ICON: chronic rhinosinusitis

Platelet-rich plasma following endoscopic sinus surgery in patients with chronic sinusitis: A systematic review and meta-analysis of randomised controlled trials

INTRODUCTION

To comprehensively evaluate the reported clinical effectiveness of platelet-rich plasma (PRP) in patients with chronic sinusitis undergoing endoscopic sinus surgery (ESS).

METHODS

We performed a systematic review and meta-analysis of randomised controlled trials (RCTs). Five digital online databases (PubMed, Scopus, Web of Science, Google Scholar and Cochrane CENTRAL) were searched from inception up to 1st May 2023. Our specific outcomes involved postoperative nasal endoscopy scores measured via Lund-Kennedy score or Meltzer score, olfactory sensation scores and pre-operative anosmia duration. All data were pooled as standardised mean difference (SMD) with a 95% confidence interval (CI), using the RevMan software.

RESULTS

Six RCTs were included in this systematic review and meta-analysis, with a total of 169 patients. The risk of bias in the included RCTs was low in three RCTs, some concerns in one RCT and high risk in two RCTs. The overall analysis of the postoperative nasal endoscopy scores showed that the PRP group had lower scores compared to the control group (n = 3 RCTs, SMD = -1.19; 95% CI [-1.94, -0.44], p = .002). There was no significant difference between the PRP and control groups regarding anosmia duration (n = 2 RCTs, SMD = 0.21; 95% CI [-0.17, 0.59], p = 0.28) or olfactory sensation scores, despite the PRP group having higher scores (n = 2 RCTs, SMD = 0.53; 95% CI [-0.32, 1.39], p = 0.22).

CONCLUSION

This study highlights the potential advantages of using PRP as an additional treatment for individuals with chronic sinusitis undergoing ESS. The improvements associated with PRP include facilitating wound healing, reducing inflammation and enhancing surgical outcomes. To optimise the use of PRP in clinical settings, future research should focus on conducting larger trials with standardised protocols.

Exploring the immunopathology of type 2 inflammatory airway diseases

Significant advancements have been achieved in understanding the roles of different immune cells, as well as cytokines and chemokines, in the pathogenesis of eosinophilic airway conditions. This review examines the pathogenesis of Chronic Rhinosinusitis with Nasal Polyps (CRSwNP), marked by complex immune dysregulation, with major contributions from type 2 inflammation and dysfunctional airway epithelium. The presence of eosinophils and the role of T-cell subsets, particularly an imbalance between Treg and Th17 cells, are crucial to the disease's pathogenesis. The review also investigates the pathogenesis of eosinophilic asthma, a unique asthma subtype. It is characterized by inflammation and high eosinophil levels, with eosinophils playing a pivotal role in triggering type 2 inflammation. The immune response involves Th2 cells, eosinophils, and IgE, among others, all activated by genetic and environmental factors. The intricate interplay among these elements, chemokines, and innate lymphoid cells results in airway inflammation and hyper-responsiveness, contributing to the pathogenesis of eosinophilic asthma. Another scope of this review is the pathogenesis of Eosinophilic Granulomatosis with Polyangiitis (EGPA); a complex inflammatory disease that commonly affects the respiratory tract and small to medium-sized blood vessels. It is characterized by elevated eosinophil levels in blood and tissues. The pathogenesis involves the activation of adaptive immune responses by antigens leading to T and B cell activation and eosinophil stimulation, which causes tissue and vessel damage. On the other hand, Allergic Bronchopulmonary Aspergillosis (ABPA) is a hypersensitive response that occurs when the airways become colonized by aspergillus fungus, with the pathogenesis involving activation of Th2 immune responses, production of IgE antibodies, and eosinophilic action leading to bronchial inflammation and subsequent lung damage. This analysis scrutinizes how an imbalanced immune system contributes to these eosinophilic diseases. The understanding derived from this assessment can steer researchers toward designing new potential therapeutic targets for efficient control of these disorders.

The cyclooxygenase-2 upregulation mediates production of PGE2 autacoid to positively regulate interleukin-6 secretion in chronic rhinosinusitis with nasal polyps and polyp-derived fibroblasts

Chronic rhinosinusitis (CRS) can be traditionally classified as CRSwNP [with nasal polyps (NPs)] and CRSsNP (without NPs) based on the clinical phenotypes but recently suggested to be classified by the endotypes. We have identified overexpression of the cyclooxygenase-2 (COX-2) gene in NP tissues of Taiwanese CRSwNP patients. Therefore, in this study, we sought to investigate its protein expression/location/distribution in NP specimens and explore its roles in nasal polyposis. The COX-2 protein and mRNA expression was found higher in NPs than that in the control and CRSsNP patients' nasal tissues, mainly located at the epithelium and subepithelial stroma. Consistently, the CRS-related peptidoglycan (PGN) and bradykinin provoked COX-2 mRNA and protein upregulation in the human NP-derived fibroblasts and caused PGE2, thromboxane A2 (TXA2), and interleukin (IL-6) secretion in culture medium. Further analysis revealed that the PI3K/Akt activation and COX-2 induction were necessarily required for PGN-induced IL-6 production/secretion and the induced PGE2, but not TXA2, was speculated to affect IL-6 protein trafficking and production. Finally, the IL-6 increase observed in vitro could also be detected in NP tissues. Collectively, we demonstrated here that COX-2 protein and IL-6 are overexpressed in human NP tissues. In response to PGN challenge, the PI3K/Akt activation and COX-2-mediated PGE2 autacoid correlates with extracellular IL-6 protein trafficking/production in NP-derived fibroblasts, which can additionally contribute to the production of Th17-related cytokines such as IL-17 and TNF-α. This study also suggests COX-2 as a special biomarker for CRSwNP endotyping and may highlight the importance of COX-2 inhibitors in treating CRSwNP.

Immune endotyping and gene expression profile of patients with chronic rhinosinusitis with nasal polyps in the aspirin-exacerbated respiratory disease (AERD) and the non-AERD subgroups

BACKGROUND

Chronic Rhinosinusitis (CRS) is a paranasal sinus inflammatory disease and is divided into two subgroups defined as CRS with nasal polyps (CRSwNP) and CRS without nasal polyps (CRSsNP). CRSwNP displays a T helper (Th)2 biased phenotype, and based on sensitivity or tolerance to aspirin or non-steroidal anti-inflammatory drugs (NSAID), is further subdivided into Aspirin-exacerbated respiratory disease (AERD) and non-AERD groups. Considering the challenge of diagnosis and treatment in patients with CRSwNP, particularly the AERD subtype, and the significance of endotyping in these patients, we examined the immune profile and endotyping based on gene expression analysis in the AERD and the non-AERD groups of patients with CRSwNP.

MATERIAL AND METHOD

In this study, 21 patients were enrolled and were categorized into AERD (N = 10) and non-AERD (N = 11) groups based on their sensitivity to aspirin. After the special washing period, nasal polyps were biopsied in both groups, and the infiltration of eosinophils, neutrophils, plasma cells, and lymphocytes was compared between the AERD and the non-AERD groups. Also, gene expression levels of transcription factors including Tbet, GATA3, RoRγt, and FoxP3 and inflammatory cytokines including interleukin (IL)1β, IL1RAP (IL1 receptor accessory protein), IL2, IL4, IL5, IL10, IL13, IL17, TNFα, and IFNγ were investigated by quantitative Real-time PCR (qRT-PCR). Statistical analyses were performed using analytical tests including Kolmogorov-Smirnov, Mann-Whitney, and T-test. A P value less than 0.05 was considered statistically significant.

RESULTS

The mean ± SD age of the studied groups was 37 ± 8.7 years old (21-50) for the AERD, and 40.4 ± 7.7 years old (31-52) for the non-AERD. LMS/EPOS/SNOT scores and pulmonary function tests showed no difference between the two groups. Serum immunoglobulin E (IgE) levels were found to be higher in patients with AERD (p = 0.04), however, the peripheral blood counts of eosinophils were comparable in the two groups. In the histopathologic analysis, the AERD group showed higher percentages of eosinophils (p = 0.04), neutrophils (p = 0.04), and plasma cells (p = 0.04) than the non-AERD group. Additionally, the gene expression levels of GATA3 (p = 0.001), IL4 (p = 0.04), IL5 (p = 0.007), and IL17 (p = 0.03) were significantly higher in the AERD than the non-AERD groups.

CONCLUSION

Higher gene expression levels of GATA3, IL4, IL5, and IL17 were observed in the AERD group compared with the non-AERD group. These findings point to distinct patterns of inflammation in patients with AERD, with a predominance of Th2 inflammation.

Reduced Glycolysis and Cytotoxicity in Staphylococcus aureus Isolates from Chronic Rhinosinusitis as Strategies for Host Adaptation

Chronic rhinosinusitis (CRS) is a multifactorial infection of the nasal cavity and sinuses. In this study, nasal swabs from control donors (N = 128) and patients with CRS (N = 246) were analysed. Culture methods and metagenomics revealed no obvious differences in the composition of the bacterial communities between the two groups. However, at the functional level, several metabolic pathways were significantly enriched in the CRS group compared to the control group. Pathways such as carbohydrate transport metabolism, ATP synthesis, cofactors and vitamins, photosynthesis and transcription were highly enriched in CRS. In contrast, pathways related to lipid metabolism were more representative in the control microbiome. As S. aureus is one of the main species found in the nasal cavity, staphylococcal isolates from control and CRS samples were analysed by microarray and functional assays. Although no significant genetic differences were detected by microarray, S. aureus from CRS induced less cytotoxicity to lung cells and lower rates of glycolysis in host cells than control isolates. These results suggest the differential modulation of staphylococcal virulence by the environment created by other microorganisms and their interactions with host cells in control and CRS samples. These changes were reflected in the differential expression of cytokines and in the expression of Agr, the most important quorum-sensing regulator of virulence in S. aureus. In addition, the CRS isolates remained stable in their cytotoxicity, whereas the cytotoxic activity of S. aureus isolated from control subjects decreased over time during in vitro passage. These results suggest that host factors influence the virulence of S. aureus and promote its adaptation to the nasal environment during CRS.

Advancements in acoustic drug delivery for paranasal sinuses: A comprehensive review

Chronic rhinosinusitis (CRS) impacts patients' quality of life and healthcare costs. Traditional methods of drug delivery, such as nasal sprays and irrigation, have limited effectiveness. Acoustic Drug Delivery (ADD) using a nebulizer offers targeted delivery of drug to the sinuses, which may improve the treatment of CRS. This review examines the influence of aerosol particle characteristics, aero-acoustic parameters, inlet flow conditions, and acoustic waves on sinus drug delivery. Key findings reveal that smaller particles improve the ADD efficiency, whereas larger sizes or increased density impair it. The oscillation amplitude of the air plug in the ostium is crucial for the ADD efficiency. Introducing acoustic waves at the NC-sinus system's resonance frequency improves aerosol deposition within sinuses. Future research should address advanced models, optimizing particle characteristics, investigating novel acoustic waveforms, incorporating patient-specific anatomy, and evaluating long-term safety and efficacy. Tackling these challenges, ADD could offer more effective and targeted treatments for sinus-related conditions such as CRS.

A Decade of Pathogenesis Advances in Non-Type 2 Inflammatory Endotypes in Chronic Rhinosinusitis: 2012-2022

Chronic rhinosinusitis (CRS) is a heterogeneous disease characterized by localized inflammation of the upper airways. CRS includes two main phenotypes, namely, CRS with nasal polyps and CRS without nasal polyps. The phenotype-based classification method cannot reflect the pathological mechanism. The endotype-based classification method has been paid more and more attention by researchers. It is mainly divided into type 2 and non-type 2 endotypes. The mechanism driving the pathogenesis of non-type 2 inflammation is currently unknown. In this review, the PubMed and Web of Science databases were searched to conduct a critical analysis of representative literature works on the pathogenesis of non-type 2 inflammation in CRS published in the past decade. This review summarizes the latest evidence that may lead to the pathogenesis of non-type 2 inflammation. It is the main method that analyzing the pathogenesis from the perspective of immunology. Genomics and proteomics technique provide new approaches to the study of the pathogenesis. Due to differences in race, environment, geography, and living habits, there are differences in the occurrence of non-type 2 inflammation, which increase the difficulty of understanding the pathogenesis of non-type 2 inflammation in CRS. Studies have confirmed that non-type 2 endotype is more common in Asian patients. The emergence of overlap and unclassified endotypes has promoted the study of heterogeneity in CRS. In addition, as the source of inflammatory cells and the initiation site of the inflammatory response, microvessels and microlymphatic vessels in the nasal mucosal subepithelial tissue participate in the inflammatory response and tissue remodeling. It is uncertain whether CRS patients affect the risk of infection with SARS-CoV-2. In addition, the pathophysiological mechanism of non-type 2 CRS combined with COVID-19 remains to be further studied, and it is worth considering how to select the befitting biologics for CRS patients with non-type 2 inflammation.

The interplay of inflammation and remodeling in the pathogenesis of chronic rhinosinusitis: current understanding and future directions

Chronic rhinosinusitis (CRS), a common clinical condition characterized by persistent mucosal inflammation and tissue remodeling, has a complex pathogenesis that is intricately linked to innate and adaptive immunity. A number of studies have demonstrated that a variety of immune cells and cytokines that play a vital role in mediating inflammation in CRS are also involved in remodeling of the nasal mucosa and the cells as well as different cytokines involved in remodeling in CRS are also able to exert some influence on inflammation, even though the exact relationship between inflammation and remodeling in CRS has not yet been fully elucidated. In this review, the potential role of immune cells and cytokines in regulating inflammation and remodeling of CRS mucosa has been described, starting with the immune cells and cytokines that act together in inflammation and remodeling. The goal is to aid researchers in understanding intimate connection between inflammation and remodeling of CRS and to offer novel ideas for future research.

Odontogenic Factors Associated with Maxillary Sinus Schneiderian Membrane Thickness and their Relationship to Chronic Sinonasal Symptoms: An Ambispective Cohort Study

Odontogenic sinusitis is a common maxillary sinus disease. It develops due to the violation of the Schneiderian membrane due to pathological, iatrogenic, or traumatic causes from dental and dentoalveolar structures. The aim of this cohort study was to investigate local and systemic factors associated with Schneiderian mucosal thickening (MT) in patients referred for evaluation of apical periodontitis (AP) and examine their relationship with chronic sinonasal symptoms. Cone-beam computed tomography (CBCT) scans of 197 patients referred for evaluation of endodontic diseases were reviewed. Mucosal thickening in relation to the affected tooth was measured in the coronal section in millimeters at the maximum area perpendicular to the bone. Based on this measurement, the sinus floor was categorized for MT as present (>1 mm) or absent (<1 mm). The sociodemographic and clinical characteristics of the study participants were assessed and compared according to the presence or absence of MT. Furthermore, the relationship between odontogenic sinusitis and chronic sinonasal symptoms was assessed using a chronic sinusitis survey. Male patients had a higher MT than female patients. The presence of periapical lesions and inadequate endodontic treatment were significantly associated with MT. The multivariate logistic regression model showed that the presence of AP increased the odds of MT by approximately 2.5 times (p = 0.028), and nasal obstruction was significantly higher in patients diagnosed with mucosal thickness at different times of their follow-up period (p = 0.018). MT was 2.5 times more likely in the presence of apical periodontitis, and nasal obstruction was the most significant factor associated with the presence of MT.

MEX3B inhibits collagen production in eosinophilic nasal polyps by downregulating epithelial cell TGFBR3 mRNA stability

Although the expression of Mex3 RNA-binding family member B (MEX3B) is upregulated in human nasal epithelial cells (HNECs) predominately in the eosinophilic chronic rhinosinusitis (CRS) with nasal polyps (CRSwNP) subtype, its functions as an RNA binding protein in airway epithelial cells remain unknown. Here, we revealed the role of MEX3B based on different subtypes of CRS and demonstrated that MEX3B decreased the TGF-β receptor III (TGFBR3) mRNA level by binding to its 3' UTR and reducing its stability in HNECs. TGF-βR3 was found to be a TGF-β2-specific coreceptor in HNECs. Knocking down or overexpressing MEX3B promoted or inhibited TGF-β2-induced phosphorylation of SMAD2 in HNECs, respectively. TGF-βR3 and phosphorylated SMAD2 levels were downregulated in CRSwNP compared with controls and CRS without nasal polyps with a more prominent downregulation in the eosinophilic CRSwNP. TGF-β2 promoted collagen production in HNECs. Collagen abundance decreased and edema scores increased in CRSwNP compared with control, again more prominently in the eosinophilic type. Collagen expression in eosinophilic CRSwNP was negatively correlated with MEX3B but positively correlated with TGF-βR3. These results suggest that MEX3B inhibits tissue fibrosis in eosinophilic CRSwNP by downregulating epithelial cell TGFBR3 expression; consequently, MEX3B might be a valuable therapeutic target against eosinophilic CRSwNP.

Numerical analysis of the ostiomeatal complex aeration using the CFD method

We aimed to analyse ostiomeatal complex (OMC) aeration using the computational fluid dynamics (CFD) method of simulation based on human craniofacial computed tomography (CT) scans. The analysis was based on CT images of 2 patients: one with normal nose anatomy and one with nasal septal deviation (NSD). The Reynolds-Average Simulation approach and turbulence model based on linear eddy viscosity supplemented with the two-equation k-[Formula: see text] SST model were used for the CFD simulation. As a result, we found differences in airflow velocity through the ostiomeatal complex in patients with a normal nose and those with NSD. In a patient with NSD, the flow is turbulent in contrast to the normal nose (laminar flow). A faster (more intensive) airflow through the OMC was observed in the wider nasal cavity of the patient with NSD than on the narrower side. In addition, we want to emphasise the higher speed of airflow through the apex uncinate process area towards the ostiomeatal complex during exhalation, which, in the presence of secretions in the nose, predisposes to its easier penetration into the sinuses of the anterior group.

Chronic Rhinosinusitis Outcome Registry (CHRINOSOR): Establishment of an International Outcome Registry Driven by mHealth Technology

BACKGROUND

Real-world evidence (RWE) is a valuable instrument to better understand the patient journey and effectiveness of therapies. RWE on the prevalence of uncontrolled chronic rhinosinusitis (CRS) and CRS natural course of disease across Europe is scarce. In addition, there is limited RWE that enables comparison of the effectiveness of marketed therapies including topical or systemic corticosteroids, sinus surgery, or biologics.

OBJECTIVE

To establish an international CHRonic rhINOSinusitis Outcome Registry (CHRINOSOR) based on real-world data collection enabled by mobile health technology.

METHODOLOGY

A digital platform, Galenus Health, supporting patients and physicians in the management of chronic respiratory diseases, is used to collect data on patient profile, disease history, patient outcomes, and a set of relevant clinical outcomes. Adult patients with a diagnosis of CRS are eligible for inclusion.

RESULTS

A collaborative scientific network of 17 university ear-nose-throat (ENT) clinics from 10 European countries has been established with the aim to collect real-world data in a longitudinal and standardized manner. The Galenus Health digital platform is currently being implemented in these ENT clinics taking into account legal, privacy, and data security aspects. Up to 300 patients have already been included.

CONCLUSIONS

CHRINOSOR is a collaborative effort that aims at improving our understanding of CRS, its comorbidities, and the effectiveness of its treatments. Ultimately, these insights will guide us as scientific community to develop future care pathways informed by RWE.

Analysis of CRSsNP Proteome Using a Highly Multiplexed Approach in Nasal Mucus

BACKGROUND

Chronic rhinosinusitis without nasal polyps (CRSsNP) represents a phenotype of CRS, whose immunological mechanisms are still unclear. So far there are neither suitable biomarkers to determine the course of the disease nor an individual therapy.

OBJECTIVE

The purpose of this study was to characterize the CRSsNP endotype by identifying and validating non-invasive proteomic biomarkers.

METHODS

A highly-multiplexed proteomic array consisting of antibodies against 2000 proteins was used to identify proteins that are differentially expressed in the nasal mucus of the CRSsNP and control groups (n = 7 per group). The proteins identified to be most differentially expressed were validated in matched nasal mucus samples using western blots and enzyme-linked immunosorbent assay (ELISA). Validation was also done in a second cohort using western blots (CRSsNP n = 25, control n = 23) and ELISA (n = 30 per group). Additionally, immunohistochemistry in CRSsNP and control tissue samples was performed to characterize the selected proteins further.

RESULTS

Out of the 2000 proteins examined, 7 from the most differentially expressed proteins were chosen to be validated. The validation results showed that 4 proteins were significantly upregulated in CRSsNP mucus, including macrophage inflammatory protein-1beta (MIP-1β), resistin, high mobility group box 1 (HMGB1), and forkhead box protein 3 (FOXP3). Cartilage acidic protein 1 (CRTAC1) was not significantly upregulated. Two proteins were significantly downregulated including scavenger receptor class F member 2 (SCARF2) and P-selectin. All proteins selected are mainly associated with inflammation, cell proliferation/differentiation, apoptosis and cell-cell or cell-matrix interaction.

CONCLUSION

Proteomic analysis of CRSsNP and control mucus has confirmed known and revealed novel disease-associated proteins that could potentially serve as a new biosignature for CRSsNP. Analysis of the associated pathways will specify endotypes of CRSsNP and will lead to an improved understanding of the pathophysiology of CRSsNP. Furthermore, our data contribute to the development of a reproducible, non-invasive, and quantitative "liquid biopsy" for rhinosinusitis.

Type 2 inflammation in asthma and other airway diseases

Chronic inflammatory airway diseases, including asthma, chronic rhinosinusitis, eosinophilic COPD and allergic rhinitis are a global health concern. Despite the coexistence of these diseases and their common pathophysiology, they are often managed independently, resulting in poor asthma control, continued symptoms and poor quality of life. Understanding disease pathophysiology is important for best treatment practice, reduced disease burden and improved patient outcomes.

The pathophysiology of type 2 inflammation is driven by both the innate immune system triggered by pollutants, viral or fungal infections involving type 2 innate lymphoid cells (ILC2) and the adaptive immune system, triggered by contact with an allergen involving type 2 T-helper (Th2) cells. Both ILC2 and Th2 cells produce the type-2 cytokines (interleukin (IL)-4, IL-5 and IL-13), each with several roles in the inflammation cascade. IL-4 and IL-13 cause B-cell class switching and IgE production, release of pro-inflammatory mediators, barrier disruption and tissue remodelling. In addition, IL-13 causes goblet-cell hyperplasia and mucus production. All three interleukins are involved in trafficking eosinophils to tissues, producing clinical symptoms characteristic of chronic inflammatory airway diseases.

Asthma is a heterogenous disease; therefore, identification of biomarkers and early targeted treatment is critical for patients inadequately managed by inhaled corticosteroids and long-acting β-agonists alone. The Global Initiative for Asthma guidelines recommend add-on biological (anti IgE, IL-5/5R, IL-4R) treatments for those not responding to standard of care. Targeted therapies, including omalizumab, mepolizumab, reslizumab, benralizumab, dupilumab and tezepelumab, were developed on current understanding of the pathophysiology of type 2 inflammation. These therapies offer hope for improved management of type 2 inflammatory airway diseases.

Asthma is a heterogenous disease. Targeted therapies have been developed based on the pathophysiology of type 2 inflammation. These therapies offer hope for improved management of type 2 inflammatory airway diseases.https://bit.ly/3HCkrvQ

Biological Therapy of Severe Asthma and Nasal Polyps

Chronic rhinosinusitis is a common disease worldwide and can be categorized into chronic rhinosinusitis with nasal polyps and chronic rhinosinusitis without nasal polyps. Chronic rhinosinusitis with nasal polyps is common in patients with asthma and, particularly, severe asthma. Severe asthma is effectively treated with biologics and the coexistence of severe asthma with chronic rhinosinusitis with nasal polyps presents a phenotype that is more likely to respond to such treatment. In this review, we focus on the link between asthma and nasal polyps, and we review the treatment effect of various monoclonal antibodies in patients with severe asthma and nasal polyps as well as in patients with nasal polyps without asthma or with mild-to-moderate asthma. With the enhancement of our armamentarium with new monoclonal antibodies the right choice of biologic becomes an important target and one that is difficult to achieve due to the lack of comparative head-to-head studies.

Cost–Utility Analysis of Dupilumab for the Treatment of Chronic Rhinosinusitis with Nasal Polyps (CRSwNP) in Italy

The objective of this analysis was to estimate the incremental cost–utility ratio (ICUR) of dupilumab as an add-on treatment to best supportive care (BSC), versus BSC alone, in Italy for severe uncontrolled chronic rhinosinusitis with nasal polyps (CRSwNP). A simulation of outcomes and costs was undertaken using a 1-year decision tree, followed by a lifetime horizon Markov model. Clinical data were derived from a pooled analysis of two studies (SINUS-24 NCT02912468 and SINUS-52 NCT02898454). The Italian National Healthcare Service (NHS) perspective was considered. Model robustness was tested through sensitivity analyses. In the base-case analysis, treatment with dupilumab + BSC resulted in an increase in quality of life-adjusted survival (+1.02 quality-adjusted life years (QALY-gained)), compared to the BSC alone. The resulted ICUR was €21,817 per QALY-gained and it is below the acceptability threshold commonly used in Italy. Both one-way deterministic and probabilistic sensitivity analyses confirmed the robustness of base-case results. The cost–utility analysis showed that dupilumab, as an add-on treatment to BSC, is a cost-effective therapeutic alternative to BSC in the treatment of patients with severe uncontrolled chronic rhinosinusitis with nasal polyps, confirming that it is economically sustainable.

May Staphylococcus lugdunensis Be an Etiological Factor of Chronic Maxillary Sinuses Infection?

Staphylococcus lugdunensis is an opportunistic pathogen found in the healthy human skin microbiome bacterial community that is able to cause infections of diverse localization, manifestation, and course, including laryngological infections, such as necrotizing sinusitis. Chronic maxillary sinusitis is a disease present in up to one third of European and American populations, and its etiology is not fully described. Within this study, we aimed to characterize 18 S. lugdunensis strains recovered from maxillary sinuses and evaluate them as etiological agents of chronic disease. We performed MLST analysis, the complex analysis of both phenotypic and genetic virulence factors, antibiotic susceptibility profiles, and biofilm formation assay for the detection of biofilm-associated genes. Altogether, S. lugdunensis strains were clustered into eight different STs, and we demonstrated several virulence factors associated with the chronic disease. All tested strains were able to produce biofilm in vitro with numerous strains with a very strong ability, and overall, they were mostly susceptible to antibiotics, although we found resistance to fosfomycin, erythromycin, and clindamycin in several strains. We believe that further in-depth analysis of S. lugdunensis strains from different niches, including the nasal one, should be performed in the future in order to reduce infection rate and broaden the knowledge about this opportunistic pathogen that is gaining attention.

Chronic Rhinosinusitis, S. aureus Biofilm and Secreted Products, Inflammatory Responses, and Disease Severity

Chronic rhinosinusitis (CRS) is a persistent inflammation of the nasal cavity and paranasal sinuses associated with tissue remodelling, dysfunction of the sinuses’ natural defence mechanisms, and induction of different inflammatory clusters. The etiopathogenesis of CRS remains elusive, and both environmental factors, such as bacterial biofilms and the host’s general condition, are thought to play a role. Bacterial biofilms have significant clinical relevance due to their potential to cause resistance to antimicrobial therapy and host defenses. Despite substantial medical advances, some CRS patients suffer from recalcitrant disease that is unresponsive to medical and surgical treatments. Those patients often have nasal polyps with tissue eosinophilia, S. aureus-dominant mucosal biofilm, comorbid asthma, and a severely compromised quality of life. This review aims to summarise the contemporary knowledge of inflammatory cells/pathways in CRS, the role of bacterial biofilm, and their impact on the severity of the disease. Here, an emphasis is placed on S. aureus biofilm and its secreted products. A better understanding of these factors might offer important diagnostic and therapeutic perceptions for recalcitrant disease.

A review of phase III clinical trials of US FDA-approved biologic therapies for chronic rhinosinusitis with nasal polyposis

Chronic rhinosinusitis with nasal polyposis is a heterogenous disease with complex underlying pathophysiologic mechanisms. Biologics have been proven to be an effective add-on therapeutic option in severe and/or refractory cases. Currently, dupilumab, omalizumab and mepolizumab have phase III data to support their use in these patients and have received approval from the United States Food and Drug Administration specifically for the treatment of nasal polyposis. Each of these biologics has shown its ability to reduce nasal polyp size and improve nasal congestion/obstruction and sense of smell, but additional research is needed to directly compare the efficacy and safety of the different biologic agents for different nasal polyposis endotypes.

Managing Chronic Rhinosinusitis with Nasal Polyps in the Elderly: Challenges and Solutions

The proportion of the population over 65 years old continues to grow. Chronic rhinosinusitis is common in this population and causes a reduction in quality of life and an increase in health care utilization. Diagnosis of chronic rhinosinusitis with nasal polyps follows the same principles for elderly patients as in the general population, but the elderly population presents some diagnostic challenges worth considering. Presbynasalis, the anatomic and functional changes of the nose and paranasal sinuses associated with aging must be accounted for when caring for these patients. In addition, polypharmacy and other medical issues that can cause similar symptoms must be considered. Medical therapy is generally similar to the general population but with additional concerns given the propensity for geriatric patients to be on multiple medications and to suffer from multiple medical issues. Sinus surgery should be considered following the same indications as in the general population. While some authors have found higher complication rates in endoscopic sinus surgery, others have found higher rates of success. As always, the risks of surgery must be considered with the possible benefits on a patient-to-patient basis.

Characterization of human nasal organoids from chronic rhinosinusitis patients

Patient-derived organoids grown in three-dimensional cultures provide an excellent platform for phenotypic high-throughput screening and drug-response research. Organoid technology has been applied to study stem cell biology and various human pathologies. This study investigates the characteristics and cellular morphology of organoids derived from primary human nasal epithelial cells (HNECs) of chronic rhinosinusitis (CRS) patients. Nasal organoids were cultured up to 20 days and morphological, cell composition and functional parameters were measured by immunofluorescence, RT-qPCR, western blot and FACS analysis. The results showed that nasal organoids expressed the stem cell marker leucine-rich repeat-containing G-protein-coupled receptor 5 (LGR5), and markers for apical junction genes, goblet cells and ciliated cells. Moreover, we were able to regrow and expand the nasal organoids well after freezing and thawing. This study provides an effective and feasible method for development of human nasal organoids, suitable for the phenotypic high-throughput screening and drug response research.

Summary: This study provides an effective and feasible method for development of human nasal organoids from chronic rhinosinusitis patients, suitable for phenotypic high-throughput screening and drug-response research.

Clinical efficiency of allergen-specific immunotherapy with fungal allergens in patients with chronic polypous rhinosinusitis against the background of fungal sensitization

Fungal flora is one of the causes of inflammatory, including polypous, processes in the nasal cavity. In this regard, studies aimed at reducing the effect of fungal sensitization (FS) on the course of chronic polypous rhinosinusitis (CPRS) are relevant. The objective of the study was to evaluate the effect of various treatment options on the clinical course of the disease in patients with chronic polypous rhinosinusitis against the background of sensitization to fungi. The study included 90 patients with chronic polypous rhinosinusitis in combination with FS. The patients were divided into two groups - the first clinical group (G1) and the second clinical group (G2). G1 patients received allergen-specific immunotherapy (ASIT) according to the scheme. G2 patients received basic treatment. Evaluation of the clinical efficiency of ASIT was made based on complaints, assessment of symptom severity on a visual analog scale (VAS), and rhinoendoscopic examination. The treatment outcomes were evaluated on a 4-point scale, with excellent results (4 points) - complete remission of the disease during the follow-up period (6-12 months); good (3 points) - exacerbation of the disease 1-2 times a year, in mild form and removed by expectant treatment; satisfactory (2 points) - the number of exacerbations did not decrease. The use of ASIT therapy is pathogenetically justified and leads to a significant improvement in the clinical condition of patients with CPRS with FS.

Rhinosinusitis: clinical-based phenotyping

Rhinosinusitis (RS) is a common disease and is currently classified into two main types: acute RS (ARS) and chronic RS (CRS), which in turn includes CRS with or without nasal polyps. Different guidelines consider this classification. However, in clinical practice, other phenotypes exist. The current article would propose new clinical-based phenotyping of RS, including the following clinical phenotypes: simple catarrhal RS, Acute RS, acute bacterial RS, severe (complicated) acute RS, chronic RS, and recurrent chronic RS. Treatment strategy should be tailored considering the clinical phenotype and could include phytomedicines, intranasal non-pharmacological remedies, and local bacteriotherapy. In conclusion, RS requires thorough diagnostic work-up, and the therapeutic approach should be mainly based on appropriate management.

Vascular permeability in chronic rhinosinusitis enhances accumulation and retention of nanoscale pegylated liposomes

Chronic rhinosinusitis (CRS) is a debilitating inflammatory disorder of the sinonasal mucosa that substantially diminishes patient quality of life. Progress surrounding management of this disease has been crippled by a lack of therapeutic innovation. It has been posited that increased vascularity within the diseased sinuses of patients with CRS may allow for improved systemic drug delivery via nanoscale liposomal carriers. Such a system could enhance drug distribution, accumulation, and retention within the sinuses, ultimately leading to improved patient outcomes. PEGylated liposomes loaded with indocyanine green (ICG) were synthesized, characterized and systemically administered in a mouse model of CRS. Accumulation and retention of ICG in sinonasal tissue were evaluated. Compared to healthy controls, CRS mice showed significant sinonasal tissue accumulation and retention of PEGylated liposomal ICG for up to 21 days (P < 0.001). Conversely, free ICG was eliminated from the body after 24 h in both groups.

Influence of the Microbiome on Chronic Rhinosinusitis With and Without Polyps: An Evolving Discussion

Chronic rhinosinusitis (CRS) is widely prevalent within the population and often leads to decreased quality of life, among other related health complications. CRS has classically been stratified by the presence of nasal polyps (CRSwNP) or the absence nasal polyps (CRSsNP). Management of these conditions remains a challenge as investigators continue to uncover potential etiologies and therapeutic targets. Recently, attention has been given to the sinunasal microbiota as both an inciting and protective influence of CRS development. The healthy sinunasal microbiologic environment is largely composed of bacteria, with the most frequent strains including Staphylococcus aureus, Streptococcus epidermidis, and Corynebacterium genera. Disruptions in this milieu, particularly increases in S. aureus concentration, have been hypothesized to perpetuate both Th1 and Th2 inflammatory changes within the nasal mucosa, leading to CRS exacerbation and potential polyp formation. Other contributors to the sinunasal microbiota include fungi, viruses, and bacteriophages which may directly contribute to underlying inflammation or impact bacterial prevalence. Modifiable risk factors, such as smoking, have also been linked to microbiota alterations. Research interest in CRS continues to expand, and thus the goal of this review is to provide clinicians and investigators alike with a current discussion on the microbiologic influence on CRS development, particularly with respect to the expression of various phenotypes. Although this subject is rapidly evolving, a greater understanding of these potential factors may lead to novel research and targeted therapies for this often difficult to treat condition.

Correlation of Clinical Symptoms With Nasal Endoscopy and Radiological Findings in the Diagnosis of Chronic Rhinosinusitis: A Prospective Observational Study

Introduction: In the diagnosis of chronic rhinosinusitis (CRS), computed tomography (CT) of the nose and paranasal sinuses (PNS) remains the gold standard investigation. Though the diagnostic nasal endoscopy (DNE) is an equally effective and easily available investigation for diagnosis of CRS, its reliability and clinical significance to that of patient’s symptoms have to be proven.

Objective: The purpose of this study is to determine the correlations between the symptom severity score, radiological score, and the endoscopic score in the diagnosis of CRS. 

Methods: This prospective observational study included 70 patients with CRS. It was conducted in a tertiary care institute from January 2019 to June 2020. All patients were subjected to DNE and CT nose and PNS. Symptom score was assessed using Visual Analogue Scale (VAS) score of 0-10. DNE and CT scores were calculated using the Lund-Kennedy endoscopic scoring system and the Lund-Mackay CT scoring system, respectively. The correlation between these scores were done using Pearson’s correlation coefficient (p-value).

Results: The mean and standard deviation of the symptom score by VAS was 7 ± 1.7; the Lund-Kennedy score was 7.6 ± 2.3, and the Lund-Mackay score was 14.3 ± 6.5, respectively. The symptom score had moderate correlation with the Lund-Kennedy Score (r = 0.643, p < 0.001) and high degree of correlation with the Lund-Mackay Score (r = 0.835, p < 0.001). The Lund-Kennedy score had a positive correlation with The Lund-Mackay score.

Conclusion: DNE can be utilized as an early diagnostic tool in the clinical evaluation of CRS and is equally effective as CT in diagnosing the same. At the same time, a CT scan can be done in patients with positive symptoms and can be reserved as a second-level investigation for those patients with negative endoscopic findings but who become symptomatic on follow-up.

Breathing freely is possible! How to help patients with bronchial asthma and polyposis rhinosinusitis?

On June 2325, under the auspices of the Year of Science and Technology in Russia, the 17th International Interdisciplinary Congress of Allergology and Rhinosinusitis was held in Moscow. The 17th International Interdisciplinary Congress of Allergology and Immunology, where the results of current research, approaches to therapy and prevention of diseases based on modern clinical guidelines were presented. The event included a symposium "Breathe freely it is possible! How to help patients with bronchial asthma and polyposis rhinosinusitis?" with the participation of leading Russian specialists.

miR-1287-5p upregulation inhibits the EMT and pro-inflammatory cytokines in LPS-induced human nasal epithelial cells (HNECs)

BACKGROUND

Chronic rhinosinusitis is an intractable symptom that influences daily lives of patients. miR-1287-5p was discovered to play a suppressive role in cervical cancer and HBV-related infection.

PURPOSE

This study investigated the potential role of miR-1287-5p in the in-vitro model of chronic rhinosinusitis.

METHODS

GSE169376 dataset was analyzed and differential miRNAs in nasal mucosa tissues in the chronic rhinosinusitis group were screened out. LPS was used to treat HNECs for 12h, 24h and 48h. Cells underwent LPS treatment after SNAI1 downregulation, miR-1287-5p upregulation or pretreatment of the HMGB1 inhibitor, Glycyrrhizin. RT-PCR was used to measure the RNA expression of miR-1287-5p, SNAI1 and HMGB1. ELISA was used for the detection of IL-6, IL-8, TNF-α changes. Targetscan and starBase were used to predict the targets (SNAI1 and HMGB1) of miR-1287-5p. Dual-luciferase reporter assays were applied to validate this. Western blot was used to analyze the protein changes of Snai1, Vimentin, E-cadherin and HMGB1.

RESULTS

miR-1287-5p was downregulated in the chronic rhinosinusitis group and decreased after LPS treatment in HNECs. The upregulation of miR-1287-5p inhibited IL-6, IL-8, TNF-α and EMT. miR-1287-5p targeted and inhibited SNAI1 and HMGB1. SNAI1 downregulation led to inhibition in EMT while loss of HMGB1 contributed to the decrease in pro-inflammatory cytokines. Knockdown of SNAI1 decreased HMGB1, resulting in the reduction of pro-inflammatory cytokines while HMGB1 inhibitor reduced SNAI1 and thus suppressed the EMT process.

CONCLUSION

miR-1287-5p downregulation was associated with chronic rhinosinusitis and its upregulation inhibited the EMT and inflammation in LPS-induced HNECs through Snai1/HMGB1 pathway.

Clinical evaluation and nasoendoscopic scores of patients with chronic rhinosinusitis in Ilorin, Nigeria

Introduction

chronic rhinosinusitis (CRS) is characterised by inflammation of the mucosal lining of the nose and paranasal sinuses for at least 12 weeks duration. Other than the diagnostic criteria that is based on clinical features; nasoendoscopy and/or computerized tomographic scan have been included in the diagnosis. This study seeks to outline the clinical evaluation and nasoendoscopic assessment of CRS patients.

Methods

a hospital-based analytical study carried out on 154 participants. Clinical assessment and nasoendoscopy were performed and scored according to the discharge, inflammation and polyps/oedema (DIP) scale. Statistical analysis was carried out and results were presented in charts and tables.

Results

of the 154 participants, 71 (46.1%) were males and 83 (53.9%) females with a male to female ratio of 1: 1.7. Nasal discharge and blockage were the commonest symptoms. Nasoendoscopy had higher yield in the examination of intranasal polyps (NPs) over anterior rhinoscopy. The prevalence of NPs was 26.6%. The result of DIP nasoendoscopic findings revealed more participants with moderate scores. There was a significant statistical difference between the presence of NPs on nasoendoscopy and DIP score.

Conclusion

nasoendoscopy is an important aspect in the diagnosis and evaluation of patients with CRS. It provides a better visualization of NPs; therefore, it should be made routine in the clinical assessment and treatment of patients with CRS. The nasal endoscopic scoring of CRS should be considered as a common practice in clinical setting as well.

Ancestry-based variation in maxillary sinus anatomy: Implications for health disparities in sinonasal disease

Paranasal sinus drainage is mediated by mucociliary transport and gravity. However, human orthograde posture, along with the superior positioning of the maxillary sinus (MS) ostium, increases reliance on the mucociliary system. Previous research has thus suggested that differences in MS size and shape may impede mucociliary clearance, potentially contributing to disparities in sinusitis susceptibility. To further investigate this hypothesis, this study collected 29 three-dimensional (3D) coordinate landmarks and seven linear measurements of MS morphology from 167 computed tomography (CT) scans of crania of European, East Asian, or Equatorial African ancestry. MANOVA results reveal the Asian-derived individuals are characterized by both a significantly taller MS (F = 14.15, p <  0.0001) and a significantly greater distance from the MS floor to the ostium (F = 17.22, p <  0.0001) compared to those of European and African ancestry. A canonical variate (CV) analysis conducted on 3D landmark data provides corroborative results, distinguishing Asian-derived individuals predominantly on the basis of a relatively lower MS floor. As a greater distance between the MS floor and ostium may impede mucociliary clearance, our results suggest MS anatomy may be a more prominent factor in chronic sinusitis among individuals of Asian ancestry compared to those of European and African ancestries. This provides tentative evidence of an anatomical etiology for chronic sinusitis even in the absence of anatomical variants/abnormalities (e.g., nasal polyps, concha bullosa, Haller's cells, and Agger nasi cells). Further research into the relationship between MS anatomy and sinusitis, in addition to socioeconomic inequalities of healthcare, is warranted to continue evaluating possible contributions to health disparities.

Computed Tomography Evaluation of Unilateral Chronic Maxillary Sinusitis With Osteitis

BACKGROUND

Computed tomography (CT) is the preferred noninvasive method for the evaluation of osteitis in chronic sinusitis. Some scholars believe that the bone changes associated with chronic sinusitis always show high attenuation (high density) and are positively correlated with the severity of the disease. However, sinus bone remodeling is a complex process that may cause high or low attenuation. There have been few reports on the spread of osteitis. Therefore, additional research on sinus CT is necessary.

OBJECTIVE

To observe bony changes in chronic maxillary sinusitis (CMS) by CT and reveal the mechanism.

METHODS

A retrospective study was conducted in 45 patients with unilateral CMS with bony changes in the sinus walls. The patients' clinical data and CT results were analyzed and compared between the affected and normal sides. We propose the location, involvement, attenuation, and thickness method to evaluate CMS with osteitis.

RESULTS

Of the 45 patients, 40 (88.9%), 2, 12, and 7 had posterior external, medial, anterior, and superior lesions, respectively. The nasal region, sphenoid bone, palatine bone, and zygomatic arch were involved in 3, 12, 8, and 18 (40%) patients, respectively. Computed tomography indicated high attenuation in 30 (75.0%) and low attenuation in 10 (25.0%) patients; 6 (15.0%) showed new bone marrow cavities. The bone thickness was significantly different between the affected and normal sides in 40 patients (P < .001), including members of both the high- and low-attenuation groups (high-attenuation group: P < .001; low-attenuation group: P < .01). However, there was no significant difference in the thickness of the affected side between the high- and low-attenuation groups (P > .05).

CONCLUSIONS

Chronic rhinosinusitis with bony changes may occur in the maxillary sinus walls and spread to adjacent bones. Both increased and decreased attenuation may occur in these circumstances. Analyzing the CT features of bone changes in unilateral CMS can improve the accuracy of disease diagnosis.

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.

Burden of Disease in Chronic Rhinosinusitis with Nasal Polyps

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a predominantly type 2 inflammation-mediated disease of the nasal mucosa and paranasal sinuses with an under-recognized clinical, humanistic, and economic burden. Patients with CRSwNP experience a high symptom burden, including nasal congestion, loss of smell, and rhinorrhea, which has a negative impact on physical and mental health-related quality of life, including sleep quality. Existing medical and surgical interventions, including local and systemic corticosteroids and endoscopic sinus surgery, may be associated with recurrence of nasal polyps and associated symptoms and with an increased risk of short- and long-term adverse effects, especially with repeated or long-term use. Because type 2 inflammation is implicated in the pathogenesis of several coexisting diseases, patients with CRSwNP often have comorbid asthma and/or nonsteroidal anti-inflammatory drug-exacerbated respiratory disease. These patients, as well as those with high corticosteroid use and/or sinonasal surgical history, have more severe disease and associated symptom burden and represent a difficult-to-treat population under the existing management paradigm. This article reviews the clinical, humanistic, and economic burden of CRSwNP; it highlights the unmet need for effective and safe CRSwNP therapies that effectively control symptoms and minimize recurrence by targeting the underlying type 2 inflammatory disease pathophysiology.

Indirect Treatment Comparison of Biologics in Chronic Rhinosinusitis with Nasal Polyps

BACKGROUND

Among patients with chronic rhinosinusitis with nasal polyps (CRSwNP), randomized clinical trials (RCTs) of biologics, such as anti-interleukin-4/interleukin-13 (dupilumab) and anti-immunoglobulin E (omalizumab), have demonstrated efficacy compared with intranasal corticosteroids (INCS). However, no head-to-head RCTs exist between biologics.

OBJECTIVE

To perform an indirect treatment comparison (ITC) of the efficacy of biologics plus INCS versus placebo (INCS) as a common comparator.

METHODS

Embase, MEDLINE, and Cochrane were searched for RCTs of biologics in CRSwNP. Bucher ITCs were performed for outcomes at week 24: nasal polyp score (NPS) (range, 0-8), nasal congestion (NC) (range, 0-3), loss of smell (range, 0-3), University of Pennsylvania Smell Identification Test (range, 0-40), total symptom score (range, 0-12), 22-item sinonasal outcome test (range, 0-110), and responder analyses based on NPS or NC improvement of 1 point or greater.

RESULTS

Assessment of trial design, baseline characteristics, and outcome measures suggested that ITC was feasible with four phase 3 RCTs: dupilumab SINUS-24 and SINUS-52 (NCT02912468/NCT02898454) and omalizumab POLYP 1 and POLYP 2 (NCT03280550/NCT03280537). In the intent-to-treat population, dupilumab had significantly greater improvements from baseline to week 24 versus omalizumab across key outcomes: NPS (least squares mean difference [95% confidence interval], -1.04 [-1.63 to -0.44]), NC (-0.35 [-0.60 to -0.11]), loss of smell (-0.66 [-0.90 to -0.42]), University of Pennsylvania Smell Identification Test (6.70 [4.67-8.73]), and total symptom score (-1.18 [-1.95 to -0.41]). Improvement in the 22-item sinonasal outcome test was greater in dupilumab versus omalizumab but was not statistically significant. Dupilumab patients were significantly more likely to achieve ≥1-point improvement in NPS (odds ratio [95% CI] = 3.58 [1.82-7.04]) and NC (2.13 [1.12-4.04]) versus omalizumab.

CONCLUSIONS

Although ITCs have limitations, these results demonstrated that dupilumab had consistently greater improvements in key CRSwNP outcomes versus omalizumab at week 24.

Antibiotic Treatment for Chronic Rhinosinusitis: Prescription Patterns and Associations With Patient Outcome and the Sinus Microbiota

Background

Chronic rhinosinusitis (CRS) is a common and debilitating inflammatory condition of the sinuses, afflicting 5% of the general population. Although antibiotics are frequently prescribed for the medical management of CRS, there is surprisingly little evidence to support their efficacy. In this study, we aimed to establish associations between medication usage, the sinus microbiota and patients’ clinical outcomes.

Methods

Antibiotic prescription patterns for the year before sample collection of 156 CRS patients, 45 disease control patients (mostly requiring septoplasty and inferior turbinate reduction) and 35 healthy control subjects were examined and analyzed together with previously published bacterial 16S rRNA gene amplicon data from our group.

Results

The highest antibiotic usage was observed among the two CRS patient categories. Despite heavy antibiotic usage, CRS patients’ clinical outcomes as indicated by patient questionnaires and radiologic scores were similar to those patients that did not receive any antibiotics. The sinus microbiota was dominated by members of the bacterial genera Corynebacterium and Staphylococcus in all three cohorts. Bacterial community dispersion as measured by principal coordinate analysis was significantly higher in CRS patients compared to healthy control subjects, but not disease control patients. Pairwise comparisons within cohorts revealed differences in the relative 16S rRNA gene sequence abundances of the genera Staphylococcus and Lawsonella between antibiotic users and non-users. However, overall antibiotic effects were minimal and unpredictable.

Conclusion

The unpredictable effects of antibiotic treatment on the sinus microbiota found in this study, together with the lack of differences in patients’ symptom scores between cohorts, do not support preoperative antibiotic treatment for CRS patients.

Real-life assessment of chronic rhinosinusitis patients using mobile technology: The mySinusitisCoach project by EUFOREA

BACKGROUND

Chronic rhinosinusitis (CRS) is a chronic inflammatory disease associated with a substantial personal and socioeconomic burden. Monitoring of patient-reported outcomes by mobile technology offers the possibility to better understand real-life burden of CRS.

METHODS

This study reports on the cross-sectional evaluation of data of 626 users of mySinusitisCoach (mSC), a mobile application for CRS patients. Patient characteristics of mSC users were analysed as well as the level of disease control based on VAS global rhinosinusitis symptom score and adapted EPOS criteria.

RESULTS

The mSC cohort represents a heterogeneous group of CRS patients with a diverse pattern of major symptoms. Approximately half of patients reported nasal polyps. 47.3% of all CRS patients were uncontrolled based on evaluation of VAS global rhinosinusitis symptom score compared to 40.9% based on adapted EPOS criteria. The impact of CRS on sleep quality and daily life activities was significantly higher in uncontrolled versus well-controlled patients. Half of patients had a history of FESS (functional endoscopic sinus surgery) and reported lower symptom severity compared to patients without a history of FESS, except for patients with a history of more than 3 procedures. Patients with a history of FESS reported higher VAS levels for impaired smell.

CONCLUSION

Real-life data confirm the high disease burden in uncontrolled CRS patients, clearly impacting quality of life. Sinus surgery improves patient-reported outcomes, but not in patients with a history of more than 3 procedures. Mobile technology opens a new era of real-life monitoring, supporting the evolution of care towards precision medicine.

Chronic rhinosinusitis with nasal polyps management in the age of biologics

Background: Chronic rhinosinusitis is one of the most common medical conditions seen in the U.S. population. Chronic rhinosinusitis with nasal polyps (CRSwNP) in adults has predominately a type 2 inflammatory endotype that usually is treated with medical management that consists of inhaled corticosteroids, saline solution irrigation, oral corticosteroid bursts, and, at times, leukotriene antagonists and antibiotics. If medical management fails, then surgical intervention is usually recommended. Various biologics that target type 2 inflammation are now available, which have been or will be approved for use in these patients. Objective: To determine where biologics that affect the type 2 pathway fit into the algorithm of treatment for CRSwNP. Methods: A review of the literature on standard-of-care measures and surgical interventions in CRSwNP and an analysis of recent studies on the efficacy and safety of biologics in this condition. Results: Standard of care with medication and surgical interventions fail in some patients with CRSwNP. Biologics that affect the type 2 inflammatory pathway led to a decrease in nasal polyp size, improved nasal congestion, and improved quality of life both in patients who had surgery and those who had not had surgery for CRSwNP. Also, they showed efficacy and safety in patients whether or not they had comorbid asthma. These agents do not cure the patient with CRSwNP, and will be required chronically for control. Conclusion: Shared decision-making should be used in determining the use of certain medications, surgical management, and biologics in patients with CRSwNP. In patients for whom surgery has already failed and in patients with moderate-to-severe CRSwNP who have other type 2 comorbidities, e.g., asthma, a trial of biologics is a rational course.

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.

The Clinical and Radiological Characterizations of the Allergic Phenotype of Chronic Rhinosinusitis with Nasal Polyps

Purpose

The allergic phenotype of chronic rhinosinusitis (CRS) and central compartment atopic disease (CCAD) have been described. The CCAD is a radiological phenotype in patients with CRS that presents as a central mucosal disease due to allergy. The subset of patients having chronic rhinosinusitis with nasal polyps (CRSwNP) has not been well characterized. We aim to describe the clinical and radiological characterizations of patients presenting with the allergic phenotype of CRSwNP.

Patients and Methods

A cross-sectional study at a tertiary hospital was performed. Adult patients diagnosed with CRSwNP who had both allergology and radiological assessments were enrolled. The symptoms of allergic rhinitis, Lund-Kennedy (LK) endoscopic scoring, Lund-Mackay (LM) computed tomography scan of paranasal sinuses (CTPNS) scoring, CCAD features, skin prick test (SPT) and level of specific IgE were assessed. All the patients underwent SPT for house dust mites.

Results

A total of 38 patients were enrolled. Symptoms, endoscopic and CTPNS scores were higher in the allergy and CCAD groups compared to the nonallergy and nonCCAD groups. The symptom of "need to blow nose" was statistically significant in allergy vs nonallergy (p=0.01) and CCAD vs nonCCAD (p=0.02). There were significant differences in the endoscopic scores in both allergy and CCAD (allergy vs nonallergy, p=0.01; CCAD vs nonCCAD, p=0.03), and CT scores in both allergy and CCAD (allergy vs nonallergy, p=0.02; CCAD vs nonCCAD, p=0.02). All patients with CCAD have worse scoring than nonCCAD (LK score, p=0.03; LM score, p=0.02). Patients with allergy have more polypoidal involvement of the middle turbinates (left middle turbinate, p=0.141; right middle turbinate, p=0.074) and CCAD (left middle turbinate, p=0.017; right middle turbinate, p=0.009) than nonallergy and nonCCAD patients.

Conclusion

Allergic phenotype of CRSwNP has a worse clinical and radiological disease burden. Optimal treatment of allergy is essential for a better outcome.

Chronic Rhinosinusitis with Nasal Polyps and Asthma

Patients with chronic rhinosinusitis with nasal polyps (CRSwNP) characterized by a type 2 immune signature often have severe and recurrent disease. Lower airway conditions such as asthma are common comorbidities and share similar pathophysiology. CRSwNP with asthma is characterized by tissue eosinophilia and high local IgE levels. Clinically, CRSwNP with comorbid asthma is associated with more severe sinonasal symptoms and worse quality of life, and it is more difficult to treat both medically and surgically. Asthma in the presence of nasal polyposis is also more difficult to control, being more exacerbation prone, with increased airway obstruction and more extensive eosinophilic inflammation. Aspirin/nonsteroidal anti-inflammatory drug-exacerbated respiratory disease (AERD) is a recognized phenotype of CRSwNP with comorbid asthma. Patients with CRSwNP with comorbid AERD are among those with the most severe and difficult-to-treat disease, and tend to have severe NP. The shared pathophysiology of the upper and lower airways has important implications for both the diagnosis and management of respiratory comorbidities. However, in clinical practice, the nose and lungs are often treated as separate entities. The underlying systemic inflammatory link between CRSwNP and asthma provides a compelling rationale for systemic treatment with novel biologics targeting shared underlying type 2 inflammatory pathways.

Multiparametric Analysis of Factors Associated With Eosinophilic Chronic Rhinosinusitis With Nasal Polyps

INTRODUCTION

Previous studies have reported a diverse range of threshold values for blood eosinophilia. In addition, a single predictive biomarker for eosinophilic chronic rhinosinusitis (CRS) with nasal polyps (ECRSwNP) has not yet been identified.

OBJECTIVES

The aim of this study is to compare the clinical characteristics of ECRSwNP and non-ECRSwNP to evaluate the preoperative risk of tissue eosinophilia of chronic rhinosinusitis with nasal polyps (CRSwNP) through a multiparametric statistical analysis.

METHODS

One hundred ten patients with evidence of chronic polypoid rhinosinusitis were included in this study and clinical records were retrospectively reviewed. Eosinophilic CRSwNP was diagnosed based on the presence of at least 10 eosinophils per high-power field. The demographic and clinical features of ECRSwNP and non-ECRSwNP are described. The values of blood eosinophilia as predictors of tissue eosinophilia have been identified using receiver operating characteristic curves. As the predictive value of the identified cutoff through regression analysis was low, we evaluated whether other risk factors could be statistically associated with ECRSwNP, and from this, a new predictive model was proposed for the identification of eosinophilic nasal polyps before surgery.

RESULTS

We found that the best method for predicting ECRSwNP is based on a model having asthma, blood eosinophil percentage, posterior ethmoid value in Lund-Mackay score, and modified Lund-Kennedy score as explanatory variables.

CONCLUSIONS

This study provides new data for a better understanding of the polypoid CRS endotypes, and the proposed model allows the endotype to be identified preoperatively.

Increased Serum Periostin Levels and Eosinophils in Nasal Polyps Are Associated with the Preventive Effect of Endoscopic Sinus Surgery for Asthma Exacerbations in Chronic Rhinosinusitis Patients

BACKGROUND

Eosinophilic nasal polyps (NPs) are associated with the presence of asthma in chronic rhinosinusitis (CRS) patients. Serum periostin has been considered a relevant biomarker for unified airway diseases.

OBJECTIVE

To determine the utility of biomarkers including serum periostin that reflects reduction of exacerbations of comorbid asthma in CRS patients.

METHODS

We prospectively recruited 56 CRS patients who were subjected to undergo endoscopic sinus surgery (ESS) (20 with asthma) between October 2015 and December 2017 and followed them for 1 year after ESS. Blood eosinophil count, serum periostin, and fractional nitric oxide (FeNO) were measured at enrollment. How these type 2-driven biomarkers reflect comorbid asthma was determined using receiver operating characteristic (ROC) analysis. The frequency of asthma exacerbations during 1 year was counted both before and after ESS. Associations between preoperative biomarkers including eosinophils in NPs and asthma exacerbations were evaluated.

RESULTS

Blood eosinophil count, FeNO, and serum periostin levels were significantly higher in CRS patients with asthma than in those without (p < 0.01 for all) and discriminated comorbid asthma among CRS patients (p < 0.05; AUC > 0.80 for all). The increased preoperative serum periostin correlated with lower absolute number of postoperative exacerbations (ρ = -0.49, p = 0.03) and its relative reduction after ESS (ρ = 0.53, p = 0.03) in asthmatic patients. Increased eosinophils in NPs were also associated with reduced asthma exacerbations.

CONCLUSION

Preoperative increased serum periostin and eosinophils in NPs are associated with the preventive effect of ESS for asthma exacerbations in CRS patients comorbid with asthma.

Rhinosinusitis without nasal polyps in COPD

The validity of the united airway disease concept for rhinosinusitis (RS) and chronic obstructive pulmonary disease (COPD) has been questioned because of methodological limitations in previous studies. In this study we investigated the prevalence of RS without nasal polyps (RSsNP) and the severity of sinonasal symptoms in COPD and a corresponding control group. We also evaluated the diagnostic accuracy of these symptoms for RSsNP in COPD. 90 COPD patients and 93 controls were included in an observational cross-sectional study where globally accepted diagnostic criteria of RS and COPD (EPOS 2012 and GOLD) were incorporated; symptomatic and endoscopic criteria for the diagnosis of RS, and spirometry with reversibility for diagnosis of COPD. RS symptoms were identified by responses to the sinonasal outcome test (SNOT-22), nasal endoscopy identified signs of sinonasal disease and discriminated between RS with and without nasal polyps, and visual analogue scales (VAS) rated the severity of sinonasal symptoms. We found RSsNP in 51% of our COPD patients which is threefold greater than in the control group (p<0.001). Nasal discharge (72%) and nasal obstruction (62%) were the two most frequently reported symptoms in COPD. The diagnostic accuracy for RSsNP is better for the composite VAS for rhinological symptoms than for facial symptoms. We conclude that RSsNP is present in 51% of our COPD patients, which is significantly more prevalent compared to a corresponding control group. These results suggest that COPD is associated with RS.

Rhinosinusitis is associated with COPD and is significantly more prevalent (51%) compared to controlshttps://bit.ly/2YrIsmm

Use of biologics in chronic sinusitis with nasal polyps

PURPOSE OF REVIEW

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a heterogeneous inflammatory condition with different endotypes between patients from eastern or western countries. Targeted biologics are currently used to treat CRSwNP, but the outcomes widely vary. This review focuses on the present use of biologics for treating CRSwNP.

RECENT FINDINGS

Monoclonal biologics have been used as an innovative therapy for multiple allergic diseases and comorbid allergic conditions. Over the past several decades, numerous biomarkers have been investigated and were found to be closely correlated with CRSwNP, improving the understanding of inflammatory patterns and endotype classifications for CRSwNP and prompting discussion regarding the use of biologics in CRSwNP. Efficacies vary in reports of different research groups, but it has been found that patients with TH-2-driven inflammatory patterns respond better to the use of biologics than those with non-TH-2-driven CRSwNP. These findings suggest the importance and urgency of developing criteria for biologics in CRSwNP.

SUMMARY

Precisely determining patient criteria, identifying treatment biomarkers based on endotyping for CRSwNP and determinations of contraindications for long-term utilization may be useful for optimizing treatment strategies and improving the therapeutic efficacy of biologics to achieve long-term control starting at early stages.

Updates on current evidence for biologics in chronic rhinosinusitis

PURPOSE OF REVIEW

The purpose of this review is to present the most important recent developments concerning biologics as a therapeutic option for chronic rhinosinusitis (CRS).

RECENT FINDINGS

mAb anti-IL-4 receptor α (Dupilumab) was recently approved by Food and Drug Administration (FDA) for patients with CRSwNP and four other biologics are under investigation, with promising preliminary results.

SUMMARY

CRS is a disease associated with a significant symptom burden and high-indirect costs. Despite recent advances in combined approaches, persistent symptoms or recurrences are not uncommon. Monoclonal antibodies, used mainly to treat asthma, have recently been shown to have a positive impact on controlling the symptoms of CRS and reducing the need for endoscopic sinus surgery. Dupilumab, mepolizumab, reslizumab, benralizumab and omalizumab are discussed and their mechanism of action, risk and current evidence on efficacy are presented. Preliminary studies show encouraging results with relatively few side effects. Once the high cost of such therapies is addressed, they could prove an important adjuvant therapy for patients with CRS. Large-scale clinical trials designed to evaluate them are called for.

Chronic rhinosinusitis: assessment of changes in nociceptive neurons

BACKGROUND

Pain is a major symptom of chronic rhinosinusitis (CRS). It is mainly associated with CRS without nasal polyps (CRSsNP) and has a major impact in the decision to move on to surgery. Patients with CRS with nasal polyps (CRSwNP) are characterized by trigeminal hypoesthesia and suffer from less pain. The aim of this study was to investigate whether CRS induces alterations in the peripheral nociceptive neurons, mainly focusing on quantitative changes.

METHODS

Sinus mucosa and inferior turbinate (IT) samples were obtained from patients with CRS, and IT tissue of healthy patients served as controls. Reverse transcription quantitative polymerase chain reaction (RT-qPCR) was performed for neuronal markers including CNTNAP2, FAM19A1, GFRA2, NEFH, NTRK1, PLXNC1, RET, SCN10A, SCN11A, TRPV1, and PGP 9.5; enzyme-linked immunosorbent assay (ELISA) was performed for KCNK18, SCN10A, MRGPRD, and MAP2. For PGP 9.5, immunohistochemistry was additionally used to analyze tissue slides.

RESULTS

We included 35 patients with CRSsNP, 47 patients with CRSwNP, and 18 control patients. No differences in expression of the neuronal markers were observed between CRSsNP, CRSwNP, and controls. SCN10A was the only marker exclusively expressed on nociceptive neurons in sinus tissue. No histological difference in nerve fibers was observed between sinus mucosa of both phenotypes.

CONCLUSION

Our results indicate that the nociceptive nerve density in CRSwNP is not lower than in CRSsNP, as was assumed previously. The nociceptive neurons in sinonasal mucosa cannot be classified into subtypes due to the lack of specificity of the respective marker genes. Our findings question the generally accepted claim that nasal polyp tissue does not contain any nerves.