Paranasal Sinus Hypoplasia and Sinonasal Anatomical Variants in Cystic Fibrosis Adult Patients: A Computed- Tomography-Based Volumetric Comparison with Healthy Controls

Objectives: In this retrospective study, we performed a volumetric analysis of paranasal cavity pneumatization in a population of adult patients with cystic fibrosis compared to healthy controls, providing parcel evaluation of each sinus, and analyzing the prevalence of major anatomical sinonasal variants in the two groups. Methods: We compared paranasal sinus volumes of 89 adult patients with cystic fibrosis and 144 healthy controls who underwent paranasal sinus computed tomography. Volumes were segmented and extracted on tomographic images using the freely available software MRIcron 2019, then compared using a t-test; the z-score test was used to determine whether the two groups differ significantly in terms of major anatomical variants prevalence. Results: Overall sinus volumes in patients with cystic fibrosis patients differ significantly as compared to the healthy population (p < 0.00001). Furthermore, with the only exception of ethmoid sinus pneumatization, which was similar in both populations, all the other sinuses were statistically different. No significant difference emerged concerning anatomical variants' prevalence. Conclusions: Our results further stress the impact of cystic fibrosis on sinus structure in adult patients, better revealing the consequences of the disease on upper airways and in optimizing the management of patients with sinonasal manifestations.

Evaluation of otorhinolaryngologic, audiologic, and genetic findings in children with cystic fibrosis: A tertiary care experience

OBJECTIVES

To evaluate otorhinolaryngologic findings and the relationship between aminoglycoside (AG) exposure and hearing loss in paediatric patients with cystic fibrosis (cwCF). We also aimed to investigate the genetic predisposition to AG ototoxicity by screening for m.1555A>G mutations.

METHODS

CwCF who underwent otorhinolaryngologic and audiologic examinations were retrospectively included. Clinical characteristics, ear-nose-throat related symptoms, and a history of ototoxic drug exposure were recorded. m.1555A>G mutations were retrospectively screened among patients with audiologic evaluations.

RESULTS

Two hundred thirty-four cwCF were included in this study with a median age of 10.7 (range, 6.8-14.2) years. Nasal obstruction (14.1%) was the most common symptom. Fifty-two (22.2%) patients had chronic rhinosinusitis (CRS) with nasal polyps (CRSwNP). There was a positive correlation between CRSwNP and the symptom of nasal obstruction (r:.234, p < .001), snoring (r:.179, p = .006), and sleeping with mouth open (r:.138, p = .034). One hundred forty-nine (63.6%) patients had audiologic evaluations; 14 (9.4%) had hearing impairment. No statistical significance existed between ototoxicity and IV AG exposure (p = .90). Six (42.8%) of 14 patients did not receive ototoxic drugs. One hundred nineteen (50.8%) patients were screened for m.1555A>G mutations, and none were detected.

CONCLUSIONS

Almost a quarter of the study population had CRSwNP. Neither the relationship between AGs exposure and hearing loss nor the genetic predisposition to AG ototoxicity could be shown in cwCF.

The development of paranasal sinuses in patients with cystic fibrosis: sinuses volume analysis

BACKGROUND

Cystic fibrosis (CF) is a severe systemic disease that affects many aspects of patients' lives. It is known that the progression of the disease adversely affects lower and upper airways including the paranasal sinuses. However, its impact on sinus development in the pediatric population is not fully examined. The purpose of this study was to evaluate the development of the paranasal sinuses in a pediatric population with CF and compare it to a control group consisting of healthy children.

METHODS

The results of computed tomography (CT) scans of children with the disease and the control group were evaluated. The study included 114 CT images of children in the study group and 126 images of healthy children aged 0-18 years. The volumes of maxillary, frontal, and sphenoid sinuses were analyzed. The obtained results were compared with those of the control group and analyzed statistically.

RESULTS

The volume and the development of the paranasal sinuses in both groups increased with age, but statistically significant differences were found between the study and the control group.

CONCLUSIONS

The obtained results provide valuable knowledge regarding the impact of the CF on sinuses development. Also, they may be important in understanding the progression of the disease and its influence on the quality and length of life of patients. The results may contribute to enhanced diagnostics and have implications for improving therapy for patients with chronic sinusitis associated with CF.

Chronic rhinosinusitis in cystic fibrosis: a review of therapeutic options

PURPOSE

Chronic rhinosinusitis (CRS) is observed in almost 100% of patients with cystic fibrosis (CF). CF-related CRS treatment is extremely challenging because of the underlying genetic defect leading to its development. CRS in CF is often refractory to standard therapy, while recurrences after surgical treatment are inevitable in the majority of patients. This study provides a precise review of the current knowledge regarding possible therapeutic options for CF-related CRS.

METHODS

The Medline and Web of Science databases were searched without a time limit using the terms "cystic fibrosis" in conjunction with "otorhinolaryngological manifestation", "rhinology" and "sinusitis".

RESULTS

Precise guidelines for CF-induced CRS therapy are lacking due to the lack of large cohort randomized controlled trials. None of the existing therapeutic agents has already been recommended for CRS in CF. Therapy targeting the underlying genetic defect, intranasal dornase alfa administration, and topical delivery of colistin and tobramycin showed promising results in CF-related CRS therapy. Besides the potential effectiveness of nasal steroids, strong recommendations for their usage in CF have not been provided yet. Systemic corticosteroid usage is controversial due to its potential negative influence on pulmonary disease. Ibuprofen revealed some positive effects on CF-related CRS in molecular and small cohort studies. Intranasal irrigation with saline solutions could relieve sinonasal symptoms. Nasal decongestants are not recommended. Endoscopic sinus surgery is the first-line surgical option for refractory CRS. Extensive surgical approaches should be considered as they could improve long-term outcomes in CRS.

CONCLUSION

Further studies are warranted to establish consensus for CF-related CRS therapy.

The prevalence of CFTR mutations in patients with chronic rhinosinusitis: A systematic review and meta-analysis

OBJECTIVES

Undetected cystic fibrosis transmembrane regulator (CFTR) mutations may predispose individuals to develop CRS independent of formal CF diagnosis. The objective of this study was to determine the prevalence of CFTR mutations among individuals with CRS.

DESIGN

A systematic search following PRISMA guidelines was performed. A meta-analysis was performed to calculate pooled estimates for the prevalence of any CFTR mutation and for the DF508 mutation.

SETTING AND PARTICIPANTS

The systematic search included all studies identifying adults diagnosed with CRS, with no limitation to region or publication date. Studies had to identify a sample of patients previously diagnosed with CRS but not with CF and reporting testing for the prevalence of CF or the CFTR gene mutation.

MAIN OUTCOME MEASURES

Prevalence of CFTR mutations among the general CRS population, with subgroup analysis of individuals with the dF508 mutation.

RESULTS AND CONCLUSIONS

The 6 included studies represented five countries: the United States, the UK, France, Poland and Finland. The pooled prevalence of CFTR mutations of any kind in CRS subjects without CF was 5.65% (RE 95% CI 2.99 - 10.41). The overall prevalence for the dF508 mutation was 4.22% (RE 95% CI 1.71 - 10.07). These estimates were significantly higher than the baseline estimated prevalence of CFTR carrier status of 3%-4% in the general population. However, the clinical relevance of the presence of CFTR mutations in CRS patients who have not been diagnosed with CF is currently unclear. Future studies should include sweat chloride testing as a measure of CFTR function.

Ion concentrations in nasal airway surface liquid: a prediction model for the identification of cystic fibrosis carriers

BACKGROUND

Cystic fibrosis (CF) carriers seem to have a higher risk to develop chronic rhino-sinusitis (CRS), although the full underlying mechanisms are unknown. Ion concentrations in nasal airway surface liquid (ASL) may be influenced by the heterozygosity for CF gene mutation, with possible impacts on the development of CRS.

METHODS

A cheap and feasible standardized technique was designed to measure the ion levels in nasal ASL. With this purpose we collected, under basal conditions, samples from the nasal cavity of 165 adults: 14 homozygous for CF, 83 carriers and 68 healthy controls. Sodium (Na) and Chlorine (Cl) concentrations were then evaluated among different groups.

RESULTS

Statistical analysis revealed a significant difference of Na and Cl values between controls and carriers and between controls and homozygotes. Receiver operating characteristic (ROC) curves and derived indicators (Youden's index and Area Under the Curve, AUC) were used to further evaluate the diagnostic capability of Na and Cl concentrations to differentiate heterozygotes from controls. ROC curves demonstrated that the optimal diagnostic cut-off value of Na is at 124, and the optimal cut-off value of Cl is at 103,2.

CONCLUSION

ASL sampling can be considered a new diagnostic tool for providing quantitative information on nasal ion composition. According to our findings, Na and Cl concentrations of nasal ASL could represent a useful tool to assess heterozygotes and healthy controls.

The Risks of Complications During Endoscopic Sinus Surgery in Cystic Fibrosis Patients: An Anatomical and Endoscopic Study

OBJECTIVE/HYPOTHESIS

An increasing proportion of adult cystic fibrosis (CF) patients is being referred to endoscopic sinus surgery (ESS) in order to relieve the symptoms of chronic rhinosinusitis (CRS). Given that CFTR mutations profoundly alter sinonasal development, we want to explore the relationship between their peculiar surgical anatomy and the risk of postoperative complications.

STUDY DESIGN

Retrospective case-control study.

METHODS

Paranasal sinuses CT scans of 103 CF adult patients with CRS were compared to those belonging to a cohort of 100 non-CF adult patients to explore their anatomical differences. Secondly, CF and non-CF patients who received primary/revision ESS were analyzed in order to assess their preoperative CT scan in terms of surgically relevant variants, and according to the CLOSE checklist. Surgical outcomes were statistically compared in order to explore the differences between groups.

RESULTS

CF group presented more frequently with smaller and less pneumatized paranasal sinuses and a higher Lund-Mckay score compared with controls. No anatomical differences emerged in terms of genotype stratification. Non-CF CRS patients undergoing ESS showed a significantly deeper olfactory fossa and a more frequent supraorbital pneumatization compared to CF patients (P < .001 and P = .031, respectively). Whereas this latter group underwent more often aggressive surgical procedures (P = .001), no difference in terms of postoperative adverse events was found (P = .620).

CONCLUSIONS

Despite receiving more often aggressive ESS procedures, adult CF patients do not show an increased risk of postoperative complication and this may be linked to a different proportion of anatomical and surgically-relevant variants.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E2481-E2489, 2021.

Sinus Development and Pneumatization in a Primary Ciliary Dyskinesia Cohort

Background

Primary ciliary dyskinesia (PCD) is a genetically diverse disease which causes impaired mucociliary clearance, and results in pulmonary, otologic, and rhinologic disease in affected patients. Genetic mutations in multiple genes impair the ability of patients to clear mucous from the lungs, middle ear, and sinonasal cavity and lead to chronic pulmonary and sinonasal symptoms.

Methods

We identified 17 PCD patients who had available CT scans. Volumes for bilateral maxillary, sphenoid, and frontal sinuses were calculated. A control population of patients who had preoperative CT scans for endoscopic endonasal resection of skull base pathology without sinonasal cavity involvement was also identified.

Results

The mean age of PCD was 33 and ranged from 13 to 54 years. Patients were age- and gender-matched to a control group that underwent resection of anterior skull-base tumors and had a mean age of 35 that ranged between 17–53 years old. The volumes for all thee sinus cavities were significantly smaller (p < 0.007) compared to the control population. The average Lund-Mackay score was 10.6 in the PCD cohort (range 6–16) in comparison to an average of 0.7 in the control cohort (range 0–2).

Conclusions

Overall sinus volumes were smaller in patients with PCD compared to our control population. Future studies will be aimed at understanding defects in sinus development as a function of specific genetic mutations in PCD patients. Ultimately, a better understanding of the underlying pathophysiology of PCD will allow us to identify the optimal treatment practices for this unique patient group.

Chronic rhinosinusitis in patients with cystic fibrosis-Current management and new treatments

OBJECTIVES

The purpose of this article is to provide a state-of-the-art review of the literature and summarize the latest publications on medical and surgical treatment of cystic fibrosis (CF) chronic rhinosinusitis (CRS), with an emphasis on describing recent advancements in cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapies.

METHODS

A comprehensive literature review was conducted utilizing the PubMed database with search phrases detailed within the body of the article. Abstracts were reviewed to include publications detailing medical, surgical, and CFTR modulating therapies for CF CRS. Findings from studies not previously reviewed and publications regarding CFTR modulators were emphasized.

RESULTS

No clear guidelines for treatment of CF CRS are available. Nasal saline rinses, topical steroids, topical antibiotics, and topical dornase alfa are reported medical therapies. Ivacaftor has some sinonasal symptomatic benefit. A new triple therapy CFTR modulator, elexacaftor/tezacaftor/ivacaftor, is capable of treating 90% of patients with CF and has shown the greatest FEV1 improvement of any CFTR modulator yet. There is no clear consensus on surgical indications or technique, though aggressive surgery in recalcitrant disease has shown some symptomatic benefit. Endoscopic sinus surgery after lung transplantation may benefit some patients in whom the sinuses serve as a reservoir for recurrent pulmonary infections by decreasing rates of bronchiolitis obliterans syndrome and improving 5 year survival.

CONCLUSION

As lifespan increases for patients with CF, further investigation into medical therapy, CFTR modulator sinonasal outcomes, and surgical technique and outcomes for CF CRS is needed.

LEVEL OF EVIDENCE

5.

Cystic Fibrosis: The Sense of Smell

Background

Cystic fibrosis (CF) is a multisystem disease that involves the upper airways with chronic rhinosinusitis (CRS) causing nasal congestion, rhinorrhea, mouth breathing, facial pain, and olfactory dysfunction. Twelve percent to 71% of CF patients report smelling alterations with an impact on nutrition and quality of life.

Objectives

The goal was to study olfaction performance in CF patients with CRS that worsens quality of life.

Methods

A total of 121 subjects were enrolled in this study. Seventy-one had CF and underwent ear, nose, and throat evaluation with nasal endoscopy, sinonasal outcome test 22 (SNOT-22), visual analog scale (VAS), and “Sniffin’ Sticks.” Fifty subjects were age-matched with healthy controls.

Results

All 71 CF patients were affected by CRS; 59 of 71 (83.1%) had CRS without nasal polyps and 12 of 71 (16.9%) had CRS with early nasal polyps. None of the 50 controls had CRS. Total SNOTT-22 mean values in the 71 CF patients were 38.10 ± 21.08 points. If considering only the 59 CF patients without nasal polyps, the SNOTT-22 mean value was 36.76 ± 21.52 points. Moreover, based on the VAS scores, the degree of nasal symptoms was classified as mild for facial pain, smell alteration, nasal discharge, and sneezing and resulted in moderate symptoms for nasal blockage and headache. Among the CF patients, 55 of 71 (76.5%) declared to be normosmic, while the smelling ability assessed by “Sniffin’ Sticks” showed that only 4 of 71 (5.63%) were normosmic, 58 (81.69%) were hyposmic, and 9 (12.68%) were anosmic. In the controls, 41(82%) were normosmic, 9 (18%) were hyposmic, and none were reported to be anosmic ( P < .001).

Conclusions

We confirm that most CF patients have a relevant olfactory impairment, although only a low percentage declares such alteration. A careful evaluation with simple and rapid tests helps to select the patients who may benefit from specific therapies.

The Unified Airway: Does Asthma Influence Paranasal Sinus Pneumatization?

Asthma has been implicated as a driving force in lower airway remodeling; however, its effect on upper airway development has not been studied. Clinical disease, particularly cystic fibrosis (CF), has been associated with anatomical paranasal sinus variation, although the mechanism for these variations remains unclear. The purpose of this study was to determine whether asthma is associated with altered sinus pneumatization. Five hundred ninety-one computed tomography scans, including 303 adolescents (age 13-18) and 288 adults (age > 18), were evaluated using the Assessment of Pneumatization of the Paranasal Sinuses (APPS) instrument. The APPS score is validated for assessing anatomical variation and total sinus volume. A diagnosis of asthma was ascertained from the medical record, and patients with CF were included as a positive control group. Patients with asthma had mean APPS score of 9.66, compared to 9.85 for participants without asthma (P = .585). Subgroup analysis demonstrated similar findings among adults (P = .817) and adolescents (P = .585). Patients with a diagnosis of CF had significant sinus hypoplasia according to a mean APPS scores of 3.50 (P < .001). Sinus hypoplasia persisted in both adults (P < .001) and adolescents (P < .001) with CF. The presence of asthma is not associated with altered paranasal sinus pneumatization. In contrast, CF is associated with significantly reduced sinus pneumatization. These findings suggest that aberrant sinus pneumatization may not be a feature of asthma and that chronic mucosal respiratory disease is not a generalizable cause for altered paranasal sinus pneumatization.