Biologic Therapy in Pediatric Chronic Rhinosinusitis: A Systematic Review

OBJECTIVE

Provide clinicians with current evidence for biologic therapy in children with chronic rhinosinusitis with nasal polyposis (CRSwNP).

DATA SOURCES

PubMed, MEDLINE, Cochrane, and clinical trial registries.

REVIEW METHODS

Key search terms related to biologic therapy in pediatric CRSwNP were identified via a structured query of current medical literature and clinical trial databases.

CONCLUSIONS

There is a dearth of active clinical trials and research studies for biologics targeting pediatric CRSwNP. There is an ongoing compassionate-use clinical trial involving Dupilumab for children with nasal polyps as well as only 1 published work specifically focused on Dupilumab for pediatric CRSwNP in the setting of aspirin-exacerbated respiratory disease.

IMPLICATIONS FOR PRACTICE

For children with atopic dermatitis, asthma, and chronic idiopathic urticaria, biologic therapies such as Omalizumab, Dupilumab, and Mepolizumab have gained Food and Drug Administration approval. The role of biologic therapy in pediatric CRSwNP demonstrates significant promise in the comprehensive management of the unified airway. Additional Phase III trials are necessary to broaden clinical indications for children with comorbid conditions and complex sinonasal disease.

Translation and Validation of the Sinus and Nasal Quality of Life Surgery Survey in Serbian

Objective

The aim of this study was to translate the Sinus and Nasal Quality of Life Surgery Survey into the Serbian language to evaluate the test-retest reliability and validity.

Study Design

The study included 49 consecutive patients between 12 and 18 years old with rhinologic symptoms. Patients were given a paper survey to complete along with a link to complete the online survey within the same day.

Setting

The study was conducted at the University Children's Hospital Clinic for Pulmonology and Allergology between January 2023 and March 2023.

Methods

Responses between the paper and online survey were compared and regression analysis was performed to evaluate the relationship. Internal reliability and test-retest reliability were assessed using Cronbach's α coefficient and intraclass correlation coefficient. All data were collected and analyzed using SPSS 29.0.

Results

Pearson correlation coefficient between the paper and online survey was very high and statistically significant (r = 0.999; P < .001). Each item had a high correlation (0.993-1.000), where the lowest correlation coefficient was obtained from question 2 (0.993). Average scores in each item differed slightly for only item 2 (mean difference = -0.041), but not to the level of statistical significance. Bland-Altman plot indicated no proportional bias between the 2 versions. Linear regression analysis suggested a high level of agreement between the 2 versions (slope = 1.00, R 2 = 0.999).

Conclusion

The survey is a useful questionnaire to evaluate the quality of life in patients with rhinologic symptoms. The high correlation between the paper and online survey shows the reliability of the questionnaire regardless of administration modality.

[Pediatric chronic rhinosinusitis]

Pediatric chronic rhinosinusitis (PCRS) differs from adult chronic rhinosinusitis (CRS) in several aspects. The confrontation with the environment takes place in the growing sinus system, and the immune system is also developing. The inflammatory mechanisms differ to some extent from those of adult CRS patients. The adenoid vegetations play an important role, particularly during the first 6 years of life. Other pathogenetic aspects are important (e.g., asthma, gastroesophageal reflux disease, immunodeficiency). Genetically determined systemic diseases such as cystic fibrosis cause specific challenges in diagnostics and treatment already in childhood. Consistent conservative therapy is often successful, but surgical procedures that have been proven to be effective and associated with few complications are also increasingly used.

Impact of COVID-19 on nationwide pediatric complicated sinusitis trends throughout 2018-2022

OBJECTIVES

To describe and analyze the trends of pediatric sinusitis cases from 2018 to 2022 across the country utilizing the Pediatric Hospital Information System (PHIS) database focusing on volumes, socioeconomics, and severity of cases.

STUDY DESIGN

Retrospective Cohort Study.

METHODS

A retrospective cohort study using the Pediatric Health Information System (PHIS) database, which consists of 50 children's hospitals was performed. Regions were defined according to PHIS guidelines. We evaluated percentage of sinusitis cases demographic and socioeconomic information and subgrouped by region throughout 2018-2022.

RESULTS

In all regions there were a greater number of sinusitis cases post-COVID compared to pre-COVID, with notable increases in major and extreme severity. The years 2020 and 2021 saw a decrease in total sinusitis cases in all locations. Both surgical intervention and severity of sinusitis were significant factors affecting length of stay. Age and severity were the most significant predictors regarding the odds of having sinus surgery. Age and insurance type were significant predictors of severity, with increasing age and government insurance associated with higher odds of major or extreme severity of sinusitis.

CONCLUSIONS

There appears to be a trend of both increased number and worsening severity of acute sinusitis cases in the post-COVID era compared to pre-COVID. There was a decrease in cases in 2020-2021 during the pandemic, consistent with trends of other communicable diseases.

Pediatric chronic rhinosinusitis

PURPOSE

An up-to-date overview of diagnosis, differential diagnosis, comorbidities, and current medical and surgical management of pediatric chronic rhinosinusitis (PCRS).

METHODS

Review of current evidence-based literature on PCRS.

RESULTS

Diagnosis of PCRS seems to be improving based on recent evidence using nasal endoscopy as well as computed tomography scanning. Recent literature supports the fact that chronic adenoiditis can be an independent etiology of symptoms of chronic sinusitis, that are very similar to chronic adenoiditis. Allergic rhinitis and immune deficiency play important roles in the management of PCRS. Surgery for PCRS has evolved significantly in the last 15-20 years to include adenoidectomy as well as endoscopic sinus surgery.

CONCLUSIONS

PCRS is very common in children causing poor QOL for these children. Medical management remains the main stay of treatment with attention to management of co-morbidities that may contribute to the disease severity. Making the correct diagnosis will help with the choice of surgical intervention if medical management fails.

Predictors of Success of Adenoidectomy in the Treatment of Pediatric Chronic Rhinosinusitis

Objectives: There is consensus for adenoidectomy as treatment of chronic rhinosinusitis (CRS) in children younger than 6 years but less consensus for those aged 6 years and older. The present clinical research study investigated predictors of adenoidectomy success for pediatric CRS. Methods: A retrospective chart review was conducted for 107 children who presented to an otolaryngology clinic and had an adenoidectomy for CRS after failure of maximal medical therapy. Results: The majority of sample was male (N = 63; 58.9%) with mean age of 4.88 (SD = 2.54) and mean Lund-Mackay score of 7.76 (SD = 3.87). Patients who had success with adenoidectomy were older on average [mean (M) = 5.46; SD = 2.83] than patients who failed the procedure (M = 4.36; SD = 2.40; F = 4.06, P = .047). This equated to 67.9% of children aged 6 years and older and 39.2% of children younger than 6 years succeeding with the surgery. Conclusions: Adenoidectomy is a good first-line surgery for children aged 12 years and younger, especially in the 6 to 12 years group which had a high rate of success with 68% experiencing remission of symptoms after surgery.

Endotypes of Nasal Polyps in Children: A Multidisciplinary Approach

Nasal polyps (NPs) are rarely reported in childhood and usually represent red flags for systemic diseases, such as cystic fibrosis (CF), primary ciliary dyskinesia (PCD) and immunodeficiencies. The European Position Paper released in 2020 (EPOS 2020) provided a detailed classification and defined the correct diagnostic and therapeutic approaches. We report a one-year experience of a multidisciplinary team, made up of otorhinolaryngologists, allergists, pediatricians, pneumologists and geneticists, with the aim of ensuring a personalized diagnostic and therapeutic management of the pathology. In 16 months of activity, 53 patients were admitted (25 children with chronic rhinosinusitis with polyposis and 28 with antro-choanal polyp). All patients underwent phenotypic and endo-typic assessment, using proper classification tools for nasal pathology (both endoscopic and radiological), as well as adequate cytological definition. An immuno-allergic evaluation was carried out. Pneumologists evaluated any lower airway respiratory disease. Genetic investigations concluded the diagnostic investigation. Our experience enhanced the complexity of children's NPs. A multidisciplinary assessment is mandatory for a targeted diagnostic and therapeutic pathway.

Novel prognostic factors for successful treatment of pediatric chronic rhinosinusitis using the sinus and nasal quality of life survey (SN-5H)

INTRODUCTION

Chronic rhinosinusitis (CRS) is strongly associated with significant impairment of quality of life (QoL) in children. The SN-5 questionnaire is an important assessment tool for pediatric CRS. This study aimed to evaluate potential prognostic factors for treatment of pediatric CRS within the Hebrew version of the SN-5 questionnaire.

METHODS

A prospective study in pediatric otolaryngology unit. Patients were treated either surgically or pharmacologically. Following informed consent, parents of pediatric CRS patients completed the translated and validated Hebrew version (SN-5H) prior to treatment and after three months. We analyzed the results of both treatment arms according to success (achieving minimal clinically important difference; MCID).

RESULTS

102 children aged 5-12 years and their caregivers participated (74 CRS patients and 28 controls without CRS). SN-5H items scores were significantly higher in CRS patients compared to controls (p < 0.001). Baseline activity scores were higher, while baseline emotional scores were lower in MCID( +) CRS patients, compared to MCID(-) CRS patients (p < 0.05). High emotional stress and low activity scores at baseline were associated with poorer odds to achieve MCID.

CONCLUSIONS

The SN-5H questionnaire is invaluable tool for assessing pediatric CRS patients. Psychosocial aspects of CRS significantly affect QoL and should be addressed in the office pre-treatment. The SN-5H can aid in highlighting patients in need for further reassurance and psychosocial support to manage expectations, and to improve QoL.

Adenoid hypertrophy in children: a narrative review of pathogenesis and clinical relevance

Adenoids (nasopharyngeal tonsils), being part of Waldeyer's ring, are masses of lymphoid tissues located at the junction of the roof and the posterior wall of the nasopharynx. Adenoids play an important role in the development of the immune system and serve as a defence against infections, being the first organs that come into contact with respiratory and digestive antigens. The causes of adenoid hypertrophy are not fully known. They are most likely associated with aberrant immune reactions, infections, environmental exposures and hormonal or genetic factors. The aim of this review is to summarise the current knowledge of adenoid hypertrophy in children and associated diseases. Adenoid hypertrophy has many clinical manifestations that are frequent in the paediatric population and is accompanied by various comorbidities.

Care for Patients with Type-2 Chronic Rhinosinusitis

In the last 20 years, growing interest in chronic rhinosinusitis (CRS) has become evident in medical literature; nevertheless, it is still difficult to identify the real prevalence of the disease. Epidemiological studies are few and focused on heterogeneous populations and diagnostic methods. Recent research has contributed to identifying CRS as a disease characterized by heterogeneous clinical scenarios, high impact on quality of life, and elevated social costs. Patient stratification with phenotypes and identification of the pathobiological mechanism at the origin of the disease (endotype) and its comorbidities are pivotal in the diagnostic process, and they should be addressed in order to properly tailor treatment. A multidisciplinary approach, shared diagnostic and therapeutic data, and follow-up processes are therefore necessary. Oncological multidisciplinary boards offer models to imitate in accordance with the principles of precision medicine: tracing a diagnostic pathway with the purpose of identifying the patient’s immunological profile, monitoring therapeutical processes, abstaining from having only a single specialist involved in treatment, and placing the patient at the center of the therapeutic plan. Awareness and participation from the patient’s perspective are fundamental steps to optimize the clinical course, improve quality of life, and reduce the socioeconomic burden.

Chronic and Recurrent Sinusitis in Children, as Manifestation of Immune Dysfunction and Atopic Background

Rhinosinusitis in children, as in adults, can be classified by duration (acute, recurrent, and chronic) and by cause (viral, bacterial, and inflammatory) and needs to be treated accordingly after careful investigation which include through clinical history, laboratory tests, and, if necessary, nasal endoscopy and imaging studies.

The relative proportion of comorbidities among rhinitis and rhinosinusitis patients and their impact on visit burden

Background

The aim was to evaluate the relative proportion of Non‐steroidal anti‐inflammatory drug exacerbated respiratory disease (NERD) and other comorbidities, and their impact on the burden of outpatient visits due to allergic rhinitis (AR), non‐allergic rhinitis (NAR), acute rhinosinusitis (ARS), and chronic rhinosinusitis with nasal polyps (CRSwNP) and without (CRSsNP).

Methods

We used hospital registry data of a random sample of 5080 rhinitis/rhinosinusitis patients diagnosed during 2005–2019. International Statistical Classification of Diseases and Related Health Problems (ICD10) diagnoses, visits, and other factors were collected from electronic health records by using information extraction and data processing methods. Cox's proportional hazards model was used for modeling the time to the next outpatient visit.

Results

The mean (±standard deviation) age of the population was 33.6 (±20.7) years and 56.1% were female. The relative proportion of AR, NAR, ARS, CRSsNP and CRSwNP, were 33.5%, 27.5%, 27.2%, 20.7%, and 10.9%, respectively. The most common other comorbidities were asthma (44.4%), other chronic respiratory diseases (38.5%), musculoskeletal diseases (38.4%), and cardiovascular diseases (35.7%). Non‐steroidal anti‐inflammatory drug exacerbated respiratory disease existed in 3.9% of all patients, and 17.7% of the CRSwNP group. The relative proportion of subjects having 1, 2, 3 and ≥ 4 other diseases were 18.0%, 17.6%, 17.0%, 37.0%, respectively. All diseases except AR, ARS, and mouth breathing, were associated with a high frequency of outpatient visits.

Conclusions

Our results revealed a high relative proportion of NERD and other comorbidities, which affect the burden of outpatient visits and hence confirm the socioeconomic impact of upper airway diseases.

Pediatric Rhinosinusitis

Rhinosinusitis is a common diagnosis encountered by providers of all disciplines. Pediatric acute and chronic rhinosinusitis account for up to 2% of the total annual visits to the outpatient clinics and emergency departments. Once correct diagnosis is made, appropriate treatment measures can be initiated. It is important to recognize rhinosinusitis in children due to the potential serious complications and the impact it may have on quality of life of those children. Medical management is the mainstay of treatment, and, fortunately, it is successful in most of those children. When medical management fails, or a complication occurs, surgery may be required.

Pediatric chronic sinusitis: diagnosis and management

PURPOSE OF REVIEW

Review the diagnosis and management of pediatric chronic sinusitis given recent advances in both surgical and medical management.

RECENT FINDINGS

Balloon catheter dilation (BCD) of the sinuses has been used as an adjunct to adenoidectomy or in lieu of traditional endoscopic sinus surgery. BCD has been shown to be a safe technique in children although its efficacy compared to maxillary sinus irrigation or traditional sinus surgery cannot be determined based on current studies.

SUMMARY

New advances in BCD and biologics may serve as useful adjuncts in surgical and medical therapy respectively with additional research needed to better delineate the optimal indications for each in the treatment continuum.

Barrier Impairment and Type 2 Inflammation in Allergic Diseases: The Pediatric Perspective

Allergic diseases represent a global burden. Although the patho-physiological mechanisms are still poorly understood, epithelial barrier dysfunction and Th2 inflammatory response play a pivotal role. Barrier dysfunction, characterized by a loss of differentiation, reduced junctional integrity, and altered innate defence, underpins the pathogenesis of allergic diseases. Epithelial barrier impairment may be a potential therapeutic target for new treatment strategies Up now, monoclonal antibodies and new molecules targeting specific pathways of the immune response have been developed, and others are under investigation, both for adult and paediatric populations, which are affected by atopic dermatitis (AD), asthma, allergic rhinitis (AR), chronic rhinosinusitis with nasal polyps (CRSwNP), or eosinophilic esophagitis (EoE). In children affected by severe asthma biologics targeting IgE, IL-5 and against IL-4 and IL-13 receptors are already available, and they have also been applied in CRSwNP. In severe AD Dupilumab, a biologic which inhibits both IL-4 and IL-13, the most important cytokines involved in inflammation response, has been approved for treatment of patients over 12 years. While a biological approach has already shown great efficacy on the treatment of severe atopic conditions, early intervention to restore epithelial barrier integrity, and function may prevent the inflammatory response and the development of the atopic march.

A follow-up study of mucociliary clearance and trace element and mineral status in children with chronic rhinosinusitis before and three months after endoscopic sinus surgery

BACKGROUND

The existing data demonstrate the potential role of trace elements in nasal mucociliary clearance, although the association between trace element and mineral status and ciliary function in children with chronic rhinosinusitis is insufficiently studied. Therefore, the objective of the present study is evaluation of trace element and mineral status and mucociliary function in pediatric CRS patients before and after functional endoscopic sinus surgery.

METHODS

The present study involved 30 children with chronic rhinosinusitis without nasal polyps. During this follow-up the patients were examined preoperatively (point 0), underwent functional endoscopic sinus surgery, and were repeatedly examined at three months postoperatively (point 1). At both points the patients were subjected to quality-of-life assessment using SNOT-20 questionnaire; endoscopic and computer tomography examination of the nasal sinuses; evaluation of ciliary function and mucosal cytology using high-speed videomicroscopy; assessment of blood count and inflammatory markers; as well as analysis of trace element and mineral levels in whole blood, serum, and hair using inductively-coupled plasma mass-spectrometry.

RESULTS

The obtained data demonstrate that endoscopic sinus surgery significantly improved sinonasal pathology in children with chronic rhinosinusitis, as evidenced by significantly reduced Lund-Mackay, Lund-Kennedy, and SNOT-20 scores. At the same time, no significant improvement of ciliary functions or mucosal cytology was observed postoperatively. Trace element status assessment demonstrated that postoperative serum Zn, whole blood Mg and Cu were significantly lower as compared to preoperative values. In contrast, serum Mn and Cr, as well as whole blood Cr and hair Se were characterized by a significant increase at three months postoperatively. Multiple linear regression analysis demonstrated that serum Zn is significantly associated with the number of ciliated cells and cell viability, whereas serum Mn and whole blood Cu concentrations are inversely associated with cell viability and ciliary length, respectively. Hair Se was found to be associated with the number of neutrophils in the mucosa biopsy.

CONCLUSION

Redistribution of trace elements and minerals may at least partially mediate prolonged recovery of mucosal ciliary function in children with chronic rhinosinusitis in three months after functional sinus surgery, although the particular mechanisms of these alterations in trace element levels are to be discovered.

Nasal Polyps in Children: The Early Origins of a Challenging Adulthood Condition

Nasal polyps (NPs) are benign inflammatory masses causing chronic nasal obstruction, usually associated with underlying chronic rhinosinusitis (CRS), which are rarely reported in childhood. The interest in NPs has recently increased due to new therapeutic options, namely biological agents, such as dupilumab, and an update of the European position paper on this topic was released in 2020, providing a detailed classification for these lesions and also discussing diagnostic and therapeutic approaches also in children. In childhood, NPs usually represent red flags for systemic diseases, such as cystic fibrosis and immunodeficiencies. This review outlines the recent data on NPs in childhood, focusing on predisposing factors for CRS as well as on the potential endotypes in this particular age group, for which further studies are required in order to better clarify their pathogenesis and to identify molecular biomarkers that could help achieve more personalized treatments.

Effects of the Traditional Mediterranean Diet in Childhood Recurrent Acute Rhinosinusitis

Introduction: There are more and more studies that demonstrate the anti-inflammatory effects of the traditional Mediterranean diet (TMD). The aim of the study was to assess the effects of an intervention with the TMD in patients with recurrent acute and chronic rhinosinusitis. Material and Methods: We performed a pretest–posttest comparison study in 114 patients (56 girls and 58 boys) aged one to five years who had three or more acute rhinosinusitis episodes in the period of 1 year. They were included for a year in the nutritional program “Learning to eat from the Mediterranean”. The anthropometric, clinical, and therapeutic characteristics were studied. Results: All the studied indicators showed a positive and statistically significant evolution. Of the patients, 53.5% did not have any episode of acute rhinosinusitis, and 26.3% had only one, compared to the 3.37 they had on average in the previous year. The use of antibiotics decreased by 87.6%. The degree of satisfaction of the families was very high. The Mediterranean Diet Quality Index (KIDMED) that assesses the quality of the TMD rose from 7.7 to 11 points. Conclusions: The adoption of the TMD could have promising effects in the prevention and treatment of recurrent acute and chronic rhinosinusitis, limiting the pharmacological and surgical intervention in many of these patients.

Effects of pulsed ultrasound on olfactory dysfunction in patients with chronic rhinosinusitis: A pilot study

BACKGROUND

and purpose. Olfactory dysfunction is a common symptom of chronic rhinosinusitis (CRS). This study aimed to evaluate the effects of therapeutic pulsed ultrasound (PUS) on olfactory dysfunction in patients with CRS.

MATERIALS AND METHODS

Patients with CRS underwent treatment with PUS for 10 sessions, three days a week. The outcome measures were the Smell Identification Test (SIT) and 20-item Sino-Nasal Outcome Test (SNOT-20).

RESULTS

Fifteen patients (9 male, mean age 48.9 ± 9.7 years) with disease duration of 55.13 ± 65.4 months participated. Analyses showed olfactory dysfunction was completely resolved (Cohen's d = 5.62). The SNOT-20 scores showed significant improvement of CRS symptoms after treatment (Cohen's d = 1.55). Effects remained at one-month follow-up.

CONCLUSION

Therapeutic PUS improved the olfactory dysfunction and sino-nasal symptoms in patients with CRS. The PUS can be considered as a promising strategy to target chronic rhinosinusitis.

Serum, Whole Blood, Hair, and Mucosal Essential Trace Element and Mineral Levels in Children with Verified Chronic Rhinosinusitis Undergoing Functional Endoscopic Sinus Surgery

The objective of the present study was to assess hair, serum, whole blood, and excised tissue essential element content in children with chronic rhinosinusitis (CRS). Eighty-eight children with chronic rhinosinusitis and 66 healthy controls were enrolled in the present study. Evaluation of endoscopic Lund-Kennedy and computed tomography Lund-Mackay scores, as well as tissue sampling, was performed only in children with chronic rhinosinusitis. Assessment of Sino-Nasal Outcome Test-20 (SNOT-20) scores was performed in both cases and controls. Hair, whole blood, blood serum, and excised mucosal tissue (only in patients) analysis was performed using inductively coupled argon plasma mass-spectrometry. The obtained data demonstrate that whole blood Ca, Mg, Se, and Zn, as well as hair Ca, Cu, Mg, and Zn levels in the examined patients were significantly lower as compared with the control values. Only serum Zn concentration in children with CRS exceeded the respective control values, whereas serum Cu levels only tended to decrease in CRS. In turn, hair Fe content in children with CRS exceeded that in healthy controls. Regression analysis demonstrate that hair Ca levels, as well as whole blood Ca, Se, and Zn concentrations, were considered as negative predictors, whereas increased hair iron level was significantly directly associated with CRS. Significant associations between hair, serum, whole blood, and tissue element levels and Lund-Kennedy and Lund-Mackay scores were also revealed. Generally, the obtained data demonstrate that chronic rhinosinusitis is associated with impaired essential metal levels in pediatric patients with chronic rhinosinusitis. The observed alterations may contribute to CRS pathogenesis through modulation of mucociliary clearance, immunity, inflammatory response, and redox environment.

A Pilot Investigation of the Pediatric Nasal Microbiome

This proof-of-concept study demonstrates that sinonasal microbiome sequencing with suctioned nasal secretions in children is technically feasible. Eighteen children were enrolled: 11 with symptoms of rhinosinusitis and 7 controls. Samples were collected via a sterile flexible respiratory suction catheter into a suction trap. Samples were analyzed with 16S ribosomal RNA sequencing and subsequent phylogenic mapping. The log2-fold differential abundance in class demonstrated significantly higher quantities of bacteria from the classes Negativicutes, Bacilli, Mollicutes, and Alphaproteobacteria as compared with controls, with a false discovery rate-corrected P value <.01 for all 4. The experimental group showed a higher range of alpha diversity than the control group, although none of the measures of alpha diversity showed a statistically significant difference. Overall our study demonstrates that sinonasal microbiome sequencing with suctioned nasal secretions is a readily available and technically feasible alternative for study of the pediatric sinonasal microbiome.

Paranasal sinusitis at the initiation of chemotherapy is a risk factor for invasive fungal disease in children and adolescents with cancer

BACKGROUND

The impact of paranasal sinusitis on the clinical outcome of patients with cancer remains unknown. The aim of this study was to determine whether paranasal sinusitis at the initiation of chemotherapy (SAI) affects the development of infectious complications in children and adolescents with cancer.

METHODS

A retrospective cohort analysis of patients aged 0-20 years with cancer who received chemotherapy was performed. SAI was defined as the presence of a fluid level or mucosal swelling or total opacity on sinus computed tomography examination before the initiation of chemotherapy. The primary outcome measures were the incidence of bacteremia, septic shock, and invasive fungal disease (IFD, including proven, probable, and possible cases).

RESULTS

SAI was observed in 57 (44%) of 130 enrolled patients. There were no significant differences in age, sex, and disease distribution between the patients with SAI (SAI group) and those without (non-SAI group). There was no significant difference in the 1-year cumulative incidence of bacteremia or septic shock after treatment initiation between the two groups (bacteremia, SAI group 33% vs. non-SAI group 35%, P = 0.53; septic shock, SAI group 4% vs. non-SAI group 4%, P = 0.87). The 1-year cumulative incidence of IFD was higher in the SAI group than in the non-SAI group (22% vs. 6%, P = 0.012). Cumulative incidence analysis after inverse probability of treatment weighting adjustment showed that the SAI group was more likely to develop IFD (HR: 3.5, 95% CI: 1.1-11.2, P = 0.033).

CONCLUSIONS

Our findings suggest that patients with SAI may be at higher risk for IFD during chemotherapy.

The role of house dust mite immunotherapy in Indonesian children with chronic rhinosinusitis allergy: A randomized control trial

Background

Chronic rhinosinusitis allergy (CRA) is a disease that is commonly found in children and is mostly caused by allergy to house dust mites (HDM). The use of HDM immunotherapy can be considered in children with allergies.

Objectives

Analyzing the impact of mite immunotherapy on disease burden in Indonesian children with CRA.

Methods

A randomized control trial study was conducted to participants in 2 groups, namely the immunotherapy group (n = 25) and the non-immunotherapy group (n = 25). Participants were given HDM immunotherapy for 14 weeks, which was given once per week. Participants during therapy were evaluated for rhinosinusitis symptoms and measured their immunity status (specific IgE), sleep quality (SDSC), quality of life (SN5), and family coping (F-COPES) pre-post therapy. Statistical analysis used in this study included paired t-test, Wilcoxon test, independent t-test, or Mann Whitney test with p < 0.05.

Results

The value of specific IgE in the immunotherapy group was 4.12 ± 7.75 kU/l (pre-test) and 1.52 ± 2.42 kU/l (post-test; p < 0.001), while in the non-immunotherapy group was 1.47 ± 3.28 kU/l (pre-test) and 1.18 ± 2.81 kU/l (post-test; p = 0.317). The SDSC value in the immunotherapy group was 42.16 ± 2.75 (pre-test) and 30.32 ± 3.22 (post-test; p < 0.001), while in the non-immunotherapy group was 41.92 ± 2.75 (pre-test) and 41.84 ± 2.87 (post-test; p = 0.987). The F-COPES value in the immunotherapy group was 101.56 ± 5.78 (pre-test) and 105.20 ± 4.31 (post-test; p = 0.015), while in the non-immunotherapy group was 100.36 ± 9.63 (pre-test) and 99.96 ± 9.98 (post-test; p = 0.224). The SN-5 value in the immunotherapy group was 30.04 ± 2.78 (pre-test) and 11.00 ± 2.33 (post-test; p < 0.001), while in the non-immunotherapy group was 30.04 ± 2.78 (pre-test) and 30.04 ± 2.78 (post-test; p = 0.767). There was a significant comparison between the immunotherapy group and the non-immunotherapy group on the specific IgE (p = 0.013), SDSC (p < 0.001), and SN-5 (p < 0.001) values. Meanwhile, there was no significant difference in the F-COPES value (p = 0.129).

Conclusions

The administration of HDM immunotherapy can improve the participant's immunity, quality of life, and sleep disorder.

International consensus statement on allergy and rhinology: rhinosinusitis 2021

I.

EXECUTIVE SUMMARY

BACKGROUND: The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR-RS-2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence-based findings of the document.

METHODS

ICAR-RS presents over 180 topics in the forms of evidence-based reviews with recommendations (EBRRs), evidence-based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary.

RESULTS

ICAR-RS-2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence-based management algorithm is provided.

CONCLUSION

This ICAR-RS-2021 executive summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS.

Adult chronic rhinosinusitis

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

Efficacy and safety of paranasal sinus balloon catheter dilation in pediatric chronic rhinosinusitis: a systematic review

Objective

Chronic rhinosinusitis (CRS) negatively affects quality of life (QoL), and balloon catheter sinuplasty (BCS) has shown good outcomes in adult patients. However, there has not been much research on the effects of BCS on pediatric patients. The objective of this review is to systematically assess the literature for studies demonstrating the effectiveness and safety of BCS in pediatric CRS patients.

Data sources

PubMed, Embase and Cochrane Library.

Study selection

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis recommendations (PRISMA) to conduct our study. Observational- and interventional-based studies reporting efficacy and/or side effects of BCS among pediatric populations were included. Efficacy was evaluated by clinically reliable measures including Sino-Nasal 5 (SN-5) QoL scale. Antibiotic usage and revision surgery were also evaluated.

Data extraction

Articles were screened, and data were obtained. Study design, sample size and demographics, treated sinuses, criteria of inclusion, adjunct procedure(s), follow-up time, and outcomes measured were reported.

Main findings

Out of 112 articles identified, 10 articles were included: two interventional controlled trials and eight observational studies. All studies evaluating QoL by SN-5 showed a remarkable reduction in SN-5 score postoperatively. Improvement in the computed tomography (CT) and endoscopic findings for up to 1 year after operation was reported. Furthermore, the majority of patinets treated with BCS did not recieve any course of sinusitis-indicated antibiotics during long-term follow-up, and they had low surgical revision rates. Minor side effects were reported, most commonly synechia.

Conclusion

Available evidence suggests that BCS is safe and effective for the treatment of CRS in pediatric patients. Future randomized controlled studies with large sample size are warranted. Such studies can further determine the efficacy of BCS in managing children with CRS.

Factors Associated with Refractory Nasal Congestion Following Adenoidectomy

OBJECTIVE

The objective of this study was to better characterize factors associated with refractory rhinitis in pediatric patients who underwent adenoidectomy compared to those who had symptom resolution.

METHODS

The authors conducted a case series of patients younger than 18 years old who underwent adenoidectomy at Boston Medical Center from October 2012 to December 2018. Patients who underwent tonsillectomy and adenoidectomy or who underwent adenoidectomy for indications other than rhinitis were excluded. Patients who had refractory rhinitis symptoms postoperatively were compared to those who had resolution of their symptoms using Chi-square analysis and t-tests.

RESULTS

One hundred three patients who had refractory symptoms following adenoidectomy were compared to 139 patients who had resolution of symptoms. Patients who had refractory symptoms had significantly higher proportion of use (89.3%, P = .0011) and higher mean number of preoperative (1.50, P = .0226) and postoperative (1.10, P < .0001) medications, including nasal saline, intranasal steroids, antihistamines, and/or antibiotics. They were more likely to receive postoperative allergy evaluations (50%, P = .0068) and repeat surgery (30.1%, P < .0001), and had a higher proportion of reported history of allergies (24.3%, P = .0089).

CONCLUSION

Use and number of preoperative medications, reported history of allergies, and postoperative allergy evaluation were significantly higher in patients with refractory chronic rhinitis following adenoidectomy. This study identified differences in patients who developed refractory symptoms that may help clinical decision making for surgical management.

Pediatric Chronic Rhinosinusitis: Unmet Needs

Pediatric chronic rhinosinusitis (CRS) remains an elusive diagnostic medical condition, largely based on imperfect diagnostic criteria, lack of controlled studies of therapy, lack of measure for resolution, and lack of information of pediatric sinus microbiome dysbiosis. The true prevalence of pediatric CRS is unknown, and symptoms often over-lap with other diagnoses. We review the unmet needs in pediatric CRS, to highlight potential research opportunities to improve understanding and therapy of the disease process.

Pediatric Versus Adult Chronic Rhinosinusitis

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

The Pediatric Sinus Staging System: A Computed Tomography-Based Approach to Grading Pediatric Sinus Disease

OBJECTIVES/HYPOTHESIS

Pediatric chronic rhinosinusitis (CRS) is a prevalent disease with few objective measurements available to predict which patients will require surgical intervention. The Lund-Mackay (LM) score for computed tomography (CT) scans is one objective data point available for the adult population; however, a dedicated scoring system in the pediatric population has not been popularized. We present a Pediatric Sinus Staging System (PSSS) that considers both opacification and the varying developmental stages of each sinus.

STUDY DESIGN

Retrospective chart review.

METHODS

We analyzed CT scans of pediatric patients with a diagnosis of CRS. Both LM and PSSS scores were calculated for each scan. Groups were formed based on treatment outcomes and included patients who were treated successfully with medical therapy and/or adenoidectomy (med/adenoid), patients who required functional endoscopic sinus surgery (FESS), and patients who required revision FESS.

RESULTS

Overall, 76 patient scans were reviewed. PSSS values were significantly less than LM for the control group (P = .001) and significantly higher for patients with cystic fibrosis (P = .027) and with CRS with polyps (P = .001). The ideal cutoff for PSSS to distinguish between med/adenoid and single FESS treatment with a sensitivity 90.6% and specificity of 50.0% was ≥2.

CONCLUSIONS

The PSSS gives a more descriptive score by accounting for the opacification and pneumatization of each sinus. Our current results show similar values between PSSS and LM scores, which suggests internal validity. In addition, a PSSS score of ≥2 may help physicians better counsel families on the likelihood of requiring FESS. Further investigation is needed to fully validate the PSSS.

LEVEL OF EVIDENCE

3b Laryngoscope, 131:E642-E648, 2021.

Current and emerging biologic therapies for allergic rhinitis and chronic rhinosinusitis

Introduction: Allergic rhinitis and chronic rhinosinusitis, with and without nasal polyps, are the most common chronic inflammatory diseases of the upper airways. They both cause relevant respiratory symptoms and a substantial detriment to patients' quality of life, mainly in uncontrolled and severe patients.Areas covered: This review aims to present the most recent evidence on current and emerging biologic therapies for allergic rhinitis and chronic rhinosinusitis and discuss their potential implementation in clinical practice. To select relevant literature for inclusion in this review, we conducted a literature search using the PubMed database, using terms 'biologics OR biological agents', 'allergic rhinitis' and 'chronic rhinosinusitis'. The literature review was performed for publication years 2009-2019, restricting the articles to humans and English language publications.Expert opinion: Biological therapies represent a potential step forward in providing individualized care for all patients with uncontrolled severe upper airway diseases. Biologics recently showed promising results for the treatment of severe uncontrolled allergic rhinitis and chronic rhinosinusitis with nasal polyps with or without associated asthma. Endotyping inflammatory pathways and identifying related biomarkers remain the major challenge for positioning biologics in the care pathway of chronic respiratory diseases.

Rhinosinusitis in Pediatric Primary Ciliary Dyskinesia: Impact of Disease

Objectives

Primary ciliary dyskinesia (PCD) is a genetic disorder characterized by abnormal respiratory cilia ultrastructure and/or function causing defective mucociliary clearance. We investigated the extent and severity of rhinosinusitis in a large cohort of children with PCD and explored associations among risk factors, including genotype and sinus disease.

Study Design

Retrospective chart review.

Setting

Tertiary academic children’s hospital.

Subjects and Methods

A review was conducted with a patient registry at the PCD Foundation Center at our institution. Demographic, imaging, clinical, and operative data were reviewed through the institutional electronic health record system.

Results

Fifty-four subjects were identified with mean and median age at diagnosis of 5.2 and 4.0 years. The male:female ratio was 35%:65%. Sinus symptoms were present in 46 (85%) subjects, 22 of whom had chronic rhinosinusitis. Nineteen (35%) subjects underwent operative intervention, consisting of endoscopic sinus surgery (ESS; 16 patients) and maxillary lavage (3 patients). Nineteen subjects underwent adenoidectomy for PCD-related indications. Five sinus-related admissions in 3 subjects were noted during the study period, and no complication of rhinosinusitis occurred in the cohort. Genetic test results were available in 27 subjects, in whom 23 (85%) had biallelic mutations in a PCD gene. Demographic factors, Lund-Mackay score, and PCD genotype were not found to be predictors for ESS or hospitalization in our cohort.

Conclusion

While rhinosinusitis was common in our PCD cohort, most patients did not require ESS. Since complications of rhinosinusitis were uncommon, we recommend judicious surgical management tailored to the patient’s symptoms.

Anatomical variation of the sphenoid sinus in paediatric patients and its association with age and chronic rhinosinusitis

OBJECTIVE

To report the prevalence of different anatomical variations of the sphenoid sinus and its related structures among paediatric patients with or without chronic rhinosinusitis.

METHODS

Computed tomography scans of 50 paediatric patients with chronic rhinosinusitis were reviewed and compared to 50 scans of paediatric patients without chronic rhinosinusitis. The type of sphenoid sinus pneumatisation and the surrounding structures were thoroughly analysed. The patients were divided into three groups according to age.

RESULTS

Mean age was 10.9 years (range, 4-16 years). The sellar configuration was the commonest in all groups, while the conchal type was the least common. There were significant differences between paediatric patients with or without sinusitis in: sphenoid sinus pneumatisation type, vidian canal type and Onodi cell presence. In addition, there were significant differences between age groups in: sphenoid sinus pneumatisation type, single sinus septum and multiple septa presence, and internal carotid artery bulging.

CONCLUSION

Age and sinusitis have a significant impact on sphenoid pneumatisation type and surrounding structure variation. Recognition of these variations can be useful for mapping this region, and enables a safer and more efficient endoscopic surgical procedure.

Can Symptoms Differentiate Between Chronic Adenoiditis and Chronic Rhinosinusitis in Pediatric Patients

The purpose of this article is to differentiate pediatric patients with chronic adenoiditis from those with chronic rhinosinusitis (CRS) based on presenting symptoms. A chart review from a tertiary care facility with pediatric patients who presented with suspected CRS from 2006 to 2014 was identified. We compared patient characteristics, clinical symptoms, duration of symptoms, and past medial history using univariate and multivariate logistic regression models. Based on recent literature, utilizing the computed tomography (CT) score, we identified those children with CRS versus those with chronic adenoiditis. Of the 99 pediatric patients included, 22 patients had diagnosis of adenoiditis and 77 had diagnosis of CRS. When purulent rhinorrhea was present with facial pain, CRS was statistically more prevalent than chronic adenoiditis (P = .017). Symptoms including cough (P = .022), rhinorrhea (P = .27), and facial pressure (P = .98) were not predictive of one diagnosis over the other. Past medical history of asthma or allergy was similar in both groups. Smoke exposure was associated with CT scores >5 (odds ratio 2.4, 95% confidence interval, 0.799-7.182). We conclude that purulent rhinorrhea in the presence of facial pain is more indicative of CRS versus chronic adenoiditis. For all other children, an adenoidectomy without the need for a CT scan can be entertained.

The Role of the Adenoids in Pediatric Chronic Rhinosinusitis

There are several mechanisms by which the adenoids contribute to pediatric chronic rhinosinusitis (PCRS), particularly with children aged 12 years and younger. Understanding the role that the adenoids play in PCRS is crucial when attempting to treat these patients. A literature review was performed to address this problem and provide information surrounding this topic. This review will provide a better understanding of how adenoids contribute to PCRS, and also of the medical and surgical treatment options.

Clinical Guidelines on Chronic Rhinosinusitis in Children

PURPOSE OF REVIEW

Pediatric chronic rhinosinusitis (CRS) is a prevalent problem that can elude diagnosis. In addition, given the burgeoning interest in pediatric sinonasal disease, treatment modalities are constantly evolving.

RECENT FINDINGS

The diagnosis of pediatric CRS is primarily based on clinical history and signs supported by objective findings (i.e., nasal endoscopy and/or computed tomography (CT) imaging). Cultures are indicated in patients who have not responded to medical therapy or have significant comorbidities. Nasal saline irrigation, nasal saline spray, and oral antibiotics are currently recommended for initial medical management. In children with CRS who have failed medical therapy, a stepwise approach to surgical intervention can lead to significant improvements in quality of life. This review provides an overview of the current guidelines and recent literature regarding the diagnosis, microbiology, and treatment options of CRS in the pediatric population.

Chronic Rhinosinusitis in Children

Purpose of review

Pediatric chronic rhinosinusitis (CRS) is a common condition that is often misdiagnosed and can be challenging to treat. This review aims to 1) Review definitions, presentation, complications, and management of CRS in children. 2) Highlight the paucity of evidence in the management of pediatric CRS.

Recent findings

There are few studies supporting the usual recommended medical therapy for pediatric CRS (antibiotics, nasal saline irrigations, intranasal steroid). Adenoidectomy remains a mainstay of surgical treatment, but recent evidence demonstrates the utility of balloon sinuplasty and functional endoscopic sinus surgery (FESS) for patients who fail adenoidectomy alone.

Summary

Pediatric CRS is distinct from ARS and adult CRS. It is a common problem that is poorly studied, in part because of significant symptomatic overlap with related conditions. Recent evidence supports the use of surgical treatment in children who fail medical management. However, further outcome studies are needed to better evaluate the effectiveness of current medical and surgical management protocols.

Adenoidectomy With Balloon Catheter Sinuplasty: A Randomized Trial for Pediatric Rhinosinusitis

OBJECTIVES/HYPOTHESIS

To compare treatment outcomes in pediatric patients with chronic rhinosinusitis (CRS) using adenoidectomy and maxillary sinus irrigation with or without balloon catheter sinuplasty (BCS).

METHODS

Prospective, randomized, and blinded. Patients between 2 and 12 years who met clinical and computed tomography criteria for CRS unresponsive to maximal medical therapy and no prior sinus- or adenoid-related procedures were eligible. Twenty-five patients were randomized, had surgery, and completed the follow-up. The control group underwent adenoidectomy with maxillary sinus irrigation alone; the treatment group underwent the same, with the addition of maxillary BCS for the maxillary sinus irrigation. Patients and parents were blinded to group assignment throughout the follow-up time frame. A validated questionnaire, the Sinus and Nasal Quality of Life Survey (SN-5), was used to measure health status changes and quality of life (QOL) at baseline, 6 months, and 12 months postintervention. Data was analyzed using t tests and multivariate linear regression.

RESULTS

There were 12 patients in the BCS group and 13 in the control group. Other than a higher atopic history in the control group (P = 0.047), there were no significant differences (P = 0.07) in the two groups (demographics and baseline SN-5 scores). Following surgery, both groups demonstrated similar improvement in QOL scores and median SN-5 scores in all domains (number of sinus infections, nasal obstruction, allergy symptoms, emotional distress, and activity limitations).

CONCLUSION

The addition of BCS to adenoidectomy/maxillary sinus irrigation did not provide additional QOL and sinonasal symptom improvement in the surgical treatment of pediatric CRS.

LEVEL OF EVIDENCE

1b Laryngoscope, 128:2893-2897, 2018.

Chronic Rhinosinusitis in Children: Pathophysiology, Evaluation, and Medical Management

PURPOSE OF REVIEW

Pediatric chronic rhinosinusitis (CRS) is a common disorder that carries significant morbidity. The diagnosis requires sinus symptoms that persist despite standard medical therapy greater than 3 months. Viral infections, allergies, and anatomic differences in children lead to chronic obstruction of the osteomeatal complex.

RECENT FINDINGS

Chronic rhinosinusitis as a diagnosis is a conglomeration of multiple phenotypes and endotypes. As such, the diagnosis and management are complex. New survey studies provide some consensus on prevalence and management of this disease in children. In this review, we highlight the differential diagnosis of pediatric CRS, including non-eosinophilic/infectious variants, eosinophilic variants with and without nasal polyps, allergic fungal sinusitis, aspirin-exacerbated respiratory disease, primary immunodeficiency, and disorders of mucociliary clearance. Further, we detail treatment options that should be considered. Finally, we feature emerging potential treatment options of CRS, including anti-immunoglobulin E, interleukin-5, and interleukin-4 receptor alpha subunit.

Prevalence of Potential Adult Chronic Rhinosinusitis Symptoms in the United States

Objective To determine the prevalence of chronic rhinosinusitis-related symptoms in the United States. Study Design Cross-sectional analysis of a national database. Setting Representative sampling of the US adult population. Subjects and Methods The National Health and Nutrition Examination Survey data set, taste and smell supplement 2013-2014 was analyzed for sinonasal question responses regarding discolored nasal mucus, nasal blockage, sinus pain, and dysosmia. The individual prevalences as well as the prevalence of 2 or more of these symptoms (which would be compatible with a diagnosis of chronic rhinosinusitis) were determined for the US population. Results After excluding adults with an intercurrent head cold, 113.5 million adults (mean age 58.2 years; 52.6% female) were analyzed. Individual symptom prevalences were dysosmia (9.17 million, 8.1%), nasal blockage (6.9 million, 6.0%), sinus pain (2.37 million, 2.1%), and discolored mucous (1.28 million, 1.1%). Overall, 14.8 million (13.0%) adults had exactly 1 sinonasal symptom, and 2.37 million adults (2.1%) responded with 2 or more cardinal symptoms for chronic rhinosinusitis. With respect to sex, 1.9% of males reported 2 or more symptoms compatible with chronic rhinosinusitis vs 2.2% of females ( P = .690), which is not statistically significant. Conclusion Of US adults, 2.1% meet symptom criteria for the potential diagnosis of chronic rhinosinusitis at any given time. Further objective corroboration with a physical exam and determination of duration of symptoms would be required to determine the true prevalence of chronic rhinosinusitis, but this point prevalence represents the potential population at risk for chronic rhinosinusitis in the United States.