Chronic rhinosinusitis: management for optimal outcomes

Differential effects of postoperative oral corticosteroid on eosinophilic vs. non-eosinophilic CRSwNP subtypes

PURPOSE

The efficacy of postoperative oral corticosteroids on surgical outcomes in chronic rhinosinusitis with nasal polyps (CRSwNP) patients following endoscopic sinus surgery (ESS) remains controversial. This study evaluated the potential benefits of postoperative oral corticosteroids on surgical outcomes in CRSwNP patients and investigated the differential effects on eosinophilic CRSwNP (ECRSwNP) and noneosinophilic CRSwNP (NECRSwNP).

MATERIALS AND METHODS

Patients with bilateral CRSwNP who underwent ESS were enrolled and randomized to receive either oral prednisolone (30 mg/day) or placebo for 2 weeks after surgery. Visual analog scale (VAS) and Sino-Nasal Outcome Test 22 (SNOT-22) scores were chosen as the subjective outcomes, evaluated at preoperative baseline and 1, 3, and 6 months postoperatively. Lund-Kennedy Endoscopic Scores (LKESs) were used as the objective outcome, evaluated at preoperative baseline and at 2 weeks and 2, 3, and 6 months postoperatively.

RESULTS

In total, 100 patients with bilateral CRSwNP were enrolled, of whom only 82 completed the 6-month follow-up. The subjective outcomes showed no significant difference at each follow-up points. Of the objective outcomes, the corticosteroid group reporting a trend of improvement in LKESs at 6 months postoperatively (p = 0.05). After stratification by tissue eosinophils, only patients with NECRSwNP (<10 eosinophils/HPF) demonstrated a significant improvement in LKESs at 3 months postoperatively (p = 0.03).

CONCLUSIONS

Postoperative oral corticosteroids did not provide additional improvements in VAS and SNOT-22 scores; nevertheless, a trend of LKES improvement was noted at 6 months postoperatively. After stratification by tissue eosinophils, this effect was significant only among NECRSwNP patients at 3 months follow-up.

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

BACKGROUND

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

OBJECTIVE

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

Endoscopic assistance in the diagnosis and treatment of odontogenic maxillary sinus disease

PURPOSE

Endoscopic sinus surgery has become an increasingly popular treatment for most surgical cases of chronic sinusitis. However, in some cases, a modification of the classic Caldwell-Luc operation is unavoidable. The purpose of this paper is to present the outcome of 20 cases with pathology of the maxillary sinus which was approached endoscopically on diagnostic or interventional purpose. The primary indication for endoscopy for 11 cases was acute or chronic odontogenic sinusitis. For six cases, endoscopy was performed for removing a foreign body from the sinus cavity and for the remaining three cases, for diagnostic purpose only.

METHODS

A 4-mm rigid endoscope was used through the middle nasal meatus (eight cases) or via a puncture at the canine fossa (seven cases). A combined endoscopic approach was used in five cases. In three cases, endoscopy was combined with Caldwell-Luc technique. For the majority of the patients, the operation was performed under local anesthesia (16 cases).

RESULTS

The mean follow-up period was 9.1 months. No major complications were observed. One patient died 18 months after an endoscopically assisted detection of malignancy. Results were depended on the surgical procedure pursued and the underlying sinus pathology. Laborious surgery and chronic sinusitis gave the less satisfactory results.

CONCLUSIONS

Endoscopy of the maxillary sinus can be applied in a variety of indications. Alone or in combination with conventional surgery, it is a minimally invasive and highly diagnostic tool.

Comparison of efficacy of mometasone furoate versus clarithromycin in the treatment of chronic rhinosinusitis without nasal polyps in Chinese adults

BACKGROUND

Although both nasal steroids and macrolide antibiotics have been recommended for the treatment of chronic rhinosinusitis without nasal polyps (CRSsNPs), whether there is any difference in their clinical efficacy remains unexplored. In addition, few studies have investigated their clinical efficacy in a Chinese population living in China, who present distinct inflammatory patterns compared with white patients in western countries. This study compares the efficacy of mometasone furoate and clarithromycin treatment in CRSsNP in Chinese adults in a preliminary prospective, open-label, randomized trial.

METHODS

Forty-three CRSsNP patients were randomized to receive mometasone furoate nasal spray at 200 μg (n = 21) or clarithromycin tablet at 250 mg (n = 22) once daily for 12 weeks. Patients were assessed before the treatment and after 4, 8, and 12 weeks after treatment. Subjective symptoms were scored on a visual analog scale. Endoscopy physical findings were scored according to Lanza-Kennedy scoring system. Moreover, smoking and atopic status and coexistence of allergic rhinitis (AR) and asthma were recorded.

RESULTS

Before the treatment, no significant difference in symptoms and nasal endoscopic physical findings were found between mometasone furoate and clarithromycin group. As early as 4 weeks after dosing, a significant reduction of total symptom scores, nasal obstruction, headache, rhinorrhea and overall burden scores, and mucosal swelling and nasal discharge scores were observed in both groups. No significant difference in symptom or endoscopic scores was observed between these two groups at any posttreatment observation time point. The coexistence of AR was correlated with lower scores of mucosal edema and nasal secretion in the mometasone furoate group after 12-week treatment.

CONCLUSION

Mometasone furoate and clarithromycin show a comparable clinical effect for CRSsNPs in Chinese adults. Mometasone furoate is more effective in improving edema and secretion for CRSsNP patients with concomitant AR.

Impact of Nasal Symptoms on the Quality of Life of Fresh Inductees in High Altitude

BACKGROUND

Troops deployed in high altitude areas of Ladakh face nasal problems in the form of obstructive nasal symptoms and recurrent epistaxis. This study analyses the changes in the nasal mucociliary transit times (NMTT) and deterioration in quality of life of troops on first high altitude induction.

METHODS

A prospective study on 100 healthy volunteers was done. Mucociliary transit time was measured and a standardized quality of life questionnaire (RQLQ) administered at onset and after a period of three months in high altitude. Thereafter the subjects were divided into two groups and the study group was administered normal saline nasal drops. The observations were taken and results were statistically analysed after a period of three months.

RESULT

The mucociliary transit time was prolonged after a three month stay in high altitude (p< 0.005). Normal saline nasal drops were successful in improving the nasal mucociliary transit times (p < 0.05). There was a statistically significant derangement in the quality of life which was improved by administering normal saline nasal drops (p<0.05).

CONCLUSION

An increased muco-cilliary transport time after exposure to high altitude denotes a deranged physiology of the nasal mucosa. This leads to a statistically significant adverse impact on the quality of life of the troops deployed. The use of normal saline nasal drops is a simple and effective method of reversing some of these changes.

The effects of methylprednisolone and cefazolin sodium on antioxidant status in experimentally induced maxillary sinusitis

CONCLUSION

Sinusitis is accompanied by deteriorated antioxidant status, which can be alleviated with administration of cefazolin sodium or methylprednisolone. Steroids improve sinusitis when combined with antibiotics.

OBJECTIVE

To evaluate the antioxidant status in response to treatment of maxillary sinusitis with methylprednisolone and cefazolin sodium.

MATERIALS AND METHODS

Twenty-eight rabbits were inoculated with Staphylococcus aureus and then treated with saline, methylprednisolone, cefazolin sodium, and methylprednisolone plus cefazolin sodium, twice daily for 7 days. After the animals were sacrificed, mucosa samples were obtained to determine catalase (CAT), superoxide dismutase (SOD), and glutathione reductase (GPx) activities and levels of nitric oxide (NO) and malondialdehyde (MDA).

RESULTS

Catalase activity among untreated rabbits and those treated with either methylprednisolone or cefazolin sodium was not different. Activities of SOD and GPx were lower for rabbits treated with cefazolin sodium than for those treated with methylprednisolone and for untreated rabbits (p<0.0001). Rabbits treated with cefazolin sodium had lower NO and MDA levels than those treated with methylprednisolone and untreated rabbits (p<0.0001). Combined administration of cefazolin sodium with methylprednisolone increased CAT, SOD, and GPx activities further and decreased NO and MDA levels further in comparison with their administration alone (p<0.0001).

Criteria to screen for chronic sinonasal disease

BACKGROUND

Sinusitis and rhinitis are associated with uncontrolled asthma. There are no simple, validated tools to screen for these diseases. The objective of this study was to assess instruments to assist in the diagnosis of chronic sinonasal disease.

METHODS

Participants without acute sinonasal symptoms underwent an extensive evaluation. The results were submitted to an expert panel that used the Delphi method to achieve consensus. Using the consensus diagnosis of the panel, we determined the sensitivity and specificity of test procedures to diagnose chronic sinonasal disease. We determined the reproducibility of the most sensitive and specific instrument in a separate cohort.

RESULTS

Fifty-nine participants were evaluated, and the expert panel reached consensus for all (42 participants with chronic sinonasal disease, 17 participants without chronic sinonasal disease). A six-item questionnaire based on the frequency of nasal symptoms was the most sensitive tool used to diagnose sinonasal disease (minimum specificity, 0.90). Reproducibility testing in a separate cohort of 63 participants (41 chronic sinonasal disease with asthma, 22 chronic sinonasal disease without asthma) showed a concordance correlation coefficient of 0.91 (95% CI, 0.85 to 0.94) when this questionnaire was limited to five items (ie, excluding a question on smell). This five-item questionnaire had a sensitivity of 0.90 (95% CI, 0.77 to 0.97), a specificity of 0.94 (95% CI, 0.71 to 1.00), and an area under the receiver operating characteristic curve of 0.97 (95% CI, 0.93 to 1.0). Sinus CT scans and nasal endoscopy lacked sensitivity for use in the diagnosis of chronic sinonasal disease.

CONCLUSIONS

We have developed a sensitive, specific, and reproducible instrument to screen for chronic sinonasal disease. Validation studies of this five-item questionnaire are needed, including in patients with asthma.

Nasal and sinus endoscopy for medical management of resistant rhinosinusitis, including postsurgical patients

Nasal endoscopy has been practiced by allergists since the early 1980s; however, allergists in general have not embraced endoscopic evaluation of patients with sinus disease, either before or after surgery. Allergists are in a unique position to render medical (as opposed to surgical) care of patients with sinusitis. There has been a growing realization that endoscopy is a valuable procedure for the evaluation and medical treatment of patients with difficult sinusitis. This has resulted in the need for a resource to allow allergists to understand the nature of endoscopic findings in patients with sinusitis, either preoperatively or postoperatively. This article introduces the findings at endoscopy that are common in patients with sinusitis, including those that may be seen after surgery. The findings include perforation of the septum, retained secretions, small surgical ostium caused by postoperative ostial stenosis, previous Caldwell Luc procedure, recirculation of mucus, hyperplastic nasal disease, synechiae, recurrent disease in previously unaffected sinuses, empty nose syndrome, frontal sinus disease, dental disease, and other, more complicated entities.

Rhinosinusitis: Developing guidance for clinical trials

The Rhinosinusitis Initiative was developed by 5 national societies. The current guidance document is an expansion of the 2004 publication, "Rhinosinusitis: Establishing definitions for clinical research and patient care" and provides templates for clinical trials in antimicrobial, anti-inflammatory, and symptom-relieving therapies for the following: (1) acute presumed bacterial rhinosinusitis, (2) chronic rhinosinusitis (CRS) without nasal polyps, (3) CRS with nasal polyps, and (4) classic allergic fungal rhinosinusitis. In addition to the templates for clinical trials and proposed study designs, the Rhinosinusitis Initiative has developed 6 appendices, which address (1) health outcomes, (2) nasal endoscopy and staging of CRS, (3) radiologic imaging, (4) microbiology, (5) laboratory measures, and (6) biostatistical methods.

Rhinosinusitis: developing guidance for clinical trials

The Rhinosinusitis Initiative was developed by 5 national societies. The current guidance document is an expansion of the 2004 publication "Rhinosinusitis: Establishing definitions for clinical research and patient care" and provides templates for clinical trials in antimicrobial, anti-inflammatory, and symptom-relieving therapies for the following: (1) acute presumed bacterial rhinosinusitis, (2) chronic rhinosinusitis (CRS) without nasal polyps, (3) CRS with nasal polyps, and (4) classic allergic fungal rhinosinusitis. In addition to the templates for clinical trials and proposed study designs, the Rhinosinusitis Initiative has developed 6 appendices, which address (1) health outcomes, (2) nasal endoscopy and staging of CRS, (3) radiologic imaging, (4) microbiology, (5) laboratory measures, and (6) biostatistical methods.

Drug management in chronic rhinosinusitis: identification of the needs

Chronic rhinosinusitis (CRS) is a group of multifactorial diseases characterized by inflammation of the mucosa of the nose and paranasal sinuses with a history of at least 12 weeks of persistent symptoms despite maximal medical therapy. The precise role played by infection and immunoglobin E (IgE)-mediated hypersensitivity remains unclear. Diagnosis of CRS is based upon medical history, nasal endoscopy and computed tomography scan of the sinuses. The CRS with polyps visible in the middle meatus must be distinguished from the CRS without polyps. Based on the current knowledge about the pathogenesis of CRS, it is admitted that an optimal medical treatment must consider all favorizing factors and control efficaciously the inflammation process. In case of failure of medical treatment, endoscopic sinus surgery should be proposed. However, some well-validated data and scientific evidences are missing, even for the most frequently used medications. After a review of the actual definitions and classifications, a short description of the current knowledge about pathogenesis of CRS is provided in order to justify the actual therapeutic rationales and identify the needs for an effective treatment of CRS.

Allergy and Chronic Rhinosinusitis

The association between chronic rhinosinusitis (CRS) and allergy of the upper respiratory system has been discussed for many years,but much of this discussion has been anecdotal. Although epidemiologic evidence supports the increased prevalence of CRS among patients who have allergic rhinitis, and treatment of upper airway inflammation and allergy has been shown to decrease morbidity in patients who have CRS, but pathophysiologic mechanisms linking the two disease states have not been well elucidated. This article examines data supporting the link between upper airway allergic disease and CRS. It proposes a frame work for the treatment of CRS, with consideration of managing the allergic inflammation commonly noted in this disease. Finally, it discusses avenues for potential future research in evaluating the comorbidities of allergic inflammation and CRS.

Nasal rinsing with hypertonic solution: an adjunctive treatment for pediatric seasonal allergic rhinoconjunctivitis

BACKGROUND

Recent but limited evidence suggests that nasal lavage with hypertonic saline may be useful as an adjunctive treatment modality in the management of pediatric allergic rhinitis. The aim of this study was to clarify whether nasal irrigation with hypertonic solution should be routinely recommended to children with seasonal grass pollen rhinoconjunctivitis.

METHODS

Fourty-four children with seasonal grass pollen rhinoconjunctivitis were recruited. Twenty-two patients were randomized to receive three-times daily nasal rinsing with hypertonic saline during the pollen season, which lasted 7 weeks. Twenty-two patients were allocated to receive no nasal irrigation and were used as controls. Twenty patients per group completed the study. A mean daily rhinoconjunctivitis score based on the presence of nasal discharge and obstruction as well as ocular symptoms as reddening and itching were calculated for each week of the pollen season. Patients were allowed to use oral antihistamines when required and the mean number of drugs taken per week was also calculated.

RESULTS

The mean weekly rhinoconjunctivitis score in the active group was reduced during the whole pollen period. This difference was statistically significant in week 6 and 7 of therapy. A markedly reduced intake of oral antihistamines was also observed in patients allocated to nasal rinsing, being statistically significant in 5 of the 7 weeks. No adverse effect was reported in the active group.

CONCLUSIONS

This study supports the use of nasal rinsing with hypertonic saline in the pediatric patient with seasonal allergic rhinoconjunctivitis. This treatment proved to be tolerable, inexpensive and effective.

Therapeutic options in the management of headache attributed to rhinosinusitis

Sinus headache is a common diagnosis when patients have facial pain and pressure accompanying their headache. However, acute sinus headache is in fact rare, and the headache must accompany acute bacterial rhinosinusitis (ABRS), a diagnosis which is based both on clinical and radiological evidence. In fact, sinus headache is a misnomer. The only headache related to sinus disease, as recognised by the International Headache Society (IHS), is headache attributed to rhinosinusitis (HARS; section 11.5 of IHS criteria). Many patients who are diagnosed with sinus headache and treated with antibiotics have a primary headache, usually migraine. This is an important distinction and the treatment is very different. This review covers the most recent definitions, epidemiology, pathophysiology, diagnostics and treatment of ABRS and the resulting headache as defined by the IHS.