the patients with asthma were most likely to have other allergic diseases as well-CRS (OR = 4.8; 95% CI, 2.02- 5.82), AR (OR= 2.5, 95% CI, 2.10-3), ARS (OR = 1.8; 95% CI, 2.10-3), followed by eczema (OR = 1.4; 95% CI, 1.13-1.67).We found that those individuals with CRS were most likely to have painkiller hypersensitivity (OR= 2.1; 95% CI, 1.21-3.83). Furthermore, smoking has been found more than 1.5 folds in patients with ARS. After adjusting variables, there was no correlation between education, occupation, and ethnicity with the studied diseases. Conclusion: Rhinosinusitis is a common condition among Iranian patients. This study confirmed that inflammation of the upper and lower airways can occur simultaneously. Gender, education, occupation, and ethnicity were found to be irrelevant in the development of either AR, asthma, ARS, or CRS.

Tobacco Use Increases the Adjusted Risk of Revision Endoscopic Sinus Surgery in Patients With Chronic Rhinosinusitis

BACKGROUND

Large epidemiologic studies have suggested that a history of tobacco use may be associated with an increased risk of developing chronic rhinosinusitis (CRS). The impact of tobacco use on revision rates of endoscopic sinus surgery (ESS), however, remains limited.

OBJECTIVE

This study seeks to define the independent risk of tobacco use (active or prior) on revision rates of ESS among a large cohort of patients with CRS.

METHODS

A state population database was queried for patients age ≥18 years with CRS who underwent at least one ESS between 1996 and 2018. Demographic characteristics, history of ESS, and tobacco use status were compared across patients with CRS, using t tests for continuous variables and χ² tests for categorical variables. Unadjusted and adjusted logistic regression models were used to understand the impact of tobacco status on revision surgery.

RESULTS

The final analysis included 34 350 patients (29 916 CRS with no revision surgery and 4434 CRS with revision surgery). Unadjusted regression analysis demonstrated an increased odds of undergoing revision ESS (OR 1.12, 95% CI: 1.00-1.25, P = .05) among males with a history of tobacco use and CRS. Adjusted regression analysis demonstrated that the risk of revision ESS among CRS patients with a history of asthma and tobacco use was 1.72-fold, while the risk among CRS patients who were tobacco users without asthma was 1.11-fold.

CONCLUSION

History of tobacco use is an independent risk factor for revision ESS among patients with CRS.

Vascular permeability in chronic rhinosinusitis enhances accumulation and retention of nanoscale pegylated liposomes

Chronic rhinosinusitis (CRS) is a debilitating inflammatory disorder of the sinonasal mucosa that substantially diminishes patient quality of life. Progress surrounding management of this disease has been crippled by a lack of therapeutic innovation. It has been posited that increased vascularity within the diseased sinuses of patients with CRS may allow for improved systemic drug delivery via nanoscale liposomal carriers. Such a system could enhance drug distribution, accumulation, and retention within the sinuses, ultimately leading to improved patient outcomes. PEGylated liposomes loaded with indocyanine green (ICG) were synthesized, characterized and systemically administered in a mouse model of CRS. Accumulation and retention of ICG in sinonasal tissue were evaluated. Compared to healthy controls, CRS mice showed significant sinonasal tissue accumulation and retention of PEGylated liposomal ICG for up to 21 days (P < 0.001). Conversely, free ICG was eliminated from the body after 24 h in both groups.

Long-acting implantable corticosteroid matrix for chronic rhinosinusitis: Results of LANTERN Phase 2 randomized controlled study

Background

Topical steroids are first‐line treatment for chronic rhinosinusitis (CRS), but fail to provide adequate symptom control for all patients. Designed for medical treatment failures, LYR‐210 is an implantable matrix that locally elutes mometasone furoate to inflamed sinonasal tissue for up to 24 weeks in CRS patients. In an open‐label phase 1 study, LYR‐210 demonstrated clinically relevant improvement in the 22‐item Sino‐Nasal Outcome Test (SNOT‐22). Safety and efficacy of LYR‐210 in CRS were evaluated in the LANTERN Phase 2 study.

Methods

Sixty‐seven surgically naive adult CRS patients who were inadequately controlled by previous medical management and seeking an alternative treatment enrolled in a multicenter, blinded, controlled, dose‐ranging study. Patients had moderate‐to‐severe disease based on SNOT‐22 and composite 7‐day average scores of the 4 cardinal CRS symptoms (4CS), with diagnosis confirmed by nasal endoscopy and magnetic resonance imaging. Patients were randomized (1:1:1) to saline irrigation–only control or bilateral in‐office administration of LYR‐210 (2500 μg) or LYR‐210 (7500 μg). Safety and efficacy were evaluated over 24 weeks.

Results

Both LYR‐210 doses were safe and well‐tolerated over the 24‐week treatment period. LYR‐210 demonstrated rapid and durable dose‐dependent symptom improvement based on 4CS and SNOT‐22, with LYR‐210 (7500 μg) achieving statistical significance as early as 8 weeks and out to 24 weeks compared with control. LYR‐210 (7500 μg) reduced rescue treatment use and radiographic ethmoid opacification at week 24.

Conclusions

LYR‐210 is the first implantable sinonasal treatment to achieve up to 24 weeks of benefit from a single administration in surgically naive CRS patients with and without nasal polyps.

Emergency radiologic approach to sinus disease

Sinus disease is commonly encountered, especially in the acute care setting. Imaging can support a diagnosis of sinusitis, help identify an etiology, and delineate intracranial and extracranial complications. Suspicion of complicated rhinosinusitis is an indication for contrast-enhanced computed tomography or magnetic resonance imaging. It is important for radiologists to be familiar with patient risk factors that predispose to uncommon but aggressive forms of sinus disease such as invasive fungal sinusitis. Lastly, many conditions, ranging from benign to malignant, can mimic rhinosinusitis clinically and on imaging. Radiologists can help by recognizing these entities and facilitating appropriate referral and follow-up. This article reviews the breadth of sinus disease commonly encountered in the emergency setting, potential complications, and mimics.

Induction of the endogenous sialoglycan ligand for eosinophil death receptor Siglec-8 in chronic rhinosinusitis with hyperplastic nasal polyposis

Siglec-8, an immune-inhibitory sialoglycan binding lectin (S8), is expressed on the surface of eosinophils and mast cells, potent mediators of allergic inflammation. When S8 engages endogenous sialoglycan ligands, eosinophils undergo apoptosis and mast cell mediator release is inhibited. In the human airway, Siglec-8 ligands (S8L) are sialylated keratan sulfate chains carried on isoforms of the protein Deleted in Malignant Brain Tumors-1 (DMBT1), an immunoregulatory protein that we recently identified as the endogenous ligand for S8, DMBT1S8. We herein report that S8L is overexpressed in chronic rhinosinusitis with nasal polyposis (CRSwNP), a prevalent eosinophilic laden airway disease. Quantification and comparison of the degree to which DMBT1 carries the S8L by immunoblot analysis and lectin blot overlay, respectively, from nasal lavage showed that the S8L/DMBT1 ratio was significantly increased in CRSwNP vs control or CRS patients. We identified the histological sites of S8L and DMBT1 expression in fresh surgically resected human nasal polyps. Histochemistry of diseased polyps and adjacent non-diseased middle turbinate tissue from CRSwNP demonstrated colocalization of S8L and DMBT1 with highest staining in submucosal glands >> epithelium > stoma. S8L expression was specifically elevated in the submucosal glands and epithelium of polyp tissue compared to middle turbinate. We hypothesize that expression of the isoform of DMBT1 carrying the Siglec-8 binding sialoglycan, DMBT1S8, is induced in polyps of CRSwNP specifically at the site of disease, is produced in the submucosal glands of polyps and secreted into the lumen of the sinonasal cavity as a host response to mitigate eosinophil-mediated inflammation.

Endoscopic polypectomy performed in clinic for chronic rhinosinusitis with nasal polyps: study protocol for the EPIC multicentre randomised controlled trial

INTRODUCTION

Chronic rhinosinusitis (CRS) is common, with a Canadian prevalence of 5%, and associated with significant morbidity. Understandably, CRS impairs workplace productivity but that productivity substantially increases following surgical treatment. CRS with nasal polyps (CRSwNP), the most common type of CRS, is usually treated with a combination of medications and endoscopic sinus surgery (ESS). Historically, surgical treatment has only been performed in the operating room at a cost of about $C3500. However, recent studies have shown that a de-escalated procedure, endoscopic polypectomy performed in clinic (EPIC), can provide an improvement in patient symptoms to levels equal to those for ESS. Moreover, EPIC has additional proposed advantages including shorter recovery time, significantly lower cost to the healthcare system and shorter wait time for the patient. There is currently insufficient evidence to draw conclusions about the superiority of polypectomy or ESS for the management of CRSwNP.

METHODS AND ANALYSIS

We designed a multicentre, open-label, randomised controlled trial to evaluate whether EPIC was non-inferior to the current clinical standard, ESS for the treatment of CRSwNP. The primary outcome is the Sinonasal Outcome Test-22 score measured at baseline and at 3 months after surgery. Other outcomes include peak nasal inspiratory flow, quality of life measured by the EuroQoL 5 Dimensions 5 Levels questionnaire and work impairment using the Work Productivity and Activity Impairment Questionnaire.We aim to recruit 140 patients from sites across Canada. Participants will be randomly assigned to EPIC or ESS and followed up for 3 months in clinic after the procedure. Additionally, participants will enter a 5-year long-term follow-up period.

ETHICS AND DISSEMINATION

This study was approved by the Ottawa Health Sciences Network Research Ethics Board for all sites in Ontario, Canada (study number CTO0801). Sites located outside of Ontario obtained approval from their local/institutional research ethics board.

TRIAL REGISTRATION NUMBER

NCT02975310.

Radiologic sinus inflammation and symptoms of chronic rhinosinusitis in a population-based sample

BACKGROUND

Chronic rhinosinusitis (CRS) epidemiology has been largely studied using symptom-based case definitions, without assessment of objective sinus findings.

OBJECTIVE

To describe radiologic sinus opacification and the prevalence of CRS, defined by the co-occurrence of symptoms and sinus opacification, in a general population-based sample.

METHODS

We collected questionnaires and sinus CT scans from 646 participants selected from a source population of 200 769 primary care patients. Symptom status (CRS_S ) was based on guideline criteria, and objective radiologic inflammation (CRS_O ) was based on the Lund-Mackay (L-M) score using multiple L-M thresholds for positivity. Participants with symptoms and radiologic inflammation were classified as CRS_S+O . We performed negative binomial regression to assess factors associated with L-M score and logistic regression to evaluate factors associated with CRS_S+O . Using weighted analysis, we calculated estimates for the source population.

RESULTS

The proportion of women with L-M scores ≥ 3, 4, or 6 (CRS_O ) was 11.1%, 9.9%, and 5.7%, respectively, and 16.1%, 14.6%, and 8.7% among men. The respective proportion with CRS_S+O was 1.7%, 1.6%, and 0.45% among women and 8.8%, 7.5%, and 3.6% among men. Men had higher odds of CRS_S+O compared to women. A greater proportion of men (vs women) had any opacification in the frontal, anterior ethmoid, and sphenoid sinuses.

CONCLUSION

In a general population-based sample in Pennsylvania, sinus opacification was more common among men than in women and opacification occurred in different locations by sex. Male sex, migraine headache, and prior sinus surgery were associated with higher odds of CRS_S+O .

Characterization of Chronic Sinonasal Disease Symptoms in an Urban Homeless Population

BACKGROUND

The urban homeless population has increased exposure to risk factors associated with chronic rhinosinusitis (CRS). However, a gap in knowledge of the prevalence of sinonasal symptoms in these demographic limits complete understanding of CRS epidemiology. There is a need to elucidate sinonasal disease burden in this vulnerable patient population to bring awareness to any existing disparities.

OBJECTIVE

To assess the prevalence, severity, and associated factors of CRS clinical symptoms and health-care barriers in an urban homeless population.

METHODS

Homeless adults completed a sociodemographic questionnaire and the 22-item Sinonasal Outcome Test (SNOT-22) and EuroQol-5 Dimension-3 Level-Visual Analog Scale surveys. Responses were categorized by potential CRS symptoms defined as reporting at least 2 CRS cardinal symptoms. Risk factors associated with potential CRS symptoms were analyzed with multivariate regression models.

RESULTS

Fifty-six (16%) out of 341 total subjects reported potential CRS symptoms. Those with potential CRS symptoms had a higher median SNOT-22 score (53 vs 22, P < .001) than those without. Logistic regression models identified history of smoking (odds ratio [OR], 6.54; 95% confidence interval [CI], 2.04-21.04) and duration of homelessness over 3 months (OR, 3.46; CI, 1.51-7.94) as factors associated with potential CRS symptoms. Duration of homelessness over 3 months was associated with higher SNOT-22 scores (standardized beta coefficient [β], 0.48; CI, 0.39-0.57). Among those reporting 2 or more CRS cardinal symptoms, 18% had ever been seen by any physician for their symptoms.

CONCLUSIONS

Our study estimates a high prevalence of potential CRS symptoms in the urban homeless population. Longer duration of homelessness was associated with potential CRS symptoms and poor CRS-specific quality of life scores. Disparities in access to care emphasize the need for increased preventive efforts designed for this unique patient group.

Mucociliary transport as a link between chronic rhinosinusitis and trace element dysbalance

Chronis rhinosinusitis is considered as a widespread public health issue with a prevalence of 10%. The disease significantly reduces quality of life and increases the risk of cardiovascular diseases as well as certain forms of cancer. Alteration of mucociliary clearance frequently observed in the patients and plays a significant role in disease pathogenesis. Certain studies have demonstrated that patients with chronic rhinosinusitis are characterized by significant reduction of essential trace elements and toxic metal overload. However, the particular mechanisms of the role of trace element dysbalance in chronic rhinosinusitis are unclear. We hypothesize that exposure to toxic trace elements (arsenic, nickel, cadmium) damages ciliary mucosal epithelium thus affecting mucociliary transport. In turn, altered mucociliary transport results in reduced removal of the inhaled metal-containing particles from nasal mucosa leading to their absorption and further aggravation of toxicity. Essential trace elements (zinc, selenium) play a significant role in regulation of mucociliary transport and immunity, thus their deficiency (either dietary or due to antagonism with toxic metals) may be associated with impaired functions and increased toxic metal toxicity. Therefore, a vicious circle involving metal accumulation and toxicity, essential element deficiency, impairment of mucociliary transport and metal particle removal, resulting in further accumulation of metals and aggravation of toxic effects is formed. The present hypothesis is supported by the findings on the impact of trace elements especially zinc and arsenic on mucociliary clearance, the role of mucociliary transport in heavy metal particles elimination from the airways, trace element dysbalance in chronic rhinosinusitis, as well as toxic and essential metal antagonism. The data from hypothesis testing and its verification may be used for development of therapeutic approach for management of chronic rhinosinusitis. Particularly, the use of essential elements (zinc, selenium) may reduce toxic metal toxicity thus destroying the vicious circle of heavy metal exposure, toxicity, alteration of mucociliary clearance, and aggravation of chronic rhinosinusitis. Essential element supplementation may be considered as a tool for management of chronic refractory rhinosinusitis. In addition, analysis of essential and toxic trace element status may provide an additional diagnostic approach to risk assessment of chronic rhinosinusitis in highly polluted environments.

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

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

Longitudinal evaluation of clustering of chronic sinonasal and related symptoms using exploratory factor analysis

BACKGROUND

Sinonasal symptoms are common and can have several underlying causes. When symptoms occur in specified patterns lasting 3 months or more they meet criteria for chronic rhinosinusitis (CRS). Approaches to CRS symptom measurement do not specify how to measure symptoms and treat specified sinonasal symptoms as generally interchangeable, suggesting that such symptoms should cluster on 1 or 2 latent factors.

METHODS

We used questionnaire responses to 37 questions on the presence, severity, bother, and frequency of cardinal sinonasal and related symptoms lasting 3 months, from 3535 subjects at 3 time points over 16 months. We completed 5 exploratory factor analyses (EFA) to identify symptom clustering, 1 for each time point and 2 for the differences between adjacent questionnaires. The baseline EFA was used to provide factor scores that were described longitudinally and examined by CRS status.

RESULTS

Five EFAs identified the same 5 factors (blockage and discharge, pain and pressure, asthma and cold/flu symptoms, smell loss, and ear and eye [mainly allergy] symptoms), with clustering determined by symptom frequency, severity, and degree of bother. Responses to individual questions showed changes over time but when combined into factor scores showed less longitudinal change. All symptom factor scores were progressively higher from never to past to current CRS status.

CONCLUSIONS

Although the current approaches to symptom characterization in CRS imply a single underlying latent construct, our results suggest that there are at least 3 latent constructs relevant to CRS. Further studies are needed to evaluate whether these clusters have identifiable underlying pathobiologies.

SNOT-22-based clusters in chronic rhinosinusitis without nasal polyposis exhibit distinct endotypic and prognostic differences

BACKGROUND

Endotypic and prognosticating features of chronic rhinosinusitis without nasal polyposis (CRSsNP) are poorly understood. Our objectives were to use an unbiased symptom-based approach to: (1) study symptoms, clinical and endotypic features; and (2) identify features predicating outcomes from endoscopic sinus surgery (ESS).

METHODS

Clinical, computed tomography (CT), histopathology, and 22-item Sino-Nasal Outcome Test (SNOT-22) data was collected on 146 adult CRSsNP patients who underwent ESS. Unsupervised network modeling of presurgical SNOT-22 scores was performed to classify symptom-based clusters. Subject characteristics and post-ESS SNOT-22 scores were compared between clusters.

RESULTS

Baseline characteristics of the subject population were as follows: females, 56.2%; revision ESS status in 35%; asthma prevalence, 32.6%; median Lund-Mackay CT score, 8; and median SNOT-22 total score, 43. Network mapping and unsupervised clustering of preoperative SNOT-22 scores revealed 4 clusters: (A) severely burdened with high scores in all 4 subdomains; (B) moderately burdened with high scores in the rhinologic subdomain; (C) moderately burdened with high scores in psychological-sleep subdomains; and (D) mildly burdened. The number of previous ESS and asthma prevalence differed significantly between clusters; CT scores were similar. Asthma burden and tissue eosinophilia were greatest in cluster A (p = 0.03). All groups showed significant improvement at 3 months post-ESS (p < 0.0001). At 6 months, patients in cluster C tended to worsen.

CONCLUSION

SNOT-22-based network modeling of CRSsNP patients yielded 4 clusters with distinct features. Asthma prevalence and tissue eosinophilia were highest in the cluster with highest SNOT-22 scores. All patients showed significant improvement from ESS at 3 months; those with high sleep-psychosocial symptoms tended to show worsening at 6 months.

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.

Blood Eosinophils and World Trade Center Exposure Predict Surgery in Chronic Rhinosinusitis. A 13.5-Year Longitudinal Study

RATIONALE

The World Trade Center (WTC) collapse generated caustic airborne particulates that caused chronic rhinosinusitis in exposed Fire Department of New York firefighters. Surgery was performed when symptoms remained uncontrolled despite medical management.

OBJECTIVES

To identify predictors of surgical intervention for chronic rhinosinusitis in firefighters exposed to airborne irritants at the WTC collapse site.

METHODS

We assessed in 8,227 firefighters with WTC exposure between September 11, 2001 (9/11), and September 25, 2001, including WTC-site arrival time, months of rescue and recovery work, and eosinophil concentration measured between 9/11 and March 10, 2003. We assessed the association of serum cytokines and immunoglobulins with eosinophil concentration and surgery for rhinosinusitis in 112 surgical cases and 376 control subjects with serum available from the first 6 months after exposure to the WTC collapse site.

MEASUREMENTS AND MAIN RESULTS

Between 9/11 and March 10, 2015, the surgery rate was 0.47 cases per 100 person-years. In the first 18 months post-9/11, surgical patients had higher mean blood eosinophil levels than study cohort patients (219 ± 155 vs. 191 ± 134; P < 0.0001). Increased surgery risk was associated with increasing blood eosinophil counts (hazard ratio [HR], 1.12 per 100 cells/μl; 95% confidence interval [CI], 1.07-1.17; P < 0.001); arriving at the WTC site on 9/11 or September 12, 2001 (HR, 1.43; 95% CI, 1.04-1.99; P = 0.03); and working 6 months or longer at the WTC site (HR, 1.48; 95% CI, 1.14-1.93; P < 0.01). Median blood eosinophil levels for surgical patients were above levels for the cohort in all 18-month intervals March 11, 2000, through March 10, 2015, using 51,163 measurements representing 97,733 person-years of observation. Increasing age, increasing IL-17A, and low IgA in serum from 2001 to 2002 predicted blood eosinophil concentration in surgical patients but not in control subjects (R(2) = 0.26, P < 0.0001; vs. R(2) = 0.008, P = 0.56).

CONCLUSIONS

Increasing blood eosinophil concentration predicts surgical intervention for chronic rhinosinusitis, particularly in those with intense acute and prolonged exposure to airborne irritants. WTC-exposed Fire Department of New York firefighters who underwent irritant-associated sinus surgery are immunologically different from the cohort. Surgical patients have a higher blood eosinophil levels that is associated with mediators of mucosal immunity.

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.

LL-37 causes cell death of human nasal epithelial cells, which is inhibited with a synthetic glycosaminoglycan

LL-37 is an immune peptide that regulates innate and adaptive immune responses in the upper airways. Elevated levels of LL-37 have been linked to cell death and inflammatory diseases, such as chronic rhinosinusitis (CRS). Glycosaminoglycans (GAGs) are polysaccharides that are found on respiratory epithelial cells and serve important roles in mucosal surface repair. Recent findings suggest that a synthetic glycosaminoglycan (GM-0111) can protect against LL-37-induced sinonasal mucosal inflammation and cell death in a murine model of acute RS. Herein, we elucidated the mechanisms by which LL-37 causes sinonasal inflammation and how GM-0111 can prevent these mechanisms. When challenged with LL-37, human nasal epithelial cells (HNEpCs) and mouse macrophages (J774.2) demonstrated increased release of adenosine triphosphate (ATP) and interleukin (IL)-6 and -8, as well as cell death and lysis. These cellular responses were all blocked dose-dependently by pre-treatment with GM-0111. We identified that LL-37-induced cell death is associated with caspase-1 and -8 activation, but not activation of caspase-3/7. These responses were again blocked by GM-0111. Our data suggest that LL-37 causes cellular death of HNEpCs and macrophages through the pro-inflammatory necrotic and/or pyroptotic pathways rather than apoptosis, and that a GM-0111 is capable of inhibiting these pro-inflammatory cellular events.

Prognostic value of nasal cytology and clinical factors in nasal polyps development in patients at risk: can the beginning predict the end?

BACKGROUND

We evaluated the prognostic value of nasal cytology and clinical factors in predicting nasal polyp (NP) development in patients with history of nonallergic chronic sinonasal inflammation.

METHODS

This was a retrospective case-control study of 295 patients followed at our institution for a mean of 85.70 ± 19.41 months. According to the inclusion criteria we enrolled 84 cases with persistent eosinophilic nonallergic sinonasal inflammation (group A) and 106 cases with neutrophilic inflammation (group B), both without evidence of NPs at the baseline. We considered as controls 105 patients affected by nonallergic noninfectious vasomotor rhinitis without evidence of inflammation at nasal cytology (group C). Patients were checked every 6 months for NPs. Temporal analyses was performed by Kaplan-Mayer curves and odds ratios were evaluated by logistic regression analyses.

RESULTS

The percentage of patients that developed NPs was higher in group A (29/84 [34.52%]) than in group B (17/106 [16.03%]) and group C (5/104 [4.7%]) (p < 0.05). Logistic regression analyses showed that eosinophilic patients had a higher risk of NP development over the years than neutrophilic patients compared to controls (odds ratio [OR], 10.55 vs 3.2). We also demonstrated that hypereosinophilia, asthma, and aspirin intolerance may increase the OR differently in eosinophilic patients.

CONCLUSION

Our data suggest that early identification of inflammatory patterns and associated clinical factors in patients affected by chronic nonallergic sinonasal inflammation have a prognostic value that can help to identify patients with different risks of NP development. Our data confirm that detection of nasal eosinophilic inflammation represents an early marker for identification of a more aggressive inflammatory phenotype.

Factors influencing the need for endoscopic sinus surgery in adult patients with cystic fibrosis

BACKGROUND

Risk factors in adult patients with cystic fibrosis (CF) associated with surgical intervention have not been delineated.

OBJECTIVE

To identify characteristics of adult patients with CF and with chronic rhinosinusitis that predict surgical intervention with endoscopic sinus surgery (ESS).

METHODS

Patients were identified in a tertiary sinus center by the International Classification of Diseases, Ninth Revision codes 277.00-277.03, which represent CF. Charts were reviewed for the CF transmembrane conductance regulator (CFTR) gene mutation, Lund-Mackay score (LMS), the 22-item Sino-Nasal Outcome Test (SNOT-22) score, previous ESS, and occurrence of ESS after presentation. The Fisher exact test was used to test frequency of events between the groups, and the Mann Whitney U test and the t-test were used to compare means among LMS, SNOT-22, and age. The Cox proportional hazard analysis was used to calculate hazard ratios (HR) for the impact of LMS, SNOT-22 score, previous ESS, and CFTR gene mutation status on the occurrence of ESS after presentation.

RESULTS

One hundred and fifteen patients met the inclusion criteria for the study. Patients with a history of surgery more often underwent ESS after presentation (p ≤ 0.01). The LMS and the SNOT-22 score were not significantly different between the groups of previous ESS and no previous ESS (p = 0.23 and p = 0.28, respectively). A severe mutation genotype was predictive of ESS after presentation (p = 0.03). SNOT-22 scores did not differ between the severe and mild groups (36.0 and 32.4, respectively; p = 0.57), but the mean LMS was significantly higher in the severe mutation group (12.5 and 9.7; p ≤ 0.01). Univariate Cox proportional hazard analysis revealed an increased occurrence of ESS for patients with severe mutations (HR, 3.6; p ≤ 0.01) or a history of ESS (HR, 2.3; p ≤ 0.01).

CONCLUSION

The occurrence of ESS in adult patients with CF was predicted by previous ESS intervention as well as the severity of CFTR mutation.

[The use of intranasal glucocorticosteroids in the treatment of rhinosinusitis: Focus on mometasone furoate]

The authors discuss the mechanism of action, effectiveness, and safety of intranasal glucocorticosteroids (inGCS) used to treat acute, recurrent and chronic rhinosinusitis (RS). The last version of the European guidelines concerning the application of inGCS assigns the highest level of evidence-Ia and the highest strength of recommendations-A to these medications when applied for the treatment of acute and polypoid rhinosinusitis. Moreover, they acquire the status of the agents of choice for the therapy of chronic RS without polyps. Mometasone furoate is one of the best explored preparations of this group of medicines. It is possessed of favourable pharmacodynamic and pharmacokinetic properties when prescribed for local application. The new mometasone furoate preparation in the form of an intranasal spray Dezrinit produced by "Teva" Ltd. was registered in the Russian Federation. In a comparative randomized clinical trial (RCT), the preparation was shown to be an equivalent to the Nasonex spray.

Associations between Unconventional Natural Gas Development and Nasal and Sinus, Migraine Headache, and Fatigue Symptoms in Pennsylvania

BACKGROUND

Unconventional natural gas development (UNGD) produces environmental contaminants and psychosocial stressors. Despite these concerns, few studies have evaluated the health effects of UNGD.

OBJECTIVES

We investigated associations between UNGD activity and symptoms in a cross-sectional study in Pennsylvania.

METHODS

We mailed a self-administered questionnaire to 23,700 adult patients of the Geisinger Clinic. Using standardized and validated questionnaire items, we identified respondents with chronic rhinosinusitis (CRS), migraine headache, and fatigue symptoms. We created a summary UNGD activity metric that incorporated well phase, location, total depth, daily gas production and inverse distance-squared to patient residences. We used logistic regression, weighted for sampling and response rates, to assess associations between quartiles of UNGD activity and outcomes, both alone and in combination.

RESULTS

The response rate was 33%. Of 7,785 study participants, 1,850 (24%) had current CRS symptoms, 1,765 (23%) had migraine headache, and 1,930 (25%) had higher levels of fatigue. Among individuals who met criteria for two or more outcomes, adjusted odds ratios for the highest quartile of UNGD activity compared with the lowest were [OR (95% CI)] 1.49 (0.78, 2.85) for CRS plus migraine, 1.88 (1.08, 3.25) for CRS plus fatigue, 1.95 (1.18, 3.21) for migraine plus fatigue, and 1.84 (1.08, 3.14) for all three outcomes together. Significant associations were also present in some models of single outcomes.

CONCLUSIONS

This study provides evidence that UNGD is associated with nasal and sinus, migraine headache, and fatigue symptoms in a general population representative sample. Citation: Tustin AW, Hirsch AG, Rasmussen SG, Casey JA, Bandeen-Roche K, Schwartz BS. 2017. Associations between unconventional natural gas development and nasal and sinus, migraine headache, and fatigue symptoms in Pennsylvania. Environ Health Perspect 125:189-197; http://dx.doi.org/10.1289/EHP281.

Nasal and sinus symptoms and chronic rhinosinusitis in a population-based sample

BACKGROUND

The objective of this study was to describe the first US-based study to use the European Position Paper on Rhinosinusitis (EPOS) criteria to study the prevalence of chronic rhinosinusitis (CRS) in a general-population sample.

METHODS

A CRS symptom questionnaire was mailed to 23 700 primary care patients from Geisinger Clinic, a health system serving 45 counties in Pennsylvania. CRS cases were categorized into four unique subgroups based on EPOS symptoms: obstruction and discharge with no smell loss or pain/pressure; smell loss without pain/pressure; facial pain and/or pressure without smell loss; and both smell loss and pain/pressure. All cases were required to have nasal obstruction or discharge. Logistic regression was used to evaluate potential factors associated with CRS subgroups.

RESULTS

We found that 11.9% of patients met criteria for CRS. Prevalence peaked at 15.9% between ages 50 and 59 years and then dropped to 6.8% after age 69. The odds of CRS was higher among patients who were white, younger, smokers, had a history of Medical Assistance, and had other diseases. When CRS subgroups were modeled separately, these associations were no longer significant for some CRS subgroups. Comorbid diseases were most strongly associated with CRS cases who reported smell loss and facial pain and/or pressure and had the weakest associations with CRS cases who did not report these symptoms.

CONCLUSIONS

CRS is a highly prevalent and heterogeneous condition. Differences in risk factors and health outcomes across symptom subgroups may be indicative of differences in etiology that have implications for disease management.

Immunopathogenesis of Chronic Rhinosinusitis and Nasal Polyposis

Chronic rhinosinusitis (CRS) is a troublesome, chronic inflammatory disease that affects over 10% of the adult population, causing decreased quality of life, lost productivity, and lost time at work and leading to more than a million surgical interventions annually worldwide. The nose, paranasal sinuses, and associated lymphoid tissues play important roles in homeostasis and immunity, and CRS significantly impairs these normal functions. Pathogenic mechanisms of CRS have recently become the focus of intense investigations worldwide, and significant progress has been made. The two main forms of CRS that have been long recognized, with and without nasal polyps, are each now known to be heterogeneous, based on underlying mechanism, geographical location, and race. Loss of the immune barrier, including increased permeability of mucosal epithelium and reduced production of important antimicrobial substances and responses, is a common feature of many forms of CRS. One form of CRS with polyps found worldwide is driven by the cytokines IL-5 and IL-13 coming from Th2 cells, type 2 innate lymphoid cells, and probably mast cells. Type 2 cytokines activate inflammatory cells that are implicated in the pathogenic mechanism, including mast cells, basophils, and eosinophils. New classes of biological drugs that block the production or action of these cytokines are making important inroads toward new treatment paradigms in polypoid CRS.

Chronic rhinosinusitis: the rationale for current treatments

INTRODUCTION

Chronic rhinosinusitis (CRS) is a broad clinical syndrome linked by mucosal inflammation. Primary treatment modalities are corticosteroids and antibiotics with surgery an option for failures, but the level of supporting evidence is generally low. The primary reason is that CRS is a symptom complex and not a specific disease. Areas covered: The primary treatment modalities for CRS are corticosteroids, antibiotics and surgery. Corticosteroids, which have very broad anti-inflammatory properties, also have the strongest evidence for efficacy. Antibiotics are likely effective in a subpopulation of patients but the various phenotypes and endotypes that make up CRS have thus far been poorly defined. Early surgery as well as biologics may also be more efficacious and cost effective in some phenotypes as well. Expert commentary: A better understanding of the inflammatory pathways that drive CRS will permit investigators to separate patient groups. This will allow for clinical trials that target specific subpopulations and more personalized therapy for CRS patients in the future.

The association between airline flight and sinonasal symptoms

BACKGROUND

Airplane cabin supply air has been shown to contain multiple possible respiratory irritants. In addition, changes in barometric pressure in flight may contribute to specific respiratory conditions. Therefore, there may be an association between commercial airline flight and sinus disease.

METHODS

Participants of the Secondhand-Smoke, Air Quality and Respiratory Health Among Flight Attendants Study were administered an online questionnaire pertaining to their flight experience and respiratory health. Working years, working days per month, and number of trips per month were quantified, as well as smoking exposure and self-reported physician diagnoses of sinusitis, asthma, and rhinitis. The sinonasal outcomes were quantified using a Respiratory Questionnaire Survey (RQS) score. Multivariable analyses were performed to evaluate the associations between flight time and sinus disease.

RESULTS

A total of 579 participants met the inclusion criteria for this study, with cohort prevalence of sinusitis, asthma, and rhinitis of 25.3%, 14.4%, and 20.5%, respectively. Tertiles 2 and 3 of working days per month were associated with higher RQS scores compared to tertile 1 (p for trend <0.01). Individual symptoms significantly associated with increasing number of working days per month included "need to blow nose," "sneezing," and "thick nasal discharge," and the number of international trips per month was significantly associated with "coughing" and "facial pain and pressure," among other symptoms.

CONCLUSION

This is the largest study to analyze the relations between airline flight time and sinonasal disease. The results suggest a possible association between sinusitis diagnosis, symptom scores, and specific sinonasal symptoms, and airline flight time.

Higher Body Mass Index and Increased Prevalence of Paranasal Sinus Disease

Background

We hypothesized that higher body mass index (BMI) was associated with increased prevalence of paranasal sinus disease and examined the hypothesis in Japanese adults.

Methods

This was a cross-sectional study including 1350 Japanese adults aged 40 years or more who participated in a health check-up program focusing on brain diseases and metabolic syndrome. Participants were divided into quartiles of BMI levels. Paranasal sinus disease was confirmed by a head MRI scan. The association between BMI and paranasal sinus disease was examined using logistic regression analysis, which was adjusted for age, sex, waist:hip ratio, hemoglobin A1c, systolic blood pressure, smoking status, alcohol intake, and white blood cell count.

Results

Of the 1350 participants, 151 (11.2%) had paranasal sinus disease. In relation to those in the lowest quartile of BMI, the odds ratios of having the disease among those in the 2nd, 3rd, and 4th quartiles of BMI were 1.89 (95% confidence interval [CI], 1.03–3.48), 2.26 (95% CI, 1.20–4.23) and 2.26 (95% CI, 1.14–4.51), respectively. When BMI was analysed as a continuous variable, an increase of one unit in BMI was significantly associated with increased odds of having the disease, with an OR of 1.08 (95% CI, 1.01–1.16).

Conclusions

The present study suggests that patients with higher BMI are more likely to have paranasal sinus disease.

Immune Mechanisms of Chronic Rhinosinusitis

Chronic rhinosinusitis (CRS) is a common inflammatory disease that results in a significant decrease in patient quality of life and a large economic burden. However, the lack of population-based epidemiologic studies and robust model systems has made it difficult to fully elucidate the key inflammatory pathways that drive the chronic inflammatory responses observed in CRS. This review will highlight the wide variety of factors that likely contribute to CRS disease pathogenesis. Defects in the innate immune function of the airway epithelium, including decreases in barrier function, mucociliary clearance, and production of antimicrobial peptides, all likely play a role in the initial inflammatory response. Subsequent recruitment and activation of eosinophils, mast cells, and innate lymphoid cells (ILCs) further contributes to the chronic inflammatory response and directly activates adaptive immune cells, including T and B cells. However, development of new tools and model systems is still needed to further understand the chronicity of this inflammatory response and which specific factors are necessary or sufficient to drive CRS pathogenesis. Such studies will be critical for the development of improved therapeutic strategies aimed at treating this highly prevalent and costly disease.

Review: Immunology of sinusitis, trauma, asthma, and sepsis

Background:

This review article is important for allergists/immunologists and otolaryngologists. It discussed chronic rhinosinusitis, epidemiology, pathogenesis, innate adaptive immunology, nuclear factor–kappa B related to inflammation, sepsis, complement, reactive oxygen species, asthma, sinusitis, elderly pathogenesis, oxidative stress, depression, seasonal variation, vitamin D, genetic susceptibility and sepsis, hereditary angioedema related to trauma and stress.

Objective:

The objective of this review is to link chronic rhinosinusitis, epidemiology, innate and adaptive immunology, NF-kappa B related to inflammation, sepsis, complement, reactive oxygen species, asthma and sinusitis.

Methods:

A literature search was conducted from several articles, prospective studies, recent reviews and earlier reports. A synergistic relationship develops between activation of the innate immune system and the loss of organ barrier functions. Many complex factors, such as genetics, physical agents, mediators in the development of organ failure both in asthma, sinusitis, stress, depression and trauma, leading to posttraumatic organ failure. Asthma and sepsis, a common condition encountered in hospital environments remains an important cause of death at intensive care units where allergists/immunologists and otolaryngologists are frequently consulted. The patient's immune surveillance could fail to eliminate the pathogen, allowing it to spread and there is a proinflammatory mediator release with inappropriate activation.

Conclusion:

This review discussed chronic rhinosinusitis, sinusitis related to trauma, the innate and adaptive immunology, NF-kappa B related to inflammation, sepsis, complement, inflammation, reactive oxygen species, asthma pathogenesis, and asthma in the elderly, oxidative stress, depression, seasonal variation and vitamin D, cytokines, genetic susceptibility related to sepsis, hereditary angioedema related to trauma and stress.

Gender-specific differences in chronic rhinosinusitis patients electing endoscopic sinus surgery

BACKGROUND

The objective of this study was to investigate gender-specific differences in chronic rhinosinusitis (CRS) patients electing endoscopic sinus surgery (ESS).

METHODS

This study was a retrospective review of CRS patients electing ESS (2011-2013) at a tertiary-care center.

RESULTS

ESS was elected by 272 patients (mean age 54.6 years; 48.5% female). Mean Lund-Mackay computed tomography (CT) score was 10.9; total 22-item Sino-Nasal Outcome Test (SNOT-22) score was 41.8. Compared to men, women electing ESS had lower CT score (10.1 vs 11.7; p = 0.01) but higher total SNOT-22 score (44.9 vs 39; p = 0.02). Women reported significantly worse postnasal drainage (p < 0.0001) and embarrassment (p = 0.0021). SNOT-22 scores declined with advancing age (women, p = 0.003; men, p = 0.0005). Reduction in CT scores with age was seen only in males (p = 0.03). Stratifying by age, females aged 61 to 80 years had higher SNOT-22 scores compared to male counterparts (p = 0.04), whereas CT scores were similar. More women underwent surgery for CRS without nasal polyps (CRSsNP) (54.9%) whereas more men underwent surgery for CRS with nasal polyps (CRSwNP) (57.4%), but this difference missed statistical significance (p = 0.052). Women with CRSwNP had higher SNOT-22 scores than men (p = 0.02) for similar CT scores. Men electing ESS for CRSsNP had higher CT scores than women (p = 0.02). Women with CRSsNP aged 18 to 40 years reported higher SNOT-22 scores than men (p = 0.003), even though CT scores were lower (p = 0.005).

CONCLUSION

Equivalent numbers of men and women underwent ESS for CRS. Overall, women electing ESS had higher total SNOT-22 scores and lower Lund-Mackay CT scores than men. Women reported more problems with postnasal drainage (CRS overall, CRSsNP, and CRSwNP), embarrassment (CRS overall and CRSwNP), and facial pain (CRSwNP). Gender differences in CRS are poorly understood and merit further study.

Pathogenesis of nasal polyposis

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a complex inflammatory condition that affects a large proportion of the population world-wide and is associated with high cost of management and significant morbidity. Yet, there is a lack of population-based epidemiologic studies using current definitions of CRSwNP, and the mechanisms that drive pathogenesis in this disease remain unclear. In this review, we summarize the current evidence for the plethora of factors that likely contribute to CRSwNP pathogenesis. Defects in the innate function of the airway epithelial barrier, including diminished expression of antimicrobial products and loss of barrier integrity, combined with colonization by fungi and bacteria likely play a critical role in the development of chronic inflammation in CRSwNP. This chronic inflammation is characterized by elevated expression of many key inflammatory cytokines and chemokines, including IL-5, thymic stromal lymphopoietin and CCL11, that help to initiate and perpetuate this chronic inflammatory response. Together, these factors likely combine to drive the influx of a variety of immune cells, including eosinophils, mast cells, group 2 innate lymphoid cells and lymphocytes, which participate in the chronic inflammatory response within the nasal polyps. Importantly, however, future studies are needed to demonstrate the necessity and sufficiency of these potential drivers of disease in CRSwNP. In addition to the development of new tools and models to aid mechanistic studies, the field of CRSwNP research also needs the type of robust epidemiologic data that has served the asthma community so well. Given the high prevalence, costs and morbidity, there is a great need for continued research into CRS that could facilitate the development of novel therapeutic strategies to improve treatment for patients who suffer from this disease.

Geographic Variation of Endoscopic Sinus Surgery in Canada: An Alberta-Based Small Area Variation Analysis

OBJECTIVE

With an estimated 10,000 to 15,000 endoscopic sinus surgery (ESS) cases performed in Canada each year, identifying potential unwarranted practice patterns is important. The objective of this study is to examine the rates and geographic variation of ESS in the province of Alberta, Canada.

STUDY DESIGN

Small area variation analysis.

SETTING

Province of Alberta, Canada.

SUBJECTS AND METHODS

The National Ambulatory Care Reporting System database was searched to identify all patients who received ESS between April 1, 2010, and March 31, 2013, in Alberta, Canada. The annual adjusted rates of ESS per 1000 people were calculated for each Alberta health zone and health status area. Geographic variations were evaluated with the extremal quotient, weighted coefficient of variation, and systematic component of variance. Chi-squared-test was used to quantify the significance of variation of the adjusted ESS rates across regions.

RESULTS

The annual adjusted rate of ESS was 0.33 per 1000 people in Alberta, Canada. The mean extremal quotient for health status areas was 6.9, indicating a 7-fold difference between the highest and lowest regions. The mean coefficient of variation was 41.0, and the mean systematic component of variance was 10.5, which demonstrates "very high" variation.

CONCLUSION

This study observed very high geographic variation in the rates of ESS across the province of Alberta. Given the negative impact of unwarranted surgical variation on quality of care, outcomes from this study indicate a need to further evaluate the delivery of care for ESS in Canada to improve overall health system performance.

Occupational and environmental risk factors for chronic rhinosinusitis: a systematic review

BACKGROUND

Chronic rhinosinusitis (CRS) is a prevalent and disabling paranasal sinus disease, with a likely multifactorial etiology potentially including hazardous occupational and environmental exposures. We completed a systematic review of the occupational and environmental literature to evaluate the quality of evidence of the role that hazardous exposures might play in CRS.

METHODS

We searched PubMed for studies of CRS and following exposure categories: occupation, employment, work, industry, air pollution, agriculture, farming, environment, chemicals, roadways, disaster, and traffic. We abstracted information from the final set of articles across 6 primary domains: study design; population; exposures evaluated; exposure assessment; CRS definition; and results.

RESULTS

We identified 41 articles from 1080 manuscripts: 37 occupational risk papers, 1 environmental risk paper, and 3 papers studying both categories of exposures. None of the 41 studies used a CRS definition consistent with current diagnostic guidelines. Exposure assessment was generally dependent on self-report or binary measurements of exposure based on industry of employment. Only grain, dairy, and swine operations among farmers were evaluated by more than 1 study using a common approach to defining CRS, but employment in these settings was not consistently associated with CRS. The multiple other exposures did not meet quality standards for reporting associations or were not evaluated by more than 1 study.

CONCLUSION

The current state of the literature allows us to make very few conclusions about the role of hazardous occupational or environmental exposures in CRS, leaving a critical knowledge gap regarding potentially modifiable risk factors for disease onset and progression.

Measurement and comparison of health utility assessments in chronic rhinosinusitis

BACKGROUND

Chronic rhinosinusitis (CRS) is a common condition encountered in primary care medicine and is estimated to affect 12.5% of the United States population. This study aims to compare methods of assessing health utility in CRS.

METHODS

A cross-sectional sample of CRS patients (n = 137) were interviewed using direct health utility assessment measures: the visual analogue scale (VAS), time trade-off (TTO), and standard gamble (SG). General quality of life (QOL) scores were obtained via the 36-item Short Form Health Survey (SF-36) and converted to SF-6D health utility values using a Bayesian algorithm. Disease-specific QOL was measured with the 22-item Sino-Nasal Outcome Test (SNOT-22). A selected subgroup of patients (n = 51) not initiating surgery or new treatment for CRS were re-interviewed within 3 weeks.

RESULTS

The mean ± SD health utilities were VAS 0.69 ± 0.19; TTO 0.80 ± 0.27; SG 0.93 ± 0.11; and SF-6D 0.72 ± 0.12; they differed significantly (p < 0.001). Only VAS scores differed based on disease state classification or the presence of nasal polyposis. Correlations between methods of determining health utility were weak, but significant. VAS, TTO, and SF-6D scores were significantly associated with SNOT-22 (p < 0.001 for all); however, SG and SNOT-22 were poorly correlated (Spearman correlation = -0.33). The test-retest reliability of TTO (Spearman correlation = 0.71) and SG (0.73) was strong.

CONCLUSION

CRS patients show significant impairment in QOL, with health utility values similar to those of patients with acquired immune deficiency syndrome (AIDS) or intermittent claudication using similar methods. The method of ascertainment significantly affects measured health utility, but the degree of impairment warrants improved recognition and appropriate treatment of the condition.

Chronic rhinosinusitis: an under-researched epidemic

Background

Chronic rhinosinusitis (CRS) is a highly prevalent inflammatory disease with significant impacts on patient quality of life and daily productivity. Evaluating the volume of research on CRS, relative to similar chronic diseases, may provide insight into current disparities in research prioritization.

Methods

A systematic review was performed using Ovid MEDLINE (R) (1970 – December 31st, 2014) to define the volume of research publications for CRS, asthma, and diabetes mellitus (DM). Primary outcomes were overall volume of research publications and volume of publications per year. A subgroup analysis was performed using chi-square (χ2) omnibus test with 2×3 contingency tables to identify significant differences in the proportion of total randomized controlled trials, systematic reviews, meta-analyses, and economic evaluation publications between CRS, asthma, and DM groups.

Results

There were substantial disparities in the volume of research published over the last 45 years for CRS (n = 7,962), asthma (n = 136,652), and DM (n = 337,411). Although the volume of research for CRS in increasing, the disparities in the annual publication volumes between CRS, asthma, and DM appeared consistent over the last 45 years.

Conclusions

Outcomes from this review have demonstrated a large disparity in the volume of published research for CRS compared to asthma and DM. Given the similarities in prevalence rates, impact on quality of life and economic burden, the relative under supply of CRS research should prompt efforts to increase research prioritization for this chronic disease.

Expression and Regulation of Interleukin-9 in Chronic Rhinosinusitis

Background

The pathogenesis of human chronic rhinosinusitis (CRS) remains controversial. Recent evidence has suggested that interleukin (IL)-9 is vital in eliciting inflammatory response, stimulating cell proliferation and preventing apoptosis, through binding to the IL-9 receptor (IL-9R). However, little is known about the roles of both molecules in the etiology of CRS. Therefore, this study aimed to assess IL-9 and IL-9R expression and determine their rolesin the pathophysiology of CRS.

Methods

Immunohistochemistry was used to assess IL-9 and IL-9R immunolabeling. In addition, Western blotting and real-time polymerase chain reaction (PCR) were used for IL-9 and IL-9R protein and mRNA level quantitation, respectively, in CRS and control subjects. Furthermore, the effects of various stimulators at different concentrations and time on IL-9 were evaluated using nasal explant cultures.

Results

IL-9 and IL-9R were overexpressed in CRS, especially in CRS with nasal polyps. Interestingly, IL-9 expression was closely related to that of IL-9R. In addition, IL-9 mRNA levels were increased by treatment with IL-4, IL-17A, IL-1beta, and the IL-4 and transforming growth factor (TGF) beta1 combination, but suppressed by interferon gamma and IL-27.

Conclusion

IL-9 and IL-9R were overexpressed in CRS at both protein and mRNA levels. In addition, IL-4, IL-17A, IL-1beta, and the IL-4 and TGF-beta1 combination contributed to increased IL-9 levels. Our findings indicate that IL-9 may play a proinflammatory role after IL-9R binding to induce mucosal epithelial cell growth, gland epithelial cell proliferation, and inflammatory cell infiltration in CRS. Future studies are required to further define the role of IL-9 in CRS etiology.

Role of platelet-derived growth factor-α in eosinophilic and non-eosinophilic chronic rhinosinusitis with nasal polyps

BACKGROUND

The pathogenesis of human chronic rhinosinusitis with nasal polyps (CRSwNP) comprising eosinophilic CRSwNP (ECRSwNP) and non-eosinophilic (nECRSwNP) is not completely understood. Recent evidence has suggested that platelet-derived growth factor receptor alpha (PDGFRα) is implicated in cell growth, transformation, proliferation, migration, and vascular permeability and platelet-derived growth factor-A (PDGF-A) is a specific ligand for PDGFRα. However, little is known about their roles in CRSwNP. Therefore, we aimed to investigate the expression and role of PDGFRα and PDGF-A in CRSwNP.

METHODS

PDGFRα protein expression was investigated by immunohistochemistry method and messenger RNA (mRNA) expression of PDGFRα and PDGF-A were assessed by real-time polymerase chain reaction (PCR) in CRSwNP patients and control subjects. Moreover, the effects of various stimulators with different concentrations and time on PDGFRα were evaluated on nasal explant culture.

RESULTS

Quantitative analysis of immunostaining for PDGFRα showed an obvious elevation in immunolabeling of PDGFRα in CRSwNP groups compared with controls. Furthermore, PDGFRα protein was significantly stronger expressed in ECRSwNP group than nECRSwNP group and atopic patients showed stronger expression of PDGFRα protein than nonatopic patients. The mRNA of PDGFRα and PDGF-A were overexpressed in CRSwNP, especially in ECRSwNP. PDGFRα mRNA expression was closely related to PDGF-A mRNA. In nasal explant culture and stimulation, PDGFRα mRNA was augmented by interleukin 4 (IL-4), IL-5, or IL-1β respectively, but suppressed by IL-27.

CONCLUSION

PDGFRα may play a pivotal role in the pathophysiology of ECRSwNP and nECRSwNP by combining with PDGF-A. IL-4, IL-5, or IL-1β may be critical for PDGFRα gene expression.