Clinical practice guideline (update): adult sinusitis

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.

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.

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.

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.

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.

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.

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.

Awareness Among Primary Care Physicians Regarding the Alarm Symptoms and Signs of Rhinosinusitis

Background Rhinosinusitis is a common condition. Primary care physicians (PCPs) play a vital role in diagnosing and managing rhinosinusitis, including identifying alarm symptoms and signs. However, limited research exists on PCPs' awareness of these alarm symptoms. Objectives This study aimed to assess the awareness of PCPs in Saudi Arabia regarding the alarm symptoms and signs of rhinosinusitis and identify knowledge gaps. Methodology A descriptive cross-sectional study was conducted among 153 PCPs in Taif, Saudi Arabia. An online questionnaire covering demographic data and multiple-choice questions on alarm symptoms and signs of rhinosinusitis was administered. Knowledge level was assessed based on the score of the responses to knowledge items. Data analysis was performed using IBM SPSS software (IBM Corp., Armonk, NY). Results The study revealed a low awareness of alarm symptoms and signs of rhinosinusitis among PCPs. Knowledge gaps were observed in recognizing symptoms and appropriate referral pathways. Participants showed inadequate awareness of severe headaches, frontal swelling, anosmia, cacosmia, and nasal bleeding or crustation as alarm symptoms. The average knowledge score was 4.57 ± 1.91 out of 10. Conclusion The study highlights the need to improve PCP awareness of alarm symptoms and signs of rhinosinusitis in Saudi Arabia. Educational programs should be developed to address knowledge gaps and enhance understanding of guidelines, facilitating early identification and referral of severe cases and improving patient outcomes.

Frontal Sinus Anatomy Variations in Race and Sex Using the International Frontal Sinus Anatomy Classification

Objective: To identify frontal sinus anatomical variations grouped by patient sex, race, and presence of chronic rhinosinusitis with frontal sinus involvement (CRFS) using the International Frontal Sinus Anatomy Classification (IFAC) system. Methods: A retrospective review from 2015 to 2020 was performed of consecutive adult patients with computed tomography sinus imaging. Prevalence of frontal sinus cells using the IFAC system was recorded. Comparisons were made between patient race, sex, and CRFS groups. Results: A total of 184 patients (368 sides) were included, 90 (48.9%) of which had CRFS. The racial distribution was 50 white (27.2%), 50 black (27.2%), 45 Hispanic/Latino (24.5%), and 39 Asian (21.2%) patients. The supra agger cell was most prevalent in the white population (P = 0.009), and supraorbital ethmoid cells were more prevalent in the Asian population (P = 0.017). Patients with frontal sinus disease were more likely to have a supraorbital ethmoid cell (P = 0.024). Overall, CRFS was more prevalent in the Asian population (P = 0.013). Conclusion: Significant differences in frontal sinus anatomy and disease exist between patient race and sex. Supraorbital ethmoid cells are associated with the development of CRFS. These patterns in frontal sinus anatomy should be noted prior to frontal sinus surgery to improve surgical awareness and outcomes.

Intranasal trigeminal function in chronic rhinosinusitis: a review

INTRODUCTION

Chronic rhinosinusitis (CRS) affects 5-12% of the general population with significant effects on quality of life. Chronic inflammation also seems to affect intranasal trigeminal sensitivity.

AREAS COVERED

A systematic literature search was done in Scopus, Web of Science, and PubMed in February 2023. The review addressed intranasal trigeminal function in patients with CRS and summarized current knowledge on trigeminal function as it relates to the symptoms, assessment, and treatment of CRS.

EXPERT OPINION

Olfaction and trigeminal function are synergistic and this interaction may contribute to trigeminal dysfunction in CRS. Aside from anatomic blockage through polypoid mucosal changes, trigeminal dysfunction may affect the perception of nasal obstruction in CRS. Upregulated immune defense mechanisms leading to damage of nerve endings, changes in nerve growth factor release or other mechanisms may be responsible for trigeminal dysfunction in CRS. Since the pathophysiology of trigeminal dysfunction in CRS is poorly understood, current treatment recommendations are directed toward the therapy of CRS as an underlying cause, although the effect of surgery and corticosteroids on trigeminal function remains unclear. A standardized and validated trigeminal test that is accessible and easy to use in clinical settings would be beneficial for future studies.

Inflammation resolution and specialized pro-resolving lipid mediators in chronic rhinosinusitis

INTRODUCTION

In chronic rhinosinusitis (CRS), a complex pathophysiology results from varied pro-inflammatory stimuli but is consistently characterized by classic cellular, molecular, and microbial alterations. Normally, endogenous specialized pro-resolving mediators (SPM) actively promote resolution of inflammation through numerous pathways, including those involved in host antimicrobial defense. However, these pathways appear to be disrupted in CRS.

AREAS COVERED

This paper describes features of CRS in the context of chronic tissue inflammation, and potential mechanisms by which specialized pro-resolving mediators promote active resolution of tissue inflammation.

EXPERT OPINION

Temporal phases of resolution must be tightly regulated to successfully resolve inflammation in CRS while preserving tissue functions such as barrier maintenance and special sensory function. Dysregulation of SPM enzymatic pathways has been recently shown in CRS and is associated with disease phenotypes and microbial colonization patterns. Current research in animal models and in vitro human cell culture, as well as human dietary studies, demonstrate relevant changes in cell signaling with lipid mediator bioavailability. Further clinical research may provide insight into the therapeutic value of this approach in CRS.

A Rare Case of Chronic Rhinosinusitis With Elevated Levels of Immunoglobulin G4

Chronic rhinosinusitis is a condition characterized by inflammation of the paranasal sinuses causing several symptoms, including facial pain, anosmia, nasal drainage, and obstruction for a minimal duration of three months. It is a commonly occurring disease and is diagnosed through direct visualization or the detection of inflammation on a CT scan. A mucosal tissue biopsy typically reveals stromal fibrosis and an increase in submucosal glands, and infiltration of mixed mononuclear cells, neutrophils, and eosinophils may also be present but typically makes up less than 10% of the total cells. T helper type 2 releasing cytokines, interleukins (IL-5 and IL-13), as well as histamine, are frequently found in high concentrations in polyp tissue. We report a case of rare chronic rhinosinusitis. The patient's specimen shows a very high number of immunoglobulin G4 (IgG4)-positive plasma cells.

Does the Protrusion of Corticobasal Implants in the Maxillary Sinuses Affect Sinus Health? A Retrospective Study

AIM

The aim of this retrospective study is to investigate the effect of corticobasal implant penetration in the nasal and maxillary sinuses on sinus health and implant survival rate in cases of severely atrophid ridges.

MATERIALS AND METHODS

This retrospective study was conducted on thirty patients with 172 implants who underwent corticobasal implant treatment between 2014 and 2018. Implants were divided into two groups according to the penetration depths (Group A, <4 mm; Group B, 4 mm). Inclusion criteria for the study included: (A) patients with severe maxillary ridge resorption with an immediately loaded corticobasal implant-supported prosthesis that showed implant protrusion inside the maxillary sinus on cone-beam computed tomography (CBCT); and (B) patients with a preoperative and postoperative follow-up CBCT scan using the same standard technique and machine. (C) Patients without any history of sinusitis before implant insertion patients who fulfilled the inclusion criteria were recalled for follow-up. The presence of sinus complications was clinically assessed according to the clinical practice guidelines for adult sinusitis of the American Academy of Otolaryngology-Head and Neck Surgery and Radiologically using CBCT. Moreover, patient satisfaction was evaluated using yes-or-no questions. The result was statistically analyzed using Fisher's Exact test.

RESULTS

Despite the differences in implant penetration depths, no clinical signs of sinusitis were evident in any patient. One patient presented with transient epistaxis after the surgery, and 2 patients with nine implants revealed nonsignificant thickening of the sinus membrane radiologically (p = 0.055). All implants showed optimum bone-implant contact with a 100% survival rate. A significant relationship was reported between the thickness of the membrane and the patient's gender, hypertension, and smoking habits. (p = 0.001*, p = 0.002*, and p = 0.034*, respectively).

CONCLUSION

Penetration of corticobasal implants in the maxillary sinus did not compromise the health of the maxillary sinus or implant survival rate.

CLINICAL SIGNIFICANCE

Limited posterior maxillary bony support and maxillary sinus pneumatization present challenges in implant dentistry and increase the possibility of implant protrusion inside the maxillary and nasal cavities. Hence, studying the effect of this protrusion on the maxillary sinuses' health and implant survival is highly significant.

Experience of People With Chronic Sinusitis During COVID-19 Lockdown in Saudi Arabia: Insights and Lessons

Background This study aims to evaluate the effect of the COVID-19 lockdown period on chronic rhinosinusitis (CRS) symptoms control. Methodology This cross-sectional study was carried out on adult patients (aged ≥18 years) who visited King Abdulaziz University Hospital within six months before the lockdown starting date. Background information, including patients' diagnosis, presence of rhinitis, number of previous surgeries, and medications, was collected. CRS symptom burden was measured using a validated Arabic version of the 22-item Sino-Nasal Outcome Test (SNOT-22). Study participants were required to complete the survey two months after the start of the lockdown. Results Out of 66 patients, 43 agreed to participate. The majority of respondents (34, 75.6%) were diagnosed with CRS with nasal polyps. The study revealed no differences between pre- and post-lockdown total symptom scores. Conclusions The COVID-19 pandemic has affected the health system worldwide in many ways. Regarding the scope of our study, CRS symptoms, fortunately, did not worsen with the pandemic. This is considered the first reported study to assess such symptom control among people with CRS in Saudi Arabia during the COVID-19 lockdown period.

Tobacco use increases the risk of chronic rhinosinusitis among patients undergoing endoscopic sinus surgery

BACKGROUND

Although it has been postulated that tobacco use, as well as other environmental exposures, may contribute to chronic rhinosinusitis (CRS), the data remain limited. Here, we utilised a large state population database to assess the association between tobacco use and CRS prevalence among patients undergoing endoscopic sinus surgery (ESS).

METHODS

Employing a case-control study design, the Utah Population Database was queried for patients age >18 with a diagnosis of CRS and tobacco use who underwent ESS between 1996 and 2018. Smoking status was compared between patients with CRS (n = 34 350) and random population controls matched 5:1 on sex, birth year, birthplace, time residing in Utah, and pedigree (i.e., familial) information (n = 166 020). Conditional logistic regression models were used for comparisons between CRS patients and their matched controls. All analyses were repeated, additionally adjusting for race, ethnicity, tobacco use, asthma history, and interaction between tobacco use and asthma history.

RESULTS

A total of 200 370 patients were included in the final analysis. Patients with CRS were significantly more likely to demonstrate a history of tobacco use than controls (19.6% vs. 15.0%; p < .001), with an adjusted odds ratio (aOR) of 1.42, 95% confidence interval 1.37-1.47; p < .001. More patients with CRS and comorbid asthma used tobacco (19.5%) than controls with asthma (15.0%; p < .001).

CONCLUSION

History of tobacco use may portend increased risk for the development of CRS among patients undergoing ESS compared to healthy controls.

International consensus statement on allergy and rhinology: Allergic rhinitis - 2023

BACKGROUND

In the 5 years that have passed since the publication of the 2018 International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis (ICAR-Allergic Rhinitis 2018), the literature has expanded substantially. The ICAR-Allergic Rhinitis 2023 update presents 144 individual topics on allergic rhinitis (AR), expanded by over 40 topics from the 2018 document. Originally presented topics from 2018 have also been reviewed and updated. The executive summary highlights key evidence-based findings and recommendation from the full document.

METHODS

ICAR-Allergic Rhinitis 2023 employed established evidence-based review with recommendation (EBRR) methodology to individually evaluate each topic. Stepwise iterative peer review and consensus was performed for each topic. The final document was then collated and includes the results of this work.

RESULTS

ICAR-Allergic Rhinitis 2023 includes 10 major content areas and 144 individual topics related to AR. For a substantial proportion of topics included, an aggregate grade of evidence is presented, which is determined by collating the levels of evidence for each available study identified in the literature. For topics in which a diagnostic or therapeutic intervention is considered, a recommendation summary is presented, which considers the aggregate grade of evidence, benefit, harm, and cost.

CONCLUSION

The ICAR-Allergic Rhinitis 2023 update provides a comprehensive evaluation of AR and the currently available evidence. It is this evidence that contributes to our current knowledge base and recommendations for patient evaluation and treatment.

Clinical outcomes of dupilumab therapy in chronic rhinosinusitis with nasal polyps in a Canadian tertiary care rhinology practice

BACKGROUND

In 2020, dupilumab became the first monoclonal antibody therapy to be approved by Health Canada for the treatment of chronic rhinosinusitis with nasal polyps (CRSwNP). The primary aim of this study was to characterize the outcomes in an initial cohort of patients with CRSwNP who have undergone dupilumab therapy.

METHODS

A retrospective study was conducted of patients with CRSwNP who were treated with dupilumab. Demographic information, comorbidities, number of previous surgeries, and insurance information were collected. The primary outcome were changes in the sinonasal outcome test (SNOT-22) scores from baseline to timepoints after receiving dupilumab.

RESULTS

Forty-eight patients were considered for dupilumab therapy, and 27 (56%) received coverage or were able to fund the medication independently. Patients waited an average of 3.6 months to obtain access to the medication. The mean age of the patients was 43. Forty-one percent (11/27) of patients had aspirin exacerbated respiratory disease, and 96% (26/27) had a diagnosis of asthma. The mean length of time on dupilumab was 12.1 months. The baseline SNOT-22 score was 60.6. The mean decrease at 1 month, 3 months, 6 months, and 12 months after starting dupilumab was 8.8, 26.5, 42.8, and 33.8, respectively. There were no serious adverse events.

CONCLUSION

Patients treated with dupilumab in a Canadian tertiary care rhinology clinic demonstrated substantial clinical improvement as measured by disease-specific sinonasal outcomes. Further studies are needed to determine the longer-term effectiveness and adverse event profile of this novel therapy.

Work productivity and activity impairment in patients with chronic rhinosinusitis undergoing endoscopic sinus surgery-A prospective, multi-institutional study

BACKGROUND

Productivity loss and activity limitations due to chronic rhinosinusitis (CRS) are known to contribute to the significant economic and personal burden of disease. The purpose of this study was to assess productivity and activity impairment before and after endoscopic sinus surgery (ESS) for medically refractory CRS.

METHODS

This investigation was a prospective, multi-institutional, observational cohort study. Patients diagnosed with medically refractory CRS completed the Work Productivity and Activity Impairment-Specific Health Problem (WPAI-SHP) questionnaire before surgery and approximately 6 months after the procedure. Factors associated with minimal clinical important differences (MCIDs) for productivity and activity impairment were identified.

RESULTS

A total of 279 study participants were screened for inclusion, of whom 176 (63.1%) with postoperative follow-up were included in the final cohort. Preoperative productivity and activity impairment were observed in 63.2% and 69.8% of the patients, respectively. Among these patients, postoperative improvement equaling at least 1 MCID was reported in both productivity (76.1%) and activity (76.4%) impairments. Multivariate regression identified sphenoidotomy (odds ratio [OR], 4.18; 95% confidence interval [CI], 1.03-17.02) as the only factor associated with increased likelihood of productivity improvement, whereas septoplasty during ESS (OR, 8.45; 95% CI, 2.33-30.68) and migraine (OR, 0.35; 95% CI, 0.12-0.96) were associated with differential odds of activity improvement.

CONCLUSION

CRS is associated with a substantial burden on productivity and activity that significantly improves after treatment with ESS. These data may facilitate improved patient counseling and shared decision-making regarding surgical management for CRS.

Comparative study of clinical symptoms of chronic rhinosinusitis with nasal polyps patients

AIM

The aim of this study is to explore the clinical characteristics in chronic rhinosinusitis with nasal polyps (CRSwNP) patients with different serum specific IgE (SIgE) and eosinophilic granulocyte infiltration status.

METHODS

This retrospective observational study included patients diagnosed with CRSwNP and underwent functional endoscopic sinus surgery at the Yinchuan First People's Hospital between June 2019 and June 2021. A total of 192 patients with CRSwNP were included (100 males). The patients were 41.7 ± 15.1 years old. The disease course ranged 4.6-18.2 months. The visual analog scale (VAS) score (p < .001), endoscopic score (p = .014), computerized tomography (CT) score (p < .00) and the sino-nasal outcome Test-22 (SNOT-22) score (p < .001) were significantly different among patients with SIgE-positive combined eosinophilic chronic rhinosinusitis (ECRS), patients with SIgE-positive combined non-ECRS, patients with SIgE-negative combined ECRS, and patients with SIgE-negative combined non-ECRS.

RESULTS

In pairwise comparison, the VAS score (20.72 ± 2.24 vs. 13.09 ± 1.62, 13.84 ± 1.34, and 12.67 ± 1.20, respectively), endoscopic score (8.09 ± 1.04 vs. 7.06 ± 0.98, 7.69 ± 1.18, and 7.75 ± 1.07, respectively), CT score (13.18 ± 1.66 vs. 8.79 ± 0.88, 11.08 ± 1.12, and 11.08 ± 1.12, respectively), and SNOT-22 score (27.62 ± 2.31 vs. 12.09 ± 1.83, 14.84 ± 1.84, and 12.97 ± 1.50, respectively) was significantly higher in patients with SIgE-positive combined ECRS compared to patients with SIgE-positive combined non-ECRS, patients with SIgE-positive combined non-ECRS (all p < .0083). The VAS score, endoscopic score, and CT score might be higher in CRSwNP patients with SIgE-positive combined ECRS.

CONCLUSION

In this study, the VAS score, endoscopic score, and CT score were higher in the patients with SIgE-positive combined ECRS. This study might provide a reference for treatment in patients with CRSwNP.

What do we mean when we have a "sinus infection?"

INTRODUCTION

Sinus infections are a common reason patients seek medical care. However, the intended meaning of the term sinus infection among patients and otolaryngologists is incompletely understood.

METHODS

In this multi-institutional cross-sectional study, a semantics-based questionnaire was provided to consecutive patients presenting to otolaryngology clinics at six academic centers from June 2020 until May 2021. The primary outcome was respondent definitions for sinus infection from a list of 28 proposed terms covering six general categories. Secondary outcome measures included differences between geographic regions.

RESULTS

Responses were obtained from 560 patients (54% female, mean age 48.9 years) and 29 otolaryngologists (42% female, mean age 37.4 years). Patients and otolaryngologists selected a median of 10 and 11 terms, respectively, to define a sinus infection. Among patients the most frequently selected symptom categories were mucus (500, 89.3%), pressure/pain (480, 85.7%), and airflow (468, 83.6%). Compared to patients, clinicians selected with greater frequency the symptom categories of pressure/pain (14.3% difference; 95% CI, 7.6% to 22.5%), mucus (10.7% difference; 95% CI, 4.7% to 18.3%) and airflow (13.0% difference; 95% CI, 4.8% to 21.7%). Multiple categories were selected by 96% of patients and 100% of providers.

CONCLUSION

The definition of sinus infection appears variable for both patients and otolaryngologists, though patients appear to apply a broader range of symptoms to the term sinus infection. There were no pronounced geographic differences in the description of a sinus infection in this US sample population. Patients commonly described sinus infection in the context of pain-related symptoms. Appreciation of these semantic differences may enable more effective patient-clinician communication.

A comparative analysis of endoscopic sinus surgery versus biologics for treatment of chronic rhinosinusitis with nasal polyposis

BACKGROUND

Comparative effectiveness research between endoscopic sinus surgery (ESS) and biologic therapy for severe chronic rhinosinusitis with nasal polyposis (CRSwNP) is a nascent field as new therapeutic modalities become clinically available.

METHODS

A prospective, multicenter cohort of CRSwNP patients, undergoing ESS between 2011 and 2019, were compared to phase-3 biologic trial data. Patients undergoing ESS received baseline nasal endoscopy quantified via Lund-Kennedy (LK) grading. Patients meeting inclusion criteria, modified from Dupilumab-LIBERTY-NP-24&52, omalizumab-POLYP-1&2, and Mepolizumab-SYNAPSE clinical trials, were included in this study. Baseline characteristics and outcome measures were compared between these cohorts at 24 weeks and 52 weeks, when possible.

RESULTS

A total of 111 CRSwNP patients met modified inclusion criteria. There were no statistically significant differences in baseline age, sex, asthma status, aspirin-exacerbated respiratory disease status, smell identification, LK-polyp score, and Lund-Mackay computed tomography (CT) scores between ESS and biologic groups. At 24 weeks, ESS demonstrated significantly greater improvements in 22-item Sino-Nasal Outcome Test (SNOT-22) compared to one (of two) dupilumab trials (p < 0.05) and both omalizumab trials (p < 0.001). ESS associated with significantly lower nasal polyp scores (NPS) compared to dupilumab (p < 0.001) and omalizumab (p < 0.001), despite comparable improvements in smell identification (p > 0.05). At 52 weeks, ESS resulted in statistically similar improvement in SNOT-22 scores compared to dupilumab (p = 0.21), but NPS remained significantly lower in the ESS group compared to dupilumab (p < 0.001) and mepolizumab (p < 0.001).

CONCLUSION

At 24 weeks and 52 weeks, ESS offers comparable SNOT-22 improvements compared to dupilumab. ESS and dupilumab offer comparable improvement in smell identification at 24 weeks. Compared to omalizumab, ESS offers superior SNOT-22 improvements. ESS offers significantly greater reductions in polyp size compared to omalizumab, dupilumab, and mepolizumab therapies.

Does the Prosthetic Phase of Dental Implants Justify the Prescription of Preventive Antibiotics in Healthy Patients? A Systematic Review

Recently published surveys data show that the routine prescription of preventive antibiotics (PA) in the prosthetic phase of dental implants is more common than might be expected. The present study aimed to answer the PICO (population, intervention, comparison, and outcome) question "In healthy patients starting the implant prosthetic phase, does the prescription of PA compared with not prescribing PA decrease the incidence of infectious complications?" by a systematic literature review. A search was performed in 5 databases. The criteria employed were those described in the PRISMA Declaration. Studies included were those that provided information on the need to prescribe PA in the prosthetic phase of implants, that is, in second-stage surgeries, impression-taking, and prosthesis placement. The electronic search identified 3 studies that met the established criteria. The prescription of PA in the prosthetic phase of implants does not show a justified benefit/risk ratio. Preventive antibiotic therapy (PAT) may be indicated in the second stages or in peri-implant plastic surgery procedures lasting more than 2 hours and/or where soft tissue grafts are used extensively. In these cases, given the current lack of evidence, it is recommended to prescribe 2 g of amoxicillin 1 hour before surgery and, in allergic patients, to prescribe 500 mg of azithromycin 1 hour preoperatively.

Management of the Upper Airway Distress During Pregnancy

Pregnancy can induce significant upper airway distress in women by the induction of rhinitis of pregnancy (ROP). Pregnancy can also exacerbate underlying rhinopathies. Little is known regarding the pathophysiology of the ROP. Diagnosis of other coexistent rhinopathies is key. Treatment regimens closely mirror standard treatments for other rhinopathies that are independent of pregnancy and are generally accepted as safe. Early recognition of the progression of rhinitis in the pregnant patient into complications of rhinosinusitis is important to prevent harm to both mother and fetus.

Patient Perspectives on the Drivers and Deterrents of Antibiotic Treatment of Acute Rhinosinusitis: a Qualitative Study

BACKGROUND

Antibiotics are prescribed in >80% of outpatient acute rhinosinusitis (ARS) visits, despite the low incidence of bacterial infection. Previous studies have shown patient expectations are the most robust predictor of antibiotics prescription in ARS. However, patient perceptions are not well known or understood.

OBJECTIVE

To understand patient perceptions regarding what drives or deters them from wanting, seeking, and taking antibiotic treatment of ARS.

DESIGN

Iterative thematic analysis of semi-structured interviews.

PARTICIPANTS

Nineteen adults diagnosed with ARS within the prior 60 days at the Northwestern Medicine General Internal Medicine clinic in Chicago, IL.

MAIN MEASURES

Perceptions of patients with ARS.

KEY RESULTS

We interviewed 19 patients, identifying the following drivers of antibiotic use: (1) symptoms, especially discolored rhinorrhea, and seeking relief, (2) belief that antibiotics are a convenient and/or effective way to relieve/cure sinusitis, and (3) desire for tangible outcomes of a clinic visit. For deterrents, the following themes emerged: (1) concern about antibiotic resistance, (2) preference for other treatments or preference to avoid medications, and (3) desire to avoid a healthcare visit. Patients identified that a trustworthy physician's recommendation for antibiotics was a driver, and a recommendation against antibiotics was a deterrent to taking antibiotics; a delayed antibiotic prescription also served as a deterrent. Antibiotic side effects were viewed neutrally by most participants, though they were a deterrent to some.

CONCLUSIONS

Patients have misconceptions about the indications and effectiveness of antibiotics for ARS. Intimate knowledge of key antibiotic drivers and deterrents, from the perspective of patients with ARS, can be leveraged to engage and increase patients' knowledge, and set appropriate expectations for antibiotics for ARS.

Synthesis, characterization and evaluation of hyaluronic acid-based polymers for nasal delivery

Epidemiological research has found that between 5 and 12 percent of the population suffers from chronic rhinosinusitis. Patients are dealing with local side effects such as nasal dryness, sporadic sneezing, and nasal pain in addition to the inflammation. The aim of this study was to synthesize a polymer based on hyaluronic acid in order to provide lubrication combined with a ligand leading to a covalent binding on the nasal mucosa. Hyaluronic acid (HA) was modified with L-cysteine ethyl ester hydrochloride (CYS) via amid bond formation. Ellman's assay, together with spectroscopic techniques like IR and ¹H NMR, confirmed that HACys had been successfully synthesized. It was demonstrated that HACys is safe for administration on the nasal mucosa. The mucoadhesive potential was determined by 3.26-fold with the rotating cylinder assay and 1.4-fold in terms of bioadhesive examination, respectively. Further, the stability of the modified polymer was improved by 7.6-fold compared to the unmodified polymer. Spraying the formulation on the nasal mucosa, the residence time of a model drug was 1.74-fold prolonged at the site of action compared to unmodified polymer. In light of these findings, modified hyaluronic acid (HACys) displayed compelling properties such as lubricity, targeted application, long-lasting effect, and safety and therefore could be an excellent candidate for nasal application.

[Possibilities of usage of modern herbal medicinal product in the treatment of patients with acute viral rhinosinusitis]

INTRODUCTION

The issues of epidemiology, etiopathogenesis, diagnostics and clinic of acute catarrhal rhinosinusitis are considered, the possibility of using the herbal medicinal product Sinupret extract in the treatment of patients with acute viral rhinosinusitis is substantiated.

OBJECTIVE

To evaluate the efficacy and safety of using the drug Sinupret extract in patients with acute viral rhinosinusitis.

MATERIAL AND METHODS

A comparative study of the efficacy and safety of clinical use in patients of the drug Sinupret extract in patients with acute viral rhinosinusitis was carried out in comparison with symptomatic treatment.

RESULTS AND DISCUSSION

After analyzing and processing the results obtained using statistical methods for the main group, a faster rate of decrease in the severity of complaints (data with the use of the MSS visual analogue scale), the severity of inflammation in the nasal cavity and nasopharynx, the amount of discharge from the nose and its viscosity were confirmed. Restoration of respiratory function according to rhinomanometry and mucociliary transport according to the results of the saccharin test also occurred more quickly in patients of the main group compared to the control group. The effectiveness of using Sinupret extract is also confirmed by the results of photoplethysmography.

CONCLUSIONS

The use of the drug Sinupret extract not only contributes to a more rapid improvement in the general well-being of patients and a decrease in the severity of complaints, but also leads to an improvement in the objective picture of the disease (rhinoscopy, the results of anterior active rhinomanometry, saccharin test) compared with the control group, favorably affects the quality life of patients, causes a decrease in economic and social costs against the background of the development of acute viral rhinosinusitis.

Association of cytokine profile with prior treatment failure and revision surgery in chronic rhinosinusitis

BACKGROUND

Inflammatory patterns in chronic rhinosinusitis (CRS) may predict disease severity, need for multiple sinus surgeries, and treatment response. This study analyzes nasal mucus inflammatory cytokine patterns in patients with (CRSwNP) and without (CRSsNP) nasal polyposis and their association with revision sinus surgery.

METHODS

A total of 319 CRS patients who underwent sinus surgery were included. Cytokines were quantified in intraoperative mucus specimens using a multiplex flow cytometric bead assay. Cytokine expression patterns in patients with 0, 1, and ≥2 previous surgeries were analyzed using Kruskal-Wallis and principal component (PC) regression analyses.

RESULTS

There were 122 (38%) patients with CRSsNP and 197 (62%) with CRSwNP. On univariate analysis, interleukin (IL)-1β, IL-6, IL-8, and IL-21 were associated with increasing number of sinus surgeries in CRSsNP, as were IL-2, IL-4, IL-5, IL-6, IL-9, IL-17A, and tumor necrosis factor (TNF)-α in CRSwNP. PC analysis with continuous Poisson regression in CRSwNP demonstrated that high IL-5 and IL-13 and low IL-1β, IL-12, and IL-21 were associated with more prior surgeries. In CRSsNP low IL-13 and high IL-5 and regulated-on-activation, normal T-cell-expressed and secreted (RANTES) were associated with more prior surgeries. Age remained a significant covariate in the full regression model for CRSsNP, but was nonsignificant in CRSwNP.

CONCLUSION

In CRSwNP, elevated IL-5 and IL-13 levels were higher at time of surgery in patients with more prior surgeries. Type 2 cytokines in CRSsNP demonstrated mixed associations with revision surgery. For both phenotypes, IL-10, IL-12, and IL-21 were consistently lower as number of prior surgeries increased, suggesting that treatment-resistant disease may be modulated by impairment in these signaling pathways.

Olfaction and Gustation in Children With Primary Ciliary Dyskinesia

Objective

Primary ciliary dyskinesia (PCD) is a rare autosomal recessive disorder whereby abnormal cilia cause a wide array of respiratory tract manifestations including chronic rhinosinusitis. The purpose of this study was to determine whether olfaction and gustation are impaired in children with PCD.

Study Design

Cross-sectional study.

Setting

Tertiary pediatric academic hospital.

Methods

Children with confirmed PCD based on having at least 1 of 3 approved diagnostic criteria as per The American Thoracic Society guidelines were recruited from The PCD Clinic in our tertiary care pediatric hospital. Odor identification ability was tested using the Universal Sniff (U-Sniff) test and taste threshold was measured using an electrogustometer. The main outcome of this study is to determine the incidence of olfactory dysfunction in children with PCD and investigate if there is an associated gustatory dysfunction.

Results

Twenty-five children participated (14 male, 11 female), The median age was 10.8 years (range: 4.1-17.9 years). Only 4/25 (16%) complained of olfactory dysfunction prior to testing. None of the patients complained of dysgeusia. However, 48% (12/25) scored less than 7 on the U-Sniff, signifying hyposmia or anosmia. In contrast, scores obtained by electrogustometry were in the normal range. There was no correlation between performance on the U-Sniff and electrogustometry testing.

Conclusion

Olfactory impairment in children with PCD is common but underrecognized by patients. This is not associated with abnormal gustation. Among other, this places children with PCD at an increased risk with respect to smelling a fire or detecting spoiled or poisonous food.

Use of low-level laser therapy for patients with chronic rhinosinusitis: a single-blind, sham-controlled clinical trial

Chronic rhinosinusitis (CRS) is one of the most common conditions all over the world. The purpose of this study was to investigate the effects of low-level laser therapy (LLLT) in patients with CRS. Fourteen adult patients with CRS participated in this single-blind, sham-controlled clinical trial (12 male, mean age 40 years). Patients received five successive sessions of sham laser followed by five successive sessions of real laser after 2 days. Ga-Al-As laser of 830 nm in a continuous mode at a power output of 30 mW and energy dose of 1 J was applied on the cheeks and the forehead for the maxillary and frontal sinuses, respectively. Laser was delivered on six points over each sinus, each point for 33 s. Four measurements were taken. The total symptom score (TSS) was calculated as the primary outcome measure. The effects of LLLT on TSS were evaluated by using repeated measure ANOVA. The percentage improvement of real laser and sham laser was compared by Wilcoxon signed ranked test. Cohen's d was used to calculate the effect size. Total symptom score significantly improved after real laser (p = 0.015, Cohen's d = 0.69). The percentage improvement for real laser (34.12 ± 46.43) was significantly better than the sham laser (5.02 ± 37.34, Z =  - 2.23, p = 0.026). No significant improvements were observed after sham laser. This study indicates that five-session active LLLT when compared with sham is effective in the treatment of CRS symptoms.