Prevalence of asthma, aspirin sensitivity and allergy in chronic rhinosinusitis: data from the UK National Chronic Rhinosinusitis Epidemiology Study

[Diagnosis and drug therapy of chronic rhinosinusitis]

Chronic rhinosinusitis is one of the most common chronic diseases of the upper respiratory tract and is associated with a significant reduction in quality of life. Precise diagnostic workup is therefore necessary to provide patients with adequate treatment. The introduction of biologics has opened up new options for the treatment of severely affected patients with chronic rhinosinusitis with nasal polyps in the sense of precision medicine that goes beyond the mere control of symptoms. This has been accompanied by a certain degree of standardization with regard to diagnostic procedures and the assessment of disease-specific quality of life. Against the background of the 2025 congress theme "Individualization vs. standardization in otorhinolaryngology," this paper examines and summarizes the diagnosis and drug therapy of chronic rhinosinusitis, with a focus on biologic therapy.

Traditional Chinese medicine in chronic rhinosinusitis: Mechanisms and postoperative recovery

BACKGROUND

Chronic rhinosinusitis (CRS) is inflammation of the sinuses and nasal passages that lasts for >3 months. Its pathogenesis is complex, treatment is difficult, and it has multiple effects on patients. Although surgical treatment can effectively relieve the symptoms, the recurrence rate is high, and there are postoperative complications such as infection. At present, nasal spray hormone, antibiotics and other western drugs are used in clinical treatment, but there are drug dependence and toxic side effects. However, traditional Chinese medicine (TCM) has made remarkable progress in the treatment and promotion of postoperative recovery, guided by its unique TCM theory, and has little toxic and side effects, providing more treatment options for patients.

PURPOSE

The review aims to elucidate the mechanism of CRS from the aspects of traditional medicine and modern medicine, and evaluate the influence of TCM compound, components of TCM, TCM nasal irrigation, TCM fumigation and other auxiliary treatment methods on CRS, providing a new perspective for the application of TCM in CRS.

METHODS

We conducted the literature retrieval with PubMed, Web of Science, Google Scholar and CNKI databases in a systematic manner (up to July 2024). The keywords included "sinusitis", "chronic rhinosinusitis", "nasal polyps", "herbal medicine", "medicinal plants", "traditional Chinese medicine", "oxidative stress", "pathogenic microbial", "anatomic structure" and so on. The obtained literatures were comprehensively sorted out. For image creation, Figdraw 2.0 was methodically employed.

RESULTS

The pathogenesis of CRS involves various interaction mechanisms such as bacterial biofilm formation, oxidative stress injury and impaired ciliary mucosa clearance. It is worth noting that TCM exerts therapeutic effects by targeting the above-mentioned pathological processes. Clinical studies have confirmed that TCM comprehensive therapy can significantly improve sinus symptom score, accelerate postoperative mucosal epithelialization, and promote postoperative rehabilitation of CRS. We also discussed the toxic side effects and clinical applications of related drugs.

CONCLUSION

In TCM, CRS is classified under the diagnostic category of Bi Yuan. Its pathogenesis is attributed to exogenous invasion of the six climatic pathogens (Liu Yin: wind, cold, summer heat, dampness, dryness, and fire), spleen-stomach qi deficiency, internal damp-heat accumulation, and qi-blood stasis. Guided by TCM principles, therapeutic strategies are individualized through syndrome differentiation, which tailors interventions to the patient's unique clinical manifestations. Therapeutic modalities include oral herbal formulations (e.g., decoctions or granules), acupuncture, and acupoint application. These approaches aim to restore physiological balance by harmonizing yin and yang, resolving meridian obstructions, and enhancing lung qi circulation to alleviate nasal congestion and improve ventilation.

Gene Expression of Extracellular Matrix Proteins, MMPs, and TIMPs in Post-Operative Tissues of Chronic Rhinosinusitis Patients

Chronic rhinosinusitis (CRS) is a persistent inflammatory condition of the sinus mucosa characterized by significant tissue remodeling. This study aimed to evaluate the gene expression of extracellular matrix (ECM) proteins, matrix metalloproteinases (MMPs), and tissue inhibitors of metalloproteinases (TIMPs) in post-operative tissues of CRS patients. A total of 30 patients diagnosed with CRS, divided into CRSwNP (with nasal polyps) and CRSsNP (without nasal polyps) groups, were compared with a control group of 10 individuals undergoing nasal surgeries for non-CRS conditions. Gene expression analysis was conducted using quantitative real-time PCR, and plasma cytokine levels were measured via ELISA. Results indicated significantly higher expression of collagen I, collagen III, fibronectin, vimentin, periostin, and tenascin C in CRS tissues, especially in CRSsNP patients. Conversely, elastin expression was markedly lower. MMP-2, MMP-9, TIMP-1, and TIMP-2 expression was significantly altered, with CRSsNP showing lower levels compared to CRSwNP and controls. TGF-β1 expression was elevated in both CRS groups, particularly in CRSsNP, highlighting its role in fibrosis and ECM remodeling. Additionally, increased plasma concentrations of TSLP and TGF-β1 suggest epithelial activation and immune dysregulation in CRS. These findings underscore distinct remodeling profiles in CRS endotypes, emphasizing the need for targeted therapeutic strategies based on molecular phenotyping. Understanding ECM dysregulation and inflammatory pathways in CRS may lead to improved, individualized treatment approaches.

Identification of Novel Staphylococcus aureus Core and Accessory Virulence Patterns in Chronic Rhinosinusitis

Staphylococcus aureus (S. aureus) colonizes the nasal cavities of both healthy individuals and patients with chronic rhinosinusitis (CRS) with (CRSwNP) and without (CRSsNP) nasal polyps. Treatment-resistant S. aureus biofilms and intracellular persistence are common in CRS patients, requiring the expression of specific virulence factor genes to transition into these forms. We hypothesized that S. aureus isolates from non-diseased controls, CRSsNP patients, and CRSwNP patients would exhibit distinct virulence factor patterns contributing to persistence and intracellular survival in CRS patients. Nasal swabs from seventy-seven individuals yielded S. aureus cultures in eight non-diseased controls, eight CRSsNP patients, and five CRSwNP patients. Whole-genome sequencing analyzed stress, antimicrobial resistance, and virulence genes, including plasmids and prophages. Four virulence factor gene patterns emerged: a core set (hlgA, icaC, hlgB, hlgC, hld, and aur) present in all isolates, and accessory sets, including the enterotoxin gene cluster (seo, sem, seu, sei, and sen) and a partial/complete invasive virulence factor set (splE, splA, splB, lukE, and lukD) (p = 0.001). CRSwNP isolates exhibited incomplete carriage of the core set, with frequent loss of scn, icaC, and hlgA (p < 0.05). These findings suggest that S. aureus has clusters of virulence factors that may act in concert to support the survival and persistence of the bacteria, resulting in enhanced pathogenicity. This may manifest clinically with resistant disease and refractoriness to antibiotics.

Impact of Biologics on Surgery in Chronic Rhinosinusitis with Polyps and Allergic Fungal Sinusitis

OBJECTIVE

To compare the efficacy of th2-targeted biologic medications (dupilumab, omalizumab, and mepolizumab) on absolute risk reduction (ARR) of functional endoscopic sinus surgery (FESS) in patients with chronic rhinosinusitis with nasal polyposis (CRSwNP) and allergic fungal rhinosinusitis (AFRS).

METHODS

The TriNetX Research Network database was queried for each mAb's market lifespan through March 2024. Adults with CRSwNP were propensity score matched against non-mAb controls based on age, sex, race, and asthma diagnosis. The primary outcome was rate of FESS, with secondary outcomes including inpatient admission, emergency department (ED) visit, and incidence of acute sinusitis. Subgroup analysis was performed for patients with AFRS.

RESULTS

All mAbs decreased FESS risk (dupilumab, ARR 11.48%, 95% CI 9.82%-13.15%, p < 0.001; omalizumab, ARR 12.02%, 95% CI 4.36%-19.68%, p = 0.002; mepolizumab, ARR 10.32%, 95% CI 5.24%-15.40%, p < 0.001) in CRSwNP patients. Only dupilumab also reduced risk of inpatient admission (ARR 8.59%, 95% CI 7.04%-10.15%, p < 0.001), ED visit (ARR 5.94%, 95% CI 4.28%-7.61%, p < 0.001), and acute sinusitis (ARR 2.60%, 95% CI 1.09%-4.12%, p = 0.001). In AFRS patients, only dupilumab reduced the risk of all outcomes: FESS (ARR 6.97%, 95 CI 2.86%-11.09%, p = 0.001), inpatient admission (ARR 16.93%, 95% CI 11.30%-22.57%, p < 0.001), ED visit (ARR 13.15%, 95% CI 7.15%-19.14%, p < 0.001), and acute sinusitis (ARR 7.17%, 95% CI 2.18%-12.17%, p = 0.005).

CONCLUSION

Although all mAbs reduced FESS risk in CRSwNP, only dupilumab reduced secondary outcomes as well. Similarly, only dupilumab improved all outcomes in AFRS patients. These data demonstrate the potential of mAbs in reducing disease burden and enhancing patient outcomes in CRSwNP and AFRS.

LEVEL OF EVIDENCE

NA Laryngoscope, 135:593-601, 2025.

Eosinophilic Rhinosinusitis With Nonsteroidal Anti-inflammatory Drug (NSAID)-Exacerbated Respiratory Disease: A Case Report of Sodium Phosphate Corticosteroids-Induced Complications

Nonsteroidal anti-inflammatory drug (NSAID)-exacerbated respiratory disease (N-ERD) is a hypersensitivity disorder characterized by asthma, nasal polyposis, and NSAID intolerance. Eosinophilic chronic rhinosinusitis (ECRS) coexists with N-ERD in approximately 7.4% of cases. As sodium succinate corticosteroids (SSC) may exacerbate respiratory symptoms in patients with N-ERD, sodium phosphate corticosteroids (SPC) are generally recommended as an alternative. This report presents a case in which SPC additives possibly triggered an N-ERD attack during surgery in a patient with ECRS and bronchial asthma. A 58-year-old woman with a history of bronchial asthma was suspected of having ECRS and underwent surgery for diagnostic and therapeutic purposes. During the procedure, a rapid intravenous injection of hydrocortisone sodium phosphate (HSP) led to complete ventilation failure. Postoperative skin prick testing confirmed a positive reaction to HSP. Although anaphylactic shock was initially suspected, the possibility that additives in HSP induced N-ERD attack was also considered. N-ERD is primarily induced by COX-1 inhibitors, but additives such as parabens may also trigger the condition. Furthermore, rapid intravenous administration of corticosteroids has been reported to exacerbate asthma, potentially contributing to this patient's reaction. Since N-ERD is typically acquired later in life, it should be considered even in patients with no prior history of NSAID-induced attacks, particularly when factors such as severe asthma and olfactory dysfunction are present. This case highlights the importance of selecting suitable medications in patients with N-ERD to prevent life-threatening attacks.

Exploring E-Vape Aerosol Penetration into Paranasal Sinuses: Insights from Patient-Specific Models

Background: Acute and chronic sinusitis significantly impact patients' quality of life. Effective drug delivery to paranasal sinuses is crucial for treating these conditions. However, medications from conventional devices like nasal drops, sprays, and nebulized mists often fail to penetrate the small ostia and reach the sinuses. This study aims to assess the effectiveness of e-vape-generated aerosols entering and filling paranasal sinus cavities, particularly the maxillary sinus. Methods: The aerosol droplets were generated using an electronic vaporizer (e-vape) and were composed solely of vegetable glycerin (VG) and propylene glycol (PG). Patient-specific, transparent nose-sinus models, including one with post-uncinectomy surgery, were used to evaluate the effectiveness of these e-vape-generated VG-PG aerosols in entering the sinuses under unidirectional and bidirectional airflow conditions. Visualizations from various nasal model views and lighting conditions were recorded. Particle size distribution measurements of the e-vape aerosol were conducted using a laser diffraction particle size analyzer. Results: E-vape-generated VG-PG droplets effectively enter paranasal sinuses under specific administration conditions. E-vape aerosol droplet size measurements revealed a mean particle size ranging from 2.895 to 3.359 μm, with a median particle size (D50) averaging 2.963 μm. The speed of aerosol entering the paranasal sinuses is directly proportional to the ostia size; larger ostia result in faster sinus entry. A continuous moderate flow is necessary to gradually fill the paranasal sinus cavities. The aerosol entry into sinuses was observed at 2 L/min and decreased with increasing flow rate. The mechanisms of aerosol entry involve maintaining a positive pressure gradient across the ostial canal, a non-equilibrium transverse pressure distribution, and a two-way flow through the ostium. Gravitational forces and recirculation currents further enhance the deposition of e-vape aerosols. Comparative tests showed that traditional delivery devices exhibited limited penetration into paranasal sinuses. Conclusions: This study demonstrated that e-vape-generated aerosols could serve as a vehicle for delivering active pharmaceutical ingredients (APIs) directly to the paranasal sinuses, improving treatment outcomes.

Oral and intranasal aspirin desensitisation for non-steroidal anti-inflammatory drug (NSAID)-exacerbated respiratory disease

BACKGROUND

NSAID-exacerbated respiratory disease (N-ERD) is a hypersensitivity to non-steroidal anti-inflammatory drugs (NSAIDs), such as aspirin or ibuprofen, accompanied by chronic rhinosinusitis (with or without nasal polyps) or asthma. The prevalence of hypersensitivity to NSAIDs is estimated to be 2%. The first line of treatment is the avoidance of NSAIDs. Another treatment option is aspirin treatment after desensitisation (ATAD). Desensitisation can be induced by repeated administration of aspirin at fixed time intervals. The clinical benefit of aspirin might occur through inhibition of interleukin 4 and a reduction in prostaglandin D2. This therapy can be useful for people who have progressive airway disease and are in great need of medical intervention (mostly systemic corticosteroids) or surgery. An up-to-date Cochrane review is vital to investigate the effects of this therapy.

OBJECTIVES

To assess the effectiveness of oral or intranasal aspirin desensitisation, as monotherapy or as adjunctive therapy, in adults with NSAID-exacerbated respiratory disease.

SEARCH METHODS

The Cochrane Ear Nose and Throat (ENT) Information Specialist searched the Cochrane ENT and Airways Trials Registers; Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid Embase; Web of Science; ClinicalTrials.gov; International Clinical Trials Registry Platform and additional sources for published and unpublished trials. The date of the search was 10 February 2023.

SELECTION CRITERIA

Randomised controlled trials that compared ATAD with placebo were eligible. We included studies of adults with NSAID-exacerbated respiratory disease (i.e. intolerance to NSAID established, e.g. by aspirin challenge test), with chronic rhinosinusitis or asthma, or both. Participants had to be followed up for at least three months.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. The primary outcomes were health-related quality of life, asthma control, and significant serious and non-serious adverse events. The secondary outcomes were changes in airway assessments, nasal endoscopy score, medication use, symptom scores, and chronic rhinosinusitis and asthma exacerbations (description of exacerbation for which systemic corticosteroid or sinus surgery was needed). We used the GRADE approach to rate the certainty of the evidence.

MAIN RESULTS

We included five studies with a total of 211 participants (146 analysed). All studies compared oral ATAD at different dosages with placebo and were performed in tertiary care centres. All participants had a diagnosis of chronic rhinosinusitis with nasal polyps. In four studies, participants also had a confirmed diagnosis of asthma and two studies reported that participants had previous surgery for nasal polyps. Outcomes were analysed at six and 36 months follow-up. However, only one study reported data for 36 months follow-up. All but one study reported source of funding. Mid-term follow-up (six months, ATAD versus placebo) ATAD may improve health-related quality of life, assessed with Sino-Nasal Outcome Test (SNOT) scores (mean difference (MD) -0.54, 95% confidence interval (CI) -0.76 to -0.31; 3 studies, 85 participants; minimum clinically important difference (MCID) 9.0 points for total score; low-certainty evidence). In this analysis, SNOT-22 scores were divided by 22 and SNOT-20 scores were divided by 20. The mean reduction (11.9 points) in SNOT score (based on SNOT-22) is larger than the MCID. It is uncertain if asthma control may be improved after ATAD. Asthma control was measured using the Asthma Control Test (ACT) in one study and the Asthma Control Questionnaire (ACQ) in another study, so data were not pooled. The MD on the ACQ was -2.00 (total score 0 to 6) (95% CI -4.30 to 0.30; 1 study, 15 participants; MCID 0.5 points; very low-certainty evidence). The MD on the ACT was 5.90 (total score 5 to 25) (95% CI 2.93 to 8.87; 1 study, 30 participants; MCID 3 points; very low-certainty evidence). All but one study reported on adverse events. Seven participants in the active treatment group developed a gastrointestinal disorder and dropped out (129 participants, very low-certainty evidence). We are uncertain of the effect of ATAD on nasal airflow, measured by peak nasal inspiratory flow scores (MD 32.90 L/min, 95% CI -12.44 to 78.24; 1 study, 15 participants; very low-certainty evidence). It is uncertain if the dosage of intranasal or inhaled corticosteroids may be reduced with ATAD (inhaled corticosteroids: -1197.60 µg, 95% CI -1744.93 to -650.27; intranasal corticosteroids: -120.50 µg, 95% CI -206.49 to -34.51; 1 study; 15 participants; very low-certainty evidence). Symptom scores may not differ between ATAD and placebo, but the evidence is very uncertain (sneezing: MD -0.70, 95% CI -1.45 to 0.05; smell: MD -2.20, 95% CI -4.74 to 0.34; nasal blockage: MD -0.90, 95% CI -1.90 to 0.10; 1 study, very low-certainty evidence). No study assessed nasal endoscopy at this time point. Long-term follow-up (36 months, ATAD versus placebo) ATAD may improve quality of life, as measured with the Rhinosinusitis Disability Index (RSDI) score (MD-18.10, 95% CI -32.82 to -3.38; 1 study; 31 participants; low-certainty evidence). ATAD may result in little to no difference in the size of nasal polyps (MD -1.20, 95% CI -2.72 to 0.32; 1 study, 31 participants; very low-certainty evidence). No adverse events were reported in either group over the total study period of 36 months (1 study; 31 participants; very low-certainty evidence). Data on peak nasal inspiratory flow, changes in dosage of inhalation or intranasal corticosteroids and symptom scores were not reported at this time point.

AUTHORS' CONCLUSIONS

Aspirin treatment after desensitisation may improve health-related quality of life for people with N-ERD with a follow-up of six months. With respect to asthma control, adverse events, peak nasal inspiratory flow score, nasal endoscopy scores, changes in dosage of inhaled or intranasal corticosteroids, nasal and bronchial symptom scores, exacerbations or worsening of asthma and chronic rhinosinusitis (including the need for surgery), the evidence is inconclusive for the short-term and long-term. We did not find data on peak expiratory flow. It is difficult to interpret the results adequately, due to the potential influence of the use of any co-medications for chronic rhinosinusitis or asthma. Future research should emphasise longer duration of follow-up, report baseline disease characteristics and report on compliance and exacerbations for which additional medication or surgery is warranted.

Upper airway comorbidities of asthma

Asthma, characterized as a chronic heterogeneous airway disease, often presents with common comorbid conditions. The concept of "one airway, one disease" was coined more than 20 years ago, emphasizing the connection between asthma and upper airway comorbidities (UACs) such as allergic or nonallergic rhinitis, chronic rhinosinusitis with or without nasal polyps, and aspirin/nonsteroidal anti-inflammatory drug-exacerbated respiratory disease. Since then, numerous studies have demonstrated that UACs are closely related and affect asthma phenotypes. Recognizing these UACs and managing them are crucial aspects of comprehensive asthma care. Addressing these conditions as part of asthma treatment can lead to better control of symptoms, improved lung function, and better quality of life. Moreover, it is important to explore the field of respiratory biologics, which represents the latest advancements in medical treatment options for patients with asthma and UACs.

Women suffering from chronic rhinosinusitis in Norway are more likely to take sick leave

BACKGROUND

Chronic rhinosinusitis (CRS) decreases the quality of life and affects the working life of sufferers. There is a scarcity of studies of how CRS affects sick leave at the population level, particularly for women.

MATERIALS AND METHODS

Data from questionnaires were collected in Telemark, Norway in 2013 (N = 15,484) and again in 2018 (N = 13,966). Odds ratios with 95% confidence intervals (CI) for having sick leave in the last 12 months, adjusted for sex, asthma, smoking and age, were calculated, as well as the relationship to occupational groups. Comparisons were made between women and men.

RESULTS

Subjects with CRS had 64% increased odds for taking sick leave compared to subjects without CRS (OR 1.64, 95% CI 1.45-1.85) in 2013, with similar results in 2018 (OR 1.60, 95% CI 1.41-1.81). Women with CRS were almost twice as likely to take sick leave than men with CRS (OR 1.96, 95% CI 1.56-2.46) in 2013. Sick leave was more common in subjects with CRS in some occupational groups.

CONCLUSION

CRS is a chronic and debilitating disease that appears to affect sick leave on a population level, with women being more affected than men. Optimised treatment for CRS might reduce sick leave and associated costs.

Therapeutic Effects of Vitamins and Nutritional Supplements on Sinusitis: A Narrative Review

Sinusitis, one of the most prevalent and undertreated disorders, is a term used to describe inflammation of the paranasal sinuses caused by either infectious or non-infectious sources. Bacterial, viral, or fungal infections can all cause sinusitis. Sinusitis is classified into 3 types: acute, subacute, and chronic. Acute sinusitis lasts for less than 1 month, subacute sinusitis lasts from 1 to 3 months, and chronic sinusitis persists for over 3 months. This condition affects a significant portion of the population, imposing a substantial burden on the healthcare system. Antibiotics are the gold standard of bacterial sinusitis treatment. However, due to the rise of antimicrobial resistance, especially in immune-compromised patients, it is necessary to investigate potential adjunctive therapies. Based on the literature, vitamins (eg, vitamin D) have antioxidant, anti-inflammatory, and immune-modulatory properties and may effectively treat sinusitis and reduce mucous membrane inflammation. Besides vitamins, many other supplements like quercetin, sinupret, and echinacea have immunomodulatory effects and have shown promising results in sinusitis treatment. In this review, we look at the therapeutic role, safety, and efficacy of vitamins and nutritional supplements in sinusitis treatment.

Comparative safety of monoclonal antibodies in chronic inflammatory airway diseases (chronic sinusitis with nasal polyposis and asthma): A network meta-analysis

OBJECTIVE

Several monoclonal antibodies (MoAbs) targeting specific type 2 immune reactions have been developed as innovative therapeutic approaches for chronic inflammatory airway diseases, such as chronic sinusitis with nasal polyps (CRSwNP) and asthma. However, the clinical safety of these MoAbs and how to choose them are not clear. Therefore, we aimed to assess the systemic drug- and dose-based safety of MoAbs in chronic airway inflammation using network meta-analysis (NMA).

METHODS

Electronic databases were systematically searched for relevant studies published in English between January 2009 and December 2022. Eligible studies must have clearly reported adverse events (AEs) among the MoAbs' safety data.

RESULTS

1). Regarding serious AEs, mepolizumab was significantly safer than placebo; in terms of permanent treatment discontinuation, reslizumab and dupilumab were significantly safer than benralizumab. 2). Regarding asthma worsening, dupilumab was associated with the best safety profile; was safer than dupilumab/300 mg/q2-4w. 3). In terms of injection-site reactions, dupilumab posed a higher risk than placebo; dupilumab/300 mg/qw posed a higher risk than dupilumab/300 mg/q2w and dupilumab/300 mg/q2-4w; lebrikizumab/250 mg/q4w posed a higher risk than lebrikizumab/37.5 mg/q4w; mepolizumab/100 mg/q4w posed a higher risk than mepolizumab/75 mg/q4w; benralizumab/30 mg/q4-8w posed a higher risk than benralizumab/20 mg/q4-8w. 4) In CRSwNP patients combined with asthma, the risks of experiencing AEs were not increased.

CONCLUSION

Overall, biologics are safe and well tolerated in chronic inflammatory airway disease. This drug- and dose-based NMA provides further evidence on the different safety profiles of different emerging MoAbs. This information may help guide rational drug use and provide clinical recommendations for choosing MoAbs.

TRIAL REGISTRATION

SYSTEMATIC REVIEW REGISTRATION (PROSPERO #CRD42023387610).

[Results of a survey on the current management of chronic rhinosinusitis with nasal polyps in Germany]

INTRODUCTION

With a prevalence of 0.55% to 4%, chronic rhinosinusitis with nasal polyps (CRSwNP) is a relevant part of the daily work of German otolaryngologists. The aim of the questionnaire-based data collection was to assess the current treatment status of CRSwNP in Germany.

MATERIAL AND METHODS

For this purpose, 24 questions within an anonymized online questionnaire were sent to all German ENT departments.

RESULTS

Of 160 contacted ENT departments, 50 participated in the survey (31.3%). Among these, 76% performed more than 100 sinus surgeries annually and 38% treated more than 50 patients with biologics. Saline irrigations (80%) and intranasal glucocorticoids (GCS, 96%) were the most common conservative therapies. Systemic GCSs (52%) and intranasal GCS irrigation (20%) were less common. 80% of departments used biologics in the therapy of CRSwNP with an overall preference for dupilumab (70%). For therapy of aspirin intolerance, biologics (52%) were preferred to aspirin desensitization (26%). Prior to treatment with biologics clinical workup included the nasal polyp score (90%), the SNOT-22 questionnaire (84%), surrogate markers of type 2 inflammation (60%-72%), and computer tomography (50%). Final treatment success was assessed after 24 weeks (50%).

CONCLUSION

Mostly, the responding departments followed German and European recommendations for diagnosis and therapy of CRSwNP. Therapy with biologics is widely used. The value of preoperative systemic GCS and the frequent performance of CT before initiation of therapy with a biologic should be debated in regard to its currently widespread use.

Factors Contributing to the Recurrence of Chronic Rhinosinusitis With Nasal Polyps After Endoscopic Sinus Surgery: A Systematic Review

Chronic rhinosinusitis with nasal polyposis (CRSwNP) occurs due to the inflammation of sinonasal tissue. Cases of CRSwNP more commonly demand revision endoscopic sinus surgery (ESS) as compared to patients without polyposis. The recurrence rate varies widely depending on various factors, such as the extent of surgery, patient compliance with postoperative care, and the severity of the underlying disease. Studies conducted on chronic rhinosinusitis (CRS) patients showing recurrence or relapse of nasal polyps post endoscopic sinus surgery were included. We used the modified Newcastle-Ottawa scale (NOS) for cross-sectional studies and cohort studies. Only 15 articles met our inclusion and exclusion criteria after the full-text screening. The studies enrolled participants between 2009 and 2022, including 2,515 ESS patients. The mean age of the included subjects ranged between 37.1 and 57.57 years. In conclusion, CRSwNP is a chronic inflammatory disease that can impose a significant burden on patients, healthcare systems, and society. Asthma, aspirin intolerance, peripheral eosinophilia, interleukin-5 (IL-5) expression, T2 profile, and intense sinus opacification have been noted to be independent predictors of the condition in different studies. Recurrent polyposis in CRS signals a more aggressive disease course, requiring close follow-up and revision surgeries in the long run.

Imaging of chronic rhinosinusitis with nasal polyps in the era of biological therapies

PURPOSE OF REVIEW

Chronic rhinosinusitis (CRS) is a chronic inflammatory disorder of the sinonasal cavities classified into two major phenotypes: CRS with nasal polyps (CRSwNP) and without nasal polyps (CRSsNP). The diagnosis of CRS is based on clinical symptoms associated with imaging and/or nasal endoscopy findings of mucosal inflammation.

RECENT FINDINGS

Recently, novel biological therapies have emerged as therapeutic options for CRSwNP. Imaging is helpful in deciding whether surgery is likely to be beneficial and in guiding surgery. It can also help demonstrate a clinical response to medical therapy. However, specific guidelines concerning the role of imaging in CRwNP are lacking.

SUMMARY

This article provides a comprehensive and critical multidisciplinary review of the role of conventional radiology, computed tomography (CT), and magnetic resonance imaging (MRI) in the diagnosis and characterization of CRSwNP. Since the complete characterization of nasal polyps on CT or MR images is very challenging, we provide a critical review of the best imaging methods and essential reporting elements used to assess nasal polyps.

CHI3L1 on fibrinolytic system imbalance in chronic rhinosinusitis with nasal polyp

Background

Chronic rhinosinusitis (CRS) is an inflammatory disease affecting more than 10% of the global adult population. It is classified into Th1, Th2, and Th17 endotypes and eosinophilic and non-eosinophilic types. Th2-based inflammation and eosinophilic CRS (ECRS) are associated with tissue remodeling and fibrinolytic system impairment.

Objective

To elucidate the role of eosinophils in inducing fibrin deposition in CRS nasal polyp tissues and explore potential regulatory mechanisms.

Methods

We analyzed the expression of genes related to the serpin family and fibrinolytic system using Gene Expression Omnibus and Next-generation sequencing data. Differentially expression genes (DEGs) analysis was used to compare control and nasal polyp tissues, followed by KEGG and Gene ontology (GO) analysis. We measured the expression and correlation of plasminogen activator-1 (PAI-1), tissue plasminogen activator (t-PA), urokinase plasminogen activator (u-PA), and urokinase plasminogen activator surface receptor (u-PAR) in CRS tissues, and evaluated the effect of eosinophils on the fibrinolytic system using a cytokine array and co-culture.

Results

Nasal polyp tissues showed upregulated PAI-1, u-PA, and u-PAR expression and downregulated t-PA expression. Fibrinolytic system-related genes positively correlated with Th2 cytokines, except for t-PA. Eosinophil-derived Chitinase-3-like protein 1 (CHI3L1) increased PAI-1 expression and decreased t-PA levels in fibroblasts and epithelial cells. The inhibition of CHI3L1 suppresses these alterations.

Conclusion

CHI3L1 contributes to fibrin deposition by impairing the fibrinolytic system during nasal polyp formation. The regulation of CHI3L1 expression may inhibit fibrin deposition and edema in ECRS, presenting a potential treatment for this condition.

Proteomic and metabolomic proof of concept for unified airways in chronic rhinosinusitis and asthma

BACKGROUND

The pathogenesis of chronic rhinosinusitis with nasal polyps (CRSwNP) with comorbid asthma remains unclear.

OBJECTIVE

To assess upper and lower airway unity and identify a possible common pathogenesis in CRSwNP with asthma.

METHODS

This study analyzed the expression of proteins and metabolites in nasal lavage fluid cells (NLFCs) and induced sputum cells (ISCs). Differentially expressed proteins and their function-related metabolites in the upper and lower airways of patients having CRSwNP with or without asthma were identified; relevant signaling pathways were analyzed, and key pathway-related proteins were identified. Parallel reaction monitoring was used to verify these target proteins.

RESULTS

Protein or metabolite expression between NLFCs and ISCs was highly correlated and conservative on the basis of expression profiles and weighted gene coexpression network analysis. There were 17 differentially coexpressed proteins and their function-related 13 metabolites that were identified in the NLFCs and ISCs of CRSwNP, whereas 11 proteins and 11 metabolites were identified in CRSwNP with asthma. An asthma pathway was involved in the copathogenesis of upper and lower airways in whether CRSwNP or CRSwNP with asthma. The asthma pathway-related proteins proteoglycan 2 and eosinophil peroxidase, as the core of the protein-metabolism interaction networks between the upper and lower airways, were both highly coexpressed in NLFCs and ISCs in patients having either CRSwNP or CRSwNP with asthma by parallel reaction monitoring validation.

CONCLUSION

Proteomics and metabolomics reveal upper and lower airway unity. Asthma pathway-related proteins proteoglycan 2 and eosinophil peroxidase from the upper airway could be used to assess the potential risk of lower airway dysfunction in CRSwNP.

Management of chronic rhinosinusitis with nasal polyps in the Asia-Pacific region and Russia: Recommendations from an expert working group

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a chronic inflammatory condition of the nasal and paranasal tissues, characterized by the presence of bilateral nasal polyps. An expert panel of specialists from the Asian-Pacific region and Russia was convened to develop regional guidance on the management of CRSwNP through a consensus approach. The present article presents the chief observations and recommendations from this panel to provide guidance for clinicians in these areas. Etiology and pathogenetic mechanisms in CRSwNP are heterogeneous and complex. In many patients, CRSwNP is primarily driven by type 2 inflammation, although this may be less important in Asian populations. Frequent comorbidities include asthma and other inflammatory diseases such as non-steroidal anti-inflammatory drug (NSAID)/aspirin-exacerbated respiratory disease or atopic dermatitis. Clinical management of CRSwNP is challenging, and a multidisciplinary approach to evaluation and treatment is recommended. While many patients respond to medical treatment (topical irrigation and intranasal corticosteroids, and adjunctive short-term use of systemic corticosteroids), those with more severe/uncontrolled disease usually require endoscopic sinus surgery (ESS), although outcomes can be unsatisfactory, requiring revision surgery. Biological therapies targeting underlying type 2 inflammation offer additional, effective treatment options in uncontrolled disease, either as an alternative to ESS or for those patients with persistent symptoms despite ESS.

Pre-asthma: a useful concept? A EUFOREA paper. Part 2-late onset eosinophilic asthma

The concept of pre-diabetes has led to provision of measures to reduce disease progression through identification of subjects at risk of diabetes. We previously considered the idea of pre-asthma in relation to allergic asthma and considered that, in addition to the need to improve population health via multiple measures, including reduction of exposure to allergens and pollutants and avoidance of obesity, there are several possible specific means to reduce asthma development in those most at risk (pre- asthma). The most obvious is allergen immunotherapy (AIT), which when given for allergic rhinitis (AR) has reasonable evidence to support asthma prevention in children (2) but also needs further study as primary prevention. In this second paper we explore the possibilities for similar actions in late onset eosinophilic asthma.

Impact of Aeroallergen Sensitization on Chronic Rhinosinusitis

PURPOSE

This study investigated the impact of aeroallergens on the development and progression of chronic rhinosinusitis (CRS), with a focus on the specific associations between aeroallergens and CRS according to allergen type, number, and extent of sensitization.

METHODS

The medical records of 256 CRS patients were retrospectively analyzed. All were divided into nonallergic, house dust mite (HDM)-allergic, pollen-allergic, and double allergic groups via specific immunoglobulin E (IgE) testing. Clinical characteristics, computed tomography (CT) scores, olfactory functions, and demographic data were compared. Correlation analysis was performed to explore the relationships between the extent of allergen sensitization and CRS severity. Binary logistic regression analysis was used to identify risk factors for hyposmia and anosmia.

RESULTS

The allergic group exhibited higher total CT scores than the nonallergic group (P = 0.001). Sensitivity to HDM or pollen allergens alone was not significantly associated with increased CRS severity. No significant differences were observed between the effects of HDM and pollen allergens on CRS severity. However, the double allergic group exhibited significantly higher CT scores (P < 0.001, < 0.001, and 0.003) than the other groups. Although the prevalence rates of anosmia and hyposmia were notably higher in the double allergic group, the difference was not statistically significant. The maximum specific IgE levels to HDM and pollen allergens positively correlated with the CT scores (P = 0.001 and 0.001, respectively).

CONCLUSIONS

Allergen sensitization, particularly to multiple common allergens, contributed to CRS severity. CRS patients sensitized to both HDM and pollen allergens tended to experience the diminished olfactory function. These findings underscore the importance of considering the allergen sensitization pattern when assessing CRS severity and its potential progression.

Management of CRSwNP in Latin America: A multidisciplinary consensus from an expert working group

Chronic rhinosinusitis with nasal polyps (CRSwNP) is an inflammatory condition of the nasal and paranasal tissues, characterized by the presence of bilateral nasal polyps. While etiology and pathogenetic mechanisms are heterogeneous and complex, in most patients, disease is mediated predominantly through type 2 inflammatory processes. Clinical management is challenging, and a multidisciplinary approach is preferred. Principal treatment approaches are the use of local/systemic corticosteroids and sinonasal surgery, although outcomes can be unsatisfactory. Recent availability of biological therapies targeting underlying inflammatory processes can offer effective treatment options in uncontrolled disease. Specialist guidelines greatly assist clinical decision-making, although as these are chiefly written from a global/international perspective, they may not wholly accommodate disease patterns and clinical practice at a regional level. An expert panel of specialists from Latin America was convened to develop regional guidance on the management of CRSwNP through a consensus approach. The present article presents the chief observations and recommendations which can provide guidance for clinicians in the Latin American region.

Multidisciplinary Decision-Making-ITAlian Consensus After Two Years of Real Practice on the Management of Severe Uncontrolled CRSwNP by Biologics (ITACA Study)

PURPOSE OF REVIEW

We aimed to reach an Italian multidisciplinary consensus on some crucial aspects of treatment decision making in CRSwNP, following 2 years of clinical experience in order to support specialists in the management of CRSwNP in clinical practice. We addressed issues relating to therapeutic decision-making and shared criteria for the treatment choice, as well as appropriate timing and criteria for evaluating treatment response, and highlighted the need for repeated multidisciplinary assessments.

RECENT FINDINGS

A national survey has been conducted recently to understand how rhinology practice has changed in Italy with the advent of biologics and how this affects patients with uncontrolled, severe CRSwNP. Despite the many published consensus documents, practical recommendations, and protocols on the use of biologics in CRSwNP, heterogenous behaviors in practice are still observed mainly conditioned by the novelty of the topic. The consensus procedure followed a modified Delphi approach. The scientific board included 18 otorhinolaryngologists and 8 allergists, who selected the 4 main topics to be addressed and developed overall 20 statements. Consensus on these statements was sought by a larger group of 48 additional experts, through two rounds of voting, the first web-based, the second in presence with discussion and possible refinement of the statements. The statements reaching an average score ≥ 7 at the second voting round were approved. Five statements were proposed for each of the following topics: baseline evaluation of patients eligible for biologic therapy; choice between different therapeutic options; assessment of the response to biologic treatment; multidisciplinary management. At the first voting round, 19 out of the 20 statements reached a mean score ≥ 7. Following the discussion and a few consequent amendments, at the second round of voting all the 20 statements were approved.

Airways Type-2 Related Disorders: Multiorgan, Systemic or Syndemic Disease?

Chronic rhinosinusitis (CRS) has recently undergone a significant paradigm shift, moving from a phenotypical classification towards an "endotype-based" definition that places more emphasis on clinical and therapeutic aspects. Similar to other airway diseases, like asthma, most cases of CRS in developed countries exhibit a dysregulated type-2 immune response and related cytokines. Consequently, the traditional distinction between upper and lower airways has been replaced by a "united airway" perspective. Additionally, type-2 related disorders extend beyond respiratory boundaries, encompassing conditions beyond the airways, such as atopic dermatitis. This necessitates a multidisciplinary approach. Moreover, consideration of possible systemic implications is crucial, particularly in relation to sleep-related breathing diseases like Obstructive Sleep Apnoea Syndrome (OSAS) and the alteration of systemic inflammatory mediators such as nitric oxide. The trends in epidemiological, economic, and social burden are progressively increasing worldwide, indicating syndemic characteristics. In light of these insights, this narrative review aims to present the latest evidence on respiratory type-2 related disorders, with a specific focus on CRS while promoting a comprehensive perspective on the "united airways". It also introduces a novel concept: viewing these conditions as a multiorgan, systemic, and syndemic disease.

Management of Chronic Rhinosinusitis with Nasal Polyps (CRSwNP) in the Pan-Arab Region: Consensus Recommendations from a Multidisciplinary Expert Working Group

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a chronic and often debilitating inflammatory condition of the nasal and paranasal tissues. An expert panel of specialists from the Gulf region (the Kingdom of Saudi Arabia, Kuwait, Oman and the United Arab Emirates) and from Egypt gathered to evaluate existing guidance and develop regional guidance on the management of CRSwNP through a consensus approach. The present article presents the main observations and recommendations from this panel. CRSwNP diagnosis requires the presence of bilateral, endoscopically visualized polyps in the middle meatus (via nasal endoscopy or CT). In most patients, CRSwNP is mediated through predominantly type 2 inflammatory processes and is often observed in patients with asthma and other allergic disease. While many patients respond to medical treatment (principally topical irrigation and intranasal corticosteroids, and adjunctive short-term use of systemic corticosteroids), clinical management of CRSwNP is challenging, and a multidisciplinary approach for complete evaluation and treatment is recommended. Patients with more severe/uncontrolled disease (despite adequate medical therapies) require a complete endoscopic sinus surgery (ESS), although outcomes can be unsatisfactory, and further revision surgery is common. Biological therapies targeting underlying inflammatory processes offer additional, effective treatment options for those patients with persistent symptoms despite complete ESS, and also in those patients where surgery may be contraindicated.

The Unified Airway Hypothesis: Evidence From Specific Intervention With Anti-IL-5 Biologic Therapy

The unified airway hypothesis proposes that upper and lower airway diseases reflect a single pathological process manifesting in different locations within the airway. Functional, epidemiological, and pathological evidence has supported this well-established hypothesis for some time. However, literature on the pathobiologic roles/therapeutic targeting of eosinophils and IL-5 in upper and lower airway diseases (including asthma, chronic rhinosinusitis with nasal polyps [CRSwNP], and nonsteroidal anti-inflammatory drug-exacerbated respiratory disease) has recently emerged. This narrative review revisits the unified airway hypothesis by searching the scientific literature for recent learnings and clinical trial/real-world data that provide a novel perspective on its relevance for clinicians. According to the available literature, eosinophils and IL-5 have important pathophysiological roles in both the upper and lower airways, although the impact of eosinophils and IL-5 may vary in asthma and CRSwNP. Some differential effects of anti-IL-5 and anti-IL-5-receptor therapies in CRSwNP have been observed, requiring further investigation. However, pharmaceutical targeting of eosinophils and IL-5 in patients with upper, lower, and comorbid upper and lower airway inflammation has led to clinical benefit, supporting the hypothesis that these are linked conditions manifesting in different locations. Consideration of this approach may improve patient care and aid clinical decision making.

COVID-19 and chronic rhinosinusitis: management and comorbidity - what have we learned?

INTRODUCTION

Approximately 5%-12% of the population worldwide suffer from chronic rhinosinusitis (CRS). CRS is defined as a chronic respiratory disease and is considered to be a risk factor for COVID-19 patients.

AREAS COVERED

A non-systematic literature research was conducted on COVID-19 and treatment options for CRSwNP. The latest international publications in medical databases, international guidelines, and the internet were reviewed. Since there were no publications on all aspects of this topic during the pandemic, we included our own experience in this report. Based on the conducted literature research in addition to our previously reported experience, we discuss the treatment of CRSwNP during the COVID-19 pandemic and what can be taken for future pandemics.

EXPERT OPINION

Intranasal corticosteroids remain the standard treatment for CRS in patients with SARS-CoV-2 infection. Indications for surgical treatment of CRS should be critically evaluated and reserved for patients with complications and those with no other treatment options. For this purpose, COVID-19 status should be known if possible and, in case of unclear status (emergency), using appropriate personal protective equipment. Systemic corticosteroids should be avoided were possible. Biological treatment should be continued under careful monitoring in uninfected patients and should be temporarily interrupted during COVID-19 infection.

A EUFOREA comment on a lost comorbidity of asthma

"Epidemiology of comorbidities and their association with asthma control" (Tomisa, G., Horváth, A., Sánta, B. et al. Epidemiology of comorbidities and their association with asthma control. Allergy Asthma Clin Immunol 17, 95 (2021). https://doi.org/10.1186/s13223-021-00598-3 ) is an interesting paper reflecting data collection from more than 12,000 asthmatic patients in Hungary regarding their condition and associated comorbidities. We found it valuable that the paper provides an overview of asthma comorbidities not usually considered in similar reports. Nevertheless, we believe that chronic rhinosinusitis (CRS) with or without nasal polyps (CRSwNP or CRSsNP) should have been listed due to its high incidence and prevalence, its association with asthma which is also endorsed in both GINA and EPOS, as well as in several peer-reviewed scientific papers, and to reflect the role of this comorbidity in poor control and a most severe presentation of asthma for the patient. Consequently, several targeted therapies (especially monoclonal antibodies) used for several years in severe forms of asthma are now indicated also for the effective treatment of nasal polyps.

The Role of Fractional Exhaled Nitric Oxide in Diagnosing Asthmatic Type 2 Chronic Rhinosinusitis With Nasal Polyps

BACKGROUND

Fractional exhaled nitric oxide (FeNO) is useful in the management of asthma and predicting the efficacy of standard corticosteroids and biologics. However, the diagnostic value of FeNO in asthmatic chronic rhinosinusitis with nasal polyps (CRSwNP) remains unclear.

OBJECTIVE

We assessed FeNO levels in patients with CRSwNP and evaluated the diagnostic value of FeNO for screening type 2 CRSwNP (T2-CRSwNP) with asthma.

METHODS

We enrolled 94 patients who were diagnosed with CRSwNP and underwent functional endoscopic sinus surgery. FeNO levels, the blood eosinophil percentage, total IgE, spirometry tests (FEV1/FVC), Lund-Mackay CT score, and percentage of patients with comorbid asthma were compared among CRSwNP subgroups. Spearman rank correlation test was used to assess the degree of association between variables. ROC curve analysis was conducted to evaluate the diagnostic capability to differentiate T2-CRSwNP based on clinical and histological classifications.

RESULTS

FeNO levels and the blood eosinophil percentage were significantly higher in patients with T2-CRSwNP(h) based on histological data (P < .05). FeNO was correlated with the blood eosinophil percentage (r = 0.420, P < .001) and FEV1/FVC (r = -0.324, P = .001). A FeNO level of 27 ppb had a good ability to discriminate patients with asthmatic T2-CRSwNP(h) (AUC = 0.848; 95% CI = 0.7602-0.9361; sensitivity = 90.9%; specificity = 63.9%). The optimal cutoff values for FeNO and the blood eosinophil percentage for diagnosing asthmatic T2-CRSwNP(h) were 68 ppb and 5.6% (sensitivity = 95.5%; specificity = 86.1%; AUC = 0.931; 95% CI = 0.8832-0.9791). In the diagnosis of severe T2-CRSwNP(c) based on clinical data, a FeNO level of 36 ppb showed the highest AUC (0.816; 95% CI = 0.7173-0.914; sensitivity = 72.7%; specificity = 79.2%).

CONCLUSION

FeNO is a useful marker for screening asthmatic T2-CRSwNP even prior to biopsy or asthma evaluation and may assist in selecting a proper treatment.

Tobacco use increases the risk of chronic rhinosinusitis among patients undergoing endoscopic sinus surgery

BACKGROUND

Although it has been postulated that tobacco use, as well as other environmental exposures, may contribute to chronic rhinosinusitis (CRS), the data remain limited. Here, we utilised a large state population database to assess the association between tobacco use and CRS prevalence among patients undergoing endoscopic sinus surgery (ESS).

METHODS

Employing a case-control study design, the Utah Population Database was queried for patients age >18 with a diagnosis of CRS and tobacco use who underwent ESS between 1996 and 2018. Smoking status was compared between patients with CRS (n = 34 350) and random population controls matched 5:1 on sex, birth year, birthplace, time residing in Utah, and pedigree (i.e., familial) information (n = 166 020). Conditional logistic regression models were used for comparisons between CRS patients and their matched controls. All analyses were repeated, additionally adjusting for race, ethnicity, tobacco use, asthma history, and interaction between tobacco use and asthma history.

RESULTS

A total of 200 370 patients were included in the final analysis. Patients with CRS were significantly more likely to demonstrate a history of tobacco use than controls (19.6% vs. 15.0%; p < .001), with an adjusted odds ratio (aOR) of 1.42, 95% confidence interval 1.37-1.47; p < .001. More patients with CRS and comorbid asthma used tobacco (19.5%) than controls with asthma (15.0%; p < .001).

CONCLUSION

History of tobacco use may portend increased risk for the development of CRS among patients undergoing ESS compared to healthy controls.

A Supplement with Ribes Nigrum, Boswellia Serrata, Bromelain and Vitamin D to Stop Local Inflammation in Chronic Sinusitis: A Case-Control Study

Although chronic sinusitis widely affects the adult population, the treatments currently used did not always satisfactorily solve the symptoms. Traditional therapy with steroids and antibiotics presents risks and benefits and the new drugs, i.e., monoclonal antibody, are valid solutions despite being quite expensive. Natural molecules could be a valid treatment that combines good efficacy and low price. We conducted a case -control study to evaluate the benefit of an oral supplement with Ribes nigrum, Boswellia serrata, Bromelain and Vitamin D on chronic sinusitis symptoms. 60 patients were randomly assigned to one of the three groups: control using nasal steroids only, treatment 1 using nasal steroid and 1 dose of the oral supplement for 30 days and treatment 2 in which patients used nasal steroid and two oral supplement doses daily for 15 days. Conditions of the nasal mucosa and a blood sample (WBC, IgE and CRP) were analyzed at T0, T1 (15 days after treatment) and T2 (30 days after treatment. Patients treated with the supplement improved their nasal findings (hyperemia of mucosa and rhinorrhea) with statistically significant differences from the control. Our preliminary data suggest that the addition of supplement containing Ribes nigrum, Boswellia serrata, Vitamin D and Bromelain to the traditional local therapy (nasal spray with cortisone) can be a supporting therapy to modulate the local inflammation in the nose in patients affected by chronic sinusitis.

Demographic and clinical profile of patients with chronic rhinosinusitis in Saudi Arabia

OBJECTIVES

To determine the clinical features of patients with chronic rhinosinusitis at a tertiary hospital in Riyadh, Saudi Arabia.

METHODS

A cross-sectional study was carried out at King Abdulaziz University Hospital, Riyadh, Saudi Arabia. We enrolled 660 male and female participants with medical records indicating a history of chronic rhinosinusitis between 2021 and 2022. Quantitative and descriptive analyses of age, gender, nationality, presence of polyps, aspirin sensitivity, presence of urticaria, asthma, and allergies were performed.

RESULTS

Of the 660 enrolled patients, 60% (n=396) were male and 40% (n=264) were female. Additionally, 67.7% (447) had nasal polyps, 32% had a history of asthma, 10% had hypersensitivity to aspirin, 1.4% reported a history of urticaria, 9.7% reported allergies to medications, 7.9% reported food allergies, 26% reported multiple allergies, and 1.8% reported environmental allergies.

CONCLUSION

Our study revealed the following: Samter's triad was present in 6.9% of participants with chronic rhinosinusitis; the greatest prevalence of chronic rhinosinusitis with nasal polyps was observed among those older than 50 years. The prevalence of urticaria was not significantly different among groups; a higher rate of environmental allergies was observed among those with CRSwNP than among those without nasal polyps; and a higher prevalence of aspirin hypersensitivity was observed among those with CRSwNP than among non-polyps group.

French health insurance data for chronic rhinosinusitis with nasal polyps between 2011 and 2018: A STROBE-compliant analysis

AIMS

The main aim of the present study was to report the annual volume of surgeries performed for chronic rhinosinusitis with nasal polyps (CRSwNP) in France, based on health insurance data. The secondary objectives were to describe the different characteristics of the surgeries and their complications, and to estimate the number of patients eligible for biotherapy.

MATERIAL AND METHODS

This was a descriptive observational retrospective study using data from French national health insurance databases for the period 2011-2018. Inclusion criteria comprised all hospital stays with procedures related to CRSwNP according to the French Common Classification of Medical Acts and consistent with French practices.

RESULTS

Ninety-two thousand one hundred and fourty one patients (92,141) for 92,884 admissions for CRSwNP surgery were analyzed, providing an accurate representation of CRSwNP surgery in France between 2011 and 2018. The revision surgery rate for patients operated on in 2011 was 13.0% (1,457/11,212), corresponding to an average annual rate of 1.86% over 7 years. In the 11,750 sinus surgery admissions in 2018, the complications rate was only 0.65% (77/11,750).

CONCLUSION

Sinus surgery is safe (0.65% complications) and reliable (estimated revision rate, 5.5%: 5,078/92,884). This study provides the first evaluation of the target population for biotherapy in France.

Empfehlungen zur Überprüfung der Wirksamkeit und Verlaufsdokumentation von Mepolizumab bei chronischer Rhinosinusitis mit Nasenpolypen (CRSwNP) im deutschen Gesundheitssystem – Empfehlungen des Ärzteverbandes Deutscher Allergologen (AeDA) und der AGs Klinische Immunologie, Allergologie und Umweltmedizin und Rhinologie und Rhinochirurgie der Deutschen Gesellschaft für HNO-Heilkunde, Kopf- und Halschirurgie (DGHNOKHC)

BACKGROUND

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a multifactorial inflammatory disease of the mucous membranes of the nose and sinuses. Eosinophilic inflammation is described as a common endotype. The anti-IL5 antibody mepolizumab was approved in November 2021 as an add-on therapy to intranasal glucocorticosteroids for the treatment of adults with severe chronic rhinosinusitis with nasal polyps when systemic glucocorticosteroids or surgery do not provide adequate disease control. While national and international recommendations exist for the use of mepolizumab in CRSwNP, it has not yet been adequately specified how this therapy is to be monitored, what follow-up documentation is necessary, and when it should be terminated if necessary.

METHODS

A literature search was performed to analyze previous data on the treatment of CRSwNP with mepolizumab and to determine the available evidence by searching Medline, Pubmed, the national and international trial and guideline registries and the Cochrane Library. Human studies published in the period up to and including 10/2022 were considered.

RESULTS

Based on the international literature and previous experience by an expert panel, recommendations for follow-up, adherence to therapy intervals and possible therapy breaks, as well as termination of therapy when using mepolizumab for the indication CRSwNP in the German health care system are given on the basis of a documentation sheet.

CONCLUSIONS

Understanding the immunological basis of CRSwNP opens up new non-surgical therapeutic approaches with biologics for patients with severe, uncontrolled courses. Here, we provide recommendations for follow-up, adherence to therapy intervals, possible therapy pauses, or discontinuation of therapy when mepolizumab is used as add-on therapy with intranasal glucocorticosteroids to treat adult patients with severe CRSwNP that cannot be adequately controlled with systemic glucocorticosteroids and/or surgical intervention.

The link between allergic rhinitis and chronic rhinosinusitis

PURPOSE OF REVIEW

Allergic rhinitis and chronic rhinosinusitis (CRS) are common disorders affecting millions of people worldwide. Although allergic rhinitis and CRS are distinct clinical entities, certain CRS endotypes share similar pathological mechanisms as those seen in patients with allergic rhinitis. This review assesses the literature behind the similarities and differences seen in patients with CRS and allergic rhinitis, and the role atopy might play in the pathophysiology of CRS.

RECENT FINDINGS

In examining the associations between allergic rhinitis and CRS, most studies have focused primarily on CRS with nasal polyps and type 2 inflammation in CRS. Recent studies have demonstrated the similarities and differences in pathologic mechanisms behind allergic rhinitis and CRS, with an emphasis on patient endotypes, genetics, and the nasoepithelial immunologic barrier. Related immunopathology shared by allergic rhinitis and type 2 inflammation in CRS has allowed for therapeutic overlap with biologic treatments.

SUMMARY

Allergic rhinitis and CRS often present as comorbid conditions, and understanding the relationship between allergic rhinitis and CRS is important when considering treatment options. Advances in understanding the genetics and immunology, as well as biologic and immunotherapeutic treatments have improved outcomes in patients with CRS, especially in the setting of atopy.

Multidisciplinary approaches to identifying and managing global airways disease: Expert recommendations based on qualitative discussions

Background

Chronic rhinosinusitis with nasal polyps (CRSwNP) and asthma frequently co-exist and share pathologic features. Taking a "global" treatment approach benefits diagnosis and treatment of both, but care is often siloed by specialty: joined-up clinics are uncommon. Our objectives were to explore expert opinion to give practical suggestions to identify adults needing global airways care; enhance cross-specialty working; and widen knowledge to support diagnosis and management, integrate with existing care pathways, and supplement existing guidelines.

Methods

Sixteen practicing physicians from northern Europe were invited for their national and/or international standing in treating asthma and/or chronic rhinosinusitis. Appreciative Inquiry techniques were used to guide their discussions.

Results

Key themes arising were screening and referral, collaboration on management, awareness and education, and research. Provided are screening criteria and suggestions for specialist referrals, and pointers for physicians to optimize their knowledge of global airways disease. Collaborative working is underscored, and practical suggestions are given for multidisciplinary teamworking within global airways clinics. Research gaps are identified.

Conclusion

This initiative provides practical suggestions for optimizing the care of adults with CRSwNP and asthma. Discussion of the role of allergy and drug exacerbations on these conditions, and care for patients with other global airways diseases were beyond scope; however, we expect some principles of our discussion will likely benefit patients with related conditions. The suggestions bridge asthma and CRSwNP management guidelines, envisioning interdisciplinary, global airway clinics relevant to various clinical settings. They highlight the value of joint screening for early recognition and referral of patients.

Association between outdoor air pollution and chronic rhinosinusitis patient reported outcomes

BACKGROUND

The aetiology of chronic rhinosinusitis (CRS) is multifactorial with a complex interplay between environmental, microbial endogenous and genetic factors. The impact of outdoor air pollution on prevalence or severity of CRS remains largely unknown.

METHODS

Real-life geolocation data (2017-2018, Belgium) from 278 CRS patients (2576 health records) using the mySinusitisCoach mobile application were analysed to calculate the patients' individual exposure to outdoor air pollutants (ozone (O₃), black carbon (BC), nitrogen dioxide (NO₂) and particulate matter with diameter < 2.5 μm (PM_2.5)) and to associate these pollutants with the patients' sinus related symptoms measured at multiple occasions by visual analogue scale (VAS).

RESULTS

The adjusted seasonal model for the spring-summer (n = 1000 health entries, N = 83 patients) population revealed an increase of 6.07 (p < 0.0001) in overall CRS symptom scoring for an interquartile range (IQR) increase in exposure to O₃ (26.9 μg/m³). An increase of 1.69 (p = 0.05) in total CRS symptom scoring was observed for an IQR increase of PM_2.5 (7.1 µg/m³) exposure. Sex-stratified analysis in the spring-summer population showed significant interaction between air pollution and sex with male patients having higher total CRS symptom scores for an IQR increase in exposure to PM_2.5 (3.52, p = 0.001), and O₃ (8.33, p < 0.0001), while no significant association with symptom severity was seen in the female patients. In the analysis stratified by comorbid asthma, CRS patients with comorbid asthma had higher total CRS symptoms for an IQR increase in exposure to PM_2.5 (2.58, p = 0.04) and O₃ (7.72, p < 0.0001) while the patients without comorbid asthma had no significant symptom increases.

CONCLUSION

Exposure to outdoor air pollution is associated with increased symptom severity in CRS patients. The extent to which CRS patients are sensitive to outdoor air pollution exposure varies per season and depends on their sex and comorbid asthma status. mHealth technology has the potential to reveal novel insights on the patients' exposome and disease severity in the real-life situation.

Multiple reasons underlaying uncontrolled disease in the majority of chronic rhinosinusitis patients

Background

Up to 40% of patients with chronic rhinosinusitis (CRS) remain uncontrolled despite guidelines of care being available, with an enormous socio-economic impact. The reasons for uncontrolled disease can be arbitrarily divided into disease-related, diagnosis-related, treatment-related, and patient-related factors. The relative contribution of each factor in uncontrolled CRS remains speculative. This explorative study aimed at determining the factors responsible for uncontrolled CRS in a tertiary care center, thereby identifying the most commons reasons for uncontrolled disease in CRS.

Methods

Patients with uncontrolled CRS (n = 187) were asked to fill out a questionnaire and underwent a clinical examination at the outpatient clinic of the University Hospital of Leuven, Belgium. Two independent physicians evaluated the (multiple) reason(s) for uncontrolled disease.

Results

In uncontrolled CRS, 66% of patients showed two or more reasons for uncontrolled disease according to the physicians' evaluation. Disease-related factors (70%) were most often considered the reason for uncontrolled disease, followed by treatment- (45%), patient- (42%), and diagnosis- (32%) related factors.

Conclusion

In case of uncontrolled CRS, the different contributing factors to the uncontrolled nature need to be carefully addressed during diagnostic and therapeutic actions in order to define strategies to improve CRS care. Most uncontrolled CRS patients have multiple reasons contributing to their disease status, with disease-related factors being the most common factor.

Nasal cytology as a reliable non-invasive procedure to phenotype patients with type 2 chronic rhinosinusitis with nasal polyps

BACKGROUND

The identification of type-2 inflammation in patients with chronic rhinosinusitis with nasal polyps (CRSwNP) acquires a crucial role in the endotypization needed for selecting patients for biological drugs targeting type-2 inflammation: to date, the parameters used include systemic and histological biomarkers. The aim of this study was to investigate whether nasal cytology could identify type-2 inflammation in patients with CRSwNP.

METHODOLOGY

Thirty-three consecutive patients with CRSwNP underwent nasal cytology sampling at the level of the lower nasal turbinate, and of the polypoid tissue, and surgical polyp tissue sample was collected. The cellularity of the 3 collected samples were compared.

RESULTS

Mean nasal polyp tissue, nasal polyps cytology and inferior turbinate cytology eosinophils counts were 43.7 ± 39.6 cells/HPF, 32.8 ± 44.7 cells/HPF and 27.6 ± 58.0 cells/HPF respectively with inferior turbinate cytology eosinophils significantly lower than nasal polyp tissue count (p = 0.007). Both mean nasal polyps cytology eosinophils and mean inferior turbinate cytology eosinophils were significantly higher in patients with type-2 CRSwNP (52.5 ± 67.0 cells/HPF vs 12.2 ± 17.3 cells/HPF, p = 0.012, and 32.0 ± 62.1 cells/HPF vs 2.9 ± 2.9 cells/HPF, p = 0.020 respectively).

CONCLUSIONS

Nasal cytology is suitable tool for assessing local biomarkers of type-2 inflammation in CRSwNP.

Schlenter W, Welkoborsky HJ, Wollenberg B, Bergmann C, Cuevas M, Beutner C, Gröger M, Becker S. Dokumentation von Biologika-Therapien bei chronischer Rhinosinusitis mit Polyposis nasi (CRSwNP): Dupilumab, Omalizumab und Mepolizumab

Hintergrund: Die chronische Rhinosinusitis mit Nasenpolypen (CRSwNP) ist eine multifaktorielle entzündliche Erkrankung der paranasalen Schleimhäute, der als Endotyp meistens eine Typ-2-Inflammation zugrunde liegt. Mittlerweile sind drei Antikörper (Dupilumab, Omalizumab und Mepolizumab) für die Therapie der schweren CRSwNP zugelassen. Eine Dokumentation der Erkrankungsschwere im Behandlungsverlauf ist unverzichtbar.

Methoden: In einer Literaturrecherche in Medline, Pubmed sowie den nationalen und internationalen Studien- und Leitlinienregistern und der Cochrane Library wurde die Immunologie der CRSwNP analysiert und die Evidenz zur Wirkung von Dupilumab, Omalizumab und Mepolizumab bei dieser Erkrankung ermittelt. Hieraus wurden drei Positionspapiere durch unsere Autorengruppe erstellt, die Grundlage dieser zusammenfassenden Übersichtsarbeit sind.

Ergebnisse: Basierend auf den Angaben aus der internationalen Literatur werden von einem Expertengremium Empfehlungen für die Anwendung von Dupilumab, Omalizumab und Mepolizumab bei CRSwNP im deutschen Gesundheitssystem gegeben.

Schlussfolgerung: Dupilumab, Omalizumab und Mepolizumab sind zugelassen für Patienten ab 18 Jahren mit schwerer CRSwNP als Zusatztherapie zu intranasalen Glukokortikosteroiden (INCS), wenn, bei Dupilumab und Mepolizumab, durch eine Therapie mit systemischen Glukokortikosteroiden und/oder chirurgischem Eingriff keine ausreichende Krankheitskontrolle erzielt werden kann. Eine Therapie mit Omalizumab ist angezeigt, wenn eine Therapie mit INCS keine suffiziente Kontrolle der Erkrankung ergibt. Es werden dezidierte Empfehlungen zur Dokumentation der Anwendung im Deutschen Gesundheitssystem gegeben, die auf den hierzu bereits publizierten Positionspapieren unserer Autorengruppe basieren.

Zitierweise: Klimek L, Förster-Ruhrmann U, Beule AG, Chaker AM, Hagemann J, Klimek F, Casper I, Huppertz T, Hoffmann TK, Dazert S, Deitmer T, Olze H, Strieth S, Wrede H, Schlenter W, Welkoborsky H-J, Wollenberg B, Bergmann C, Cuevas M, Beutner C, Gröger M, Becker S. Indicating biologics for chronic rhinosinusitis with nasal polyps (CRSwNP): Recommendations by German Allergy and ORL-societies AeDA and DGHNO for Dupilumab, Omalizumab and Mepolizumab. Allergo J Int 2022;31:149-60

https://doi.org/10.1007/s40629-022-00220-x

The efficacy of itraconazole, fluticasone and doxycycline in chronic rhinosinusitis

BACKGROUND

Different treatment strategies for chronic rhinosinusitis (CRS) have been evaluated. Here we aimed to investigate the effects of fluticasone spray alone and in combination with itraconazole or doxycycline.

METHODS

This is an open-label clinical trial performed in 2020-2021 in Isfahan on patients with CRS. This survey's Iranian Registry of Clinical Trials (IRCT) code was IRCT20200825048515N50 (https://en.irct.ir/trial/60826). Demographic data of all patients including age and gender and duration of CRS, were obtained. The SNOT-22 and Lund-Kennedy questionnaires were evaluated and recorded for the symptomatology of CRS. Patients were randomly assigned to the treatment groups to receive 100 mg of doxycycline with intranasal fluticasone spray, intranasal fluticasone spray alone, or itraconazole 100 mg capsules with intranasal fluticasone spray. After one month of treatment, the scores and patient satisfaction were evaluated and compared.

RESULTS

Data of 104 patients was analyzed. Patients had improvements in their symptoms and SNOTT-22 scores. The mean SNOTT-22 score was 55.36±8.36 in all patients. During the study, patients had improvements in their symptoms and SNOTT-22 scores. The mean final SNOTT-22 score was 47.77±7.36 at the end of the survey (P=0.02). Our data also demonstrated significant improvements in the Lund-Kennedy score in all patients during the study (P<0.05).

CONCLUSION

There were no significant differences between the clinical condition of patients receiving intranasal fluticasone, intranasal fluticasone in combination with doxycycline or itraconazole.

Efficacy and Safety of Dupilumab Versus Omalizumab in Chronic Rhinosinusitis With Nasal Polyps and Asthma: EVEREST Trial Design

BACKGROUND

Chronic rhinosinusitis with nasal polyps (CRSwNP) and asthma are chronic type 2 inflammatory diseases that are frequently associated with each other. Dupilumab inhibits the dual signaling pathways of interleukin (IL)-4 and IL-13, which are key and central drivers of type 2 inflammation in CRSwNP. Omalizumab blocks the action of immunoglobulin E. Head-to-head studies are required to investigate the comparative efficacy and safety of these interventions. EVEREST (EValuating trEatment RESponses of dupilumab vs omalizumab in Type 2 patients) trial is designed to evaluate whether the efficacy of dupilumab is superior to omalizumab in treating patients with CRSwNP and comorbid asthma (ClinicalTrials.gov Identifiers: NCT04998604).

OBJECTIVE

Here, we describe the EVEREST study design to compare the efficacy and safety of dupilumab compared to omalizumab over 24 weeks of treatment in patients with severe CRSwNP and comorbid asthma.

METHODS

EVEREST is a global, phase 4 multicenter, randomized (1:1), double-blind, active-controlled trial. Approximately 422 adult patients with severe CRSwNP, symptoms of nasal congestion and loss of smell, and coexisting asthma will be recruited across 15 countries. The primary objective is to assess the efficacy of dupilumab compared to omalizumab in reducing the nasal polyp size and improving the sense of smell. The key secondary objectives are to evaluate the comparative efficacy in improving CRSwNP symptoms (eg, nasal congestion) and lung function. The safety will be evaluated in terms of treatment-emergent adverse events (AEs), serious AEs, and AEs of special interest.

CONCLUSIONS

EVEREST is the first head-to-head trial assessing the comparative efficacy and safety of 2 biologics in patients with severe CRSwNP and comorbid asthma. The study will provide evidence to help optimize treatment plans for patients that suffer from severe CRSwNP and comorbid asthma.

The effects of functional endoscopic sinus surgery on chronic obstructive pulmonary disease (COPD) and asthma: A comparative study

PURPOSE

Chronic Rhinosinusitis (CRS) can be accompanied by asthma and, rarely by chronic obstructive pulmonary disease (COPD). Functional endoscopic sinus surgery (FESS) is the most common surgical approach for CRS which also improves asthma symptoms, but little is known about its effects on COPD. This study investigates the effects of FESS on COPD and asthma symptoms in CRS patients referred to a university hospital in northern Iran.

MATERIALS AND METHODS

In a prospective study, patients with COPD or asthma and CRS who were candidates for FESS underwent endoscopic examination, spirometry, and evaluation of symptoms of CRS, COPD, and asthma before, and 2 and 6 months after FESS. Statistical analyzes were performed using SPSS software version 21 and the level of significance was considered as P < 0.05.

RESULTS

Eighty-two CRS patients (45 with asthma/ mean age: 49.24 ± 12.75 years and 37 patients with COPD/ mean age: 61.43 ± 6.93 years) enrolled. In asthmatic patients, the mean FEV1 and FVC, and ACT (Asthma Control Test) score increased significantly after FESS (P < 0.001). In COPD cases, spirometry indices decreased, but CAT (COPD Assessment Test) score improved significantly (from 15.70 to 32.11) after FESS (P < 0.001). The mean SNOT score in both groups was significantly reduced.

CONCLUSIONS

In CRS patients with COPD, FESS improves the condition of SNOT-22 and CAT, although does not increase spirometry parameters. In asthmatic patients, FESS improves pulmonary function and asthma symptoms. So both patient groups (i.e. CRS with COPD and with asthma) will benefit from FESS.

Personalized Management of Patients with Chronic Rhinosinusitis with Nasal Polyps in Clinical Practice: A Multidisciplinary Consensus Statement

Chronic rhinosinusitis (CRS) is a sino-nasal chronic inflammatory disease, occurring in 5–15% of the general population. CRS with nasal polyps (CRSwNP) is present in up to 30% of the CRS population. One-third of CRSwNP patients suffer from disease that is uncontrolled by current standards of care. Biologics are an emerging treatment option for patients with severe uncontrolled CRSwNP, but their positioning in the treatment algorithm is under discussion. Effective endotyping of CRSwNP patients who could benefit from biologics treatment is required, as suggested by international guidelines. Other issues affecting management include comorbidities, such as allergy, non-steroidal anti-inflammatory drug–exacerbated respiratory disease, and asthma. Therefore, the choice of treatment in CRSwNP patients depends on many factors. A multidisciplinary approach may improve CRSwNP management in patients with comorbidities, but currently there is no shared management model. We summarize the outcomes of a Delphi process involving a multidisciplinary panel of otolaryngologists, pulmonologists, and allergist-immunologists involved in the management of CRSwNP, who attempted to reach consensus on key statements relating to the diagnosis, endotyping, classification and management (including the place of biologics) of CRSwNP patients.

STAT6 Blockade Abrogates Aspergillus-Induced Eosinophilic Chronic Rhinosinusitis and Asthma, A Model of Unified Airway Disease

Unified airway disease, including concurrent asthma and chronic rhinosinusitis (CRS), is a common, but poorly understood disorder with no curative treatment options. To establish a murine model of chronic unified eosinophilic airway inflammation, mice were challenged with Aspergillus niger, and sinonasal mucosa and lung tissue were evaluated by immunohistochemistry, flow cytometry, and gene expression. Inhalation of A niger conidia resulted in a Th2-biased lung and sinus inflammation that typifies allergic asthma and CRS. Gene network and pathway analysis correlated with human disease with upregulation of not only the JAK-STAT and helper T-cell pathways, but also less expected pathways governing the spliceosome, osteoclast differentiation, and coagulation pathways. Utilizing a specific inhibitor and gene-deficient mice, we demonstrate that STAT6 is required for mycosis-induced sinus inflammation. These findings confirm the relevance of this new model and portend future studies that further extend our understanding of the immunopathologic basis of airway mycosis and unified airway disease.

Positionspapier: Empfehlungen zur Anwendung von Mepolizumab bei chronischer Rhinosinusitis mit Polyposis nasi (CRSwNP) im deutschen Gesundheitssystem – Empfehlungen des Ärzteverbandes Deutscher Allergologen (AeDA) und der AGs Klinische Immunologie, Allergologie und Umweltmedizin und Rhinologie und Rhinochirurgie der Deutschen Gesellschaft für HNO-Heilkunde, Kopf- und Hals-Chirurgie (DGHNO-KHC)

BACKGROUND

 Chronic rhinosinusitis with nasal polyps (CRSwNP) is a multifactorial inflammatory disease of the paranasal sinus mucosa with eosinophilic inflammation as the most common endotype. The anti-IL5 antibody mepolizumab was approved for the treatment of severe CRSwNP in the EU in November 2021.

METHODS

 A literature search was performed to analyze the immunology of CRSwNP and determine the available evidence by searching Medline, Pubmed, and the German national and international trial and guideline registries and the Cochrane Library. Human studies published in the period up to and including 12/2021 that investigated the effect of mepolizumab in CRSwNP were considered.

RESULTS

 Based on the international literature and previous experience, recommendations for the use of mepolizumab in CRSwNP in the German health care system are given by an expert panel on the basis of a documentation form.

CONCLUSIONS

 Understanding about the immunological basis of CRSwNP opens new non-surgical therapeutic approaches with biologics for patients with severe courses. Mepolizumab is approved since November 2021 for add-on therapy with intranasal corticosteroids for the treatment of adult patients with severe CRSwNP who cannot be adequately controlled with systemic corticosteroids and/or surgical intervention.

Mepolizumab for chronic rhinosinusitis with nasal polyps: treatment efficacy by comorbidity and blood eosinophil count

BACKGROUND

In the Phase III SYNAPSE study, mepolizumab reduced nasal polyp (NP) size and nasal obstruction in chronic rhinosinusitis with NP (CRSwNP).

OBJECTIVE

To assess the efficacy of mepolizumab in patients from SYNAPSE grouped by comorbid asthma, aspirin-exacerbated respiratory disease (AERD), and baseline blood eosinophil count (BEC).

METHODS

SYNAPSE, a randomized, double-blind, 52-week study (NCT03085797), included patients with severe bilateral CRSwNP eligible for surgery despite intranasal corticosteroid treatment. Patients received 4-weekly subcutaneous mepolizumab 100 mg or placebo plus standard of care for 52 weeks. Co-primary endpoints were change in total endoscopic NP score (Week 52) and nasal obstruction visual analog scale (VAS) score (Weeks 49-52). Subgroup analyses by comorbid asthma and AERD status, and post hoc by BEC, were exploratory.

RESULTS

Analyses included 407 patients (289 with asthma; 108 with AERD; 371 and 278 with BEC counts ≥150 or ≥300 cells/μL, respectively). The proportion of patients with ≥1-point improvement from baseline in NP score was higher with mepolizumab versus placebo across comorbid diseases (asthma: 52.9% vs 29.5%; AERD: 51.1% vs 20.6%) and baseline BEC subgroups (<150 cells/μL: 55.0% vs 31.3%; ≥150 cells/μL: 49.5% vs 28.1%; <300 cells/μL: 50.7% vs 29.0%; ≥300 cells/μL: 50.4% vs 28.1%). A similar trend was observed in patients without comorbid asthma or AERD. More patients had >3-point improvement in nasal obstruction VAS score with mepolizumab versus placebo across comorbid subgroups.

CONCLUSION

Mepolizumab reduced polyp size and nasal obstruction in CRSwNP regardless of the presence of comorbid asthma or AERD.

CLINICAL IMPLICATION

Mepolizumab should be considered for the treatment of CRSwNP, particularly in patients with comorbid asthma or AERD.

Cumulative comorbidity burden does not worsen outcomes in management of chronic rhinosinusitis

BACKGROUND

The impact of multiple coexisting medical comorbidities on treatment outcomes in chronic rhinosinusitis (CRS) is unknown. In this study we sought to evaluate the effect of comorbidities on sinonasal quality of life (QOL) and general health utility values by utilizing the Functional Comorbidity Index (FCI) in CRS patients.

METHODS

Patients with CRS were prospectively enrolled in a cross-sectional study of medical and surgical therapies. The 22-item Sino-Nasal Outcome Test (SNOT-22) and Medical Outcomes Study Short-Form 6D (SF-6D) scores were recorded at enrollment and 6-month follow-up; Lund-Kennedy endoscopy and Lund-Mackay computed tomography scores were recorded at enrollment. The FCI was calculated using the electronic medical record. The impact of cumulative comorbidity burden on baseline and posttreatment outcomes was assessed using univariate and bivariate correlations.

RESULTS

A total of 428 participants with CRS were included. The average (mean standard ± deviation) FCI score was 3.03 ± 2.28 (range, 0-12). Significant linear correlations were identified between increasing FCI score and baseline SNOT-22 and SF-6D scores (R = 0.166, p = 0.001 and R = -0.245, p < 0.001, respectively). There was no correlation between FCI and change in SNOT-22 or SF-6D scores after CRS treatment (R = 0.066, p = 0.17 and R = -0.087, p = 0.074, respectively). Achievement of a minimally clinically important difference was also independent of FCI.

CONCLUSION

Although cumulative comorbidity burden, as measured by FCI, is associated with worse baseline SNOT-22 and SF-6D scores, it does not appear to limit posttreatment improvement in either outcome measure. On average, patients with high comorbidity burden report substantial improvement in both QOL and health utility after CRS treatment, similar to those with fewer comorbidities.

BMI as a risk factor for the development of chronic rhinosinusitis: a prospective population-based study

PURPOSE

Obesity is a growing, global health problem and previous cross-sectional studies have demonstrated an association between obesity and chronic rhinosinusitis (CRS). There is, however, a lack of prospective studies regarding the impact of obesity on developing (new-onset) CRS.

METHODS

Questionnaire-based data (n = 5769) relating to new-onset CRS and Body Mass Index (BMI) were collected in 2013 and 2018 from the Telemark population study in Telemark, Norway. Odds ratios for the risk of new-onset CRS in 2018 in relation to BMI in 2013 were calculated, adjusted for smoking habits, asthma, gender and age.

RESULTS

When comparing the group with normal weight (18.5 ≤ BMI < 25) with the obese group (BMI ≥ 30), the odds of new-onset CRS was 53% higher [OR 1.53 (1.11, 2.10)] in the obese group.

CONCLUSION

CRS is a multifactorial disease with different phenotypes and it is important to consider obesity when assessing patients with CRS in a clinical setting.

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.