[Guideline for "rhinosinusitis"-long version : S2k guideline of the German College of General Practitioners and Family Physicians and the German Society for Oto-Rhino-Laryngology, Head and Neck Surgery]

[Diagnosis and drug therapy of chronic rhinosinusitis]

Chronic rhinosinusitis is one of the most common chronic diseases of the upper respiratory tract and is associated with a significant reduction in quality of life. Precise diagnostic workup is therefore necessary to provide patients with adequate treatment. The introduction of biologics has opened up new options for the treatment of severely affected patients with chronic rhinosinusitis with nasal polyps in the sense of precision medicine that goes beyond the mere control of symptoms. This has been accompanied by a certain degree of standardization with regard to diagnostic procedures and the assessment of disease-specific quality of life. Against the background of the 2025 congress theme "Individualization vs. standardization in otorhinolaryngology," this paper examines and summarizes the diagnosis and drug therapy of chronic rhinosinusitis, with a focus on biologic therapy.

The Introduction of the Global Traditional, Complementary, and Integrative Healthcare (TCIH) Research Agenda on Antimicrobial Resistance and Its Added Value to the WHO and the WHO/FAO/UNEP/WOAH 2023 Research Agendas on Antimicrobial Resistance

Background/Objectives: Given the magnitude and urgency of the global antimicrobial resistance (AMR) problem and the insufficiency of strategies to reduce antimicrobial use, there is a need for novel strategies. Traditional, Complementary, and Integrative Healthcare (TCIH) provides strategies and solutions that contribute to reducing (inappropriate) antimicrobial use, preventing or treating infections in both human and veterinary medicine, and may contribute to promoting the health/resilience of humans and animals and reducing AMR. The aims of this study were to present the core results of a global TCIH research agenda for AMR and its added value to two existing global AMR research agendas published in 2023. Methods: A survey, interviews, and consensus meetings among network members, as an adapted version of the nominal group technique, were executed to develop the global TCIH research agenda. A comparison of the global TCIH research agenda with the two existing global AMR research agendas was performed. The TCIH additions to these two existing global AMR research agendas were determined. Results: The global TCIH research agenda adds to 19 of 40 research priorities of the World Health Organization (WHO) AMR research agenda 2023 and three of the five pillars of the WHO/Food and Agriculture Organization of the United Nations (FAO)/United Nations Environment Programme (UNEP)/World Organisation for Animal Health (WOAH) research agenda 2023. In addition, the TCIH research agenda adds two new research themes with four new research priorities and three new research priorities to already existing themes of the two global AMR research agendas. Conclusions: The global TCIH research agenda fits with and adds to two global AMR research agendas and can be used as an additional strategy to reduce AMR and (inappropriate) use of antibiotics.

[Occupational diseases related to otorhinolaryngology]

In the German Ordinance on Occupational Diseases (BKV), there are currently 82 occupational diseases listed, of which 18 partially or completely fall within the field of ENT medicine due to the associated health disorders. Noise-induced hearing loss is usually the focus of attention for the ENT specialist, but it has long since ceased to be the only occupational disease. In order to help uncover possible causalities between occupational noxious substances and diseases, it is important that physicians report their own observations and new scientific findings regarding suspected cases to the German Social Accident Insurance, especially in situations where cancer may be linked to occupational influences.

The Diagnosis and Treatment of Chronic Rhinosinusitis

BACKGROUND

Chronic rhinosinusitis (CRS) is a heterogeneous condition characterized by local chronic inflammation of the mucous membranes of the nose and paranasal sinuses. It affects approximately 5% of the population.

METHODS

This review is based on relevant publications retrieved by a selective search of the literature, with particular attention to current national and international guidelines.

RESULTS

CRS is defined by, and diagnosed on the basis of, a combination of symptoms and objective findings of nasal endoscopy and imaging studies. It markedly impairs quality of life and gives rise to both direct and indirect health care costs. In 20-45% of cases, CRS is associated with comorbid bronchial asthma and a significantly elevated risk of further diseases (e.g., COPD, OR 1.73; depression, HR 1.50; obstructive sleep apnea, OR 1.91; carcinoma, OR 1.14-5.30). CRS is primarily treated medically with topical steroids (standardized mean difference of nasal symptoms, -0.63 (95% confidence interval [-0.89; -0.37]; standardized mean difference of quality of life as measured by SNOT -22, -5.46 [-8.08; -2.84]), as well as with nasal lavage and, as an option, systemic steroids (and antibiotics where appropriate). If appropriate medical treatment fails to bring about adequate and sustained improvement, endoscopic sinus surgery is indicated. This improves the individual symptoms, the overall symptom score, and patients' quality of life. Severe refractory CRS with nasal polyposis can be treated with biological agents.

CONCLUSION

CRS calls for individually adapted medical and/or surgical treatment.

[Results of a survey on the current management of chronic rhinosinusitis with nasal polyps in Germany]

INTRODUCTION

With a prevalence of 0.55% to 4%, chronic rhinosinusitis with nasal polyps (CRSwNP) is a relevant part of the daily work of German otolaryngologists. The aim of the questionnaire-based data collection was to assess the current treatment status of CRSwNP in Germany.

MATERIAL AND METHODS

For this purpose, 24 questions within an anonymized online questionnaire were sent to all German ENT departments.

RESULTS

Of 160 contacted ENT departments, 50 participated in the survey (31.3%). Among these, 76% performed more than 100 sinus surgeries annually and 38% treated more than 50 patients with biologics. Saline irrigations (80%) and intranasal glucocorticoids (GCS, 96%) were the most common conservative therapies. Systemic GCSs (52%) and intranasal GCS irrigation (20%) were less common. 80% of departments used biologics in the therapy of CRSwNP with an overall preference for dupilumab (70%). For therapy of aspirin intolerance, biologics (52%) were preferred to aspirin desensitization (26%). Prior to treatment with biologics clinical workup included the nasal polyp score (90%), the SNOT-22 questionnaire (84%), surrogate markers of type 2 inflammation (60%-72%), and computer tomography (50%). Final treatment success was assessed after 24 weeks (50%).

CONCLUSION

Mostly, the responding departments followed German and European recommendations for diagnosis and therapy of CRSwNP. Therapy with biologics is widely used. The value of preoperative systemic GCS and the frequent performance of CT before initiation of therapy with a biologic should be debated in regard to its currently widespread use.

[Chronic rhinosinusitis with nasal polyposis : A retrospective analysis of therapeutic approaches in 463 patients]

BACKGROUND

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a multifactorial inflammatory disease, the treatment of which has undergone significant changes in recent years. In addition to surgical approaches, topical and systemic steroids, and adaptive acetylsalicylic acid (ASA) desensitization, three specific antibodies have complemented the therapeutic portfolio since 2019.

METHODS

A retrospective evaluation of all patients who presented as outpatients for the first time due to CRSwNP in 2007 and 2008 (collective A) and 2017 and 2018 (collective B) was performed, up to and including June 2023.

RESULTS

The clinical courses of 463 patients (mean age 49.1 years, range 5-82 years; 65.9% male) were included in the analysis. Conservative treatment with nasal corticosteroids started before initial presentation was more frequent in collective B (collective A 43.9% vs. collective B 72.2%). In 278 of the 463 patients (60%; A: 62%, B: 58%), at least one operation on the nasal sinuses had been performed after initial presentation; in 101 of these patients (36.3%) recurrent polyposis (within mean follow-up of 2.4 years) required further treatment. The indication for ASA provocation/desensitization was applied less frequently in collective B, also due to a high discontinuation rate (at least 38%) of the maintenance therapy. Of the total cohort, 16 patients (3.5%; A: n = 8, B: n = 8) were meanwhile switched to antibody therapy at recurrence.

CONCLUSION

A step-by-step guideline-orientated approach is recommended in the treatment of CRSwNP. Systemic antibodies as an add-on to nasal corticosteroids are a relatively new therapeutic option for treatment-refractory CRSwNP, which reduces the indication for ASA desensitization, which is associated with a relatively high incidence of side effects and poor compliance.

[Modern management of chronic rhinosinusitis]

Chronic rhinosinusitis is a common disease. Due to the significant reduction of the quality of life, possible serious complications and economic consequences, a sufficient therapy is essential. With the entry of biologics into the treatment of chronic rhinosinusitis, relevant innovations have emerged in recent years. This article is aimed at providing an up-to-date overview of the conservative and surgical treatment options for chronic rhinosinusitis.

Pädiatrische Rhinologie

The following review article highlights key topics in pediatric rhinology that are currently the focus in research and at conferences as well as in the interdisciplinary discussion between otorhinolaryngologists and pediatricians. In particular, congenital malformations such as choanal atresia or nasal dermoid cysts are discussed, followed by statements on the current procedures for sinogenic orbital complications as well as on the diagnosis and therapy of chronic rhinosinusitis in children. Furthermore, updates on the role of the ENT specialist in the care for children with cystic fibrosis and primary ciliary dyskinesia are provided.

Reduced Glycolysis and Cytotoxicity in Staphylococcus aureus Isolates from Chronic Rhinosinusitis as Strategies for Host Adaptation

Chronic rhinosinusitis (CRS) is a multifactorial infection of the nasal cavity and sinuses. In this study, nasal swabs from control donors (N = 128) and patients with CRS (N = 246) were analysed. Culture methods and metagenomics revealed no obvious differences in the composition of the bacterial communities between the two groups. However, at the functional level, several metabolic pathways were significantly enriched in the CRS group compared to the control group. Pathways such as carbohydrate transport metabolism, ATP synthesis, cofactors and vitamins, photosynthesis and transcription were highly enriched in CRS. In contrast, pathways related to lipid metabolism were more representative in the control microbiome. As S. aureus is one of the main species found in the nasal cavity, staphylococcal isolates from control and CRS samples were analysed by microarray and functional assays. Although no significant genetic differences were detected by microarray, S. aureus from CRS induced less cytotoxicity to lung cells and lower rates of glycolysis in host cells than control isolates. These results suggest the differential modulation of staphylococcal virulence by the environment created by other microorganisms and their interactions with host cells in control and CRS samples. These changes were reflected in the differential expression of cytokines and in the expression of Agr, the most important quorum-sensing regulator of virulence in S. aureus. In addition, the CRS isolates remained stable in their cytotoxicity, whereas the cytotoxic activity of S. aureus isolated from control subjects decreased over time during in vitro passage. These results suggest that host factors influence the virulence of S. aureus and promote its adaptation to the nasal environment during CRS.

Factors Influencing Recurrence after Surgical Treatment of Odontogenic Maxillary Sinusitis: An Analysis from the Oral and Maxillofacial Surgery Point of View

The aim of the study was to determine the factors influencing the development of recurrence after the surgical treatment of odontogenic maxillary sinusitis in an oral and maxillofacial surgery clinic over a 7-year period. Demographic and anamnesis data, clinical and radiological findings, treatment and outcome were analyzed. A multivariable analysis was performed to find associations between patient age, causative focus, surgical access for sinus revision, multilayer closure with a buccal fat pad, inferior meatal antrostomy (IMA) for temporary sinus drainage and sinusitis recurrence. A total of 164 patients with a mean age of 51.7 years were included. Sinusitis recurrence was observed in nine patients (5.48%) within 6 months after primary surgery. No significant correlation was detected between patient age, causative focus, surgical access for sinus revision, multilayer closure with a buccal fat pad, IMA for sinus drainage and the development of recurrence (p > 0.05). Patients with a history of antiresorptive-related osteonecrosis of the jaw showed a significant tendency toward disease recurrence (p = 0.0375). In conclusion, except for antiresorptive administration, none of the investigated variables were related to a higher risk of sinusitis recurrence. We encourage a combined approach of intraoral removal of the infective focus and sinus drainage via FESS, as well as an individual treatment decision in a multidisciplinary setting with collaboration between dentistry, maxillofacial surgery and otorhinolaryngology to avoid sinusitis recurrence.

[Treatment of chronic rhinosinusitis with nasal polyps (CRSwNP) with monoclonal antibodies (biologics): S2k guideline of the German Society of Oto-Rhino-Laryngology, Head and Neck Surgery (DGHNO-KHC), and the German College of General Practitioners and Family Physicians (DEGAM)]

Monoclonal antibodies (so-called biologics) can be prescribed for chronic rhinosinusitis with nasal polyps (CRSwNP) within the scope of their market authorization. However, their prescription is limited to severe CRSwNP without disease control, whereby certain requirements must be met. Dupilumab, omalizumab, and mepolizumab have currently gained market authorization, with adequate evidence for their efficacy and safety available in the literature. It can be assumed that other biologics will be approved for this indication in the future. The severity of disease and the efficacy of treatment should be assessed objectively and subjectively before treatment initiation and after an appropriate duration, respectively. The documentation sheet proposed in this guideline chapter can be used for the assessments. In the presence of relative contraindications, a treatment should only be initiated after differentiated consideration by an experienced physician in the sense of a case-by-case decision. In summary, this guideline chapter aims to contribute to high-quality care of adult patients with these therapies in view of the increasing evidence for treatment with these substances and the increasing number of market authorizations of different biologics.

Prevalence of Antibiotic Prescription in Patients with Acute Rhinosinusitis Treated by General Practitioners and Otolaryngologists in Germany-A Retrospective Cohort Study

(1) Background: The goal of this retrospective cohort study, based on real-world data and conducted in Germany, was to investigate the prevalence of antibiotic (AB) prescription in patients with acute rhinosinusitis (ARS). (2) Methods: Data from the Disease Analyzer database were used for this cross-sectional study. Patients aged ≥18 years diagnosed with acute sinusitis by general practitioners (GPs) and ear, nose, throat (ENT) specialists between January 2012 and December 2020 were included. The main outcome of the study was the proportion of patients with ARS who received an AB prescription on the day of diagnosis or within three days afterwards. The proportion was estimated separately for patients treated by GPs and ENTs, and also for five age groups, as well as women and men. (3) Results: In total, 308,095 patients were diagnosed with ARS (187,838 by GPs and 120,257 by ENTs). 50.9% of patients treated by GPs and 50.0% treated by ENTs received an AB prescription. AB prevalence increased with age from 46.9% in the age group 18−30 years to 55.5% in the age group > 60 years. (4) Conclusions: We have shown a high prevalence of potentially inappropriate AB prescription for adult patients with ARS in both GP and ENT practices and also among both women and men and in several age groups. There is an urgent need for interventions to reduce inappropriate AB use.

Contribution of Symptomatic, Herbal Treatment Options to Antibiotic Stewardship and Microbiotic Health

Epithelial surfaces in humans are home to symbiotic microbes (i.e., microbiota) that influence the defensive function against pathogens, depending on the health of the microbiota. Healthy microbiota contribute to the well-being of their host, in general (e.g., via the gut-brain axis), and their respective anatomical site, in particular (e.g., oral, urogenital, skin, or respiratory microbiota). Despite efforts towards a more responsible use of antibiotics, they are often prescribed for uncomplicated, self-limiting infections and can have a substantial negative impact on the gut microbiota. Treatment alternatives, such as non-steroidal anti-inflammatory drugs, may also influence the microbiota; thus, they can have lasting adverse effects. Herbal drugs offer a generally safe treatment option for uncomplicated infections of the urinary or respiratory tract. Additionally, their microbiota preserving properties allow for a more appropriate therapy of uncomplicated infections, without contributing to an increase in antibiotic resistance or disturbing the gut microbiota. Here, herbal treatments may be a more appropriate therapy, with a generally favorable safety profile.

Schlenter W, Welkoborsky HJ, Wollenberg B, Bergmann C, Cuevas M, Beutner C, Gröger M, Becker S. Dokumentation von Biologika-Therapien bei chronischer Rhinosinusitis mit Polyposis nasi (CRSwNP): Dupilumab, Omalizumab und Mepolizumab

Hintergrund: Die chronische Rhinosinusitis mit Nasenpolypen (CRSwNP) ist eine multifaktorielle entzündliche Erkrankung der paranasalen Schleimhäute, der als Endotyp meistens eine Typ-2-Inflammation zugrunde liegt. Mittlerweile sind drei Antikörper (Dupilumab, Omalizumab und Mepolizumab) für die Therapie der schweren CRSwNP zugelassen. Eine Dokumentation der Erkrankungsschwere im Behandlungsverlauf ist unverzichtbar.

Methoden: In einer Literaturrecherche in Medline, Pubmed sowie den nationalen und internationalen Studien- und Leitlinienregistern und der Cochrane Library wurde die Immunologie der CRSwNP analysiert und die Evidenz zur Wirkung von Dupilumab, Omalizumab und Mepolizumab bei dieser Erkrankung ermittelt. Hieraus wurden drei Positionspapiere durch unsere Autorengruppe erstellt, die Grundlage dieser zusammenfassenden Übersichtsarbeit sind.

Ergebnisse: Basierend auf den Angaben aus der internationalen Literatur werden von einem Expertengremium Empfehlungen für die Anwendung von Dupilumab, Omalizumab und Mepolizumab bei CRSwNP im deutschen Gesundheitssystem gegeben.

Schlussfolgerung: Dupilumab, Omalizumab und Mepolizumab sind zugelassen für Patienten ab 18 Jahren mit schwerer CRSwNP als Zusatztherapie zu intranasalen Glukokortikosteroiden (INCS), wenn, bei Dupilumab und Mepolizumab, durch eine Therapie mit systemischen Glukokortikosteroiden und/oder chirurgischem Eingriff keine ausreichende Krankheitskontrolle erzielt werden kann. Eine Therapie mit Omalizumab ist angezeigt, wenn eine Therapie mit INCS keine suffiziente Kontrolle der Erkrankung ergibt. Es werden dezidierte Empfehlungen zur Dokumentation der Anwendung im Deutschen Gesundheitssystem gegeben, die auf den hierzu bereits publizierten Positionspapieren unserer Autorengruppe basieren.

Zitierweise: Klimek L, Förster-Ruhrmann U, Beule AG, Chaker AM, Hagemann J, Klimek F, Casper I, Huppertz T, Hoffmann TK, Dazert S, Deitmer T, Olze H, Strieth S, Wrede H, Schlenter W, Welkoborsky H-J, Wollenberg B, Bergmann C, Cuevas M, Beutner C, Gröger M, Becker S. Indicating biologics for chronic rhinosinusitis with nasal polyps (CRSwNP): Recommendations by German Allergy and ORL-societies AeDA and DGHNO for Dupilumab, Omalizumab and Mepolizumab. Allergo J Int 2022;31:149-60

https://doi.org/10.1007/s40629-022-00220-x

Clinical Assessment of Chronic Rhinosinusitis

Chronic rhinosinusitis (CRS) is a common disease that affects >10% of the adult population in Europe and the United States. It has been delineated phenotypically into CRS without nasal polyps and CRS with nasal polyps. Both have a high disease burden and an overlapping spectrum of symptoms such as nasal obstruction, olfactory dysfunction, facial pain, pressure, and nasal discharge. Primary assessment includes evaluation of patient symptoms and impact on quality of life, nasal endoscopic examination, and imaging. Significant progress has been made in the understanding of CRS pathophysiology. There is a move toward describing CRS in terms of the predominant endotype or inflammatory pattern pathomechanism rather than the traditional classification of patients with and without nasal polyps. An increased elucidation of the disease endotypes, as characterized by their inflammatory pathways and mediators, is leading to a tailored more personalized treatment approach to the different disease subtypes.

[Management strategies for chronic rhinosinusitis with nasal polyps]

Chronic rhinosinusitis with (CRwNP) or without (CRsNP) nasal polyps can have a great impact on quality of life. Typical symptoms include nasal obstruction, olfactory dysfunction, nasal discharge, and facial pain or pressure. Diagnostic gold standard is nasal endoscopy followed by CT scan of the paranasal sinuses. Besides first-line treatment with topical or systemically applied glucocorticoids, nasal rinsing, and surgical therapy, monoclonal antibodies have been approved in Germany since 2019.

[Dupilumab has an additional benefit in treatment of chronic rhinosinusitis with nasal polyps]

BACKGROUND

For patients with severe chronic rhinosinusitis with nasal polyps (CRSwNP) which cannot be controlled by continuous therapy with intranasal corticosteroids (INCS) and systemic corticosteroids and/or surgical treatment, there were no approved curative options for a long time. For CRSwNP treatment with T2-addressing biologics is possible. On October 24, 2019, the European Commission granted extended approval for dupilumab as the first biological agent for treatment of insufficiently controlled severe CRSwNP. The Federal Joint Committee (G‑BA) evaluates the benefits of reimbursable drugs with new active ingredients. This includes assessment of the additional benefit and its therapeutic relevance.

METHODS

A meta-analysis was performed using individual patient data based on two phase III studies. Both studies examined the safety and efficacy of dupilumab as an add-on therapy to INCS for treatment of CRSwNP in adults inadequately controlled with systemic corticosteroids and/or surgery compared to INCS alone.

RESULTS

Based on the present data, the G‑BA decided that there is an indication of a considerable additional benefit of dupilumab compared to mometasone furoate.

CONCLUSION

For patients with severe CRSwNP inadequately controlled with INCS and systemic corticosteroids and/or surgery, there is an indication of a considerable additional benefit for the administration of dupilumab as an add-on therapy to INCS compared to mometasone furoate alone.

Positionspapier: Empfehlungen zur Anwendung von Omalizumab bei chronischer Rhinosinusitis mit Polyposis nasi (CRSwNP) im deutschen Gesundheitssystem – Empfehlungen des Ärzteverbandes Deutscher Allergologen (AeDA) und der AGs Klinische Immunologie, Allergologie und Umweltmedizin und Rhinologie und Rhinochirurgie der Deutschen Gesellschaft für HNO-Heilkunde, Kopf- und Halschirurgie (DGHNOKHC)

Hintergrund Die chronische Rhinosinusitis mit Nasenpolypen (CRSwNP) ist eine multifaktorielle entzündliche Erkrankung der paranasalen Schleimhäute, der als Endotyp meistens eine TH2-Inflammation zugrunde liegt. IgE-Antikörper spielen dabei eine wichtige Rolle. Der anti-IgE-Antikörper Omalizumab wurde im August 2020 für die Therapie der schweren CRSwNP zugelassen.

Methoden In einer Literatursuche wurde die Immunologie der CRSwNP analysiert und die Evidenz zur Wirkung von Omalizumab bei dieser Erkrankung ermittelt durch Recherchen in Medline, Pubmed sowie den nationalen und internationalen Studien- und Leitlinien-Registern und der Cochrane Library.

Ergebnisse Basierend auf diesen Angaben aus der internationalen Literatur werden von einem Expertengremium Empfehlungen für die Anwendung von Omalizumab bei CRSwNP im deutschen Gesundheitssystem gegeben.

Schlussfolgerung Omalizumab ist zugelassen für Patienten ab 18 Jahren mit schwerer chronischer Rhinosinusitis mit Nasenpolypen als Zusatztherapie zu intranasalen Kortikosteroiden (INCS), wenn durch eine Therapie mit INCS keine ausreichende Krankheitskontrolle erzielt werden kann.

Management of patients with chronic rhinosinusitis during the COVID-19 pandemic-An EAACI position paper

BACKGROUND

Chronic rhinosinusitis is regarded as a chronic airway disease. According to WHO recommendations, it may be a risk factor for COVID-19 patients. In most CRSwNP cases, the inflammatory changes affecting the nasal and paranasal mucous membranes are type-2 (T2) inflammation endotypes.

METHODS

The current knowledge on COVID-19 and on treatment options for CRS was analyzed by a literature search in Medline, Pubmed, international guidelines, the Cochrane Library and the Internet.

RESULTS

Based on international literature, on current recommendations by WHO and other international organizations as well as on previous experience, a panel of experts from EAACI and ARIA provided recommendations for the treatment of CRS during the COVID-19 pandemic.

CONCLUSION

Intranasal corticosteroids remain the standard treatment for CRS in patients with SARS-CoV-2 infection. Surgical treatments should be reduced to a minimum and surgery preserved for patients with local complications and for those with no other treatment options. Systemic corticosteroids should be avoided. Treatment with biologics can be continued with careful monitoring in noninfected patients and should be temporarily interrupted during the course of the COVID-19 infection.

Biologics for atopic diseases: Indication, side effect management, and new developments

With the advent of biologicals, more and more therapeutics are available that specifically address specific switch points in the pathomechanism of immunologically dominated diseases. Thus, the focus of diagnostics and therapy (precision medicine) is more on the individual disease characteristics of the individual patient. Regarding the different phenotypes of atopic diseases, severe asthma was the first entity for which biologicals were approved, followed by urticaria, and finally atopic dermatitis and chronic rhinosinusitis with nasal polyps. Experience in the treatment of severe bronchial asthma has shown that the intensity of the response to biological therapy depends on the quality of clinical and immunological phenotyping of the patients. This also applies to different diseases of the atopic form, as patients can suffer from several atopic diseases at the same time, each with different characteristics. Biologics are already emerging that may represent a suitable therapy for allergic bronchial asthma, which often occurs together with severe neurodermatitis, and chronic rhinosinusitis with nasal polyps. In practice, however, the question of possible combinations of biologicals for the therapy of complex clinical pictures of individual patients is increasingly arising. In doing so, the side effect profile must be taken into account, including hypersensitivity reactions, whose diagnostic and logistical management must aim at a safe and efficient therapy of the underlying disease. Increased attention must also be paid to biological therapy in pregnancy and planned (predictable) vaccinations as well as existing infections, such as SARS-CoV-2 infection. Before starting a biological therapy, the immune status should be checked with regard to chronic viral and bacterial infections and, if necessary, the vaccination status should be refreshed or missing vaccinations should be made up for before starting therapy. Currently, reliable data on the effect of biologicals on the immunological situation of SARS-CoV-2 infection and COVID-19 are not available. Therefore, research and development of suitable diagnostic methods for detection of immunologically caused side effects as well as detection of potential therapy responders and non-responders is of great importance.

Gelomyrtol for acute or chronic sinusitis: A protocol for systematic review and meta-analysis

BACKGROUND

Sinusitis is a common condition worldwide, significantly affecting the quality of life of patients. Due to the limitations of conventional medicines, such as serious side effects and low efficacies, Gelomyrtol may be a promising treatment for sinusitis. As no related systematic review has been published, the purpose of this study will be to evaluate the safety and efficacy of Gelomyrtol for acute or chronic sinusitis.

METHODS

PubMed, EMBASE, the Cochrane Library, the Web of Science, the Chinese National Knowledge Infrastructure Database, the Chinese Biomedical Literature Database, the Wan Fang Database, and the Chongqing VIP Chinese Science, and Technology Periodical Database will be searched from their commencement until July 2020. Randomized controlled trials of Gelomyrtol for acute or chronic sinusitis will be selected in any language. Primary outcomes will include the Sino-Nasal Outcome Test-22 (SNOT-22) score, quality of life score as measured by SF-36, and the change in computed tomography (CT) score. Study selection, data extraction, and deviation risk assessment will be carried out by 2 investigators independently. RevMan V.5.3 software will be used to analyze the study data.

RESULTS

The study will provide high-quality evidence for estimating the efficacy and safety of Gelomyrtol in the treatment of acute or chronic sinusitis.

CONCLUSIONS

This systematic review will explore whether Gelomyrtol is an effective and safe intervention in the treatment of acute or chronic sinusitis.

ETHICS AND DISSEMINATION

As no patient data will be used in this study, ethical approval will not be required. The review will be published as an article or a conference presentation in a peer-reviewed journal.

REGISTRATION

OSF registration number: DOI 10.17605/OSF.IO/MTEU2.

Positionspapier: Empfehlungen zur Behandlung der chronischen Rhinosinusitis während der COVID-19-Pandemie im deutschen Gesundheitssystem – Empfehlungen des Ärzteverbandes Deutscher Allergologen (AeDA) und der Deutschen Gesellschaft für HNO-Heilkunde, Kopf- und Halschirurgie (DGHNO-KHC) – Diese Empfehlungen basieren auf dem EAACI Positionspapier „Treatment of chronic RhinoSinusitis with nasal polyps (CRSwNP) in the COVID-19 pandemics – An EAACI Position Paper”, Allergy, 2020 und wurden auf die Situation im deutschen Gesundheitswesen angepasst

Hintergrund  Von der chronischen Rhinosinusitis (CRS) sind weltweit etwa 5–12 % der Allgemeinbevölkerung betroffen. Die CRS gilt als chronische Atemwegserkrankung, die nach den Empfehlungen der WHO ein Risikofaktor für COVID-19-Patienten sein kann. Die entzündlichen Veränderungen der Nasenschleimhäute bei chronischer Rhinosinusitis mit Nasenpolypen (CRSwNP) sind in den meisten Fällen vom Entzündungsendotyp 2 (T2).

Methoden  Der aktuelle Wissensstand sowohl zu COVID-19 als auch zu den Behandlungsmöglichkeiten von CRSwNP wurde durch eine Literaturrecherche in Medline, Pubmed, internationalen Leitlinien, der Cochrane Library und im Internet analysiert.

Ergebnisse  Auf Grundlage der internationalen Literatur, der aktuellen Empfehlungen der WHO und anderer internationaler Organisationen sowie der bisherigen Erfahrungen gab ein Expertengremium von EAACI und ARIA Empfehlungen für die Behandlung von CRSwNP während der COVID-19-Pandemien.

Schlussfolgerung  Intranasale Kortikosteroide stellen die Standardbehandlung für CRS bei Patienten mit einer SARS-CoV-2-Infektion dar. Chirurgische Behandlungen sollten auf ein Minimum reduziert werden und nur bei Patienten mit lokalen Komplikationen und solchen, für die keine anderen Behandlungsmöglichkeiten bestehen, durchgeführt werden. Systemische Kortikosteroide sollten bei COVID-19-Patienten vermieden werden. Die Behandlung mit Biologika kann bei nicht infizierten Patienten unter sorgfältiger Überwachung fortgesetzt werden und sollte während einer SARS-CoV-2-Infektion vorübergehend unterbrochen werden.

Digital diaphanoscopy of the maxillary sinuses: A revival of optical diagnosis for rhinosinusitis

PURPOSE

The non-invasive diagnosis of acute rhinosinusitis (ARS) remains an unresolved problem of modern otolaryngology. Analog diaphanoscopy of reduced transillumination (shading) could be enhanced by a digital image processing of the maxillary sinuses. By this means, the limited ergonomics of this safe and low-cost method can be overcome, and merits renewed the investigation. Here, we compared the diagnostic sensitivity and specificity of digital diaphanoscopy and computed tomography (CT) in detecting shading in the maxillary sinus.

MATERIALS AND METHODS

We examined 103 adults using both digital diaphanoscopy of the maxillary sinus and native-phase cranial CT. We developed a scoring system for investigation of shading in the maxillary sinus using diaphanoscopy and compared the sensitivity and specificity with that of CT. Also, we documented a follow-up of acute rhinosinusitis.

RESULTS

In diagnosing shading in the maxillary sinus, digital diaphanoscopy had a sensitivity of 86% and a specificity of 88%. Digital diaphanoscopy can be used not only in the screening of ARS but also for documentation of its course.

CONCLUSION

This study supports the role of modern digital diaphanoscopy in the diagnosis of shading in the maxillary sinus, especially in patients with ARS when CT imaging is not recommended. The ergonomics of analog diaphanoscopy could be significantly improved for physicians and patients by the implementation of modern hardware and software components. Further development of the technique and the use of several discrete wavelengths will improve this method's sensitivity and specificity.

[Recurrent infections of the upper aerodigestive tract in patients with primary immunodeficiency]

BACKGROUND

Primary immunodeficiency is a rare disease of humoral and cellular immune defense, which can lead to severe and recurrent infections of different organs. The diagnosis of this disease is often difficult, and its early identification is necessary for adequate treatment and control.

OBJECTIVE

This study aimed to analyze ear, nose, and throat (ENT) infections in adults and children with a primary immunodeficiency. We attempted to characterize possible warning signs that should trigger an immunologic diagnostic workup.

MATERIALS AND METHODS

The current study comprised a retrospective case series of patients with primary immunodeficiencies. The type of immunodeficiency and the number of ENT infections were recorded.

RESULTS

A total of 85 Patients were included in the study. 56 patients (66%) had an acute exacerbation of chronic rhinosinusitis (n = 28), cervical lymphadenitis (n = 16), acute tonsillitis (n = 14), and acute otitis media (n = 6). Reporting detailed information about the frequencies and dates of infections was not possible, due to the retrospective nature of the analysis.

CONCLUSION

The prevalence of ENT infections in patients with a primary immunodeficiency is increased compared to the normal population. For the ENT specialist, these findings underline the necessity of including primary immunodeficiency in the differential diagnosis and initiating targeted diagnostic methods where indicated. Interdisciplinary collaboration with rheumatologists and immunologists is highly recommended, particularly for pediatric patients.

[T-cell immune responses in chronic inflammatory diseases of the nasal mucosa]

Acute rhinosinusitis and chronic rhinosinusitis are inflammatory diseases of the mucosal membranes due to mislead immunological reactions to aeroallergens. T‑cells are divided into different groups based on their cytokine secretion: T‑helper type 1 (Th1) and type 2 (Th2) cells. The allergic immune response is caused by activation of specific Th2 cells. With specific immunotherapy, the mislead hyperactivated "allergic" immune response is reduced to a reaction within the normal range. The inflammatory forms of chronic rhinosinusitis are called endotypes, and, in the future, could enable a targeted, pathomechanistic therapy. These endotype-based treatment approaches target specific signaling pathways that have already shown good effects for chronic rhinosinusitis with nasal polyps using monoclonal antibodies. However, so far, only selected patients with non-rhinologic indications, off-label treatments, or in clinical trials have benefited from these treatments.

[Immunodeficiency in chronic rhinosinusitis : An important and often underestimated cause]

BACKGROUND

Chronic rhinosinusitis (CRS) is one of the most frequent chronic diseases. Among these patients the prevalence of immune defects is higher than in the healthy general population.

METHODS

A selective review of the literature was carried out in PubMed and Medline covering the period between 2008 and 2019. Additionally, recent German publications in journals not listed in the abovementioned databases were analyzed.

RESULTS

The diagnostic workflow with respect to the immunodeficiency consists of a detailed anamnesis and physical examination, laboratory tests and the antibody reaction to polysaccharide vaccines and antigens. Beside antibiotic treatment, vaccinations and immunoglobulin replacement are available. Notwithstanding the above, functional endoscopic surgery of the paranasal sinuses should be performed according to guideline recommendations.

CONCLUSION

Patients with CRS who do not sufficiently respond to conservative and surgical treatment should be checked for underlying immunodeficiencies.

[Manifestation of eosinophilic granulomatosis with polyangiitis in the head and neck area over time taking systemic disease activity into consideration]

BACKGROUND

Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare granulomatous vasculitis of the small and medium sized blood vessels of unknown etiology. A regular involvement of the head and neck area is known. Since it is not yet known whether the inflammatory processes in the head and neck area are parallel to the systemic disease activity, the course of systemic and local disease activity was investigated in a comparative study.

MATERIAL AND METHODS

Between 1990 and 2010 the disease progression of 25 patients with a total of 90 consultations and an average observation period of 7.02 years was recorded. The anamnesis, clinical observation and testing were performed in order to describe ear nose and throat (ENT) manifestations. Moreover, systemic data, such as the Birmingham Vasculitis Activity Score (BVAS), the Vasculitis Damage Index (VDI) and the serological parameters C‑reactive protein (CRP), eosinophilic cationic protein (ECP) and absolute eosinophil count (EOS) were collected. In order to define the activity in the head and neck area the existing manifestations were summarized and statistically compared to the systemic data using Spearman's rank correlation coefficient.

RESULTS

Overall the statistical analysis showed a very weak correlation between the disease activity in the ENT area and systemic disease activity, which is not considered as significant. Comparing activity in the nose region to systemic activity, significant values were found in 22.9% of all consultations. Comparing activity in the ear region to systemic activity, 11.8% of all consultations showed significant values.

CONCLUSION

The results indicate that the disease activity in the head and neck area is independent of the systemic activity. Moreover, they point out a potential independent autoimmune inflammatory process in the mentioned regions; therefore, treatment should include long-term follow-up and an interdisciplinary management.

[Immunology of chronic rhinosinusitis with nasal polyps as a basis for treatment with biologicals]

BACKGROUND

Chronic rhinosinusitis (CRS) is a heterogeneous and multifactorial inflammation of the nasal and paranasal mucosa. Until now, no internationally standardized classification could be developed. In most cases, CRS is phenotypically classified according to chronic rhinosinusitis with (CRScNP) and without nasal polyps (CRSsNP). However, recent studies could show that there are numerous endotypes within these phenotypes based on different inflammatory mechanisms. This review describes the important immunological mechanisms of CRScNP and highlights modern treatment options with biologicals directly addressing particular immunological processes.

METHODS

Current knowledge on immunological and molecular processes of CRS, particularly CRScNP, was extracted from Medline, PubMed, national and international study- and guideline-registers, and the Cochrane library by a systematic review of the literature.

RESULTS

Based on current literature, various immunological mechanisms for CRS and CRScNP could be identified. Relevant studies for the treatment of eosinophilic conditions such as asthma or CRScNP are presented and, if available, results of these studies are discussed.

CONCLUSION

The growing insight into the underlying immunological mechanisms of CRScNP could pave the way for new personalized treatment options such as biologicals in the future.

[Orbital complications]

A disease or symptom of disease spreading from the vicinity of the orbit to the internal structures of the orbit is referred to as an orbital complication. Orbital complications can have a traumatic, inflammatory, allergic, or autoimmunologic cause. They are more frequent in children than adults. The present review aims to provide a description of orbital complications, their etiology, pathogenesis, and treatment. Recent literature in the field is acknowledged and discussed, and results from the authors' own patient groups are analyzed. Particular attention is paid to orbital complications due to acute sinusitis and those caused by acute hemorrhage. The term "orbital phlegmon" frequently used for orbital complications with inflammatory causes is confusing and should be replaced by differentiated grading. Diagnosis and treatment of orbital complications requires interdisciplinary collaboration, whereby inclusion of ophthalmologists is particularly important. Treatment of orbital complications depends on their cause. In inflammatory cases affecting only the preseptal tissues and compartment, conservative therapy is indicated. If clinical findings worsen within 24 h of conservative therapy, or if the patient presents with a high-grade orbital complication with loss of visual acuity or impairment of globe mobility, surgery is required. In cases of acute hemorrhage into the orbit, a procedure for decreasing intra-orbital pressure is mandatory (i. e., canthotomy, cantholysis, orbital decompression).

Increased phosphorylation of eNOS in nasal polyps of chronic rhinosinusitis patients can be diminished by 1,8-cineol

INTRODUCTION

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a significant health problem, but the pathogenesis remains unclear to date. Nitric oxide (NO) has known airway modulating functions. Therefore, we investigated nitric oxide production to determine the role of eNOS in nasal polyps, with additional analysis of the effect of the monoterpene oxide 1,8-cineol on the possible regulation of eNOS signaling and thus NO production.

METHODS

We determined eNOS expression, as well as regulatory and effector proteins like NOSTRIN and CASP8, using whole genome microarray, immunohistochemistry and western blot. To evaluate the influence of 1,8-cineol on eNOS signaling, we examined tissue samples of nasal polyps of patients with CRSwNP incubated with 100 μM 1,8-cineol using quantitative real-time PCR, western blot and phosphorylation arrays.

RESULTS

Microarray analysis revealed an increased gene expression of eNOS (1.40-fold) as well as a decreased gene expression of NOSTRIN (0.53-fold) and CASP8 (0.44-fold) in nasal polyps. At the protein level, we detected 2.3-fold higher protein expression of eNOS and significant higher phosphorylation levels of eNOS in nasal polyps (19.7-fold, p ≤ 0.001) compared to inferior turbinates. Additionally, 1,8-cineol did not influence NOSTRIN and CASP8, but decreased the eNOS phosphorylation significantly (p ≤ 0.05).

DISCUSSION

Our study demonstrated for the first time that nasal polyps exhibit an increased phosphorylation of eNOS, which could be important for vascular permeability and the associated edema and elevated inflammation. Additionally, we detected that 1,8-cineol affects the eNOS phosphorylation significantly and thus its activation. This could be important to handle the elevated inflammation and edema formation by regulating the vascular permeability.