Air Pollution Exposure and the Development of Chronic Rhinosinusitis in the Active Duty Population

Long-Term Particulate Matter Exposure May Increase Risk of Chronic Rhinosinusitis WIth Nasal Polyposis: Results from an Exposure-Matched Study

BACKGROUND

Particulate matter ⩽2.5 µm in diameter (PM2.5) and its role in chronic rhinosinusitis (CRS) pathogenesis have gained heightened attention. We previously demonstrated that PM2.5 exposure may bias the nasal mucosa in CRS toward a Type 2 inflammatory pathway. However, there are limited data comparing cytokine changes in CRS sinonasal tissue to non-CRS patients as it relates to PM2.5 exposure. We hypothesized that long-term exposure preferentially increases the risk of manifesting CRS with nasal polyposis (CRSwNP).

METHODS

We performed a retrospective analysis of 376 patients (308 CRS, 68 controls) who underwent endoscopic sinus or skull base surgery. A spatiotemporal machine-learning model estimated daily PM2.5 levels for 1 year prior to each patient's surgery date. Cytokines were quantified using a multiplex flow cytometric bead assay and compared to estimated PM2.5 exposure using Spearman correlation and multivariate regression. Patients with high and low 12-month PM2.5 exposures were matched across age, sex, income, and rurality using a nearest neighbor algorithm. Multivariate adjusted logistic regression was used to estimate the odds of CRS based on PM2.5 exposure.

RESULTS

Reduced IL-10 levels were associated with higher PM2.5 exposures in control patients (β = -0.735, p = 0.0196). In exposure-matched logistic regression analysis, high 12-month PM2.5 exposure was an independent predictor of CRSwNP (β = 1.97, OR: 7.22, p = 0.0001) after adjustment for age, income, rurality, and comorbid asthma/allergic rhinitis. A similar relationship was not identified for CRSsNP.

CONCLUSIONS

PM2.5 exposure is associated with reduced IL-10 in control patients compared to CRS and may increase odds of CRSwNP development.

Characterizing air pollution exposure methodologies in rhinology: a scoping review

ABST RACTCharacterization of air pollution assessment methodologies in rhinologic disease research is lacking. A scoping review was thus conducted to survey exposure methods in studies examining common rhinologic conditions: allergic rhinitis (AR) and chronic rhinosinusitis (CRS). Several medical databases were queried for variables relating to (1) adults with a diagnosis of CRS or AR and (2) air pollution exposure. Data was extracted for pollutants assessed, method of quantifying exposure, assessment of residential stability, inclusion of authors with expertise in environmental exposure assessment, and disease-related outcomes. Thirty-four articles were included for analysis - 16 for AR and 18 for CRS. Fifteen studies originated from East Asia, 10 from North America, and 6 from Europe. The most common pollutant studied was PM2.5 (28 studies), with most studies investigating multiple pollutants. Twenty-one studies used a nearby air monitor to quantify exposure, 9 studies reported whether subjects had residential stability for the period assessed, and 17 studies included authors with climate science background. Timeframes included both acute and chronic exposure. Current methods to quantify air pollution exposure in rhinology vary considerably and inconsistently employ expertise from environmental scientists. Future investigations may benefit from multidisciplinary collaboration, reporting of residential stability, and standardized reporting metrics.

The Role of the Environment and Occupational Exposures in Chronic Rhinosinusitis

PURPOSE OF REVIEW

The purpose of the review is to summarize the current literature and evaluate how different environmental exposures may contribute to the development and course of chronic rhinosinusitis (CRS). The review aims to explore the relationship between host factors and environmental exposures in the pathogenesis of CRS.

RECENT FINDINGS

Recent studies have helped establish the role of air pollutants, tobacco smoke, occupational exposures, and microplastics in the pathogenesis of CRS. These exposures have been shown to cause epithelial dysfunction and promote inflammation through different mechanisms and to different degrees. The pathogenesis of CRS is complex and multifactorial, with environmental exposures playing a key role in its onset and exacerbation. Research indicates that pollutants can damage the sinonasal epithelial barrier and disrupt the microbiome, leading to increased inflammation. A deeper understanding of the mechanisms behind this inflammatory process and its link to environmental exposures could enhance strategies for preventing and treating CRS.

Ambient particulate matter and frequency of outpatient visits for chronic rhinosinusitis in the United States

BACKGROUND

Emerging evidence has underscored the harmful effects of air pollution on the upper airway. We investigated the relationship between ambient particulate matter (PM) level and the frequency of outpatient visits for chronic rhinosinusitis (CRS).

METHODS

We conducted an ecological cohort study of US adults enrolled in The Merative MarketScan outpatient database from 2007 to 2020. For each geographical subunit (core-based statistical area [CBSA]), we calculated the annual rate of CRS-related outpatient visits per 1000 well-patient checkup visits (CRS-OV). Using data from the Environmental Protection Agency's Air Quality System, we mapped the rolling statistical average of daily PM2.5 and PM10 over the preceding year onto each CBSA × year combination. We employed multivariable negative binomial regression modeling to estimate the association between PM levels and subsequent CRS-OV.

RESULTS

Across 3933 observations (CBSA × year combinations), encompassing ∼4 billion visits, the median CRS-OV was 164 (interquartile range 110-267). The mean PM2.5 level was 8.9 µg/m3 (SD 2.6) and the mean PM10 level was 20.2 µg/m3 (SD 7.2). Adjusting for patient demographics and respiratory comorbidities, a compounded rise in subsequent CRS-OV was observed with increasing PM levels. Each µg/m3 rise in PM2.5 independently predicted a 10% increase in CRS-OV (adjusted incidence rate ratio [aIRR]) 1.10, 95% confidence interval [CI] 1.08-1.13) and each µg/m3 rise in PM10 independently predicted a 3% increase in CRS-OV (aIRR 1.03, 95% CI 1.02-1.04).

CONCLUSION

Elevated ambient PM2.5 and PM10 levels are associated with a subsequent compounded increase in the frequency of CRS-OV, with PM2.5 predicting a more pronounced rise compared to PM10.

The Impact of Occupational Exposures on Chronic Rhinosinusitis: A Scoping Review

Chronic rhinosinusitis (CRS) is a prevalent and burdensome condition worldwide, characterized by inflammation of the paranasal sinuses. Ideally, instead of treating CRS, we would identify ways to prevent the development of this chronic condition. Occupational exposures may be an excellent target for prevention. Occupational exposures have been shown to play a critical role in the pathogenesis of multiple lower airway diseases, such as asthma, silicosis, asbestosis, and hypersensitivity pneumonitis. However, evidence for the association between occupational exposures and the development of upper airway disease, like CRS, is less well-defined. This manuscript examines the association between occupational exposures and CRS. A scoping review of the literature following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines identified 19 relevant studies. The populations examined and the methods and criteria used for defining CRS diagnosis and occupational variables significantly varied between the studies. Diagnosis of CRS was most often determined by self-reported symptoms or medical record review. Occupational variables ranged from employment status to occupation type to specific exogenous compounds encountered. Overall, substantial evidence demonstrates a general association between occupational exposures and CRS diagnosis; however, limitations in study methodologies, including variations in CRS diagnostic criteria, occupational exposures, assessment methods, and populations, hinder drawing more specific conclusions. Moving forward, rigorous research methodologies and standardized criteria are essential to draw conclusions supported by multiple studies. Critical components of future studies should include large, diverse populations, use of consensus CRS diagnostic criteria, and inclusion of many specific and quantitatively defined exposures. Ultimately, such efforts can help inform preventative measures and interventions for CRS, thus mitigating the burden of CRS on individuals and populations worldwide.

The Impact of Acute Peri-operative Particulate Matter Exposure on Endoscopic Sinus Surgery Outcomes: A Preliminary Multi-site Investigation

BACKGROUND

Environmental exposures have been postulated to play an important role in the pathophysiology of chronic rhinosinusitis (CRS). Particulate matter (PM) is one of the most widely studied ambient air pollutants, but its peri-operative impact on CRS is unknown.

OBJECTIVE

To determine the effect of acute, peri-operative PM exposure on outcomes after endoscopic sinus surgery (ESS).

METHODS

Participants with CRS who self-selected ESS were prospectively enrolled. The 22-item SinoNasal Outcome Test (SNOT-22) and Medical Outcomes Study Questionnaire Short-Form 6-D (SF-6D) health utility values scores were recorded. Using residence zip codes, a secondary analysis of patient exposure to PM <2.5 μm and <10 μm (PM2.5 and PM10, respectively) was performed for the month of surgery utilizing data from Environmental Protection Agency air quality monitors. Spearman's correlation coefficients (ρ), 95% confidence intervals (CIs), and effect estimates (β) were used to determine the magnitudes of association. Simple, multivariate regression analysis was also completed.

RESULTS

One hundred and seven patients from four geographically unique institutions across the US were enrolled with a follow-up of 6 months. Patients with higher peri-operative PM2.5 exposure had less improvement in their SNOT-22 scores after ESS compared to those with less exposure using both univariate analysis (ρ = 0.26, 95% CI: 0.08, 0.43; P  =  .01) and after covariate adjustment with multivariate analysis (B  =  1.06, 95% CI: 0.001, 2.14, P  =  .05). Similar associations were not found with SF-6D outcomes or with PM10 as an exposure of interest. No significant correlations were found between peri-operative PM levels and Lund-Kennedy endoscopy scores post-operatively.

CONCLUSION

Preliminary data from this pilot study reveal that PM exposure at the time of ESS may negatively associate with post-operative improvement in sinonasal quality-of-life. Larger, population-based studies with more standardized PM exposure windows are needed to confirm the clinical significance of the present findings.

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.

The Relationship between Fine Particle Matter (PM2.5) Exposure and Upper Respiratory Tract Diseases

PM2.5 is one of the most harmful components of airborne pollution and includes particles with diameters of less than 2.5 μm. Almost 90% of the world's population lives in areas with poor air quality exceeding the norms established by the WHO. PM2.5 exposure affects various organs and systems of the human body including the upper respiratory tract which is one of the most prone to its adverse effects. PM2.5 can disrupt nasal epithelial cell metabolism, decrease the integrity of the epithelial barrier, affect mucociliary clearance, and alter the inflammatory process in the nasal mucosa. Those effects may increase the chance of developing upper respiratory tract diseases in areas with high PM2.5 pollution. PM2.5's contribution to allergic rhinitis (AR) and rhinosinusitis was recently thoroughly investigated. Numerous studies demonstrated various mechanisms that occur when subjects with AR or rhinosinusitis are exposed to PM2.5. Various immunological changes and alterations in the nasal and sinonasal epithelia were reported. These changes may contribute to the observations that exposure to higher PM2.5 concentrations may increase AR and rhinosinusitis symptoms in patients and the number of clinical visits. Thus, studying novel strategies against PM2.5 has recently become the focus of researchers' attention. In this review, we summarize the current knowledge on the effects of PM2.5 on healthy upper respiratory tract mucosa and PM2.5's contribution to AR and rhinosinusitis. Finally, we summarize the current advances in developing strategies against PM2.5 particles' effects on the upper respiratory tract.

The Impact of Ambient and Wildfire Air Pollution on Rhinosinusitis and Olfactory Dysfunction

PURPOSE OF REVIEW

With increasing industrialization, exposure to ambient and wildfire air pollution is projected to increase, necessitating further research to elucidate the complex relationship between exposure and sinonasal disease. This review aims to summarize the role of ambient and wildfire air pollution in chronic rhinosinusitis (CRS) and olfactory dysfunction and provide a perspective on gaps in the literature.

RECENT FINDINGS

Based on an emerging body of evidence, exposure to ambient air pollutants is correlated with the development of chronic rhinosinusitis in healthy individuals and increased symptom severity in CRS patients. Studies have also found a robust relationship between long-term exposure to ambient air pollutants and olfactory dysfunction. Ambient air pollution exposure is increasingly recognized to impact the development and sequelae of sinonasal pathophysiology. Given the rising number of wildfire events and worsening impacts of climate change, further study of the impact of wildfire-related air pollution is a crucial emerging field.

The Impact of Social Determinants and Air Pollution on Healthcare Disparities in Chronic Rhinosinusitis With Nasal Polyps

BACKGROUND/OBJECTIVE

Multiple factors affect healthcare disparities in chronic rhinosinusitis (CRS) with and without nasal polyps. These factors include access to care, economic burdens to treatment, and differences in air pollution and air quality. In this paper, we will discuss how socioeconomic status, race, and air pollution burden influence healthcare disparities in the diagnosis and treatment outcomes of chronic rhinosinusitis with nasal polyps (CRSwNP).

METHODS

A literature search was performed via PubMed for articles related to CRSwNP, healthcare disparities, race, socioeconomic status, and air pollution in September 2022. Original studies from 2016 to 2022, landmark articles, and systematic reviews were included. We summarized these articles to cohesively discuss factors contributing to healthcare disparities in CRSwNP.

RESULTS

Literary search produced 35 articles. Individual factors such as socioeconomic status, race, and air pollution influence CRSwNP severity and treatment outcomes. Correlations were noted with socioeconomic status, race, and air pollution exposure and CRS severity and post-surgical outcomes. Air pollution exposure was also associated with histopathologic changes in CRSwNP. Lack of access to care was a notable contributor to healthcare disparities in CRS.

CONCLUSION

Healthcare disparities in the diagnosis and treatment of CRSwNP differentially affect racial minorities and individuals of lower socioeconomic status. Increased air pollution exposure in areas of lower socioeconomic status is a compounding factor. Clinician advocacy for greater healthcare access and reductions in environmental exposures for patients, among other societal changes, may help improve disparities.

Climate change, the environment, and rhinologic disease

BACKGROUND

The escalating negative impact of climate change on our environment has the potential to result in significant morbidity of rhinologic diseases.

METHODS

Evidence based review of examples of rhinologic diseases including allergic and nonallergic rhinitis, chronic rhinosinusitis, and allergic fungal rhinosinusitis was performed.

RESULTS

The lower socioeconomic population, including historically oppressed groups, will be disproportionately affected.

CONCLUSIONS

We need a systematic approach to improve healthcare database infrastructure and funding to promote diverse scientific collaboration to address these healthcare needs.