Evidence-based surgery for chronic rhinosinusitis with and without nasal polyps

Inflammation resolution and specialized pro-resolving lipid mediators in chronic rhinosinusitis

INTRODUCTION

In chronic rhinosinusitis (CRS), a complex pathophysiology results from varied pro-inflammatory stimuli but is consistently characterized by classic cellular, molecular, and microbial alterations. Normally, endogenous specialized pro-resolving mediators (SPM) actively promote resolution of inflammation through numerous pathways, including those involved in host antimicrobial defense. However, these pathways appear to be disrupted in CRS.

AREAS COVERED

This paper describes features of CRS in the context of chronic tissue inflammation, and potential mechanisms by which specialized pro-resolving mediators promote active resolution of tissue inflammation.

EXPERT OPINION

Temporal phases of resolution must be tightly regulated to successfully resolve inflammation in CRS while preserving tissue functions such as barrier maintenance and special sensory function. Dysregulation of SPM enzymatic pathways has been recently shown in CRS and is associated with disease phenotypes and microbial colonization patterns. Current research in animal models and in vitro human cell culture, as well as human dietary studies, demonstrate relevant changes in cell signaling with lipid mediator bioavailability. Further clinical research may provide insight into the therapeutic value of this approach in CRS.

Effect of recombinant human acidic fibroblast growth factor on nasal mucosal healing after endoscopic sinus surgery

BACKGROUND

Postoperative nasal treatment is an important factor affecting the outcomes of endoscopic sinus surgery (ESS) in patients with chronic rhinosinusitis (CRS). This study aimed to determine the effect of recombinant human acidic fibroblast growth factor (rh-aFGF) on nasal mucosal healing after ESS.

METHODS

This study is a prospective, single-blind, and randomized controlled clinical study. Fifty-eight CRS patients with nasal polyps (CRSwNP) with bilateral ESS were enrolled and randomly given 1 mL of budesonide nasal spray and 2 mL of rh-aFGF solution (rh-aFGF group) or 1 mL of budesonide nasal spray and 2 mL of rh-aFGF solvent (budesonide group)-infiltrated Nasopore nasal packing after ESS. Preoperative and postoperative scores for Sino-Nasal Outcome Test (SNOT-22), Visual Analogue Scale (VAS), and Lund-Kennedy were collected and analyzed.

RESULTS

Forty-two patients completed the 12-week follow-up. Postoperative SNOT-22 scores and VAS scores showed no significant differences between the two groups. In terms of the Lund-Kennedy scores, there was a statistically significant difference between the two groups at the 2-, 4-, 8-, and 12-week postoperative visits, but not at the 1-week visit. Twelve weeks after surgery, the nasal mucosa had completely epithelialized in 18 patients in the rh-aFGF group and in 12 patients in the budesonide group (χ² = 4.200, P = 0.040).

CONCLUSION

The combined application of rh-aFGF and budesonide significantly improved postoperative endoscopic appearance in the nasal mucosal healing process.

Efficacy of Topical High Volume Budesonide Nasal Irrigation in Post FESS Patients of Chronic Rhinosinusitis With or Without Nasal Polyposis

Chronic rhinosinusitis (CRS) is a chronic inflammatory process of nasal mucosa and paranasal sinuses, lasting more than 12 weeks, without complete resolution of symptoms. CRS is treated medically, followed by Endoscopic sinus surgery (ESS) if necessary, and supplemented by post-operative topical treatment with highly variable clinical outcomes. However, till date there is no consensus on the composition and duration of maximal medical treatment. Despite proven role of topical steroids, the mode of delivery, dose and duration of topical intranasal corticosteroids still remains debatable. Studies found that high volume sinonasal irrigation (> 50 ml) using budesonide is most efficient method but still there is not sufficient data to prove this and results are variable with multiple modifiable factors therefore, this study has been conducted. (1) To determine the difference in mean decrease in Lund-Kennedy endoscopic scores and SNOT-22 scores among post ESS patients with high volume budesonide nasal irrigation nasal cavity and control nasal cavity of chronic rhinosinusitis patients. (2) To determine safety by measuring serum cortisol levels and intra ocular pressure. This is hospital based interventional, randomised, double blind, control trial study. A total of 66 patients of CRS with previous failed medical therapy were included. Same patients nasal cavities were divided into control and case nasal cavities, to avoid demographic bias. All subjects had a baseline SNOT-22 scores (Sino Nasal Outcome Test scores), Lund Kennedy endoscopy score, NCCT PNS score. All patients were undergone ESS procedure. After nasal pack removal, nasal cavities were randomly assigned 1:1 to receive normal saline irrigation (control group) or 1 mg of budesonide irrigation (case group) for transnasal irrigation twice daily for 12 weeks. A total of 66 patients with 132 nasal cavities were included in the study. Out of which 16 were female and 50 were male with mean age 33 year and mean duration of symptoms was 38.19 months. Mean duration of follow up was for 3 months. Mean decrement in SNOT-22 score in control nasal cavity from 52.54(16.309) to 30.06 (18.16) and in endoscopic score from 6.53 (1.33) to 3.93 (1.6) which is statically significant (p value < 0.05) in both scores. Mean decrement in SNOT-22 score in case nasal cavity from 53.73 (15.75) to 21.15 (13.52) and in endoscopic score from 6.74 (1.8) to 2.77 (1.4) which is statically significant (p value < 0.05) in both scores. Decrement in SNOT-22 scores and endoscopy scores in case nasal cavity in comparision to control nasal cavity were compared by student 't' test and found to be statically significant (p value equals to 0.0001). In subjective outcomes 57.57% shows total improvement in control nasal cavities while 72.73% case nasal cavities shows total improvement. Our study shows high volume budesonide irrigation is safe and superior over normal saline irrigation and results were statistically comparable. Still further studies with larger sample size and longer duration of irrigation needed.Based on available evidence, high volume budesonide irrigation is statically safe and superior over normal saline irrigation.

Predictive Values of Serum IL-33 and sST2 in Endotypes and Postoperative Recurrence of Chronic Rhinosinusitis with Nasal Polyps

Background. Chronic rhinosinusitis with nasal polyps (CRSwNP) is a common inflammatory disease with high heterogeneity and postoperative recidivation. The IL-33/ST2 axis is known to be involved in Th2 immune responses. This study is aimed at exploring levels of serum IL-33 and soluble ST2 (sST2) in CRSwNP patients and their potential for predicting CRSwNP endotypes and postoperative recurrence. Methods. The present study recruited 149 CRSwNP patients, 80 of whom were noneosinophilic (neCRSwNP) and 69 eosinophilic (eCRSwNP), as well as 60 healthy controls (HCs). Serum samples were collected from all participants, and sST2 and IL-33 concentrations were measured using ELISA. Multivariate analysis, receiver operating characteristic (ROC) curves, and Kaplan-Meier curves were used to evaluate the value of serum sST2 and IL-33 levels in distinguishing CRSwNP endotypes and predicting postoperative recurrence. Results. The levels of serum sST2 and IL-33 in CRSwNP patients were significantly higher than those in HCs, especially in the eCRSwNP group. Increased sST2 and IL-33 levels were associated with eosinophil counts and percentages in both tissue and blood. Multivariate regression and ROC curve analysis showed that serum sST2 and IL-33 exhibited potential for distinguishing CRSwNP endotypes, and the combination of serum IL-33 and sST2 showed even more predictive power. Finally, 124 CRSwNP patients completed the entire 3-year follow-up. Multivariate analysis and Kaplan-Meier curves showed that serum sST2 and IL-33 levels were associated with recurrence; serum sST2 and IL-33 each exhibited potential for predicting postoperative recurrence, and combining serum sST2 and IL-33 exhibited better accuracy and practicability. Conclusion. Our results suggested that serum sST2 and IL-33 levels were upregulated in CRSwNP patients and related to the degree of mucosal eosinophil infiltration and postoperative recurrence. Serum sST2 and IL-33 might serve as objective biomarkers for distinguishing phenotypes and predicting recurrence in CRSwNP, and their combined use outperformed either marker alone.

miR-29b Regulates TGF-β1-Induced Epithelial-Mesenchymal Transition by Inhibiting Heat Shock Protein 47 Expression in Airway Epithelial Cells

Tissue remodeling contributes to ongoing inflammation and refractoriness of chronic rhinosinusitis (CRS). During this process, epithelial-mesenchymal transition (EMT) plays an important role in dysregulated remodeling and both microRNA (miR)-29b and heat shock protein 47 (HSP47) may be engaged in the pathophysiology of CRS. This study aimed to determine the role of miR-29b and HSP47 in modulating transforming growth factor (TGF)-β1-induced EMT and migration in airway epithelial cells. Expression levels of miR-29b, HSP47, E-cadherin, α-smooth muscle actin (α-SMA), vimentin and fibronectin were assessed through real-time PCR, Western blotting, and immunofluorescence staining. Small interfering RNA (siRNA) targeted against miR-29b and HSP47 were transfected to regulate the expression of EMT-related markers. Cell migration was evaluated with wound scratch and transwell migration assay. miR-29b mimic significantly inhibited the expression of HSP47 and TGF-β1-induced EMT-related markers in A549 cells. However, the miR-29b inhibitor more greatly induced the expression of them. HSP47 knockout suppressed TGF-β1-induced EMT marker levels. Functional studies indicated that TGF-β1-induced EMT was regulated by miR-29b and HSP47 in A549 cells. These findings were further verified in primary nasal epithelial cells. miR-29b modulated TGF-β1-induced EMT-related markers and migration via HSP47 expression modulation in A549 and primary nasal epithelial cells. These results suggested the importance of miR-29b and HSP47 in pathologic tissue remodeling progression in CRS.

Efficacy and safety of treatment with biologicals for severe chronic rhinosinusitis with nasal polyps: A systematic review for the EAACI guidelines

This systematic review evaluates the efficacy and safety of biologicals for chronic rhinosinusitis with nasal polyps (CRSwNP) compared with the standard of care. PubMed, Embase, and Cochrane Library were searched for RCTs. Critical and important CRSwNP-related outcomes were considered. The risk of bias and the certainty of the evidence were assessed using GRADE. RCTs evaluated (dupilumab-2, omalizumab-4, mepolizumab-2, and reslizumab-1) included 1236 adults, with follow-up of 20-64 weeks. Dupilumab reduces the need for surgery (NFS) or oral corticosteroid (OCS) use (RR 0.28; 95% CI 0.20-0.39, moderate certainty) and improves with high certainty smell evaluated with UPSIT score (mean difference (MD) +10.54; 95% CI +9.24 to +11.84) and quality of life (QoL) evaluated with SNOT-22 (MD -19.14; 95% CI -22.80 to -15.47), with fewer treatment-related adverse events (TAEs) (RR 0.95; 95% CI 0.89-1.02, moderate certainty). Omalizumab reduces NFS (RR 0.85; 95% CI 0.78-0.92, high certainty), decreases OCS use (RR 0.38; 95% CI 0.10-1.38, moderate certainty), and improves high certainty smell (MD +3.84; 95% CI +3.64 to +4.04) and QoL (MD -15.65; 95% CI -16.16 to -15.13), with increased TAE (RR 1.73; 95% CI 0.60-5.03, moderate certainty). There is low certainty for mepolizumab reducing NFS (RR 0.78; 95% CI 0.64-0.94) and improving QoL (MD -13.3; 95% CI -23.93 to -2.67) and smell (MD +0.7; 95% CI -0.48 to +1.88), with increased TAEs (RR 1.64; 95% CI 0.41-6.50). The evidence for reslizumab is very uncertain.

Patient perspectives on endoscopic sinus surgery for chronic rhinosinusitis

Background

Through shared decision-making, physicians and patients can elect endoscopic sinus surgery (ESS) when maximal medical therapy fails in patients with chronic rhinosinusitis (CRS). In this study, we aim to explore the most important themes with regards to patients’ perspectives on ESS. Our objective was to define the patient experience and ensure that we have congruent physician and patient goals for obtaining success.

Methods

Semi-structured face-to-face interviews were conducted with 22 patients at a tertiary-care institution in Montreal. Three themes were established a priori: living with CRS, objectives and expectations and criteria for success. This thematic approach allowed the identification, analysis and reporting of patterns found across the data set. A phenomenological methodological orientation was used. Interviews were audio-recorded and transcribed verbatim for continuous analysis. These were coded by hand by a single coder who read the transcripts multiple times and relistened to the recordings.

Results

Exploration of themes on patients’ perspectives on ESS for CRS yielded multiple anecdotal findings, and some recurring patterns. There is a tendency for patients to focus on one principal symptom that drives their decrease in QoL. Headaches and nasal congestion seemed to impact patients’ QoL the most amongst rhinologic symptoms. Hyposmia was rarely spontaneously by patients but was often a significant source of distress when prompted during interviews. Objectives and expectations seemed to be inversely proportional to number of previous surgeries and severity of symptoms preoperatively. There was a clear association between preoperative expectations and postoperative satisfaction. There was no clear pattern in the improvement magnitude or time improved postoperatively for patients to consider the surgery a success.

Conclusions

Patients’ level of satisfaction postoperatively and with their care in general is multifactorial. We believe the topic of goals and expectations regarding ESS should be discussed preoperatively for every patient with CRS. This includes patients with seemingly minor disease and patients naive to surgery, as can sometimes have exceedingly high expectations. Preoperative counselling must also include an assessment of what symptom is the most cumbersome to that particular patient, as patients tend to focus a lot on one or two symptoms. Postoperatively, we encourage clinicians to be attentive to the change in each patient’s principal complaints within the context of a personalized approach and to refer back to patients’ preoperative goals in their assessment of operative success.

Graphical abstract

International consensus statement on allergy and rhinology: rhinosinusitis 2021

I.

EXECUTIVE SUMMARY

BACKGROUND: The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR-RS-2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence-based findings of the document.

METHODS

ICAR-RS presents over 180 topics in the forms of evidence-based reviews with recommendations (EBRRs), evidence-based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary.

RESULTS

ICAR-RS-2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence-based management algorithm is provided.

CONCLUSION

This ICAR-RS-2021 executive summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS.

Tualang honey versus steroid impregnated nasal dressing following endoscopic sinus surgery: a randomized controlled trial

OBJECTIVES

Recurrence rate of nasal polyps is high following endoscopic sinus surgery. To improve the surgical outcome, steroid impregnated nasal dressing is used postoperatively We aimed to compare the effect of Tualang honey impregnated nasal dressing with steroid impregnated nasal dressing on wound healing and surgical outcomes in post endoscopic sinus surgery patients.

METHODS

A prospective, randomized, controlled trial was carried out at two tertiary hospitals. 32 patients diagnosed with chronic rhinosinusitis and had underwent endoscopic sinus surgery were enrolled. The study group received 2 mL of Tualang honey nasal dressing and the control group received nasal dressing with 2 mL of triamcinolone 20 mg/mL as positive control. A 2 cm nasal dressing was placed longitudinally into the middle meatuses of both nasal cavities. Postoperative healing assessments of edema, crusting, secretions, scarring and symptoms were performed at postoperative day 7, 14, 28 and at 3 months using Sinonasal Outcome Test 22 questionnaire and modified Lund-Kennedy scoring system.

RESULTS

There were no significant differences noted in the scores of Sinonasal Outcome Test 22 and modified Lund-Kennedy at Day 7, 14 and 28 (p>0.05) for both groups. At 3rd month, patients in the triamcinolone group had lesser symptoms and better endoscopic findings (p<0.05).

CONCLUSION

Tualang honey is not as effective as steroid in achieving good wound healing and surgical outcomes in post endoscopic sinus surgery patients. Thus, it is not suitable as a substitute for steroid to reduce symptoms and prevent recurrence of disease.

Clinical predictors of revision surgery for chronic rhinosinusitis with nasal polyposis within 5-year follow-up

BACKGROUND

Chronic rhinosinusitis with nasal polyposis (CRSwNP) remains a difficult-to-cure disease. The aim of this study was to determine the potential long-term predictors of revision sinus surgery for CRSwNP.

METHODS

Prospectively gathered patients with bilateral CRSwNP who received primary endoscopic sinus surgery were enrolled. Clinical variables, including the preoperative Lund-Mackay score (LMS), were collected to clarify possible risk factors for revision surgery within a 5-year follow-up. The symptomatic burden was measured using a 10-cm visual analog scale (VAS) before and 1 year after surgery. Further survival analysis was performed to present the revision-free survival in Kaplan-Meier plotting.

RESULTS

Eighty four qualified patients were identified and all of them experienced significant improvement in VAS after primary surgery. The 5-year revision rate was 19.05%, and the mean time of revision surgery was 25.31 ± 17.11 months postoperatively. Nasal allergy (OR = 9.287; p = 0.011) and LMS (OR = 1.29; p = 0.06) were found to be the independent risk factors for revision surgery. The discriminatory power of LMS for revision surgery was acceptable (AUC = 0.79) with the best cutoff point located at LMS > 13.5. Patients with both nasal allergy and LMS≧14 had only half of revision-free survival in comparison to overall survival (38.1% vs. 80.95%, p < 0.001).

CONCLUSIONS

In patients with CRSwNP who have concurrent nasal allergy and higher preoperative LMS may indicate an advanced disease status and eventually be in a high risk of revision surgery after a long-term follow-up. An outcome-based staging system will be helpful in the future to improve the prognosis for CRSwNP.

Presentation and outcomes of chronic rhinosinusitis following liver and kidney transplant

Objective

This study aims to describe presenting characteristics of patients diagnosed with non-invasive chronic rhinosinusitis (CRS) following liver or kidney transplant and determine factors associated with disease-related complications, selection of endoscopic sinus surgery (ESS), and disease resolution in this population.

Study design

Retrospective chart review.

Setting

An academic tertiary care center (Mayo Clinic, Rochester, Minnesota).

Subjects and methods

Liver and kidney transplant recipients evaluated by Mayo Clinic otolaryngologists for CRS between 1998 and 2018 were identified. Univariate and multivariate logistic regression analyses were used to determine patient factors and treatment modalities associated with developing complications, selection of ESS, and disease resolution.

Results

Fifty-seven patients met inclusion criteria. No patients developed intraorbital or intracranial complications of their CRS. Multivariate modeling demonstrated that the presence of polyps (P = 0.036) was associated with undergoing ESS within one year of presentation. A higher Lund–Mackay (LM) computed tomography score (P = 0.023) and older age (P = 0.018) were significantly associated with decreased disease resolution. No other factors were significantly associated with the use of endoscopic sinus surgery within one year of otolaryngology presentation or resolution of CRS in this cohort.

Conclusion

The risk of developing CRS-related intraorbital or intracranial complications in this immunecompromised patient cohort may be lower than originally thought. For liver- and kidney-recipients stable on immunosuppressive medication for many years, prognostic factors for CRS may mirror those for immunocompetent patients.

Ethmoidal drug-eluting stent therapy is not superior to nasal corticosteroid spray in the prevention of endoscopic sinus surgery: Results from a randomised, clinical trial

OBJECTIVES

To evaluate whether an ethmoidal drug-eluting stent (DES) (the Relieva Stratus™ MicroFlow Spacer) could better prevent endoscopic sinus surgery (ESS) than standard non-invasive therapy using corticosteroid nasal spray in patients suffering from chronic rhinosinusitis (CRS).

DESIGN

Prospective, randomised clinical trial.

SETTING

Tertiary referral centre.

PARTICIPANTS

Sixty-three adult patients with ethmoidal involvement in cone beam computerised tomography (CBCT) whose first-line medical treatment with topical corticosteroids had failed and who were candidates for ESS were randomised either to a DES group, which received triamcinolone acetonide stents (n = 34), or to a topical intranasal corticosteroid group (n = 29) that used optimally dosed triamcinolone acetonide nasal spray.

OUTCOME MEASURES

Patients were followed up prospectively for 6 months and at 36 months. Freedom from ESS was the primary endpoint. Further, we identified those factors predicting ESS.

RESULTS

At 6 months, ESS could be prevented in almost half of the patients in both groups (DES 13/28, 46.4%, nasal spray 14/29, 48.3%). At 36 months, 20/28 (71.4%) patients in the DES group and 18/29 (62.1%) in the nasal spray group had been operated. The differences were not statistically significant at either timepoint. Patients who smoked (14/19, 73.7% vs 16/38, 42.1%) were more likely to be operated at 6 months.

CONCLUSION

Endoscopic sinus surgery can be prevented using both therapies in the medium term in almost half of cases with neither therapy being statistically superior. This effect was somewhat diminished in the long term with a trend towards more patients being operated in the DES group. Considering the additional costs, the need for general anaesthesia and the potential side effects associated with DES, its potential clinical role appears to be limited. Smoking was significantly associated with ESS.

Efficacy and safety of steroid-impregnated implants following sinus surgery: A meta-analysis

OBJECTIVES

The purpose of this meta-analysis was to discuss the efficacy and safety of bioabsorbable steroid-impregnated implants following endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) patients.

METHODS

PubMed, Cochrane, EMBASE, Web of Science, and the Cochrane Central Register of Controlled Trials were comprehensively searched for studies comparing the experimental group (bioabsorbable steroid-impregnated implants) with the control group (bioabsorbable nonsteroid-impregnated implants). Lund-Kennedy scores, Perioperative Sinus Endoscopy (POSE) scores, polyp change, significant adhesion, middle turbinate lateralization, and adverse events were extracted from the final eligible studies. RevMan 5.3 software was used to analyze the data.

RESULTS

Eight randomized controlled trials were included in our analysis. The experimental group showed no significant differences from the control group in Lund-Kennedy scores (weighted mean difference (WMD) -0.40; 95% confidence interval [confidence interval (CI)] -1.05 to -0.62; P = 0.23). The experimental group had lower POSE scores compared with the control group, and there was a significant difference (WMD -1.88; 95% CI -2.32 to -1.43, P < 0.00001). The pooled results also demonstrated significant differences in polyp change, significant adhesion, and middle turbinate lateralization between the two groups. In addition, there was no significant difference with respect to adverse events between the two groups (odds ratio (OR) 0.38; 95% CI: 0.07 to 2.03; P = 0.26).

CONCLUSION

Bioabsorbable steroid-impregnated implants following ESS are effective in improving the endoscopic appearance of the healing process, and the safety profile appears to be favorable for the treatment of CRS patients.

LEVEL OF EVIDENCE

1A Laryngoscope, 2019.

Asthma-COPD Overlap and Chronic Airflow Obstruction: Definitions, Management, and Unanswered Questions

Asthma-chronic obstructive pulmonary disease (COPD) overlap (ACO) is a common clinical presentation of chronic airways disease in which patients show some features usually associated with asthma, and some usually associated with COPD. There is ongoing debate over whether ACO is a discrete clinical entity, or if it is part of a continuum of airways disease. Furthermore, there is considerable variation among current definitions of ACO, which makes diagnosis potentially challenging for clinicians. Treating ACO may be equally challenging because ACO is an understudied population, and the evidence base for its management comes largely from asthma and COPD studies, the relevance of which deserves careful consideration. In this review, we synthesize the various approaches to ACO diagnosis and evaluate the role of currently available diagnostic tests. We describe the potential benefits of existing asthma and COPD therapies in treating patients with ACO, and the value of a "treatable traits" approach to ACO management. Throughout the review, we highlight some of the pressing, unanswered questions surrounding ACO that are relevant to the clinical community. Ultimately, addressing these questions is necessary if we are to improve clinical outcomes for this complex and heterogeneous patient population.

Precision Medicine in Rhinosinusitis

PURPOSE OF REVIEW

Our scope is the presentation of research and clinical progresses in relation to precision medicine that are expected to alter our clinical practice in relation to chronic rhinosinusitis (CRS). Current knowledge on phenotypes and endotypes, biomarkers, and clinical markers for diagnosis, medical and surgical therapy, and prognosis is presented as well as the role of precision medicine in United Airway Disease and SCUAD (severe-uncontrolled chronic upper airway inflammation).

RECENT FINDINGS

Current technological progresses, mostly in relation to molecular biology and information technology, have permitted more detailed pathophysiological assessments and multidimensional approaches in airways diseases. Based on the concept of united airways diseases, new classification schemes, called endotypes, have been proposed for CRS. In addition, novel biological treatments that have been introduced for the treatment of asthma show great promise as well for severe uncontrolled cases of CRS with nasal polyps. Central to this approach are new biomarkers that are being examined in relation to complex bio-clinical traits of CRS. As this narrative review of the aforementioned precision medicine initiatives in relation to CRS advances, a modification of current practice is expected not only for severe chronic upper airways diseases in tertiary centers but also for milder and more common cases that are being encountered in the community.

Mucocele development after endoscopic sinus surgery for nasal polyposis: A long-term analysis

The aim of the present study was to determine the prevalence of long-term mucocele development after functional endoscopic sinus surgery (FESS) for nasal polyposis, to search for a statistical relationship with preoperative variables and to analyze the management of this complication. A retrospective analysis of 153 patients who underwent FESS for nasal polyposis, with a minimum of 7 years of follow-up, was performed. Mucocele diagnosis was based on regular clinical and radiologic evaluation. Univariate and multivariate statistical analysis was performed. The postoperative mucocele rate was 13.1% (20 patients). The mean delay between surgery and mucocele diagnosis was 6.25 years. A high preoperative Lund-Mackay score (>19) was a risk factor for postoperative mucocele (p = 0.04). Asthma and aspirin intolerance did not increase the risk of this complication. Endoscopic marsupialization of mucoceles was successful in 19 patients, with only one recurrent frontal mucocele. One patient required external approaches for two frontal mucoceles. In conclusion, mucocele risk after FESS for nasal polyposis is significant, especially in case of a high preoperative Lund-Mackay score (>19). Long-term clinical follow-up is recommended, imaging being prescribed based on symptoms or abnormal findings on clinical examination. Endoscopic marsupialization is very effective, but frontal mucoceles are more likely to recur.

Diseases of the nasal cavity

Despite garnering minimal attention from the medical community overall, olfaction is indisputably critical in the manner in which we as humans interact with our surrounding environment. As the initial anatomical structure in the olfactory pathway, the nasal airway plays a crucial role in the transmission and perception of olfactory stimuli. The goal of this chapter is to provide a comprehensive overview of olfactory disturbances as it pertains to the sinonasal airway. This comprises an in-depth discussion of clinically relevant nasal olfactory anatomy and physiology, classification systems of olfactory disturbance, as well as the various etiologies and pathophysiologic mechanisms giving rise to this important disease entity. A systematic clinical approach to the diagnosis and clinical workup of olfactory disturbances is also provided in addition to an extensive review of the medical and surgical therapeutic modalities currently available.

Current healthcare pathways in the treatment of rhinosinusitis in Germany

BACKGROUND

In the outpatient setting in Germany, patients with rhinosinusitis usually present at general practices (GP) or ear, nose, and throat practices (ENT) for initial diagnosis and treatment.

OBJECTIVES

The aim of this study was to analyze the referral patterns of rhinosinusitis patients in GPs and ENT practices in Germany, with respect to existing recommendations.

MATERIAL AND METHODS

The study sample included patients from 940 GP and 106 ENT practices from Disease Analyzer database (IQVIA) who received an acute sinusitis (AS) or chronic sinusitis (CS), or nasal polyp (NP) in 2015.

RESULTS

The total numbers of patients in GP versus ENT practices were 24,648 versus 12,095 (AS), 26,768 versus 19,826 (CS), and 516 versus 1773 patients (NP). Referrals to ENT practices were made by GP in 12.3% (AS), 14.8% (CS), and 40.5% (NP). The percentages of patients in GP versus ENT practices with subsequent hospital admissions were 6.9 versus 3.3% (AS), 6.3 versus 6.5% (CS), and 9.5 versus 13.8% (NP), respectively.

CONCLUSIONS

Although 40% of patients with NP who consult GPs are referred to ENT practices, it remains unclear how the other 60% are being treated. The hospital admission rates of patients with CS as well as of patients with NP were found to be surprisingly low.

How often is sinus surgery performed for chronic rhinosinusitis with versus without nasal polyps?

BACKGROUND

There currently are no data on the relative frequency of endoscopic sinus surgeries (ESS) performed for chronic rhinosinusitis with nasal polyposis (CRSwNP) versus chronic rhinosinusitis without nasal polyposis (CRSsNP) in the United States.

OBJECTIVES

To compare the rate of surgical interventions for CRSwNP and CRSsNP.

METHODS

Cases identified by CPT codes were extracted from the 2009-2011 State Ambulatory Surgery Databases for California, Florida, Maryland, and New York. Patient demographics, extent of surgery, mean charges, and operating room (OR) time were compared.

RESULTS

A total of 97,228 ESS cases were performed in the four states; 29.3% of surgeries were for patients with CRSwNP, 66.0% of patients with CRSsNP, and 4.8% for other indications. The proportion of ESS for CRSwNP varied across states, with California having the highest percentage (34.6%) and Maryland having the lowest (26.4%) (p < 0.0001). Patients with Medicaid (33.8%) and Medicare (32.2%) had higher rates of surgery for CRSwNP compared with patients with private insurance (29.9%) (p < 0.001). Surgeons who performed a higher volume of sinus surgery compared to lower volume surgeons performed a lower percentage of surgery for CRSwNP (24.4 versus 33.5%; p < 0.001). ESS cases for CRSwNP were more extensive (relative risk of four sinus surgeries of 1.88; p < 0.0001), used image guidance more frequently (relative risk, 1.39; p < 0.0001), and were less likely to include a balloon procedure (relative risk, 0.69; p < 0.0001). Patients with CRSwNP had longer OR times (ESS that involved all four sinuses took 14 minutes longer) (p < 0.0001), but no difference in charges compared with patients with CRSsNP who underwent a similar extent of surgery.

CONCLUSION

Almost 30% of ESS were performed for CRSwNP, and these cases were, on average, more extensive, used more OR time, and more often used image guidance than surgeries for CRSsNP. The rate of surgery performed for CRSwNP varied based on geography, payer, and surgical volume, which indicted that patient selection impacted surgical management.

Frontal sinus revision rate after nasal polyposis surgery including frontal recess clearance and middle turbinectomy: A long-term analysis

OBJECTIVE

To determine the frontal sinus revision rate after nasal polyposis (NP) surgery including frontal recess clearance (FRC) and middle turbinectomy (MT), to search for predictive factors and to analyse surgical management.

METHODS

Longitudinal analysis of 153 patients who consecutively underwent bilateral sphenoethmoidectomy with FRC and MT for NP with a minimum follow-up of 7 years. Decision of revision surgery was made in case of medically refractory chronic frontal sinusitis or frontal mucocele. Univariate and multivariate analysis incorporating clinical and radiological variables were performed.

RESULTS

The frontal sinus revision rate was 6.5% (10/153). The mean time between the initial procedure and revision surgery was 3 years, 10 months. Osteitis around the frontal sinus outflow tract (FSOT) was associated with a higher risk of frontal sinus revision surgery (p=0.01). Asthma and aspirin intolerance did not increase the risk, as well as frontal sinus ostium diameter or residual frontoethmoid cells. Among revised patients, 60% required multiple procedures and 70% required frontal sinus ostium enlargement.

CONCLUSIONS

Our long-term study reports that NP surgery including FRC and MT is associated with a low frontal sinus revision rate (6.5%). Patients developing osteitis around the FSOT have a higher risk of frontal sinus revision surgery. As mucosal damage can lead to osteitis, FSOT mucosa should be preserved during initial NP surgery. However, as multiple procedures are common among NP patients requiring frontal sinus revision, frontal sinus ostium enlargement should be considered during first revision in the hope of reducing the need of further revisions.

Randomized controlled trial of steroid-soaked absorbable calcium alginate nasal packing following endoscopic sinus surgery

OBJECTIVES/HYPOTHESIS

To evaluate the potential efficacy of steroid-soaked, absorbable calcium alginate nasal packing following endoscopic sinus surgery.

STUDY DESIGN

Prospective, randomized, single-blinded, placebo-controlled trial.

METHODS

Twenty-two patients (44 nostrils) who had chronic rhinosinusitis with polyps underwent bilateral endoscopic sinus surgery. Only those with an intersinus difference in Lund-Mackay severity score of 1 or less were included. In each patient, one randomly selected nostril was packed with calcium alginate soaked with 2 mL of triamcinolone (40 mg/mL) (triamcinolone group), whereas the contralateral nostril received an identical packing soaked in 2 mL of normal saline (saline group). Two independent investigators blinded to the packing allocation scored the surgical field using the validated Perioperative Sinus Endoscopy (POSE) scores 1, 4, and 8 weeks after surgery.

RESULTS

All 44 nostrils were analyzed; the Lund-Mackay scores did not differ significantly between the groups before surgery. Eight weeks after surgery, the total POSE scores were significantly lower in the triamcinolone group (P = .014). The POSE scoring parameters were then compared between groups, and the following variables were significantly different: middle turbinate synechiae with the lateral wall (P = .037), polypoid degeneration of the ethmoid cavity (P = .006), and sphenoid sinus severity (P = .036).

CONCLUSIONS

This study demonstrated that steroid-soaked, absorbable nasal packing can be used to enhance wound healing after endoscopic sinus surgery and to prevent polypoid changes in the nasal mucosa.

LEVEL OF EVIDENCE

1b. Laryngoscope, 128:311-316, 2018.

The treatment of the pulmonary and extrapulmonary manifestations of cystic fibrosis

Cystic fibrosis (CF) is a complex multisystem disease with considerable between patient variability in its manifestations and severity. In the past several decades, the range of treatments and the evidence to support their use for the pulmonary and extrapulmonary manifestations of CF have increased dramatically, contributing to the improved median survival of patients. As therapy for CF has evolved, new challenges including treatment adherence, medication intolerance and allergy, medical complications and coping with the burden of disease in the context of having a family and managing employment have arisen. While the majority of current therapy focuses primarily on improving symptoms, new therapies (CFTR modulators) target the underlying genetic defect.

Effectiveness of extensive sinus surgery with post-operative medical management for chronic rhinosinusitis

OBJECTIVE

To prospectively assess treatment outcomes of chronic rhinosinusitis patients undergoing functional endoscopic sinus surgery and post-operative medical treatment over a prolonged follow-up period.

METHODS

Patients undergoing functional endoscopic sinus surgery in the tertiary referral practice of a single surgeon were studied prospectively. Symptoms were scored by patients pre-operatively and over a minimum follow-up period of 12 months.

RESULTS

The study comprised 200 non-consecutive patients. The median pre-operative symptom score was 16 (out of a maximum of 25) (95 per cent confidence interval = 15 to 17). Symptom scores reduced to a median of 7 (95 per cent confidence interval = 6 to 8) after 12 months of follow up (p < 0.0001). The median symptom score improved for all symptoms and across all patient subgroups.

CONCLUSION

Extensive functional endoscopic sinus surgery offers significant and durable symptom improvement in patients with chronic rhinosinusitis refractory to medical treatment. This improvement extends to all patient subgroups. Prolonged medical therapy is recommended after functional endoscopic sinus surgery.

The prognostic role of serum eosinophil and basophil levels in sinonasal polyposis

BACKGROUND

Predicting which patients are at a higher risk for recurrent chronic rhinosinusitis with nasal polyps (CRSwNP) is one of the most challenging problems in clinical rhinology. A direct association between CRSwNP recurrence rates and serum eosinophil and basophil counts was reported. This study aimed to identify best-fitting cutoffs for binarizing preoperative serum eosinophils and basophils (counts/percentages) for prognostic purposes in cases of CRSwNP recurrence after surgery. A secondary endpoint was to distinguish said cutoffs for prognosticating recurrence in subcohorts of patients with histologically diagnosed eosinophilic/non-eosinophilic CRSwNP.

METHODS

A retrospective study was performed on 280 patients (127 eosinophilic and 153 non-eosinophilic CRSwNP) examining the prognostic role of serum eosinophil and basophil levels.

RESULTS

For all patients examined, mean preoperative serum eosinophil and basophil levels were significantly higher in patients whose CRSwNP recurred. Patients with eosinophil counts ≥0.24 cells × 10⁹ /L and percentages ≥3.7% had odds ratios (ORs) of 2.57 and 2.19 for recurrence; patients with basophil counts ≥0.03 cells × 10⁹ /L and percentages ≥0.5% had ORs of 2.19 and 2.24, respectively. Among histologically eosinophilic CRSwNP patients, mean eosinophils and basophils (counts/percentages) were significantly higher in cases that recurred. Serum eosinophil and basophil values were directly correlated. The recurrence odds were OR 2.52 for high eosinophils (≥5.9%), and OR 2.52 and 2.69 for high basophils (≥0.04 cells × 10⁹ /L and ≥0.5%, respectively).

CONCLUSION

High serum eosinophil and basophil values should be further investigated because they could pinpoint patients at higher risk of eosinophilic-type CRSwNP recurrence. These preliminary results support the increasing interest in the role of basophils in CRSwNP.

Evidence and evidence gaps in therapies of nasal obstruction and rhinosinusitis

Therapeutic decisions in otorhinolaryngology are based on clinical experience, surgical skills, and scientific evidence. Recently, evidence-based therapies have gained increased attention and importance due to their potential to improve the individual patient's treatment and their potential at the same time to reduce treatment costs. In clinical practice, it is almost impossible to stay ahead of the increasing mass of literature and on the other hand critically assess the presented data. A solid scientific and statistical knowledge as well as a significant amount of spare time are required to detect systematic bias and other errors in study designs, also with respect to assessing whether or not a study should be part of an individual therapeutic decision. Meta-analyses, reviews, and clinical guidelines are, therefore, of increasing importance for evidence-based therapy in clinical practice. This review is an update of the availability of external evidence for the treatment of nasal obstruction and rhinosinusitis. It becomes evident that both groups of diseases differ significantly in the availability of external evidence. Furthermore, it becomes obvious that surgical treatment options are normally based on evidence of significantly lower quality than medical treatment options.

Formulation, functional evaluation and ex vivo performance of thermoresponsive soluble gels - A platform for therapeutic delivery to mucosal sinus tissue

Mucoadhesive in situ gelling systems (soluble gels) have received considerable attention recently as effective stimuli-transforming vectors for a range of drug delivery applications. Considering this fact, the present work involves systematic formulation development, optimization, functional evaluation and ex vivo performance of thermosensitive soluble gels containing dexamethasone 21-phosphate disodium salt (DXN) as the model therapeutic. A series of in situ gel-forming systems comprising the thermoreversible polymer poloxamer-407 (P407), along with hydroxypropyl methyl cellulose (HPMC) and chitosan were first formulated. The optimized soluble gels were evaluated for their potential to promote greater retention at the mucosal surface, for improved therapeutic efficacy, compared to existing solution/suspension-based steroid formulations used clinically. Optimized soluble gels demonstrated a desirable gelation temperature with Newtonian fluid behaviour observed under storage conditions (4-8°C), and pseudoplastic fluid behaviour recorded at nasal cavity/sinus temperature (≈34°C). The in vitro characterization of formulations including rheological evaluation, textural analysis and mucoadhesion studies of the gel form were investigated. Considerable improvement in mechanical properties and mucoadhesion was observed with incorporation of HPMC and chitosan into the gelling systems. The lead poloxamer-based soluble gels, PGHC4 and PGHC7, which were carried through to ex vivo permeation studies displayed extended drug release profiles in conditions mimicking the human nasal cavity, which indicates their suitability for treating a range of conditions affecting the nasal cavity/sinuses.

Validation of virtual-reality-based simulations for endoscopic sinus surgery

BACKGROUND

Virtual reality (VR) simulators provide an alternative to real patients for practicing surgical skills but require validation to ensure accuracy. Here, we validate the use of a virtual reality sinus surgery simulator with haptic feedback for training in Otorhinolaryngology - Head & Neck Surgery (OHNS).

METHODS

Participants were recruited from final-year medical students, interns, resident medical officers (RMOs), OHNS registrars and consultants. All participants completed an online questionnaire after performing four separate simulation tasks. These were then used to assess face, content and construct validity. anova with post hoc correlation was used for statistical analysis.

RESULTS

The following groups were compared: (i) medical students/interns, (ii) RMOs, (iii) registrars and (iv) consultants. Face validity results had a statistically significant (P < 0.05) difference between the consultant group and others, while there was no significant difference between medical student/intern and RMOs. Variability within groups was not significant. Content validity results based on consultant scoring and comments indicated that the simulations need further development in several areas to be effective for registrar-level teaching. However, students, interns and RMOs indicated that the simulations provide a useful tool for learning OHNS-related anatomy and as an introduction to ENT-specific procedures.

CONCLUSIONS

The VR simulations have been validated for teaching sinus anatomy and nasendoscopy to medical students, interns and RMOs. However, they require further development before they can be regarded as a valid tool for more advanced surgical training.

Deliberate hypotension with propofol under anaesthesia for functional endoscopic sinus surgery (FESS)

BACKGROUND

Functional endoscopic sinus surgery (FESS) is a minimally invasive technique that is used to treat chronic sinusitis. Small bleeding areas can reduce operative visibility and result in destruction of surrounding structures. Deliberate hypotension (lowering the mean arterial blood pressure to between 50 and 65 mm Hg in normotensive patients) using a range of pharmacological agents during general anaesthesia reduces blood loss in many operations. This review was originally published in 2013 and updated in February 2016.

OBJECTIVES

We aimed to compare the use of propofol versus other techniques for achieving deliberate intraoperative hypotension during FESS procedures with regard to blood loss and operative conditions.

SEARCH METHODS

We searched the following databases in the updated review: the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 2), MEDLINE (1950 to February 2016), Embase (1980 to February 2016), LILACS (1982 to February 2016), and ISI Web of Science (1946 to February 2016). We also searched the reference lists of relevant articles and conference proceedings and contacted the authors of included trials.

SELECTION CRITERIA

We sought all randomized controlled trials comparing propofol with other techniques for deliberate hypotension during FESS with regard to blood loss and operative conditions in both adults and children. Our primary outcome was total blood loss (TBL). Other outcomes included surgical field quality, operation time, mortality within 24 hours, complications, and failure to reach target blood pressure.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Two review authors independently extracted details of trial methodology and outcome data from the reports of all trials considered eligible for inclusion. We made all analyses on an intention-to-treat basis where possible. When I2 was less than 40% and the P value from the Chi2 test was higher than 0.10, we pooled data using the fixed-effect model. Otherwise, we pooled data using the random-effects model.

MAIN RESULTS

We found no new studies. This updated review therefore includes four studies with 278 participants. Most analyses were based on data from few participants and low-quality evidence, so our results should be interpreted with caution. Deliberate hypotension with propofol did not decrease TBL (millilitres) when compared with inhalation anaesthetics in either children (1 study; 70 participants; very low-quality evidence), or adults (1 study; 88 participants; moderate-quality evidence). Propofol improved the quality of the surgical field by less than one category on a scale from 0 (no bleeding) to 5 (severe bleeding) (mean difference -0.64, 95% CI -0.91 to -0.37; 4 studies; 277 participants; low-quality evidence), but no difference in operation time was reported (3 studies; 214 participants; low-quality evidence). Failure to lower blood pressure to target was less common in the propofol group (risk ratio of failure with propofol 0.24, 95% CI 0.09 to 0.66; 1 study; 88 participants; moderate-quality evidence).

AUTHORS' CONCLUSIONS

Using propofol to achieve deliberate hypotension probably improves the surgical field, but the effect is small. Deliberate hypotension with propofol did not decrease TBL and the operation time. However, due to the very low quality of the evidence, this conclusion is not definitive. Randomized controlled trials with good-quality methodology and large sample size are required to investigate the effectiveness of deliberate hypotension with propofol for FESS.

Chronic rhinosinusitis: the rationale for current treatments

INTRODUCTION

Chronic rhinosinusitis (CRS) is a broad clinical syndrome linked by mucosal inflammation. Primary treatment modalities are corticosteroids and antibiotics with surgery an option for failures, but the level of supporting evidence is generally low. The primary reason is that CRS is a symptom complex and not a specific disease. Areas covered: The primary treatment modalities for CRS are corticosteroids, antibiotics and surgery. Corticosteroids, which have very broad anti-inflammatory properties, also have the strongest evidence for efficacy. Antibiotics are likely effective in a subpopulation of patients but the various phenotypes and endotypes that make up CRS have thus far been poorly defined. Early surgery as well as biologics may also be more efficacious and cost effective in some phenotypes as well. Expert commentary: A better understanding of the inflammatory pathways that drive CRS will permit investigators to separate patient groups. This will allow for clinical trials that target specific subpopulations and more personalized therapy for CRS patients in the future.

Cost utility analysis of endoscopic sinus surgery for chronic rhinosinusitis with and without nasal polyposis

OBJECTIVE

To evaluate the cost-effectiveness of endoscopic sinus surgery (ESS) compared to medical therapy for patients with chronic rhinosinusitis (CRS) with and without nasal polyposis (NP).

STUDY DESIGN

Cohort-style Markov decision-tree economic model with a 36-year time horizon.

METHODS

Two cohorts of 229 CRS patients with and without NP who underwent ESS were compared with a matched cohort of 229 CRS patients from the Medical Expenditures Survey Panel database (Agency for Healthcare Research and Quality, Rockville, MD) who underwent medical management. Utility scores were calculated from sequential patient responses to the EuroQol five-dimensions questionnaire. Decision-tree analysis and a 10-state Markov model utilized published event probabilities and primary data to calculate long-term costs and utility. The primary outcome was the incremental cost per quality-adjusted life year (QALY). Thorough sensitivity analyses were performed.

RESULTS

The reference case for CRS with NP yielded an incremental cost-effectiveness ratio (ICER) for ESS versus medical therapy of $5,687.41/QALY. The reference case for CRS without NP yielded an ICER of $5,405.44/QALY. The cost-effectiveness acceptability curve in both cases demonstrated 95% certainty that the ESS strategy was the most cost-effective option at a willingness-to-pay threshold of $20,000/QALY or higher. These results were robust to one-way and probabilistic sensitivity analysis.

CONCLUSION

This study demonstrates the cost-effectiveness of ESS compared to medical therapy alone for the management of CRS patients both with and without NP. The presence of nasal polyps was not found to affect the overall cost-effectiveness of ESS.

LEVEL OF EVIDENCE

2C. Laryngoscope, 127:29-37, 2017.

Defining appropriateness criteria for endoscopic sinus surgery during management of uncomplicated adult chronic rhinosinusitis: a RAND/UCLA appropriateness study

BACKGROUND

Appropriate indications for endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) are currently poorly defined. The lack of clear surgical indications for ESS likely contributes to the large geographic variation in surgical rates and contributes to reduced quality of care. The objective of this study was to define appropriateness criteria for ESS during management of adult patients with uncomplicated CRS.

METHODS

The RAND/UCLA appropriateness methodology was performed. An international, multidisciplinary panel of 10 experts in CRS was formed and completed 2 rounds of a modified Delphi ranking process along with a face-to-face meeting.

RESULTS

A total of 624 clinical scenarios were ranked, 312 scenarios each for CRS with and CRS without nasal polyps. For adult patients with uncomplicated CRS with nasal polyps, ESS can be appropriately offered when the CT Lund-Mackay score is ≥ 1 and there has been a minimum trial of a topical intranasal corticosteroid plus a short-course of systemic corticosteroid with a post-treatment total SNOT-22 score ≥ 20. For adult patients with uncomplicated CRS without nasal polyps, ESS can be appropriately offered when the CT Lund-Mackay score is ≥ 1 and there has been a minimum trial of a topical intranasal corticosteroid plus either a short-course of a broad spectrum/culture-directed systemic antibiotic or the use of a prolonged course of systemic low-dose anti-inflammatory antibiotic with a post-treatment total SNOT-22 score ≥ 20.

CONCLUSION

This study has developed and reported of list of appropriateness criteria to offer ESS as a treatment "option" during management of uncomplicated adult CRS. The extent or technique of ESS was not addressed in this study and will depend on surgeon and patient factors. Furthermore, these criteria are the minimal threshold to make ESS a treatment "option" and do not imply that all patients meeting these criteria require surgery. The decision to perform ESS should be made after an informed patient makes a preference-sensitive decision to proceed with surgery. Applying these appropriateness criteria for ESS may optimize patient selection, reduce the incidence of unwarranted surgery, and assist clinicians in providing high-quality, patient-centered care to patients with CRS.

Pediatric Severe Chronic Upper Airway Disease (P-SCUAD)

The term SCUAD (severe chronic upper airway disease) has been previously introduced to describe cases with upper airway disorders and symptoms not adequately controlled despite correct diagnosis and management. It has been so far applied mainly in adults and no specific focus has been given on the pediatric population. When the term SCUAD is considered for children specifically, a series of issues may arise. These issues involve accurate definition, epidemiology, clinical characteristics, pathophysiology, and socioeconomic implications. These issues seem to clearly differentiate adult from pediatric SCUAD. We attempt to shed light on these issues in an effort to provide directions for future guideline development and research. In this context, P-SCUAD (pediatric severe chronic upper airway disease) is hereby introduced.

Orphan diseases of the nose and paranasal sinuses: Pathogenesis - clinic - therapy

Rare rhinological diseases are a diagnostic challenge. Sometimes it takes months or even years from the primary manifestation of the disease until the definitive diagnosis is establibshed. During these times the disease proceeds in an uncontrolled or insufficiently treated way. (Irreversible) damage results and sometimes life-threatening situations occur. The unexpected course of a (misdiagnosed) disease should lead to further diagnostic reflections and steps in order to detect also rare diseases as early as possible. The present paper discusses granulomatous diseases of the nose and paranasal sinuses caused by mycobacteria, treponema, Klebsiella, fungi, and protozoa as well as vasculitis, sarcoidosis, rosacea, cocaine-induced midline destruction, nasal extranodal NK/T cell lymphoma, and cholesterol granuloma. Furthermore, diseases with disorders of the mucociliary clearance such as primary ciliary dyskinesia and cystic fibrosis are presented, taking into consideration the current literature.

Comprehensive review on endonasal endoscopic sinus surgery

Endonasal endoscopic sinus surgery is the standard procedure for surgery of most paranasal sinus diseases. Appropriate frame conditions provided, the respective procedures are safe and successful. These prerequisites encompass appropriate technical equipment, anatomical oriented surgical technique, proper patient selection, and individually adapted extent of surgery. The range of endonasal sinus operations has dramatically increased during the last 20 years and reaches from partial uncinectomy to pansinus surgery with extended surgery of the frontal (Draf type III), maxillary (grade 3-4, medial maxillectomy, prelacrimal approach) and sphenoid sinus. In addition there are operations outside and beyond the paranasal sinuses. The development of surgical technique is still constantly evolving. This article gives a comprehensive review on the most recent state of the art in endoscopic sinus surgery according to the literature with the following aspects: principles and fundamentals, surgical techniques, indications, outcome, postoperative care, nasal packing and stents, technical equipment.

Absorbable Steroid-Impregnated Spacer After Endoscopic Sinus Surgery to Reduce Synechiae Formation

OBJECTIVE

Middle meatal synechiae formation after endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) leads to higher rates of revision surgery. We aimed to determine if there are different rates of postoperative synechiae following ESS for CRS between patients who received a nonabsorbable spacer (NAS) placed in the ethmoid cavity versus patients who had a steroid-impregnated absorbable spacer (AS) placed at the middle meatal entry.

METHODS

We conducted a retrospective cohort study of patients who underwent ESS for CRS at a single tertiary referral center from October 2009 to October 2013. We collected data on synechiae formation between the middle turbinate and lateral nasal wall within 1 month of surgery and postoperative epistaxis.

RESULTS

One hundred forty-six patients with 252 nasal cavities (52.0%) received steroid-impregnated AS, and 128 patients with 233 nasal cavities (48.0%) received NAS. Synechiae formation occurred in 2.0% of cavities with AS and 5.6% of cavities with NAS, but this difference was not statistically significant (OR = 0.34, P = .052). One patient in each cohort had significant postoperative epistaxis requiring additional nasal packing (P > .99).

CONCLUSION

Steroid-impregnated absorbable spacers had statistically insignificant reduction in postoperative synechiae formation when compared to nonabsorbable spacers. Low rates of postoperative epistaxis were observed regardless of the type of spacer used.

Topical therapy with high-volume budesonide nasal irrigations in difficult-to-treat chronic rhinosinusitis

INTRODUCTION

Chronic rhinosinusitis (CRS) is termed difficult-to-treat when patients do not reach acceptable level of control despite adequate surgery, intranasal corticosteroid treatment and up to 2 short courses of systemic antibiotics or corticosteroids in the preceding year. Recently, high-volume corticosteroid nasal irrigations have been recommended for CRS treatment.

OBJECTIVE

To assess high-volume budesonide nasal irrigations for difficult-to-treat CRS.

METHODS

Prospective uncontrolled intervention trial. Participants were assessed before- and 3 months after nasal irrigation with 1mg of budesonide in 500 mL of saline solution daily for 2 days. Subjective (satisfactory clinical improvement) and objective (SNOT-22 questionnaire and Lund-Kennedy endoscopic scores) assessments were performed.

RESULTS

Sixteen patients were included, and 13 (81.3%) described satisfactory clinical improvement. SNOT-22 mean scores (50.2-29.6; p=0.006) and Lund-Kennedy mean scores (8.8-5.1; p=0.01) improved significantly. Individually, 75% of patients improved SNOT-22 scores, and 75% improved Lund-Kennedy scores after high volume budesonide nasal irrigations.

CONCLUSION

High-volume corticosteroid nasal irrigations are a good option in difficult-to-treat CRS control of disease, reaching 81.3% success control and significant improvement of SNOT-22 and Lund-Kennedy scores.

Post-operative steroid treatment for eosinophilic-type sinonasal polyposis

CONCLUSIONS

The preliminary finding of significantly lower eosinophilic-type CRSwNP recurrence rates in patients with associated asthma or ASA intolerance treated post-operatively with local nasal and oral steroids warrants further investigation in larger, prospective series.

OBJECTIVE

A high recurrence rate after functional endoscopic sinus surgery (FESS) has been widely reported in patients with eosinophilic-type chronic rhinosinusitis with nasal polyps (CRSwNP). This study compared the influence of two post-operative medical treatments - local nasal steroids alone vs local nasal and oral steroids - on the recurrence of eosinophilic-type CRSwNP.

METHOD

Between January 2009-December 2010, 32 patients with eosinophilic-type CRSwNP received local steroid nasal therapy after FESS (Group A); from January 2011 onwards, another 28 patients were treated post-operatively with the same nasal treatment plus two cycles a year of oral steroids (Group B). All patients in both groups had a follow-up of at least 36 months.

RESULTS

Groups A and B did not differ significantly in recurrence rate (31.25% vs 32.14%, p = 1) or disease-free interval (p = 0.91), but Group B patients who were asthmatic or ASA-intolerant had a significantly lower recurrence rate than Group A patients with asthma or ASA intolerance (p = 0.04 and p = 0.004, respectively).

Severe Chronic Upper Airway Disease (SCUAD) in children. Definition issues and requirements

OBJECTIVES

Upper airway diseases are extremely common, and a significant proportion of patients are not adequately controlled by contemporary treatment algorithms. The term SCUAD (Severe Chronic Upper Airway Disease) has been previously introduced to describe such cases. However, this term has not been adequately focused on children.

METHODS

This study aims to address the necessity of the term, as well as further details specifically for children. For this purpose, a review was performed of the current literature, with specific focus on issues regarding SCUAD in children.

RESULTS

Paediatric SCUAD represents a heterogeneous group of patients and has significant clinical and socioeconomic implications. Relevant literature is generally lacking and questions regarding definition and pathogenesis remain unanswered.

CONCLUSIONS

Accurate definition and acknowledgement of paediatric SCUAD cases may lead to better design of future clinical and molecular research protocols. This may provide improved understanding of the underlying disease processes, more accurate data regarding socioeconomic burden, and, above all, more successful treatment and prevention strategies.

Can a panel of clinical, laboratory, and pathological variables pinpoint patients with sinonasal polyposis at higher risk of recurrence after surgery?

PURPOSE

Despite improved surgical and medical therapies, recurrence remains a significant problem in chronic rhinosinusitis with nasal polyps (CRSwNP), given a recently-reported long-term revision rate of 15%-20%. In this prospective study uni- and multivariate statistical analyses were used to identify clinical, laboratory and conventional pathological parameters for pinpointing CRSwNP patients at higher risk of recurrence after functional endoscopic sinus surgery (FESS).

MATERIALS AND METHODS

The investigation concerned 179 consecutive patients undergoing FESS for CRSwNP, and 24 of them developed recurrent CRSwNP after FESS.

RESULTS

A univariate statistical model disclosed significant associations between recurrent CRSwNP and serum basophil counts (p=0.03) and percentages (p=0.02). The recurrence rate was higher for patients with eosinophilic-type CRSwNP (p=0.01). In a multivariate logistic model, eosinophilic-type CRSwNP (p=0.025) and serum basophil percentage (statistical trend, p=0.079) retained their independent prognostic significance in relation to CRSwNP recurrence. The discriminatory power of a three-variable panel (age <65 years, serum basophil percentage and eosinophilic type) featured an AUC (ROC) of 0.7028 (an acceptable discriminatory power according to the Hosmer-Lemeshow scale).

CONCLUSIONS

Although our panel achieved an acceptable discriminatory power for CRSwNP recurrence, other parameters (including biomarkers) capable of predicting outcome and orienting postoperative treatment decisions need to be investigated in CRSwNP.

Management of the upper airway in cystic fibrosis

PURPOSE OF REVIEW

Upper airway disease engenders significant morbidity for patients with cystic fibrosis and is increasingly recognized as having a much greater role in pulmonary outcomes and quality of life than originally believed. Widespread disparate therapeutic strategies for cystic fibrosis chronic rhinosinusitis underscore the absence of a standardized treatment paradigm. This review outlines the most recent evidence-based trends in the management of upper airway disease in cystic fibrosis.

RECENT FINDINGS

The unified airway theory proposes that the sinuses are a focus of initial bacterial colonization which seeds the lower airway and may play a large role in maintaining lung infections. Mounting evidence suggests more aggressive treatment of the sinuses may confer significant improvement in pulmonary disease and quality of life outcomes in cystic fibrosis patients. However, there is a lack of high-level evidence regarding medical and surgical management of cystic fibrosis chronic rhinosinusitis that makes generalizations difficult.

SUMMARY

Well designed clinical trials with long-term follow-up concerning medical and surgical interventions for cystic fibrosis sinus disease are required to establish standardized treatment protocols, but increased interest in the sinuses as a bacterial reservoir for pulmonary infections has generated considerable attention.