Can a panel of clinical, laboratory, and pathological variables pinpoint patients with sinonasal polyposis at higher risk of recurrence after surgery?

MicroRNA-125b Is a Potential Predictor of Surgical Outcomes in Chronic Rhinosinusitis with Nasal Polyps

BACKGROUND

Despite advances in surgical techniques, recurrence rates after endoscopic sinus surgery (ESS) for chronic rhinosinusitis with nasal polyps (CRSwNP) remain high and difficult to predict.

OBJECTIVE

This study aimed to evaluate the potential role of microRNA 125b (miR-125b) in predicting disease evolution following ESS.

METHODS

We conducted a prospective study including patients undergoing first ESS for CRSwNP in our department between January 2020 and November 2021. We determined miR-125b levels from nasal polyps and pursued a standardized follow-up for at least 18 months for each patient.

RESULTS

A total of 86 patients were included in the study. Higher postoperative endoscopy scores were associated with more severe disease at presentation on computed tomography scan, presence of concomitant asthma, and higher values of miR-125b. Even after multivariate repeated measures analysis and adjustments for confounders, miR-125b remained statistically significant. Moreover, miR-125 was the most important factor in predicting disease evolution at 18 months.

CONCLUSION

A clear, robust relation between nasal polyp control evaluated through objective measures and miR-125b values was observed. This finding indicates the potential role of miR-125b in predicting the course of the disease following ESS.

Interaction of eosinophilic and neutrophilic inflammation in patients with chronic rhinosinusitis

PURPOSE OF REVIEW

In the past year, the endotype of chronic rhinosinusitis (CRS) has been studied from a new perspective. Eosinophilic and neutrophilic inflammation are not independent processes in the pathogenesis of CRS. In this review, we will focus on recent research on mixed eosinophilic-neutrophilic inflammation in CRS and discuss the mechanism and potential treatments.

RECENT FINDINGS

Traditionally, patients with eosinophilic CRS (ECRS) present with severe clinical manifestations, comorbidities, and a higher recurrence rate. Recent studies have found that approximately 40% of patients with ECRS present with neutrophilic infiltration, while patients with predominantly eosinophilic infiltration along with neutrophilic inflammation present with more complex inflammation, clinical manifestations and exhibit refractory characteristics.

SUMMARY

The complex inflammatory profile and refractory clinical characteristics of mixed eosinophilic-neutrophilic inflammation in CRS are current challenges for clinicians. We summarize the features of eosinophilic and neutrophilic inflammation and current studies on the mechanisms of mixed eosinophilic-neutrophilic inflammation and suggest potentially effective therapeutic methods. We hope that this review will help with determining precise treatment options for patients.

Tissue Eosinophilia is Superior to an Analysis by Polyp Status for the Chronic Rhinosinusitis Transcriptome: An RNA Study

OBJECTIVE

RNA sequencing (transcriptomics) is used to study biological pathways. However, the yield of data depends on comparing well-characterized cohorts. We compared tissue eosinophilia versus nasal polyp (NP) status as the metric to characterize transcriptomic mechanisms at play in eosinophilic and non-eosinophilic chronic rhinosinusitis (CRS) versus controls.

METHODS

RNA sequencing was conducted on sinonasal tissue samples of CRS and controls. Analyses were conducted based on polyp status [with nasal polyps (CRSwNP) and without nasal polyps (CRSsNP)] as well as tissue eosinophil levels per high power field (eos/hpf)[non-eosinophilic (<10 eos/hpf, neCRS) or eosinophilic (≥10 eos/hpf, eCRS)]. The yield of differentially expressed genes (DEGs) and biological pathways through Ingenuity Pathway Analysis (IPA) were compared.

RESULTS

CRS tissue differed from controls by 736 statistically significant DEGs. Both NP status and tissue eosinophilia were effective in differentiating CRS from controls and into two distinct subgroups. Statistically significant DEGs identified when comparing CRS by NP status were 60, whereas 110 DEGs were identified using eosinophil cutoff ≥10 and <10 eos/hpf. Additionally, heatmaps showed greater homogeneity within each CRS subgroup when analyzed by tissue eosinophilia versus NP status. On IPA, the IL-17 signaling pathway was significantly different only by tissue eosinophilia status, not NP status, being higher in CRS <10 eos/hpf.

CONCLUSION

Tissue eosinophilia is superior to an analysis by NP status for the study of CRS transcriptome by RNA sequencing in identifying DEGs. Classification of CRS samples by eosinophil counts agnostic of NP status may offer advantageous insights into CRS pathogenetic mechanisms.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:2480-2489, 2023.

Risk Factors for Abnormal Small Airway Function Indicators in Nasal Polyp Patients with and without Asthma

INTRODUCTION

Small airway dysfunction (SAD) is associated with type 2 inflammation in patients who have non-asthmatic chronic rhinosinusitis with nasal polyps (CRSwNPs); however, the risk factors for abnormal small airway function indicators in CRSwNP patients with and without asthma remain unclear.

METHODS

We retrospectively analyzed 41 asthmatic and 109 non-asthmatic CRSwNP patients. Clinical characteristics were compared between groups, correlations between small airway function and clinical parameters were calculated, and independent risk factors for every small airway indicator were identified in each group.

RESULTS

Asthmatic CRSwNP patients had significantly reduced small airway function, and the proportion of patients with SAD was higher in asthmatic CRSwNP patients (65.85%) than in patients without asthma (9.17%). With regard to specific airway function indicators, age and a patient's blood eosinophil (%) were identified as independent risk factors for lower FEF50% %pred and FEF25-75% pred, with age being an independent risk factor for FEF75% %pred in asthmatic CRSwNP patients. In non-asthmatic CRSwNP patients, allergic rhinitis comorbidity was found to be an independent risk factor for FEF50% %pred, FEF75% %pred, and FEF25-75% %pred.

CONCLUSION

Physicians should pay greater attention to risk factors for abnormal small airway function indicators in patients with CRSwNPs to prevent the occurrence of SAD.

Innovative treatments for severe uncontrolled chronic rhinosinusitis with nasal polyps

INTRODUCTION

In recent years, endotypes of chronic rhinosinusitis (CRS) based on the underlying immune mechanisms provided a better understanding of this heterogeneous disease and are frequently applied in diagnosis and treatment.

AREAS COVERED

In this manuscript, we aim to review novel treatment approaches for this often uncontrolled disease and highlight endotype-driven medical algorithms that could be beneficial in daily clinical practice.

EXPERT OPINION

With the development of endotyping and the mucosal inflammatory concept, several type 2-targeted biologics and surgical options are nowadays available for treating CRS. However, a better understanding based on clinical trials and real-life experience in daily practice is needed to optimize patient selection, biological drug selection, treatment duration, prediction, and long-term follow-up strategies. Indirect comparison analysis suggested that dupilumab might be the most effective biologic for treating CRS with nasal polyps, but the role and timing of surgery remain unclear. More real-life studies and comparative trials are needed for the optimal integration of biologics into clinical pathways in combination with established treatment approaches such as nasal and oral glucocorticosteroids and adequate surgery to provide long-term perspectives.

A review of current biomarkers in chronic rhinosinusitis with or without nasal polyps

INTRODUCTION

Chronic rhinosinusitis (CRS) is a heterogeneous disease with a variety of cellular and molecular pathophysiologic mechanisms. Biomarkers have been explored in CRS using various phenotypes, such as polyp recurrence after surgery. Recently, the presence of regiotype in CRS with nasal polyps (CRSwNP) and the introduction of biologics for the treatment of CRSwNP has indicated the importance of endotypes, and there is a need to elucidate endotype-based biomarkers.

AREAS COVERED

Biomarkers for eosinophilic CRS, nasal polyps, disease severity, and polyp recurrence have been identified. Additionally, endotypes are being identified for CRSwNP and CRS without nasal polyps using cluster analysis, an unsupervised learning technique.

EXPERT OPINION

Endotypes in CRS have still being established, and biomarkers capable of identifying endotypes of CRS are not yet clear. When identifying endotype-based biomarkers, it is necessary to first identify endotypes clarified by cluster analysis for outcomes. With the application of machine learning, the idea of predicting outcomes using a combination of multiple integrated biomarkers, rather than a single biomarker, will become mainstream.

Managing Chronic Rhinosinusitis with Nasal Polyps in the Elderly: Challenges and Solutions

The proportion of the population over 65 years old continues to grow. Chronic rhinosinusitis is common in this population and causes a reduction in quality of life and an increase in health care utilization. Diagnosis of chronic rhinosinusitis with nasal polyps follows the same principles for elderly patients as in the general population, but the elderly population presents some diagnostic challenges worth considering. Presbynasalis, the anatomic and functional changes of the nose and paranasal sinuses associated with aging must be accounted for when caring for these patients. In addition, polypharmacy and other medical issues that can cause similar symptoms must be considered. Medical therapy is generally similar to the general population but with additional concerns given the propensity for geriatric patients to be on multiple medications and to suffer from multiple medical issues. Sinus surgery should be considered following the same indications as in the general population. While some authors have found higher complication rates in endoscopic sinus surgery, others have found higher rates of success. As always, the risks of surgery must be considered with the possible benefits on a patient-to-patient basis.

Twelve-year long-term postoperative outcomes in patients with chronic rhinosinusitis with nasal polyps

BACKGROUND

Evidence regarding long-term postoperative follow-up of chronic rhinosinusitis with nasal polyps (CRSwNP) patients is scarce in the literature. The objective of the present study was to report long-term 12-year postoperative outcomes for CRSwNP patients.

METHODS

CRSwNP patients were prospectively followed after endoscopic sinus surgery. Sinonasal symptoms, nasal polyp score (NPS), Barcelona Smell Test 24 (BAST-24), Lund-Mackay Score (LMS), and Medical Outcome Study Short Form-36 (SF-36) questionnaire were assessed before and 12 years after surgery.

RESULTS

At long-term follow-up (median, 12 years), a strong improvement was noted for all patients (N=76) in nasal symptoms score, NPS, BAST-24, and LMS scores compared with baseline. No long-term improvement in SF-36 was found.

CONCLUSION

Patients with CRSwNP have a long-term 12-year postoperative improvement in nasal symptoms, polyp size, computed tomography, and olfaction.

Sex and age-related differences in chronic rhinosinusitis with nasal polyps electing ESS

PURPOSE

Sex and age of patients are variables affecting across the board all chronic rhinosinusitis with nasal polyps (CRSwNP) endotypes. The main aim of this investigation was to compare the clinical, laboratory, pathological and prognostic characteristics of CRSwNP in male vs female patients stratified according to age (young-adult [20 years ≤ age ≤ 40 years], and elderly [age ≥ 65 years]). This is the first study that analyzed the association of the above-mentioned features with age and sex combination in CRSwNP electing endoscopic sinus surgery (ESS).

MATERIALS AND METHODS

One hundred and five consecutive young-adult patients (62 males and 43 females) and 67 elderly patients (44 males and 23 females) with CRSwNP who had undergone ESS were enrolled.

RESULTS

The recurrence rate resulted associated with the age and sex combination (p = 0.0165). Young-adult males' recurrence rate (29.0%) was higher than young-adult females (11.6%) and elderly males (4.5%). Allergy resulted associated with age and sex combination (p = 0.0158). Young-adult males' allergy rate (50.0%) was higher than elderly males' (29.5%) and elderly females' (13%). Moreover, allergy rate was higher in young-adult females (41.9%) than in elderly females.

CONCLUSION

Our data suggest the possibility of an interaction between sex and age in the recurrence of nasal polyposis after ESS. More studies are needed to understand the role of sex hormones in pathogenesis and prognosis of CRSwNP.

Long-term evaluation of nasal polyposis recurrence: A focus on multiple relapses and nasal cytology

PURPOSE

Recurrence of chronic rhinosinusitis with nasal polyps (CRSwNP) is highly variable, reaching 55-60% of cases. Different results about clinical parameters as recurrence predictors has been reported. The aim of this retrospective study was to evaluate CRSwNP recurrence risk after a long-term follow-up (up to 20 years). Moreover, the role of nasal cytology was assessed.

MATERIALS AND METHODS

Sixty-one patients who underwent functional endoscopic sinus surgery for CRSwNP were enrolled. Clinical parameters were recorded. Nasal cytology was performed at follow-up examinations. The Kaplan-Meier method was used to obtain the recurrence-free survival curves. The median number of recurrences per year was evaluated.

RESULTS

Five- and 10-year recurrence rates were 30.29% and 66.06%, respectively. Median recurrence-free survival was 106 months. Asthma and Aspirin-Exacerbated Respiratory Disease represented predictors of multiple recurrences (p < 0.05). Intranasal steroids were the main treatment to prevent relapses (p < 0.05). Patients with normal cytology at follow-up evaluation had a lower probability to have first recurrence within 10 years (59% of cases), compared to neutrophil or eosinophil infiltrate (100% and 88% of cases, respectively) (p < 0.05).

CONCLUSIONS

CRSwNP has a high recurrence risk, also more than 10 years after surgery. Nasal cytology may identify subjects with a higher risk of early recurrence.

The development of the mucosal concept in chronic rhinosinusitis and its clinical implications

In the last 2 decades, an increasing understanding of pathophysiological mechanisms in chronic rhinosinusitis opened an avenue from phenotyping to endotyping, from eosinophilic inflammation to type 2 immunity, and from the "ventilation and drainage" paradigm to the mucosal concept for therapeutic considerations. With the advent of type 2 endotyping and targeted biomarkers, precise endotype-driven therapeutic options are possible including biologics and adapted surgical approaches. We here aim to focus on the complexity and heterogeneity of the features of chronic rhinosinusitis (CRS) endotypes, especially for those with nasal polyps, including its history, latest developments, clinical associations and endotype-driven solutions. In order to better manage uncontrolled severe CRS in clinical practice, medical decisions based on a profound understanding of the pathology and immunology of this heterogeneous disease, aiding a precision-medicine based approach for patient's treatment are pivotal.

Sulfurous-arsenical-ferruginous thermal water nasal inhalation and irrigation in children with recurrent upper respiratory tract infections: Clinical outcomes and predictive factors

PURPOSE

Recurrent upper respiratory disorders (RURD) are among the most common problems diagnosed in pediatric otolaryngology practice. Although several preliminary studies have demonstrated beneficial effects of thermal water inhalations for RURD, inhalation of thermal water has not been included among validated management protocols. The effects of sulfurous-arsenical-ferruginous thermal water nasal irrigations have been confirmed also in prospective, randomized studies. The main aim of this explorative, retrospective, observational study has been to compare the clinical outcome in pediatric patients with RURD treated with sulfurous-arsenical-ferruginous thermal water inhalation versus combined inhalation and nasal irrigation.

METHODS

Two hundred and fifty-three pediatric patients with RURD were considered; 231 underwent thermal water inhalations (inhalation of hot humid air and aerosol) only, while 22 underwent nasal irrigations combined with inhalations. Subjective overall efficacy perception and treatment tolerability were scored as categorical variables (from 0 = no efficacy/worst tolerability to 3 = maximal efficacy/best tolerability).

RESULTS

Nasal obstruction, sneezing, serous, mucous, and purulent rhinorrhea, cough, and snoring improved respectively in 80.2%, 72.9%, 79.0%, 93.8%, 92.3%, 64.8%, and 60.4% of patients referring these symptoms at presentation, respectively. No statistically significant differences between inhalations alone and combined inhalations and irrigations emerged. The median overall efficacy perception score was 2 while the median treatment tolerability score was 3.

CONCLUSIONS

This investigation found that sulfurous-arsenical-ferruginous water treatment was a well-tolerated therapeutic option for selected pediatric patients with RURD. These promising preliminary results should be confirmed in prospective, randomized, double-blind settings, also using minimally invasive but objective and quantitative evaluation methods.

Efficacy of triamcinolone acetonide-impregnated Gelfoam nasal pack in management of chronic sinusitis with nasal polyps following endoscopic sinus surgery: a perfectly matched, placebo-controlled trial study

PURPOSE

This perfectly matched, double-blinded, placebo-controlled trial study was performed to investigate the efficacy of triamcinolone acetonide (TAA)-impregnated Gelfoam nasal pack in management of different endotypes of chronic rhinosinusitis with nasal polyps (CRSwNP) following endoscopic sinus surgery (ESS).

METHODS

One hundred and four patients with bilateral CRSwNP undergoing ESS were selected and randomized to receive TAA-soaked nasal packing in one nostril and saline-impregnated dressing contra-laterally. Validated Perioperative Sinus Endoscopy (POSE) scoring system was used to assess the participants' condition at postoperative months 1, 3, 6, 12, and 18.

RESULTS

The treatment side of eosinophilic CRSwNP (EosCRSwNP) group had significantly better endoscopic scores than the contralateral control side in all follow-up visits (P < 0.05 for all comparisons) except for the first postoperative month. No significant difference was detected between the TAA- and saline-treated nostrils in the non-eosinophilic CRSwNP (nonEosCRSwNP) subgroup during the follow-up period. Intergroup comparisons revealed a borderline better POSE score for the treatment side of the EosCRSwNP group compared with the treatment nostril of the nonEosCRSwNP group at months 12 (P = 0.041) and 18 (P = 0.044). At the end of the study period, the treatment side of the EosCRSwNP group demonstrated better clinical response than the saline-treated side in terms of the total POSE scores (P = 0.019), middle turbinate synechia (P = 0.008), middle meatal narrowing (P = 0.010), ethmoid polypoid changes (P = 0.039), ethmoid polyposis (P = 0.027), ethmoid cavity secretions (P = 0.042), and sphenoid severity (P = 0.018).

CONCLUSION

TAA-soaked Gelfoam dressing following bilateral ESS was found to be an effective method for treating CRSwNP particularly for the eosinophilic endotype of the disease.

Artificial intelligence for cellular phenotyping diagnosis of nasal polyps by whole-slide imaging

Background

artificial intelligence (AI) for cellular phenotyping diagnosis of nasal polyps by whole-slide imaging (WSI) is lacking. We aim to establish an AI chronic rhinosinusitis evaluation platform 2.0 (AICEP 2.0) to obtain the proportion of inflammatory cells for cellular phenotyping diagnosis of nasal polyps and to explore the clinical significance of different phenotypes of nasal polyps on the WSI.

Methods

a total of 453 patients were enrolled in our study. For the development of AICEP 2.0, 179 patients (WSIs) were obtained from the Third Affiliated Hospital of Sun Yat-Sen University (3HSYSU) from January 2008 to December 2018. A total of 24,625 patches were automatically extracted from the regions of interest under a 400× HPF by Openslide and the number of inflammatory cells in these patches was counted by two pathologists. For the application of AICEP 2.0 in a prospective cohort, 158 patients aged 14–70 years old with chronic rhinosinusitis with nasal polyps (CRSwNP) who had undergone endoscopic sinus surgery at 3HSYSU from June 2020 to December 2020 were included for preoperative demographic characteristics. For the application of AICEP 2.0 in a retrospective cohort, 116 patients with CRSwNP who had undergone endoscopic sinus surgery from May 2016 to June 2017 were enrolled for the recurrence rate. The proportion of inflammatory cells of these patients on WSI was calculated by our AICEP 2.0.

Findings

for AICEP 2.0, the mean absolute errors of the ratios of eosinophils, lymphocytes, neutrophils, and plasma cells were 1.64%, 2.13%, 1.06%, and 1.22%, respectively. The four phenotypes of nasal polyps were significantly different in clinical characteristics (including asthma, itching, sneezing, total IgE, peripheral eosinophils%, tissue eosinophils%, tissue neutrophils%, tissue lymphocytes%, tissue plasma cells%, and recurrence rate; P <0.05), but there were no significant differences in age distribution, onset time, total VAS score, Lund-Kennedy score, or Lund-Mackay score. The percentage of peripheral eosinophils was positively correlated with the percentage of tissue eosinophils (r = 0.560, P <0.001) and negatively correlated with tissue lymphocytes% (r = -0.489, P <0.001), tissue neutrophils% (r = -0.225, P = 0.005), and tissue plasma cells% (r = -0.266, P = 0.001) in WSIs.

Evaluation of Diffuse Type 2 Dominant or Eosinophilic Chronic Rhinosinusitis With Corticosteroid Irrigation After Surgical Neosinus Cavity Formation

Importance

Eosinophilic chronic rhinosinusitis (eCRS), contemporarily classified as diffuse type 2 dominant chronic rhinosinusitis (CRS), is characterized by eosinophil-dominant mucosal inflammation. Contemporary management of eCRS as an inflammatory airway condition is multimodal with corticosteroid irrigations after the surgical creation of a neosinus cavity.

Objectives

To assess long-term treatment outcomes in patients with primary diffuse type 2 CRS or eCRS receiving multimodal treatment.

Design, Setting, and Participants

A prospective cohort study of patients seen in a tertiary rhinology practice recruited from May 2010 to November 2018 was conducted. Follow-up duration was 12 months or more following endoscopic sinus surgery (ESS) with a neosinus cavity formed. Data analysis was performed from August to November 2020. Consecutive adult (≥18 years) patients diagnosed with primary diffuse type 2 dominant CRS or eCRS based on the European Position Paper on Rhinosinusitis and Nasal Polyps 2020 criteria were included. Type 2 inflammation was defined as more than 10 eosinophils per high-power field obtained from sinus mucosal biopsy and managed with neosinus cavity ESS and ongoing corticosteroid irrigations. Exclusion criteria were less than 12 months of follow-up and secondary CRS.

Interventions

Endoscopic sinus surgery with complete removal of intersinus bony partitions to create a neosinus cavity. Nasal irrigation (240 mL) with betamethasone, 1 mg, or budesonide, 1 mg, daily for 3 to 6 months after ESS and tapered to an as-needed basis (minimum, 2-3 per week).

Main Outcomes and Measures

Poor control was defined as polyp recurrence (polyp growth in >1 sinus area on a single side), use of long-term systemic therapy (biologic therapy or ≥3 consecutive months of oral corticosteroids), and revision surgery involving polypectomy. The disease in patients with no poor control criteria was defined as well controlled, and the disease in those with 1 or more criteria was considered poorly controlled. Maintenance medical therapy use and patient-reported outcomes based on the 22-item Sinonasal Outcomes Test for preoperative and last follow-up were collected.

Results

Of the 222 participants recruited with primary diffuse type 2 dominant CRS or eCRS and minimum of year of follow-up, 126 were men (56.8%). Mean (SD) age was 54.8 (13.6) years, and median (SD) follow-up was 2.2 (2.2) years. Of the 222 patients, 195 (87.8%) had well-controlled disease, 16 (7.2%) had polyp recurrence, 7 (3.2%) continued to receive long-term oral corticosteroid therapy, 5 (2.3%) received biologic therapy, and 8 (3.6%) underwent a revision polypectomy. Clinically meaningful change on the 22-item Sinonasal Outcomes Test and the nasal subdomain score was maintained at the last follow-up in 134 patients (67.0%). Poor disease control was not associated with poor adherence to irrigation use.

Conclusions and Relevance

The findings of this cohort study suggest that long-term disease control and reduction in symptom burden in patients with primary diffuse type 2 CRS or eCRS might be achieved when managed as an inflammatory disorder. Maintenance corticosteroid irrigations in the population examined appeared to be successfully self-tapered to disease activity.

Structured histopathology for endotyping and planning rational treatment in chronic rhinosinusitis

In chronic rhinosinusitis (CRS), endotyping, being based on the pathogenic mechanism, provides a precise picture appropriate for use in clinical practice. Structured histopathological examination of CRS is considered a necessary step in efforts to establish its pathogenesis and improve our endotyping capabilities. Herein we discuss the associations between histopathology and clinical characteristics of CRS patients to assist medical and surgical treatment choices.

Clinical predictors of revision surgery for chronic rhinosinusitis with nasal polyposis within 5-year follow-up

BACKGROUND

Chronic rhinosinusitis with nasal polyposis (CRSwNP) remains a difficult-to-cure disease. The aim of this study was to determine the potential long-term predictors of revision sinus surgery for CRSwNP.

METHODS

Prospectively gathered patients with bilateral CRSwNP who received primary endoscopic sinus surgery were enrolled. Clinical variables, including the preoperative Lund-Mackay score (LMS), were collected to clarify possible risk factors for revision surgery within a 5-year follow-up. The symptomatic burden was measured using a 10-cm visual analog scale (VAS) before and 1 year after surgery. Further survival analysis was performed to present the revision-free survival in Kaplan-Meier plotting.

RESULTS

Eighty four qualified patients were identified and all of them experienced significant improvement in VAS after primary surgery. The 5-year revision rate was 19.05%, and the mean time of revision surgery was 25.31 ± 17.11 months postoperatively. Nasal allergy (OR = 9.287; p = 0.011) and LMS (OR = 1.29; p = 0.06) were found to be the independent risk factors for revision surgery. The discriminatory power of LMS for revision surgery was acceptable (AUC = 0.79) with the best cutoff point located at LMS > 13.5. Patients with both nasal allergy and LMS≧14 had only half of revision-free survival in comparison to overall survival (38.1% vs. 80.95%, p < 0.001).

CONCLUSIONS

In patients with CRSwNP who have concurrent nasal allergy and higher preoperative LMS may indicate an advanced disease status and eventually be in a high risk of revision surgery after a long-term follow-up. An outcome-based staging system will be helpful in the future to improve the prognosis for CRSwNP.

Systematic literature review of the epidemiology and clinical burden of chronic rhinosinusitis with nasal polyposis

OBJECTIVES

We conducted a systematic literature review (SLR) to determine the epidemiology and clinical burden of chronic rhinosinusitis with nasal polyps (CRSwNP) and to describe how the addition of biologics has affected outcomes for patients with CRSwNP.

METHODS

The SLR adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Embase, MEDLINE, and Evidence-Based Medicine Reviews databases were searched using OVID. Relevant studies published between 1 January 2008 and 8 February 2019, for epidemiology, and 1 January 2008 and 16 February 2019, for clinical burden, and relevant conference abstracts from 1 January 2017 to 7 March 2019, for epidemiology and 1 January 2017-16 February 2019 for clinical burden were included.

RESULTS

For the epidemiology and clinical burden SLR, 147 and 119 records, respectively, met the inclusion criteria. We found the prevalence of CRSwNP was 1-2.6% and was greater in men. Asthma, allergy, and allergic rhinitis were the most common comorbidities identified. Reported risk factors included asthma, gene polymorphisms, age, and eosinophilia. Studies indicated that dupilumab, mepolizumab, and omalizumab each improved different clinical outcomes. Non-biologics (drugs such as corticosteroids or antibiotics, surgery, or aspirin desensitization) improved clinical outcomes as well.

CONCLUSIONS

CRSwNP is fairly prevalent in the general population. Despite the significant efficacy of existing treatments, several unmet needs remain. The high burden of uncontrolled symptoms, frequent recurrence of nasal polyps after surgery, and long-term adverse effects of oral corticosteroids indicate that new therapies addressing these unmet needs should be developed. Although data on biologics from randomized controlled trials look promising, the efficacy of biologics in the real world has yet to be established. The SLR of the epidemiology and clinical burden of CRSwNP revealed key gaps in the literature. There was a paucity of prevalence data across many geographic areas, and no prevalence projections could be determined. Studies showed varying efficacy of non-biologics and no studies directly compared biologics for efficacy. Data regarding clinical efficacy of agents for eosinophilic CRSwNP or severe CRSwNP were lacking, and these patient populations would be served by more trials.

Nasal polyps in eosinophilic granulomatosis with polyangiitis: Structured histopathology and CD105 expression

PURPOSE

Distinguishing the prodromal nasal polyposis of eosinophilic granulomatosis with polyangiitis (EGPA) from chronic rhinosinusitis with nasal polyps (CRSwNP) is a challenge for rhinologists and rheumatologists. It has recently been reported that angiogenesis and CD105 expressed on vascular endothelial cells could have a role in the pathogenesis and development of nasal polyps. This exploratory study examined the structured histopathology of nasal polyps in patients with EGPA and CRSwNP, comparing CD105 expression in their nasal tissue with that of a control group with no chronic sinonasal inflammation.

METHODS

A structured histopathological study was performed on surgical specimens of nasal tissue from 32 adults (13 with EGPA, 14 with CRSwNP, 5 controls), considering CD105 as a marker to determine microvessel density (MVD).

RESULTS

The mean eosinophil count was higher in EGPA patients with tissue inflammation (p = .002), and in CRSwNP patients with sub-epithelial edema (p = .009). Neutrophil infiltration was significantly associated with severe tissue inflammation in EGPA patients (p = .04), but with the absence of fibrosis in CRSwNP patients (p = .04). In the EGPA group, CD105-MVD correlated with tissue eosinophil count (p = .05). Mean CD105-MVD was significantly higher in EGPA patients with mucosal ulceration (p = .004). In the CRSwNP group, a CD105-MVD correlated positively and significantly with tissue eosinophil count (p = .01).

CONCLUSION

Alongside the known abundance of eosinophils, other cells might contribute to inflammatory processes. Neutrophils may amplify inflammation, eosinophil recruitment and tissue damage. CD105 expression in CRSwNP and EGPA nasal polyps supports the hypothesized involvement of angiogenesis in the pathogenesis and development of nasal polyps.

Neutrophil infiltrates and eosinophil aggregates in chronic rhinosinusitis with nasal polyps and EGPA

INTRODUCTION/OBJECTIVES

The histopathological study of inflammatory cells and their tendency to form aggregates in chronic rhinosinusitis with nasal polyps (CRSwNP) has shown promising results in determining the pathogenesis and predicting clinical outcome. Bilateral nasal polyps also occur in over 70% of patients with eosinophilic granulomatosis with polyangiitis (EGPA). The study aim was to investigate neutrophil infiltrates and eosinophil aggregates in CRSwNP and EGPA tissues of Caucasian patients.

METHOD

A histopathological study was performed on surgical specimens of nasal polyps from 144 adults (15 with allergic fungal rhinosinusitis; 19 with nonsteroidal anti-inflammatory drugs-exacerbated respiratory disease (NERD); 16 with intrinsic asthma; 21 with extrinsic asthma; 21 with allergy; 22 with eosinophil CRSwNP (ECRSwNP); 17 with non-ECRSwNP; 13 with EGPA).

RESULTS

Focusing on the presence of tissue eosinophil aggregates, NERD and ECRSwNP were the sub-cohorts with the highest rate. Neutrophil infiltrate rate was significantly higher in EGPA sub-cohort than in all CRSwNP sub-cohorts apart from non-ECRSwNP.

CONCLUSIONS

Structured histopathology is increasingly identifying the different histotypes of CRSwNP. This analysis can be used to better understand CRSwNP endotypes and develop targeted therapies. The response to therapy and therefore control of CRSwNP relapses definitely depends on our ability to act on the underlying inflammatory pattern. Key points • Systematic analysis of how neutrophil infiltrates and eosinophilic aggregates are distributed in the different phenotypes of CRSwNP and EGPA. • Neutrophil infiltrates and eosinophil aggregates are strong risk factors for nasal polyps' refractoriness. • NERD and ECRSwNP are the sub-cohorts of CRSwNP with the highest rate of tissue eosinophil aggregates. • Neutrophil infiltrates are significantly higher in EGPA.

Distinct Clinical Pathology and Microbiota in Chronic Rhinosinusitis With Nasal Polyps Endotypes

OBJECTIVES/HYPOTHESIS

Eosinophilic and noneosinophilic chronic rhinosinusitis with nasal polyps (ECRSwNP and NECRSwNP) show distinguished clinical pathology, but their underlying mechanism remains unclear. We aimed to investigate the clinical, hematological, and histopathological changes in chronic rhinosinusitis with nasal polyps (CRSwNP) endotypes and its association with microbiota.

STUDY DESIGN

A comparative cross-sectional study.

METHODS

A comparative study of 46 patients with CRSwNP (34.69 ± 16.39 years old) who underwent endoscopic sinus surgery were recruited and subdivided into ECRSwNP and NECRSwNP groups based on eosinophilic tissue inflammation; 12 healthy controls were also included. A structured histopathological analysis was conducted, and complete blood count was determined in patients. Endoscopic-guided middle meatus swabs and fecal samples were collected from the patients and controls and subsequently subjected to 16S rRNA gene sequencing on Illumina MiSeq.

RESULTS

Compared to NECRSwNP, ECRSwNP showed a statistically significant increase in the computed tomography score, endoscopic score, blood eosinophil percentage, tissue eosinophil count, inflammation degree, subepithelial edema, and eosinophil aggregation. Airway microbiota communities differed among the three groups. The abundance of Moraxella and Parvimonas was significantly higher in the ECRSwNP group. Distinct microbiota dysbiosis in CRSwNP endotypes was found to be correlated with different clinical pathologies. Moreover, the gut microbiota in ECRSwNP and NECRSwNP showed dysbiosis, that is, significant decrease in the abundance of Actinobacteria in the former and significant increase in the abundance of Enterobacterales and several genera in NECRSwNP.

CONCLUSIONS

Significant clinical pathology and microbiota changes were evident in patients with ECRSwNP and NECRSwNP. Distinct microbiota dysbiosis was correlated with different clinical pathologies. Understanding these differences may improve the prognosis and treatment of chronic rhinosinusitis.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E34-E44, 2021.

Topography of polyp recurrence in eosinophilic chronic rhinosinusitis

BACKGROUND

Eosinophilic chronic rhinosinusitis (eCRS) is an inflammatory endotype of CRS. Contemporary treatment includes creation of a "neo-sinus" cavity and postoperative corticosteroid irrigations. Not all patients gain control with local therapy. This study aims to determine, in patients with polyp recurrence, the most common sinuses involved.

METHODS

A prospective case-series was conducted on consecutive adult (≥18 years) post-FESS eCRS patients followed for a minimum of 12 months. All patients had a neo-sinus cavity created surgically and used corticosteroid irrigations daily for 3-6 months, then tapered to disease control. Sinus cavities were assessed by endoscopy on last follow-up. Polyp recurrence was defined as a score of 5 or 6 in the MLMES in ≥3 sinus cavities. Patient-reported outcomes based on SNOT22 and NSS, frequency of corticosteroid irrigations, and courses of systemic antibiotics and corticosteroid were collected. The pattern of sinus involvement was analyzed.

RESULT

A total of 342 sinus cavities were assessed (mean ± standard deviation, 54.9 ± 13.4 years, 43.2% female). Polyp recurrence occurred in 4.3% (6.4% of patients, n = 7 unilateral) of sinus cavities. Frontal and ethmoid sinus cavities were most affected in those with polyp recurrence, compared to the maxilla and sphenoid (100% vs 100% vs 53% vs 53%, p < 0.01). Although those patients with polyp recurrence utilized more systemic corticosteroids courses per year (0.4 ± 0.4 vs 0.1 ± 0.3, p < 0.01), the use of corticosteroid irrigations was similar (% >4/week; 66.7% vs 48.9%, p = 0.13). Prior surgery was more common in patients with polyp recurrence (86.7% vs 53.5%, p = 0.01).

CONCLUSION

The frontal and ethmoid sinuses were most affected in those patients with polyp recurrence. Whether the disease is more active in this location or topical therapy has limited access requires further evaluation.

A classification of chronic rhinosinusitis with nasal polyps based on structured histopathology

AIMS

In chronic rhinosinusitis with nasal polyps (CRSwNP), tools based on objective evidence, such as histopathology, are needed to assist clinical decision-making. The main aim of this exploratory investigation was to determine whether structured histopathology could be used to classify CRSwNP in homogeneous histological clusters.

METHODS AND RESULTS

A cohort of 135 CRSwNP patients was assessed, on the basis of clinicopathological features: allergic fungal rhinosinusitis (17 patients); non-steroidal anti-inflammatory drug-exacerbated respiratory disease (19 patients); intrinsic asthma (18 patients); extrinsic asthma (21 patients); allergy (21 patients); histologically eosinophilic (22 patients); and histologically non-eosinophilic (17 patients). For structured histopathology, we considered: the degree of inflammation; eosinophil count; eosinophil aggregates; neutrophil infiltration; goblet cell hyperplasia; basement membrane thickening; fibrosis; hyperplastic/papillary changes; squamous metaplasia; mucosal ulceration; and subepithelial oedema. Cluster analysis identified four distinct sets of cases. On discriminant analysis, the global error rate was 1.48%, and the stratified error rates were 4.34%, 0%, 0%, and 0% for clusters 1, 2, 3 and 4, respectively. Cluster 1 was characterised by infrequent fibrosis (<4.5% of cases). Cluster 2 mainly featured neutrophil infiltration in 100% of cases, hyperplastic/papillary changes in 70% of cases, and fibrosis in 65% of cases. Cluster 3 showed fibrosis in 100% of cases. Cluster 4 showed hyperplastic/papillary changes in 100% of cases, and fibrosis in 92% of cases.

CONCLUSIONS

This study shows that cluster analysis can identify different histotypes among CRSwNP patients. The next step will be to investigate, in a larger series, the clinical (e.g. prognostic) implications of identifying such homogeneous clusters of patients with CRSwNP on the basis of their structured histopathology.

Asthma Is the Dominant Factor for Recurrence in Chronic Rhinosinusitis

BACKGROUND

Factors associated with recurrence of chronic rhinosinusitis (CRS) are still poorly recognized.

OBJECTIVE

To evaluate which risk factors could influence the risk of recurrence among patients undergoing endoscopic sinus surgery in long-term follow-up.

METHODS

Patients with CRS who underwent endoscopic sinus surgery were followed for an average period of 12 years in a nonconcurrent cohort. After surgery, patients were considered to an additional endoscopic sinus surgery if appropriate medical therapy failed during this period. The presence of nasal polyps, asthma, nonsteroidal anti-inflammatory drug-exacerbated respiratory disease, smoking habits, peripheral blood eosinophilia, and atopy were assessed. The recurrence-free interval between groups (with or without these risk factors) was analyzed by Kaplan-Meyer curves, and the indication for a revisional surgery was considered to be the unfavorable event.

RESULTS

A total of 201 patients were enrolled in this study. Patients with chronic rhinosinusitis with nasal polyps (CRSwNP) were more likely than patients with chronic rhinosinusitis without nasal polyps (CRSsNP) to need revisional surgery (adjusted hazard ratio, 2.02). Asthma was the only factor that was significantly related to recurrence both in patients with CRSsNP (hazard ratio, 5.54) and in patients with CRSwNP (hazard ratio, 3.27). Although eosinophilia itself was not related to a higher chance of recurrence, its presence influenced the outcome of CRSwNP compared with CRSsNP and the impact of asthma among patients with CRSwNP.

CONCLUSIONS

Prognosis in patients with CRSwNP was inferior to that in patients with CRSsNP. Asthma was the only factor that increased the chance of recurrence in patients with either CRSsNP or CRSwNP.

Significance of IgG4-positive cells in severe eosinophilic chronic rhinosinusitis

BACKGROUND

IgG4 production is regulated by type 2 (IL-4 and IL-13) and regulatory (IL-10) cytokines involved in the pathophysiology of chronic rhinosinusitis (CRS). We sought to determine the pathophysiological characteristics of IgG4-positive cells in sinonasal tissues in CRS, especially eosinophilic CRS (ECRS).

METHODS

IgG4-positive cells in uncinate tissues (UT) and nasal polyps (NP) were examined by immunohistochemistry. Associations between the number of IgG4-positive cells and clinicopathological factors were analyzed. Receiver operating characteristics (ROC) analysis was performed to determine the cut-off value of IgG4-positive cells in tissue that can predict the post-operative course.

RESULTS

IgG4 was mainly expressed in infiltrating plasma and plasmacytoid cells, and the number of IgG4-positive cells was significantly higher in NP, especially those from severe ECRS patients, than in UT. In CRS patients, the number of IgG4-positive cells significantly and positively correlated with blood and tissue eosinophilia, radiological severity, and serum level of total IgE. The number of infiltrating IgG4-positive cells was significantly higher in patients with a poor post-operative course (sustained sinus shadow 6 months after surgery) than in those with a good one. The number of IgG4-positive cells in NP could discriminate patients with a good or a poor post-operative course (area under the curve: 0.769). Also, 73.3% sensitivity and 82.5% specificity were achieved when the cut-off value was set at 17 cells/high-power field.

CONCLUSIONS

Our results suggest that the local expression of IgG4 on cells may be used as a biomarker that reflects the pathophysiology of CRS, including the post-operative course.

Are panels of clinical, laboratory, radiological, and microbiological variables of prognostic value in deep neck infections? An analysis of 301 consecutive cases

BACKGROUND

Deep neck infections (DNIs) are often clinically challenging, and may be life-threatening.

OBJECTIVE

The present retrospective study aimed to identify panels of clinical, laboratory, radiological, and microbiological parameters that could identify patients with DNIs at higher risk of complications or long-term hospitalization.

MATERIALS AND METHODS

The investigation concerned 301 consecutive patients with DNIs treated at our institution between 2000 and 2014.

RESULTS

The discriminatory power of a combination of two variables (unknown origin of the infection and the need for surgical treatment) in terms of deep neck infection complications occurrence featured an AUC (ROC) of 0.6701. The power of a panel of four variables (age, leukocyte count, need for surgical treatment, days elapsing from hospitalization to surgical procedure) to identify DNIs necessitating long-term hospitalization featured an AUC (ROC) of 0.7929.

CONCLUSION

Using the scale proposed by Hosmer and Lemeshow, the four-variable panel showed an amply acceptable, nearly excellent discriminatory power for long-term hospitalization.

SIGNIFICANCE

Although this panel achieved promising results for prognostic purposes, other parameters potentially capable of predicting the outcome of DNIs and orienting treatment decisions need to be investigated.

Role of blood inflammatory cells in chronic rhinosinusitis with nasal polyps

BACKGROUND/OBJECTIVE

The pathophysiological and prognostic role of blood inflammatory cells in chronic rhinosinusitis with nasal polyps (CRSwNP) emerging from recent studies was investigated.

MATERIAL AND METHODS

The main available evidence and largely-recent publications were critically analyzed.

RESULTS

Several authors reported a direct association between blood eosinophilia and CRSwNP recurrence rates. In some large series, a direct association between recurrent CRSwNP and blood basophil values emerged too. CRSwNP patients' blood eosinophil and basophil values were strongly related. It was also found that preoperative neutrophil-to-lymphocyte, eosinophil-to-lymphocyte, and basophil-to-lymphocyte ratios were significantly higher in patients who experienced a disease relapse than in those who did not. In histologically-confirmed eosinophilic-type CRSwNP treated with endoscopic sinus surgery, mean blood eosinophil values dropped significantly from before to after the surgical procedure.

CONCLUSIONS/SIGNIFICANCE

CRSwNP endotypes have different inflammatory profiles reflected in the relative proportions of different types of blood cells. The available data support the theory that blood eosinophil and basophil levels should be included in the routine preoperative work-up of CRSwNP patients in order to give patients accurate prognostic information, adopt rational follow-up protocols after surgery, and provide dedicated postoperative medical treatments.

Non-Eosinophilic Chronic Rhinosinusitis With Nasal Polyps: Eosinophil, Basophil, and Neutrophil Blood Counts Before and After Surgery

OBJECTIVES

Research selectively investigating non-eosinophilic chronic rhinosinusitis with nasal polyps (CRSwNP) is lacking. The inflammatory patterns seen in non-eosinophilic CRSwNP are still poorly understood. The present study is the first to compare blood eosinophil, basophil, and neutrophil counts before/after surgery in patients with non-eosinophilic CRSwNP stratified by their clinical features.

METHODS

The study concerned 107 consecutive patients with histologically confirmed non-eosinophilic CRSwNP who underwent endoscopic sinus surgery (ESS).

RESULTS

Statistical analysis ruled out any significant change in mean blood eosinophil, basophil, and neutrophil counts after ESS. A significant positive correlation emerged between blood eosinophil and basophil counts in both pre- and post-ESS laboratory tests. In the subcohort of allergic patients, a significant negative correlation was found after ESS between eosinophil and neutrophil levels and between basophil and neutrophil levels.

CONCLUSIONS

In eosinophilic CRSwNP, ESS can clear polyps, remove inflammatory tissue, and reduce the inflammatory cytokines it generates, with a consequent reduction in blood eosinophil levels. The different results in non-eosinophilic CRSwNP support the conviction that the 2 types of CRSwNP are entities with distinct inflammatory response patterns.

Chronic Rhinosinusitis-Could Phenotyping or Endotyping Aid Therapy?

OBJECTIVES

We reviewed the phenotyping and endotyping of chronic rhinosinusitis (CRS) and treatment options.

METHODS

We searched PubMed, Google, Google Scholar, and the Proquest Central Database of the Kırıkkale University Library.

RESULTS

Phenotypes are observable properties of an organism produced by the environment acting upon the genotype, that is, patients with a particular disorder are subgrouped according to common characteristics. Currently, CRS is usually phenotyped as being with (CRSwNP) or without (CRSsNP) nasal polyps. However, this is not immutable as some individuals progress from nonpolyp to polypoid CRS over time. Phenotypes of CRS are also based on inflammatory patterns, generally CRSwNP is eosinophilic, CRSsNP neutrophilic; but there is a spectrum, rather than a clear-cut division into 2 types. An endotype is a subtype of a condition defined by a distinct functional or pathobiological mechanism. Endotypes of CRS can be (1) nontype Th2, (2) moderate type Th2, and (3) severe type Th2 immune reactions, based on cytokines and mediators such as IL4, 5, 13. CRS endotyping can also include a (1) type 2 cytokine-based approach, (2) eosinophil-mediated approach, (3) immunoglobulin E-based approach, and (4) cysteinyl leukotriene-based approach. Subdivisions of CRSwNP can be made into nonsteroidal anti-inflammatory drug-exacerbated respiratory disease, allergic fungal sinusitis, and eosinophil pauci-granulomatous arteritis by testing. General treatment for all CRS is nasal douching. The place of surgery needs careful reconsideration. Endotype-directed therapies include glucocorticosteroids, antibiotics, aspirin, antifungals, anticytokines, and immunoglobulin replacement. The recognition of united airways and the co-occurrence of CRSwNPs and severe asthma should lead to common endotyping of both upper and lower airways in order to better direct therapy.

CONCLUSION

Endotyping can allow for the identification of groups of patients with CRS with a high likelihood of successful treatment, such as patients with a moderate type 2 immune reaction or those with acquired immune deficiency.

Highlights of eosinophilic chronic rhinosinusitis with nasal polyps in definition, prognosis, and advancement

Background

Tissue eosinophils are characteristic of inflammation in most but not all patients with chronic rhinosinusitis with nasal polyps (CRSwNP) and may be useful for defining subgroups and making treatment choices. However, no consistent diagnostic criteria for CRSwNP with eosinophilic inflammation have been established.

Methods

Related literature review was performed and current developments in the diagnosis of eosinophilic CRSwNP were summarized. Details in histopathology, definition of tissue eosinophilia, eosinophil as an indicator of disease recurrence, eosinophilic shift, and related biomarkers in CRSwNP are included in this review article.

Results

Mucosal eosinophilia exhibits significant geographic and ethnic differences and may increase over time. Tissue eosinophilia can be defined using a cutoff value based on reference values from healthy mucosa, but typical disease‐specific values should also be employed to increase sensitivity and specificity for clinical use. Recent developments highlight the diagnostic criteria for eosinophilic CRSwNP based on cluster analysis, which were also associated with clinical outcomes. Additionally, some promising eosinophil‐relevant biomarkers, such as eosinophilic cation protein and interleukin 5 (IL‐5), may be clinically applied as diagnostic or predictive tools for CRSwNP in the future.

Conclusion

Sinonasal tissue eosinophilia is present in a majority of CRSwNP patients but is currently more common in the West than in the East. Cutoff values of eosinophils as the diagnostic criteria of eosinophilic CRSwNP are subject to change with geographic and ethnic differences over time. It will be important to identify validated eosinophil‐related biomarkers in different continents/countries for future research and for the introduction of precision medicine.

An Evaluation of SPARC Protein as a Serum Biomarker of Chronic Rhinosinusitis

OBJECTIVE

Precision medicine initiatives for chronic rhinosinusitis (CRS) management suggest tailoring treatment to the patient's individual disease profile; however, serum biomarkers for evaluation of disease activity or predicting response to therapy are lacking in CRS. Epithelial-to-mesenchymal transition (EMT) has been described as a component of barrier dysfunction in CRS. SPARC (secreted protein acidic and rich in cysteine) is a marker of EMT that has previously been identified in sinus epithelium by gene expression profiling. We wished to determine if SPARC could represent a serum biomarker for CRS by verifying (1) if SPARC could be detected in serum, (2) whether levels were sensitive to disease burden reduction following surgery, and (3) if it could predict response to therapy.

STUDY DESIGN

Prospective.

SETTING

Tertiary care center.

SUBJECTS

Patients with CRS undergoing endoscopic sinus surgery (ESS).

METHODS

Twenty-six patients undergoing ESS for CRS were prospectively recruited. Serum was collected at the time of surgery and 4 months following ESS and SPARC level measured using enzyme-linked immunosorbent assay. Postoperative outcome was characterized as "remission" or "unfavorable" based on symptomatology and endoscopy.

RESULTS

SPARC could be detected and measured in serum in all subjects. Following ESS, SPARC levels decreased by 33% ( P = .005) but did not predict evolution at 4 months postsurgery ( P = .94).

CONCLUSION

SPARC may be an interesting serum biomarker of disease activity in CRS, as it can be reliably measured and decreases following successful reduction of disease burden after surgery. However, it does not predict post-ESS evolution, suggesting that the link between EMT and outcome is not linear.

Endotypes of Chronic Rhinosinusitis Across Ancestry and Geographic Regions

PURPOSE OF REVIEW

Preliminary studies have suggested differences in endotypes of chronic rhinosinusitis (CRS) across ancestry/ethnic groups. Eosinophilic CRS (ECRS) is the predominant subtype for Western/European ancestry CRS patients and non-eosinophilic CRS (nECRS) for Asian patients. This review aims to re-analyze CRS endotypes across ancestry populations using one consistent criteria to existing data.

RECENT FINDINGS

Although tissue eosinophilia is the most commonly used criterion for ECRS, various cut-off points are suggested. Surrogate markers have been extensively studied. Sixty-six cohorts with study criteria were included with a total of 8557 patients. Raw data from 11 studies 544 patients were re-analyzed using number of tissue eosinophils. At lower cut-off values of ≥ 5 and ≥ 10 cells/HPF, most patients of Asian and Western/European ancestry were classified as ECRS without difference. In contrast, at cut-off points of ≥ 70 and ≥ 120 cells/HPF, the majority of both groups became reclassified as nECRS. After applying one consistent criteria to existing data, differences across ancestry and geographic populations in endotypes of CRS were no longer evident.

Nasal polyposis pathophysiology: Endotype and phenotype open issues

PURPOSE

Endotyping chronic rhinosinusitis with nasal polyps (CRSwNP) poses a challenge for rhinologists nowadays. Phenotyping CRSwNP proved inappropriate as an approach to their classification because of their common clinical features. Endotyping, being based on the pathogenic mechanism, provides a precise picture more appropriate for use in clinical practice. Patients' treatment and follow-up can thus be tailored to cope with the degree of aggressiveness of a specific CRSwNP endotype. The aim of this study was to analyze the available information about the main currently accepted endotypes of CRSwNP; furthermore, we reported and commented evidence regarding some clinical conditions associated with nasal polyposis which could be related with new endotypes.

MATERIALS AND METHODS

Pubmed and Scopus electronic database were searched. The main available studies about CRSwNP endotyping published predominantly in the last 5 years were critically analyzed.

RESULTS

The pathophysiological features of some asthma-related CRSwNP (allergic fungal rhinosinusitis, aspirin-exacerbated respiratory disease) are quite well understood, including them among known endotypes of CRSwNP. On the other hand, because of their known pathophysiological mechanisms, some well-known diseases associated with aggressive forms of CRSwNP, such as eosinophilic granulomatosis with polyangiitis, primary ciliary dyskinesia and cystic fibrosis, should be investigated as potentially related with CRSwNP endotypes.

CONCLUSIONS

CRSwNP comprises several inflammatory endotypes defined by different pathogenic mechanisms. These endotypes correlate with the disease's clinical manifestations and behavior. A thorough understanding of CRSwNP endotypes will enable targeted medical therapies and tailored follow-up protocols.

Cortactin expression in nasal polyps of Aspirin-Exacerbated Respiratory Disease (AERD) patients

PURPOSE

The term aspirin-exacerbated respiratory disease (AERD) refers to a combination of asthma, chronic rhinosinusitis with nasal polyposis (CRSwNP), and acute respiratory tract reactions to nonsteroidal anti-inflammatory drugs. AERD has now been included among the CRSwNP endotypes, and is considered one of the most aggressive in terms of disease recurrence. Cortactin is a multi-domain protein with a part in several cellular mechanisms involving actin assembly and cytoskeleton arrangement. Cortactin seems to have a role in inflammatory responses and to be implicated in human airway secretion and contraction mechanisms. The novel aim of the present study was to examine cortactin expression in nasal polyps of a consecutive cohort of AERD patients and in nasal mucosa of a control group of patients.

MATERIALS AND METHODS

Cortactin expression was assessed immunohistochemically in nasal polyps from 18 consecutive AERD patients who underwent endoscopic sinus surgery and in nasal mucosa of 19 patients without chronic rhinosinusitis.

RESULTS

Concomitant allergy was found in 11 AERD patients, most of them male (8 cases; p = 0.02). Cortactin expression in nasal polyps was definitely high (+3) in 17 out of 18 cases, in both epithelial cells (cytoplasmic and membranous immunoreactivity) and activated fibroblasts. A higher cortactin expression was seen in female than in male AERD patients (p = 0.05).

CONCLUSIONS

Given this preliminary evidence of cortactin upregulation in the polyps of AERD patients, prospective studies could further investigate the role of cortactin in the biology of AERD, and the potential role of cortactin-targeted approaches in integrated AERD treatments.

Blood eosinophil-to-basophil ratio in patients with sinonasal polyps: Does it have a clinical role?

BACKGROUND

In a recent preliminary study, eosinophil and basophil counts were calculated in chronic rhinosinusitis with nasal polyps (CRSwNP) using conventional histologic and immunohistochemical methods. The tissue eosinophil-to-basophil ratio differed in the CRSwNP endotypes considered.

OBJECTIVE

To compare the blood eosinophil-to-basophil ratio (bEBR) in a large series of patients with CRSwNP with that in a control group of consecutive rhinological patients with no evidence of nasal, paranasal, or systemic inflammatory disorders.

METHODS

A retrospective study was performed on 334 patients with CRSwNP to compare the preoperative bEBR among different endotypes and with controls (69 cases).

RESULTS

The mean bEBR was significantly higher in the CRSwNP group than in the control group (P = .0006). The eosinophil and basophil counts were significantly and directly correlated in the CRSwNP cases (P = .0000). The mean bEBR was significantly higher in the sub-cohorts of CRSwNP with allergy (P = .0007), asthma (P = .0000), and aspirin-exacerbated respiratory disease (P = .0153). The mean bEBR was significantly higher in the sub-cohort with eosinophilic CRSwNP than in the sub-cohort with noneosinophilic CRSwNP (P = .0000).

CONCLUSION

This study confirms the increasingly interesting role emerging for blood eosinophils and basophils in different CRSwNP endotypes. The bEBR seems to be a parameter worth investigating in different CRSwNP endotypes, because it is significantly higher in patients with allergy, asthma, and aspirin-exacerbated respiratory disease.

Sinonasal polyposis in the elderly

BACKGROUND/OBJECTIVE

The main end point of this investigation was to review our experience gained from 2009 to 2015 of treating chronic rhinosinusitis with nasal polyps (CRSwNP) in elderly patients (≥65 years old) with functional endoscopic sinus surgery. Secondary aims were to analyze the prognostic variables for CRSwNP in elderly patients and to compare the demographic, clinical, laboratory, histologic, and prognostic characteristics of CRSwNP in elderly versus young adult patients (20-40 years old).

METHODS

Forty-three consecutive elderly patients and 71 consecutive young adult patients with CRSwNP were enrolled.

RESULTS

Significant associations were found in the elderly group between CRSwNP recurrence and allergy (p = 0.037), CRSwNP recurrence and asthma (p = 0.017), and CRSwNP recurrence and acetyl salicylic acid (ASA) intolerance (p = 0.032) but not between recurrence and eosinophilic/noneosinophilic CRSwNP histology. Significant associations emerged in the young adult group between CRSwNP recurrence and asthma (p = 0.009), and ASA intolerance (p = 0.016), and serum eosinophil count (p = 0.02). The recurrence rate was also significantly higher for young adult patients with eosinophilic-type CRSwNP (p = 0.001). CRSwNP recurred less often in the elderly than in the young adult patients (p = 0.05).

CONCLUSION

The present preliminary investigation found a lower recurrence rate after functional endoscopic sinus surgery for CRSwNP in elderly patients than in young adult patients. Further investigations on larger, prospective series are mandatory to support the hypothesis that, although eosinophilic-type CRSwNP is generally considered a variant at high risk of recurrence and that probably warrants stricter postoperative follow-up and adjuvant postoperative medical treatment, these considerations could not be applied to elderly patients.

The prognostic role of serum eosinophil and basophil levels in sinonasal polyposis

BACKGROUND

Predicting which patients are at a higher risk for recurrent chronic rhinosinusitis with nasal polyps (CRSwNP) is one of the most challenging problems in clinical rhinology. A direct association between CRSwNP recurrence rates and serum eosinophil and basophil counts was reported. This study aimed to identify best-fitting cutoffs for binarizing preoperative serum eosinophils and basophils (counts/percentages) for prognostic purposes in cases of CRSwNP recurrence after surgery. A secondary endpoint was to distinguish said cutoffs for prognosticating recurrence in subcohorts of patients with histologically diagnosed eosinophilic/non-eosinophilic CRSwNP.

METHODS

A retrospective study was performed on 280 patients (127 eosinophilic and 153 non-eosinophilic CRSwNP) examining the prognostic role of serum eosinophil and basophil levels.

RESULTS

For all patients examined, mean preoperative serum eosinophil and basophil levels were significantly higher in patients whose CRSwNP recurred. Patients with eosinophil counts ≥0.24 cells × 10⁹ /L and percentages ≥3.7% had odds ratios (ORs) of 2.57 and 2.19 for recurrence; patients with basophil counts ≥0.03 cells × 10⁹ /L and percentages ≥0.5% had ORs of 2.19 and 2.24, respectively. Among histologically eosinophilic CRSwNP patients, mean eosinophils and basophils (counts/percentages) were significantly higher in cases that recurred. Serum eosinophil and basophil values were directly correlated. The recurrence odds were OR 2.52 for high eosinophils (≥5.9%), and OR 2.52 and 2.69 for high basophils (≥0.04 cells × 10⁹ /L and ≥0.5%, respectively).

CONCLUSION

High serum eosinophil and basophil values should be further investigated because they could pinpoint patients at higher risk of eosinophilic-type CRSwNP recurrence. These preliminary results support the increasing interest in the role of basophils in CRSwNP.

Are neutrophil-, eosinophil-, and basophil-to-lymphocyte ratios useful markers for pinpointing patients at higher risk of recurrent sinonasal polyps?

PURPOSE

Despite advances in the diagnosis and treatment of chronic rhinosinusitis with nasal polyps (CRSwNP), their recurrence rate remains significant. There is a need for promptly-obtainable, inexpensive, minimally-invasive prognostic parameters to enable rhinologists to identify patients at higher risk of recurrent CRSwNP. The prognostic role of the neutrophil-to-lymphocyte ratio (NLR) and eosinophil-to-lymphocyte ratio (ELR), previously discussed as potential markers of inflammation, has already been investigated in CRSwNP. The aim of the present study was to test the prognostic value of the NLR and ELR, and also of the basophil-to-lymphocyte ratio (BLR) (given the emerging role of basophils in CRSwNP) in a large series of CRSwNP.

MATERIALS AND METHODS

The study concerned 240 patients who underwent FESS for CRSwNP from 2009 to 2014 and had a postoperative follow-up longer than 12months. We considered patients with recurrences as those with endoscopic evidence of at least grade I polyposis.

RESULTS

In our series, the mean NLR, ELR and BLR were significantly higher in patients whose disease recurred than in those remaining recurrence-free (p=0.03, p=0.0001, and p=0.0002, respectively), but the discriminatory power of the NLR, ELR, or BLR in terms of disease recurrence was unacceptable (AUCs=0.600, 0.678, and 0.662, respectively).

CONCLUSIONS

The heterogeneous prognostic role of NLR, ELR and BLR identified in the clinically and pathologically different sub-cohorts of CRSwNP considered supports the hypothesis that CRSwNPs with a similar clinical picture may differ considerably in terms of the biological and pathogenic mechanisms of polyp formation and growth.