Prevalence of chronic rhinosinusitis in Sao Paulo

Association Between Smoking and Chronic Rhinosinusitis: A Systematic Review and Meta-Analysis

OBJECTIVE

Chronic rhinosinusitis (CRS) is a prevalent inflammatory disease of the upper airway. The impact of smoking on CRS has not been clearly established. We aim to clarify the association between first-hand cigarette smoking and the prevalence and prognoses of CRS.

REVIEW METHODS

PubMed, Embase, SCOPUS, and Cochrane Library were searched from inception until May 15, 2022. Three blinded reviewers selected relevant studies, extracted data, and evaluated study bias following a PROSPERO-registered protocol (CRD42022345585). We used random-effects meta-analyses to pool the prevalence of smoking in CRS, association between smoking status and CRS, and association of smoking with quality of life (QOL) before and after functional endoscopic sinus surgery (FESS). We also performed descriptive analyses of olfactory function, CT scores, and endoscopy scores before and after FESS.

RESULTS

We included 23 cross-sectional studies, 19 cohort studies, two case-control studies, and one prospective clinical trial. The pooled prevalence of ever-smokers was 40% (95% CI = 0.30-0.51) and 33% (95% CI = 0.25-0.43) in patients with and without CRS. Compared to never-smokers, active smokers and past smokers had 1.35 (95% CI = 1.18-1.55) and 1.23 (95% CI = 1.17-1.29) higher odds of having CRS. Among patients with CRS, non-smokers reported higher initial QOL than smokers (standardized mean difference [SMD] = 0.23, 95% CI = 0.11-0.35), although post-FESS QOL was similar (SMD = 0.10, 95% CI = -0.30-0.51). Descriptive analysis found no significant correlations between smoking and post-FESS olfactory function and endoscopy scores.

CONCLUSIONS

Cigarette smoking is associated with higher prevalence and odds of CRS. Clinicians should be aware that smoking predisposes to CRS, but does not negatively impact the rhinologic outcomes of FESS. Laryngoscope, 134:2513-2524, 2024.

Association Between Dietary Factors and Chronic Sinusitis Among Korean Individuals: Insights From a Large Population-Based Study in Asia

Objective: Population-based studies on chronic sinusitis have predominantly focused on Europe and the Americas, but research on chronic sinusitis within large Asian populations remains scarce. This study aims to explore the link between dietary factors and chronic sinusitis among ethnic Koreans in Asia. Design: A cross-sectional study. Setting: Data were collected from the Korean National Health and Nutrition Examination Survey (KNHANES) in 2012. Participants: Participants in the study were included based on a doctor's diagnosis of chronic sinusitis, as determined through the ear, nose, and throat examination questionnaires. Results: Adolescents [adjusted P value (aP) < .001, adjusted odds ratio (aOR) = 1.881, 95% confidence interval (CI) = 1.380-2.564] and individuals with college and higher education (aP = .042, aOR = 1.298, 95% CI = 1.009-1.669) were more likely to develop chronic rhinosinusitis. In addition, levels of dietary fat [P = .001, interquartile range (IQR) = 34.085] and energy intake (P = .004, IQR = 981.106) were associated with an increased risk of chronic sinusitis. Moreover, high dietary inflammatory index (aP < .001, aOR = 0.547, 95% CI = 0.415-0.721), and high intake of fried pork chops (aP = .028, aOR = 1.335, 95% CI = 1.033-1.777), bread (aP = .024, aOR = 1.364, 95% CI = 1.042-1.786), and rice (aP = .021, aOR = 1.382, 95% CI = 1.051-1.818) were risk factors for chronic sinusitis, while cucumber consumption (aP < .001, aOR = 0.547, 95% CI = 0.415-0.721) was a protective factor for chronic sinusitis. Conclusion: This study revealed a significant correlation between diet and development of chronic sinusitis. These findings suggest that promoting an anti-inflammatory dietary pattern and providing guidance on healthy eating habits could help reduce the incidence of chronic sinusitis and enhance its management.

Olfaction and Quality of Life in Patients with Eosinophilic CRS Undergoing Endoscopic Sinus Surgery

Introduction  Chronic rhinosinusitis (CRS) is a common inflammatory disease. This high prevalence leads to high direct and indirect public health costs, which include medical visits, laboratory tests and imaging, pharmacotherapy, hospitalizations, and surgical treatment. Furthermore, CRS has a substantial impact on patient quality of life, affecting productivity and being a common cause of absence from work CRS-associated olfactory dysfunction is highly prevalent, the actual effectiveness of surgical intervention remains inconsistent. Although there are studies evaluating the postoperative course of patients with eosinophilic Chronic rhinosinusitis (eCRS) treated with high-volume budesonide irrigation, there is little objective information regarding the impact of this intervention on olfactory status and quality of life. Objective  To conduct a pre- and postoperative analysis of olfaction and quality of life in patients with eCRS treated with surgical intervention followed by high-volume budesonide nasal irrigation. Methods  Prospective, descriptive, uncontrolled study of patients with eCRS. All patients underwent pre- and postoperative nasal endoscopy, SNOT-22 questionnaire, and the University of Pennsylvania Smell Identification Text (UPSIT), always by the same previously trained examiner. The SNOT-22 questionnaire and the UPSIT were readministered to all patients at 3 months, 6 months, and 1 year postoperatively, and scores compared with those obtained preoperatively. Results  Twenty patients were included in the study, 13 males and 7 females, between the ages of 23 and 65; 8 patients had comorbid asthma. Quantitative evaluation using the UPSIT test showed a significant improvement in olfaction 3 months after surgery, which remained 6 months and 1 year after surgery (p = 0.0063). There was no significant association between eosinophil concentrations in polypoid tissue and postoperative SNOT-22 and UPSIT results. Patients with tissue eosinophils >50 had a lower preoperative UPSIT score. As early as 3 months postoperatively, a significant improvement in quality of life was already noticeable, as represented by a decrease in SNOT-22 values, which persisted through the 1-year postoperative follow-up evaluation (p = 0.0005). Quantitative evaluation using the UPSIT test showed a significant improvement in olfaction 3 months after surgery, which remained 6 months and 1 year after surgery (p = 0.0063). Conclusion  Surgery effectively controlled eCRS in patients who adhered to high-volume budesonide nasal irrigation postoperatively. There were significant improvements in quality of life and olfaction, which persisted at least up to one year postoperatively.

Development of a mobile app for the evaluation of patients with chronic rhinosinusitis

OBJECTIVE

To develop a mobile application with a standardized routine, to be used by general otolaryngologists for evaluating patients with chronic rhinosinusitis.

METHODS

A systematic review was made to identify outcomes, recommendations and what tests that would be used in the routine evaluation of patients with chronic rhinosinusitis; establish an expert consensus on items to be included in this routine evaluation of patients with chronic rhinosinusitis using the Delphi method; development of an application for use on a mobile device, with the routine evaluation of patients with chronic rhinosinusitis.

RESULTS

Based on the systematic review, the outcomes used in studies about chronic rhinosinusitis were identified, as well as guidelines recommendations, which showed discrepancies between them. These recommendations and outcomes were presented to specialists in chronic rhinosinusitis, until a consensus was reached. As a result of the Delphi method, the flowchart of the routine evaluation of patients with chronic rhinosinusitis was defined, and then was used for the development of the mobile application.

CONCLUSION

The creation of the mobile application for evaluating patients with chronic rhinosinusitis followed an adequate methodology of elaboration made by specialists in the field of chronic rhinosinusitis, standardizing the investigation of these patients.

LEVEL OF EVIDENCE

Level 5.

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.

Outcomes of endoscopic sinus surgery in patients with central compartment atopic disease

Background

Central compartment atopic disease (CCAD) is a subtype of chronic rhinosinusitis (CRS). Research focusing on the endoscopic sinus surgery (ESS) outcomes of CCAD is limited. This study aimed to evaluate the outcomes of ESS in CCAD and compared to 2 following subtypes: chronic rhinosinusitis with nasal polyps (CRSwNP) and concomitant polypoid disease in the central compartment (CRSwNP/CC) and CRSwNP not otherwise specified (CRSwNP NOS).

Methods

This case-control study enrolled patients with bilateral CRSwNP who underwent ESS and had at least 1 year of follow-up. Patients were classified into CCAD, CRSwNP/CC, and CRSwNP NOS. The demographic data, preoperative disease severity, and surgery outcomes, including CRS control status, endoscopic score, and symptom scores at 1 year postoperatively, were collected. We defined well controlled and partly controlled as appropriate disease control.

Results

This study screened 259 patients and enrolled 138 patients with complete medical records and 1-year follow-up (CCAD N = 51, CRSwNP/CC N = 55, CRSwNP NOS N = 32). Among them, appropriate disease control was achieved in 84.3% of patients (43/51) in the CCAD group, 69.1% (38/55) in the CRSwNP/CC group, and 93.7% (30/32) in the CRSwNP NOS group (P = 0.029). Then we performed post-hoc analysis using appropriate disease control and uncontrolled. There was a significant difference between CRSwNP/CC and CRSwNP NOS (P = 0.007), but no significant difference compared CCAD group to CRSwNP/CC group (P = 0.065) and CRSwNP NOS group (P = 0.199). There were significant differences in endoscopic E-score among groups (P < 0.001). In post-hoc analysis, we found that CRSwNP/CC (Median [IQR], 33.32 [42.14]) had a significantly worse E-score than CCAD (8.33 [16.67]) and CRSwNP NOS (4.17 [8.30]). Also, postoperative olfactory visual analog scale (VAS) scores significantly differed among groups (P = 0.043). However, post-hoc analysis showed no difference between any 2 groups. There were no differences in postoperative VAS scores of obstruction (P = 0.159), rhinorrhea (P = 0.398), and headache/facial pain (P = 0.092).

Conclusion

Most CCAD patients had good surgical outcomes 1 year after surgery. Meanwhile, the CRSwNP/CC group had the fewest patients under appropriate disease control.

Host-microbe interactions in chronic rhinosinusitis biofilms and models for investigation

Chronic rhinosinusitis (CRS) is a debilitating condition characterized by long-lasting inflammation of the paranasal sinuses. It affects a significant portion of the population, causing a considerable burden on individuals and healthcare systems. The pathogenesis of CRS is multifactorial, with bacterial infections playing a crucial role in CRS development and persistence. In recent years, the presence of biofilms has emerged as a key contributor to the chronicity of sinusitis, further complicating treatment and exacerbating symptoms. This review aims to explore the role of biofilms in CRS, focusing on the involvement of the bacterial species Staphylococcus aureus and Pseudomonas aeruginosa, their interactions in chronic infections, and model systems for studying biofilms in CRS. These species serve as an example of how microbial interplay can influence disease progression and exemplify the need for continued investigation and innovation in CRS research.

Diverse Endotypes of Chronic Rhinosinusitis and Clinical Implications

Chronic rhinosinusitis (CRS) is a highly heterogeneous disease characterized by inflammation in the nasal and sinus mucosa. The CRS phenotypes, based on the presence or absence of nasal polyps, are known as CRS with nasal polyps (CRSwNP) and CRS without nasal polyps (CRSsNP). However, this classification has limitations in fully capturing the mechanisms and clinical manifestations of CRS. To address the heterogeneity of CRS, there has been a growing focus on classifying the condition into distinct endotypes. Endotype classification involves grouping patients based on specific molecular, immunological, and clinical characteristics, allowing for more personalized and targeted treatment approaches.This review delves into the current state of endotype classifications for CRS. It explores the role of geographic factors, microbiome, and subphenotype in shaping different endotypes. Additionally, the review examines how various clinical features are associated with specific endotypes, providing valuable insights into tailoring treatment options for better outcomes and transitions between different endotypes.Overall, this review offers a comprehensive and up-to-date perspective on the intricate realm of CRS endotype classifications. By unraveling the molecular and clinical intricacies, this review lays the foundation for more precise, effective, and individualized treatment strategies in the management of CRS.

Advancements in acoustic drug delivery for paranasal sinuses: A comprehensive review

Chronic rhinosinusitis (CRS) impacts patients' quality of life and healthcare costs. Traditional methods of drug delivery, such as nasal sprays and irrigation, have limited effectiveness. Acoustic Drug Delivery (ADD) using a nebulizer offers targeted delivery of drug to the sinuses, which may improve the treatment of CRS. This review examines the influence of aerosol particle characteristics, aero-acoustic parameters, inlet flow conditions, and acoustic waves on sinus drug delivery. Key findings reveal that smaller particles improve the ADD efficiency, whereas larger sizes or increased density impair it. The oscillation amplitude of the air plug in the ostium is crucial for the ADD efficiency. Introducing acoustic waves at the NC-sinus system's resonance frequency improves aerosol deposition within sinuses. Future research should address advanced models, optimizing particle characteristics, investigating novel acoustic waveforms, incorporating patient-specific anatomy, and evaluating long-term safety and efficacy. Tackling these challenges, ADD could offer more effective and targeted treatments for sinus-related conditions such as CRS.

The Management of Chronic Rhinosinusitis With Nasal Polyps (CRSwNP) With Biologics

Chronic rhinosinusitis with nasal polyps affects a significant portion of the worldwide population. This illness is associated with several chronic conditions and has an important impact on patient quality of life, leading to a great societal economic burden. In recent years, biologic medications have been developed and found to be effective in the treatment of chronic rhinosinusitis with nasal polyps. This review focuses on these treatment options and their ability to improve patient outcomes, including quality of life. It also reviews available evidence with regards to patient selection, monitoring of patients after treatment initiation, and comparison of different biologics and with other treatment options such as sinus surgery.

Analysis of risk factors affecting olfactory dysfunction in patients with chronic rhinosinusitis: Highlighting the role of metabolic syndrome

Objective

This study aims to evaluate the relationship between chronic sinusitis (CRS) and metabolic syndrome (MS) in a Chinese population and to explore the risk factors for olfactory dysfunction in patients with CRS.

Methods

A total of 387 CRS patients were enrolled. Olfactory function was assessed by the Sniffin' Sticks 12-item test and MS was diagnosed according to the guidelines. Logistic regression analysis was performed on CRS patients to screen independent risk factors of olfactory dysfunction, adjusted for confounding factors.

Results

Among 387 patients, average age of visit and duration of onset were 48.7 years and 1.8 years, respectively. The prevalence of MS was 15.0%. CRS patients with MS were more likely to be older (51.2 vs. 46.8, p = .004), predominantly male (p < .001) and have a higher proportion of olfactory dysfunction (62.1% vs. 44.1%, p = .018) than those without MS. In multivariate logistic regression analysis, MS was associated with olfactory dysfunction in CRS patients (OR: 2.06, 95% CI: 1.14-3.72, p = .016). This association remained significant after controlling for confounding factors. In addition, nasal polyps (OR: 13.41, 95% CI: 8.11-22.17, p < .001) and allergic rhinitis (OR: 3.16, 95% CI: 1.67-5.99, p < .001) were also risk factors for olfactory dysfunction after adjusting for confounding factors.

Conclusions

MS is associated with olfactory dysfunction in patients with CRS. MS, nasal polyps, and allergic rhinitis are risk factors for olfactory dysfunction in CRS patients.

Level of evidence

IV.

Body Mass Index and Related Risk Factor of Sinusitis Among Adults in Saudi Arabia: A Cross-Sectional Study

BACKGROUND

Chronic rhinosinusitis (CRS) is a widespread condition worldwide that is leading to a significant burden on society in terms of healthcare consumption and productivity loss. Multiple risk factors have been implicated in the pathogenesis of CRS, such as nasal allergies, bronchial asthma, smoking, nasal polyps, and immune system-related diseases. The present study aimed to assess the prevalence of CRS, the most common risk factors, and the association between diabetes, body mass index (BMI), and CRS in Saudi Arabia.

METHODS

A cross-sectional study was conducted through random sampling that included 3602 participants from different regions of Saudi Arabia from November 2022 to January 2023. Electronic questionnaires were used for data collection.

RESULTS

A total of 3602 individuals responded to our questionnaires; 948 (26.3%) were diagnosed by physicians as having chronic rhinosinusitis, and 75.1% were females. The majority (41.5%) were between the ages of 18 and 28 years. We found that smoking was significantly associated with sinusitis (OR 2.01, 95% CI 1.23-5.69) (p value 0.003) and that obesity was also significantly associated with sinusitis, 17.0% of persons with sinusitis were obese class I (BMI 30-35 kg/m²); 7.8% were obese class II (BMI>35 kg/m²); and 29.4% were overweight, whereas 45.8% were of normal weight. All percentages differ significantly from persons with normal weight (p value = 0.000). The most common risk factors for sinusitis were nasal allergies (44.4%), stuffy nose (22.8%), and deviation of the nasal septum (19.2%). All percentages differ significantly from persons without comorbidity (p value = 0.000).

CONCLUSION

The present study showed a slight increase in the prevalence of CRS in Saudi Arabia, which is attributable to increased exposure to allergens. The most common risk factors were nasal allergies, nasal blockage, deviation of the nasal septum, and asthma. There was a significant correlation between CRS and BMI in the form of increased prevalence in overweight and obese compared to normal-weight individuals.

Prevalence and risk factors of chronic rhinosinusitis among Chinese: A systematic review and meta-analysis

Background

Chronic rhinosinusitis (CRS) can be seen in people of all ages. CRS heavily affects the quality of a patient's daily life and also causes tremendous economic burdens on patients' families and society. The prevalence of CRS in different countries varies and no systematic review of the prevalence of CRS among Chinese has been published previously. The objective of this systematic review and meta-analysis is to determine the prevalence of CRS among Chinese and to explore the main risk factors of CRS among Chinese.

Methods

Using relevant keywords, data resources including PubMed, Scopus, Web of Science, Google Scholar, Embase, Cochrane Library, Chinese National Knowledge of Infrastructure (CNKI), WANGFANG, VIP, and China Biomedical Literature database (CMB) were searched to obtain literature reporting the prevalence of and risk factors of CRS among Chinese which were clearly diagnosed with CRS from inception to 30 June 2022. The random/fixed effect model was used for meta-analysis, and the I² index was employed to assess heterogeneity among studies. All analyses were performed by using the STATA version 16.0 software. The study was registered with PROSPERO, register number. CRD42022341877.

Result

A total of 12 relevant kinds of literature were qualified for the present systematic review, including 4,033 patients. The results showed that the overall prevalence of CRS among Chinese was 10% (95%CI: 0.06-0.13, I² = 99.6%, P < 0.001). The prevalence of CRS among Chinese who lived in urban cities was 18% (95%CI: -0.07 to 0.43, I² = 99.9%, P < 0.001), which was obviously lower than the prevalence of CRS among Chinese who lived in rural areas (27%, 95%CI: -0.14 to 0.68, I² = 99.8%, P < 0.001). The prevalence of CRS among Chinese before 2010 was 23% (95%CI: -0.05 to 0.50, I² = 99.8%, P < 0.001), which was remarkably higher than the prevalence of CRS among Chinese after 2010 (7%, 95%CI: 0.05-0.09, I² = 99.0%, P < 0.001). The prevalence of CRS among Chinese who were divorced was 17% (95%CI: 0.12-0.22, I² = 0.0%, P = 0.436), while the prevalence of CRS among Chinese who were married, widowed, and unmarried was 9% (95%CI: 0.06-0.11, I² = 88.1%, P = 0.004), 9% (95%CI: 0.06-0.11, I² = 0.0%, P = 0.863), and 9% (95%CI: 0.08-0.10, I² = 0.0%, P = 0.658), respectively. The prevalence of CRS among Han and minority Chinese was 8% (95%CI: 0.07-0.10, I² = 69.6%, P = 0.070) and 12% (95%CI: 0.10-0.15, I² = 38.6%, P = 0.202), respectively. The prevalence of CRS among Chinese who was never exposed to moldy or damp environments was 8% (95%CI: 0.08-0.09, I² = 0.0%, P = 0.351), the prevalence of CRS among Chinese who was occasionally exposed to moldy or damp environments was 16% (95%CI: 0.10-0.22, I² = 78.9%, P = 0.030), and the prevalence of CRS among Chinese who was frequently or every day exposed to moldy or damp environments was up to 20% (95%CI: 0.15-0.24, I² = 0.0%, P = 0.558).

Conclusion

This meta-analysis shows that the prevalence of CRS among Chinese is at a high level. People who have some risk factors, such as occasional or frequent or everyday exposure to moldy or damp environments, have a higher prevalence of CRS. We should attach more importance to the risk factors of CRS in clinical practice and disseminate scientific information and carry out education to lower the prevalence of CRS in China.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=341877, identifier: CRD42022341877.

Computed Tomography Evaluation of the Paranasal Sinuses in Adults with Primary Ciliary Dyskinesia

Introduction  Primary ciliary dyskinesia is a rare inherited disease that results in a malfunction of mucociliary clearance and sinonasal complaints. Aplasia/hypoplasia of the frontal and sphenoid sinuses has been described as more frequent in this population. However, to date, no studies have provided a detailed description of computed tomography findings in adult patients with a diagnosis of this condition. Objective  To describe the computed tomography (CT) findings of adult patients with primary ciliary dyskinesia. Methods  Retrospective observational study of adult patients with primary ciliary dyskinesia who underwent CT. Results  Twenty-one adults were included in the study. Aplasia occurred in 38.1% of frontal sinuses and in 14.3% of sphenoid sinuses. Likewise, hypoplasia occurred in 47.6% of the frontal sinuses, in 54.8% of the sphenoid sinuses and in 40.5% of the maxillary sinuses. Furthermore, trabecular loss was identified in 61.9% ethmoidal sinuses. The mean Lund-Mackay score was 13.5. In addition, 9.5% of the patients had concha bullosa, 47.6% had marked bilateral inferior turbinate hypertrophy, 38.1% had marked middle turbinate hypertrophy, and 47.6% had marked septal deviation. Finally, we identified images suggestive of fungus ball, mucocele, osteoma, a possible antrochoanal polyp, and frontal bone erosions. Conclusion  The present study provides a detailed description of CT findings in patients with primary ciliary dyskinesia. We also describe abnormalities that must be identified for safer surgical planning and that suggest a diagnosis of primary ciliary dyskinesia if found in patients with a consistent clinical picture.

Epidemiology of Chronic Rhinosinusitis: Prevalence and Risk Factors

Knowledge of chronic rhinosinusitis (CRS) epidemiology may directly impact patient care: aiding patient identification and establishing accurate diagnosis as well as informing treatment decisions. The objective of this review is to summarize the current evidence on the epidemiology of CRS, with a focus on prevalence and risk factors. Although the presence of either symptoms or objective findings alone have yielded CRS prevalence estimates of over 10%, the presence of both-consistent with guideline-based diagnostic criteria for CRS-has suggested that the true prevalence of CRS is consistently less than 5%, with approximately one-third of patients with CRS having nasal polyps, in epidemiologic studies from around the world. In comparison, the prevalence of CRS endotypes-pathophysiologic subclassification of CRS most commonly as related to type 2 or non-type 2 inflammation-has been found to vary significantly by region. The epidemiology of CRS is modified and ultimately determined by risk factors: genetic/hereditary, demographic, environmental, and imparted by predictive pre-/comorbid disease. The understanding of these epidemiologic relationships may help the provider to optimally identify and understand each individual's CRS disease process, thereby improving both diagnosis and treatment.

The classification, diagnosis, and treatment of rhinosinusitis

Background: Rhinosinusitis, one of the most common conditions encountered by clinicians, affects quality of life and reduces work productivity. Despite its high prevalence and economic burden, there are considerable differences in practice regarding the management of rhinosinusitis. Based on many studies, including the updated guidelines, classifications have been subdivided, and new treatments have been added.Current Concepts: Rhinosinusitis can be classified as acute rhinosinusitis (ARS) or chronic rhinosinusitis (CRS) with a cut-off duration of 12 weeks. It is diagnosed based on subjective symptoms and objective findings on computed tomography or endoscopy. Viral infections account for the majority of the causes of ARS, with watchful waiting without antibiotics as its important initial management. Meanwhile, CRS is divided into primary and secondary CRS, which is further subdivided by anatomic distribution and endotype. Particularly, the Type 2 endotype is characterized by a high recurrence rate and high resistance to current therapies. Biologics using monoclonal antibodies could therefore be used as new therapeutic options for the treatment of primary type 2 CRS. Furthermore, given the chronicity of CRS, it is important to recognize that endoscopic sinus surgery and continuous postoperative medical treatment are important for its management.Discussion and Conclusion: Accurate diagnoses based on diagnostic criteria and subdivided classifications are necessary to determine the treatment plan and prognosis. In particular, it is important to differentiate the endotype of CRS and provide appropriate treatments to improve the patient’s symptoms and quality of life.

Acoustic drug delivery to the maxillary sinus

Acoustic drug delivery (ADD) is an innovative method for drug delivery to the nose and paranasal sinuses and can be used to treat chronic rhinosinusitis (CRS). The underlying mechanism of ADD is based on the oscillatory exchange of air between the nasal cavity (NC) and the maxillary sinus (MS) through the ostium, which assists with the transfer of the drug particles from the NC to the sinuses. This study aims to examine the efficacy of ADD for drug delivery to the MS using an acoustic wave applied to nebulised aerosols entering the nostril. Here, the effect of acoustic frequency, amplitude, and nebulisation flowrate on the efficiency of ADD to the MS is investigated experimentally. A computational fluid dynamics model was also developed to understand the deposition and transport patterns of the aerosols. The results showed that superimposing an acoustic frequency of 328 Hz, which is the resonance frequency of the selected 3D printed model of the NC-MS combination, on the nebulised aerosols could improve the efficiency of the drug delivery to the MS by 75-fold compared with non-acoustic drug delivery case (p < 0.0001). The experimental data also shows that an increase in the amplitude of excitation, increases the concentration of aerosol deposition in the MS significantly; however, it reaches to a plateau at a sound pressure level of 120 dB re 20 µPa.

Increased lipopolysaccharide content is positively correlated with glucocorticoid receptor-beta expression in chronic rhinosinusitis with nasal polyps

Introduction

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a common and frequently occurring disease of the upper respiratory tract. The nasal instillation of the Gram‐negative (G⁻) bacterial product lipopolysaccharide (LPS) can induce not only acute sinusitis but also the development of CRSwNP in animal models. Nevertheless, the expression and distribution of LPS in patients with CRSwNP have not been investigated. And the study was to investigate the expression of LPS and its relationship with glucocorticoid receptors (GRs) in CRSwNP.

Methods

Multiple methods, including bacterial culture and immunohistochemistry, were used to detect and analyze nasal bacteria, plasma LPS content, and the levels of LPS and GR‐α/β, cluster of differentiation 68 (CD68), and myeloperoxidase (MPO) expression, as well as their relationship in CRSwNP.

Results

The number of G⁻ bacteria and Escherichia coli (E. coli) was not significantly different between CRSwNP subjects and the controls. However, the positive rate of LPS was much higher than that of E. coli in CRSwNP subjects and was significantly higher in noneosinophilic CRSwNP subjects than in eosinophilic CRSwNP subjects. Moreover, the LPS levels were positively correlated with GR‐β but not GR‐α expression in CRSwNP. Immunofluorescence assays showed that LPS was mainly detected in CD68⁺ macrophages and MPO⁺ neutrophils, in addition to histiocytes, in CRSwNP.

Conclusions

Persistent LPS in CRSwNP can lead to unresolved mucosal inflammation, eventually leading to tissue remodeling and the development of CRSwNP. Our findings suggest that increased LPS content and possible resistance to glucocorticoids may be one of the important pathogenic mechanisms of G⁻ bacteria in CRSwNP.

Nasal nebulization inhalation of budesonide for chronic rhinosinusitis with nasal polyps: A protocol for systematic review and meta-analysis

BACKGROUND

Chronic rhinosinusitis and nasal polyps (CRNP) is a common public health concern for general population, and is thought to negatively impact their quality of life. Although previous studies have reported that nasal nebulization inhalation of budesonide (NNIB) can benefit patients with such condition, its conclusions are still inconsistent. Thus, this study will assess the efficacy and safety of NNIB for the treatment of CRNP.

METHODS

To identify any associated studies, we will comprehensively and systematically search Cochrane Library, PubMed, EMBASE, Web of Science, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Allied and Complementary Medicine Database, Chinese Biomedical Literature Database, and China National Knowledge Infrastructure. We will search all electronic databases from inception to the present with no limitations of language and publication status. Two independent reviewers will undertake selection of study, data collection, and study quality evaluation, respectively. Another reviewer will help to settle down any different opinions between both of them. Study quality will be checked using Cochrane risk of bias tool, and statistical analysis will be performed using RevMan 5.3 software.

RESULTS

This study will assess the efficacy and safety of NNIB for the treatment of CRNP through assessing primary outcomes of nasal symptoms and polyp sizes, and secondary outcomes of serum cortisol levels, health-related quality of life, and any expected and unexpected adverse events.

CONCLUSION

The results of this study will summarize the up-to-date evidence on assessing the efficacy and safety of NNIB for the treatment of CRNP.

STUDY REGISTRATION NUMBER

INPLASY202040108.

Chinese Society of Allergy and Chinese Society of Otorhinolaryngology-Head and Neck Surgery Guideline for Chronic Rhinosinusitis

The current document is based on a consensus reached by a panel of experts from the Chinese Society of Allergy and the Chinese Society of Otorhinolaryngology-Head and Neck Surgery, Rhinology Group. Chronic rhinosinusitis (CRS) affects approximately 8% of Chinese adults. The inflammatory and remodeling mechanisms of CRS in the Chinese population differ from those observed in the populations of European descent. Recently, precision medicine has been used to treat inflammation by targeting key biomarkers that are involved in the process. However, there are no CRS guidelines or a consensus available from China that can be shared with the international academia. The guidelines presented in this paper cover the epidemiology, economic burden, genetics and epigenetics, mechanisms, phenotypes and endotypes, diagnosis and differential diagnosis, management, and the current status of CRS in China. These guidelines-with a focus on China-will improve the abilities of clinical and medical staff during the treatment of CRS. Additionally, they will help international agencies in improving the verification of CRS endotypes, mapping of eosinophilic shifts, the identification of suitable biomarkers for endotyping, and predicting responses to therapies. In conclusion, these guidelines will help select therapies, such as pharmacotherapy, surgical approaches and innovative biotherapeutics, which are tailored to each of the individual CRS endotypes.

Socioeconomic status impacts postoperative productivity loss and health utility changes in refractory chronic rhinosinusitis

BACKGROUND

Social determinants of health can have a substantial impact on treatment outcomes. Prior study has shown that socioeconomic status influences the likelihood of improvement in quality-of-life (QOL) following endoscopic sinus surgery (ESS). However, the impact of socioeconomic factors on changes in productivity loss and health utility after ESS remains unknown.

METHODS

Adult patients (≥18 years of age) with chronic rhinosinusitis (CRS) who underwent ESS were prospectively enrolled into a multi-institutional cohort study. Productivity losses were calculated using the human capital approach and monetized using U.S. government-estimated wage rates. Health utility values (HUVs) were derived from the Medical Outcomes Study Short-Form-12 survey using University of Sheffield algorithms. Independent socioeconomic factors of interest included: age, gender, ethnicity, insurance status, educational attainment, and household income categorized via the Thompson-Hickey model.

RESULTS

A total of 229 patients met inclusion criteria, and 163 (71%) provided postoperative follow-up. All subjects reported significant, within-subject improvement in both mean monetized productivity loss (p < 0.001) and HUV postoperatively (p < 0.001). Using paired sample statistics, patients with lowest income (≤$25,000/year) and with Medicare insurance did not report significant improvement in productivity loss (p ≥ 0.112) or HUV (p ≥ 0.081), although sample size limitations may have contributed to this finding. Patients in higher income tiers ($25,001 to $100,000/year and $100,001+/year) and those with employer-provided/private health insurance reported significant postoperative improvements in productivity loss and HUV (all p ≤ 0.003).

CONCLUSION

Socioeconomic factors, including income and insurance provision, may impact improvements in productivity loss and HUV following ESS. Further research to validate these findings, ascertain mechanisms behind these results, and improve these outcomes is warranted.

A Case Report of Aggressive Chronic Rhinosinusitis with Nasal Polyps Mimicking Sinonasal Malignancy

Introduction

Cases of extensive nasal polyps rarely occur and may mimic more aggressive lesions of the nose and paranasal sinuses. A case of extensive nasal polyposis with unusually aggressive behavior and its management is presented.

Presentation of Case

A 27-year-old male patient visited the emergency department of a tertiary center, complaining of recurrent episodes of epistaxis. The patient presented with a large polypoid lesion protruding from the right nostril and producing asymmetry of the face. Diagnostic imaging illustrated a lesion of the right maxillary sinus producing excessive bone remodeling and extension into neighboring structures in every direction. Fine limits were noted, however, with no invasive characteristics. Biopsy under local anesthesia was performed, showing findings consistent with nonspecific inflammation. Open surgery through a lateral rhinotomy under general anesthesia was performed, and the mass was readily mobilized and removed. No macroscopic invasion of neighboring structures was noted. Permanent histology confirmed the diagnosis of nasal polyposis. Postoperative follow-up has shown no evidence of recurrence after 12 months.

Conclusion

Nasal polyps do not typically expand in an aggressive manner, producing bone resorption or extending into neighboring structures. However, nasal polyposis should be included in the differential diagnosis of nasal tumors with such behavior.

Immunity-targeted approaches to the management of chronic and recurrent upper respiratory tract disorders in children

Background

Upper respiratory tract infections (URTIs), including rhinitis, nasopharyngitis, tonsillitis and otitis media (OM), comprise of 88% of total respiratory infections, especially in children. Therefore effective prevention and treatment of RTIs remain a high priority worldwide. Preclinical and clinical data highlight the rationale for the use and effectiveness of immunity‐targeted approaches, including targeted immunisations and non‐specific immunomodulation in the prevention and management of recurrent upper RTIs.

Objective of review

The idea of this review was to summarise the current evidence and address key questions concerning the use of conservative and immunity‐targeted approaches to recurrent and chronic URTIs, with a focus on the paediatric population.

Search strategy/Evaluation method

Literature searches were conducted in March 2017 and updated in September 2017 using: Academic Search Complete; CENTRAL; Health Source: Nursing/Academic Edition; MEDLINE; clinicaltrials.gov; and Cochrane databases. In total, 84 articles were retrieved and reviewed. Two independent researchers focused on primary and secondary endpoints in systematic reviews, meta‐analyses and randomised, controlled trials, using immunity‐directed strategies as the control group or within a subpopulation of larger studies. Existing guidelines and interventional/observational studies on novel applications were also included.

Results

Children are particularly susceptible to RTIs due to the relative immaturity of their immune systems, as well as other potential predisposing factors such as day care attendance and/or toxic environmental factors (eg increased pathogenic microbial exposure and air pollutants). Recurrent URTIs can affect otherwise healthy children, leading to clinical sequelae and complications, including the development of chronic conditions or the need for surgery. Available pre‐clinical and clinical data highlight the rationale for the use and effectiveness of immunity‐targeted approaches, including targeted immunisations (flu and pneumococcal vaccines) and non‐specific immunomodulation (bacterial lysates), in the prevention and management of recurrent croup, tonsillitis, otitis media, recurrent acute rhinosinusitis and chronic rhinosinusitis.

Conclusions

In this review, we summarise the current evidence and provide data demonstrating that some immunity‐targeted strategies, including vaccination and immunomodulation, have proved effective in the treatment and prevention of recurrent and chronic URTIs in children.

Socioeconomic factors impact quality of life outcomes and olfactory measures in chronic rhinosinusitis

BACKGROUND

Healthcare disparities related to socioeconomic factors may adversely impact disease states and treatment outcomes. Among patients with chronic rhinosinusitis (CRS), the impact of socioeconomic factors on outcomes following endoscopic sinus surgery (ESS) remains uncertain.

METHODS

Adult patients with refractory CRS were prospectively enrolled into an observational, multi-institutional cohort study between March 2011 and June 2015. Socioeconomic factors analyzed included household income, insurance status, years of education completed, race, age, and ethnicity. Income was stratified according to the Thompson and Hickey model. The 22-item Sino-Nasal Outcome Test (SNOT-22) and Brief Smell Identification Test (BSIT) were completed preoperatively and postoperatively.

RESULTS

A total of 392 patients met inclusion criteria. Higher age and male gender were associated with better mean preoperative SNOT-22 scores (both p < 0.02), whereas Medicare insurance status and male gender were associated with worse preoperative mean BSIT scores (both p < 0.02). Postoperatively, higher household income ($100,001+/year) and lower age were associated with a greater likelihood of improving at least 1 minimal clinically important difference (MCID) on SNOT-22 scores (OR = 2.40 and 1.03, respectively, both p < 0.05), while no factors were associated with increased odds of achieving a MCID on BSIT scores.

CONCLUSIONS

Preoperative olfactory function and postoperative quality of life (QOL) improvement were associated with metrics of socioeconomic status in patients with CRS electing ESS. The odds of experiencing a clinically meaningful QOL improvement were more than twice as likely for patients with the highest household income level compared to other income tiers. Further investigation is warranted to identify barriers to postoperative improvement.

Regional differences in endoscopic sinus surgery in Finland: a nationwide register-based study

OBJECTIVES

Endoscopic sinus surgery (ESS) is a common operation typically performed due to chronic rhinosinusitis (CRS). There are limited data on the nationwide ESS rate and factors contributing to its regional variation. The aim was to evaluate factors causing variation of ESS rate.

DESIGN

Cross-sectional nationwide observational study.

SETTING

A ll patients undergoing ESS in Finland 2013-2015.

POPULATION

Nationwide Finnish population aged 15 years or over.

MAIN OUTCOME MEASURES

ESS rate per 1000 inhabitants between 2013 and 2015 in all 21 hospital districts and independent factors for multilevel model analyses.

METHODS

We used the Finnish register data of all patients with CRS who underwent ESS in 2013-2015. Patients aged under 15 years and those with ESS due to neoplasia were excluded. The age and gender standardised ESS rates were calculated, and multilevel Poisson regression models were used to evaluate variation in ESS in the 21 hospital districts. The likelihood ratio test was applied to assess the statistical significance of random components in the models.

RESULTS

The nationwide annual rate of ESS is 0.71 per 1000 people in Finland. Hospital district rates varied from 0.25/1000 (95% CI 0.18 to 0.32) to 1.15/1000 (95% CI 1.09 1.21). Compared with males, females undergo ESS significantly more frequently (57% of the procedures), more often due to CRS without nasal polyps, and at a younger age (mean age 44.2 and 46.2 years, correspondingly). Multilevel analyses showed that lower age (between 24 years and 45 years) and availability/ease of medical services were independently associated with higher ESS rates.

CONCLUSIONS

This study confirms marked regional variation in the ESS rate in Finland, explained only in part by patients' age and differing availability of medical services. To analyse ESS across different CRS phenotypes or to compare quality registers on ESS properly, more research on regional variation is needed.

Longitudinal evaluation of clustering of chronic sinonasal and related symptoms using exploratory factor analysis

BACKGROUND

Sinonasal symptoms are common and can have several underlying causes. When symptoms occur in specified patterns lasting 3 months or more they meet criteria for chronic rhinosinusitis (CRS). Approaches to CRS symptom measurement do not specify how to measure symptoms and treat specified sinonasal symptoms as generally interchangeable, suggesting that such symptoms should cluster on 1 or 2 latent factors.

METHODS

We used questionnaire responses to 37 questions on the presence, severity, bother, and frequency of cardinal sinonasal and related symptoms lasting 3 months, from 3535 subjects at 3 time points over 16 months. We completed 5 exploratory factor analyses (EFA) to identify symptom clustering, 1 for each time point and 2 for the differences between adjacent questionnaires. The baseline EFA was used to provide factor scores that were described longitudinally and examined by CRS status.

RESULTS

Five EFAs identified the same 5 factors (blockage and discharge, pain and pressure, asthma and cold/flu symptoms, smell loss, and ear and eye [mainly allergy] symptoms), with clustering determined by symptom frequency, severity, and degree of bother. Responses to individual questions showed changes over time but when combined into factor scores showed less longitudinal change. All symptom factor scores were progressively higher from never to past to current CRS status.

CONCLUSIONS

Although the current approaches to symptom characterization in CRS imply a single underlying latent construct, our results suggest that there are at least 3 latent constructs relevant to CRS. Further studies are needed to evaluate whether these clusters have identifiable underlying pathobiologies.

Sinus computed tomography predicts clinical response to corticosteroids in chronic rhinosinusitis with nasal polyps

Background

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a heterogeneous inflammatory disease usually characterized by chronic eosinophilia in the sinonasal mucosa, which often requires glucocorticoid (GC) therapy. However, the therapeutic response varies markedly between individuals. The objective of this study was to evaluate the diagnostic values of sinus computed tomography (CT) for GC-sensitivity in patients with CRSwNP.

Methods

We conducted a prospective, single-blinded study of 47 consecutive patients with CRSwNP. These patients were given a course of oral prednisone (30 mg daily for 14 days) and subsequently classified into objectively GC-sensitive and -insensitive subgroup according to the change in nasal polyp size score, or subjectively GC-sensitive and -insensitive subgroup according to the change in total nasal symptom score. The following parameters were compared between GC-sensitive and GC-insensitive subgroups: Lund-Mackay scores, olfactory cleft (OC) scores, and blood eosinophil counts and ratio (percentage of the total white blood cells).

Results

25/47 (53.2%) and 29/47 (61.7%) patients were objectively and subjectively sensitive to GC therapy, respectively. The OC score and the blood eosinophil counts and ratio in GC-sensitive subgroup were significantly higher than those in GC-insensitive subgroup, defined either objectively or subjectively. Multivariate logistic regression revealed that OC score was independent risk factor for objective or subjective GC-sensitivity. The OC score exhibited comparable accuracy with the blood eosinophil ratio as predictor of objective and subjective GC-sensitivity (the OC score AUC = 0.775 and 0.829, respectively). A OC score of 3.5 could act as a reliable indicator for predicting the clinical response to GC therapy in CRSwNP.

Conclusion

Our prospective findings validate the potential value of sinus CT scan in predicting GC-sensitivity in CRSwNP patients.

The burden of chronic rhinosinusitis and its effect on quality of life among patients re-attending an otolaryngology clinic in south western Uganda

BACKGROUND

Worldwide, the burden of chronic rhinosinusitis (CRS) is variable, but not known in Uganda. CRS has significant negative impact on quality of life (QOL) and as such QOL scores should guide adjustments in treatment strategies. However, most of these studies have been done in the west. Our hypothesis was that QOL scores of the majority of CRS patients in low- to- middle income countries are poorer than those among patients without CRS. The aim of this study was to determine the burden of CRS among patients re-attending the Otolaryngology clinic and whether CRS is related to poor QOL.

METHODS

A cross sectional study was conducted at Mbarara Regional Referral Hospital Otolaryngology clinic. One hundred and twenty-six adult re-attendees were consecutively recruited. Data was collected using a structured questionnaire and the Sinonasal Outcome Test 22 (SNOT 22) questionnaire measured QOL.

RESULTS

The proportion of re-attendees with CRS was 39.0% (95% CI 30-48%). Majority of CRS patients had poor quality of life scores compared to non-CRS (88% versus 20% p < 01). The poor quality of life scores on the SNOT 22 were almost solely as a result of the functional, physical and psychological aspects unique to CRS.

CONCLUSIONS

CRS is highly prevalent among re-attendees of an Otolaryngology clinic at a hospital in resource limited settings and has a significant negative impact on the QOL of these patients.

Upper airway involvement in bronchiectasis is marked by early onset and allergic features

The association of bronchiectasis with chronic rhinosinusitis (CRS) has been reported. However, apart from primary ciliary dyskinesia (PCD) and cystic fibrosis (CF), predisposing conditions have not been established. We aimed to define clinical and laboratory features that differentiate patients with bronchiectasis with upper airway symptoms (UASs) and without PCD from patients without UASs.

We reviewed charts of adults with bronchiectasis, excluding CF and PCD. UASs were defined as nasal discharge most days of the year, sinusitis or nasal polyps. Laboratory data included IgG, total IgE, blood eosinophils, sputum bacteriology and lung function. A radiologist blinded to UAS presence scored bronchiectasis (Reiff score) and sino-nasal pathology (Lund–Mackay score).

Of 197 patients, for the 70 (35%) with UASs, symptoms started earlier (34±25 versus 46±24 years; p=0.001), disease duration was longer (median 24 versus 12 years; p=0.027), exacerbations were more frequent (median 3 versus 2 per year; p=0.14), and peripheral blood eosinophil (median 230 versus 200 μL⁻¹; p=0.015) and total IgE (median 100 versus 42 IU·mL⁻¹; p=0.085) levels were higher. The sinus computed tomography score was independently associated with exacerbations, with 1 point on the Lund–Mackay score associated with a 1.03-fold increase in the number of exacerbations per year (95% CI 1.0–1.05; p=0.004).

These findings may implicate a higher disease burden in patients with UASs. We hypothesise that UASs precede and may in some cases lead to the development of bronchiectasis.

Involvement of the upper airway in patients with bronchiectasis is associated with an early age of onset and allergic featureshttp://ow.ly/1BuK30gWDrN

Longitudinal Evaluation of Chronic Rhinosinusitis Symptoms in a Population-Based Sample

BACKGROUND

Chronic rhinosinusitis (CRS) is a prevalent and disabling condition of the nose and sinuses. The natural history of CRS symptoms in a general population sample has not been previously studied.

OBJECTIVE

In a general population-based sample from Pennsylvania, we used 2 questionnaires mailed 6 months apart to estimate the prevalence of, and identify predictors for, stability or change in symptoms over time.

METHODS

We mailed the baseline and 6-month follow-up questionnaires to 23,700 primary care patients and 7,801 baseline responders, respectively. We categorized nasal and sinus symptoms using European Position Paper on Rhinosinusitis (EPOS) epidemiologic criteria. We defined 6 symptom groups over time on the basis of the presence of CRS symptoms at baseline and follow-up. We performed multivariable survey logistic regression controlling for confounding variables comparing persistent versus nonpersistent, recurrent versus stable past, and incident versus never.

RESULTS

There were 4,966 responders at follow-up: 558 had persistent symptoms, 190 recurrent symptoms, and 83 new symptoms meeting EPOS criteria for CRS. The prevalence of persistent symptoms was 4.8% (95% CI, 3.8-5.8), whereas the annual cumulative incidence of new symptoms was 1.9% and of recurrent symptoms was 3.2%. More severe symptoms at baseline were associated with persistence, whereas minor symptoms, allergies, and multiple treatments were associated with the development of new symptoms.

CONCLUSIONS

Less than half with nasal and sinus symptoms meeting CRS EPOS criteria in our general, regional population had symptom persistence over time, with symptom profiles at baseline and age of onset being strongly associated with stability of symptoms.

Chronic Rhinosinusitis without Nasal Polyps

Chronic rhinosinusitis without nasal polyps (CRSsNP) is more prevalent than chronic rhinosinusitis with nasal polyps (CRSwNP). Certain diseases predispose to whereas others are associated with CRSsNP. Predisposing diseases include allergic and nonallergic upper and lower airway diseases, epithelial cell disorders, immunodeficiencies, autoimmune diseases, and some infectious diseases. In addition, environmental and host factors, examples of which include smoking, a higher incidence of abnormal biofilms, and innate immune defects, play a role in the pathogenesis of this disease. CRSsNP is characterized by histologic abnormalities, including basement membrane thickening (fibrosis) and goblet cell hyperplasia. Neutrophils and several chemokines, TGF-β and C-X-C motif chemokine ligand (CXCL)-8, play a role in CRSsNP remodeling. However, there are conflicting data about CRSsNP endotypes, for example, whether it is characterized by neutrophilia or eosinophilia or both. In spite of advancements and the understanding of the pathogenesis of this disease, additional study is necessary to better comprehend its underlying mechanisms, endotypes, and evidence-based treatment strategies.

The transcriptional program, functional heterogeneity, and clinical targeting of mast cells

Cildir et al. discuss the recent findings in transcriptional regulation of mast cell development and activation and provide insights into the plasticity and clinical targeting of mast cell functions.

Mast cells are unique tissue-resident immune cells that express an array of receptors that can be activated by several extracellular cues, including antigen–immunoglobulin E (IgE) complexes, bacteria, viruses, cytokines, hormones, peptides, and drugs. Mast cells constitute a small population in tissues, but their extraordinary ability to respond rapidly by releasing granule-stored and newly made mediators underpins their importance in health and disease. In this review, we document the biology of mast cells and introduce new concepts and opinions regarding their role in human diseases beyond IgE-mediated allergic responses and antiparasitic functions. We bring to light recent discoveries and developments in mast cell research, including regulation of mast cell functions, differentiation, survival, and novel mouse models. Finally, we highlight the current and future opportunities for therapeutic intervention of mast cell functions in inflammatory diseases.

Economics of Chronic Rhinosinusitis

PURPOSE OF REVIEW

The objective of this article is to provide an updated review of the economic burden of chronic rhinosinusitis (CRS) and discuss how both medical and surgical interventions impact direct and indirect costs related to CRS. By understanding the economics of CRS, clinicians may improve the patient-centeredness of their care and help distinguish between low and high value interventions.

RECENT FINDINGS

Direct costs related to CRS are primarily driven by outpatient physician visits, prescription medical therapy, and endoscopic sinus surgery (ESS). CRS produces large indirect costs and these costs often vary based on the severity of the patients CRS-specific QoL impairment. The overall direct cost related to CRS is estimated to range between $10 and $13 billion per year in the USA. The overall indirect cost related to CRS-related losses in work productivity is estimated to be in excess of $20 billion per year. In the appropriate patients with refractory CRS, ESS provides significant reductions in both direct and indirect costs; however, continued medical therapy alone may be a high value intervention in select patients who have lower severity in their baseline QoL and work productivity.

The role of infection and antibiotics in chronic rhinosinusitis

OBJECTIVE

To review the current understanding of the role of infection and antibiotics in chronic rhinosinusitis.

REVIEW METHODS

PubMed literature search.

RESULTS

Chronic rhinosinusitis (CRS) in adults is an inflammatory condition and the role of infection is unclear. Biofilms are present in both CRS and normal patients so their role in CRS is unknown. Sinus cultures in CRS demonstrate a mixture of aerobic and anaerobic bacteria but may be hard to interpret due to contaminating nasal flora. Staphylococcus aureus is common in CRS patients but also present in 20-30% of nasal cultures in the normal population; eradicating this organism did not lead to symptom improvement versus placebo in a randomized controlled trial (RCT). In CRS patients who develop an episode of acute rhinosinusitis (ARS), bacteria typical of ARS can generally be cultured and require short-course treatment. For CRS, topical antibacterial or antifungal agents have shown no benefit over placebo in RCTs, although RCTs of topical antibacterial agents have been small. Oral macrolides and doxycycline, antibiotics with anti-inflammatory properties, are the only systemic antibiotics that have been evaluated in RCTs. One RCT found 3 weeks of doxycycline beneficial in patients with polyps but follow up was short (<3 months); RCTs of prolonged macrolide therapy have produced mixed results, and most show no benefit after cessation of therapy. Long-term antibiotic therapy may produce side effects and select increasingly resistant flora. The American Academy of Otolaryngology-Head and Neck Surgery guidelines recommend against treatment of CRS with antifungal agents but do not comment on the role of antibacterial treatment.

CONCLUSION

The role of infection in CRS is unknown, and the only well-defined role for antibiotics is for treatment of ARS episodes or their infectious complications.

LEVEL OF EVIDENCE

N/A.

Nasal and sinus symptoms and chronic rhinosinusitis in a population-based sample

BACKGROUND

The objective of this study was to describe the first US-based study to use the European Position Paper on Rhinosinusitis (EPOS) criteria to study the prevalence of chronic rhinosinusitis (CRS) in a general-population sample.

METHODS

A CRS symptom questionnaire was mailed to 23 700 primary care patients from Geisinger Clinic, a health system serving 45 counties in Pennsylvania. CRS cases were categorized into four unique subgroups based on EPOS symptoms: obstruction and discharge with no smell loss or pain/pressure; smell loss without pain/pressure; facial pain and/or pressure without smell loss; and both smell loss and pain/pressure. All cases were required to have nasal obstruction or discharge. Logistic regression was used to evaluate potential factors associated with CRS subgroups.

RESULTS

We found that 11.9% of patients met criteria for CRS. Prevalence peaked at 15.9% between ages 50 and 59 years and then dropped to 6.8% after age 69. The odds of CRS was higher among patients who were white, younger, smokers, had a history of Medical Assistance, and had other diseases. When CRS subgroups were modeled separately, these associations were no longer significant for some CRS subgroups. Comorbid diseases were most strongly associated with CRS cases who reported smell loss and facial pain and/or pressure and had the weakest associations with CRS cases who did not report these symptoms.

CONCLUSIONS

CRS is a highly prevalent and heterogeneous condition. Differences in risk factors and health outcomes across symptom subgroups may be indicative of differences in etiology that have implications for disease management.

Factors affecting revision rate of chronic rhinosinusitis

Objective

Chronic rhinosinusitis (CRS) is a variable multifactorial disease. It can be divided into forms with nasal polyps (CRSwNP) and without (CRSsNP). Sinus and/or nasal polypectomy surgery are considered if maximal conservative treatment is insufficient. The predictive factors of the need of revision surgery comprise mostly the CRSwNP phenotype and are not fully understood.

Study Design

The aim of this follow‐up study was to evaluate the factors associated with the revision surgery rate in CRS patients with variable extent of disease.

Methods

Data of CRS patients (N = 178) undergoing sinus surgery and/or nasal polypectomy in 2001 to 2010 were used. Patient characteristics and follow‐up data were collected from patient records and questionnaires. Associations were analyzed by Fisher's exact, Mann Whitney U, and the Kaplan‐Meier method with log‐rank test. Unadjusted Cox's proportional hazard models were used for 12 variables and were fitted for the need for revision sinus surgery and/or nasal polypectomy during follow‐up of in average 9 years.

Results

The proportion of CRS patients who had undergone revision in 5 years was 9.6%. After adjustment, the following factors associated significantly with the need for recurrent CRS surgery: allergic rhinitis, corticosteroid treatment, previous surgery of CRS, and recurrent NP.

Conclusion

Increased risk of progressive CRS phenotypes with the need for revision surgery would putatively be recognized by relatively simple clinical questions. Further studies with increased sample size are needed to evaluate whether these predictive factors would be relevant for developing better detection and management of progressive CRS.

Level of Evidence

2b.

Occupational and environmental risk factors for chronic rhinosinusitis in China: a multicentre cross-sectional study

Background

Chronic rhinosinusitis (CRS) is defined as a condition of inflammation in the paranasal sinus mucosa persisting for more than 12 weeks. We previously reported that the prevalence of CRS was about 8 % in China. Here, we aim to investigate the occupational and environmental risk factors associated with CRS.

Methods

Data were collected from seven Chinese cities: Urumqi, Changchun, Beijing, Wuhan, Chengdu, Huaian and Guangzhou. CRS was diagnosed according to the European Position Paper on Rhinosinusitis and Nasal Polyps (EP³OS) document. Participants were asked to complete a standardized questionnaire, which was developed by the Global Allergy and Asthma European Network (GA²LEN) project and covered sociodemographic characteristics, CRS-related symptoms and occupational and environmental exposures. We evaluated the association between CRS and various occupational and environmental factors using odds ratios (ORs) and 95 % confidence intervals (95 % CIs).

Results

The total study population consisted of 10,633 subjects, 850 (7.99 %) of whom were defined as having CRS according to the EP³OS criteria. We found that there were significant associations between occupational and environmental factors and CRS. Specifically, having a clearance-related job, occupational exposure to dust, occupational exposure to poisonous gas, a pet at home or carpet at home or at the workplace were risk factors for CRS. Additionally, the method used to keep warm in winter, the duration of time spent using air conditioning in summer and the frequency of exposure to mouldy or damp environments were significantly different in subjects with and without CRS.

Conclusions

Our data showed that some occupational and environmental exposures are strongly associated with CRS, which aids in understanding the epidemiology of CRS.

A survey on chronic rhinosinusitis: opinions from experts of 50 countries

Chronic rhinosinusitis (CRS) is a very prevalent inflammatory disease. Treatments vary in different countries. In the present study, we explored the approaches of physicians in 50 countries. In this cross-sectional study, a rhinosinusitis survey (RSS) was completed by Honorary and Corresponding Members (otorhinolaryngologists) of the Italian Society of Rhinology. In 79.1 % of the 50 countries, the proportion of patients suffering from CRS was 15 %. Nasal symptoms were more intense in winter (46 % of countries), and spring and autumn (22 %). The most common symptoms were nasal obstruction (86 %), postnasal drip (82 %) and headache (52 %). The most common investigative modalities in the assessment of CRS are paranasal sinus CT, fiberoptic endoscopy, and anterior rhinoscopy. CRS patients were principally treated by otorhinolaryngologists (70 %). Medical treatments included nasal corticosteroids (90 %), nasal washes (68 %), and nasal decongestants (32 %). In 88 % of countries, more than 50 %, or "about 50 %", of all patients reported subjective symptom improvement after treatment. In most of the countries, surgery was required by 20-35 % of all CRS patients. During post-surgery follow-up, nasal washes (90 %), nasal corticosteroids (76 %), and systemic antibiotics (32 %) were prescribed. In 20-40 % of all patients, CRS was associated with nasal polyps. In such patients, the medical treatment options were nasal corticosteroids (90 %), systemic corticosteroids (50 %), nasal washes (46 %), and systemic antibiotics (34 %). Treatment of CRS patients varies in different countries. Paranasal sinus CT is the most common investigative modality in the assessment of CRS, and nasal corticosteroids are the first-line treatment, in the absence or presence of nasal polyps.

Epidemiology of chronic rhinosinusitis, selected risk factors, comorbidities, and economic burden

Chronic rhinosinusitis (CRS) is a relevant and prevalent medical condition in Germany, Europe and the world. If analysed in detail, the prevalence of CRS shows regional and temporary variety. In this review, currently available data regarding the prevalence of CRS is therefore sorted by country and/or region, time point of data collection and the CRS-definition employed. Risk factors like smoking and gastroesophageal reflux are discussed regarding their influence on CRS prevalence. Moreover, comorbidities of CRS, like asthma, conditions of the cardiovascular system and depression are listed and their influence on CRS is discussed. Furthermore, data on CRS prevalence in special cohorts, like immunocompromised patients, are presented. To estimate the economic burden of CRS, current data e.g. from Germany and the USA are included in this review.

Are atopy and eosinophilic bronchial inflammation associated with relapsing forms of chronic rhinosinusitis with nasal polyps?

Background

The aetiopathogenesis of chronic rhinosinusitis with nasal polyps (CRSwNP) is still unknown. The role of atopy and the concept of united airways in such patients are still a matter of debate. In this pilot study we aimed at evaluating the degree of eosinophilic inflammation and the frequency of atopy in a cohort of CRSwNP patients candidate for Functional Endoscopic Sinus Surgery (FESS) and assessing the association between these factors and relapsing forms of CRSwNP.

Methods

30 patients (18 men, 12 women) with CRSwNP eligible for FESS were evaluated before and after surgery. Preoperative investigation included: history of previous relapse after FESS, clinical and laboratory allergologic assessment, spirometry, methacholine challenge, blood eosinophilia and determination of the fraction of nitric oxide in exhaled air (FeNO). Nasal fibroendoscopy, spirometry and FeNO determination were also assessed prospectively at 3 and 27 months post-FESS.

Results

18/30 subjects were atopic, 6/18 (33 %) were monosensitized, 16/30 (53 %) were asthmatics and 10/30 (33 %) had non steroidalantinflammatory drugs (NSAIDs) hypersensitivity. Twenty-one patients (70 %) were classified as relapsers, 15/18 (83 %) among atopics, 6/12 (50 %) among non atopics (p = 0.05). Among patients with NSAIDs hypersensitivity, 9/10 (90 %) were relapsers. The median IgE concentration was 161.5 UI/mL in relapsers and 79 UI/mL in non-relapsers (ns). The mean FeNO decreased after FESS (43.1–26.6 ppb) in 84 % of patients, but this effect disappeared over time (FeNO = 37.7 ppb at 27 months). Higher levels of FeNO pre-FESS were detected in atopics, and in particular in relapsing ones (median 51.1 ppb vs 22.1, ns). Higher levels of FeNO pre-FESS were detected in asthmatic patients, especially in those who relapsed (median: 67 vs 64.85 ppb in non-relapsed patients, ns). The Tiffeneau Index (FEV1/FVC) was significantly lower in asthmatic relapsers than in non relapsers asthmatics (94.7 ± 11.1 versus 105 ± 5.9—p = 0.04). Patients with asthma and atopy had a major risk of relapse (p = 0.05).

Conclusion

In our pilot study, atopy, severe asthma, bronchial inflammation, NSAIDs hypersensitivity and high level of total IgE are possible useful prognostic factors for the proneness to relapse after FESS. The role of allergy in CRSwNP pathogenesis should consequently be given deeper consideration. Allergen specific immunotherapy, combined with anti-IgE therapy, may have an immunomodulatory effect preventing polyps relapse and need to be investigated.

Electronic supplementary material

The online version of this article (doi:10.1186/s12948-015-0026-8) contains supplementary material, which is available to authorized users.

Epidemiology of chronic rhinosinusitis: results from a cross-sectional survey in seven Chinese cities

BACKGROUND

Chronic sinusitis (CRS) is a common otorhinolaryngologic disease that is frequently encountered in everyday practice, but there is a lack of precise data regarding the prevalence of CRS in developing countries. We performed a national investigation in China to determine the prevalence and associated factors of CRS.

METHODS

We conducted a cross-sectional investigation in 2012. A stratified four-stage sampling method was used to select participants randomly from seven cities in mainland China. All participants were interviewed face-to-face via a standardized questionnaire. Unconditional logistic regression analyses were conducted to examine the association between smoking and sinusitis after adjusting for socio-demographic factors.

RESULTS

This study included a total of 10 636 respondents from seven cities. The overall prevalence of CRS was 8.0% and ranged from 4.8% to 9.7% in seven centres. Chronic sinusitis affected approximately 107 million people in mainland China. Chronic sinusitis was particularly prevalent among people with specific medical conditions, including allergic rhinitis, asthma, chronic obstructive pulmonary disease and gout. The prevalence was slightly higher among males (8.79%) than females (7.28%) (P = 0.004), and the prevalence varied by age group, ethnicity and marital status and education (P < 0.05), but not by household per capita income or living space (P > 0.05). Both second-hand tobacco smoke and active smoking were independent risk factors for CRS (P = 0.001).

CONCLUSIONS

Chronic sinusitis is an important public health problem in China. Our study provides important information for the assessment of the economic burden of CRS and the development and promotion of public health policies associated with CRS particularly in developing countries.

The burden of revision sinonasal surgery in the UK-data from the Chronic Rhinosinusitis Epidemiology Study (CRES): a cross-sectional study

OBJECTIVES

The aim of this study was to investigate the surgical revision rate in patients with chronic rhinosinusitis (CRS) in the UK CRS Epidemiology Study (CRES). Previous evidence from National Sinonasal Audit showed that 1459 patients with CRS demonstrated a surgical revision rate 19.1% at 5 years, with highest rates seen in those with polyps (20.6%).

SETTING

Thirty secondary care centres around the UK.

PARTICIPANTS

A total of 221 controls and 1249 patients with CRS were recruited to the study including those with polyps (CRSwNPs), without polyps (CRSsNPs) and with allergic fungal rhinosinusitis (AFRS).

INTERVENTIONS

Self-administered questionnaire.

PRIMARY OUTCOME MEASURE

The need for previous sinonasal surgery.

RESULTS

A total of 651 patients with CRSwNPs, 553 with CRSsNPs and 45 with AFRS were included. A total of 396 (57%) patients with CRSwNPs/AFRS reported having undergone previous endoscopic nasal polypectomy (ENP), of which 182 of the 396 (46%) reported having received more than one operation. The mean number of previous surgeries per patient in the revision group was 3.3 (range 2-30) and a mean duration of time of 10 years since the last procedure. The average length of time since their first operation up to inclusion in the study was 15.5 years (range 0-74). Only 27.9% of all patients reporting a prior ENP had received concurrent endoscopic sinus surgery (ESS; n=102). For comparison, surgical rates in patients with CRSsNPs were significantly lower; 13% of cases specifically reported ESS, and of those only 30% reported multiple procedures (χ(2) p<0.001).

CONCLUSIONS

This study demonstrated that there is a high burden of both primary and revision surgery in patients with CRS, worst in those with AFRS and least in those with CRSsNPs. The burden of revision surgery appears unchanged in the decade since the Sinonasal Audit.

Interleukin-1β regulates the expression of glucocorticoid receptor isoforms in nasal polyps in vitro via p38 MAPK and JNK signal transduction pathways

BACKGROUND

To explore the upstream signal transduction mechanisms responsible for the imbalanced expression of glucocorticoid receptor (GR) isoforms in chronic rhinosinusitis (CRS) mucosa.

METHODS

An in vitro model of Glucocorticoid resistance was established by inducing nasal polyp tissue with IL-1β. Changes in the protein and mRNA expression of GRα, GRβ and the key enzymes in the p38 MAPK and JNK signal pathways were measured, respectively, before and after being induced with different doses of IL-1β and specific inhibitors of p38 MAPK, JNK, ERK, PI3K and PKC. The Glucocorticoid sensitivity was measured using in vitro Glucocorticoid binding assay. Analysis of variance (ANOVA) was used to analyze the data.

RESULTS

The mRNA and protein expression levels of GRα, GRβ and key enzymes of the p38 MAPK and JNK pathways increased both in time- and concentration-dependent manners in IL-1β-induced nasal polyp tissue. The expression of GRβ increased more significantly than that of GRα, and the GRα/GRβ ratio decreased in time- and concentration-dependent manners. Statistically significant differences were found in the GRα/GRβ ratio and the mRNA expression of phospho-p38 MAPK and phospho-JNK between the IL-1β-induced groups and the control groups (P < 0.05). Either a specific inhibitor of the p38 MAPK pathway or a specific inhibitor of the JNK pathway increased the GRα/GRβ ratio and the Glucocorticoid affinity. None of the specific inhibitors of ERK, PI3K or PKC had any influence on the expression of GR isoforms.

CONCLUSION

Our results demonstrated that the imbalanced expression of GR isoforms in nasal polyp tissue induced by IL-1β in vitro is mediated through the p38 MAPK and JNK signal pathways.

ICON: chronic rhinosinusitis

Chronic rhinosinusitis (CRS) is a public health problem that has a significant socio-economic impact. Moreover, the complexity of this disease due to its heterogeneous nature based on the underlying pathophysiology - leading to different disease variants - further complicates our understanding and directions for the most appropriate targeted treatment strategies. Several International/national guidelines/position papers and/or consensus documents are available that present the current knowledge and treatment strategies for CRS. Yet there are many challenges to the management of CRS especially in the case of the more severe and refractory forms of disease. Therefore, the International Collaboration in Asthma, Allergy and Immunology (iCAALL), a collaboration between EAACI, AAAAI, ACAAI, and WAO, has decided to propose an International Consensus (ICON) on Chronic Rhinosinusitis. The purpose of this ICON on CRS is to highlight the key common messages from the existing guidelines, the differences in recommendations as well as the gaps in our current knowledge of CRS, thus providing a concise reference. In this document we discuss the definition of the disease, its relevance, pharmacoeconomics, pathophysiology, phenotypes and endotypes, genetics and risk factors, natural history and co-morbidities as well as clinical manifestations and treatment options in both adults and children comprising pharmacotherapy, surgical interventions and more recent biological approaches. Finally, we have also highlighted the unmet needs that wait to be addressed through future research.

Facial structure alterations and abnormalities of the paranasal sinuses on multidetector computed tomography scans of patients with treated mucosal leishmaniasis

BACKGROUND/OBJECTIVES

Mucosal leishmaniasis (ML) is a progressive disease that affects cartilage and bone structures of the nose and other upper respiratory tract structures. Complications associated with ML have been described, but there is a lack of studies that evaluate the structural changes of the nose and paranasal sinuses in ML using radiological methods. In this study, we aimed to assess the opacification of the paranasal sinuses in patients with treated ML and any anatomical changes in the face associated with ML using multidetector computed tomography scans (MDCT) of the sinuses. We compared the findings with a control group.

METHODOLOGY/PRINCIPAL FINDINGS

We evaluated 54 patients with treated ML who underwent CT scans of the sinuses and compared them with a control group of 40 patients who underwent orbital CT scans. The degree of sinus disease was assessed according to the Lund-Mackay criteria. Forty of the 54 patients with a history of ML (74.1%) had a tomographic score compatible with chronic sinusitis (Lund-Mackay ≥4). CT scans in the leishmaniasis and control groups demonstrated significant differences in terms of facial structure alterations. Patients from the ML group showed more severe levels of partial opacification and pansinus mucosal thickening (42.6%) and a greater severity of total opacification. Patients from the ML group with a Lund-Mackay score ≥4 presented longer durations of disease before treatment and more severe presentations of the disease at diagnosis.

CONCLUSION/SIGNIFICANCE

CT scans of the sinuses of patients with ML presented several structural alterations, revealing a prominent destructive feature of the disease. The higher prevalence in this study of chronic rhinosinusitis observed in CT scans of patients with treated ML than in those of the control group suggests that ML can be considered a risk factor for chronic rhinosinusitis in this population (p<0.05).

Update on the management of chronic rhinosinusitis

Chronic rhinosinusitis (CRS) is a common disorder characterized by mucosal inflammation of the nose and paranasal sinuses with sinonasal symptoms persisting for greater than 12 weeks. The etiology of CRS is incompletely understood. Current understanding supports inflammation, rather than infection, as the dominant etiologic factor. CRS significantly impacts patients' quality of life and health care expenditure. There is no standard management of CRS. Treatment strategies differ based on divergent etiologies of the various CRS subclasses. Both systemic and topical agents are used. These interventions differ in CRS with nasal polyposis (CRSwNP), CRS without nasal polyposis (CRSsNP) and specific situations such as allergic fungal rhinosinusitis or aspirin-exacerbated respiratory disease. Antibiotics are the most commonly prescribed medication for CRS, but their role in management is not strongly supported by high-level studies. This paper provides a succinct review of the evidence supporting or refuting common therapeutic agents in the management of CRS. Novel and emerging strategies will also be discussed.