Chronic rhinosinusitis: an under-researched epidemic

Epigenetic responses to rhinovirus exposure in airway epithelial cells are correlated with key transcriptional pathways in chronic rhinosinusitis

BACKGROUND

Viruses may drive immune mechanisms responsible for chronic rhinosinusitis with nasal polyposis (CRSwNP), but little is known about the underlying molecular mechanisms.

OBJECTIVES

To identify epigenetic and transcriptional responses to a common upper respiratory pathogen, rhinovirus (RV), that are specific to patients with CRSwNP using a primary sinonasal epithelial cell culture model.

METHODS

Airway epithelial cells were collected at surgery from patients with CRSwNP (cases) and from controls without sinus disease, cultured, and then exposed to RV or vehicle for 48 h. Differential gene expression and DNA methylation (DNAm) between cases and controls in response to RV were determined using linear mixed models. Weighted gene co-expression analysis (WGCNA) was used to identify (a) co-regulated gene expression and DNAm signatures, and (b) genes, pathways, and regulatory mechanisms specific to CRSwNP.

RESULTS

We identified 5585 differential transcriptional and 261 DNAm responses (FDR <0.10) to RV between CRSwNP cases and controls. These differential responses formed three co-expression/co-methylation modules that were related to CRSwNP and three that were related to RV (Bonferroni corrected p < .01). Most (95%) of the differentially methylated CpGs (DMCs) were in modules related to CRSwNP, whereas the differentially expressed genes (DEGs) were more equally distributed between the CRSwNP- and RV-related modules. Genes in the CRSwNP-related modules were enriched in known CRS and/or viral response immune pathways.

CONCLUSION

RV activates specific epigenetic programs and correlated transcriptional networks in the sinonasal epithelium of individuals with CRSwNP. These novel observations suggest epigenetic signatures specific to patients with CRSwNP modulate response to viral pathogens at the mucosal environmental interface. Determining how viral response pathways are involved in epithelial inflammation in CRSwNP could lead to therapeutic targets for this burdensome airway disorder.

Comprehensive analysis of mitophagy-related genes in diagnosis and heterogeneous endothelial cells in chronic rhinosinusitis: based on bulk and single-cell RNA sequencing data

Background: Chronic rhinosinusitis (CRS) is a complex inflammatory disorder affecting the nasal and paranasal sinuses. Mitophagy, the process of selective mitochondrial degradation via autophagy, is crucial for maintaining cellular balance. However, the role of mitophagy in CRS is not well-studied. This research aims to examine the role of mitophagy-related genes (MRGs) in CRS, with a particular focus on the heterogeneity of endothelial cells (ECs). Methods: We employed both bulk and single-cell RNA sequencing data to investigate the role of MRGs in CRS. We compiled a combined database of 92 CRS samples and 35 healthy control samples from the Gene Expression Omnibus (GEO) database and we explored the differential expression of MRGs between them. A logistic regression model was built based on seven key genes identified through Random Forests and Support Vector Machines - Recursive Feature Elimination (SVM-RFE). Consensus cluster analysis was used to categorize CRS patients based on MRG expression patterns and weighted gene co-expression network analysis (WGCNA) was performed to find modules of highly correlated genes of the different clusters. Single-cell RNA sequencing data was utilized to analyze MRGs and EC heterogeneity in CRS. Results: Seven hub genes-SQSTM1, SRC, UBA52, MFN2, UBC, RPS27A, and ATG12-showed differential expression between two groups. A diagnostic model based on hub genes showed excellent prognostic accuracy. A strong positive correlation was found between the seven hub MRGs and resting dendritic cells, while a significant negative correlation was observed with mast cells and CD8+ T cells. CRS could be divided into two subclusters based on MRG expression patterns. WGCNA analysis identified modules of highly correlated genes of these two different subclusters. At the single-cell level, two types of venous ECs with different MRG scores were identified, suggesting their varying roles in CRS pathogenesis, especially in the non-eosinophilic CRS subtype. Conclusion: Our comprehensive study of CRS reveals the significant role of MRGs and underscores the heterogeneity of ECs. We highlighted the importance of Migration Inhibitory Factor (MIF) and TGFb pathways in mediating the effects of mitophagy, particularly the MIF. Overall, our findings enhance the understanding of mitophagy in CRS, providing a foundation for future research and potential therapeutic developments.

Evaluating the Efficacy and Trend of Sinus Surgery

Introduction  From April 2009 to December 2016, 661 consecutive patients undergoing sinus surgery completed a quality of life (QOL) questionnaire (SNOT-22) preoperatively and at 3, 6, and 12 months postoperatively.

Objective  (1) To evaluate the long-term efficacy of sinus surgery using QOL instruments. (2) To determine the optimal evaluation time for surgical efficacy. (3) To determine if surgical results improve with yearly experience.

Methods  The prospective study patients were split into two groups: Group A, those who completed the initial preoperative evaluation and all postoperative evaluations, and Group B, who completed the preoperative questionnaire and at least one but not all of the postoperative questionnaires. Group A included 93 patients. Group B included 240 patients at 3 months, 180 at 6 months, and 121 at 12 months postoperatively.

Results  Group A efficacy reported at 3 months was 82.8%, 80.6% at 6 months, and 84.9% at 12 months postoperatively. Group B efficacy reported at 3 months was 71.3%, 78.3% at 6 months, and 84.3% at 12 months postoperatively. An 8-year trend analysis of year-to-year 12 months postoperative data illustrates a significant improvement with an analysis of variance (ANOVA) linear rate of 1.594 ( p ≤0.12).

Conclusion  The 8-year trend at 12 months postoperatively shows a positive improvement in surgical results. Patients undergoing sinus surgery at tertiary medical center showed 84.9% improvement in sinus disease symptoms by 12 months postoperatively. Long-term improvement analysis showed no difference between 6 months postoperatively and 12 months, signifying 6 months as an effective evaluation for surgical efficacy.

Characterization of Chronic Sinonasal Disease Symptoms in an Urban Homeless Population

BACKGROUND

The urban homeless population has increased exposure to risk factors associated with chronic rhinosinusitis (CRS). However, a gap in knowledge of the prevalence of sinonasal symptoms in these demographic limits complete understanding of CRS epidemiology. There is a need to elucidate sinonasal disease burden in this vulnerable patient population to bring awareness to any existing disparities.

OBJECTIVE

To assess the prevalence, severity, and associated factors of CRS clinical symptoms and health-care barriers in an urban homeless population.

METHODS

Homeless adults completed a sociodemographic questionnaire and the 22-item Sinonasal Outcome Test (SNOT-22) and EuroQol-5 Dimension-3 Level-Visual Analog Scale surveys. Responses were categorized by potential CRS symptoms defined as reporting at least 2 CRS cardinal symptoms. Risk factors associated with potential CRS symptoms were analyzed with multivariate regression models.

RESULTS

Fifty-six (16%) out of 341 total subjects reported potential CRS symptoms. Those with potential CRS symptoms had a higher median SNOT-22 score (53 vs 22, P < .001) than those without. Logistic regression models identified history of smoking (odds ratio [OR], 6.54; 95% confidence interval [CI], 2.04-21.04) and duration of homelessness over 3 months (OR, 3.46; CI, 1.51-7.94) as factors associated with potential CRS symptoms. Duration of homelessness over 3 months was associated with higher SNOT-22 scores (standardized beta coefficient [β], 0.48; CI, 0.39-0.57). Among those reporting 2 or more CRS cardinal symptoms, 18% had ever been seen by any physician for their symptoms.

CONCLUSIONS

Our study estimates a high prevalence of potential CRS symptoms in the urban homeless population. Longer duration of homelessness was associated with potential CRS symptoms and poor CRS-specific quality of life scores. Disparities in access to care emphasize the need for increased preventive efforts designed for this unique patient group.

Novel therapeutic targets for allergic airway disease in children

The aim of precision medicine is setting up targeted therapies for selected patients that would ideally have high effectiveness and few side effects. This is made possible by targeted therapy drugs that selectively act on a specific pathway. Precision medicine is spreading to many medical specialties, and there is increasing interest in the context of allergic airway diseases, such as allergic rhinitis, chronic rhinosinusitis, and asthma. This review is an update of new targets in the treatment of childhood allergic upper airway diseases and asthma, including the most recent biologic drugs that have already been licensed or are in the pipeline to be tested with children.

The Effect of Spray Cryotherapy on Microbial Biofilms in Chronic Rhinosinusitis

PURPOSE OF REVIEW

Microbial biofilms seem to play an active role in the pathogenesis of chronic rhinosinusitis (CRS). They represent an adaptive defense resource enabling resistance to antibiotics and host defense mechanisms. Biofilms are thought to be accountable for refractory cases of sinusitis by perpetuating local inflammation. The objective of this study was to assess the effectiveness of spray cryotherapy as a biofilm disruption agent in CRS in an in vitro model.

RECENT FINDINGS

A total of 23 patients with CRS undergoing endoscopic sinus surgery (ESS) were included. Rhinosinusal mucosa samples were harvested. Half of sample was left intact while the other half was treated with spray cryotherapy, so patients served as their own witnesses. Subsequently, they were processed to hematoxylin-eosin (HE) and toluidine blue (TB) staining and analyzed by light microscopy. Biofilms were detected in 17 of 23 patients with CRS. Staining by HE showed strong correlation with the results of TB staining protocol. The in vitro CRS study demonstrated that spray cryotherapy removed polymicrobial biofilms from the mucosa surface in 70.6% of cases and induced important structural changes in the remaining samples. Thus far, cryotherapy has proven to be a reliable method for the disruption of microbial biofilms in CRS with nasal polyps, in vitro conditions. Spray cryotherapy could be a considerable benefit in the management of recalcitrant CRS.

Quality indicators for the diagnosis and management of chronic rhinosinusitis

BACKGROUND

Chronic rhinosinusitis (CRS) has been identified as a high-priority disease category for quality improvement. To this end, this study aimed to develop CRS-specific quality indicators (QIs) to evaluate diagnosis and management that relieves patient discomfort, improves quality of life, and prevents complications.

METHODS

A guideline-based approach, proposed in 2012 by Kötter et al. was used to develop QIs for CRS. Candidate indicators (CIs) were extracted from 3 practice guidelines and 1 international consensus statement on the diagnosis and management of CRS. Guidelines were evaluated using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool. Each CI and its supporting evidence was summarized and reviewed by an expert panel based on validity, reliability, and feasibility of measurement. Final QIs were selected from CIs utilizing the modified RAND Corporation-University of California, Los Angeles (RAND/UCLA) appropriateness methodology.

RESULTS

Thirty-nine CIs were identified after literature review and evaluated by our panel. Of these, 9 CIs reached consensus as being appropriate QIs, with 4 requiring additional discussion. After a second round of evaluations, the panel selected 9 QIs as appropriate measures of high-quality care.

CONCLUSION

This study proposes 9 QIs for the diagnosis and management of patients with CRS. These QIs can serve multiple purposes, including documenting the quality of care; comparing institutions and providers; prioritizing quality improvement initiatives; supporting accountability, regulation, and accreditation; and determining pay-for-performance initiatives.

The impact of chronic airway disease on symptom severity and global suffering in Canadian rhinosinusitis patients

Background

Patients with Chronic Rhinosinusitis (CRS) can suffer from a significant decline in their quality of life. CRS patients have a high prevalence of comorbid conditions and it is important to understand the impact of these conditions on their CRS-related quality of life. This study measures the impacts of chronic pulmonary comorbidities on quality of life, pain, and depression scores among patients with CRS awaiting Endoscopic Sinus Surgery (ESS).

Methods

This study is based on cross-sectional analysis of prospectively collected patient-reported outcome data collected pre-operatively from patients waiting for ESS. Surveys were administered to patients to assess sino-nasal morbidity (SNOT-22), depression and pain. The impact of pulmonary comorbidity on SNOT-22 scores, pain and depression was measured.

Results

Two hundred fifthy-three patients were included in the study, 91 with chronic pulmonary comorbidity. The mean SNOT-22 scores were significantly higher among patients with chronic pulmonary comorbidities than among patients without (37 and 48, respectively). This difference is large enough to be clinically significant. Patients with chronic pulmonary comorbidities reported slightly higher depression scores than those without.

Conclusions

This study found that among CRS patients waiting for ESS, chronic pulmonary comorbidities are strongly associated with significantly higher symptom burden.

SNOT-22-based clusters in chronic rhinosinusitis without nasal polyposis exhibit distinct endotypic and prognostic differences

BACKGROUND

Endotypic and prognosticating features of chronic rhinosinusitis without nasal polyposis (CRSsNP) are poorly understood. Our objectives were to use an unbiased symptom-based approach to: (1) study symptoms, clinical and endotypic features; and (2) identify features predicating outcomes from endoscopic sinus surgery (ESS).

METHODS

Clinical, computed tomography (CT), histopathology, and 22-item Sino-Nasal Outcome Test (SNOT-22) data was collected on 146 adult CRSsNP patients who underwent ESS. Unsupervised network modeling of presurgical SNOT-22 scores was performed to classify symptom-based clusters. Subject characteristics and post-ESS SNOT-22 scores were compared between clusters.

RESULTS

Baseline characteristics of the subject population were as follows: females, 56.2%; revision ESS status in 35%; asthma prevalence, 32.6%; median Lund-Mackay CT score, 8; and median SNOT-22 total score, 43. Network mapping and unsupervised clustering of preoperative SNOT-22 scores revealed 4 clusters: (A) severely burdened with high scores in all 4 subdomains; (B) moderately burdened with high scores in the rhinologic subdomain; (C) moderately burdened with high scores in psychological-sleep subdomains; and (D) mildly burdened. The number of previous ESS and asthma prevalence differed significantly between clusters; CT scores were similar. Asthma burden and tissue eosinophilia were greatest in cluster A (p = 0.03). All groups showed significant improvement at 3 months post-ESS (p < 0.0001). At 6 months, patients in cluster C tended to worsen.

CONCLUSION

SNOT-22-based network modeling of CRSsNP patients yielded 4 clusters with distinct features. Asthma prevalence and tissue eosinophilia were highest in the cluster with highest SNOT-22 scores. All patients showed significant improvement from ESS at 3 months; those with high sleep-psychosocial symptoms tended to show worsening at 6 months.

Clinical predictors of chronic rhinosinusitis: do the Canadian clinical practice guidelines for acute and chronic rhinosinusitis predict CT-confirmation of disease?

BACKGROUND

The diagnosis of chronic rhinosinusitis (CRS) based on clinical presentation alone remains challenging. To improve the accuracy of clinical diagnosis, the Canadian Rhinosinusitis Guidelines recommend the use of specific symptom and endoscopic criteria. Our study objective was to determine whether symptom and endoscopic criteria, as defined by the Canadian Rhinosinusitis Guidelines, accurately predict CT-confirmed CRS diagnosis.

METHODS

A retrospective cohort study of 126 patients who underwent CT sinuses based on clinical suspicion of possible CRS. The presence of symptom and endoscopic criteria, as defined by the Canadian Rhinosinusitis Guidelines, were compared between patients with and without a CT-confirmed CRS diagnosis using two-tailed Fisher's exact tests. Positive predictive values and likelihood ratios were determined for each symptom and endoscopic finding.

RESULTS

Overall, 56.3% of patients had a CT-confirmed diagnosis of CRS. With the exception of nasal polyps, none of the symptom or endoscopic criteria had a statistically significant correlation with positive CT sinuses. For symptom criteria, positive predictive values ranged from 52.4% to 63.4%; likelihood ratios ranged from 0.85 to 1.34. For endoscopic criteria, positive predictive values and likelihood ratios were 71.4% and 1.94 (edema); 63.0% and 1.32 (discharge); and 92.9% and 10.1 (nasal polyps). 35.2% of patients with CT-confirmed CRS had normal endoscopic exams.

CONCLUSION

The Canadian Rhinosinusitis Guidelines' symptom and endoscopic criteria for CRS, with the exception of nasal polyps on endoscopy, do not accurately predict CT-confirmed disease. In addition, a normal endoscopic exam does not rule out CRS.

Risk Factors of Chronic Rhinosinusitis After Functional Endoscopic Sinus Surgery

BACKGROUND Clinical data of 288 chronic rhinosinusitis patients were retrospectively analyzed to investigate the risk factors of clinical prognosis, aiming to provide clinical evidence for the diagnosis and treatment of chronic rhinosinusitis. MATERIAL AND METHODS A total of 288 patients diagnosed with chronic rhinosinusitis in the Department of Otolaryngology of the First Affiliated Hospital of Xinjiang Medical University were recruited. Among all participants, 177 were male and 111 were female, aged from 22 to 83 years, (52±14) years on average. Subsequent follow-up was conducted to evaluate surgical efficacy. Influencing factors of clinical prognosis were analyzed by univariate and multivariate logistic regression analyses. RESULTS After functional endoscopic sinus surgery by Messerklinger technique, 187 (64.9%) patients were fully recovered, 72 (25.0%) presented with improvement, and 28 (10.1%) were untreated. Univariate logistic regression analysis revealed that 11 variables were correlated with the clinical prognosis of chronic rhinosinusitis. Multivariate logistic regression analysis demonstrated that age, history of allergic rhinitis, severity of dysosmia, history of nasosinusitis surgery, and long-term use of nasal decongestant were the risk factors, whereas comprehensive therapy after surgery was a protective factor. CONCLUSIONS More emphasis should be placed upon the factors associated with the clinical prognosis of patients with chronic rhinosinusitis following undergoing endoscopic sinus surgery, offering consolidated evidence for the prevention and treatment of chronic rhinosinusitis.

CHEER National Study of Chronic Rhinosinusitis Practice Patterns: Disease Comorbidities and Factors Associated with Surgery

Objectives (1) Describe national patterns of chronic rhinosinusitis (CRS) care across academic and community practices. (2) Determine the prevalence of comorbid disorders in CRS patients, including nasal polyposis, allergic rhinitis, asthma, and cystic fibrosis. (3) Identify demographic, clinical, and practice type factors associated with endoscopic sinus surgery (ESS). Study Design Multisite cross-sectional study. Setting Otolaryngology's national research network CHEER (Creating Healthcare Excellence through Education and Research). Subjects and Methods A total of 17,828 adult patients with CRS were identified, of which 10,434 were seen at community practices (59%, n = 8 sites) and 7394 at academic practices (41%, n = 10 sites). Multivariate logistic regression was used to evaluate the association between demographic, practice type, and clinical factors and the odds of a patient undergoing ESS. Results The average age was 50.4 years; 59.5% of patients were female; and 88.3% were Caucasian. The prevalence of comorbid diseases was as follows: allergic rhinitis (35.1%), nasal polyposis (13.3%), asthma (4.4%), and cystic fibrosis (0.2%). In addition, 24.8% of patients at academic centers underwent ESS, as compared with 12.3% at community sites. In multivariate analyses, nasal polyposis (odds ratio [OR], 4.28), cystic fibrosis (OR, 2.42), and academic site type (OR, 1.86) were associated with ESS ( P < .001), while adjusting for other factors. Conclusions We describe practice patterns of CRS care, as well as demographic and clinical factors associated with ESS. This is the first study of practice patterns in CRS utilizing the CHEER network and may be used to guide future research.

A survey on chronic rhinosinusitis: opinions from experts of 50 countries

Chronic rhinosinusitis (CRS) is a very prevalent inflammatory disease. Treatments vary in different countries. In the present study, we explored the approaches of physicians in 50 countries. In this cross-sectional study, a rhinosinusitis survey (RSS) was completed by Honorary and Corresponding Members (otorhinolaryngologists) of the Italian Society of Rhinology. In 79.1 % of the 50 countries, the proportion of patients suffering from CRS was 15 %. Nasal symptoms were more intense in winter (46 % of countries), and spring and autumn (22 %). The most common symptoms were nasal obstruction (86 %), postnasal drip (82 %) and headache (52 %). The most common investigative modalities in the assessment of CRS are paranasal sinus CT, fiberoptic endoscopy, and anterior rhinoscopy. CRS patients were principally treated by otorhinolaryngologists (70 %). Medical treatments included nasal corticosteroids (90 %), nasal washes (68 %), and nasal decongestants (32 %). In 88 % of countries, more than 50 %, or "about 50 %", of all patients reported subjective symptom improvement after treatment. In most of the countries, surgery was required by 20-35 % of all CRS patients. During post-surgery follow-up, nasal washes (90 %), nasal corticosteroids (76 %), and systemic antibiotics (32 %) were prescribed. In 20-40 % of all patients, CRS was associated with nasal polyps. In such patients, the medical treatment options were nasal corticosteroids (90 %), systemic corticosteroids (50 %), nasal washes (46 %), and systemic antibiotics (34 %). Treatment of CRS patients varies in different countries. Paranasal sinus CT is the most common investigative modality in the assessment of CRS, and nasal corticosteroids are the first-line treatment, in the absence or presence of nasal polyps.

Disparities in grant funding for Chronic rhinosinusitis

OBJECTIVES/HYPOTHESIS

The objective of this study was to identify the level of grant funding for chronic rhinosinusitis (CRS) with the purpose of elucidating if disparities exist compared to other common chronic diseases.

STUDY DESIGN

Review of four major health research grant agencies from the United States (National Institutes of Health), Canada (Canadian Institute of Health Research), and United Kingdom (National Institute of Health Research and Medical Research Council).

METHODS

Research operating grants awarded in the fields of CRS, asthma, diabetes, and dementia were identified using database-specific search strategies. Searches were limited to the previous 10 years (2004-2014). Comparator chronic diseases were chosen to have similar prevalence rates and low mortality risk. Research efficiency was calculated as the monetary value of grants awarded per paper published.

RESULTS

There is a large disparity in the number of grants awarded for research in CRS (n = 196; $74,774,384), asthma (n = 13,226; $8,358,861,941), diabetes (n = 54,902; $47,282,739,735), and dementia (n = 34,569; $16,709,900,125). In terms of research efficiency, CRS researchers received eight to 12 times less financial support per paper published compared to those in our comparator conditions.

CONCLUSIONS

This study has demonstrated that over the last 10 years, CRS is disproportionately underfunded (∼$75 million) compared to other similarly prevalent chronic diseases such as asthma (∼$8.3 billion), diabetes (∼$47.2 billion), and dementia (∼$16.7 billion). We feel this justifies further research into identifying and reducing barriers to obtaining grant support for CRS.

LEVEL OF EVIDENCE

NA.

Geographic Variation of Endoscopic Sinus Surgery in Canada: An Alberta-Based Small Area Variation Analysis

OBJECTIVE

With an estimated 10,000 to 15,000 endoscopic sinus surgery (ESS) cases performed in Canada each year, identifying potential unwarranted practice patterns is important. The objective of this study is to examine the rates and geographic variation of ESS in the province of Alberta, Canada.

STUDY DESIGN

Small area variation analysis.

SETTING

Province of Alberta, Canada.

SUBJECTS AND METHODS

The National Ambulatory Care Reporting System database was searched to identify all patients who received ESS between April 1, 2010, and March 31, 2013, in Alberta, Canada. The annual adjusted rates of ESS per 1000 people were calculated for each Alberta health zone and health status area. Geographic variations were evaluated with the extremal quotient, weighted coefficient of variation, and systematic component of variance. Chi-squared-test was used to quantify the significance of variation of the adjusted ESS rates across regions.

RESULTS

The annual adjusted rate of ESS was 0.33 per 1000 people in Alberta, Canada. The mean extremal quotient for health status areas was 6.9, indicating a 7-fold difference between the highest and lowest regions. The mean coefficient of variation was 41.0, and the mean systematic component of variance was 10.5, which demonstrates "very high" variation.

CONCLUSION

This study observed very high geographic variation in the rates of ESS across the province of Alberta. Given the negative impact of unwarranted surgical variation on quality of care, outcomes from this study indicate a need to further evaluate the delivery of care for ESS in Canada to improve overall health system performance.