Endoscopic sinus surgery for chronic rhinosinusitis with nasal polyps: Clinical outcome and predictive factors of recurrence

Study protocol: the biologics in severe chronic rhinosinusitis with nasal polyps survey

INTRODUCTION

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a frequent condition affecting approximately 2% of the population. Medical treatment consists long-term use of intranasal corticosteroids and short-term use of oral corticosteroids, in adjunct with saline solution rinses. Surgical management is proposed in patients who failed after medical treatment. In France, two biologics are reimbursed in case of severe uncontrolled CRSwNP despite medical treatment and endoscopic sinus surgery. Waiting for head-to-head biologics comparison, studies should report the efficacy and safety of biologics in large real-life cohorts. This study protocol describes the aims and methods of a prospective, observational, national, multicentric cohort of patients with CRSwNP treated with biologics.

METHODS AND ANALYSIS

The BIOlogics in severe nasal POlyposis SurvEy is a French multicentre prospective observational cohort study. The main aim is to assess the efficacy and tolerance of biologics in patients with CRSwNP, with or without association with other type 2 diseases, and to determine the strategies in case of uncontrolled disease under biologics. Patients over 18 years old requiring biologics for CRSwNP in accordance with its marketing approval in France (ie, severe nasal polyposis, with lack of control under nasal corticosteroid, systemic corticosteroids and surgery) are invited to participate. Collected data include topical history of surgical procedures and biologics, medication and use of systemic corticosteroids, visual analogical scales for specific symptoms, Sino-Nasal Outcome Test-22 questionnaire, nasal polyp score, asthma control test, Lund-Mackay score on CT scan and IgE concentration and eosinophilic count on blood sample.

TRIAL REGISTRATION

NCT05228041/DRI_2021/0030.

Hyperuricemia Increases the Risk of Postoperative Recurrence in Chinese Patients with Chronic Rhinosinusitis

Background

Elevated serum uric acid is crucial in the pathophysiology of chronic inflammatory diseases. However, its impact on chronic rhinosinusitis (CRS) recurrence risk is unknown. This study investigates the association between elevated serum uric acid and the risk of CRS recurrence.

Methods

A retrospective cohort study was conducted on 1004 CRS patients (including 638 males and 366 females) who received functional endoscopic sinus surgery. All patients were followed up for more than 2 years, and categorized into subgroups based on phenotype, gender, and postoperative recurrence. Cox regression analysis was performed to evaluate the associations between serum uric acid and the risk of CRS recurrence.

Results

After categorization, 104 males had hyperuricemia, and 54 females presented hyperuricemia. The rate of recurrent CRS in the hyperuricemia group was significantly higher compared to the non-hyperuricemia group in both males and females (P<0.05). In both male and female patients, the rate of hyperuricemia and uric acid levels were elevated in the recurrent CRS group in comparison with the non-recurrent CRS group (P<0.05). Unadjusted and adjusted Cox regression analysis demonstrated that serum uric acid was an independent risk factor for CRS recurrence (P<0.05). The receiver operator characteristic curve showed that serum uric acid was a potential biomarker for predicting the recurrence of CRS and its phenotypes in both genders (P<0.05).

Conclusion

There is a close relationship between elevated serum uric acid and the recurrence risk of CRS and its phenotypes, suggesting that serum uric acid may be a novel biomarker for predicting recurrent CRS.

Potential Indications of Dupilumab in Th-2 Inflammatory Disease

Dupilumab is a fully humanized IgG4 monoclonal antibody, inhibiting IL-4 and IL-13 signaling, which are the main cytokines involved in type 2 inflammatory diseases. Its introduction was a breakthrough in the treatment of moderate-to-severe atopic dermatitis, but it is also used in other inflammatory diseases, including asthma, eosinophilic esophagitis and chronic rhinosinusitis with nasal polyposis. Recent advances in the understanding of inflammatory pathways have revealed that Th2-type inflammation is involved in a wider range of diseases than previously thought. The aim of our review is to examine off-label therapeutic indications of dupilumab, including bullous dermatoses (pemphigus, bullous pemphigoid) and alopecia areata, and to investigate its potential applications in cancer patients on anti-PD1 therapy.

[A comparative study of the effectiveness of azoximer bromide and surgery on the quality of the life of patients with chronic rhinosinusitis without nasal polyps]

OBJECTIVE

The aim of this study was to compare the effects of azoximer bromide and surgery on the quality of life of patients with chronic rhinosinusitis (CRS) without polyps. We also wanted to examine changes in the patient's emotional state and the nature of their complaints.

MATERIAL AND METHODS

The results of using the Visual Analogue Scale (VAS) and the Sino-Nasal Outcome Test-22 (SNOT-22) questionnaire in patients with CRS without severe or moderate-severe polyps, before treatment and 3 months after treatment, are presented. Patients, depending on their choice, were treated with functional endoscopic intervention or a course of 6 mg/ml azoximer bromide (1 ml per day, a course of at least 10 days).

RESULTS

The median [interquartile range] score for VAS in patients before azoximer bromide treatment was 6.7 [6.3; 7.05] points, after treatment 4.2 [3.50; 4.70] points. The median [interquartile range] of VAS scores in patients before surgical treatment was 6.4 [6.1; 6.9] points, and after 4.8 [4.50; 5.30] points. The median [interquartile range] of the SNOT-22 score before azoximer bromide treatment was 33 [32; 36] points, after treatment - 24 [22; 25] points. The median [interquartile range] of the SNOT-22 score before surgery was 34 [32; 36] points, after treatment - 19 [18; 21.25] points.

CONCLUSION

Azoximer bromide treatment and surgery improve the quality of life of patients with CRS (according to the visual analog scale and all SNOT-22 domains) during a control survey after 3 months (p<0.001). Surgical treatment has a stronger impact on the quality of life, which is more noticeable in the influence on the domains "Rhinological symptoms", "Extranasal symptoms", "Ear/facial symptoms" (p<0.05). According to the domains "Psychological dysfunction", "Sleep dysfunction", surgical intervention had no advantages in affecting the quality of life, compared with taking azoximer bromide (p<0.05).

Risk Factors for Recurrence of Nasal Polyps after Endoscopic Sinus Surgery in Patients with Allergic Chronic Rhino Sinusitis

Rhino sinusitis, is a common inflammatory disease that affects the nasal cavity and paranasal sinuses in millions of individuals. Chronic sinusitis patients complain of a combination of nasal obstruction, rhinorrhea, post nasal drip and facial pain. To identify the risk factors of the recurrence of nasal polyps in chronic rhino sinusitis patients after endoscopic sinus surgery. After a review of 60 patients with chronic rhino sinusitis with failed medical treatment requiring FESS presenting in Kasr Alainy Hospital in Cairo University and October 6 University Hospital from May 2022 to March 2023. All patients were subjected to history taking, clinical examination including endoscopy, subjective evaluation of symptoms and CT-scan. Of our patients, six patients (15%) were diagnosed with recurrence of nasal polyps with chronic rhino sinusitis and needed revision surgery. There are multiple risk factors related to the recurrence of nasal polyps including smoking followed by having a history of an asthma, the presence of an allergy, septal deviation, prior sinus surgery, and turbinate hypertrophy. Other factors, as proper medical treatment such as topical steroids and treatment of allergy had a significant role in decreasing the recurrence rate. Risk factors related to the recurrence of nasal polyps should be avoided before surgery. The avoidance of risk factors protects the patients from the recurrence of nasal polyps, the hazards of anaesthesia on surgical treatment, and the financial cost of surgery. Follow up is important in the prevention of recurrence of nasal polyps and improves the symptoms.

The role of intranasal corticosteroids in chronic rhinosinusitis with nasal polyposis treated with dupilumab

PURPOSE

Dupilumab represents an innovative and effective therapy for refractory/recurrent severe chronic rhinosinusitis with nasal polyps (CRSwNP). Intranasal corticosteroids should be used during treatment with biological agents. However, adherence to nasal therapy may not be complete. The aim of this study was to evaluate the role of intranasal corticosteroids in patients with CRSwNP who underwent treatment with dupilumab.

MATERIALS AND METHODS

Fifty-two patients treated with dupilumab for CRSwNP were enrolled. Clinical parameters (age, sex, comorbidities, blood eosinophils, Nasal Polyp Score - NPS, Visual Analogue Scale - VAS - for smell loss, Asthma Control Test - ACT), quality of life (Sino Nasal Outcome Test 22 - SNOT-22 questionnaire), nasal cytology, and adherence to regular administration of intranasal corticosteroids were recorded before treatment (T0), and after 3 (T1), 6 (T2), and 12 months (T3).

RESULTS

NPS, VAS for smell, ACT and SNOT-22 total score and subscores improved during treatment (p < 0.05). Blood eosinophils reached a peak at T1-T2 and then decreased toward baseline at T3. Adherence to regular treatment with intranasal steroids was 61.5 %. No statistically significant differences in all the clinical outcomes were observed between patients who regularly used intranasal steroids and other subjects (p > 0.05). Nasal cytology showed a decrease of eosinophils and an increase of neutrophils during treatment.

CONCLUSIONS

Dupilumab is still effective in patients who are using topical nasal steroids with variable adherence (real world settings).

Management paradigms for chronic rhinosinusitis in individuals with asthma: An evidence-based review with recommendations

BACKGROUND

Despite the significant morbidity associated with chronic rhinosinusitis (CRS) in individuals with asthma (CRSwA), there is a paucity of codified, evidence-based management strategies for CRS in this population.

METHODS

Using PubMed, Embase, and Cochrane Review Databases, a systematic review was performed covering management strategies for CRSwA. A total of 5903 articles were screened, and 70 were included for full-text analysis. After application of exclusion criteria, 53 articles comprised the qualitative synthesis. The level of evidence was graded and benefit-harm assessments, as well as value judgment and recommendations, were provided RESULTS: Strong evidence confirms the benefit of oral and topical medications on sinonasal-specific outcomes in individuals with CRSwA; there is low-grade evidence demonstrating that these agents improve lung function and/or asthma control. Moderate to strong evidence suggests that endoscopic sinus surgery (ESS) improves both sinonasal- and asthma-specific quality of life. Although there is insufficient to low evidence to indicate that ESS improves pulmonary function in this population, data indicate a positive impact of this intervention on asthma control. Biologic medications strongly improve both subjective and objective sinonasal- and asthma-specific outcomes.

CONCLUSION

Evidence supports managing CRS in individuals with CRSwA in a stepwise fashion, starting with traditional nonbiologic oral and topical medication, and escalating to second-line treatments, such as ESS and biologics. Optimal treatment of individuals who have CRSwA often requires concurrent, directed management of asthma, as not all CRS interventions impact asthma status.

Understanding the Impact of Chronic Rhinosinusitis with Nasal Polyposis on Smell and Taste: An International Patient Experience Survey

The aim is to understand the patient experience of living with chronic rhinosinusitis with nasal polyposis (CRSwNP), clinician interactions and how symptoms, smell and taste disturbance are managed. An anonymized, online survey was distributed through a UK charity, Fifth Sense, a UK otolaryngology clinic and online support groups to capture qualitative and quantitative data. Data were collected from 1st December 2022 to 1st February 2023. A total of 124 individuals participated. The majority were female (66%) and in the age range of 41-70 years; 74.2% of participants were from the UK with the rest from North America, Europe and Asia. A total of 107 participants declared they had CRSwNP. Rhinologists and general otolaryngology clinicians scored the highest for patient satisfaction whilst general practitioners scored the lowest. Satisfaction with the management of smell and taste disturbance was lower amongst all clinicians compared to overall satisfaction. Ratings correlated with response to therapy and clinician interactions. Respondents reported hyposmia/anosmia to be the most debilitating symptom. Surgery and oral steroids were considered to be effective; however, the benefit lasted less than six months (62%). Hyposmia/anosmia is a key CRSwNP symptom that has limited treatment options and is frequently undervalued by clinicians. There is a need for more effective management options, education and patient support.

Allergic Rhinitis as an Independent Risk Factor for Postoperative Recurrence of Children Chronic Sinusitis

(1) Background: The recurrence rate of childhood recurrent sinusitis varies widely between 12% and 50%, with the postoperative recurrence risk factors remaining largely unidentified. We sought to enhance the understanding of chronic rhinosinusitis (CRS) via a retrospective observational childhood cohort. (2) Methods: The study recruited 125 cases. Demographic data and univariate and multivariate logistic regression analyses were conducted to investigate potential risk factors of childhood recurrent sinusitis following functional endoscopic sinus surgery (FESS). (3) Results: A postoperative recurrence rate of 21.6% was determined. Among the participants, 21 cases presented a history of allergic rhinitis (AR), with the remaining 104 cases being AR-free. A significantly heightened recurrence rate was noted in those bearing a history of AR compared to their counterparts devoid of such history (p < 0.000). The fully adjusted logistic regression model indicated a 21.04-fold increased risk of postoperative recurrence in childhood CRS bearing a history of AR compared to those without an AR history (p = 0.000), highlighting the history of AR as an independent risk factor for postoperative childhood recurrent sinusitis (p = 0.001); (4) Conclusions: The data implicate AR as an independent risk factor for postoperative childhood recurrent sinusitis.

Innovative treatments for severe uncontrolled chronic rhinosinusitis with nasal polyps

INTRODUCTION

In recent years, endotypes of chronic rhinosinusitis (CRS) based on the underlying immune mechanisms provided a better understanding of this heterogeneous disease and are frequently applied in diagnosis and treatment.

AREAS COVERED

In this manuscript, we aim to review novel treatment approaches for this often uncontrolled disease and highlight endotype-driven medical algorithms that could be beneficial in daily clinical practice.

EXPERT OPINION

With the development of endotyping and the mucosal inflammatory concept, several type 2-targeted biologics and surgical options are nowadays available for treating CRS. However, a better understanding based on clinical trials and real-life experience in daily practice is needed to optimize patient selection, biological drug selection, treatment duration, prediction, and long-term follow-up strategies. Indirect comparison analysis suggested that dupilumab might be the most effective biologic for treating CRS with nasal polyps, but the role and timing of surgery remain unclear. More real-life studies and comparative trials are needed for the optimal integration of biologics into clinical pathways in combination with established treatment approaches such as nasal and oral glucocorticosteroids and adequate surgery to provide long-term perspectives.

How to manage recurrences after surgery in CRSwNP patients in the biologic era: a narrative review

Objective

This narrative review analyses factors affecting recurrence of Chronic rhinosinusitis with nasal polyps (CRSwNP) after surgery, such as type, extension and completeness of endoscopic sinus surgery (ESS). We also described new implications in the management of recurrences after the advent of biologics.

Methods

We identified four topics: definition of disease state; factors linked to recurrence of polyps; evaluation and management of recurrence in clinical practice.

Results

We analysed the differences between exacerbation and recurrence, as well as the concept of "controlled disease". We focused on potential predictors of recurrence after ESS, such as type 2 inflammation, asthma, aspirin-exacerbated respiratory disease, incomplete initial surgery and lack of adherence to long-term post-operative local corticosteroids. We discussed the new aspects of diagnosis and treatment of recurrences after surgery, summarising our suggestions in a detailed algorithm for practical management of patients with recurrent disease.

Conclusions

The results emphasised the importance of accurate evaluation of patients with CRSwNP recurrence, focusing on the reasons of failure and risk of disease progression, in order to guide personalised interventions. It is crucial to define the concept of appropriate surgery, which affects the choice between starting a biologic or repeating surgery.

Elevated body mass index increased the risk of recurrence in Chinese patients with chronic rhinosinusitis

BACKGROUND

Elevated body mass index (BMI) has been associated with an increased prevalence of chronic rhinosinusitis (CRS). However, the impact of BMI on the risk of recurrence of CRS is unknown. This study aimed to investigate the association between BMI and the risk of CRS recurrence.

MATERIAL AND METHODS

A retrospective cohort study was conducted and recruited 1057 CRS patients who underwent functional endoscopic sinus surgery (FESS). All subjects were classified into four groups: "underweight", "normal weight", "overweight", and "obese". Multivariate regression analysis was performed to examine the associations between BMI categories and other factors and the risk of CRS recurrence.

RESULTS

The rate of recurrent CRS was significantly higher in the overweight group and obese group than in the normal weight group (P < 0.05). Unadjusted and adjusted logistic regression analyses demonstrated that overweight and obesity exhibited an increased risk of CRS recurrence as compared to patients with normal weight (P < 0.05). Furthermore, all patients were divided into primary CRS group and recurrent CRS group, and the BMI, duration of disease and rate of allergic rhinitis were vastly increased in the recurrent group than in the primary group (P < 0.05). Univariate and multivariate regression analysis showed that BMI and duration of disease were the dominant risk factors of CRS recurrence (P < 0.05).

CONCLUSION

Overweight and obesity presented significant impacts on the CRS recurrence, and elevated BMI were associated with an increased risk of CRS recurrence independently from traditional risk factors. A longer duration of disease was correlated with a higher risk of CRS recurrence.

Cluster analysis of patients with chronic rhinosinusitis and asthma after endoscopic sinus surgery

BACKGROUND

Patients with chronic rhinosinusitis with nasal polyps and asthma (CRSwAS) are highly heterogenous in severity and prognosis. The clinical phenotypes and inflammatory endotypes of CRSwAS and their association with outcomes of endoscopic sinus surgery (ESS) have not been fully studied yet.

OBJECTIVE

We aimed to find out the clinical phenotypes of CRSwAS and explore their relationship with ESS outcomes using cluster analysis.

METHODS

We recruited 103 consecutive adult patients with CRSwAS who had undergone ESS and been followed up for more than 1 year. For cluster analysis, we collected the data from 63 variables pertaining to demographic characteristics, preoperative disease status, surgical techniques, postoperative medical treatment, and outcomes. Eosinophilic CRS was defined as greater than or equal to 10 eosinophils/high-power field, and sinus computed tomography was evaluated by Lund-Mackay sinus computed tomography score (LM score).

RESULTS

We screened 92 eligible patients and 13 preoperative variables for balanced iterative reducing and clustering using hierarchies cluster analysis. Patients with CRSwAS were divided into 4 clusters with distinct ESS outcomes: (1) cluster 1, characterized by aspirin-exacerbated respiratory disease, eosinophilic CRS, high preoperative LM score, moderate-to-severe asthma, and uncontrolled CRS after ESS; (2) cluster 2, characterized as having female dominance (66.67%), non-aspirin-exacerbated respiratory disease, eosinophilic CRS, high preoperative LM score, moderate-to-severe asthma, and uncontrolled CRS after ESS; (3) cluster 3, characterized as having female dominance (95.83%), noneosinophilic CRS, low preoperative LM score, moderate asthma, and controlled CRS after ESS; and (4) cluster 4, characterized as men-only, smoker, noneosinophilic CRS, low preoperative LM score, mild asthma, and controlled CRS after ESS.

CONCLUSION

CRSwAS has distinct clusters, each corresponding to unique clinical and inflammatory characteristics and ESS outcomes.

Predictive factors of revision endoscopic sinus surgery

PURPOSE

Despite endoscopic sinus surgery (ESS) being the standard best treatment for chronic rhinosinusitis with nasal polyps (CRSwNP), there still remains a high recurrence rate of nasal polyps after ESS. The aim of this study was to analyze the impact of ESS in the treatment of CRSwNP and identify possible predictors for revision surgery.

METHODS

We conducted a cross-sectional retrospective study of patients with CRSwNP submitted to ESS between the years 2013 and 2021.

RESULTS

We analyzed 517 cases, of which 15.1% were submitted to revision ESS. The presence of hyposmia/anosmia, asthma, intolerance/allergy to non-steroid inflammatory drugs, non-steroidal anti-inflammatory drug exacerbated respiratory disease, and bilateral polyposis were more frequent in patients who needed revision surgery. Initial values of peripheral eosinophilia and Lund-Mackay scores were significantly higher in this sub-group of patients. Lund-Mackay score was the only independent risk factor for revision surgery.

CONCLUSIONS

Factors like peripheral eosinophilia and Lund-Mackay score were associated with a higher probability of revision ESS. Applying these concepts to the clinical practice could help predict the evolution of patient's pathology in the post-operative period and identify in advance those cases that may need a multidisciplinary approach.

The link between allergic rhinitis and chronic rhinosinusitis

PURPOSE OF REVIEW

Allergic rhinitis and chronic rhinosinusitis (CRS) are common disorders affecting millions of people worldwide. Although allergic rhinitis and CRS are distinct clinical entities, certain CRS endotypes share similar pathological mechanisms as those seen in patients with allergic rhinitis. This review assesses the literature behind the similarities and differences seen in patients with CRS and allergic rhinitis, and the role atopy might play in the pathophysiology of CRS.

RECENT FINDINGS

In examining the associations between allergic rhinitis and CRS, most studies have focused primarily on CRS with nasal polyps and type 2 inflammation in CRS. Recent studies have demonstrated the similarities and differences in pathologic mechanisms behind allergic rhinitis and CRS, with an emphasis on patient endotypes, genetics, and the nasoepithelial immunologic barrier. Related immunopathology shared by allergic rhinitis and type 2 inflammation in CRS has allowed for therapeutic overlap with biologic treatments.

SUMMARY

Allergic rhinitis and CRS often present as comorbid conditions, and understanding the relationship between allergic rhinitis and CRS is important when considering treatment options. Advances in understanding the genetics and immunology, as well as biologic and immunotherapeutic treatments have improved outcomes in patients with CRS, especially in the setting of atopy.

Economic Burden Associated With Nasal Polyposis Recurrence Among Commercially Insured Patients in the United States

OBJECTIVE

To compare health care resource utilization (HRU) and costs among commercially insured patients with nasal polyposis (NP) with and without recurrence after endoscopic sinus surgery (ESS).

STUDY DESIGN

Retrospective matched cohort study.

SETTING

Adults with initial ESS or an NP excision after a new NP diagnosis were identified in Optum's Clinformatics Data Mart Database (October 1, 2014-December 31, 2019).

METHODS

The index date was the date of NP recurrence, identified with a claims-based algorithm for the recurrent cohort, or a random date for the nonrecurrent cohort. Patients in both cohorts were matched 1:1 on baseline characteristics (12 months preindex) via propensity scores and exact matching factors. Annual HRU and costs (2019 US$) were compared between the matched cohorts at 12 months postindex.

RESULTS

NP recurrence was identified among 3343 of 16,693 patients with initial ESS; after matching, each cohort comprised 1574 patients (median age, 54 years; 40% female) with similar baseline health care costs (recurrent, $34,420; nonrecurrent, $33,737). At 12 months postindex, the recurrent cohort had higher HRU, including 36% and 51% more outpatient and emergency department visits, respectively (all P < .01). Mean health care costs were $9676 higher in the recurrent cohort ($24,039) relative to the nonrecurrent cohort ($14,363, P < .01). The mean cost difference between cohorts was driven by $8211 in additional outpatient costs, as well as $6062 in additional NP-related outpatient costs, in the recurrent cohort (all P < .01).

CONCLUSION

NP recurrence is associated with a substantial economic burden, which appears to be driven by outpatient services.

The burden of chronic rhinosinusitis with nasal polyps and its relation to asthma in Finland

Background

Chronic rhinosinusitis with nasal polyps (CRSwNP) is commonly associated with asthma. Treatment of CRSwNP includes intranasal and systemic corticosteroids, with non‐responsive patients commonly considered for endoscopic sinus surgery (ESS). This nationwide register‐based study evaluated the incidence, prevalence, and treatment burden of CRSwNP in Finland, and their association with the presence and severity of comorbid asthma.

Methods

Electronic health records of patients diagnosed with CRSwNP between 1.1.2012 and 31.12.2018 in Finnish specialty and primary care were included in the study. The patients were divided into subgroups based on presence, severity, and control of asthma: no asthma, mild to moderate asthma, severe controlled asthma, and severe uncontrolled asthma. A mean cumulative count of ESS was calculated over time per subgroup.

Results

The prevalence of CRSwNP increased from 602.2 to 856.7 patients per 100,000 population between years 2012 and 2019 (p < 0.001). A total of 18,563 patients (59.9% male) had incident CRSwNP between 2012 and 2019, with 27% having asthma, 6% having severe asthma, and 1.5% having severe uncontrolled asthma. In the no asthma, severe controlled asthma, and severe uncontrolled asthma subgroups, systemic corticosteroids were used by 54.1%, 94.9% and 99.3% (p < 0.001), respectively, while the ESS count 3 years post diagnosis was 0.49, 0.68 and 0.80, respectively.

Conclusions

The prevalence of CRSwNP showed a significant increase in the recent decade in Finland. Comorbid asthma, and in particular severe asthma, increased the probability of receiving systemic corticosteroids and undergoing ESS. Thus, improved management of CRSwNP in patients with comorbid asthma is urgently needed.

Exploration of Predictive Biomarkers for Postoperative Recurrence in Chronic Rhinosinusitis with Nasal Polyps Based on Serum Multiple-Cytokine Profiling

Background

Functional nasal endoscopic surgery (FESS) is an effective treatment approach for chronic rhinosinusitis with nasal polyps (CRSwNP) patients, but some patients still suffer from postoperative recurrence. This study is aimed at investigating the expression of multiple cytokines in CRSwNP and revealing their relationships with postoperative recurrence.

Methods

A total of 72 patients with CRSwNP, including 36 primary and 36 recurrent patients, were enrolled. Serum samples were obtained, 30 cytokine levels were measured by multiplex analysis, and the association between cytokine levels and recurrence was assessed. The most potential cytokines were further validated in another independent cohort with 60 primary and 60 recurrent CRSwNP patients.

Results

The results of multiple cytokine profiling exhibited that the levels of eotaxin, G-CSF, IFN-α, IL-13, IL-17A, IL-5, MCP-1, and RANTES were vastly changed in the recurrent group in comparison with the primary group. Receiver-operating characteristic (ROC) curves highlighted that serum levels of eotaxin, IL-17A, and RANTES were strongly predictive of postoperative recurrence (area under the curve (AUC) > 0.7, P < 0.05). Further validation results showed that elevated serum eotaxin, IL-17A, and RANTES levels were enhanced in the recurrent group. The ROC curve showed that serum eotaxin (AUC = 0.729, P < 0.001) and RANTES (AUC = 0.776, P < 0.001) exhibited stronger ability than serum IL-17A (AUC = 0.617, P = 0.027) in predicting CRSwNP recurrence.

Conclusion

Our data suggested that serum multiple cytokine profiling was associated with postoperative recurrence of CRSwNP, and eotaxin and RANTES might serve as potential biomarkers for predicting postoperative recurrence. These results might contribute to the understanding of the underlying mechanisms of recurrence and provide novel clues for precision therapy in CRSwNP.

Clinical and economic burden of chronic rhinosinusitis with nasal polyposis: A U.S. administrative claims analysis

Background: Limited data exist on the clinical and economic burden of chronic rhinosinusitis with nasal polyposis (CRSwNP). Objective: To describe patient characteristics, health-care resource utilization (HCRU), and health-care costs among patients with CRSwNP with and without comorbid asthma (primary analysis) and with surgical management of nasal polyps (secondary analysis). Methods: This was a retrospective study of patients diagnosed with CRSwNP conducted using administrative claims data from January 1, 2013, through March 31, 2019. Study outcomes were assessed over a 2-year follow-up. Results were stratified by baseline asthma status (primary analysis) and presented separately for patients with surgically managed CRSwNP (secondary analysis). Results: The primary analysis included 10,999 patients with CRSwNP (2649 with asthma, 8350 without asthma). Patients with versus without asthma had higher medication use, HCRU, and all-cause medical costs (mean ± standard deviation $34,667 ± $42,234 versus $27,122 ± $45,573; p < 0.001) across the full follow-up period. CRSwNP-related medical costs were significantly higher for patients with versus without asthma in year 2 of follow-up. In the surgical management analysis (n = 4943), most categories of medication use and CRSwNP-related HCRU declined from baseline levels during follow-up, and CRSwNP-related pharmacy costs in year 2 were less than half of baseline levels. Conclusion: Patients diagnosed with CRSwNP and asthma had a greater burden of illness than those without asthma. Higher CRSwNP-related medical costs in year 2 of follow-up for patients with asthma may indicate worsening symptoms over time. Among patients with surgically managed CRSwNP, HCRU and costs increased in year 1 of follow-up but decreased below baseline levels in year 2, potentially reflecting improved symptom severity.

Systematic review and meta-analysis of the curative effects and safety of endoscopic sinus surgery in children with chronic sinusitis with nasal polyps

BACKGROUND

At present, the surgical treatment of sinusitis with nasal polyps has made great progress, but its recurrence rate is still high. Therefore, this time, meta-analysis is used to study the therapeutic effect of endoscopic sinus surgery on children with chronic sinusitis with nasal polyps, analyze its effectiveness and safety, and provide theoretical basis for clinical treatment.

METHODS

Boolean logic searching was adopted to retrieve articles from various databases, including PubMed, Medline, and Chinese National Knowledge Infrastructure (CNKI), published from the establishment of the database to December 30, 2021. The following search terms were used: "endoscopic sinus surgery", "antrochoanal polyps", "chronic sinusitis with nasal polyps", and "nasal polyps". Comparative studies on traditional surgical treatment and endoscopic sinus surgery were also screened out. Review Manager was utilized for meta-analysis.

RESULTS

A total of 9 references were included in the study, and most of them were low risk bias (medium and high quality). Meta-analysis showed that there was no statistical heterogeneity between the control group and the experimental group (Chi²=0.03, I²=0%, P=0.98). According to the fixed effect model analysis, the number of patients with polyp formation in the experimental group was significantly less than that in the control group (Z=2.65, P=0.008). Compared with the control group, there is no statistical heterogeneity in the postoperative recurrence (Chi²=1.59, I²=0%, P=0.45). According to the analysis of fixed effect model, the postoperative recurrence in the experimental group is significantly less than that in the control group (Z=2.92, OR =2.78, 95% CI: 1.40-5.52, P=0.004). Compared with the control group, the results of postoperative visual analogue scale (VAS) were statistically different (Chi²=12.63, I²=84%, P=0.002). According to the random effect model analysis, the VAS score of the experimental group was significantly lower than that of the control group (Z=18.06, MD =4.51, 95% CI: 3.96-5.05, P<0.00001).

DISCUSSION

Endoscopic sinus surgery could reduce the postoperative recurrence and pain of patients, and showed high curative effects and safety in the treatment of children with chronic sinusitis with nasal polyps.

Construction and analysis of a ceRNA network and patterns of immune infiltration in chronic rhinosinusitis with nasal polyps: based on data mining and experimental verification

Recent studies have revealed the significant role of the competing endogenous RNA (ceRNA) network in human diseases. However, systematic analysis of the ceRNA mechanism in chronic rhinosinusitis with nasal polyps (CRSwNP) is limited. In this study, we constructed a competitive endogenous RNA (ceRNA) network and identified a potential regulatory axis in CRSwNP based on bioinformatics analysis and experimental verification. We obtained lncRNA, miRNA, and mRNA expression profiles from the Gene Expression Omnibus. After analysis of CRSwNP patients and the control groups, we identified 565 DE-lncRNAs, 23 DE-miRNAs, and 1799 DE-mRNAs by the DESeq2 R package or limma R package. Enrichment analysis of 1799 DE-mRNAs showed that CRSwNP was associated with inflammation and immunity. Moreover, we identified 21 lncRNAs, 8 miRNAs and 8 mRNAs to construct the lncRNA-miRNA-mRNA ceRNA network. A potential MIAT/miR-125a/IRF4 axis was determined according to the degree and positive correlation between a lncRNA and its competitive endogenous mRNAs. The GSEA results suggested that IRF4 may be involved in immune cell infiltration. The validation of another dataset confirmed that MIAT and IRF4 were differentially expressed between the CRSwNP and control groups. The area under the ROC curve (AUC) of MIAT and IRF4 was 0.944. The CIBERSORT analysis revealed that eosinophils and M2 macrophages may be involved in the CRSwNP process. MIAT was correlated with dendritic cells and M2 macrophages, and IRF4 was correlated with dendritic cells. Finally, to validate the key genes, we performed in-silico validation using another dataset and experimental validation using immunohistochemistry, immunofluorescence, and Western blot. In summary, the constructed novel MIAT/miR-125a/IRF4 axis may play a critical role in the development and progression of CRSwNP. We believe that the ceRNA network and immune cell infiltration could offer further insight into novel molecular therapeutic targets for CRSwNP.

Using machine learning for the personalised prediction of revision endoscopic sinus surgery

BACKGROUND

Revision endoscopic sinus surgery (ESS) is often considered for chronic rhinosinusitis (CRS) if maximal conservative treatment and baseline ESS prove insufficient. Emerging research outlines the risk factors of revision ESS. However, accurately predicting revision ESS at the individual level remains uncertain. This study aims to examine the prediction accuracy of revision ESS and to identify the effects of risk factors at the individual level.

METHODS

We collected demographic and clinical variables from the electronic health records of 767 surgical CRS patients ≥16 years of age. Revision ESS was performed on 111 (14.5%) patients. The prediction accuracy of revision ESS was examined by training and validating different machine learning models, while the effects of variables were analysed using the Shapley values and partial dependence plots.

RESULTS

The logistic regression, gradient boosting and random forest classifiers performed similarly in predicting revision ESS. Area under the receiving operating characteristic curve (AUROC) values were 0.744, 0.741 and 0.730, respectively, using data collected from the baseline visit until six months after baseline ESS. The length of time during which data were collected improved the prediction performance. For data collection times of 0, 3, 6 and 12 months after baseline ESS, AUROC values for the logistic regression were 0.682, 0.715, 0.744 and 0.784, respectively. The number of visits before or after baseline ESS, the number of days from the baseline visit to the baseline ESS, patient age, CRS with nasal polyps (CRSwNP), asthma, non-steroidal anti-inflammatory drug exacerbated respiratory disease and immunodeficiency or suspicion of it all associated with revision ESS. Patient age and number of visits before baseline ESS carried non-linear effects for predictions.

CONCLUSIONS

Intelligent data analysis identified important predictors of revision ESS at the individual level, such as the frequency of clinical visits, patient age, Type 2 high diseases and immunodeficiency or a suspicion of it.

Increased B Cell-Activating Factor Expression Is Associated with Postoperative Recurrence of Chronic Rhinosinusitis with Nasal Polyps

Background

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a common upper airway inflammatory disease with a high postoperative recurrence rate. This study is aimed at exploring the expression of B cell-activating factor (BAFF) in CRSwNP and its association with postoperative recurrence.

Methods

A total of 80 CRSwNP patients, including 40 primary CRSwNP patients and 40 recurrent CRSwNP patients, 40 chronic rhinosinusitis without nasal polyps (CRSsNP) patients, and 40 healthy controls (HC) were enrolled in this study, and the serum and tissue samples were collected. The circulating and tissue BAFF expressions were detected by enzyme-linked immunosorbent assay reverse transcription-polymerase chain reaction and immunohistochemistry. Their clinical values for predicting postoperative recurrence of CRSwNP were evaluated.

Results

We determined serum levels of BAFF were remarkably increased in the CRSwNP group than the CRSsNP and HC groups (P < 0.05), and higher concentrations of BAFF were associated with peripheral eosinophil percentage (r = 0.614, P < 0.001). The serum BAFF concentrations were significantly higher in the recurrent CRSwNP group in comparison with the primary group (P < 0.05). Multivariate analysis and receiver operating characteristic (ROC) curve presented that serum BAFF levels were associated with the postoperative recurrence in CRSwNP patients (P < 0.05). Moreover, tissue BAFF levels were significantly increased in the CRSwNP group than the HC group, especially in the recurrent CRSwNP group (P < 0.05), and enhanced BAFF RNA expressions were correlated with serum BAFF levels (r = 0.703, P < 0.001).

Conclusion

Our results elucidated that the BAFF expression was enhanced in CRSwNP patients and associated with postoperative recurrence. BAFF could be a serologic biomarker for predicting postoperative recurrence in CRSwNP patients.

Long-term evaluation of nasal polyposis recurrence: A focus on multiple relapses and nasal cytology

PURPOSE

Recurrence of chronic rhinosinusitis with nasal polyps (CRSwNP) is highly variable, reaching 55-60% of cases. Different results about clinical parameters as recurrence predictors has been reported. The aim of this retrospective study was to evaluate CRSwNP recurrence risk after a long-term follow-up (up to 20 years). Moreover, the role of nasal cytology was assessed.

MATERIALS AND METHODS

Sixty-one patients who underwent functional endoscopic sinus surgery for CRSwNP were enrolled. Clinical parameters were recorded. Nasal cytology was performed at follow-up examinations. The Kaplan-Meier method was used to obtain the recurrence-free survival curves. The median number of recurrences per year was evaluated.

RESULTS

Five- and 10-year recurrence rates were 30.29% and 66.06%, respectively. Median recurrence-free survival was 106 months. Asthma and Aspirin-Exacerbated Respiratory Disease represented predictors of multiple recurrences (p < 0.05). Intranasal steroids were the main treatment to prevent relapses (p < 0.05). Patients with normal cytology at follow-up evaluation had a lower probability to have first recurrence within 10 years (59% of cases), compared to neutrophil or eosinophil infiltrate (100% and 88% of cases, respectively) (p < 0.05).

CONCLUSIONS

CRSwNP has a high recurrence risk, also more than 10 years after surgery. Nasal cytology may identify subjects with a higher risk of early recurrence.

Clinical and biological markers in disease and biologics to treat chronic rhinosinusitis

PURPOSE OF REVIEW

Chronic rhinosinusitis (CRS) is a heterogeneous disorder with diverse responses to conventional anti-inflammatory medical and surgical treatments. Even for the newly developed mAbs targeting type 2 (T2) reaction, a considerable number of patients with CRS with nasal polyps (CRSwNP) exhibited unsatisfying response. Identifying patients with a tendency to poor prognosis is critical for selecting targeted therapies to improve the treatment outcome. This review focuses on clinical and biological markers associated with prognosis of CRS patients under conventional medical and surgical treatments and provides an update summary of potential markers for T2 biologics.

RECENT FINDINGS

Allergic rhinitis, asthma, prior sinus surgery, nasal polyps, tissue eosinophilia and neutrophilia, blood eosinophilia and high levels of Charcot-Leyden crystal, cystatin SN, chemokine (C-C motif) ligand 17, macrophage inflammatory protein-1β and interleukin (IL)-5 in nasal secretions have been associated with poor prognosis in CRS patients under conventional medical and surgical treatments. Blood eosinophil level might be a biomarker for anti-IL-5 (mepolizumab) and anti-IL-5R (benralizumab) biologic in patients with refractory CRSwNP.

SUMMARY

Several clinical and biological markers have been associated with poor response to conventional treatments in CRS patients; however, majority of them should be verified by large-scale multicentre studies. More efforts are needed to identify biomarkers for biologics.

The development of the mucosal concept in chronic rhinosinusitis and its clinical implications

In the last 2 decades, an increasing understanding of pathophysiological mechanisms in chronic rhinosinusitis opened an avenue from phenotyping to endotyping, from eosinophilic inflammation to type 2 immunity, and from the "ventilation and drainage" paradigm to the mucosal concept for therapeutic considerations. With the advent of type 2 endotyping and targeted biomarkers, precise endotype-driven therapeutic options are possible including biologics and adapted surgical approaches. We here aim to focus on the complexity and heterogeneity of the features of chronic rhinosinusitis (CRS) endotypes, especially for those with nasal polyps, including its history, latest developments, clinical associations and endotype-driven solutions. In order to better manage uncontrolled severe CRS in clinical practice, medical decisions based on a profound understanding of the pathology and immunology of this heterogeneous disease, aiding a precision-medicine based approach for patient's treatment are pivotal.

Risk Model Establishment of Endoscopic Sinus Surgery for Patients with Chronic Rhinosinusitis: a Multicenter Study in Korea

BACKGROUND

Endoscopic sinus surgery (ESS) is the mainstay treatment for refractory chronic rhinosinusitis (CRS). Since various factors may contribute to the surgical outcome, it is challenging for physicians to predict surgical outcomes. The aim of study was to analyze the prognostic factors of postoperative outcomes and to establish the prediction model with the risk factors that impact the postoperative outcomes.

METHODS

Medical records of CRS patients who underwent ESS at 9 institutions in 2005, 2010, and 2016 were retrospectively reviewed. We classified the patients into 2 groups based on postoperative objective endoscopic outcomes. Demographics, nose-specific symptoms, olfactory function, eosinophil counts in blood (EoB) and nasal tissue (EoT), and Lund-Mackay CT score (LMS) were collected. Univariate and multivariate analyses were performed and established a prediction equation for postoperative endoscopic objective outcomes.

RESULTS

In total (n = 1,249), 27.0% were not satisfied under postoperative endoscopic examination. Of 10 variables, LMS (> 5), sinus dominancy (maxillary sinus and ethmoid sinus), EoB (> 210), and EoT (> 100) were statistically significant in univariate analysis (P < 0.05, all). In multivariate analysis, EoT (> 100) and LMS (> 5) were significantly associated with poor postoperative outcome. Furthermore, 5 significant variables were employed to establish the risk model of postoperative outcomes and P (the value of prediction probability) = 1 / (1 + exp [-0.392 + 1.088 × EoT (> 100) + 0.123 × mean LMS (> 5) - 0.366 × sinus dominancy (maxillary) + 0.064 × sinus dominancy (similar) + 0.200 × EoB (4%) + 0.344 × EoB (> 210)] was developed.

CONCLUSION

Tissue eosinophil count and radiographic severity predispose to a poorer outcome of ESS and the risk model established may be helpful to predict postoperative outcomes of ESS.

OnabotulinumtoxinA injection towards the SPG for treating symptoms of refractory chronic rhinosinusitis with nasal polyposis: a pilot study

BACKGROUND AND OBJECTIVE

The main objective of this prospective, open, uncontrolled pilot study was to investigate the safety of administering onabotulinumtoxinA (BTA) towards the sphenopalatine ganglion (SPG) in 10 patients with refractory chronic rhinosinusitis with nasal polyposis (CRSwNP) using a novel injection tool, the MultiGuide^®.

MATERIAL AND METHODS

A one-month baseline period was followed by bilateral injections of 25 U BTA in the SPG and a follow-up of 12 weeks. The primary outcome was adverse events (AE), and the main efficacy outcome was a 50% reduction in visual analogue scale (VAS) symptoms for nasal obstruction and rhinorrhea in months 2 and 3 post-treatment compared to baseline.

RESULTS

We registered 13 AEs, none of which were serious, however, one patient experienced diplopia which moderately affected his daily activities. The symptoms slowly improved and resolved 4 weeks after injection. Five patients were treatment responders with at least 50% median reduction in the nasal obstruction, and four were treatment responders concerning rhinorrhea.

CONCLUSIONS

Injection of BTA toward the SPG using the MultiGuide^® in patients with CRSwNP appears to be safe but with a potential for moderately disabling side effects. The study indicates a beneficial effect on nasal obstruction.

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.

Factors affecting upper airway control of NSAID-exacerbated respiratory disease: A real-world study of 167 patients

BACKGROUND

Nonsteroidal anti-inflammatory drug (NSAID) exacerbated respiratory disease (N-ERD) is a triad with asthma, chronic rhinosinusitis with nasal polyps, and NSAID intolerance. Uncontrolled N-ERD forms a major public health problem due to frequent and difficult-to-treat exacerbations and/or requiring putatively frequent endoscopic sinus surgeries (ESS). Our aim was to study factors affecting control of N-ERD.

METHODS

Retrospective patient record data (patient characteristics, prior sinus surgeries, follow-up data in 2020) from 167 N-ERD patients undergoing consultation at three tertiary hospitals from 2001 to 2017 was used. Outcome measurements reflecting uncontrolled N-ERD were revision ESS, corticosteroids/biological therapy, and antibiotic courses during 2016-2020. Associations were analyzed by using nonparametric tests, Cox's proportional hazard, and binary logistic regression models.

RESULTS

Nasal polyp eosinophilia increased the risk of revision surgery during the follow-up (adjusted hazard ratio [aHR] 3.21, confidence interval 1.23-8.38). Also baseline oral corticosteroids (OCS; HR, 1.73, 1.04-2.89) and baseline surgery without total ethmoidectomy increased the risk of revision ESS (HR, 2.17, 1.07-4.42) in unadjusted models. In addition, both baseline OCS (adjusted odds ratio [aOR] 2.78, 1.23-6.26) and a history of ≥4 previous ESS (aOR, 2.15, 0.98-4.70) were associated with the use of OCS/biological therapy during the follow-up, but not with high number of antibiotics.

CONCLUSIONS

Nasal polyp eosinophilia, baseline OCS, and a history of recurrent ESS predict uncontrolled N-ERD. These factors might be clinically useful in risk-estimation of uncontrolled disease and for organizing follow-ups. Prospective cohort studies with larger sample size are needed to further study the factors affecting the upper airway control of N-ERD.

Open, prospective, multicenter study on postoperative intranasal phototherapy in nasal polyposis

BACKGROUND

The therapeutic effect of ultraviolet (UV) light is generally attributed to its immunosuppressive and immunomodulatory effects. Since chronic inflammation is the major factor in the development of nasal polyposis, we have previously used mixed ultraviolet-visible light (mUV-VIS, Rhinolight®) phototherapy for the treatment of nasal polyps.

AIMS

In the present open, multicenter study, our aim was to delineate whether mUV-VIS applied postoperatively in vivo together with intranasal steroid treatment could reduce the recurrence of nasal polyps.

METHODS

After functional endoscopic sinus surgery, one group of patients received mUV-VIS light together with standard intranasal steroid (mometason furoate 2 × 200 μg) application for a 12-week treatment period, whereas the other patient group obtained only intranasal steroid for the same duration. We recorded nasal endoscopy images and obtained demographical and clinical data, total nasal score (TNS), and nasal obstruction symptom evaluation (NOSE). We performed acoustic rhinometry and measured nasal inspiratory peak flow. Follow-up was 12 months.

RESULTS

We found that the recurrence of nasal polyps was significantly diminished, and based on video-endoscopic measurements, the size and grade of recurrent polyps were significantly smaller in the phototherapy-receiving group. Nasal obstruction values and NOSE were significantly better throughout the follow-up period in the mUV-VIS light-treated group than in the intranasal steroid monotreatment group.

CONCLUSIONS

Rhinophototherapy together with standard nasal steroid application may have a supportive role in the treatment of recurrent bilateral nasal polyps.

[Neutrophil extracellular traps in the pathogenesis of chronic rhinosinusitis]

The review presents the current understanding of the pathogenesis of chronic rhinosinusitis. The causes of damage to the mucous membrane of the paranasal sinuses are most often the result of a combination of immunological, infectious and anatomical factors. This indicates the need for a multidisciplinary approach to the study of the pathogenesis of this pathology. There is no single universally recognized classification of chronic rhinosinusitis, which takes into account histological and immunological changes in the mucous membrane of the paranasal sinuses. The discovery of the mechanism of completion of the life cycle of neutrophils - the formation of a neutrophil extracellular trap or NETosis, different from necrosis and apoptosis, opened up new prospects in the study of the pathogenesis of inflammatory processes, including rhinosinusitis. Neutrophil extracellular traps reduce the permeability of the epithelial barrier in the mucous membrane of the paranasal sinuses. This determines their possible role in the etiopathogenesis of rhinosinusitis. In recent years, more and more attention has been paid to the feasibility, effectiveness and safety of therapy that affects the immune component of the inflammatory process, including NETosis. The data obtained in the study of extracellular traps can be used in clinical practice. It is neutrophil extracellular traps that can become a potential target in the treatment of patients with chronic rhinosinusitis.

Clinical and Biological Markers Predict the Efficacy of Glucocorticoid- and Macrolide-Based Postoperative Therapy in Patients With Chronic Rhinosinusitis

BACKGROUND

Although subsequent anti-inflammatory treatments are indispensable for patients with chronic rhinosinusitis (CRS) undergoing sinus surgery, few studies have explored the factors influencing the efficacy of postoperative anti-inflammatory treatment.

OBJECTIVE

We aimed to develop prediction models for the response to glucocorticoid- and macrolide-based postoperative therapy in CRS patients.

METHODS

We performed a post-hoc analysis of our previous study comparing the efficacy of fluticasone propionate and clarithromycin in the postoperative treatment of CRS patients. Clinical characteristics and treatment outcome information were collected. In addition, diseased sinonasal mucosal tissues obtained during surgery were processed for Bio-Plex analysis of protein levels of 34 biomarkers. Classification trees were built to predict refractory CRS based on clinical characteristics and biological markers for patients treated with fluticasone propionate or clarithromycin. A random forest algorithm was used to confirm the discriminating factors that formed the classification trees.

RESULTS

One year after surgery, 22.7% of the patients (17/75) treated with fluticasone propionate, and 24.3% of those (18/74) treated with clarithromycin were diagnosed with refractory CRS. Nasal tissue IL-8 and IgG3 levels and headache VAS scores in the fluticasone propionate group, and nasal tissue IgG4 levels and overall burden of symptoms VAS scores in the clarithromycin group, were identified as discriminating factors forming the classification tree to predict refractory CRS. The overall predictive accuracy of the model was 89.3% and 87.8% for fluticasone propionate- and clarithromycin-based postsurgical treatment, respectively.

CONCLUSIONS

Classification trees built using clinical and biological parameters could be helpful in identifying patients with poor response to fluticasone propionate- and clarithromycin-based postoperative treatment.

The Role of Epigenetics in the Chronic Sinusitis with Nasal Polyp

PURPOSE OF REVIEW

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a common and heterogeneous inflammatory disease. The underlying epigenetic mechanisms and treatment of CRSwNP are partially understood. Of the different epigenetic changes in CRSwNP, histone deacetylases (HDACs), methylation of DNA, and the levels of miRNA are widely studied. Here, we review the human studies of epigenetic mechanisms in CRSwNP.

RECENT FINDINGS

The promoters of COL18A1, PTGES, PLAT, and TSLP genes are hypermethylated in CRSwNP compared with those of controls, while the promoters of PGDS, ALOX5AP, LTB4R, IL-8, and FZD5 genes are hypomethylated in CRSwNP. Promoter hypermethylation suppresses the gene expression, while promoter hypomethylation increases the gene expression. Studies have shown the elevation in the levels of HDAC2, HDAC4, and H3K4me3 in CRSwNP. In CRSwNP patients, there is also an upregulation of certain miRNAs including miR-125b, miR-155, miR-19a, miR-142-3p, and miR-21 and downregulation of miR-4492. Epigenetics takes part in the immunology of CRSwNP and may give rise to endotypes of CRSwNP. Both HDAC2 and the miRNA including miR-18a, miR-124a, and miR-142-3p may take function in the regulation of glucocorticoid resistance. HDAC inhibitors and KDM2B have shown effectiveness in decreasing nasal polyp, and DNA methyltransferase (DNMT) or HDAC inhibitors may have a potential efficacy for the treatment of CRSwNP. Recent advances in the epigenetics of CRSwNP have led to the identification of several potential therapeutic targets for this disease. The use of epigenetics may provide novel and effective biomarkers and therapies for the treatment of nasal polyp.

The Effect of Dupilumab on Intractable Chronic Rhinosinusitis with Nasal Polyps in Japan

Objectives/Hypothesis

Dupilumab, which blocks the shared receptor component for interleukin‐4 and interleukin‐13, reduced polyp size, sinus opacification, and symptom severity, and was well tolerated in patients with chronic rhinosinusitis with nasal polyps (CRSwNP) in the SINUS‐52 study (NCT02898454). We assessed dupilumab in patients enrolled at Japanese centers.

Methods

Patients on a background of mometasone furoate nasal spray, received dupilumab 300 mg every 2 weeks (q2w) for 52 weeks (Arm A); dupilumab 300 mg q2w for 24 weeks, followed by every 4 weeks (q4w) for 28 weeks (Arm B); or placebo (Arm C). Co‐primary endpoints were week 24 nasal polyp score (NPS), nasal congestion (NC) score, and sinus Lund–Mackay CT (LMK‐CT) scores. Symptoms, sense of smell, health‐related quality of life, and safety were assessed during the 52‐week treatment period.

Results

Of 49 patients enrolled in Japan, 45 completed the study. Week 24 least squares (LS) mean improvement versus placebo were as follows: NPS (Arm A: −3.1, P < .0001; Arm B: −2.1, P = .0011); NC score (Arm A: −1.2, P < .0001; Arm B: −0.9, P < .0001); and LMK‐CT (Arm A: −5.1, P = .0005; Arm B: −2.8, P = .0425). The most common treatment‐emergent adverse event in dupilumab and placebo‐treated patients was nasopharyngitis.

Conclusion

Dupilumab provided rapid, significant, and clinically meaningful improvements for patients with CRSwNP in Japan. Dupilumab was well tolerated, and safety and efficacy were consistent with the overall study population.

Level of Evidence

2 Laryngoscope, 131:E1770–E1777, 2021

Clinical predictors of revision surgery for chronic rhinosinusitis with nasal polyposis within 5-year follow-up

BACKGROUND

Chronic rhinosinusitis with nasal polyposis (CRSwNP) remains a difficult-to-cure disease. The aim of this study was to determine the potential long-term predictors of revision sinus surgery for CRSwNP.

METHODS

Prospectively gathered patients with bilateral CRSwNP who received primary endoscopic sinus surgery were enrolled. Clinical variables, including the preoperative Lund-Mackay score (LMS), were collected to clarify possible risk factors for revision surgery within a 5-year follow-up. The symptomatic burden was measured using a 10-cm visual analog scale (VAS) before and 1 year after surgery. Further survival analysis was performed to present the revision-free survival in Kaplan-Meier plotting.

RESULTS

Eighty four qualified patients were identified and all of them experienced significant improvement in VAS after primary surgery. The 5-year revision rate was 19.05%, and the mean time of revision surgery was 25.31 ± 17.11 months postoperatively. Nasal allergy (OR = 9.287; p = 0.011) and LMS (OR = 1.29; p = 0.06) were found to be the independent risk factors for revision surgery. The discriminatory power of LMS for revision surgery was acceptable (AUC = 0.79) with the best cutoff point located at LMS > 13.5. Patients with both nasal allergy and LMS≧14 had only half of revision-free survival in comparison to overall survival (38.1% vs. 80.95%, p < 0.001).

CONCLUSIONS

In patients with CRSwNP who have concurrent nasal allergy and higher preoperative LMS may indicate an advanced disease status and eventually be in a high risk of revision surgery after a long-term follow-up. An outcome-based staging system will be helpful in the future to improve the prognosis for CRSwNP.

[Analysis of intestinal flora in patients with chronic rhinosinusitis based on highthroughput sequencing]

OBJECTIVE

To investigate the changes in diversity, relative abundance and distribution of intestinal flora in patients with chronic rhinosinusitis and nasal polyps (CRSwNP) using high-throughput sequencing technology identify the intestinal flora significantly related to pathogenesis and progression of CRSwNP.

METHODS

Ten patients with CRSwNP hospitalized in the Department of Otolaryngology-Head and Neck Surgery of Guangdong Provincial People's Hospital were selected as the case group with 10 healthy volunteers recruited in the same period as the control group. Fecal genomic DNA extraction kit was used to extract the DNA in the fecal samples, and the DNA fragment length was measured and quantified. The V3 and V4 highly variable regions of the 16S rDNA gene of prokaryotes were amplified followed by library construction, Illumina MiSeq sequencing, sequence alignment and species identification analysis. The relative abundance, diversity and distribution characteristics of the intestinal flora were analyzed, and the relevant metabolic pathways were predicted.

RESULTS

Compared with the control group, the patients with CRSwNP had significant changes in the overall structure of the intestinal flora, highlighted by increased abundance of Saccharopolyspora and decreased contents of Ruminococcae, Coprococcus, Collinsella and Dialister. Among the metabolic pathways predicted to be associated with CRSwNP, 9 showed significant changes in patients with CRSwNP as compared with the control group (P < 0.05).

CONCLUSIONS

Patients with CRSwNP have significant changes in the structural characteristics of intestinal flora related with multiple metabolic pathways, and these changes may play an important role in the development of chronic rhinosinusitis.

Effect of Endoscope Sinus Surgery on Pulmonary Function in Cystic Fibrosis Patients: A Meta-Analysis

OBJECTIVE

The objective of this study was to quantify the effect of endoscopic sinus surgery on pulmonary function in patients with cystic fibrosis and chronic rhinosinusitis.

METHODS

The PubMed, MEDLINE, Cochrane Library, and Embase databases were searched for studies published in English, without any language and time restrictions from their inception to March 1, 2020. Studies examining pulmonary function outcomes in patients with cystic fibrosis and chronic rhinosinusitis following endoscopic sinus surgery were included. Primary outcomes were pulmonary function tests, including forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), FEV1/FVC, peak expiratory flow (PEF), and forced expiratory flow between 25% and 75% of vital capacity (FEF_25-75 ).

RESULTS

A total of 12 studies with 570 patients were included for data extraction and meta-analysis. For FEV₁ (%), the summarized mean difference (MD) was -6.92 (95% confidence interval [CI] = -19.67 to 5.83, P = .29) and 0.70 (95% CI = -3.81 to 5.21, P = .76) for the postoperative results after 6 months and 12 months, respectively. The pooled MDs for FVC (%) and FEV1/FVC ratio (%) for the postoperative results after 6 months were 0.60 (95% CI = -4.12 to 5.31, P = .80) and -1.29 (95% CI = -6.14 to 3.55, P = .60).

CONCLUSION

Endoscopic sinus surgery in chronic rhinosinusitis patients with cystic fibrosis did not improve the pulmonary function in chronic rhinosinusitis patients with cystic fibrosis. More prospective studies and meta-analyses addressing the same topic are needed in the future. Laryngoscope, 131:720-725, 2021.

The Effect of Vidian Neurectomy on Pulmonary Function in Patients with Allergic Rhinitis and Chronic Rhinosinusitis with Nasal Polyps

BACKGROUND

At present, the effect of operation intervention on pulmonary function is not clear in patients with allergic rhinitis and chronic rhinosinusitis with nasal polyps (AR&CRSwNP). This study was conducted to investigate the effect of vidian neurectomy on pulmonary function and airway hyperresponsiveness (AHR) in patients with AR&CRSwNP.

METHODS

The incidences of AHR, bronchial asthma (BA) and pulmonary function impairment in 112 patients with AR&CRSwNP were investigated. Subsequently, we evaluated the outcome of vidian neurectomy and its effect on pulmonary function and AHR. Furthermore, we explored the correlation between postoperative level of eosinophilic cationic protein (ECP) and the changes of pulmonary function indices or dose of methacholine.

RESULTS

In this study, the incidences of pulmonary function impairment, bronchial asthma, and AHR in patients with AR&CRSwNP were 61.61%, 69.64%, and 66.96%, respectively. Particularly, vidian neurectomy effectively alleviated nasal symptoms, improved pulmonary function, and reduced AHR in AR&CRSwNP patients. Furthermore, the postoperative level of ECP, IgE, Interleukin-4 and Interleukin-IL-5 was dramatically decreased, and there was an obvious inverse correlation between ECP level and pulmonary function index or dose of methacholine.

CONCLUSIONS

Vidian neurectomy is effective in alleviating nasal symptoms, improving pulmonary function, and reducing the risk of AHR of patients with AR&CRSwNP by decreasing the level of ECP.

Chinese Society of Allergy and Chinese Society of Otorhinolaryngology-Head and Neck Surgery Guideline for Chronic Rhinosinusitis

The current document is based on a consensus reached by a panel of experts from the Chinese Society of Allergy and the Chinese Society of Otorhinolaryngology-Head and Neck Surgery, Rhinology Group. Chronic rhinosinusitis (CRS) affects approximately 8% of Chinese adults. The inflammatory and remodeling mechanisms of CRS in the Chinese population differ from those observed in the populations of European descent. Recently, precision medicine has been used to treat inflammation by targeting key biomarkers that are involved in the process. However, there are no CRS guidelines or a consensus available from China that can be shared with the international academia. The guidelines presented in this paper cover the epidemiology, economic burden, genetics and epigenetics, mechanisms, phenotypes and endotypes, diagnosis and differential diagnosis, management, and the current status of CRS in China. These guidelines-with a focus on China-will improve the abilities of clinical and medical staff during the treatment of CRS. Additionally, they will help international agencies in improving the verification of CRS endotypes, mapping of eosinophilic shifts, the identification of suitable biomarkers for endotyping, and predicting responses to therapies. In conclusion, these guidelines will help select therapies, such as pharmacotherapy, surgical approaches and innovative biotherapeutics, which are tailored to each of the individual CRS endotypes.

Efficacy and safety of delivery of topical medication on to the frontal sinus at different head positions after frontal sinusotomy

PURPOSE

Effective topical medications delivery to the frontal sinus is crucial to recovery from frontal sinusotomy. However, finding a way to deliver local medications to the frontal sinus is still a major challenge. The objective of this study was to evaluate the influence of various head positions on postoperative frontal sinus drug deposition. The safety and efficacy were also evaluated in postoperative chronic rhinosinusitis (CRS) patients.

METHODS

Full house surgery was performed on six fresh frozen cadaver heads. The fluorescein solution was dropped into the nasal sinuses in three different head positions, and the fluorescein deposition was evaluated. A prospective cohort study was performed to validate the results in 20 postoperative CRS patients. The cortisol level, symptom VAS and the frontal recess endoscopy scores were evaluated pre- and postoperatively.

RESULTS

The frontal recess delivery of fluorescein was better in the Mygind and vertex-to-floor positions than in the head back position. The cortisol level of patients dropped markedly after taking oral methylprednisolone, but returned to baseline when replaced with budesonide drops. The pre- and postoperative symptom VAS scores did not differ significantly between the two groups. Endoscopic scores of the vertex-to-floor group were significantly better than those of the Mygind group.

CONCLUSION

Both the Mygind and the vertex-to-floor head positions were optimal for delivery of topical medications to the frontal recess. When applying the steroid drops, both positions were found to be safe and associated with effective relief of symptoms. The vertex-to-floor position can better improve the endoscopic scores of frontal recess and frontal sinus.

Dupilumab in the treatment of chronic rhinosinusitis with nasal polyposis

Chronic rhinosinusitis with nasal polyposis (CRSwNP) imparts a significant healthcare challenge, resulting in diminished quality of life for patients and high costs with resource utilization for disease management. Understanding of CRSwNP pathophysiology has progressively evolved and the identification of various inflammatory biomarkers has led to the development of monoclonal antibodies that target the underlying mechanisms of inflammation. Dupilumab, which targets IL-4 and IL-13 signaling, serves as a novel agent for CRSwNP treatment. Three clinical trials, NCT01920893, SINUS-24 and SINUS-52, have shown that dupilumab improves both subjective patient-reported outcomes and objective physician-evaluated metrics for CRSwNP. The favorable findings have resulted in approval by the US FDA in June 2019 as the first biologic therapy for CRSwNP.

Assessing Cut-off Points of Eosinophils, Nasal Polyp, and Lund-Mackay Scores to Predict Surgery in Nasal Polyposis: A Real-World Study

Background

Developing tools to identify chronic rhinosinusitis with nasal polyps (CRSwNP) patients requiring surgical treatment would help clinicians treat patients more effectively. The aim of this retrospective cross-sectional study was to identify cut-off values ​​for eosinophil percentage, nasal polyps (NP), and Lund-Mackay (LM) scores that may predict the need for surgical treatment in Finnish CRSwNP patients.

Methods

Data of CRSwNP patients (N = 378) undergoing consultation for ESS in 2001–19 were used. Data was collected from patient records and Lund-Mackay scores were determined from sinus computed tomography scans. The percentage of eosinophils was microscopically evaluated from the polyp samples available (n = 81). Associations were analyzed by Mann Whitney U test, and cut-off values by the area under the receiver operating characteristic curve (AUROC).

Results

ESS was performed to 293 (77.5%) of patients. Polyp eosinophilia was associated significantly with ESS (p = 0.001), whereas peripheral blood eosinophil count, LM- score and endoscopic NP- score were not (p > 0.05). AUROC values (95% CI) for detecting those needing ESS were for polyp eosinophilia 0.71 (0.60–0.83), p = 0.001, for LM score 0.59 (0.50–0.67), p = 0.054; for NP score 0.56 (0.48–0.64), p = 0.17, and for blood eosinophil count 0.68 (0.46–0.90), p = 0.08. With the threshold value of polyp eosinophilia (>25%), the sensitivity and specificity were optimal for detecting the group needing ESS from the group not undergoing ESS. The cut-off value of blood eosinophil count (>0.26 × 10⁹/L) had relatively good, yet statistically insignificant (underpowered), predictive potential. Moderate cut-off values were found for endoscopic LM score (≥14/24) and NP score (≥4/8).

Conclusions

Polyp eosinophilia (>25%) predicted ESS among Finnish hospital-level CRSwNP patients. A future challenge would be to find less invasive and cost-effective clinical factors predicting uncontrolled CRSwNP.

Systemic Immune Profile in Patients With CRSwNP

The immune pathogenesis of chronic rhinosinusitis with nasal polyps (CRSwNP) remains obscure. Our aim was to compare humoral immunity and white blood cell counts in patients with CRSwNP and controls. A prospective case-control study was carried out in 37 patients with CRSwNP and 34 controls without CRS. Clinical data were gathered through a systematic interview. Computed tomography scan, skin prick test, spirometry, and immunological parameters (leukocyte differential count, immunoglobulin classes, and immunoglobulin [Ig] G subclasses) in serum specimens were obtained. Statistical analysis was performed using SPSS v.23. The prevalence of chronic lower respiratory diseases was greater in the CRSwNP group (P < .001), but atopic disease had no significant difference. A significantly higher eosinophil (P < .001) and basophil relative count (P = .022) and a lower relative neutrophil count (P = .013) were found among CRSwNP group. Patients with CRSwNP had higher IgG1 (P = .022), but lower IgG2 (P = .014) and IgG3 (P = .018) serum levels compared to controls; IgG4, total IgG, IgA, IgM, and IgE serum levels did not differ between groups, as well as the prevalence of immunoglobulin classes or IgG subclasses deficiency. The variation observed in peripheral relative leukocyte count and the systemic IgG1 subclass shift are similar to what is known to happen in nasal polyp tissue. A unique systemic immune profile seems to be present in patients with CRSwNP.

Advanced age adversely affects chronic rhinosinusitis surgical outcomes

BACKGROUND

Patient-specific and disease-specific factors shape the course of chronic rhinosinusitis (CRS) and its response to treatment, with optimal management involving interventions tailored to these factors. Recent evidence suggests CRS inflammatory signatures depend on age. The objective of this study was to determine whether age also influences quality-of-life (QOL) and postoperative outcomes.

METHODS

Retrospective analysis of prospectively collected QOL data from 403 adults with medically refractory CRS who underwent functional endoscopic sinus surgery (FESS) at a tertiary care medical center between 2014 and 2018 was undertaken. Total and subdomain scores from the 22-item Sino-Nasal Outcome Test (SNOT-22) and the Short Form 8 Health Survey (SF-8) measure of general health completed at preoperative and postoperative visits were reviewed.

RESULTS

Patients were divided into young (18 to 39 years, n = 100), middle-aged (40 to 59 years, n = 172), and elderly (≥60 years, n = 131) groups. Baseline total SNOT-22 scores differed between groups (p = 0.01), with middle-aged patients having the highest symptom burden and elderly patients having the lowest. Similar patterns were observed for SNOT-22 subdomains. Elderly patients reported smaller improvements and were less likely to achieve a minimally important clinical difference. CRS patients had worse SF-8 scores compared to the general population, and elderly patients were the least likely to match population norms following surgery. Age was an independent predictor of QOL outcomes after FESS.

CONCLUSION

Age may play a significant role in CRS pathophysiology, symptom burden, and surgical outcomes. Elderly patients report smaller improvements in disease-specific and general health QOL after surgery. CRS management in the elderly population should incorporate age-dependent differences in symptom burden and expectations into treatment algorithms.

Food-Specific IgE and IgG Antibodies in Patients With Chronic Rhinosinusitis With Nasal Polyps: A Case-Control Study

EPOS 2012 states that investigation is needed to study a possible role for food allergy in the initiation and perpetuation of chronic rhinosinusitis with nasal polyps (CRSwNP). Our main goal was to compare serum levels of food-specific immunoglobulin G (IgG) and IgE antibodies in patients with CRSwNP and controls. A prospective case-control study with 33 patients with CRSwNP and 31 controls without CRS was carried out. Clinical data were gathered through a systematic interview and blood sample was collected. Enzyme-linked immunosorbent assay tests using OmegaDiagnostics kit with 40 food allergens for detection of specific IgG antibodies were performed and food-specific IgE antibodies were determined by immunoassay using ImmunoCAP. Immunoglobulin classes and IgG subclasses levels were also evaluated. Statistical analysis was performed using SPSS v.23. The overall sum of food IgG antibodies was significantly lower in CRSwNP compared to control group, and this difference was also observed for different specific IgG antibodies (corn, soya, grain legumes, pear and apple, berries, citric fruit). In controls, a positive correlation between IgG1 and the sum of food IgG antibodies was seen, but in CRSwNP group a negative correlation was found. In addition, a significant higher level of IgG1 and lower IgG2 and IgG3 was found among patients with CRSwNP. Levels of serum-specific IgE antibodies against multiallergen food mix (fx5) and against shrimp, strawberry, orange, rye, or egg yolk, as well as the sum of food IgE antibodies, did not differ significantly between the groups. These findings suggest that food allergy does not have an important role in CRSwNP etiopathogenesis, whether it is IgG or IgE mediated. Moreover, the observed suppression of specific IgG antibodies against food allergens, its negative correlation with IgG1 and the IgG1 switching in CRSwNP, can be related to deviated IgG responses against other targets (eg, airborne particles) and warrants future investigation.

Escalation in mucus cystatin 2, pappalysin-A, and periostin levels over time predict need for recurrent surgery in chronic rhinosinusitis with nasal polyps

BACKGROUND

Chronic rhinosinusitis with nasal polyps (CRSwNP) is treated using oral/topical steroids and surgery. Despite maximal medical therapy, some patients remain recalcitrant. Mucus cystatin 2, pappalysin-A, and periostin can predict the presence of CRSwNP and correlate with disease severity. This study was designed to determine whether prospective sampling of these mucus proteins could predict medical failure and the need for revision surgery.

METHODS

This investigation was an institutional review board-approved, prospective study of 66 patients with CRSwNP. All patients underwent surgery, administration of topical/oral steroids, and outpatient mucus sampling at 10 time-points over 2 years. Five proteins, including cystatin 2 (CST2), pappalysin-A (PAPP-A), and periostin (PST), were analyzed and correlated with subjective parameters (including scores on the 22-item Sino-Nasal Outcomes Test [SNOT-22]). Variables were then analyzed and compared between those requiring revision surgery within 2 years (n = 5) and those with stable disease (n = 61).

RESULTS

All patients demonstrated a significant decline in CST2, PAPP-A, and periostin after their initial surgery. The recalcitrant group demonstrated escalations in all proteins despite steroids, with levels higher than those of the stable group at 1 year (CST2: 258.1 ± 205.2 pg/mL vs 235.3 ± 275.7 pg/mL, p = 0.86; PAPP-A: 170.3 ± 150.4 pg/mL vs 74.6 ± 106.7 pg/mL, p < 0.05; periostin: 188.8 ± 192.4 ng/mL vs 54.5 ± 47.6 ng/mL, p < 0.001). Escalation in all proteins correlated significantly with worsening SNOT-22 score at each time-point (domain 1: 8.2 ± 1.3 vs 5.5 ± 1.1; p < 0.05).

CONCLUSION

Early recurrences and medical recalcitrance in CRSwNP may be predicted noninvasively through the serial, prospective sampling of mucus CST2, PAPP-A, and periostin levels. These biosignatures may help to predict disease course and guide individualized therapy.

Asthma Is the Dominant Factor for Recurrence in Chronic Rhinosinusitis

BACKGROUND

Factors associated with recurrence of chronic rhinosinusitis (CRS) are still poorly recognized.

OBJECTIVE

To evaluate which risk factors could influence the risk of recurrence among patients undergoing endoscopic sinus surgery in long-term follow-up.

METHODS

Patients with CRS who underwent endoscopic sinus surgery were followed for an average period of 12 years in a nonconcurrent cohort. After surgery, patients were considered to an additional endoscopic sinus surgery if appropriate medical therapy failed during this period. The presence of nasal polyps, asthma, nonsteroidal anti-inflammatory drug-exacerbated respiratory disease, smoking habits, peripheral blood eosinophilia, and atopy were assessed. The recurrence-free interval between groups (with or without these risk factors) was analyzed by Kaplan-Meyer curves, and the indication for a revisional surgery was considered to be the unfavorable event.

RESULTS

A total of 201 patients were enrolled in this study. Patients with chronic rhinosinusitis with nasal polyps (CRSwNP) were more likely than patients with chronic rhinosinusitis without nasal polyps (CRSsNP) to need revisional surgery (adjusted hazard ratio, 2.02). Asthma was the only factor that was significantly related to recurrence both in patients with CRSsNP (hazard ratio, 5.54) and in patients with CRSwNP (hazard ratio, 3.27). Although eosinophilia itself was not related to a higher chance of recurrence, its presence influenced the outcome of CRSwNP compared with CRSsNP and the impact of asthma among patients with CRSwNP.

CONCLUSIONS

Prognosis in patients with CRSwNP was inferior to that in patients with CRSsNP. Asthma was the only factor that increased the chance of recurrence in patients with either CRSsNP or CRSwNP.