The value of biomarkers in the therapy of CRSwNP with biologicals-a long-term follow-up of dupilumab therapy

PURPOSE

Since its release, Dupilumab has shown great results in treating severe uncontrolled CRSwNP. However, there is a lack of real-world data beyond 12 months of follow-up, and it is not clear to what extent biomarkers are appropriate for monitoring and predicting the Dupilumab therapy success. Hence, this study aims to analyze biomarkers for monitoring therapy, predicting therapy success and assess the effect of Dupilumab in real-world settings.

METHODS

The follow-up was performed with 104 patients retrospectively up to 22 months, assessing SNOT-22, NPS, olfactometry, ACS, FEV-1, and blood biomarkers (total serum IgE, Eosinophils, ECP). Patients were divided into subgroups depending on their pretherapeutic biomarker levels and subsequent development was analyzed.

RESULTS

There was substantially improvement in all clinical parameters up to 1 year and then continuously up to month 22. Patients with initially elevated baseline blood eosinophil counts (> 0.5 billion/L) had a trend of better SNOT-22 development after 1 year (- 12.19 points, p = 0.03). The course of total serum IgE showed moderate correlation with almost all clinical variables obtained. Therapy was well tolerated with only mild and transient adverse events.

CONCLUSION

Dupilumab has considerably reduced symptoms and disease severity even beyond 1 year of treatment, supporting its role as targeted and effective treatment option for CRSwNP. Our data shows that total serum IgE is a promising biomarker for the monitoring during the treatment with Dupilumab. Elevated pre-therapeutic serum eosinophil counts may be a predictor of good subjective response to therapy. Larger cohorts and a long-term-follow-up over years are needed to further consolidate these findings.

The Impact of Dupilumab on Work Productivity and Emotional Health in CRSwNP: A Multicentric Study in Northeast Italy

Chronic rhinosinusitis with nasal polyps (CRSwNP) in the severe forms is associated with a poor quality of life. Dupilumab has been suggested as an add-on treatment option for severe CRSwNP. Severe CRSwNP patients treated with Dupilumab in different rhinological units were considered for this study via their evaluation at the baseline at first and the consequential follow-up at 6-, 12-, and 24 months from the first administration. At baseline (T0) and at each follow-up, patients underwent NPS, Sinonasal Outcome Test (SNOT)-22, Visual Analogue Scale (VAS) for smell, and Sniffin' sticks identification test (SSIT). The SNOT-22 domains for function and emotion were also analysed separately. Two hundred and seventeen patients with at least 6 months of follow-up were included. All parameters have improved during treatment (p < 0.0001). Noticeably, both the function and emotion SNOT-22 domains have improved within 6 months of treatment and have continued to progress during every interval within 12 months from the baseline, positively influencing patients' emotivity and augmenting their social and economic performances. Dupilumab improves the QoL of CRSwNP patients with good effects on the reported productivity and emotional health. Clinicians should pay attention to these two aspects when dealing with patients affected by severe CRSwNP.

Nasal polyp syndrome: a patient-centred term for CRSwNP by EUFOREA

Chronic Rhinosinusitis with Nasal Polyps (CRSwNP) is a chronic inflammatory disease of the nose and paranasal sinus cavities that significantly affects well-being and social function, particularly in young adults and middle-aged populations. CRSwNP is a common health condition in the Western world, with an estimated prevalence of 3%. Despite worldwide evidence-based treatment guidelines such as the European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS) 2020 and the European Forum for Research and Education in Allergy and Airway Diseases (EUFOREA) chronic rhinosinusitis (CRS) pocket guide, a significant number of patients remain undiagnosed and/or uncontrolled with repeated oral corticosteroids (OCS) treatments and/or (multiple) endoscopic sinus surgeries (ESS).

Clinical symptoms of chronic rhinosinusitis with nasal polyps (eosinophilic and non-eosinophilic) are related to sinus computed tomography but not to endoscopic findings

BACKGROUND

In the clinical assessment of chronic rhinosinusitis with nasal polyps (CRSwNP), evaluation of symptoms, nasoendoscopy findings and sinus computed tomography (CT) scan staging is employed in the management plan. Although prior studies have been done to assess the correlation of the three modalities in CRSwNP, such evaluation in patients with eosinophilic and non-eosinophilic types of CRSwNP requires further investigation. The aim of this study was to correlate the sinus CT scan staging to symptom and endoscopic scores in both types of CRSwNP.

MATERIAL AND METHOD

Patients with CRSwNP were classified into 2 types, eosinophilic and non-eosinophilic. Both types were assessed by Sino-Nasal Outcome Test 22 (SNOT-22) symptom score, nasal endoscopy Lund Kennedy grading (LK) score and sinus CT Lund Mackay (LM) staging score. All three modalities were correlated.

RESULTS

Forty-four patients were recruited for this study. There was significant correlation between sinus CT and symptom scores in the eosinophilic (r=.51, p=.031) and the non-eosinophilic (r=.76, p<.001) types. There was no significant correlation between symptom and nasoendoscopic scores in the eosinophilic (r=.12, p=.641) and the non-eosinophilic (r=.22, p=.276) types. There was also no significant correlation between sinus CT and nasoendoscopic scores in the eosinophilic (r=.20, p=.418) and the non-eosinophilic (r=.14, p=.508) types.

CONCLUSIONS

Sinus CT staging correlates well with the symptom score for both the eosinophilic and the non-eosinophilic types of CRSwNP. The good correlation suggests both modalities are a reliable guide for their evaluation and management planning.

Patients Unmet Needs in Chronic Rhinosinusitis With Nasal Polyps Care: A Patient Advisory Board Statement of EUFOREA

Background: European patients with chronic rhinosinusitis with nasal polyps (CRSwNP) have had only limited occasions to unite to have their voices heard, hence missing the opportunity to contribute to the improvement of CRSwNP care.

Aims: To identify unmet needs in CRSwNP from the perspective of CRSwNP patients from the Patient Advisory Board (PAB) of the European Forum for Research and Education in Allergy and Airways diseases (EUFOREA).

Methodology: Semi-structured interviews were conducted individually with 15 European patients with CRSwNP and with a disease history of more than 2 years. Patients shared their burden of the disease and frustrations related to CRSwNP care, experiences with key pillars of current treatment options, shortcomings of the current care pathways and recommendations for improvement of care. A panel of 30 members of the Patient Advisory Board reviewed the interview report and provided further input during 2 virtual meetings.

Results: CRSwNP patients indicated the need for greater awareness from society and physicians of the disease burden with impact on social function and well-being. Along with a loss of ability to smell and the continuous presence of secretions in the nose, most patients reported poor sleep quality and psychological impact as the most bothersome symptoms. Patients' frustrations relate primarily to the underestimation of the disease burden, the lack of coordination of care and the limited treatment options available to them. Treatment options with oral corticosteroids and/or sinus surgery both have positive and negative aspects, including the lack of long-lasting efficacy. Better coordination of care, more patient-centered care, greater public awareness, increases in research on the disease mechanisms and better therapeutic options would be warmly welcomed by CRSwNP patients.

Conclusions: This statement of the EUFOREA Patient Advisory Board on CRSwNP provides novel insights on the underestimation of the burden of CRSwNP and shortcomings of current care. Multiple recommendations made by the patients can underpin action plans for implementation of better care for CRSwNP among all physicians treating patients with this disabling disease.

Clinical symptoms of chronic rhinosinusitis with nasal polyps (eosinophilic and non-eosinophilic) are related to sinus computed tomography but not to endoscopic findings

BACKGROUND

In the clinical assessment of chronic rhinosinusitis with nasal polyps (CRSwNP), evaluation of symptoms, nasoendoscopy findings and sinus computed tomography (CT) scan staging is employed in the management plan. Although prior studies have been done to assess the correlation of the three modalities in CRSwNP, such evaluation in patients with eosinophilic and non-eosinophilic types of CRSwNP requires further investigation. The aim of this study was to correlate the sinus CT scan staging to symptom and endoscopic scores in both types of CRSwNP.

MATERIAL AND METHOD

Patients with CRSwNP were classified into 2 types, eosinophilic and non-eosinophilic. Both types were assessed by Sino-Nasal Outcome Test 22 (SNOT-22) symptom score, nasal endoscopy Lund Kennedy grading (LK) score and sinus CT Lund Mackay (LM) staging score. All three modalities were correlated.

RESULTS

Forty-four patients were recruited for this study. There was significant correlation between sinus CT and symptom scores in the eosinophilic (r=.51, p=.031) and the non-eosinophilic (r=.76, p<.001) types. There was no significant correlation between symptom and nasoendoscopic scores in the eosinophilic (r=.12, p=.641) and the non-eosinophilic (r=.22, p=.276) types. There was also no significant correlation between sinus CT and nasoendoscopic scores in the eosinophilic (r=.20, p=.418) and the non-eosinophilic (r=.14, p=.508) types.

CONCLUSIONS

Sinus CT staging correlates well with the symptom score for both the eosinophilic and the non-eosinophilic types of CRSwNP. The good correlation suggests both modalities are a reliable guide for their evaluation and management planning.

Burden of Disease in Chronic Rhinosinusitis with Nasal Polyps

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a predominantly type 2 inflammation-mediated disease of the nasal mucosa and paranasal sinuses with an under-recognized clinical, humanistic, and economic burden. Patients with CRSwNP experience a high symptom burden, including nasal congestion, loss of smell, and rhinorrhea, which has a negative impact on physical and mental health-related quality of life, including sleep quality. Existing medical and surgical interventions, including local and systemic corticosteroids and endoscopic sinus surgery, may be associated with recurrence of nasal polyps and associated symptoms and with an increased risk of short- and long-term adverse effects, especially with repeated or long-term use. Because type 2 inflammation is implicated in the pathogenesis of several coexisting diseases, patients with CRSwNP often have comorbid asthma and/or nonsteroidal anti-inflammatory drug-exacerbated respiratory disease. These patients, as well as those with high corticosteroid use and/or sinonasal surgical history, have more severe disease and associated symptom burden and represent a difficult-to-treat population under the existing management paradigm. This article reviews the clinical, humanistic, and economic burden of CRSwNP; it highlights the unmet need for effective and safe CRSwNP therapies that effectively control symptoms and minimize recurrence by targeting the underlying type 2 inflammatory disease pathophysiology.

[Management strategies for chronic rhinosinusitis with nasal polyps in adults]

INTRODUCTION

Chronic rhinosinusitis with nasal polyps (CRSwNP) is one of the categories of chronic rhinosinusitis and is defined by the presence of bilateral polyps. It is frequently associated with other conditions (asthma, atopy, aspirin intolerance), which worsen its prognosis.

STATE OF ART

The pathophysiology of CRSwNP is still poorly understood. The genesis of polyps is thought to be based on an initial epithelial lesion caused by environmental factors in the context of self-maintained chronic local inflammation. Multiple local and general factors can be involved in this inflammation, which is mainly of Th2 type in Europe. Abnormalities of the epithelial barrier and the immune system (eosinophilia, cytokines, T and B lymphocytes), genetic factors and pathogens, including Staphylococcus aureus, have been incriminated. The treatment of CRSwNP is mainly based on the application of local corticosteroids. Surgery remains an important part of patient management where CRSwNP becomes resistant to topical therapy. The management of CRSwNP may be at a turning point thanks to the arrival of biological therapies (anti-IgE, anti-IL-5, anti-IL-4/IL-13) the initial results of which are promising.

PERSPECTIVES/CONCLUSIONS

With the new concept of endotypes, current avenues of research are moving towards a better understanding of the inflammatory mechanisms of CRSwNP. Immunotherapy appears to be a promising future for the treatment of CRSwNP.

Evaluation of a Bioengineered Honey and Its Synthetic Equivalent as Novel Staphylococcus aureus Biofilm-Targeted Topical Therapies in Chronic Rhinosinusitis

Background

Chronic rhinosinusitis (CRS) is a common condition which affects the quality of life of millions of patients worldwide and has a significant impact on health-care resources. While Staphylococcus aureus bacterial biofilms play an important role in this disease, antimicrobial therapy is rarely effective and may promote antibiotic resistance. Thus, development of novel biofilm-targeting and antibiotic-sparing therapies is highly desirable and urgently required.

Objective

This in vitro study evaluated the antimicrobial activity of a novel synthetic honey-equivalent product which was designed to have the same reactive oxygen release profile as the engineered honey SurgihoneyRO™.

Methods

Treatment efficacy was investigated by assessment of planktonic growth, biofilm viability, thickness, and biomass using 12 CRS-related S. aureus mucosal bacterial strains.

Results

Both SurgihoneyRO™ and the synthetic honey-equivalent product inhibited growth of planktonic methicillin-resistant and methicillin-sensitive S. aureus strains, with the synthetic honey-equivalent product exhibiting a lower minimum inhibitory concentration. Treatment of established S. aureus biofilms reduced biofilm viability with 24-hour treatment resulting in a 2-log reduction in viability of biofilms formed by methicillin-resistant strains and a 1-log reduction in biofilms formed by methicillin-sensitive strains.

Conclusions

This preliminary study shows that the synthetic honey-equivalent product provides marked antimicrobial activity against S. aureus biofilms, with the potential for development in the clinical setting as an adjunctive biofilm-targeted therapy in CRS. The ultimate aim of such a product would be to reduce the need for antibiotics, steroids, and invasive surgical procedures in CRS patients as well as improving clinical outcomes following endoscopic sinus surgery.

Assessment of chronic sinonasal dysfunction and cross-cultural adaptation of the DyNaChron questionnaire

OBJECTIVE

Sinonasal pathologies generate six principal symptoms with major organic and psychosocial impact that can be studied on a self-administered questionnaire assessing chronic sinonasal dysfunction independently of etiology. The objective of the present study was to translate, culturally adapt and validate the DyNaChron questionnaire for Arabic-speaking Moroccan patients.

METHODS

The translation and cross-cultural adaptation of DyNaChron followed international guidelines. 164 patients filled out the questionnaire at day 0 and day 7 (without treatment) and day 60 after treatment. A prospective multicenter study validated the questionnaire for internal consistency, test-retest reliability and sensitivity to change.

RESULTS

Mean age was 35 years, with male predominance (63%). Nasal obstruction was the most frequent symptom (97.6%). Internal consistency on Cronbach alpha was high (0.97). Reproducibility on intraclass correlation (ICC) was excellent (0.84). Sensitivity to change was excellent for the majority of patients (effect size=0.97-6.69; SRM=2.47-6.74).

CONCLUSION

This study of a cross-cultural Moroccan adaptation of the DyNaChron questionnaire showed good validity, reproducibility and sensitivity to change, and better representation of all symptoms generated by chronic sinonasal dysfunction. It can be used to evaluate the psychosocial and organic impact of chronic sinonasal dysfunction and to assess treatment.

Peak nasal inspiratory flow correlates with quality of life in functional endoscopic sinus surgery

OBJECTIVES

Whilst nasal function and airflow improve subjectively following functional endoscopic sinus surgery (FESS), a clinically useful and objective tool for quantifying such improvement is lacking. The peak nasal inspiratory flow (PNIF) metre offers convenient and objective measures of nasal patency. However, it has not yet been established whether changes in PNIF after surgery reflect changes in subjective disease burden. In this study we aimed to determine whether changes in PNIF correlate with commonly used subjective symptom and quality of life outcome measures following FESS for chronic rhinosinusitis (CRS).

DESIGN

Prospective cohort.

SETTING

Royal National Throat Nose and Ear Hospital.

PARTICIPANTS

Thirty-seven patients undergoing FESS for CRS, with or without polyps (21 male, mean age 48.8).

MAIN OUTCOME MEASURES

PNIF, "SNOT-22", "NOSE" and "VAS" questionnaires were performed before and after surgery.

RESULTS

In all patients, there was a strong negative correlation between change in PNIF and change in "SNOT-22" score following surgery (Pearson r=-.64, P<.0001). Strong negative correlations were also seen during subgroup analysis of patients with and without polyps (r=-.57, P=.006 and r=-.67, P=.005, respectively). Change in PNIF correlated significantly with change in "NOSE" score following surgery in all patients and those without polyps (r=-.54, P=.0005 and r=-.68, P=.003). There were no significant correlations between PNIF and VAS (nasal obstruction).

CONCLUSIONS

Changes in PNIF after FESS appear to best reflect improvements in quality of life in CRS as measured using the "SNOT-22" questionnaire.

Single nucleotide polymorphisms related to cystic fibrosis in chronic rhinositus-a pilot study

BACKGROUND

The clinical association between cystic fibrosis (CF) and chronic rhinosinusitis (CRS) is well known. Studies have identified several non-CF transmembrane conductance regulator single nucleotide polymorphisms (SNPs) associated with disease severity in CF patients. We hypothesized that prevalence of these SNPs would be different between CRS patients and age/gender-matched non-CRS controls.

METHODS

This is a targeted SNP study of 1231 CRS patients identified through a large university hospital database who were compared with 8796 age- and gender-matched controls without a history of rhinitis, sinusitis, allergies, or asthma. Prevalence of 5 relevant SNPs was compared between groups, with p < 0.05 considered significant. Stratification by race and gender was performed among groups when statistically appropriate.

RESULTS

CRS patients exhibited a statistically significant (p = 0.036) lower prevalence of rs12883884 (associated with an ion transporter) compared with controls. This association was lost when patients were stratified by race. CRS patients manifested a greater prevalence of rs1403543 (chromosome 23) in both Caucasian and African American subgroups (p = 0.036 and p = 0.026, respectively). Statistical significance disappeared among Caucasians when stratified by gender, but persisted among African American women (p = 0.047). rs12188164 and rs12793173 were both more prevalent in African Americans with CRS than controls (p = 0.042 and p = 0.020, respectively). A trend was also observed for decreased prevalence of rs12883884 in CRS patients compared with controls in the African American subgroup (p = 0.086).

CONCLUSION

The identified SNPs were differentially prevalent in CRS compared with control groups, with some variability as a function of race and gender. Further research is required to confirm these findings and elucidate clinical significance.

Comorbidities of asthma and the unified airway

BACKGROUND

Asthma is a comorbid condition that may be seen by otolaryngic allergists when treating their patients with allergic rhinitis (AR). Often asthma is overlooked when aggressive treatment could prevent the development or progression of early disease.

METHODS

This article is a retrospective review of the current literature on asthma as a comorbidity of the unified airway. The unified airway and asthma are clearly defined. The epidemiology, morbidity, mortality, pathophysiologic mechanisms, and the chronicity of asthma are reviewed.

RESULTS

The otolaryngic allergist will become familiar the unified airway concept and the close relationships between AR, chronic rhinosinusitis, and asthma.

CONCLUSION

Otolaryngologists should be aware of the unified airway in order to most effectively treat their patients with AR. Knowledge of the close relationships between asthma and AR will help prevent progression of disease, identify early asthma, and improve the outcomes and quality of life for our patients.

WITHDRAWN: Systemic antibiotics for chronic rhinosinusitis without nasal polyps in adults

Review withdrawn from Issue 4, 2016. Review replaced by 'Systemic and topical antibiotics for chronic rhinosinusitis' (Head 2016).

The editorial group responsible for this previously published document have withdrawn it from publication.

Do patients with chronic rhinosinusitis benefit from consultation with an ENT-doctor?

CONCLUSION

By consulting an ENT-doctor, patients with chronic rhinosinusitis (CRS), in the general population, receive disease information and adjustment of treatment which can improve disease-specific Quality-of-Life and may improve objective measurements.

OBJECTIVES

This study aims to follow persons with clinical diagnosed CRS from the general population, to evaluate their benefit from consultation with an ENT-doctor in terms of severity of symptoms and Quality-of-Life.

METHODS

As part of a trans-European study, selected respondents to a survey questionnaire were invited for a clinical visit. Based on the European Position Paper on Rhinosinusitis and Nasal Polyps, persons were diagnosed with CRS and followed for 2 years. Quality-of-Life was measured using the Sino Nasal Outcome Test 22 and European Quality-of-Life - 5 Dimensions. Clinical examination included rhinoscopy, acoustic rhinometry, peak nasal inspiratory flow, smell test, and skin prick test.

RESULTS

Out of 91 persons with CRS, only 42% had previously consulted an ENT-doctor, and 51% were in current treatment for CRS. Most patients were advised medical treatment and 20% underwent surgery. Disease-specific Quality-of-Life, peak nasal inspiratory flow, olfactory function, and the nasal volume significantly increased over the 2-year period.

Cellular and molecular mechanisms of chronic rhinosinusitis and potential therapeutic strategies: review on cytokines, nuclear factor kappa B and transforming growth factor beta

BACKGROUND

Chronic rhinosinusitis is characterised by persistent inflammation of the sinonasal mucosa. Multiple pathophysiological mechanisms are likely to exist. Previous research has focused predominantly on T-helper type cytokines to highlight the inflammatory mechanisms. However, proteins such as nuclear factor kappa B and transforming growth factor beta are increasingly recognised to have important roles in sinonasal inflammation and tissue remodelling.

OBJECTIVE

This review article explores the roles of T-helper type cytokines, nuclear factor kappa B and transforming growth factor beta in the pathophysiological mechanisms of chronic rhinosinusitis. An understanding of these mechanisms will allow for better identification and classification of chronic rhinosinusitis endotypes, and, ultimately, improved therapeutic strategies.

The role of rhinosinusitis in severe asthma

The prevalence of asthma is approximately 5% to 10% in the general population. Of these, approximately 5% to 10% are severe asthmatics who respond poorly to asthmatic drugs, including high-dose inhaled steroids. Severe asthmatics have persistent symptoms, frequent symptom exacerbation, and severe airway obstruction even when taking high-dose inhaled steroids. The medical costs of treating severe asthmatics represent ~50% of the total healthcare costs for asthma. Risk factors for severe asthma are genetic and environmental, including many kinds of aeroallergens, β-blockers, and anti-inflammatory drugs. Gastroesophageal reflux disease and factors such as denial, anxiety, fear, depression, socioeconomic status, and alcohol consumption can exacerbate asthma. Rhinitis and asthma usually occur together. There is increasing evidence that allergic rhinitis and rhinosinusitis may influence the clinical course of asthma. This review discusses the role of rhinosinusitis in severe asthma.

Disease-specific quality-of-life questionnaires in rhinitis and rhinosinusitis: review and evaluation

Quality of life (QoL) measurements are the best approximation of the burden of disease for the patient. Patient-reported outcome measurements (PROMs) estimate health-related quality of life (HRQoL). PROMs can be generic or disease-specific. Generic PROMs allow comparisons between different diseases but can be relatively insensitive for measuring changes within a disease. Recommended QoL questionnaires in allergic rhinitis and rhinoconjunctivitis are the RQLQ (or adapted versions), in chronic rhinosinusitis, the SNOT-22 or RSOM-31, and in acute rhinosinusitis, the modified SNOT-16. PROMs can be used both for daily clinical work and for research. In daily practice, a quick evaluation of the questionnaire directly indicates how the patient is doing. It makes sure that symptoms important for the patient are not overlooked and, during the consultation, the physician can elaborate on specific aspects of the symptomatology. It is important, especially in research, to realize that disease-specific questionnaires are only validated for specific diseases and are not automatically valid for other diseases.

Chronic rhinosinusitis in Europe--an underestimated disease. A GA²LEN study

BACKGROUND

Chronic rhinosinusitis (CRS) is a common health problem, with significant medical costs and impact on general health. Even so, prevalence figures for Europe are unavailable. In this study, conducted by the GA²LEN network of excellence, the European Position Paper on Rhinosinusitis and nasal Polyps (EP³OS) diagnostic criteria are applied to estimate variation in the prevalence of Chronic rhinosinusitis (CRS) for Europe.

METHOD

A postal questionnaire was sent to a random sample of adults aged 15-75 years in 19 centres in Europe. Participants reported symptoms of CRS, and doctor diagnosed CRS, allergic rhinitis, age, gender and smoking history. Definition of CRS was based on the EP³OS diagnostic criteria: the presence of more than two of the symptoms: (i) nasal blockage, (ii) nasal discharge, (iii) facial pain/pressure or (iv) reduction in sense of smell, for >12 weeks in the past year--with at least one symptom being nasal blockage or discharge.

RESULTS

Information was obtained from 57,128 responders living in 19 centres in 12 countries. The overall prevalence of CRS by EP³OS criteria was 10.9% (range 6.9-27.1). CRS was more common in smokers than in nonsmokers (OR 1.7: 95% CI 1.6-1.9). The prevalence of self-reported physician-diagnosed CRS within centres was highly correlated with the prevalence of EP³OS-diagnosed CRS.

CONCLUSION

This is the first European international multicentre prevalence study of CRS. In this multicentre survey of adults in Europe, about one in ten participants had CRS with marked geographical variation. Smoking was associated with having CRS in all parts of Europe.

Systemic antibiotics for chronic rhinosinusitis without nasal polyps in adults

BACKGROUND

Chronic rhinosinusitis (CRS) is a common health problem which significantly affects quality of life. A wide range of medical and surgical therapies have been used to treat CRS. Both systemic and topical antibiotics are used with the aim of eliminating infection and inflammation, altering bacterial biofilm formation, reversing ostial occlusion and improving symptoms. Various groups of systemic antibiotics have been studied; clinical cure rates reported are inconsistent and range from 50% to 95%.

OBJECTIVES

To determine the effectiveness and adverse reactions associated with systemic antibiotic therapy for CRS in adults.

SEARCH STRATEGY

We searched the Cochrane ENT Group Trials Register; CENTRAL (2010, Issue 2); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ISRCTN and additional sources for published and unpublished trials. The date of the most recent search was 10 June 2010.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing systemic antibiotics with placebo for chronic rhinosinusitis in adults.

DATA COLLECTION AND ANALYSIS

Two authors extracted data independently, compared results and resolved disagreements by discussion. We assessed treatment effect by calculating the risk ratio (RR) and 95% confidence intervals (CI) of cure at a specific time point for each trial. We used mean difference (MD) and 95% CI for continuous variables (severity scores, duration of symptoms, etc.).

MAIN RESULTS

We included one study involving 64 patients. We assessed the overall risk of bias in this study as high. The study reported that roxithromycin could reduce the mean response score of patients by 0.73 points on a 1 to 6-point scale (95% CI 0.32 to 1.14, P = 0.0005) compared to those on placebo at three months after the start of treatment. This study also used sinonasal outcome test-20 (SNOT-20) comparing between pre and post-treatment at six, 12 and 24 weeks. The mean change in SNOT-20 from baseline at 24 weeks in the roxithromycin group was not significantly more than in the placebo group, at 0.27 points (95% CI -0.24 to 0.78, P = 0.30) on a 0 to 5-point scale.

AUTHORS' CONCLUSIONS

There is limited evidence from one small study to support the use of systemic antibiotics for the curative treatment of chronic rhinosinusitis in adults. Further good quality trials, with large sample sizes, are needed to evaluate the use of antibiotics in chronic rhinosinusitis.

United airways: the impact of chronic rhinosinusitis and nasal polyps in bronchiectasic patient's quality of life

BACKGROUND

The nose and the bronchi belong, in anatomical and physiopathological terms, to the concept of united airways. Associations between upper and lower airways diseases have been demonstrated in allergic rhinitis and asthma, nasal polyposis (NP) and asthma, chronic rhinosinusitis (CRS) and chronic obstructive pulmonary disease, and more recently CRS/NP and bronchiectasis (BQ).

OBJECTIVE

To evaluate the impact of CRS on quality of life (QoL) of patients with BQ, and to correlate these findings with the pulmonary status, nasal symptoms, and general health status.

METHODS

In a prospective study, patients with BQ (n = 80) were evaluated for CRS and NP using EP(3)OS criteria, and severity of BQ using chest high resolution computed tomography (HRCT)-scan. Quality of life was assessed in all patients by using specific [Sinonasal Outcome Test-20 (SNOT-20), St George Respiratory Questionnaire (SGRQ)], and generic (Short Form-36; SF-36) questionnaires.

RESULTS

Using SNOT-20, patients with CRS had worse QoL (2.1 +/- 0.1; P < 0.001) than patients without CRS (0.4 +/- 0.06). Using SGRQ total score, patients with CRS had worse QoL (43.7 +/- 2.2; P < 0.001) than patients without CRS (24.7 +/- 2.5). Using SF-36, patients with CRS had worse QoL, both in the physical summary (64 +/- 3.4; P < 0.05) and the mental summary (65.5 +/- 4.7; P < 0.05), than patients without CRS (physical summary [PS]: 76.2 +/- 3.3; mental summary [MS]: 78.3 +/- 5.3, respectively). Sinonasal Outcome Test-20 was correlated with SGRQ total score (r = 0.72; P < 0.01), and SF-36 physical summary (r = -0.63; P < 0.01). St George Respiratory Questionnaire was correlated with SF-36 on physical summary (r = -0.58; P < 0.05) and with forced expiratory volume in 1 s (r = -0.41; P < 0.05).

CONCLUSION

These results suggested that CRS, measured by both specific and generic questionnaires, has a considerable impact on the QoL of patients with BQ.

Chronic rhinosinusitis and nasal polyps: the role of generic and specific questionnaires on assessing its impact on patient's quality of life

Chronic rhinosinusitis (CRS) including nasal polyps is a chronic inflammatory disease of the nasal and paranasal sinus mucosa that, despite differing hypotheses of its cause, remains poorly understood. Primary symptoms are nasal blockage, loss of smell, rhinorrhea, and facial pain or pressure. Chronic rhinosinusitis causes significant physical symptoms, has a negative impact on quality of life (QoL), and can substantially impair daily functioning. A global evaluation of patients must include, together with nasal symptoms, nasal endoscopy, and CT scan, the measurement of QoL. To assess QoL in CRS, specific and generic questionnaires may be used. Chronic rhinosinusitis has a considerable impact on a patient's QoL but comorbidities, such as asthma and atopy, have an accumulative negative effect. Both medical and surgical treatments lead to a similar improvement on the QoL of CRS and nasal polyp patients.

Anti-inflammatory treatment of chronic rhinosinusitis: a shifting paradigm

Treatment of chronic rhinosinusitis still represents an unmet medical need. Presently, the US Food and Drug Administration has not approved any drugs for the treatment of this common condition. Various inflammatory processes are involved in the pathogenesis of chronic rhinosinusitis. Treatment of infection and surgical intervention to correct anatomic abnormalities often are inadequate in management when singly employed. Anti-inflammatory therapy such as topical cortico-steroids and more recently long-term, low-dose macrolide therapy has been integrated into the treatment algorithm for chronic rhinosinusitis. Better classification and point-of-care identification of inflammatory features may improve choice of anti-inflammatory therapy and thus outcome.

Quality-assessment of disease-specific quality of life questionnaires for rhinitis and rhinosinusitis: a systematic review

The aim of this systematic review was to give a quality-assessed review of the existing disease-specific health related quality of life (QOL) questionnaires concerning rhinitis and rhinosinusitis for adults. The quality is assessed by defining the characteristics of a QOL questionnaire with assessment criteria. The results of the construction, description, feasibility, and the psychometric performance of the instruments are provided. We finally provide a clinician's guide to choose a questionnaire based on the measurement goals, the discriminant validity, responsiveness and the points obtained in the quality assessment. Of the top scoring instruments regarding the overall quality assessment, only four health related QOL questionnaires for rhinitis and rhinosinusitis met our criteria for the discriminant validity and responsiveness.

Rhinitis, rhinosinusitis and quality of life in children

Quality of life (QoL) or, rather, health-related QoL, is currently regarded as a crucial aspect of the general well-being of patients and, in consequence, of the effects of a disease and its treatment. This is particularly true for respiratory allergy (asthma and rhinitis), which are chronic diseases and also for sinusitis (rhinosinusitis). A number of questionnaires (instruments), either generic or specific, have been developed and validated to assess the QoL in adults and children, for asthma and rhinitis, whereas there are few specific instruments for chronic rhinosinusitis. The literature provides strong evidence of the effects of allergic rhinitis, asthma and their treatments on QoL in paediatric patients, as well as in adults, whereas the number of experimental data on rhinosinusitis is limited, especially in children. Clinical trials evidenced some controversial points, mainly the weak correlation existing between QoL and traditional objective parameters. It has become clear that the QoL questionnaires measure the aspects of the disease that partially differ from the routinely evaluated parameters and that QoL should integrate, not replace, the objective measurements.

Anti-inflammatory treatment of chronic rhinosinusitis: A shifting paradigm

Treatment of chronic rhinosinusitis still represents an unmet medical need. Presently, the US Food and Drug Administration has not approved any drugs for the treatment of this common condition. Various inflammatory processes are involved in the pathogenesis of chronic rhinosinusitis. Treatment of infection and surgical intervention for correction of anatomical abnormalities often are inadequate in management when singly employed. Anti-inflammatory therapy such as topical cortico-steroids and more recently long-term, low-dose macrolide therapy have been integrated into the treatment algorithm for chronic rhinosinusitis. Better classification and point-of-care identification of inflammatory features may improve choice of anti-inflammatory therapy and thus outcome.

Radical surgery: effect on quality of life and pain in chronic rhinosinusitis

OBJECTIVES

Despite effective medical therapy and repetitive endoscopic sinus surgery in the treatment of chronic rhinosinusitis, there still remains a small group of patients without improvement of symptoms. This study evaluates the effect of radical surgery on quality of life and pain in these patients with recalcitrant disease.

STUDY DESIGN

A prospective, questionnaire-based study was conducted in 23 patients who underwent Denker's procedure for refractory chronic rhinosinusitis. Quality of life and pain were evaluated before surgery and 12 months and 2 years after surgery with the SF-36 and McGill Pain Questionnaire.

RESULTS

Seven of the eight mean scores of the SF-36 postoperatively improved after surgery, with statistical significance for Role Physical (RP) P=0.048. Bodily pain showed a strong tendency to significance. Results of the McGill Pain Questionnaire show a significant improvement in most of the subscores after surgery implying less pain.

CONCLUSION

Radical surgery improves the physical burden of chronic rhinosinusitis and pain experience in patients with therapy resistant chronic rhinosinusitis.

A meta-analysis demonstrates no significant differences between patient and population preferences

BACKGROUND AND OBJECTIVES

To summarize and quantify mean differences between directly elicited patient and population health state evaluations (= preferences) and to identify factors explaining these differences.

MATERIALS AND METHODS

Two meta-analyses of observational studies comparing directly elicited patient and population preferences for two stratified health state classifications: actual/hypothetical and hypothetical/hypothetical health states.

RESULTS

Thirty-three articles comparing directly elicited patient and population preferences were included, yielding 78 independent preference estimates. These preference estimates served as input for the two stratified health state classifications. Data on health state assessments, elicitation methods, assessment method, and population characteristics was extracted by one reviewer, and checked by two other reviewers. These parameters were used to explain sources of heterogeneity. Overall, patients' actual health state preferences were not significantly higher than populations hypothetical health state preferences (summary mean difference [SMD] = -0.01, 95% confidence interval [CI] = -0.01, 0.03). Nor did preferences for hypothetical health states differ between patients and population (SMD -0.00, 95% CI = -0.02, 0.02). Most parameters substantially influenced the SMD, although the magnitude and direction differed for the two strata used (all P-values <.05).

CONCLUSIONS

The actual/hypothetical and hypothetical/hypothetical meta-analyses demonstrated no significant differences between patient and population preferences, suggesting that both can be used to allocate scarce resources.

Reliability, validity and responsiveness of a Norwegian version of the Chronic Sinusitis Survey

BACKGROUND

The Chronic Sinusitis Survey (CSS) is a valid, disease-specific questionnaire for assessing health status and treatment effectiveness in chronic rhinosinusitis. In the present study, we developed a Norwegian version of the CSS and assessed its psychometric properties.

METHODS

In the pooled data set of 65 patients from a trial of treatment for chronic sinusitis with long-standing symptoms and signs of sinusitis on computed tomography (CT), we assessed the reliability, validity and responsiveness of the CSS.

RESULTS

Test-retest reliability of the two CSS scales and the total scale ranged 0.87-0.92, while internal consistency reliability ranged 0.31-0.55. CSS subscale scores were associated with other items on sinusitis symptoms, and with the Mental health and Bodily pain scale of the SF-36. There was little association of the CSS scale scores with sinus CT findings. The patients with chronic sinusitis had worse scores on all three CSS scales than a healthy reference population (n = 42) (p < 0.001). The CSS sinus symptoms subscale and the total scale were sensitive to improvement in global symptoms during 12 weeks.

CONCLUSION

The Norwegian version of the CSS had acceptable test-retest reliability, but lower internal consistency reliability than the accepted standard criteria. The results support the construct validity of the measure and the sinusitis symptoms subscale and the total scales were responsive to change. This supports the use of the questionnaire in interventions for chronic sinusitis, but points at problems with the internal consistency reliability.

Maximal medical therapy for chronic rhinosinusitis

Chronic rhinosinusitis (CRS) is widely recognized as one of the most common, if not the most common, chronic disease entities. This article discusses CRS without nasal polyposis. The discussion of maximal medical therapy concentrates on the best available evidence from published clinical trials.

[Quality of life. An important parameter in respiratory tract diseases]

Sinusitis is one of the most frequent diseases in humans. Despite severe complications sinusitis may be considered a non-serious disease compared to other illnesses. Therefore, sinusitis is sometimes erroneously regarded as a banal disorder. It is mostly unknown that patients suffering from sinusitis may have a marked impairment of their quality of life (QOL). The term health-related QOL comprises physical and psychological well-being as well as aspects of daily life and social life from the patient's perspective. Validated measures (questionnaires) are able to quantify the impairment of QOL as well as the influence of therapy on QOL. Especially in the treatment of sinusitis, QOL becomes a relevant additional parameter due to the fact that clinical and subjective, patient-based criteria do not correlate sufficiently. This article provides an overview of available QOL questionnaires on sinusitis, highlights results of QOL studies in sinusitis, and elucidates the relevance of QOL in clinical trials as well as in the relation between the physician and the patient.

Nasal polyposis and its impact on quality of life: comparison between the effects of medical and surgical treatments

BACKGROUND

Nasal polyposis (NP) is not a life-threatening disorder but may have a great impact on the quality of life (QoL). The objective of this study: (i) to investigate the health burden incurred by NP compared with the Spanish general population using the Short Form-36 Health Survey (SF-36) questionnaire; (ii) to compare the QoL outcome after medical or surgical treatment; and (iii) to assess and compare the effect of medical and surgical treatment on nasal symptoms.

METHODS

About 109 patients with nasal polyps were included. Fifty-three patients were randomly allocated to receive oral prednisone for 2 weeks and 56 to undergo endoscopic sinus surgery. All patients administered intranasal budesonide for 12 months. Patients were evaluated for nasal symptoms, polyp size, and QoL.

RESULTS

In comparison with the Spanish general population, patients with NP had worse scores on all SF-36 domains except for physical functioning. Nonasthmatic patients with NP had better QoL than asthmatic patients with NP on role physical functioning, body pain, and vitality (P <0.05). At 6 and 12 months, a significant improvement on all of SF-36 domains was observed after both medical and surgical treatment reaching the levels of general population (P <0.05). Nasal symptoms and polyp size improved after both medical and surgical treatment at 6 and 12 months (P <0.05).

CONCLUSION

These results suggest that NP has considerable impact on a patient's QoL and that both medical and surgical treatment led to similar effects in improving QoL.

Chronic rhinosinusitis: management for optimal outcomes

Chronic rhinosinusitis is characterized by nasal purulence accompanied by malaise, postnasal drip and nasal dryness or crusting. It is a condition that is very difficult to treat and can be very disabling to the patients. A clinical diagnosis is based on history and evaluation with endoscopy, and computerized tomographic scanning. The etiology of chronic rhinosinusitis is multifactorial and comprises a vicious cycle of pathophysiological, anatomical, and constitutive factors. Predisposing factors include ciliary impairment, allergy, nasal polyposis, and immune deficiency. Treatment is aimed at reducing mucosal inflammation and swelling, controlling infection, and restoring aeration of the nasal and sinus mucosa. The choice of treatment is influenced by many factors including past medication, duration of symptoms and the presence of allergy/nasal polyps. Pharmacologic treatment, with local or systemic corticosteroids such as mometasone furoate, fluticasone propionate, beclometasone dipropionate or oral prednisolone coupled with nasal lavage with isotonic saline solutions are the cornerstones of disease management. Systemic antibiotics including amoxicillin/clavulanic acid, ciprofloxacin, clarithromycin, and trimethoprim/sulfamethoxazole (cotrimoxazole) are often administered to patients with chronic sinusitis and underlying bacterial infection. In patients with underlying allergy, additional treatment with antihistamines should be considered. Aeration of the sinuses may temporarily be improved with local nasal decongestants such as oxymetazoline. If symptoms persist after aggressive medical treatment, surgery should be considered. Surgery should be functional and involve widening the natural drainage openings of the sinuses and preserving the ciliated epithelium as much as possible. In the case of nasal polyposis surgery is more aggressive involving removal of the diseased polypous mucosa. It is recommended that medical treatment should be continued post sinus surgery.

Measures of health-related quality of life for adults with acute sinusitis. A systematic review

CONTEXT

Symptoms suggestive of acute sinusitis are a common reason for patients to visit primary care providers. Since objective measures of outcome have not been shown to be related to patient reported outcomes, measures of treatment success have focused on symptom relief and improved health-related quality of life (HRQL). Assessing the appropriate role of treatment - for example, antibiotics for patients with acute sinusitis - requires valid, reliable, and responsive measures of outcome. We identified symptom scores and HRQL instruments for adults with sinusitis and assessed their performance characteristics.

DATA SOURCES

Articles identified through computer searches of the medline, premedline, and embase databases, the Cochrane Library, and internet documents; inquiries to experts in sinusitis and outcomes assessment; and review of reference lists.

STUDY SELECTION

Studies that used HRQL instruments or evaluated the performance characteristics of symptom scores in adults with sinusitis, published in English after 1966.

DATA EXTRACTION

Two reviewers independently extracted data on study design, setting, and patient characteristics; instrument length and format; and instrument validity, reliability, responsiveness to change, and interpretability. Study quality was assessed using a 10-point score.

DATA SYNTHESIS

Of 1,340 articles in the original search, 29 articles using 16 HRQL instruments and 5 symptoms scores met inclusion and exclusion criteria. The overall quality of these studies was low; only 4 studies scored higher than 4 of 10 points. Four studies included patients with acute sinusitis, but only 2 included exclusively acute sinusitis patients. Three instruments have been shown to meet basic requirements for validity, reliability, and responsiveness: the Chronic Sinusitis Survey, the Rhinosinusitis Outcome Measure-31, and the Sinonasal Outcome Test-16. No instrument has been validated in a primary care setting or for patients with acute sinusitis.

CONCLUSIONS

Few validated measures of sinusitis-specific HRQL are available. The 3 instruments shown to be valid, reliable, and responsive have been assessed in patients with chronic sinusitis. No measure has been validated in primary care settings or for patients with acute sinusitis. A lack of valid, responsive outcome measures may limit current treatment recommendations for patients with acute sinusitis.

A hampered chemoattractant-induced cytoskeletal rearrangement in granulocytes of patients with unexplained severe chronic and relapsing infections of the upper and lower airways. In vitro restoration by G-CSF exposure

Granulocytes play a major role in host defense against bacterial infections. Severe inborn defects in granulocyte function are associated with fulminant bacterial infections in early childhood. Subtle disturbances in granulocyte function might contribute to an enhanced susceptibility to bacterial infections in adulthood. We investigated chemoattractant (N-formyl-methionyl-leucyl-phenylalanine, fMLP and casein) induced cytoskeletal rearrangements (polarization) of blood granulocytes in 77 adults with chronic and recurrent therapy-resistant infections of the upper and lower airways. These infections could not be explained by B- and/or T-cell defects or local anatomic abnormalities. Besides polarization, chemotaxis of blood granulocytes was measured in 33 patients, as well as granulocyte superoxide production in eight patients. The chemoattractant-induced cytoskeletal rearrangement in patient blood granulocytes was significantly lower as compared to healthy control values with both fMLP and casein as stimuli. About two-thirds of the patients showed a defective polarization response to fMLP. Granulocyte colony-stimulating factor (G-CSF) when added in vitro corrected the defective polarization responses; responses in the normal range were not enhanced. The chemotactic motility of patient blood granulocytes was also slightly, but significantly lowered. However, it did not correlate to the lowered polarization. Granulocyte superoxide production was comparable in patients and in healthy controls. Our data thus show that subtle abnormalities in chemoattractant-induced cytoskeletal and motile function of blood granulocytes are frequent in patients with severe therapy-refractory bacterial infections of the upper and lower airways.