The usefulness of computed tomography scans in cystic fibrosis patients with chronic sinusitis

Elexacaftor-Tezacaftor-Ivacaftor Therapy for Chronic Sinus Disease in Cystic Fibrosis

Importance

Cystic fibrosis (CF) is a multiorgan genetic disease with progressive upper and lower airway involvement. The effects of CF transmembrane conductance regulator (CFTR) modifier therapies on CF-related upper airway disease, specifically chronic rhinosinusitis (CRS), are not characterized.

Objective

To determine the outcome of elexacaftor-tezacaftor-ivacaftor (ETI) on CRS as measured by changes in sinus computed tomography (CT) metrics and on clinical parameters in individuals with CF.

Design, Setting, and Participants

This prospective longitudinal cohort study was conducted at the CF center of a tertiary care hospital between October 1, 2019, and July 31, 2021. A total of 64 participants with CF were included in the analysis.

Intervention

Sinus CT was obtained within 1 month of initiation of ETI therapy (baseline), and within 1 month of 1 year of ETI therapy. Images were independently analyzed by pulmonology, radiology, and otolaryngology physicians, using the Lund-Mackay and Sheikh-Lind scoring systems. Percent predicted forced expiratory volume in 1 second (ppFEV1), body mass index (BMI), and microbiologic data collected at initiation of ETI therapy and 3-month intervals for 1 year were also measured.

Main Outcomes and Measures

The study hypothesis was that ETI therapy will improve CRS as measured by changes in sinus CT at initiation and 1 year after ETI therapy and clinical parameters in individuals with CF.

Results

Among the 64 participants (39 [60.9%] female; median age, 18.5 [IQR, 16.0-28.5] years; 64 [100%] White), improvement in CRS was noted by improvements in sinus CT scans using both sinus CT scoring systems after 1 year of ETI therapy. The reduction in the median total score using the Lund-Mackay sinus CT scoring system (from 5.8 [IQR, 5.0-7.0] to 3.3 [IQR, 2.6-4.2]) and the Sheikh-Lind scoring system (from 3.8 [IQR, 3.0-5.0] to 2.2 [IQR, 2.0-2.5]) was noted. Increases in ppFEV1 and BMI were also observed by 3 months of ETI therapy with persistent improvement through 1 year of treatment. Similarly, after 1 year of ETI therapy, participants with CF had reductions in positivity for Pseudomonas aeruginosa and Staphylococcus aureus in oropharyngeal cultures.

Conclusion and Relevance

This cohort study found that use of ETI therapy was associated with improved CRS outcomes in participants with CF as quantified by improved sinus CT scans measured by 2 radiographic scoring systems and was also associated with improved clinical outcomes. Despite improvement in CT scan scores, most people with CF continue to have scores that indicate severe sinus disease.

The management of cystic fibrosis chronic rhinosinusitis: An evidenced-based review with recommendations

BACKGROUND

Cystic fibrosis (CF) chronic rhinosinusitis (CRS) has emerged as a distinct diagnostic entity, unique from other endotypes of CRS in its presentation, pathophysiology, diagnosis, treatment, and outcomes. As the sinonasal health of this patient population may have broad effects on pulmonary health and quality of life, a comprehensive understanding of the diagnostic and therapeutic approach to CF CRS is essential. In recognizing recent scientific advances and unique treatment modalities specific to this challenging patient population, in this review we systematically evaluate the scientific literature and provide an evidenced-based review with recommendations (EBRR) for fundamental management principles of CF CRS.

METHODS

A systematic review of the literature was performed. Studies evaluating interventions for the management of CF CRS were included. An iterative review process was implemented in accordance with EBRR guidelines. A treatment recommendation was generated based on an assessment of the benefits, harms, and the overall grade of evidence.

RESULTS

We evaluated the published literature on 5 unique topics. Each of the following therapeutic categories was investigated explicitly for treatment outcomes in patients with CF CRS: (1) nasal saline; (2) intranasal corticosteroids (INCS); (3) topical antibiotics; (4) cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapy; and (5) endoscopic sinus surgery (ESS).

CONCLUSION

Based on the currently available evidence, nasal saline, ESS, and CFTR modulators are recommended in the management of CF CRS when appropriate. INCS and topical antibiotics are options. Clinical judgment and experience are essential in caring for patients with this uniquely challenging disorder.

The Risks of Complications During Endoscopic Sinus Surgery in Cystic Fibrosis Patients: An Anatomical and Endoscopic Study

OBJECTIVE/HYPOTHESIS

An increasing proportion of adult cystic fibrosis (CF) patients is being referred to endoscopic sinus surgery (ESS) in order to relieve the symptoms of chronic rhinosinusitis (CRS). Given that CFTR mutations profoundly alter sinonasal development, we want to explore the relationship between their peculiar surgical anatomy and the risk of postoperative complications.

STUDY DESIGN

Retrospective case-control study.

METHODS

Paranasal sinuses CT scans of 103 CF adult patients with CRS were compared to those belonging to a cohort of 100 non-CF adult patients to explore their anatomical differences. Secondly, CF and non-CF patients who received primary/revision ESS were analyzed in order to assess their preoperative CT scan in terms of surgically relevant variants, and according to the CLOSE checklist. Surgical outcomes were statistically compared in order to explore the differences between groups.

RESULTS

CF group presented more frequently with smaller and less pneumatized paranasal sinuses and a higher Lund-Mckay score compared with controls. No anatomical differences emerged in terms of genotype stratification. Non-CF CRS patients undergoing ESS showed a significantly deeper olfactory fossa and a more frequent supraorbital pneumatization compared to CF patients (P < .001 and P = .031, respectively). Whereas this latter group underwent more often aggressive surgical procedures (P = .001), no difference in terms of postoperative adverse events was found (P = .620).

CONCLUSIONS

Despite receiving more often aggressive ESS procedures, adult CF patients do not show an increased risk of postoperative complication and this may be linked to a different proportion of anatomical and surgically-relevant variants.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E2481-E2489, 2021.

Sinonasal computed tomography in pediatric cystic fibrosis: do we know the indications?

OBJECTIVES

To investigated the correlation between sinonasal computed tomography (SNCT) findings and sinonasal symptoms, genotype, chronic colonization by Pseudomonas aeruginosa, forced expiratory volume in the first second (FEV1), body mass index (BMI), Shwachman-Kulczycki (SK) score, and Bhalla score in patients with cystic fibrosis.

METHODS

We retrospectively reviewed the medical records of 61 patients aged 2-16 years who received care at the Pediatric Cystic Fibrosis Center of our institution over a 10-year period. SNCT findings were graded using the Lund-Mackay scoring system. For patients who had SNCT scans performed at two different time points, the findings from both examinations were compared.

RESULTS

Patients with chronic P. aeruginosa colonization and patients with atelectasis had higher Lund-Mackay scores (p = 0.04 and p = 0.01, respectively). There was no difference in Lund-Mackay scores between sinonasal symptomatic and asymptomatic patients (p = 0.45). Among patients who had two SNCT scans available (n = 11), those with no evidence of bronchiectasis on chest CT had decreased Lund-Mackay scores compared to those with evidence of bronchiectasis, who had an increase in their scores (p = 0.03). Variations in the Bhalla score were positively and variations in the SK score were negatively correlated with variations in the Lund-Mackay score (r = 0.74, p = 0.01; and r = -0.85, p < 0.01).

CONCLUSIONS

Associations between SNCT findings, chronic P. aeruginosa colonization, SK score, and chest CT findings were demonstrated. Further studies with larger sample sizes are needed to evaluate patient follow-up and assess the benefits of the sinonasal treatment strategy adopted for patients who exhibit pulmonary deterioration despite controlling for other factors associated with exacerbation.

Novel Computed Tomography Scoring System for Sinus Disease in Adults With Cystic Fibrosis

OBJECTIVE

There is no easy to use scoring system for computed tomography (CT) scans of the sinuses that is specific to cystic fibrosis (CF). We propose a simple and easily implemented scoring system to quantify severity of sinus disease in adults with CF.

STUDY DESIGN

Case series with chart review.

SETTING

Academic tertiary-care referral center.

SUBJECTS

Sixty-nine adult patients with CF and 50 age-matched controls.

METHODS

We validated a scoring system for CF sinus disease. The CT scans were interpreted by 3 physicians on 2 separate sittings. Parameters include maxillary opacification, nasal obstruction, lateral nasal wall displacement, uncinate process absence/demineralization, and presence/absence of mucocele.

RESULTS

Patients with CF aged 21 to 30 years (mean = 24.7 ± 2.49). In CF cohort (n = 69), intrarater reliability for the 10 CT categories ranged from .70 to 1.00. Twenty-six (87%) were in the excellent range, and the remaining 4 (13%) were evaluated as good. In the non-CF cohort (n = 50), reliabilities ranged from .44 to 1.00. Twenty-seven (90%) were in the excellent range. For interrater reliability, in the CF cohort, 10 CT categories across the 3 raters ranged from .55 to 1.00. Excellent reliability was achieved in 15 (50%) of the observations. In the non-CF cohort, reliabilities ranged from .44 to 1.00.

CONCLUSION

A novel and easy to use CT scoring system for CF sinus disease in adults was validated with inter- and intrarater reliability. This new CF sinus disease-specific scoring system can be used by clinicians, surgeons, and radiologists.

Lund-Mackay and modified Lund-Mackay score for sinus surgery in children with cystic fibrosis

OBJECTIVE

Patients with cystic fibrosis (CF) frequently present with severe sinonasal disease often requiring radiologic imaging and surgical intervention. Few studies have focused on the relationship between radiologic scoring systems and the need for sinus surgery in this population. The objective of this study is to evaluate the Lund-Mackay (LM) and modified Lund-Mackay (m-LM) scoring systems in predicting the need for sinus surgery or revision surgery in patients with CF.

METHODS

We performed a retrospective chart review of CF patients undergoing computed tomography (CT) sinus imaging at a tertiary care pediatric hospital from 1995 to 2008. Patient scans were scored using both the LM and m-LM systems and compared to the rate of sinus surgery or revision surgery. Receiver-operator characteristics curves (ROC) were used to analyze the radiological scoring systems.

RESULTS

A total of 41 children with CF were included in the study. The mean LM score for patients undergoing surgery was 17.3 (±3.1) compared to 11.5 (±6.2) for those treated medically (p<0.01). For the m-LM, the mean score of patients undergoing surgery was 20.3 (±3.5) and 13.5 (±7.3) for those medically treated (p<0.01). Using a ROC curve with a threshold score of 13 for the LM, the sensitivity was 89.3% (95% CI of 72-98) and specificity of 69.2% (95% CI of 39-91). At an optimal score of 19, the m-LM system produced a sensitivity of 67.7% (95% CI of 48-84) and specificity of 84.6% (95% CI of 55-98).

CONCLUSION

The modified Lund-Mackay score provides a high specificity while the Lund-Mackay score a high sensitivity for CF patients who required sinus surgery. The combination of both radiologic scoring systems can potentially predict the need for surgery in this population.

Chronic rhinosinusitis and nasal polyposis in cystic fibrosis: update on diagnosis and treatment

Although cystic fibrosis (CF) is an irreversible genetic disease, advances in treatment have increased the life expectancy of CF patients. Upper airway involvement, which is mainly due to pathological changes in the paranasal sinuses, is prevalent in CF patients, although many are only mildly symptomatic (with few symptoms). The objective of this literature review was to discuss the pathophysiology and current therapeutic management of chronic rhinosinusitis (CRS) in CF patients. The review was based on current evidence, which was classified in accordance with the Oxford Centre for Evidence-Based Medicine criteria. When symptomatic, CRS with nasal polyps can affect quality of life and can lead to pulmonary exacerbations, given that the paranasal sinuses can be colonized with pathogenic bacteria, especially Pseudomonas aeruginosa. Infection with P. aeruginosa plays a crucial role in morbidity and mortality after lung transplantation in CF patients. Although clinical treatment of the upper airways is recommended as initial management, this recommendation is often extrapolated from studies of CRS in the general population. When sinonasal disease is refractory to noninvasive therapy, surgery is indicated. Further studies are needed in order to gain a better understanding of upper airway involvement and improve the management of CRS in CF patients, with the objective of preserving lung function and avoiding unnecessary invasive procedures.

Medical reversal of chronic sinusitis in a cystic fibrosis patient with ivacaftor

BACKGROUND

Chronic sinusitis is universal in cystic fibrosis (CF) and our current treatments are ineffective in reversing sinus disease. The objective of this work was to determine if increasing CF transmembrane conductance regulator (CFTR) activity by ivacaftor could treat CF sinus disease and assess its effect on primary sinus epithelial cultures.

METHODS

Case report of 1 patient with long-standing chronic sinus disease and a new diagnosis of CF with a mild mutation (P205S) and a severe mutation (G551D). We discuss clinical changes in symptoms, radiographic findings, nasal potential difference testing, and nasal pH values before and after treatment with ivacaftor. We then developed primary sinonasal epithelial cell cultures from a biopsy of the patient to determine changes in airway surface liquid (ASL) pH and ASL viscosity after ivacaftor treatment.

RESULTS

Ivacaftor treatment reversed CT findings of CF sinus disease, increased nasal voltage and pH, and resolved sinus symptoms after 10 months of therapy. Ivacaftor significantly increased ASL pH and decreased ASL viscosity in primary airway cultures.

CONCLUSION

This report documents the reversal of CF sinus disease. Based on our in vivo and in vitro results, we speculate that ivacaftor may reverse CF sinusitis by increasing ASL pH and decreasing ASL viscosity. These studies suggest that CFTR modulation may be effective in treating CF and perhaps non-CF sinusitis.

Effect of the F508del genotype on outcomes of endoscopic sinus surgery in children with cystic fibrosis

OBJECTIVE

Numerous authors have sought to describe genotype-phenotype correlations in cystic fibrosis (CF), notably to pancreatic insufficiency and lung disease. However, few studies have focused on the association between the F508del genotype and response to sinus surgery. The objective of this study is to assess the effect of the F508del genotype on sinonasal disease severity and outcomes following functional endoscopic sinus surgery (FESS) in a pediatric population.

METHODS

A retrospective chart review of 153 children with CF seen at a tertiary care pediatric hospital from 1995 to 2008 was performed. Patients were classified into one of three groups according to F508del genotype, either as homozygous, heterozygous or not carrying a F508del mutation. The sinonasal disease phenotype of the three groups was compared based on clinical and radiological findings, extent of endoscopic sinus surgery and rate of revision surgery.

RESULTS

The relationship between the F508del genotype and pancreatic insufficiency was confirmed (p<0.05). There was no association between the F508del genotype and increased need for FESS (p=0.75). Moreover, no association was established between F508del homozygosity and presence of nasal polyps, Lund-Mackay score, extent of surgery or length of postoperative hospitalization. The rates of revision surgery did not differ significantly among the three genotypes analyzed (p=0.59).

CONCLUSION

There is no clear association between the F508del genotype and an increased need for FESS, extent of surgery, or revision surgery. Given the phenotypic variability of sinonasal disease in patients with CF, a prospective study is needed to better understand outcomes following FESS and the contribution of gene modifiers to this effect.

Bacterial sinusitis can be a focus for initial lung colonisation and chronic lung infection in patients with cystic fibrosis

A major purpose of treating patients with cystic fibrosis (CF) is to prevent or delay chronic lung infections with CF-pathogenic Gram-negative bacteria. In the intermittent stage, bacteria can usually be eradicated from the lungs with antibiotics, but following eradication, the next lung colonisations often occur with bacteria of identical genotype. This may be due to re-colonisation from the patient's paranasal sinuses. In our study, we found that approximately two-thirds of CF patients having sinus surgery (FESS) had growth of CF-lung-pathogenic Gram-negative bacteria in their sinuses (Pseudomonas aeruginosa, Achromobacter xylosoxidans, Burkholderia cepacia complex). The environment in the sinuses is in many ways similar to that of the lower respiratory tract, e.g. low oxygen concentration in secretions. Sinus bacteria are more difficult to eradicate than in the lungs, thus, having good conditions for adapting to the environment in the lungs. In the presence of bacteria, the environment of the sinuses differs from that of the lower respiratory tract by having a higher immunoglobulin A (IgA): IgG ratio, and reduced inflammation. We found a significant correlation between the concentration of IgA against P. aeruginosa (standard antigen and alginate) in nasal secretions and saliva and CF patients' infection status (not lung colonised, intermittently colonised or chronically lung-infected with P. aeruginosa). This supports the hypothesis that infections often originate in the sinuses and can be a focus for initial lung colonisation or for maintaining lung infections in CF patients. We are confident that anti-P. aeruginosa IgA can be used as an early supplementary tool to diagnose P. aeruginosa colonisation; P. aeruginosa being the microorganism causing most morbidity and mortality in CF patients. This is important since urgent treatment reduces morbidity when CF patients are early colonised with P. aeruginosa, however, there is a lack of diagnostic tools for detecting the early colonisation in the lungs and in the sinuses. We initiated a treatment strategy for CF patients to prevent sino-nasal bacteria being seeded into the lower airways: we recommended extensive functional endoscopic FESS with creation of sufficient drainage from all involved sinuses with subsequent i.v. antibiotics and at least 6 months of twice daily nasal irrigation with saline and antibiotics. By this strategy, sinus bacteria could be eradicated in a large proportion of patients. Essentially, growth of CF-pathogenic bacteria from the lower respiratory tract was decreased following the treatment. Furthermore, a number of patients have been free from CF-pathogenic bacteria for more than one year after FESS, and thus re-classified as "not lung colonised". We also corroborated that CF patients obtain an improved quality of life and reduction in their symptoms of chronic rhinosinusitis after FESS. It is primarily intermittently lung colonised CF patients with CF-pathogenic bacteria in their sinuses that seem to benefit from the treatment strategy. This is in accordance with the fact that we did not see a significant increase in lung function and only a small decrease in specific antibodies after FESS; a high systemic immune and inflammatory response and a decreasing lung function is generally not present in patients who primarily have sinus CF-pathogenic bacteria. It is important that guidelines are created for how CF patients with CF-pathogenic bacteria in the sinuses are to be treated, including criteria for who may likely benefit from FESS, and who may be treated exclusively with conservative therapy, e.g. saline and antibiotic irrigations.

Sinonasal alterations in computed tomography scans in cystic fibrosis: a literature review of observational studies

BACKGROUND

Almost all cystic fibrosis (CF) patients reveal upper airway involvement in computed tomography (CT) scans. Sinonasal pathology has become a challenging issue because there are few studies to guide appropriate management. The objective of this study was to provide information about paranasal sinus CT manifestations in CF patients, mainly in adulthood.

METHODS

We performed a literature review of descriptive studies about CT sinonasal findings in CF patients using the following databases: MEDLINE, EMBASE, Web of Science, LILACS, Scielo, and Cochrane.

RESULTS

Eighteen articles were included in this review. There was a high variability in methodological aspects for most of the studies. The most prevalent findings reported were opacification of sinuses, presence of frontal and sphenoidal aplasia or hypoplasia, underdevelopment of paranasal sinuses, and medial bulging of the lateral nasal wall in CT scans.

CONCLUSION

There are few studies in the CF adult population regarding sinonasal CT alterations. Many studies report specific pathological features in CF upper airways that could help in the diagnosis of doubtful cases.

New insights into the pathogenesis of cystic fibrosis sinusitis

BACKGROUND

People with cystic fibrosis (CF) sinus disease have developmental sinus abnormalities with airway bacterial infection, inflammation, impaired mucociliary clearance and thick obstructive mucus. The pathophysiology of airway disease in CF is not completely understood, and current treatments in CF sinus disease ameliorate symptoms but do not provide a cure.

METHODS

This manuscript reviews the history of CF, its manifestations in sinus disease, and the potential impact and relationship of CF on the upper and lower airway.

RESULTS

There is increasing evidence that CF sinus disease may affect CF lung disease, the most common cause of mortality in CF. We have been limited in treating the symptoms of advanced CF sinus disease with our current therapies.

CONCLUSIONS

Recent discoveries in the pathophysiology of CF using the CF porcine animal model and exciting treatments that address the primary gene defect that may translate into improved outcomes in CF and non-CF sinusitis in humans.

Cystic fibrosis chronic rhinosinusitis: a comprehensive review

BACKGROUND

Advances in the care of patients with cystic fibrosis (CF) have improved pulmonary outcomes and survival. In addition, rapid developments regarding the underlying genetic and molecular basis of the disease have led to numerous novel targets for treatment. However, clinical and basic scientific research focusing on therapeutic strategies for CF-associated chronic rhinosinusitis (CRS) lags behind the evidence-based approaches currently used for pulmonary disease.

METHODS

This review evaluates the available literature and provides an update concerning the pathophysiology, current treatment approaches, and future pharmaceutical tactics in the management of CRS in patients with CF.

RESULTS

Optimal medical and surgical strategies for CF CRS are lacking because of a dearth of well-performed clinical trials. Medical and surgical interventions are supported primarily by level 2 or 3 evidence and are aimed at improving clearance of mucus, infection, and inflammation. A number of novel therapeutics that target the basic defect in the cystic fibrosis transmembrane conductance regulator channel are currently under investigation. Ivacaftor, a corrector of the G551D mutation, was recently approved by the Food and Drug Administration. However, sinonasal outcomes using this and other novel drugs are pending.

CONCLUSION

CRS is a lifelong disease in CF patients that can lead to substantial morbidity and decreased quality of life. A multidisciplinary approach will be necessary to develop consistent and evidence-based treatment paradigms.

Surgical management of chronic rhinosinusitis in cystic fibrosis: a systematic review

BACKGROUND

The objective of this work was to systematically review literature on the effectiveness of surgical management for chronic rhinosinusitis (CRS) in cystic fibrosis (CF) patients.

METHODS

We performed a literature search encompassing the last 25 years in PubMed, Embase, and Cochrane CENTRAL. Inclusion criteria included English language papers containing original data, more than 6 subjects, and measurable clinical outcomes. Data was systematically collected on study design, patient demographics, clinical characteristics and outcomes, and level-of-evidence. Two investigators independently reviewed all manuscripts. A quality assessment of the included studies was performed.

RESULTS

The initial search yielded 416 abstracts, of which 24 articles met inclusion criteria, detailing 680 adult and pediatric CF patients who underwent surgical therapy. Surgical treatment included primarily endoscopic sinus surgery (ESS) (22/24). Outcome measures included sinonasal symptoms (14/24), endoscopic findings (8/24), pulmonary function testing (8/24), recurrence or revision surgery (5/24), hospitalization (4/24), need for antibiotic therapy (2/24), radiographic findings (2/24), and pulmonary exacerbations (1/24). The level-of-evidence was predominantly Level 4 (21/24); there were no Level 1 evidence studies. Most studies found improvement in symptom measures and endoscopic findings but no improvement in lower airway function after surgical therapy. Postoperative measures of the other outcomes were inconclusive or inconsistent.

CONCLUSION

For adult and pediatric CF sinusitis, ESS yielded clinical improvement as measured primarily by sinonasal symptoms and endoscopic findings. It is unclear if surgical intervention modifies lower airway disease. Future prospective studies with predetermined, objective, and validated outcome measures are needed to determine the effectiveness of surgical intervention for CF-related CRS. Overall evidence Grade B/C.

Retrospective analysis of chronic rhinosinusitis in patients with cystic fibrosis

INTRODUCTION

Chronic rhinosinusitis is very common in patients with cystic fibrosis. This can be explained by the unified airway concept, where the same pathophysiological phenomenon that affects the lungs, affects the paranasal sinuses. The management of these cases is difficult.

OBJECTIVE

To describe the teamwork of otolaryngologists and bronchopulmonary specialists in patients with cystic fibrosis.

METHOD

We performed a descriptive, retrospective study over the last 17 years, which included 14 patients with chronic rhinosinusitis and cystic fibrosis attended at a private hospital.

RESULTS

Of the patients, 64% were male and the median age was 23 years. The most frequent mutations found were ΔF508, M470 and R553. All of the patients with ΔF508 mutation had nasal polyps. 100% of the patients had clinical findings of chronic rhinosinusitis. All the patients had had endoscopic nasal surgery. The median number of endoscopic surgeries was 2.

CONCLUSIONS

Given the high prevalence of chronic rhinosinusitis in patients with cystic fibrosis, everyone should have a computed tomography scan of the paranasal sinuses during the initial assessment, considering that sinus germs are the ones that colonise the lower airway. The otolaryngologist should be part of the cystic fibrosis team. Before receiving a lung transplant or in cases of chronic headache, endoscopic surgery should be performed in patients in whom medical treatment fails to clear the sinuses because this infection is the one that colonises the lower airway.

Radiological sinonasal findings in adults with cystic fibrosis

BACKGROUND

Care of cystic fibrosis (CF) patients has extended the expected survival far into adulthood. The morphological changes of adult CF patients' paranasal sinuses have not been thoroughly addressed.

METHODS

A retrospective review was performed of computed tomography imaging of adult CF patients at an academic medical center. Developmental changes, bone sclerosis, mucoceles, and degree of inflammation (using a modified Lund-Mackay scoring system) were assessed.

RESULTS

Forty-five patients were included in the study. The majority of frontal and sphenoid sinuses were either aplastic or hypoplastic. Maxillary hypoplasia was less commonly seen. Seven patients had mucoceles. Sclerosis of the sinuses was a common finding, affecting 84.4% of patients. Inflammation of the sinuses was also common, with a median modified Lund-Mackay score of 15.0 (out of a median 20 possible).

CONCLUSION

Poor development of the sinuses seen in pediatric CF patients persists into adulthood. Inflammation of the sinuses is a common finding. Bone sclerosis, likely caused by chronic inflammation, affects a large majority of these patients.

Nasal and sinus disease in cystic fibrosis

Paranasal and sinus disease is present in almost every patient with cystic fibrosis. However, symptoms are rarely reported. Some aspects including polyposis and microbial flora change with patient age. Endoscopy and computerised tomography have broadened our understanding of how this disease affects the sinuses, including an increased recognition of polyposis than previously thought and identification of several disease specific entities such as abnormalities of the lateral nasal wall and uncinate process. Few randomised, controlled trials evaluating medical or surgical treatments of CF sinus disease exist. Sinus surgery may provide some benefit, though there are no established selection criteria for appropriate candidates. A link between sinus disease and lower respiratory tract function may contribute to general health and survival following lung transplantation. Complications of sinonasal disease in CF are rare and include mucoceles and periorbital abscesses.