Defining appropriateness criteria for endoscopic sinus surgery during management of uncomplicated adult chronic rhinosinusitis: a RAND/UCLA appropriateness study

Patient perspectives on recall period and response options in patient-reported outcome measures for chronic rhinosinusitis symptomatology: An international multi-centered study

BACKGROUND

Existing patient-reported outcome measures (PROMs) for chronic rhinosinusitis (CRS) use a variety of recall periods and response scales to assess CRS symptom burden. Global perspectives of CRS patients regarding optimal recall periods and response scales for CRS PROMs are unknown.

METHODS

This was a multi-center, cross-sectional study recruiting 461 CRS patients from sites across the United States, Saudi Arabia, New Zealand, and Austria. Participants chose which CRS symptom recall period (1 day, 2 weeks, 1 month, >1 month) was most reflective of their current disease state and upon which to best base treatment recommendations (including surgery). Participants also chose which of six response scales (one visual analogue scale and five Likert scales ranging from four to eight items) was easiest to use, understand, and preferred.

RESULTS

A plurality of participants (40.0%) felt their CRS symptoms' current state was best reflected by a 1-month recall period. However, most patients (56.9%) preferred treatment recommendations to be determined by symptoms experienced over a >1 month period. The four- and five-item Likert scales were the easiest to understand (26.0% and 25.4%, respectively) and use (23.4% and 26.7%, respectively). The five-item (26.4% rating it most preferred and 70.9% rating it preferred) and four-item Likert (22.3% rating it most preferred and 56.4% rating it preferred) response scales were most preferred.

CONCLUSION

Future PROMs for CRS should consider assessment of symptoms over a 1-month period and use a four- or five-item Likert response scale to reflect global patient preferences. These findings also inform interpretation of current CRS PROMs.

Orally administered Chinese herbal therapy to assist post-surgical recovery for chronic rhinosinusitis-A systematic review and meta-analysis

This systematic review and meta-analysis aims to: assess the effectiveness and safety of orally administered Chinese herbal medicines (CHMs) as adjuncts to the post-surgical management of chronic rhinosinusitis (CRS); inform clinicians of the current evidence; identify the best available evidence; and suggest directions for further research. Randomised controlled trials (RCTs) were identified from searches of nine databases plus clinical trial registries. Participants were adults and/or children diagnosed with sinusitis or rhinosinusitis, with or without nasal polyps, who had received surgery. Interventions were CHMs used orally following surgery for CRS as additions to conventional post-surgical management. Controls received conventional post-surgical management without CHMs. Studies reported results for Sino-Nasal Outcome Test (SNOT), visual analogue scales (VAS), Lund-Mackay computed tomography score (LM), Lund-Kennedy endoscopic score (LK), mucociliary transport time (MTT), mucociliary transport rate (MTR), mucociliary clearance (MC) or quality of life (QoL). Twenty-one RCTs were included. All used oral CHMs following functional endoscopic sinus surgery (FESS). The pooled results showed no significant difference between groups for SNOT-20 at the end of treatment (EoT) but there was a significant difference at follow up (FU) in favour of additional CHMs. The VAS for total nasal symptoms (VAS-TNS) showed greater improvements in the CHM groups at EoT and FU. Only FU data were reported for LM which showed greater improvement in the CHM groups. LK showed greater improvements at EoT and FU. The measures of mucociliary transport (MTT, MTR, and MC) each showed significantly greater improvement at EoT in the group that received additional CHMs. No study reported QoL. Adverse events were not serious, but reporting was incomplete. The meta-analyses suggested the addition of oral CHMs to conventional management following FESS may improve recovery. However, most studies were not blinded, and substantial heterogeneity was evident in some meta-analyses. Blinded studies are required to further investigate the roles of oral CHMs in post-surgical recovery. Systematic review registration number: The protocol was registered in PROSPERO (CRD42019119586).

Intranasal Spray Characteristics for Best Drug Delivery in Patients With Chronic Rhinosinusitis

OBJECTIVES

To determine parameter combinations for effective drug delivery of intranasal spray steroids to the ostiomeatal complex (OMC) and maxillary sinus (MS) in patients with chronic rhinosinusitis (CRS).

METHODS

Each patient's sinonasal cavity was reconstructed from computed tomography scans. Intranasal airflow and drug particle transport were simulated using computational fluid dynamic modeling. Airflow simulations were performed at 15 Pascal inhalation pressure. Intranasal spray particles of 1-100 μm were simulated at release speeds of 1, 5, and 10 m/s from 6 release locations (Bottom, Center, Top, Lateral, Lateral-Bottom, and Lateral-Top) at a nozzle insertion depth of 15 mm. Drug delivery simulations were performed in the head tilted forward position.

RESULTS

Maximal OMC deposition was 0.78%-12.44%, while maximal MS deposition was 0.02%-1.03% across all simulations. In general, particles between 6 and 10 μm had the best OMC (at 1 m/s particle velocity) and MS (at 10 m/s particle velocity) deposition. Particles ranging from 21 to 30 μm also had superior OMC deposition. The lateral and lateral-top spray release locations produced maximum OMC deposition, but no one release location demonstrated an increase in MS deposition.

CONCLUSION

This preliminary study suggests that it is challenging to determine a common set of intranasal spray parameter combinations for effective drug delivery to the OMC and MSs. Although drug particle size and spray particle velocity seem to impact particle deposition patterns, spray release location appears to vary with anatomical differences between subjects, particularly when the MS is the target location for particle deposition. Laryngoscope, 133:1036-1043, 2023.

Minimal Radiographic Mucosal Thickness or Opacification Criterion for Sinus-Specific Endoscopic Sinus Surgery for Chronic Rhinosinusitis

OBJECTIVE

Primary chronic rhinosinusitis (CRS) is typically a diffuse process and the extent of endoscopic sinus surgery (ESS) performed for medically recalcitrant CRS is impacted by many factors. However, some third-party payors have implemented policies to authorize coverage for ESS in a sinus-by-sinus manner based on a minimal measurement of millimeters of mucosal thickening or sinus opacification in the corresponding sinus that is being surgically addressed. Our objective was to determine whether such policies are based on scientific evidence that in patients with medically recalcitrant CRS, a minimum measurement of mucosal thickening or sinus opacification is a predictor of CRS in that sinus or improved outcomes after ESS on a sinus-by-sinus basis.

DATA SOURCES

Medline, Embase, Scopus, and Web of Science databases, from inception through May 2022.

REVIEW METHODS

A systematic review was performed. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were followed.

RESULTS

We identified 6070 abstracts which were screened and from which 112 studies ultimately underwent a full-text review. From these studies, we found that none investigated (or provided evidence of) whether any minimal degree of radiographic mucosal thickening or sinus opacification predicted CRS or better outcomes after ESS in a sinus-specific manner.

CONCLUSION

We were unable to find evidence supporting a minimum millimeter measurement of mucosal thickening or sinus opacification as predictors of CRS or better post-ESS outcomes in a sinus-specific manner in patients with medically recalcitrant CRS. The extent of ESS for CRS should be determined through personalized medical decision-making that considers all patient-specific factors.

Current evaluation and management of patients with chronic rhinosinusitis and nasal polyps

INTRODUCTION

A clear understanding of the pathophysiology of chronic rhinosinusitis with nasal polyps (CRSwNP) and its close association with other airway pathologies, especially asthma, helps to comprehend the concept of the united airway and the importance of a multidisciplinary approach and the actual roll of biologic therapy.

AREAS COVERED

This expert review is the synthesis of a working group on the current state of the art of the evaluation and management of CRSwNP. A thorough analysis of the literature has been conducted for the latest studies and results, specially the European (EPOS 2020) and American (ICAR-RS 2021) guidelines.

EXPERT OPINION

The roles of optimal medical treatment and indications for surgery are becoming clearer, but much research is still needed regarding the extent and radicality when surgery is indicated. The main objectives of this review were to provide a clear and updated description of treatments, their indication, follow-up, and response criteria. These steps are considering the broad spectrum of inflammation endophenotypes and the biologic therapy available. Understanding the role and limitations of each specialty is key for providing greatest benefit to the patient.

Outcomes of Non-Mucosa Sparing Endoscopic Sinus Surgery (Partial Reboot) in Refractory Chronic Rhinosinusitis with Nasal Polyposis: An Academic Hospital Experience

OBJECTIVE

The reboot approach could be an effective treatment option to lower recurrence rates (RRs) in recalcitrant Chronic Rhinosinusitis with Nasal Polyps (CRSwNP). The purpose of this study was to investigate RR, recurrence-free survival (RFS), quality of life (QoL) improvement, and oral corticosteroid (OCS) intake in pluri-operated CRSwNP patients treated with partial reboot surgery.

METHODS

A consecutive sample of patients with recalcitrant CRSwNP, ineligible for monoclonal antibodies, underwent partial reboot surgery. The 22-item SinoNasal Outcome Test (SNOT-22), Visual Analogue Scales (VAS) scores, OCS intake, and endoscopic Nasal Polyp Score (NPS) were collected pre and postoperatively. The main outcomes were RR and RFS, and comparison of disease-free time with previous endoscopic surgeries.

RESULTS

Thirty pluri-operated patients were enrolled. Before the reboot, all had experienced disease recurrence at a mean recurrence time of 8.08 ± 2.83 months after surgery. After reboot, 7 (23.3%) had recurrence at a mean time of 16.67 ± 3.07 months (p = 0.02); none needed additional revision surgery till time of data collection. RR at 12, 18, and 24 months follow-up resulted significantly lower for reboot than other previous surgeries (p = 0.010, p = 0.002, p = 0.016, respectively); RFS difference resulted significant (log-rank test = 4.16; p = 0.04). Differences between pre-and post-operative total and single-items scores of SNOT-22 were significant (p = 0.001), as well as VAS scores (p = 0.001). Before the reboot, 21 patients (70%) took ≥2 OCS courses per year; at the latest follow-up visit, none had taken any course of OCS after reboot.

CONCLUSIONS

The reboot approach showed lower RR, longer RFS, improved QoL, and zeroing of OCS uptake. Larger samples and longer follow-up studies are needed to assess long-term efficacy and safety of this procedure.

LEVEL OF EVIDENCE

Level 4. According to the Oxford Center for Evidence-Based Medicine 2011 level of evidence guidelines, this non-randomized retrospective cohort study is classified as level 4 evidence Laryngoscope, 2022. Laryngoscope, 2022.

Is there a Role for Antibiotics in the Treatment of Chronic Rhinosinusitis?

Rhinosinusitis is one of the most common reasons for adult outpatient antibiotic prescriptions, though there is little clinical evidence to support this practice, especially for chronic rhinosinusitis. Despite considerable research, the etiology of chronic rhinosinusitis, including the pathogenic role of microbes, remains poorly understood. Rigorous studies of the efficacy of antibiotic treatment of chronic sinusitis are surprisingly few in number and the results are somewhat conflicting. This article will review the rationales for and against the treatment of chronic rhinosinusitis with antibiotics, based on current evidence and understanding of pathophysiology, and will also summarize the current guidelines.

Chronic Rhinosinusitis Outcomes of Patients With Aspirin-Exacerbated Respiratory Disease Treated With Budesonide Irrigations: A Case Series

BACKGROUND

Pathophysiology-targeting treatments exist for aspirin-exacerbated respiratory disease (AERD) through aspirin desensitization and biologics, such as dupilumab. With increasing attention paid to these treatments, which may be associated with significant side effects and/or cost, there is little description of chronic rhinosinusitis with nasal polyps (CRSwNP) response to treatment with intranasal corticosteroids and saline irrigations in AERD.

OBJECTIVE

To determine the effect of intranasal budesonide irrigations for the treatment of CRSwNP in AERD.

METHODS

This is an observational study of 14 AERD patients presenting to a rhinology clinic for CRS who were treated with twice daily high volume, low pressure irrigations with 240 mL of saline to which a 0.5 mg/2 mL respule of budesonide was added. All participants completed a 22-item Sinonasal Outcome Test (SNOT-22) at enrollment and at follow up 1 to 6 months later. Polyp scores were also calculated at each time point.

RESULTS

SNOT-22 scores ranged from 26 to 98 (median: 40.5) at enrollment and 3 to 85 (median: 38.5) at follow-up. Polyp scores ranged from 2 to 6 (median: 4) at enrollment at 0 to 6 (median: 2) at follow-up. Over the treatment period, change in SNOT-22 score ranged from -38 to 16 (median: -18) and change in polyp score ranged from -2 to 0 (median: -0.5). Approximately 57% of participants experienced at least 1 minimal clinically important difference in SNOT-22 score and 21% of participants had a SNOT-22 score <20 at follow-up.

CONCLUSION

Medical management with intranasal corticosteroids and saline irrigations alone leads to significant improvement in sinonasal symptomatology in a subset of AERD.

Patient-reported chronic rhinosinusitis disease control is a valid measure of disease burden

BACKGROUND

Disease control is an important treatment goal for chronic uncurable conditions such as chronic rhinosinusitis (CRS). The objective of this study was to determine whether patient-reported CRS disease control is a valid reflection of disease burden.

METHODS

Prospective longitudinal study of 300 CRS patients (35% CRS with nasal polyps, 65% CRS without nasal polyps). At enrollment and at a subsequent follow-up timepoint, all participants were asked to rate their CRS disease control as "not at all," "a little," "somewhat," "very," or "completely", as well as to complete a 22-item Sinonasal Outcome Test (SNOT-22) and the 5-dimension EuroQol general health questionnaire from which the visual analogue scale (EQ-5D VAS) was used.

RESULTS

At enrollment and follow-up timepoints, patient-reported CRS disease control was significantly correlated with SNOT-22 and EQ-5D VAS scores. The change in patient-reported CRS disease control was significantly correlated with change in SNOT-22 and change in EQ-5D VAS scores. There was significant cross-sectional and longitudinal correlation between patient-reported control and all SNOT-22 subdomain scores. A SNOT-22 score of ≤ 25 points or lower, or an EQ-5D VAS score of ≥77 was predictive of having well - (i.e. "very" or "completely") controlled CRS.

CONCLUSIONS

Patient-reported CRS disease control is a valid measure of CRS disease burden and general QOL. A patient-reported assessment of CRS disease control could be considered as a component of a more comprehensive measure of CRS disease control.

Treatment options for chronic rhinosinusitis with nasal polyps

Background: The management of chronic rhinosinusitis with nasal polyps (CRSwNP) is evolving, with an emphasis on treating the underlying type 2 inflammation. Objective: The objective was to summarize the updated evidence-based medical and surgical treatment recommendations for CRSwNP, including the position of biologics in the treatment algorithm. Methods: This review compared and contrasted the therapeutic recommendations presented by the European Position Paper on Rhinosinusitis and Nasal Polyps 2020 and the International Consensus Statement on Allergy and Rhinology: Rhinosinusitis 2021. Results: The long-term use of intranasal corticosteroids and the short-term use of oral corticosteroids are strongly recommended, whereas corticosteroid-eluting implants are considered an option. Although the use of saline solution rinses is recommended, there is uncertainty as to whether irrigation is more effective than sprays. Oral aspirin (ASA) desensitization, followed by ASA ≥ 300 mg daily for patients with ASA-exacerbated respiratory disease may be considered. In general, the use of antifungal agents offers no benefit and potential harm. Although the use of oral antibiotics for an acute exacerbation is still debated, oral and topical antibiotics are discouraged for subacute or chronic use. Antileukotrienes are inferior to intranasal corticosteroids and are unlikely to provide added benefit when used concomitantly. It is unlikely that the benefit of oral antihistamines and decongestants outweigh the potential harm. Dupilumab is recommended for severe CRSwNP when consensus-determined criteria are met. Omalizumab may be an option with concomitant poorly controlled asthma. Mepolizumab and reslizumab may be used, particularly in patients with concomitant uncontrolled asthma. In allergic fungal rhinosinusitis, oral and topical antifungals, antileukotrienes, allergen immunotherapy, and omalizumab are therapeutic options. Although surgical intervention is recognized to be of benefit for CRSwNP, there are no evidence-based criteria to indicate when maximum medical treatment has failed. Conclusion: An evidence-based CRSwNP treatment algorithm for when to recommend surgery and/or initiate or discontinue biologics to maximize quality of life and cost-effectiveness is still lacking.

Radiographic disease severity in chronic rhinosinusitis patients and health care utilization

OBJECTIVES

Chronic rhinosinusitis (CRS) affects approximately 12% of the population and leads to increased health care utilization and indirect costs exceeding $20 billion annually in the United States. The Lund-Mackay score (LMS) measures radiographic disease severity for CRS but poorly correlates with symptom scores. The association between LMS and health care utilization in CRS patients has not yet been investigated. The study aimed to assess the association between health care utilization and CRS radiographic severity using LMS.

METHODS

CRS patients enrolled in a clinical registry were evaluated. Nasal endoscopy findings and LMS were recorded for patients with sinus CT imaging. Patient symptom scores, demographic characteristics, and health care utilization measures were collected. The relationship between these factors and LMS was examined.

RESULTS

A total of 556 patients met inclusion criteria. Mean age was 45.3 years, 53.4% were male, and 41.7% had nasal polyps. There was no difference in sex, smoking history, 22-item Sino-nasal Outcome Test scores, or past medical history factors between patients with high (≥8, n = 410) and low (<8, n = 146) LMS. Among high LMS patients, 73.7% underwent endoscopic sinus surgery (ESS) compared to 55.5% with low LMS (P < .01), and a greater percentage of patients had nasal polyps (49.3% vs 20.5%, P < .01). On multivariable logistic regression, high LMS patients used fewer antibiotic courses (OR: 0.68 [0.51-0.91]), but were more likely to be managed with ESS (OR: 2.28 [1.41-3.73]), and have nasal polyps (OR: 2.11 [1.16-3.93]) compared to low LMS patients. There was no significant difference in the number of steroid courses, over the counter pill use, provider visits, work/school days missed, or symptom duration between the two LMS groups.

CONCLUSION

CRS patients with severe radiographic disease are more likely to have nasal polyps, undergo ESS, and take fewer antibiotic courses. However, there is no association between radiographic disease severity and other measures of health care utilization.

LEVEL OF EVIDENCE

2b, individual retrospective cohort study.

Endoscopic sinus surgery for chronic rhinosinusitis: 22-item Sino-Nasal Outcome Test 5-year results

BACKGROUND

Currently, limited data exist as to long-term disease-specific outcomes after endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS). In this report, we present outcomes data collected over 5 years in a large prospective cohort of patients who underwent surgical treatment for CRS.

METHODS

Patients who completed the 22-item Sino-Nasal Outcome Test (SNOT-22) before ESS were asked to complete the same survey at yearly intervals for 5 years thereafter. The impact of patients' demographics and clinical characteristics on clinical outcome was measured using mixed effects modeling for univariate and multivariable analysis. Multivariable logistic regression threshold analyses were also performed.

RESULTS

Among the 925 patients enrolled in the study, the SNOT-22 was completed after ESS by 641 patients (69.3%) at 1 year and 338 patients (36.5%) at 5 years. The mean preoperative SNOT-22 score of 48.5 (standard error [SE], 0.69) improved at all subsequent yearly time-points, including 5 years (mean, 25.8; SE, 1.08; p < 0.0001). SNOT-22 scores over time were impacted by nasal polyps (p < 0.001), environmental allergies (p = 0.010), diabetes (p = 0.032), and preoperative Lund-Mackay score (p < 0.001).

CONCLUSION

Endoscopic sinus surgery appears to be effective at improving the quality of life of patients with CRS for both the short and long term. The successful outcome of such surgery, however, is influenced by a variety of clinical factors, which should be taken into account by clinicians who are considering surgical treatment of CRS for select patients.

Impact of CFTR Therapy on Chronic Rhinosinusitis and Health Status: Deep Learning CT Analysis and Patient Reported Outcomes

RATIONALE

Elexacaftor/tezacaftor/ivacaftor (ETI) in triple combination improves pulmonary health for people with cystic fibrosis (PwCF) however its impact on objective measures of sinus disease and health utility is unestablished.

OBJECTIVES

To evaluate the impact of ETI on chronic rhinosinusitis (CRS) and general health status incorporating computed tomography (CT), quality-of-life (QOL) and productivity loss.

METHODS

Adult PwCF+CRS with CF transmembrane conductance regulator genotype F508del/F508del or F508del/minimal function who clinically initiated ETI participated in a prospective, observational study. The primary endpoint was change in percent sinus CT opacification (%SO) after 6 months of ETI assessed via deep learning-based methods. Secondary endpoints included changes in sinonasal QOL, health utility value and productivity loss, which were evaluated monthly via validated metrics.

RESULTS

30 PwCF provided baseline data; 25 completed the study. At baseline, the cohort had substantial CRS, with mean 22-question SinoNasal Outcome Test (SNOT-22) score 33.1 and mean sinus CT %SO 63.7%. At 6-month follow-up, %SO improved by mean 22.9% (p<0.001). %SO improvement trended toward greater magnitude for those naïve to prior modulator therapy (p=0.09). Mean SNOT-22 scores and health utility improved by 15.3 and 0.068 [6.8%] (all p<0.007). Presenteeism, activity impairment and overall productivity loss improved (all p<0.049). Improvements in SNOT-22 scores and health utility occurred by one month and remained improved over the study.

CONCLUSIONS

ETI is associated with substantial improvements in sinus CT opacification and productivity loss, and clinically meaningful improvements in sinonasal QOL and health utility. Most improvements were rapid, robust and durable over the study.

Choosing the Right Patient for Biologic Therapy in Chronic Rhinosinusitis with Nasal Polyposis: Endotypes, Patient Characteristics, and Defining Failures of Standard Therapy

There are many phenotypes of chronic sinusitis and clinical variables that differ between patients. The ability to accurately diagnose, predict prognosis, and select the appropriate treatment depends on the understanding of disease endotypes. Chronic sinusitis is in the early stages of disease endotyping. The ability to identify endotypes is at the forefront of clinical research. Endotyping of chronic sinusitis uses clinical information, radiographic studies, and pathophysiologic data. Understanding of the full spectrum of chronic sinusitis is in its infancy. A personalized approach to treatment will consider standard medical therapies, sinus surgeries, and targeted use of biologic agents.

Safety review of current systemic treatments for severe chronic rhinosinusitis with nasal polyps and future directions

Introduction: Chronic rhinosinusitis is a common condition characterized by inflammation of the nasal and sinus linings, rhinorrhea, nasal blockage, facial pain, and loss of sense of smell for longer than 12 weeks. CRS can occur with or without nasal polyps.Areas covered: First-line treatment in chronic rhinosinusitis with nasal polyps is long-term intranasal corticosteroids, which have few adverse events associated with their use, as second-generation intranasal corticosteroids having a bioavailability of <0.5%. Systemic corticosteroids are used when intranasal steroids fail to achieve symptom control. However, the repeated use of oral corticosteroids is associated with numerous adverse events and the benefit from a course of oral corticosteroids is lost within three to six months.Expert opinion: Antibiotics are commonly prescribed in nasal polyposis although there is also very little evidence for their use outside of acute infection. Macrolide antibiotics are also associated with a transient increase in the risk of arrhythmias. Biologics offer a steroid-sparing alternative to the treatment of severe nasal polyposis. They have shown to be relatively well tolerated in studies to date; however, studies suggest that there is no disease modifying effect and that any benefit is lost within weeks of finishing treatment.

International consensus statement on allergy and rhinology: rhinosinusitis 2021

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.

The relationship of chronic rhinosinusitis and depression

PURPOSE OF REVIEW

The aim of this article is to identify and describe the relationship between chronic rhinosinusitis (CRS) and comorbid depression, including the patient factors that may increase the risk of depression. The impact of comorbid depression on quality of life, response to treatment and healthcare utilization will also be assessed.

RECENT FINDINGS

CRS is associated with a significantly increased prevalence of depression, where 9-26% of patients with CRS will have physician-diagnosed depression. An additional 40% will have undiagnosed depression that can be identified through screening tools. Patients without polyps are more likely to experience comorbid depression, as are patients with significant sleep dysfunction, olfactory dysfunction, and pain. CRS symptoms do improve with medical and surgical therapy in depressed patients, though baseline and posttreatment scores are worse. A similar degree of benefit from therapy is seen in both depressed and nondepressed patients. CRS treatment does seem to improve depression, whereas the effect of depression specific therapy is unknown. Depressed patients have a significantly larger economic burden because of their increased healthcare utilization and productivity losses.

SUMMARY

Depression is a highly prevalent and impactful comorbidity in patients with CRS. Increased awareness of this relationship may improve patients' overall quality of care.

NSAID-ERD Syndrome: the New Hope from Prevention, Early Diagnosis, and New Therapeutic Targets

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.

Indications and Outcomes for Patients With Limited Symptoms Undergoing Endoscopic Sinus Surgery

BACKGROUND

Previous research have suggested that chronic rhinosinusitis (CRS) patients with lower symptomatic scores, demonstrated by a 22-item Sinonasal Outcome Test (SNOT-22) score <20, may not achieve meaningful quality of life improvement following endoscopic sinus surgery (ESS). However, indications for ESS are continuing to be defined and many low SNOT-22 scoring patients still undergo elective surgery for CRS and other benign sinonasal pathologies. The outcomes for these patients have not been previously studied.

OBJECTIVES

We sought to evaluate surgical indications and outcomes for those patients with limited symptoms undergoing ESS.

METHODS

We screened 2829 ESS procedures from 2010-2018 to identify patients with a preoperative SNOT-22 score <20. We reviewed disease characteristics, preoperative Lund-Mackay (LM) scores, and pre- and postoperative SNOT-22 scores in patients with at least 3 months' follow-up.

RESULTS

Of all surgical ESS patients screened, 114 had low preoperative SNOT-22 scores (4.0%). Indications for these surgeries included CRS (50.0%), odontogenic sinus disease (11.4%), mucocele (10.5%), recurrent acute sinusitis (7.0%), fungal ball (5.3%), and silent sinus syndrome (4.4%). Specifically, among CRS patients, 45.6% had pulmonary comorbidities and/or systemic immunodeficiencies. Moreover, 100% of CRS patients with nasal polyps and 73.1% of CRS without polyps had LM scores >5. Patients with preoperative SNOT-22 scores between 15 and 19 achieved an average 6.5 point reduction (P < .001) postoperatively, whereas those with scores between 10 and 14 had a 5.4 point reduction (P < .001), and preoperative scores <9 resulted in no significant decrease in postoperative symptom scores (P = .98). Overall, there was a 3.3 point SNOT-22 reduction among all patients at 3 months postoperatively (P < .001).

CONCLUSION

Patients with limited sinonasal symptoms may benefit from surgical treatment despite asymptomatic clinical presentations. A case-by-case analysis of comorbidities or unique clinical features should inform surgical decision-making for patients with lower SNOT-22 scores.

Current and Future Treatments of Rhinitis and Sinusitis

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.

The Utility and Feasibility of Extending Beyond Traditional Patient Descriptions in Daily Practice

OBJECTIVES/HYPOTHESIS

Institutional and national programs have endorsed the use of validated instruments in daily practice, but their utility for frontline clinicians is unknown. Our first objective was thus to determine if routinely obtained patient descriptions accurately predict disease-specific validated instrument results. Our second objective was to assess the feasibility of deploying an electronic system to obtain and document patient-reported descriptions of health status.

STUDY DESIGN

Prospective assessment of consecutive eligible ambulatory care patients.

METHODS

For the first objective, patients presenting with the same chief complaint at consecutive visits provided concurrent routine symptom descriptions and validated instrument responses. To determine whether patients' routine descriptions predicted scores from disease-specific instruments, receiver operator characteristic (ROC) curves, sensitivity/specificity, Spearman ρ correlation, and regression models were utilized. For the second objective, feasibility assessment focused on percent with successful response capture, time to questionnaire completion, and impact on physician time needed to obtain and document patient histories.

RESULTS

For the first objective, among patients with hearing loss, eustachian tube dysfunction, nasal obstruction, and chronic rhinosinusitis, the areas under the ROC curves were 0.38 to 0.83. Spearman ρ coefficients were 0.25 to 0.46. Sensitivity and specificity ranged from 15.9% to 87.8%, with correct classification in 42.3% to 55.2% of cases. For the second objective, there was a 91% completion rate. Completion times were 7:18 to 12:37 for new patients and 3:23 to 6:41 for established patients. Physician time savings were estimated at 11 minutes per patient.

CONCLUSIONS

Using validated instruments and electronic data collection systems in daily practice has practical and clinical implications. These topics warrant further study.

LEVEL OF EVIDENCE

2c Laryngoscope, 130:S1-S13, 2020.

Predictors of efficacy for combination oral and topical corticosteroids to treat patients with chronic rhinosinusitis with nasal polyps

BACKGROUND

A short-course oral corticosteroid taper and topical intranasal corticosteroids may be used to maximize the success of medical management for chronic rhinosinusitis with nasal polyps (CRSwNP). In this study, we sought to identify characteristics that would be predictive of efficacy for this combination regimen.

METHODS

Sixty-four patients with CRS, bilateral polyps, a polyp score of at least 3, and a 22-item Sino-Nasal Outcome Test (SNOT-22) score ≥20 were prospectively enrolled and uniformly treated with a 15-day prednisone taper and twice daily dilute budesonide irrigations. Participants were assessed at enrollment and at follow up, 2 to 5 months later. Clinical and demographic characteristics were assessed at enrollment. At both time points, CRS symptoms were assessed with SNOT-22, and polyp score (range, 0 to 6) was assessed endoscopically. Associations were determined with regression.

RESULTS

Pretreatment SNOT-22 score (adjusted β = -0.83; 95% CI, -1.08 to -0.58; p < 0.001) and comorbid asthma (adjusted β = 15.75; 95% CI, 4.74 to 26.75; p = 0.007) were associated with a change in SNOT-22 experienced over the study period. Achieving a greater-than-1 minimal clinically important difference (MCID) improvement in SNOT-22 score was also associated with pretreatment SNOT-22 score (adjusted OR = 1.09; 95% CI, 1.04 to 1.14; p < 0.001) and comorbid asthma (adjusted OR = 0.13; 95% CI, 0.03 to 0.72; p = 0.019). SNOT-22 score ≥47 had 81.5% sensitivity and 78.4% specificity to detect patients experiencing 1 MCID improvement. Pretreatment polyp score was not associated with any outcome metric.

CONCLUSION

In treatment of CRSwNP with prednisone and budesonide irrigations, pretreatment endoscopy was not informative of treatment response. Pretreatment SNOT-22 and comorbid asthma may be more predictive.

The efficacy of diluted topical povidone-iodine rinses in the management of recalcitrant chronic rhinosinusitis: a prospective cohort study

PURPOSE

Recalcitrant chronic rhinosinusitis is a persistent inflammatory condition of the sinonasal mucosa despite adequate medical therapy and sinus surgery. This study aimed to demonstrate the effectiveness and safety of dilute povidone-iodine (PVP-I) sinonasal rinses as an adjunctive therapy.

METHODS

Prospective cohort study. Twenty-nine recalcitrant CRS patients with endoscopic evidence of ongoing inflammation and purulent discharge were prescribed 0.08% diluted PVP-I rinses. Changes to endoscopic modified Lund-Kennedy (MLK) scores at 7 weeks post-PVP-I rinsing served as the primary outcome measure.

RESULTS

The median MLK-discharge score significantly decreased in all patients by 1.50 points post-PVP-I rinsing (p value < 0.01). The total MLK score significantly decreased in all patients by 1.50 points (p value = 0.01). Up to a 17% reduction in serum inflammatory markers was measured post-PVP-I rinsing. Sinonasal culture revealed a shift from moderate-heavy growth to lighter bacterial growth overall. Subjective SNOT-22 scores significantly improved overall by ≥ 1 minimal clinically important difference (MCID > 12; baseline median = 33; follow-up median = 20; p value < 0.01; n = 22). TSH levels increased non-significantly within normal ranges (baseline median = 1.59 mU/L; follow-up median = 1.92 mU/L; p = 0.10; n = 15). Mucociliary clearance time increased non-significantly within normal ranges (baseline median = 9 min; follow-up median = 10 min; p value = 0.53; n = 17). Olfactory Sniffin'16 scores non-significantly decreased within age-related normal ranges (baseline median = 14; follow-up median = 13; p value = 0.72; n = 18).

CONCLUSION

A dilute 0.08% PVP-I sinonasal rinse as an ancillary therapy in recalcitrant CRS significantly reduces signs of infection alongside notable symptom improvement, without affecting thyroid function, mucociliary clearance or olfaction.

What is the most appropriate treatment for chronic rhinosinusitis?

Chronic rhinosinusitis (CRS) is a common, treatable disease that affects approximately 11% of British adults. It places an enormous burden on patients, with significant detriment to their quality of life, and the health service as it consumes vast numbers of both primary and secondary care resources. However, there is considerable variability in treatment strategies and prescribing practices. This review summarises the key recommendations from landmark guidelines in the treatment of CRS and critically appraises the evidence for treatment.

Complications Are Rare From Middle Turbinate Resection: A Prospective Case Series

Background

When chronic rhinosinusitis with nasal polyps (CRSwNP) fails to respond to medical therapy, endoscopic sinus surgery (ESS) plays an integral role in management. Some studies have shown that middle turbinate resection (MTR) during ESS leads to decreased polyp recurrence and revision ESS rates. Other studies suggest MTR can lead to complications.

Objective

The purpose of this study was to assess the safety of MTR during ESS for CRSwNP by determining the incidences of intraoperative cerebrospinal fluid (CSF) leak, postoperative epistaxis requiring operative intervention, and postoperative complete frontal stenosis.

Methods

A multiinstitutional, prospective case series of 91 adult CRSwNP patients was conducted. Patients with medically refractory CRSwNP underwent primary or revision ESS plus MTR by 3 surgeons. Two of the surgeons performed partial MTRs, and one of the surgeons performed complete MTRs. Patients were evaluated for the following complications: intraoperative CSF leak during MTR, postoperative epistaxis requiring operative intervention, and postoperative complete frontal ostial stenosis. Secondary outcomes included changes from preoperative to postoperative 22-item Sinonasal Outcome Test (SNOT-22) scores and revision ESS rates.

Results

Unilateral or bilateral complete ESSs with MTRs were performed on 91 CRSwNP patients. In total, 173 MTRs were performed. Two surgeons performed 97 partial MTRs on 49 patients, and the third surgeon performed 76 complete MTRs on 42 patients. One CSF leak occurred during partial MTR (1/173, 0.57%). No patients suffered postoperative epistaxis requiring operative intervention, and no patients developed complete frontal stenosis. From preoperatively to postoperatively, mean SNOT-22 scores decreased from 53.7 to 13.1 ( P = .001). No revision ESS was needed during the follow-up period. Mean follow-up time was 7.5 ± 5.4 months.

Conclusions

Partial and complete MTR during ESS for CRSwNP in this cohort resulted in very low, acceptable intraoperative and short-term postoperative complication rates and no detriment to SNOT-22 scores.

Socioeconomic status impacts postoperative productivity loss and health utility changes in refractory chronic rhinosinusitis

BACKGROUND

Social determinants of health can have a substantial impact on treatment outcomes. Prior study has shown that socioeconomic status influences the likelihood of improvement in quality-of-life (QOL) following endoscopic sinus surgery (ESS). However, the impact of socioeconomic factors on changes in productivity loss and health utility after ESS remains unknown.

METHODS

Adult patients (≥18 years of age) with chronic rhinosinusitis (CRS) who underwent ESS were prospectively enrolled into a multi-institutional cohort study. Productivity losses were calculated using the human capital approach and monetized using U.S. government-estimated wage rates. Health utility values (HUVs) were derived from the Medical Outcomes Study Short-Form-12 survey using University of Sheffield algorithms. Independent socioeconomic factors of interest included: age, gender, ethnicity, insurance status, educational attainment, and household income categorized via the Thompson-Hickey model.

RESULTS

A total of 229 patients met inclusion criteria, and 163 (71%) provided postoperative follow-up. All subjects reported significant, within-subject improvement in both mean monetized productivity loss (p < 0.001) and HUV postoperatively (p < 0.001). Using paired sample statistics, patients with lowest income (≤$25,000/year) and with Medicare insurance did not report significant improvement in productivity loss (p ≥ 0.112) or HUV (p ≥ 0.081), although sample size limitations may have contributed to this finding. Patients in higher income tiers ($25,001 to $100,000/year and $100,001+/year) and those with employer-provided/private health insurance reported significant postoperative improvements in productivity loss and HUV (all p ≤ 0.003).

CONCLUSION

Socioeconomic factors, including income and insurance provision, may impact improvements in productivity loss and HUV following ESS. Further research to validate these findings, ascertain mechanisms behind these results, and improve these outcomes is warranted.

Clarithromycin and endoscopic sinus surgery for adults with chronic rhinosinusitis with and without nasal polyps: study protocol for the MACRO randomised controlled trial

Background

Chronic rhinosinusitis (CRS) is a common source of ill health; 11% of UK adults reported CRS symptoms in a worldwide population study. Guidelines are conflicting regarding whether antibiotics should be included in primary medical management, reflecting the lack of evidence in systematic reviews. Insufficient evidence to inform the role of surgery contributes to a fivefold variation in UK intervention rates. The objective of this trial is to establish the comparative effectiveness of endoscopic sinus surgery (ESS) or a prolonged course of antibiotics (clarithromycin) in adult patients with CRS in terms of symptomatic improvement and costs to the National Health Service compared with standard medical care (intranasal medication) at 6 months.

Methods/design

A three-arm parallel-group trial will be conducted with patients who remain symptomatic after receiving appropriate medical therapy (either in primary or secondary care). They will be randomised to receive: (1) intranasal medication plus ESS, (2) intranasal medication plus clarithromycin (250 mg) or (3) intranasal medication plus a placebo. Intranasal medication (current standard medical care) is defined as a spray or drops of intranasal corticosteroids and saline irrigations. The primary outcome measure is the SNOT-22 questionnaire, which assesses disease-specific health-related quality of life. The study sample size is 600. Principal analyses will be according to the randomised groups irrespective of compliance. The trial will be conducted in at least 16 secondary or tertiary care centres with an internal pilot at six sites for 6 months.

Discussion

The potential cardiovascular side effects of macrolide antibiotics have been recently highlighted. The effectiveness of antibiotics will be established through this trial, which may help to reduce unnecessary usage and potential morbidity. If ESS is shown to be clinically effective and cost-effective, the trial may encourage earlier intervention. In contrast, if it is shown to be ineffective, then there should be a significant reduction in surgery rates. The trial results will feed into the other components of the MACRO research programme to establish best practice for the management of adults with CRS and design the ideal patient pathway across primary and secondary care.

Trial registration

ISRCTN36962030. Registered on 17 October 2018.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3314-7) contains supplementary material, which is available to authorized users.

Expert panel process to optimise the design of a randomised controlled trial in chronic rhinosinusitis (the MACRO programme)

BACKGROUND

MACRO (Defining best Management for Adults with Chronic RhinOsinusitis) is an NIHR-funded programme of work designed to establish best practice for adults with chronic rhinosinusitis (CRS). The 7-year programme comprises three consecutive workstreams, designed to explore NHS care pathways through analysis of primary and secondary data sources, and to undertake a randomised controlled trial to evaluate a longer-term course of macrolide antibiotics and endoscopic sinus surgery for patients with CRS. A number of outstanding elements still required clarification at the funding stage. This paper reports an expert panel review process designed to agree and finalise the MACRO trial design, ensuring relevance to patients and clinicians whilst maximising trial recruitment and retention.

METHODS

An expert panel, consisting of the MACRO Programme Management Group, independent advisors, and patient contributors, was convened to review current evidence and the mixed-method data collected as part of the programme, and reach agreement on MACRO trial design. Specifically, agreement was sought for selection of macrolide antibiotic, use of orally administered steroids, inclusion of CRS phenotypes (with/without nasal polyps), and overall trial design.

RESULTS

A 12-week course of clarithromycin was agreed as the main trial comparator due to its increasing use as a first- and second-line treatment for patients with CRS, and the perceived need to establish its role in CRS management. Orally administered steroids will be used as a rescue medication during the trial, rather than routinely either pre or post trial randomisation, to limit any potential effects on surgical outcomes and better reflect current UK prescribing habits. Both CRS phenotypes will be included in a single trial to ensure that the MACRO trial is both pragmatic and generalisable to primary care. A modified, three-arm trial design was agreed after intense discussions and further exploratory work. Inclusion criteria were amended to ensure that the patients recruited would be considered eligible for the treatment offered in the trial due to having already received appropriate medical therapy as deemed suitable by their ENT surgeon. A proposed 6-week run-in period prior to randomisation was removed due to the new criteria prior to randomisation.

CONCLUSION

The expert panel review process resulted in agreement on key elements and an optimal design for the MACRO trial, considered most likely to be successful in terms of both recruitment potential and ability to establish best management of patients with CRS.

NAVIGATE I: Randomized, Placebo-Controlled, Double-Blind Trial of the Exhalation Delivery System With Fluticasone for Chronic Rhinosinusitis With Nasal Polyps

BACKGROUND

Chronic rhinosinusitis is a common, high-morbidity chronic inflammatory disease, and patients often experience suboptimal outcomes with current medical treatment. The exhalation delivery system with fluticasone (EDS-FLU) may improve care by increasing superior/posterior intranasal corticosteroid deposition.

OBJECTIVE

To evaluate the efficacy and safety of EDS-FLU versus EDS-placebo in patients with nasal polyps (NP). Coprimary end points were change in nasal congestion and polyp grade. Key secondary end points were Sino-Nasal Outcome Test-22 (SNOT-22) and Medical Outcomes Study Sleep Scale-Revised (MOS Sleep-R). Other prespecified end points included all 4 cardinal symptoms of NP, 36-Item Short Form Health Survey (SF-36), Patient Global Impression of Change (PGIC), Rhinosinusitis Disability Index (RSDI), and key indicators for surgical intervention.

DESIGN

Randomized, double-blind, EDS-placebo-controlled, multicenter study.

METHODS

Three hundred twenty-three subjects with NP and moderate-severe congestion/obstruction, most with history of corticosteroid use (94.4%) and/or prior surgery (60.4%), were randomized to EDS-FLU 93 µg, 186 µg, or 372 µg or EDS-placebo twice daily (BID) for 24 weeks (16 double-blind + 8 single-arm extension with EDS-FLU 372 µg BID).

RESULTS

All EDS-FLU doses produced significant improvement in both coprimary end points ( P < .05) and in SNOT-22 total score ( P ≤ .005). EDS-FLU significantly improved all 4 cardinal symptoms of NP ( P < .05), including congestion/obstruction, facial pain/pressure, rhinorrhea/post-nasal drip, and hyposmia/anosmia. Approximately 80% of subjects reported improvement with EDS-FLU, with 65% reporting "much" or "very much" improvement by week 16. Adverse events were generally local in nature and similar to other intranasal steroids studied for similar durations in similar populations, with the most common being epistaxis.

CONCLUSIONS

In patients with chronic rhinosinusitis with NP (CRSwNP) who were symptomatic despite high rates of prior intranasal steroid use and/or surgery, EDS-FLU produced statistically significant and clinically meaningful improvements compared to EDS-placebo in multiple subjective and objective outcomes (symptoms, SNOT-22, RSDI, SF-36, PGIC, and NP grade), including all 4 cardinal symptoms of CRSwNP.

Automated classification of osteomeatal complex inflammation on computed tomography using convolutional neural networks

BACKGROUND

Convolutional neural networks (CNNs) are advanced artificial intelligence algorithms well suited to image classification tasks with variable features. These have been used to great effect in various real-world applications including handwriting recognition, face detection, image search, and fraud prevention. We sought to retrain a robust CNN with coronal computed tomography (CT) images to classify osteomeatal complex (OMC) occlusion and assess the performance of this technology with rhinologic data.

METHODS

The Google Inception-V3 CNN trained with 1.28 million images was used as the base model. Preoperative coronal sections through the OMC were obtained from 239 patients enrolled in 2 prospective chronic rhinosinusitis (CRS) outcomes studies, labeled according to OMC status, and mirrored to obtain a set of 956 images. Using this data, the classification layer of Inception-V3 was retrained in Python using a transfer learning method to adapt the CNN to the task of interpreting sinonasal CT images.

RESULTS

The retrained neural network achieved 85% classification accuracy for OMC occlusion, with a 95% confidence interval for algorithm accuracy of 78% to 92%. Receiver operating characteristic (ROC) curve analysis on the test set confirmed good classification ability of the CNN with an area under the ROC curve (AUC) of 0.87, significantly different than both random guessing and a dominant classifier that predicts the most common class (p < 0.0001).

CONCLUSION

Current state-of-the-art CNNs may be able to learn clinically relevant information from 2-dimensional sinonasal CT images with minimal supervision. Future work will extend this approach to 3-dimensional images in order to further refine this technology for possible clinical applications.

Appropriateness Criteria for Surgery in the Management of Adult Recurrent Acute Rhinosinusitis

OBJECTIVES/HYPOTHESIS

Endoscopic sinus surgery (ESS) is frequently performed for recurrent acute rhinosinusitis (RARS). Appropriate indications for surgery among patients with RARS have not yet been rigorously determined. The objective of this study was to define appropriateness criteria for ESS in the management of adult RARS.

STUDY DESIGN

Application of RAND-UCLA appropriateness methodology.

METHODS

A panel of nine multidisciplinary experts in RARS was formed to evaluate RARS scenarios generated from current evidence. The panel completed two rounds of a modified Delphi-ranking process and a teleconference.

RESULTS

A total of 32 clinical scenarios were ranked in each round. For adult patients with RARS, ESS can appropriately be offered as a treatment option when patients experience ≥ four annual episodes, and there is confirmation of at least one episode via computed tomography or nasal endoscopy, and the patient and clinician jointly participate in shared decision making, and the patient has either failed a trial of topical nasal steroids or experienced RARS-related productivity loss.

CONCLUSIONS

This study has defined appropriateness criteria for ESS as a management option for adult patients with RARS. These criteria are intended to represent a minimum threshold for which ESS should be considered in the treatment of RARS and do not suggest that all patients who meet these criteria should undergo surgery. These criteria may serve as a baseline set of indications for ESS in patients with RARS.

LEVEL OF EVIDENCE

NA Laryngoscope, 129:37-44, 2019.

Precision medicine: why surgeons deviate from "appropriateness criteria" in the management of chronic rhinosinusitis and effects on outcomes

BACKGROUND

In uncomplicated chronic rhinosinusitis (CRS), a consensus regarding appropriate medical therapy (AMT) before surgical intervention has been published in the form of "appropriateness criteria" for endoscopic sinus surgery (ESS). We sought to determine why tertiary surgeons may deviate from the suggested criteria and evaluated whether those deviations result in change in outcomes.

METHODS

Patients with uncomplicated CRS were prospectively enrolled over the course of 1 year. The 22-item Sino-Nasal Outcomes Test (SNOT-22), a general health outcome out of 100, and a physician form, indicating management pathway and decision making, was completed at each visit over a 6-month follow-up period. A descriptive analysis was used to quantify reasons for veering from the "appropriateness criteria," and repeated linear regression modeling was used to measure whether compliance impacted SNOT-22, general health, and Lund-Kennedy (LK) scores over the period of study.

RESULTS

One hundred fifty-five patients were enrolled. Sixty-eight percent followed the appropriate management pathway based on their presentation and the suggested criteria. Disparate reasons were documented for deviation in the other 32%, and, despite establishing several predictive categories, "other" was the most common reason, with various explanations well documented. SNOT-22, general health, and LK scores were not statistically impacted by compliancy status (p > 0.05).

CONCLUSION

The suggested "appropriateness criteria" predict a management pathway for the majority of CRS patients. However, in a tertiary sinus center, surgeons may deviate from that model with a significant minority of their patients, for multiple reasons, without causing a change in outcomes.

Consensus guidelines on the optimal management in interventional EUS procedures: results from the Asian EUS group RAND/UCLA expert panel

OBJECTIVES

Interventional endoscopic ultrasonography (EUS) procedures are gaining popularity and the most commonly performed procedures include EUS-guided drainage of pancreatic pseudocyst, EUS-guided biliary drainage, EUS-guided pancreatic duct drainage and EUS-guided celiac plexus ablation. The aim of this paper is to formulate a set of practice guidelines addressing various aspects of the above procedures.

METHODS

Formulation of the guidelines was based on the best scientific evidence available. The RAND/UCLA appropriateness methodology (RAM) was used. Panellists recruited comprised experts in surgery, interventional EUS, interventional radiology and oncology from 11 countries. Between June 2014 and October 2016, the panellists met in meetings to discuss and vote on the clinical scenarios for each of the interventional EUS procedures in question.

RESULTS

A total of 15 statements on EUS-guided drainage of pancreatic pseudocyst, 15 statements on EUS-guided biliary drainage, 12 statements on EUS-guided pancreatic duct drainage and 14 statements on EUS-guided celiac plexus ablation were formulated. The statements addressed the indications for the procedures, technical aspects, pre- and post-procedural management, management of complications, and competency and training in the procedures. All statements except one were found to be appropriate. Randomised studies to address clinical questions in a number of aspects of the procedures are urgently required.

CONCLUSIONS

The current guidelines on interventional EUS procedures are the first published by an endoscopic society. These guidelines provide an in-depth review of the current evidence and standardise the management of the procedures.

NAVIGATE II: Randomized, double-blind trial of the exhalation delivery system with fluticasone for nasal polyposis

BACKGROUND

Chronic rhinosinusitis is common and sometimes complicated by nasal polyps (NPs). Corticosteroid nasal sprays are often unsatisfactory because they are ineffective at delivering medication to high/deep sites of inflammation.

OBJECTIVE

We sought to assess whether an exhalation delivery system with fluticasone (EDS-FLU) capable of high/deep drug deposition improves outcomes.

METHODS

Patients (n = 323) 18 years and older with moderate-to-severe congestion and NPs were randomized to twice-daily EDS-FLU (93, 186, or 372 μg) or exhalation delivery system (EDS)-placebo for 24 weeks (16 double-blind plus 8 open-label when all received 372 μg). Coprimary end points were change in nasal congestion/obstruction at 4 weeks and summed bilateral polyp grade at 16 weeks. Secondary end points included symptoms, polyp elimination, and functioning.

RESULTS

EDS-FLU was superior on both coprimary end points (P < .001 vs EDS-placebo, all doses). Mean polyp grade improved continuously through week 24 (P < .009, all comparisons), with polyps eliminated on at least 1 side in approximately 25% of patients at week 24 versus 8.7% with EDS-placebo (P ≤ .014, all comparisons). Sino-Nasal Outcomes Test scores also improved significantly versus those in patients receiving EDS-placebo (-21.1 to -21.4 vs -11.7 at week 16, P < .05 all doses). At the end of the double-blind period, EDS-FLU (all doses) significantly improved all 4 defining disease symptoms. In most patients (68%), those receiving EDS-FLU reported "much" or "very much" improvement. The number of patients eligible for surgery decreased by 62%-67%. The safety profile was similar to that reported in prior trials evaluating conventional corticosteroid nasal sprays in comparable populations.

CONCLUSION

EDS-FLU produces clinically and statistically significant improvement in all 4 diagnostically defining disease symptoms, polyp grade, and quality of life in patients with chronic rhinosinusitis with NPs.

Appropriateness criteria predict outcomes for sinus surgery and may aid in future patient selection

OBJECTIVES

Appropriateness criteria to determine surgical candidacy for chronic rhinosinusitis (CRS) have recently been described. This study stratified patients who underwent endoscopic sinus surgery (ESS) according to these new appropriateness criteria and evaluated postoperative improvements among appropriateness categories.

METHODS

Adult patients with uncomplicated CRS electing ESS were prospectively enrolled in a multi-institutional cohort study between March 2011 and June 2015 to assess outcomes. Subsequently, appropriateness criteria that consider preoperative medical therapy, 22-item SinoNasal Outcome Test (SNOT-22) scores, and Lund-Mackay computed tomography scores were retrospectively applied.

RESULTS

A total of 92.6% (436 of 471) were categorized as "appropriate" ESS candidates, 3.8% (18 of 471) as "uncertain," and 3.6% (17 of 471) as "inappropriate." Among uncertain patients, two-thirds (12 of 18) had identifiable reasons for undergoing ESS, most commonly oral corticosteroid intolerance (n = 6). Postoperative follow-up was available for 79% (n = 372). Clinically significant SNOT-22 improvements occurred in both appropriate and uncertain groups (all P < 0.050) but not among the inappropriate group. The inappropriate group reported less mean improvement in SNOT-22 total score compared to appropriate (P = 0.008) and uncertain (P = 0.006) groups.

CONCLUSION

The vast majority of patients (∼93%) who underwent ESS in a multi-institutional research program were identified as appropriate candidates for surgical intervention, as defined by current appropriateness criteria. Valid considerations frequently exist for offering ESS to patients categorized as uncertain. Appropriate and uncertain candidates report similar, clinically significant SNOT-22 improvements following surgery. Patients classified as inappropriate reported significantly less improvement following ESS. Surgical appropriateness criteria may assist in predicting outcomes of ESS.

LEVEL OF EVIDENCE

2b. Laryngoscope, 2448-2454, 2018.

THE 2017 13TH ANNUAL DAVID W. KENNEDY, MD, LECTURE The evolution of outcomes in sinus surgery for chronic rhinosinusitis: past, present, and future

This is an edited transcript from the 2017 13th Annual David W. Kennedy, MD, Lecture, presented to the American Rhinologic Society during the 63rd Annual Meeting.

Medical therapy, refractory chronic rhinosinusitis, and productivity costs

PURPOSE OF REVIEW

The purpose of this review is to address the most recent advances in the medical therapy for chronic rhinosinusitis (CRS), define recalcitrant and refractory CRS, and discuss the productivity costs associated with CRS.

RECENT FINDINGS

Recent studies evaluating anti-IL-4 receptor α antibodies and calcium channel blockers have demonstrated promising early results during management of CRS. Recent appropriateness criteria have been developed to assist clinicians with defining which patients have 'refractory' CRS and may be considered candidates for endoscopic sinus surgery. Productivity costs appear to be associated with disease severity and can be reduced with appropriate interventions.

SUMMARY

Topical corticosteroid therapy and high volume saline irrigation continue to be the cornerstone to medical therapy, whereas use of systemic corticosteroids and antibiotics depends on CRS phenotype and presence of acute exacerbation. More research is needed before routine use of novel immunomodulatory therapies such as anti-IL5, anti-IgE, anti-IL4, and calcium channel blockers. Clinicians should apply an appropriate definition for refractory CRS when discussing role of sinus surgery. Assessing the degree of work productivity impairment can assist in treatment decision-making and may help predict treatment outcomes.

Analysis of factors associated with electing endoscopic sinus surgery

OBJECTIVE

Medically refractory chronic rhinosinusitis (CRS) can be managed with appropriate continued medical therapy (CMT) or surgery followed by CMT. Patients who initially elect CMT and do not experience adequate symptom resolution may "cross over" to endoscopic sinus surgery (ESS). Our objective was to identify patient covariates associated with this subset of patients who elect this change in treatment modality.

STUDY DESIGN

Retrospective analysis of a prospective, multi-center cohort of adult patients with CRS enrolled between March 2011 and June 2015 in academic, tertiary referral clinics.

METHODS

Subjects who initially elected CMT were followed up to 18 months, provided a comprehensive medical history, and completed the 22-item SinoNasal Outcome Test (SNOT-22) at baseline and during 6-month follow-up intervals. Hazard regression modeling was used to identify covariates associated with elective change in treatment modality.

RESULTS

One hundred seventy-nine subjects were followed for an average 15.1 (standard deviation ± 4.6) months. Subjects who elected ESS (55 of 179) had significantly worse average endoscopy scores and reported worse SNOT-22 sleep dysfunction scores at baseline (P ≤ 0.026). For each single increasing (worsening) point of Lund-Kennedy endoscopy score, the hazard ratio (HR) of crossover increased by ∼6%. Similarly, for every point of worsening in baseline SNOT-22 total score, the hazard of treatment crossover increased by ∼2%. After covariate adjustment, only baseline SNOT-22 sleep dysfunction scores were associated with an increased risk of treatment crossover (HR = 1.07; 95% confidence interval: 1.02-1.11; P = 0.003).

CONCLUSION

Baseline total SNOT-22 and endoscopy scores are associated with treatment crossover, but reported sleep dysfunction is the only significant independent predictor of treatment crossover.

LEVEL OF EVIDENCE

2c. Laryngoscope, 128:304-310, 2018.

Oral corticosteroid prescribing habits for rhinosinusitis: The American Rhinologic Society membership

BACKGROUND

In the field of otolaryngology, oral corticosteroids (OCS) are widely prescribed for rhinosinusitis. Although there is evidence in the literature regarding specific OCS dosing protocols, it is not known to what extent these recommendations are being followed.

OBJECTIVE

To examine the current state of OCS prescribing habits for rhinosinusitis by American Rhinologic Society members.

METHODS

An anonymous online survey was sent to all American Rhinologic Society members. Dosing, frequency, tapering, and overall prescribing habits for OCS were assessed in chronic rhinosinusitis with polyposis (CRSwP) and in chronic rhinosinusitis without polyposis and acute bacterial rhinosinusitis. The CRSwP group was subdivided into aspirin-exacerbated respiratory disease, allergic fungal sinusitis, and not otherwise specified. Results were compared with current guidelines. Descriptive statistics were used to analyze data.

RESULTS

Ninety-three surveys were completed (response rate, 12.9%). Prednisone was the most common OCS prescribed. In the CRSwP-aspirin-exacerbated respiratory disease group (n = 86), the median starting dose was 60 mg (range, 4-80 mg) and the average duration was 8 days (range, 2-28 days). In the CRSwP-allergic fungal sinusitis group (n = 81), the median starting dose was 50 mg (range, 20-60 mg), and the average duration was 6 days (range, 2-35 days). In the CRSwP-not otherwise specified group (n = 84), the median starting dose was 50 mg (range, 20-80 mg) and the average duration was 5 days (range, 1-21 days). OCS were prescribed for chronic rhinosinusitis without polyposis and acute bacterial rhinosinusitis by 66.0 and 62.4% of respondents, respectively.

CONCLUSION

Significant heterogeneity existed in OCS prescribing habits for rhinosinusitis. Discrepancies were observed between survey results and evidence-based recommendations. Developing standardized OCS treatment protocols for rhinosinusitis may improve the quality of care by optimizing clinical outcomes and reducing the risk of complications.

Surgical therapy vs continued medical therapy for medically refractory chronic rhinosinusitis: a systematic review and meta-analysis

BACKGROUND

The currently accepted treatment paradigm of treating chronic rhinosinusitis (CRS) first with appropriate medical therapy (AMT) and then with surgery if patients are refractory to AMT, has been criticized for lack of evidence. The objective of this study was to reassess the literature and establish the highest level of evidence possible regarding further management of CRS patients refractory to AMT.

METHODS

This study was a systematic review (SR) with meta-analysis (MA). Adult CRS patients who received AMT and then underwent either medical or surgical therapy in moderate to high level prospective studies were included. Outcomes assessed were disease-specific quality of life (QOL), nasal endoscopy, health-state utility, missed work days, change in cardinal symptoms of CRS, economic impact, and adverse events.

RESULTS

A total of 970 manuscripts were identified; 6 studies were ultimately included in the SR with 5 included in the MA. Compared to continued medical therapy, endoscopic sinus surgery (ESS) significantly improved patient-based QOL scores (p < 0.00001) and nasal endoscopy scores (p < 0.00001). Difference in missed work days depended heavily on patient choice of intervention. Unpooled analysis showed improvements in olfaction, health utility scores, and cost-effectiveness.

CONCLUSION

On meta-analysis, for CRS patients refractory to AMT, ESS significantly improves objective endoscopic scoring outcomes vs continued medical therapy alone. In patients with refractory CRS who have significant reductions in baseline QOL, ESS results in significant improvements. Continued medical therapy appears to maintain outcomes in patients with less severe baseline QOL. Unpooled analysis demonstrates improvement in health utility, olfaction, and cost-effectiveness following ESS compared to continued medical therapy alone, in medically refractory CRS.

Recent advances in the surgical management of rhinosinusitis

Rhinosinusitis affects a significant portion of the US population, and its management imposes a substantial burden on the healthcare system. The treatment of chronic rhinosinusitis includes initial medical management prior to consideration of surgical intervention. However, if surgery does become necessary, several factors must be considered in order to optimize outcomes. This review evaluates surgical patient selection, perioperative medical management, and the extent of operative intervention, with the goal of improving surgical results, decreasing the need for revision surgery, and enhancing the patient's quality of life. Specific variations in patient genotypes and phenotypes will be further explored with regard to their implications on surgical outcomes. Additionally, the evidence behind pre- and post-operative antibiotic and steroid use will be evaluated. Finally, we will review evolving surgical tools and techniques that are currently being utilized for the treatment of specific subsets of rhinosinusitis.

Chronic rhinosinusitis: the rationale for current treatments

INTRODUCTION

Chronic rhinosinusitis (CRS) is a broad clinical syndrome linked by mucosal inflammation. Primary treatment modalities are corticosteroids and antibiotics with surgery an option for failures, but the level of supporting evidence is generally low. The primary reason is that CRS is a symptom complex and not a specific disease. Areas covered: The primary treatment modalities for CRS are corticosteroids, antibiotics and surgery. Corticosteroids, which have very broad anti-inflammatory properties, also have the strongest evidence for efficacy. Antibiotics are likely effective in a subpopulation of patients but the various phenotypes and endotypes that make up CRS have thus far been poorly defined. Early surgery as well as biologics may also be more efficacious and cost effective in some phenotypes as well. Expert commentary: A better understanding of the inflammatory pathways that drive CRS will permit investigators to separate patient groups. This will allow for clinical trials that target specific subpopulations and more personalized therapy for CRS patients in the future.

Low 22-item sinonasal outcome test scores in chronic rhinosinusitis: Why do patients seek treatment?

OBJECTIVES/HYPOTHESIS

Patients with chronic rhinosinusitis (CRS) who experience minimal reductions in quality of life (QoL) may present for treatment despite QoL scores comparable to controls without CRS. This study seeks to identify cofactors influencing patients with CRS and low 22-item Sinonasal Outcome Test (SNOT-22) scores to seek care.

STUDY DESIGN

Prospective, multicenter, observational cohort.

METHODS

Patients with CRS were enrolled between April 2011 and September 2015. Patients with sinonasal mucocele or unilateral sinus opacification were excluded. Control subjects without CRS were enrolled for comparison. Low-SNOT CRS was defined as a SNOT-22 score < 20.

RESULTS

A total of 774 subjects (low-SNOT CRS, n = 38; high-SNOT CRS, SNOT-22 ≥ 20, n = 641; controls without CRS, n = 95) were enrolled. Low SNOT scores were identified in 6% of subjects with CRS. After adjustment, low-SNOT CRS and control groups without CRS reported similar baseline average SNOT-22 total scores (P = .879). Unexpectedly, compared to controls, low-SNOT CRS patients had significantly better average psychological (2.1 ± 2.3 vs. 5.8 ± 6.0; P = .030) and sleep dysfunction (2.7 ± 3.4 vs. 6.0 ± 5.2; P = .016) scores. Fourteen of 38 (37%) low-SNOT patients elected to undergo endoscopic sinus surgery (ESS), with a significantly lower likelihood of reporting a minimal clinically important difference (MCID) when compared to high-SNOT patients (43% vs. 82%; P < .001) after a mean follow-up of ∼15 months.

CONCLUSIONS

Low-SNOT CRS patients represent an outlier population for which measures of QoL fail to identify factors influencing the decision to seek treatment. Low-SNOT CRS patients electing ESS have a decreased likelihood of reporting MCIDs following ESS. Further study is required to identify novel factors associated with treatment-seeking behavior in this population.

LEVEL OF EVIDENCE

3B Laryngoscope, 127:22-28, 2017.