Prognostic value of the Sinonasal Outcome Test 22 (SNOT-22) in chronic rhinosinusitis

Comparative real-world outcomes of dupilumab versus endoscopic sinus surgery in the treatment of severe CRSwNP patients

INTRODUCTION

Management of severe chronic rhinosinusitis with nasal polyps (CRSwNP) has changed significantly in recent years, with different treatments now available including biologics and endoscopic sinus surgery (ESS), although there are still few comparative studies. We aimed to compare 1-year outcomes of patients with severe CRSwNP treated with dupilumab or ESS plus intranasal corticosteroids (INCS).

METHODS

In this retrospective, real-life, observational, cohort study, we enrolled 101 patients with severe CRSwNP who were treated with INCS and either ESS (n = 49) or dupilumab (n = 52). The following outcomes were considered: nasal polyp score (NPS), Sino Nasal Outcome Test-22 (SNOT-22), visual analogue scale (VAS) for specific symptoms, Sniffin' Sticks identification test (SSIT), need for oral corticosteroids (OCS) and local eosinophilia detected by nasal cytology.

RESULTS

ΔNPS was significantly higher in the surgery group up to 12 months when the difference with dupilumab group was no longer significant (ΔNPS: 4 vs. 4.1). ΔVAS rhinorrhoea, ΔVAS smell and ΔSNOT-22 were significantly higher in the dupilumab group at 12 months (p < .05). SSIT scores were significantly better in the dupilumab group starting from the first month of follow-up (p < .05). In the dupilumab group, only 6.1% of patients had detectable local eosinophilia compared to 57% in the surgery group alongside with a lower need for OCS (16.3% vs. 61%).

CONCLUSIONS

Both dupilumab and ESS were effective in improving outcomes in patients with severe CRSwNP over 12 months. Nevertheless, patients treated with dupilumab had greater improvement in terms of SNOT-22, VAS rhinorrhoea, VAS smell and SSIT scores, with better control of local inflammation and less need for OCS.

Temporal trends of blood eosinophilia in severe uncontrolled CRSwNP treated with dupilumab: a real-life study

PURPOSE

Induced eosinophilia is commonly related to dupilumab treatment. We analysed the temporal trends of blood eosinophilia in patients with severe uncontrolled CRSwNP during the first year of treatment with dupilumab in real-life setting to evaluate its correlation with outcomes of response and adverse events (AEs).

METHODS

Seventy-four patients with severe uncontrolled CRSwNP treated with dupilumab at our institution were enrolled. At each visit, we evaluated AEC, outcomes of response to treatment and AEs.

RESULTS

A significant increase in AEC was observed since the first month with a peak at 3 months; at 12 months, the values returned comparable to those at baseline. A ≥ 50% increase of the baseline AEC with a value greater than 500 cells/mm3 was documented in 38/74 patients (Group A) regardless of the time of observation, whereas in 36/74 patients (Group B), no changes were observed. Analysing the blood eosinophilia trend over time in group A, we observed a temporary eosinophilia with early onset (within 6 months), persistent eosinophilia with early onset, and eosinophilia with late onset. No differences in terms of outcomes of response to treatment or AEs were found between Group A and Group B, or between patients who developed an AEC ≥ 1500 cells/mm3 or not.

CONCLUSION

In our series, we observed that an increase in AEC with different temporal trends may be observed in CRSwNP patients during the first year of treatment with dupilumab. In our series, eosinophilia is not correlated with a negative outcome of response to treatment or a risk of AEs.

Dupilumab's impact on nasal citology: Real life experience after 1 year of treatment

BACKGROUND

Biologic agents are considered a new revolutionized therapy for severe and recurrent forms of CRSwNP which disease burden is not sufficiently controlled by conservative and/or surgical treatments. Recent Research has focused on evaluating their real-life efficacy in CRSwNP, as only limited reports on real-life data are available. However, in most studies, the response to treatment is evaluated in terms of improvement in Nasal Polyp Score (NPS) or in Sino-Nasal Outcome test (SNOT-22) scores. However, both criteria do not consider nasal immunophlogosis, which can be easily assessed by nasal cytology. The aim of our study was to evaluate changings in the nasal inflammatory infiltrate of CRSwNP patients treated with Dupilumab for 12 months.

METHODS

27 patients suffering from severe CRSwNP treated with Dupilumab were recruited. Nasal cytology findings, NPS, SNOT-22, ACT scores and blood eosinophil count at T0 (before treatment) and at T1 (after 1 year of treatment) were compared.

RESULTS

After 1 year of biological therapy with Dupilumab, NPS, SNOT-22 and, among the 17 asthmatic patients, ACT scores improved significantly. At T1, a statistically significant percentage of patients showed negative citology. Moreover, a significant reduction in the mast cell-eosinophilic pattern and an increase of neutrophils and bacteria was reported.

CONCLUSIONS

The response to treatment can be considered both in the case of negative nasal cytology and in the case of the appearance of neutrophils and bacteria. In this context, eosinophils, the specific target of biological therapies, play a crucial role in regulating tissue homeostasis and, consequently, the nasal immunophlogosis.

Efficacy of dupilumab in real-life settings: a STROBE study

BACKGROUND

Dupilumab, a monoclonal antibody targeting IL-4 and IL-13, has demonstrated its efficacy in several clinical trials. However, to date, real-life data remains limited.

OBJECTIVE

The aim of our study was to assess the real-life impact of dupilumab on patients with severe and uncontrolled chronic rhinosinusitis with nasal polyps (CRSwNP) quality of life.

MATERIALS AND METHODS

This was a retrospective, monocentric, observational, real-life study, conducted in accordance with the STROBE guidelines. The following parameters were collected before treatment and at 1, 4, and 12 months: Sino-Nasal Outcome Test-22 (SNOT-22), nasal polyp score (NPS), Sniffin' Sticks-16 (SST-16), visual analog scale (VAS) for loss of smell, nasal congestion score (NCS), gustatory VAS, asthma control, oral corticosteroid usage, surgery rates, and occurrence of side effects.

RESULTS

The study included 47 patients. SNOT-22 scores decreased from 52.4 ± 24.3 to 12.7 ± 10.5 at 12 months (p < 0.001). NPS decreased from 6.15 ± 1.71 to 1.57 ± 1.40 at 12 months (p < 0.001). SST-16 scores increased from 1.6 ± 2.83 to 9.1 ± 5.4 at 12 months (p < 0.001). NCS decreased from 2.45 ± 0.72 to 0.38 ± 0.63 at 12 months (p < 0.001). Prior to treatment, 72.3% were using oral corticosteroids, compared to 17.0% at 12 months (p < 0.01). Two patients required additional surgery, and 17% reported completely uncontrolled asthma, compared to 0% at 12 months (p < 0.01).

CONCLUSION

Our real-life results confirm the efficacy of Dupilumab in the treatment of severe and uncontrolled CRSwNP.

Eosinophilic Patterns in Patients with Seasonal Allergy Affected by Bronchial Asthma and Rhinitis/Rhinosinusitis: Efficacy of Benralizumab in Patients with the Persistent Pattern

BACKGROUND

Eosinophilia can be influenced by multiple factors. This study aims to set a protocol for monitoring blood absolute eosinophil count (AEC) in patients with seasonal allergy affected by bronchial asthma (BA), allergic rhinitis (AR), or chronic rhinosinusitis with or without nasal polyposis (CRSw/sNP).

METHODS

We planned a total of four annual blood samples to measure AEC in- and out-seasonal pollen exposure (i.e., one measurement every three months for one year).

RESULTS

We identified two distinct groups of patients (non-eosinophilic and eosinophilic). Patients in the eosinophilic group presented with four different patterns (episodic, transient, floating, and persistent). Most patients with episodic, transient, and floating patterns were affected by mild allergy and the increase in eosinophils was related to allergen exposure. In contrast, patients with the persistent pattern mostly presented with more severe allergy (i.e., severe BA and relapsing CRSwNP) and the eosinophilia was unrelated to allergen exposure. The subgroup of patients with severe BA, relapsing CRSwNP, and persistent eosinophilc pattern were treated with benralizumab, which induced a noteworthy improvement in both severe BA and CRSwNP.

CONCLUSIONS

Multiple AEC measurements in patients with seasonal allergy can better reflect patient's eosinophilic status and help define the relationship of AEC enhancement with allergen exposure.

Evaluating Sinus Microbiology by Transplant Status in Persons With Cystic Fibrosis: A Matched Cohort Study

Objective

Sinus disease is prevalent in persons with cystic fibrosis (PwCF) and may be a reservoir of airway infection in postlung transplant (pTx) patients. The microbial composition of cystic fibrosis sinuses and its associations with chronic rhinosinusitis (CRS) is relatively unexplored. We aimed to examine the sinus and lower airway microbiome and their associations with CRS in PwCF and pTxPwCF.

Study Design

Prospective single-centre study.

Setting

A total of 31 sex and age (±2 years) matched PwCF and pTxPwCF.

Methods

Demographic and clinical data along with sinus swabs and sputum were collected. CRS was assessed using Sinonasal Outcome Test-22 (SNOT-22) (patient reported outcome) and Lund-McKay (computed tomography sinus) scores. Samples underwent MiSeq Illumina sequencing of the universal 16S ribosomal RNA gene.

Results

A total of 31 PwCF (15 pTxPwCF) were included. Aggregate airways microbiome composition was dominated by Pseudomonas (46%), Haemophilus (14%), Staphylococcus (11%), Streptococcus (10%), and Fusobacterium (6%). α-diversity was significantly lower in post-Tx samples across both sputum and sinus samples (P = .005). β-diversity was significantly different between sputum (P = .004), but not sinus (P = .75) samples by transplant status. While there was a trend in higher β-diversity associated with lower SNOT-22 score at time of first visit, this did not reach significance (P = .05).

Conclusion

Sinus and airway microbiomes differed in PwCF and pTxPwCF, but the prevalent organisms remained consistent. Elucidating the relationship of the microbiome with clinical status to better understand when to intervene accordingly is needed to optimize sinus disease management in PwCF.

Normative data for interpreting the SNOT-22

Objectives

The Sino-Nasal Outcome Test 22 (SNOT-22) is a validated patient-reported outcome instrument to evaluate the health-related quality of life (HRQoL) in patients with chronic rhinosinusitis (CRS). There are no published normative SNOT-22 scores, limiting its interpretation.

Methods

Symptom scores from 1,000 SNOT-22 questionnaires were analysed by principal component analysis (PCA) and exploratory factor analyses. Data were derived from a survey with 1,000 healthy Europeans (reference cohort) who were recruited using the Respondi panel for market and social science research. This subsample was quoted to the population distribution of the German Microcensus and selected from a non-probability panel.

Results

The overall normative SNOT-22 score can be detected to be 20.2 ± 19.44. Male (18.49 ± 19.15) and older (> 50 years old; 18.3 ± 17.49) participants had overall lower SNOT-22 mean results than females (21.8 ± 19.6) and younger (21.4 ± 20.55) participants, indicating higher levels of satisfaction. PCA proposed two SNOT-22 domains ("physiological well-being" and "psychological well-being"), which explained 65% of the variance.

Conclusions

These are the first published (German) normative scores for the SNOT-22 and provide a clinical reference point for the interpretation of data.

Biologics in severe uncontrolled chronic rhinosinusitis with nasal polyps: A bicentric experience

BACKGROUND AND AIM

The introduction of biologics in the management of chronic rhinosinusitis with nasal polyposis (CRSwNP) has allowed new therapeutic options and Dupilumab represents the first approved biological agent. Aim of this paper is to provide a multicentric study in a real-life setting of treatment with Dupilumab for severe uncontrolled CRSwNP in Italy.

METHODS

A retrospective data collection was performed from the departments of Otolaryngology of two major health institutions in Rome: San Camillo Forlanini Hospital and Tor Vergata University. Both centres contributed to the study providing information about patients affected by severe uncontrolled CRSwNP and treated with Dupilumab.

RESULTS

A total of 83 patients were included in the study (43 males; 40 females; mean age: 55.8 years). Monitoring our patients, we observed improvement in reduction of nasal polyposis and nasal obstruction, respectively measured through NPS and PNIF. Concerning the CRSwNP symptoms and their impact on quality of life, we found an improvement in the olfaction, as measured respectively by SSIT-16 and SNOT-22.

CONCLUSIONS

Dupilumab has demonstrated broad efficacy in CRSwNP management. Further studies are needed to confirm our results and to establish biomarkers to identify endotypes and predict response to biologics treatment in CRSwNP.

Diagnostic therapeutic assistance pathway (PDTA) of type 2 chronic rhinosinusitis

Chronic rhinosinusitis (CRS) is a complex and heterogeneous disorder whose etiopathogenetic picture is not yet completely known and is classically divided into CRS with (CRSwNP) and without nasal polyps (CRSsNP). But today the distinction is made with type 2 and nontype 2 variants. A rational and defined pathway for the diagnosis of chronic rhinosinusitis is an indispensable means to be able to arrive at a correct identification of the patient. This typing is essential to be able to arrive at the correct course of treatment, which turns out to be different for different types of patients. For this reason, the realization of a diagnostic therapeutic pathway represents a fundamental way for the otolaryngologist specialist but not only, since today diagnostics has a multidisciplinary framework. In the present work, precise indications have been developed to arrive at a correct diagnosis. The various diagnostic pathways and processes to arrive at a correct therapeutic framing have been highlighted. Therapy ranging from medical therapy to surgical therapy without neglecting the new biological therapies. It does not represent a guideline but a diagnostic method that can be adapted to all the various territorial realities.

A Systematic Review and Meta-analysis of SNOT-22 Outcomes After Sinus Surgery

Background: All stakeholders in the healthcare system have prioritized and will continue to prioritize enhancing care quality. The measurement of sinus-specific quality of life (QOL) is potentially the most commonly used QOL parameter for chronic rhinosinusitis (CRS). Objective: A systematic review and meta-analysis were used in this study to determine the mean change in patients' scores on the 22-item Sino-Nasal Outcome Test (SNOT-22) before and after endoscopic sinus surgery (ESS) for CRS. Methods: PubMed, Google Scholar, and ScienceDirect were searched for articles that compared SNOT-22 scores before and after ESS in adult patients with CRS and were published between January 2000 and March 2023. The mean post-op change, 95% confidence interval (CI), forest plot, and inverse variance weighting were all generated using a random effects model. A mixed-effects meta-regression was used to analyze the effect of patient-specific characteristics across studies. Results: Fifteen prospective patient cohorts published from 2009 to 2023 were included in this meta-analysis. At an average follow-up of 25.5 months, all studies demonstrated a statistically significant difference in mean SNOT-22 scores between baseline and post-op time periods (P < .05), ranging from 5.1 to 55.4. Across all studies, the mean SNOT-22 changed significantly by 26.02 (95% CI: 12.83-38.60). According to a stepwise multivariate analysis, studies with higher mean age and mean pre-op SNOT-22 scores had greater changes in SNOT-22 scores following ESS, whereas trials with longer mean follow-up duration had smaller changes in SNOT-22 scores. Conclusion: Research utilizing the SNOT-22 instrument has demonstrated that endoscopic sinus surgery (ESS) leads to enhanced quality of life (QOL) outcomes. The literature reports that improvement is influenced by the initial SNOT-22 score, the mean age of the patients, and the duration of the follow-up period.

Endotypes of Nasal Polyps in Children: A Multidisciplinary Approach

Nasal polyps (NPs) are rarely reported in childhood and usually represent red flags for systemic diseases, such as cystic fibrosis (CF), primary ciliary dyskinesia (PCD) and immunodeficiencies. The European Position Paper released in 2020 (EPOS 2020) provided a detailed classification and defined the correct diagnostic and therapeutic approaches. We report a one-year experience of a multidisciplinary team, made up of otorhinolaryngologists, allergists, pediatricians, pneumologists and geneticists, with the aim of ensuring a personalized diagnostic and therapeutic management of the pathology. In 16 months of activity, 53 patients were admitted (25 children with chronic rhinosinusitis with polyposis and 28 with antro-choanal polyp). All patients underwent phenotypic and endo-typic assessment, using proper classification tools for nasal pathology (both endoscopic and radiological), as well as adequate cytological definition. An immuno-allergic evaluation was carried out. Pneumologists evaluated any lower airway respiratory disease. Genetic investigations concluded the diagnostic investigation. Our experience enhanced the complexity of children's NPs. A multidisciplinary assessment is mandatory for a targeted diagnostic and therapeutic pathway.

Real-Life Effectiveness of Mepolizumab in Refractory Chronic Rhinosinusitis with Nasal Polyps

The aim of this study was to evaluate the efficacy of mepolizumab in patients affected by chronic rhinosinusitis with nasal polyps (CRSwNP) in real-life. A single-center retrospective observational study was conducted on severe CRSwNP patients treated with mepolizumab. Nasal endoscopic polyp score (NPS), visual analogue scale (VAS) symptom score, sinonasal outcome test (SNOT-22), asthma control test (ACT) score, fractional exhaled nitric oxide (FeNO), eosinophils blood cells and prednisone intake were assessed at baseline and after 6 months. A total of 55 patients were included; 49 patients (89%) presented with asthma; aspirin exacerbated respiratory disease (AERD) in 28 patients (51%). A statistically significant decrease in the SNOT-22 score was observed (median difference -63; 95% CI: -68; -58; p < 0.001) with median t0 76 and IQR (61;90) to t6 10 (5;15). A reduction in NPS, median t0 NPS 4; (IQR:4;6), median t6 NPS 1; (IQR:0;1) p < 0.001, was greater in patients with AERD. The median baseline VAS score was 6 (IQR:6;7) and the differences between t0 and t6 were statistically significant p < 0.001. Significant changes in blood eosinophils cells, median t0 500 cell/mcl (IQR:340;830), median t6 97 cell/mcl (IQR:60;160) p < 0.001, were greater in patients with AERD. Mepolizumab treatment effects have been demonstrated with significantly reduced symptoms, polyp scores, blood eosinophils and systemic corticosteroid use, resulting in an increased health-related quality of life in patients with severe CRSwNP, regardless of the presence or absence of asthma or AERD.

Sense of smell in chronic rhinosinusitis: A multicentric study on 811 patients

Introduction

The impairment of the sense of smell is often related to chronic rhinosinusitis (CRS) with or without nasal polyps (CRSwNP, CRSsNP). CRSwNP is a frequent condition that drastically worsens the quality of life of those affected; it has a higher prevalence than CRSsNP. CRSwNP patients experience severe loss of smell with earlier presentation and are more likely to experience recurrence of their symptoms, often requiring revision surgery.

Methods

The present study performed a multicentric data collection, enrolling 811 patients with CRS divided according to the inflammatory endotype (Type 2 and non-Type 2). All patients were referred for nasal endoscopy for the assessment of nasal polyposis using nasal polyp score (NPS); Sniffin' Sticks olfactory test were performed to measure olfactory function, and SNOT-22 (22-item sinonasal outcome test) questionnaire was used to assess patients' quality of life; allergic status was evaluated with skin prick test and nasal cytology completed the evaluation when available.

Results

Data showed that Type 2 inflammation is more common than non-type 2 (656 patients versus 155) and patients suffer from worse quality of life and nasal polyp score. Moreover, 86.1% of patients with Type 2 CRSwNP were affected by a dysfunction of the sense of smell while it involved a lesser percentage of non-Type 2 patients. Indeed, these data give us new information about type-2 inflammation patients' characteristics.

Discussion

The present study confirms that olfactory function weights on patients' QoL and it represents an important therapeutic goal that can also improve patients' compliance when achieved. In a future - and present - perspective of rhinological precision medicine, an impairment of the sense of smell could help the clinician to characterize patients better and to choose the best treatment available.

Spotlight on a Short-Time Treatment with the IL-4/IL-13 Receptor Blocker in Patients with CRSwNP: microRNAs Modulations and Preliminary Clinical Evidence

Already used for the treatment of some allergic and inflammatory diseases, such as asthma or atopic dermatitis, dupilumab has also been approved as add-on therapy for patients with CRSwNP, and it could represent the keystone to reducing the remission time as well as to improve healing and quality of life. On the other hand, the role of miRNAs as potential biomarkers of immune modulation is emerging. We analyzed the effects of a short-time treatment with dupilumab in patients with CRSwNP, analyzing the immune response modification as well as miRNAs modulations. First, in this early observation stage, all patients experienced remarkable improvement and were clinically stable. Indeed, we observed a significant decrease in CD4+ T cells and a significant reduction in total IgE (p < 0.05) and serum IL-8 levels (p < 0.01), indicating a reduction in the general inflammatory condition. In addition, we analyzed a panel of about 200 circulating miRNAs. After treatment, we noted a significant downregulation of hsa-mir-25-3p (p-value = 0.02415) and hsa-mir-185-5p (p-value = 0.04547), two miRNAs involved in the proliferation, inflammation, and dug-resistance, in accordance with the clinical status of patients. All these preliminary data aimed to identify new biomarkers of prognosis, identifiable with non-invasive procedures for patients. Further, these patients are still under observation, and others with different levels of responsiveness to treatment need to be enrolled to increase the statistical data.

A prospective study on the efficacy of dupilumab in chronic rhinosinusitis with type 2 inflammation

Objective

Treatment for chronic rhinosinusitis with nasal polyps (CRSwNP) includes endoscopic sinus surgery and topic and/or systemic corticosteroids, which have only temporary effects. The development of biologic therapies has provided a new treatment paradigm for CRSwNP. Dupilumab is the only biological approved in Italy for CRSwNP, but its efficacy in a real-life context is still scarce.

Methods

We carried out a monocentric prospective study at our institution with a 6-month follow-up on patients administered biweekly 300 mg dupilumab therapy for CRSwNP, prescribed according to EPOS 2020 criteria. Patients were evaluated at baseline and every 2 months.

Results

Median values at baseline and 6 months were, respectively, 3/12 and 8/12 for the Brief Smell Identification Test (p = 0.005), 5/8 and 2/8 for the Nasal Polyp Score (p < 0.001), 10/20 and 6/20 for the Lund-Kennedy score (p < 0.001), 65/110 and 14/110 for the Sinonasal Outcome Test (p < 0.001), and 15/25 and 23/25 for the Asthma Control Test score (p = 0.009). Adverse events were mild, consisting mainly in discomfort at the site of injection. Four patients developed asymptomatic hypereosinophilia. The treatment was not discontinued in any patient.

Conclusions

Dupilumab was confirmed to be an effective and safe treatment for CRSwNP, as previously seen in registrational studies.

Mepolizumab Improves Outcomes of Chronic Rhinosinusitis with Nasal Polyps in Severe Asthmatic Patients: A Multicentric Real-Life Study

Objective: The upcoming introduction of mepolizumab represents a promising treatment for chronic rhinosinusitis with nasal polyps (CRSwNP). The present study aimed to evaluate the effectiveness of mepolizumab on sinonasal outcomes of comorbid CRSwNP and severe asthma in a real-life setting. The primary endpoint was to evaluate changes in the SinoNasal Outcome Test (SNOT)-22 score, Nasal Polyp (NP) score, and blood eosinophil count during a 12-month treatment with mepolizumab. Secondary endpoints were to quantify mepolizumab’s effects on the mentioned parameters, identify clinical variables influencing the degree of response to treatment, and portray responder and nonresponder patients. Methods: A multicentric retrospective no-profit observational study on severe asthmatic patients, treated with mepolizumab, and comorbid CRSwNP was conducted. All patients were followed for at least 12 months. SNOT-22 score, NP score, and blood eosinophil count (and other CRS-specific variables) were collected at baseline and after 12 months. Results: Forty-three patients were included. A statistically significant reduction was observed for SNOT-22 score (mean t0 SNOT-22 54.8 ± 25.9; mean t12 SNOT-22 31.5 ± 21.3, p < 0.0001), NP score (median t0 NPS 3 (IQR 3); median t12 NPS 2 (IQR 4), p < 0.0001), and blood eosinophil count (mean t0 blood eosinophils 804.7 ± 461.5 cell/µL; mean t12 blood eosinophils 107.5 ± 104.6 cell/µL, p < 0.0001) after 12 months of treatment. Twenty patients (47%) gained improvement both in clinical and endoscopic outcome. Mepolizumab responder patients presented a t0 SNOT-22 significantly higher than nonresponders (p = 0.0011). Conclusions: Mepolizumab improved CRSwNP outcomes in a population of severe asthmatic patients. No clinical feature emerged to outline the profile of a “typical” responder patient, except for baseline SNOT-22 score, which seemed to affect the response to treatment. Further studies would be necessary to supplement these preliminary evaluations.

Adverse effects of dupilumab in chronic rhinosinusitis with nasal polyps. Case report and narrative review

Herein we review the current literature on the adverse effects related to biological therapy with the monoclonal antibody dupilumab in patients with type 2 inflammation prevalent phenotype chronic rhinosinusitis with nasal polyps (CRSwNP). Our review shows that the side effects of dupilumab may be linked to the prevalent type 2 inflammation phenotype (asthma, dermatitis, CRSwNP). We also report the first case of cutaneous rash as a side effect of dupilumab in a patient with CRSwNP.

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.

Effectiveness of Dupilumab in the Treatment of Patients with Severe Uncontrolled CRSwNP: A "Real-Life" Observational Study in the First Year of Treatment

The aim of this study was to evaluate the efficacy of dupilumab in the treatment of severe uncontrolled Chronic Rhinosinusitis with Nasal Polyps (CRSwNP), with or without asthma as add-on therapy with intra-nasal corticosteroids in a real-life setting over the first year of treatment. Our data demonstrated that subcutaneous 300 mg dupilumab administered at home via a pre-filled auto-injector every two weeks, based on indications set by the Italian Medicines Agency, was rapidly effective in reducing the size of polyps, decreasing symptoms of disease, improving quality of life, and recovering olfaction. Significant improvement was observed after only 15 days of treatment, and it progressively increased at 6 and 12 months. Dupilumab was also effective in reducing the local nasal eosinophilic infiltrate, in decreasing the need for surgery and/or oral corticosteroids, and in improving control of associated comorbidities such as chronic eosinophilic otitis media and bronchial asthma. After 12 months of treatment, 96.5% of patients had a moderate/excellent response. From our data, it was evident that there was a group of patients that showed a very early response within one month of therapy, another group with early response within six months from baseline, and a last group that improved later within 12 months. The results of this study support the use of dupilumab as an effective option in the current standard of care for patients affected by severe uncontrolled CRSwNP.

Image guidance for endoscopic sinus surgery in patients with chronic rhinosinusitis: a systematic review and meta-analysis protocol

INTRODUCTION

Endoscopic sinus surgery (ESS) is a current procedure for treating patients with chronic rhinosinusitis (CRS). Image-guided surgery (IGS) for ESS may help reduce complications and improve precision. However, it is uncertain in which cases IGS is beneficial. This work aims to compare ESS with and without IGS in patients with CRS.

METHODS AND ANALYSIS

PubMed, Embase, Scopus, Web of Science, Scielo, Cochrane Central Register of Controlled Trials, CINAHL, LILACS and Clinicaltrials.gov will be searched for reported clinical trials comparing the quality of life and perioperative outcomes of ESS with and without navigation. The search is planned for 20 April 2022. Three independent authors will select eligible articles and extract their data. The risk of bias will be assessed using the Cochrane Handbook for Systematic Reviews of Interventions. The Grading of Recommendation Assessment, Development and Evaluation method will evaluate the strength of the evidence. Data synthesis will be performed using the Review Manager software V.5.4.1. To assess heterogeneity, I² statistics will be computed. Additionally, meta-analysis will be performed if the included studies are sufficiently homogenous.

ETHICS AND DISSEMINATION

This study reviews published data, and thus it is not necessary to obtain ethical approval. The findings of this systematic review will be published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42020214791.

Efficacy of Biologics on Refractory Eosinophilic Otitis Media Associated with Bronchial Asthma or Severe Uncontrolled CRSwNP

Eosinophilic otitis media (EOM) is a difficult-to-treat otitis media characterized by eosinophilic accumulation in the middle ear mucosa and effusion. It is resistant to conventional treatments and strongly associated with asthma and chronic rhinosinusitis with nasal polyps (CRSwNP). The aim of our study is to evaluate the effectiveness of biologics drugs in the control of EOM. This is a retrospective no-profit real-life observational study, involving patients affected by refractory EOM and in treatment with different biologics for concomitant severe eosinophilic asthma or severe uncontrolled CRSwNP (Dupilumab: n = 5; Omalizumab: n = 1; Mepolizumab: n = 1; Benralizumab: n = 1). We analyzed data at baseline and at the 6-month follow-up, including specific nasal and otological parameters. We observed an improvement of all nasal outcomes, including NPS, SNOT-22, VAS, and smell function. Regarding specific otological parameters, we observed a significant reduction in the mean value of COMOT-15 score and of Otitis Severity Score at 6-month follow-up compared to baseline (p < 0.05). Finally, we observed an improvement in terms of air conduction hearing levels during the treatment. Our results demonstrated that anti type-2 inflammatory pathway biologics can be effective in improving symptoms control and in reducing the severity of eosinophilic otitis media when treating coexisting type-2 diseases, such as asthma and or CRSwNP.

When rhinosinusitis is not just rhinosinusitis: Clinical characteristics and phenotypes of patients with type 2 chronic rhinosinusitis with nasal polyps

BACKGROUND AND AIM

Chronic rhinosinusitis (CRS) is a chronic and recurrent disease that negatively affects patients' quality of life. CRS has two main phenotypes: CRS with nasal polyps (CRSwNP) and CRS without polyps (CRSsNP). Minimal research has been conducted to study the variability in patients' characteristics. Therefore, we conducted this study to examine these differences.

METHODS

A retrospective cohort study included patients with both CRSwNP and CRSsNP. Outcomes included symptom severity, radiographic severity, and number of sinus surgeries. Symptom severity was assessed using the Sino-nasal Outcome Test and the Lund-Mackay CT score was used to determine radiographic severity. Further subgroup analysis was done based on the presence or absence of comorbid asthma.

RESULTS

A total of 110 and 106 patients were included in the CRSwNP and CRSsNP groups, respectively. The mean age in the CRSwNP and CRSsNP groups was 50.2 and 48.7, and the proportion of female patients was 40.9% and 58.5%, respectively. No significant difference in symptom severity was noted between CRSwNP and CRSsNP group (68.1±18.6 vs. 73.2±21.27; P=0.097), while the Lund-Mackay score was significantly lower in the CRSsNP group (7.4±2.3 vs. 11.9±3.6; P=0.016). Also, the number of surgeries was significantly lower in the CRSsNP group as compared to the CRSwNP group (P=0.023). Subgroup analysis revealed statistically significant differences between those with and without asthma in patients with CRSwNP in terms of Lund-Mackay scores and number of surgeries (P=0.038 and 0.043), respectively. However, no significant differences were noted in the CRSsNP group (P>0.05).

CONCLUSIONS

There is a clear variability in the characteristics of patients with CRSsNP and CRSwNP. A similar difference was noted in the CRSwNP group when patients were stratified based on the presence of absence of asthma. This warrants further investigation of potential correlation with the prognosis and optimum treatment strategies of this patient population.

A Practical Clinical Protocol for Monitoring Patients with Severe Uncontrolled Chronic Rhinosinusitis with Nasal Polyposis Treated with Biologics

Objectives:

Chronic rhinosinusitis with nasal polyposis (CRSwNP) is a pathological condition which leads to high healthcare-related costs and low quality of life for patients. The introduction of new biological therapies (monoclonal antibodies, MAbs) in CRSwNP patients has allowed new therapeutic options for non-responders to conventional therapies and Dupilumab represents the first approved biological agent. The aim of this paper is to provide a practical clinical multidisciplinary protocol which might help clinicians involved in this field to monitor the clinical outcomes.

Methods:

Our centre of Rhinology and Rhino-Allergology has developed a dedicated collection form to observe the outcomes of patients treated with Dupilumab. Our research started from the indications given in EPOS 2020 as main reference. We then implemented these references in an electronic database trying to apply Evidence Based Medicine (EBM) in current clinical practice.

Results:

The result consists of three parts: an anamnestic collection data, a clinician reported outcome and two patient reported outcomes (PROMs) questionnaire, the visual analogue scale (VAS) and the Sino-Nasal Outcome Test-22 (SNOT-22). The tables we propose should provide an adequate correlation with the patients’ adherence to therapy and their treatment outcomes. Such periodical evaluation (after a month, after 3 months, after 6 months and at one year) should quickly allow to monitor if the patient is correctly assuming the therapy and the eventual objective improvements.

Conclusions:

We propose a practical monitoring protocol formulated to analyse both objective and subjective aspects of patients with severe uncontrolled CRSwNP treated with MAbs, thus helping to define in future a better comparison between the clinical results of different institutes.

A prospective pilot study on the effects of endoscopic sinus surgery on upper and lower airway performance

Objective

Methods

Results

Conclusions

Chronic rhinosinusitis with nasal polyposis (CRSwNP): the correlation between expression of Galectin-10 and Clinical-Cytological Grading (CCG)

BACKGROUND

Chronic rhinosinusitis with nasal polyps (CRSwNP) is typically characterized by Type 2 inflammation. Several biomarkers of eosinophilic inflammation, including Galectin-10, also known as Charcot-Leyden crystal protein (CLCP), have been identified to establish eosinophilic infiltration of polyps, a reliable predictor of recurrence.Objective: We aimed to evaluate the Galectin-10 expression in nasal polyps of patients with CRSwNP and to assess the correlation of Charcot-Leyden crystals expression to the severity of CRSwNP according to Clinical-Cytological Grading (CCG).

METHODS

A double-label immunofluorescence was performed to evaluate the expression of Gal-10, CD15, Tryptase, and CD63 and their eventual co-localization on histological samples of 18 patients with CRSwNP. Double-positive Gal-10+CD15+ and Galectin-10+Tryptase+ inflammatory cells were counted by confocal microscopy.

RESULTS

Galectin-10 was detectable in all examined tissues from CRSwNP patients, and its expression increased as low, medium and high CCG tissues were examined, respectively. Galectin-10 was extensively present in inflammatory cells, while limited Galectin-10 deposits were detected around mucosal epithelial cells.

CONCLUSION

We showed the strong correlation between CCG and Galectin-10 expression, mainly colocalized with infiltrating eosinophils and mast-cells, in patients affected by CRSwNP.

The predictive utility of the 22-item sino-nasal outcome test (SNOT-22): A scoping review

BACKGROUND

The 22-item sino-nasal outcome test (SNOT-22) is a widely used and powerful patient-reported outcomes measure for chronic rhinosinusitis (CRS). More recently; however, the SNOT-22 has been evaluated as a predictive tool for multiple conditions. The objective of this scoping review is to investigate the extent to which SNOT-22 is used in this manner and present this information in a way useful for clinicians.

METHODS

A systematic search of PubMed, Scopus, Cochrane Library, and Web of Science was performed. Studies that evaluated SNOT-22s predictive utility were considered for eligibility in this scoping review.

RESULTS

A total of 39 studies met eligibility. The SNOT-22 was found to be used as a predictive tool in three broad categories: (1) to predict a diagnosis, (2) to predict an outcome of an intervention, and (3) to predict a patient treatment preference. Thirteen studies were included in the diagnosis category, which made up ten different individual predictions. Twenty-four studies were included in the outcomes category and investigated 17 different individual predictions. Finally, two studies were included in the patient preferences category, which together made one prediction.

CONCLUSIONS

The SNOT-22 is a versatile tool that has the potential to be used in predicting various diagnoses, outcomes, and patient preferences. However, care must be taken in applying these predictions to clinical practice, as further research must be done in validating these predictions based on SNOT-22 responses.

Development of a questionnaire to investigate socio-cultural differences in the perception of smell, taste and flavour

Objectives

Clinical experience and daily life indicate that the importance of smell, taste and flavour is variable among individuals. Therefore, the aim of this research was to develop a questionnaire to investigate the importance attributed to smell, taste and flavour and socio-cultural differences among individuals.

Methods

Cross-cultural adaptation of the questionnaire was executed by two professional translators and one bilingual investigator and pre-tested on a pilot group of 25 subjects with normal smell and taste abilities. The final version of the questionnaire was sent by e-mail to 850 healthy subjects. The Google form consisted of three parts: "The importance of olfaction" developed by Croy et al. in 2010, "The importance of taste and flavour" developed by our team and a section to collect demographic data. The questions were classified into "association", "application", "consequence" and "aggravation". Statistical differences were assessed using t-test with p ≤ 0.05. Correlations were calculated using Spearman's test. Internal consistency was assessed using the Cronbach's Alpha, while test-retest reliability was analysed by calculating the Intraclass Correlation Coefficients (ICC2k).

Results

The questionnaire received a non-response rate of 10.7%. Calculation of Cronbach's alpha showed good internal reliability (a = 0.87). Test-retest evaluation was satisfactory for all subscales, with an overall ICC2k = 0.84 (CI 0.79-0.89). Statistical analysis showed that smell, taste and flavour appeared to be more important for women when compared to men (p < 0.001). No statistical differences were seen between individuals with various educational background (p > 0.05), and the importance of smell (r = 0.16; p < 0.01), taste and flavour (r = 0.08; p < 0.05) did not decline with age.

Conclusions

The development of this original test provides an overview into the importance of smell, taste and flavour among individuals. Although further research is needed, it can help in the evaluation and investigation of aspects that influence people to seek medical attention in the presence of sensory alterations.

Exploring the role of nasal cytology in chronic rhinosinusitis

Objective

Characterising the eosinophilic profile represents the main step in chronic rhinosinusitis (CRS) endotyping. The aim of the study is to verify the correlation between different methods for tissue eosinophilia quantification.

Methods

33 CRS patients undergoing endoscopic sinus surgery and 30 controls undergoing non-CRS surgeries were enrolled. Blood venous sampling, nasal biopsy on uncinate process (UP), nasal cytology on inferior turbinate (IT) and middle meatus (MM) were performed.

Results

Differences in eosinophil count in blood (P=0.0001), UP (P<0.0001), IT (P = 0.01) and MM (P = 0.0006) were significant between CRS cases and controls. A weak correlation was found between UP and blood eosinophil count (r = 0.34, P = 0.006) and between UP and IT eosinophil count (r = 0.30, P = 0.017). Moderate correlation between UP and MM (r = 0.51, P < 0.0001) was shown. ROC analysis predicted eosinophilic CRS with an overall low sensitivity. Once allergic patients were excluded from the analysis, the sensitivity decreased for sampling on IT and increased for MM sampling.

Conclusions

This study suggests that MM cytology gives more accurate information on the degree of tissue eosinophilia. Replication in wide and unbiased cohorts is necessary to verify these results and define accurate thresholds.

The SWI/SNF complex in eosinophilic and non eosinophilic chronic rhinosinusitis

Introduction

Chronic rhinosinusitis (CRS) can be classified as eosinophilic (eCRS) or non-eosinophilic (neCRS) based on infiltration type. The SWI/SNF complex may be involved in the pathophysiology of CRS.

Aim

To assess the expression of the SWI/SNF complex in both CRS groups; to correlate blood eosinophil count (BEC), and histopathology eosinophil count (HPEC) with the SWI/SNF expression level in eCRS and neCRS.

Materials and methods

The study population consisted of 96 patients (68 eCRS, 28 neCRS). Immunohistochemical staining was performed on sinonasal mucosa for assessment of SWI/SNF protein expression. Type of tissue infiltration was assessed in samples obtained from examined groups (HPEC). The diagnostic value of eCRS was 10 cells/HPF (high power field). Complete blood count was analysed in order to calculate BEC.

Results

BEC and HPEC correlated negatively with all the SWI/SNF subunits. HPEC and BEC correlated positively with clinical findings (L-M and SNOT-22), while SWI/SNF correlated negatively with clinical findings (L-M and SNOT-22).

Conclusions

The SWI/SNF was observed in both eCRS and neCRS, with lower expression in former. The meaning of its negative correlation with BEC, HPEC and clinical findings in eCRS group remains to be understood.

The effect of N95 and surgical masks on mucociliary clearance function and sinonasal complaints

PURPOSE

The aim of this study was to reveal the effect of N95 and surgical masks on mucociliary clearance function and sinonasal complaints.

METHODS

Sixty participants were enrolled in this study, including 30 people in N95 mask group and 30 people in surgical mask group. Two interviews, three days apart, were performed with all participants. The participants were asked not to use any mask before the first interview while they were asked to use the determined mask just before the second interview for 8 h. In both interviews, the mucociliary clearance times (MCTs) were measured and participants were asked to score ten distinct sinonasal complaints using visual analog scale (VAS). Data obtained from first interview were named pre-mask data, data obtained from second interview were called after-mask data. In both groups, pre-mask MCTs and VAS scores were compared with after-mask MCTs and VAS scores.

RESULTS

After-mask MCTs (mean = 13.03 ± 6.05 min) were significantly longer than pre-mask MCTs (mean = 10.19 ± 4.21 min) in N95 mask group (p = 0.002). No significant difference was found between after-mask and pre-mask MCTs (mean = 12.05 ± 5.21 min, mean = 11.00 ± 5.44 min, respectively) in surgical mask group (p = 0.234). When after-mask VAS scores were compared with pre-mask VAS scores, it was found that N95 mask use increased nasal blockage and postnasal discharge, surgical mask usage increased nasal blockage.

CONCLUSION

While the use of N95 mask leads to nasal blockage and postnasal discharge, surgical mask use results in nasal blockage. N95 masks cause impairment in mucociliary clearance function. But all these effects are mild. Surgical masks have not been found to have any effect on mucociliary clearance function.

Effects of biological therapies on chronic rhinosinusitis in severe asthmatic patients

Objective

The introduction of monoclonal antibody (mAb) therapies represents a promising treatment for refractory chronic rhinosinusitis (CRS). We assessed the effects of selected mAbs (omalizumab, mepolizumab, benralizumab) on CRS in severe asthmatic patients in a real-life setting.

Methods

A prospective observational study on severe asthmatic patients, treated with 3 different mAb (omalizumab, mepolizumab, benralizumab), and comorbid CRS was conducted. All patients were followed for 52 weeks. The degree of nasal control, SinoNasal Outcome Test (SNOT) 22, Nasal Polyp Score (NPS), Lund Kennedy Score (LKS) were collected at baseline and at 52-week.

Results

40 patients (33 with nasal polyps) were studied. 33 patients (82.5%) had uncontrolled nasal disease at baseline, and 15 (37.5%) were uncontrolled after 52 weeks. Significant improvement was observed for SNOT 22 (P < 0.001), SNOT 1-12 (P < 0.001) and degree of nasal control (P < 0.001). Differences in NPS (P = 0.130) and LKS (P = 0.124) were not significant. Net change in the above-mentioned parameters among the three treatment groups was not significantly different.

Conclusions

The study shows an improvement of nasal symptoms after 52 weeks of mAb treatment, which was not associated with significant improvement of endoscopic findings. Larger studies are needed to assess the real-life efficacy of mAbs in CRS.

Endoscopic sinus surgery outcomes in CRS: quality of life and correlations with NOSE scale in a prospective cohort study

BACKGROUND

To evaluate the impact of endoscopic sinus surgery (ESS) on clinical outcomes, quality of life (QoL) and Nasal Obstruction and Symptom Evaluation (NOSE) scale in patients with CRSwNP and CRSsNP. An additional question that needs to be investigated is whether there is a correlation between patients at the age of relapse.

METHODOLOGY/PRINCIPAL

A prospective cohort study of 150 subjects [96 males, 54 females, mean age: 51.99 ± (15.73)]. The SNOT-22 and NOSE questionnaires were used to measure the patients' QoL and their nasal blockage symptoms, respectively. Endoscopic and computerized tomography (CT) scores depicted the objective findings.

RESULTS

Following ESS, the endoscopic scale showed a significant improvement in 83.85% of patients. QoL measured with SNOT-22 improved by 78.85% and with NOSE scale by 92.10%. Also, a statistically significant correlation was found between NOSE, SNOT-22 and the Lund-Kennedy scale. Recurrence was observed in 13 patients during follow-up. There was no statistically significant correlation between age, gender, smoking and recurrence tendency. Patients with baseline SNOT-22 and NOSE scores lower than 30 typically fail to obtain a clinically meaningful benefit. Patients with a rate greater than or equal to 40 achieved a minimal clinically important difference (MCID) of 83.9% and had an average symptom reduction (RI) rate of 60.3%.

CONCLUSIONS

ESS is an important treatment option for symptomatic patients with CRSwNP and CRSsNP. Both objective and subjective measurements including QoL improved significantly, and the results stabilized at 12 to 18 months. The NOSE scale is a sensitive outcome measure in the CRS population, including subjects with and without nasal polyps. In our study, SNOT-22 and NOSE are excellent predictors of postoperative improvement.