Factors Affecting the Control of Chronic Rhinosinusitis With Nasal Polyps: A Comparison in Patients With or Without NERD

Multi-Disciplinary Expert Perspective on the Management of Type 2 Inflammation-Driven Severe CRSwNP: A Brief Overview of Pathophysiology and Recent Clinical Insights

Severe chronic rhinosinusitis with nasal polyposis (CRSwNP) is a disabling airway disease that significantly impacts patients' lives through the severity of symptoms, the need for long-term medical treatment and the high risk of recurrence post-surgery. Biological agents targeting type 2 immune responses underlying the pathogenesis of CRSwNP have shown effectiveness in reducing polyp size and eosinophilic infiltrate, and in decreasing the need for additional sinus surgeries. However, despite recent progress in understanding and treating the disease, type 2 inflammation-driven severe CRSwNP continues to pose challenges to clinical management due to several factors such as persistent inflammation, polyp recurrence, heterogeneity of disease, and comorbidities. This article presents the findings of a scientific discussion involving a panel of ear, nose and throat (ENT) specialists and pulmonologists across Sweden and Finland. The discussion aimed to explore current management practices for type 2 inflammation-driven severe CRSwNP in the Nordic region. The main topics examined encompassed screening and referral, measurements of disease control, treatment goals, and future perspectives. The experts emphasized the importance of a collaborative approach in the management of this challenging patient population. The discussion also revealed a need to broaden treatment options for patients with type 2 inflammation-driven CRSwNP and comorbid conditions with shared type 2 pathophysiology. In light of the supporting evidence, a shift in the disease model from the presence of polyps to that of type 2 inflammation may be warranted. Overall, this discussion provides valuable insights for the scientific community and can potentially guide the future management of CRSwNP.

Influence of Prior Endoscopic Sinus Surgery Extent on Dupilumab Effectiveness in CRSwNP Patients

BACKGROUND

Guidelines recommend that the vast majority of patients with severe uncontrolled chronic rhinosinusitis with nasal polyps (CRSwNP) should have at least one endoscopic sinus surgery (ESS) prior to starting biologics. Because ESS can be performed with a variable extension, the aim of this study would be to evaluate the association between surgical extensiveness, as measured by ACCESS score, and outcomes collected in patients treated with Dupilumab.

MATERIALS AND METHODS

This is a multicentric retrospective study; patients affected by CRSwNP who were subjected to Dupilumab therapy and who underwent at least one ESS prior to Dupilumab initiation were included. ACCESS score was assigned to each patient's pre-Dupilumab CT scan. Subjective and objective parameters (SNOT-22, NPS, VAS scores, Sniffin' Sticks) were collected before and during the administration of therapy. Statistical correlations between ACCESS scores and clinical outcomes were investigated.

RESULTS

A total of 145 patients were included; mean time from last previous ESS was 68.6 months, and on average, patients were subjected to 2.2 surgeries. Many correlations with ACCESS scores were demonstrated: better NPS at all timepoints and subjective scores (30-days SNOT-22, VAS nasal obstruction, and rhinorrhea) were achieved in patients with low ACCESS score (more extensive ESS). On the other hand, significantly worse VAS loss of smell values were demonstrated in patients with lower ACCESS scores.

CONCLUSION

Dupilumab patients subjected to a prior extensive ESS may have reduced size of polyps and improved subjective indicators, together with a decreased chance to recover smell, when compared with patients who underwent a minimal excision.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:1556-1563, 2024.

Comorbidities of chronic rhinosinusitis in children and adults

BACKGROUND

Chronic rhinosinusitis (CRS) is a chronic inflammatory disease of the nose and paranasal sinuses lasting ≥12 weeks. CRS may exist with (CRSwNP) or without (CRSsNP) nasal polyps. The aim was to evaluate conditions associated with CRS in a randomized hospital cohort. We hypothesized that comorbidities and surgical procedures differ between pediatric and adult patients.

METHODS

This study consisted of hospital registry data of a random sample of rhinosinusitis patients (age range 0-89 years) with the diagnosis of J32 or J33, correspondingly, registered during outpatient visits from 2005 to 2019 (n = 1461). The covariates of interest were collected from electronic health records based on ICD-10 codes and keyword searches.

RESULTS

Among pediatric patients (n = 104), the relative proportions of CRSsNP and CRSwNP were 86% and 14% respectively. The relative proportions of adult patients (n = 1357) with CRSsNP and CRSwNP were 60% and 40%, respectively. The following comorbidities significantly differed (p < 0.05) between pediatric and adult populations: allergy, chronic otitis media, and tonsillar diseases. In total, 41 % of the children and 46% of the adults underwent baseline endoscopic sinus surgery (ESS). Additional surgeries of the ear, nose and pharynx were significantly more common among children compared with adults. Risk of revision after baseline ESS was associated (p < 0.05) with allergy, asthma, eosinophilia, CRSwNP, immunodeficiency or its suspicion, non-steroidal anti-inflammatory drug exacerbated respiratory disease, and number of any diseases ≥2.

CONCLUSIONS

Our study showed that comorbidities differ between pediatric and adult rhinosinusitis patients, as allergy, asthma and allergy, chronic otitis media, mental health disorders, and tonsils disease were significantly more prevalent among pediatric patients. Children and adults were equally treated with ESS. Notably, children underwent additional surgery on adenoids and tonsils more frequently. The effectiveness of ESS in multimorbid adults should be assessed at an individual level.

Heterogeneity in the definition of chronic rhinosinusitis disease control: a systematic review of the scientific literature

PURPOSE

Disease control is conceptually recognized to be an important outcome measure for chronic rhinosinusitis (CRS). However, inconsistent usage is a significant factor in disadoption of important concepts and it is presently unclear how consistently the construct of CRS 'control' is being defined/applied. The objective of this study was to determine the heterogeneity of CRS disease control definitions in the scientific literature.

METHODS

Systematic review of PubMed and Web of Science databases from inception through December 31, 2022. Included studies used CRS disease control as an explicitly stated outcome measure. The definitions of CRS disease control were collected.

RESULTS

Thirty-one studies were identified with more than half published in 2021 or later. Definitions of CRS control were variable, although 48.4% of studies used the EPOS (2012 or 2020) criteria to define control, 14 other unique definitions of CRS disease control were also implemented. Most studies included the burden CRS symptoms (80.6%), need for antibiotics or systemic corticosteroids (77.4%) or nasal endoscopy findings (61.3%) as criteria in their definitions of CRS disease control. However, the specific combination of these criteria and prior time periods over which they were assessed were highly variable.

CONCLUSION

CRS disease control is not consistently defined in the scientific literature. Although many studies conceptually treated 'control' as the goal of CRS treatment, 15 different criteria were used to define CRS disease control, representing significant heterogeneity. Scientific derivation of criteria and collaborative consensus building are needed for the development of a widely-accepted and -applied definition of CRS disease control.

Surgery for chronic rhinosinusitis with nasal polyps: An update

This update aimed to evaluate surgical indications in the management of chronic rhinosinusitis with nasal polyps (CRSwNP). It was conducted and reported according to the criteria stipulated by the Synthesis Without Meta-analysis (SwiM) guidelines. From the PubMed-National Library of Medicine database, 1098 articles were identified for the period 2006-2021 using the key words "nasal polyps" and "surgery". After screening and analysis, 39 publications were selected. The efficacy of surgery on functional improvement in CRSwNP, measured by the specific quality-of-life score SNOT-22, is established, and improvement in olfactory function is expected in 50% of patients. The rate of surgical revision is at least 10-15% at 4 years, but the disease can be controlled for several years, with the interval between primary surgery and symptomatic recurrence exceeding 10 years in some cases. The criteria for surgery are not clearly defined in the literature. However, several authors consider failure of ≥ 8 weeks' well-conducted local medical treatment and use of more than 2 courses of systemic corticosteroids as a reliable indication. No studies or meta-analyses are currently available to determine the superiority of one surgical technique over another.

Prognostic factors for post-operative outcomes in chronic rhinosinusitis with nasal polyps: a systematic review

INTRODUCTION

Chronic rhinosinusitis with nasal polyps (CRSwNP) has a high recurrence rate after surgery despite the availability of medical treatments. Multiple clinical and biological factors have been associated with poor post-operative outcomes in patients with CRSwNP. However, these factors and their prognostic values have not yet been extensively summarized.

AREAS COVERED

This systematic review included 49 cohort studies exploring the prognostic factors for post-operative outcomes in CRSwNP. A total of 7802 subjects and 174 factors were included. All investigated factors were classified into three categories according to their predictive value and evidence quality, of which 26 factors were considered plausible for post-operative outcome prediction. Previous nasal surgery, ethmoid-to-maxillary (E/M) ratio, fractional exhaled nitric oxide, tissue eosinophil count or percentage, tissue neutrophil count, tissue IL-5, tissue eosinophil cationic protein, and CLC or IgE in nasal secretion provided more reliable information for prognosis in at least two studies.

EXPERT OPINION

Exploring predictors through noninvasive or minimally invasive methods for specimen collection is recommended for future work. Models combining multiple factors must be established, as no single factor is effective for the whole population.

Current understanding of disease control and its application in patients with chronic rhinosinusitis

Background

Disease control is a primary treatment goal for patients with chronic rhinosinusitis (CRS). This study aims to summarize the evaluation parameters of disease control and then identify predictors of poorly controlled CRS.

Methods

A systematic review of the literature was performed on PubMed, Google Scholar, Scopus, and Cochrane databases to identify studies relating to disease control in CRS.

Results

The concept of disease control in patients with CRS involved the longitudinal assessment of the disease state and was also an important goal of treatment. As a metric of the disease state, the disease control reflected the ability to keep disease manifestations within certain limits, the efficacy after treatment, and the impact on quality of life. Validated measurements, such as EPOS2012 criteria, EPOS2020 criteria, Sinus Control Test, and patient/physician-reported global level of CRS control, have been utilized in clinical practice. These existing disease control instruments incorporated various disease manifestations and categorized patients into two (well-controlled and poor-controlled), three (uncontrolled, partly controlled, and controlled), or five (not at all, a little, somewhat, very, and completely) control categories. Eosinophilia, high computerized tomography score, bilateral sinonasal disease, asthma, allergic rhinitis, female gender, aspirin intolerance, revision surgery, low serum amyloid A, and specific T cell subtype would predict poorly controlled CRS.

Conclusion

The concept of disease control and its application were gradually developed in patients with CRS. The existing disease control instruments demonstrated a lack of uniformity regarding the controlled criteria and included parameters.

Cluster analysis of patients with chronic rhinosinusitis and asthma after endoscopic sinus surgery

BACKGROUND

Patients with chronic rhinosinusitis with nasal polyps and asthma (CRSwAS) are highly heterogenous in severity and prognosis. The clinical phenotypes and inflammatory endotypes of CRSwAS and their association with outcomes of endoscopic sinus surgery (ESS) have not been fully studied yet.

OBJECTIVE

We aimed to find out the clinical phenotypes of CRSwAS and explore their relationship with ESS outcomes using cluster analysis.

METHODS

We recruited 103 consecutive adult patients with CRSwAS who had undergone ESS and been followed up for more than 1 year. For cluster analysis, we collected the data from 63 variables pertaining to demographic characteristics, preoperative disease status, surgical techniques, postoperative medical treatment, and outcomes. Eosinophilic CRS was defined as greater than or equal to 10 eosinophils/high-power field, and sinus computed tomography was evaluated by Lund-Mackay sinus computed tomography score (LM score).

RESULTS

We screened 92 eligible patients and 13 preoperative variables for balanced iterative reducing and clustering using hierarchies cluster analysis. Patients with CRSwAS were divided into 4 clusters with distinct ESS outcomes: (1) cluster 1, characterized by aspirin-exacerbated respiratory disease, eosinophilic CRS, high preoperative LM score, moderate-to-severe asthma, and uncontrolled CRS after ESS; (2) cluster 2, characterized as having female dominance (66.67%), non-aspirin-exacerbated respiratory disease, eosinophilic CRS, high preoperative LM score, moderate-to-severe asthma, and uncontrolled CRS after ESS; (3) cluster 3, characterized as having female dominance (95.83%), noneosinophilic CRS, low preoperative LM score, moderate asthma, and controlled CRS after ESS; and (4) cluster 4, characterized as men-only, smoker, noneosinophilic CRS, low preoperative LM score, mild asthma, and controlled CRS after ESS.

CONCLUSION

CRSwAS has distinct clusters, each corresponding to unique clinical and inflammatory characteristics and ESS outcomes.

The burden of chronic rhinosinusitis with nasal polyps and its relation to asthma in Finland

Background

Chronic rhinosinusitis with nasal polyps (CRSwNP) is commonly associated with asthma. Treatment of CRSwNP includes intranasal and systemic corticosteroids, with non-responsive patients commonly considered for endoscopic sinus surgery (ESS). This nationwide register-based study evaluated the incidence, prevalence, and treatment burden of CRSwNP in Finland, and their association with the presence and severity of comorbid asthma.

Methods

Electronic health records of patients diagnosed with CRSwNP between 1.1.2012 and 31.12.2018 in Finnish specialty and primary care were included in the study. The patients were divided into subgroups based on presence, severity, and control of asthma: no asthma, mild to moderate asthma, severe controlled asthma, and severe uncontrolled asthma. A mean cumulative count of ESS was calculated over time per subgroup.

Results

The prevalence of CRSwNP increased from 602.2 to 856.7 patients per 100,000 population between years 2012 and 2019 (p < 0.001). A total of 18,563 patients (59.9% male) had incident CRSwNP between 2012 and 2019, with 27% having asthma, 6% having severe asthma, and 1.5% having severe uncontrolled asthma. In the no asthma, severe controlled asthma, and severe uncontrolled asthma subgroups, systemic corticosteroids were used by 54.1%, 94.9% and 99.3% (p < 0.001), respectively, while the ESS count 3 years post diagnosis was 0.49, 0.68 and 0.80, respectively.

Conclusions

The prevalence of CRSwNP showed a significant increase in the recent decade in Finland. Comorbid asthma, and in particular severe asthma, increased the probability of receiving systemic corticosteroids and undergoing ESS. Thus, improved management of CRSwNP in patients with comorbid asthma is urgently needed.

Using machine learning for the personalised prediction of revision endoscopic sinus surgery

BACKGROUND

Revision endoscopic sinus surgery (ESS) is often considered for chronic rhinosinusitis (CRS) if maximal conservative treatment and baseline ESS prove insufficient. Emerging research outlines the risk factors of revision ESS. However, accurately predicting revision ESS at the individual level remains uncertain. This study aims to examine the prediction accuracy of revision ESS and to identify the effects of risk factors at the individual level.

METHODS

We collected demographic and clinical variables from the electronic health records of 767 surgical CRS patients ≥16 years of age. Revision ESS was performed on 111 (14.5%) patients. The prediction accuracy of revision ESS was examined by training and validating different machine learning models, while the effects of variables were analysed using the Shapley values and partial dependence plots.

RESULTS

The logistic regression, gradient boosting and random forest classifiers performed similarly in predicting revision ESS. Area under the receiving operating characteristic curve (AUROC) values were 0.744, 0.741 and 0.730, respectively, using data collected from the baseline visit until six months after baseline ESS. The length of time during which data were collected improved the prediction performance. For data collection times of 0, 3, 6 and 12 months after baseline ESS, AUROC values for the logistic regression were 0.682, 0.715, 0.744 and 0.784, respectively. The number of visits before or after baseline ESS, the number of days from the baseline visit to the baseline ESS, patient age, CRS with nasal polyps (CRSwNP), asthma, non-steroidal anti-inflammatory drug exacerbated respiratory disease and immunodeficiency or suspicion of it all associated with revision ESS. Patient age and number of visits before baseline ESS carried non-linear effects for predictions.

CONCLUSIONS

Intelligent data analysis identified important predictors of revision ESS at the individual level, such as the frequency of clinical visits, patient age, Type 2 high diseases and immunodeficiency or a suspicion of it.

A Practical Clinical Protocol for Monitoring Patients with Severe Uncontrolled Chronic Rhinosinusitis with Nasal Polyposis Treated with Biologics

Objectives:

Chronic rhinosinusitis with nasal polyposis (CRSwNP) is a pathological condition which leads to high healthcare-related costs and low quality of life for patients. The introduction of new biological therapies (monoclonal antibodies, MAbs) in CRSwNP patients has allowed new therapeutic options for non-responders to conventional therapies and Dupilumab represents the first approved biological agent. The aim of this paper is to provide a practical clinical multidisciplinary protocol which might help clinicians involved in this field to monitor the clinical outcomes.

Methods:

Our centre of Rhinology and Rhino-Allergology has developed a dedicated collection form to observe the outcomes of patients treated with Dupilumab. Our research started from the indications given in EPOS 2020 as main reference. We then implemented these references in an electronic database trying to apply Evidence Based Medicine (EBM) in current clinical practice.

Results:

The result consists of three parts: an anamnestic collection data, a clinician reported outcome and two patient reported outcomes (PROMs) questionnaire, the visual analogue scale (VAS) and the Sino-Nasal Outcome Test-22 (SNOT-22). The tables we propose should provide an adequate correlation with the patients’ adherence to therapy and their treatment outcomes. Such periodical evaluation (after a month, after 3 months, after 6 months and at one year) should quickly allow to monitor if the patient is correctly assuming the therapy and the eventual objective improvements.

Conclusions:

We propose a practical monitoring protocol formulated to analyse both objective and subjective aspects of patients with severe uncontrolled CRSwNP treated with MAbs, thus helping to define in future a better comparison between the clinical results of different institutes.

Th17/Treg cells regulated by interleukin 6 in the pathogenesis of chronic rhinosinusitis with nasal polyps

PURPOSE

To be investigated whether Th17/Treg cells regulated by Interleukin-6 in the pathogenesis of chronic rhinosinusitis with nasal polyps.

METHODS

The distributions of Th17 and Treg cells in peripheral blood mononuclear cells (PBMCs) and tissues got from 46 CRSwNP patients and 14 controls were evaluated. Th17 and Treg cells and cells-related cytokines in serum were assessed in means of cytometric bead array (CBA) multiplex assays and enzyme-linked immunosorbent assays (ELISAs). Spleen cells were isolated from spleen of 20 normal BALB/c mice (male), isolated and purified with CD4 antibody immunomagnetic bead kit. CD4+ cells were divided into three groups, including TGF-β1, TGF-β1+ IL-6 and control (PBS). Treg and Th17 cells and cells related cytokines were detected by flow cytometry (FCM) after collecting spleen cells. The level of IL-10 and IL-17 in supernatant was measured by ELISA.

RESULTS

Th17/Treg ratio and the level of IL-6 in both ECRSwNP (P < 0.05) and non-ECRSwNP (P < 0.05) were significantly increased when compared with control group, these were consistent with the previous findings. Experiments in vitro suggested that the level of Th17 cells in IL-6+ TGF-β1 group was significantly increased than TGF-β1 group and control group (P < 0.05). The ratio of cells expressed RoRγt in IL-6+ TGF-β1 group was much higher than TGF-β1 group (P < 0.05).

CONCLUSION

IL-6 might regulate the function of Th17 and Treg cells and the Th17/Treg ratio and have a role in the pathogenesis of CRSwNP.