Subepithelial neutrophil infiltration as a predictor of the surgical outcome of chronic rhinosinusitis with nasal polyps

Correlation between inflammatory biomarkers and disease control in chronic rhinosinusitis with nasal polyps

BACKGROUND

Chronic rhinosinusitis with nasal polyps (CRSwNP) may have a heterogeneous response to medical/surgical treatments based on endotypes. Data correlating biomarkers and severity of the disease are lacking. We aimed to determine if IL-5 and calprotectin may be useful in defining severity of disease and identifying uncontrolled patients.

METHODS

This was a case-control study including 81 patients with diffuse CRSwNP who underwent at least one previous surgery and treated with intranasal steroids. We enrolled 39 uncontrolled patients (SNOT-22 ≥ 40 and two or more cycles of systemic corticosteroids in last year) (Group A) and 42 controlled one (SNOT-22 < 40 and less than two cycles of systemic corticosteroids in last year) (Group B). We analyzed IL-5 and calprotectin in both nasal secretions and nasal polyp tissue.

RESULTS

Calprotectin and IL-5 were significantly higher in Group A in both secretions and tissue, and the higher the number of previous surgeries, the higher the levels detected in nasal secretions. At univariate analyses, smoking, asthma, non-steroidal anti-inflammatory drugs-exacerbated respiratory disease (NSAID-ERD), blood eosinophilia, neutrophils, and eosinophils at nasal cytology were significantly associated with uncontrolled disease. Multivariate analyses showed that asthma, NSAID-ERD, and IL-5 in nasal secretion/polyp tissue were significantly related to the risk of uncontrolled disease.

CONCLUSIONS

Our data suggest that asthma, NSAID-ERD, and IL-5 in nasal secretions/tissue may be helpful to identify more severe patients, as they are related to the risk of uncontrolled disease. Nonetheless, high levels of calprotectin and neutrophilia were also observed in uncontrolled patients, especially after multiple surgeries.

Are artificial intelligence large language models a reliable tool for difficult differential diagnosis? An a posteriori analysis of a peculiar case of necrotizing otitis externa

Key Clinical Message

Large language models have made artificial intelligence readily available to the general public and potentially have a role in healthcare; however, their use in difficult differential diagnosis is still limited, as demonstrated by a case of necrotizing otitis externa.

Abstract

This case report presents a peculiar case of necrotizing otitis externa (NOE) with skull base involvement which proved diagnostically challenging. The initial patient presentation and the imaging performed on the 78-year-old patient suggested a neoplastic rhinopharyngeal lesion and only after several unsuccessful biopsies the patient was transferred to our unit. Upon re-evaluation of the clinical picture, a clinical hypothesis of NOE with skull base erosion was made and confirmed by identifying Pseudomonas aeruginosa in biopsy specimens of skull base bone and external auditory canal skin. Upon diagnosis confirmation, the patient was treated with culture-oriented long-term antibiotics with complete resolution of the disease. Given the complex clinical presentation, we chose to submit a posteriori this NOE case to two large language models (LLM) to test their ability to handle difficult differential diagnoses. LLMs are easily approachable artificial intelligence tools that enable human-like interaction with the user relying upon large information databases for analyzing queries. The LLMs of choice were ChatGPT-3 and ChatGPT-4 and they were requested to analyze the case being provided with only objective clinical and imaging data.

The Evolution and Application of Artificial Intelligence in Rhinology: A State of the Art Review

OBJECTIVE

To provide a comprehensive overview on the applications of artificial intelligence (AI) in rhinology, highlight its limitations, and propose strategies for its integration into surgical practice.

DATA SOURCES

Medline, Embase, CENTRAL, Ei Compendex, IEEE, and Web of Science.

REVIEW METHODS

English studies from inception until January 2022 and those focusing on any application of AI in rhinology were included. Study selection was independently performed by 2 authors; discrepancies were resolved by the senior author. Studies were categorized by rhinology theme, and data collection comprised type of AI utilized, sample size, and outcomes, including accuracy and precision among others.

CONCLUSIONS

An overall 5435 articles were identified. Following abstract and title screening, 130 articles underwent full-text review, and 59 articles were selected for analysis. Eleven studies were from the gray literature. Articles were stratified into image processing, segmentation, and diagnostics (n = 27); rhinosinusitis classification (n = 14); treatment and disease outcome prediction (n = 8); optimizing surgical navigation and phase assessment (n = 3); robotic surgery (n = 2); olfactory dysfunction (n = 2); and diagnosis of allergic rhinitis (n = 3). Most AI studies were published from 2016 onward (n = 45).

IMPLICATIONS FOR PRACTICE

This state of the art review aimed to highlight the increasing applications of AI in rhinology. Next steps will entail multidisciplinary collaboration to ensure data integrity, ongoing validation of AI algorithms, and integration into clinical practice. Future research should be tailored at the interplay of AI with robotics and surgical education.

Artificial intelligence, machine learning, and deep learning in rhinology: a systematic review

PURPOSE

This PRISMA-compliant systematic review aims to analyze the existing applications of artificial intelligence (AI), machine learning, and deep learning for rhinological purposes and compare works in terms of data pool size, AI systems, input and outputs, and model reliability.

METHODS

MEDLINE, Embase, Web of Science, Cochrane Library, and ClinicalTrials.gov databases. Search criteria were designed to include all studies published until December 2021 presenting or employing AI for rhinological applications. We selected all original studies specifying AI models reliability. After duplicate removal, abstract and full-text selection, and quality assessment, we reviewed eligible articles for data pool size, AI tools used, input and outputs, and model reliability.

RESULTS

Among 1378 unique citations, 39 studies were deemed eligible. Most studies (n = 29) were technical papers. Input included compiled data, verbal data, and 2D images, while outputs were in most cases dichotomous or selected among nominal classes. The most frequently employed AI tools were support vector machine for compiled data and convolutional neural network for 2D images. Model reliability was variable, but in most cases was reported to be between 80% and 100%.

CONCLUSIONS

AI has vast potential in rhinology, but an inherent lack of accessible code sources does not allow for sharing results and advancing research without reconstructing models from scratch. While data pools do not necessarily represent a problem for model construction, presently available tools appear limited in allowing employment of raw clinical data, thus demanding immense interpretive work prior to the analytic process.

Neutrophilic inflammation in chronic rhinosinusitis

PURPOSE OF REVIEW

Over the last years, extensive research has been done on neutrophils and their contribution in chronic rhinosinusitis (CRS), and made it clear that they are more than just a bystander in this disease. In this article, we will review all recent publications on this topic and look to what the future hold regarding therapeutics targeting the neutrophilic inflammation in CRS.

RECENT FINDINGS

Evidence is growing that the presence of neutrophils are associated with a worse disease outcome in certain CRS patient groups. They are highly activated in type 2 inflammations and exhibit damaging properties through their proteases, contributing to the chronicity of the disease. Several recent studies identified useful biomarkers and targets for future therapeutics.

SUMMARY

The findings we review in this manuscript are of utmost importance in unraveling the complexity of CRS and provide us with the necessary knowledge for future clinical practices.

Increased IL-1α expression in chronic rhinosinusitis with nasal polyps

PURPOSE

To examine whether and how interleukin (IL)-1α is involved in chronic rhinosinusitis with nasal polyps (CRSwNP).

METHODS

Nasal polyp (NP) and control tissues were collected from CRSwNP patients and control subjects. The expression of IL-1α and other proinflammatory cytokines (IL-1β, IL-8 and IL-13, etc.), as well as neutrophil and eosinophil accumulation, were examined in sinonasal tissues using immunohistochemical (IHC), immunofluorescent (IF) staining, qPCR, and Luminex, respectively. Moreover, the regulation of IL-1α expression and its effects on other proinflammatory cytokines were evaluated in cultured nasal epithelial cells (NECs).

RESULTS

The mRNA and protein levels of IL-1α were significantly higher in NP tissues compared to that in control tissues. IL-1α in polyp tissues was mainly located in epithelial cells and neutrophils. Polyps IL-1α level was significantly associated with IL-8, IL-1β, IL-6, IL-4 and IL-13 production, as well as tissue neutrophil infiltration. Moreover, poly (I:C), lipopolysaccharides, Flagellin, R848 and cytokines (IL-4, IL-5, and IL-13) significantly increased the expression of IL-1α in cultured NECs in vitro, and recombinant IL-1α significantly promoted production of IL-8 and CXCL1 in cultured NECs.

CONCLUSIONS

These findings provided the evidence that IL-1α were significantly increased in NP tissues, which may contribute to tissue neutrophilia in CRSwNP patients in China.

Neutrophils Play an Important Role in the Recurrence of Chronic Rhinosinusitis with Nasal Polyps

Despite the heterogeneity of chronic rhinosinusitis (CRS), a clear link exists between type 2 immunity and the severity of CRS with nasal polyps (CRSwNP). However, recent studies have demonstrated that patients with severe type 2 CRSwNP also display abundant neutrophilic inflammation. Therefore, we investigated the factors associated with the recurrence of CRSwNP following sinus surgery using a machine-learning algorithm. We collected the demographics, clinical variables, and inflammatory profiles of 210 patients with CRSwNP who underwent sinus surgery. After one year, we evaluated whether each patient showed recurrence. Machine-learning methods, such as decision trees, random forests, and support vector machine models, have been used to predict the recurrence of CRSwNP. The results indicated that neutrophil inflammation, such as tissue and serum neutrophils, is an important factor affecting the recurrence of surgical CRSwNP. Specifically, the random forest model showed the highest accuracy in detecting recurrence among the three machine-learning methods, which revealed tissue neutrophilia to be the most important variable in determining surgical outcomes. Therefore, our machine-learning approach suggests that neutrophilic inflammation is increased in patients with difficult-to-treat CRSwNP, and the increased presence of neutrophils in subepithelial regions is closely related to poor surgical outcomes in patients with CRSwNP.

Increased Expression of SERPINB10 Associated with Postoperative Recurrence in Chronic Rhinosinusitis with Nasal Polyps

Background

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a common upper airway inflammatory disorder with a high rate of postoperative recurrence. SERPINB10 is a proinflammatory cytokine expressed on epithelial cells, but its role in CRSwNP has not been described. This study is aimed at exploring the SERPINB10 expression in CRSwNP and its relationship with postoperative recidivation.

Methods

We recruited 140 individuals, consisting of 60 patients with CRSwNP, 40 patients with chronic rhinosinusitis without nasal polyps (CRSsNP), and 40 healthy controls (HCs). Tissue specimens were collected during the surgery, and SERPINB10 expression was determined by reverse transcription-polymerase chain reaction, western blotting, and immunofluorescence. We determined the tissue SERPINB10 expression levels in CRSwNP and examined its clinical value in predicting postoperative recurrence.

Results

We determined that tissue SERPINB10 mRNA and protein levels were increased in the CRSwNP group, especially in the recurrent CRSwNP group, compared with the CRSsNP and HC groups (p < 0.05), and SERPINB10 mRNA levels were correlated with peripheral and tissue eosinophil counts and percentages (p < 0.05). Binary logistic regression analysis and receiver operating characteristic (ROC) curves suggested that the expressions of tissue SERPINB10 mRNA were significantly linked to postoperative recurrence in CRSwNP patients (AUC = 0.741, p < 0.001).

Conclusion

Elevated local SERPINB10 levels in patients with CRSwNP were related to tissue eosinophilic inflammation and disease recurrence. These data suggested that SERPINB10 might contribute to the eosinophilic inflammation in CRSwNP and appeared to be a potential biomarker for the prediction of relapse after surgery.

Effectiveness of Dupilumab in the Treatment of Patients with Uncontrolled Severe CRSwNP: A "Real-Life" Observational Study in Naïve and Post-Surgical Patients

Background: Chronic rhinosinusitis with nasal polyps (CRSwNP) represents 25−30% of all CRS cases, and in the most severe forms it is associated with a poor quality of life and a high rate of nasal polyps’ recurrence after surgery. Dupilumab has been suggested as a treatment option for severe CRSwNP. Methods: Patients with severe CRSwNP receiving dupilumab from January 2021 were followed up at 1, 3, 6, 9 and 12 months from the first administration and were considered for this study. At baseline and at each follow-up, patients underwent nasal endoscopy and completed the Sinonasal Outcome Test (SNOT)-22, a Visual Analogue Scale (VAS) for smell/nasal obstruction, the Nasal Congestion Score and the Asthma Control Test. Peak nasal inspiratory flow (PNIF), a smell test, nasal cytology and blood eosinophilia were also evaluated. Results: Forty-seven patients were included in the study. Of these, 33 patients had a history of previous surgery (ESS) and had recurrent nasal polyps, while 14 patients were naïve to nasal surgery. Both subjective and objective parameters improved after biological treatment and were correlated with each other (p < 0.05), except for the SNOT-22 and the nasal polyp’s score. No correlations were found between nasal and blood eosinophilia. No differences were observed when comparing the post-surgical and the naïve groups. Conclusions: Dupilumab improves nasal obstruction and the sense of smell and reduces the level of local inflammation in severe CRSwNP patients in a similar way in both naïve and post-surgical patients.

Chinese Central Compartment Atopic Disease: The Clinical Characteristics and Cellular Endotypes Based on Whole-Slide Imaging

Purpose

Histopathologic characterizations of central compartment atopic disease (CCAD) by whole-slide imaging remains lacking. We aim to study clinical presentations and cellular endotyping diagnosis of Chinese CCAD using artificial intelligence (AI).

Methods

A total of 72 patients diagnosed with chronic rhinosinusitis with nasal polyps (CRSwNP) were enrolled. CCAD was defined by positive result of serology specific IgE, endoscopic and radiological findings. The aeroallergen sensitization status, endoscopic results, radiological findings, and symptoms were evaluated and compared between patients with CCAD (n=14), eosinophilic CRSwNP (ENP, n=32) and non-eosinophilic CRSwNP (NENP, n=26). The cellular endotypes including eosinophils, neutrophils, lymphocytes, and plasma cells were analyzed by the AI chronic rhinosinusitis evaluation platform 2.0.

Results

CCAD was most common in male (71.43%). The positive rate of aeroallergen in patients with CCAD is 100%, which is much higher than those in patients with ENP (40.63%) and NENP (23.08%). Allergic rhinitis incidence was found to be 57.14% in Chinese CCAD subjects, which is obviously higher when compared with those in patients with ENP (21.88%) or NENP (0.00%). The presence of asthma was not significantly different between groups. Chinese CCAD population demonstrated mild symptoms and lower endoscopic and radiological scores than those in patients with ENP and NENP. For cellular endotypes in CCAD subjects, the median of eosinophils, neutrophils, lymphocytes, and plasma cells was 26.55%, 0.49%, 60.85%, and 7.33%, respectively. The proportion of eosinophils in nasal tissue and peripheral blood mononuclear cells from the CCAD group is between the proportions in those patients with ENP and NENP.

Conclusion

Chinese CCAD was associated with aeroallergen sensitivity, and displayed an eosinophil-dominant inflammatory pattern. Thus, proper management with allergy control and topical steroids could be recommended for CCAD treatment.

Rethinking neutrophils and eosinophils in chronic rhinosinusitis

Chronic rhinosinusitis (CRS) often is characterized by an eosinophilic inflammatory pattern, nowadays referred to as type 2 inflammation, although the mucosal inflammation is dominated by neutrophils in about a third of the patients. Neutrophils are typically predominant in 50% of patients with CRS without nasal polyps, but also are found to play a role in patients with severe type 2 CRS with nasal polyp disease. This review aims at summarizing the current understanding of the eosinophilic and neutrophilic inflammation in CRS pathophysiology, and provides a discussion of their reciprocal interactions and the clinical impact of the mixed presentation in patients with severe type 2 CRS with nasal polyps. A solid understanding of these interactions is of utmost importance when treating uncontrolled severe CRS with nasal polyps with biologicals that are preferentially directed toward type 2 inflammation. We here focus on recent findings on both eosinophilic and neutrophilic granulocytes, their subgroups and the activation status, and their interactions in CRS.

Characterization of Cytokines and Proliferation Marker Ki67 in Chronic Rhinosinusitis with Nasal Polyps: A Pilot Study

Background and Objectives: Chronic rhinosinusitis (CRS) is a condition that affects as much as 10.9% of the population and, along with presence of nasal polyps, is associated with significant morbidity and decreased quality of life. Studies on molecular pathways that have been activated in nasal polyp tissue are mainly based on cytokine concentration detection. Therefore, our aim is to investigate the complex appearance, relative distribution and interlinks of IL-1, IL-4, IL-6, IL-7, IL-8, IL-10, IL-12 and Ki 67 in chronic rhinosinusitis with nasal polyps (CRSwNP) affected human nasal mucosa. Materials and Methods: Samples of nasal polyps were obtained from 12 patients with previously diagnosed CRSwNP and no prior surgery. Control group consisted of samples from 17 otherwise healthy individuals with isolated nasal septum deviation. Tissues were stained for IL-1, IL-4, IL-6, IL-7, IL-8, IL-10, IL-12 and Ki67 immunohistochemically. Non-parametric statistic, Mann–Whitney U test and Spearman’s rank correlation coefficient were used. Results: All factors, except connective tissue cytokine IL-10 and proliferation marker Ki-67, had increased presence in connective tissue and decreased presence in epithelium of nasal polyps when compared to controls. Very strong and strong positive correlations between factors were observed. Conclusions: Decreased appearance of IL-1α, IL-4, IL-6, IL-7, IL-8, IL-10, IL-12 positive structures in the nasal epithelium with selective increase of IL-1α and IL-12 in nasal subepithelial connective tissue characterize the cytokine endotype with dysfunctional epithelial barrier and local stimulation of immune response in the connective tissue in case of chronic rhinosinusitis with polyps. Decrease of IL-6 in both—epithelium and connective tissue with strong correlation between it and IL-7 and IL-10 in connective tissue suggests significant stimulation of this regulatory cytokine and, possibly, the important role in pathogenesis of the development in nasal polyps. Correlations between Ki67 and cytokines indicate possible involvement of IL-4, IL-7 and IL-12 in regulation of cellular proliferation.