V Brazilian Consensus on Rhinitis - 2024

Since we published the "IV Brazilian Consensus on Rhinitis", in2017, several advances have been achieved and have enabled a further understanding of the different aspects of "Rhinitis". This new guideline, developed jointly by ASBAI, SBP and SBORL, represents a relevant milestone in the updated and integrated management of the different forms of the disease, and it aims to unify evidence-based approaches to improve the diagnosis and treatment of this common and often underestimated condition. The document covers a wide range of topics, including clear definitions of the different phenotypes and endotypes of rhinitis, risk factors, updated diagnostic criteria, and recommended methods for clinical and laboratory investigation. We stress the importance of detailed clinical history and objective assessment, as well as tools for control and assessing severity tools an accurate diagnostic approach to the disease. Regarding treatment, it emphasizes the treatment customization, considering the severity of symptoms, the presence of comorbidities and the impact on the patient's quality of life. We discuss different drug treatment, in addition to non-pharmacological measures, such as environmental control and specific immunotherapy; and the possible role of immunobiological agents. Furthermore, the consensus addresses issues related to patient education, prevention and management of special situations, such as rhinitis in children, in pregnant women and in the elderly. In short, the "V Brazilian Consensus on Rhinitis" represents a comprehensive and updated guide for healthcare professionals involved in the diagnosis and management of rhinitis, aiming to improve patients' quality of life through an integrated and evidence-based approach.

Biologics in Chronic Rhinosinusitis: Current and Emerging

Chronic rhinosinusitis (CRS) is categorized phenotypically into CRS with and without nasal polyps (CRSwNP, CRSsNP). Endotyping categorizes the disease based on immune cell activity and inflammatory mechanisms into Type 1, Type 2, and Type 3. The Type 2 endotype is the most researched and associated with asthma, atopic disease, and severe CRSwNP. For patients with poorly controlled CRSwNP, there are 3 approved biologic treatments: omalizumab, dupilumab, and mepolizumab. Many other biologics are being tested in Type 2, non-Type 2, and mixed endotypes in CRSwNP and CRSsNP. These studies will play a significant role in shaping the future of CRS management.

When It's Not Allergic Rhinitis: Clinical Signs to Raise a Patient's Suspicion for Chronic Rhinosinusitis

OBJECTIVE

To identify predictors of chronic rhinosinusitis (CRS) in patients presenting with the chief complaint of nasal allergies.

STUDY DESIGN

Cross-sectional study.

SETTING

Tertiary care, academic center.

METHODS

Clinical and demographic characteristics were collected from participants who were patients presenting with the chief complaint of nasal allergies. From all participants, a 22-item Sinonasal Outcome Test (SNOT-22) was collected, and a modified Lund-Kennedy endoscopy score was calculated from nasal endoscopy. Association was sought between having CRS and variables of clinical and demographic characteristics, SNOT-22, and endoscopy score.

RESULTS

A total of 219 patients were recruited and 91.3% were diagnosed with allergic rhinitis; 45.2% were also diagnosed with CRS. Approximately half of the patients with CRS reported no intranasal corticosteroid usage. Having CRS was associated with male sex (odds ratio [OR] = 2.29, 95% confidence interval [CI]: 1.30-4.04, P = .004), endoscopy score (OR = 1.96, 95% CI: 1.59-2.42, P < .001), and the SNOT-22 nasal subdomain score (OR = 1.07, 95% CI: 1.03-1.11, P = .001) related to SNOT-22 items: "need to blow nose," "thick nasal discharge," "sense of taste/smell," and "blockage/congestion of nose." At least moderate (item score ≥3) "blockage/congestion of nose" or "thick nasal discharge," mild "need to blow nose" (item score ≥2) or very mild decreased "sense of taste/smell" (item score ≥1), and any nasal endoscopy findings (endoscopy score ≥1) were statistically significant predictors of CRS.

CONCLUSION

Moderate or more severe nasal obstruction or discharge symptoms, any decreased sense of smell/taste, or positive nasal endoscopy findings in patients believing they have allergic rhinitis should prompt further evaluation of CRS to avoid delays in treatment.

Enhancing nasal endoscopy: Classification, detection, and segmentation of anatomic landmarks using a convolutional neural network

KEY POINTS

A convolutional neural network (CNN)-based model can accurately localize and segment turbinates in images obtained during nasal endoscopy (NE). This model represents a starting point for algorithms that comprehensively interpret NE findings.

Nasal endoscopy: What have we been missing?

Despite the widespread adoption of nasal endoscopy (NE) in the evaluation of sinonasal disease, its diagnostic potential may still be underutilized. Developments in endoscopic technology have led to significant improvements in video quality and maneuverability. However, there is concern that NE continues to be used primarily for the identification of gross pathology, with relative neglect of more subtle findings such as surface features of inflammation and mucus. With fewer technical limitations to perceive these abnormalities, there is potential to greatly improve the diagnostic value of NE. The reader is herein asked to consider several important visual nuances encountered during NE, with the hope that this engenders an appreciation of the versatility of NE as a diagnostic tool.

Endoscopic and Radiologic Central Compartment Disease as Predictors of Perennial Inhalant Allergen Sensitization in Chronic Rhinosinusitis

BACKGROUND

Central compartment atopic disease (CCAD) is a recently described variant of chronic rhinosinusitis (CRS) strongly associated with atopy. The association between central compartment disease (CCD) and inhalant allergy is not well established in South-East Asia, where perennial allergic rhinitis is common.

OBJECTIVES

The primary objective was to evaluate endoscopic and radiologic CCD as predictors of perennial allergen sensitization in primary CRS. The secondary objective was to compare clinical characteristics of CCAD with other CRS subtypes (CRSwNP and CRSsNP).

METHODS

A retrospective study of consecutive patients with primary CRS who underwent endoscopic sinus surgery at our institution was performed. Allergen sensitization was confirmed by skin or serum testing. Endoscopy records and computed tomography scans of paranasal sinuses were reviewed for CCD. The diagnostic accuracy of endoscopic and radiologic CCD in predicting atopy was calculated.

RESULTS

There were 104 patients (43 CCAD, 30 CRSwNP and 31 CRSsNP). Endoscopic CCD was significantly associated with aeroallergen sensitization (odds ratio (OR) 3.99, 95% confidence interval (CI) 1.65-9.67, P = 0.002). Endoscopic CCD predicted atopy with 57% sensitivity, 72% specificity, 69% positive predictive value and positive likelihood ratio of 2.05. Radiologic CCD was not associated with aeroallergen sensitization (OR 0.728, 95%CI 0.292-1.82, P = 0.496). There were more CCAD patients who reported hyposmia (86% vs 42%, P < 0.001) and had anosmia on olfactory testing than CRSsNP (65% vs 14%, P = 0.015). The prevalence of atopy was significantly higher in CCAD than CRSwNP and CRSsNP (70% vs 37% and 42%, P = 0.015 and P = 0.05, respectively). Median serum total immunoglobulin E was higher in CCAD (283 IU/ml) and CRSwNP (127 IU/ml) than CRSsNP (27 IU/ml, P = 0.006 and P = 0.042, respectively).

CONCLUSIONS

Endoscopic CCD was a better predictor of inhalant allergy than radiologic CCD in primary CRS, in a locale of perennial allergic rhinitis.

Outcomes of endoscopic sinus surgery in patients with central compartment atopic disease

Background

Central compartment atopic disease (CCAD) is a subtype of chronic rhinosinusitis (CRS). Research focusing on the endoscopic sinus surgery (ESS) outcomes of CCAD is limited. This study aimed to evaluate the outcomes of ESS in CCAD and compared to 2 following subtypes: chronic rhinosinusitis with nasal polyps (CRSwNP) and concomitant polypoid disease in the central compartment (CRSwNP/CC) and CRSwNP not otherwise specified (CRSwNP NOS).

Methods

This case-control study enrolled patients with bilateral CRSwNP who underwent ESS and had at least 1 year of follow-up. Patients were classified into CCAD, CRSwNP/CC, and CRSwNP NOS. The demographic data, preoperative disease severity, and surgery outcomes, including CRS control status, endoscopic score, and symptom scores at 1 year postoperatively, were collected. We defined well controlled and partly controlled as appropriate disease control.

Results

This study screened 259 patients and enrolled 138 patients with complete medical records and 1-year follow-up (CCAD N = 51, CRSwNP/CC N = 55, CRSwNP NOS N = 32). Among them, appropriate disease control was achieved in 84.3% of patients (43/51) in the CCAD group, 69.1% (38/55) in the CRSwNP/CC group, and 93.7% (30/32) in the CRSwNP NOS group (P = 0.029). Then we performed post-hoc analysis using appropriate disease control and uncontrolled. There was a significant difference between CRSwNP/CC and CRSwNP NOS (P = 0.007), but no significant difference compared CCAD group to CRSwNP/CC group (P = 0.065) and CRSwNP NOS group (P = 0.199). There were significant differences in endoscopic E-score among groups (P < 0.001). In post-hoc analysis, we found that CRSwNP/CC (Median [IQR], 33.32 [42.14]) had a significantly worse E-score than CCAD (8.33 [16.67]) and CRSwNP NOS (4.17 [8.30]). Also, postoperative olfactory visual analog scale (VAS) scores significantly differed among groups (P = 0.043). However, post-hoc analysis showed no difference between any 2 groups. There were no differences in postoperative VAS scores of obstruction (P = 0.159), rhinorrhea (P = 0.398), and headache/facial pain (P = 0.092).

Conclusion

Most CCAD patients had good surgical outcomes 1 year after surgery. Meanwhile, the CRSwNP/CC group had the fewest patients under appropriate disease control.

Inflammatory characteristics of central compartment atopic disease

BACKGROUND

Central compartment atopic disease (CCAD) is an emerging phenotype of chronic rhinosinusitis with nasal polyposis (CRSwNP) characterized by prominent central nasal inflammatory changes. This study compares the inflammatory characteristics of CCAD relative to other phenotypes of CRSwNP.

METHODS

A cross-sectional analysis of data from a prospective clinical study was performed on patients with CRSwNP who were undergoing endoscopic sinus surgery (ESS). Patients with CCAD, aspirin-exacerbated respiratory disease (AERD), allergic fungal rhinosinusitis (AFRS), and non-typed CRSwNP (CRSwNP NOS) were included and mucus cytokine levels and demographic data were analyzed for each group. Chi-squared/Mann-Whitney U tests and partial least squares discriminant analysis (PLS-DA) were performed for comparison and classification.

RESULTS

A total of 253 patients were analyzed (CRSwNP, n = 137; AFRS, n = 50; AERD, n = 42; CCAD, n = 24). Patients with CCAD were the least likely to have comorbid asthma (p = 0.0004). The incidence of allergic rhinitis in CCAD patients did not vary significantly compared to patients with AFRS and AERD, but was higher compared to patients with CRSwNP NOS (p = 0.04). On univariate analysis, CCAD was characterized by less inflammatory burden, with reduced levels of interleukin 6 (IL-6), IL-8, interferon gamma (IFN-γ), and eotaxin relative to other groups and significantly lower type 2 cytokines (IL-5, IL-13) relative to both AERD and AFRS. These findings were supported by multivariate PLS-DA, which clustered CCAD patients into a relatively homogenous low-inflammatory cytokine profile.

CONCLUSIONS

CCAD has unique endotypic features compared to other patients with CRSwNP. The lower inflammatory burden may be reflective of a less severe variant of CRSwNP.

Targeting Epithelium Dysfunction and Impaired Nasal Biofilms to Treat Immunological, Functional, and Structural Abnormalities of Chronic Rhinosinusitis

Chronic rhinosinusitis (CRS) with (CRSwNP) or without (CRSsNP) nasal polyps is a prevalent and heterogeneous disorder existing as a spectrum of clinical conditions with complex underlying pathomechanisms. CRS comprises a broad syndrome characterized by multiple immunological features involving complex interactions between the genes, the microbiome, host- and microbiota-derived exosomes, the epithelial barrier, and environmental and micromilieu exposures. The main pathophysiological feature is an epithelial barrier disruption, accompanied by microbiome alterations and unpredictable and multifactorial immunologic overreactions. Extrinsic pathogens and irritants interact with multiple epithelial receptors, which show distinct expression patterns, activate numerous signaling pathways, and lead to diverse antipathogen responses. CRSsNP is mainly characterized by fibrosis and mild inflammation and is often associated with Th1 or Th17 immunological profiles. CRSwNP appears to be associated with moderate or severe type 2 (T2) or Th2 eosinophilic inflammation. The diagnosis is based on clinical, endoscopic, and imaging findings. Possible CRS biomarkers from the peripheral blood, nasal secretions, tissue biopsies, and nasally exhaled air are studied to subgroup different CRS endotypes. The primary goal of CRS management is to maintain clinical control by nasal douching with isotonic or hypertonic saline solutions, administration of nasal and systemic steroids, antibiotics, biologic agents, or, in persistent and more severe cases, appropriate surgical procedures.

Novel insights into central compartment atopic disease - a literature review

INTRODUCTION

Central compartment atopic disease (CCAD) is a newly recognized variant subtype of chronic rhinosinusitis (CRS). Although CCAD has been reported to be correlated with allergy, there is still a considerable gap in our knowledge regarding CCAD.

AREAS COVERED

We have conducted a thorough analysis of the literature on CCAD. This review provides current understanding and therapeutic strategies of CCAD. In this article, we will review the clinical presentations and parameters, allergy-related etiology, endotypes, and recommended management of CCAD.

EXPERT OPINION

CCAD is considered as an aeroallergen-driven type 2/eosinophilic inflammatory pattern. Although CCAD can be diagnosed by endoscopy and radiology, as well as allergen test, pathogenesis and management strategies leave much to be desired, and further studies are needed.

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 characteristics of central compartment atopic disease in Southern China

BACKGROUND

Central compartment atopic disease (CCAD) is a newly reported subset of chronic rhinosinusitis. It was considered associated with inhalant antigen. However, CCAD in Chinese population is not fully studied yet.

DESIGN

Prospective cohort study.

OBJECTIVE

This study aimed to describe the clinical manifestations of CCAD and compared the following two subtypes: sinonasal polyps and concomitant polypoid disease in the central compartment (CRSwNP/CC) and CRSwNP not otherwise specified (CRSwNP NOS). Also, we compared the clinical manifestations of atopy CCAD and non-atopy CCAD.

METHODS

We consecutively enrolled CRSwNP patients without prior sinus surgery, and assessed the nasal endoscopy and computed tomography of the paranasal sinuses. Allergy was confirmed by skin or serum testing. Eosinophilic CRSwNP (ECRS) was considered as tissue eosinophils to total inflammatory cells >10%.

RESULTS

We enrolled a total of 116 patients, including 39 with CCAD, 38 with CRSwNP/CC and 39 with CRSwNP NOS. Atopy was detected in 37.1% of the CCAD group, an incidence showing no significant difference from those in the other two groups (37.1% in the CRSwNP/CC group, 31.0% in the CRSwNP NOS group; p = 0.846). However, the incidence of ECRS in the CCAD group was the highest among the different groups (97.4% in the CCAD group vs. 67.6% in the CRSwNP/CC group vs. 35.1% in the CRSwNP NOS group; p = 0.000). In addition, the incidence of asthma in the CCAD group (33.3%) was significantly higher than that in the CRSwNP NOS group (10.3%), but quite similar to CRSwNP/CC (34.2%). In the subgroup analysis of CCAD, only total serum IgE and sIgE demonstrated significant differences between atopy CCAD and non-atopy CCAD.

CONCLUSION

CCAD in Southern China may associate with asthma and significant eosinophilia, with a lower incidence of systemic allergy based on skin and serum testing.

The link between allergic rhinitis and chronic rhinosinusitis

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

A Prospective Analysis of Systemic and Local Aeroallergen Sensitivity in Central Compartment Atopic Disease

OBJECTIVE

To compare systemic allergen sensitivity and local allergen sensitivity in the sinonasal tissue of patients with a recently identified subtype of chronic rhinosinusitis strongly associated with allergy: central compartment atopic disease (CCAD).

STUDY DESIGN

Prospective cohort study.

SETTING

Academic tertiary care rhinology clinic.

METHODS

Fifteen participants with endoscopic and radiographic evidence of CCAD underwent systemic allergy testing with skin testing and measurement of serum specific immunoglobulin E (sIgE) to 15 regionally common aeroallergens. Local allergen sensitivity was determined by measuring sIgE to these same 15 allergens in their sinonasal tissue. sIgE testing was performed by ImmunoCAP assay.

RESULTS

Of the 15 participants, 14 were sensitive to at least 1 allergen locally in the central compartment and systemically on skin or serum testing. Among all participants, 4 were sensitive to allergens on central compartment sIgE testing that they were not sensitive to on skin and serum sIgE testing (range, 1-8 discordant allergens). Comparisons between local and systemic aeroallergen sensitivity results showed statistically significant correlations (P < .05) ranging from weak to strong.

CONCLUSION

Systemic allergy testing is recommended in the initial workup for CCAD. Local allergen sensitivities may be present in a subset of patients with CCAD. Further study of the clinical significance of these sensitivities should be undertaken in CCAD, with evaluation of the role of medical therapies and allergen immunotherapy in the treatment of CCAD.

A comparison of central compartment atopic disease and lateral dominant nasal polyps

BACKGROUND

The characteristics and surgical outcomes of central compartment atopic disease (CCAD) vary by region and race. Therefore, we aimed to identify the risk factors, symptom severity, and prognosis of CCAD in the Asian population.

METHODS

This case-control study recruited patients diagnosed with chronic rhinosinusitis with nasal polyps who underwent functional endoscopic sinus surgery (FESS) at a tertiary hospital in Taiwan. Patients were classified into CCAD and lateral-dominant nasal polyp (LDNP) groups based on endoscopic and computed tomography imaging findings. The demographic data, symptom severity scores, and surgical outcomes of the 2 groups were analyzed.

RESULTS

Our study included 442 patients (CCAD group: n = 51; LDNP group: n = 391). We found that CCAD was strongly related to both asthma (9.8% vs 3.5%, p = 0.04) and allergic rhinitis symptoms (43.3% vs 26.6%, p = 0.01). Higher eosinophil counts were detected in blood serum (5.8% vs 2.8%, p < 0.01) and histopathologic profiles (57.0 vs 17.3, p < 0.01) among patients with CCAD. Improvements in 22-item Sino-Nasal Outcome Test (SNOT-22) score and mucociliary clearance time (MCT) after surgical intervention revealed that the CCAD group had a better response to FESS (SNOT-22 score: -31.82 vs -22.66, p < 0.01; MCT: -233.06 vs -191.93 seconds, p = 0.03). The revision FESS rate was not different between the 2 groups.

CONCLUSION

Polyps originating from the central compartment were found to be related to asthma and allergic rhinitis in Taiwanese patients. A higher eosinophil count was suggested in both serum and local nasal tissue from patients with CCAD. FESS serves as an effective treatment for symptom relief in patients with CCAD.

Chinese Central Compartment Atopic Disease: The Clinical Characteristics and Cellular Endotypes Based on Whole-Slide Imaging

Purpose

Histopathologic characterizations of central compartment atopic disease (CCAD) by whole-slide imaging remains lacking. We aim to study clinical presentations and cellular endotyping diagnosis of Chinese CCAD using artificial intelligence (AI).

Methods

A total of 72 patients diagnosed with chronic rhinosinusitis with nasal polyps (CRSwNP) were enrolled. CCAD was defined by positive result of serology specific IgE, endoscopic and radiological findings. The aeroallergen sensitization status, endoscopic results, radiological findings, and symptoms were evaluated and compared between patients with CCAD (n=14), eosinophilic CRSwNP (ENP, n=32) and non-eosinophilic CRSwNP (NENP, n=26). The cellular endotypes including eosinophils, neutrophils, lymphocytes, and plasma cells were analyzed by the AI chronic rhinosinusitis evaluation platform 2.0.

Results

CCAD was most common in male (71.43%). The positive rate of aeroallergen in patients with CCAD is 100%, which is much higher than those in patients with ENP (40.63%) and NENP (23.08%). Allergic rhinitis incidence was found to be 57.14% in Chinese CCAD subjects, which is obviously higher when compared with those in patients with ENP (21.88%) or NENP (0.00%). The presence of asthma was not significantly different between groups. Chinese CCAD population demonstrated mild symptoms and lower endoscopic and radiological scores than those in patients with ENP and NENP. For cellular endotypes in CCAD subjects, the median of eosinophils, neutrophils, lymphocytes, and plasma cells was 26.55%, 0.49%, 60.85%, and 7.33%, respectively. The proportion of eosinophils in nasal tissue and peripheral blood mononuclear cells from the CCAD group is between the proportions in those patients with ENP and NENP.

Conclusion

Chinese CCAD was associated with aeroallergen sensitivity, and displayed an eosinophil-dominant inflammatory pattern. Thus, proper management with allergy control and topical steroids could be recommended for CCAD treatment.

Precision Medicine in Chronic Rhinosinusitis: Where Does Allergy Fit In?

Chronic rhinosinusitis (CRS) is a clinical syndrome stemming from persistent inflammation of the sinonasal mucosa. Phenotypically, it is traditionally and widely described according to the presence or absence of polyps. While this distinction is simple to use, it has little bearing on prognosis and treatment, for CRS is essentially an inflammatory disease resulting from dysregulated interaction between a multitude of host and environmental factors. Allergy is merely one of them and, like many of the proposed aetiologies, has been subject to much debate which will be discussed here. As our understanding of CRS continues to evolve, previous so-called conventional wisdom about phenotypes (e.g. CRS with nasal polyps is associated with Type 2 inflammation) is being challenged, and new phenotypes are also emerging. In addition, there is growing interest in defining the endotypes of CRS to deliver precise and personalised treatment, especially pertaining to the development of biologics for the group of severe, difficult-to-treat CRS patients. A proposed model of precision medicine tailored to management of CRS will also be introduced to readers, which can be continually modified to adapt to new discoveries about this exciting condition.

Pathophysiological and Clinical Aspects of Chronic Rhinosinusitis: Current Concepts

Adult chronic rhinosinusitis (CRS) is a chronic inflammation of the mucosa of the nose and paranasal sinuses. According to the latest EPOS guidelines CRS should be regarded as primary or secondary with distinction between diffuse and localized disease. Further pathophysiologic research identified different inflammatory patterns leading to the term “endotyping of CRS.” The primary focus of endotyping is to define a dominant inflammatory type allowing for better orientation of therapy. The current approach proposes the differentiation between type 2 (eosinophilic) and non-type 2 inflammatory responses. In this review pathophysiological concepts of CRS will be discussed, focusing on the different inflammatory endotypes of T cells with special attention to the eosinophilic type 2 inflammatory response. The contribution of innate and adaptive immune system responses is presented. The possibility of endotyping based on sinonasal secretions sampling is brought to attention because it is indicative of corticosteroid responsiveness and available to most ENT surgeons. Furthermore, the clinical aspects of the three distinct phenotypes are analyzed in view of their characteristics, the related endoscopic findings, typical radiological imaging, histopathology findings, their relation toward allergy and obvious therapeutical implications. This overview will enable clinicians to relate pathophysiological patterns with clinical observations by explaining the different inflammatory mechanisms, hence providing a better understanding of therapy.

Central compartment atopic disease: outcomes compared with other subtypes of chronic rhinosinusitis with nasal polyps

BACKGROUND

Central compartment atopic disease (CCAD) is a variant of chronic rhinosinusitis (CRS) with nasal polyps (CRSwNP) characterized by polypoid changes of the superior nasal septum, middle (MT), and/or superior turbinates (ST). This study evaluates surgical outcomes in patients with CCAD compared with other CRSwNP subtypes.

METHODS

Retrospective analysis was performed at Emory University from May 2012 to November 2019. Patients undergoing primary endoscopic sinus surgery (ESS) for CCAD, aspirin-exacerbated respiratory disease (AERD), allergic fungal rhinosinusitis (AFRS), and CRSwNP not otherwise specified (CRSwNP NOS) were included consecutively, beginning with the earliest date of CCAD patient. Outcome measures included polyp recurrence, revision ESS, oral steroid use, and oral antibiotic use. Pearson chi-square and univariate analysis of variance (ANOVA) were performed for group comparisons.

RESULTS

Data was collected for 132 patients (CCAD = 38, AERD = 20, AFRS = 37, CRSwNP NOS = 37; 58 females, mean age 42.9 years [range, 13-85 years]). CCAD patients demonstrated polyp recurrence less frequently than expected, whereas AFRS patients had polyp recurrence more frequently than expected (p = 0.003; phi 0.32). CCAD patients underwent revision ESS less frequently than expected; AFRS and CRSwNP NOS underwent revision ESS more frequently than expected (p = 0.03; phi 0.26). CRSwNP NOS patients received more total antibiotic courses than those with CCAD (p = 0.01; eta-squared 0.09) and more courses of antibiotics per month than those with AFRS (p = 0.03; eta-squared 0.07). There was no significant difference in follow-up measures across groups (number of visits, total months, or visits per month).

CONCLUSION

Rates of polyp recurrence and revision ESS were significantly lower in CCAD patients compared with patients with other CRSwNP subtypes, suggesting durable benefit of ESS and postoperative medical therapy in CCAD patients.

Clinical characteristics and cytokine profiles of central-compartment-type chronic rhinosinusitis

BACKGROUND

The clinical characteristics of central-compartment-type chronic rhinosinusitis (CRS) in East Asian individuals are not clear. We sought to investigate the clinical features and the cytokine profiles of central-compartment-type CRS in our patient group.

METHODS

Adult patients diagnosed with bilateral CRS were recruited, and patients who had previously undergone sinus surgery and pansinusitis (Lund-Mackay scores >23) were excluded. Central-compartment-type CRS was defined by both endoscopic and radiological features. The symptoms, inhalant allergen sensitization status, endoscopic findings, and radiological assessments were recorded and compared between patients with central-compartment-type CRS and other types of CRS. We also examined the extent of tissue eosinophilia and specific cytokine protein levels (eosinophil cationic protein [ECP], myeloperoxidase [MPO], immunoglobulin E [IgE], interleukin [IL]-4, IL-5, and IL-13) in the sinonasal tissues.

RESULTS

Central-compartment-type CRS was found in 16 (23.9%) patients, and non-central-compartment-type CRS was found in 51 (76.1%) patients. Hyposmia or anosmia as the major symptom was more common in the central-compartment-type CRS group. The numbers of eosinophils in tissue and serum were significantly higher in the central-compartment-type CRS patients. The presence of allergen sensitization was not significantly different between groups. The levels of IL-5 and IL-13 were increased in middle turbinate tissues of patients with central-compartment-type CRS.

CONCLUSION

Central-compartment-type CRS was associated with hyposmia or anosmia, eosinophilic subtypes, and elevated levels of IL-5 and IL-13 in middle turbinate tissues but not necessarily correlated with allergic disease in our patients.

Nasal polyp epithelial atypia and exposure to nickel and copper

BACKGROUND

Possible factors for cell atypia in nasal mucosa include noxious chemicals: ammonia, formaldehyde and heavy metals.

AIMS

Case presentation of a nasal polyp with epithelial dysplasia in a worker exposed to nickel and copper salt dust.

CASE REPORT

A 27-year-old man complained of impaired nasal breathing and mild right-sided epistaxis. He was exposed to copper and nickel salt dust for 6 years. Clinical examination showed a polypoid lesion arising from the right middle turbinate. Histopathological examination of the excised lesion showed high-grade epithelial dysplasia. Duration of exposure and concentration of heavy metals in serum suggest the biological plausibility of exposure to these factors and development of epithelial dysplasia in the nasal mucosa.

CONCLUSIONS

Epithelial dysplasia may occasionally be noted in inflammatory nasal polyps, especially in workers exposed to heavy metals.

Chronic Rhinosinusitis and Allergy: Increased Allergen Sensitization Versus Real Allergic Rhinitis Multimorbidity: a Systematic Review

PURPOSE OF REVIEW

The objective of this article is to provide a recent update of the association between allergic inflammation and chronic rhinosinusitis. The systematic approach of this review article critically evaluates the literature published over the past few years and summarizes the specific pathophysiologic pathway of chronic sinonasal inflammation that has been postulated.

RECENT FINDINGS

From a systematic search of the Ovid Medline and Embase, 11 studies were included in a qualitative analysis of the association between systemic allergy and chronic rhinosinusitis (CRS). Of the 11 studies, four showed an association, three were inconclusive, and four did not show any association. From the systematic search, 50 studies suggested four possible pathophysiologic pathways that may explain the association of allergic inflammation and CRS, namely, (1) staphylococcal enterotoxin, (2) the innate immunity pathway, (3) mast cell-associated inflammation, and (4) dysbiosis of microbiota. The association of systematic allergy and CRS remains inconclusive. The recent advances in the study of the pathophysiologic pathway of CRS may lead to the possibility of a targeted treatment option for CRS.

The Role of Allergic Rhinitis in Chronic Rhinosinusitis

This literature review collates and summarizes recent literature to explore the relationship between chronic rhinosinusitis (CRS) and allergy. The relationship between CRS and allergy is not fully understood. However, current evidence suggests a relationship between allergy and specific endotypes of CRS with nasal polyposis, including allergic fungal rhinosinusitis and central compartment atopic disease. Specific endotypes of CRS with nasal polyps seem to have an association with allergy. More evidence is necessary to better characterize this relationship. Level of evidence: 5.

Is Respiratory Epithelial Adenomatoid Hamartoma Related to Central Compartment Atopic Disease?

BACKGROUND

Respiratory epithelial adenomatoid hamartoma (REAH) is a benign lesion of the sinonasal tract that may mimic more concerning pathology. Clinical factors associated with REAH have not been well characterized.

OBJECTIVE

To report our findings on patients with this pathologic diagnosis.

METHODS

A retrospective chart review of patients with REAH between September 2006 and November 2019 was conducted. Data collected included clinical allergic rhinitis and asthma history, additional sinonasal diagnoses, prior sinus surgery, and the location of the REAH within the sinonasal cavity.

RESULTS

Twenty-six patients were identified (53.8% male, mean age 62 years [range, 29-93]). Bilateral REAH occurred in 50%. REAH was located at the superior nasal septum in 84.6% cases, with the remainder identified in sinus contents submitted for pathology, making definitive site uncertain. Concurrent sinonasal inflammatory disorders were identified in 18 patients (69.2%), including chronic rhinosinusitis with nasal polyps-not otherwise specified (6), chronic rhinosinusitis without nasal polyps (4), aspirin-exacerbated respiratory disease (2), allergic fungal rhinosinusitis (1), central compartment atopic disease (5), and IgG4-related sclerosing disease (1). Eight patients had isolated REAH. Adequate allergy records were available for 19 patients, of which 18 of 19 (94.7%) had clinical allergic rhinitis.

CONCLUSIONS

REAH is a benign sinonasal lesion commonly located within the central compartment of the nasal cavity, a site of significant allergen exposure. Affected patients have a high incidence of allergy along with chronic inflammatory conditions. The coexistence of REAH within inflammatory nasal mucosa in a consistent anatomic location, suggests REAH may have a similar etiology to central compartment atopic disease, with resultant respiratory glandular ingrowth within long-standing reactive changes of mucosa derived from ethmoid embryologic origin.

Central compartment atopic disease: prevalence of allergy and asthma compared with other subtypes of chronic rhinosinusitis with nasal polyps

BACKGROUND

Central compartment atopic disease (CCAD) is a recently described variant of chronic rhinosinusitis with nasal polyp (CRSwNP) associated with inhalant allergy. An association with asthma was noted to be uncommon within our clinical practice. The purpose of this study was to determine allergy and asthma prevalence in CCAD and other CRSwNP subtypes.

METHODS

A retrospective analysis at a tertiary care institution was performed over the period from 2015 to 2019. CRSwNP was grouped into the following subtypes: allergic fungal rhinosinusitis (AFRS); aspirin-exacerbated respiratory disease (AERD); CCAD; and CRSwNP not otherwise specified (CRSwNP NOS). Patients with sinonasal polyps and concomitant polypoid disease in the central compartment (CRSwNP/CC) were analyzed as a separate cohort for the purpose of this study. Prevalence of allergy and asthma was compared between groups.

RESULTS

Three hundred fifty-six patients were included. CRSwNP NOS was the most common subtype (37.1%) and CRSwNP/CC was the least common (3.7%), with other CRS subtypes ranging between 11.5% and 24.2%. Asthma prevalence was highest in AERD (100%) and CRSwNP NOS (37.1%), but substantially lower in AFRS (19.0%) and CCAD (17.1%). Asthma was significantly more common in AERD and CRSwNP NOS when compared with CCAD (p < 0.001 and p = 0.039, respectively). Prevalence of allergy was significantly higher in AFRS (100%), CCAD (97.6%), CRSwNP/CC (84.6%), and AERD (82.6%) when compared with CRSwNP NOS (56.1%) (p < 0.001).

CONCLUSION

CCAD represents a clinically distinct phenotype of CRSwNP with a high prevalence of allergy and low prevalence of asthma. Patients with both CCAD and diffuse sinonasal polyps had an allergy prevalence approaching that of CCAD and an asthma prevalence approaching CRSwNP NOS.

Application of Clinical Scores in the Differential Diagnosis of Chronic Rhinosinusitis With Nasal Polyps in a Chinese Population

Background

Eosinophilic (Eos) and non-eosinophilic (non-Eos) chronic rhinosinusitis with nasal polyps (CRSwNP) react differently to clinical treatment, with eosinophilic chronic rhinosinusitis with nasal polyps (Eos CRSwNP) being more likely to recur after surgery.

Objective

To explore the clinical value of the visual analog scale (VAS), nasal endoscopy score (Lund–Kennedy, L–K), computed tomography (CT) score (Lund–Mackay scoring system, L–M), and blood Eos percentage in the differential diagnosis of Eos CRSwNP and non-Eos CRSwNP.

Methods

Ninety-nine patients with CRSwNP were enrolled in this study and assigned to 2 groups (Eos CRSwNP and non-Eos CRSwNP). The blood Eos percentage and VAS, L–K, and L–M scores in the 2 groups of patients were compared. A receiver operating characteristic (ROC) was used to assess the usefulness of VAS, L–K, and L–M scores for differentiating Eos CRSwNP and non-Eos CRSwNP.

Results

There were significantly differences between the Eos CRSwNP group and non-Eos CRSwNP group in the following scores: blood Eos percentage, mean VAS score, olfaction/VAS, general discomfort/L–K, edema score/L–K, olfactory cleft (OC) score via endoscopy, mean L–M score, anteriorethmoid sinus score, posterior ethmoid sinus score, sphenoid sinus score, frontal sinus score, and OC score via CT. An ROC analysis showed that blood Eos percentage had the highest area under the ROC curve (AUC) value (0.749); however, several other scores (olfaction score/VAS, edema score/L–K, and mean L–M score) also had high AUC values. The combination of olfaction score/VAS and blood Eos percentage had the highest clinical convenience score as well as high sensitivity and specificity. A combination of cutoff values for the 2 predictors (blood Eos percentage ≥3.85%, olfaction score/VAS score ≥3) showed a sensitivity of 75.5% and a specificity of 78.0%.

Conclusion

The olfaction score/VAS score and the blood Eos percentage can be combined to differentiate Eos CRSwNP from non-Eos CRSwNP in a Chinese population.

Central compartment involvement in aspirin-exacerbated respiratory disease: the role of allergy and previous sinus surgery

BACKGROUND

Evidence for a relationship between allergy and chronic rhinosinusitus with nasal polyps (CRSwNP) is equivocal. Central compartment (CC) atopic disease is a nasal inflammatory condition related to inhalant allergy. CC involvement is common in aspirin-exacerbated respiratory disease (AERD), a subset of CRSwNP, and we hypothesize it is related to allergic status.

METHODS

This study was a retrospective analysis of a single-institution database for the January 2016 to February 2019 time period. Data regarding endoscopic CC findings, clinical allergy history, and results of allergy testing were collected. Statistical analysis was performed, with significance set at p < 0.05.

RESULTS

Seventy-two AERD patients met the inclusion criteria. Fifty-nine patients had CC involvement (53 bilateral, 6 unilateral). For patients with documented allergy status, 100% of patients with endoscopic CC disease had clinical allergic rhinitis (AR), and 45 of 48 (93.8%) had positive allergy testing. Thirteen patients had no CC involvement (4 with clinical AR; 3 of 7 with positive allergy testing). CC endoscopic findings in AERD were significantly associated with clinical allergy (p < 0.0001, phi = 0.771). Overall, patients with CC involvement averaged 3.8 surgeries vs 3.2 for those without CC involvement (p = not statistically significant). However, patients with septal involvement averaged 4.2 surgeries vs 2.0 for those without septal involvement (p = 0.004). As the number of sinus surgeries increases, middle turbinate (MT) resection (r = 0.300, p = 0.022) and septal involvement (r = 0.372, p = 0.004) significantly increase. All patients with MT resection had septal disease, whereas none without CC disease had MT resection.

CONCLUSION

Most AERD patients exhibit AR, and this correlates with CC disease. As the number of surgeries increases, MT resection may predispose to polyposis of the septum.

Clinically relevant phenotypes in chronic rhinosinusitis

BACKGROUND

Chronic rhinosinusitis (CRS) is a complex disease that incorporates many different conditions. Currently, primary CRS is considered a disease of broad airway inflammation, however, the previous classification of CRS with and without nasal polyposis fails to adequately classify patients based upon their etiology of illness. Our aim with this review is discuss the clinical presentation, radiology, endoscopy, histopathology, and treatment algorithm of three different phenotypes of primary CRS: central compartment atopic disease, eosinophilic CRS, and non-eosinophilic CRS.

METHODS

A narrative review of a tertiary rhinology center's research themes and how they are applied to clinical protocols and practice was assessed.

DISCUSSION

Diagnosis and treatment of upper and lower airway conditions become increasingly important as phenotypes and endotypes are being described. There are well-described therapies to treat the different phenotypes of CRS, based upon the presumed underlying cause of the inflammatory process. Research continues to shed more light on different endotypes and phenotypes of airway inflammation, however, clinical differentiation of CRS can be applied in clinic practice with three simple phenotypes of CRS. Understanding these different phenotypes and their etiologies allows for further management beyond the 'maximum medical therapy and then surgery' approach that has often been used in the management of CRS.

Chronic Rhinosinusitis: Does Allergy Play a Role?

A few chronic rhinosinusitis (CRS) variants have demonstrated a strong association with environmental allergy, including allergic fungal rhinosinusitis (AFRS) and central compartment atopic disease (CCAD). However, the overall relationship between CRS and allergy remains poorly defined. The goal of this review is to evaluate the relationship between CRS and allergy with a focus on specific CRS variants.

The relationship between allergy and chronic rhinosinusitis

OBJECTIVE

To summarize the current evidence regarding a relationship between chronic rhinosinusitis (CRS) and allergy.

METHODS

Literature review.

RESULTS

Despite frequent assumption of an association between CRS and allergy the relationship between these entities remains poorly defined. Certain CRS entities, however, have demonstrated a strong association with allergy-namely allergic fungal rhinosinusitis and central compartment atopic disease.

CONCLUSION

Studies are heterogeneous and largely retrospective in design with inconclusive evidence for an association between CRS and allergy. Knowledge of CRS endotypes is important in order to understand which entities may or may not be associated with allergy. Level of Evidence: 5.

Diagnostic Algorithm for Evaluating Nasal Airway Obstruction

Nasal obstruction is a common symptom and can have a large impact on patient quality of life. There are numerous causes, including anatomic, congenital, inflammatory, infectious, neoplastic, toxic, and systemic. An algorithmic approach can aid in ensuring all pertinent patient information is incorporated into the final diagnosis and treatment plan. Key components include a thorough history, physical examination including modified Cottle and Cottle maneuver, patient-reported outcome measures and/or quality of life questionnaires, examination with and without decongestion, and nasal endoscopy. The resultant information can then be effectively used to narrow the differential and guide the next steps in management.

Polypoid change of middle turbinate is associated to an increased risk of polyp recurrence after surgery in patients with chronic rhinosinusitis with nasal polyps

BACKGROUND

Chronic rhinosinusitis with nasal polyps (CRSwNP) affects approximately 4% of general population. Patients with CRSwNP have greater burden of CRS symptoms and higher rate of relapse after either medical or surgical treatments. The aim of this study was to evaluate the association between polypoid change of anterior free border of middle turbinate and rate of relapse in patients with CRSwNP.

METHODS

A controlled prospective cohort study was performed. Seventy-seven adult patients with CRSwNP in whom their MT polypoid change was proved and 77 patients without MT polypoid change were recruited. Allergy, asthma, aspirin hypersensitivity, Lund Kennedy and Lund Mackay scores and eosinophilic scores of polyp and middle turbinate were recorded. Patient's health-related quality of life was assessed using the 22-item Sino-Nasal Outcome Test (SNOT-22) questionnaire. All patients were evaluated 12 months after ESS. Polyp relapse, Lund Kennedy scores and SNOT-22 scores were documented.

RESULTS

The relapse rate in patients with MT polypoid change was significantly higher than the control group (37.14 vs. 20.58, p value = 0.03). Eosinophil score of nasal polyps and MT specimens were significantly higher in patients with MT polypoid change than patients without polypoid change. The postoperative Lund Kennedy and SNOT-22 scores in patients with MT polypoid change were significantly higher than the control group.

CONCLUSION

This study showed a significant association between polypoid change of anterior free border of middle turbinate and nasal polyp relapse. This new and simple criterion of severity of CRSwNP could have clinical implications.

Allergic phenotype of chronic rhinosinusitis based on radiologic pattern of disease

OBJECTIVES/HYPOTHESIS

Polypoid edema of the middle turbinate is a marker of inhalant allergy. Extensive edematous changes may result in limited central nasal and sinus disease, which has been called central compartment atopic disease (CCAD). Radiologically, this is seen as soft tissue thickening in the central portion of the sinonasal cavity with or without paranasal sinus involvement. When the sinuses are involved, the soft tissue thickening spares the sinus roof or lateral wall (centrally limited). This centrally limited radiological pattern was assessed among chronic rhinosinusitis (CRS) patients and compared to allergy status.

STUDY DESIGN

Diagnostic cross-sectional study.

METHODS

This study included consecutive CRS patients without prior sinus surgery. Computed tomography (CT) scans of the paranasal sinuses were blindly assessed and allergy status was confirmed by serum or skin testing. Individual sinus cavities were defined as either centrally limited or diffuse disease. The radiological pattern that may predict allergy was determined, and its diagnostic accuracy was calculated.

RESULTS

One hundred twelve patients diagnosed to have CRS, representing 224 sides, were assessed (age 46.31 ± 13.57 years, 38.39% female, 41.07% asthma, Lund-Mackay CT score 15.88 ± 4.35, 56.25% atopic). The radiological pattern defined by centrally limited changes in all of the paranasal sinuses was associated with allergy status (73.53% vs. 53.16%, P = .03). This predicted atopy with 90.82% specificity, 73.53% positive predictive value, likelihood positive ratios of 2.16, and diagnostic odds ratio of 4.59.

CONCLUSIONS

A central radiological pattern of mucosal disease is associated with inhalant allergen sensitization. This group may represent a CCAD subgroup of patients with mainly allergic etiology.

LEVEL OF EVIDENCE

3b Laryngoscope, 128:2015-2021, 2018.

International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis

BACKGROUND

Critical examination of the quality and validity of available allergic rhinitis (AR) literature is necessary to improve understanding and to appropriately translate this knowledge to clinical care of the AR patient. To evaluate the existing AR literature, international multidisciplinary experts with an interest in AR have produced the International Consensus statement on Allergy and Rhinology: Allergic Rhinitis (ICAR:AR).

METHODS

Using previously described methodology, specific topics were developed relating to AR. Each topic was assigned a literature review, evidence-based review (EBR), or evidence-based review with recommendations (EBRR) format as dictated by available evidence and purpose within the ICAR:AR document. Following iterative reviews of each topic, the ICAR:AR document was synthesized and reviewed by all authors for consensus.

RESULTS

The ICAR:AR document addresses over 100 individual topics related to AR, including diagnosis, pathophysiology, epidemiology, disease burden, risk factors for the development of AR, allergy testing modalities, treatment, and other conditions/comorbidities associated with AR.

CONCLUSION

This critical review of the AR literature has identified several strengths; providers can be confident that treatment decisions are supported by rigorous studies. However, there are also substantial gaps in the AR literature. These knowledge gaps should be viewed as opportunities for improvement, as often the things that we teach and the medicine that we practice are not based on the best quality evidence. This document aims to highlight the strengths and weaknesses of the AR literature to identify areas for future AR research and improved understanding.