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Böscke R. [Difficult-to-treat chronic rhinosinusitis-when the standard treatment is not effective and biologics are not available]. HNO 2024; 72:231-241. [PMID: 38472346 DOI: 10.1007/s00106-024-01443-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2024] [Indexed: 03/14/2024]
Abstract
BACKGROUND In recent years, significant improvements have been made in the treatment options for uncontrolled chronic rhinosinusitis (CRS) refractory to standard medical and surgical therapy. This is the result of a better understanding of the pathophysiology and the resulting development of biologicals for CRS with nasal polyps (CRSwNP). However, biologics are not (yet) available for all patients in Europe. OBJECTIVE Based on the session "Difficult-to-treat CRS, when biologics are not available" at the 29th Congress of the European Rhinologic Society (ERS) 2023 in Sofia, Bulgaria, the treatment options for uncontrolled CRS with the exclusion of biologics will be discussed. MATERIALS AND METHODS The content of the presentations "Is there a place for antibiotics?" "Indications for revision surgery," "Novel systemic treatment options," "Novel local treatment options," and "Phototherapy for nasal polyps" are outlined and supported by a review of the literature. RESULTS Various treatment options are available for managing uncontrolled CRS, even if biologic treatments are unavailable. Treatment options for type‑2 (T2) CRS include steroid rinses, repeated short-term oral steroids, steroid-eluting stents, and extended sinus surgery. In the case of nonsteroidal anti-inflammatory drug (NSAID)-exacerbated respiratory disease (NERD), acetylsalicylic acid (ASA) desensitization can be considered. Non-T2 endotypes or CRS without nasal polyps (CRSsNP) may benefit from several weeks of macrolides and xylitol rinses. CONCLUSION To accurately assess the efficacy of second-line therapies for treatment of difficult-to-treat CRS within an endotype-specific framework, additional controlled clinical trials are needed that take into account the heterogeneity of CRS endotypes.
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Affiliation(s)
- Robert Böscke
- Universitätsklinik für Hals-Nasen-Ohren-Heilkunde, Evangelisches Krankenhaus Oldenburg, Medizinischer Campus der Carl-von-Ossietzky Universität Oldenburg, Steinweg 13-17, 26122, Oldenburg, Deutschland.
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2
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Weber RK, Hildenbrand T, Kühnel T, Hoffmann TK, Betz C, Sommer F. ["Radical" versus "functional" surgery of the paranasal sinuses-A contradiction?]. HNO 2024; 72:102-112. [PMID: 37880356 DOI: 10.1007/s00106-023-01378-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2023] [Indexed: 10/27/2023]
Abstract
BACKGROUND AND OBJECTIVE The terms "functional" and "radical" paranasal sinus surgery were often considered to be different operations which were mutually exclusive. This overview aims to look at the basics of these terms and surgical procedures and to work out the resulting surgical concepts for clinically relevant indications. MATERIAL AND METHODS Selective literature analysis using the data base PubMed, corresponding textbooks and resulting secondary literature regarding functional and radical or extended paranasal sinus surgery. Similarly, the current literature regarding clinically relevant indications for sinus surgery were analyzed. RESULTS AND CONCLUSION Modern pathophysiological knowledge, anatomically and pathophysiologically substantiated endoscopic surgical procedures and the usage of up to date technical possibilities have resulted in concepts which combine functional and so-called radical or extended surgery of the paranasal sinuses that complement each other and sometimes even overlap. The preoperative diagnosis and definition of underlying diseases are decisive and should be as precise as possible, as the extent and surgical details mainly depend on them: a sole creation of free drainage pathways, an additional creation of anatomical access for subsequent topical treatment or a complete (radical) removal of a pathological process.
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Affiliation(s)
- Rainer K Weber
- Sektion Nasennebenhöhlen- und Schädelbasischirurgie, Traumatologie, Klinik für Hals‑, Nasen- und Ohrenheilkunde, Städtisches Klinikum Karlsruhe, Moltkestraße 90, 76133, Karlsruhe, Deutschland.
- Sinus Academy, Karlsruhe, Deutschland.
| | - Tanja Hildenbrand
- Klinik für Hals‑, Nasen- und Ohrenheilkunde, Universitätsklinikum Freiburg, Freiburg, Deutschland
| | - Thomas Kühnel
- Klinik für Hals-Nasen-Ohrenheilkunde, Universitätsklinikum Regensburg, Regensburg, Deutschland
| | - Thomas K Hoffmann
- Klinik für Hals‑, Nasen- und Ohrenheilkunde, Kopf- und Halschirurgie, Universitätsklinikum Ulm, Ulm, Deutschland
| | - Christian Betz
- Klinik für Hals‑, Nasen- und Ohrenheilkunde, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Fabian Sommer
- Klinik für Hals‑, Nasen- und Ohrenheilkunde, Kopf- und Halschirurgie, Universitätsklinikum Ulm, Ulm, Deutschland
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3
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Lv C, Li C, Qu J, Dong Y, Huang Z, Sun Y, Cui S, Huang Q, Wang B, Huo M, Zhou B. The Impact of the Nasal Mucosal Flap on Tissue Remodeling After Sinus Bone Drilling in Rabbit Models. Am J Rhinol Allergy 2024; 38:23-30. [PMID: 37936308 DOI: 10.1177/19458924231207547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2023]
Abstract
BACKGROUND Frontal sinus surgery remained a challenge of restenosis or obliteration of the drainage pathway caused by the scarring and neo-osteogenesis after mucosal stripping and bone drill-out. The pedicled or free nasal mucosal flap is typically used to repair the exposed bone surface to avoid or reduce recurrence. OBJECTIVE This study aimed to explore the histopathological mechanism of mucosal flaps repairing bare bone after mucosal resection and bone drill-out in the rabbit model. METHODS Thirty New Zealand white rabbits were used. Sixteen rabbits were selected as the experimental group, and Staphylococcus aureus was used to establish the CRS model (CRS group). Fourteen healthy rabbits were allocated to the control group (NCRS group). Each group was divided into two subgroups with or without mucosal flap repair (CRS-FLAP, CRS-NFLAP, NCRS-FLAP, and NCRS-NFLAP, respectively). The bony anterior and lateral walls of the maxillary sinus of each rabbit were abraded by the drill. The bare bone was then covered with a flap in FLAP subgroups. Bone remodeling and mucosal morphological changes were observed and compared by histopathological hematoxylin and eosin and Masson staining. RESULTS In the CRS-NFLAP subgroup, the regenerated epithelium lacked typical structure, accompanied by numerous inflammatory cell infiltration and collagen deposition. Conversely, the inflammatory reaction was mild in the CRS-FLAP subgroup, and there was less collagen deposition. The restored mucosal structure was like the normal mucosa. The epithelium in the NCRS-NFLAP subgroup was partially exfoliated, with few cilia, goblet cells, and glandular structures. Compared with the NCRS-NFLAP subgroup, the CRS-NFLAP subgroup showed significant bone remodeling with enhanced activity of osteoblast and osteoclast cells. CONCLUSIONS Pedicled mucosal flap repair could significantly reduce local mucosal and bone remodeling in a rabbit model of CRS.
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Affiliation(s)
- Cao Lv
- Department of Otolaryngology-Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
- Key Laboratory of Otolaryngology-Head and Neck Surgery, Ministry of Education, Beijing, China
- Department of Otolaryngology, The Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Cheng Li
- Department of Otolaryngology-Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
- Key Laboratory of Otolaryngology-Head and Neck Surgery, Ministry of Education, Beijing, China
| | - Jing Qu
- Department of Otolaryngology-Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
- Key Laboratory of Otolaryngology-Head and Neck Surgery, Ministry of Education, Beijing, China
- Department of Otolaryngology, Beijing Huaxin Hospital, First Hospital of Tsinghua University, Beijing, China
| | - Yi Dong
- Department of Otolaryngology-Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
- Key Laboratory of Otolaryngology-Head and Neck Surgery, Ministry of Education, Beijing, China
| | - Zhenxiao Huang
- Department of Otolaryngology-Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
- Key Laboratory of Otolaryngology-Head and Neck Surgery, Ministry of Education, Beijing, China
| | - Yan Sun
- Department of Otolaryngology-Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
- Key Laboratory of Otolaryngology-Head and Neck Surgery, Ministry of Education, Beijing, China
| | - Shunjiu Cui
- Department of Otolaryngology-Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
- Key Laboratory of Otolaryngology-Head and Neck Surgery, Ministry of Education, Beijing, China
| | - Qian Huang
- Department of Otolaryngology-Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
- Key Laboratory of Otolaryngology-Head and Neck Surgery, Ministry of Education, Beijing, China
| | - Bin Wang
- Department of Otolaryngology-Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
- Key Laboratory of Otolaryngology-Head and Neck Surgery, Ministry of Education, Beijing, China
| | - Mingrui Huo
- Department of Otolaryngology-Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
- Key Laboratory of Otolaryngology-Head and Neck Surgery, Ministry of Education, Beijing, China
| | - Bing Zhou
- Department of Otolaryngology-Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
- Key Laboratory of Otolaryngology-Head and Neck Surgery, Ministry of Education, Beijing, China
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4
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Conti DM, Correa EJ, Scadding GK. Is endoscopic sinus surgery sufficient to modify the evolution of adult AERD? Aspirin desensitization as a maintenance factor: systematic review. FRONTIERS IN ALLERGY 2023; 4:1250178. [PMID: 37744694 PMCID: PMC10516441 DOI: 10.3389/falgy.2023.1250178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 08/28/2023] [Indexed: 09/26/2023] Open
Abstract
Introduction Aspirin desensitization (AD) and aspirin therapy after desensitization (ATAD) are therapeutic interventions for patients with aspirin-exacerbated respiratory disease (AERD). Our aim is to investigate whether its addition to endoscopic sinus surgery (ESS) improves the overall prognosis of the disease. Methods A systematic review of the current literature including adult patients with a positive diagnosis of AERD undergoing endoscopic sinus surgery (ESS) in the context or in absence of upper airway comorbidity, prior to AD + ATAD. Conclusion This review concludes that the surgical approach is beneficial in AERD, but its effects are short-lived. Surgery should be considered initially with subsequent AD + ATAD in AERD patients, due to the sustained improvement achieved compared to those receiving ESS alone.
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Affiliation(s)
- Diego M. Conti
- The European Forum for Research and Education in Allergy and Airway Diseases Scientific Expert Team Members, Brussels, Belgium
| | - Eduardo J. Correa
- Otolaryngology Department, Hospital Comarcal de la Línea de La Concepción, Cádiz, Spain
| | - Glenis K. Scadding
- Department of Allergy & Rhinology, Royal National ENT Hospital, London, United Kingdom
- Division of Immunity and Infection, University College, London, United Kingdom
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Almosnino G, Little RE. Surgical management of rhinosinusitis for the allergist-immunologist. Ann Allergy Asthma Immunol 2023; 131:311-316. [PMID: 37220810 DOI: 10.1016/j.anai.2023.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 05/10/2023] [Accepted: 05/12/2023] [Indexed: 05/25/2023]
Abstract
Chronic rhinosinusitis (CRS) is a common chronic inflammatory disease characterized by inflammation of the sinus, with or without nasal passage inflammation, occurring for more than 12 weeks at a time. CRS has historically been classified in 2 categories: CRS without nasal polyps or CRS with nasal polyps (25%-30% of cases). The mainstay of treatment for CRS with or without nasal polyps is medical management, and options may include a combination of saline irrigation, nasal steroids, allergy medications, antibiotics, oral steroids, and treatment with targeted monoclonal antibodies. Unfortunately, up to 60% of patents report symptoms refractory to maximal medical therapy. As such, a combined approach of surgery and medical therapy may be offered. Endoscopic sinus surgery for CRS is approached in a stepwise fashion, ranging from the simplest technique, such as polyp removal, to more expanded approaches that open the paranasal sinuses and allow gravity-dependent drainage. This review article provides a review and in-depth explanation of various surgical approaches for CRS, including the indications, techniques, and respective outcomes for each one.
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Affiliation(s)
- Galit Almosnino
- Dartmouth Hitchcock Medical Center, Section of Otolaryngology Head and Neck Surgery, Lebanon, New Hampshire
| | - Ryan E Little
- Dartmouth Hitchcock Medical Center, Section of Otolaryngology Head and Neck Surgery, Lebanon, New Hampshire.
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6
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Petalas K, Goudakos J, Konstantinou GN. Targeting Epithelium Dysfunction and Impaired Nasal Biofilms to Treat Immunological, Functional, and Structural Abnormalities of Chronic Rhinosinusitis. Int J Mol Sci 2023; 24:12379. [PMID: 37569753 PMCID: PMC10419026 DOI: 10.3390/ijms241512379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 07/25/2023] [Accepted: 07/30/2023] [Indexed: 08/13/2023] Open
Abstract
Chronic rhinosinusitis (CRS) with (CRSwNP) or without (CRSsNP) nasal polyps is a prevalent and heterogeneous disorder existing as a spectrum of clinical conditions with complex underlying pathomechanisms. CRS comprises a broad syndrome characterized by multiple immunological features involving complex interactions between the genes, the microbiome, host- and microbiota-derived exosomes, the epithelial barrier, and environmental and micromilieu exposures. The main pathophysiological feature is an epithelial barrier disruption, accompanied by microbiome alterations and unpredictable and multifactorial immunologic overreactions. Extrinsic pathogens and irritants interact with multiple epithelial receptors, which show distinct expression patterns, activate numerous signaling pathways, and lead to diverse antipathogen responses. CRSsNP is mainly characterized by fibrosis and mild inflammation and is often associated with Th1 or Th17 immunological profiles. CRSwNP appears to be associated with moderate or severe type 2 (T2) or Th2 eosinophilic inflammation. The diagnosis is based on clinical, endoscopic, and imaging findings. Possible CRS biomarkers from the peripheral blood, nasal secretions, tissue biopsies, and nasally exhaled air are studied to subgroup different CRS endotypes. The primary goal of CRS management is to maintain clinical control by nasal douching with isotonic or hypertonic saline solutions, administration of nasal and systemic steroids, antibiotics, biologic agents, or, in persistent and more severe cases, appropriate surgical procedures.
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Affiliation(s)
| | - John Goudakos
- Department of Otorhinolaryngology-Head and Neck Surgery, 424 General Military Training Hospital, 56429 Thessaloniki, Greece;
| | - George N. Konstantinou
- Department of Allergy and Clinical Immunology, 424 General Military Training Hospital, Dorilaiou 10, Kalamaria, 55133 Thessaloniki, Greece
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Pendolino AL, Bandino F, Navaratnam A, Ross T, Qureishi A, Randhawa P, Andrews P. The role of large cavity sinus surgery in the management of chronic rhinosinusitis in non-steroidal anti-inflammatory drug exacerbated respiratory disease: a single-centre experience and long-term outcomes. J Laryngol Otol 2023; 137:883-889. [PMID: 36443933 DOI: 10.1017/s0022215122002468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This study aimed to discuss the role of large cavity functional endoscopic sinus surgery in the management of chronic rhinosinusitis with nasal polyps in patients with non-steroidal anti-inflammatory drug exacerbated respiratory disease. METHODS This was a retrospective review of patients undergoing large cavity functional endoscopic sinus surgery for non-steroidal anti-inflammatory drug exacerbated respiratory disease from January 2016 to March 2022. Population characteristics, pre- and post-operative number of functional endoscopic sinus surgical procedures, endoscopic polyp grade, Lund-Mackay score and nasal symptoms were recorded. RESULTS Thirteen consecutive patients with a median age of 47 years were included. They all failed maximal medical treatment and/or conservative functional endoscopic sinus surgery and underwent large cavity sinus surgery followed by post-operative maximal medical therapy. All patients showed an improvement in nasal symptoms with improved Lund-Mackay scores post-operatively. The median length of follow up was 1.5 years. CONCLUSION Large cavity functional endoscopic sinus surgery seems to halt the progression of chronic rhinosinusitis with nasal polyps in non-steroidal anti-inflammatory drug exacerbated respiratory disease. In this case series, large cavity functional endoscopic sinus surgery combined with optimal post-operative medical treatment appeared to switch off chronic rhinosinusitis with nasal polyps in patients with non-steroidal anti-inflammatory drug exacerbated respiratory disease.
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Affiliation(s)
- A L Pendolino
- Department of ENT, Royal National ENT & Eastman Dental Hospitals, London, United Kingdom
- Ear Institute, University College London, United Kingdom
| | - F Bandino
- Department of ENT, Royal National ENT & Eastman Dental Hospitals, London, United Kingdom
| | - A Navaratnam
- Department of ENT, Royal National ENT & Eastman Dental Hospitals, London, United Kingdom
| | - T Ross
- Department of ENT, Royal National ENT & Eastman Dental Hospitals, London, United Kingdom
| | - A Qureishi
- ENT Department, Oxford University Hospital, United Kingdom
| | - P Randhawa
- Department of ENT, Royal National ENT & Eastman Dental Hospitals, London, United Kingdom
| | - P Andrews
- Department of ENT, Royal National ENT & Eastman Dental Hospitals, London, United Kingdom
- Ear Institute, University College London, United Kingdom
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8
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De Corso E, Settimi S, Montuori C, Cantiani A, Corbò M, Di Bella GA, Sovardi F, Pagella F, Rigante M, Passali GC, Paludetti G, Galli J. How to manage recurrences after surgery in CRSwNP patients in the biologic era: a narrative review. ACTA OTORHINOLARYNGOLOGICA ITALICA : ORGANO UFFICIALE DELLA SOCIETA ITALIANA DI OTORINOLARINGOLOGIA E CHIRURGIA CERVICO-FACCIALE 2023; 43:S3-S13. [PMID: 37698095 PMCID: PMC10159635 DOI: 10.14639/0392-100x-suppl.1-43-2023-01] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 01/30/2023] [Indexed: 09/13/2023]
Abstract
Objective This narrative review analyses factors affecting recurrence of Chronic rhinosinusitis with nasal polyps (CRSwNP) after surgery, such as type, extension and completeness of endoscopic sinus surgery (ESS). We also described new implications in the management of recurrences after the advent of biologics. Methods We identified four topics: definition of disease state; factors linked to recurrence of polyps; evaluation and management of recurrence in clinical practice. Results We analysed the differences between exacerbation and recurrence, as well as the concept of "controlled disease". We focused on potential predictors of recurrence after ESS, such as type 2 inflammation, asthma, aspirin-exacerbated respiratory disease, incomplete initial surgery and lack of adherence to long-term post-operative local corticosteroids. We discussed the new aspects of diagnosis and treatment of recurrences after surgery, summarising our suggestions in a detailed algorithm for practical management of patients with recurrent disease. Conclusions The results emphasised the importance of accurate evaluation of patients with CRSwNP recurrence, focusing on the reasons of failure and risk of disease progression, in order to guide personalised interventions. It is crucial to define the concept of appropriate surgery, which affects the choice between starting a biologic or repeating surgery.
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Affiliation(s)
- Eugenio De Corso
- Unit of Otorhinolaryngology, “A. Gemelli” University Hospital Foundation IRCCS, Rome, Italy
| | - Stefano Settimi
- Unit of Otorhinolaryngology, “A. Gemelli” University Hospital Foundation IRCCS, Rome, Italy
- Department of Head, Neck and Sensory Organs, Catholic University of Sacred Heart, Rome, Italy
| | - Claudio Montuori
- Department of Head, Neck and Sensory Organs, Catholic University of Sacred Heart, Rome, Italy
| | - Alessandro Cantiani
- Department of Head, Neck and Sensory Organs, Catholic University of Sacred Heart, Rome, Italy
| | - Marco Corbò
- Department of Head, Neck and Sensory Organs, Catholic University of Sacred Heart, Rome, Italy
| | | | - Fabio Sovardi
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Fabio Pagella
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Mario Rigante
- Unit of Otorhinolaryngology, “A. Gemelli” University Hospital Foundation IRCCS, Rome, Italy
| | - Giulio Cesare Passali
- Unit of Otorhinolaryngology, “A. Gemelli” University Hospital Foundation IRCCS, Rome, Italy
- Department of Head, Neck and Sensory Organs, Catholic University of Sacred Heart, Rome, Italy
| | - Gaetano Paludetti
- Unit of Otorhinolaryngology, “A. Gemelli” University Hospital Foundation IRCCS, Rome, Italy
| | - Jacopo Galli
- Unit of Otorhinolaryngology, “A. Gemelli” University Hospital Foundation IRCCS, Rome, Italy
- Department of Head, Neck and Sensory Organs, Catholic University of Sacred Heart, Rome, Italy
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9
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Treatment Strategy of Uncontrolled Chronic Rhinosinusitis with Nasal Polyps: A Review of Recent Evidence. Int J Mol Sci 2023; 24:ijms24055015. [PMID: 36902445 PMCID: PMC10002552 DOI: 10.3390/ijms24055015] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 02/26/2023] [Accepted: 03/03/2023] [Indexed: 03/08/2023] Open
Abstract
Chronic rhinosinusitis (CRS) is recognized as a heterogeneous disease with a wide range of clinical features, resulting in significant morbidity and cost to the healthcare system. While the phenotypic classification is determined by the presence or absence of nasal polyps and comorbidities, the endotype classification has been established based on molecular biomarkers or specific mechanisms. Research on CRS has now developed based on information based on three major endotypes: types 1, 2, and 3. Recently, biological therapies targeting type 2 inflammation have been clinically expanded and may be applied to other inflammatory endotypes in the future. The purpose of this review is to discuss the treatment options according to the type of CRS and summarize recent studies on new therapeutic approaches for patients with uncontrolled CRS with nasal polyps.
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10
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Reyes Orozco F, Ulloa R, Lin M, Xepoleas M, Paoletti M, Liu X, Hur K. Adverse Events Associated With Image-Guided Sinus Navigation in Endoscopic Sinus Surgery: A MAUDE Database Analysis. Otolaryngol Head Neck Surg 2023; 168:501-505. [PMID: 35727630 DOI: 10.1177/01945998221107547] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 05/28/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The utilization of image-guided navigation during endoscopic sinus surgery (ESS) has increased significantly since its introduction. However, the most common associated complications are still unknown. This study describes and analyzes adverse events related to image-guided ESS. STUDY DESIGN Cross-sectional analysis. SETTING The Food and Drug Administration's 2018-2022 MAUDE database (Manufacturer and User Facility Device Experience). METHODS The MAUDE database was searched for all reports on adverse events involving sinus navigation systems used in ESS from 2018 to 2022. Reported events were reviewed and categorized. RESULTS During the study period, there were 1857 adverse events from 1565 reports, which were divided into device-related (n = 1834, 98.8%) and patient-related (n = 23, 1.2%) complications. The most common device-related complications were nonfunctionality of the system (n = 512, 27.9%), device imprecision (n = 427, 23.3%), and device sensing problems (n = 277, 15.1%). The most common patient-related complications were cerebrospinal fluid (CSF) leak (n = 14, 60.9%), intracranial injury (n = 4, 17.4%), and bleeding/hemorrhage (n = 3, 13.1%). Imprecision was associated with increased risk of navigation abortion by the surgeon (odds ratio, 1.50 [95% CI, 1.38-1.65]; P < .001) and increased risk of CSF leak (odds ratio, 16.5 [95% CI, 3.66-74.0]; P < .001) as compared with other device-related complications. CONCLUSIONS The most commonly reported device- and patient-related adverse events associated with image-guided sinus navigation systems were device nonfunction, imprecision, device sensing difficulties, and CSF leak. When imprecise navigation occurred, there was an increased likelihood of CSF leak and navigation abortion by the surgeon. Health care providers should be mindful of these possible complications when electing to use image-guided sinus navigation during ESS.
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Affiliation(s)
- Francis Reyes Orozco
- Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Ruben Ulloa
- Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Matthew Lin
- Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Meredith Xepoleas
- Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Marcus Paoletti
- Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Xuan Liu
- Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Kevin Hur
- Tina and Rick Caruso Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
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11
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Gong MJ, Wang YS, Lou M, Ma RP, Hu ZZ, Zheng GX, Zhang Y. HO-1: a new marker for predicting postoperative recurrence of CRSwNP. Acta Otolaryngol 2023; 143:170-175. [PMID: 36705254 DOI: 10.1080/00016489.2023.2168054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Chronic rhinosinusitis with polyps (CRSwNP) is a subtype of chronic rhinosinusitis and is highly prone to recurrence; therefore, it is urgent to find appropriate markers to predict recurrence of CRSwNP after surgery. PURPOSE We aim to investigate the expression of HO-1 in CRSwNP and assess its value of predicting postoperative recurrence of CRSwNP. METHODS We recruited 77 participants and collected clinical data of all. We use Immunohistochemical staining to determine the expression of HO-1 in tissues. We use Spearman correlation test to analyze the correlation between HO-1 positive cell count and clinical score, and ROC curve to assess the value of HO-1 positive cell count in predicting recurrence of CRSwNP. RESULTS HO-1 positive cells were macrophages and significantly increased in CRSwNP; HO-1 positive cell count was negatively correlated with preoperative SNOT-22 score; HO-1 can predict postoperative recurrence of CRSwNP, AUC = 0.80, p = 0.004. CONCLUSION HO-1 is a biochemical marker of CRSwNP and can predict postoperative recurrence of CRSwNP.
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Affiliation(s)
- Min-Jie Gong
- Department of Otolaryngology Head and Neck Surgery, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Yu-Sheng Wang
- Department of Otolaryngology Head and Neck Surgery, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Miao Lou
- Department of Otolaryngology Head and Neck Surgery, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Rui-Ping Ma
- Department of Otolaryngology Head and Neck Surgery, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Zhen-Zhen Hu
- Department of Otolaryngology Head and Neck Surgery, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Guo-Xi Zheng
- Department of Otolaryngology Head and Neck Surgery, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Ya Zhang
- Department of Otolaryngology Head and Neck Surgery, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
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Naclerio R, Mullol J, Stevens WW. A Decade of Clinical Advances in Chronic Rhinosinusitis: 2012-2022. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:43-50. [PMID: 36610759 DOI: 10.1016/j.jaip.2022.10.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 10/21/2022] [Accepted: 10/21/2022] [Indexed: 01/07/2023]
Abstract
The field of chronic rhinosinusitis (CRS) is constantly evolving. In the past 10 years, key advancements in basic and translational research as well as clinical studies have improved our understanding and management of CRS. Notably, treatment options have expanded to include novel therapeutic drugs, devices, and surgical techniques. Assessments of patient symptoms and their impact on quality of life have become more standardized. Progress has also been made in both determining the true prevalence of CRS and recognizing comorbidities that can impact CRS severity. Practice guidelines have also shifted from expert opinion to more data-driven analyses. This review highlights major clinical advancements made in the field of CRS over the past 10 years as well as identifies current gaps in knowledge that can form the basis for new areas of study over the next decade.
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Affiliation(s)
- Robert Naclerio
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Md
| | - Joaquim Mullol
- Rhinology Unit and Smell Clinic, Department of Otorhinolaryngology, Hospital Clinic Barcelona, University of Barcelona; Clinical and Experimental Respiratory Immunoallergy, Institute of Biomedical Investigations 'August Pi i Sunyer' (IDIBAPS) Centre for Biomedical Investigations in Respiratory Diseases (CIBERES), Institute of Health Carlos III, Barcelona, Catalonia, Spain
| | - Whitney W Stevens
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Ill.
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13
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Boiko NV, Stagnieva IV, Lodochkina OE, Kurbatova NV. [Experience with dupilumab in the treatment of chronic rhinosinusitis with nasal polyps]. Vestn Otorinolaringol 2023; 88:46-53. [PMID: 37767590 DOI: 10.17116/otorino20228804146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2023]
Abstract
Chronic rhinosinusitis (CRS) with nasal polyps is the most severe form of inflammatory diseases of the paranasal sinuses, especially in combination with comorbid asthma. A new avenue for the personalized treatment of severe forms of eosinophilic inflammation are biologics based on humanized monoclonal antibodies. OBJECTIVE To study the effectiveness of targeted therapy in patients with CRS with nasal polyps and comorbid asthma. MATERIAL AND METHODS 19 patients selected for biological therapy according to international criteria were studied. The patients were randomly divided into 2 groups. The first group included 10 patients treated with dupilumab. Dupilumab was administered subcutaneously 300 mg every 2 weeks for 24 weeks. Group 2 included 9 patients treated with reslizumab for severe eosinophilic asthma with comorbid CRS with nasal polyps. Reslizumab was administered intravenously 3 mg/kg body weight once every 4 weeks for 24 weeks. These patients constituted the comparison group. Both drugs are used in treatment of eosinophilic inflammation but have different biological targets. RESULTS Comparative analysis of the dynamics of the main indicators characterizing the clinical course of CRS with nasal polyps and asthma (SNOT-22, control of asthma symptoms - ACT, the results of SCT of the paranasal sinuses according to the Lund-Mackay score) revealed a positive trend in patients of both groups, more pronounced in patients receiving dupilumab. CONCLUSION Changes in CT of the paranasal sinuses, characterized by the Lund-Mackay score, the results of SNOT-22 and ACT are the most demonstrative and can be used to assess the results of treatment with biologics in patients with chronic rhinosinusitis with nasal polyps.
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Affiliation(s)
- N V Boiko
- Rostov State Medical University of the Ministry of Health of Russia, Rostov-on-Don, Russia
| | - I V Stagnieva
- Rostov State Medical University of the Ministry of Health of Russia, Rostov-on-Don, Russia
| | - O E Lodochkina
- Rostov State Medical University of the Ministry of Health of Russia, Rostov-on-Don, Russia
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14
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Aspirin-Exacerbated Respiratory Disease and the Unified Airway. Otolaryngol Clin North Am 2022; 56:107-124. [DOI: 10.1016/j.otc.2022.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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15
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Wang F, Chu W, Deng Z, Jing Q, Xie B. A Potential Role of B7-H4 Expression in Predicting the Recurrence of Chronic Rhinosinusitis with Nasal Polyps. J Inflamm Res 2022; 15:3421-3431. [PMID: 35711239 PMCID: PMC9192352 DOI: 10.2147/jir.s361868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 06/02/2022] [Indexed: 11/30/2022] Open
Abstract
Background Chronic rhinosinusitis with polyps (CRSwNP) is a common chronic inflammatory disease of the nasal cavity and sinuses with a high rate of postoperative recurrence. In this study, we aim to investigate the expression of B7-H4 in CRSwNP and its association with postoperative recurrence. Methods A total of 80 CRSwNP patients, including 40 primary CRSwNP (pCRSwNP) patients and 40 recurrent CRSwNP (rCRSwNP) patients, 27 chronic rhinosinusitis without polyps (CRSsNP) and 32 healthy controls (HC) were enrolled in this study, and the serum, nasal polyps and middle turbinate tissue samples were collected. Peripheral and tissue B7-H4 expressions were detected by enzyme-linked immunosorbent assay (ELISA) and reverse transcription-polymerase chain reaction (RT-PCR) and immunofluorescence, and their clinical values in predicting postoperative recurrence of CRSwNP were evaluated. Results We identified significantly higher tissue B7-H4 mRNA levels in the CRSwNP group than in the HC group, and elevated B7-H4 levels were associated with tissue eosinophil count and percentage (r = 0.469, P < 0.001; r = 0.521, P < 0.001). B7-H4 mRNA and protein levels were significantly higher in the rCRSwNP group than the pCRSwP group. Multivariate analysis and receiver operating characteristic (ROC) curves showed that tissue B7-H4 levels were associated with postoperative recurrence in patients with CRSwNP (P < 0.05). In addition, serum B7-H4 levels were significantly increased in the CRSwNP group than the CRS and HC groups, especially in the rCRSwNP group (P < 0.05), and the ROC curve presented a predictive ability of serum B7-H4 in predicting postoperative recurrence. Conclusion Our results indicated that B7-H4 level was clearly enhanced in CRSwNP patients and associated with postoperative recurrence. Serum B7-H4 might serve as a simple and convenient biomarker for early predicting postoperative recurrence in CRwNP patients.
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Affiliation(s)
- Fengjun Wang
- Department of Otolaryngology Head and Neck Surgery, Xiangya Hospital of Central South University, Changsha, Hunan, People's Republic of China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital of Central South University, Changsha, Hunan, 410008, People's Republic of China
| | - Wei Chu
- Department of Pathology, The People's Hospital of Shimen County, Changde, Hunan, People's Republic of China
| | - Zhenghao Deng
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital of Central South University, Changsha, Hunan, 410008, People's Republic of China.,Department of Pathology, Xiangya Hospital of Central South University, Changsha, Hunan, People's Republic of China
| | - Qiancheng Jing
- The Affiliated Changsha Central Hospital, Department of Otolaryngology Head and Neck Surgery, Hengyang Medical School, University of South China, Changsha, Hunan, People's Republic of China
| | - Bin Xie
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital of Central South University, Changsha, Hunan, 410008, People's Republic of China.,Department of Pathology, Xiangya Hospital of Central South University, Changsha, Hunan, People's Republic of China
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16
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Hopkins C, Lee SE, Klimek L, Soler ZM. Clinical Assessment of Chronic Rhinosinusitis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:1406-1416. [PMID: 35183784 DOI: 10.1016/j.jaip.2022.02.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 01/27/2022] [Accepted: 02/06/2022] [Indexed: 12/15/2022]
Abstract
Chronic rhinosinusitis (CRS) is a common disease that affects >10% of the adult population in Europe and the United States. It has been delineated phenotypically into CRS without nasal polyps and CRS with nasal polyps. Both have a high disease burden and an overlapping spectrum of symptoms such as nasal obstruction, olfactory dysfunction, facial pain, pressure, and nasal discharge. Primary assessment includes evaluation of patient symptoms and impact on quality of life, nasal endoscopic examination, and imaging. Significant progress has been made in the understanding of CRS pathophysiology. There is a move toward describing CRS in terms of the predominant endotype or inflammatory pattern pathomechanism rather than the traditional classification of patients with and without nasal polyps. An increased elucidation of the disease endotypes, as characterized by their inflammatory pathways and mediators, is leading to a tailored more personalized treatment approach to the different disease subtypes.
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Affiliation(s)
| | - Stella E Lee
- Division of Otolaryngology-Head & Neck Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Ludger Klimek
- Center for Rhinology and Allergology, Wiesbaden, Germany
| | - Zachary M Soler
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC
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17
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Nuutinen M, Haukka J, Virkkula P, Torkki P, Toppila-Salmi S. Using machine learning for the personalised prediction of revision endoscopic sinus surgery. PLoS One 2022; 17:e0267146. [PMID: 35486626 PMCID: PMC9053825 DOI: 10.1371/journal.pone.0267146] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 04/03/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Revision endoscopic sinus surgery (ESS) is often considered for chronic rhinosinusitis (CRS) if maximal conservative treatment and baseline ESS prove insufficient. Emerging research outlines the risk factors of revision ESS. However, accurately predicting revision ESS at the individual level remains uncertain. This study aims to examine the prediction accuracy of revision ESS and to identify the effects of risk factors at the individual level. METHODS We collected demographic and clinical variables from the electronic health records of 767 surgical CRS patients ≥16 years of age. Revision ESS was performed on 111 (14.5%) patients. The prediction accuracy of revision ESS was examined by training and validating different machine learning models, while the effects of variables were analysed using the Shapley values and partial dependence plots. RESULTS The logistic regression, gradient boosting and random forest classifiers performed similarly in predicting revision ESS. Area under the receiving operating characteristic curve (AUROC) values were 0.744, 0.741 and 0.730, respectively, using data collected from the baseline visit until six months after baseline ESS. The length of time during which data were collected improved the prediction performance. For data collection times of 0, 3, 6 and 12 months after baseline ESS, AUROC values for the logistic regression were 0.682, 0.715, 0.744 and 0.784, respectively. The number of visits before or after baseline ESS, the number of days from the baseline visit to the baseline ESS, patient age, CRS with nasal polyps (CRSwNP), asthma, non-steroidal anti-inflammatory drug exacerbated respiratory disease and immunodeficiency or suspicion of it all associated with revision ESS. Patient age and number of visits before baseline ESS carried non-linear effects for predictions. CONCLUSIONS Intelligent data analysis identified important predictors of revision ESS at the individual level, such as the frequency of clinical visits, patient age, Type 2 high diseases and immunodeficiency or a suspicion of it.
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Affiliation(s)
- Mikko Nuutinen
- Haartman Institute, University of Helsinki, Helsinki, Finland
- Nordic Healthcare Group, Helsinki, Finland
| | - Jari Haukka
- Department of Public Health, University of Helsinki, Helsinki, Finland
| | - Paula Virkkula
- Department of Otorhinolaryngology-Head and Neck Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Paulus Torkki
- Department of Public Health, University of Helsinki, Helsinki, Finland
| | - Sanna Toppila-Salmi
- Haartman Institute, University of Helsinki, Helsinki, Finland
- Skin and Allergy Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
- * E-mail:
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18
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Damask C. AERD: Current Roles for Aspirin Desensitization, Surgery, and Biologic Therapies. CURRENT OTORHINOLARYNGOLOGY REPORTS 2022. [DOI: 10.1007/s40136-022-00399-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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19
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Kato A, Peters AT, Stevens WW, Schleimer RP, Tan BK, Kern RC. Endotypes of chronic rhinosinusitis: Relationships to disease phenotypes, pathogenesis, clinical findings, and treatment approaches. Allergy 2022; 77:812-826. [PMID: 34473358 PMCID: PMC9148187 DOI: 10.1111/all.15074] [Citation(s) in RCA: 83] [Impact Index Per Article: 41.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 08/25/2021] [Indexed: 02/06/2023]
Abstract
Chronic rhinosinusitis (CRS) is a common clinical syndrome that produces significant morbidity and costs to our health system. The study of CRS has progressed from an era focused on phenotype to include endotype-based information. Phenotypic classification has identified clinical heterogeneity in CRS based on endoscopically observed features such as presence of nasal polyps, presence of comorbid or systemic diseases, and timing of disease onset. More recently, laboratory-based findings have established CRS endotype based upon specific mechanisms or molecular biomarkers. Understanding the basis of widespread heterogeneity in the manifestations of CRS is advanced by findings that the three main endotypes, Type 1, 2, and 3, orchestrate the expression of three distinct large sets of genes. The development and use of improved methods of endotyping disease in the clinic are ushering in an expansion of the use of biological therapies targeting Type 2 inflammation now and perhaps other inflammatory endotypes in the near future. The purpose of this review is to discuss the phenotypic and endotypic heterogeneity of CRS from the perspective of advancing the understanding of the pathogenesis and improvement of treatment approaches and outcomes.
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Affiliation(s)
- Atsushi Kato
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Anju T Peters
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Department of Otolaryngology - Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Whitney W Stevens
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Department of Otolaryngology - Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Robert P Schleimer
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Department of Otolaryngology - Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Bruce K Tan
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Department of Otolaryngology - Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Robert C Kern
- Department of Otolaryngology - Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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20
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Age related non-type 2 inflammation and its association with treatment outcome in patients with chronic rhinosinusitis with nasal polyp in Korea. Sci Rep 2022; 12:1671. [PMID: 35102253 PMCID: PMC8803874 DOI: 10.1038/s41598-022-05614-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 01/11/2022] [Indexed: 11/18/2022] Open
Abstract
This study aimed to investigate the effect of age in patients with chronic rhinosinusitis with nasal polyp (CRSwNP). 269 patients were divided into eosinophilic and non-eosinophilic groups based on tissue eosinophilia, defined by eosinophils accounting for more than 20% of the total inflammatory cells. Patients were then further divided into younger and older groups based on the age of 35 years. Clinical characteristics including blood eosinophil, Lund Mackay score, and modified Lund-Kennedy (mLK) scores were compared. Levels of 14 cytokines from nasal tissues of an additional 78 patients were analyzed. Tissue eosinophilia was significantly associated with age and the proportion of non-eosinophilic CRSwNP was significantly higher in younger patients as compared to older patients (79.2% vs 56.6%). There was no difference in clinical characteristics and cytokine levels between the younger and older patients with eosinophilic CRSwNP. In contrast, in patients with non-eosinophilic CRSwNP, younger patients had significantly lower preoperative blood eosinophils and higher mLK scores at three and six months, postoperatively, compared to older patients. Alpha-1 antitrypsin and IL-5 levels were significantly lower in younger patients than in older patients in non-eosinophilic CRSwNP. This study suggests a potential association between age, non-type 2 inflammation and treatment outcome in CRSwNP.
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21
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Wen S, Cheng S, Xie S, Zhang H, Xie Z, Jiang W. Serum YKL-40 Levels Predict Endotypes and Associate with Postoperative Recurrence in Patients with Chronic Rhinosinusitis with Nasal Polyps. J Asthma Allergy 2021; 14:1295-1306. [PMID: 34744439 PMCID: PMC8565991 DOI: 10.2147/jaa.s335964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 10/08/2021] [Indexed: 12/02/2022] Open
Abstract
Background Chronic rhinosinusitis with nasal polyps (CRSwNP) is a global health concern with high heterogeneity and rate of postoperative recidivation. YKL-40 is a pivotal pro-inflammatory mediator to promote Th2 immune response which is involved in many inflammatory diseases. This study aimed to investigate the predictive value of serum YKL-40 in CRSwNP endotypes and postoperative recurrence. Methods We recruited 80 primary CRSwNP, 40 recurrent CRSwNP patients and 40 healthy controls (HCs) in this study, and the serum and tissue specimens were collected. The middle turbinate mucosa tissue collected from patients undergoing septoplasty was used as control. Serum YKL-40 concentrations were detected by enzyme-linked immunosorbent assay (ELISA), and tissue YKL-40 mRNA and protein levels were examined using quantitative real-time polymerase chain reaction (qRT-PCR) and immunohistochemistry (IHC). The difference of YKL-40 expression was compared among different group. Multivariate analysis and receiver operating characteristic (ROC) curve were performed to evaluate the value of serum YKL-40 in discriminating eosinophilic CRSwNP (eCRSwNP) and predicting postoperative recurrence. Results The serum YKL-40 levels in CRSwNP patients were higher than HCs, especially in eCRSwNP patients (p < 0.05). The elevated YKL-40 levels positively correlated with blood eosinophil percentage, tissue eosinophil counts and percentages (p < 0.05). The serum YKL-40 levels in recurrent CRSwNP patients were markedly enhanced than primary CRSwNP patients (p < 0.05). The YKL-40 mRNA and protein levels were significantly elevated in CRSwNP patients compared to HCs, especially in eCRSwNP and recurrent CRSwNP group. Multivariate analysis and ROC curve exhibited that serum YKL-40 might be a promising indicator in distinguishing CRSwNP endotypes and predicting postoperative recurrence. Conclusion Our data suggested that YKL-40 might be unregulated in CRSwNP and associated with mucosal eosinophilia and recurrence. Serum YKL-40 appeared to a novel biomarker for predicting CRSwNP endotypes and postoperative recurrence of CRSwNP.
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Affiliation(s)
- Sihui Wen
- Department of Otolaryngology Head and Neck Surgery, Xiangya Hospital of Central South University & Hunan Province Key Laboratory of Otolaryngology Critical Diseases, Changsha, Hunan, 410008, People's Republic of China
| | - Shenghao Cheng
- Department of Otolaryngology Head and Neck Surgery, Xiangya Hospital of Central South University & Hunan Province Key Laboratory of Otolaryngology Critical Diseases, Changsha, Hunan, 410008, People's Republic of China
| | - Shaobing Xie
- Department of Otolaryngology Head and Neck Surgery, Xiangya Hospital of Central South University & Hunan Province Key Laboratory of Otolaryngology Critical Diseases, Changsha, Hunan, 410008, People's Republic of China
| | - Hua Zhang
- Department of Otolaryngology Head and Neck Surgery, Xiangya Hospital of Central South University & Hunan Province Key Laboratory of Otolaryngology Critical Diseases, Changsha, Hunan, 410008, People's Republic of China
| | - Zhihai Xie
- Department of Otolaryngology Head and Neck Surgery, Xiangya Hospital of Central South University & Hunan Province Key Laboratory of Otolaryngology Critical Diseases, Changsha, Hunan, 410008, People's Republic of China
| | - Weihong Jiang
- Department of Otolaryngology Head and Neck Surgery, Xiangya Hospital of Central South University & Hunan Province Key Laboratory of Otolaryngology Critical Diseases, Changsha, Hunan, 410008, People's Republic of China
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22
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Kuan EC, Kennedy WP, Patel NN, Goshtasbi K, Kohanski MA, Tong CC, Papagiannopoulos P, Kennedy DW, Palmer JN, Adappa ND, Bosso JV. Pre-intervention SNOT-22 scores predict outcomes in aspirin exacerbated respiratory disease. Am J Otolaryngol 2021; 42:103025. [PMID: 33836482 DOI: 10.1016/j.amjoto.2021.103025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 03/28/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE This study evaluated whether stratified preoperative, pre- aspirin desensitization (AD) sinonasal symptom scores predict postoperative, post-AD outcomes in Aspirin exacerbated respiratory disease (AERD). MATERIALS AND METHODS Retrospective chart review of patients with aspirin challenge-proven AERD who underwent endoscopic sinus surgery followed by AD was performed. Preoperative, postoperative/pre-AD, and postoperative/post-AD sinonasal symptom scores were collected (22-item Sino-Nasal Outcomes Test, SNOT-22). A longitudinal linear mixed-effects model was used for data analysis. RESULTS Forty-seven patients (59.6% female) aged 48.0 ± 13.2 were included. Average time from surgery to AD was 70.0 ± 52.8 days. Preoperative SNOT-22 scores (n = 47) were divided into tertiles (cutoffs of 36 and 54 indicating mild [22.5 ± 13.7], moderate [44.3 ± 12.2], and severe [72.9 ± 19.7] disease). This corresponded to 12 (25.5%), 18 (38.3%), and 17 (36.2%) subjects being categorized into mild, moderate, and severe tertiles, respectively. Postoperative, pre-AD SNOT-22 in all disease groups decreased and were not significantly different (12.3 ± 13.7, 11.1 ± 12.2, 22.7 ± 19.7; p = 0.074). At short-term post-AD, only the severe group worsened (35.0 ± 20.3, p < 0.001), whereas other groups demonstrated negligible change (9.3 ± 14.3 and 14.4 ± 12.2). At long-term post-AD, all groups redemonstrated convergence in symptom scores (23.7 ± 20.9, 19.4 ± 15.4, and 31.0 ± 27.6, p = 0.304). CONCLUSION Preoperative SNOT-22 scores may be used as a predictor of postoperative, post-AD patient-reported outcomes in AERD. Patients with mild and moderate disease may derive benefit from surgery and AD alone, while those with severe disease may require additional interventions (e.g., biologics).
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23
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Orlandi RR, Kingdom TT, Smith TL, Bleier B, DeConde A, Luong AU, Poetker DM, Soler Z, Welch KC, Wise SK, Adappa N, Alt JA, Anselmo-Lima WT, Bachert C, Baroody FM, Batra PS, Bernal-Sprekelsen M, Beswick D, Bhattacharyya N, Chandra RK, Chang EH, Chiu A, Chowdhury N, Citardi MJ, Cohen NA, Conley DB, DelGaudio J, Desrosiers M, Douglas R, Eloy JA, Fokkens WJ, Gray ST, Gudis DA, Hamilos DL, Han JK, Harvey R, Hellings P, Holbrook EH, Hopkins C, Hwang P, Javer AR, Jiang RS, Kennedy D, Kern R, Laidlaw T, Lal D, Lane A, Lee HM, Lee JT, Levy JM, Lin SY, Lund V, McMains KC, Metson R, Mullol J, Naclerio R, Oakley G, Otori N, Palmer JN, Parikh SR, Passali D, Patel Z, Peters A, Philpott C, Psaltis AJ, Ramakrishnan VR, Ramanathan M, Roh HJ, Rudmik L, Sacks R, Schlosser RJ, Sedaghat AR, Senior BA, Sindwani R, Smith K, Snidvongs K, Stewart M, Suh JD, Tan BK, Turner JH, van Drunen CM, Voegels R, Wang DY, Woodworth BA, Wormald PJ, Wright ED, Yan C, Zhang L, Zhou B. International consensus statement on allergy and rhinology: rhinosinusitis 2021. Int Forum Allergy Rhinol 2021; 11:213-739. [PMID: 33236525 DOI: 10.1002/alr.22741] [Citation(s) in RCA: 357] [Impact Index Per Article: 119.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 11/09/2020] [Indexed: 02/06/2023]
Abstract
I. EXECUTIVE SUMMARY BACKGROUND: The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR-RS-2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence-based findings of the document. METHODS ICAR-RS presents over 180 topics in the forms of evidence-based reviews with recommendations (EBRRs), evidence-based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary. RESULTS ICAR-RS-2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence-based management algorithm is provided. CONCLUSION This ICAR-RS-2021 executive summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS.
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Affiliation(s)
| | | | | | | | | | - Amber U Luong
- University of Texas Medical School at Houston, Houston, TX
| | | | - Zachary Soler
- Medical University of South Carolina, Charleston, SC
| | - Kevin C Welch
- Feinberg School of Medicine, Northwestern University, Chicago, IL
| | | | | | | | | | - Claus Bachert
- Ghent University, Ghent, Belgium.,Karolinska Institute, Stockholm, Sweden.,Sun Yatsen University, Gangzhou, China
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - David A Gudis
- Columbia University Irving Medical Center, New York, NY
| | - Daniel L Hamilos
- Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | | | - Richard Harvey
- University of New South Wales and Macquarie University, Sydney, New South Wales, Australia
| | | | | | | | | | - Amin R Javer
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | | | | | | | | | | | | | | | | | - Valerie Lund
- Royal National Throat Nose and Ear Hospital, UCLH, London, UK
| | - Kevin C McMains
- Uniformed Services University of Health Sciences, San Antonio, TX
| | | | - Joaquim Mullol
- IDIBAPS Hospital Clinic, University of Barcelona, Barcelona, Spain
| | | | | | | | | | | | | | | | | | | | - Alkis J Psaltis
- University of Adelaide, Adelaide, South Australia, Australia
| | | | | | | | - Luke Rudmik
- University of Calgary, Calgary, Alberta, Canada
| | - Raymond Sacks
- University of New South Wales, Sydney, New South Wales, Australia
| | | | | | | | | | | | | | | | | | | | | | | | | | - De Yun Wang
- National University of Singapore, Singapore, Singapore
| | | | | | | | - Carol Yan
- University of California San Diego, La Jolla, CA
| | - Luo Zhang
- Capital Medical University, Beijing, China
| | - Bing Zhou
- Capital Medical University, Beijing, China
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Jonstam K, Alsharif S, Bogaert S, Suchonos N, Holtappels G, Jae‐Hyun Park J, Bachert C. Extent of inflammation in severe nasal polyposis and effect of sinus surgery on inflammation. Allergy 2021; 76:933-936. [PMID: 32770835 PMCID: PMC7984056 DOI: 10.1111/all.14550] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 07/27/2020] [Accepted: 07/30/2020] [Indexed: 11/26/2022]
Affiliation(s)
- Karin Jonstam
- Division of Ear, Nose and Throat Diseases Department of Clinical Science, Intervention and Technology Karolinska Institutet Stockholm Sweden
- Department of Ear, Nose and Throat Diseases Karolinska University Hospital Stockholm Sweden
| | - Saeed Alsharif
- Upper Airway Research Laboratory Department of Otorhinolaryngology Ghent University Ghent Belgium
- Department of Otolaryngology Supply Base, Saudi Royal Army Taif Saudi Arabia
| | - Stijn Bogaert
- Department of Otorhinolaryngology, Head and Neck Surgery St. Elisabeth‐Hospital Ruhr University Bochum Bochum Germany
| | | | - Gabriele Holtappels
- Upper Airway Research Laboratory Department of Otorhinolaryngology Ghent University Ghent Belgium
| | - Jonas Jae‐Hyun Park
- Department of Otorhinolaryngology, Head and Neck Surgery Witten/Herdecke University Hagen Germany
| | - Claus Bachert
- Division of Ear, Nose and Throat Diseases Department of Clinical Science, Intervention and Technology Karolinska Institutet Stockholm Sweden
- Department of Ear, Nose and Throat Diseases Karolinska University Hospital Stockholm Sweden
- Upper Airway Research Laboratory Department of Otorhinolaryngology Ghent University Ghent Belgium
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Stevens WW, Jerschow E, Baptist AP, Borish L, Bosso JV, Buchheit KM, Cahill KN, Campo P, Cho SH, Keswani A, Levy JM, Nanda A, Laidlaw TM, White AA. The role of aspirin desensitization followed by oral aspirin therapy in managing patients with aspirin-exacerbated respiratory disease: A Work Group Report from the Rhinitis, Rhinosinusitis and Ocular Allergy Committee of the American Academy of Allergy, Asthma & Immunology. J Allergy Clin Immunol 2020; 147:827-844. [PMID: 33307116 DOI: 10.1016/j.jaci.2020.10.043] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 10/13/2020] [Accepted: 10/20/2020] [Indexed: 11/25/2022]
Abstract
Aspirin-exacerbated respiratory disease (AERD) is characterized by the clinical triad of chronic rhinosinusitis with nasal polyps, asthma, and an intolerance to medications that inhibit the cycloxgenase-1 enzyme. Patients with AERD on average have more severe respiratory disease compared with patients with chronic rhinosinusitis with nasal polyps and/or asthma alone. Although patients with AERD traditionally develop significant upper and lower respiratory tract symptoms on ingestion of cycloxgenase-1 inhibitors, most of these same patients report clinical benefit when desensitized to aspirin and maintained on daily aspirin therapy. This Work Group Report provides a comprehensive review of aspirin challenges, aspirin desensitizations, and maintenance aspirin therapy in patients with AERD. Identification of appropriate candidates, indications and contraindications, medical and surgical optimization strategies, protocols, medical management during the desensitization, and recommendations for maintenance aspirin therapy following desensitization are reviewed. Also included is a summary of studies evaluating the clinical efficacy of aspirin therapy after desensitization as well as a discussion on the possible cellular and molecular mechanisms explaining how this therapy provides unique benefit to patients with AERD.
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Affiliation(s)
- Whitney W Stevens
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Ill.
| | - Elina Jerschow
- Division of Allergy and Immunology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY
| | - Alan P Baptist
- Division of Allergy and Clinical Immunology, Department of Medicine, University of Michigan Medical School, Ann Arbor, Mich
| | - Larry Borish
- Departments of Medicine and Microbiology, University of Virginia Health System, Charlottesville, Va
| | - John V Bosso
- Division of Rhinology, Department of Otorhinolaryngology/Head & Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Kathleen M Buchheit
- Division of Allergy and Clinical Immunology, Department of Medicine, Brigham and Women's Hospital, Boston, Mass
| | - Katherine N Cahill
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Paloma Campo
- Allergy Unit, IBIMA-Hospital Regional Universitario de Málaga, Málaga, Spain
| | - Seong H Cho
- Division of Allergy and Immunology, Morsani College of Medicine, University of South Florida, Tampa, Fla
| | - Anjeni Keswani
- Division of Allergy/Immunology, Department of Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Joshua M Levy
- Department of Otolaryngology-Head & Neck Surgery, Emory University School of Medicine, Atlanta
| | - Anil Nanda
- Asthma and Allergy Center, Lewisville and Flower Mound, Tex; Division of Allergy and Immunology, University of Texas Southwestern Medical Center, Dallas, Tex
| | - Tanya M Laidlaw
- Division of Allergy and Clinical Immunology, Department of Medicine, Brigham and Women's Hospital, Boston, Mass
| | - Andrew A White
- Division of Allergy, Asthma, and Immunology, Scripps Clinic, San Diego, Calif
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Appropriate extent of surgery for aspirin-exacerbated respiratory disease. World J Otorhinolaryngol Head Neck Surg 2020; 6:235-240. [PMID: 33336179 PMCID: PMC7729211 DOI: 10.1016/j.wjorl.2020.07.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 07/19/2020] [Accepted: 07/24/2020] [Indexed: 11/20/2022] Open
Abstract
The current literature lacks strong guidelines regarding surgical management of patients with aspirin-exacerbated respiratory disease (AERD), who present with the clinical triad of chronic rhinosinusitis with nasal polyposis (CRSwNP), bronchial asthma, and aspirin/nonsteroidal anti-inflammatory drug intolerance. To further define the effectiveness of sinus surgery in treating AERD patients, this review article discusses current evidence regarding outcomes associated with more extensive surgery, the benefits of frontal sinus surgery on polyposis, and the role of Draf III intervention. Numerous studies suggest that Draf III frontal sinusotomy may be an efficacious early intervention due to increased neo-ostial patency and subsequent distribution of topical therapies. Future studies that further investigate the efficacy and safety of extensive surgery in AERD patients are warranted.
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Schlosser RJ. Aspirin-exacerbated respiratory disease: personalized medical and surgical approaches. Int Forum Allergy Rhinol 2020; 10:1035-1036. [PMID: 32634286 DOI: 10.1002/alr.22634] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 06/01/2020] [Indexed: 12/20/2022]
Affiliation(s)
- Rodney J Schlosser
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC
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Treatable traits in chronic rhinosinusitis with nasal polyps. Curr Opin Allergy Clin Immunol 2020; 19:373-378. [PMID: 31135395 DOI: 10.1097/aci.0000000000000544] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
PURPOSE OF REVIEW Chronic rhinosinusitis with nasal polyps (CRSwNP) is a complex inflammatory sinonasal disease that deserves a multidisciplinary precision medicine approach. In a precision medicine model, a more pragmatic approach taking in consideration disease features that are potentially treatable should be considered. RECENT FINDINGS Several treatable traits in CRSwNP can be identified: from disease-related ones, to extra-ENT features, to behavioral and environmental factors. This review article summarizes primarily the recent findings of CRSwNP-related treatable traits and how they can be modified by given treatments. SUMMARY The advent of biological agents acting directly to the endotype underlying CRSwNP pushes the scientific community to integrate clinical, surgical and immunological evaluations for each single patient; this naturally leads to the identification of specific treatable traits that can serve as possible outcomes for any single biological.
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Bosso JV, Locke TB, Kuan EC, Tripathi SH, Ig-Izevbekhai KI, Kalaf LT, Kohanski MA, Palmer JN, Adappa ND. Complete endoscopic sinus surgery followed by aspirin desensitization is associated with decreased overall corticosteroid use. Int Forum Allergy Rhinol 2020; 10:1043-1048. [PMID: 32558306 DOI: 10.1002/alr.22604] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 05/05/2020] [Accepted: 05/06/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND Aspirin-exacerbated respiratory disease (AERD) is an aggressive respiratory tract inflammatory disorder manifesting as asthma, chronic rhinosinusitis with nasal polyposis, and a respiratory sensitivity to aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs). Corticosteroids, both systemic and topical/inhaled, are used to treat inflammation of the upper and lower airways. Our objective was to examine the potential impact of complete endoscopic sinus surgery (ESS) and aspirin desensitization (AD) on short-term and long-term corticosteroid use. METHODS For this pilot study, a retrospective chart review of all patients with AERD who underwent ESS followed by AD was performed. Daily prednisone use, average daily prednisone dose, and inhaled corticosteroid use were analyzed at the following time points: preoperative, postoperative/pre-AD, and 2 to 3 months, 4 to 6 months, 7 to 12 months, and 13 to 24 months following AD. RESULTS A total of 125 patients underwent ESS followed by AD. Compared to preoperatively, patients who underwent ESS and AD were less likely to be on daily prednisone at all time points and upon long-term follow-up (32% preoperatively vs 10% at 13 to 24 months, McNemar's test = 9.00, p = 0.009). Average daily prednisone dose decreased from 10.6 ± 7.9 mg preoperatively to 3.8 ± 2.6 mg at 13 to 24 months following AD (Mann-Whitney U; W = 122, p = 0.01). Similarly, high-dose and medium-dose inhaled corticosteroid use decreased from 18% to 7% and from 36% to 22% respectively (Pearson's chi-square = 8.06, p = 0.05). CONCLUSION In our AERD cohort who underwent ESS followed by AD, there was an observed decrease in overall systemic and topical/inhaled corticosteroid use. These findings can have implications for treatment given the potentially hazardous side effects of corticosteroid use.
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Affiliation(s)
- John V Bosso
- Department of Otolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA
| | - Tran B Locke
- Department of Otolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA
| | - Edward C Kuan
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, CA
| | - Siddhant H Tripathi
- Department of Otolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA
| | - Kevin I Ig-Izevbekhai
- Department of Otolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA
| | - Laila T Kalaf
- Department of Otolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA
| | - Michael A Kohanski
- Department of Otolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA
| | - James N Palmer
- Department of Otolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA
| | - Nithin D Adappa
- Department of Otolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA
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Grose E, Lee DJ, Yip J, Cottrell J, Sykes J, Lee JK, Lee JM. Surgical outcomes in aspirin-exacerbated respiratory disease without aspirin desensitization. Int Forum Allergy Rhinol 2020; 10:1149-1157. [PMID: 32558318 DOI: 10.1002/alr.22626] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 04/21/2020] [Accepted: 05/08/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Aspirin-exacerbated respiratory disease (AERD) represents a severe endotype of chronic rhinosinusitis with nasal polyposis. Although aspirin desensitization (AD) has emerged as an effective therapeutic option, the natural history of AERD without AD remains unclear. METHODS A retrospective review was conducted of AERD patients who underwent endoscopic sinus surgery (ESS) without AD between 2010 and 2019. The primary outcomes were revision surgery rate and time to revision surgery. Secondary outcomes included changes in 22-item Sino-Nasal Outcome Test (SNOT-22) scores and Lund-Kennedy endoscopy scores (LKES). A subgroup analysis was performed for patients on monoclonal antibody therapy (MAT). RESULTS Of 141 patients, 37 (26.2%) underwent revision ESS with a median time to revision of 3.3 (interquartile range [IQR], 2.2-4.9) years. The probability of remaining free of revision surgery at 1, 3, and 5 years was: 98.2% (95% confidence interval [CI], 95.7-100.0%), 78.8% (95% CI, 70.2-88.4%), and 44.8% (95% CI, 32.4-62.1%), respectively. SNOT-22 scores decreased by 34 (IQR, 18-52) points at 6 months and 27 (IQR, 20-46) points at 1 year postoperatively. In the revision cohort, the decrease in SNOT-22 score was not sustained at 1 year postoperatively. No difference was found in time to revision compared with those without MAT (p = 0.23). CONCLUSION A significant proportion of AERD patients benefit from ESS and medical therapy alone without AD. This study presents preliminary results on the impact of MAT on surgical outcomes as it is limited by the small sample size. Further research on the use of MAT in AERD is needed.
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Affiliation(s)
- Elysia Grose
- Division of Rhinology, Department of Otolaryngology-Head & Neck Surgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Daniel J Lee
- Division of Rhinology, Department of Otolaryngology-Head & Neck Surgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Jonathan Yip
- Division of Rhinology, Department of Otolaryngology-Head & Neck Surgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Justin Cottrell
- Division of Rhinology, Department of Otolaryngology-Head & Neck Surgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Jenna Sykes
- Adult Cystic Fibrosis Centre, Department of Respirology, St. Michael's Hospital, Toronto, ON, Canada
| | - Jason K Lee
- Toronto Allergists, Toronto, ON, Canada.,Evidence Based Medical Educator, Toronto, ON, Canada
| | - John M Lee
- Division of Rhinology, Department of Otolaryngology-Head & Neck Surgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
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Dominas C, Gadkaree S, Maxfield AZ, Gray ST, Bergmark RW. Aspirin-exacerbated respiratory disease: A review. Laryngoscope Investig Otolaryngol 2020; 5:360-367. [PMID: 32596477 PMCID: PMC7314471 DOI: 10.1002/lio2.387] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 03/09/2020] [Accepted: 03/16/2020] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES Aspirin-exacerbated respiratory disease (AERD) is a chronic respiratory condition characterized by a triad of symptoms: asthma, chronic rhinosinusitis with nasal polyposis, and a respiratory reaction to aspirin and other cyclooxygenase-1 inhibitors, also known as nonsteroidal anti-inflammatory drugs. The objective of this review is to provide otolaryngologists with an overview of the pathophysiology, diagnosis, and treatment of this under-recognized condition. DATA SOURCES AND METHODS Foundational papers on AERD were reviewed, focusing on the clinical otolaryngology and allergy/immunology literature and other high impact journals or trials. RESULTS AERD results from increased production of pro-inflammatory leukotrienes and a decrease in production of anti-inflammatory prostaglandins associated with the dysregulation of multiple enzymes influencing eicosanoid metabolism. Diagnosis hinges on a high index of suspicion, careful history, and confirmatory testing for all three elements. Treatments include endoscopic sinus surgery; topical, inhaled, or oral corticosteroids; aspirin desensitization; leukotriene modifying drugs; and the new class of biologics such as dupilumab. CONCLUSION AERD is an under-recognized disease associated with substantial patient-reported morbidity. We expect rapid progress in the pathophysiological understanding of this disease and available treatments in the coming decades. LEVEL OF EVIDENCE 5.
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Affiliation(s)
- Christine Dominas
- Division of Otolaryngology‐Head and Neck SurgeryBrigham and Women's HospitalBostonMassachusettsUSA
| | - Shekhar Gadkaree
- Division of Otolaryngology‐Head and Neck SurgeryBrigham and Women's HospitalBostonMassachusettsUSA
- Department of Otolaryngology‐Head and Neck SurgeryHarvard Medical SchoolBostonMassachusettsUSA
- Department of Otolaryngology‐Head and Neck SurgeryMassachusetts Eye and Ear InfirmaryBostonMassachusettsUSA
| | - Alice Z. Maxfield
- Division of Otolaryngology‐Head and Neck SurgeryBrigham and Women's HospitalBostonMassachusettsUSA
- Department of Otolaryngology‐Head and Neck SurgeryHarvard Medical SchoolBostonMassachusettsUSA
| | - Stacey T. Gray
- Department of Otolaryngology‐Head and Neck SurgeryHarvard Medical SchoolBostonMassachusettsUSA
- Department of Otolaryngology‐Head and Neck SurgeryMassachusetts Eye and Ear InfirmaryBostonMassachusettsUSA
| | - Regan W. Bergmark
- Division of Otolaryngology‐Head and Neck SurgeryBrigham and Women's HospitalBostonMassachusettsUSA
- Department of Otolaryngology‐Head and Neck SurgeryHarvard Medical SchoolBostonMassachusettsUSA
- Center for Surgery and Public HealthBrigham and Women's HospitalBostonMassachusettsUSA
- Patient Reported Outcomes, Value and Experience (PROVE) CenterBrigham and Women's HospitalBostonMassachusettsUSA
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32
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Lal D, Borish L, Detwiller KY, Gray ST, Joshi S, Kern RC, Laidlaw TM, Marino MJ, Payne SC, Peters AT, Soler ZM, Rank MA. A case for multidisciplinary management of chronic rhinosinusitis with nasal polyposis. Int Forum Allergy Rhinol 2020; 10:795-797. [DOI: 10.1002/alr.22557] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 02/26/2020] [Accepted: 03/03/2020] [Indexed: 12/18/2022]
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Associations between the Quality of Life and Nasal Polyp Size in Patients Suffering from Chronic Rhinosinusitis without Nasal Polyps, with Nasal Polyps or Aspirin-Exacerbated Respiratory Disease. J Clin Med 2020; 9:jcm9040925. [PMID: 32231056 PMCID: PMC7230739 DOI: 10.3390/jcm9040925] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 03/20/2020] [Accepted: 03/23/2020] [Indexed: 12/31/2022] Open
Abstract
Chronic rhinosinusitis (CRS) is a common disease that substantially impairs the quality of life (QoL). Here, we aimed to assess patients' QoL in different subtypes of CRS and correlated this with nasal polyp size to improve the clinical understanding of the burden of disease. In this retrospective single-center study, 107 patients with the following diagnoses were analyzed: CRS without nasal polyps (CRSsNP), CRS with nasal polyps (CRSwNP), or aspirin-exacerbated respiratory disease (AERD). Sino-Nasal Outcome Test-20 German Adapted Version (SNOT-20 GAV) scores and their correlation with endoscopic Total Polyp Scores (TPS) were evaluated. The mean SNOT-20 GAV scores were highest in patients with AERD (AERD = 43.4, CRSwNP = 36.3, CRSsNP = 30.9). A statistically significant correlation of total SNOT-20 GAV score with TPS was observed in CRSwNP patients (r = 0.3398, p = 0.0195), but not in AERD patients (r = 0.2341, p = 0.1407). When analyzing single SNOT-20 parameters, a strong correlation with TPS was observed for blockage/congestion of the nose, particularly in AERD patients (r = 0.65, p < 0.0001). The impact of nasal polyp size on the QoL differs amongst the subgroups of CRS. Nasal symptoms have the greatest impact on QoL in patients suffering from AERD. CRSwNP and AERD patients should be separately analyzed in clinical investigations and interpretations due to significant differences in QoL.
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Laidlaw TM, Levy JM. NSAID-ERD Syndrome: the New Hope from Prevention, Early Diagnosis, and New Therapeutic Targets. Curr Allergy Asthma Rep 2020; 20:10. [PMID: 32172365 DOI: 10.1007/s11882-020-00905-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
PURPOSE OF REVIEW This review summarizes the latest information on the appropriate identification, evaluation, and treatment of patients with nonsteroidal anti-inflammatory drug (NSAID)-exacerbated respiratory disease (NSAID-ERD), also known as aspirin-exacerbated respiratory disease (AERD). Within the framework of our understanding of the underlying pathophysiology of NSAID-ERD, we also provide an update regarding new surgical techniques and newly available or upcoming medical therapies that may benefit these patients. RECENT FINDINGS There have been considerable developments regarding recommendations for both the extent and timing of sinus surgery for NSAID-ERD. The last few years have also given us several new biologic medications that warrant consideration in the treatment of patients with recalcitrant NSAID-ERD. Further clinical trials are underway to investigate additional medications that may decrease the type 2 inflammation that dominates this disease. Despite the severe lower respiratory inflammation and recurrent nature of the nasal polyps in patients with NSAID-ERD, significant recent advances now afford much-improved quality of life for these patients. Careful collaboration between Allergy/Immunology and Rhinology specialists is imperative to ensure proper treatment of patients with NSAID-ERD.
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Affiliation(s)
- Tanya M Laidlaw
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA, USA.
| | - Joshua M Levy
- Department of Otolaryngology - Head and Neck Surgery, Emory University School of Medicine, Atlanta, GA, USA
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Loftus CA, Soler ZM, Desiato VM, Koochakzadeh S, Yoo F, Storck KA, Schlosser RJ. Factors impacting revision surgery in patients with chronic rhinosinusitis with nasal polyposis. Int Forum Allergy Rhinol 2020; 10:289-302. [DOI: 10.1002/alr.22505] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 10/24/2019] [Accepted: 11/15/2019] [Indexed: 12/12/2022]
Affiliation(s)
- Catherine A. Loftus
- Department of Otolaryngology–Head and Neck SurgeryMedical University of South Carolina Charleston SC
| | - Zachary M. Soler
- Department of Otolaryngology–Head and Neck SurgeryMedical University of South Carolina Charleston SC
| | - Vincent M. Desiato
- Department of Otolaryngology–Head and Neck SurgeryMedical University of South Carolina Charleston SC
| | - Sina Koochakzadeh
- Department of Otolaryngology–Head and Neck SurgeryMedical University of South Carolina Charleston SC
| | - Frederick Yoo
- Department of Otolaryngology–Head and Neck SurgeryMedical University of South Carolina Charleston SC
| | - Kristina A. Storck
- Department of Otolaryngology–Head and Neck SurgeryMedical University of South Carolina Charleston SC
| | - Rodney J. Schlosser
- Department of Otolaryngology–Head and Neck SurgeryMedical University of South Carolina Charleston SC
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Patel GB, Kern RC, Bernstein JA, Hae-Sim P, Peters AT. Current and Future Treatments of Rhinitis and Sinusitis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:1522-1531. [PMID: 32004747 DOI: 10.1016/j.jaip.2020.01.031] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 01/17/2020] [Accepted: 01/17/2020] [Indexed: 02/07/2023]
Abstract
Advances in understanding the pathogenic mechanisms of both rhinitis and chronic rhinosinusitis have resulted in new treatment options, especially for chronic rhinosinusitis. A review of relevant medical and surgical clinical studies shows that intranasal corticosteroids, antihistamines, and allergen immunotherapy continue to be the best treatments for chronic rhinitis. Dupilumab is the first biologic approved for chronic rhinosinusitis with polyps. Omalizumab, mepolizumab, and benralizumab may have a future role in the treatment of chronic rhinosinusitis. Novel corticosteroid delivery devices such as an exhalation delivery system for fluticasone and bioabsorbable sinus implants provide enhanced and localized distribution of corticosteroids. Surgical management tailored to the underlying disease process improves clinical outcomes in chronic rhinosinusitis with or without nasal polyposis. Advances in the understanding of the heterogeneous nature of rhinitis and rhinosinusitis have resulted in more precise treatments. Improving the understanding of different endotypes should provide better knowledge to determine appropriate current and new therapies to treat these diseases.
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Affiliation(s)
- Gayatri B Patel
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Robert C Kern
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | | | - Park Hae-Sim
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea
| | - Anju T Peters
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Ill.
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Rosati D, Rosato C, Pagliuca G, Cerbelli B, Della Rocca C, Di Cristofano C, Martellucci S, Gallo A. Predictive markers of long-term recurrence in chronic rhinosinusitis with nasal polyps. Am J Otolaryngol 2020; 41:102286. [PMID: 31727332 DOI: 10.1016/j.amjoto.2019.102286] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Revised: 08/29/2019] [Accepted: 09/04/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND In last years, many attempts were made to recognize chronic rhinosinusitis with nasal polyps (CRSwNP) phenotypes focusing on identifying relevant key pathogenic molecules. Polyps recurrence rate ranges from 4% to 60%, so it's clear that not all clinical and immunologic factors associated with recurrence are known. OBJECTIVE We investigate the inflammatory profile in patients with long term recurrent and non-recurrent CRSwNPs and if a specific profile is associated with recurrence, comparing eosinophilic, neutrophilic and lymphocytic infiltration, as well as IL-5 and IL-8 expression to long term recurrence rate. METHODS This prospective study included 44 adult patients with CRSwNP treated with endoscopic sinus surgery between 2008 and 2010. Long term follow-up data (8-10 years) indicated that among 44 patients, 18 (40.1%) experienced long term recurrence of nasal polyposis needing maximal medical treatment or revision surgery. We realized two groups: one with patients who didn't present long term recurrence (26 patients) and another with patients who presented long term recurrence (18 patients) and in both groups eosinophilic, neutrophilic and lymphocytic infiltration and IL-5 and IL-8 expression were measured. RESULTS The parameters that reached statistical significance (p < 0.05) comparing the two groups were eosinophilic infiltration and IL-5 expression, whereas neutrophilic and lymphocytic infiltration, as IL-8 expression didn't show any significant difference. Asthma and aspirin intolerance seemed significantly more frequent in patients with recurrence, while allergy presented not statistically significant difference between two groups. CONCLUSIONS We can conclude that high eosinophilic infiltration and high IL-5 expression in CRSwNP correlate with higher rate of long term recurrence, while neutrophilic and lymphocytic infiltration, and IL-8 expression don't correlate with it. These findings provide the opportunity to improve our ability to predict the prognosis of surgical intervention, although it is still needed to explore the optimal predictor of outcome in CRSwNP.
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Affiliation(s)
- Davide Rosati
- Department of Sensory Organs, "Sapienza University" of Rome, Azienda Policlinico Umberto I, Rome, Italy.
| | | | | | - Bruna Cerbelli
- UOC of Pathology, Department of Medical-Surgical Sciences and Bio-Technologies, Sapienza University of Rome, Latina, Italy
| | - Carlo Della Rocca
- UOC of Pathology, Department of Medical-Surgical Sciences and Bio-Technologies, Sapienza University of Rome, Latina, Italy
| | - Claudio Di Cristofano
- UOC of Pathology, Department of Medical-Surgical Sciences and Bio-Technologies, Sapienza University of Rome, Latina, Italy
| | - Salvatore Martellucci
- Department of Sensory Organs, "Sapienza University" of Rome, Azienda Policlinico Umberto I, Rome, Italy
| | - Andrea Gallo
- Department of Sensory Organs, "Sapienza University" of Rome, Azienda Policlinico Umberto I, Rome, Italy
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Loftus CA, Soler ZM, Koochakzadeh S, Desiato VM, Yoo F, Nguyen SA, Schlosser RJ. Revision surgery rates in chronic rhinosinusitis with nasal polyps: meta-analysis of risk factors. Int Forum Allergy Rhinol 2019; 10:199-207. [PMID: 31752051 DOI: 10.1002/alr.22487] [Citation(s) in RCA: 90] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 10/21/2019] [Accepted: 10/24/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Wide variations in revision endoscopic sinus surgery (ESS) rates for chronic rhinosinusitis with nasal polyposis (CRSwNP) have been reported. It is important to understand expected revision rates and factors that impact the need for revision. METHODS A literature search was conducted on PubMed, Scopus, and the Cochrane Database of Systematic Reviews. Following PRISMA guidelines, a systematic review and meta-analysis was performed on studies that reported revision surgery data for CRSwNP patients. RESULTS Forty-five studies with 34,220 subjects were meta-analyzed, with an overall revision rate of 18.6% (95% confidence interval, 14.1%-23.6%). Studies with extractable follow-up data reported a mean revision rate of 16.2% over a weighted mean follow-up of 89.6 months. Factors associated with increased revision rates included allergic fungal rhinosinusitis (28.7%), aspirin-exacerbated respiratory disease (27.2%), asthma (22.6%), prior polypectomy (26.0%), and publication prior to 2008 (22.7%) (p < 0.05 for all). CONCLUSION Although polyps can recur after ESS, reported long-term ESS revision rates are approximately 14% to 24%. Identifying risk factors for revision surgery can help manage patient expectations and determine optimal personalized treatments.
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Affiliation(s)
- Catherine A Loftus
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC
| | - Zachary M Soler
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC
| | - Sina Koochakzadeh
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC
| | - Vincent M Desiato
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC
| | - Frederick Yoo
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC
| | - Shaun A Nguyen
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC
| | - Rodney J Schlosser
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC
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Bachert C, Zhang N, Hellings PW, Bousquet J. Endotype-driven care pathways in patients with chronic rhinosinusitis. J Allergy Clin Immunol 2019; 141:1543-1551. [PMID: 29731100 DOI: 10.1016/j.jaci.2018.03.004] [Citation(s) in RCA: 130] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 03/26/2018] [Accepted: 03/26/2018] [Indexed: 12/13/2022]
Abstract
Chronic rhinosinusitis (CRS) has been differentiated clinically into CRS without nasal polyps and CRS with nasal polyps, with both forms subjected to glucocorticosteroid and antibiotic treatments and, if not successful, to nasal and sinus surgery tailored to endoscopic and computed tomographic scan findings. The elaboration of endotypes based on pathomechanisms involving different immune responses offers new possibilities in terms of prediction of prognosis and risks and sophisticated guidance in personalized pharmacotherapy, surgical approaches, and innovative treatment approaches in the CRS field with various biologics. Surgical approaches can vary from classical functional endoscopic sinus surgery to extended and "reboot" approaches, with the idea to completely remove the dysfunctional and inflamed mucosa and replace it with a newly grown healthy mucosa. Biologics in this field are targeting the type 2 cytokines IL-4, IL-5, and IL-13, as well as IgE. Phase I and II study results are promising, and phase III studies are currently being performed. The development of endotype-driven integrated care pathways appreciating these innovations are now needed for the management of CRS.
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Affiliation(s)
- Claus Bachert
- Upper Airways Research Laboratory and Department of Oto-Rhino-Laryngology, Ghent University and Ghent University Hospital, Ghent, Belgium; Division of ENT Diseases, CLINTEC, Karolinska Institute, University of Stockholm, Stockholm, Sweden.
| | - Nan Zhang
- Upper Airways Research Laboratory and Department of Oto-Rhino-Laryngology, Ghent University and Ghent University Hospital, Ghent, Belgium
| | - Peter W Hellings
- Department of Oto-Rhino-Laryngology, Leuven University Hospital, Leuven, Belgium
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Histopathologic analysis in the diagnosis and management of chronic rhinosinusitis. Curr Opin Otolaryngol Head Neck Surg 2019; 27:20-24. [DOI: 10.1097/moo.0000000000000510] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Bhalla V, Sykes KJ, Villwock JA, Beahm DD, McClurg SW, Chiu AG. Draf IIB with superior septectomy: finding the "middle ground". Int Forum Allergy Rhinol 2018; 9:281-285. [PMID: 30548455 DOI: 10.1002/alr.22228] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Revised: 09/10/2018] [Accepted: 10/02/2018] [Indexed: 11/09/2022]
Abstract
BACKGROUND Previous studies have demonstrated a high failure rate of endoscopic sinus surgery (ESS) with Draf IIa in patients with diffuse polyposis, asthma, and aspirin-exacerbated respiratory disease. A high percentage of these patients progress to endoscopic modified Lothrop procedure (EMLP). We describe a modification of the Draf IIb with a superior septectomy (IIb+SS), which may provide similar therapeutic benefit as demonstrated by the distribution of sinus irrigations in the sinus cavity with ESS with IIb+SS vs ESS with EMLP. METHODS ESS with IIb+SS was performed on 6 cadaver heads. Fluorescein-dyed irrigations were performed on each head and penetration was recorded using video endoscopy. EMLP was subsequently performed on each head with repeat dye-irrigation and video endoscopy. The videos were reviewed by 4 blinded fellowship-trained rhinologists, and irrigant penetration of the maxillary, ethmoid, frontal, sphenoid sinuses, and olfactory cleft was graded 0 to 3 (3 implying complete staining). RESULTS The mean scores when comparing IIb+SS to EMLP were as follows: overall 1.99 vs 1.97 (p = 0.816), maxillary sinus 2.67 vs 2.38 (p = 0.128), ethmoid sinus 1.88 vs 1.98 (p = 0.536), sphenoid sinus 2.58 vs 2.50 (p = 0.467), frontal sinus 1.13 vs 1.38 (p = 0.073), and olfactory cleft 1.71 vs 1.63 (p = 0.529). There was no significant difference between subsites. Interrater reliability was good (Cronbach's alpha = 0.781). CONCLUSION Performing ESS with IIb+SS provides similar irrigation delivery benefits to ESS with EMLP, without the need for altering natural sinus outflow and creating circumferential scarring. Further studies evaluating its use in patients that are high risk for revision surgery are needed.
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Affiliation(s)
- Vidur Bhalla
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas Medical Center, Kansas City, KS.,Saint Luke's Hospital of Kansas City, Kansas City, MO
| | - Kevin J Sykes
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas Medical Center, Kansas City, KS
| | - Jennifer A Villwock
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas Medical Center, Kansas City, KS
| | - D David Beahm
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas Medical Center, Kansas City, KS
| | | | - Alexander G Chiu
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas Medical Center, Kansas City, KS
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Affiliation(s)
- Andrew A White
- From the Division of Allergy, Asthma, and Immunology, Scripps Clinic, San Diego, CA
| | - Donald D Stevenson
- From the Division of Allergy, Asthma, and Immunology, Scripps Clinic, San Diego, CA
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Tajudeen BA, Schwartz JS, Bosso JV. The role of aspirin desensitization in the management of aspirin-exacerbated respiratory disease. Curr Opin Otolaryngol Head Neck Surg 2018; 25:30-34. [PMID: 27849653 DOI: 10.1097/moo.0000000000000331] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Aspirin-exacerbated respiratory disease (AERD) is a progressive inflammatory disease of the upper and lower airways characterized by marked eosinophilic nasal polyposis, asthma, and respiratory reactions to medications that inhibit the cyclooxygenase pathway. Aspirin desensitization has proven to be an effective tool in the management of this disease when used in a multidisciplinary setting. The purpose of this article is to review the current literature regarding AERD, aspirin desensitization, and share our opinion regarding the most optimal multidisciplinary approach to these complex patients. RECENT FINDINGS Numerous studies, including randomized, double-blind, placebo-controlled trials, have demonstrated the therapeutic effectiveness of aspirin desensitization with significant improvement in number of sinus infections per year, olfactory scores, nasal symptom scores, asthma symptom scores, sinus operations, hospitalizations, emergency room visits, and oral steroid use. Furthermore, the role of surgery is becoming increasingly important for recalcitrant sinus disease with recent studies showing comprehensive surgery as more beneficial to disease management. SUMMARY Aspirin desensitization is an effective therapeutic tool in the management of AERD. A multidisciplinary approach is critical between the otorhinolaryngologist and allergist to provide the most optimal care for this complex patient population.
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Affiliation(s)
- Bobby A Tajudeen
- aDepartment of Otorhinolaryngology - Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, USA bDepartment of Otolaryngology - Head and Neck Surgery, McGill University, Montreal, Quebec, Canada cDepartment of Otorhinolaryngology - Head and Neck Surgery, The University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Miglani A, Divekar RD, Azar A, Rank MA, Lal D. Revision endoscopic sinus surgery rates by chronic rhinosinusitis subtype. Int Forum Allergy Rhinol 2018; 8:1047-1051. [PMID: 29851243 DOI: 10.1002/alr.22146] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Revised: 04/13/2018] [Accepted: 05/01/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Revision surgery rates following endoscopic sinus surgery (ESS) range between 7% and 50% and are influenced by many factors. This study investigates ESS outcomes for chronic rhinosinusitis (CRS) subtypes. METHODS Retrospective review of adult CRS patients undergoing ESS with a single surgeon (2010-2015) was conducted. Outcomes were analyzed by CRS subtypes. RESULTS ESS was performed in 424 CRS patients (CRS with nasal polyps [CRSwNP], n = 170; CRS without polyps [CRSsNP], n = 254). Most patients (309; 72.9%) could not be specifically subtyped; 115 (27.1%) were subtyped as follows: aspirin-exacerbated respiratory disease (AERD), n = 47 (11.1%); allergic fungal sinusitis (AFS), n = 39 (9.2%); immunodeficiency, n = 21 (5.0%); granulomatosis with polyangiitis (GPA), n = 5 (1.2%); and eosinophilic granulomatosis with polyangiitis (EGPA), n = 3 (0.7%). All subgroups experienced clinically meaningful reduction in postoperative 22-item Sino-Nasal Outcome Test (SNOT-22) scores. At median follow-up of 28 months (interquartile range [IQR], 10-47 months), 19 patients (4%) underwent revision ESS (CRSwNP, n = 6; CRSsNP, n = 13). Revision ESS rates were 3.5% and 5.1% for CRSwNP and CRSsNP, respectively. Revision ESS rate for subtypes were: AERD 2%; AFS 2%; immunodeficiency 14%; GPA 40%; EGPA 0%; and "all other CRS" 4% at median follow-up duration of 36, 28, 41, 37, 44, and 26 months, respectively. CONCLUSION All CRS subtypes demonstrated clinically meaningful improvement in postoperative SNOT-22 scores following ESS. Our overall revision ESS rate was 4% (3.5% in CRSwNP). AFS, AERD, and EGPA groups demonstrated low revision rates, while immunodeficiency and GPA patients required more revision surgery. A contemporary understanding of CRSwNP subtypes facilitated surgical and medical strategies in improving outcomes for AERD, AFS, and EGPA patients. CRSsNP subtypes with immunodeficiency and GPA merit further investigation to optimize outcomes.
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Affiliation(s)
- Amar Miglani
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic in Arizona, Phoenix, AZ
| | | | - Antoine Azar
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic in Arizona, Phoenix, AZ
| | - Matthew A Rank
- Division of Allergy, Asthma, and Clinical Immunology, Mayo Clinic in Arizona, Phoenix, AZ
| | - Devyani Lal
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic in Arizona, Phoenix, AZ
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Evaluation of a Dermoplasty Technique for the Control on Nasal Polyps. Indian J Otolaryngol Head Neck Surg 2018; 71:1343-1350. [PMID: 31750175 DOI: 10.1007/s12070-018-1414-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 05/28/2018] [Indexed: 10/16/2022] Open
Abstract
To evaluate the efficacy of a dermoplasty technique in controlling nasal polyps comparing to the conventional endoscopic approach. Prospective observational study Tertiary private hospital. Twenty-nine patients underwent surgery for replacement of the middle meatus mucosa with skin. Some patients (41.4%) suffered from allergies, 44.8% from asthma, and 27.6% from aspirin intolerance. Polyps were staged according to the Lildholdt system, and patients completed a sino-nasal outcome test (SNOT-22) pre and post-operatively. Also, patients were interrogated as for medication relevant to the nose received pre and post-operatively. In twenty-six patients dermoplasty was applied in one nostril while the contralateral was treated with the conventional endoscopic technique allowing us to compare the two techniques in the same patient. Median follow-up period was 1.2 years (IQR 0.8, 2.0; range 0.4-5.8). Median drop in SNOT-22 score was 38.2 percentage units. Patients (79.3%) controlled symptoms by topical corticosteroids for 2.5-3 months per year at most. Seventy percent (70.8%) reported improvement in subjective olfaction. Results compare favorably to those reported in the literature after functional endoscopic approach. Lildholdt stage dropped post-operatively on both sides but significantly more (p value < 0.001) on the dermoplasty side comparing to the conventional endoscopic side. Dermoplasty appears to outbalance the conventional endoscopic removal of polyps and clearance of paranasal sinuses. No matter how extensive the removal of endonasal tissue, it is not sufficient for controlling nasal polyps unless mucosa is prevented from recovering the denuded areas by the use of a skin graft.
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Zhang X, Ye T, Huang Z, Huang Q, Xian J, Li J, Zhou B. Clinical Predictors of Frontal Ostium Restenosis After Draf 3 Procedure for Refractory Chronic Rhinosinusitis. Am J Rhinol Allergy 2018; 32:287-293. [PMID: 29741096 DOI: 10.1177/1945892418773625] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Background The Draf 3 procedure has been demonstrated to be effective in the treatment of refractory frontal sinus disease. A variety of clinical factors may contribute to the change of frontal neo-ostium (FNO) area after this procedure. Imaging plays a vital role in the evaluation and follow-up after surgery and provides useful prognostic information. Objectives (1) To investigate the influence of local anatomic factors on FNO after a Draf 3 procedure by radiological measurements on imaging software and (2) to explore other predictive factors of FNO restenosis. Methods Twenty-four patients with chronic rhinosinusitis who underwent a Draf 3 procedure and were followed up for more than 12 months (2012-2014) were enrolled in this study. Data on patient demographics, medical history, and computed tomography scans were collected. Anatomic dimensions were measured with OsiriX® (Pixmeo, Geneva, Switzerland). Stenotic ostium was defined as a loss of more than 50% of the original intraoperative area. Multivariate linear regression was used to assess independent factors linked to frontal neo-osteogenesis 1 year after the surgery. A receiver operating characteristic curve was built for the cutoff value of preoperative dimension to predict restenosis of FNO area. Results A significant association was demonstrated between the minimum anteroposterior diameter (FOAPMIN) of the frontal ostium preoperatively and FNO area 1 year postoperatively. Multivariate linear regression showed that FOAPMIN of the frontal ostium preoperatively and the percentage of serum eosinophils (EOSs) correlated with the contour area of the FNO 1 year postoperatively. FOAPMIN ≤ 3.592 mm yielded a sensitivity of 95% and a specificity of 75% for the diagnosis of FNO restenosis. Conclusions Both FOAPMIN and EOS are independent predictors of the contour area of the FNO 1 year postoperatively. Patients with a higher risk of developing frontal ostium restenosis can be identified preoperatively by measurements of the frontal sinus anatomic dimensions.
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Affiliation(s)
- Xiaoqing Zhang
- 1 Department of Otolaryngology-Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Ting Ye
- 2 Department of Otolaryngology-Head and Neck Surgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, China
| | - Zhenxiao Huang
- 1 Department of Otolaryngology-Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Qian Huang
- 1 Department of Otolaryngology-Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Junfang Xian
- 3 Department of Radiology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Jing Li
- 3 Department of Radiology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Bing Zhou
- 1 Department of Otolaryngology-Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
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Shen J, Chan N, Wrobel BB. The endoscopic modified lothrop procedure: Review of single institution experience and long-term outcomes. Laryngoscope Investig Otolaryngol 2018; 3:105-109. [PMID: 29721542 PMCID: PMC5915830 DOI: 10.1002/lio2.145] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 01/18/2018] [Accepted: 02/13/2018] [Indexed: 12/03/2022] Open
Abstract
Background Endoscopic Modified Lothrop Procedure (EMLP) has become a fundamental practice in rhinology. Improvements in symptom burden, ostial patency, morbidity, and costs have surpassed that of an open approach to the frontal sinus. Long‐term efficacy has not been well established. Objective This study details the long‐term outcomes of EMLP and risk factors for subsequent surgical revision at a single institution. Methods This study utilized a retrospective review of patients who underwent EMLP from September 2006 to February 2017 by a single surgeon at an academic tertiary referral center. Patient demographics, indications, symptom burden, and endoscopic assessment of frontal ostium patency were analyzed for their effect on surgical outcome. Risk factors for failures were identified. Results Seventy‐six consecutive patients with an average age of 58.1 years met the inclusion and exclusion criteria and underwent EMLP for chronic rhinosinusitis (CRS, 59%), neoplasm (26%), and mucoceles (15%). The average number of standard endoscopic sinus surgeries prior to EMLP was 2.9. The mean follow‐up of the cohort was 34.8 months, at the end of which, EMLP was successful in 78% of all patients, requiring no further surgery. Ninety percent of patients reported significant clinical improvement at the most recent follow‐up. Subgroup analysis of CRS patients revealed an equally high success rate but a higher likelihood of ostial closure. Recurrent disease necessitated revision endoscopic surgery in 17 patients, the majority of whom suffered CRS. Only tissue eosinophilia was identified to significantly increase the risk of revision surgery. Conclusions The majority of the patients who undergo EMLP achieve sustained patency of the frontal sinus outflow tract and adequate symptom improvement. Prominent tissue eosinophilia identifies patients at risk of requiring additional frontal sinus surgery. Level of Evidence 4.
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Affiliation(s)
- Jasper Shen
- Caruso Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine University of Sothern California Los Angeles California U.S.A
| | - Nadia Chan
- Department of Otolaryngology-Head and Neck Surgery Loma Linda University Loma Linda California U.S.A
| | - Bozena B Wrobel
- Caruso Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine University of Sothern California Los Angeles California U.S.A
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Abuzeid WM, Vakil M, Lin J, Fastenberg J, Akbar NA, Fried MP, Fang CH. Endoscopic modified Lothrop procedure after failure of primary endoscopic sinus surgery: a meta-analysis. Int Forum Allergy Rhinol 2017; 8:605-613. [PMID: 29210504 DOI: 10.1002/alr.22055] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2017] [Revised: 11/01/2017] [Accepted: 11/09/2017] [Indexed: 01/14/2023]
Abstract
BACKGROUND The endoscopic modified Lothrop procedure (EMLP) has been used as a salvage technique for frontal sinusitis following failed endoscopic sinus surgery (ESS). We aim to examine the safety and efficacy of the EMLP following failure of primary ESS. METHODS All English-language publications from 2000 to 2016 reporting the use of EMLP after primary ESS were identified using the PubMed database and evaluated per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Random effects summaries of patient demographics, comorbidities, and surgical outcomes were obtained through meta-analysis. RESULTS Eleven studies constituting 778 patients were included and 86.5% had chronic rhinosinusitis (CRS). Mean follow-up duration was 28.4 months. The mean number of surgeries prior to EMLP was 3.5. Symptom improvement was reported in 82.3%. Subgroup analysis of 7 studies in which all 357 patients had CRS revealed a mean follow-up of 31.5 months. Symptom improvement occurred in 75.9% of cases and 23.1% experienced polyp recurrence. The cerebrospinal fluid leak rate was 2.5%. Restenosis of the neo-ostium occurred in 17.1% with complete closure occurring in 3.9% of cases. The reoperation rate after EMLP was 9.0%. Aspirin sensitivity was associated with an increased risk of cerebrospinal fluid (CSF) leak (p = 0.0339) and a reduced incidence of neo-ostium closure (p = 0.0001). Aspirin sensitivity and asthma were associated with a reduced incidence of reoperation (p ≤ 0.001) and increased symptom improvement (p < 0.005). Restenosis or closure of the frontal neo-ostium was associated with less symptom improvement (p < 0.04) but not with reoperation. CONCLUSION The EMLP is an effective salvage procedure for refractory frontal sinusitis based on data from higher-volume centers.
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Affiliation(s)
- Waleed M Abuzeid
- Department of Otorhinolaryngology-Head and Neck Surgery, Albert Einstein College of Medicine, Bronx, NY
| | - Mayand Vakil
- Department of Otorhinolaryngology-Head and Neck Surgery, Albert Einstein College of Medicine, Bronx, NY
| | - Juan Lin
- Department of Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx, NY
| | - Judd Fastenberg
- Department of Otorhinolaryngology-Head and Neck Surgery, Albert Einstein College of Medicine, Bronx, NY
| | - Nadeem A Akbar
- Department of Otorhinolaryngology-Head and Neck Surgery, Albert Einstein College of Medicine, Bronx, NY
| | - Marvin P Fried
- Department of Otorhinolaryngology-Head and Neck Surgery, Albert Einstein College of Medicine, Bronx, NY
| | - Christina H Fang
- Department of Otorhinolaryngology-Head and Neck Surgery, Albert Einstein College of Medicine, Bronx, NY
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Adappa ND, Ranasinghe VJ, Trope M, Brooks SG, Glicksman JT, Parasher AK, Palmer JN, Bosso JV. Outcomes after complete endoscopic sinus surgery and aspirin desensitization in aspirin-exacerbated respiratory disease. Int Forum Allergy Rhinol 2017; 8:49-53. [PMID: 29105347 DOI: 10.1002/alr.22036] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 09/25/2017] [Accepted: 10/08/2017] [Indexed: 11/05/2022]
Abstract
BACKGROUND In this study we assessed patient outcomes after complete endoscopic sinus surgery (ESS) and aspirin desensitization for patients with aspirin-exacerbated respiratory disease (AERD). METHODS A retrospective chart review was conducted for patients with aspirin challenge-proven AERD who underwent complete ESS followed by aspirin desensitization. Outcomes assessed included need for revision surgery and quality-of-life measures using the 22-item Sino-Nasal Outcomes Test (SNOT-22). Data were collected preoperatively, postoperatively prior to desensitization, and then at intervals post-desensitization through 30 months after aspirin desensitization. A longitudinal linear mixed-effects model was used for data analysis. RESULTS Thirty-four patients met the inclusion criteria for this study. Thirty-two patients successfully completed aspirin desensitization and were subsequently followed for 30 months after desensitization. Two patients were unable to complete desensitization. Five patients discontinued aspirin maintenance therapy due to gastrointestinal and respiratory side effects. Within the follow-up period, there were only 3 (9.4%) revision sinus surgeries. Notably, 1 of these revision cases occurred in a patient who had discontinued aspirin maintenance therapy. After surgical treatment and prior to desensitization patients had significant reductions in SNOT-22 scores. Our results demonstrate that total SNOT-22 scores remained statistically unchanged from immediate post-desensitization throughout the 30-month follow-up period. CONCLUSION Complete sinus surgery followed by timely aspirin desensitization and maintenance therapy is an effective combination in the long-term management of sinus disease in patients with AERD.
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Affiliation(s)
- Nithin D Adappa
- Division of Rhinology, Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA
| | - Viran J Ranasinghe
- Division of Rhinology, Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA
| | - Michal Trope
- Division of Rhinology, Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA
| | - Steven G Brooks
- Division of Rhinology, Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA
| | | | - Arjun K Parasher
- Department of Otolaryngology-Head and Neck Surgery, University of South Florida, Tampa, FL.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - James N Palmer
- Division of Rhinology, Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA
| | - John V Bosso
- Division of Rhinology, Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA
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