Modified Lund Mackay Postoperative Endoscopy Score for defining inflammatory burden in chronic rhinosinusitis

The Burden of Nonsteroidal Anti-Inflammatory Drug-Exacerbated Respiratory Disease: Interplay Between Quality of Life and Economic Implications

Nonsteroidal anti-inflammatory drug-exacerbated respiratory disease (NSAID-ERD) presents a significant challenge in clinical management owing to recalcitrant disease with accompanying profound impacts on patient quality of life. Although asthma represents a significant component of this disease, quality of life disruptions are driven primarily by recalcitrant sinonasal problems, olfactory dysfunction, and the associated psychosocial and dietary implications. This review delves into specific quality of life metrics used to assess NSAID-ERD and the associated health care burden and financial implications of this disease, offering insights into the comparative challenges in chronic rhinosinusitis with nasal polyps when available. The article reviews the associated costs and cost-effectiveness of NSAID-ERD-directed therapies, including endoscopic sinus surgery, aspirin desensitization, and biologic therapy. Although some of these emerging treatment approaches show promise, they also present numerous unanswered questions, reflecting the dynamic nature of this field. As the landscape of NSAID-ERD management continues to evolve, this review provides insights into the challenges faced by clinicians and underscores the need for further research to optimize patient care and quality of life outcomes.

Preliminary study on AI-assisted diagnosis of bone remodeling in chronic maxillary sinusitis

OBJECTIVE

To construct the deep learning convolution neural network (CNN) model and machine learning support vector machine (SVM) model of bone remodeling of chronic maxillary sinusitis (CMS) based on CT image data to improve the accuracy of image diagnosis.

METHODS

Maxillary sinus CT data of 1000 samples in 500 patients from January 2018 to December 2021 in our hospital was collected. The first part is the establishment and testing of chronic maxillary sinusitis detection model by 461 images. The second part is the establishment and testing of the detection model of chronic maxillary sinusitis with bone remodeling by 802 images. The sensitivity, specificity and accuracy and area under the curve (AUC) value of the test set were recorded, respectively.

RESULTS

Preliminary application results of CT based AI in the diagnosis of chronic maxillary sinusitis and bone remodeling. The sensitivity, specificity and accuracy of the test set of 93 samples of CMS, were 0.9796, 0.8636 and 0.9247, respectively. Simultaneously, the value of AUC was 0.94. And the sensitivity, specificity and accuracy of the test set of 161 samples of CMS with bone remodeling were 0.7353, 0.9685 and 0.9193, respectively. Simultaneously, the value of AUC was 0.89.

CONCLUSION

It is feasible to use artificial intelligence research methods such as deep learning and machine learning to automatically identify CMS and bone remodeling in MSCT images of paranasal sinuses, which is helpful to standardize imaging diagnosis and meet the needs of clinical application.

A comparison of effectiveness between Posisep and Merocel nasal packing after endoscopic sinus surgery: Findings from a randomized, double-blinded, controlled trial

BACKGROUND

The effectiveness of nonabsorbable and biodegradable nasal packing is still controversial, and the choice of nasal packing type can alter the outcome of endoscopic sinus surgery. This study compared the effectiveness of Posisep and Merocel as nasal packing materials with regard to hemostasis, adhesion, wound healing, patient's satisfaction and health-related quality of life after endoscopic sinus surgery (ESS).

METHODS

A prospective, randomized, double-blinded, controlled trial was conducted in patients with chronic rhinosinusitis refractory undergoing symmetrical bilateral ESS. At the completion of surgery, a nasal packing (either Merocel or Posisep) was randomly chosen and placed into the middle meatus of each nasal cavity. All patients were scheduled for follow-up visits at 24 hours, 5 days, 3 weeks, and 5 weeks days after surgery. Health-related quality of life was measured using the Sino-Nasal Outcome Test (SNOT-22). The overall inflammatory burden of chronic rhinosinusitis was measured by the Lund-Mackay postoperative endoscopic score (LMES).

RESULTS

Among 62 patients included in data analysis (n = 31 for each group), the mean age was 42.4 years and 54.8% were females. Patients with Posisep after ESS had more improvement and better symptoms measured through SNOT-22 and LMES at 24 hours, 5 days, and 3 weeks than those with Merocel after ESS. While some aspects measured by LMES such as discharge and scarring were still better until 5 weeks after surgery, all symptoms measured by SNOT-22 were similar between the 2 groups 5 weeks after surgery.

CONCLUSION

Posisep containing chitosan provided patients with a better quality of life throughout the early recovery period compared with Merocel. Although more studies are needed, our findings support the use of Posisep after ESS.

Clinically meaningful changes in efficacy outcomes in chronic rhinosinusitis with nasal polyposis

PURPOSE OF REVIEW

Chronic rhinosinusitis with nasal polyps (CRSwNP) carries a high disease burden, and many studies have been done investigating the efficacy of various medical and surgical therapies. However, outcome metrics have varied across these studies, making it difficult to compare therapeutic efficacy on a large scale. In this article, we discuss various outcome metrics used across prior studies as well as the relationship between these measures.

RECENT FINDINGS

Outcome metrics in CRSwNP studies include both clinically assessed and patient-reported outcome measures (PROMs). The former includes olfaction testing, scoring systems based on imaging and endoscopic evaluation, and histopathological and immunohistochemical evaluation of sinus tissue, and the latter includes quality-of-life instruments, symptom severity scales, and disease-control instruments. Recent studies evaluating the efficacy of new biologics have used a combination of both types of metrics.

SUMMARY

Both clinical metrics and patient-reported outcomes provide utility in evaluating disease severity and control in patients with CRSwNP, although there are nuances when comparing therapies in this population as patients with CRSwNP are heterogeneous and may have symptoms across several domains. However, PROMs in conjunction with clinical metrics provide useful information to assess patient symptoms and response to interventions.

Semi-Supervised Deep Learning Semantic Segmentation for 3D Volumetric Computed Tomographic Scoring of Chronic Rhinosinusitis: Clinical Correlations and Comparison with Lund-Mackay Scoring

Background: The traditional Lund-Mackay score (TLMs) is unable to subgrade the volume of inflammatory disease. We aimed to propose an effective modification and calculated the volume-based modified LM score (VMLMs), which should correlate more strongly with clinical symptoms than the TLMs. Methods: Semi-supervised learning with pseudo-labels used for self-training was adopted to train our convolutional neural networks, with the algorithm including a combination of MobileNet, SENet, and ResNet. A total of 175 CT sets, with 50 participants that would undergo sinus surgery, were recruited. The Sinonasal Outcomes Test-22 (SNOT-22) was used to assess disease-specific symptoms before and after surgery. A 3D-projected view was created and VMLMs were calculated for further comparison. Results: Our methods showed a significant improvement both in sinus classification and segmentation as compared to state-of-the-art networks, with an average Dice coefficient of 91.57%, an MioU of 89.43%, and a pixel accuracy of 99.75%. The sinus volume exhibited sex dimorphism. There was a significant positive correlation between volume and height, but a trend toward a negative correlation between maxillary sinus and age. Subjects who underwent surgery had significantly greater TLMs (14.9 vs. 7.38) and VMLMs (11.65 vs. 4.34) than those who did not. ROC-AUC analyses showed that the VMLMs had excellent discrimination at classifying a high probability of postoperative improvement with SNOT-22 reduction. Conclusions: Our method is suitable for obtaining detailed information, excellent sinus boundary prediction, and differentiating the target from its surrounding structure. These findings demonstrate the promise of CT-based volumetric analysis of sinus mucosal inflammation.

A systematic review to examine the relationship between objective and patient-reported outcome measures in sinonasal disorders: recommendations for use in research and clinical practice

BACKGROUND

Common sinonasal disorders include chronic rhinosinusitis (CRS), allergic rhinitis (AR), and a deviated nasal septum (DNS), which often coexist with shared common symptoms including nasal obstruction, olfactory dysfunction, and rhinorrhea. Various objective outcome measures and patient-reported outcome measures (PROMs) are used to assess disease severity; however, there is limited evidence in the literature on the correlation between them. This systematic review aims to examine the relationship between them and provide recommendations.

METHODS

A search of MEDLINE and EMBASE identified studies quantifying correlations between objective outcome measures and PROMs for the sinonasal conditions using a narrative synthesis.

RESULTS

In total, 59 studies met inclusion criteria. For nasal obstruction, rhinomanometry shows a lack of correlation whereas peak nasal inspiratory flow (PNIF) shows the strongest correlation with PROMs (r > 0.5). The Sniffin' Stick test shows a stronger correlation with PROMs (r > 0.5) than the University of Pennsylvania Smell Identification Test (UPSIT) (r < 0.5). Computed tomography (CT) sinus scores show little evidence of correlation with PROMs and nasal endoscopic ratings (weak correlation, r < 0.5).

CONCLUSION

Overall, objective outcome measures and PROMs assessing sinonasal symptoms are poorly correlated, and we recommend that objective outcome measures be used with validated PROMs depending on the setting. PNIF should be used in routine clinical practice for nasal obstruction; rhinomanometry and acoustic rhinometry may be useful in research. The Sniffin' Sticks test is recommended for olfactory dysfunction with UPSIT as an alternative. CT scores should be excluded as a routine CRS outcome measure, and endoscopic scores should be used in combination with PROMs until further research is conducted.

Clinical outcome of endonasal endoscopic prelacrimal approach in managing different maxillary pathologies

Background

The aim of the study was to evaluate the treatment outcomes of endoscopic prelacrimal recess approaches (EPLAs) in managing different sinus pathologies, analyzing associated adverse events and post-treatment quality-of-life.

Methods

We enrolled 21 consecutive patients (22 lesions) who received endoscopic sinus surgical procedures with EPLAs in two tertiary medical institutes between 2015 and 2018. Quality-of-life and self-rated symptom severity data were collected using the 22-item Sino-Nasal Outcomes Test (SNOT-22) and 10-point visual analog scales (VAS), respectively.

Results

A total of 21 patients (mean age (standard deviation) 51.7 (14.5) years; 16(76.2%) male) were followed up for 12.7 months. The most common symptoms were nasal discharge and nasal airway obstructions. Nine lesions (40.9%) were sinonasal papilloma's, seven lesions were other types of neoplasms (31.8%; five benign and two malignant), two were trauma-related (9.1%), and four inflammatory diseases (18.2%). Patients with non-papilloma lesions had higher presurgical SNOT-22 than those with papillomas (P-value = 0.021). After EPLAs, non-papilloma patients had significant improvements in SNOT-22 and VAS (P-values = 0.012 and 0.012, respectively), while those with papillomas had only marginally significant improvements in VAS (P-value = 0.061). The most common adverse events was temporary cheek/tooth numbness (n = 11), and patients with sinonasal papillomas were more likely to have post-treatment complications than those with other disease entities.

Conclusions

EPLAs were found to effectively manage various sinus diseases. Short-term life-quality improvements were promising. Future large-scale studies with longer follow-up periods are recommended.

The evaluation of three treatment protocols using oral prednisone and oral meloxicam for therapy of canine idiopathic lymphoplasmacytic rhinitis: a pilot study

Background

Idiopathic lymphoplasmacytic rhinitis (LPR) is a common inflammatory disorder of the nasal cavity in dogs due to unknown etiology. It is characterised by non-specific clinical signs, including nasal discharge, epistaxis and breathing problems. Diagnosis is usually based on the histopathologic identification of infiltrating plasmocytes and lymphocytes in the nasal mucosa and the exclusion of other underlying diseases. Treatment strategies include glucocorticoids, non-steroidal anti-inflammatory drugs, antibiotics and antifungal medications. The aim of this study was to evaluate the efficacy of various therapeutic protocols for managing canine lymphoplasmacytic rhinitis based on the results of clinical, endoscopic and histological examinations, and to determine the relapse rate for LPR in dogs.

Twenty dogs of different breeds and both sexes, aged 1 to 14 years, were divided into four groups, each consisting of five dogs, including three experimental groups diagnosed with LPR and a control group.

The dogs from the first experimental group were administered prednisone orally at 1 mg/kg/day in the first 4 weeks and 0,5 mg/kg/day in the following 2 weeks. The second group of dogs was administered meloxicam orally at 0,1 mg/kg/day in the first 3 weeks, followed by prednisone at 1 mg/kg/day in the following 2 weeks and 0,5 mg/kg/day in the last week of the treatment. The dogs from the third experimental group were administered meloxicam orally at 0,1 mg/kg/day for 6 weeks. The control group of dogs was administered empty gelatin capsules (placebo) orally for 6 weeks. Clinical signs, endoscopic and histopathologic lesions were scored before and after treatment. Groups were compared using Chi- squared statistics in a 2 × 2 table for pre- versus post-treatment scores.

Results

Clinical signs persisted in the group treated with meloxicam and were mostly resolved in prednisone-treated dogs. However, endoscopic and histological changes were still observed in these two groups after treatment. The severity of all diagnostic features was reduced in the group treated with meloxicam for 3 weeks followed by prednisone for 3 weeks. The significant differences (p < 0.05) were noted between experimental and control groups. The dogs showed a statistically significant reduction in characteristics of the LPR before and after treatment, as measured by clinical signs (Group 1vs.4 p = 0.00, group 2 vs 4 p = 0.00, group 3 vs 4 p = 0,01), by endoscopy (1 vs 4 p = 0,01, 2 vs 4 p = 0,00, 3 vs 4 p = 0,03), and by histopathology (groups 1 vs 4 p = 0,00, 2 vs 4 p = 0,00, 3 vs 4 p = 0,03). The significant differences were noted between experimental groups, as measured by endoscopy (group 2vs 3 p = 0,04), and by relapse rate (groups 1 and 2 p = 0,03, groups 2 and 3 p = 0,01).

Conclusions

The three treatment protocols administered to dogs improved clinical, endoscopic and histological status. However, oral administration of meloxicam for 3 weeks, followed by prednisone for 3 weeks, appeared to be the most successful treatment. These patients remained asymptomatic for 6 months.

Endoscopic sinus surgery in adult patients with chronic rhinosinusitis with nasal polyps (PolypESS): study protocol for a randomised controlled trial

BACKGROUND

Chronic rhinosinusitis with nasal polyps is a chronic disease frequently seen in otorhinolaryngological practice. Along with its chronic disease burden it creates high societal costs. Therapy consists of long-term use of medication and, if insufficient, endoscopic sinus surgery. No consensus exists on the right timing and extent of disease that warrants surgery. Furthermore, there is lack of clinical knowledge about the benefit of surgery over medication only. The current trial evaluates the clinical effectiveness and cost-effectiveness of endoscopic sinus surgery in addition to drug treatment versus medication exclusively in the adult patient group with nasal polyps.

METHODS

A prospective, multicentre, superiority, randomised controlled (PolypESS) trial in 238 patients aged 18 years or older selected for primary or revision endoscopic sinus surgery by the otorhinolaryngologist was designed. Patients will be randomised to either endoscopic sinus surgery in addition to medication or medical therapy only. Relevant data will be collected prior to randomisation, at baseline and 3, 6, 12, 18 and 24 months after start of treatment. Complete follow-up will be 24 months. Primary outcome is disease-specific Health-related Quality of Life quantified by the SNOT-22 after 12-month follow-up. Secondary outcomes are generic Health-related Quality of Life, cost-effectiveness, objective signs of disease and adverse effects of treatment. Subgroup analyses will be performed to verify whether treatment effects differ among patient phenotypes.

DISCUSSION

The PolypESS trial will investigate tailored care in adult patients with chronic rhinosinusitis with nasal polyps and will result in improved clinical pathways to help to determine in which circumstances to perform surgery.

TRIAL REGISTRATION

Dutch Trial Register, NTR4978 . Registered on 27 November 2014.

Development of a clinically relevant endoscopic grading system for chronic rhinosinusitis using canonical correlation analysis

BACKGROUND

Diagnostic nasal endoscopy is a routine measure of sinonasal inflammation in patients with chronic rhinosinusitis (CRS). Although multiple staging systems have been proposed and evaluated, evidence of association between concurrent symptoms and endoscopic findings remains discordant. The goal of this study is to identify the relevant endoscopic attributes associated with symptom burden, and to systematically derive a weighted endoscopic scale that optimizes prediction of concurrent symptoms.

METHODS

Reported baseline symptom (22-item Sino-Nasal Outcome Test [SNOT-22]) and endoscopic evaluation scores (Lund-Kennedy [LK]) were obtained from patients with CRS enrolled in a prospective cohort study. Canonical correlation analysis of the SNOT-22 subdomains and LK variables was completed.

RESULTS

A total of 629 patients were included in analysis including 343 with prior endoscopic sinus surgery. Significant canonical correlations outperformed aggregate correlations in explaining variance of the data (33% vs 3%, respectively). The first canonical correlation was dominated by the rhinologic symptom domain and the endoscopic polyp score (r = 0.54; p < 0.05) whereas additional significant canonical correlation was found between the extra-rhinologic symptom subdomain and the edema score in patients without prior ESS (r = 0.21; p < 0.05), and discharge in patients with prior ESS (r = 0.22; p < 0.05). All other domains and endoscopic variables did not significantly contribute to the canonical correlation.

CONCLUSION

Although aggregate symptoms and endoscopic scores demonstrate minimal correlation, a weighted combination of symptom domains and endoscopic attributes greatly improves this correlation. A simple approximation of the weights of each of the endoscopic variables of polyps, edema, discharge, scarring, and crusting, is an approximate ratio of 4:2:1:0:0, respectively.

Impact of postoperative endoscopy upon clinical outcomes after endoscopic sinus surgery

BACKGROUND

After endoscopic sinus surgery (ESS), endoscopy is used to gauge surgical success and clinical outcomes. Prior studies have not examined this topic prospectively using validated outcome metrics across multiple institutions.

METHODS

A multi-institutional, prospective study of patients with chronic rhinosinusitis (CRS) who underwent ESS completed the 22-item Sino-Nasal Outcome Test (SNOT-22), missed productivity, and medication usage questionnaires 6 months postoperatively. Lund-Kennedy endoscopy scoring (LKES) was performed with reviewers blinded to patient-reported data. A control cohort of non-CRS patients was recruited for comparison.

RESULTS

Complete data was available on 183 CRS patients and 48 non-CRS control patients. Approximately 50% of patients achieve perfect or near perfect endoscopy (LKES 0 to 2) after ESS. Postoperative endoscopy correlated with total SNOT-22 scores (r = 0.278, p < 0.001), with the strongest correlations to rhinologic and extranasal subdomains in the nasal polyp cohort. Improved postoperative endoscopy was associated with decreased antibiotic and oral steroid usage, but had little association with missed productivity. Among patients who achieved near perfect postoperative endoscopy, those with nasal polyps had SNOT-22 scores that were similar to non-CRS control patients (mean SNOT-22 scores 17.7 and 16.3, respectively). However, CRS patients without nasal polyps remained more symptomatic than non-CRS controls and CRS with nasal polyps patients despite nearly perfect endoscopy (mean SNOT-22 score 21.6).

CONCLUSION

Postoperative endoscopy correlates with SNOT-22 and medication usage in CRS patients. Polyp patients who achieve near perfect endoscopy have similar symptoms to healthy controls; however, nonpolyp patients with near perfect endoscopy still have rhinologic and extranasal symptoms that are worse than healthy controls.