Chronic rhinosinusitis in Europe--an underestimated disease. A GA²LEN study

Systemic and topical antibiotics for chronic rhinosinusitis

BACKGROUND

This review is one of six looking at the primary medical management options for patients with chronic rhinosinusitis.Chronic rhinosinusitis is common and is characterised by inflammation of the lining of the nose and paranasal sinuses leading to nasal blockage, nasal discharge, facial pressure/pain and loss of sense of smell. The condition can occur with or without nasal polyps. Systemic and topical antibiotics are used with the aim of eliminating infection in the short term (and some to reduce inflammation in the long term), in order to normalise nasal mucus and improve symptoms.

OBJECTIVES

To assess the effects of systemic and topical antibiotics in people with chronic rhinosinusitis.

SEARCH METHODS

The Cochrane ENT Information Specialist searched the Cochrane ENT Trials Register; CENTRAL (2015, Issue 8); MEDLINE; EMBASE; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 29 September 2015.

SELECTION CRITERIA

Randomised controlled trials (RCTs) with a follow-up period of at least three months comparing systemic or topical antibiotic treatment to (a) placebo or (b) no treatment or (c) other pharmacological interventions.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane. Our primary outcomes were disease-specific health-related quality of life (HRQL), patient-reported disease severity and the commonest adverse event - gastrointestinal disturbance. Secondary outcomes included general HRQL, endoscopic nasal polyp score, computerised tomography (CT) scan score and the adverse events of suspected allergic reaction (rash or skin irritation) and anaphylaxis or other very serious reactions. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics.

MAIN RESULTS

We included five RCTs (293 participants), all of which compared systemic antibiotics with placebo or another pharmacological intervention.The varying study characteristics made comparison difficult. Four studies recruited only adults and one only children. Three used macrolide, one tetracycline and one a cephalosporin-type antibiotic. Three recruited only patients with chronic rhinosinusitis without nasal polyps, one recruited patients with chronic rhinosinusitis with nasal polyps and one had a mixed population. Three followed up patients for 10 to 12 weeks after treatment had finished. Systemic antibiotics versus placebo Three studies compared antibiotics with placebo (176 participants).One study (64 participants, without polyps) reported disease-specific HRQL using the SNOT-20 (0 to 5, 0 = best quality of life). At the end of treatment (three months) the SNOT-20 score was lower in the group receiving macrolide antibiotics than the placebo group (mean difference (MD) -0.54 points, 95% confidence interval (CI) -0.98 to -0.10), corresponding to a moderate effect size favouring antibiotics (moderate quality evidence). Three months after treatment, it is uncertain if there was a difference between groups.One study (33 participants, with polyps) provided information on gastrointestinal disturbances and suspected allergic reaction (rash or skin irritation) after a short course of tetracycline antibiotic compared with placebo. We are very uncertain if antibiotics were associated with an increase in gastrointestinal disturbances (risk ratio (RR) 1.36, 95% CI 0.22 to 8.50) or skin irritation (RR 6.67, 95% CI 0.34 to 128.86) (very low quality evidence). Systemic antibiotics plus saline irrigation and intranasal corticosteroids versus placebo plus saline irrigation and intranasal corticosteroids One study (60 participants, some with and some without polyps) compared a three-month course of macrolide antibiotic with placebo; all participants also used saline irrigation and 70% used intranasal corticosteroids. Disease-specific HRQL was reported using SNOT-22 (0 to 110, 0 = best quality of life). Data were difficult to interpret (highly skewed and baseline imbalances) and it is unclear if there was an important difference at any time point (low quality evidence). To assess patient-reported disease severity participants rated the effect of treatment on a five-point scale (-2 for "desperately worse" to 2 for "cured") at the end of treatment (three months). For improvement in symptoms there was no difference between the antibiotics and placebo groups; the RR was 1.50 (95% CI 0.81 to 2.79; very low quality evidence), although there were also slightly more people who felt worse after treatment in the antibiotics group. There was no demonstrable difference in the rate of gastrointestinal disturbances between the groups (RR 1.07, 95% CI 0.16 to 7.10). General HRQL was measured using the SF-36. The authors stated that there was no difference between groups at the end of treatment (12 weeks) or two weeks later. Systemic antibiotics versus intranasal corticosteroids One study (43 participants, without polyps) compared a three-month course of macrolide antibiotic with intranasal corticosteroids. Patient-reported disease severity was assessed using a composite symptom score (0 to 40; 0 = no symptoms). It is very uncertain if there was a difference as patient-reported disease severity was similar between groups (MD -0.32, 95% CI -2.11 to 1.47; low quality evidence). Systemic antibiotics versus oral corticosteroids One study (28 participants, with polyps) compared a short course of tetracycline antibiotic (unclear duration, ˜20 days) with a 20-day course of oral corticosteroids. We were unable to extract data on any of the primary efficacy outcomes. It is uncertain if there was a difference ingastrointestinal disturbances (RR 1.00, 95% CI 0.16 to 6.14) or skin irritation (RR 2.00, 95% CI 0.20 to 19.62) as the results for these outcomes were similar between groups (very low quality evidence).

AUTHORS' CONCLUSIONS

We found very little evidence that systemic antibiotics are effective in patients with chronic rhinosinusitis. We did find moderate quality evidence of a modest improvement in disease-specific quality of life in adults with chronic rhinosinusitis without polyps receiving three months of a macrolide antibiotic. The size of improvement was moderate (0.5 points on a five-point scale) and only seen at the end of the three-month treatment; by three months later no difference was found.Despite a general understanding that antibiotics can be associated with adverse effects, including gastrointestinal disturbances, the results in this review were very uncertain because the studies were small and few events were reported.No RCTs of topical antibiotics met the inclusion criteria.More research in this area, particularly evaluating longer-term outcomes and adverse effects, is required.

Causes of Chronic Cough in Non-smoking Patients

Chronic cough is a common medical problem. The aim of the study was to analyze chronic cough causes in non-smoking patients and to search for demographic factors associated with different cough reasons. The etiology of cough was determined by medical history, diagnostic tests and response to specific treatment. Patients with significant abnormalities in the chest radiograph or spirometry were not included. The study included 131 non-smoking patients; median age 54 years, 77 % female. The most frequent causes of cough were gastroesophageal reflux disease (GERD) (62 %) and upper airway cough syndrome (UACS) (46 %). Cough variant asthma and non-asthmatic eosinophilic bronchitis (NAEB) were diagnosed in 32 (25 %) and 19 (15 %) patients, respectively. Other cough causes were found in 27 patients (21 %). Asthma was a significantly more common cause of chronic cough in women than in men (31 % vs. 3 %, p = 0.005). A reverse relationship was demonstrated for UACS (39 % vs. 67 %, p = 0.01). Patients with chronic cough aged >50 yrs were more likely to be diagnosed with less common cough causes. In conclusion, the most common chronic cough reasons are GERD and UACS. Asthma-related cough is diagnosed more frequently in females, while UACS-related cough is more frequent in males.

Effect of Chronic Rhinosinusitis With or Without Nasal Polyp on Quality of Life in South Korea: 5th Korea National Health and Nutrition Examination Survey Korean

OBJECTIVES

This is the first study of its kind to investigate the relationship between chronic rhinosinusitis (CRS) with or without nasal polyps (NP) and health-related quality of life (HRQoL) in the general adult Korean population. We sought to evaluate the association after adjustment for confounding factors. We also evaluated HRQoL according to presence of NP in CRS patients.

METHODS

In this cross-sectional study we used nationally representative samples from the 5th Korea National Health and Nutrition Examination Survey (2010-2012). A total of 17,490 participants were included in the study, of which 613 were diagnosed with CRS. Univariate analysis was conducted on healthy versus CRS groups, segregated by gender with weighted prevalence of demographic characteristics, socioeconomic status, and comorbid diseases. Subanalysis was carried out to evaluate the relationship between CRS with or without NP and HRQoL using EuroQol 5-dimension (EQ-5D) and visual analog scale (EQ-VAS). The odds ratios for EQ-5D were estimated by multiple logistic regression analyses with confounder adjustment.

RESULTS

Weighted prevalence of CRS of adult male was found to be 3.7% and CRS with nasal polyps (CRSwNP) 0.5%, while female CRS was 3.3% and CRSwNP 0.3%. There was no significant difference between the groups (P#x0003d;0.332). The scores for female, EQ-5D index (P for trend<0.001) and EQ-VAS (P for trend=0.002) showed decreasing trend from healthy participants to CRS without nasal polyps (CRSsNP) and from CRSsNp to CRSwNP. After adjusting for demographic characteristics, socioeconomic status, and comorbid diseases, EQ-5D scores; EQ-5D index (P<0.001) and EQ-VAS (P<0.001) exhibited poorer HRQoL compared to healthy participants, exclusively within the female group.

CONCLUSION

These data suggest that female patients with CRS are at higher risk of poor HRQoL. In addition, HRQoL of female CRSwNP was lower compared to those of CRSsNP and healthy participants.

Food Sensitization in Medically Resistant Chronic Rhinosinusitis with or without Nasal Polyposis

BACKGROUND

Nasal polyposis is a common nasal mass with unknown etiology. It has been assumed that allergy predisposes to polyp formation. Our objective was to compare the prevalence of food sensitization in medically resistant chronic rhinosinusitis patients with or without nasal polyposis.

METHODS

One hundred and fifty-five patients who fulfilled the inclusion and exclusion criteria were incorporated into this study. The results of their total serum IgE and food-specific IgE levels were examined.

RESULTS

The average age was 33 years (± 13) with 96 males and 59 females. The percentage of patients in each group that had a positive result for at least one tested allergen was 84% (88 patients in the sinusitis without polyposis group and 42 patients in nasal polyposis group). Patients without nasal polyposis reacted to an average of 4.6 foodstuffs, whereas patients with nasal polyposis reacted to 4.1. Egg white, sheefish and cherry were the most common type of sensitized food. There were no significant differences in the prevalence, type, number of positive food allergens and class level between the two groups.

CONCLUSIONS

Food sensitization is common in medically resistant chronic rhinosinusitis. Since food sensitization prevalence, type and severity do not significantly differ between the two groups studied, food atopy is unlikely to be a major factor in nasal polyposis pathogenesis.

Inflammatory endotypes of chronic rhinosinusitis based on cluster analysis of biomarkers

BACKGROUND

Current phenotyping of chronic rhinosinusitis (CRS) into chronic rhinosinusitis with nasal polyps (CRSwNP) and chronic rhinosinusitis without nasal polyps (CRSsNP) might not adequately reflect the pathophysiologic diversity within patients with CRS.

OBJECTIVE

We sought to identify inflammatory endotypes of CRS. Therefore we aimed to cluster patients with CRS based solely on immune markers in a phenotype-free approach. Secondarily, we aimed to match clusters to phenotypes.

METHODS

In this multicenter case-control study patients with CRS and control subjects underwent surgery, and tissue was analyzed for IL-5, IFN-γ, IL-17A, TNF-α, IL-22, IL-1β, IL-6, IL-8, eosinophilic cationic protein, myeloperoxidase, TGF-β1, IgE, Staphylococcus aureus enterotoxin-specific IgE, and albumin. We used partition-based clustering.

RESULTS

Clustering of 173 cases resulted in 10 clusters, of which 4 clusters with low or undetectable IL-5, eosinophilic cationic protein, IgE, and albumin concentrations, and 6 clusters with high concentrations of those markers. The group of IL-5-negative clusters, 3 clusters clinically resembled a predominant chronic rhinosinusitis without nasal polyps (CRSsNP) phenotype without increased asthma prevalence, and 1 cluster had a TH17 profile and had mixed CRSsNP/CRSwNP. The IL-5-positive clusters were divided into a group with moderate IL-5 concentrations, a mixed CRSsNP/CRSwNP and increased asthma phenotype, and a group with high IL-5 levels, an almost exclusive nasal polyp phenotype with strongly increased asthma prevalence. In the latter group, 2 clusters demonstrated the highest concentrations of IgE and asthma prevalence, with all samples expressing Staphylococcus aureus enterotoxin-specific IgE.

CONCLUSION

Distinct CRS clusters with diverse inflammatory mechanisms largely correlated with phenotypes and further differentiated them and provided a more accurate description of the inflammatory mechanisms involved than phenotype information only.

Inflammatory Diseases of the Lung Induced by Conventional Cigarette Smoke: A Review

Smoking-induced lung diseases were extremely rare prior to the 20th century. With commercialization and introduction of machine-made cigarettes, worldwide use skyrocketed and several new pulmonary diseases have been recognized. The majority of pulmonary diseases caused by cigarette smoke (CS) are inflammatory in origin. Airway epithelial cells and alveolar macrophages have altered inflammatory signaling in response to CS, which leads to recruitment of lymphocytes, eosinophils, neutrophils, and mast cells to the lungs-depending on the signaling pathway (nuclear factor-κB, adenosine monophosphate-activated protein kinase, c-Jun N-terminal kinase, p38, and signal transducer and activator of transcription 3) activated. Multiple proteins are upregulated and secreted in response to CS exposure, and many of these have immunomodulatory activities that contribute to disease pathogenesis. In particular, metalloproteases 9 and 12, surfactant protein D, antimicrobial peptides (LL-37 and human β defensin 2), and IL-1, IL-6, IL-8, and IL-17 have been found in higher quantities in the lungs of smokers with ongoing inflammation. However, many underlying mechanisms of smoking-induced inflammatory diseases are not yet known. We review here the known cellular and molecular mechanisms of CS-induced diseases, including COPD, respiratory bronchiolitis-interstitial lung disease, desquamative interstitial pneumonia, acute eosinophilic pneumonia, chronic rhinosinusitis, pulmonary Langerhans cell histiocytosis, and chronic bacterial infections. We also discuss inflammation induced by secondhand and thirdhand smoke exposure and the pulmonary diseases that result. New targeted antiinflammatory therapeutic options are currently under investigation and hopefully will yield promising results for the treatment of these highly prevalent smoking-induced diseases.

Surgical versus medical interventions in CRS and nasal polyps: comparative evidence between medical and surgical efficacy

CRS with nasal polyps (CRSwNP) is a subgroup of CRS, where polyps can be visualised in the middle meatus. In the general population, the prevalence is estimated to lie between 0.2 and 4 %. Up to 15 % of patients with asthma have nasal polyps and up to 45 % of patients with nasal polyps have asthma. The management of CRSwNP involves primary medical management, with surgery normally reserved for recalcitrant cases. Surgical techniques for CRSwNP range from simple polypectomy and endoscopic sinus surgery (ESS) to radical nasalisation with removal of the middle turbinates. We have reviewed the comparative literature regarding medical and surgical interventions in CRSwNP, with emphasis on outcomes, complications, cost-effectiveness and on the timing of surgery. Similar outcomes are reported for medical and surgical management, but there is sufficient evidence to support the role of surgery once symptoms have failed to adequately respond. There is insufficient evidence to define the optimal timing and extent of surgery.

Children with recurrent pneumonia and non-cystic fibrosis bronchiectasis

BACKGROUND

Recurrent pneumonia (RP) is one of the most frequent causes of pediatric non-cystic fibrosis (CF) bronchiectasis (BE) and a consequent accelerated decline in lung function. The aim of this study was to analyse the clinical records of children with RP in attempt to identify factors that may lead to an early suspicion of non-CF BE.

METHODS

We recorded the demographic and clinical data, and lung function test results of children without CF attending our outpatient RP clinic between January 2009 to December 2013 who had undergone chest high-resolution computed tomography ≥ 8 weeks after an acute pneumonia episode and ≤ 6 months before enrolment.

RESULTS

The study involved 42 patients with RP: 21 with and 21 without non-CF BE. The most frequent underlying diseases in both groups were chronic rhinosinusitis with post-nasal drip and recurrent wheezing (81 % and 71.4 % of those with, and 85.7 % and 71.4 % of those without BE). FEV1 and FEF25-75 values were significantly lower in the children with non-CF BE than in those without (77.9 ± 17.8 vs 96.8 ± 12.4, p = 0.004; 69.3 ± 25.6 vs 89.3 ± 21.9, p = 0.048). Bronchodilator responsiveness was observed in seven children with BE (33.3 %) and two without (9.5 %; p = 0.13).

CONCLUSIONS

Reduced FEV1 and FEF25-75 values seem associated with an increased risk of developing non-CF BE in children with RP. This suggests a need for further studies to confirm the diagnostic usefulness use of spirometry in such cases.

Long-term follow-up after ESS and balloon sinuplasty: Comparison of symptom reduction and patient satisfaction

CONCLUSION

This is the first controlled study of balloon sinuplasty's long-term efficacy with the follow-up time over 5 years. The results are in accordance with a previous 2-year-follow-up study. Both techniques retained the efficacy and patient satisfaction on average 6 years after the surgery.

BACKGROUND

Endoscopic sinus surgery (ESS) and balloon sinuplasty are considered as a treatment for chronic rhinosinusitis (CRS) after a failure of conservative therapy. High cost and lack of long-term follow-up studies restrain the use of balloon sinuplasty.

OBJECTIVE

The aim of this study was to compare long-term efficacy and satisfaction in CRS patients who had undergone maxillary sinus operation with either balloon sinuplasty or ESS technique. Previous or additional sinonasal operations were exclusion criteria.

MATERIALS AND METHODS

Study patients were recruited from 208 CRS-patients who underwent either ESS or balloon sinuplasty. Patients with nasal polyposis (gradus ≥ 2), previous sinonasal surgery, unilateral disease, or immune deficiency were excluded. Altogether 45 patients in the ESS group and 40 patients in the balloon group were included. Of these, 30 and 28, respectively, answered to a phone interview held on average 6 years after primary surgery. Symptom reduction and long-term satisfaction were evaluated by using symptom scores of 19 parameters altogether.

RESULTS

Both groups experienced improvement in symptoms and were equally satisfied with the operation. The number of patient-reported acute exacerbations was higher among the balloon dilated patients. Also, the reduction of thick nasal discharge was less evident in the balloon sinuplasty group. Four patients in the balloon sinuplasty group underwent revision surgery. There were no revisions in the ESS group.

The Heterogeneity Hidden in Allergic Rhinitis and Its Impact on Co-Existing Asthma in Adults: A Population-Based Survey

BACKGROUND

It has been suggested that there is some overlap between allergic rhinitis (AR), sinusitis and polyposis, but this has not been fully documented. The present study aimed to evaluate the prevalence of these co-existing diseases and their impact on bronchial asthma in the general population of Italy.

METHODS

Within the frame of the multicentre Gene Environment Interactions in Respiratory Diseases (GEIRD) study, a postal screening questionnaire including questions about self-reported symptoms of asthma, AR, AR with sinusitis without nasal polyps (AR + SsNP) and AR with sinusitis with nasal polyps (AR + SwNP) was administered. Random samples of subjects aged between 20 and 44 years (n = 5,162) answered the postal questionnaire in 4 Italian centres (Pavia, Sassari, Turin, Verona). In AR subjects, the association among AR only, AR + SsNP, AR + SwNP and bronchial asthma was estimated by the relative risk ratio (RRR) using multinomial regression models.

RESULTS

The prevalence of AR in the sample was 25.4% (95% CI 24.2-26.6). A self-reported diagnosis of AR + SsNP and AR + SwNP was reported by 5.7% (95% CI 5.0-6.3) and by 1.2% (95% CI 0.9-1.5) of the subjects, respectively. Current asthma was reported by 17.5% of the AR subjects. In the adjusted multivariate analysis, the risk of having current asthma (RRR = 2.31, 95% CI 1.29-4.15), of having at least 1 asthma attack per year (RRR = 2.30, 95% CI 1.19-4.46) and of having had an emergency department admission for respiratory diseases (RRR = 5.61, 95% CI 1.81-23.92) was higher for subjects with AR + SwNP than subjects with AR only.

CONCLUSIONS

The diagnosis of AR in the epidemiological setting includes heterogeneous upper airway diseases that affect the clinical features of AR and its interactions with asthma.

African American Patients with Chronic Rhinosinusitis Have a Distinct Phenotype of Polyposis Associated with Increased Asthma Hospitalization

BACKGROUND

Chronic rhinosinusitis (CRS) is a common inflammatory disease of the upper airways that is often categorized into subtypes including "with" and "without" nasal polyps. However, the influence of multiple important epidemiologic factors, including race, on CRS has not been investigated.

OBJECTIVE

The present study assessed various phenotypic characteristics of CRS in patients, living in the United States, with different racial backgrounds.

METHODS

We performed a large retrospective cohort study of patients with CRS treated at a large urban tertiary care referral center in Chicago.

RESULTS

African American (AA) patients with CRS living in Chicago were more likely to report hyposmia as a symptom of CRS. Furthermore, AA patients with CRS who failed medical therapy and required surgical intervention had a significantly higher frequency of nasal polyposis and aspirin-exacerbated respiratory disease, and a higher disease severity index on computed tomography imaging than did white patients with CRS. The increased polyposis in AAs was associated with increased hospitalization for asthma. There were no differences in the prevalence of atopy, asthma, atopic dermatitis, food allergy, duration of disease, or number of surgeries between different races.

CONCLUSIONS

AAs with refractory CRS are at increased risk for nasal polyposis, smell loss, aspirin-exacerbated respiratory disease, and a greater severity of disease based on imaging, resulting in increased health care utilization.

Safety of long-term high-volume sinonasal budesonide irrigations for chronic rhinosinusitis

BACKGROUND

Off-label high-volume sinonasal budesonide irrigations are commonly used during the management of chronic rhinosinusitis (CRS). Although short-term use (4 to 8 weeks) has been demonstrated to be safe, the long-term effects on the hypothalamic-pituitary-adrenal (HPA) axis remain unclear. The objective of this study is to determine whether CRS patients using long-term (minimum greater than 12 months) budesonide sinonasal irrigations have evidence of HPA axis suppression.

METHODS

Patients with CRS being managed with high-volume sinonasal budesonide irrigations were recruited from 2 tertiary level rhinology clinics between March 2014 and July 2015. Inclusion criteria were as follows: (1) adult (age greater than 18 years); (2) guideline-based diagnosis of CRS; (3) previous endoscopic sinus surgery; (4) minimum of twice daily high-volume sinonasal budesonide irrigation (concentration of 1 mg per irrigation; total daily dose of 2 mg); and (5) a minimum of 12-month duration. Exclusion criteria included systemic corticosteroid use within 3 months of HPA axis testing. The primary outcomes were morning (am) serum cortisol levels and, when indicated, cosyntropin stimulation levels.

RESULTS

A total of 35 patients fulfilled eligibility criteria and underwent HPA axis testing. Mean duration of budesonide sinonasal irrigation therapy use was 38.2 months (2.9 years). The mean ± standard deviation (SD) am serum cortisol was 431.2 ± 146.9 nmol/L (normal, 200 to 650 nmol/L). Subsequent cosyntropin stimulation tests, in indicated patients (n = 19), demonstrated no evidence of HPA axis suppression.

CONCLUSION

Outcomes from this study suggest that daily high-volume sinonasal budesonide irrigations fail to produce evidence of HPA axis suppression with prolonged courses lasting longer than 2 years.

The Olfactory Cleft Endoscopy Scale correlates with olfactory metrics in patients with chronic rhinosinusitis

BACKGROUND

Olfactory loss affects a majority of patients with chronic rhinosinusitis (CRS). Traditional objective measures of disease severity, including endoscopy scales, focus upon the paranasal sinuses and often have weak correlation to olfaction.

METHODS

Adults with CRS were prospectively evaluated by blinded reviewers with a novel Olfactory Cleft Endoscopy Scale (OCES) that evaluated discharge, polyps, edema, crusting, and scarring of the olfactory cleft. Objective olfactory function was assessed using "Sniffin' Sticks" testing, including composite threshold-discrimination-identification (TDI) scores. Olfactory-specific quality of life was evaluated using the short modified version of the Questionnaire of Olfactory Disorders (QOD-NS). Interrater and intrarater reliability was assessed among 3 reviewers for OCES grading. Multivariate linear regression was then used to test associations between OCES scores and measures of olfaction, controlling for potential confounding factors.

RESULTS

The OCES score was evaluated in 38 patients and had a high overall reliability (intraclass correlation coefficient [ICC] = 0.92; 95% confidence interval [CI], 0.91 to 0.96). The OCES significantly correlated with objective olfaction as measured by TDI score (p < 0.001), with TDI score falling by 1.13 points for every 1-point increase in OCES score. Similar significant associations were found for threshold, discrimination, and identification scores (p < 0.003 for all) after controlling for age, gender, race, and reviewer/review. The OCES was also highly associated with patient-reported QOD-NS scores (p = 0.009).

CONCLUSION

A novel olfactory cleft endoscopy scale, OCES, shows high reliability and correlates with both objective and patient-reported olfaction in patients with CRS. Further studies to determine prognostic value and responsiveness to change are warranted.

Epidemiology of chronic rhinosinusitis, selected risk factors, comorbidities, and economic burden

Chronic rhinosinusitis (CRS) is a relevant and prevalent medical condition in Germany, Europe and the world. If analysed in detail, the prevalence of CRS shows regional and temporary variety. In this review, currently available data regarding the prevalence of CRS is therefore sorted by country and/or region, time point of data collection and the CRS-definition employed. Risk factors like smoking and gastroesophageal reflux are discussed regarding their influence on CRS prevalence. Moreover, comorbidities of CRS, like asthma, conditions of the cardiovascular system and depression are listed and their influence on CRS is discussed. Furthermore, data on CRS prevalence in special cohorts, like immunocompromised patients, are presented. To estimate the economic burden of CRS, current data e.g. from Germany and the USA are included in this review.

Pathophysiology of chronic rhinosinusitis, pharmaceutical therapy options

Research in immunology has brought great progress in knowledge of inflammatory processes in the last 2 decades, which also has an impact on the upper airways. Our understanding of the pathophysiology of chronic rhinosinusitis developed from a rather mechanistic point of view with a focus on narrow clefts and mucociliary clearance to the appreciation of a complex network of immunological pathways forming the basis of disease. We today differentiate various forms of inflammation, we start to understand complex immune-regulatory networks and the reasons for their failure, and have already developed innovative approaches for therapy for the most severely ill subjects. Due to this new knowledge in inflammation and remodeling processes within mucosal tissue, specifically on the key driving factors, new diagnostic tools and therapeutic approaches for chronic rhinosinusitis have developed; the differentiation of endotypes based on pathophysiological principles will be crucial for the use of innovative therapies, mostly humanized monoclonal antibodies. Several hundred of those antibodies are currently developed for various indications and will impact our specialty as well as pneumology to a great extent.

Correlation between symptoms and objective findings may improve the symptom-based diagnosis of chronic rhinosinusitis for primary care and epidemiological studies

BACKGROUND

In primary care and epidemiological studies of chronic rhinosinusitis (CRS), symptom-based diagnosis is common, yet limited, because endoscopic and radiological signs are not considered.

OBJECTIVES

To evaluate the correlation between symptoms and objective findings of CRS to improve its symptom-based diagnosis for primary care and epidemiological studies by using data from a large-scale nationwide epidemiological study, the Korean National Health and Nutrition Examination Survey (KNHANES).

DESIGN

Cross-sectional study.

SETTING

Data from 2008 to 2012 KNHANES.

PARTICIPANTS

29,225 Adults aged >19 years.

OUTCOME MEASURES

Questionnaires targeted two major (nasal blockage and anterior/posterior nasal drip) and two minor (facial pain/pressure and reduction or loss of smell) symptoms. Nasal polyps or mucopurulent discharge from the middle meatus was defined as positive endoscopic findings for diagnosing CRS.

RESULTS

Of the four symptoms, reduction or loss of smell was the symptom most significantly related to positive endoscopic findings in multivariable analysis (OR=1.936 (95% CI 1.604 to 2.337)). The combinations of symptoms showed higher ORs than individual symptoms and combinations of reduction or loss of smell with other symptoms were statistically more reliable for positive endoscopic findings than other combinations.

CONCLUSIONS

Our results show that reduction or loss of smell was the symptom most significantly related to positive nasal endoscopic findings. Therefore, symptom-based diagnosis of CRS can be improved by considering reduction or loss of smell as an important symptom for positive endoscopic findings of CRS.

The Role of the Fibroblast in Inflammatory Upper Airway Conditions

Upper airway inflammation is one of the most frequent health care presentations. This is perhaps not surprising with our exposure to a myriad of environmental microbes, pollutants, and allergens. The precise pathophysiological mechanisms that cause persistent, exaggerated, upper airway inflammation rather than acute resolving illness remain unclear. Analysis of upper airway specimens identifies specific inflammatory cells, cytokine signatures, and fibrotic airway remodeling. Recent research has highlighted the role of stromal cells in the generation and persistence of chronic inflammation. Rather than simply being scaffolding or extracellular matrix-secreting cells on which organ systems are built, stromal cells including fibroblasts and osteocytes have their own independent immunologic functions. Here, we review the emerging inflammatory roles of upper airway fibroblasts, the majority of which appear to influence immune cell chemotaxis and amplify the inflammatory response.

Osteitis and chronic rhinosinusitis: a review of the current literature

Chronic rhinosinusitis is a common debilitating condition characterized by inflammation of the nose and paranasal sinuses. Osteitis is an associated finding but it is not clear whether it is cause or effect. This review will report on studies that have examined the role of osteitis in CRS, with the ultimate aim of clarifying the definition, pathogenesis and clinical implications of this relatively new clinical entity. Literature searches of Medline, EMBASE and CENTRAL using the search terms osteitis, rhinosinusitis, sinusitis, rhinitis, chronic disease, and recurrence were performed. 21 articles were identified and reviewed. The papers highlighted key pathological features including periosteal thickening, new woven bone formation, bone resorption, fibrosis and inflammatory cell infiltration. Radiological grading systems and basic science research into the role of matrix metalloproteinases and P-glycoprotein were also identified and reviewed.

Disparities in grant funding for Chronic rhinosinusitis

OBJECTIVES/HYPOTHESIS

The objective of this study was to identify the level of grant funding for chronic rhinosinusitis (CRS) with the purpose of elucidating if disparities exist compared to other common chronic diseases.

STUDY DESIGN

Review of four major health research grant agencies from the United States (National Institutes of Health), Canada (Canadian Institute of Health Research), and United Kingdom (National Institute of Health Research and Medical Research Council).

METHODS

Research operating grants awarded in the fields of CRS, asthma, diabetes, and dementia were identified using database-specific search strategies. Searches were limited to the previous 10 years (2004-2014). Comparator chronic diseases were chosen to have similar prevalence rates and low mortality risk. Research efficiency was calculated as the monetary value of grants awarded per paper published.

RESULTS

There is a large disparity in the number of grants awarded for research in CRS (n = 196; $74,774,384), asthma (n = 13,226; $8,358,861,941), diabetes (n = 54,902; $47,282,739,735), and dementia (n = 34,569; $16,709,900,125). In terms of research efficiency, CRS researchers received eight to 12 times less financial support per paper published compared to those in our comparator conditions.

CONCLUSIONS

This study has demonstrated that over the last 10 years, CRS is disproportionately underfunded (∼$75 million) compared to other similarly prevalent chronic diseases such as asthma (∼$8.3 billion), diabetes (∼$47.2 billion), and dementia (∼$16.7 billion). We feel this justifies further research into identifying and reducing barriers to obtaining grant support for CRS.

LEVEL OF EVIDENCE

NA.

Clinical and biological markers of difficult-to-treat severe chronic rhinosinusitis

Chronic rhinosinusitis (CRS) is a chronic inflammatory disease of the upper airways of which two major phenotypes exist, CRS without nasal polyps (CRSsNP) and CRS with nasal polyps (CRSwNP). Some patients with CRS have suboptimal response to current guideline treatments. These patients remain severe and uncontrolled by treatment and have a poor quality of life. It is highly important to identify both clinical and biological markers, so-called biomarkers, in this subset of patients. The presence of nasal polyps and comorbidity with asthma and with aspirin-exacerbated respiratory disease (AERD) are the most common clinical traits that have been associated to difficult-to-treat severe CRS. In addition to clinical traits, numerous biological markers, with known etiopathogenic roles in CRS, have been associated to difficult-to-treat or recalcitrant CRS. This review summarizes the existing knowledge of the clinical and biological markers associated to difficult-to-treat or uncontrolled severe CRS.

Increased expression of α7nAChR in chronic rhinosinusitis: The intranasal cholinergic anti-inflammatory hypothesis

OBJECTIVE

Chronic rhinosinusitis results from a dysfunctional host-environment interaction at the site of interface, in the nose and paranasal sinuses. A parasympathetic-mediated anti-inflammatory reflex is known to have a pivotal role in the control of damage induced by immune response to injury and infection; acetylcholine released by peripheral nerves interacts with nicotinic acetylcholine receptor subunit α7 - α7nAChR - of innate immune cells, inhibiting pro-inflammatory signalling. This work aims to investigate whether cholinergic function is implicated in chronic rhinosinusitis.

METHODS

α7nAChR mRNA and protein levels were measured in nasal biopsy specimens of 14 patients with CRSwNP, 8 with CRSsNP and 10 control subjects, undergoing surgery.

RESULTS

Gene expression levels of α7nAChR did not differ between groups; protein expression was significantly higher in CRSwNP than in CRSsNP (p=0.041), and both of these patient groups showed significant higher levels than controls (CRSwNP vs Controls - p=0.001; CRSsNP vs Controls - p=0.041).

CONCLUSION

Elevated α7nAChR protein levels suggest that the cholinergic system is involved in the inflammatory response of chronic rhinosinusitis. This can shed light on both, the disease pathophysiology and the development of future treatment options.

Rhinosinusitis in morbidity registrations in Dutch General Practice: a retro-spective case-control study

Background

There is only limited accurate data on the epidemiology of rhinosinusitis in primary care.

This study was conducted to assess the incidence of acute and chronic rhinosinusitis by analysing data from two Dutch general practice registration projects. Several patient characteristics and diseases are related to the diagnosis rhinosinusitis.

Methods

The Continuous Morbidity Registration (CMR) and the Transitionproject (TP) are used to analyse the data on rhinosinusitis in primary practice. Both registries use codes to register diagnoses.

Results

In the CMR 3244 patients are registered with rhinosinusitis and in the TP 5424 CMR: The absolute incidence of (acute) rhinosinusitis is 5191 (18.8 per 1000 patient years). Regarding an odds ratio of 5.58, having nasal polyps is strongest related to rhinosinusitis compared to the other evaluated comorbidities. A separate code for chronic rhinosinusitis exists, but is not in use.

TP: Acute and chronic rhinosinusitis are coded as one diagnosis. The incidence of rhinosinusitis is 5574 or 28.7 per 1000 patient years. Patients who visit their general practitioner with “symptoms/complaints of sinus”, allergic rhinitis and “other diseases of the respiratory system” have the highest chances to be diagnosed with rhinosinusitis. Medication is prescribed in 90.6 % of the cases.

Conclusions

Rhinosinusitis is a common diagnosis in primary practice. In the used registries no difference could be made between acute and chronic rhinosinusitis, but they give insight in comorbidity and interventions taken by the GP in case of rhinosinusitis.

Risk factors for chronic rhinosinusitis

PURPOSE OF REVIEW

To review the recent literature on risk factors for chronic rhinosinusitis (CRS) with an emphasis on genetic, comorbid diseases and environmental factors associated with CRS. Through identifying potential risk factors for CRS, we aim to glean insights into the underlying pathogenic mechanisms essential for developing effective therapeutic strategies.

RECENT FINDINGS

Recent findings demonstrate that genetics and comorbid medical conditions including airway diseases, gastroesophageal reflux disease, inflammatory and autoimmune diseases, and various demographic and environmental factors are associated with having a CRS diagnosis. Limitations of current studies include variable application of disease definitions, lack of prospective longitudinal studies and a disproportionate focus on tertiary care populations.

SUMMARY

CRS has a broad spectrum of associations ranging from genetics to comorbid diseases and environmental factors. These predisposing factors may provide valuable information for possible designing of therapeutic and preventive interventions. However, to better understand whether these associations cause CRS, further studies are needed to independently replicate findings, establish temporal relationships between exposure and disease onset, evaluate the influence of exposure dose on disease severity, and to understand the biological effects of these risk factors in the context of CRS.

Commentary on gender differences in prevalence, treatment, and quality of life of patients with chronic rhinosinusitis

Objective:

To examine the existing evidence on gender differences in the prevalence, treatment, and quality of life of patients with chronic rhinosinusitis (CRS).

Methods:

Review of the literature and expert opinion.

Results:

From a sociologic standpoint, women have historically been considered more likely to report symptoms, seek medical care, and give poorer self-evaluation of health, which may bias data toward increased prevalence and a greater effect of CRS on quality of life in women. However, the influence of gender seems to be restricted primarily to the evaluation of general quality of life, whereas the disease-specific health-related quality of life is not different between genders. Furthermore, migraine headaches, which are more common among women, may be misdiagnosed as CRS, which contributes to gender differences in the prevalence of CRS. The degree to which reported differences in prevalence and health utilization represent biologic or physiologic differences between genders is not known; however, differences in anatomic size, tobacco susceptibility, and hormonal factors have been speculated to increase the overall susceptibility to CRS in women compared with men.

Conclusions:

Focused research that examines the effect of gender on the development, treatment, and outcomes of CRS is warranted.

Association of Mucosal Organisms with Patterns of Inflammation in Chronic Rhinosinusitis

Background

Chronic rhinosinusitis is a multifactorial process disease in which bacterial infection or colonization may play an important role in the initiation or persistence of inflammatory response. The association between mucosal bacteria presence and inflammatory patterns has only been partially explored.

Objective

To demonstrate specific mucosal microorganisms possible association with inflammatory patterns.

Methods

We collected nasal polyps or sinus tissues from a clinical selection of six patient groups with defined sinus disease using tissue biomarkers. In the tissues, we detected bacteria using peptide nucleic acid fluorescence in situ hybridization (PNA-FISH).

Results

After reviewing a total of 115 samples (15–20 samples per group), the mucosal presence of Staphylococcus aureus was correlated with IL-5 and SE-IgE positive chronic rhinosinusitis with nasal polyps and nasal polyps from cystic fibrosis patients. Chronic rhinosinusitis without nasal polyps with TNFα >20 pg/ml was associated with the mucosal presence of Pseudomonas aeruginosa.

Conclusion

This study identifies the relationship between intramucosal microbes and inflammatory patterns, suggesting that bacteria may affect the type of inflammation in chronic rhinosinusitis. Additional investigation is needed to further identify the nature of the relationship.

Mycoplasma pneumoniaeandChlamydophila pneumoniae: a comparative study in patients with nasal polyposis and healthy controls

Introduction:

The role played byMycoplasma pneumoniaeandChlamydophila pneumoniaein the pathogenesis of chronic rhinosinusitis with nasal polyps has been the object of ongoing debate. We used real-time polymerase chain reaction to investigate the prevalence of both microorganisms in the nasal tissue samples of patients and controls.

Methods:

We extracted DNA from nasal polyp samples obtained during functional endoscopic sinus surgery and the inferior turbinate samples of controls undergoing septoplasty. We used the highly sensitive real-time polymerase chain reaction to detect the presence ofM pneumoniaeandC pneumoniaeDNA.

Results:

Patients with chronic rhinosinusitis with nasal polyps consisted of 62 individuals (39 men; mean age 51 years); the control group consisted of 24 individuals (13 men; mean age 45 years). All samples from both groups were negative forM pneumoniaeandC pneumoniaeDNA.

Conclusion:

We have demonstrated that the likelihood ofM pneumoniaeandC pneumoniaeacting as an ongoing inflammatory stimulus in chronic rhinosinusitis with nasal polyps is slim.

Underrecognized comorbidities of chronic obstructive pulmonary disease

COPD is associated with different comorbid diseases, and their frequency increases with age. Comorbidities severely impact costs of health care, intensity of symptoms, quality of life and, most importantly, may contribute to life span shortening. Some comorbidities are well acknowledged and established in doctors’ awareness. However, both everyday practice and literature searches provide evidence of other, less recognized diseases, which are frequently associated with COPD. We call them underrecognized comorbidities, and the reason why this is so may be related to their relatively low clinical significance, inefficient literature data, or data ambiguity. In this review, we describe rhinosinusitis, skin abnormalities, eye diseases, different endocrinological disorders, and gastroesophageal reflux disease. Possible links to COPD pathogenesis have been discussed, if the data were available.

Do patients with chronic rhinosinusitis benefit from consultation with an ENT-doctor?

CONCLUSION

By consulting an ENT-doctor, patients with chronic rhinosinusitis (CRS), in the general population, receive disease information and adjustment of treatment which can improve disease-specific Quality-of-Life and may improve objective measurements.

OBJECTIVES

This study aims to follow persons with clinical diagnosed CRS from the general population, to evaluate their benefit from consultation with an ENT-doctor in terms of severity of symptoms and Quality-of-Life.

METHODS

As part of a trans-European study, selected respondents to a survey questionnaire were invited for a clinical visit. Based on the European Position Paper on Rhinosinusitis and Nasal Polyps, persons were diagnosed with CRS and followed for 2 years. Quality-of-Life was measured using the Sino Nasal Outcome Test 22 and European Quality-of-Life - 5 Dimensions. Clinical examination included rhinoscopy, acoustic rhinometry, peak nasal inspiratory flow, smell test, and skin prick test.

RESULTS

Out of 91 persons with CRS, only 42% had previously consulted an ENT-doctor, and 51% were in current treatment for CRS. Most patients were advised medical treatment and 20% underwent surgery. Disease-specific Quality-of-Life, peak nasal inspiratory flow, olfactory function, and the nasal volume significantly increased over the 2-year period.

Biofilms in chronic rhinosinusitis: what is new and where next?

Background:

Chronic rhinosinusitis is a common, heterogeneous condition. An effective means of mitigating disease in chronic rhinosinusitis patients remains elusive. A variety of causes have been implicated, with the biofilm theory gaining increasing prominence.

Objective:

This article reviews the literature on the role of biofilms in chronic rhinosinusitis, in terms of pathophysiology and with regard to avenues for future treatment.

Methods:

A systematic review of case series was performed using databases with independently developed search strategies, including Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, Cochrane library, and Zetoc, in addition to conference proceedings and a manual search of literature, with the last search conducted on 18 January 2014. The search terms included the following, used in various combinations to maximise the yield of articles identified: ‘biofilms’, ‘chronic rhinosinusitis’, ‘DNase’, ‘extracellular DNA’ and ‘biofilm dispersal’.

Results:

The existing evidence lends further support for the role of biofilms (particularly the Staphylococcus aureus phenotype) in more severe, recalcitrant disease and poorer surgical outcomes.

Conclusion:

Multimodality treatment, with a shift in paradigm to incorporate anti-biofilm strategies, is likely to form the mainstay of future recalcitrant chronic rhinosinusitis management.

Passive smoke exposure in chronic rhinosinusitis as assessed by hair nicotine

BACKGROUND

Prevalence of passive smoke exposure is relatively unknown in chronic rhinosinusitis (CRS). Previous studies have attempted to establish this relationship using subjective, questionnaire-based methodologies to assess smoke exposure, thus introducing the potential for error bias. The purpose of this study was to accurately determine the prevalence of passive smoke exposure in CRS and control patients using hair nicotine levels as a quantitative measure of cigarette smoke exposure.

METHODS

Hair samples were obtained at time of surgery from 569 patients: 404 undergoing surgery for CRS and 165 controls undergoing surgery for repair of cerebrospinal fluid leak, removal of pituitary tumors, or adenoidectomy from 2007 to 2013. Patient charts were reviewed for reported smoking status. Hair nicotine was quantified using reversed-phase high-performance liquid chromatography. Nonsmoking patients were classified as passive smoke exposed or smoke naïve according to the hair nicotine results. Statistical analysis was performed to test for differences in demographic information and smoke exposure prevalence between CRS, CRS subtypes, and controls.

RESULTS

The prevalence of passive smoke exposure in CRS as documented by hair nicotine was lower than previously reported subjective estimates. Passive smoke exposure rates were equivalent between those with CRS versus controls and significantly higher in children. Severity of passive smoke exposure was also equivalent between CRS subsets and controls. Annual passive smoke exposure prevalence did not change over time.

CONCLUSION

There is no clear evidence of avoidance of passive smoke exposure in the CRS population compared with controls. Passive smoke exposure also remained stable over time despite recent regional implementation of smoking bans. Given the constancy of exposure, it is critical that the impact of passive smoke on CRS exacerbation, outcomes, and pathophysiology be evaluated in large-scale clinical studies.

Steroid-eluting sinus stents for improving symptoms in chronic rhinosinusitis patients undergoing functional endoscopic sinus surgery

BACKGROUND

Functional endoscopic sinus surgery (FESS) has become a well-established approach for treating patients with chronic rhinosinusitis (CRS) refractory to medical management. However, the surgical outcome may be compromised by postoperative inflammation, polyposis and adhesions, which often require subsequent intervention. Bioabsorbable, steroid-eluting sinus stents are inserted into the nose, sinuses or both following surgery to prevent stenosis of the sinus openings during the postoperative healing period. The slow release of corticosteroid aims to decrease mucosal oedema and expedite wound healing. Whether a steroid-eluting stent offers any beneficial effects in terms of improving sinonasal symptoms has not been systematically reviewed.

OBJECTIVES

To assess the safety and efficacy of steroid-eluting sinus stent placement in CRS patients after FESS.

SEARCH METHODS

The Cochrane Ear, Nose and Throat Disorders Group (CENTDG) Trials Search Co-ordinator searched the CENTDG Trials Register; Central Register of Controlled Trials (CENTRAL 2015, Issue 4); PubMed; EMBASE; CINAHL; Web of Science; Clinicaltrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 14 May 2015.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) comparing steroid-eluting sinus stents with non-steroid-eluting sinus stents, nasal packing or no treatment in adult CRS patients undergoing FESS.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by The Cochrane Collaboration.

MAIN RESULTS

We identified no RCTs that met our inclusion criteria. Among the 159 records retrieved using our search strategy, 21 trials had the potential to be included given that they had tested sinus stents, spacers and packing materials for patients with CRS undergoing FESS. However, we excluded these trials from the review because they met some but not all of the inclusion criteria.

AUTHORS' CONCLUSIONS

We are unable to provide evidence to establish whether steroid-eluting sinus stents have potential advantages and disadvantages for patients with CRS undergoing FESS. Future, high-quality RCTs are needed to assess whether or not steroid-eluting sinus stents confer any beneficial effects, over those of surgery alone, when compared to non-steroid sinus stents.

Efficacy of ESS in chronic rhinosinusitis with and without nasal polyposis: a Danish cohort study

Endoscopic sinus surgery (ESS) for patients with severe chronic rhinosinusitis (CRS) has become a well-established treatment in cases where medical therapy fails. Even though CRS patients are divided into two subgroups, CRS with nasal polyposis (CRSwNP) and CRS without nasal polyposis (CRSsNP), most studies present only results for the total cohort. This prospective cohort study evaluated the efficacy of ESS on both quality of life and olfactory function measures, in a cohort of Danish CRS patients diagnosed according to the EPOS criteria, with results analysed separately for the CRSwNP and CRSsNP subgroups. All 97 CRS patients who underwent ESS over an 18-month trial period were evaluated preoperative by SNOT-22 score, Sniffin' Sticks score, modified Lund-Kennedy endoscopic score and Lund-Mackay CT score. Patient outcomes were reevaluated at clinical follow-up 1 and 6 months postoperative. ESS efficiently and immediately improved quality of life for both CRSwNP and CRSsNP patients, with over 50 % reduction in SNOT-22 score 1 month after surgery, which sustained 6 months postoperative. Olfactory function measured by Sniffin' Sticks score showed overall improvement in both groups. ESS efficiently improved quality of life in both CRSwNP and CRSsNP patients, and surgery lead to an overall improvement in olfactory function. However, a minor proportion of patients experienced deterioration in olfactory function after ESS.

May chronic rhinosinusitis in children be diagnosed by clinical symptoms?

OBJECTIVES

Chronic rhinosinusitis (CRS) is a common disease in childhood but is often underdiagnosed because the symptoms are subtle and similar to other nasal pathologies. No clinical symptom is pathognomonic, and consensus documents suggest nasal fibroendoscopy (NF) or imaging criteria (computed tomography, magnetic resonance imaging) as the gold standards for diagnosis of CRS. However, considering the frequent unavailability of such tools to physicians, we designed this study to evaluate whether combinations of symptoms may achieve a clinical diagnosis of CRS in children as confirmed by NF.

METHODS

The study population consisted of 275 children with a clinical diagnosis of CRS, in 228 of whom diagnosis of CRS was confirmed by NF, while in 47 diagnosis was not confirmed by NF and they served as the control group. The symptoms considered were nasal obstruction, nasal discharge, cough, facial pain, and halitosis, using for statistical analysis multivariate logistic regression, Wald tests, and receiver operating characteristic (ROC) curve.

RESULTS

The multivariate logistic regression for CRS symptoms indicated rhinorrea as the strongest predictor of CRS. With three symptoms the probability of CRS was from 60% to 75% without rhinorrea and 77-91% in the presence of this symptom, with four symptoms the probability was over 93%, and with all the five symptoms the probability of having CRS was virtually 100%.

CONCLUSIONS

These findings suggest that an initial symptoms assessment may help to recognize children with a high probability of CRS, thus reducing the need of NF or imaging techniques.

Nocturnal GERD - a risk factor for rhinitis/rhinosinusitis: the RHINE study

BACKGROUND

It has been suggested that gastroesophageal reflux disease (GERD) is a risk factor for developing rhinitis/rhinosinusitis, but data are lacking. This is a prospective 10-year follow-up study of a large multicenter cohort from Northern Europe, evaluating the relationship between nocturnal GERD and noninfectious rhinitis (NIR).

METHODS

The study comprised 5417 subjects born between 1945 and 1973, who answered a questionnaire in 1999-2001 and again in 2010-2012. Noninfectious rhinitis was defined as having nasal obstruction, secretion, and/or sneezing without having the common cold. Odds ratios for developing NIR in relation to age, gender, BMI, smoking, asthma, and nocturnal GERD were calculated.

RESULTS

During the 10-year observation period, 1034 subjects (19.1%) developed NIR. Subjects reporting nocturnal gastroesophageal reflux in both 1999 and 2010 had more NIR in 2010 (2.8% vs 1.2%, P < 0.001). There was a significant dose-response relationship between the number of reflux episodes/week in 1999 and the risk of having NIR in 2010, P = 0.02. In the multiple regression adjusted for age, gender, BMI, tobacco smoke, and asthma, those with nocturnal GERD in 1999 (≥3 episodes of nocturnal gastroesophageal reflux symptoms per week) had an OR of 1.6 (95% CI 1.0-2.5, P = 0.03) to develop NIR in 2010. Smoking was associated both with an increased risk of developing NIR (30.7% vs 24.0%, P < 0.001) and with the development of nocturnal GERD.

CONCLUSION

This large, population-based, 10-year study indicates that nocturnal GERD was a risk factor for noninfectious rhinitis/rhinosinusitis. GERD should therefore be considered in patients with rhinitis of known and unknown origin.

Influence of self-reported chronic rhinosinusitis on health-related quality of life: a population-based survey

Chronic rhinosinusitis (CRS) is a frequently occurring chronic respiratory disease. There is evidence that effective treatment of CRS can improve patients’ quality of life, but the data regarding the extent to which CRS impairs patients’ quality of life (QoL) is sparse. This study aimed to evaluate the effect of self-reported CRS on health-related QoL and to determine whether the influence was associated with gender, age and socio-economic status. A four-stage random sampling method was used to select the participants from the general population in Guangzhou, China. All participants were interviewed face-to-face at their homes using a standardized questionnaire. The health-related QoL of each participant was assessed using the SF-36 Health Survey. The scores of the SF-36 after adjusting for gender, age, socioeconomic conditions, smoking and some important comorbid conditions were compared between the CRS group and the non-CRS group using analysis of covariance. A multiple linear regression model with interaction terms was established to determine whether CRS affected QoL to the same degree across the different subpopulations. Among a total of 1,411 participants aged at least 15 years, 118 persons (8.4%) had self-reported CRS. Subjects with CRS had an increased prevalence of allergic rhinitis, chronic obstructive pulmonary disease and gout than subjects without CRS. The CRS group had lower scores in all eight domains and the physical and mental component summary than those without CRS (P<0.05), and the greatest differences were in role emotional function (RE), general health (GH) and role physical function (RP). The impairments of the CRS participants in RE and RP were greater among the females than the males. Moreover, physical domains were affected to greater degrees among the elderly and those with high-level education. In conclusion, CRS is a common chronic disorder. Persons with self-reported CRS perceived themselves as having impaired QoL in both the physical and mental domains. These findings shed new light on the health burden of CRS and should be taken into account by clinicians involved in the care of CRS patients.

Prevalence of Chronic Rhinosinusitis in a Population of Patients with Gastroesophageal Reflux Disease

Background

An increased coexistence of gastroesophageal reflux disease (GERD) and chronic rhinosinusitis (CRS) has been reported in epidemiologic and register studies, and reflux has been shown more frequently in patients with CRS in studies using esophagus pH manometry compared to participants without CRS. A discussion is ongoing about whether there might be an association between these two diseases and, if so, whether the association is causal.

Objective

The purpose of this study was to clinically investigate the prevalence and symptom severity scores of CRS among patients with GERD. The results were compared with those of a randomly assigned control group from the general Danish population.

Method

In this case–control study, 82 patients with GERD were examined for CRS using the European Position Paper on Rhinosinusitis and Nasal Polyps criteria, which combine patient history and anterior/posterior rhinoscopy results. Sinonasal-related quality of life was assessed by using the Sino-Nasal Outcome Test 22 (SNOT-22). These results were compared with those of a population-based control group examined for CRS in the same way.

Results

The prevalence of CRS among patients with GERD was 20.7% (95% confidence interval [CI], 12.0%-29.5%), significantly higher than the CRS prevalence of 8.5% (95% CI, 6.8%-10.2%) in the background population. Patients with GERD and CRS had an average SNOT-22 score of 43.8, whereas patients with CRS from the background population scored, on average, 28.1. Having GERD increased the mean SNOT-22 score in patients with CRS by 15.7 (95% CI, 6.5-24.9).

Conclusion

The results of this study provide additional evidence of an association between GERD and CRS and indicate that GERD may play a role in the development of CRS. The results also show that sinonasal-related quality of life is decreased in patients with CRS who also suffer from GERD.

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.