Epidemiology of Chronic Rhinosinusitis: Prevalence and Risk Factors

Knowledge of chronic rhinosinusitis (CRS) epidemiology may directly impact patient care: aiding patient identification and establishing accurate diagnosis as well as informing treatment decisions. The objective of this review is to summarize the current evidence on the epidemiology of CRS, with a focus on prevalence and risk factors. Although the presence of either symptoms or objective findings alone have yielded CRS prevalence estimates of over 10%, the presence of both-consistent with guideline-based diagnostic criteria for CRS-has suggested that the true prevalence of CRS is consistently less than 5%, with approximately one-third of patients with CRS having nasal polyps, in epidemiologic studies from around the world. In comparison, the prevalence of CRS endotypes-pathophysiologic subclassification of CRS most commonly as related to type 2 or non-type 2 inflammation-has been found to vary significantly by region. The epidemiology of CRS is modified and ultimately determined by risk factors: genetic/hereditary, demographic, environmental, and imparted by predictive pre-/comorbid disease. The understanding of these epidemiologic relationships may help the provider to optimally identify and understand each individual's CRS disease process, thereby improving both diagnosis and treatment.

Pediatric chronic sinusitis: diagnosis and management

PURPOSE OF REVIEW

Review the diagnosis and management of pediatric chronic sinusitis given recent advances in both surgical and medical management.

RECENT FINDINGS

Balloon catheter dilation (BCD) of the sinuses has been used as an adjunct to adenoidectomy or in lieu of traditional endoscopic sinus surgery. BCD has been shown to be a safe technique in children although its efficacy compared to maxillary sinus irrigation or traditional sinus surgery cannot be determined based on current studies.

SUMMARY

New advances in BCD and biologics may serve as useful adjuncts in surgical and medical therapy respectively with additional research needed to better delineate the optimal indications for each in the treatment continuum.

Outcome of Immunoglobulin Replacement Therapy in Adults With Rhinosinusitis

OBJECTIVE

To evaluate the outcome of immunoglobulin (IG) replacement therapy in adults with rhinosinusitis and primary humoral immunodeficiency disorders (PID).

STUDY DESIGN

Retrospective cohort study.

METHODS

Retrospective chart review of adult (18 years and older) patients who were diagnosed with PID and had the diagnosis of recurrent acute rhinosinusitis (RARS) and chronic rhinosinusitis (CRS) and who are on IG replacement therapy. Demographic data, associated conditions, and duration of treatment were reviewed. Number of yearly sinus infections, sinus CT Lund-Mackay (LM) score, and need for functional endoscopic sinus surgery (FESS) were reviewed before and after starting IG therapy.

RESULTS

Fifty-eight patients were included. Average age was 52 years (18-79 years). About 74% were female. Thirty patients (51.7%) had common variable immunodeficiency (CVID), 18 (31.1%) had hypogammaglobulinemia, and 10 (17.2%) had specific antibody deficiency (SAD). About 79% of patients had allergic rhinitis and 74% had asthma. Pretreatment LM score was 7.6 (±2.2, range of 0-24) compared to posttreatment score of 3.5 (±1.3, range of 0-16) (P = .01). Eleven patients (19%) had FESS pretreatment compared to only two patients (3.4%) requiring ESS after starting treatment on IG therapy (P = .004). Prior to starting IG therapy, five patients (8.6%) had more than 10 sinus infections per year, 33 patients (56.9%) had 5 to 10 infections, and 20 patients (34.5%) had 1 to 5 infections per year. After starting on IG, 34 patients (58.6%) had no infections reported anymore (P < .001), and 24 patients (41.4%) had only 1 to 5 infections reported per year CONCLUSION: IG therapy is a promising treatment option for recurrent rhinosinusitis in patients with PID.

LEVEL OF EVIDENCE

4 Laryngoscope, 2021.

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.

Unbiased Measure of General Quality of Life in Chronic Rhinosinusitis Reveals Disease Modifiers

INTRODUCTION

Chronic rhinosinusitis (CRS) is associated with a significant decrease in general health-related quality of life (QOL). The EuroQol 5-dimensional questionnaire measures general health-related quality of life through a health utility value (EQ-5D HUV)-based on five domains reflecting mobility, self-care, activities of daily life, pain/discomfort, and anxiety/depression-and an unbiased visual analog scale (EQ-5D VAS). We sought to identify characteristics of CRS patients with a high EQ-5D HUV but low EQ-5D VAS score.

MATERIALS AND METHODS

Retrospective cross-sectional study of 300 CRS patients with EQ-5D HUV equal to 1.0 (reflecting perfect health). All patients completed a 22-item Sinonasal Outcome Test (SNOT-22)-from which nasal, sleep, ear/facial discomfort, and emotional subdomain scores were calculated, as well as the EQ-5D. Low EQ-5D VAS was defined as a score less than 80.

RESULTS

On multivariate analysis, low EQ-5D VAS was associated with only the SNOT-22 sleep subdomain score (odds ratio [OR] = 1.07, 95%CI: 1.02-1.12, P = .003). Comorbid asthma was also associated with lower EQ-5D VAS (OR = 2.16, 95%CI: 1.02-4.59, P = .045). In contrast, polyps were negatively associated with having a lower EQ-5D VAS (OR = 0.34, 95%CI: 0.17-0.69, P = .003).

CONCLUSION

There are patients with perfect general health-related QOL according to a health utility value-based methodology (like the EQ-5D HUV) who report low general health-related QOL on an unbiased measure like the EQ-5D VAS. In CRS patients with perfect EQ-5D HUV, poor sleep and asthma were associated with low QOL on the EQ-5D VAS, while polyps were negatively associated with low QOL.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:1206-1211, 2021.

Emotional and Personality Traits are Determinants of Activity Avoidance in Chronic Rhinosinusitis Patients

OBJECTIVES

Chronic rhinosinusitis (CRS), like other sinonasal diseases, may be associated with avoidance of daily activities. Our goal was to identify characteristics associated with avoidance of activities due to CRS.

MATERIALS AND METHODS

A total of 194 CRS patients were recruited. CRS symptom burden was assessed with the 22-item Sinonasal Outcome Test (SNOT-22). SNOT-22 nasal, sleep, ear/facial discomfort and emotional/psychological subdomain scores were calculated. Depressed mood was assessed using the two-item Patient Health Questionnaire (PHQ-2). Personality traits including conscientiousness, neuroticism, agreeableness, openness, and extraversion were assessed using the Big Five Inventory-10 (BFI-10) questionnaire. As the primary outcome, participants rated how often in the prior week that they had avoided any activities in day-to-day life due to their nasal or sinus symptoms on a scale of "never," "rarely," "sometimes," "often," or "extremely often." Ordinal regression models, with bootstrap validation, were used to identify associations between activity avoidance and participants' characteristics.

RESULTS

On multivariable analysis, SNOT-22 score (odds ratio [OR] = 1.03, 95% CI, 1.01-1.04, P = .026), and conscientiousness personality trait (OR = 1.38, 95% CI, 1.05-1.81, P = .019) were positively associated with activity avoidance while age (OR = 0.98, 95% CI, 0.96-0.99, P = .049) was negatively associated with activity avoidance. Of CRS symptom burden/SNOT-22 subdomains, only the emotional/psychological subdomain score (OR = 1.28, 95% CI, 1.12-1.46, P < .001) was associated with activity avoidance.

CONCLUSION

Younger age and the conscientiousness personality trait were associated with activity avoidance in CRS patients. Of CRS-associated symptomatology, sadness and embarrassment were associated with activity avoidance. Emotional traits and personality most strongly predict avoidance of activities in CRS patients.

LEVEL OF EVIDENCE

2c. Laryngoscope, 131:707-712, 2021.

Longitudinal improvement in nasal obstruction symptoms of chronic rhinosinusitis directly associates with improvement in mood

PURPOSE

The effects of nasal obstruction in patients with chronic rhinosinusitis (CRS) are associated with depressed mood. We sought to validate this finding by determining whether improvement in nasal obstruction would translate to improvement in depressed mood.

METHODS

This was a prospective observational study of 150 patients undergoing medical management for CRS. Data were collected at two timepoints: enrollment and a subsequent follow-up visit 3-12 months later. Impact of nasal obstruction was measured using the Nasal Obstruction Symptom Evaluation (NOSE) instrument and depressed mood was measured using the 2-item Patient Health Questionnaire (PHQ-2). Sinonasal symptoms associated with CRS were also measured using the 22-item Sinonasal Outcome Test (SNOT-22). Clinical and demographic characteristics were collected. The relationship between changes in PHQ-2 and NOSE scores was determined with correlation and linear regression.

RESULTS

Change in PHQ-2 score was significantly correlated with change in NOSE score (ρ = 0.30, p < 0.001). After controlling for covariates, change in PHQ-2 score was associated with change in NOSE score (adjusted linear regression coefficient [β] = 0.014, 95% CI 0.006-0.022, p = 0.001). We confirmed these relationships, finding that change in PHQ-2 was associated (adjusted β  = 0.037, 95% CI 0.013-0.061, p = 0.003) with change in the nasal subdomain score of the SNOT-22. Improvement in NOSE score by greater than 22 points was predictive of improvement in PHQ-2 score with sensitivity 54.5% and 83.8% specificity (p < 0.001).

CONCLUSION

These results provide evidence that improvements in nasal manifestations/symptoms of CRS translate to significant improvements in mood.

Chronic rhinosinusitis control from the patient and physician perspectives

OBJECTIVES

The concept of disease control incorporates independent disease characteristics that are longitudinally reflective of disease status and which can be used to make treatment decisions. Chronic rhinosinusitis (CRS) is a chronic condition for which the determination of disease control by both the patient and the treating physician is important. Our objectives were to determine CRS disease characteristics that are associated with patient-reported and physician-rated CRS disease control.

STUDY TYPE

Cross-sectional.

METHODS

A total of 209 participants were prospectively recruited. Participants were asked to rate their global level of CRS control as "not at all," "a little," "somewhat," "very," and "completely." All participants completed a 22-item Sinonasal Outcome Test (SNOT-22) and also reported the number of sinus infections, CRS-related antibiotic courses taken, CRS-related oral corticosteroid courses taken, and missed days of work or school due to CRS, all in the last 3 months. Clinical and demographic characteristics were also collected from each participant. A Lund-Kennedy endoscopy score was calculated for each participant from nasal endoscopy. Two rhinologists were then given each participant's SNOT-22 score (as well as SNOT-22 nasal, sleep, otologic/facial pain, and emotional subdomain scores), endoscopy score, and the number of sinus infections, CRS-related antibiotics, CRS-related oral corticosteroid courses and missed days of work or school due to CRS in the preceding 3 months as reported by the patient. The two rhinologists were blinded to all other participant characteristics and each rhinologist independently rated every participant's global control level as "not at all," "a little," "somewhat," "very," and "completely." Associations were sought between CRS disease characteristics (SNOT-22 score, endoscopy score, sinus infections, CRS-related antibiotic usage, CRS-related oral corticosteroid usage, and lost productivity due to CRS) and patient-reported CRS control as well as mean physician-rated CRS control.

RESULTS

Patient-reported global CRS control was associated only with SNOT-22 (adjusted relative risk [RR] = 0.99, 95% CI: 0.98-0.99, P < .001) but no other CRS disease characteristic. Patient-reported CRS control was specifically associated only with nasal symptoms and not extra-nasal symptoms of CRS. Physician-rated CRS control was associated with SNOT-22 score (adjusted RR [for each 1-unit increase of SNOT-22] = 0.99, 95% CI: 0.98-0.99, P < .001), number of acute bacterial CRS exacerbations-reflected by number of antibiotic courses taken (or sinus infections)-in the last 3 months (adjusted RR = 0.89, 95% CI: 0.82-0.98, P = .014) and the number of CRS-related oral corticosteroid courses taken in the last 3 months (adjusted RR = 0.87, 95% CI: 0.78-0.97, P = .012). Nasal, sleep, and otologic/facial pain symptoms were all associated with physician-rated CRS control. Having used at least one course of antibiotics or oral corticosteroids in the last 3 months was the optimal threshold for detecting poorly controlled CRS.

CONCLUSIONS

Patients and physicians use different criteria to determine the level of CRS control. While both rely on the burden of CRS symptomatology, patients consider primarily nasal symptoms while physicians include nasal and extra-nasal symptoms of CRS in determining CRS control. Physicians also independently consider CRS-related antibiotic use, as a reflection of acute bacterial CRS exacerbations, and CRS-related oral corticosteroid use in the determination of global CRS control.

LEVEL OF EVIDENCE

2c.

Changes in chronic rhinosinusitis symptoms differentially associate with improvement in general health-related quality of life

BACKGROUND

Previous work has shown that the symptoms of chronic rhinosinusitis (CRS) differentially associate with decreased general health-related quality of life (QOL).

OBJECTIVE

We sought to determine whether longitudinal changes in different types of CRS symptomatology lead to correspondingly different magnitude changes in general health-related QOL.

METHODS

Prospective observational study of 145 patients undergoing medical management for CRS. Chronic rhinosinusitis symptom severity was measured using the 22-item Sinonasal Outcome Test (SNOT-22) and associated nasal, sleep, ear/facial discomfort, and emotional subdomains of the SNOT-22. General health-related QOL was measured using the 5-dimensional EuroQoL questionnaire's visual analog scale (EQ-5D VAS). These data were collected at 2 time points: at enrollment and at a subsequent follow-up visit within the next 2 to 6 months. Associations were sought between the changes in SNOT-22 and EQ-5D VAS.

RESULTS

The change in SNOT-22 was associated with change in EQ-5D VAS (adjusted linear regression coefficient [β] = -0.37, 95%CI: -0.51 to -0.24, P < .001). The change in EQ-5D VAS was only associated with changes in the sleep (adjusted β = -0.42, 95% confidence interval [95%CI]: -0.81 to -0.04, P = .034) and ear/facial discomfort (adjusted β = -1.00, 95%CI: -1.89 to -0.10, P = .031) subdomains but not nasal (adjusted β = -0.12, 95%CI: -0.52 to 0.28, P = .564) or emotional (adjusted β = -0.17, 95%CI: -1.83 to 1.49, P = .840) subdomains.

CONCLUSION

Changes in the severity of sleep and ear/facial discomfort symptoms associate most greatly with the change in general health-related QOL that CRS patients experience during routine medical management. Reduction of these extranasal symptoms of CRS may therefore lead to the greatest improvement in general health-related QOL.

Reciprocal Predictive Accuracy of Sinonasal Symptom Severity, Nasal Endoscopy, and Frequency of Past Chronic Rhinosinusitis Exacerbations

Objective We sought to determine whether chronic rhinosinusitis (CRS) symptom severity, endoscopic exam findings, and acute exacerbation of CRS (AECRS) frequency-all important and distinct clinical manifestations of CRS-would be predictive of each other and, therefore, inform when further assessment of each other metric should be pursued. Study Design Cross-sectional cohort study. Setting Tertiary academic rhinology clinic. Subjects and Methods In total, 241 patients with CRS were prospectively recruited and completed the 22-item Sinonasal Outcome Test (SNOT-22) to reflect CRS symptom severity. AECRS frequency was assessed using the number of sinus infections as well as CRS-related antibiotics and CRS-related oral corticosteroids used in the past 3 months. An endoscopy score was calculated for each patient. Results SNOT-22 score and AECRS were predictive of each other while AECRS and endoscopy score were not predictive of each other. SNOT-22 score could be used to predict having had, in the past 3 months, at least 1 sinus infection (area under the curve [AUC] = 0.727; P < .001), at least 1 CRS-related antibiotic used (AUC = 0.691; P < .001), or at least 1 CRS-related oral corticosteroid course used (AUC = 0.655; P < .001). Having a SNOT-22 score ≥30 could be predicted by reporting at least 1 sinus infection (AUC = 0.634; P < .001), CRS-related antibiotics (AUC = 0.614; P < .001), or CRS-related oral corticosteroids (AUC = 0.616; P < .001) in the past 3 months. These relationships held for patients with and without nasal polyps. Conclusion The predictive power of CRS outcome measures reflecting symptomatology, AECRS frequency, and endoscopic findings may be of clinical utility in situations where time or resources are limited to perform an ideally full assessment of patients with CRS.

Relationship between chronic rhinosinusitis exacerbation frequency and asthma control

OBJECTIVES/HYPOTHESIS

To determine the association between the frequency of acute chronic rhinosinusitis (CRS) exacerbations (AECRS) and the degree of asthma control in asthmatic CRS patients.

STUDY DESIGN

Cross-sectional study.

METHODS

We prospectively recruited 108 asthmatic CRS patients as participants. Asthma control was assessed using the Asthma Control Test (ACT). The frequency of AECRS was assessed using three previously described indirect metrics for AECRS: the frequency of patient-reported sinus infections, CRS-related antibiotics use, and CRS-related oral corticosteroids use in the last 3 months. CRS symptom severity was measured using the 22-item Sinonasal Outcome Test (SNOT-22). Associations between ACT score and metrics for AECRS were performed using linear regression while controlling for clinical and demographic characteristics, including SNOT-22 score.

RESULTS

ACT score was significantly and negatively associated with the frequency of patient-reported sinus infections (adjusted linear regression coefficient [β] = -1.2, 95% confidence interval [CI]: -2.3 to -0.1, P = .033), CRS-related antibiotics courses (adjusted β = -1.4, 95% CI: -2.3 to -0.5, P = .004), and CRS-related oral corticosteroid courses (adjusted β = -1.5, 95% CI: -2.5 to -0.5, P = .004) in the last 3 months, independent of characteristics including SNOT-22 score. Poor asthma control could be detected using one or more sinus infections (70.6% sensitivity, 47.3% specificity), CRS-related antibiotics (50.0% sensitivity, 73.0% specificity), or CRS-related oral corticosteroids (58.8% sensitivity, 71.6% specificity) in the last 3 months.

CONCLUSIONS

AECRS are negatively associated with the level of asthma control in asthmatic CRS patients, independent of CRS symptom severity. These results highlight AECRS as a distinct clinical manifestation of CRS that should be routinely assessed in CRS patients.

LEVEL OF EVIDENCE

2c. Laryngoscope, 128:1033-1038, 2018.

Depression symptoms and lost productivity in chronic rhinosinusitis

BACKGROUND

Chronic rhinosinusitis (CRS) is associated with significant losses of patient productivity that cost billions of dollars every year. The causative factors for decreases in productivity in patients with CRS have yet to be determined.

OBJECTIVE

To determine which patterns of CRS symptoms drive lost productivity.

METHODS

Prospective, cross-sectional cohort study of 107 patients with CRS. Sinonasal symptom severity was measured using the 22-item Sinonasal Outcomes Test, from which sleep, nasal, otologic or facial pain, and emotional function subdomain scores were calculated using principal component analysis. Depression risk was assessed with the 2-item Patient Health Questionnaire (PHQ-2), whereas nasal obstruction was assessed with the Nasal Obstruction Symptom Evaluation (NOSE) instrument. Lost productivity was assessed by asking participants how many days of work and/or school they missed in the last 3 months because of CRS. Associations were sought between lost productivity and CRS symptoms.

RESULTS

A total of 107 patients were recruited. Patients missed a mean (SD) of 3.1 (12.9) days of work or school because of CRS. Lost productivity was most strongly associated with the emotional function subdomain (β = 7.48; 95% confidence interval [CI], 5.71-9.25; P < .001). Reinforcing this finding, lost productivity was associated with PHQ-2 score (β = 4.72; 95% CI, 2.62-6.83; P < .001). Lost productivity was less strongly associated with the nasal symptom subdomain score (β = 2.65; 95% CI, 0.77-4.52; P = .007), and there was no association between lost productivity and NOSE score (β = 0.01; 95% CI, -0.12 to 0.13; P = .91).

CONCLUSION

Symptoms associated with depression are most strongly associated with missed days of work or school because of CRS. Further treatment focusing on depression-associated symptoms in patients with CRS may reduce losses in productivity.

The 22-item Sino-Nasal Outcome Test accurately reflects patient-reported control of chronic rhinosinusitis symptomatology

BACKGROUND

Patient-reported control of chronic rhinosinusitis (CRS) symptoms is associated with the quality of life impact of CRS. We sought to determine if 22-item Sino-Nasal Outcome Test (SNOT-22) score is predictive of patient-perceived CRS symptom control.

METHODS

Prospective cross-sectional study of 202 patients with CRS. Participants were asked to rate their CRS symptom control as "not at all," "a little," "somewhat," "very," and "completely." The severity of patient CRS symptomatology was measured using the SNOT-22. The relationship between SNOT-22 score and patient-reported CRS symptom control was determined using regression, analysis of variance (ANOVA), and receiver operating characteristic (ROC) curve analysis.

RESULTS

SNOT-22 was negatively associated with patient-reported CRS symptom control (adjusted β = -0.03; 95% CI, -0.04 to -0.02; p < 0.001), after controlling for demographic and clinical characteristics. There was a significant difference in SNOT-22 scores of participants reporting each level of symptom control (p < 0.001) with the greatest differences between participants who rated their CRS symptom control as "not at all," "a little," and "somewhat," which we deem poor CRS symptom control, and the group who described their level of CRS symptom control described as "very" and "completely," which we deem well-controlled CRS symptoms. These results were true across all SNOT-22 subdomains scores as well. Using ROC analysis, a SNOT-22 score of 35 identified patients reporting poor vs well-controlled CRS symptom control with 71.4% sensitivity and 85.5% specificity.

CONCLUSION

SNOT-22 score is associated with how well patients feel their CRS symptomatology is controlled. Moreover, SNOT-22 score can be used to accurately distinguish patients with poor vs well-controlled CRS symptoms.

A contemporary analysis of clinical and demographic factors of chronic rhinosinusitis patients and their association with disease severity

BACKGROUND

Chronic rhinosinusitis (CRS) is highly prevalent, significantly decreases quality of life and leads to tremendous health care costs every year. No recent study has characterised the prevalence of potentially CRS-modifying patient characteristics and simultaneously shown their impact on CRS severity.

AIMS

We sought to determine the prevalence of potential clinical and demographic CRS-modifying characteristics and their associations with CRS symptom severity in a large contemporary cohort of CRS patients.

METHODS

Retrospective review of CRS patients who visited our rhinology clinics between February 2016 and February 2017 was conducted. CRS symptom severity was measured using the 22-item Sinonasal Outcomes Test (SNOT-22) questionnaire, which all patients received. Association was sought between SNOT-22 score (as dependent variable) and patients' clinical and demographic characteristics using linear regression.

RESULTS

Of the 572 included patients, the mean age was 51.1 years (SD = 15.8) and the mean SNOT-22 score was 34.3 (SD = 22.6). Prevalence of granulomatous diseases, immunodeficiency and cystic fibrosis were each approximately 5%. Prevalence of aeroallergen hypersensitivity was 42.3% and prevalence of asthma was 27.8%. More severe CRS symptomatology was associated with smoking tobacco (adjusted β = 5.47, p = 0.034) and comorbid asthma (adjusted β = 12.02, p < 0.001), whilst less severe symptomatology was associated with older age (adjusted β = -0.23, p = 0.002) and diagnosis of cystic fibrosis (adjusted β = -11.87, p = 0.009).

CONCLUSIONS

In a contemporary cohort of CRS patients, prevalence of disease-modifying comorbidities ranged from approximately 5 to over 40%. Smoking tobacco and asthma were associated with more severe CRS symptomatology, whilst older age and diagnosis of cystic fibrosis were associated with less severe CRS symptomatology.

Guidelines for the Antibiotic Use in Adults with Acute Upper Respiratory Tract Infections

These guidelines were developed as part of the 2016 Policy Research Servicing Project by the Korea Centers for Disease Control and Prevention. A multidisciplinary approach was taken to formulate this guideline to provide practical information about the diagnosis and treatment of adults with acute upper respiratory tract infection, with the ultimate aim to promote the appropriate use of antibiotics. The formulation of this guideline was based on a systematic literature review and analysis of the latest research findings to facilitate evidence-based practice, and focused on key questions to help clinicians obtain solutions to clinical questions that may arise during the care of a patient. These guidelines mainly cover the subjects on the assessment of antibiotic indications and appropriate selection of antibiotics for adult patients with acute pharyngotonsillitis or acute sinusitis.

Immunoglobulin replacement therapy reduces chronic rhinosinusitis in patients with antibody deficiency

BACKGROUND

Patients with primary antibody deficiencies have an increased frequency of sinonasal and pulmonary infections. Immunoglobulin (Ig) replacement is a standard therapy for common variable immunodeficiency (CVID) and other antibody deficiency diseases. Although there is convincing evidence that Ig replacement reduces pulmonary infections, there is little evidence that it reduces sinus infections or abates chronic rhinosinusitis (CRS). This study aims to identify the impact of Ig replacement on CRS in antibody deficiencies.

METHODS

A single-center, retrospective chart review of adult patients from 1995 to 2015 was performed. Inclusion criteria were diagnosis of CVID or specific antibody deficiency (SAD), history of CRS requiring medical and/or surgical management within the year prior to presentation, treatment with Ig replacement therapy, and follow-up interval of at least 1 year after initiating Ig replacement. Patients with secondary immune deficiencies were excluded. Thirty-one patients met criteria. Data collected included pretreatment and posttreatment Lund-Mackay scores, and frequency of sinusitis and pulmonary infections requiring rescue antibiotics. Statistical analysis was performed using Wilcoxon signed-rank tests.

RESULTS

A significant decline in the Lund-Mackay score was evidenced from pretreatment to posttreatment (p < 0.01). Treatment also resulted in significantly lower rates of sinusitis (p < 0.01) and pulmonary infections (p < 0.01). Additionally, 56% of patients who were on prophylactic antibiotics prior to Ig replacement were able to discontinue their use.

CONCLUSION

We present objective evidence showing that Ig replacement therapy has a positive impact on the frequency of sinusitis and confirm its positive impact on pulmonary infections in adult patients with CVID and SAD.

Immune deficiency in chronic rhinosinusitis: screening and treatment

INTRODUCTION

Chronic rhinosinusitis (CRS) is a prevalent disease with a high annual cost of treatment. Immune deficiencies are more common in individuals with CRS and should be especially considered in those patients who are refractory to medical and surgical therapy. Areas covered: We performed a literature search in PubMed of the terms "immunodeficiency" and "sinusitis" or "rhinosinusitis" from 2006 through March 2016. All abstracts were reviewed to determine if they pertained to human disease; relevant articles were evaluated in their entirety and included in this review. Expert commentary: CRS is a common disease; in those patients with frequent exacerbations or who are refractory to treatment, an immunodeficiency evaluation should be considered. Treatment includes vaccination, antibiotic therapy, immunoglobulin replacement and surgery.

Prevalence and pattern of humoral immunodeficiency in chronic refractory sinusitis

The purpose of this study is to readdress the issue of primary humoral immunodeficiency frequency and pattern in medically resistant chronic rhinosinusitis (CRS) based on the new guidelines for CRS diagnosis and management. Two hundred and fifty-seven consecutive patients with refractory CRS were included in this study. The results of their IgA, IgM, IgG, and IgG subclasses were analyzed and compared with 75 age- and gender-matched control groups. The average age of CRS patients was 34 years (SD ± 13). In the refractory CRS group, there was no significant difference between patients with or without humoral immunodeficiency based on age, gender and status of allergy, polyps and revision. Low level of one of the major immunoglobulin isotypes was found in 15 patients (6 %). Six patients had low IgG, two had low IgA, and seven had low IgM. IgG subclasses were low in 37 patients (14 %), and IgG4 was the most common deficient subclass. Multiple immunoglobulins deficiencies were found in eight patients. Compared with the control group, CRS patients had a significant higher prevalence of major immunoglobulins as well as total major immunoglobulins and IgG subclasses deficiency. Because of high prevalence of subtle humoral immunodeficiency in medically resistant CRS and inability to find unique clinical and demographic characteristic of these patients, we recommend routine screening of major immunoglobulins and IgG subclasses on the group of CRS patients who failed medical treatment.