Cystic Fibrosis Increases Long-Term Revision Rates of Endoscopic Sinus Surgery in Patients With Comorbid Chronic Rhinosinusitis

Effects of Elexacaftor-Tezacaftor-Ivacaftor on Nasal and Sinus Symptoms in Children With Cystic Fibrosis

BACKGROUND

New CFTR Modulator triple therapy Elexacaftor-Ivacaftor-Tezacaftor (ETI) prove efficacy in pulmonary outcomes. However, its impact on nasal sinus symptoms in children has not been specifically studied. The aim of this study is to evaluate the impact of this therapy on nasal sinus symptomatology in children aged 6-12 years.

METHODS

A prospective, single-center cohort study was conducted over a 12-month follow-up period in children aged 6-12 years at the initiation of ETI therapy. The primary outcome was evolution of the SN-5 score, a validated pediatric questionnaire measuring quality of life related to nasal sinus symptoms. A decrease of 0.5 points is considered clinically significant. Secondary outcomes included changes in clinical examination findings (obstructive turbinate hypertrophy, polyps, presence of pus in the middle meatus, and externalized mucocele), quality of life measured by the Visual Analog Scale (VAS), and number of antibiotic courses during the study period.

RESULTS

Twenty-six patients were included between March and September 2023, with no lost to follow-up. The initial mean SN-5 score was 2.88 (95% CI {1.91; 3.85}). After 1 year, the mean SN-5 score was significantly lower (1.41, 95% CI {1.00; 1.88}, Delta = 1.47, p < 0.001). The VAS related to symptoms also improved (Delta = 1.7, p < 0.001), and the number of antibiotic courses decreased (25 vs. 69, p < 0.001). A trend toward improvement in clinical examination parameters was observed.

CONCLUSION

ETI therapy appears to significantly improve nasal sinus symptoms in children aged 6-12 years, as evidenced by improved quality-of-life scales and reduced antibiotic use.

Factors that predict pursuing sinus surgery in the era of highly effective modulator therapy

BACKGROUND

Comorbid chronic rhinosinusitis (CRS) remains unresolved for many people with cystic fibrosis (PwCF). While highly effective modulator therapy improves quality-of-life and symptom severity, the impact of this intervention and other factors associated with pursuing endoscopic sinus surgery (ESS) remains understudied.

METHODS

Adult PwCF + CRS were enrolled into a prospective, observational, multi-institutional study. Participants completed validated outcome measures to evaluate respiratory symptom severity, depression, headache, and sleep quality, as well as nasal endoscopy, sinus computed tomography (CT), and olfactory testing. Bivariate comparisons and regression modeling evaluated treatment cofactors, disease characteristics, and outcome measures associated with pursuing ESS.

RESULTS

Sixty PwCF were analyzed, including 24 (40%) who elected ESS. Pursuing ESS was associated with worse SinoNasal Outcome Test (SNOT-22) total, rhinologic, psychological, and sleep dysfunction domain scores; worse Patient Health Questionnaire-9-Revised depression scores; worse Pittsburgh Sleep Quality Index total scores; worse weight, role, emotion, and eating domain scores on the Cystic Fibrosis Questionnaire-Revised; more severe disease on nasal endoscopy; and lack of modulator therapy (all p < 0.050). Multivariable regression identified that worse SNOT-22 total score was associated with electing ESS (odds ratio [OR] 1.09, 95% confidence interval [CI] 1.02-1.16, p = 0.015) and elexacaftor/tezacaftor/ivacaftor (ETI) treatment (OR 0.04, 95% CI 0.004-0.34, p = 0.004) was associated with pursing medical therapy.

CONCLUSIONS

Worse sinonasal symptom burden, lack of ETI treatment, sleep quality, depression, and nasal endoscopy scores were associated with electing ESS, while lung disease severity and sinus CT scores were not. ETI use was associated with lower odds of pursuing ESS independent of sinonasal symptom burden.

Surgical management of rhinosinusitis for the allergist-immunologist

Chronic rhinosinusitis (CRS) is a common chronic inflammatory disease characterized by inflammation of the sinus, with or without nasal passage inflammation, occurring for more than 12 weeks at a time. CRS has historically been classified in 2 categories: CRS without nasal polyps or CRS with nasal polyps (25%-30% of cases). The mainstay of treatment for CRS with or without nasal polyps is medical management, and options may include a combination of saline irrigation, nasal steroids, allergy medications, antibiotics, oral steroids, and treatment with targeted monoclonal antibodies. Unfortunately, up to 60% of patents report symptoms refractory to maximal medical therapy. As such, a combined approach of surgery and medical therapy may be offered. Endoscopic sinus surgery for CRS is approached in a stepwise fashion, ranging from the simplest technique, such as polyp removal, to more expanded approaches that open the paranasal sinuses and allow gravity-dependent drainage. This review article provides a review and in-depth explanation of various surgical approaches for CRS, including the indications, techniques, and respective outcomes for each one.