Aberrant expressions of TAM receptors are associated with postoperative recurrence in chronic rhinosinusitis with nasal polyps

OBJECTIVES

TAM receptors (TYRO3, AXL, and MER) play important roles in inflammatory responses, but their effects in chronic rhinosinusitis with nasal polyps (CRSwNP) remain elucidated. We aim to evaluate the values of TAM receptors in disease severity and postoperative recurrence of CRSwNP.

METHODS

We initially enrolled 160 patients with CRSwNP who were treated with functional endoscopic sinus surgery (FESS) and postoperative recurrence was evaluated during the follow-up period. Circulating TAM receptor levels were detected by enzyme-linked immunosorbent assay (ELISA), and tissue expressions were measured by real-time polymerase chain reaction (RT-PCR) and immunohistochemical (IHC). The relationships between TAM receptor levels and postoperative recurrence were examined.

RESULTS

A total of 150 patients completed the follow-up schedule, 49 patients experienced postoperative recurrence and the remaining 101 patients were non-recurrent. In recurrent CRSwNP patients, serum levels of TAM receptors were increased compared to those in non-recurrent patients and were positively correlated with disease severity scores (P < 0.05). Circulating TYRO3 and MER were identified as potential predictors of postoperative recurrence based on receiver operating characteristics (ROC) and Kaplan-Meier plots (P < 0.05). Furthermore, tissue TAM receptor levels, as determined by both RT-PCR and IHC, were enhanced in the recurrent group than in the non-recurrent group (P < 0.05) and were predictive of postoperative recurrence (P < 0.05). Interestingly, circulating TYRO3 and MER concentrations, as well as tissue TYRO3 expression, were found to be significantly increased in patients who experienced postoperative recurrence (P < 0.05). IHC images from the same patients revealed that TAM expressions were enhanced in the recurrent tissues compared to their baseline tissue levels.

CONCLUSIONS

Our laboratory results demonstrated that TAM receptors were increased in recurrent CRSwNP patients and associated with postoperative recurrence. Moreover, the new laboratory findings suggested that measuring circulating levels of TAM receptors might serve as a promising new approach to assess disease progression and predict the risk of postoperative recurrence.

Multivariate analysis of clinical and radiological risk factors for revision endoscopic sinus surgery in patients with chronic rhinosinusitis with nasal polyps: can phenotype predict recurrence?

OBJECTIVE

This study aimed to analyse clinical and radiological features (phenotypes) to predict revision risk after functional endoscopic sinus surgery in patients with chronic rhinosinusitis with nasal polyps.

METHOD

Phenotype characteristics of the patients with chronic rhinosinusitis with nasal polyps who underwent functional endoscopic sinus surgery were analysed retrospectively.

RESULTS

The rates of asthma, aspirin sensitivity, smoking and a positive prick test result were significantly higher in revision functional endoscopic sinus surgery cases (p < 0.001, 0.001, < 0.001 and < 0.001, respectively). Multivariate analysis demonstrated that only gender, pre-operative nasal steroid use, pre-operative systemic steroid use, intra-operative systemic steroid use and smoking were significant risk factors for revision functional endoscopic sinus surgery (p = 0.034, 0.001, 0.010, 0.007 and 0.001, respectively). In addition, only eosinophilia and aspirin sensitivity were significant risk factors for multiple revision functional endoscopic sinus surgery procedures (p = 0.043 and 0.005, odds ratio = 2.4 and 5.2).

CONCLUSION

Beyond the endotype of chronic rhinosinusitis with nasal polyps, defining clinical and radiological factors enables a valid prediction of patients at high risk of revision functional endoscopic sinus surgery.

[Decision-making in the treatment of chronic rhinosinusitis with nasal polyps in the era of biologics]

Chronic rhinosinusitis is one of the most common chronic diseases in the population. Chronic rhinosinusitis with nasal polyps (CRSwNP) in adults is predominantly characterized by a type 2 inflammatory endotype. If sufficient control cannot be achieved through primary drug therapy, surgical intervention is usually recommended as the next stage of treatment. Nowadays, various biologics are available that have been or will be approved for use in these patients. This review summarizes the presentations from the 29th Congress of the European Rhinologic Society in Sofia 2023 and the latest findings on decision-making in the treatment of CRSwNP. Standard therapy with medication and sinus surgery fails in some patients with CRSwNP. Biologics that act on the type 2 inflammatory pathway led to a reduction in the nasal polyp score (NPS), an improvement in nasal obstruction, and an improvement in quality of life without significant side effects. Biomarkers such as total IgE, serum eosinophils, and Osteoprotegerin (OPG) can provide indications of the success of the treatment. In summary, it can be said that for many patients with recurrent CRSwNP, a combination of paranasal sinus surgery and treatment with a biologic that is precisely tailored to the patient's endotype is the best option. However, the question of which surgical approach and which biologic at which time and for which patient is still ongoing and requires further studies.

Incidence of subsequent surgical decompression following minimally invasive approaches to treat lumbar spinal stenosis: A retrospective review

BACKGROUND CONTEXT

Surgical decompression is the definitive treatment for managing symptomatic lumbar spinal stenosis; however, select patients are poor surgical candidates. Consequently, minimally invasive procedures have gained popularity, but there exists the potential for failure of therapy necessitating eventual surgical decompression.

PURPOSE

To evaluate the incidence and characteristics of patients who require surgical decompression following minimally invasive procedures to treat lumbar spinal stenosis.

STUDY DESIGN/SETTING

Retrospective review.

PATIENT SAMPLE

Patients who underwent minimally invasive procedures for lumbar spinal stenosis (Percutaneous Image-guided Lumbar Decompression [PILD] or interspinous spacer device [ISD]) and progressed to subsequent surgical decompression within 5 years.

OUTCOME MEASURES

The primary outcome was the rate of surgical decompression within 5 years following the minimally invasive approach. Secondary outcomes included demographic and comorbid factors associated with increased odds of requiring subsequent surgery.

METHODS

Patient data were collected using the PearlDiver-Mariner database. The rate of subsequent decompression was described as a percentage while univariable and multivariable regression analysis was used for the analysis of predictors.

RESULTS

A total of 5278 patients were included, of which 3222 (61.04%) underwent PILD, 1959 (37.12%) underwent ISD placement, and 97 (1.84%) had claims for both procedures. Overall, the incidence of subsequent surgical decompression within 5 years was 6.56% (346 of 5278 patients). Variables associated with a significantly greater odds ratio (OR) [95% confidence interval (CI)] of requiring subsequent surgical decompression included male gender and a prior history of surgical decompression by 1.42 ([1.14, 1.77], p = 0.002) and 2.10 times ([1.39, 3.17], p < 0.001), respectively. In contrast, age 65 years and above, a diagnosis of obesity, and a Charlson Comorbidity Index score of three or greater were associated with a significantly reduced OR [95% CI] by 0.64 ([0.50, 0.81], p < 0.001), 0.62 ([0.48, 0.81], p < 0.001), and 0.71 times ([0.56, 0.91], p = 0.007), respectively.

CONCLUSIONS

Minimally invasive procedures may provide an additional option to treat symptomatic lumbar spinal stenosis in patients who are poor surgical candidates or who do not desire open decompression; however, there still exists a subset of patients who will require subsequent surgical decompression. Factors such as gender and prior surgical decompression increase the likelihood of subsequent surgery, while older age, obesity, and a higher Charlson Comorbidity Index score reduce it. These findings aid in selecting suitable surgical candidates for better outcomes in the elderly population with lumbar spinal stenosis.

Management of CRSwNP in Latin America: A multidisciplinary consensus from an expert working group

Chronic rhinosinusitis with nasal polyps (CRSwNP) is an inflammatory condition of the nasal and paranasal tissues, characterized by the presence of bilateral nasal polyps. While etiology and pathogenetic mechanisms are heterogeneous and complex, in most patients, disease is mediated predominantly through type 2 inflammatory processes. Clinical management is challenging, and a multidisciplinary approach is preferred. Principal treatment approaches are the use of local/systemic corticosteroids and sinonasal surgery, although outcomes can be unsatisfactory. Recent availability of biological therapies targeting underlying inflammatory processes can offer effective treatment options in uncontrolled disease. Specialist guidelines greatly assist clinical decision-making, although as these are chiefly written from a global/international perspective, they may not wholly accommodate disease patterns and clinical practice at a regional level. An expert panel of specialists from Latin America was convened to develop regional guidance on the management of CRSwNP through a consensus approach. The present article presents the chief observations and recommendations which can provide guidance for clinicians in the Latin American region.

Multidisciplinary Decision-Making-ITAlian Consensus After Two Years of Real Practice on the Management of Severe Uncontrolled CRSwNP by Biologics (ITACA Study)

PURPOSE OF REVIEW

We aimed to reach an Italian multidisciplinary consensus on some crucial aspects of treatment decision making in CRSwNP, following 2 years of clinical experience in order to support specialists in the management of CRSwNP in clinical practice. We addressed issues relating to therapeutic decision-making and shared criteria for the treatment choice, as well as appropriate timing and criteria for evaluating treatment response, and highlighted the need for repeated multidisciplinary assessments.

RECENT FINDINGS

A national survey has been conducted recently to understand how rhinology practice has changed in Italy with the advent of biologics and how this affects patients with uncontrolled, severe CRSwNP. Despite the many published consensus documents, practical recommendations, and protocols on the use of biologics in CRSwNP, heterogenous behaviors in practice are still observed mainly conditioned by the novelty of the topic. The consensus procedure followed a modified Delphi approach. The scientific board included 18 otorhinolaryngologists and 8 allergists, who selected the 4 main topics to be addressed and developed overall 20 statements. Consensus on these statements was sought by a larger group of 48 additional experts, through two rounds of voting, the first web-based, the second in presence with discussion and possible refinement of the statements. The statements reaching an average score ≥ 7 at the second voting round were approved. Five statements were proposed for each of the following topics: baseline evaluation of patients eligible for biologic therapy; choice between different therapeutic options; assessment of the response to biologic treatment; multidisciplinary management. At the first voting round, 19 out of the 20 statements reached a mean score ≥ 7. Following the discussion and a few consequent amendments, at the second round of voting all the 20 statements were approved.

Management of Chronic Rhinosinusitis with Nasal Polyps (CRSwNP) in the Pan-Arab Region: Consensus Recommendations from a Multidisciplinary Expert Working Group

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a chronic and often debilitating inflammatory condition of the nasal and paranasal tissues. An expert panel of specialists from the Gulf region (the Kingdom of Saudi Arabia, Kuwait, Oman and the United Arab Emirates) and from Egypt gathered to evaluate existing guidance and develop regional guidance on the management of CRSwNP through a consensus approach. The present article presents the main observations and recommendations from this panel. CRSwNP diagnosis requires the presence of bilateral, endoscopically visualized polyps in the middle meatus (via nasal endoscopy or CT). In most patients, CRSwNP is mediated through predominantly type 2 inflammatory processes and is often observed in patients with asthma and other allergic disease. While many patients respond to medical treatment (principally topical irrigation and intranasal corticosteroids, and adjunctive short-term use of systemic corticosteroids), clinical management of CRSwNP is challenging, and a multidisciplinary approach for complete evaluation and treatment is recommended. Patients with more severe/uncontrolled disease (despite adequate medical therapies) require a complete endoscopic sinus surgery (ESS), although outcomes can be unsatisfactory, and further revision surgery is common. Biological therapies targeting underlying inflammatory processes offer additional, effective treatment options for those patients with persistent symptoms despite complete ESS, and also in those patients where surgery may be contraindicated.

Anatomical findings in patients with chronic rhinosinusitis without nasal polyps requiring revision surgery

OBJECTIVES

For the treatment of chronic rhinosinusitis functional endoscopic sinus surgery is a well-established therapy with high initial success rates. However, a significant proportion of patients have persistent disease requiring revision surgery. To date, studies including data of large patient collectives are missing. In this study, we aimed to identify anatomic factors increasing the need for revision surgery in a large patient collective with chronic rhinosinusitis without nasal polyps.

METHODS

Data were collected retrospectively on patients with recurrent or persistent chronic rhinosinusitis without nasal polyps requiring revision surgery. The patients' symptomatology, endoscopic and radiographic findings were analyzed. Preoperatively, patients were evaluated with endoscopic examination of the nose and paranasal sinuses. In all individuals computed tomography of the sinuses was performed. Images were evaluated according to the Lund-Mackay system. Information was also collected intraoperatively.

RESULTS

253 patients were included. The most common anatomic factor was incomplete anterior ethmoidectomy (51%), followed by residual uncinated process (37%), middle turbinate lateralization (25%), incomplete posterior ethmoidectomy (20%), frontal recess scarring (19%), and middle meatal stenosis (9%). Other factors such as persistent sphenoid pathology was less frequent.

CONCLUSION

Iatrogenic causes with inadequate resection of obstructing structures seem to be a principal risk factor for recurrent chronic rhinosinusitis and the need for revision sinus surgery. Meticulous attention in the area of the ostiomeatal complex during surgery with ventilation of obstructed anatomy as well as avoidance of scarring and turbinate destabilization may reduce the failure rate after primary endoscopic sinus surgery.

LEVEL OF EVIDENCE

2b.

Endoscopic sinus surgery outcomes in patients with chronic rhinosinusitis and immunoglobulin deficiencies

BACKGROUND

Patients with chronic rhinosinusitis (CRS) and immunoglobulin deficiencies (ID) have more recalcitrant sinonasal disease and a subset of these patients undergo surgical management for their CRS. However, there is a paucity of literature on the surgical outcomes in this patient population and appropriate treatment algorithms for CRS in patients with ID. The objective of this study was to better elucidate the outcomes of endoscopic sinus surgery (ESS) in patients with ID in terms of disease-specific quality-of-life scores and the need for revision surgery.

METHODS

A case-control study was performed comparing adult patients with ID and healthy controls that had undergone ESS for CRS. Patients were matched based on age, sex, CRS phenotype, and preoperative Lund-Mackay score. The revision surgery rates, time to revision surgery, and changes in sinonasal outcome tests (SNOT-22) were evaluated.

RESULTS

Thirteen patients with CRS and ID were matched to 26 control patients with CRS. The revision surgery rate for cases and controls was 31% and 12%, respectively, but there was no statistical difference (p > 0.05). There was a clinically meaningful reduction in SNOT-22 scores in both groups from the preoperative to postoperative period [mean of 12 points in patients with ID (p = 0.323) and 25 points in controls (p < 0.001)], however, there was again no significant difference between cases and controls (p > 0.05).

CONCLUSION

Our data suggests that patients with ID have clinically meaningful improvement in SNOT-22 scores after ESS but may have higher revision rates than immunocompetent patients with CRS. ID are rare disease entities, thus most attempts at studying this cohort would be limited by sample size. Further homogenous data on immunoglobulin deficient patients is required for future meta-analysis to better understand the impact of ESS in patients with ID.

Revision of endoscopic sinus surgery in adults: A population-based study in Taiwan

OBJECTIVE

This study aimed to elucidate the revision rate, time to revision, and factors associated with revision of endoscopic sinus surgery (ESS) in Taiwan.

DESIGN

Retrospective study.

SETTING

Population-based analysis.

PARTICIPANT

We identified all in-hospital patients, aged >20 years, who underwent ESS between 2000 and 2008 from the Taiwan National Health Insurance Research Database, and followed up with them until 2018.

MAIN OUTCOME MEASURES

Factors associated with revision surgery were analyzed using multivariable Cox proportional hazard model.

RESULTS

Overall, 66 592 patients were identified (mean age, 46.3 years; 62% males). The revision rate was 14.5% (9644/66 592) and time to revision surgery was 5.9 years. Multivariable Cox proportional hazard model showed that young age, male gender (hazard ratio [HR] = 1.18; 95% confidence interval [CI], 1.13-1.23), having nasal polyposis (HR = 1.17; 95% CI, 1.12-1.22), having allergic rhinitis (HR = 1.08; 95% CI, 1.04-1.13), having asthma (HR = 1.26; 95% CI, 1.14-1.39), and surgical time of >4 h (HR = 1.11; 95% CI, 1.06-1.16) were associated with increased risk of revision surgery. Concurrent septal surgery (HR = 0.81; 95% CI, 0.76-0.87), turbinate surgery (HR = 0.91; 95% CI, 0.85-0.97), or septal and turbinate surgery (HR = 0.68; 95% CI, 0.64-0.73) were associated with decreased risks of revision surgery.

CONCLUSION

In Taiwan, risk factors for revision ESS are young age, male gender, having nasal polyposis, having allergic rhinitis, having asthma, and long surgical times. Concurrent septal or turbinate surgery decreases the risk of revision.

A comparative analysis of endoscopic sinus surgery versus biologics for treatment of chronic rhinosinusitis with nasal polyposis

BACKGROUND

Comparative effectiveness research between endoscopic sinus surgery (ESS) and biologic therapy for severe chronic rhinosinusitis with nasal polyposis (CRSwNP) is a nascent field as new therapeutic modalities become clinically available.

METHODS

A prospective, multicenter cohort of CRSwNP patients, undergoing ESS between 2011 and 2019, were compared to phase-3 biologic trial data. Patients undergoing ESS received baseline nasal endoscopy quantified via Lund-Kennedy (LK) grading. Patients meeting inclusion criteria, modified from Dupilumab-LIBERTY-NP-24&52, omalizumab-POLYP-1&2, and Mepolizumab-SYNAPSE clinical trials, were included in this study. Baseline characteristics and outcome measures were compared between these cohorts at 24 weeks and 52 weeks, when possible.

RESULTS

A total of 111 CRSwNP patients met modified inclusion criteria. There were no statistically significant differences in baseline age, sex, asthma status, aspirin-exacerbated respiratory disease status, smell identification, LK-polyp score, and Lund-Mackay computed tomography (CT) scores between ESS and biologic groups. At 24 weeks, ESS demonstrated significantly greater improvements in 22-item Sino-Nasal Outcome Test (SNOT-22) compared to one (of two) dupilumab trials (p < 0.05) and both omalizumab trials (p < 0.001). ESS associated with significantly lower nasal polyp scores (NPS) compared to dupilumab (p < 0.001) and omalizumab (p < 0.001), despite comparable improvements in smell identification (p > 0.05). At 52 weeks, ESS resulted in statistically similar improvement in SNOT-22 scores compared to dupilumab (p = 0.21), but NPS remained significantly lower in the ESS group compared to dupilumab (p < 0.001) and mepolizumab (p < 0.001).

CONCLUSION

At 24 weeks and 52 weeks, ESS offers comparable SNOT-22 improvements compared to dupilumab. ESS and dupilumab offer comparable improvement in smell identification at 24 weeks. Compared to omalizumab, ESS offers superior SNOT-22 improvements. ESS offers significantly greater reductions in polyp size compared to omalizumab, dupilumab, and mepolizumab therapies.

A Decade of Clinical Advances in Chronic Rhinosinusitis: 2012-2022

The field of chronic rhinosinusitis (CRS) is constantly evolving. In the past 10 years, key advancements in basic and translational research as well as clinical studies have improved our understanding and management of CRS. Notably, treatment options have expanded to include novel therapeutic drugs, devices, and surgical techniques. Assessments of patient symptoms and their impact on quality of life have become more standardized. Progress has also been made in both determining the true prevalence of CRS and recognizing comorbidities that can impact CRS severity. Practice guidelines have also shifted from expert opinion to more data-driven analyses. This review highlights major clinical advancements made in the field of CRS over the past 10 years as well as identifies current gaps in knowledge that can form the basis for new areas of study over the next decade.

Significance of leukocyte-specific transcript 1 levels in nasal mucosal tissue to predict recurrence of nasal polyps

OBJECTIVE

Chronic Rhinosinusitis with Polyps (CRSwNP) is characterized by high heterogeneity and postoperative recurrence rate. This study aims to explore the clinical significance of tissue Leukocyte-Specific Transcript 1 (LST1) in predicting CRSwNP recurrence.

METHODS

We enrolled 62 CRSwNP patients including 30 primary CRSwNP and 32 recurrent CRSwNP patients, and 40 Healthy Controls (HC). Tissue samples were collected. Tissue LST1 expression was assessed by Reverse Transcription-Polymerase Chain Reaction (RT-PCR), Western Blotting (WB) and Immunofluorescence (IF) staining. The predictive values of LST1 expression for CRSwNP postoperative recurrence were assessed through the Receiver Operating Characteristic (ROC) curves.

RESULTS

The tissue levels of LST1 were significantly increased in the CRSwNP group than the HC group, especially in the recurrent group, and the elevated LST1 mRNA levels were positively correlated with the peripheral eosinophil percentages, tissue eosinophil counts and percentages. IF staining results showed that the LST1 protein levels were higher in CRSwNP patients, especially in the recurrent patients than in the HC group. ROC curves highlighted that tissue LST1 levels were associated with recurrent CRSwNP and exhibited a higher predictive ability for postoperative CRSwNP recurrence.

CONCLUSION

This was the first report suggesting that LST1 expression was upregulated and associated with mucosal eosinophil infiltration and CRSwNP recurrence. Tissue LST1 could be a promising biomarker for predicting postoperative recurrence in CRwNP patients.

LEVEL OF EVIDENCE

Level 5.

Clinical and economic burden of chronic rhinosinusitis with nasal polyposis: A U.S. administrative claims analysis

Background: Limited data exist on the clinical and economic burden of chronic rhinosinusitis with nasal polyposis (CRSwNP). Objective: To describe patient characteristics, health-care resource utilization (HCRU), and health-care costs among patients with CRSwNP with and without comorbid asthma (primary analysis) and with surgical management of nasal polyps (secondary analysis). Methods: This was a retrospective study of patients diagnosed with CRSwNP conducted using administrative claims data from January 1, 2013, through March 31, 2019. Study outcomes were assessed over a 2-year follow-up. Results were stratified by baseline asthma status (primary analysis) and presented separately for patients with surgically managed CRSwNP (secondary analysis). Results: The primary analysis included 10,999 patients with CRSwNP (2649 with asthma, 8350 without asthma). Patients with versus without asthma had higher medication use, HCRU, and all-cause medical costs (mean ± standard deviation $34,667 ± $42,234 versus $27,122 ± $45,573; p < 0.001) across the full follow-up period. CRSwNP-related medical costs were significantly higher for patients with versus without asthma in year 2 of follow-up. In the surgical management analysis (n = 4943), most categories of medication use and CRSwNP-related HCRU declined from baseline levels during follow-up, and CRSwNP-related pharmacy costs in year 2 were less than half of baseline levels. Conclusion: Patients diagnosed with CRSwNP and asthma had a greater burden of illness than those without asthma. Higher CRSwNP-related medical costs in year 2 of follow-up for patients with asthma may indicate worsening symptoms over time. Among patients with surgically managed CRSwNP, HCRU and costs increased in year 1 of follow-up but decreased below baseline levels in year 2, potentially reflecting improved symptom severity.

Using machine learning for the personalised prediction of revision endoscopic sinus surgery

BACKGROUND

Revision endoscopic sinus surgery (ESS) is often considered for chronic rhinosinusitis (CRS) if maximal conservative treatment and baseline ESS prove insufficient. Emerging research outlines the risk factors of revision ESS. However, accurately predicting revision ESS at the individual level remains uncertain. This study aims to examine the prediction accuracy of revision ESS and to identify the effects of risk factors at the individual level.

METHODS

We collected demographic and clinical variables from the electronic health records of 767 surgical CRS patients ≥16 years of age. Revision ESS was performed on 111 (14.5%) patients. The prediction accuracy of revision ESS was examined by training and validating different machine learning models, while the effects of variables were analysed using the Shapley values and partial dependence plots.

RESULTS

The logistic regression, gradient boosting and random forest classifiers performed similarly in predicting revision ESS. Area under the receiving operating characteristic curve (AUROC) values were 0.744, 0.741 and 0.730, respectively, using data collected from the baseline visit until six months after baseline ESS. The length of time during which data were collected improved the prediction performance. For data collection times of 0, 3, 6 and 12 months after baseline ESS, AUROC values for the logistic regression were 0.682, 0.715, 0.744 and 0.784, respectively. The number of visits before or after baseline ESS, the number of days from the baseline visit to the baseline ESS, patient age, CRS with nasal polyps (CRSwNP), asthma, non-steroidal anti-inflammatory drug exacerbated respiratory disease and immunodeficiency or suspicion of it all associated with revision ESS. Patient age and number of visits before baseline ESS carried non-linear effects for predictions.

CONCLUSIONS

Intelligent data analysis identified important predictors of revision ESS at the individual level, such as the frequency of clinical visits, patient age, Type 2 high diseases and immunodeficiency or a suspicion of it.

Current Insight into Treatment of Chronic Rhinosinusitis: Phenotypes, Endotypes and Implications for Targeted Therapeutics

Chronic rhinosinusitis (CRS) is characterized by persistent locoregional mucosal inflammation of the paranasal sinuses and upper airway that has substantial associated health care costs¹. Personalized approaches to care that incorporate use of molecular biomarkers, phenotypes and inflammatory endotypes is a major focus of research at this time, and the concurrent rise of targeted therapeutics and biologic therapies has the potential to rapidly advance care and improve outcomes. Recent findings suggest that improved understanding of CRS phenotypic and endotypic heterogeneity, and incorporation of these characteristics into clinical care pathways, may facilitate more effective selection of surgical and/or therapeutic interventions². Ultimately, these personalized approaches have the potential to target specific inflammatory pathways, increase efficacy, reduce costs, and limit side effects. This review summarizes recent advances in the identification and characterization of CRS phenotypes, endotypes, and biomarkers and reviews potential implications for targeted therapeutics.

Developments and Emerging Trends in the Global Treatment of Chronic Rhinosinusitis From 2001 to 2020: A Systematic Bibliometric Analysis

Background

Research on the treatment of chronic rhinosinusitis (CRS) has increased in recent decades. We undertook a bibliometric and visualization analysis of studies on CRS treatment to track research trends and highlight current research “hotspots”.

Methods

Original publications related to CRS treatment were obtained from the Science Citation Index-Expanded (SCI-E) and Social Sciences Citation Index (SSCI) databases in the Web of Science Core Collection (WoSCC) of Clarivate Analytics between 2001 and 2020. The country/region, institution, author, journal, references, and keywords involved in this topic were extracted using CiteSpace and VOSviewer to identify and analyze the research focus and trends in this field.

Results

In the previous two decades (especially after 2015), the number of publications on CRS treatment has grown markedly. With regard to publications and access to collaborative networks, the leading country was the USA. High-frequency keywords were “CRS,” “endoscopic sinus surgery,” “sinusitis,” “nasal polyps,” “asthma,” “rhinosinusitis,” “management,” “diagnosis,” “outcomes,” and “quality of life.” Inspection of keyword bursts suggested that “clinical practice guideline,” “adult CRS,” “innate lymphoid cell,” “recurrence,” and “mepolizumab” are the emerging research hotspots. The timeline view of the cluster map revealed that biologic agents have become an up-and-coming “hot topic” in CRS treatment in recent years.

Conclusion

Academic understanding of CRS treatment has improved markedly over the past 20 years. We study analyzed the papers objectively, methodically, and comprehensively, and identified hotspots and prospective trends in the field of CRS treatment. These results will aid rhinologists in gaining greater insight into CRS treatment strategies and identifying the changing dynamics of CRS research.

Demographic Variation in Chronic Rhinosinusitis by Subtype and Region: A Systematic Review

BACKGROUND

Chronic rhinosinusitis (CRS) describes a heterogenous group of diseases including CRS with (CRSwNP) or without nasal polyps (CRSsNP), aspirin-exacerbated respiratory disease (AERD), and allergic fungal rhinosinusitis (AFRS). It affects 10 to 15% of the US population and is more common in women and White patients. However, these estimates are based on survey and database studies with innate diagnostic inaccuracy. Additionally, few studies report subtype-specific demographics. We explore the demographic differences of CRS in the U.S. by subtype and region.

OBJECTIVE

To characterize demographic differences between the CRS population and the overall US population, and also between different CRS subtype populations.

METHODS

We performed a systematic review for articles reporting on US demographics of adults with CRS. Study participants were required to have been diagnosed using consensus criteria. Data on demographics, geographic region, and CRS subtype were analyzed.

RESULTS

Our study analyzed 31 unique studies representing 8409 patients with 50.7% females and weighted mean age of 48.0 years. Compared to the overall US population, CRS patients were predominantly White (78.5%) and non-Hispanic (94.5%) with under-representation of other races. Grouped by subtype, CRSwNP affected a significantly higher proportion of men (59.8%). AFRS affected a significantly higher proportion of Black patients (53.8%) while CRSsNP was more prevalent in White patients (84.2%). When grouped by region, the South had a significantly higher proportion of female (53%) and Black (17.8%) CRS patients. The West had a significantly higher proportion of Asian (4.5%) and Hispanic (12.3%) patients.

CONCLUSIONS

Significant demographic differences exist in CRS patients based on subtype and region. These data provide an estimation of the demographic make-up of CRS, but further high-level demographic studies are needed.

Central compartment atopic disease: outcomes compared with other subtypes of chronic rhinosinusitis with nasal polyps

BACKGROUND

Central compartment atopic disease (CCAD) is a variant of chronic rhinosinusitis (CRS) with nasal polyps (CRSwNP) characterized by polypoid changes of the superior nasal septum, middle (MT), and/or superior turbinates (ST). This study evaluates surgical outcomes in patients with CCAD compared with other CRSwNP subtypes.

METHODS

Retrospective analysis was performed at Emory University from May 2012 to November 2019. Patients undergoing primary endoscopic sinus surgery (ESS) for CCAD, aspirin-exacerbated respiratory disease (AERD), allergic fungal rhinosinusitis (AFRS), and CRSwNP not otherwise specified (CRSwNP NOS) were included consecutively, beginning with the earliest date of CCAD patient. Outcome measures included polyp recurrence, revision ESS, oral steroid use, and oral antibiotic use. Pearson chi-square and univariate analysis of variance (ANOVA) were performed for group comparisons.

RESULTS

Data was collected for 132 patients (CCAD = 38, AERD = 20, AFRS = 37, CRSwNP NOS = 37; 58 females, mean age 42.9 years [range, 13-85 years]). CCAD patients demonstrated polyp recurrence less frequently than expected, whereas AFRS patients had polyp recurrence more frequently than expected (p = 0.003; phi 0.32). CCAD patients underwent revision ESS less frequently than expected; AFRS and CRSwNP NOS underwent revision ESS more frequently than expected (p = 0.03; phi 0.26). CRSwNP NOS patients received more total antibiotic courses than those with CCAD (p = 0.01; eta-squared 0.09) and more courses of antibiotics per month than those with AFRS (p = 0.03; eta-squared 0.07). There was no significant difference in follow-up measures across groups (number of visits, total months, or visits per month).

CONCLUSION

Rates of polyp recurrence and revision ESS were significantly lower in CCAD patients compared with patients with other CRSwNP subtypes, suggesting durable benefit of ESS and postoperative medical therapy in CCAD patients.

Guidance for contemporary use of biologics in management of chronic rhinosinusitis with nasal polyps: discussion from a National Institutes of Health-sponsored workshop

BACKGROUND

Biologic medications are emerging as options for treating chronic rhinosinusitis with nasal polyps (CRSwNP). Several questions remain regarding patient selection, indications, clinical efficacy, and cost effectiveness.

METHODS

In November 2019, a group of physicians and scientists gathered to consider strategies for future studies regarding biologics. During the discussion, gaps in knowledge highlighted a need for a consensus on the present day use of biologics in polyp patients.

RESULTS

The goal of this guideline is to propose recommendations for the current use of biologics in CRSwNP as new evidence continues to emerge and inform practice.

CONCLUSION

We suggest that physicians evaluate patients on an individual basis and closely monitor for improvement due to the high cost and unknown long-term effects of biologics.

Surgical outcomes in aspirin-exacerbated respiratory disease without aspirin desensitization

BACKGROUND

Aspirin-exacerbated respiratory disease (AERD) represents a severe endotype of chronic rhinosinusitis with nasal polyposis. Although aspirin desensitization (AD) has emerged as an effective therapeutic option, the natural history of AERD without AD remains unclear.

METHODS

A retrospective review was conducted of AERD patients who underwent endoscopic sinus surgery (ESS) without AD between 2010 and 2019. The primary outcomes were revision surgery rate and time to revision surgery. Secondary outcomes included changes in 22-item Sino-Nasal Outcome Test (SNOT-22) scores and Lund-Kennedy endoscopy scores (LKES). A subgroup analysis was performed for patients on monoclonal antibody therapy (MAT).

RESULTS

Of 141 patients, 37 (26.2%) underwent revision ESS with a median time to revision of 3.3 (interquartile range [IQR], 2.2-4.9) years. The probability of remaining free of revision surgery at 1, 3, and 5 years was: 98.2% (95% confidence interval [CI], 95.7-100.0%), 78.8% (95% CI, 70.2-88.4%), and 44.8% (95% CI, 32.4-62.1%), respectively. SNOT-22 scores decreased by 34 (IQR, 18-52) points at 6 months and 27 (IQR, 20-46) points at 1 year postoperatively. In the revision cohort, the decrease in SNOT-22 score was not sustained at 1 year postoperatively. No difference was found in time to revision compared with those without MAT (p = 0.23).

CONCLUSION

A significant proportion of AERD patients benefit from ESS and medical therapy alone without AD. This study presents preliminary results on the impact of MAT on surgical outcomes as it is limited by the small sample size. Further research on the use of MAT in AERD is needed.

Effect of Functional Endoscopic Sinus Surgery on Outcomes in Chronic Rhinosinusitis​

PURPOSE OF REVIEW

Chronic rhinosinusitis (CRS) has a significant negative impact on quality of life (QoL). Surgical treatment of CRS is indicated when medical therapy fails to achieve adequate symptom control. This review summarizes the latest information on the outcomes after endoscopic sinus surgery (ESS) with relation to QoL, revision rates, olfaction, absenteeism, asthma control, use of systemic medications, quality of sleep and complications. We also provide an update regarding the factors that can impact outcomes.

RECENT FINDINGS

CRS has classically been divided into two phenotypes depending on the presence or absence of nasal polyps. However, this is an oversimplification as many factors impact disease burden and outcome after treatment. It has been demonstrated that in many cases, ESS fails to meet the expectations of the patients. Evidence based patient counselling is key to help surgeons guide their patients in the best possible way to make well-informed decisions. Repeatedly it has been demonstrated that ESS improves QoL, improves olfaction, leads to better asthma control and less use of systemic antibiotics. However, various patient characteristics including phenotype, disease burden, comorbidities, age, gender and surgical technique can influence the outcome after ESSIt is of paramount importance to include a follow-up period when discussing revision rates. Based on available data, the genuine revision rate is probably 15-20% after five to ten years of follow-up. The revision rate is also affected by various factors and comorbidities.