Chronic rhinosinusitis in elderly patients is associated with an exaggerated neutrophilic proinflammatory response to pathogenic bacteria

Delta neutrophil index levels can be a good indicator to predict patients with chronic rhinosinusitis who need surgery

OBJECTIVES

Predicting the need for surgical treatment among patients with chronic rhinosinusitis (CRS) is challenging. The delta neutrophil index (DNI) has been proposed as a useful laboratory marker of immature granulocytes, which indicates infection or severe inflammation in several diseases. This study evaluated DNI as an early predictor of the need for surgery in patients with CRS.

METHODS

A total of 117 patients diagnosed with CRS were enrolled in this retrospective and observational study. Medical records, including symptoms data, WBC count, ESR level, LUC count, Lund-Mackay scores, and DNI, were reviewed. The receiver operating characteristic (ROC) curves were analyzed to determine the optimal cut-off values for predicting surgery.

RESULTS

Among 117 patients, 49 patients (41.9%) needed surgical intervention. The areas under the WBC, ESR, LUC, and DNI ROC curves were .571, .600, .592, and .782, respectively. The optimal cut-off value of DNI to predict surgery was .9%. The prognostic precision of DNI showed that the sensitivity was 59.2% and the specificity was 98.5%. In the analysis of risk factors, DNI levels were significantly associated with surgical intervention (odds ratio, 2.22; 95% confidence interval, 1.48-3.34; P < .01).

CONCLUSIONS

The level of DNI, which reflects the severity of the disease, may be a useful predictor for determining the need for surgical intervention in patients with CRS. This is the first literature to verify the role of DNI in upper airway disease.

Particulate matter exposure is associated with increased inflammatory cytokines and eosinophils in chronic rhinosinusitis

BACKGROUND

Chronic rhinosinusitis (CRS) is thought to result from complex interactions between the host immune system, microbiota, and environmental exposures. Currently, there is limited data regarding the impact of ambient particulate matter ≤2.5 μm in diameter (PM2.5) in the pathogenesis of CRS, despite evidence linking PM2.5 to other respiratory diseases. We hypothesized that PM2.5 may result in differential cytokine patterns that could inform our mechanistic understanding of the effect of environmental factors on CRS.

METHODS

We conducted an analysis of data prospectively collected from 308 CRS patients undergoing endoscopic sinus surgery. Cytokines were quantified in intraoperative mucus specimens using a multiplex flow cytometric bead assay. Clinical and demographic data including zip codes were extracted and used to obtain tract-level income and rurality measures. A spatiotemporal machine learning model was used to estimate daily PM2.5 levels for the year prior to each patient's surgery date. Spearman correlations and regression analysis were performed to characterize the relationship between mucus cytokines and PM2.5. RESULTS: Several inflammatory cytokines including IL-2, IL-5/IL-13, IL-12, and 21 were significantly correlated with estimated average 6, 9, and 12-month preoperative PM2.5 levels. These relationships were maintained for most cytokines after adjusting for age, income, body mass index, rurality, polyps, asthma, and allergic rhinitis (AR) (p < .05). There were also higher odds of asthma (OR = 1.5, p = .01) and AR (OR = 1.48, p = .03) with increasing 12-month PM2.5 exposure. Higher tissue eosinophil counts were associated with increasing PM2.5 levels across multiple timeframes (p < .05).

CONCLUSIONS

Chronic PM2.5 exposure may be an independent risk factor for development of a mixed, type-2 dominant CRS inflammatory response.

Frailty is an independent predictor of postoperative rescue medication use after endoscopic sinus surgery

INTRODUCTION

The modified five-item frailty index (mFI-5) is a validated risk stratification tool with the ability to predict adverse outcomes following surgery. In this study, we sought to use mFI-5 to assess the potential relationship between unhealthy aging and postoperative endoscopic sinus surgery (ESS) outcomes.

METHODS

Patients who underwent sinus surgery at Vanderbilt between 2014 and 2018 were identified and assessed using the mFI-5, which is calculated based on the presence of five comorbidities: diabetes mellitus, hypertension requiring medication, chronic obstructive pulmonary disease, congestive heart failure, and non-independent functional status. Multivariate regression analyses were performed to quantify the association of mFI-5 score on need for rescue oral antibiotics, oral steroids, and antibiotic irrigations within 1 year following ESS, adjusting for relevant potential confounders.

RESULTS

Four hundred and three patients met inclusion criteria.  Within 6 months of surgery, 312 (77%) required rescue antibiotics, 243 (60%) required oral corticosteroids (OCS), and 31 (8%) initiated antibiotic irrigations. Increasing mFI-5 scores were significantly associated with higher postoperative use of rescue antibiotics (p < 0.0001), OCS (p = 0.032), and antibiotic irrigation (p < 0.0001). Frailty scores remained as an independent predictor of these outcomes after adjustment for age, polyp status, preoperative sinonasal outcomes test (SNOT-22) score, and revision surgery status.

CONCLUSIONS

Modified frailty scores may be a useful clinical tool to predict the need for postoperative rescue medication use after ESS.

Diverse Endotypes of Chronic Rhinosinusitis and Clinical Implications

Chronic rhinosinusitis (CRS) is a highly heterogeneous disease characterized by inflammation in the nasal and sinus mucosa. The CRS phenotypes, based on the presence or absence of nasal polyps, are known as CRS with nasal polyps (CRSwNP) and CRS without nasal polyps (CRSsNP). However, this classification has limitations in fully capturing the mechanisms and clinical manifestations of CRS. To address the heterogeneity of CRS, there has been a growing focus on classifying the condition into distinct endotypes. Endotype classification involves grouping patients based on specific molecular, immunological, and clinical characteristics, allowing for more personalized and targeted treatment approaches.This review delves into the current state of endotype classifications for CRS. It explores the role of geographic factors, microbiome, and subphenotype in shaping different endotypes. Additionally, the review examines how various clinical features are associated with specific endotypes, providing valuable insights into tailoring treatment options for better outcomes and transitions between different endotypes.Overall, this review offers a comprehensive and up-to-date perspective on the intricate realm of CRS endotype classifications. By unraveling the molecular and clinical intricacies, this review lays the foundation for more precise, effective, and individualized treatment strategies in the management of CRS.

Disparities in access to health care in adults with sinusitis in the United States

BACKGROUND

Sinusitis can significantly decrease quality of life, is costly in both health care expenditure and lost productivity, and can lead to complications if treatment is delayed. Our objective was to explore disparities in health care access among adults with sinusitis based on sociodemographic factors.

METHODS

A total of 32,994 participants (representing 244,838,261 US adults) who completed the 2016 National Health Interview Survey (NHIS) were analyzed, of whom 12.17% were diagnosed with sinusitis at least once in the prior 12 months. Multivariate regression analyses were performed.

RESULTS

In regression analyses, female sex (odds ratio [OR], 2.00 [95% confidence interval (CI), 1.79-2.24]; p < 0.001) and older age groups were associated with increased odds of having sinusitis. Within the sinusitis cohort, Asian race (OR, 5.97 [95% CI, 1.61-22.12]; p = 0.008) and Hispanic ethnicity (OR, 6.97 [95% CI, 3.22-15.06]; p < 0.001) were associated with increased odds of obtaining foreign medications. Individuals with Medicaid had decreased odds of delaying care (OR, 0.37 [95% CI, 0.25-0.56]; p < 0.001) or not receiving care due to cost (OR, 0.40 [95% CI, 0.24-0.65]; p < 0.001), but increased odds of delaying care due to transportation barriers (OR, 4.64 [95% CI, 2.52-8.55]; p < 0.001). Uninsured individuals had higher odds for delaying care (OR, 4.97 [95% CI, 3.35-7.38]; p < 0.001) and not receiving care (OR, 5.46 [95% CI, 3.56-8.38]; p < 0.001) due to cost. Income >$100,000 was associated with a nearly 90% reduction in inability to obtain care due to cost (OR, 0.11 [95% CI, 0.05-0.21]; p < 0.001) and an over 99% reduction in inability to obtain care due to transportation issues compared with income < $35,000 (OR, 0.01 [95% CI, 0.00-0.04]; p< 0.001).

CONCLUSION

Significant disparities in health care access based on race, health insurance status, and income exist among adults with sinusitis in the United States.

Epithelial Barrier Theory: The Role of Exposome, Microbiome, and Barrier Function in Allergic Diseases

Allergic diseases are a major public health problem with increasing prevalence. These immune-mediated diseases are characterized by defective epithelial barriers, which are explained by the epithelial barrier theory and continuously emerging evidence. Environmental exposures (exposome) including global warming, changes and loss of biodiversity, pollution, pathogens, allergens and mites, laundry and dishwasher detergents, surfactants, shampoos, body cleaners and household cleaners, microplastics, nanoparticles, toothpaste, enzymes and emulsifiers in processed foods, and dietary habits are responsible for the mucosal and skin barrier disruption. Exposure to barrier-damaging agents causes epithelial cell injury and barrier damage, colonization of opportunistic pathogens, loss of commensal bacteria, decreased microbiota diversity, bacterial translocation, allergic sensitization, and inflammation in the periepithelial area. Here, we review scientific evidence on the environmental components that impact epithelial barriers and microbiome composition and their influence on asthma and allergic diseases. We also discuss the historical overview of allergic diseases and the evolution of the hygiene hypothesis with theoretical evidence.

Mepolizumab in chronic rhinosinusitis with nasal polyposis

Chronic rhinosinusitis with nasal polyposis (CRSwNP) is a heterogeneous upper airway disease that is prevalent globally. Recent research into the molecular basis of the disease has led to the development of biologics as a new therapeutic option for severe and recalcitrant forms of CRSwNP. Mepolizumab is a monoclonal antibody targeting IL-5, one of the signature cytokines of the type 2 immune response and which plays an important role in the pathogenesis of CRSwNP. Here we present the latest evidence behind mepolizumab, examining disease pathophysiology and pharmacology, as well as data from clinical trials, real-life studies and meta-analyses. As we welcome this promising step forward into precision medicine, we discuss practical issues and future perspectives on mepolizumab and biologics for CRSwNP.

Epithelial innate immune response to Pseudomonas aeruginosa-derived flagellin in chronic rhinosinusitis

BACKGROUND

Pseudomonas aeruginosa is a common colonizing pathogen in the upper respiratory tract and is associated with recalcitrant chronic rhinosinusitis (CRS). Herein we sought to characterize the effect of P. aeruginosa-derived flagellin on human sinonasal epithelial cell (HSNEC) immune responses and determine whether these pathways are disrupted in CRS.

METHODS

Air-liquid interface cultures were established from CRS and healthy control donors. Cells were incubated with P. aeruginosa-derived flagellin for 24 hours and transcriptional changes were assessed using whole transcriptome RNA sequencing. Apical and basolateral secretion of the pro-inflammatory cytokines in interleukin (IL)-1β, tumor necrosis factor (TNF)-α, and IL-6 were measured after stimulation by lipopolysaccharide or flagellin and responses were compared between CRS and healthy control patients.

RESULTS

HSNECs were weakly responsive to lipopolysaccharide, whereas flagellin stimulated a profound innate immune response dominated by TNF-α, IL-1β, and IL-17 signaling and activation of the IL-17C/IL-23 axis. CRS-derived HNSECs showed an altered innate immune response to flagellin, characterized by a profound increase in TNF-α secretion coupled with reduced IL-6 secretion.

CONCLUSIONS

Flagellin activates a potent innate immune response in HSNECs characterized by pro-inflammatory mediators and cytokines/chemokines associated with neutrophilic inflammation. HSNECs from CRS patients have a dysregulated innate immune response to flagellin characterized by an imbalance between IL-6 and TNF-α secretion.

Histopathological Differences in Adult and Elderly Patients With Chronic Rhinosinusitis

BACKGROUND

Adult and elderly patients with chronic rhinosinusitis (CRS) undergo similar therapeutic management. Few studies have undertaken sinonasal tissue-level comparisons of these groups. This study examines histopathological differences between adults (>18, <65 years) and the elderly (≥65 years) with CRS, with the goal of optimizing medical management.

METHODS

In a retrospective cohort analysis, demographic factors, comorbidities, and a structured histopathological report of 13 variables were compared across adult and elderly patients with CRS who underwent functional endoscopic sinus surgery. These cohorts of adult and elderly patients included patients with and without nasal polyps (NP).

RESULTS

Three hundred adult (158 aCRSsNP, 142 aCRSwNP) and 77 elderly (38 eCRSsNP, 39 eCRSwNP) patients were analyzed. Mean age of the adult cohort was 44.4 ± 12.4 years, while that of the elderly cohort was 71.9 ± 5.9 years (P < .001). Significantly more adults compared to elderly individuals demonstrated a positive atopic status (79.7% vs 64.0%, P = .004). Elderly patients exhibited higher rates of comorbid diabetes mellitus than adult patients (21.6% vs 10.3%, P = .009). Adults exhibited more tissue eosinophilia (43.4% vs 28.6%, P = .012) and presence of eosinophil aggregates (25.0% vs 14.3%, P = .029) compared to elderly patients, regardless of NP status. Conversely, the elderly demonstrated significantly more fungal elements (11.7% vs 3.0%, P = .004), and trended toward increased overall inflammation (63.6% vs 55.3%, P = .118) and tissue neutrophilia (35.1% vs 27.3%, P = .117), compared to adults.

CONCLUSION

Sinonasal tissue of adult and elderly patients with CRS demonstrates clear histopathological differences. Patient comorbidities, in addition to histopathological characterizations, may provide further context for management optimization.

LEVEL OF EVIDENCE

2.

SHORT SUMMARY

Sinonasal tissue samples from adult and elderly patients with CRS demonstrate clear histopathological differences. These patient populations also exhibit unique comorbidities. These distinctions have the potential to inform and optimize management of this condition.

Neutrophil Extracellular Traps in Airway Diseases: Pathological Roles and Therapeutic Implications

Neutrophils are important effector cells of the innate immune response that fight pathogens by phagocytosis and degranulation. Neutrophil extracellular traps (NETs) are released into the extracellular space to defend against invading pathogens. Although NETs play a defensive role against pathogens, excessive NETs can contribute to the pathogenesis of airway diseases. NETs are known to be directly cytotoxic to the lung epithelium and endothelium, highly involved in acute lung injury, and implicated in disease severity and exacerbation. This review describes the role of NET formation in airway diseases, including chronic rhinosinusitis, and suggests that targeting NETs could be a therapeutic strategy for airway diseases.

Endotyping Chronic Rhinosinusitis with Nasal Polyps: Understanding Inflammation Beyond Phenotypes

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a heterogenous group of inflammatory conditions impacting the nose and paranasal sinuses. Our understanding of the underlying pathobiology of CRSwNP has substantially improved due to ongoing translational research efforts. Advances in treatment options, including targeted respiratory biologic therapy for CRSwNP, allow for more personalized approaches for CRSwNP patient care. Patients with CRSwNP are typically classified to one or more endotype based on the presence of type 1, type 2, and type 3 inflammation. This review will discuss recent advances in our understanding of CRSwNP and how this may impact current and future treatment approaches for patients with CRSwNP.

Epidemiological Characteristics, Pathogenesis and Clinical Implications of Sinusitis in the Era of COVID-19: A Narrative Review

Sinusitis is a common condition with various forms and different etiologies. In the era of COVID-19, a large number of studies covered the association between sinusitis and COVID-19, while others reported the impact of COVID-19 on the development of acute invasive fungal rhinosinusitis (AIFR), together with the most commonly associated predisposing factors. Fungal sinusitis, particularly AIFR, can be life-threatening. It is important to dissect this association and improve current evidence and management. Therefore, we conducted this literature review to highlight the association between COVID-19 and sinusitis based on evidence from the available studies in the literature. Evidence shows that chronic sinusitis might have a negative impact on COVID-19 outcomes. However, current results are conflicting, and further studies are needed. On the other hand, COVID-19 can also cause olfactory dysfunction, which is usually temporary. In addition, we found several studies that indicated the association between COVID-19 and AIFR. The condition is usually associated with severe morbidities, as affected patients are usually immunocompromised, including those with uncontrolled diabetes, malignancy, immunosuppression, AIDS, the administration of chemotherapy and other immunosuppressive drugs, and COVID-19.

Phenotypes of Chronic Rhinosinusitis and Peripheral Blood Leukocytes Parameters in Elderly Patients

Background and Objectives: Chronic rhinosinusitis (CRS) is a common disease that can be differentiated into two phenotypes, with or without polyps (CRSwNP) or CRSsNP), which may be unilateral (UNIL) or bilateral (BIL). CRS may have an impact on absolute neutrophils and lymphocytes count in peripheral blood. The aim of the study was to investigate whether the incidence of a specific CRS phenotype changes with age and to compare the values of neutrophils, lymphocytes and neutrophil-to-lymphocyte ratio in the peripheral blood between groups of patients below and above 65 years of age with different CRS phenotypes. Material and Methods: A total of 235 patients aged 65 and over were examined, including 140 (59.6%) males. The group of patients <65 years of age comprised 160 subjects, including 103 (64.4%) males. In both groups, the sequence of frequency of particular phenotypes was similar: the most common phenotype was bilateral CRSwNP followed by CRSsNP BIL, CRSsNP UNIL, and finally, CRSwNP UNIL. Direct comparisons between determined phenotype in both groups of different ages revealed that, in the group ≥65 years, CRSwNP BIL occurred significantly more often than in the group <65 years of age. In fact, in the <65 group, bilateral CRSsNP was more common. The absolute neutrophils and lymphocytes counts were significantly higher in the whole group of patients with CRS ≥65 years of age and absolute number of neutrophils was higher in ≥65 years of age group with bilateral CRSsNP. Conclusions: The higher number of neutrophils in the whole ≥65 years of age group and in older patients with bilateral CRSsNP may indicate that CRS, despite of phenotype, may be an important source of infection that requires surgical treatment in elderly patients as well.

Persistent discharge or edema after endoscopic sinus surgery in patients with chronic rhinosinusitis is associated with a type 1 or 3 endotype

BACKGROUND

Patients with chronic rhinosinusitis (CRS) may have persistence of polyps, discharge, or edema after endoscopic sinus surgery (ESS). Inflammation in CRS can be classified into three endotypes, with the presence of polyps associated with the type 2 endotype. Here, we evaluate the endotypic underpinnings of discharge or edema without polyps after ESS.

METHODS

At a visit 6-12 months post ESS, patients underwent endoscopy and completed the CRS-PRO and SNOT-22. Luminex analysis of middle meatal mucus obtained at that visit was performed for IFN-γ, ECP, and IL-17a. Type 1, 2, and 3 endotypes were defined as greater than the 90th percentile expression of each marker, respectively, in controls. Wilcoxon rank-sum and chi-squared tests were used to compare cytokine levels and endotype prevalence between those with and without endoscopic findings.

RESULTS

A total of 122 CRS patients completed a clinical exam (median: 8.2 months post ESS). Of the 122 patients, 107 did not have polyps on endoscopy. Of these 107 patients, 48 had discharge, 44 had edema, and 46 had neither discharge nor edema. Compared with those patients without any findings, patients with discharge or edema reported significantly worse severity as measured by CRS-PRO (10.5 vs. 7.0, p = 0.009; 12.0 vs. 7.0, p < 0.001; respectively), and had higher post-ESS IFN-γ, ECP, and IL-17a. Patients with discharge had higher prevalence of only T1 and T3 endotypes, while patients with edema had higher prevalence of only the T3 endotype.

CONCLUSIONS

Post-ESS discharge or edema in the absence of polyps was associated with higher patient-reported outcome severity and was more strongly associated with type 1 or 3 inflammation.

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

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

Chinese Guideline on Allergen Immunotherapy for Allergic Rhinitis: The 2022 Update

In the last few decades, there has been a progressive increase in the prevalence of allergic rhinitis (AR) in China, where it now affects approximately 250 million people. AR prevention and treatment include allergen avoidance, pharmacotherapy, allergen immunotherapy (AIT), and patient education, among which AIT is the only curative intervention. AIT targets the disease etiology and may potentially modify the immune system as well as induce allergen-specific immune tolerance in patients with AR. In 2017, a team of experts from the Chinese Society of Allergy (CSA) and the Chinese Allergic Rhinitis Collaborative Research Group (C2AR2G) produced the first English version of Chinese AIT guidelines for AR. Since then, there has been considerable progress in basic research of and clinical practice for AIT, especially regarding the role of follicular regulatory T (TFR) cells in the pathogenesis of AR and the use of allergen-specific immunoglobulin E (sIgE) in nasal secretions for the diagnosis of AR. Additionally, potential biomarkers, including TFR cells, sIgG4, and sIgE, have been used to monitor the incidence and progression of AR. Moreover, there has been a novel understanding of AIT during the coronavirus disease 2019 pandemic. Hence, there was an urgent need to update the AIT guideline for AR by a team of experts from CSA and C2AR2G. This document aims to serve as professional reference material on AIT for AR treatment in China, thus improving the development of AIT across the world.

Endoscopic Sinus Surgery in Older Patients With Significant Medical Comorbidities

BACKGROUND

Endoscopic sinus surgery (ESS) offers excellent outcomes for patients with chronic rhinosinusitis (CRS) in the general population. It is unclear whether older patients with significant medical comorbidities experience similar benefits.

OBJECTIVE

The purpose of this study is to evaluate whether increasing medical comorbidity is associated with worse sinonasal quality of life outcomes after ESS in older patients.

METHODS

This is a retrospective study of CRS patients 55 years or older who underwent elective ESS at an academic institution from July 2017 to June 2019. 22-Item Sino-Nasal Outcomes Test (SNOT-22) scores were gathered at baseline as well as at 3 and 6 months following surgery. Data on demographics, medical comorbidities, preoperative Lund-Mackay (LM) scores, and postoperative complications were extracted from the medical record. The Charlson Comorbidity Index (CCI) was calculated for each patient. Multivariate linear regression was used to evaluate a potential association between CCI and change in SNOT-22 scores at 3 months postoperatively.

RESULTS

A total of 205 patients met inclusion criteria with a mean (SD) CCI score of 2 (2.4) and a CCI score range of 0 to 11. The mean (SD) LM score was 8 (5.3). Rates of asthma and nasal polyposis were 28.3% and 36.6%, respectively. The mean (SD) improvement in SNOT-22 scores at 3 and 6 months compared to baseline was 17.9 (19.7) and 20.9 (18.1) points, respectively. After adjusting for covariates, there was no significant association between CCI and change in SNOT-22 scores.

CONCLUSION

Greater medical comorbidity is not associated with worse SNOT-22 outcomes postoperatively, although future studies are needed to determine if comorbidities are associated with higher complication rates. A multidisciplinary approach to perioperative care is critical in maintaining the safety and efficacy of ESS in this patient population.

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

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

Endotypes of chronic rhinosinusitis: Relationships to disease phenotypes, pathogenesis, clinical findings, and treatment approaches

Chronic rhinosinusitis (CRS) is a common clinical syndrome that produces significant morbidity and costs to our health system. The study of CRS has progressed from an era focused on phenotype to include endotype-based information. Phenotypic classification has identified clinical heterogeneity in CRS based on endoscopically observed features such as presence of nasal polyps, presence of comorbid or systemic diseases, and timing of disease onset. More recently, laboratory-based findings have established CRS endotype based upon specific mechanisms or molecular biomarkers. Understanding the basis of widespread heterogeneity in the manifestations of CRS is advanced by findings that the three main endotypes, Type 1, 2, and 3, orchestrate the expression of three distinct large sets of genes. The development and use of improved methods of endotyping disease in the clinic are ushering in an expansion of the use of biological therapies targeting Type 2 inflammation now and perhaps other inflammatory endotypes in the near future. The purpose of this review is to discuss the phenotypic and endotypic heterogeneity of CRS from the perspective of advancing the understanding of the pathogenesis and improvement of treatment approaches and outcomes.

Age-Associated Changes of Nasal Bacterial Microbiome in Patients With Chronic Rhinosinusitis

Age-related changes in nasal bacterial microbiota of patients with chronic rhinosinusitis (CRS) remains unclear. In this study, we aimed to identify distinct characteristics of nasal bacterial microbiota between aged and younger patients with CRS through 16S rDNA gene sequencing. Patients with CRS undergoing endoscopic sinus surgery were recruited and separated into aged (≥60 years, median age = 66 years, N = 17) and younger (<60 years, median age = 35.5 years, N = 14) patients. Diversity, bacterial composition and metabolic activities of nasal microbiota between aged and younger patients were compared. Results have shown that levels of OTUs (p = 0.0173) and microbiota diversity (all p < 0.05) decreased significantly in aged patients. The abundance of phylum Actinobacteria, and genus Corynebacterium were significantly higher in aged patients, while the abundance of phylum Bacteroidetes, Fusobacteria, and genus Fusobacterium, Peptoniphilus were significantly higher in younger patients. In addition, predicted functional profiles have revealed that 41 KEGG pathways involving in 12 metabolic pathways, 4 genetic information processing, 3 environmental information processing, 4 cellular processes, 8 organismal systems, 6 human diseases, and 4 unclassified pathways were identified. Among which, the vast majority of metabolic activities are involved in replication and repair, membrane transport, translation, and the metabolism of amino acid, carbohydrate, energy, cofactors and vitamins, and nucleotide. On the level of the thirdly bacterial metabolic pathways, purine metabolism, glycine, serine and threonine metabolism, valine, leucine and isoleucine biosynthesis, glycolysis/gluconeogenesis and phenylalanine, tyrosine and tryptophan biosynthesis are significantly up-regulated while carbon fixation pathways in prokaryotesand methane metabolism are significantly down-regulated in aged patients. Overall, our analysis revealed that age-related physiological and pathological changes on the nasal mucosal surface may alter the host immune response and be highly associated with the nasal bacterial microbiota of patients with CRS. However, future studies are needed to elucidate the causal relationship.

Clinical and biological markers in disease and biologics to treat chronic rhinosinusitis

PURPOSE OF REVIEW

Chronic rhinosinusitis (CRS) is a heterogeneous disorder with diverse responses to conventional anti-inflammatory medical and surgical treatments. Even for the newly developed mAbs targeting type 2 (T2) reaction, a considerable number of patients with CRS with nasal polyps (CRSwNP) exhibited unsatisfying response. Identifying patients with a tendency to poor prognosis is critical for selecting targeted therapies to improve the treatment outcome. This review focuses on clinical and biological markers associated with prognosis of CRS patients under conventional medical and surgical treatments and provides an update summary of potential markers for T2 biologics.

RECENT FINDINGS

Allergic rhinitis, asthma, prior sinus surgery, nasal polyps, tissue eosinophilia and neutrophilia, blood eosinophilia and high levels of Charcot-Leyden crystal, cystatin SN, chemokine (C-C motif) ligand 17, macrophage inflammatory protein-1β and interleukin (IL)-5 in nasal secretions have been associated with poor prognosis in CRS patients under conventional medical and surgical treatments. Blood eosinophil level might be a biomarker for anti-IL-5 (mepolizumab) and anti-IL-5R (benralizumab) biologic in patients with refractory CRSwNP.

SUMMARY

Several clinical and biological markers have been associated with poor response to conventional treatments in CRS patients; however, majority of them should be verified by large-scale multicentre studies. More efforts are needed to identify biomarkers for biologics.

Highlights in the advances of chronic rhinosinusitis

Chronic rhinosinusitis (CRS) is a complex upper airway inflammatory disease with a broad spectrum of clinical variants. As our understanding of the disease pathophysiology evolves, so too does our philosophy towards the approach and management of CRS. Endotyping is gaining favour over phenotype-based classifications, owing to its potential in prognosticating disease severity and delivering precision treatment. Endotyping is especially useful in challenging CRS with nasal polyposis cases, for whom novel treatment options such as biologicals are now available. The latest European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS2020) reflects these changes with updated rhinosinusitis classifications and new integrated care pathways. With the coronavirus disease 2019 (COVID-19) pandemic, physicians and rhinologists have to balance the responsibility of managing their patients' upper airway while adequately protecting themselves from droplet and aerosol transmission. This review summarises the key updates from EPOS2020, endotype-based classification and biomarkers. The role of biologicals in CRS and the lessons we can draw from their use in severe asthma will be examined. Finally, the principles of CRS management during COVID-19 will also be discussed.

Epithelial-Cell-Derived Extracellular Vesicles in Pathophysiology of Epithelial Injury and Repair in Chronic Rhinosinusitis: Connecting Immunology in Research Lab to Biomarkers in Clinics

Epithelial barrier disruption and failure of epithelial repair by aberrant epithelial-mesenchymal transition (EMT)-induced basal cells observed in nasal mucosa of chronic rhinosinusitis (CRS) are speculated to play important roles in disease pathophysiology. Microparticles (MPs) are a type of extracellular vesicle (EV) released by budding or shedding from the plasma membrane of activated or apoptotic cells. MPs are detected in nasal lavage fluids (NLFs) and are now receiving attention as potential biomarkers to evaluate the degree of activation of immune cells and injury of structural cells in nasal mucosa of subjects with sinus disease. There are three types of epithelial-cell-derived MPs, which are defined by the expression of different epithelial specific markers on their surface: EpCAM, E-cadherin, and integrin β6 (ITGB6). When these markers are on MPs that are also carrying canonical EMT/mesenchymal markers (Snail (SNAI1); Slug (SNAI2); alpha-smooth muscle actin (αSMA, ACTA2)) or pro- and anti-coagulant molecules (tissue factor (TF); tissue plasminogen activator (tPA); plasminogen activator inhibitor-1 (PAI-1)), they provide insight as to the roles of epithelial activation for EMT or regulation of coagulation in the underlying disease. In this review, we discuss the potential of epithelial MPs as research tools to evaluate status of nasal mucosae of CRS patients in the lab, as well as biomarkers for management and treatment of CRS in the clinic.

Pathophysiological and Clinical Aspects of Chronic Rhinosinusitis: Current Concepts

Adult chronic rhinosinusitis (CRS) is a chronic inflammation of the mucosa of the nose and paranasal sinuses. According to the latest EPOS guidelines CRS should be regarded as primary or secondary with distinction between diffuse and localized disease. Further pathophysiologic research identified different inflammatory patterns leading to the term “endotyping of CRS.” The primary focus of endotyping is to define a dominant inflammatory type allowing for better orientation of therapy. The current approach proposes the differentiation between type 2 (eosinophilic) and non-type 2 inflammatory responses. In this review pathophysiological concepts of CRS will be discussed, focusing on the different inflammatory endotypes of T cells with special attention to the eosinophilic type 2 inflammatory response. The contribution of innate and adaptive immune system responses is presented. The possibility of endotyping based on sinonasal secretions sampling is brought to attention because it is indicative of corticosteroid responsiveness and available to most ENT surgeons. Furthermore, the clinical aspects of the three distinct phenotypes are analyzed in view of their characteristics, the related endoscopic findings, typical radiological imaging, histopathology findings, their relation toward allergy and obvious therapeutical implications. This overview will enable clinicians to relate pathophysiological patterns with clinical observations by explaining the different inflammatory mechanisms, hence providing a better understanding of therapy.

Sinus Microbiota in Patients With Eosinophilic and Non-Eosinophilic Chronic Rhinosinusitis With Nasal Polyps

Chronic rhinosinusitis with nasal polyps (CRSwNP) is characterized by Th2-skewed inflammation and increased colonization by Staphylococcus aureus. CRSwNP can be distinguished as eosinophilic (ECRSwNP) and non-eosinophilic (NECRSwNP) by the infiltration of eosinophils. The local microbiota plays an important role in the persistent inflammation of CRSwNP. To evaluate the bacterial community composition on the distinct types of CRSwNP patients, we collected nasal swabs from 16 ECRSwNP patients, 18 NECRSwNP patients, and 39 healthy control subjects. The microbiome structure for all the samples were analyzed by high-throughput 16S rRNA gene sequencing. Concentration of S. aureus was determined using TaqMan quantitative polymerase chain reaction (qPCR) targeting the nuclease (nuc) gene. The result showed significant differences in the sinus microbiome among healthy control subjects and CRSwNP patients. Microbiota community diversity was significantly lower in NECRSwNP samples compared to that of healthy control subjects. Interestingly, the abundance of several pathogenic bacteria was diverse between ECRSwNP and NECRSwNP patients. Although Staphylococcus prevailed in all groups, the abundance of Staphylococcus was significantly higher in the healthy control group than the ECRSwNP group. More importantly, the abundance of S. aureus was much higher in NECRSwNP patients. This study highlights that microbiota composition may contribute to the different clinical types of CRSwNP, inspiring new therapeutic strategies to resolve this chronic inflammation process.

Management of Chronic Rhinosinusitis with Nasal Polyposis in the Era of Biologics

Purpose of Review

Chronic rhinosinusitis with nasal polyposis (CRSwNP) is a phenotypic designation of the broader condition of chronic rhinosinusitis. The advent of targeted biologics has shown promise in targeting different aspects of the inflammatory pathway, yet there remains a lack of consensus on the correct timing and use of these medications. This review seeks to provide a concise update of the available literature on the pathophysiology of CRSwNP, the evolution and cost utility of biologics as it pertains to management of patients with CRSwNP, and evidence for each available biologic and its use in CRSwNP.

Recent Findings

There are two biologics with FDA approval for use in CRSwNP: dupilumab and omalizumab. Recent clinical trials of other biologic therapies targeting type 2 inflammatory pathways have also demonstrated efficacy both in symptom scores and nasal polyp reduction. However, studies have questioned the cost utility of these medications compared to other interventions. Furthermore, timing of use with respect to other interventions including surgery remains challenging.

Healthcare Resource Utilization for Chronic Rhinosinusitis in Older Adults

Objectives: Chronic rhinosinusitis (CRS) is a common and costly health problem in the United States. While often associated with younger adults, CRS can affect the elderly. As the aging population increases in the United States, the cost burden of CRS in older adults is important to assess. The objective of this study is to characterize healthcare resource utilization (HCRU) and healthcare expenditure (HCE) for CRS in this population. Methods: Patients meeting criteria for CRS with three years of continuous data were identified on IBM^® Marketscan Research Databases over a five-year period (2013–2017). Medication utilization, outpatient visits, surgery, and expenditures related to CRS were assessed for older adults (>65) and compared with other age groups. As a secondary analysis, multivariable generalized linear models were utilized to compare HCE while adjusting for baseline medication utilization. Results: A total of 238,825 patients met the inclusion criteria, of which 20,927 were older adults. Older adults had the highest overall prevalence of nasal polyps (10%) and asthma (16%) among adult groups. Surgery rate was lower than other adult groups, but medication utilization was the highest. Mean overall HCE at two years was highest in older adults (USD 2545 vs. 2298 in young adults). However, HCE was highest for the young adult group after adjusting for baseline medication usage. Conclusion: Older adults had a higher rate of CRS-related co-morbidities as well as the highest CRS-related medication utilization and unadjusted two-year HCE. Although the reasons for this are unclear, possibilities include greater disease severity and preference for medical versus surgical management. HCE for CRS is expected to increase as the aging population grows.

miR-1287-5p upregulation inhibits the EMT and pro-inflammatory cytokines in LPS-induced human nasal epithelial cells (HNECs)

BACKGROUND

Chronic rhinosinusitis is an intractable symptom that influences daily lives of patients. miR-1287-5p was discovered to play a suppressive role in cervical cancer and HBV-related infection.

PURPOSE

This study investigated the potential role of miR-1287-5p in the in-vitro model of chronic rhinosinusitis.

METHODS

GSE169376 dataset was analyzed and differential miRNAs in nasal mucosa tissues in the chronic rhinosinusitis group were screened out. LPS was used to treat HNECs for 12h, 24h and 48h. Cells underwent LPS treatment after SNAI1 downregulation, miR-1287-5p upregulation or pretreatment of the HMGB1 inhibitor, Glycyrrhizin. RT-PCR was used to measure the RNA expression of miR-1287-5p, SNAI1 and HMGB1. ELISA was used for the detection of IL-6, IL-8, TNF-α changes. Targetscan and starBase were used to predict the targets (SNAI1 and HMGB1) of miR-1287-5p. Dual-luciferase reporter assays were applied to validate this. Western blot was used to analyze the protein changes of Snai1, Vimentin, E-cadherin and HMGB1.

RESULTS

miR-1287-5p was downregulated in the chronic rhinosinusitis group and decreased after LPS treatment in HNECs. The upregulation of miR-1287-5p inhibited IL-6, IL-8, TNF-α and EMT. miR-1287-5p targeted and inhibited SNAI1 and HMGB1. SNAI1 downregulation led to inhibition in EMT while loss of HMGB1 contributed to the decrease in pro-inflammatory cytokines. Knockdown of SNAI1 decreased HMGB1, resulting in the reduction of pro-inflammatory cytokines while HMGB1 inhibitor reduced SNAI1 and thus suppressed the EMT process.

CONCLUSION

miR-1287-5p downregulation was associated with chronic rhinosinusitis and its upregulation inhibited the EMT and inflammation in LPS-induced HNECs through Snai1/HMGB1 pathway.

Estimating COVID-19 Infection and Severity Risks in Patients with Chronic Rhinosinusitis: A Korean Nationwide Cohort Study

Background

Basic studies suggest that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection can affect chronic rhinosinusitis (CRS), but there is unclear real-world evidence regarding the association of underlying CRS with the risk for SARS-CoV-2 infection and severe coronavirus disease 19 (COVID-19).

Objective

We aimed to determine whether CRS is associated with increased risk for SARS-CoV-2 infection and severe COVID-19.

Methods

Altogether, 219,959 adult patients who tested for SARS-CoV-2 in South Korea from January 1 to May 15, 2020 (excluding self-referral) were identified in this nested case-control study with propensity score matching. Data on SARS-CoV-2 test results and COVID-19 worsened outcomes (ie, the need for oxygen therapy, intensive care, or mechanical ventilation, and death) were obtained from the Health Insurance Review and Assessment Service of Korea.

Results

In this matched cohort, 380 of 12,217 patients with CRS (3.1%) tested positive for SARS-CoV-2 infection, compared with 310 patients without CRS (2.5%; adjusted odds ratio = 1.22; 95% confidence interval, 1.04-1.42). Moreover, 60 of 286 COVID-19 patients with CRS (21.0%) had severe COVID-19 outcomes, compared with 38 without CRS (13.3%; adjusted odds ratio = 1.71; 95% confidence interval, 1.09-2.71). Subgroup analysis identified that CRS patients with an absence of nasal polyps, prior intranasal corticosteroid use, or nonatopic type had a greater risk for SARS-CoV-2 infection and severe COVID-19 outcomes.

Conclusions

In patients with CRS, prior intranasal corticosteroid use, the absence of nasal polyps, or nonatopic type was associated with increased risk for SARS-CoV-2 infection and severe COVID-19 in the Korean nationwide cohort. Clinicians should be cautious in determining prognosis and care for patients with CRS amid the COVID-19 pandemic.

Chronic Rhinosinusitis with Nasal Polyps: Age and Disease Severity Differences in the Levels of Inflammatory Markers

Background and objectives: The aim of our study was to analyze the concentrations of inflammatory markers in the nasal tissue of patients with chronic rhinosinusitis with nasal polyps (CRSwNPs) and controls of different age groups, as well as to find associations between age, inflammation development, and NPs. Materials and methods: Patients were divided into two groups-patients with CRSwNPs and control subjects who had nasal surgery for another reason beside CRS. Our analysis was performed across three different age groups (18-30 years, 31-50 years, and 51 years and more). Tissue biopsies from the sinus cavity for all study participants were taken and frozen at -80 °C, until use. The concentrations of IL-1β, IL-2, IL-4, IL-5, IL-6, IL-7, IL-10, IL-13, IL-21, and IL-22, were quantified using a magnetic bead-based multiplex assay. Results: In the group aged 18-30 years, the levels of inflammatory markers IL-1, IL-2, IL-5, and IL-22 were significantly higher in patients with CRSwNPs than the control subjects. Among patients aged 31-50 years, significantly higher concentrations of IL-2, IL-4, IL-5, and IL-22 were recorded in patients with CRSwNPs, as compared to the control subjects. In the oldest group (aged 51 years and more), patients with CRSwNPs had significantly higher concentrations of IL-2, IL-4, and IL-22, as compared to the control group. In the CRSwNP group, only the concentration of IL-21 was significantly higher among patients aged 31-50 years, as compared with those aged 51 years and older (p = 0.013). Conclusions: IL-2 and IL-22 levels were significantly higher in patients with CRSwNP than the control, across all age groups. Only the concentration of IL-21 was higher among patients with CRSwNP in the middle age group, as compared to the oldest group. IL-2, IL-4, and IL-22 levels correlated with the severity of CRSwNPs. Elevated concentrations of IL-2, IL-4, and IL-22 were determined in patients' groups with higher sinonasal outcome test (SNOT-22) scores, pointing to more severe clinical symptoms.

Elevated mucus interleukin-17A levels are associated with increased prior sinus surgery for chronic rhinosinusitis

BACKGROUND

Recent advances in molecular biology have enabled the identification of potential inflammatory endotypes of chronic rhinosinusitis (CRS), with prior work suggesting differential short-term surgical outcome trajectories based on cytokine signatures. However, there is a paucity of data assessing long-term treatment failure and need for revision surgery based on inflammatory biomarkers.

METHODS

Retrospective analysis of prospectively collected cross-sectional data from 231 patients electing surgical therapy for CRS. Intraoperative mucus specimens were quantitatively sampled for inflammatory cytokines using a multiplex flow cytometric bead assay. Univariate Spearman correlations between cytokine levels and prior number of surgeries were assessed. A stepwise adjusted multivariate Poisson regression analysis was used to model patient-reported prior sinus surgery counts as a function of cytokine levels.

RESULTS

Several cytokines (interleukin [IL]-1β, IL-4, IL-5, IL-6, IL-8, IL-10, IL-13, IL-17A, tumor necrosis factor α [TNF-α], interferon γ [IFN-γ], and eotaxin) demonstrated significant positive correlations with number of prior surgeries. However, only higher IL-17A levels were independently associated with a higher number of prior sinus surgeries (β = 0.345, p = 0.0003) after adjusting for the significant covariates of age (β = 0.018, p = 0.0036), Lund-Mackay score (β = -0.046, p = 0.02), history of aspirin-exacerbated respiratory disease (β = 1.01, p < 0.0001) and allergic fungal rhinosinusitis (β = 1.08, p < 0.0001). Higher levels of regulated on activation, normal T-cell expressed and secreted (RANTES) were conversely associated with a lower number of prior surgeries (β = -0.17, p = 0.048).

CONCLUSION

An IL-17A-predominant cytokine profile is linked to an increased number of prior sinus surgeries. Thus, type 3 inflammatory markers may indicate a particularly difficult-to-treat, recalcitrant CRS endotype.

[Neutrophil extracellular traps in the pathogenesis of chronic rhinosinusitis]

The review presents the current understanding of the pathogenesis of chronic rhinosinusitis. The causes of damage to the mucous membrane of the paranasal sinuses are most often the result of a combination of immunological, infectious and anatomical factors. This indicates the need for a multidisciplinary approach to the study of the pathogenesis of this pathology. There is no single universally recognized classification of chronic rhinosinusitis, which takes into account histological and immunological changes in the mucous membrane of the paranasal sinuses. The discovery of the mechanism of completion of the life cycle of neutrophils - the formation of a neutrophil extracellular trap or NETosis, different from necrosis and apoptosis, opened up new prospects in the study of the pathogenesis of inflammatory processes, including rhinosinusitis. Neutrophil extracellular traps reduce the permeability of the epithelial barrier in the mucous membrane of the paranasal sinuses. This determines their possible role in the etiopathogenesis of rhinosinusitis. In recent years, more and more attention has been paid to the feasibility, effectiveness and safety of therapy that affects the immune component of the inflammatory process, including NETosis. The data obtained in the study of extracellular traps can be used in clinical practice. It is neutrophil extracellular traps that can become a potential target in the treatment of patients with chronic rhinosinusitis.

Inflammatory heterogeneity in aspirin-exacerbated respiratory disease

BACKGROUND

Aspirin-exacerbated respiratory disease (AERD) is a mechanistically distinct subtype of chronic rhinosinusitis with nasal polyps (CRSwNP). Although frequently associated with type 2 inflammation, literature characterizing the milieu of inflammatory cytokines and lipid mediators in AERD has been conflicting.

OBJECTIVE

We sought to identify differences in the upper airway inflammatory signature between CRSwNP and AERD and determine whether endotypic subtypes of AERD may exist.

METHODS

Levels of 7 cytokines representative of type 1, type 2, and type 3 inflammation, and 21 lipid mediators were measured in nasal mucus from 109 patients with CRSwNP, 30 patients with AERD, and 64 non-CRS controls. Differences in inflammatory mediators were identified between groups, and patterns of inflammation among patients with AERD were determined by hierarchical cluster analysis.

RESULTS

AERD could be distinguished from CRSwNP by profound elevations in IL-5, IL-6, IL-13, and IFN-γ; however, significant heterogeneity existed between patients. Hierarchical cluster analysis identified 3 inflammatory subendotypes of AERD characterized by (1) low inflammatory burden, (2) high type 2 cytokines, and (3) comparatively low type 2 cytokines and high levels of type 1 and type 3 cytokines. Several lipid mediators were associated with asthma and sinonasal disease severity; however, lipid mediators showed less variability than cytokines.

CONCLUSIONS

AERD is associated with elevations in type 2 cytokines (IL-5 and IL-13) and the type 1 cytokine, IFN-γ. Among patients with AERD, the inflammatory signature is heterogeneous, supporting subendotypes of the disease. Variability in AERD immune signatures should be further clarified because this may predict clinical response to biologic medications that target type 2 inflammation.

Chronic rhinosinusitis: phenotypes and endotypes

PURPOSE OF REVIEW

Chronic rhinosinusitis (CRS) is a broad classification of airway inflammation that affects a significant portion of the population. The current model of delineating patients suffering from CRS is dated and is no longer as simple as the presence of polyps or no polyps. Continued advances in the endotype descriptions of CRS have allowed for new phenotypic descriptions that aid in driving management and research efforts.

RECENT FINDINGS

Geographic differences exist between patient presentations, which require a molecular evaluation of the driving forces. Increased understanding of these differences allows for patient-specific treatment decisions.

SUMMARY

New descriptions of CRS phenotypes allow for more targeted therapy for patients, particularly to those with difficult to control disease. The previously broad classification of CRS with or without nasal polyps is no longer sufficient at driving these treatment decisions.

Operative and postoperative outcomes in elderly patients undergoing endoscopic sinus surgery

PURPOSE

Chronic rhinosinusitis (CRS) is increasingly common in the elderly population (≥ 65 years old). Compared to their younger counterparts, differences exist in the etiology of CRS and outcomes of Endoscopic Sinus Surgery (ESS) for elderly patients. The aim of this study is to determine if differences in surgical outcomes are present between these two patient populations to facilitate patient pre-operative counseling by their healthcare providers.

METHODS

Retrospective chart review conducted at a single tertiary care center for patients undergoing ESS between June 2014 and June 2019. Patients were classified into two cohorts (adult and elderly) based on age (< 65 and ≥ 65 years old). Demographics, surgical, and postoperative variables were extracted from our institution's electronic medical records. ANOVA and t-test analysis were performed to determine the presence of significant differences between the two cohorts. SNOT-22 scores were used to determine QOL improvements.

RESULTS

Compared to the adult cohort, elderly patients had significant QOL improvement after surgical treatment (p = 0.001), but had a similar successful response to treatment (p = 0.74). Elderly patients had no difference in the incidence of operative/perioperative complications (p = 0.89) or intraoperative or postoperative bleeding (p = 0.301, p = 0.62), but had an increased incidence of postoperative infection (p = 0.000).

CONCLUSION

ESS remains an effective treatment modality for the management of CRS, and a safe practice for elderly patients despite the increase in complexity of their medical comorbidities and polypharmacy. QOL improvements are significant, though patient counseling should take into account that improvements may not be as pronounced as in younger patients.

Presentation and outcomes of chronic rhinosinusitis following liver and kidney transplant

Objective

This study aims to describe presenting characteristics of patients diagnosed with non-invasive chronic rhinosinusitis (CRS) following liver or kidney transplant and determine factors associated with disease-related complications, selection of endoscopic sinus surgery (ESS), and disease resolution in this population.

Study design

Retrospective chart review.

Setting

An academic tertiary care center (Mayo Clinic, Rochester, Minnesota).

Subjects and methods

Liver and kidney transplant recipients evaluated by Mayo Clinic otolaryngologists for CRS between 1998 and 2018 were identified. Univariate and multivariate logistic regression analyses were used to determine patient factors and treatment modalities associated with developing complications, selection of ESS, and disease resolution.

Results

Fifty-seven patients met inclusion criteria. No patients developed intraorbital or intracranial complications of their CRS. Multivariate modeling demonstrated that the presence of polyps (P = 0.036) was associated with undergoing ESS within one year of presentation. A higher Lund–Mackay (LM) computed tomography score (P = 0.023) and older age (P = 0.018) were significantly associated with decreased disease resolution. No other factors were significantly associated with the use of endoscopic sinus surgery within one year of otolaryngology presentation or resolution of CRS in this cohort.

Conclusion

The risk of developing CRS-related intraorbital or intracranial complications in this immunecompromised patient cohort may be lower than originally thought. For liver- and kidney-recipients stable on immunosuppressive medication for many years, prognostic factors for CRS may mirror those for immunocompetent patients.

Phenotypes in Chronic Rhinosinusitis

PURPOSE OF REVIEW

Chronic rhinosinusitis (CRS) is a heterogenous disease process affecting a significant proportion of the population and impacting quality of life and productivity. Historically, CRS has been classified broadly into CRS with nasal polyps (CRSwNP) and CRS without nasal polyps (CRSsNP). Increased understanding regarding unique presentations of CRS subsets and their underlying inflammatory profiles has led to a new system for classifying CRS phenotypes.

RECENT FINDINGS

Consideration of CRS phenotypes has traditionally been a key factor in determining treatment paradigms. Under a new phenotype classification system, physical findings will continue to drive treatment decisions, but with more precision. Recent rapidly accumulated knowledge indicates that the broad categorization of CRSwNP or CRSsNP is no longer clinically useful. Reorganization of CRS phenotypes and their underlying endotypes will lead to more targeted and efficacious therapy.

Differences in self-reported symptoms in patients with chronic odontogenic and non-odontogenic rhinosinusitis

PURPOSE

To evaluate the possible differences in self-reported symptoms between patients with chronic odontogenic rhinosinusitis (CORS) and patients with chronic non-odontogenic rhinosinusitis (CnORS).

MATERIALS AND METHODS

The study included 64 patients diagnosed with chronic rhinosinusitis according to EPOS guidelines. 32 patients had CORS, and the control group were 32 patients with CnORS. Patients were matched according to gender and age. All the patients underwent a CT scan evaluated by a radiologist, and were evaluated by an oral surgeon and otorhinolaryngologist before being assigned to one of the groups. The severity of the symptoms was assessed through questioners SNOT-22 (sino-nasal outcome test) and VAS (visual analogue scale) symptom score. Kolmogorov-Smirnov's, Fisher's and Mann-Whitney U test were used in the statistical analysis of the data.

RESULTS

People with CORS show similar symptomatology on SNOT-22 score to patients with CnORS, with no significant statistical difference between any of the SNOT-22 symptoms. VAS symptom score showed that odontogenic group had a significantly higher score for fever (p = .004) and halitosis (p = .003).

CONCLUSION

Halitosis and fever might be the most important symptoms in differentiating between CORS and CnORS symptomatology. Better diagnostic tools, such as VAS symptom score might help medical professionals to be quicker at recognizing CORS specific symptomatology, and help them treat the disease as early and adequately as possible.

Age-associated changes in chronic rhinosinusitis endotypes

BACKGROUND

Immunologic function in innate and adaptive immunity changes with the ageing process. Thus, age-related cytokine profiles in chronic rhinosinusitis (CRS) need to be investigated for precision medicine.

OBJECTIVE

The objective of this study was to characterize age-related changes in immunologic profiles according to CRS subtypes.

METHODS

Subjects in control (n = 29), CRS without nasal polyps (CRSsNP, n = 86), and CRS with nasal polyps (eosinophilic NP: ENP, n = 81; non-eosinophilic NP: NENP, n = 113) were enrolled in this study. Twenty markers for type 1/2/3 inflammation and other inflammatory processes were measured in homogenates of sinonasal tissues and statistically analysed.

RESULTS

In control tissues, type 2/3 and proinflammatory mediators showed an inverse correlation with age. CRSsNP and NENP showed an age-related increase in type 2 cytokines and a decline in type 3 cytokines. Interestingly, the age-related decrease in type 3 mediators was associated with those of CT scores in NENP. ENP showed an age-related increase in type 3 cytokines with type 2 mediators sustained at high levels. Smokers with ENP demonstrated age-associated increases in type 1/2/3 mediators as well as CT scores. These age-related patterns in each CRS were confirmed by statistically adjusting atopy status, smoking history, and disease duration.

CONCLUSION

Age-associated cytokine changes differed among CRS subtypes and control tissues. CRSsNP and NENP demonstrated a decline in type 3 mediators and increase in type 2 mediators, whereas type 3 mediators increased with age in ENP.

Bacterial Flora of the Nose and Paranasal Sinuses Among Patients Over 65 Years Old with Chronic Rhinosinusitis Who Underwent Endoscopic Sinus Surgery

PURPOSE

Chronic rhinosinusitis (CRS) is one of the most common chronic diseases in the geriatric population. However, CRS inflammatory mechanisms in older people have not been thoroughly investigated. Our work aimed to analyze the bacterial flora of the nose and paranasal sinuses in patients with CRS over 65 years of age, including comorbidities, previously performed endoscopic sinus surgery (ESS), presence or absence of polyps and the extent of the inflammatory process.

PATIENTS AND METHODS

The study involved 529 patients between 18 and 84 years of age with chronic rhinosinusitis who underwent endoscopic sinus surgery. There were 101 patients separated over 65 years of age (M = 52, K = 49, mean age 69 ± 0.7 years). The control group consisted of 168 patients aged 18-40 years with CRS. The bacterial culture of material collected from the patients during ESS was analyzed.

RESULTS

In the group of patients over 65 years of age, more frequent occurrence of Proteus spp. and Pseudomonas aeruginosa was found in comparison to younger patients. In older patients with bronchial asthma, the occurrence of S. aureus, Escherichia coli, and Citrobacter spp. was more frequent than in control group. Multiple sinus surgical procedures in older patients were associated with the dominance of Staphylococcus aureus and Escherichia coli, which was not demonstrated in the control group. There were no statistically significant differences between the occurrence of bacterial strain and the presence of polyps, both in the group of patients over 65 years of age as well as in the control group.

CONCLUSION

The bacterial flora of patients with CRS is different in older and younger patients. A different therapeutic approach should be considered in older patients with CRS, but this problem requires further studies.

Use of endotypes, phenotypes, and inflammatory markers to guide treatment decisions in chronic rhinosinusitis

OBJECTIVE

With the advent of new treatment options for Chronic Rhinosinusitis (CRS) comes the ability for physicians to provide more individualized patient care. Physicians are now tasked with identifying who may be the best candidate for a particular therapy. In this review, existing biomarkers and potentially new methods that could guide treatment choices in CRS patients will be discussed.

DATA SOURCES

Published literature obtained through PubMed searches.

STUDY SELECTION

Studies relevant to inflammatory endotypes, phenotypes, and biomarkers in CRS were included.

RESULTS

Currently, there are no clinically validated tools that determine the best therapeutic modality for CRS patients with or without nasal polyps (CRSwNP or CRSsNP). Patients with CRS can be classified into three endotypes based on the presence of type 1, type 2, or type 3 inflammation. CRS endotypes can be influenced by age and geographic location. Clinical application however may be limited since endotyping current requires basic research laboratory support. Clinical symptoms may also predict inflammatory endotypes with smell loss being indicative of type 2 inflammation. Numbers of tissue and/or peripheral eosinophils as well as levels of IgE may predict disease severity in CRSwNP but not necessarily treatment responses. Unique clinical phenotypes or biomarkers are especially lacking that predict type 1 or type 3 inflammation in CRSwNP or type 1, type 2, or type 3 inflammation in CRSsNP.

CONCLUSION

While significant progress has been made in characterizing endotypes, phenotypes, and biomarkers in CRS, additional studies are needed to determine if and how these factors could assist physicians in providing more individualized clinical care.

Risk Factors for Acute Exacerbations in Elderly Asthma: What Makes Asthma in Older Adults Distinctive?

Purpose

Asthma in the elderly (EA; ≥ 65 years of age) is increasing, adding a heavy socioeconomic burden to the healthcare system. However, little is known about risk factors associated with acute exacerbations in EA patients. The objective of this study was to investigate risk factors for acute exacerbation in EA compared to non-elderly asthma (NEA).

Methods

We combined data from 3 adult asthma cohorts under a unified protocol and database. Asthmatic patients with regular follow-up during a 1-year period were selected from the cohorts to identify the risk factors predicting acute exacerbations in EA compared to NEA.

Results

We selected a total of 1,086 patients from the merged cohort. During the observation period, 503 and 583 patients were assigned to the EA and NEA groups, respectively. The exacerbation rate was 31.0% in the EA and 33.2% in the NEA group. Multivariate logistic regression analysis revealed fixed airway obstruction, chronic rhinosinusitis (CRS), and male sex as independent risk factors for exacerbation in the EA group. In the NEA group, exacerbation increased along with an increase in eosinophil count. Bayesian analysis of the interactions among clinical factors revealed that forced expiratory volume in 1 second/forced vital capacity was directly related to exacerbation in the EA group, and eosinophil count was related to exacerbation in the NEA group.

Conclusions

We suggest that fixed airway obstruction and CRS as the important clinical factors predicting acute exacerbations in EA, whereas in NEA, eosinophil count was the strong predictor of exacerbation.

Baseline mucus cytokines predict 22-item Sino-Nasal Outcome Test results after endoscopic sinus surgery

BACKGROUND

Mucus cytokines have been linked to baseline metrics of quality of life and olfactory function in patients with chronic rhinosinusitis (CRS). However, their potential utility in predicting postoperative outcomes has not been assessed. Therefore, in this study we evaluated the role of mucus cytokines in predicting 22-item Sino-Nasal Outcomes Test (SNOT-22) scores after endoscopic sinus surgery (ESS) in a prospective cohort of CRS patients.

METHODS

One hundred forty-seven patients with CRS electing surgical therapy were enrolled in a longitudinal cohort study. Mucus was collected intraoperatively from the middle meatus and tested for interleukin (IL)-1β, IL-2, -4, -5, -6, -7,- 8, -9, -10, -12, -13, -17A, and -21; tumor necrosis factor (TNF)-α; interferon-γ; eotaxin; and RANTES (regulated-on-activation, normal T-cell expressed and secreted) expression using a multiplex flow-cytometric bead assay. Sixty-two patients were followed postoperatively (average, 10.2 months) with baseline and follow-up SNOT-22 surveys. Stepwise multivariate linear regression was used to model relationships between baseline cytokines, phenotype, and average postoperative SNOT-22 total and domain scores. A machine learning approach using a random forest algorithm was also used to investigate potential nonlinear relationships.

RESULTS

IL-5 was an independent predictor of postoperative total SNOT-22 improvement (β = -8.8, p < 0.0001), whereas IL-2 levels predicted postoperative worsening (β = 6.97, p = 0.0015). Similar relationships were also seen for postoperative SNOT-22 domain scores. The overall model was also noted to be significant fit for the data (adjusted R² = 0.398, p < 0.0001). The random forest model similarly identified IL-5, TNF-α, IL-13, and IL-2 as major predictors of postoperative SNOT-22 scores.

CONCLUSION

Mucus cytokine profiles may help identify CRS patients who are likely to obtain postoperative improvement after ESS.

Advanced age adversely affects chronic rhinosinusitis surgical outcomes

BACKGROUND

Patient-specific and disease-specific factors shape the course of chronic rhinosinusitis (CRS) and its response to treatment, with optimal management involving interventions tailored to these factors. Recent evidence suggests CRS inflammatory signatures depend on age. The objective of this study was to determine whether age also influences quality-of-life (QOL) and postoperative outcomes.

METHODS

Retrospective analysis of prospectively collected QOL data from 403 adults with medically refractory CRS who underwent functional endoscopic sinus surgery (FESS) at a tertiary care medical center between 2014 and 2018 was undertaken. Total and subdomain scores from the 22-item Sino-Nasal Outcome Test (SNOT-22) and the Short Form 8 Health Survey (SF-8) measure of general health completed at preoperative and postoperative visits were reviewed.

RESULTS

Patients were divided into young (18 to 39 years, n = 100), middle-aged (40 to 59 years, n = 172), and elderly (≥60 years, n = 131) groups. Baseline total SNOT-22 scores differed between groups (p = 0.01), with middle-aged patients having the highest symptom burden and elderly patients having the lowest. Similar patterns were observed for SNOT-22 subdomains. Elderly patients reported smaller improvements and were less likely to achieve a minimally important clinical difference. CRS patients had worse SF-8 scores compared to the general population, and elderly patients were the least likely to match population norms following surgery. Age was an independent predictor of QOL outcomes after FESS.

CONCLUSION

Age may play a significant role in CRS pathophysiology, symptom burden, and surgical outcomes. Elderly patients report smaller improvements in disease-specific and general health QOL after surgery. CRS management in the elderly population should incorporate age-dependent differences in symptom burden and expectations into treatment algorithms.

Chronic Rhinosinusitis with Nasal Polyps in Older Adults: Clinical Presentation, Pathophysiology, and Comorbidity

PURPOSE OF REVIEW

Chronic rhinosinusitis and nasal polyps (CRSwNP) is a common condition that significantly affects patients' life. This work aims to provide an up-to-date overview of CRSwNP in older adults, focusing on its aging-related clinical presentations, pathophysiology, and comorbidity associations including asthma.

RECENT FINDINGS

Recent large population-based studies using nasal endoscopy have shown that CRSwNP is a mostly late-onset disease. Age-related changes in physiologic functions, including nasal epithelial barrier dysfunction, may underlie the incidence and different clinical presentations of CRSwNP in older adults. However, there is still a paucity of evidence on the effect of aging on phenotypes and endotypes of CRSwNP. Meanwhile, late-onset asthma is a major comorbid condition in patients with CRSwNP; they frequently present with type 2 inflammatory signatures that are refractory to conventional treatments when they are comorbid. However, as they are more commonly non-atopic, causative factors other than classical atopic sensitization, such as Staphylococcus aureus specific IgE sensitization, are suggested to drive the type 2 inflammation. There are additional comorbidity associations in older patients with CRSwNP, including those with chronic otitis media and head and neck malignancy. Age is a major determinant for the incidence and clinical presentations of CRSwNP. Given the heterogeneity in phenotypes and endotypes, longitudinal investigations are warranted to elucidate the effects of aging on CRSwNP.

Neutrophils as a Protagonist and Target in Chronic Rhinosinusitis

Neutrophils have traditionally been acknowledged as the first immune cells that are recruited to inflamed tissues during acute inflammation. By contrast, their importance in the context of chronic inflammation has been studied in less depth. Neutrophils can be recruited and are largely present in the nasal mucosa of patients with chronic rhinosinusitis (CRS) both in Asians and in Caucasians. Increased infiltration of neutrophils in patients with CRS has been linked to poor corticosteroid response and disease prognosis. Meanwhile, tissue neutrophils may possess specific phenotypic features distinguishing them from resting blood counterparts and are endowed with particular functions, such as cytokines and chemokines production, thus may contribute to the pathogenesis of CRS. This review aims to summarize our current understanding of the pathophysiologic mechanisms of CRS, with a focus on the roles of neutrophils. We discuss recruitment, function, and regulation of neutrophils in CRS and outline the potential therapeutic strategies targeting neutrophils.