Peri-implantitis and maxillary sinus membrane thickening: A retrospective cohort study

OBJECTIVE

The objective of this study is to investigate the association of peri-implantitis (PI) and sinus membrane thickening and to assess the resolution of membrane thickening following intervention (implant removal or peri-implantitis treatment) aimed at arresting PI.

MATERIALS AND METHODS

Forty-five patients with 61 implants in the posterior maxillary region were retrospectively included in the study. Twenty-four patients were diagnosed with peri-implantitis (PI) and 21 had peri-implant health (PH). Cone-beam computed tomography (CBCT) scans were evaluated to assess maxillary sinus characteristics, including membrane thickening, sinus occupancy and ostium patency. The CBCT scans taken 6 months after intervention aimed at arresting disease (implant removal or treatment of PI) in the PI group were also appraised and compared to baseline scans.

RESULTS

At baseline, all parameters evaluating membrane thickness disorders yielded significant differences between groups (p < .001). Patients with posterior maxillary implants diagnosed with PI were 7× more likely to present membrane thickening compatible with pathology when compared to patients with healthy implants (OR = 7.14; p = .005). Furthermore, the likelihood was 6x greater in implants diagnosed with PI to exhibit moderate membrane thickening (OR = 6.75, p = .001). The patients receiving interventions aimed at arresting PI experienced significant enhancement in all radiographic parameters related to the sinus cavity at the 6-month follow-up (p < .001), though these variations were similarly independent of whether treatment consisted of PI treatment or implant removal.

CONCLUSIONS

Maxillary sinus membrane thickening and the permeability/obstruction of the ostium are frequently associated with the presence of PI in posterior implants. Interventions targeting disease resolution effectively reduce membrane thickness to levels compatible with maxillary sinus health.

Host-microbe interactions in chronic rhinosinusitis biofilms and models for investigation

Chronic rhinosinusitis (CRS) is a debilitating condition characterized by long-lasting inflammation of the paranasal sinuses. It affects a significant portion of the population, causing a considerable burden on individuals and healthcare systems. The pathogenesis of CRS is multifactorial, with bacterial infections playing a crucial role in CRS development and persistence. In recent years, the presence of biofilms has emerged as a key contributor to the chronicity of sinusitis, further complicating treatment and exacerbating symptoms. This review aims to explore the role of biofilms in CRS, focusing on the involvement of the bacterial species Staphylococcus aureus and Pseudomonas aeruginosa, their interactions in chronic infections, and model systems for studying biofilms in CRS. These species serve as an example of how microbial interplay can influence disease progression and exemplify the need for continued investigation and innovation in CRS research.

Epithelial innate immune response to Pseudomonas aeruginosa-derived flagellin in chronic rhinosinusitis

BACKGROUND

Pseudomonas aeruginosa is a common colonizing pathogen in the upper respiratory tract and is associated with recalcitrant chronic rhinosinusitis (CRS). Herein we sought to characterize the effect of P. aeruginosa-derived flagellin on human sinonasal epithelial cell (HSNEC) immune responses and determine whether these pathways are disrupted in CRS.

METHODS

Air-liquid interface cultures were established from CRS and healthy control donors. Cells were incubated with P. aeruginosa-derived flagellin for 24 hours and transcriptional changes were assessed using whole transcriptome RNA sequencing. Apical and basolateral secretion of the pro-inflammatory cytokines in interleukin (IL)-1β, tumor necrosis factor (TNF)-α, and IL-6 were measured after stimulation by lipopolysaccharide or flagellin and responses were compared between CRS and healthy control patients.

RESULTS

HSNECs were weakly responsive to lipopolysaccharide, whereas flagellin stimulated a profound innate immune response dominated by TNF-α, IL-1β, and IL-17 signaling and activation of the IL-17C/IL-23 axis. CRS-derived HNSECs showed an altered innate immune response to flagellin, characterized by a profound increase in TNF-α secretion coupled with reduced IL-6 secretion.

CONCLUSIONS

Flagellin activates a potent innate immune response in HSNECs characterized by pro-inflammatory mediators and cytokines/chemokines associated with neutrophilic inflammation. HSNECs from CRS patients have a dysregulated innate immune response to flagellin characterized by an imbalance between IL-6 and TNF-α secretion.

Distinct Patterns of Tissue Remodeling and Their Prognostic Role in Chronic Rhinosinusitis

INTRODUCTION

Tissue remodeling refers to structural changes that occur in damaged tissue and is associated with disease severity in asthma. However, the characteristics of tissue remodeling and its prognostic role in chronic rhinosinusitis (CRS) remain unclear. In this report, we evaluated the clinical implications of tissue remodeling in CRS.

METHODS

We performed a retrospective cohort study of adult patients who underwent endoscopic sinus surgery for bilateral CRS. The histopathology of sinus mucosa was determined by evaluating the inflammatory cell count and tissue remodeling markers (squamous metaplasia, subepithelial gland proliferation, basement membrane [BM] thickening, stromal edema, and fibrosis). Eosinophilic CRS (ECRS) was defined as an eosinophil count >15/high-power field in the biopsied tissue. Patient characteristics, allergy test grade, preoperative Lund-Mackay score (LMS), and pre- and postoperative Lund-Kennedy scores (LKSs) were analyzed.

RESULTS

Of the identified patients, 59.1% were classified as ECRS and the remaining 40.9% as non-ECRS. Regarding tissue remodeling markers, stromal edema was seen in 90.9%, BM thickening in 63.6%, and stromal fibrosis in 34.1% of patients. In cases with stromal edema and BM thickening, greater tissue eosinophilia was observed, while stromal fibrosis decreased tissue eosinophilia (p < 0.05). Prognostically, subepithelial gland proliferation alone was an independent risk factor for poor postoperative endoscopic findings (odds ratio: 8.250, 95% confidence interval: 1.128-60.319, p = 0.038).

CONCLUSIONS

Tissue eosinophilia was commonly associated with BM thickening and stromal edema. Subepithelial gland proliferation predicted a poor surgical prognosis in CRS. These findings imply that tissue remodeling provides additional information not only on the CRS endotype but also on the postsurgical prognosis.

Inter-pathologist Agreement on Structured Histopathology Reporting in Chronic Rhinosinusitis

BACKGROUND

Structured histopathology reporting is increasingly being utilized in rhinology to characterize endotypes in chronic rhinosinusitis and guide management decisions after sinus surgery.

OBJECTIVE

The goal of this investigation is to evaluate inter-observer agreement in structured histopathology reporting.

METHODS

Two experienced head and neck pathologists independently compiled structured histopathology reports for tissue samples collected during functional endoscopic sinus surgery. Cohen's standard kappa (κ) coefficients were calculated for each histopathologic variable to assess inter-pathologist agreement.

RESULTS

A total of 92 cases were analyzed. Substantial inter-pathologist agreement was reached on tissue eosinophil count (κ = 0.64, P < .001), the presence of eosinophil aggregates (κ = 0.62, P < .001), and the presence of fungal elements (κ = 0.74, P < .001). There was moderate agreement on the degree of inflammation (κ = 0.56, P < .001) and the presence of squamous metaplasia (κ = 0.46, P < .001). There was fair agreement on the presence of neutrophil infiltrates (κ = 0.33, P < .001), the presence of hyperplastic changes (κ = 0.40, P < .001), and the presence of fibrosis (κ = 0.24, P = .022). There was only slight agreement on the degree of subepithelial edema (κ = 0.20, P = .008). The κ coefficients for basement membrane thickening and mucosal ulceration were not statistically significant.

CONCLUSION

High inter-pathologist agreement was demonstrated for several salient histopathologic variables, including tissue eosinophil count and the presence of eosinophil aggregates. However, refining the definitions of certain histopathologic variables may improve the reproducibility of structured histopathology reporting.

Chronic rhinosinusitis precipitated by tumor necrosis factor alpha inhibitors is the phenotype of chronic rhinosinusitis without nasal polyps

BACKGROUND

Chronic rhinosinusitis (CRS) is a frequently observed condition in patients with immunodeficiency secondary to tumor necrosis factor alpha inhibitors (TNFαis). The histologic features of CRS caused by TNFαis have yet to be determined and may have important implications in understanding the pathophysiology of the disease process.

METHODS

A structured histopathology report was used to analyze sinus tissue removed during functional endoscopic sinus surgery (FESS). These structured histopathology variables were compared among patients with CRS on TNFαi (CRSαi), CRS without nasal polyps (CRSsNP) patients, and CRS with nasal polyps (CRSwNP) patients.

RESULTS

Eighteen CRSαi, 91 CRSwNP, and 113 CRSsNP patients undergoing FESS were analyzed. Compared to CRSsNP, CRSαi patients exhibited increased mucosal ulceration (16.7% vs 0.9%, p < 0.008), increased fibrosis (100% vs 34.5%, p < 0.001), and increased presence of Charcot-Leiden crystals (16.7% vs 0%, p < 0.002). Compared to CRSwNP, CRSαi patients demonstrated increased fibrosis (100% vs 54.9%, p < 0.001), decreased presence of subepithelial edema (44.4% vs 69.2% p < 0.043), decreased eosinophil aggregates (22.2% vs 47.3% p < 0.042), and fewer eosinophils per high-power field (44.4% vs 73.6%, p < 0.017).

CONCLUSION

CRSαi exhibits structured histopathology more similar to CRSsNP. In the appropriate clinical context, it may be reasonable that the medical regimen for these patients be focused on a more antineutrophilic, macrolide-based approach. This study provides insight into the inflammatory environment of patients with CRSαi and may have implications for disease management.

A structured histopathology-based analysis of surgical outcomes in chronic rhinosinusitis with and without nasal polyps

Objectives

Structured histopathology reporting has been recently described for detailing immunopathological characteristics of chronic rhinosinusitis (CRS), and can be utilized for subtyping CRS and personalizing management. This study scrutinized elements of structured histopathology to identify characteristics that prognosticate outcomes following endoscopic sinus surgery (ESS) for CRS patients with nasal polyps (CRSwNP) and without nasal polyps (CRSsNP).

Methods

Outcomes following ESS were measured using the patient‐reported 22‐item sinonasal outcome test (SNOT‐22). Changes in total SNOT‐22 scores at 6 and 12 months postoperatively were analyzed. Thirteen parameters reported in structured histopathology of sinus surgical tissue were studied for association with outcomes postsurgery. The overall cohort of all CRS patients was studied, along with subgroup analyses of CRSwNP and CRSsNP patients.

Results

In the entire CRS cohort (n = 171), eosinophil count >10 per high power field (HPF) was associated with greater improvement in SNOT‐22 scores at 6 months post‐ESS (P = .039). At 12 months follow‐up, no histopathological characteristic was associated with change in total SNOT‐22 score. In the CRSwNP (n = 66) subgroup, the presence of fibrosis (P = .006) and eosinophil count ≤10 per HPF (P = .025) were associated with less favorable changes in SNOT‐22 scores at 12 months follow‐up. Fibrosis remained statistically significant in multivariable analysis (P = .007).

Conclusions

At 6 months post‐ESS, tissue eosinophilia is associated with significantly higher improvement in SNOT‐22 scores, but this difference is diluted by 12 months. Fibrosis was associated with less favorable outcomes in SNOT‐22 scores for CRSwNP patients at 12 months and may be a prognosticator for poorer long‐term outcomes.

Level of Evidence

4

Histopathologic Features of Chronic Sinusitis Precipitated by Odontogenic Infection

BACKGROUND

Chronic rhinosinusitis (CRS) is a heterogeneous disease process that can arise in the context of odontogenic disease from the maxillary teeth. The histopathologic features of odontogenic CRS (CRSo) have yet to be determined and may have important implications on disease management and need for escalation of therapy.

OBJECTIVES

The objectives of this study are to characterize the histopathologic features of CRSo and determine whether the inflammatory profile of CRSo contributes to its recalcitrance to medical therapy and need for surgery in a subset of patients with this disease.

METHODS

A structured histopathology report was used to analyze sinus tissue removed during functional endoscopic sinus surgery (FESS). Histopathology variables, Lund-Mackay scores (LMS), and Sinonasal Outcome Test-22 scores were compared among CRSo patients, CRS without nasal polyps (CRSsNP) patients, and CRS with nasal polyps (CRSwNP) patients.

RESULTS

Twenty-three CRSo, 38 CRSwNP, and 53 CRSsNP patients who underwent FESS were analyzed. Compared to CRSsNP, CRSo exhibited increased moderate-severe inflammation (73.9% vs 41.5%, P < .009). Compared to CRSwNP, CRSo had decreased squamous metaplasia (0.0% vs 18.4%, P < .03) and decreased fibrosis (26.1% vs 63.2%, P < .005). Eosinophilia was prevalent in CRSo but to a lesser extent than in CRSwNP (39.1% vs 63.2%, P < .05). CRSo cases had significantly lower mean LMS compared to CRSwNP (7.83 ± 2.77 vs12.18 ± 6.77, P < .005).

CONCLUSION

CRSo exhibits histopathologic features similar to those of CRSsNP with more severe inflammation. Moreover, eosinophilia, which is not typically considered to coexist with CRSo, was present in a large portion of CRSo patients. These findings may help explain at the inflammatory level why select cases of CRSo may be recalcitrant to medical and dental therapy.