Epidemiology of chronic rhinosinusitis: results from a cross-sectional survey in seven Chinese cities

BACKGROUND

Chronic sinusitis (CRS) is a common otorhinolaryngologic disease that is frequently encountered in everyday practice, but there is a lack of precise data regarding the prevalence of CRS in developing countries. We performed a national investigation in China to determine the prevalence and associated factors of CRS.

METHODS

We conducted a cross-sectional investigation in 2012. A stratified four-stage sampling method was used to select participants randomly from seven cities in mainland China. All participants were interviewed face-to-face via a standardized questionnaire. Unconditional logistic regression analyses were conducted to examine the association between smoking and sinusitis after adjusting for socio-demographic factors.

RESULTS

This study included a total of 10 636 respondents from seven cities. The overall prevalence of CRS was 8.0% and ranged from 4.8% to 9.7% in seven centres. Chronic sinusitis affected approximately 107 million people in mainland China. Chronic sinusitis was particularly prevalent among people with specific medical conditions, including allergic rhinitis, asthma, chronic obstructive pulmonary disease and gout. The prevalence was slightly higher among males (8.79%) than females (7.28%) (P = 0.004), and the prevalence varied by age group, ethnicity and marital status and education (P < 0.05), but not by household per capita income or living space (P > 0.05). Both second-hand tobacco smoke and active smoking were independent risk factors for CRS (P = 0.001).

CONCLUSIONS

Chronic sinusitis is an important public health problem in China. Our study provides important information for the assessment of the economic burden of CRS and the development and promotion of public health policies associated with CRS particularly in developing countries.

Aspirin-exacerbated respiratory disease: evaluation and management

The clinical syndrome of aspirin-exacerbated respiratory disease (AERD) is a condition where inhibition of cyclooxygenase-1 (COX-1) induces attacks of upper and lower airway reactions, including rhinorrhea and varying degrees of bronchospasm and laryngospasm. Although the reaction is not IgE-mediated, patients can also present with anaphylactic hypersensitivity reactions, including hypotension, after exposure to COX-1 inhibiting drugs. All patients with AERD have underlying nasal polyps and intractable sinus disease which may be difficult to treat with standard medical and surgical interventions. This review article focuses on the management of AERD patients with a particular emphasis on aspirin desensitization and continuous treatment with aspirin.

Cost Utility Analysis of Dupilumab Versus Endoscopic Sinus Surgery for Chronic Rhinosinusitis With Nasal Polyps

OBJECTIVE

Both endoscopic sinus surgery (ESS) and biologic therapies have shown effectiveness for medically-refractory chronic rhinosinusitis with nasal polyps (CRSwNP) without severe asthma. The objective was to evaluate cost-effectiveness of dupilumab versus ESS for patients with CRSwNP.

STUDY DESIGN

Cohort-style Markov decision-tree economic model with a 36-year time horizon.

METHODS

A cohort of 197 CRSwNP patients who underwent ESS were compared with a matched cohort of 293 CRSwNP patients from the SINUS-24 and SINUS-52 Phase 3 studies who underwent treatment with dupilumab 300 mg every 2 weeks. Utility scores were calculated from the SNOT-22 instrument in both cohorts. Decision-tree analysis and a 10-state Markov model utilized published event probabilities and primary data to calculate long-term costs and utility. The primary outcome measure was incremental cost per quality-adjusted life year (QALY), which is expressed as an Incremental Cost Effectiveness Ratio. One-way and probabilistic sensitivity analyses were performed.

RESULTS

The ESS strategy cost $50,436.99 and produced 9.80 QALYs. The dupilumab treatment strategy cost $536,420.22 and produced 8.95 QALYs. Because dupilumab treatment was more costly and less effective than the ESS strategy, it is dominated by ESS in the base case. One-way sensitivity analyses showed ESS to be cost-effective versus dupilumab regardless of the frequency of revision surgery and at any yearly cost of dupilumab above $855.

CONCLUSIONS

The ESS treatment strategy is more cost effective than dupilumab for upfront treatment of CRSwNP. More studies are needed to isolate potential phenotypes or endotypes that will benefit most from dupilumab in a cost-effective manner.

LEVEL OF EVIDENCE

2C Laryngoscope, 131:E26-E33, 2021.

Epidemiology and differential diagnosis of nasal polyps

BACKGROUND

Chronic rhinosinusitis (CRS) is one of the most common chronic medical conditions, with a significant impact on patient quality of life. CRS is broadly classified into two groups: CRS with nasal polyposis (CRSwNP) and CRS without NP (CRSsNP). Clinically, the major subtypes of CRSwNP may be divided into eosinophilic chronic rhinosinusitis (e.g., allergic fungal rhinosinusitis and aspirin-exacerbated respiratory disease [AERD]) and nasal polyps associated with neutrophilic inflammation (e.g., cystic fibrosis [CF]). CF is characterized by mutation of the gene encoding the CF transmembrane conductance regulator. Functional endoscopic sinus surgery is usually required for most NP patients with increased frequency in patients with AERD. This study provides a review of the epidemiology and major classification of CRSwNP.

METHODS

A review was performed of the literature regarding different subtypes of CRSwNP.

RESULTS

Many definitions of CRSwNP exist and estimates of prevalence vary.

CONCLUSION

CRSwNP is a clinical syndrome with a heterogeneous inflammatory profile. Of the subtypes associated with eosinophilic inflammation, AERD remains the most recalcitrant to medical and surgical therapeutic interventions.

Cystic fibrosis chronic rhinosinusitis: a comprehensive review

BACKGROUND

Advances in the care of patients with cystic fibrosis (CF) have improved pulmonary outcomes and survival. In addition, rapid developments regarding the underlying genetic and molecular basis of the disease have led to numerous novel targets for treatment. However, clinical and basic scientific research focusing on therapeutic strategies for CF-associated chronic rhinosinusitis (CRS) lags behind the evidence-based approaches currently used for pulmonary disease.

METHODS

This review evaluates the available literature and provides an update concerning the pathophysiology, current treatment approaches, and future pharmaceutical tactics in the management of CRS in patients with CF.

RESULTS

Optimal medical and surgical strategies for CF CRS are lacking because of a dearth of well-performed clinical trials. Medical and surgical interventions are supported primarily by level 2 or 3 evidence and are aimed at improving clearance of mucus, infection, and inflammation. A number of novel therapeutics that target the basic defect in the cystic fibrosis transmembrane conductance regulator channel are currently under investigation. Ivacaftor, a corrector of the G551D mutation, was recently approved by the Food and Drug Administration. However, sinonasal outcomes using this and other novel drugs are pending.

CONCLUSION

CRS is a lifelong disease in CF patients that can lead to substantial morbidity and decreased quality of life. A multidisciplinary approach will be necessary to develop consistent and evidence-based treatment paradigms.

Prominent role of IFN-γ in patients with aspirin-exacerbated respiratory disease

BACKGROUND

Aspirin-exacerbated respiratory disease (AERD) is distinguished from aspirin-tolerant asthma/chronic sinusitis in large part by an exuberant infiltration of eosinophils that are characterized by their overexpression of metabolic pathways that drive the constitutive and aspirin-induced secretion of cysteinyl leukotrienes (CysLTs).

OBJECTIVE

We defined the inflammatory milieu that in part drives CysLT overproduction and, in particular, the role of IFN-γ in the differentiation of eosinophils.

METHODS

Quantitative real-time PCR was performed for TH1 and TH2 signature cytokines on tissue from control subjects, patients with chronic hyperplastic eosinophilic sinusitis, and patients with AERD, and their cellular source was determined. The influence of IFN-γ on maturation, differentiation, and functionality of eosinophils derived from hematopoietic stem cells was determined.

RESULTS

Gene expression analysis revealed that tissue from both aspirin-tolerant subjects and patients with AERD display a TH2 cytokine signature; however, AERD was distinguished from chronic hyperplastic eosinophilic sinusitis by the prominent expression of IFN-γ. Intracellular and immunohistochemical cytokine staining revealed that the major sources of these cytokines were the eosinophils themselves. IFN-γ promoted the maturation of eosinophil progenitors, as measured by increased mRNA and surface expression of CCR3 and sialic acid-binding immunoglobulin-like lectin 8 (Siglec-8). Additionally, IFN-γ increased the expression of genes involved in leukotriene synthesis that led to increased secretion of CysLTs. IFN-γ-matured eosinophil progenitors were also primed, as demonstrated by their enhanced degranulation.

CONCLUSIONS

High IFN-γ levels distinguish AERD from aspirin-tolerant asthma and underlie the robust constitutive and aspirin-induced secretion of CysLTs that characterize this disorder.

Antimicrobial photodynamic therapy treatment of chronic recurrent sinusitis biofilms

BACKGROUND

Chronic recurrent sinusitis (CRS) is an inflammatory disease of the facial sinuses and nasal passages that is defined as lasting longer than 12 weeks or occurring more than 4 times per year with symptoms usually lasting more than 20 days. The National Institute for Health Statistics estimates that CRS is one of the most common chronic conditions in the United States, affecting an estimated 37 million Americans. The potential etiologies of CRS include bacteria, viruses, allergies, fungi, superantigens, and microbial biofilms. In clinical practice there is a significant subpopulation of patients with CRS who remain resistant to cure despite rigorous treatment regimens including surgery, allergy therapy, and prolonged antibiotic therapy. The reason for treatment failure is thought to be related to the destruction of the sinus mucociliary defense by the chronic sinus infection resulting in the development of secondary antibiotic-resistant microbial colonization of the sinuses and biofilm formation. Antimicrobial photodynamic therapy (aPDT) is a nonantibiotic broad-spectrum antimicrobial treatment that has been demonstrated to eradicate antibiotic-resistant bacteria and biofilms. The objective of this study was to demonstrate the effectiveness of a noninvasive aPDT treatment method of eradicating antibiotic resistant biofilms/microorganisms known to cause CRS in an in vitro model.

METHODS

Antibiotic-resistant planktonic bacteria and fungi and polymicrobial biofilms of Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus (MRSA) were grown on silastic sheets and treated with a methylene blue photosensitizer and 670 nm non-thermal-activating light. Cultures of the planktonic microorganisms and biofilms were obtained before and after light treatment to determine efficacy of planktonic bacteria and biofilm reduction.

RESULTS

The in vitro CRS planktonic microorganism and biofilm study demonstrated that aPDT reduced the CRS polymicrobial biofilm by >99.9% after a single treatment.

CONCLUSION

aPDT can effectively treat CRS polymicrobial antibiotic-resistant bacteria, fungi, and biofilms in vivo. Human clinical studies are currently planned to assess the safety and efficacy of this treatment for CRS.

Gender-specific differences in chronic rhinosinusitis patients electing endoscopic sinus surgery

BACKGROUND

The objective of this study was to investigate gender-specific differences in chronic rhinosinusitis (CRS) patients electing endoscopic sinus surgery (ESS).

METHODS

This study was a retrospective review of CRS patients electing ESS (2011-2013) at a tertiary-care center.

RESULTS

ESS was elected by 272 patients (mean age 54.6 years; 48.5% female). Mean Lund-Mackay computed tomography (CT) score was 10.9; total 22-item Sino-Nasal Outcome Test (SNOT-22) score was 41.8. Compared to men, women electing ESS had lower CT score (10.1 vs 11.7; p = 0.01) but higher total SNOT-22 score (44.9 vs 39; p = 0.02). Women reported significantly worse postnasal drainage (p < 0.0001) and embarrassment (p = 0.0021). SNOT-22 scores declined with advancing age (women, p = 0.003; men, p = 0.0005). Reduction in CT scores with age was seen only in males (p = 0.03). Stratifying by age, females aged 61 to 80 years had higher SNOT-22 scores compared to male counterparts (p = 0.04), whereas CT scores were similar. More women underwent surgery for CRS without nasal polyps (CRSsNP) (54.9%) whereas more men underwent surgery for CRS with nasal polyps (CRSwNP) (57.4%), but this difference missed statistical significance (p = 0.052). Women with CRSwNP had higher SNOT-22 scores than men (p = 0.02) for similar CT scores. Men electing ESS for CRSsNP had higher CT scores than women (p = 0.02). Women with CRSsNP aged 18 to 40 years reported higher SNOT-22 scores than men (p = 0.003), even though CT scores were lower (p = 0.005).

CONCLUSION

Equivalent numbers of men and women underwent ESS for CRS. Overall, women electing ESS had higher total SNOT-22 scores and lower Lund-Mackay CT scores than men. Women reported more problems with postnasal drainage (CRS overall, CRSsNP, and CRSwNP), embarrassment (CRS overall and CRSwNP), and facial pain (CRSwNP). Gender differences in CRS are poorly understood and merit further study.

Ivacaftor improves rhinologic, psychologic, and sleep-related quality of life in G551D cystic fibrosis patients

BACKGROUND

Ivacaftor is a cystic fibrosis transmembrane conductance regulator (CFTR) potentiator that improves pulmonary function in cystic fibrosis (CF) patients with at least 1 copy of the G551D CFTR mutation. The purpose of this study is to evaluate the impact of ivacaftor on chronic rhinosinusitis (CRS) symptoms in this population.

METHODS

The G551D Observational (GOAL) study was a multicenter prospective cohort study enrolling CF patients ≥6 years with at least 1 G551D mutation. Subjects were provided 20-item Sino-Nasal Outcome Test (SNOT-20) questionnaires prior to ivacaftor therapy and at 1, 3, and 6 months afterward. The impact on rhinologic (R), psychological (P), sleep (S), and ear/facial (E) quality of life (QOL) domains was evaluated separately.

RESULTS

Of 153 subjects, 129 (84%) completed all questionnaires. Typical baseline symptom burden was low (75% with scores <1) and degree of improvement (ie, reduced scores) was greater with higher baseline scores. SNOT-20 decreased, reflecting improvement, at all follow-up intervals (1 month: [mean change ± standard deviation] -0.25 ± 0.53, p < 0.01; 3 months; -0.29 ± 0.58, p < 0.01; 6 months: -0.21 ± 0.58, p = 0.02), but less than the prespecified minimal clinically important difference (0.8). Significant improvement was observed at 1, 3, and 6 months in the R domain (1 month: -0.24, p < 0.01; 3 months: -0.34, p < 0.01; 6 months: -0.25, p < 0.01) and P domain (1 month: -0.25, p < 0.01; 3 months: -0.32, p < 0.01; 6 months: -0.26, p < 0.01), and 1 and 3 months in the S domain (1 months: -0.35, p < 0.01; 3 months: -0.32, p < 0.01; 6 months: -0.18, p = 0.07). There was no improvement in the E domain at any time point.

CONCLUSION

Ivacaftor improves QOL in the R, P, and S domains in G551D CF patients, although QOL instruments validated for CRS may not translate well to CF CRS patients because symptom burden was surprisingly low.

Understanding the relationship between olfactory-specific quality of life, objective olfactory loss, and patient factors in chronic rhinosinusitis

BACKGROUND

Chronic rhinosinusitis (CRS) significantly impacts olfaction. However, the relationship between objective olfaction and patient-reported olfactory-specific quality of life (QOL) is not well understood. Furthermore, objective olfactory testing can be time consuming, so we sought to determine if patient-reported olfactory QOL can be used as screening tool for olfactory dysfunction.

METHODS

Olfactory dysfunction was evaluated in 109 patients with CRS using the Questionnaire of Olfactory Disorders-Negative Statements (QOD-NS) and the Sniffin' Sticks Test, assessing for olfactory threshold, discrimination, identification, and overall composite scores (TDI; composite score of threshold, discrimination, and identification). Regression analysis was performed to correlate olfactory metrics and patient and disease-specific factors with QOD-NS scores. Optimal QOD-NS scores to classify patients based upon objective olfactory function were established.

RESULTS

Bivariate and multivariate regression analyses of QOD-NS and CRS-associated comorbidities, objective measures of disease, demographics, and CRS-specific QOL were performed. Non-white race, depression, and worse 22-item Sino-Nasal Outcome Test (SNOT-22) scores correlated with worse QOD-NS scores (p < 0.005). Worse TDI scores correlated with worse QOD-NS scores, and discrimination had the strongest correlation (p < 0.001). Mean ± standard deviation (SD) QOD-NS scores for normosmia, hyposmia, and anosmia were 44 ± 7.2, 35.7 ± 12.8, and 31.6 ± 10.7, respectively. Receiver operating characteristic curve analysis revealed an area under the curve of 0.770 (p < 0.001), and a QOD-NS cutoff of 38.5 to have maximal Youden's index to define normal vs abnormal TDI score.

CONCLUSION

In CRS, QOD-NS correlates with non-white race, depression, SNOT-22, and TDI score, with discrimination having the strongest correlation. The QOD-NS also appears to be a feasible tool for olfaction screening.

RESOLVE: bioabsorbable steroid-eluting sinus implants for in-office treatment of recurrent sinonasal polyposis after sinus surgery: 6-month outcomes from a randomized, controlled, blinded study

BACKGROUND

Patients with recurrent sinonasal polyposis after endoscopic sinus surgery (ESS) have limited treatment options. Safety and efficacy were previously reported for a bioabsorbable sinus implant that elutes mometasone furoate for 3 months. Here we summarize longer-term outcomes.

METHODS

A randomized, controlled, blinded study with 100 chronic rhinosinusitis with nasal polyps (CRSwNP) patients who failed medical treatment and were considered candidates for revision ESS. Treated patients (n = 57) underwent in-office implant placement. Control patients (n = 43) underwent a sham procedure. Endoscopic grading at 3 months by clinicians was corroborated by an independent review of randomized videoendoscopies by a panel of 3 sinus surgeons. Six-month follow-up included endoscopic grading and patient-reported outcomes.

RESULTS

At 6 months, treated patients experienced significant improvement in Nasal Obstruction Symptom Evaluation (NOSE) score (p = 0.021) and >2-fold improvement in mean nasal obstruction/congestion score (-1.06 ± 1.4 vs -0.44 ± 1.4; p = 0.124). Endoscopically, treated patients experienced significant reduction in ethmoid sinus obstruction (p < 0.001) and bilateral polyp grade (p = 0.018) compared to controls. Panel review confirmed a significant reduction in ethmoid sinus obstruction (p = 0.010) and 2-fold improvement in bilateral polyp grade (p = 0.099), which reached statistical significance (p = 0.049) in a subset of 67 patients with baseline polyp burden ≥2 bilaterally. At 6 months, control patients were at 3.6 times higher risk of remaining indicated for ESS than treated patients.

CONCLUSION

The symptomatic and endoscopic improvements observed confirm the efficacy of the steroid-eluting implant for in-office treatment of CRSwNP after ESS. These longer-term 6-month study results demonstrate that the steroid-eluting implant represents a durable, safe, and effective treatment strategy for this patient population.

Symptom importance, patient expectations, and satisfaction in chronic rhinosinusitis

BACKGROUND

Sinonasal symptoms and poor quality of life (QOL) prompt chronic rhinosinusitis (CRS) patients to undergo sinus surgery (ESS). However, little is known regarding the symptoms most important to patients and how these impact expectations and postoperative satisfaction.

METHODS

A prospective, multi-institutional cohort study of 100 CRS patients undergoing ESS completed a novel adaptation of the 22-item Sino-Nasal Outcome Test (SNOT-22) wherein they rated how important it was for specific symptoms to improve after surgery, along with preoperative expectations and postoperative satisfaction. The primary satisfaction measure was whether a patient would choose to undergo endoscopic sinus surgery (ESS) again. A multivariate, logistic regression model was built using demographics, objective measures, and the adapted SNOT-22 data. Spearman correlation analysis was also performed.

RESULTS

Nasal obstruction was rated as "extremely" or "very" important by 93% of patients, followed by smell/taste, thick nasal discharge, need to blow nose, postnasal discharge, and sleep symptoms (range, 61-72%). Symptoms like sadness and embarrassment were not considered important by preoperative patients (≤28%). In multivariate logistic regression, postoperative satisfaction depended on preoperative expectations being met and ESS improving their most important symptoms (odds rato, 19.6-27.5; p < 0.005). Postoperative satisfaction was not correlated with achieving a minimal clinically important difference, but it was correlated with magnitude of change in SNOT-22 (r = 0.35; p < 0.05).

CONCLUSIONS

Nasal, smell, and sleep-related symptoms were consdidered most important by this cohort. Meeting of preoperative expectations, improvement of the most important symptoms, and the magnitude of change in the SNOT-22 may drive postoperative satisfaction.

Resveratrol has salutary effects on mucociliary transport and inflammation in sinonasal epithelium

OBJECTIVE/HYPOTHESIS

Therapeutic agents that enhance mucociliary transport (via stimulation of transepithelial Cl- secretion) and inhibit inflammation could provide considerable advantages over conventional treatments for chronic rhinosinusitis (CRS). The objectives of the present study were to investigate whether the polyphenolic compound resveratrol promotes transepithelial Cl- transport and inhibits KC/IL-8 secretion in sinonasal epithelium.

STUDY DESIGN

In vitro and in vivo study.

METHODS

Transepithelial Cl- transport was investigated in primary murine nasal septal (MNSE) and human sinonasal epithelial (HSNE) cultures. In vivo activity was also measured using the murine nasal potential difference assay. CFTR R-domain phosphorylation and cAMP levels were examined as a test of cAMP/PKA-dependent activation. In vitro LPS-induced KC/IL-8 secretion was quantified and compared to a panel of intranasal steroids.

RESULTS

Resveratrol(100 μM) significantly increased CFTR-mediated Cl- transport (change in short-circuit current, ΔI(SC) ) in both MNSE (13.51 ± 0.77 vs. 4.4 ± 0.66 [control]; P < .05) and HSNE (12.28 ± 1.08 vs. 0.69 ± 0.32 [control]; P < .05). Cl- secretion across in vivo murine nasal epithelium was also enhanced (-4 ± 1.8 vs. -0.8 ± 1.7mV [control], P < .05). There was no increase in cellular cAMP or CFTR R-domain phosphorylation detected. Resveratrol also significantly inhibited KC/IL-8 secretion in a dose-dependent fashion (pg/mL) in MNSE (181 ± 39[100 μM) vs. 94 ± 16 [200 μM] vs. 16 ± 22 [500 μM] vs. 1195 ± 355 [LPS control]; P < .001). The compound robustly abrogated KC/IL-8 secretion when compared to ciclesonide (765 ± 139), triamcinolone (561 ± 124), and budesonide (742 ± 428), but had similar activity to fluticasone proprionate (65 ± 47). Similar effects were demonstrated in HSNE (975 ± 244 [100 μM] vs. 1825 ± 144 [LPS control]; P < .001) with inhibition comparable to fluticasone proprionate (785 ± 277).

CONCLUSIONS

These in vitro and in vivo findings indicate resveratrol is a potent Cl- secretagogue and anti-inflammatory agent. Future clinical trials for CRS are warranted.

Medical and Surgical Advancements in the Management of Cystic Fibrosis Chronic Rhinosinusitis

PURPOSE OF REVIEW

The purpose of this review is to provide otolaryngologists with the most up-to-date advancements in both the medical and surgical management of CF-related sinus disease.

RECENT FINDINGS

Recent studies have supported more aggressive CRS management, often with a combination of both medical and surgical therapies. Comprehensive treatment strategies have been shown to reduce hospital admissions secondary to pulmonary exacerbations in addition to improving CRS symptoms. Still, current management strategies are lacking in both high-level evidence and standardized guidelines.

SUMMARY

The unified airway model describes the bi-directional relationship between the upper and lower airways as a single functional unit and suggests that CRS may play a pivotal role in both the development and progression of lower airway disease. Current strategies for CF CRS focus primarily on amelioration of symptoms with antibiotics, nasal saline and/or topical medicated irrigations, and surgery. However, there are no definitive management guidelines and there remains a persistent need for additional studies. Nevertheless, otolaryngologists have a significant role in the overall management of CF, which requires a multi-disciplinary approach and a combination of both surgical and medical interventions for optimal outcomes of airway disease. Here we present a review of currently available literature and summarize medical and surgical therapies best suited for the management of CF-related sinus disease.

Chronic sinusitis pathophysiology: the role of allergy

BACKGROUND

Chronic hyperplastic eosinophilic sinusitis (CHES) is an inflammatory disease characterized by eosinophil infiltration of sinus tissue that can present with and without nasal polyps (NPs). Aeroallergen sensitization in CHES occurs regularly, but the causality between allergen sensitivity, exposure, and disease is unclear.

METHODS

Allergen is unlikely to directly enter healthy sinuses either by diffusion or ciliary flow, and, even this is more problematic given the loss of patency of the ostia of diseased sinuses. Inflammation and tissue eosinophilia can develop secondary to allergen exposure in the nares, with systemic humoral recirculation of allergic cells including eosinophils, Th2 lymphocytes, and eosinophil precursors that are nonspecifically recruited back to the diseased sinuses.

RESULTS

The possibility of an allergic reaction to peptides derived from bacteria (i.e., Staphylococcus or superantigens) or fungi that colonize the diseased sinus also provides a plausible allergic mechanism.

CONCLUSION

Treatments of this disease include agents directed at allergic mediators such as leukotriene modifiers and corticosteroids, although this does not necessarily signify that an IgE-dependent mechanism can be ascribed. However, more recently, omalizumab has shown promise, including in patients without obvious aeroallergen sensitization. Although many aspects of the role of allergy in CHES remain a mystery, the mechanisms that are being elucidated allow for improved understanding of this disease, which ultimately will lead to better treatments for our patients who live daily with this disease.

Cost utility analysis of endoscopic sinus surgery for chronic rhinosinusitis with and without nasal polyposis

OBJECTIVE

To evaluate the cost-effectiveness of endoscopic sinus surgery (ESS) compared to medical therapy for patients with chronic rhinosinusitis (CRS) with and without nasal polyposis (NP).

STUDY DESIGN

Cohort-style Markov decision-tree economic model with a 36-year time horizon.

METHODS

Two cohorts of 229 CRS patients with and without NP who underwent ESS were compared with a matched cohort of 229 CRS patients from the Medical Expenditures Survey Panel database (Agency for Healthcare Research and Quality, Rockville, MD) who underwent medical management. Utility scores were calculated from sequential patient responses to the EuroQol five-dimensions questionnaire. Decision-tree analysis and a 10-state Markov model utilized published event probabilities and primary data to calculate long-term costs and utility. The primary outcome was the incremental cost per quality-adjusted life year (QALY). Thorough sensitivity analyses were performed.

RESULTS

The reference case for CRS with NP yielded an incremental cost-effectiveness ratio (ICER) for ESS versus medical therapy of $5,687.41/QALY. The reference case for CRS without NP yielded an ICER of $5,405.44/QALY. The cost-effectiveness acceptability curve in both cases demonstrated 95% certainty that the ESS strategy was the most cost-effective option at a willingness-to-pay threshold of $20,000/QALY or higher. These results were robust to one-way and probabilistic sensitivity analysis.

CONCLUSION

This study demonstrates the cost-effectiveness of ESS compared to medical therapy alone for the management of CRS patients both with and without NP. The presence of nasal polyps was not found to affect the overall cost-effectiveness of ESS.

LEVEL OF EVIDENCE

2C. Laryngoscope, 127:29-37, 2017.

Eosinophil production of prostaglandin D2 in patients with aspirin-exacerbated respiratory disease

BACKGROUND

Aspirin-exacerbated respiratory disease (AERD) differs from aspirin-tolerant disease in part because of eosinophilic tissue infiltration and overexpression of arachidonic acid metabolic pathway components that lead to enhanced secretion of cysteinyl leukotrienes and prostaglandin (PG) D₂ observed constitutively and paradoxically in response to aspirin and other COX inhibitors. We have previously demonstrated the capacity of IFN-γ to drive cysteinyl leukotriene expression and response.

OBJECTIVE

We investigated eosinophils as a source of PGD₂ production in patients with AERD.

METHODS

Eosinophils were enriched from tissue and peripheral blood obtained from control subjects, patients with aspirin-tolerant disease, and patients with AERD. mRNA was extracted and evaluated for expression of hematopoietic prostaglandin D synthase (hPGDS). Expression of hPGDS protein was confirmed with Western hybridization and immunofluorescence staining. Cells were stimulated with aspirin, and secretion of PGD₂ was quantified. CD34⁺ progenitor cells were isolated and matured into eosinophils in the presence or absence of IFN-γ and hPGDS mRNA, and PGD₂ release was measured.

RESULTS

Gene expression analysis revealed that eosinophils from tissue and blood of patients with AERD display increased levels of hPGDS compared with asthmatic and control samples. Western hybridization confirmed the increase in hPGDS mRNA translated to increased protein expression. Immunofluorescence confirmed mast cells and eosinophils from tissue of patients with AERD and asthma demonstrated hPGDS expression, with higher levels in eosinophils from patients with AERD. Incubation of eosinophils from blood and tissue with aspirin stimulated PGD₂ release. IFN-γ-matured eosinophil progenitors showed enhanced hPGDS expression and increased levels of PGD₂ release at baseline and after aspirin stimulation.

CONCLUSIONS

In addition to mast cells, eosinophils represent an important source of PGD₂ in patients with AERD and identify a new target for therapeutic intervention.

Photodynamic therapy of antibiotic-resistant biofilms in a maxillary sinus model

BACKGROUND

Chronic rhinosinusitis (CRS) is one of the most common chronic conditions in the United States. There is a significant subpopulation of CRS patients who remain resistant to cure despite rigorous treatment regimens including surgery, allergy therapy, and prolonged antibiotic therapy. Antimicrobial photodynamic therapy (aPDT) is a noninvasive nonantibiotic broad spectrum antimicrobial treatment. Our previous in vitro studies demonstrated that aPDT reduced CRS polymicrobial planktonic bacteria and fungi by >99.9% after a single treatment. However, prior to human treatment, the effectiveness of aPDT to eradicate polymicrobial biofilms in a maxillary sinus cavity must be demonstrated. The objective of this study was to demonstrate the effectiveness of a noninvasive aPDT treatment of antibiotic resistant biofilms known to cause CRS in a novel anatomically correct maxillary sinus in vitro model using an enhanced photosensitizer solution.

METHODS

Antibiotic resistant polymicrobial biofilms of Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus (MRSA) were grown in an anatomically correct novel maxillary sinus model and treated with a methylene blue/ethylenediamine tetraacetic acid (EDTA) photosensitizer and 670-nm nonthermal activating light. Cultures of the biofilms were obtained before and after light treatment to determine efficacy of biofilm reduction.

RESULTS

The in vitro maxillary sinus CRS biofilm study demonstrated that aPDT reduced the CRS polymicrobial biofilm by >99.99% after a single treatment.

CONCLUSION

aPDT can effectively treat CRS polymicrobial antibiotic resistant Pseudomonas aeruginosa and MRSA biofilms in a maxillary sinus cavity model.

The role of infection and antibiotics in chronic rhinosinusitis

OBJECTIVE

To review the current understanding of the role of infection and antibiotics in chronic rhinosinusitis.

REVIEW METHODS

PubMed literature search.

RESULTS

Chronic rhinosinusitis (CRS) in adults is an inflammatory condition and the role of infection is unclear. Biofilms are present in both CRS and normal patients so their role in CRS is unknown. Sinus cultures in CRS demonstrate a mixture of aerobic and anaerobic bacteria but may be hard to interpret due to contaminating nasal flora. Staphylococcus aureus is common in CRS patients but also present in 20-30% of nasal cultures in the normal population; eradicating this organism did not lead to symptom improvement versus placebo in a randomized controlled trial (RCT). In CRS patients who develop an episode of acute rhinosinusitis (ARS), bacteria typical of ARS can generally be cultured and require short-course treatment. For CRS, topical antibacterial or antifungal agents have shown no benefit over placebo in RCTs, although RCTs of topical antibacterial agents have been small. Oral macrolides and doxycycline, antibiotics with anti-inflammatory properties, are the only systemic antibiotics that have been evaluated in RCTs. One RCT found 3 weeks of doxycycline beneficial in patients with polyps but follow up was short (<3 months); RCTs of prolonged macrolide therapy have produced mixed results, and most show no benefit after cessation of therapy. Long-term antibiotic therapy may produce side effects and select increasingly resistant flora. The American Academy of Otolaryngology-Head and Neck Surgery guidelines recommend against treatment of CRS with antifungal agents but do not comment on the role of antibacterial treatment.

CONCLUSION

The role of infection in CRS is unknown, and the only well-defined role for antibiotics is for treatment of ARS episodes or their infectious complications.

LEVEL OF EVIDENCE

N/A.

Draf III mucosal graft technique: long-term results

BACKGROUND

The Draf III procedure is an effective endoscopic approach to the treatment of frontal sinus disorders, but has a significant restenosis rate. The objective of the current study is to assess long-term success of the Draf III mucosal grafting technique.

METHODS

Patients undergoing Draf III with mucosal grafting technique were prospectively enrolled. Demographics, indication for surgery, anterior-posterior (AP) diameter of frontal ostium, and complications were recorded. Failure was defined a priori as closure ≥50% of the intraoperative AP diameter at last clinical follow-up.

RESULTS

Ninety-six patients requiring Draf III with mucosal grafting were enrolled, 67 of which (average age 54 years; range, 15-84 years) had at least 1 year of follow-up (average 34 months; range, 12-85 months) and were included in the analysis. Reasons for the procedure included chronic rhinosinusitis with frontal ostium stenosis (n = 37), tumor (n = 26), and cerebrospinal fluid leak (n = 4). Average preoperative Lund-Mackay score was 13.9 ± 7.8. Average intraoperative AP diameter was 11.0 ± 1.9 mm. The procedure was highly effective with 97% (65/67) of patients maintaining a patent frontal sinus ostium (>50% intraoperative AP diameter) for the duration of follow-up (average postoperative diameter 9.9 ± 2.2 mm). However, the 2 Draf III failures remained patent, did not need further intervention, and were considered clinically successful. Three patients required reoperation for reasons unrelated to closure of the Draf III.

CONCLUSION

Common causes of failure following Draf III procedures include osteoneogenesis and stenosis. This study provides long-term data demonstrating excellent outcomes using the mucosal grafting technique.

Diagnostic value of clinical parameters in the prediction of aspirin-exacerbated respiratory disease in asthma

Purpose

Aspirin-exacerbated respiratory disease (AERD) has attracted a great deal of attention because of its association with increased asthma severity. However, oral aspirin challenge (OAC) to diagnose AERD is a time-consuming procedure, and some patients experience serious complications. Thus, we evaluated diagnostic values of non-invasive clinical parameters to predict AERD in asthmatic patients.

Methods

A total of 836 Korean subjects were recruited from an asthma cohort. They underwent OAC, and clinical parameters including the history of aspirin hypersensitivity, nasal polyposis, and chronic sinusitis of aspirin-tolerant asthma (ATA) and AERD asthmatic patients were compared.

Results

Significant differences (P<0.01) were found in eight parameters: age at diagnosis, body mass index, FEV1%, PC20, history of urticaria, nasal polyps, chronic sinusitis, and history of aspirin hypersensitivity. After logistic regression analysis based on the eight clinical parameters, nasal polyps, history of aspirin intolerance, sinusitis, and log [PC20 methacholine] remained significantly associated with AERD (P<0.05). The sensitivity and specificity of the history of aspirin hypersensitivity to predict AERD were 64.7% and 92.0%, respectively, and the positive and negative predictive values were 56.9% and 94.1%, respectively. Overall, the accuracy of the test was 88.2%. The accuracy of the tests for nasal polyps and chronic sinusitis were 67.3% and 60.4%, respectively.

Conclusions

Among clinical parameters associated with AERD, the history of aspirin hypersensitivity has the best positive and negative predictive values for the oral aspirin challenge test. Because the false-positive and -negative rates were still high, additional non-invasive methods are needed to reduce the rate of false outcomes.

The role of secondhand smoke in sinusitis: a systematic review

BACKGROUND

The objective of this study was to systematically review existing literature on the association between sinusitis and secondhand smoke (SHS) exposure.

METHODS

We performed a literature search encompassing the last 25 years in PubMed, EMBASE, and Cochrane CENTRAL. Inclusion criteria included English language papers containing original human data with at least 7 subjects. Data was systematically collected on study design, patient demographics, clinical characteristics/outcomes, and level-of-evidence (Oxford Center for Evidence-Based Medicine). Quality assessment was performed using the Newcastle-Ottawa scale. Two investigators independently reviewed all manuscripts.

RESULTS

The initial search yielded 116 abstracts, of which 19 articles were included. Thirteen (68.4%) of the 19 articles showed a statistically significant association between sinusitis and SHS. Seven (36.8%) studies specifically evaluated chronic rhinosinusitis (CRS) with 5 (71.4%) CRS studies demonstrating a significant association between CRS and SHS. Seventeen articles were case-control studies (Level 3b). For characterizing sinusitis, 6 (31.6%) studies included computed tomography (CT) or endoscopy in the diagnostic criteria, with 5 of these studies following rhinosinusitis taskforce guidelines. For determining presence of SHS, all studies used questionnaires and 2 (10.5%) studies also reported serum or urine cotinine levels.

CONCLUSION

A majority of the studies (68.4%) included in this systematic review showed a significant association between sinusitis and SHS. Furthermore, 5 (83.3%) of the 6 studies with objective diagnostic criteria (CT, endoscopy) found a significant association between sinusitis and SHS. Further higher-quality studies with objective diagnosis of sinusitis and quantification of SHS exposure should be performed in the future to better evaluate the relationship between sinusitis and SHS.

Chronic sinusitis refractory to standard management in patients with humoral immunodeficiencies

Chronic refractory sinusitis is a common feature in patients with primary immunodeficiencies. The efficacy of standard therapeutic strategies is questionable. In an open trial we evaluated the efficacy of azithromycin, N-acetylcysteine and topical intranasal beclomethasone (100 microg twice daily for 6 weeks) in 16 patients with primary immunodeficiencies (median age 13.5 years, range 5-32 years). All patients suffered from chronic sinusitis despite regular immunoglobulin replacement therapy every 3 weeks. Magnetic resonance imaging (MRI) scans were performed before and after 6 weeks of treatment to evaluate morphological changes in the paranasal sinuses. Nasal swabs and washings were taken for microbial analysis and measurement of inflammatory mediators (IL-8, tumour necrosis factor-alpha (TNF-alpha), eosinophilic cationic protein (ECP)) before and post therapy. Inflammatory mediators in nasal secretions were significantly elevated in patients: IL-8 median 2436 pg/ml (range 441-5435 pg/ml), TNF-alpha 37.3 pg/ml (3.75-524 pg/ml) and ECP 33 ng/ml (1.5-250 ng/ml) versus age-matched healthy controls: IL-8 median 212 pg/ml (99-825 pg/ml), TNF-alpha 3.77 pg/ml (2.8-10.2 pg/ml) and ECP 1.5 ng/ml (1.5-14.8 ng/ml) (P < 0.0001). Inflammation of the maxillary sinuses was confirmed by MRI scans in all patients, additionally infection of the ethmoidal and frontal sinuses was recorded in five patients. Bacterial growth appeared in 11 out of 16 cultures. In spite of therapy, no improvement in sinal inflammation visualized by MRI was achieved. Moreover, no significant decrease in pathogens and levels of inflammatory mediators could be detected (IL-8 1141 pg/ml, 426-4556 pg/ml; TNF-alpha 13.9 pg/ml, 4.1-291.6 pg/ml; ECP 32.3 ng/ml, 3.7-58.4 ng/ml). Our results demonstrate that conventional management of sinusitis is of little benefit in patients with chronic refractory sinusitis with an underlying immunodeficiency. More studies are needed to test antibiotic regimens, probably combined with surgical drainage and anti-inflammatory agents.

When do the risks of repeated courses of corticosteroids exceed the risks of surgery?

BACKGROUND

The management of chronic rhinosinusitis with nasal polyposis (CRSwNP) becomes unclear when patients require multiple courses of corticosteroids to maintain quality of life. Repeated courses of corticosteroids carry increased risks to patients. Although endoscopic sinus surgery (ESS) is an effective therapeutic modality, it also carries inherent risks. This study aims to identify the threshold at which the risks of repeated courses of corticosteroid exceed the risks of surgery.

METHODS

An evidence-based risk analysis was simulated using literature-reported complication rates, quality of life changes, and Medicare costs. Simulations were performed from the Medicare patient perspective, societal perspective, and the universal healthcare patient perspective.

RESULTS

All 3 simulations demonstrate a breakeven threshold favoring surgery over medical therapy when patients require oral corticosteroids (OCS) more often than once every 2 years in CRSwNP, once per year in CRSwNP/asthma, or twice per year for Samter's triad patients.

CONCLUSION

This represents the first rationalized evidence-based analysis for when surgery should be considered in place of repeated courses of oral corticosteroids. This threshold provides a guide for otolaryngologists to use when making clinical decisions with patients.

Characteristics of patients treated for orbital cellulitis: An analysis of inpatient data

OBJECTIVES/HYPOTHESIS

Orbital cellulitis represents a spectrum of diseases, some of which may progress to potentially serious complications. The authors used the Nationwide Inpatient Sample (NIS) database to analyze the epidemiologic features of pediatric and adult patients admitted for the treatment of orbital cellulitis and to examine associations with surgical management.

METHODS

The NIS was queried for patients admitted for treatment of orbital cellulitis from 2002 to 2010. Patient demographics, length of stay, hospital charges, and concomitant diagnoses were analyzed.

RESULTS

There were 14,149 cases of orbital cellulitis identified with 1,717 (12.1%) having undergone surgical management. Surgical patients were older (29.6 ± 23.4) and more commonly male (62.0%) (P = 0.004 and < 0.001, respectively). Patients who had surgical intervention had longer length of stay and higher hospital charges than nonsurgical patients (P < 0.001). Our study showed that the proportion of pediatric patients age 10 to 19 years (22.1%) undergoing surgery was four times that of patients < 5 years of age (5.1%) (P < 0.001). Patients with concomitant diagnoses of acute and chronic sinusitis, acute osteomyelitis, exophthalmos, diplopia, and conjunctival edema had significantly increased odds ratio of surgical intervention. Frontal sinusitis was the site most commonly associated with surgical intervention among sinusitis patients.

CONCLUSION

This study describes the characteristics of pediatric and adult patients admitted for orbital cellulitis from a national perspective. Patients 10 to 19 years of age were most likely to undergo surgical management. Acute and chronic sinusitis, acute osteomyelitis, exophthalmos, diplopia, and conjunctival edema were concomitant diagnoses associated with significantly increased odds ratio of surgical intervention.

LEVEL OF EVIDENCE

2C. Laryngoscope, 126:554-559, 2016.