Clinical practice guideline (update): adult sinusitis

Efficacy of Clarithromycin Combined with Fluticasone Propionate on Nasal Function, Nasal Mucociliary Transport Function, and Serum Inflammatory Markers in Chronic Rhinosinusitis Patients After Functional Endoscopic Sinus Surgery

Objective: This study aims to assess the efficacy of clarithromycin (CAM) combined with fluticasone propionate (FP) in patients with chronic rhinosinusitis (CRS) after functional endoscopic sinus surgery (FESS), focusing on nasal function, nasal mucociliary transport (MCT) function, and serum inflammatory markers. Methods: The control group (n = 48) was treated with FESS alone, while the study group (n = 48) was treated with FESS plus CAM combined with FP. The clinical effects, symptom scores, nasal function, nasal MCT function, serum inflammatory marker levels, and the occurrence of adverse reactions were compared. Results: The total efficacy rate of the study group (95.83%) was significantly higher than that of the control group (83.33%). After treatment, the study group showed lower symptom scores for nasal congestion, runny nose, sneezing and dizziness, and headache compared to those in the control group. The study group also had lower nasal airway resistance, shorter distance from the minimal cross-sectional area to the nostril, and lower T&T olfactory scores. In contrast, their nasal cavity volume and minimal cross-sectional area were higher than those of the control group. Additionally, the nasal mucociliary clearance and MCT rates were higher in the study group. Serum levels of interleukin-6, interleukin-8, tumor necrosis factor-α, and procalcitonin were significantly lower in the study group compared to the control group (all P < .05). Conclusion: The use of CAM combined with FP in patients after FESS for CRS is effective, leading to the relief of clinical symptoms, improvement of nasal function, enhancement of MCT function, and reduction of inflammatory response, without increasing the incidence of adverse reactions.

Medical Management of Headache and Facial Pain in CRS: A Systematic Review and Meta-Analysis

OBJECTIVES

This study aims to characterize the effect of medical therapy on headache and facial pain/pressure among patients with chronic rhinosinusitis (CRS).

DATA SOURCES

CINAHL, PubMed, and Scopus.

METHODS

CINAHL, PubMed, and Scopus were searched from inception through April 10th, 2024, for English language articles reporting headache or facial pain/pressure outcomes in CRS patients. Inclusion was restricted to studies reporting results of the medical treatment of CRS in nonsurgical cohorts. Primary outcome measures included the sino-nasal outcome test (SNOT) and the visual analogue scale (VAS). Meta-analyses of continuous measures (mean), mean difference (Δ), and proportions (%) were conducted.

RESULTS

The initial search yielded 2429 unique articles. After a full-text review of 272 articles, 17 studies reporting outcomes for 2269 patients were included in the meta-analysis. The mean patient age was 48.6 years (range 18.0-86.0; 95% CI: 46.5 to 50.6), among which 55.4% (95% CI: 51.5 to 59.4) were male and 82.9% (95% CI: 68.8 to 93.4) had nasal polyposis. SNOT facial pain/pressure scores improved by 1.1 points (95% CI: -1.7 to -0.5; relative reduction 40.4%) with non-biologic therapies and 1.0 point (95% CI: -1.4 to -0.6; relative reduction 54.6%) with biologic therapies. On an 11-point scale, VAS headaches scores improved by 1.8 units (95% CI: -3.3 to -0.3; 42.1% relative reduction) in CRSwNP patients and 1.0 unit (95% CI: -1.7 to -0.3; 54.0% relative reduction) in CRSsNP patients.

CONCLUSIONS

Our findings suggest medical therapy significantly reduces facial pain and pressure in the CRS population. Laryngoscope, 134:4458-4465, 2024.

Laboratory and imaging findings of necrotizing otitis externa are associated with pathogen type and disease outcome: A retrospective analysis

OBJECTIVE

To examine associations of laboratory and imaging data with diagnostic parameters of necrotizing otitis externa (NOE) and its severity, and to compare between bacterial and fungal infections.

METHODS

Records of patients diagnosed with NOE during 2010-2018 at the Department of Otolaryngology, Head and Neck Surgery were reviewed retrospectively for demographics; disease characteristics; and laboratory, scintigraphy, and imaging results.

RESULTS

Of 48 patients with NOE, the mean age is 73±11.6 years; 32 (67%) were males; 83% had diabetes mellitus. Common pathogens were pseudomonas (49%) and fungi (33%). Sensitivities of the technetium-scan (SPECT ratio ≥1.5), temporal bone computed tomography (CT), and gallium-scan (SPECT ratio ≥1.3) were: 78.7%, 48.8%, and 31.4%, respectively. Gallium-scan results correlated positively with CT bone involvement (p=0.002) and hospital length of stay (p=0.0014). C-reactive protein (CRP) level correlated with hospital length of stay (p=0.028) and positive technetium-scan results (p=0.012). Fungal infection had a higher technetium SPECT ratio (2.16 vs. 1.77, p=0.04), gallium SPECT ratio (1.4 vs. 1.2, p=0.02), longer duration of systemic treatment (87.4 vs. 37.9 days, p=0.014), and longer hospital length of stay (31.6 vs. 15.2 days, p=0.004) compared to non-fungal infection. Eight (17%) patients had responded poorly to treatment. Fungal pathogens, facial nerve paresis, extra-auricular, and bilateral disease were more prevalent among the non-responders.

CONCLUSION

The technetium scan has higher sensitivity than temporal bone CT for diagnosing NOE. The gallium scan and CRP correlated well with hospital length of stay. A high rate of fungal infection was found, with significantly higher technetium and gallium SPECT ratios and worse outcome compared to bacterial infection. Fungal NOE remains therapeutically challenging.

Effects of functional endoscopic sinus surgery on asthma control in patients with comorbid chronic rhinosinusitis and asthma: A national database study

KEY POINTS

In patients with chronic rhinosinusitis and comorbid asthma, patients with surgical intervention required less asthma rescue medication, as compared to those who did not undergo surgery. Following sinus surgery, patients with chronic rhinosinusitis and asthma required more asthma medication, as compared to the time period prior to surgery.

Variability of the Microbiota in Chronic Rhinosinusitis: A Scoping Review

Objective

Chronic rhinosinusitis (CRS) is characterized by a persistent inflammation of the nasal and paranasal sinus mucosa that could be potentially linked to a dysregulation between the microbiota and the immune system. We aim to explore general, methodological, and microbiological aspects of microbiota research in CRS compared to disease-free individuals.

Data Sources

Embase, Ovid MEDLINE, PubMed, Scopus, and Web of Science.

Review Methods

All studies comparing the composition of the resident microbiota of the sinonasal cavities in 2 groups: CRS and normal participants. We conducted systematic study selection, data extraction, and analysis first using the title and abstract, and then the full texts based on predefined inclusion and exclusion criteria. Compiled and presented findings include sampling site and technique, and microbiological results such as the relative abundance and the variability of the composition of the microbiota in both groups.

Results

Twenty-seven studies, using genomic identification with 16s RNA were analyzed. Case definitions primarily followed EPOS or AAO-HNS guidelines, with endoscopic swabs (82%), and middle meatus sampling (74%) being prevalent techniques. Despite relative abundance variability, patterns emerged across studies, indicating an increase in Haemophilus (19%) and Pseudomonas (11%), and decrease in Propionibacterium (15%) and Anaerococcus (11%). Another pattern was observed, showing a decreased alpha diversity (6/19; 22%) in CRS compared to normal individuals.

Conclusion

While variations exist among studies, analysis of CRS microbiota suggests an association with dysbiosis, potentially contributing to chronic inflammation. Future research must prioritize standardized criteria for diagnostics and patient selection, fostering a more comprehensive understanding of CRS microbiota.

Search for medical information for chronic rhinosinusitis through an artificial intelligence ChatBot

Objectives

Artificial intelligence is evolving and significantly impacting health care, promising to transform access to medical information. With the rise of medical misinformation and frequent internet searches for health-related advice, there is a growing demand for reliable patient information. This study assesses the effectiveness of ChatGPT in providing information and treatment options for chronic rhinosinusitis (CRS).

Methods

Six inputs were entered into ChatGPT regarding the definition, prevalence, causes, symptoms, treatment options, and postoperative complications of CRS. International Consensus Statement on Allergy and Rhinology guidelines for Rhinosinusitis was the gold standard for evaluating the answers. The inputs were categorized into three categories and Flesch-Kincaid readability, ANOVA and trend analysis tests were used to assess them.

Results

Although some discrepancies were found regarding CRS, ChatGPT's answers were largely in line with existing literature. Mean Flesch Reading Ease, Flesch-Kincaid Grade Level and passive voice percentage were (40.7%, 12.15%, 22.5%) for basic information and prevalence category, (47.5%, 11.2%, 11.1%) for causes and symptoms category, (33.05%, 13.05%, 22.25%) for treatment and complications, and (40.42%, 12.13%, 18.62%) across all categories. ANOVA indicated no statistically significant differences in readability across the categories (p-values: Flesch Reading Ease = 0.385, Flesch-Kincaid Grade Level = 0.555, Passive Sentences = 0.601). Trend analysis revealed readability varied slightly, with a general increase in complexity.

Conclusion

ChatGPT is a developing tool potentially useful for patients and medical professionals to access medical information. However, caution is advised as its answers may not be fully accurate compared to clinical guidelines or suitable for patients with varying educational backgrounds.Level of evidence: 4.

Optimizing Corticosteroid Sinonasal Irrigation Outcomes Through 3D Printing: A Randomized Pilot Clinical Trial

Objective

Topical corticosteroid irrigation plays critical role in the management of chronic rhinosinusitis (CRS). Yet, its efficacy can be highly variable. We sought to determine if personalized, 3-dimensional (3D)-printed nasal models can optimize head positioning and irrigation parameters, therefore improving patient outcomes.

Study Design

Randomized, single-blinded clinical trial.

Setting

Tertiary medical center from November 2021 to July 2023.

Methods

Sixty-two patients with CRS were randomized into either control (CG), backfill (BG), or model (MG) groups; daily 2 mg mometasone irrigations were then performed for 2 months with either standard head-forward and natural side-tilt position (CG), a head tilt of 90° to the side with fluid entering the lower nostril (BG), or in an optimized position as determined by a patient-specific 3D printed irrigation model (MG), respectively.

Results

A total of 36 patients completed the trial (CG: N = 14/23; BG N = 11/23, MG: N = 11/16). Significant posttreatment improvement in Lund-Mackay (LM) scoring was only observed in the MG (-3.73, 95% confidence interval = -5.71, -1.75; P < .001). Patient-reported outcome measures (Nasal Obstruction Symptom Evaluation, Sinonasal Outcome Test-22, and Visual Analog Scale of nasal congestion) improved significantly among all groups. Optimal model penetration scores significantly correlated to posttreatment MG LM score (Spearman's r = 0.65, P < .05). Among all groups, patients with prior endoscopic sinus surgery (ESS) (n = 19) had objectively less opacification at baseline; however, experienced the same degree of opacification reduction and symptom reduction as those without prior ESS (n = 17).

Conclusion

The use of 3D printing to personalize head positioning may significantly improve objective corticosteroid irrigation outcomes. Mometasone irrigation may have similar subjective and objective effects on patients regardless of prior surgical history.

Level of Evidence

Level 1 prospective, randomized, single-blinded clinical trial NCT06118554.

Comprehensive evaluation of deep neck infections: A retrospective analysis of 111 cases

Purpose

Our study will analyze patients' clinical characteristics, treatment strategies, and complications with deep neck infection (DNI) using their medical records for five years.

Methods

The present study included 111 patients diagnosed with DNI in our clinic between January 2018 and March 2023. The patients' complaints at admission, sociodemographic characteristics, season of diagnosis, findings from laboratory tests, radiological imaging performed at the time of first diagnosis, abscess localization, medical and surgical treatment methods used, and complications developing during follow-up were retrospectively examined.

Results

The mean age of the patients included in the study was 38.51 ± 16.92 (6-87 years). There was a significant correlation between chronic disease, smoking behaviours, oral hygiene, and DNI among patients based on their sociodemographic characteristics and medical history (p < .005). DNI development did not differ by season (p > .005). Physical examination findings predominantly revealed neck masses (39.6%) and peritonsillar abscesses (32.4%), and patients with peritonsillar abscesses had a shorter length of hospital stay than those with other localizations. No severe complications occurred during the clinical follow-up.

Conclusion

Chronic diseases, smoking, and poor oral hygiene are the primary risk factors for developing DNIs. If an abscess is located in a critical area, it may require extended hospitalization and surgery under general anesthesia. Therefore, addressing these risk factors and encouraging good oral hygiene practices are crucial to preventing DNIs and reducing the need for intensive treatment.

Investigation of Expectations and Satisfaction After Sinus Surgery for Chronic Rhinosinusitis

OBJECTIVE

To perform the first mixed-methods analysis of patient expectations and satisfaction after endoscopic sinus surgery (ESS).

METHODS

Semi-structured interviews of subjects undergoing ESS were performed to understand pre-operative expectations and 6-month post-operative satisfaction. Descriptive statistics, logistic regression, and mediation analyses were performed. Quantitative questions were followed by qualitative probes for subjects to expand on quantitative answers. Study sample size was determined by thematic saturation based on qualitative responses. Data visualization was used to triangulate quantitative and qualitative data wherein themes emerged.

RESULTS

A total of 52 participants were included in the mixed-method analysis, and 110 were included in the mediation analysis. 56% of participants were male, with an average age of 55.7 (SD ± 2.18). Mean change in SNOT-22 was 20.8 (SD ± 3.74), and 25% of participants did not achieve a minimal clinically important difference (MCID). Of the participants who did not achieve MCID, 79% would still choose to have sinus surgery again. Qualitative interviews revealed multiple preliminary categories describing the patient experience with ESS. Regression analysis showed that the most important predictor of satisfaction was whether pre-operative expectations were met (OR = 3.8, p < 0.001). In mediation analysis, the effect of the clinical outcome on patient satisfaction was completely mediated by pre-operative expectations (indirect effect p = 0.009, direct effect p = 0.17).

CONCLUSION

Patient expectations and satisfaction are important yet understudied measures in CRS and ESS. In ESS, satisfaction with outcome is driven by the fulfillment of pre-operative expectations. Aligning such expectations is the most important intervention a sinus surgeon can perform to maximize success.

LEVEL OF EVIDENCE

4 Laryngoscope, 2024.

A Label-Efficient Framework for Automated Sinonasal CT Segmentation in Image-Guided Surgery

OBJECTIVE

Segmentation, the partitioning of patient imaging into multiple, labeled segments, has several potential clinical benefits but when performed manually is tedious and resource intensive. Automated deep learning (DL)-based segmentation methods can streamline the process. The objective of this study was to evaluate a label-efficient DL pipeline that requires only a small number of annotated scans for semantic segmentation of sinonasal structures in CT scans.

STUDY DESIGN

Retrospective cohort study.

SETTING

Academic institution.

METHODS

Forty CT scans were used in this study including 16 scans in which the nasal septum (NS), inferior turbinate (IT), maxillary sinus (MS), and optic nerve (ON) were manually annotated using an open-source software. A label-efficient DL framework was used to train jointly on a few manually labeled scans and the remaining unlabeled scans. Quantitative analysis was then performed to obtain the number of annotated scans needed to achieve submillimeter average surface distances (ASDs).

RESULTS

Our findings reveal that merely four labeled scans are necessary to achieve median submillimeter ASDs for large sinonasal structures-NS (0.96 mm), IT (0.74 mm), and MS (0.43 mm), whereas eight scans are required for smaller structures-ON (0.80 mm).

CONCLUSION

We have evaluated a label-efficient pipeline for segmentation of sinonasal structures. Empirical results demonstrate that automated DL methods can achieve submillimeter accuracy using a small number of labeled CT scans. Our pipeline has the potential to improve pre-operative planning workflows, robotic- and image-guidance navigation systems, computer-assisted diagnosis, and the construction of statistical shape models to quantify population variations.

LEVEL OF EVIDENCE

N/A.

Genetic correlation between chronic sinusitis and autoimmune diseases

Objective

The association between autoimmune diseases and chronic rhinosinusitis in observational studies remains unclear. This study aimed to explore the genetic correlation between chronic rhinosinusitis and autoimmune diseases.

Methods

We employed Mendelian randomization (MR) analysis and linkage disequilibrium score regression (LDSC) to investigate causal relationships and genetic correlations between autoimmune phenotypes and chronic rhinosinusitis. Additionally, transcriptome-wide association (TWAS) analysis was conducted to identify the shared genes between the two conditions to demonstrate their relationship. The CRS GWAS (genome-wide association study) data and other autoimmune diseases were retrieved from ieuOpenGWAS (https://gwas.mrcieu.ac.uk/), the FinnGen alliance (https://r8.finngen.fi/), the UK Biobank (https://www.ukbiobank.ac.uk/), and the EBI database (https://www.ebi.ac.uk/).

Results

Utilizing a bivariate two-sample Mendelian randomization approach, our findings suggest a significant association of chronic rhinosinusitis with various autoimmune diseases, including allergic rhinitis (p = 9.55E-10, Odds Ratio [OR] = 2,711.019, 95% confidence interval [CI] = 261.83391-28,069.8), asthma (p = 1.81E-23, OR = 33.99643, 95%CI = 17.52439-65.95137), rheumatoid arthritis (p = 9.55E-10, OR = 1.115526, 95%CI = 1.0799484-1.1522758), hypothyroidism (p = 2.08828E-2, OR = 4.849254, 95%CI = 1.7154455-13.707962), and type 1 diabetes (p = 2.08828E-2, OR = 01.04849, 95%CI = 1.0162932-1.0817062). LDSC analysis revealed a genetic correlation between the positive autoimmune phenotypes mentioned above and chronic rhinosinusitis: AR (rg = 0.344724754, p = 3.94E-8), asthma (rg = 0.43703672, p = 1.86E-10), rheumatoid arthritis (rg = 0.27834931, p = 3.5376E-2), and hypothyroidism (rg = -0.213201473, p = 3.83093E-4). Utilizing the Transcriptome-Wide Association Studies (TWAS) approach, we identified several genes commonly associated with both chronic rhinosinusitis and autoimmune diseases. Genes such as TSLP/WDR36 (Chromosome 5, top SNP: rs1837253), ORMDL3 (Chromosome 13, top SNP: rs11557467), and IL1RL1/IL18R1 (Chromosome 2, top SNP: rs12905) exhibited a higher degree of consistency in their shared involvement across atopic dermatitis (AT), allergic rhinitis (AR), and chronic rhinosinusitis (CRS).

Conclusion

Current evidence suggests a genetic correlation between chronic rhinosinusitis and autoimmune diseases like allergic rhinitis, asthma, rheumatoid arthritis, hypothyroidism, and type 1 diabetes. Further research is required to elucidate the mechanisms underlying these associations.

A cost utility analysis for the management of acute exacerbations of chronic rhinosinusitis

BACKGROUND

The management of acute exacerbations of chronic rhinosinusitis (AECRS) is understudied and the most cost-effective management of AECRS has not been previously investigated. The aim of this study is to determine the most cost-effective strategy for the initial management of AECRS.

METHODS

The study design consisted of a decision-tree economic model comparing three different initial strategies for managing a patient perceived AECRS: observation, upfront rescue medications, or clinic visit with diagnostic nasal endoscopy (DNE). The primary study outcome was the disease burden of a single AECRS, which was determined by the health utility value and the duration of symptoms. Strategies with an incremental cost-effectiveness ratio < $50,000/quality-adjusted life year (QALY) or equivalently < $137/quality-adjusted life day (QALD) were considered cost-effective.

RESULTS

Observation was the most cost-effective strategy at a willingness to pay of $137 per QALD. One-way sensitivity analysis demonstrated that observation was more effective than upfront rescue medications when the probability of bacterial infection as the cause of AECRS was <24.0%. Upfront rescue medications wer more cost effective than observation when the probability of bacterial infection exceeded 49.0%. Clinic visit with DNE was the most effective strategy to manage an AECRS, but it was not considered cost-effective.

CONCLUSION

Observation is the most cost-effective strategy for the initial management of AECRS when there is a low likelihood of bacterial infection. When the probability of bacterial etiology of AECRS exceeds 49.0%, upfront rescue medications proved to be the most cost-effective strategy.

In office sampling of eosinophil peroxidase to diagnose eosinophilic chronic rhinosinusitis

BACKGROUND

Practical biomarkers for endotypic characterization of chronic rhinosinusitis (CRS) remain elusive, hindering clinical utility. Eosinophil peroxidase (EPX) is an enzyme released by activated eosinophils. The objective of this study was to evaluate a clinic EPX assay as a marker of eosinophilic CRS.

METHODS

Subjects with and without CRS presenting to a tertiary care rhinology clinic were prospectively enrolled, and nasal cytology brushings were collected from the middle meatus during in-clinic nasal endoscopy. ELISA assay was used to quantify EPX levels, and a customized multiplex immunoassay was used to quantify inflammatory cytokine mediators. Findings were correlated with clinical data.

RESULTS

Forty-two subjects were enrolled, including 31 CRS subjects and 11 controls. Median EPX levels were 125.0 ng/mL (standard deviation [SD] 1745.8) and 6.5 ng/mL (SD 99.0) for CRS group and controls, respectively (p = 0.003). EPX levels were associated with history of asthma (p = 0.015), allergies (p = 0.028), polyps (p = 0.0006), smell loss (p = 0.006), and systemic eosinophilia or elevated immunoglobulin E (p ≤ 0.0001). Twenty-eight subjects from both the CRS and control groups had prior pathology for comparison, with histologic confirmation of local tissue eosinophilia (>10 eosinophils/hpf) in 11 subjects. This subgroup had a median EPX level of 967.5 ng/mL compared to 10.6 ng/mL in 17 subjects without local tissue eosinophilia (p = 0.0008). EPX levels were positively correlated to interleukin-5 levels (p = 0.0005).

CONCLUSION

EPX levels can be measured via well-tolerated in-clinic collection of nasal mucus. EPX levels are associated with clinical markers of type 2 inflammation and tissue eosinophilia and may provide a valuable diagnostic tool to delineate eosinophilic CRS.

Contemporary Trends in Frontal Sinus Balloon Sinuplasty: A Pilot Study

Introduction

Balloon sinuplasty (BSP) is a common treatment modality used in the management of chronic rhinosinusitis (CRS). Although it has gained popularity, minimal self-reported data on its utilization and complications have been reported. The goal of this study was to describe current practices and complications experienced during frontal sinus BSP.

Methods

An anonymous 20-question online survey was distributed to members of the American Osteopathic Colleges of Ophthalmology and Otolaryngology-Head and Neck Surgery from August 1, 2022, to August 30, 2022. The questions were listed as multiple choice or percentage sliding bars, and data were collected using a commercial online survey service site. Results were reported as frequencies, means, and percentages.

Results

Forty-two respondents participated in the survey, with the majority practicing in the following hospital settings: community (34, 80.95%), hybrid (5, 11.90%), and academic (3, 7.14%). The southeast had the largest proportion of respondents (13, 30.95%), versus the midwest (12, 28.57%), southwest (10, 23.81%), northeast (5, 11.90%), and northwest (2, 4.76%). On average, 50.52% of cases were performed in the hospital setting, 48.50% in-office, and 42.40% in surgery centers. Respondents who primarily used BSP, reported a yearly average of 35.72 cases, a median of 12 cases, and a range of 0-361 cases. Respondents who used BSP with functional endoscopic sinus surgery (FESS), reported a yearly average of 48.62 cases, a median of 31 cases, and a range of 0-189 cases. Nasal packing was utilized both intraoperatively (11.72%) and postoperatively (3.62%). Early complications included postoperative headaches (9.86%), acute bacterial sinusitis (ABRS) (3.52%), and tooth/facial numbness (0.86%). Reported long-term complications included postoperative synechiae (5.10%), orbital complications (0.14%), and skull base complications (0.10%). A previously unreported complication was identified through this study, accidental sphenopalatine fossa dilation.

Conclusions

This study contributes to the growing body of literature on frontal sinus BSP by characterizing utilization and complications from a large otolaryngologic academy.

A prospective longitudinal study assessing the impact of rhinovirus and bacterial infections in acute exacerbations of chronic rhinosinusitis

BACKGROUND

Acute exacerbations of chronic rhinosinusitis (AECRS) are thought to arise from common viral infections progressing to secondary bacterial infections. However, the pathophysiology of AECRS remains poorly understood due to a lack of prospective longitudinal studies.

METHODS

We conducted a one-year prospective longitudinal study involving chronic rhinosinusitis (CRS) adults. At baseline, we assessed subjective symptom scores using a validated upper respiratory infection questionnaire (WURSS), sinonasal outcome testing scores (SNOT-22), and endoscopic scores (modified Lund-Kennedy score). Every 2 weeks, we contacted subjects to collect WURSS and SNOT-22 scores. If WURSS scores were ≥1 and SNOT-22 scores were ≥ 8.9 compared with baseline, subjects underwent an AECRS assessment. We identified rhinovirus (RV) incidence through viral nasal brushings at each visit and bacterial infection through bacterial swabs if mucus scores were ≥1.

RESULTS

Thiry-five of 80 CRS subjects reported at least one AECRS episode during the year, predominantly occurring in the fall and winter seasons. RV infections were detected in 8 of 35 cases, bacterial infections in 17 of 35, and co-occurring infections in 7 of 35. All subjects with AECRS visits exhibited significantly higher endoscopic scores compared with baseline. Subjects with co-occurring RV and bacterial infections demonstrated higher disease severity compared with those with either RV or bacterial infection, or no infection.

CONCLUSIONS

In a one-year prospective longitudinal study involving CRS adults, we identified significant risk factors for AECRS including seasonality and the presence of RV and bacterial infections. These data suggest a standard definition of AECRS and the need to target RV and bacterial infections if we are to help reduce disease severity.

Surgical management of headache and facial pain/pressure in chronic rhinosinusitis: A systematic review and meta-analysis

BACKGROUND

Headache and facial pain are common symptoms of chronic rhinosinusitis (CRS). However, given the numerous etiologies that can cause these symptoms, the impact of sinus surgery is not well characterized.

METHODS

A systematic review was performed by searching the literature from inception through June 6, 2023. English-language articles reporting outcomes for facial pain/pressure or headache following endoscopic sinus surgery were selected for inclusion. Meta-analyses were performed using random and fixed effect models on continuous measures (mean), mean difference (Δ), and proportions (%).

RESULTS

A total of 26 articles reporting on 2839 patients were selected for inclusion. The mean patient age was 44.0 ± 3.9 (range 16.0-84.0), with an average symptom duration of 5.3 ± 2.8 years. Among these patients, 56.5% (95% confidence interval [CI]: 52.3-60.6) were male and 77.0% (95% CI: 56.6-92.3) had nasal polyposis (NP). Patients with and without NP reported substantial reductions in both 22-item sino-nasal outcome test facial pain/pressure (with NP: -1.4 [95% CI: -1.6 to -1.2; relative reduction 59.1%]; without NP: -1.5 [95% CI: -1.9 to -1.1; relative reduction 60.9%]) and visual analogue scale (VAS) headache (with NP: -2.5 [95% CI: -2.8 to -2.1; relative reduction 67.2%]; without NP: -2.8 [95% CI: -4.7 to -1.0; relative reduction 42.7%]). Symptom reductions were greater in the without NP versus with NP group; VAS facial pain/pressure: Δ0.4 (95% CI: 0.2-0.6; p = 0.0006) and VAS headache: Δ0.4 (95% CI: 0.1-0.7; p = 0.02).

CONCLUSIONS

Our findings suggest that CRS patients, regardless of polyp status, benefit from significant reductions in facial pain/pressure and headache following surgical therapy.

A randomized controlled trial on triamcinolone versus saline impregnated merocel post endoscopic sinus surgery: Our experience in a tertiary care centre

Purpose

To assess the potential benefit of impregnating Merocel (a non-absorbable nasal dressing) with a topical steroid solution, for use as a direct and slow local delivery system of steroids after sinus surgery to improve postoperative wound healing.

Methods

In this randomized controlled trial, 40 patients with bilateral chronic rhinosinusitis with nasal polyposis were subjected to functional endoscopic sinus surgery. Following the completion of the surgery, Merocel packs were inserted in the bilateral nasal cavities and infiltrated with 4 mL triamcinolone (40 mg/mL) in one nasal cavity (treatment group) and 4 mL normal saline in the other (control group). Nasal packs were removed on the third postoperative day and postoperative healing assessment was done on postoperative Weeks 1, 2, 4, and 12. The findings were noted as per Lund Kennedy (LKES) and perioperative sinus endoscopy (POSE) scores and compared on both sides.

Results

Significant (P < 0.05) improvement was noted in Lund Kennedy score for crusting and polyp at Week 12, for edema at Week 1, and nasal discharge at Weeks 1 and 12, but there was no significant improvement in scarring at any week. Overall, the difference between the treatment and control arms was statistically significant at all postoperative visits except at Week 4. Also, there was a significant improvement in POSE scores at Weeks 1, 2, and 12 but not at Week 4.

Conclusion

This study positively concludes that the nasal cavity packed with drug-soaked packs had less scarring and edema in the postoperative period and the overall wound healing was much better as compared to saline-soaked packs.

Chronic Rhinosinusitis Management: A Narrative Review Comparing Interventional Treatment With Osteopathic Manipulation

Chronic rhinosinusitis (CRS) is an inflammatory disease affecting the nasal cavity and paranasal sinuses. Diagnosis of CRS typically requires two of the following four symptoms to persist for a minimum of 12 weeks: anterior or posterior nasal drainage, hyposmia or anosmia, facial pain or pressure, or nasal obstruction. Additionally, diagnosis necessitates the visualization of inflammation on physical examination or diagnostic imaging. This review aims to compare the outcomes of CRS patients who undergo interventional treatment via functional endoscopic sinus surgery (FESS) to those who opt for noninterventional treatment with osteopathic manipulation. FESS is not the sole interventional method utilized for CRS, but it is the focus of this review since it is the gold standard surgical treatment, encompassing a variety of techniques. Although there is limited literature discussing the use of osteopathic manipulative treatment (OMT) to remedy CRS, some evidence indicates OMT can alleviate symptoms for individuals seeking non-surgical alternatives. Moreover, osteopathic manipulation for CRS may be beneficial for patients unresponsive to previous medical or surgical management. Pharmacologic treatment is typically the initial approach to CRS and is discussed briefly herein, though it largely falls beyond the scope of this review.

Evolving Utilization of Topical Budesonide Following Endoscopic Sinus Surgery

Topical budesonide irrigations are frequently prescribed after endoscopic sinus surgery (ESS) to manage mucosal inflammation. However, this off-label indication may conflict with health insurance formularies. We sought to quantify the relative frequency of postoperative budesonide prescriptions to determine if this could be considered common practice after ESS. We extracted and analyzed postoperative prescription data for patients undergoing ESS from 2016 to 2022 within our health care system. Overall, among 8157 ESS patients, 15.9% and 22.1% received topical budesonide prescriptions within 30 or 180 days postoperatively, respectively. On a year-over-year basis, budesonide prescription frequency increased significantly over time, culminating at 20.3% and 24.9% in 2022. Conversely, postoperative oral corticosteroid (OCS) prescriptions showed a decreasing frequency over the same time period (P < .001). Our results show topical budesonide irrigations are increasingly frequently prescribed after ESS and may offset postoperative OCS requirements. This argues for coverage of topical budesonide as a formulary medication after ESS.

Pathogenesis, Diagnosis, and Treatment of Infectious Rhinosinusitis

Rhinosinusitis is a common inflammatory disease of the sinonasal mucosa and paranasal sinuses. The pathogenesis of rhinosinusitis involves a variety of factors, including genetics, nasal microbiota status, infection, and environmental influences. Pathogenic microorganisms, including viruses, bacteria, and fungi, have been proven to target the cilia and/or epithelial cells of ciliated airways, which results in the impairment of mucociliary clearance, leading to epithelial cell apoptosis and the loss of epithelial barrier integrity and immune dysregulation, thereby facilitating infection. However, the mechanisms employed by pathogenic microorganisms in rhinosinusitis remain unclear. Therefore, this review describes the types of common pathogenic microorganisms that cause rhinosinusitis, including human rhinovirus, respiratory syncytial virus, Staphylococcus aureus, Pseudomonas aeruginosa, Aspergillus species, etc. The damage of mucosal cilium clearance and epithelial barrier caused by surface proteins or secreted virulence factors are summarized in detail. In addition, the specific inflammatory response, mainly Type 1 immune responses (Th1) and Type 2 immune responses (Th2), induced by the entry of pathogens into the body is discussed. The conventional treatment of infectious sinusitis and emerging treatment methods including nanotechnology are also discussed in order to improve the current understanding of the types of microorganisms that cause rhinosinusitis and to help effectively select surgical and/or therapeutic interventions for precise and personalized treatment.

Patient perspectives on chronic rhinosinusitis in cystic fibrosis: Symptom prioritization in the era of highly effective modulator therapy

BACKGROUND

Chronic rhinosinusitis (CRS) is common in people with cystic fibrosis (PwCF). Rhinologic symptom prioritization and areas that influence CRS treatment choices, including pursuing endoscopic sinus surgery (ESS), remain understudied.

METHODS

Adult PwCF + CRS were enrolled at eight centers into a prospective, observational study (2019-2023). Participants were administered the 22-SinoNasal Outcome Test (SNOT-22) survey and a modified SNOT-22 instrument examining symptom importance. We determined importance rankings for individual symptoms and SNOT-22 symptom importance subdomains in two sets of subgroups-those pursuing ESS versus continuing medical management (CMT), and those on elexacaftor/tezacaftor/ivacaftor (ETI) versus not on ETI.

RESULTS

Among 69 participants, the highest priorities were nasal congestion (n = 48, 69.6% important), post-nasal discharge (32, 46.4%), facial pain (29, 43.3%), waking up tired (27, 39.1%), and fatigue (26, 37.7%). Those electing surgery (n = 23) prioritized sleep and psychological dysfunction symptoms compared to those pursuing CMT (n = 49) (sleep median score = 19.0 [interquartile range: 12.0, 25.0] vs. 4.5 [0.0, 12.8]; p < 0.0001; psychological = 17.0 [7.0, 26.0] vs. 7.0 [0.0, 15.8]; p = 0.002). ETI users had comparable SNOT-22 total symptom importance scores to non-ETI users (p = 0.14). Non-ETI users (n = 34) showed a trend toward prioritizing sleep symptoms compared to ETI users (n = 35) (13.0 [2.8, 22.3] vs. 6.0 [2.0, 17.0]; p = 0.055).

CONCLUSIONS

Nasal congestion and post-nasal discharge were top priorities reported by PwCF + CRS. Those electing surgery prioritized sleep and psychological symptoms, highlighting their importance in pre-operative discussions. Non-ETI users' prioritization of sleep improvement may highlight their unique disease impact and therapeutic needs; however, additional investigation is required.

The causal relationship between autoimmune diseases and rhinosinusitis, and the mediating role of inflammatory proteins: a Mendelian randomization study

Observational studies have linked autoimmune diseases (ADs) with rhinosinusitis (RS) manifestations. To establish a causal relationship between ADs and RS, and to explore the potential mediating role of inflammatory mediators between ADs and RS, we utilized Mendelian randomization (MR) analysis. Using a two-sample MR methodology, we examined the causality between multiple sclerosis (MS), rheumatoid arthritis (RA), ankylosing spondylitis (AS), psoriasis (PsO), type 1 diabetes (T1D), Sjogren's syndrome (SS), celiac disease (CeD), Crohn's disease (CD), hypothyroidism (HT), Graves' disease (GD), and Hashimoto's thyroiditis and their association with chronic and acute rhinosinusitis (CRS and ARS, respectively).To achieve this, we employed three distinct MR techniques: inverse variance weighting (IVW), MR-Egger, and the weighted median method. Our analysis also included a variety of sensitivity assessments, such as Cochran's Q test, leave-one-out analysis, MR-Egger intercept, and MR-PRESSO, to ensure the robustness of our findings. Additionally, the study explored the role of inflammation proteins as a mediator in these relationships through a comprehensive two-step MR analysis. Among the ADs, MS, RA, T1D, CeD, and HT were determined as risk factors for CRS. Only CeD exhibited a causal relationship with ARS. Subsequent analyses identified interleukin-10 (IL-10) as a potential mediator for the association of MS, RA and HT with CRS, respectively., while C-X-C motif chemokine 10 levels (CXCL10) and T-cell surface glycoprotein CD6 isoform levels (CD6) were found to influence HT's effect on CRS. Our findings demonstrate a causative link between specific autoimmune diseases and rhinosinusitis, highlighting IL-10, CXCL10, and CD6 as potential mediators in this association.

Obesity is Associated with Increased Risk of New-Onset Chronic Rhinosinusitis: A United States Population-Based Cohort Study

OBJECTIVE

The aim of this study was to determine the risk of a new-encounter diagnosis of unspecified chronic rhinosinusitis (CRS), CRS with nasal polyps (CRSwNP), and eosinophilic granulomatosis with polyangiitis (EGPA) 1 and 2 years following body mass index (BMI) classification of obesity utilizing a large-population-based analytics platform.

STUDY DESIGN

Retrospective cohort analysis SETTING: The U.S. Collaborative Network within the TriNetX Analytics platform contains deidentified electronic health record (EHR) data of more than 100 million patients and was used to determine the association between obesity and a new encounter diagnosis of 3 CRS phenotypes in this study.

RESULTS

After 1:1 propensity score matching, patients with an overweight BMI and obesity were at a higher risk for a new-encounter diagnosis of unspecified CRS and CRSwNP compared to healthy-weight individuals. The obesity cohort had the greatest increased risk of new-onset unspecified CRS with a relative risk of 1.23 (95% CI: 1.20-1.25) and 1.26 (95% CI: 1.24-1.28) 1 and 2 years following BMI classification, respectively.

CONCLUSION

Our study indicates an association between obesity and new-onset unspecified CRS and CRSwNP. With the increasing prevalence of obesity in the United States population, it will be important to understand how obesity-associated CRS may affect treatment response. Future prospective studies are needed to assess causality and define a mechanistic link.

Seawater nasal wash to reduce symptom duration and viral load in COVID-19 and upper respiratory tract infections: a randomized controlled multicenter trial

PURPOSE

The objective was to assess the efficacy of seawater nasal wash on symptom duration, intranasal viral load, household transmission in COVID-19 and URTIs.

METHODS

This prospective, randomized, controlled, multicentric, parallel study included 355 mild/moderate COVID-19 and URTI adults with rhinologic symptoms ≤ 48h. Active group performed 4-daily nasal washes with undiluted isotonic seawater versus control group (without nasal wash). Symptoms were self-assessed daily using the WURSS-21 questionnaire for 3 weeks. Viral load was measured by RT-PCR on nasopharyngeal swabs collected on Day 0, Day 5, Day 14 and Day 21. Digital droplet PCR was additionally performed for SARS-CoV-2.

RESULTS

Overall COVID-19 subjects recovered earlier the ability to accomplish daily activities in the active group (- 1.6 day, p = 0.0487) with earlier improvement of taste (- 2 days, p = 0.0404). COVID-19 subjects with severe nasal symptoms at D0 showed the earliest resolution of anosmia (- 5.2 days, p = 0.0281), post-nasal drip (- 4.1 days, p = 0.0102), face pain/heaviness (- 4.5 days, p = 0.0078), headache (- 3.1 days, p = 0.0195), sore throat (- 3.3 days, p = 0.0319), dyspnea (- 3.1 days, p = 0.0195), chest congestion (- 2.8 days, p = 0.0386) and loss of appetite (- 4.5 days, p = 0.0186) with nasal wash. In URTIs subjects, an earlier resolution of rhinorrhea (- 3.5 days, p = 0.0370), post-nasal drip (- 3.7 days, p = 0.0378), and overall sickness (- 4.3 days, p = 0.0248) was reported with nasal wash. Evolution towards more severe COVID-19 was lower in active vs control, with earlier viral load reduction in youngest subjects (≥ 1.5log10 copies/10000 cells at Day 5: 88.9% vs 62.5%, p = 0.0456). In the active group, a lower percentage of SARS-CoV-2 positive household contacts (0-10.7%) was reported vs controls (3.2-16.1%) among subjects with Delta variant (p = 0.0413).

CONCLUSION

This trial showed the efficacy and safety of seawater nasal wash in COVID-19 and URTIs.

TRIAL REGISTRATION

Trial registry ClinicalTrials.gov: NCT04916639. Registration date: 04.06.2021.

Structures and functions of the normal and injured human olfactory epithelium

The olfactory epithelium (OE) is directly exposed to environmental agents entering the nasal cavity, leaving OSNs prone to injury and degeneration. The causes of olfactory dysfunction are diverse and include head trauma, neurodegenerative diseases, and aging, but the main causes are chronic rhinosinusitis (CRS) and viral infections. In CRS and viral infections, reduced airflow due to local inflammation, inflammatory cytokine production, release of degranulated proteins from eosinophils, and cell injury lead to decreased olfactory function. It is well known that injury-induced loss of mature OSNs in the adult OE causes massive regeneration of new OSNs within a few months through the proliferation and differentiation of progenitor basal cells that are subsequently incorporated into olfactory neural circuits. Although normal olfactory function returns after injury in most cases, prolonged olfactory impairment and lack of improvement in olfactory function in some cases poses a major clinical problem. Persistent inflammation or severe injury in the OE results in morphological changes in the OE and respiratory epithelium and decreases the number of mature OSNs, resulting in irreversible loss of olfactory function. In this review, we discuss the histological structure and distribution of the human OE, and the pathogenesis of olfactory dysfunction associated with CRS and viral infection.

Assessment of chronic rhinosinusitis with nasal polyps: Development of the Nasal Polyp Patient Assessment Scoring Sheet tool

Background

Chronic rhinosinusitis (CRS) is a heterogeneous disorder with a wide range of validated subjective and objective assessment tools to assess disease severity. However, a comprehensive and easy-to-use tool that integrates these measures for determining disease severity and response to treatment is still obscure. The objective of this study was to develop a standardized assessment tool that facilitates diagnosis, uniform patient monitoring, and comparison of treatment outcomes between different centers both in routine clinical practice and in research.

Methods

To develop this tool, published literature on assessment tools was searched on various databases. A panel of 12 steering committee members conducted an advisory board meeting to review the findings. Specific outcome measures to be included in a comprehensive assessment tool and follow-up sheet were then collated following consensus approval from the panel. The tool was further validated for content and revised with expert recommendations to arrive at the finalized Nasal Polyp Patient Assessment Scoring Sheet (N-PASS) tool.

Results

The N-PASS tool was developed by integrating the subjective and objective measures for CRS assessment. Based on expert opinions, N-PASS was revised to be used as an easy-to-use guidance tool that captures patient-reported and physician-assessed components for comprehensively assessing disease status and response to treatment.

Conclusion

The N-PASS tool can be used to aid in the diagnosis and management of CRS cases with nasal polyps. The tool would also aid in improved monitoring of patients and pave the way for an international disease registry.

Level of evidence

Oxford Level 3.

Trends and Frequencies of Antibiotic Prescriptions for Acute Sinusitis Outpatient Visits in Adults

OBJECTIVE

The objective of this study was to analyze the trends and frequency in which recommended first-line therapy, amoxicillin with or without clavulanate, was prescribed for acute sinusitis based on current otolaryngology and other gold standard guidelines, as well as analyze differences in prescription behaviors of otolaryngologists compared with non-otolaryngologists for outpatient adult acute sinusitis visits.

METHODS

Weighted patient data from the National Ambulatory Medical Care Survey were analyzed to calculate visit rates and trends of antibiotic prescriptions for adults diagnosed with acute sinusitis from 2007 to 2019. Visits with multiple prescribed antibiotics or concomitant diagnoses requiring antibiotics were excluded. Each visit was classified based on the type of antibiotic prescribed.

RESULTS

Acute sinusitis was diagnosed in 0.63% of all outpatient visits from 2007 to 2019 (95% confidence interval: 0.56%-0.71%). Amoxicillin had the greatest increase in prescription frequency (13.4%), whereas macrolides had the largest decrease in prescription frequency (13.9%). Among adult acute sinusitis outpatient visits in which antibiotics were prescribed, recommended first-line antibiotic therapy of amoxicillin-clavulanate or amoxicillin alone was prescribed in 40.4% of visits. The most common antibiotic prescribed was amoxicillin-clavulanate at otolaryngologist visits (20.5%) and macrolides at non-otolaryngologist visits (26.0%). A greater proportion of otolaryngologist visits resulted in no antibiotics prescribed for acute sinusitis (36.8% vs. 22.5%, p < 0.001).

CONCLUSION

Otolaryngologists engage in watchful waiting more than non-otolaryngologists. Broader dissemination of existing guidelines for acute sinusitis treatment to non-Otolaryngologist (ENT) primary care specialties that take care of acute sinusitis to improve antibiotic stewardship and appropriate antibiotic selection is needed.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:2622-2625, 2024.

Comparison of cytokine expression and disease severity between plasma cell-dominant and eosinophil-dominant patients in chronic rhinosinusitis with nasal polyps

PURPOSE

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a heterogeneous disease characterized by inflammation of the nasal and sinus mucosa. The inflammatory patterns may differ among patients, leading to different subtypes based on the dominant inflammatory cell type. This study aimed to compare the differences in cytokine expression and disease severity between plasma cell-dominant and eosinophil-dominant subtypes in patients with CRSwNP.

METHODS

This study included 53 CRSwNP patients and 19 control subjects who did not have asthma or a history of cigarette smoking. The expression of cytokines and inflammatory cells was assessed via enzyme-linked immunosorbent assay (ELISA) and immunohistochemistry, respectively.

RESULTS

Among the cytokines analyzed, only IL-6 was significantly different between the two subtypes. A greater proportion of mast cells and IgE cells was present in plasma cell-dominant CRSwNP patients than in eosinophil-dominant group. For the three disease severity scores (LMK-CT, TPS and SNOT-22), objective scores (LMK-CT and TPS) were greater in the eosinophil-dominant CRSwNP group, while the opposite result was shown for the subjective score (SNOT-22). Additionally, the percentage of plasma cell-dominant cells was significantly positively correlated with disease severity according to the TPS and SNOT-22 scores.

CONCLUSIONS

Our data revealed that plasma cell-dominant inflammation, a subtype of type 2 CRS, was significantly correlated with subjective disease severity. The study also highlights the role of IL-6, IgE and mast cells as distinguishing factors between eosinophil-dominant and plasma cell-dominant CRSwNP. This information could be useful for clinical diagnosis and personalized treatment.

Chemokine CCL19 and Its Receptors CCR7 and CCRL1 in Chronic Rhinosinusitis

Background

CCL19 has been shown to predict disease severity in COVID-19 and treatment response in rheumatoid arthritis. CCL19 can exert both pro- and anti-inflammatory effects and is elevated in chronic rhinosinusitis (CRS). However, its role in CRS remains unknown. This study sought to determine the transcriptional changes in CCL19, its receptors, and associated cytokines and their association with disease severity in CRS.

Methods

A clinical database of control subjects and patients with CRS was examined. Lund-Kennedy, Lund-Mackay, Sinonasal Outcomes Test 22 (SNOT-22), and rhinosinusitis disability index (RSDI) scores were collected at enrollment. mRNA was extracted from sinonasal tissues and subjected to multiplex gene expression analysis. Gene transcript differences between patients with CRS and controls were compared and correlated with disease severity metrics. Immunohistochemical analyses of CCL19, CCR7, and CCRL1 were conducted to compare differences in protein expression between cohorts. A subgroup analysis was performed to compare transcriptional and protein expression difference between patients with (CRSwNP) and without (CRSsNP) nasal polyps and controls.

Results

Thirty-eight subjects (control group, n=7; CRS group, n=31) were included in this study. CCRL1 (p=0.0093) and CCR7 (p=0.017) levels were significantly elevated in CRS compared to those in controls. CCL19 (p=0.038) and CCR7 (p=0.0097) levels were elevated in CRSwNP and CCRL1 was elevated in CRSsNP (p=0.0004). CCR7 expression was significantly elevated in sinonasal epithelial cells in CRSwNP (p=0.04). CCL19 expression was positively correlated with TNFA expression (p<0.0002). CCL19 and CCR7 expression was positively correlated with SNOT-22 and RSDI scores (p<0.05).

Conclusion

CCL19 and CCR7 may modulate TNF-α-driven pro-inflammatory signaling and contribute to increased disease severity in CRS. Mechanistic studies are required to further elucidate the role of CCRL1 in CRS.

Histopathologic features of biologic therapy nonresponders in chronic rhinosinusitis with nasal polyposis

BACKGROUND

Biologics are effective for chronic rhinosinusitis with nasal polyposis (CRSwNP) by reducing type 2 inflammation. Nonresponders often require functional endoscopic sinus surgery (FESS) and represent a challenging population potentially due to non-type 2 pathophysiology. This study characterizes the histopathologic features of biologic nonresponders.

METHODS

A retrospective review of 257 CRSwNP patients undergoing FESS was conducted. The biologic nonresponder group included patients with prior biologic therapy who exhibited persistent symptoms and polyp burden. Those with CRSwNP not prescribed biologic therapy were selected as controls. Demographics, comorbidities, and structured histopathology consisting of 13 variables were collected.

RESULTS

Of 257 CRSwNP patients, 20 were on biologics prior to FESS. Fourteen patients (70.0%) received dupilumab, one (5.0%) received mepolizumab, one (5.0%) received omalizumab, and four (20.0%) tried multiple biologics. The mean age for the biologic nonresponder group was 45.8 years compared to 50.4 years for the controls. Nonresponders had a significantly increased incidence of reduced tissue eosinophilia, defined as <5 per high power field (55% vs. 31.2%, p = 0.044) and increased basement membrane thickening (100% vs. 78.1%, p = 0.019). The remaining 11 variables did not reach statistical significance.

CONCLUSION

Histopathologic analysis of biologic nonresponders demonstrates decreased eosinophilia and thickened basement membranes. These findings, particularly low tissue eosinophils, are consistent with a non-type 2 CRSwNP that may be recalcitrant to biologic therapies. Histopathologic analysis done in conjunction with FESS may aid clinicians in understanding response to biologic therapies in patients with CRSwNP who have persistent symptom burden necessitating FESS.

The effectiveness of evidence-based nursing intervention for nasal irrigation after endoscopic sinus surgery in patients with chronic rhinosinusitis: a randomized controlled trial

OBJECTIVES

To evaluate its effect of an evidence-based nursing program for nasal irrigation after endoscopic sinus surgery in patients with chronic rhinosinusitis (CRS).

METHODS

A total of 66 patients with CRS were randomly divided into two groups, for which the experimental group received evidence-based nasal irrigation nursing, and the control group received conventional nursing. Differences in Sino-Nasal Outcome Test-20 (SNOT-20), visual analogue scale (VAS), Lund-Mackay CT, Endoscopic Lund Kennedy Score (LKES) and overall efficacy were assessed between the two groups.

RESULTS

2, 4 and 12 weeks after the intervention, the scores of SNOT-20, VAS, Lund-Mackay CT and LKES in the two groups were significantly lower than those before the surgery (P < 0.05). Compared with the control group, the scores were significantly lower in the experimental group (P < 0.05). 12 weeks after the intervention, the overall effective rate of treatment in the experimental group was 90.62%, while the control group was 16.43%, but the difference was not statistically significant in treatment effect (P > 0.05).

CONCLUSIONS

The implementation of nasal irrigation evidence-based nursing program for patients with CRS after endoscopic sinus surgery can promote postoperative nasal mucosal recovery, improve treatment efficiency, and help improve patient comfort, quality of life and other subjective feelings.

TRIAL REGISTRATION

The study was registered retrospectively with reference number ChiCTR2300075484 on 06/09/2023, available at: https://www.chictr.org.cn .

Endotype evaluation of Hispanic/Latinx-American patients with chronic rhinosinusitis with nasal polyps

KEY POINTS

Hispanic-American patients with chronic rhinosinusitis with nasal polyps have a comparable level of tissue eosinophilia compared to their Caucasian counterparts in the United States. Mixed inflammation involving both neutrophils and eosinophils is more common in this population compared to Caucasians. Findings from this study may indicate that Hispanic-American patients have a unique endotype or endotypes that deserves further investigation.

Effects of highly effective modulator therapy on the dynamics of the respiratory mucosal environment and inflammatory response in cystic fibrosis

BACKGROUND

While the widespread initiation of elexacaftor/tezacaftor/ivacaftor (ETI) has led to dramatic clinical improvements among persons with cystic fibrosis (pwCF), little is known about how ETI affects the respiratory mucosal inflammatory and physiochemical environment, or how these changes relate to lung function.

METHODS

We performed a prospective, longitudinal study of adults with CF and chronic rhinosinusitis (CF-CRS) followed at our CF center (n = 18). Endoscopic upper respiratory tract (paranasal sinus) aspirates from multiple visit dates, both pre- and post-ETI initiation, were collected and tested for cytokines, metals, pH, and lactate levels. Generalized estimating equations were used to identify relationships between ETI and upper respiratory tract (URT) biomarker levels, and between URT biomarkers and lung function or clinical sinus parameters.

RESULTS

ETI was associated with decreased upper respiratory mucosal cytokines B-cell activating factor (BAFF), IL-12p40, IL-32, IL-8, IL-22 and soluble tumor necrosis factor-1 (sTNFR1), and an increase in a proliferation-inducing ligand (APRIL) and IL-19. ETI was also associated with decreased URT levels of copper, manganese, and zinc. In turn, lower URT levels of BAFF, IL-8, lactate, and potassium were each associated with ~1.5% to 4.3% improved forced expiratory volume in 1 s (FEV1), while higher levels of IFNγ, iron, and selenium were associated with ~2% to 10% higher FEV1.

CONCLUSIONS

Our observations suggest a dampening of inflammatory signals and restriction in microbial nutrients in the upper respiratory tract with ETI. These findings improve our understanding of how ETI impacts the mucosal environment in the respiratory tract, and may give insight into the improved infectious and inflammatory status and the resulting clinical improvements seen in pwCF.

All chronic rhinosinusitis endotype clusters demonstrate improvement in patient-reported and clinical outcome measures after endoscopic sinus surgery

BACKGROUND

It is unclear whether chronic rhinosinusitis (CRS) endotypes show a differential response to endoscopic sinus surgery (ESS). We explored patient mucous inflammatory cytokine expression and associations with patient-reported and clinically measured post-operative outcome measures.

METHODS

Patients with CRS were prospectively recruited between 2016 and 2021 into a national multicenter, observational study. Mucus was collected from the olfactory cleft preoperatively and evaluated for 26 biomarkers using cluster analysis. Patient-reported outcome measures included the 22-item Sino-Nasal Outcome Test (SNOT-22) and Questionnaire of Olfactory Dysfunction (QOD). Additional clinical measures of disease severity included threshold, discrimination, and identification (TDI) scores using "Sniffin' Sticks" testing and Lund-Kennedy endoscopic score (LKES).

RESULTS

A total of 115 patients were clustered into type 2 inflammatory, non-type 2 inflammatory, noninflammatory, and two indeterminate clusters based on individual protein levels. Overall, the type 2 inflammatory cluster was found to have the highest mean improvement in both SNOT-22 (-28.3 [standard deviation, ±16.2]) and TDI (6.5 [standard deviation, ±7.9]) scores 6 months after ESS. However, on average, all endotype clusters demonstrated improvement in all outcome measures after ESS without statistically significant between-group differences in SNOT-22 (p = 0.738), QOD (p = 0.306), TDI (p = 0.358), or LKES (p = 0.514) measures.

CONCLUSIONS

All CRS endotype clusters responded favorably to surgery and showed improvements in patient-reported and objective outcome measures. Thus, ESS should be considered a more generalized CRS therapy, and benefits appear to not be limited to specific endotypes.

Retrospective comparison of first-line treatments for odontogenic sinusitis based on duration of symptoms

Objectives

To investigate the clinical efficacy of dental treatment and endoscopic sinus surgery (ESS), each primary/combined treatment modality, in patients with odontogenic sinusitis (ODS), according to its phase, acute or chronic.

Materials and methods

We retrospectively reviewed clinical data on 172 patients diagnosed with ODS. They were divided into two groups: acute (≤ 3 months; 90 patients) and chronic (> 3 months; 82 patients) ODS. The success rate and time to resolution of each primary/combined treatment modality were compared between the two groups.

Results

In both ODS groups, the success rate was highest with combined ESS and dental therapy, followed by ESS alone and dental therapy alone. ESS outperformed dental therapy (96.6% vs 65.5% for acute ODS, p = 0.011; 80.6% vs 56.5% for chronic ODS, p = 0.046) and led to quicker resolution of symptoms for acute ODS than dental therapy (0.9 vs 1.7 months, p = 0.012). In the comparison between ESS alone and combined therapy, no significant difference was observed for acute ODS, whereas combined therapy demonstrated a superior success rate for chronic ODS (100% vs 80.6%, p = 0.046).

Conclusions

In our study, the clinical utility of dental treatment and/or ESS depended on the morbidity period of ODS. For chronic ODS, combined ESS and dental treatment seems to be an effective first-line treatment.

Antibiotic Stewardship in Outpatient Telemedicine: Adapting Centers for Disease Control and Prevention Core Elements to Optimize Antibiotic Use

The rapid expansion of telemedicine has highlighted challenges and opportunities to improve antibiotic use and effectively adapt antibiotic stewardship best practices to outpatient telemedicine settings. Antibiotic stewardship integration into telemedicine is essential to optimize antibiotic prescribing for patients and ensure health care quality. We performed a narrative review of published literature on antibiotic prescribing and stewardship in outpatient telemedicine to inform the adaptation of the Core Elements of Outpatient Antibiotic Stewardship framework to outpatient telemedicine settings. Our narrative review suggests that in-person antibiotic stewardship interventions can be adapted to outpatient telemedicine settings. We present considerations for applying the Core Elements of Outpatient Antibiotic Stewardship to outpatient telemedicine which builds upon growing evidence describing care delivery and quality improvement in this setting. Additional applied implementation research is necessary to inform the application of effective, sustainable, and equitable antibiotic stewardship interventions across the spectrum of outpatient telemedicine.

Long-term benefits of EPs® 7630 in patients with acute sinusitis: a real-world cohort study

Background: We evaluated whether EPs® 7630 prescription in patients with acute sinusitis (AS) is associated with less frequent recurrence of AS, occurrence of chronic sinusitis or nasal polyps, or fewer antibiotic prescriptions. Methods: This retrospective cohort study used electronic medical records from the IQVIA Disease Analyzer database. Associations between initial therapy [EPs® 7630, antibiotics, intranasal corticosteroid (INCS), or corticosteroid-free nasal spray within 3 days of AS diagnosis] and AS recurrence, incidence of chronic sinusitis or nasal polyps or rate of antibiotic prescription were studied using multivariable Cox or logistic regression models, adjusting for sex, age, insurance status, month of diagnosis, and comorbidity. Results: A total of 216,360 patients were analyzed. INCS prescription was associated with a higher risk of recurrent AS (HR: 1.40; 95% CI: 1.01-1.92) and a higher incidence of chronic sinusitis or nasal polyp diagnosis (HR: 1.39; 95% CI: 1.01-1.92) compared to EPs® 7630. Initial antibiotic therapy was significantly associated with higher risk of new antibiotic prescription in the period of 31-365 days after the index date compared to EPs® 7630 (OR: 2.20; 95% CI: 1.66-2.92). Conclusion: EPs® 7630 prescription is associated with long-term benefits in AS patients. EPs® 7630 can help to reduce inappropriate antibiotic use and might reduce the risk of chronic sinusitis or nasal polyps.

Antibiotic Sensitivity and Nasal Microbiome in Patients with Acute Bacterial Rhinosinusitis

OBJECTIVES

Acute rhinosinusitis (ARS) is a common upper respiratory tract infection that is mostly of viral origin. However, little is known about the nasal microbiome profile at presentation and the changes caused by antibiotics in acute bacterial rhinosinusitis (ABRS).

METHODS

This was a prospective single-center study. Overall, 43 ARS patients were screened and were assessed with the symptom questionnaires, nasal endoscopy, and Water's view. Five healthy subjects were recruited as controls. Middle meatal mucus samples were obtained using a cotton swab (for bacterial culture and antimicrobial susceptibility testing) and the suction technique (for 16S rRNA sequencing). After 1 week of antibiotic use (amoxicillin with clavulanic acid), we enrolled 13 patients with ABRS with positive isolates and middle meatal samples for 16S rRNA sequencing were obtained again.

RESULTS

Overall, we demonstrated a significantly lower abundance of the Lactobacillaceae family in ABRS patients than in healthy controls. Resistant ABRS had different characteristics of middle meatal microbiomes when compared to sensitive ABRS as follows: (1) lower proportion of lactic acid bacteria, (2) increased pathogens such as Rhodococcus sp., Massila sp., Acinetobacter sp., and H. influenza, and (3) increased beta diversity. However, no remarkable changes were observed in the middle meatal microbiome after antibiotic use.

CONCLUSION

We showed the roles of Lactobacillaceae in ABRS, and Acinetobacter and Massilia in case of amoxicillin resistance.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:1081-1088, 2024.

[Modern pharmacotherapy of acute bacterial sinusitis: results of an open randomized clinical trial of the therapeutic equivalence of Cefixime EXPRESS and Suprax Solutab]

BACKGROUND

Acute bacterial sinusitis is one of the most common causes of prescribing systemic antibacterial drugs in otorhinolaryngology. With bacterial etiology of the disease, beta-lactam antibiotics are prescribed, in particular cefixim. Cefixim in the form of dispersible tablets has high clinical and bacteriological efficiency, as well as good tolerability in patients with acute sinusitis.

OBJECTIVE

To study the therapeutic equivalence of two drugs of cefixim (reproduced drug Cefixim Express and reference drug Suprax Solutab) in patients with acute bacterial sinusitis.

MATERIAL AND METHODS

60 adult patients with a diagnosis of acute bacterial sinusitis took part in a randomized open comparative clinical study. Patients of group 1 (n=30) received the drug Cefixim Express in the form of dispersible tablets 400 mg once a day. Group 2 (n=30) received Suprax Solutab in the form of dispersible tablets 400 mg once a day. The duration of treatment course was 7 days. All patients conducted general clinical and otorhinolaryngological examinations, assessment of symptoms of acute sinusitis, assessment of the general clinical impression of the therapy, tolerance of treatment, analysis of the frequency of unwanted phenomena before treatment, 3 days after the beginning of therapy and after the course completion (7 days).

RESULTS

Recovery occurred in 63.3% of patients in group 1 according to the inspection on the 7th day of treatment and in 66.67% of patients in group 2. The rate of clinical symptoms regression by the end of therapy was comparable in the comparison groups. Hyperemia of the nasal mucosa, purulent nasal discharge and difficulty in nasal breathing (p<0.01) regressed by the 7th day in patients of both treatment groups. The incidence of adverse reactions on the 7th day of treatment in group 1 was 10%, in group 2 - 6.7% (p>0.05).

CONCLUSION

The drug Cefixim Express has high therapeutic effectiveness in the treatment of acute bacterial sinusitis, comparable to Suprax Solutab. Cefixime EXPRESS has demonstrated a good tolerability and a favorable safety profile.

Are you congested? A comparison of definitions between otolaryngologists and their patients

OBJECTIVE

To assess for differences of intended meaning in the description of congestion-related symptoms among otolaryngology patients and clinicians.

MATERIALS AND METHODS

Between June 2020 and October 2022, a questionnaire consisting of 16 common descriptors of congestion-related symptoms within four domains (obstructive-related, pressure-related, mucus-related, and other symptoms) was completed by patients and otolaryngologists at five tertiary otolaryngology practices. The primary outcome was to assess differences in patient and clinician perceptions of congestion-related symptoms. Differences based on geographic location was a secondary outcome.

RESULTS

A total of 349 patients and 40 otolaryngologists participated. Patients selected a median of 6.8 (standard deviation [SD] 3.0) terms compared with 4.0 (SD 1.6) terms for otolaryngologists (p < 0.001). Otolaryngologists were more likely to select obstruction-related symptoms (difference 6.3%; 95% confidence interval [CI] 3.8%, 8.9%). Patients were more likely to describe congestion using pressure-related (-43.7%; -58.9%, -28.5%), mucus-related (-43.5%; -59.3%, -27.8%), and other symptoms (-44.2; -51.3%, -37.1%) compared with otolaryngologists. There were no significant differences identified based on geographic location with regard to symptom domains on multivariate analysis.

CONCLUSIONS

There are differences between otolaryngologists and their patients in the interpretation of the symptoms of congestion. Clinicians tended to have a narrower interpretation of congestion that was limited to the obstruction-related symptom domain, while patients defined congestion more broadly. This has important counseling and communication implications for the clinician.

Eosinophil Peroxidase: A Biomarker for Eosinophilic Chronic Rhinosinusitis Agnostic of Polyp Status

OBJECTIVE

To evaluate eosinophil peroxidase (EPX) as a biomarker for tissue levels of eosinophilia, cytokines, and chemokines within chronic rhinosinusitis (CRS).

METHODS

Twenty-eight subjects undergoing sinonasal surgery were prospectively enrolled. Ethmoid tissue was analyzed with an in-house EPX immunoassay and a 48-plex cytokine-chemokine array. Clinical severity was assessed using SNOT-22 and Lund-Mackay scores. Subjects were grouped as follows: controls, polyp status (CRS with [CRSwNP] and without nasal polyps [CRSsNP]), tissue eosinophilia (eosinophilic CRS [eCRS], non-eosinophilic CRS [neCRS]), or combinations thereof (eCRSwNP, eCRSsNP, neCRSsNP). eCRS was defined as >10 eosinophils per high power field (HPF). Subjects without CRS or asthma were enrolled as controls.

RESULTS

EPX was elevated in CRSwNP compared to control (p = 0.007), in eCRS compared to neCRS (p = 0.002), and in eCRSwNP along with eCRSsNP compared to neCRSsNP (p = 0.023, p = 0.015, respectively). eCRS displayed elevated IL-5 compared to neCRS (p = 0.005). No significant differences in EPX or IL-5 were observed between eCRSwNP and eCRSsNP. IL-5 was elevated in eCRSwNP (p = 0.019) compared neCRSsNP. Area under the receiver operator characteristic curve was 0.938 (95% CI, 0.835-1.00) for EPX and tissue eosinophilia, with an optimal cut-point of 470 ng/mL being 100% specific and 81.25% sensitive for tissue eosinophilia. Linear regression revealed a strong correlation between EPX and IL-5 (R2  = 0.64, p < 0.001). Comparing EPX and IL-5, only EPX displayed significant correlation with SNOT-22 (p = 0.04) and Lund-Mackay score (p = 0.004).

CONCLUSION

EPX is associated with tissue eosinophilia in CRS patients regardless of polyp status. EPX correlates with IL-5 and could be potentially considered a biomarker for anti-IL-5 therapies.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:69-78, 2024.

STAT4 Phosphorylation of T-helper Cells predicts surgical outcomes in Refractory Chronic Rhinosinusitis

Objective

Chronic rhinosinusitis (CRS) impacts an estimated 5% to 15% of people worldwide, incurring significant economic healthcare burden. There is a urgent need for the discovery of predictive biomarkers to improve treatment strategies and outcomes for CRS patients.

Study design

Cohort study of CRS patients and healthy controls using blood samples.

Setting

Out-patient clinics.

Methods

Whole blood samples were collected for flow cytometric analysis. Mechanistic studies involved the transfection of human primary T cells and Jurkat cells.

Results

Our analysis began with a 63-69 year-old female patient diagnosed with refractory CRS,. Despite undergoing multiple surgeries, she continually faced sinus infections. Whole exome sequencing pinpointed a heterozygous IL-12Rb1 mutation situated in the linker region adjacent to the cytokine binding domain. When subjected to IL-12 stimulation, the patient's CD4 T-cells exhibited diminished STAT4 phosphorylation. However, computer modeling or T-cell lines harboring the same IL-12 receptor mutation did not corroborate the hypothesis that IL-12Rb could be responsible for the reduced phosphorylation of STAT4 by IL-12 stimulation. Upon expanding our investigation to a broader CRS patient group using the pSTAT4 assay, we discerned a subset of refractory CRS patients with abnormally low STAT4 phosphorylation. The deficiency showed improvement both in-vitro and in-vivo after exposure to Latilactobacillus sakei (aka Lactobacillus sakei), an effect at least partially dependent on IL-12.

Conclusion

In refractory CRS patients, an identified STAT4 defect correlates with poor clinical outcomes after sinus surgery, which can be therapeutically targeted by Latilactobacillus sakei treatment. Prospective double-blind placebo-controlled trials are needed to validate our findings.

Reduction in healthcare resource use through 24 months following sinus surgery with steroid-eluting implants in chronic rhinosinusitis patients with and without nasal polyps: a real-world study

OBJECTIVE

To investigate the impact of steroid-eluting implants after endoscopic sinus surgery (ESS) on health care resource use (HCRU) in chronic rhinosinusitis patients with (CRSwNP) and without (CRSsNP) nasal polyps.

METHODS

This retrospective, observational cohort study using real-world evidence data included adult patients with CRS who underwent ESS in 2015-2019 with at least 24 months of data before and after ESS. Patients who received implants were matched to patients who did not based on a propensity score developed using baseline characteristics and NP status. HCRU was compared between cohorts within each CRSwNP and CRSsNP subgroup using chi-square tests (binary variables).

RESULTS

The implant cohort in the CRSwNP subgroup had fewer all-cause outpatient (90.0% vs. 93.9%, p < .001) and all-cause otolaryngology (64.3% vs. 76.4%, p < .001) visits as well as fewer endoscopy (40.5% vs. 47.4%, p = .005) and debridement (48.8% vs. 55.6%, p = .007) procedures than the non-implant cohort. The implant cohort in the CRSsNP subgroup had fewer all-cause outpatient (88.9% vs. 94.2%, p < .001) and all-cause otolaryngology (53.5% vs. 74.4%, p < .001) visits as well as fewer endoscopy (31.8% vs. 41.7%, p < .001) and debridement (36.7% vs. 53.4%, p <.001) procedures than the non-implant cohort. Revision sinus surgery was reduced in the implant cohort in both subgroups, and reached statistical significance in the CRSwNP subgroup (3.8% vs. 6.0%, p = .039) but not in the CRSsNP subgroup (3.6% vs. 4.2%, p = .539).

CONCLUSIONS

Overall, patients receiving implants had lower HCRU for 24 months after sinus surgery independent of nasal polyp status, and revision surgery was reduced in CRSwNP patients. These findings provide additional evidence that long-term reductions in HCRU may be achieved with steroid-eluting implant use during sinus surgery.What is known on this topicPatients with chronic rhinosinusitis with nasal polyps (CRSwNP) have a disproportionately higher burden of disease and consume greater healthcare resources than chronic rhinosinusitis patients without nasal polyps (CRSsNP).CRSwNP patients represent approximately 30% of CRS patients who undergo surgery, but their clinical course is disproportionally complicated by disease recurrence and revision surgery.Steroid-eluting sinus implants have been shown in clinical trials to improve short-term postoperative outcomes after endoscopic sinus surgery (ESS) in CRS patients in general.A recent real-world evidence study reported that steroid-eluting sinus implants following ESS were associated with a reduction in HCRU in CRS patients followed for 18 months, but the impact of implants on HCRU in CRSwNP and CRSsNP patients separately remains unknown. What this study addsIn this observational study, reduced HCRU was observed in CRSwNP and CRSsNP patients who receive steroid-eluting sinus implants.Use of implants in CRSwNP and CRSsNP patients was associated with a significant reduction in healthcare visits (all-cause outpatient, all-cause otolaryngology), and sinus procedures (endoscopy, debridement).Revision surgery was significantly reduced in the implant cohort of CRSwNP patients and trended lower in the implant cohort of CRSsNP patients.Use of implants had no significant impact on all-cause ER/urgent care visits or sinus-related imaging.

Clinical Characteristics of Rhinosinusitis in Children in a Tertiary Care Center

BACKGROUND

Rhinosinusitis (RS) is a term used in clinical practice to describe inflammation of the paranasal and nasal sinuses. This condition can be categorized based on the duration of symptoms into acute, subacute, and chronic RS. It is important to note that RS presents differently in pediatric patients compared to adults. In children, typical symptoms include cough, bad breath (halitosis), irritability, fatigue, and swelling around the eyes. This study aims to shed light on the prevalence and clinical characteristics of RS in the pediatric age group.

METHODS

This retrospective cohort study was conducted at King Abdullah Specialized Children's Hospital (KASCH) in Riyadh, Saudi Arabia, which is a tertiary care center under the authority of the Ministry of National Guard Health Affairs (MNGHA) in Saudi Arabia, using the medical records of all patients diagnosed with RS between 2019 and 2022.

RESULTS

In this study, 345 pediatric patients with RS were examined. A significant portion (n = 106, 30.7%) were older than 12 years, and males made up the majority (n = 210, 60.9%). Chronic RS without nasal polyps prevailed (n = 299, 86.7%), mainly affecting the maxillary sinus (n = 200, 58%). Notably, 29% (n = 100) were diagnosed after age 12. Key symptoms included nasal congestion (n = 233, 67.5%), nasal discharge (n = 202, 58.6%), and facial discomfort (n = 191, 55.4%). Most (n = 314, 91%) received medical treatment, resulting in improvement for 78.8% (n = 272). Of those not improving (n = 73, 21.2%), 47.9% (n = 35) received medical management, and the rest underwent surgery, primarily functional endoscopic sinus surgery (n = 38, 52.1%).

CONCLUSION

 RS is a common condition affecting children, with symptoms like nasal obstruction, discharge, and facial discomfort. Chronic RS, particularly in the maxillary sinus, is the most prevalent type. Medical treatment was the first choice and generally effective, but when needed, surgical intervention, mainly functional endoscopic sinus surgery, was pursued.

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.

Diverse Endotypes of Chronic Rhinosinusitis and Clinical Implications

Chronic rhinosinusitis (CRS) is a highly heterogeneous disease characterized by inflammation in the nasal and sinus mucosa. The CRS phenotypes, based on the presence or absence of nasal polyps, are known as CRS with nasal polyps (CRSwNP) and CRS without nasal polyps (CRSsNP). However, this classification has limitations in fully capturing the mechanisms and clinical manifestations of CRS. To address the heterogeneity of CRS, there has been a growing focus on classifying the condition into distinct endotypes. Endotype classification involves grouping patients based on specific molecular, immunological, and clinical characteristics, allowing for more personalized and targeted treatment approaches.This review delves into the current state of endotype classifications for CRS. It explores the role of geographic factors, microbiome, and subphenotype in shaping different endotypes. Additionally, the review examines how various clinical features are associated with specific endotypes, providing valuable insights into tailoring treatment options for better outcomes and transitions between different endotypes.Overall, this review offers a comprehensive and up-to-date perspective on the intricate realm of CRS endotype classifications. By unraveling the molecular and clinical intricacies, this review lays the foundation for more precise, effective, and individualized treatment strategies in the management of CRS.

Tissue Eosinophilia is Superior to an Analysis by Polyp Status for the Chronic Rhinosinusitis Transcriptome: An RNA Study

OBJECTIVE

RNA sequencing (transcriptomics) is used to study biological pathways. However, the yield of data depends on comparing well-characterized cohorts. We compared tissue eosinophilia versus nasal polyp (NP) status as the metric to characterize transcriptomic mechanisms at play in eosinophilic and non-eosinophilic chronic rhinosinusitis (CRS) versus controls.

METHODS

RNA sequencing was conducted on sinonasal tissue samples of CRS and controls. Analyses were conducted based on polyp status [with nasal polyps (CRSwNP) and without nasal polyps (CRSsNP)] as well as tissue eosinophil levels per high power field (eos/hpf)[non-eosinophilic (<10 eos/hpf, neCRS) or eosinophilic (≥10 eos/hpf, eCRS)]. The yield of differentially expressed genes (DEGs) and biological pathways through Ingenuity Pathway Analysis (IPA) were compared.

RESULTS

CRS tissue differed from controls by 736 statistically significant DEGs. Both NP status and tissue eosinophilia were effective in differentiating CRS from controls and into two distinct subgroups. Statistically significant DEGs identified when comparing CRS by NP status were 60, whereas 110 DEGs were identified using eosinophil cutoff ≥10 and <10 eos/hpf. Additionally, heatmaps showed greater homogeneity within each CRS subgroup when analyzed by tissue eosinophilia versus NP status. On IPA, the IL-17 signaling pathway was significantly different only by tissue eosinophilia status, not NP status, being higher in CRS <10 eos/hpf.

CONCLUSION

Tissue eosinophilia is superior to an analysis by NP status for the study of CRS transcriptome by RNA sequencing in identifying DEGs. Classification of CRS samples by eosinophil counts agnostic of NP status may offer advantageous insights into CRS pathogenetic mechanisms.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:2480-2489, 2023.

Effect of Adding Physiotherapy Program to the Conservative Medical Therapy on Quality of Life and Pain in Chronic Rhinosinusitis Patients

OBJECTIVE

: To assess the effectiveness of combining physiotherapy techniques with conservative medical treatment in chronic rhinosinusitis (CRS) patients.

METHODS

: Sixty-eight volunteers with CRS were randomly assigned. Group A received only traditional medical treatment, whereas group B received a physiotherapy program that included pulsed ultrasound therapy, sinus manual drainage techniques, and self-sinus massage technique in addition to traditional medical treatment. Interventions were applied 3 sessions a week for 4 weeks. The rhinosinusitis disability index (RSDI) served as the main outcome indicator for assessing the quality of life, and the secondary outcome measure was the pressure pain threshold (PPT) using a pressure algometer.

RESULTS

: Wilcoxon signed rank test revealed a significant reduction (p<0.001) in total RSDI values from 71.08±1.13 pretest to 47.14±1.15 posttest for group A, while it decreased from 70.64±1.20 pretreatment to 31.76±1.04 posttreatment for group B; furthermore, Mann-Whitney U-test revealed a significant difference (p<0.001) in total RSDI values between both groups when comparing the change of the pre-post data values, it was 23.94±0.95 for group A and 38.88±0.67 for group B. The independent t-test revealed a highly statistically significant increase (p<0.001) in the PPT values in the experimental group compared to the control group.

CONCLUSION

: The physiotherapy program which included pulsed ultrasound therapy, sinus manual drainage technique, and self-sinus massage technique in conjunction with conventional medical treatment was more beneficial for enhancing the quality of life and PPT than traditional medical treatment alone in CRS patients.

Management paradigms for chronic rhinosinusitis in individuals with asthma: An evidence-based review with recommendations

BACKGROUND

Despite the significant morbidity associated with chronic rhinosinusitis (CRS) in individuals with asthma (CRSwA), there is a paucity of codified, evidence-based management strategies for CRS in this population.

METHODS

Using PubMed, Embase, and Cochrane Review Databases, a systematic review was performed covering management strategies for CRSwA. A total of 5903 articles were screened, and 70 were included for full-text analysis. After application of exclusion criteria, 53 articles comprised the qualitative synthesis. The level of evidence was graded and benefit-harm assessments, as well as value judgment and recommendations, were provided RESULTS: Strong evidence confirms the benefit of oral and topical medications on sinonasal-specific outcomes in individuals with CRSwA; there is low-grade evidence demonstrating that these agents improve lung function and/or asthma control. Moderate to strong evidence suggests that endoscopic sinus surgery (ESS) improves both sinonasal- and asthma-specific quality of life. Although there is insufficient to low evidence to indicate that ESS improves pulmonary function in this population, data indicate a positive impact of this intervention on asthma control. Biologic medications strongly improve both subjective and objective sinonasal- and asthma-specific outcomes.

CONCLUSION

Evidence supports managing CRS in individuals with CRSwA in a stepwise fashion, starting with traditional nonbiologic oral and topical medication, and escalating to second-line treatments, such as ESS and biologics. Optimal treatment of individuals who have CRSwA often requires concurrent, directed management of asthma, as not all CRS interventions impact asthma status.