Asthma in ear, nose, and throat primary care patients with chronic rhinosinusitis with nasal polyps

EUFOREUM Berlin 2023: Optimizing care for type 2 inflammatory diseases from clinic to AI: A pediatric focus

The European Forum for Research and Education in Allergy and Airways diseases (EUFOREA) organized its bi-annual forum EUFOREUM in Berlin in November 2023. The aim of EUFOREUM 2023 was to highlight pediatric action plans for prevention and optimizing care for type 2 inflammatory conditions starting in childhood, with a focus on early-stage diagnosis, ensuring neither under- nor overdiagnosis, optimal care, and suggestions for improvement of care. EUFOREA is an international not-for-profit organization forming an alliance of all stakeholders dedicated to reducing the prevalence and burden of chronic respiratory diseases through the implementation of optimal patient care via educational, research, and advocacy activities. The inclusive and multidisciplinary approach of EUFOREA was reflected in the keynote lectures and faculty of the virtual EUFOREUM 2023 (www.euforea.eu/euforeum) coming from the pediatric, allergology, pulmonology, ENT, dermatology, primary health care fields and patients around the central theme of type 2 inflammation. As most type 2 inflammatory conditions may start in childhood or adolescence, and most children have type 2 inflammation when suffering from a respiratory or skin disease, the moment has come to raise the bar of ambitions of care, including prevention, remission and disease modification at an early stage. The current report provides a comprehensive overview of key statements by the faculty of the EUFOREUM 2023 and the ambitions of EUFOREA allowing all stakeholders in the respiratory field to be updated and ready to join forces in Europe and beyond.

The effect of biologics in lung function and quality of life of patients with united airways disease: A systematic review

Background

Increasing evidence supports the united airway disease concept for the management of upper and lower respiratory tract diseases, particularly in patients with asthma and chronic rhinosinusitis with nasal polyps (CRSwNP). However, evidence for a combined approach in asthma and CRSwNP is scarce.

Objective

In this systematic review, we focused on the role of biologics in the lung function and quality of life in patients with severe asthma and CRSwNP.

Methods

We conducted a systematic search of 3 electronic databases using 2 search strategies to identify studies published from January 2010 to March 2022. Quality assessment was performed with the Critical Appraisal Skills Programme.

Results

Of 1030 studies identified, 48 original studies reporting data of benralizumab (12), dupilumab (14), mepolizumab (10), omalizumab (13), and reslizumab (2) were analyzed. Primary diagnosis was mostly asthma or CRSwNP, with only 15 studies, mainly observational, performed in populations with united airway disease. In total, 18 studies reported data on quality of life (mostly 22-item Sino-Nasal Outcome Test score), 8 on lung function (mostly FEV1), and 22 on both outcomes. Significant FEV1 and 22-item Sino-Nasal Outcome Test score improvements were consistently observed after 24-week treatment, and thereafter, mostly in real-world studies that included variable proportions of patients with asthma/CRSwNP.

Conclusions

The use of biologics in patients with severe asthma and CRSwNP was overall associated with significant improvements in lung function and quality of life. However, we observed a high heterogeneity of populations and outcome measurements across studies. Notwithstanding the need of larger studies, our results reinforce the joint management of asthma and CRSwNP as united airway disease in clinical practice.

Comorbid asthma in patients with chronic rhinosinusitis with nasal polyps: did dupilumab make a difference?

BACKGROUND

The clinical heterogeneity of chronic rhinosinusitis (CRS) and bronchial asthma is attributable to different underlying inflammatory profiles. However, the similarity between CRS with nasal polyps (CRSwNP) and type-2 asthma pathophysiology speculates that one biological therapy could affect both comorbidities. Despite dupilumab, a monoclonal antibody that targets IL-4α and IL-13 receptors, being used in patients with nasal polyps and severe asthma, real-life data about its efficacy in improving the quality of life and patient symptoms is still lacking. This study's primary objective was to evaluate dupilumab treatment's effect on the frequency of olfactory symptoms and health-related quality of life tests as measured by the Sino-nasal outcome test (SNOT-22) in patients with NP. The secondary objective was the effect of dupilumab on asthma symptom control as measured by the asthma control test (ACT).

METHODS

A prospective study was conducted of 166 patients with CRSwNP, with or without asthma. The following variables were collected at baseline and after at least six months of continuous dupilumab therapy; SNOT-22, olfactory symptoms frequency, and ACT score.

RESULTS

Asthma prevalence in patients with CRSwNP was high (59.63%), and being female with a history of frequent use of oral corticosteroid (OCS) courses and repeated unsuccessful nasal and para-nasal surgeries for polyposis increased the likelihood of having underlying asthma by 2, 1 and 4 times more, respectively. Additionally, being asthmatic required a longer duration of dupilumab treatment. However, both the health-related quality of life and olfactory symptoms improved equally in both groups.

CONCLUSION

Even with associated comorbid asthma in patients with CRSwNP, treatment with dupilumab could improve the quality of life, olfactory symptoms, and asthma symptom control.

The Role of Fractional Exhaled Nitric Oxide in Diagnosing Asthmatic Type 2 Chronic Rhinosinusitis With Nasal Polyps

BACKGROUND

Fractional exhaled nitric oxide (FeNO) is useful in the management of asthma and predicting the efficacy of standard corticosteroids and biologics. However, the diagnostic value of FeNO in asthmatic chronic rhinosinusitis with nasal polyps (CRSwNP) remains unclear.

OBJECTIVE

We assessed FeNO levels in patients with CRSwNP and evaluated the diagnostic value of FeNO for screening type 2 CRSwNP (T2-CRSwNP) with asthma.

METHODS

We enrolled 94 patients who were diagnosed with CRSwNP and underwent functional endoscopic sinus surgery. FeNO levels, the blood eosinophil percentage, total IgE, spirometry tests (FEV1/FVC), Lund-Mackay CT score, and percentage of patients with comorbid asthma were compared among CRSwNP subgroups. Spearman rank correlation test was used to assess the degree of association between variables. ROC curve analysis was conducted to evaluate the diagnostic capability to differentiate T2-CRSwNP based on clinical and histological classifications.

RESULTS

FeNO levels and the blood eosinophil percentage were significantly higher in patients with T2-CRSwNP(h) based on histological data (P < .05). FeNO was correlated with the blood eosinophil percentage (r = 0.420, P < .001) and FEV1/FVC (r = -0.324, P = .001). A FeNO level of 27 ppb had a good ability to discriminate patients with asthmatic T2-CRSwNP(h) (AUC = 0.848; 95% CI = 0.7602-0.9361; sensitivity = 90.9%; specificity = 63.9%). The optimal cutoff values for FeNO and the blood eosinophil percentage for diagnosing asthmatic T2-CRSwNP(h) were 68 ppb and 5.6% (sensitivity = 95.5%; specificity = 86.1%; AUC = 0.931; 95% CI = 0.8832-0.9791). In the diagnosis of severe T2-CRSwNP(c) based on clinical data, a FeNO level of 36 ppb showed the highest AUC (0.816; 95% CI = 0.7173-0.914; sensitivity = 72.7%; specificity = 79.2%).

CONCLUSION

FeNO is a useful marker for screening asthmatic T2-CRSwNP even prior to biopsy or asthma evaluation and may assist in selecting a proper treatment.

Risk factors associated with comorbid asthma in patients with chronic rhinosinusitis with nasal polyps: a cross-sectional study

Background

Although 20–60% of patients with chronic rhinosinusitis with nasal polyps (CRSwNP) have asthma, the risk factors associated with comorbid asthma are not clear. The aim of the study was to investigate the factors associated with asthma, and develop a practical scoring system to screen asthma comorbidity in CRSwNP patients.

Methods

This report describes a cross-sectional study with consecutive CRSwNP patients. Two cohorts of CRSwNP patients named “modelling” group and “validation” group were investigated respectively. Logistic regression analysis was performed based on demographic and clinical data collected from patients in the modelling group to determine the risk factors associated with asthma, and establish a scoring system for screening comorbid asthma. Receiver operating characteristic curve was constructed to evaluate the screening system; the optimal cut-off point was established by means of the Yoden Index. The consistency between the diagnosis of asthma by the Global Initiative for Asthma (GINA) criteria and by the screening system was assessed by Kappa value in the validation group.

Results

Totally 150 patients in modelling group and 78 patients in validation group were enrolled. Female gender (odds ratio [OR] = 6.4; P < 0.001), allergic rhinitis (OR = 2.9; P = 0.021), serum total (T)-immunoglobulin (Ig) E ≥ 69.0kU/L (OR = 12.0; P < 0.001), and blood eosinophil count  ≥ 0.35 × 10⁹/L (OR = 4.0; P = 0.001) were shown to be independent risk factors for asthma in patients with CRSwNP. Based on these variables, a scoring system (FAIE) ranging from 0(no risk) to 6(high risk); was developed. The area under the receiver operating characteristic curve of the system was 0.823, and the optimal cut-off value was 3 points, with sensitivity 83.8% and specificity 68.6% for screening asthma. The asthma comorbidity determined with FAIE score ≥ 3 points in the validation group, was moderately consistent with that defined by GINA (Kappa = 0.513, P < 0.001), with sensitivity 76.9% and specificity 74.4%.

Conclusions

Female gender, allergic rhinitis, serum T-IgE level, and blood eosinophil count are independent risk factors for asthma comorbidity in patients with CRSwNP, and the FAIE system may be practical for screening comorbid asthma in these patients.

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.

Global airways – a novel Standard Tests for Asthma, allergic Rhinitis, and chronic Rhinosinusitis (STARR-15)

Background: Global airway disease, with symptoms from both upper and lower airways, is a challenging problem for clinicians. Our goal is to design one single standard test for the awareness of global airway diseases to be used in clinical setting. Material and Methods: During 2019, rhinologists and pulmonologists generated a pool of items based on literature, patient-reported outcome measures and clinical experience. The items were administered to 206 patients with known asthma, CRS, allergic rhinitis, or a combination thereof. The patients also completed the Asthma Control Questionnaire (ACQ-5) and the Sino-Nasal Outcome Test (SNOT-22). Using a mix of clinical knowledge and data-driven methods a global airways questionnaire was developed. Results: Mean ACQ score was highest in patients with all three, whereas the highest SNOT-22 score was observed in patients with CRS and asthma. After the development process, analysis of responses from 206 patients to 44 items on a new global airway’s questionnaire led to identification of 15 items that form the STARR-15 questionnaire with three underlying domains (an allergic rhinitis sub-factor, a CRS sub-factor and an asthma sub-factor). Conclusion: STARR-15 represents the first global airways questionnaire, to be used when examining patients with upper and lower airways symptoms. Future analyses are warranted to evaluate the clinical and psychometric properties of STARR-15.

Recorded prevalence of nasal polyps increases with age

INTRODUCTION

Nasal polyps are a multifactorial inflammatory condition of the upper airways. Nasal polyps typically affect middle-aged and elderly patients, average age at diagnosis is 40 to 60, and men are affected more commonly than women.

AIM

To analyse the reported prevalence of nasal polyps in the Polish population, including demographics and co-morbidities, and to estimate the costs of outpatient and hospital (inpatient) services financed by the National Health Fund.

MATERIAL AND METHODS

Statistical analysis of data extracted from the National Health Fund (NHF) registers for 2008-2018.

RESULTS

In 2018, the recorded prevalence of nasal polyps in Poland was 52.0/10,000 population (0.52%), amounting to 64.6/10,000 (0.65%) in men and 40.2/10,000 (0.40) in women. Nasal polyps were much more frequent in patients aged 55-59 (98.1/10000) and 75-79 years (98.7/10,000). Among men, the highest prevalence was found in the 75-79 age group (164.3/10,000 population), and among women in the 55-59 age group (75.1/10,000). In 2018, the Polish NHF spent PLN 17.2 million (equivalent to EUR 4.0 million/USD 4.7 million) on health services related to the diagnosis of nasal polyps. Hospital services accounted for 77.4% of the total cost.

CONCLUSIONS

Nasal polyps are more than one and a half times as prevalent in men than in women. The recorded prevalence of nasal polyps increases with age, with the rates peaking in those between 75 and 79 years old, and is more often in urban than rural areas.

Impact of asthma on endoscopic sinus surgery outcomes for chronic rhinosinusitis with polyposis - A cohort study

Introduction

Chronic rhinosinusitis with polyposis (CRSwNP) is a multifactorial naso-sinusal inflammatory disease that affects 2–4% of the adult population. It highly affects the patient quality of life (QoL) in many levels making it a public health issue. The management of CRSwNP is based on a detailed clinical history, a complete endoscopic examination and a precise computed tomographic (CT) analysis. The aim of this study is to evaluate the prevalence and severity of the various CRS clinical manifestations as well as to highlight the potential relationship between symptom scores, asthma and ESS outcomes.

Patients and methods

A retrospective cohort study was performed in the 20 August hospital, between January 2017 and December 2018, on patients diagnosed with CRS according to guidelines recommendations, and were beforehand refractory to initial medical therapy and elected to FESS. The patients were divided into two groups, the first group (G1) of patients with asthma and the second (G2) without asthma in order to expose an eventual significant difference in the improvement of symptoms after surgery. The Sino Nasal Outcome Test-22 (SNOT-22) was used to evaluate QOL.

Results

A total of 100 patients participated in the study with an average age of 44.53 years. The sex ratio was 1.04 (51% men). Asthma was present in 48% of patients while 20% of patients were intolerant to aspirin with a significant difference between the asthmatic and non-asthmatic group (p < 0.05). It appears that asthma was not objectively correlated with a higher Lund Mackay radiological score (p > 0.05). A higher significant improvement was observed between preoperative and postoperative SNOT-22 scores in group with asthma [42.7 ± 16.3 versus 11.8 ± 9.1] and in group without asthma [38.3 ± 15.1 versus 10.5 ± 14.2].

Conclusion

Asthma in CRS is an additional symptom in these patients, mainly reflected in the subset of nasal symptoms in SNOT-22. However, it did not significantly affect the quality of life of the CRSwNP population.

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Chronic rhinosinusitis with polyposis highly affects the patient quality of life in many levels making it a public health issue.

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The aim of this study is to highlight the potential relationship between symptom scores, asthma and ESS outcomes.

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SNOT-22 scores were significantly reduced in the postoperative period in the asthma and non-asthma groups, with no significant difference between the 2 groups.

Dupilumab for the treatment of chronic rhinosinusitis with nasal polyposis

Introduction: Chronic rhinosinusitis with nasal polyps (CRSwNP) affects 1-2.5% of the population and is associated with significant adverse effects on quality of life (QoL). CRSwNP is strongly correlated with (late onset) asthma with 30-70% of the CRSwNP patients having asthma. Health-care spending in rhinosinusitis is high, especially because of indirect costs.Areas covered: In the last years, the recognition of endotyping as an essential presumption to precision medicine has significantly changed the integrated care pathways in the treatment of chronic rhinosinusitis. Dupilumab is the first biological available for the treatment of CRswNP, since late 2019. Treatment with dupilumab results in a significant improvement of QoL (measured as SNOT-22), rhinosinusitis disease severity, symptoms of rhinosinusitis, and especially sense of smell, nasal polyp score, Lund-Mackay CT score, and asthma outcomes (ACQ5 and FEV1) compared to placebo.Expert opinion: At this moment, the high cost of the treatment requires careful patient selection and within the EUFOREA and EPOS2020 context, experts have tried to give guidance based on today's data. We now need trials evaluating which patients benefit most from treatment with biologicals and in which patients the treatment is cost-effective.

Bidirectional association between asthma and chronic rhinosinusitis: Two longitudinal follow-up studies using a national sample cohort

The aim of this study was to evaluate an epidemiologic association of asthma and chronic rhinosinusitis (CRS) using a national sample cohort of the Korean population. We collected data from the Korean Health Insurance Review and Assessment Service-National Sample Cohort between 2002 and 2013, and two different case-control cohorts were designed (1st: asthmatic patients matched in a 1:1 ratio with 204,119 non-asthmatics as control I, 2nd: CRS patients matched in a 1:4 ratio with 124,020 non-CRS patients as control II). Bidirectional association was examined using Cox proportional hazard models stratified by age, sex, income, and region of residence. Patients with asthma had an increased risk of developing CRS [adjusted hazard ratio (95% confidence interval) = 1.74 (1.67–1.80)], both with nasal polyps [1.55 (1.36–1.78)], without nasal polyps [1.74 (1.67–1.81)]. In the second cohort, patients with CRS had increased risk of developing asthma [1.85 (1.80–1.91)] with similar results for those with and without nasal polyps. The strongest association for risk of CRS was in 20–39 years old men with asthma [2.41 (1.97–2.96)], while the strongest association for increased risk of asthma in those with CRS group was also seen in this same subgroup [2.40 (2.18–2.63)]. CRS and asthma had a bidirectional influence on each other. CRS increased the risk of asthma, and asthma increased the risk of CRS, especially in young men.

Predictive and Diagnostic Value of Fractional Exhaled Nitric Oxide in Patients with Chronic Rhinosinusitis

Background

Fractional exhaled nitric oxide (FeNO) participates in the local defense of the upper respiratory tract. Abnormal FeNO level is directly related to the occurrence of nasal diseases. However, the clinical value of FeNO in the upper airway is limited, which greatly impedes the diagnosis and treatment of nasal diseases. Here, we assessed the level of FeNO and evaluated the diagnostic accuracy of FeNO for chronic rhinosinusitis.

Material/Methods

We enrolled 35 patients with confirmed nasal inflammation and 30 healthy subjects from December 2016 and June 2017. The FeNO level was measured using a fractional exhaled nitric oxide detector. The level of FeNO in patients with different clinicopathological factors was compared. The diagnostic potential of FeNO for chronic rhinosinusitis was evaluated by receiver operating characteristic (ROC) curve analysis.

Results

FeNO level was significantly lower in patients with nasal inflammation than in healthy subjects (P<0.05). For nasal inflammation diagnosis, FeNO had the highest area under the curve (AUC) at 0.760, with a sensitivity of 93.30% and a specificity of 68.60%. FeNO level was significantly downregulated in chronic rhinosinusitis patients relative to chronic rhinitis patients (P<0.05). FeNO had a good ability to discriminate between chronic rhinosinusitis patients and chronic rhinitis patients, with higher AUC, sensitivity, and specificity of 0.760, 93.30%, and 68.60%, respectively. However, FeNO levels were not significantly different between different histological types of chronic rhinosinusitis (P>0.05).

Conclusions

Our results show that FeNO is a useful marker for discriminating chronic rhinosinusitis, and has potential to provide valuable information in the early diagnosis of chronic rhinosinusitis.

Sinuses and Common Rhinologic Conditions

Some of the most common rhinologic disorders that may present to the primary care provider include disorders of hemostasis, such as epistaxis, or sinonasal inflammatory disorders, such as allergic rhinitis and acute or chronic rhinosinusitis. This article is written with the intent to review these common rhinologic conditions for primary care providers and to summarize symptoms, diagnostic testing, differential diagnosis, and management/treatment approaches.

Prevalence of asthma, aspirin sensitivity and allergy in chronic rhinosinusitis: data from the UK National Chronic Rhinosinusitis Epidemiology Study

BACKGROUND

Chronic rhinosinusitis (CRS) is a common disorder associated with other respiratory tract diseases such as asthma and inhalant allergy. However, the prevalence of these co-morbidities varies considerably in the existing medical literature and by phenotype of CRS studied. The study objective was to identify the prevalence of asthma, inhalant allergy and aspirin sensitivity in CRS patients referred to secondary care and establish any differences between CRS phenotypes.

METHODS

All participants were diagnosed in secondary care according to international guidelines and invited to complete a questionnaire including details of co-morbidities and allergies. Data were analysed for differences between controls and CRS participants and between phenotypes using chi-squared tests.

RESULTS

The final analysis included 1470 study participants: 221 controls, 553 CRS without nasal polyps (CRSsNPs), 651 CRS with nasal polyps (CRSwNPs) and 45 allergic fungal rhinosinusitis (AFRS). The prevalence of asthma was 9.95, 21.16, 46.9 and 73.3% respectively. The prevalence of self-reported confirmed inhalant allergy was 13.1, 20.3, 31.0 and 33.3% respectively; house dust mite allergy was significantly higher in CRSwNPs (16%) compared to CRSsNPs (9%, p < 0.001). The prevalence of self- reported aspirin sensitivity was 2.26, 3.25, 9.61 and 40% respectively. The odds ratio for aspirin sensitivity amongst those with AFRS was 28.8 (CIs 9.9, 83.8) p < 0.001.

CONCLUSIONS

The prevalence of asthma and allergy in CRS varies by phenoytype, with CRSwNPs and AFRS having a stronger association with both. Aspirin sensitivity has a highly significant association with AFRS. All of these comorbidities are significantly more prevalent than in non-CRS controls and strengthen the need for a more individualised approach to the combined airway.

Age-related prevalence of chronic rhinosinusitis and nasal polyps and their relationships with asthma onset

BACKGROUND

Chronic rhinosinusitis (CRS) is a major disease condition with high morbidity and can influence lower airway disease status in adults. However, its associations with adult asthma onset and activity have not been examined in detail in a general adult population.

OBJECTIVE

To investigate relationships between CRS with nasal polyps (CRSwNP) and asthma characteristics.

METHODS

A cross-sectional data set of 17,506 adult participants (≥18 years old) in the Korean National Health and Nutrition Examination Survey from 2010 through 2012 was analyzed. CRS was defined using structured questionnaires according to the international guideline, and presence of nasal polyps was objectively assessed using nasal endoscopy. Presence of asthma and its onset and current activity were assessed using structured questionnaires.

RESULTS

CRS was significantly related to asthma, but the relationships were distinct by CRS and asthma status. CRSwNP was significantly associated with adult-onset asthma (onset after 18 years of age) or late-onset asthma (onset after 40 years of age), whereas CRS without nasal polyps was related to childhood-onset asthma (onset before 18 years) or early-onset asthma (onset before 40 years) in adults. The 2 CRS subgroups showed significant associations with current asthma but not with past asthma. However, the comorbid asthma rate was lower than 10% among subjects with CRS.

CONCLUSION

This study found distinct age-related patterns of CRSwNP and asthma and demonstrated their significant associations in a general population. However, the low prevalence of asthma in CRSwNP is in sharp contrast to findings in Western populations, which warrants further investigation for ethnic or regional differences in relationships between CRSwNP and asthma.

Pulmonary Function of Patients with Chronic Rhinosinusitis and the Impact of Endoscopic Sinus Surgery

OBJECTIVE

The aim of this study was to compare pulmonary function tests (PFTs) among control subjects and patients with chronic rhinosinusitis (CRS) and to investigate the outcomes of endoscopic sinus surgery (ESS) on PFTs among patients with CRS.

STUDY DESIGN

Prospective study conducted from June 2015 to June 2016.

SETTING

Tertiary referral hospital.

SUBJECTS AND METHODS

The study is based on 2 groups: adult control subjects (group 1, n = 25) and adult patients with medically resistant CRS (group 2, n = 25). PFTs were used to compare the lower airway condition between the groups. Another comparison in PFTs was made among patients with CRS at 1 week preoperatively and 1 month postoperatively to evaluate the effectiveness of ESS.

RESULTS

In group 1, all subjects had an FEV1/FVC ratio ≥80% (forced expiratory volume in 1 second / forced vital capacity) with a mean of 0.84 ± 0.07, as compared with group 2, from 61% to 70% for 5 (20%) patients, 71% to 79% for 10 (40%), and ≥80% for 10 (40%). FEV1/FVC was significantly lower in group 2 than group 1 (P = .04). At 1 month postoperatively, the FEV1/FVC values of group 2 was from 61% to 70% for 2 (8%) patients, 71% to 79% for 13 (52%), and ≥80% for 10 (40%). The mean FEV1/FVC was 0.9 ± 0.50, and these values were significantly higher (P = .02) when compared with preoperative values.

CONCLUSION

This study provides objective evidence that patients with CRS may have nonmanifest lower airway affection when compared with control subjects and that ESS is efficacious in the improvement of such affection.