European Position Paper on Rhinosinusitis and Nasal Polyps 2020

Allergic Fungal Rhinosinusitis: A Contemporary Update

OBJECTIVES

To provide a contemporary update on the pathophysiology, diagnosis, and treatment of allergic fungal rhinosinusitis (AFRS).

METHODS

A review article on the pathophysiology, diagnosis, and treatment of AFRS was performed.

RESULTS

AFRS is a subtype of chronic rhinosinusitis with nasal polyps characterized by noninvasive fungal hyphae, eosinophilic mucin, and a type 2 inflammatory response, resulting in significant clinical and radiographic presentations. Although a diagnostic criterion has been used since the 1990s, advances in the pathophysiology and treatment of AFRS question the specificity and applicability of such criteria. Furthermore, the development and progression of AFRS are closely associated with the social determinants of health (SDOH) with a possible genetic component that limits sinonasal antifungal activity. Surgery followed by topical corticosteroids and nasal saline irrigations remains the mainstay of treatment with immunotherapy, antifungals, and biologics having a potential role.

CONCLUSIONS

AFRS is a complex sinonasal inflammatory disease influenced by socioeconomic, genetic, and environmental factors. Future research is needed to investigate the influence of the SDOH on AFRS, advance diagnostic methods to optimize utility in everyday clinical practice and research, and elucidate the role of potential novel medical therapies in the current treatment pathway.

Clinical effectiveness of dupilumab in CRSwNP: unaffected by baseline nasal polyp size in real-world settings

PURPOSE

This study aimed to investigate the impact of baseline nasal polyp score (NPS) on the effectiveness of dupilumab treatment in patients with chronic rhinosinusitis with nasal polyps (CRSwNP).

METHODS

In this retrospective observational study, 80 CRSwNP patients treated with dupilumab 300 mg biweekly at a tertiary referral center were stratified according to the baseline NPS into two groups: low-NPS (< 5) and high-NPS (≥ 5). Treatment outcomes were evaluated at the 6-month follow-up visit and compared.

RESULTS

Both groups showed significant clinical improvements. The NPS decreased significantly in both low- and high-NPS groups, from a mean score of 3.2 to 0.8 and from 6.1 to 1.4, respectively (p < 0.001 for both). SNOT-22 scores improved significantly in both groups (p < 0.001 for both), though the reduction was greater in the high-NPS group (35.5 vs. 23.9, p = 0.018). There were no significant differences between low- and high NPS groups in proportions of NPS reduction of ≥ 1 (89% vs. 95%, p = 0.396) and clinically significant SNOT-22 improvement (= reduction > 12 or follow-up SNOT < 40; 80% vs. 86%, p = 0.544).

CONCLUSIONS

Our results suggests that dupilumab is effective in CRSwNP treatment, regardless of baseline nasal polyp size. Both small and large polyp groups showed significant improvements in NPS and patient-reported outcome measures. Future, prospective studies are warranted to validate these findings.

Inflammatory and clinical risk factors for asthma attacks (ORACLE2): a patient-level meta-analysis of control groups of 22 randomised trials

BACKGROUND

Clinical risk factors for severe asthma attacks have been identified, but their incremental prognostic values are unclear. Additionally, the incremental contribution of type 2 inflammation, a common, treatable process, is undetermined. We aimed to quantify the prognostic value of baseline characteristics and type 2 inflammatory biomarkers, specifically blood eosinophil count and fractional exhaled nitric oxide (FeNO), to predict asthma attacks.

METHODS

In this systematic review and meta-analysis of randomised controlled trials (RCTs), Oxford Asthma Attack Risk Scale 2 (ORACLE2), we searched MEDLINE from Jan 1, 1993, to April 1, 2021, for trials investigating fixed treatment regimen effects on asthma attack rates for at least 6 months with baseline blood eosinophil count and FeNO. Eligible participants were aged 12 years or older with asthma (any severity) who had been randomly assigned to the control group of an RCT. Relevant trials were manually retrieved and reviewed by two independent reviewers (SC and IDP). Disagreements were discussed with five reviewers. Individual patient data (IPD) for meta-analysis were requested from study authors. We investigated the rate of severe asthma attacks (≥3 days of systemic corticosteroids) for at least 6 months and prognostic effects of baseline blood eosinophil count and FeNO in control group participants. Rate ratios (RRs) with 95% CIs were derived for annualised asthma attack rates from negative binomial models adjusted for key variables, including blood eosinophil count and FeNO, and interactions between these type 2 inflammatory biomarkers were explored. Certainty of evidence was assessed using GRADE. The heterogeneity of the included studies and potential for ecological bias were quantified by the concordance statistic (C-statistic). This study was registered with PROSPERO, CRD42021245337.

FINDINGS

We identified 976 potentially eligible studies. After automated screening, we manually reviewed 219 full-text articles. Of these, 19 publications comprising 23 RCTs were eligible. 6513 participants (4140 [64%] female; 2370 [36%] male; three missing) spanning 22 RCTs were included for data analysis. 5972 (92%) of 6513 patients had moderate-to-severe asthma. 4615 asthma attacks occurred during 5482 person-years of follow-up (annualised rate 0·84 per person-year). Higher blood eosinophil count or FeNO was linked to higher asthma attack risk (per 10-fold increase, RR 1·48 [95% CI 1·30-1·68] for blood eosinophil count and 1·44 [1·26-1·65] for FeNO; high-certainty evidence). Other prognostic factors were attack history (yes vs no, RR 1·94 [1·61-2·32]); disease severity (severe vs moderate, RR 1·57 [1·22-2·03]); FEV1 percentage predicted (FEV1%; per 10% decrease, RR 1·11 [1·08-1·15]); and 5-item Asthma Control Questionnaire score (ACQ-5; per 0·5 increase, RR 1·10 [1·07-1·13]). High blood eosinophil count and FeNO combined were associated with greater risk than either prognostic factor separately. Bronchodilator reversibility was associated with lower risk of severe asthma attacks (per 10% increase, RR 0·93 [0·90-0·96]), with the reduction observed primarily between 0% and 25%. Regarding heterogeneity of the included studies, the C-statistic ranged from 0·58 to 0·95, indicating major differences in patient and disease characteristics between studies. In the univariable meta-analysis per trial, we found substantial heterogeneity in associations between studies, with I2 statistics ranging from 0·56 to 0·97.

INTERPRETATION

Blood eosinophil count, FeNO, asthma attack history, disease severity, low lung function (low FEV1%), and symptoms (ACQ-5 score) are key predictors of asthma attacks. Conversely, we found that moderate bronchodilator reversibility was associated with reduced risk. These findings from high-quality multinational RCTs support incorporation of blood eosinophils and FeNO into clinical risk stratification for targeted risk reduction. More individualised clinical decision-making models should be explored.

FUNDING

National Institute of Health and Care Research Oxford Biomedical Research Centre; Association pulmonaire du Québec; Fonds de recherche du Québec-Santé; Québec Air-Intersectorialité-Respiratoire-Son network; Stichting Astma Bestrijding; Leiden University Fund; and Academy of Medical Sciences.

A comparative approach to bony changes in maxillary and frontal sinuses as indicators of upper respiratory health

OBJECTIVE

The central aspect of this study is to provide a detailed comparison of bony changes in the maxillary and frontal sinuses in human skeletal remains in an effort to assist researchers record lesions and assist with potential diagnoses.

MATERIALS

198 adult human remains from a medieval Avar population from Vienna, Austria.

METHODS

Analysis of bony changes using an endoscopic multifunctional camera with an ultra-small lens and adjustable LED lights.

RESULTS

Most common findings in both the maxillary and frontal sinuses are "pitting" and "white pitted bone". However, significant differences between the maxillary and frontal sinuses regarding the frequency and variation of bony lesions exist.

CONCLUSION

The maxillary sinuses exhibited significantly greater prevalence of bony changes compared to the frontal sinuses but frontal sinuses, which generally are less frequently affected by inflammatory, malignant, or benign lesions, may ultimately provide more informative insights in paleopathological studies concerning the health of the upper airways than the maxillary sinuses.

SIGNIFICANCE

Considering that most paleopathological studies on paranasal sinuses focus primarily on the maxillary sinuses, this study provides comparative data on the diversity of bony changes found in the frontal sinuses as a means to assist paleopathological recording and potentially eventual diagnosis.

LIMITATIONS

The lack of knowledge about the pathophysiological mechanisms underlying individual bony features complicates interpretation, particularly in paleopathological studies.

SUGGESTIONS FOR FURTHER RESEARCH

A further examination of all paranasal sinuses (including the sphenoid sinuses and ethmoidal cells) is recommended.

Quality of life in type 2 and non-type 2 endotypes in chronic rhinosinusitis with nasal polyps: A prospective trial

BACKGROUND

In current clinical practice, primary diffuse chronic rhinosinusitis with nasal polyps (CRSwNP) is classified into two endotypes: type 2 and non-type 2. Previous studies on sinonasal health-related quality of life (HRQoL) in CRS have primarily focused on differences between phenotypes. This study aimed to compare HRQoL between the two endotypes in patients with CRSwNP. The type 2 endotype had a higher median nasal polyp score (NPS) than non-types (4 and 2, respectively), but this difference did not reach significance. Loss of smell was associated with NPS, and facial pain/pressure was inversely correlated with age. Age was significantly associated with loss of smell, but only in non-type 2 CRSwNP.

METHODS

This was a prospective, monocentric study conducted between 2018 and 2023 on CRSwNP patients referred for surgery. Health-related quality of life was assessed using the German standardized SNOT-20 questionnaire. Type 2 was defined according to the updated EPOS/EUFOREA 2023 criteria.

RESULTS

A total of 122 patients with CRSwNP were included, 113 (92.6%) of whom were classified as type 2. Type 2 was associated with a significantly worse SNOT-20 German Adapted Version score. Two of the four cardinal symptoms of CRS-loss of smell and rhinorrhea-were significantly more severe and prevalent in the type 2 endotype, with loss of smell being very specific. The most prevalent symptom in both endotypes was nasal obstruction, with no difference between both endotypes. The type 2 endotype had a higher median nasal polyp score (NPS) than non-types (4 and 2, respectively), but this difference did not reach significance. Loss of smell was associated with NPS, and facial pain/pressure was inversely correlated with age. Age was significantly associated with loss of smell, but only in non-type 2 CRSwNP.

CONCLUSION

Type 2 CRSwNP has a more severe impact on HRQoL compared with non-type 2 CRSwNP. Hyposmia, rhinorrhea, and potentially NPS may offer endotypic and pathophysiological insights.

Intrapolyp Steroid Injection for Nasal Polyposis: A Systematic Review and Network Meta-Analysis

OBJECTIVE

To conduct a systematic review and network meta-analysis to evaluate the safety and efficacy of intrapolyp steroid injection compared with oral steroids, nasal steroid wash, nasal steroid spray, and a control group in patients with chronic rhinosinusitis with nasal polyps (CRSwNP).

DATA SOURCES

PubMed, Scopus, Web of Science, Embase, and CENTRAL.

REVIEW METHODS

Both randomized and non-randomized clinical trials were included. For risk of bias assessment, we used the RoB-2 and ROBINS-I tools. Our outcomes focused on safety and efficacy, including rates of visual disturbance and bleeding, as well as improvements in nasal polyps evaluated through three domains: endoscopic, radiologic, and patient-reported assessments. Safety data were pooled as events (%), while efficacy data were pooled as mean difference (MD) or standardized mean difference (SMD).

RESULTS

Eight clinical trials involving 579 patients were analyzed. The pooled analyses showed low event rates for visual disturbances (event rate = 0.64%, 95% CI [0.00%, 2.23%]) and bleeding (event rate = 0.61%, 95% CI [0.00%, 2.25%]). Additionally, intrapolyp steroid injections were found to be comparable with oral steroids, with no statistically significant differences. Moreover, intrapolyp steroid injections demonstrated some superiority over nasal sprays, nasal washes, and the control group.

CONCLUSION

This network meta-analysis confirms that intrapolyp steroid injections have a favorable safety and efficacy profile as a viable management option for CRSwNP. The injections showed comparable efficacy with oral steroids and demonstrated certain advantages over other treatments, such as nasal sprays and washes. Further research with larger sample sizes and standardized protocols are needed. Laryngoscope, 135:1872-1883, 2025.

siHIF-1α-loaded micellar nanoparticles inhibit M1 macrophage activation to ameliorate chronic rhinosinusitis

OBJECTIVE

To investigate the molecular mechanisms by which micellar nanoparticles loaded with small interfering RNA targeting hypoxia-inducible factor 1-alpha (MNP_siHIF-1α) modulate macrophage polarization and ferroptosis in chronic rhinosinusitis (CRS), offering a novel therapeutic approach to ameliorate chronic inflammation and immune dysregulation in CRS.

METHODS

Transcriptomic analysis of the GSE10406 dataset identified 3821 differentially expressed genes (DEGs) in CRS, with functional enrichment via Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG). Single-cell RNA sequencing (scRNA-seq) using the Seurat package characterized cellular heterogeneity in nasal mucosal tissues of CRS mice. In vitro, Raw264.7 macrophages were transfected with lentiviral sh-HIF-1α or oe-TFRC constructs, followed by RT-qPCR, chromatin immunoprecipitation (ChIP), dual-luciferase assays, and flow cytometry to assess HIF-1α-TFRC interactions, ROS accumulation, and M1 polarization. MNP_siHIF-1α, prepared using PCL-PEG/PPEEA diblock copolymers, was characterized via dynamic light scattering (DLS) and gel retardation assays. In vivo, CRS mice received intranasal MNP_siHIF-1α (10 mg/mL, 20 μL, thrice weekly for 4 weeks), with histopathological and inflammatory outcomes evaluated by H&E staining, immunohistochemistry, and ELISA.

RESULTS

HIF-1α was significantly upregulated in CRS tissues (p < 0.05) and activated TFRC transcription by binding its promoter, driving M1 macrophage polarization (↑NOS2, IL-6, IL-1β; p < 0.05) and ferroptosis (↑MDA, Fe2+; p < 0.05). Silencing HIF-1α reduced TFRC expression (↓42 %, p < 0.05), suppressed ROS levels (↓35 %, p < 0.05), and inhibited M1 polarization (↓50 % IL-6, p < 0.05). MNP_siHIF-1α (51.0 ± 2.3 nm, ζ-potential: +27.9 mV) achieved 95 % siRNA loading at N/P 5:1 and reduced nasal mucosal thickening (↓60 %, p < 0.01) and inflammatory cytokines (TNF-α: ↓45 %, p < 0.05) in CRS mice. Ferroptosis markers (GPX4: ↑2.1-fold, MDA: ↓55 %) confirmed therapeutic efficacy.

CONCLUSION

MNP_siHIF-1α suppresses the HIF-1α/TFRC-ROS axis, mitigates M1 macrophage-driven inflammation, and inhibits ferroptosis, significantly alleviating CRS progression. This study underscores the potential of nanotechnology-based siRNA delivery as a precision therapy for CRS, though further validation of long-term safety and clinical translation is warranted.

Effects of Different Types of Medications on Olfactory Dysfunction in CRSwNP: A Systematic Review and Network Meta-Analysis

OBJECTIVE

To evaluate the efficacy of various pharmacological treatments for olfactory disorders in patients with chronic rhinosinusitis with nasal polyps (CRSwNP).

DATA SOURCES

PubMed, Embase, Cochrane Library, and Web of Science.

METHODS

We searched the related literature in PubMed, Embase, Cochrane Library, and Web of Science up to Aug 2024 to appraise the effects of pharmacotherapy on olfactory sensation. After that, two reviewers independently screened the retrieved articles, extracted the pertinent data, and assessed the risk of bias in the included studies. Then we used Stata 14.2 to perform a network meta-analysis.

RESULTS

Ninteen randomized controlled trials (RCTs) and 2354 participants were included. Compared with placebo, biologics demonstrated the most significant improvement in subjective olfactory dysfunction (OD) [standardized mean difference (SMD) = -0.75, 95% confidence intervals (CI) (-1.08, -0.41)]. In terms of objective olfactory function improvement, biologics also exhibited the greatest effect (SMD = 0.93, 95% CI [0.56, 1.31]). Among various biologics, dupilumab was the most effective in alleviating both subjective OD (SMD = -1.30, 95% CI [-1.51, -1.09]) and objective OD (mean difference [MD] = 11.13, 95% CI [9.91, 12.35]).

CONCLUSIONS

Our research results indicated that biologics might show better performance in terms of improving the olfactory sensation of patients with CRSwNP, particularly dupilumab. However, given the limitations of this study, future research should employ more standardized olfactory assessment methods and conduct more large-scale RCTs, ultimately guiding clinicians and patients in making informed and optimal treatment choices.

LEVEL OF EVIDENCE

NA.

Development of an Open-Source Algorithm for Automated Segmentation in Clinician-Led Paranasal Sinus Radiologic Research

OBJECTIVE

Artificial Intelligence (AI) research needs to be clinician led; however, expertise typically lies outside their skill set. Collaborations exist but are often commercially driven. Free and open-source computational algorithms and software expertise are required for meaningful clinically driven AI medical research. Deep learning algorithms automate segmenting regions of interest for analysis and clinical translation. Numerous studies have automatically segmented paranasal sinus computed tomography (CT) scans; however, openly accessible algorithms capturing the sinonasal cavity remain scarce. The purpose of this study was to validate and provide an open-source segmentation algorithm for paranasal sinus CTs for the otolaryngology research community.

METHODS

A cross-sectional comparative study was conducted with a deep learning algorithm, UNet++, modified for automatic segmentation of paranasal sinuses CTs and "ground-truth" manual segmentations. A dataset of 100 paranasal sinuses scans was manually segmented, with an 80/20 training/testing split. The algorithm is available at https://github.com/rheadkaul/SinusSegment. Primary outcomes included the Dice similarity coefficient (DSC) score, Intersection over Union (IoU), Hausdorff distance (HD), sensitivity, specificity, and visual similarity grading.

RESULTS

Twenty scans representing 7300 slices were assessed. The mean DSC was 0.87 and IoU 0.80, with HD 33.61 mm. The mean sensitivity was 83.98% and specificity 99.81%. The median visual similarity grading score was 3 (good). There were no statistically significant differences in outcomes with normal or diseased paranasal sinus CTs.

CONCLUSION

Automatic segmentation of CT paranasal sinuses yields good results when compared with manual segmentation. This study provides an open-source segmentation algorithm as a foundation and gateway for more complex AI-based analysis of large datasets.

LEVEL OF EVIDENCE: 3

IL-13 May Could Enhance the Proliferation and Affect the Differentiation of Nasal Epithelium Basal Cells Through the mTOR/p70S6K1 Pathway in Chronic Rhinosinusitis With Nasal Polyps

Background: One of the hallmarks of Chronic rhinosinusitis with nasal polyps (CRSwNP) is the overexpression of IL-13, which may influence the proliferation and differentiation of nasal epithelial basal cells. However, the pathway is not clear enough, and the mTOR/p70S6K1 pathway is related to cell growth. This study was trying to explore if IL-13 could impact nasal epithelial basal cells through the mTOR/p70S6K1 pathway. Methods: PCR, western blot (WB), and immunohistochemistry (IHC) were used to compare the difference between IL-13 and the mTOR/p70S6K1 pathway-related molecules expression level between the healthy control (HC) and CRSwNP groups. WB, 5-ethynyl-2'-deoxyuridine staining, and Immunofluorescent (IF) were performed on human nasal epithelial progenitor cells (HNEPCs) to detect the proliferation ability under the effect of IL-13. In addition, qRT-PCR, WB, and IF were used to detect the differentiation ability with the stimulation of IL-13 in the air-liquid interface (ALI) system. Results: The expression of IL-13, mTOR/p70S6K1-related molecules, and proliferation-related molecules Ki67, CDK2, and cyclin E1 were upregulated in CRSwNP compared to HC. In HNEPCs, IL-13 could stimulate nasal epithelial cells proliferating through the mTOR/p70S6K1 pathway, and this phenomenon could be inhibited when mTOR (with rapamycin) and S6K1 (with PF-4708671) were blocked. In the ALI system, the effect of IL-13 added in the proliferation phase could persist in the proliferation and differentiation stage, affecting the nasal epithelial progenitor/stem cells' irregular differentiation. Conclusion: IL-13 may affect the proliferation and differentiation of nasal epithelial progenitor/stem cells through the mTOR/p70S6K1 pathway, which may affect the development of nasal polyps.

Aging and chronic inflammation: impacts on olfactory dysfunction-a comprehensive review

Olfactory dysfunction (OD) is a common nasal disease, particularly prevalent among the elderly population, significantly impacting the affected individuals' quality of life. This review focuses on the influence of aging and chronic inflammation on olfactory dysfunction, presenting insights from both the peripheral and central olfactory systems. By exploring the molecular mechanisms and pathological changes underlying the occurrence of olfactory dysfunction in relation to age-related diseases and chronic inflammation conditions, we aim to provide a comprehensive theoretical foundation for further research and offer valuable insights for more effective treatment of olfactory dysfunction.

Human beta defensin-2 protects the epithelial barrier during methicillin-resistant Staphylococcus aureus infection in chronic rhinosinusitis with nasal polyps

Objective

We investigated the effect of human beta defensin-2 (hBD-2) on nasal epithelial barrier function with methicillin-resistant Staphylococcus aureus (MRSA) infection in chronic rhinosinusitis with nasal polyps (CRSwNP).

Methods

The expression of hBD-2 was measured in nasal polyps (NPs) from CRSwNP. MRSA was treated with different concentrations of hBD-2 to assess the invasive ability. Primary human nasal epithelial cells (HNECs) cultured at the air-liquid interface (ALI) were pre-incubated with or without hBD-2 prior to MRSA infection. The cell viability, the epithelial cell integrity, and the tight junction (TJ) expression were evaluated.

Results

The expression of hBD-2 in the CRSwNP group was higher than that in the control group. In addition, the hBD-2 protein was negatively correlated with the Lund-Mackay CT score and was positively correlated with the neutrophil levels in CRSwNP. The presence of hBD-2 significantly reduced the invasive ability of MRSA in HNECs. MRSA decreased the epithelial cell integrity by diminishing the protein expression of occludin and zonula occludens-1 (ZO-1). Furthermore, hBD-2 prevented the MRSA-induced barrier disruption by increasing the mucosal permeability and the expression of occludin and ZO-1.

Conclusion

The results suggest that hBD-2 may partially attenuate the epithelial barrier disruption induced by MRSA, indicating the protective effect of hBD-2 on S. aureus infection.

Patients' perspectives regarding antibiotic treatment for acute sinusitis in Norwegian general practice. A qualitative interview study

BACKGROUND

The prescription rate for antibiotics for acute sinusitis in primary care remains high, despite evidence showing their limited effectiveness. GPs frequently encounter patient demands for antibiotics, which can influence their decision-making process.

AIM

This study aimed to explore the help-seeking and expectations of patients experiencing symptoms of acute sinusitis, with a particular focus on their desire for antibiotics. We sought to understand why patients seek their GP for sinusitis, what kind of treatment they hope to receive, and how they perceive their influence on the GP's treatment decision.

METHODS

We conducted 12 semi-structured interviews with patients who had consulted their GP for acute sinusitis from various regions across Norway. The qualitative analysis was performed using systematic text condensation.

RESULTS

We developed 3 main themes:1. 'Pain and exhaustion'- Patients primarily consulted their GP for acute sinusitis seeking medication to alleviate pain and accelerate recovery.2. 'I trust the GP, but mainly myself'- While patients expressed trust in their GPs, they also had clear expectations of receiving the specific treatment they sought. 3. 'Antibiotics works'- Most patients associated medication with antibiotics and believed they were effective against sinusitis.

CONCLUSION

Patients with sinusitis primarily visited their GP to seek relief from pain and to obtain medication that they believe could speed up recovery, which often meant antibiotics. These findings suggest a continuing need for measures targeting both doctors and patients to align treatment expectations, improve adherence to clinical guidelines, and adjust patient expectations. Better pain management of sinusitis should be emphasized.

A Randomized, Double-Blind Study Comparing Corticosteroid Irrigations and Nasal Sprays for Polyp Size Reduction in CRSwNP

OBJECTIVE

To compare the efficacy of corticosteroid irrigation (CSI) and intranasal corticosteroid spray (INCS) in reducing polyp size, improving nasal symptoms, and assessing HPA-axis suppression in non-surgical patients with chronic rhinosinusitis with nasal polyps (CRSwNP).

METHODS

Twenty-four patients from the Allergy and Rhinology Clinic, Songklanagarind Hospital, were randomized into: CSI + placebo spray (n = 13): Budesonide irrigation (0.5 mg/day) + saline spray. Placebo irrigation + INCS (n = 11): Saline irrigation + budesonide spray (512 mcg/day). Nasal symptoms were assessed using VAS-TNSS and SNOT-22. Polyp grading was evaluated via video nasal endoscopy using mLKS and Lildholdt's scale. Serum cortisol levels were measured at baseline, 4-12 weeks.

RESULTS

After 12 weeks, the CSI + placebo spray group showed a significant reduction in mLKS scores (8.54 ± 1.94 vs. 4.82 ± 1.94; p < 0.001), with greater improvement than the placebo irrigation + INCS group (Δ4 (3, 4) vs. Δ1 (0, 2); p = 0.003). VAS-TNSS and SNOT-22 scores showed no significant differences. Serum cortisol levels remained normal.

CONCLUSION

Corticosteroid irrigation is more effective than nasal sprays in improving mLKS scores in non-surgical CRSwNP patients after 12 weeks, with no evidence of HPA-axis suppression.

LEVEL OF EVIDENCE: 2

Exploring Predictors of Post-Surgical Health-Related Quality of Life and Revision Surgery in Patients With Chronic Rhinosinusitis With Nasal Polyps: A Cohort Study

OBJECTIVES

Functional endoscopic sinus surgery (FESS) has been shown to be effective in improving health-related quality of life (HRQoL) in patients with chronic rhinosinusitis with nasal polyps (CRSwNP), though patient selection remains crucial for optimising outcomes. This study aimed to identify predictors of improved postoperative HRQoL and predictors of revision surgery in CRSwNP patients undergoing FESS.

DESIGN

Cohort study.

SETTING

Tertiary referral hospital.

PARTICIPANTS

A total of 153 patients were enrolled in this study. They were asked to fill out the Endonasal Endoscopic Sinus and Skull Base Surgery Questionnaire (EES-Q) preoperatively, and then at 2 weeks, 3 months and 1 year postoperatively.

MAIN OUTCOME MEASURES

Linear mixed model (LMM) analyses were performed to evaluate the overall postoperative HRQoL and the separate health domains, as well as the impact of specific variables (sex, age, ASA classification, smoking, asthma, aspirin-exacerbated respiratory disease, allergic rhinitis, Lund-Mackay score, surgical procedure, postoperative antibiotics, postoperative prednisolone, FESS history, eosinophilia and preoperative EES-Q score) on HRQoL improvement. Using the same variables, a logistic regression analysis was performed to identify predictors of revision surgery.

RESULTS

The total EES-Q score (p < 0.001), as well as the physical (p < 0.001) and social (p < 0.001) domains, significantly improved postoperatively. In the LMM analysis, the preoperative EES-Q score was the only significant variable on the postoperative HRQoL outcome (p < 0.001). Eosinophilia was the only significant variable on revision surgery (p = 0.036).

CONCLUSIONS

FESS significantly improved postoperative HRQoL. Patients reporting worse preoperative HRQoL showed the greatest improvement postoperatively. Proven eosinophilia was the only significant predictor of revision surgery.

Impact of single versus multiple surgeries in CRSwNP patients undergoing treatment with dupilumab

BACKGROUND

Prior to the introduction of biologic drugs, the natural history of Chronic Rhinosinusitis with Nasal Polyps (CRSwNP) was characterized by multiple recurrences, thus necessitating multiple surgical interventions.

AIMS/OBJECTIVES

To understand whether Dupilumab efficacy in recurrent CRSwNP varies based on number of previous surgeries.

MATERIALS AND METHODS

This is a multicentric retrospective study on patients with CRSwNP under Dupilumab, who underwent at least one previous surgery. Correlations between number of previous surgeries and clinical outcomes at baseline and during treatment were investigated.

RESULTS

141 patients were included. Mean number of prior surgeries was 2.19 (median 2; range 1-13). For all patients, significant improvements were observed across all time points. Poorer results were observed in patients subjected to more than one prior surgery in terms of NPS at T2 (p .04), SNOT-22 at T4 (p .03), VAS for olfactory dysfunction at T3 (p .01) and T5 (p .009), VAS for nasal obstruction at T4 (p .047), VAS for rhinorrhea at T4 (p .02), VAS for craniofacial pain at T1 (p .02) and T2 (p .04) and of VAS for sleep disturbances at T1 (p .04).

CONCLUSIONS AND SIGNIFICANCE

Patients subjected to multiple surgeries have worse outcomes during treatment with Dupilumab, particularly for what concerns craniofacial pain and olfactory dysfunction.

Environment, Occupation, and Chronic Maxillary Sinusitis in Pre-Roman Italy

OBJECTIVE

To assess the frequency of chronic maxillary sinusitis (CMS) in a pre-Roman archeological skeletal assemblage from Italy and to evaluate the occurrence of CMS in combination with its environmental and sociocultural context.

MATERIALS AND METHODS

A total of 131 adult individuals from the pre-Roman site of Pontecagnano (eighth to third centuries bce) in southern Italy with intact maxillary sinuses of ≥ 50% preservation were macroscopically and microscopically observed for the presence of osseous changes per published diagnostic criteria of CMS.

RESULTS

CMS was present in 57.2% of individuals. The prevalence of CMS was higher in females than in males, and this difference was statistically significant (p = 0.043). The frequency of CMS increased with age-at-death. Bilateral CMS occurred more frequently than unilateral CMS. The differences in the prevalence of CMS in the Etruscan (700-450 bce), Samnite (450-375 bce), and final pre-Roman (375-200 bce) phases of occupation were not statistically significant.

DISCUSSION

In combination with viral and bacterial infections, occupational activities (metallurgy, ceramic and textile production, and agriculture) and environmental factors (volcanic ash, marshy environments, and sub-Saharan dust plumes) likely stimulated respiratory disease and resultant CMS in the inhabitants of Pontecagnano. This study provides a framework for future research on CMS and respiratory diseases in the Mediterranean region, in relation to environmental, climatic, and anthropogenic influences. The limited number of individuals per period prevented a proper diachronic analysis. Osteoarcheological assemblages from the Mediterranean region should be systematically analyzed for CMS to increase understanding of how climate, environment, industrialization, and urbanicity affected human health through time.

Clinical Effects and Response Time of Biological Drugs in Chronic Rhinosinusitis with Nasal Polyps Patients: Real-life Experience

OBJECTIVE

Chronic Rhinosinusitis with Nasal Polyps (CRSwNP) is a challenging condition often managed with biologic therapies. This study compares the clinical effects and response times of dupilumab, omalizumab, and mepolizumab in Italian patients with severe uncontrolled CRSwNP.

METHODS

This bicentric, retrospective study included 33 patients treated at two Italian hospitals between April and December 2023. Inclusion criteria followed EPOS 2020 guidelines, focusing on adults with bilateral polyposis, history of endoscopic sinus surgery, and evidence of type 2 inflammation. Patients self-administered biologics according to AIFA protocols. Outcomes were assessed using SNOT-22 for quality of life, Nasal Polyp Score (NPS) for polyp size, and Sniffin' Sticks-12 for olfactory function at baseline, 4 weeks, 3, 6, and 9 months.

RESULTS

All three treatment groups (dupilumab, omalizumab, mepolizumab) showed significant improvements in SNOT-22 scores from baseline to 9 months, with no significant differences between groups. Dupilumab showed the most rapid and sustained improvement in NPS, with significant reductions observed from 4 weeks onward. Both omalizumab and mepolizumab showed significant NPS reductions by 6 months. Olfactory function improved significantly in the dupilumab group, with a notable decrease in anosmic patients from 64.3% to 28.6% at 9 months. Asthma control, measured by Asthma Control Test (ACT) scores, improved across all groups.

CONCLUSION

Dupilumab, omalizumab, and mepolizumab significantly improve quality of life and reduce nasal polyp size in CRSwNP patients, with dupilumab showing the fastest response. These findings support the effectiveness of biologics in real-world settings for managing severe CRSwNP.

LEVEL OF EVIDENCE

3 Laryngoscope, 135:1628-1635, 2025.

[Specialist Guidelines of The German Respiratory Society for Diagnosis and Treatment of adult Patients Suffering from Cough]

This is the 4th edition of the Cough Guidelines of the German Respiratory Society written by respiratory, gastroenterology, ear-nose-throat specialists, including respiratory physiotherapists and speech pathology specialists; importantly, a patient representative was also involved.Compared with earlier versions we used a new methodology: after discussion in the guidelines group, we asked and answered the 12 most important and most frequent "key" questions regarding the clinical practice. The extent of the guideline could thus be significantly reduced.We added a short scientific background to each of the answers including the most recent references. The recommendations and statements were created in consensus and graded as strong, or weak. If sufficient literature was not available, we suggested discussing joint decisions with the patient.The 12 key questions are as follows:- Key question 1: The classification of cough (acute, i. e. up to three weeks duration; chronic, i. e. after 8 weeks duration and subacute in between) did not change, but we added "cough with or without expectoration as an additional classification aspect with therapeutic consequences.- Key question 2: Acute and subacute cough are mostly (but not exclusively) due to the common cold. They are the first or second most frequent symptom prompting patients to seek medical (or pharmacist's) care. Antibiotic therapy is strongly discouraged for common cold- Key question 3: We defined "Red flags" for mandatory immediate diagnostic for acute cough, which usually does not require such diagnostic procedures- Key question 4: Chronic cough overview of the most common causes for- Key question 5: Cough in acute SARS-CoV-2 infection and in long COVID - Key question 6: Refractory chronic cough and idiopathic chronic cough, two recently established entities were explained more in detail- Key question 7: To upper airway cough syndrome - Key question 8: Gastro-oesophageal-reflux-related cough - Key question 9: Cough-variant asthma and non-asthmatic eosinophilic bronchitis - Key question 10: Overview of drugs causing cough - Key question 11: Basic and personalized (due to the individual history) diagnostic procedures for patients with cough- Key question 12: Physiotherapy, speech therapy and pharmacotherapy for cough.

Cross-cultural adaptation of the CRS-PRO questionnaire into Spanish

BACKGROUND

Chronic rhinosinusitis (CRS) is a prevalent disease responsible for significant morbidity. Diagnostic criteria are well established but response to clinical and surgical treatment need greater consistency. The objective of this paper was to perform a cross-cultural adaptation of the CRS-PRO to the Spanish language for its use as a routine questionnaire in the evaluation of CRS.

METHODS

The CRS-PRO questionnaire was translated using a three-step procedure in 50 patients, following the recommendations of the International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Native speakers of both European and South American Spanish participated in the translation.

RESULTS

Of the initial 12 items, 4 were discordant among the three translators before a consensus was reached (Step 1). The item "breathe through the nose" (1/12) did not match between the back translation and the initial version of the CRS-PRO (Step 2). Step 3 generated a final revised Spanish version of the CRS-PRO. Fifty patients (average age 51.1, 48% male) completed the questionnaire. Significant gender differences were found in responses to "My face hurt" (P = .043). Significant differences in "My face hurt" also appeared for those completing the questionnaire in less than 80 s (P = .047). Differences in "problems with smell" (P = .039) were noted between chronic rhinosinusitis with and without polyposis.

CONCLUSION

This study presents the validated and Spanish-adapted version of the CRS-PRO questionnaire to evaluate CRS symptoms in the Spanish-speaking population.

Efficacy and Safety of Biologics for Chronic Rhinosinusitis With Nasal Polyps: A Meta-Analysis of Real-World Evidence

Dupilumab, omalizumab, mepolizumab, and benralizumab have demonstrated good efficacy and safety in the treatment of severe uncontrolled chronic rhinosinusitis with nasal polyps (CRSwNP) in phase 3 randomised controlled trials (RCTs). With recent regulatory approvals, there has been a surge in real-world studies (RWSs). This systematic review and meta-analysis aimed to summarise the efficacy and safety of these four biologics in real-world settings. Primary outcomes were nasal polyp score and sino-nasal outcome test-22 score. Secondary outcomes included smell identification test score, loss of smell score, nasal congestion score, overall nasal symptom score, treatment response, and adverse events (AEs) prompting discontinuation. Efficacy outcomes at 4, 6, 12, and over 12 months were summarised, and meta-analyses of mean changes from baseline were conducted. Sixty-four RWSs involving 3921 patients were included. Significant improvements in clinical outcomes were observed at most follow-up time points, with dupilumab showing particularly notable effects. The efficacy observed in these RWSs was superior to that demonstrated in phase 3 RCTs. All biologics exhibited low discontinuation rates due to AEs. Overall, biologic treatments for CRSwNP in real-world settings demonstrate strong efficacy and good safety. However, the limitations in current RWSs highlight the need for long-term, high-quality multicentre prospective studies and comprehensive healthcare database analyses.

Amphiregulin Mediates Epithelial Cell-Eosinophil Interactions and Amplifies Inflammation in Chronic Rhinosinusitis With Nasal Polyps

BACKGROUND

Eosinophils easily accumulate in the intra-epithelial layer and subepithelial regions in eosinophilic chronic rhinosinusitis with nasal polyps (ECRSwNP). While several factors influence the migration of eosinophils from peripheral blood to extravascular tissues, the triggers and role of eosinophils near the epithelial layer in CRSwNP remain unclear.

METHODS

We examined interactions between eosinophils and epithelial cells using co-culture systems. We assessed the expression of amphiregulin (AREG) in CRSwNP epithelial cells and investigated its impact on epithelial barrier function, eosinophil activation, and migration. These effects were further validated in a CRSwNP mouse model treated with an AREG-blocking antibody.

RESULTS

Co-culturing blood eosinophils and primary epithelial cells from CRSwNP patients decreased tight junction expression and increased eosinophil activation. Epithelial cells from ECRSwNP patients expressed higher levels of AREG than those from non-eosinophilic CRSwNP (non-ECRSwNP) patients, particularly in basal cells. As measured in the culture medium by ELISA, both blood eosinophils and primary epithelial cells automatically secreted AREG. Our in vitro experiments demonstrated that AREG impaired epithelial barrier function and facilitated eosinophil migration and activation. Confirmatory studies in a CRSwNP mouse model indicated that blocking AREG reduced the number of nasal polyp-like lesions, mucosal thickness, and eosinophil infiltration, while restoring the expression of tight junction proteins.

CONCLUSION

The upregulation of AREG triggers eosinophil migration and mediates the interaction between epithelial cells and eosinophils, thereby enhancing chronic inflammation in CRSwNP. Our study highlights the therapeutic potential of anti-AREG antibodies in CRSwNP, offering a promising strategy for treating human eosinophilic sinus diseases.

Tissue eosinophil level as a predictor of control, severity, and recurrence of Chronic Rhinosinusitis with Nasal Polyps

Introduction

The histopathologic study of nasal polyps establishes endotype features of chronic rhinosinusitis (CRS). A tissular eosinophil count greater than 10 per high power field (HPF) classifies this condition as type 2 inflammation. Blood and mucosal eosinophils are suggested as biomarkers of severity and control of CRS. Additionally, a tissular eosinophil count greater than 55 per HPF has been related to a high risk of recurrence in the Asian population. Our study aims to determine whether tissue eosinophil count is associated with the control, severity, and recurrence of Chronic Rhinosinusitis with Nasal Polyps (CRSwNP).

Methods

An observational study of patients with CRSwNP who underwent nasal mucosa biopsy was conducted between June 2021 and November 2023. Histopathologic features, asthma control, CRSwNP control and severity according to the POLINA consensus, quality of life parameters, recurrence of CRSwNP, and laboratory markers were recorded and compared with the tissular eosinophil count.

Results

A total of 108 cases were included. The majority (70.4%) had concomitant asthma, with 31.5% of the cases having well-controlled disease. Most patients had uncontrolled (57.4%) and severe (62%) CRSwNP. Fifty-four cases underwent surgery and 43.5% experienced recurrence. More than half had a SNOT-22 score greater than 50 points. Eighty-one percent of patients had a tissular eosinophil count greater than 10 per HPF, and 60.2% had blood eosinophilia greater than 0.3 × 10 3 . Blood eosinophilia was related to CRSwNP severity and control. No significant differences were found between tissue eosinophil count and the severity, control, and recurrence of CRSwNP.

Conclusion

Tissue eosinophil levels were not a marker of control, severity, and recurrence of CRSwNP in our data. Blood eosinophil levels, however, were a marker of CRSwNP control and severity.

Sustained Efficacy and Low Rate of Adverse Events of Dupilumab in Type-2 CRSwNP Over 48 Months

OBJECTIVE

Dupilumab is a fully humanized monoclonal antibody that interferes with the inflammatory cascade in type-2 Chronic Rhinosinusitis with Nasal Polyps (CRSwNP). Studies evaluating its safety and efficacy in the long term are still few. Our study analyzed outcomes and adverse events after 1, 3, 6, 12, 24, 36, and 48 months of dupilumab administration in patients affected by CRSwNP.

MATERIALS AND METHODS

A monocentric, retrospective study assessing blood eosinophil (BEC) and total IgE count, Sinonasal Outcome Test-22 (SNOT-22), Nasal Polyps Score (NPS), sniffin' sticks identification test (SSIT-16), and Lund-Mackay score (LMS) in patients receiving subcutaneous Dupilumab 300 mg/2 weeks for at least 1 year and up to 4 years.

RESULTS

Seventy patients were enrolled, of whom 70, 38, 25, and 12 completed a 12, 24-, 36-, and 48-month follow-up period, respectively. Patients showed a very rapid and long-lasting statistically significant improvement in their SNOT-22, NPS, and SSIT after 1 month, and this trend was kept in the following 48 months. The total IgE count has been constantly reducing over the study period. BEC increased in the first 6 months and then gradually decreased over time, reaching an even smaller value than baseline at 36 and 48 months. Four patients (5.9%) complained of severe adverse events within 6 months, with two interrupting treatment due to hypereosinophilia.

CONCLUSION

Dupilumab was safe and effective in extinguishing the symptomatologic burden of CRSwNP as early as 1 month and up to 48 months, with side events limited to the first 6 months of administration.

LEVEL OF EVIDENCE: 4

Expression of Alpha-Smooth Muscle Actin in Nasal Polyp Tissue of Chronic Rhinosinusitis Patients With and Without Aspirin Hypersensitivity

BACKGROUND

Previous research has shown that myofibroblasts in the nasal/sinus mucosa are not only structural cells but also a rich source of inflammatory mediators. Thus, they influence the immune response and play an essential role in the pathogenesis of chronic rhinosinusitis with nasal polyposis. Previous research did not provide a clear answer to the question of whether the number of myofibroblasts in nasal polyps (NPs) affects the extent of sinus disease. This cross-sectional study investigates the relationship between the number of active myofibroblasts, eosinophil count, and clinical parameters in patients with NPs with and without aspirin sensitivity.

METHODS

Patients diagnosed with NPs, with and without aspirin sensitivity, and healthy subjects were assessed according to the severity of their symptoms as well as endoscopic and radiological findings. The quantification of myofibroblasts present in the surgically excised polyp tissue/healthy nasal mucosa was conducted based on the expression of alpha-smooth muscle actin (α-SMA) in the subepithelial and perivascular compartments. Eosinophils were counted in the subepithelium of the tissue samples from all subjects.

RESULTS

Forty-nine subjects were included: 23 NP patients without, 14 NP patients with aspirin sensitivity, and 12 control participants. The highest levels of α-SMA expression and eosinophil count were observed in NP patients with aspirin sensitivity and the lowest in healthy subjects (P < .001; P < .001, respectively). A strong correlation was noted between α-SMA expression and clinical parameters, particularly with disease extent evaluated radiologically and endoscopically.

CONCLUSION

Our results suggest a positive correlation between the quantity of myofibroblasts and the severity of chronic inflammation in the sinonasal region. The number of myofibroblasts in the NP tissue may serve as a reliable marker for assessing the clinical status of the disease.

Chronic Sinusitis With Nasal Polyps and Olfactory Dysfunction: Comparing Olfactory Training and Glucocorticoid Treatment

OBJECTIVE

Few studies have compared the effectiveness of olfactory training (OT) and glucocorticoids (GC) in the phenotype of chronic sinusitis with nasal polyps (CRSwNP) with olfactory dysfunction (OD). To evaluate the effects of GC and OT on OD in patients with eosinophilic chronic rhinosinusitis with nasal polyps (ECRSwNP) and non-eosinophilic chronic rhinosinusitis with nasal polyps (NonECRSwNP).

METHODS

After 2 weeks of endoscopic sinus surgery, patients with a composite threshold discrimination identification score (TDIS) of less than 30.5 were randomly assigned to receive GC (n = 38), OT (n = 36), or both (n = 34). Retrospective phenotypic stratification of CRSwNP patients was performed based on whether eosinophils in the tissue exceeded 10% (ECRSwNP and NonECRSwNP). Follow-up assessments were conducted at 1, 3, and 6 months postintervention. Evaluations included TDIS, the 22-item Sino-Nasal outcome test (SNOT-22), Lund-Kennedy endoscopic scores (LKES), and the frequency of olfactory fluctuations (OF).

RESULTS

SNOT-22 and LKES improved significantly over time. At 1 month, TDIS change was higher in the GCwOT group than in the GC or OT groups. By 6 months, GCwOT remained superior to GC but not to OT. Follow-up showed no difference between GC and OT. In ECRSwNP patients, GCwOT showed greater TDIS changes at 3 and 6 months versus GC, with lower OF incidence (p < 0.0125). In NonECRSwNP, GCwOT outperformed OT only at 1 month.

CONCLUSION

GC combined with OT can reduce OF in patients with ECRSwNP and consistently enhance olfactory function.

LEVEL OF EVIDENCE: 2

TRIAL REGISTRATION

ChiCTR2100049551.

Cannabinoids and the Endocannabinoid System in the Treatment of Chronic Rhinosinusitis

OBJECTIVE

Recently, the endocannabinoid system (ECS) has emerged as a therapeutic target for various inflammatory diseases, including those of the respiratory tract. The objective of this scoping review is to explore the role of the ECS in the pathophysiology of CRS. Moreover, we sought to identify, appraise, and summarize the available evidence for cannabinoids as a potential treatment for CRS.

DATA SOURCES

Six databases and four clinical trial registries were searched from inception to February 2025.

REVIEW METHODS

All identified studies investigating the role of the ECS in sinonasal inflammatory disease were included for review.

RESULTS

A total of 1534 studies were identified in the initial search. Following screening and full-text analysis by three authors, five studies were included in the final scoping review. Four of the studies were preclinical and in vitro in nature, examining the effects of ECS modulation through CB1 and/or CB2 receptors. The findings of each study support a common conclusion that the ECS is implicated in regulating cellular inflammatory pathways potentially involved in sinonasal disease. The final study investigated the effect of marijuana smoking on subjective and objective measures of CRS severity. There were no clinical studies identified investigating the use of cannabinoids for the treatment of sinonasal inflammatory conditions.

CONCLUSION

Current literature examining the role of ECS in sinonasal inflammatory disease is highly limited, though it indicates ECS may play a role in the complex pathophysiology of sinonasal inflammatory disease. Further work is warranted to assess ECS as a potential therapeutic target for CRS.

The correlation between periostin and eosinophillic cationic protein demonstrate its potential biomarker of mucosal remodeling in chronic rhinosinusitis with nasal polyps

INTRODUCTION

Chronic rhinosinusitis (CRS) is classified into CRS with nasal polyps (CRSwNP), a type 2 inflammation with elevated CLC and ECP levels, and CRS without nasal polyps (CRSsNP), a non-type 2 inflammation. Periostin plays a crucial role in mucosal remodeling, but its involvement in CRSwNP remains unclear.

AIMS/OBJECTIVES

To investigate correlation between CRSwNP endotype and periostin levels.

MATERIALS AND METHODS

This cross-sectional study measured endotype biomarkers (ECP, CLC, IFN-γ, IL-17A) and periostin levels in uncinate process and nasal polyps using ELISA to assess their correlation.

RESULTS

99.6% of uncinate process and 36.67% of nasal polyp tissue samples displayed a mixed endotype pattern, while 2 samples were untype-able. Periostin levels were significantly higher in nasal polyp compared to uncinate process tissue (p = .0116) and control. Only ECP levels in the uncinate process showed a significant correlation with periostin (r = 0.326, p = .038).

CONCLUSION AND SIGNIFICANCE

Periostin is significantly elevated in nasal polyps, highlighting its role in CRSwNP. Its correlation with ECP in the uncinate process suggests involvement in inflammation, warranting further research into periostin as a therapeutic target. This study confirms periostin's role in CRSwNP, it potentially occurs with or without depending on the CRS endotype pathways.

Histopathologic features of chronic rhinosinusitis with nasal polyps in patients from high-altitude Xizang region

BACKGROUND

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a heterogeneous inflammatory disease with varying patterns across regions.

OBJECTIVE

This study aims to investigate the clinical and histopathological features of CRSwNP in Xizang, a high-altitude region in China.

MATERIALS AND METHODS

We retrospectively analyzed the histopathological features of CRSwNP patients from Shanghai and Xizang who underwent functional endoscopic sinus surgery (FESS) between 2017 and 2024. Polyp tissue samples were assessed, and statistical analyses compared features between the two regions in CRSwNP, eosinophilic CRSwNP (eCRSwNP), and noneosinophilic CRSwNP (neCRSwNP) patients.

RESULTS

Twenty-eight patients from Xizang and 35 from Shanghai were analyzed. All Shanghai patients were Han Chinese, and all Xizang patients were Tibetan. Compared to Shanghai, Tibetan patients had significantly lower rates of smoking and asthma. Overall inflammation levels in Xizang were lower, while eosinophil counts were lower in eCRSwNP patients. Neutrophil infiltration, mucosal ulceration, and squamous metaplasia were higher in Xizang patients, while neCRSwNP patients exhibited more neutrophil infiltration and less subepithelial edema.

CONCLUSIONS

The study revealed that Tibetan patients with CRSwNP have lower eosinophilic inflammation but higher neutrophil infiltration and squamous metaplasia compared to Shanghai patients, indicating the impact of high-altitude environments on inflammatory patterns.

[Diagnosis and drug therapy of chronic rhinosinusitis]

Chronic rhinosinusitis is one of the most common chronic diseases of the upper respiratory tract and is associated with a significant reduction in quality of life. Precise diagnostic workup is therefore necessary to provide patients with adequate treatment. The introduction of biologics has opened up new options for the treatment of severely affected patients with chronic rhinosinusitis with nasal polyps in the sense of precision medicine that goes beyond the mere control of symptoms. This has been accompanied by a certain degree of standardization with regard to diagnostic procedures and the assessment of disease-specific quality of life. Against the background of the 2025 congress theme "Individualization vs. standardization in otorhinolaryngology," this paper examines and summarizes the diagnosis and drug therapy of chronic rhinosinusitis, with a focus on biologic therapy.

Nasal Mucosa Regeneration After Reboot Surgery: Electron Microscopy and Histology Insights in CRSwNP

BACKGROUND

Chronic rhinosinusitis with nasal polyps (CRSwNP) often requires multiple treatments. When topical steroids prove insufficient, endoscopic sinus surgery (ESS) is the primary intervention. Among surgical options, reboot surgery is an innovative approach that offers the potential for prolonged disease control in rapidly recurring cases, delaying the need for monoclonal antibody (mAb) therapy. Our study investigates the histological and ultrastructural aspects of mucosal regeneration post-reboot surgery, providing evidence beyond clinical observations.

METHODS

Five adult patients with recurrent CRSwNP, having undergone previous ESS, were enrolled in our study along with one control patient. All underwent partial reboot surgery, and biopsies were taken at pretreatment, 3-, 12-, and 24-months post-op. Analysis included clinical history, demographics, nasal polyps score, CT scans, and ACCESS score. All biopsies were analyzed using light (LM) and electron microscopy (both in transmission and scanning mode [TEM and SEM], respectively). Clinical response was assessed with Sinonasal Outcome Test-22 (SNOT-22) and Visual Analog Scale (VAS).

RESULTS

Difference of means of SNOT-22 and VAS scores, pre versus at 24 months, were statistically significant (69.8 vs. 18.6, p = 0.043; 9.2 vs. 1.2, p = 0.038, respectively). The histological and ultrastructural analysis revealed significant changes in mucosal morphology, collagen composition, vascularity, and cell adhesion, with gradual restoration of normal epithelium and ciliary structure over time.

CONCLUSION

Evidence of mucosal regeneration was provided at LM and electron microscopy. Reboot surgery is an innovative procedure that may be considered a valid alternative to mAbs, especially in younger patients, considering costs of medication and long-term safety.

LEVEL OF EVIDENCE

Level 4.

Distinct inflammatory patterns and nasal bacterial dysbiosis in uncontrolled chronic rhinosinusitis

OBJECTIVE

The concept of disease control is increasingly gaining importance in the long-term management of chronic rhinosinusitis (CRS). Eosinophilic inflammation has been identified as a high-risk factor for uncontrolled CRS. Although evidence suggests that dysbacteriosis is involved in the pathogenesis of eosinophilic CRS, its association with disease control has not been explored. We attempt to explore the inflammatory patterns and nasal bacterial dysbiosis among patients with uncontrolled CRS.

METHODS

We performed a cross-sectional study of 48 patients with uncontrolled CRS, 44 patients with controlled CRS, and 58 healthy controls. Uncontrolled CRS was defined according to European Position Paper on Rhinosinusitis and Nasal Polyps 2020. The nasal mucus and peripheral venous blood were collected for inflammatory endotype analysis. The bacterial microbiota of the swab from the middle meatus was profiled by sequencing the V3-V4 region of the 16S rRNA gene.

RESULTS

Uncontrolled CRS showed significantly higher levels of mucus eosinophil-derived neurotoxin (EDN) (P < 0.001), blood eosinophil counts (P = 0.002), blood basophil counts (P = 0.020), and blood lymphocyte counts (P = 0.033) than patients with controlled CRS. The nasal mucus EDN level was the best predictor of uncontrolled CRS, with the highest area under the receiver operating characteristic curve (AUC) of 0.798 (95% confidence interval [CI] = 0.692-0.904) compared to other inflammatory parameters. Patients with uncontrolled CRS exhibited a significant increase in the abundance of seven genera. Except for Ralstonia and Acinetobacter, the other five genera had a mean relative abundance < 1%, including Klebsiella and Pseudomonas. By random forest analysis, we established a model for the nasal microbiome with an AUC of 0.949 (95% CI = 0.903-0.996). Upon incorporating peripheral eosinophil and basophil counts into the model, we found an enhancement in diagnostic capability, with an AUC of 0.974 (95% CI = 0.944-1.000).

CONCLUSIONS

Patients with uncontrolled CRS have distinct local and systematic inflammatory patterns and bacterial dysbiosis compared to both controlled CRS and healthy controls, which sheds light on the pathogenesis of uncontrolled status in CRS.

Inflammatory and homeostatic roles of eosinophil subpopulations in chronic rhinosinusitis with nasal polyp pathogenesis

Chronic rhinosinusitis (CRS) with nasal polyps (CRSwNP) mainly expresses type-2 endotype, featuring eosinophils as a main player in the inflammatory process. Prolonged eosinophilia in the tissues of asthma and CRSwNP patients has been associated with structural changes, leading to fixed airflow obstruction in asthma and nasal polyposis in CRSwNP. This suggests that eosinophils may belong to different subgroups playing distinct roles in pathogenesis. Recent studies highlight the roles of inflammatory eosinophils (iEOS) in driving inflammation and tissue damage, whereas tissue-resident eosinophils (rEOS) maintain homeostasis and tissue repair in the airway. Therefore, understanding both roles of eosinophil subpopulations is crucial for better CRSwNP management, including enhancing the diagnosis accuracy, predicting recurrence, and optimizing treatment strategies.

Management of intracranial and orbital complications of acute rhinosinusitis and acute otitis media in the post covid-19 era in pediatric patients

PURPOSE

Acute bacterial rhinosinusitis (ABRS) and acute otitis media (AOM) are common diseases in pediatric populations that rarely lead to intracranial infection and/or orbital complications. The incidence of these complications has increased in recent years and the main aim of this study is to analyze the tendency of this increase during the pandemic years, compared with the pre-pandemic era and to propose our management of ABRS and AOM.

METHOD

Clinical data from children, admitted to our hospital during the period from January 2018 to March 2024 with a diagnosis of complicated ABRS and AOM was collected. The sample was divided into two groups: Group A (January 2018- December 2020) and Group B (January 2021- March 2024).

RESULTS

The retrospective cohort consisted of 35 patients, seven patients (20%) belong to Group A, twenty-eight patients (80%) belong to Group B. 67.9% of subjects during the COVID-19 era tested positive for SARS CoV-2 infection on average 5.5 months prior to hospital admission. Statistical analysis showed that there was a sharp increase in surgical cases of complicated AOM and complicated ABRS, after the lock-down period, compared to the previous years.

CONCLUSION

The main findings of the present study are the significant increase of complicated ABRS and AOM as well as severe complications requiring surgical treatment, after the COVID-19 pandemic.

The Clinical Outcome of Image-Guided System in Endoscopic Sinus Surgery for Chronic Rhinosinusitis: A Systematic Review and Meta-Analysis

Objective

Although image-guided system (IGS) is considered useful in endoscopic sinus surgery (ESS), its impact on clinical outcomes needs further evaluation. This study aimed to compare clinical outcomes in patients with chronic rhinosinusitis (CRS) undergoing ESS with or without IGS.

Data Sources

Two independent reviewers searched PubMed, EMBASE, Cochrane, CNKI, WanFang, and VIP to identify comparative clinical studies on clinical outcomes of ESS with or without IGS.

Methods

The primary outcome were total complications. Secondary outcomes were recurrence, revision surgery, blood loss, surgical time, and patient-reported outcomes. A meta-analysis was performed to calculate odds ratios (OR) and weighted mean difference (WMD).

Results

A total of 16 studies were included with a total sample size of 3014 patients. Compared with non-IGS, total complications were less common in IGS group (OR = 0.52, 95% CI, 0.37 to 0.74, p < 0.01), and recurrence rate and revision surgery rate in IGS group was also lower (recurrence rate: OR = 0.31, 95% CI, 0.18 to 0.52, p < 0.001; revision surgery rate: OR = 0.59, 95% CI, 0.36 to 0.98, p = 0.04). What is more, IGS could reduce intraoperative blood loss (WMD = -10.74 mL; 95% CI, -20.92 to -0.57; p = 0.04) and surgical time (WMD = -6.25 min; 95% CI, -9.59 to -2.90, p < 0.001).

Conclusion

Compared with non-IGS, IGS-assisted ESS was associated with a lower risk of total complications, recurrence, and revision surgery, and with a reduction of intraoperative blood loss and surgical time. These findings support the clinical use of IGS as an adjunct in ESS for CRS patients.

Level of Evidence

3.

The auxiliary effect of vitamin D in the treatment of chronic rhinosinusitis with nasal polyposis, a clinical trial

BACKGROUND

Chronic Rhinosinusitis with Nasal Polyposis (CRSwNP) is a prevalent chronic inflammatory disorder of the nasal cavity and paranasal sinus with benign polypoid masses. Recent evidence highlights the immunomodulatory role of Vitamin D (Vit D) in mitigating inflammation associated with CRSwNP.

AIMS

The aim of this study is to examine the effect of Vit D on the improvement of CRSwNP.

MATERIAL AND METHODS

This randomized, double-blind clinical trial was conducted on 59 patients with CRSwNP. All patients with Vit D deficiency (25OH Vit D level < 20 ng/mL) or insufficiency (<30 ng/mL) underwent endoscopic sinus surgery (ESS). The rate of changes in the patients' symptoms were recorded before and 8 weeks after the surgery.

RESULT

All patients showed a better postsurgical improvement in terms of Visual Analogue Scale(VAS), Lund-Kennedy (LK), and Questionnaire (SNOT-22) scores. The Vit D supplement group showed better postsurgical improvement in comparison to placebo in terms of VAS and LK scores (p = 0.02, p = 0.03 respectively).

CONCLUSIONS AND SIGNIFICANCE

The administration of Vit D after ESS is relatively effective in the improvement of CRSwNP symptoms. This finding highlights the possibility of developing an efficient, safe, and cost-effective therapy for patients with CRSwNP.

Serum 25-hydroxyvitamin D levels and peripheral blood eosinophil percentages as predictive indicators for eosinophilic chronic sinusitis with nasal polyps

PURPOSE

Chronic rhinosinusitis (CRS) has a high incidence rate and different endotypes. Serum 25-hydroxyvitamin D (25(OH)D) deficiency is common in patients with eosinophilic and non-eosinophilic chronic rhinosinusitis with nasal polyps (ECRSwNP and nECRSwNP, respectively). This study explored the relationship between serum 25(OH)D levels and CRS risk and determined the value of combining serum 25(OH)D with peripheral blood markers in distinguishing between ECRSwNP and nECRSwNP.

METHODS

This study enrolled 275 CRS patients and 298 healthy controls. The relationship between serum 25(OH)D levels and CRS risk was determined using logistic regression after propensity score matching (PSM). The efficiency of various peripheral blood markers in distinguishing between ECRSwNP and nECRSwNP was assessed using a decision-tree model.

RESULTS

The final analysis included 189 CRS patients and 189 controls after 1:1 PSM. Serum 25(OH)D levels were significantly lower in CRS patients than in controls. Patients with mild CRS showed higher serum 25(OH)D levels than those with moderate or severe CRS, and ECRSwNP patients had lower serum 25(OH)D levels than nECRSwNP patients (all Ps < 0.05). Eosinophil percentages and IgE levels were independent risk factors for ECRSwNP, whereas serum 25(OH)D was an independent protective factor. 25(OH)D deficiency increased the ECRSwNP risk (OR = 3.074, P = 0.04). An eosinophil percentage ≥ 5% and a 25(OH)D level < 61.8 nmol/L could be used to predict ECRSwNP, with training and test set accuracies of 89.7% and 85.7%, respectively.

CONCLUSION

Our findings suggest that serum 25(OH)D deficiency is an independent risk factor for CRS, especially ECRSwNP. Combining serum 25(OH)D levels with peripheral eosinophil percentages could be a promising biomarker for ECRSwNP.

Targeting PDK1: A novel approach to combat hypoxia-induced epithelial-mesenchymal transition in chronic rhinosinusitis with nasal polyps

BACKGROUND

Hypoxia is a prevalent pathological process in chronic rhinosinusitis with nasal polyps (CRSwNP), leading to a cascade of pathological events, including epithelial-mesenchymal transition (EMT). However, the mechanisms underlying hypoxia-induced EMT remain unclear. This study aims to elucidate the mechanisms driving EMT under hypoxic conditions in CRSwNP.

METHODS

Transcriptome and proteome analyses of hypoxia-treated human nasal epithelial cells (HNECs) were performed to identify key molecules and pathways. The expression of hypoxia-inducible factor-1α (HIF-1α), pyruvate dehydrogenase kinase (PDK1), lactate dehydrogenase A (LDHA), and EMT markers was assessed in nasal tissues from CRSwNP patients. In vitro, cultured HNECs were exposed to hypoxia and lactate, or overexpressed PDK1, to evaluate changes in EMT markers.

RESULTS

Hypoxia activated the glycolysis-related pathway in HNECs, with PDK1 and LDHA identified as significantly upregulated glycolysis-related enzymes. The expression of PDK1 and LDHA was closely correlated with HIF-1α and EMT markers in nasal tissues. Hypoxia induced an increase in PDK1 and LDHA expression, lactate production, and EMT occurrence in HNECs. PDK1 overexpression or lactate stimulation also triggered EMT, while PDK1 inhibition attenuated hypoxia-induced EMT in HNECs.

CONCLUSIONS

This study is the first to reveal that hypoxia-induced activation of PDK1 plays a critical role in regulating EMT by promoting lactate production, thereby providing a potential therapeutic target for CRSwNP.

Benralizumab and the integrated management of co-morbid severe eosinophilic asthma with chronic rhinosinusitis with nasal polyps

BACKGROUND

Type 2 (T2) inflammation, characterized by blood and airway eosinophilia, underlies severe eosinophilic asthma (SEA) and chronic rhinosinusitis with nasal polyps (CRSwNP). In line with the Global Airways theory, SEA and CRSwNP frequently co-occur, creating a multimorbid phenotype. Separately, SEA and CRSwNP are burdensome: when concomitant, they compound each other, creating a more difficult-to-treat disease with increased complications. BODY: Current management approaches rarely control disease and are associated with substantial side-effects. Several recently developed anti-IL-5 monoclonal antibodies have shown efficacy in treating co-morbid SEA with CRSwNP by targeting T2 inflammation with systemic therapies. Of these, only benralizumab directly targets the IL-5 receptor-α, leading to rapid, sustained, near-complete eosinophil depletion. Analyses in patients with co-morbid SEA with CRSwNP are limited, although data from the ANDHI, XALOC-1, and RANS studies suggest benralizumab can effectively target inflammation underlying co-morbid disease.

CONCLUSION

Despite progress toward more effective therapies, treatment approaches remain siloed, with SEA and CRSwNP often managed separately. There is a need for the development of multidisciplinary approaches for treating patients with comorbid SEA with CRSwNP.

Effectiveness of the exhalation delivery system with fluticasone for treating chronic rhinosinusitis with nasal polyposis: a systematic review and meta-analysis

PURPOSE

We evaluated the effects of two doses (186 µg and 372 µg) of exhalation delivery system with fluticasone (EDS-FLU) on chronic rhinosinusitis (CRS) with nasal polyp as a novel sinonasal delivery system.

METHODS

We analyzed 5 studies retrieved from PubMed, SCOPUS, Embase, Web of Science, and Cochrane databases up to April 2024, focusing on subjective and objective scores, and adverse and beneficial effects (responder and complete responder rates, improvements in Patient Global Impression of Change [PGIC] scores, and surgical indication rates before and after EDS-FLU use.

RESULTS

Over 3 months, EDS-FLU significantly reduced polyp (mean difference [MD] - 1.1605; 95% confidence interval [CI] [- 1.3277; -0.9934], I2 = 61.4%) and 22-item Sinonasal Outcome Test (MD - 20.7561; 95% CI [- 22.3473; -19.1648], I2 = 0.0%) scores compared to baseline. At 1 month, nasal congestion, facial pain, olfactory dysfunction, and rhinorrhea significantly improved compared to baseline. EDS-FLU significantly reduced the surgical indication rate (odds ratio 0.2594; 95% CI [0.1910; 0.3522], I2 = 0.0%) and improved patient satisfaction, with 63.34% of patients reporting significant improvement in PGIC scores after 3 months. However, adverse effects, including epistaxis, headache, nasal congestion, and nasopharyngitis, were reported, with incidence rates ranging from 4.46 to 8.99%. There were no significant differences in beneficial or adverse effects between high and low fluticasone doses, but the high dose was associated with a higher percentage of complete responders.

CONCLUSION

Both doses of EDS-FLU significantly improved subjective and objective outcomes of CRS patients with nasal polyps. However, epistaxis and nasal septal erosive or ulcerative lesions were also considered.

The impact of the bitter taste receptor on the predisposition to chronic rhinosinusitis

Objectives

Genetic polymorphisms in bitter taste receptor 2 member 38 (TAS2R38), expressed in the cilia of sinonasal epithelial cells, have been proposed to be contributors to chronic rhinosinusitis (CRS).

Methods

We assessed the impact of the genetically determined TAS2R38 structure on predisposition to CRS and correlated the expression of the TAS2R38 with haplotypes. 86 patients (60 CRS patients, 26 controls) undergoing nasal surgery were enrolled. PCR to identify single nucleotide polymorphisms in genes encoding TAS2R38 were performed. TAS2R38 expression in sinus mucosa tissues was assessed by immunohistochemistry.

Results

Among CRS patients, the protective genotype PAV/PAV of the TAS2R38 was observed with the lowest frequency. Immunohistochemistry displayed significant overexpression of TAS2R38 in patients with CRS and in those with a non-functional AVI/AVI genotype. Under inflammatory conditions, TAS2R38 was found to translocate from the cell membrane.

Conclusions

Genetically determined TAS2R38 polymorphisms may influence susceptibility to CRS. The AVI haplotype seems to be an independent risk factor for CRS. Additionally, TAS2Rs and related signalling pathways might create a unique group of therapeutic targets in CRS.

Radiological score, asthma and NSAID-exacerbated respiratory disease predict relapsing chronic rhinosinusitis

OBJECTIVES

The aim was to evaluate the predictive potential of Sinonasal Radiological (SR) and the Lund-Mackay (LM) score of sinus computed tomography (CT) scans on postoperative relapses of chronic rhinosinusitis (CRS).

MATERIALS AND METHODS

CRS patients (n = 483, 12-80 years) underwent routine sinus CT scans. The SR score was defined by obstructed frontal recess (0 = no, 1 = yes) and visualization of middle and inferior turbinate (0 = anatomy can be easily visualized, 1 = anatomy cannot be easily visualized) on each side (a total of 0-6 points). Associations were analyzed by nonparametric, survival and Cox's proportional hazard models.

RESULTS

Revision endoscopic sinus surgery (ESS) was performed in 133 (28.0%) patients on average (min-max) of 3.2 (0-12) years after performing the sinus CT scans. Of the 408 patients who underwent the baseline ESS, high preoperative SR or LM scores significantly predicted revision ESS (p < 0.001) and peroral corticosteroid courses purchased during the follow-up (p = 0.009 and p < 0.001, respectively for SR- and LM-scores). In multivariable analysis, both SR score and asthma and/or NSAID exacerbated respiratory disease (N-ERD) were significantly associated with revision ESS risk (p = 0.035, p = 0.007, respectively).

CONCLUSION

LM and SR and a history of asthma or N-ERD predict CRS relapses, which may help in decision-making.

Adenoidectomy as day surgery: feasibility and outcomes

Objectives

Adenoidectomy performed as day surgery is a safe and cost-effective procedure, but patients may be occasionally admitted overnight due to the need for extended care. This study investigates the unplanned admission rate following day surgery adenoidectomy in children.

Methods

Data from 3,396 children who underwent adenoidectomy from 2010 to 2023 were retrospectively collected in a tertiary centre. Inclusion criteria were age > 2 years and ASA score I-II. The study focused on evaluating factors such as age, gender, duration of surgery, surgeon's experience, adverse events and multiple surgeries. Univariate and multivariate analysis were performed, and ROC curves were built for continuous variables.

Results

The unplanned admission rate was 2.3%, with postoperative nausea/vomiting being the most common complication. Respiratory complications were notably low. Factors associated with unplanned admission at multivariate analysis included the end time of surgery (p < 0.001), surgical duration (p = 0.001) and surgeon's experience (p < 0.001).

Conclusions

This study confirms the safety and feasibility of adenoidectomy as day surgery in a tertiary centre, with a low unplanned admission rate and infrequent serious complications. Further studies are needed to generalise these findings to different settings and populations.

How does asthma coexistence affect the strategic selection of biologic therapies in CRSwNP management?

Objectives

We reviewed asthma coexistence and the selection of biologic therapies in CRSwNP Management.

Methods

The literature review utilized Google and Google Scholar, in addition to PubMed, EBSCO, and Proquest Central at Kırıkkale University. We searched for " CRSwNP", "asthma", "biologic therapies", "Anti-IL-4RA", "Dupilumab", "Anti-IgE", "Omalizumab", "Anti-IL-5", "mepolizumab" from 2024 to 2000.

Results

Patients with CRSwNP frequently have co-occurring lower airway illnesses, including asthma and AERD asthma, which have a shared pathogenesis. The inflammatory bases of CRSwNP and asthma might be heterogeneous, with a type 2 or, less frequently, a non-type two inflammatory history. Lower airway inflammation and asthma control are worse in patients with asthma who also have CRSwNP. Patients with CRSwNP can now access targeted biologic medicines, a novel therapy option. The US Food and Drug Administration (FDA) has authorized three medications for CRSwNP: dupilumab, omalizumab, and mepolizumab. To treat chronic rhinosinusitis with a biological agent, the 2020 European position paper on rhinosinusitis established clear indications. A patient is considered a biologic therapy candidate if they have either undergone FESS before or did not meet FESS criteria but met three of the five. A diagnosis of concomitant asthma, necessitating an inhaled glucocorticoid controller regularly, is one of the five requirements.

Conclusion

Biologic treatments have the potential to be used in certain patients where CRSwNP and asthma coexist. The recommended treatments include omalizumab, dupilumab, and mepolizumab.

Validation of the Endoscopic Endonasal Sinus and Skull Base Surgery Questionnaire (EES-Q) for Use in Chronic Rhinosinusitis

OBJECTIVES

The Endoscopic Endonasal Sinus and Skull Base Surgery Questionnaire (EES-Q) is the only known instrument designed to assess Health-Related Quality of Life (HRQoL) in chronic rhinosinusitis (CRS) across all three health domains: physical, social, and psychological. Initially, the EES-Q was validated to evaluate the impact of endoscopic endonasal surgery (EES) on HRQoL. Our goal is to use the EES-Q for all CRS patients, regardless of their treatment phase. Previously, we demonstrated a significantly worse HRQoL in tertiary CRS patients compared to healthy individuals. The aim of this study is to validate these findings in a secondary referral cohort distributed across multiple centres, thereby extending the applicability of the EES-Q to all CRS patients.

DESIGN

Multicentre know-groups validity study.

SETTING

Five secondary referral hospitals and one tertiary referral centre.

PARTICIPANTS

A total of 100 healthy control subjects without any history of sinusitis or current hospital-based medical treatment, 100 CRS patients from a secondary centre with no history of EES, and 100 CRS patients from a tertiary centre were included.

MAIN OUTCOME MEASURES

Mann-Whitney U test was performed to identify differences in domain scores and EES-Q scores between the different cohorts.

RESULTS

The median EES-Q scores, as well as the physical, psychological, and social domain scores, were significantly higher in the secondary and tertiary cohorts compared to the healthy controls. No significant differences were observed between the secondary and tertiary cohorts.

CONCLUSION

We validated the EES-Q as an HRQoL instrument for use in CRS.

Study protocol for a randomized double-blinded placebo-controlled trial on mepolizumab for patients with chronic rhinosinusitis with nasal polyps, NSAID exacerbated respiratory disease and asthma

Background

Chronic rhinosinusitis with nasal polyps (CRSwNP) is an inflammatory disease of the nose and paranasal sinuses that significantly impactshealth-related quality of life. Nonsteroidal anti-inflammatory drug (NSAID) -exacerbated respiratory disease (N-ERD) affects approximately one fifth of CRSwNP patients. N-ERD and asthma increase the risk of uncontrolled CRSwNP as measured by frequent sinus surgeries and rescue treatment. Compared to non-N-ERD patients, those with N-ERD also have higher risk of asthma exacerbations, severe allergic reactions, and anosmia. Mepolizumab is a humanized monoclonal anti-IL-5 antibody shown to be effective in treating severe eosinophilic asthma and CRSwNP. While evidence suggests that mepolizumab alleviates respiratory symptoms in N-ERD patients, placebo-controlled studies remain limited.

Methods

The aim of this prospective randomized, placebo-controlled, multicenter study is to investigate whether mepolizumab reduces polyp size, symptom scores, and exacerbations more than placebo during the 16-week treatment period in patients with uncontrolled CRSwNP, N-ERD and asthma. Additionally, we will examine the effect of mepolizumab on drug dosage and lung and nasal function and evaluate predictive biomarkers.We will recruit 120 patients with N-ERD, nasal polyposis and asthma in three centers in Finland. Patients will be randomized into two 16-week treatment groups in 1:1 ratio (placebo or mepolizumab 100 mg every 4 weeks). The study lasts for 6 months, including recruitment visit 2-4 weeks before randomization. Participants will attend 6 visits, during four of which they will receive a subcutaneous injection of the study product. At each visit, patient-reported outcome tests, clinical examination, airway function tests, and nasal, blood, urine, and stool samples will be conducted.

Discussion

The efficacy of the 16-week anti-IL-5-treatment in this severe patient group will be analyzed, as well as possible predictive biomarkers.

Clinical Trial registration

ClinicalTrials.gov ID NCT04823585. Registered on 28.3.2021.

Seizure and cardiac arrest in a case of chronic rhinosinusitis, Churg-Strauss syndrome on autopsy

A young male in his 20s, previously diagnosed with a case of chronic rhinosinusitis with nasal polyps, was started on a course of oral steroids. He suddenly developed an episode of seizures and failed to regain consciousness. Within an hour, he suffered cardiac arrest and subsequently succumbed to the illness. An autopsy revealed bilateral consolidation of the lower lobes of the lung, left ventricular hypertrophy of the heart and cerebral oedema. Histopathological examination showed eosinophilic infiltrates in the myocardium, submucosa of oesophagus and brain. Eosinophilic vasculitis of medium-sized vessels was seen. Following this, a diagnosis of Churg-Strauss syndrome was made. This case shows that Churg-Strauss syndrome, a rare disease in itself, may infrequently present with sudden cardiac death without having any signs or symptoms of asthma previously. It highlights the need to remain vigilant with regard to secondary causes in cases of long-standing chronic rhinosinusitis.

Enhanced Therapeutic Options for Budesonide Nebulisation via Pulsating Nebuliser in Upper Respiratory Tract Diseases

Introduction: The primary treatment method for T2 immune response-related airway inflammations, such as eosinophilic inflammation, is topical glucocorticosteroid therapy. However, its effectiveness is limited by the challenge of drug penetration into the perinasal cavity. The introduction of a new generation of pulsating nebulizers has partially addressed this issue. Pulsating nebulizers (vibrating aerosol) enhance the penetration of nebulized medication into the paranasal sinuses, thereby opening a new therapeutic option for the treatment of chronic sinusitis. Consequently, a new regulatory indication has been approved for the use of budesonide in chronic rhinosinusitis with nasal polyps. Aim: The aim of the study was to compare the aerodynamic particle size distribution (APSD) of the dispersed suspensions of the test drug (TD) and the reference drug (RD) administered using the PARI SINUS2 nebulizer system, consisting of the PARI LC SPRINT SINUS nebulizer and the PARI SINUS2 compressor. Material and methods: Comparison of the APSD of the dispersed suspensions of the TD and the RD administered using the PARI SINUS2 nebulizer system. Twelve nebulizations of each formulation were tested using six PARI SINUS2 nebulizer systems, with two repetitions per system. The methods were review of studies and own research. The APSD study was conducted using a next-generation impactor (NGI) and a laser diffraction spectrometer after nebulization of 2 mL suspensions of TD and RD via the PARI SINUS2 nebulizer system. Statistical analyses included descriptive statistics as well as 90% and 95% confidence intervals for the difference in means and the ratio of means of the examined parameters. Results: The TD was well-suited to the nebulization procedure. Both formulations (TD and RD) exhibited significant variability in the aerosol droplet distribution at different levels of the NGI cascade impactor. In the case of TD, larger droplets were more easily generated, which promoted deposition of the drug at the upper levels of the impactor. The equivalence of the two forms of budesonide, RD and TD, in the treatment of chronic rhinosinusitis with nasal polyps using a pulsating nebulizer was demonstrated. These indications were acknowledged by the Office for Registration of Medicinal Products, Medical Devices and Biocidal Products (URPLWMiPB) and added to the Product Information of TD. Conclusions: Both budesonide formulations were effective. Budesonide administered via vibrational nebulization is effective in the treatment of chronic rhinosinusitis with nasal polyps.