Nasal obstruction and smell impairment in nasal polyp disease: correlation between objective and subjective parameters

Olfactory Loss in Rhinosinusitis: Mechanisms of Loss and Recovery

Chronic rhinosinusitis (CRS) is a highly prevalent disease and up to 83% of CRS patients suffer from olfactory dysfunction (OD). Because OD is specifically seen in those CRS patients that present with a type 2 eosinophilic inflammation, it is believed that type 2 inflammatory mediators at the level of the olfactory epithelium are involved in the development of this olfactory loss. However, due to the difficulties in obtaining tissue from the olfactory epithelium, little is known about the true mechanisms of inflammatory OD. Thanks to the COVID-19 pandemic, interest in olfaction has been growing rapidly and several studies have been focusing on disease mechanisms of OD in inflammatory conditions. In this paper, we summarize the most recent data exploring the pathophysiological mechanisms underlying OD in CRS. We also review what is known about the potential capacity of olfactory recovery of the currently available treatments in those patients.

The interleukin-4/interleukin-13 pathway in type 2 inflammation in chronic rhinosinusitis with nasal polyps

Chronic rhinosinusitis with nasal polyps (CRSwNP) is predominantly a type 2 inflammatory disease associated with type 2 (T2) cell responses and epithelial barrier, mucociliary, and olfactory dysfunction. The inflammatory cytokines interleukin (IL)-4, IL-13, and IL-5 are key mediators driving and perpetuating type 2 inflammation. The inflammatory responses driven by these cytokines include the recruitment and activation of eosinophils, basophils, mast cells, goblet cells, M2 macrophages, and B cells. The activation of these immune cells results in a range of pathologic effects including immunoglobulin E production, an increase in the number of smooth muscle cells within the nasal mucosa and a reduction in their contractility, increased deposition of fibrinogen, mucus hyperproduction, and local edema. The cytokine-driven structural changes include nasal polyp formation and nasal epithelial tissue remodeling, which perpetuate barrier dysfunction. Type 2 inflammation may also alter the availability or function of olfactory sensory neurons contributing to loss of sense of smell. Targeting these key cytokine pathways has emerged as an effective approach for the treatment of type 2 inflammatory airway diseases, and a number of biologic agents are now available or in development for CRSwNP. In this review, we provide an overview of the inflammatory pathways involved in CRSwNP and describe how targeting key drivers of type 2 inflammation is an effective therapeutic option for patients.

[Decision-making in the treatment of chronic rhinosinusitis with nasal polyps in the era of biologics]

Chronic rhinosinusitis is one of the most common chronic diseases in the population. Chronic rhinosinusitis with nasal polyps (CRSwNP) in adults is predominantly characterized by a type 2 inflammatory endotype. If sufficient control cannot be achieved through primary drug therapy, surgical intervention is usually recommended as the next stage of treatment. Nowadays, various biologics are available that have been or will be approved for use in these patients. This review summarizes the presentations from the 29th Congress of the European Rhinologic Society in Sofia 2023 and the latest findings on decision-making in the treatment of CRSwNP. Standard therapy with medication and sinus surgery fails in some patients with CRSwNP. Biologics that act on the type 2 inflammatory pathway led to a reduction in the nasal polyp score (NPS), an improvement in nasal obstruction, and an improvement in quality of life without significant side effects. Biomarkers such as total IgE, serum eosinophils, and Osteoprotegerin (OPG) can provide indications of the success of the treatment. In summary, it can be said that for many patients with recurrent CRSwNP, a combination of paranasal sinus surgery and treatment with a biologic that is precisely tailored to the patient's endotype is the best option. However, the question of which surgical approach and which biologic at which time and for which patient is still ongoing and requires further studies.

Assessing the effect of absorbable steroid sinus implant: a state-of-the-art systematic review

OBJECTIVES

Endoscopic sinus surgery is not a definitive treatment for chronic rhinosinusitis (CRS). The use of sinus stents after surgery to maintain sinus patency and deliver local steroids has gained popularity. The first steroid-eluting bioabsorbable implant (SEBI) approved for this indication, later Propel, was developed in 2011. This state-of-the-art review aims to summarize the available evidence, as well as to point out potential pitfalls and lack of specific analyses to guide future research on this new therapeutic option.

DATA SOURCES

Pubmed (Medline), the Cochrane Library, EMBASE, SciELO.

REVIEW METHODS

Nine research questions were defined: Are steroid-eluting Sinus implants useful for the control of CRS symptoms after surgery? Do they improve surgical field healing after CRS surgery? Do they decrease polyp regrowth after ESS? Do they decrease the need for ESS? Are they useful in symptom control as in-office procedure? Are they better than other steroid-impregnated resorbable materials? Do they have a positive impact on olfaction? Are they safe? Are they cost-effective? Retrieved articles were reviewed by two authors.

RESULTS

Twenty nine studies were included: 3 metanalysis, 1 systematic review, 10 randomized clinical trials, 4 quasi-experimental studies, 1 retrospective cohort study, 4 cost studies, 3 case series and 2 expert consensus. The review encompassed a population of 3,012 patients treated with SEBI and 2826 controls.

CONCLUSIONS

This is the first state-of-the-art review assessing steroid eluting bioabsorbable stent evidence. Despite the effort in recent years, still several questions remain unanswered. This review will hopefully guide future research efforts to better define the role of SEBI in the otolaryngology practice.

Impact of Nasal Cavity CT Opacification Upon Sinonasal Quality of Life

BACKGROUND

Current methods of quantifying inflammation in chronic rhinosinusitis (CRS) on computed tomography (CT) imaging focus on opacification of the paranasal sinuses and show limited correlation with patient-reported outcome measures.

OBJECTIVE

This study aimed to determine if quantifying CT opacification of the nasal cavity correlated with Sino-Nasal Outcomes Test scores (SNOT-22).

METHODS

Thirty patients with CRS were enrolled. Lund-Mackay and SNOT-22 scores were measured. Nasal cavity regions of interest (ROIs) were measured by 2 independent raters using ImageJ at 3 points on coronal CT scans: anteriorly at the lacrimal duct, at the approximate midpoint demarcated by the posterior aspect of the globe, and posteriorly at the transition from the hard to soft palate. Superior and inferior regions were defined based upon the root of the inferior turbinate. Percent opacification was calculated for each ROI. Analyses were conducted bilaterally and for the side with greater opacification (worse side).

RESULTS

Interrater reliability was strong for all ROIs. Lund-Mackay scores correlated with nasal blockage only (r = .495, P = .01) and did not correlate with nasal cavity ROI opacification. Inferior nasal cavity opacification for worse-sided anterior ROI and middle ROI correlated with SNOT-22 scores for nasal blockage (anterior r = .41, P = .03) (middle r = .42, P = .023) and runny nose (anterior r = .44, P = .02) (middle r = .38, P = .04). Posterior ROIs did not correlate with SNOT-22.

CONCLUSIONS

Traditional CT scoring of sinus opacification does not correlate well with nasal cavity opacification or SNOT-22. Inferior nasal cavity inflammation provides unique correlations with SNOT-22 nasal questions and may guide targeted interventions in these regions.

Psychometric Validation and Meaningful Change Thresholds of the New Nasal Polyposis Symptom Diary

OBJECTIVES

The Nasal Polyposis Symptom Diary (NPSD) is a novel and short patient-reported outcome (PRO) tool specifically developed to assess important and relevant symptoms reported by patients with chronic rhinosinusitis with nasal polyposis (CRSwNP). We evaluated the psychometric properties of 4 predefined NPSD-derived scores intended to support symptom-improvement assessments of investigational therapies for inclusion in product labeling.

METHODS

Five hundred eighteen patients with severe CRSwNP from a Phase III clinical trial (NCT03401229) completed the NPSD, comprising 11 items: 8 symptom-specific, 2 symptom-impact, and 1 optional medication-compliance. The psychometric characteristics of 3 single-item symptom scores (Nasal Blockage Score [NBS], Nasal Congestion Score [NCS], and Difficulty with Sense of Smell Score [DSS]) and a Total Symptom Score (TSS, summary of the 8 symptom-specific items) were evaluated for reliability, validity, and ability to detect change. Within-patient meaningful change thresholds (MCTs) were established using anchor- and distribution-based methods. Comparative PROs included the 22-item Sino-Nasal Outcome Test (SNOT-22) and Patient Global Impression of Severity (PGI-S).

RESULTS

The TSS exhibited strong internal consistency (Cronbach α = .88) and test-retest reliability (intraclass correlation coefficient >.80). Correlation between the TSS and SNOT-22 total score indicated good convergent validity (r = .70). All 4 NPSD scores demonstrated known-groups validity (significant differences among subgroups of patients with predetermined disease severity levels based on PGI-S categories) and were sensitive to detect change in patients' clinical status (significant differences among subgroups of patients with reported changes between 2 time-points in PGI-S and Patient Global Impression of Change scores). MCTs for improvement were established at 1.0 point for NBS, NCS, and DSS, and 4.0 points for TSS.

CONCLUSION

These findings support the reliability, validity, and suitability of the 4 NPSD-derived scores for evaluating treatment effect on CRSwNP symptoms and their use in clinical trials with predetermined MCTs for improvement.

Partial Reversal of Anosmia Following Platinum-Based Chemotherapy in a Patient With Colorectal Adenocarcinoma

Platinum-based chemotherapy is known to cause taste and smell changes (TSCs) via a host of mechanisms, including altered receptor activity, saliva/mucus production, and induction of receptor destruction via mitotic inhibition. In the literature to date, these changes have primarily resulted in worsening of taste and smell. In this case report, we document the first instance of an individual regaining their sense of olfactory detection following treatment with oxaliplatin for colorectal adenocarcinoma. We theorize that the improvement in his sense of smell may have resulted from oxaliplatin-induced destruction of his nasal polyps through the caspase-9/procaspase-9 apoptotic pathway, a pathway shared with other mechanisms of nasal polyp destruction. These findings were supported by nasal endoscopy and sphenoid sinusoscopy, which demonstrated no clinical persistence of nasal polyps, in contrast to nasal endoscopy prior to chemotherapy which demonstrated persistent nasal polyposis. Objective smell testing post-treatment revealed a diminished ability to discriminate odors. Chemotherapy-induced TSCs play a key role in poor weight gain, food aversion, emotional distress, and an overall decrease in quality of life, and patients should be informed of these potential consequences prior to starting treatment. However, in patients with anosmia secondary to nasal polyposis, treatment with platinum-based chemotherapy may provide an additional therapeutic benefit. Further studies may help elucidate the potential therapeutic benefits of these agents in managing steroid-resistant polyposis for patients suffering from olfactory dysfunction.

Influence of Age and Gender on Nasal Airway Patency as Measured by Active Anterior Rhinomanometry and Acoustic Rhinometry

In this study, we aimed to investigate the influences of age and gender on nasal airway patency, as measured by both active anterior rhinomanometry (AAR) and acoustic rhinometry (AR). The nasal airway patency of healthy subjects was evaluated using AAR and AR. In AAR, the subjects generated airflow actively through inspiration and expiration in repetitions of10, while nasal patency was measured at an inspiratory and expiratory reference pressure of 75 Pa. In AR, we assessed the geometry of the nasal cavity through the analysis of sound waves reflected from the nasal cavities in order to measure both cross-sectional areas and nasal volumes. The subjects were divided by gender, with all males and females then grouped by ages of 20–39 years, 40–59 years and ≥60 years. There were 40 subjects in each group. The mean resistance measured by AAR and the cross-sectional areas and nasal volumes measured by AR were not different between the different age groups; however, the cross-sectional areas and nasal volumes were found to be lesser in females than in males. Our results showed that nasal airway patency was not affected by age, while females were shown to have wider nasal passages than males.

Core Outcome Measures in Chronic Rhinosinusitis With Nasal Polyps: In Practice and Research

Heterogeneity in outcomes used in clinical trials prevents meta-analysis and contributes to research waste. Core outcome sets aim to address this by defining a small number of essential outcomes that should be measured in all effectiveness trials. Adoption in routine clinical practice can further improve outcomes for patients.There has been a rapid growth in therapeutic options available for patients with chronic rhinosinusitis with nasal polyps, but difficulty comparing results leads to uncertainty into optimum management, and there is a need to define a core outcome set. We consider whether work already undertaken needs to be modified for patients with nasal polyps.We recommend that a core outcome set should include assessment of disease specific quality of life, nasal polyp score, evaluation of sense of smell, alongside need for OCS and surgical treatment and complications from the disease or treatment. Further work is required to achieve international consensus regarding the choice of nasal polyp scoring system.

Association of computed tomography scores to psychophysical measures of olfaction: A systematic review and meta-analysis

BACKGROUND

While various sinus computed tomography (CT) scoring systems have been proposed and used in the literature, no single system has been identified as superior. The strength of associations between CT scoring systems and measures of olfaction also remains unclear.

METHODS

A systematic review of PubMed, CINAHL, Scopus, and the Cochrane Library was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies that reported both CT scores and measures of olfaction in a cross-sectional manner were included.

RESULTS

A total of 37 studies were eligible for meta-analysis. Of 8035 patients with chronic rhinosinusitis, 55.6% were male patients and 53.2% had chronic rhinosinusitis with nasal polyps. Analysis by meta-regression was performed of Lund-Mackay (LM) versus Smell Identification Test-40 (SIT-40; 12 studies), Brief Smell Identification Test (BSIT; 10 studies), Sniffin' Sticks (SS; 10 studies), and Toyota & Takagi (T&T) olfactometry (four studies). A significant moderate association was found between LM and SIT-40 (R²  = 0.612, p < 0.001) and LM and SS (R²  = 0.612, p < 0.001). An association between LM and BSIT approached significance (R²  = 0.461, p = 0.054). No significant associations were noted between LM and T&T olfactometry and between LM and SS when stratified by nasal polyp status.

CONCLUSION

There is a significant moderate association of current CT scoring systems to SIT-40 and SS. Further research should focus on associations of objective measures of olfaction to CT scores of the nasal cavity, sinuses, and olfactory cleft, as well as other disease markers.

Improvement of Subjective Olfactory Dysfunction in Chronic Rhinosinusitis With Nasal Polyps After Endoscopic Sinus Surgery

Objective

Olfactory impairment is a common complaint in patients with chronic rhinosinusitis with nasal polyps (CRSwNP), but the influence of endoscopic sinus surgery (ESS) on olfaction and the factors predicting olfactory impairment are not fully understood. This study aimed to assess the effect of ESS on improving olfactory dysfunction in patients with CRSwNP and to identify factors that predict prognosis.

Methods

A total of 56 patients with CRSwNP reported their self-evaluated olfactory dysfunction score preoperatively and 1 month, 3 months, and 12 months after ESS. Preoperative clinical characteristics, computed tomography (CT) scan, and sinonasal endoscopy examination results were collected before surgery. Additionally, factors that predicted olfactory loss and affected the improvement of olfaction after ESS were evaluated.

Results

Olfactory improvement can be observed 1 month after ESS. A total of 73.2% (41/56) subjects experienced sustained recovery of subjective olfaction with the self-evaluated olfactory dysfunction score improving from 2.04 to 0.64 (P < 0.001) after 12 months. The Lund–Mackay scores (r = 0.593, P < 0.001) and Lund–Kennedy scores (r = 0.265, P < 0.05) correlated with the preoperative olfactory dysfunction score. Multivariate logistic regression analysis revealed that longer duration of olfactory dysfunction, blood eosinophilia, lower Lund–Mackay scores, and peripheral distribution of CT opacification were risk factors that adversely affected the recovery of olfactory function (P < 0.05).

Conclusion

ESS improved self-evaluated olfactory function in patients with CRSwNP. Lund–Mackay scores and Lund–Kennedy scores were correlated with olfactory function prior to surgery, while a longer course of the disease, higher blood eosinophilia, lower Lund–Mackay scores, and peripheral distribution of CT opacification were risk factors for poor olfactory prognosis.

Clinical Assessment of Chronic Rhinosinusitis

Chronic rhinosinusitis (CRS) is a common disease that affects >10% of the adult population in Europe and the United States. It has been delineated phenotypically into CRS without nasal polyps and CRS with nasal polyps. Both have a high disease burden and an overlapping spectrum of symptoms such as nasal obstruction, olfactory dysfunction, facial pain, pressure, and nasal discharge. Primary assessment includes evaluation of patient symptoms and impact on quality of life, nasal endoscopic examination, and imaging. Significant progress has been made in the understanding of CRS pathophysiology. There is a move toward describing CRS in terms of the predominant endotype or inflammatory pattern pathomechanism rather than the traditional classification of patients with and without nasal polyps. An increased elucidation of the disease endotypes, as characterized by their inflammatory pathways and mediators, is leading to a tailored more personalized treatment approach to the different disease subtypes.

International consensus statement on allergy and rhinology: Olfaction

BACKGROUND

The literature regarding clinical olfaction, olfactory loss, and olfactory dysfunction has expanded rapidly over the past two decades, with an exponential rise in the past year. There is substantial variability in the quality of this literature and a need to consolidate and critically review the evidence. It is with that aim that we have gathered experts from around the world to produce this International Consensus on Allergy and Rhinology: Olfaction (ICAR:O).

METHODS

Using previously described methodology, specific topics were developed relating to olfaction. Each topic was assigned a literature review, evidence-based review, or evidence-based review with recommendations format as dictated by available evidence and scope within the ICAR:O document. Following iterative reviews of each topic, the ICAR:O document was integrated and reviewed by all authors for final consensus.

RESULTS

The ICAR:O document reviews nearly 100 separate topics within the realm of olfaction, including diagnosis, epidemiology, disease burden, diagnosis, testing, etiology, treatment, and associated pathologies.

CONCLUSION

This critical review of the existing clinical olfaction literature provides much needed insight and clarity into the evaluation, diagnosis, and treatment of patients with olfactory dysfunction, while also clearly delineating gaps in our knowledge and evidence base that we should investigate further.

Olfactory Outcomes with Dupilumab in Chronic Rhinosinusitis with Nasal Polyps

BACKGROUND

Loss of smell (LoS) is one of the most troublesome and difficult-to-treat symptoms of severe chronic rhinosinusitis with nasal polyps (CRSwNP).

OBJECTIVE

To assess the impact of dupilumab on sense of smell in severe CRSwNP.

METHODS

In the randomized SINUS-24 and SINUS-52 studies, adults with severe CRSwNP received dupilumab 300 mg subcutaneously or matching placebo every 2 weeks for 24 or 52 weeks, respectively. Smell was assessed using daily patient-reported LoS score (0-3) and University of Pennsylvania Smell Identification Test (UPSIT; 0-40). Data from the 2 studies were pooled through week 24. Relationships between patient phenotypes and smell outcomes were also assessed.

RESULTS

We randomized 724 patients (286 placebo, 438 dupilumab); mean CRSwNP duration was 11 years; 63% had prior sinonasal surgery. Mean baseline LoS was 2.74. Dupilumab produced rapid improvement in LoS, evident by day 3, which improved progressively throughout the study periods (least squares mean difference vs placebo -0.07 [95% CI -0.12 to -0.02]; nominal P < .05 at day 3, and -1.04 [-1.17 to -0.91]; P < .0001 at week 24). Dupilumab improved mean UPSIT by 10.54 (least squares mean difference vs placebo 10.57 [9.40-11.74]; P < .0001) at week 24 from baseline (score 13.90). Improvements were unaffected by CRSwNP duration, prior sinonasal surgery, or comorbid asthma and/or nonsteroidal anti-inflammatory drug-exacerbated respiratory disease. Baseline olfaction scores correlated with all measured local and systemic type 2 inflammatory markers except serum total immunoglobulin E.

CONCLUSIONS

Dupilumab produced rapid and sustained improvement in sense of smell, alleviating a cardinal symptom of severe CRSwNP.

Prevalence and Symptom Burden of Nasal Polyps in a Large Austrian Population

BACKGROUND

Although chronic rhinosinusitis with nasal polyps (CRSwNP) is a common inflammatory condition with significant morbidity and financial cost, information regarding prevalence and disease burden of this condition is scarce.

OBJECTIVE

In this study we determined nasal polyp prevalence, polyp grade, concomitant disease, and symptom burden in > 10,000 central European subjects.

METHODS

In this retrospective, cross-sectional study, 10,259 patients who had undergone routine examination of their nose by nasal endoscopy during a visit at a publicly accessible ENT outpatient facility in Vienna were included. Patient details including presenting complaint, nasal symptoms, polyp score, age, gender, treatment, asthma and allergic status were extracted retrospectively. A detailed questionnaire including history of nasal symptoms, SNOT-20 GAV, and VAS was available for 101 patients with nasal polyps.

RESULTS

Nasal polyps were detected in 189 (1.84%) of the 10,259 patients. The calculated prevalence of polyps in Austria, adjusted for age and gender, was 1.95%. The average TPS was 3.4, 72.5% had a TPS of ≤4, with males and asthmatics having significantly larger polyps. Questionnaire analysis revealed that 67% suffered from a low symptom burden of ≤36. According to current EPOS guidelines, 6% of polyp patients fulfilled and another 8% potentially fulfil the eligibility criteria for biological therapy.

CONCLUSION

Nasal polyp prevalence was calculated to be 1.95% of the Austrian population. Large polyps (TPS>4) were found in 25%, 33% suffered from a high nasal symptom burden, and between 6 to 14% of polyp patients would be eligible for biological therapy according to EPOS guidelines.

A systematic review to examine the relationship between objective and patient-reported outcome measures in sinonasal disorders: recommendations for use in research and clinical practice

BACKGROUND

Common sinonasal disorders include chronic rhinosinusitis (CRS), allergic rhinitis (AR), and a deviated nasal septum (DNS), which often coexist with shared common symptoms including nasal obstruction, olfactory dysfunction, and rhinorrhea. Various objective outcome measures and patient-reported outcome measures (PROMs) are used to assess disease severity; however, there is limited evidence in the literature on the correlation between them. This systematic review aims to examine the relationship between them and provide recommendations.

METHODS

A search of MEDLINE and EMBASE identified studies quantifying correlations between objective outcome measures and PROMs for the sinonasal conditions using a narrative synthesis.

RESULTS

In total, 59 studies met inclusion criteria. For nasal obstruction, rhinomanometry shows a lack of correlation whereas peak nasal inspiratory flow (PNIF) shows the strongest correlation with PROMs (r > 0.5). The Sniffin' Stick test shows a stronger correlation with PROMs (r > 0.5) than the University of Pennsylvania Smell Identification Test (UPSIT) (r < 0.5). Computed tomography (CT) sinus scores show little evidence of correlation with PROMs and nasal endoscopic ratings (weak correlation, r < 0.5).

CONCLUSION

Overall, objective outcome measures and PROMs assessing sinonasal symptoms are poorly correlated, and we recommend that objective outcome measures be used with validated PROMs depending on the setting. PNIF should be used in routine clinical practice for nasal obstruction; rhinomanometry and acoustic rhinometry may be useful in research. The Sniffin' Sticks test is recommended for olfactory dysfunction with UPSIT as an alternative. CT scores should be excluded as a routine CRS outcome measure, and endoscopic scores should be used in combination with PROMs until further research is conducted.

Olfaction: Sensitive indicator of inflammatory burden in chronic rhinosinusitis

BACKGROUND AND OBJECTIVE

Olfactory dysfunction has a high prevalence in chronic rhinosinusitis (CRS) patients and significantly affects quality of life. CRS is recognized as a complex disorder encompassing heterogeneous inflammatory processes in the nose and paranasal sinuses. Olfactory dysfunction in CRS patients is associated with the level of inflammatory mediators and the efficiency of inflammatory control. Learning about the association between CRS-related inflammation and olfactory function will provide clues to the pathogenesis of CRS.

STRUCTURE

The first section of this review describes the assessment of olfactory function using various measures, from ratings to MR based imaging. Then, we discuss the conductive and inflammatory mechanisms related to olfactory dysfunction in CRS: olfaction is associated with certain inflammatory patterns and is potentially a marker of CRS subtype. Finally, we review anti-inflammatory therapies including conservative and surgical approaches, and their effectiveness in olfactory dysfunction in CRS.

CONCLUSION

Assessment of olfactory function should be considered in the clinical evaluation of CRS patients, not only for detecting and quantifying patients' symptom, but also because it appears to be useful to objectively assess the efficacy of CRS treatment over time. In addition, olfaction can be expected to expand the library of CRS phenotypes and endotypes and, hence, pave the way for more precise, tailored treatment options.

Olfactory changes after endoscopic sinus surgery for chronic rhinosinusitis: A meta-analysis

BACKGROUND

Endoscopic sinus surgery (ESS) is an important treatment modality for chronic rhinosinusitis (CRS). However, its effect on olfaction remains controversial.

OBJECTIVE OF REVIEW

To assess the olfactory impact of ESS in patients with CRS.

TYPE OF REVIEW

A meta-analysis.

SEARCH STRATEGY

A systematic literature search in the PubMed, EMBASE and Cochrane Library databases was conducted to identify studies that assessed change in olfaction after ESS in patients with CRS. Search terms were related to paranasal sinus diseases, smell and endoscopy.

EVALUATION METHOD

The extracted data included authors, publication year, study type, age, sex, diagnostic criteria, surgical mode, sample size, follow-up time, olfaction measurement tool and outcome. We analysed the olfactory changes as continuous variables.

RESULTS

Thirty-five studies including 3164 patients with CRS were eligible for the meta-analysis. Among patients having CRS with nasal polyps, olfactory dysfunction improved, as assessed by the Sniffin' Sticks total score (P = .000), Sniffin' Sticks discrimination score (P = .023), Sniffin' Sticks identification score (P = .005), University of Pennsylvania Smell Identification Test (P = .046) and Visual Analogue Scale (P = .000). However, the threshold score of the Sniffin' Sticks test did not improve significantly (P = .361). Olfactory dysfunction did not improve in patients having CRS without nasal polyps according to the University of Pennsylvania Smell Identification Test (P = .404). In non-classified CRS patients, improvement in olfactory dysfunction was observed according to the University of Pennsylvania Smell Identification Test (P = .000), Visual Analogue Scale (P = .001) and Questionnaire of Olfactory Disorders-Negative Statements (P = .001). However, there were no significant improvements according to the Brief Smell Identification Test (P = .325), Sniffin' Sticks threshold score (P = .160) and Sniffin' Sticks identification score (P = .079).

CONCLUSION

Endoscopic sinus surgery may be beneficial for improvement in olfactory conditions in patients with CRS. Further thorough and comprehensive studies need to be conducted.

Clinical Research Needs for the Management of Chronic Rhinosinusitis with Nasal Polyps in the New Era of Biologics: A National Institute of Allergy and Infectious Diseases Workshop

The development of biologics targeting various aspects of type 2 inflammation for the treatment of chronic rhinosinusitis with nasal polyps (CRSwNP) will provide clinicians with powerful tools to help treat these patients. However, other therapies are also available, and positioning of biologics in a management algorithm will require comparative trials. In November 2019, the National Institute of Allergy and Infectious Diseases convened a workshop to consider potential future trial designs. Workshop participants represented a wide spectrum of clinical specialties, including otolaryngology, allergy, and pulmonary medicine, as well as expertise in CRSwNP pathophysiology and in trial methodology and statistics. The workshop discussed the current state of knowledge in CRSwNP and considered the advantages and disadvantages of various clinical trial or observational study designs and various clinical outcomes. The output from this workshop, which is presented in this report, will hopefully provide investigators with adequate information and ideas to design future studies and answer critical clinical questions. It will also help clinicians understand the current state of the management of CRSwNP and its gaps and be more able to interpret the new information to come.

Chronic rhinosinusitis with nasal polyps impact in severe asthma patients: Evidences from the Severe Asthma Network Italy (SANI) registry

BACKGROUND

The clinical and laboratory features of patients enrolled in the Severe Asthma Network in Italy (SANI) registry, a web-based observatory collecting demographic, clinical, functional and inflammatory data of patients with severe asthma were evaluated, with a special emphasis to chronic rhinosinusitis with nasal polyposis (CRSwNP).

METHODS

For each eligible patients the following information has been collected: demographic data, clinical features, asthma control in the previous month according to the GINA (Global INitiative for Asthma) Guidelines and standardized questionnaires, concomitant regular and on demand treatments and inflammatory markers.

RESULTS

695 patients with severe asthma enrolled in 66 SANI centers were analyzed. The prevalence of chronic rhinosinusitis with nasal polyposis was 40.6%. Atopic dermatitis and bronchiectasis was significantly more frequent in patients with CRSwNP than in subjects without nasal polyposis; similarly, FeNO values are significantly higher in subject with CRSwNP than in patients without nasal polyposis. Finally, patients with CRSwNP had a significantly higher number of asthma exacerbations per year, more days on oral corticosteroids and were more likely to be OCS long term users.

CONCLUSION

OCS sparing is needed in patients with severe asthma, mainly in subjects with CRSwNP, adopting adequate strategies such as a better adherence to the treatment with inhaled therapy according to the GINA recommendations, the use of biologic agents and a multidisciplinary approach of the patient.

In-office Placement of Mometasone Furoate Sinus Implants for Recurrent Nasal Polyps: A Pooled Analysis

Background

A mometasone furoate (MF) sinus implant (1350 mcg) was evaluated in 2 randomized controlled trials (RCTs) in 400 adults with nasal polyps (NP) who were candidates for revision endoscopic sinus surgery (RESS). We conducted a pooled analysis to evaluate the efficacy of MF implant in specific subgroups of NP patients.

Methods

Pooled data from 2 RCTs for 375 patients were analyzed across prespecified subjective and objective end points through day 90.

Results

At day 90, patients receiving implants and MF nasal spray (MFNS) experienced significant improvements in nasal obstruction/congestion (NO/C) score ( P = .0095), bilateral polyp grade (BPG, P = .0008), and ethmoid sinus obstruction ( P < .0001) compared to control using MFNS alone. Fewer treatment than control patients remained candidates for RESS (41.0% vs 69.3%, P < .0001). All subgroups experienced significant treatment effects, except NO/C in smokers ( P = .0509) and patients without altered smell ( P = .1873). Subgroups without asthma and with only 1 prior ESS experienced largest treatment effect on NO/C, and those with recent surgery <24 months and BPG >5 showed largest effect on endoscopic end points and RESS. Control patients with ESS <24 months were at 7 times highest risk for RESS ( P < .0001). One (0.4%) patient experienced implant-related serious adverse event (epistaxis).

Conclusion

On pooled analysis, MF implants with MFNS showed more favorable results than MFNS alone across several subjective and objective end points at day 90 and may play an important role in management of NP patients, especially those who have allergic rhinitis, expanded polyposis, altered smell, or had most recent ESS < 24 months.

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.

Patterns of olfactory dysfunction in chronic rhinosinusitis identified by hierarchical cluster analysis and machine learning algorithms

BACKGROUND

Olfactory dysfunction is a common symptom of chronic rhinosinusitis (CRS). We previously identified several cytokines potentially linked to smell loss, potentially supporting an inflammatory etiology for CRS-associated olfactory dysfunction. In the current study we sought to validate patterns of olfactory dysfunction in CRS using hierarchical cluster analysis, machine learning algorithms, and multivariate regression.

METHODS

CRS patients undergoing functional endoscopic sinus surgery were administered the Smell Identification Test (SIT) preoperatively. Mucus was collected from the middle meatus using an absorbent polyurethane sponge and 17 inflammatory mediators were assessed using a multiplexed flow-cytometric bead assay. Hierarchical cluster analysis was performed to characterize inflammatory patterns and their association with SIT scores. The random forest approach was used to identify cytokines predictive of olfactory function.

RESULTS

One hundred ten patients were enrolled in the study. Hierarchical cluster analysis identified 5 distinct CRS clusters with statistically significant differences in SIT scores observed between individual clusters (p < 0.001). A majority of anosmic patients were found in a single cluster, which was additionally characterized by nasal polyposis (100%) and a high incidence of allergic fungal rhinosinusitis (50%) and aspirin-exacerbated respiratory disease (AERD) (33%). A random forest approach identified a strong association between olfaction and the cytokines interleukin (IL)-5 and IL-13. Multivariate modeling identified AERD, computed tomography (CT) score, and IL-2 as the variables most predictive of olfactory function.

CONCLUSION

Olfactory dysfunction is associated with specific CRS endotypes characterized by severe nasal polyposis, tissue eosinophilia, and AERD. Mucus IL-2 levels, CT score, and AERD were independently associated with smell loss.

Peak nasal inspiratory flow is a useful measure of nasal airflow in functional septorhinoplasty

OBJECTIVE

To evaluate the utility of peak nasal inspiratory flow (PNIF) as a measure of nasal airflow and functional septorhinoplasty (FSRP) outcomes.

METHODS

Patients with nasal obstruction were administered Nasal Obstruction Symptom Evaluation (NOSE) questionnaire and PNIF testing between January 2015 and 2018. Surgical patients repeated these tests at 2, 4, 6, 12, and 24 months postoperatively. Patient demographics and operative techniques were recorded.

RESULTS

A total of 610 patients were evaluated for nasal obstruction with mean (standard deviation [SD]) NOSE score of 61.5 (23.2) and PNIF of 74.1 (35.4) liters per minute (L/min); correlation -0.16 (P < 0.001). Predictors of lower PNIF were female gender (β = -13.3, 95% confidence interval [CI] 7.7 to 18.2, P < .001) and higher NOSE scores (β = -0.43, 95% CI 0.19 to 0.68, P < 0.001). A total of 281 patients underwent FSRP with statistically and clinically significant improvements in both mean NOSE and PNIF scores that were stable out to 2 years. NOSE scores changed -41.0 (25.5) points, and PNIF improved 20.7 (35.5) L/min at last follow-up. Grafting material did not affect outcomes, whereas spreader grafts improved PNIF values (β = 25.46, 95% CI 5.5 to 45.4, P = 0.013). Clinically significant changes between NOSE and PNIF were concordant, although the correlation was weak (r = -0.26, P = 0.02).

CONCLUSION

Peak nasal inspiratory flow is a rapid, cheap, and easily performed test that detects nasal obstruction and clinically significant improvements in airflow following FSRP. Although PNIF does not correlate well enough with the patient experience of nasal obstruction to be used as a diagnostic tool, it does provide unique and complementary information useful for evaluating, understanding, and improving the effects of surgical techniques.

LEVEL OF EVIDENCE

2C Laryngoscope, 129:594-601, 2019.

Olfactory and middle meatal cytokine levels correlate with olfactory function in chronic rhinosinusitis

OBJECTIVES/HYPOTHESIS

The etiology of chronic rhinosinusitis (CRS)-associated olfactory loss is unclear, but may result from inflammatory changes in the olfactory epithelium that result in signaling dysfunction or loss of olfactory neurons. Several proinflammatory cytokines have been associated with CRS, but their expression within the olfactory cleft microenvironment and association with olfactory function is unknown.

STUDY DESIGN

Prospective case-control study.

METHODS

Mucus was collected from the olfactory cleft and middle meatus of 31 CRS without nasal polyps subjects, 36 CRS with nasal polyps (CRSwNP) subjects, and 12 healthy controls. Olfactory function was assessed using the validated Smell Identification Test (SIT). Site-specific levels of 14 cytokines/chemokines (interleukin [IL]-1β, IL-2, IL-4, IL-5, IL-6, IL-7, IL-8, IL-10, IL-12, IL-13, IL-17A, tumor necrosis factor-α, Eotaxin, RANTES [regulated on activation, normal T cell expressed and secreted]) were assessed using a multiplex flow cytometric bead assay and correlated with SIT scores.

RESULTS

Mucus cytokine levels in the olfactory cleft were strongly or moderately correlated with levels in the middle meatus for all but one measured inflammatory mediators. SIT scores were inversely correlated with levels of IL-2 (P = .006), IL-5 (P < .0001), IL-6 (P = .0009), IL-10 (P < .0001), and IL-13 (P < .0001), with significance largely driven by CRSwNP patients.

CONCLUSIONS

The inflammatory microenvironment within the olfactory cleft mirrors that within the middle meatus. Elevated levels of IL-2, IL-5, IL-6, IL-10, and IL-13 in olfactory cleft mucus are associated with reduced olfactory identification scores in CRS patients. Altered levels of select olfactory mucus cytokines could potentially have deleterious effects on olfactory neuron function and turnover.

LEVEL OF EVIDENCE

NA. Laryngoscope, 128:E304-E310, 2018.

A phase 3 trial of mometasone furoate sinus implants for chronic sinusitis with recurrent nasal polyps

Background

Topical intranasal corticosteroid sprays (INCSs) are standard treatment for nasal polyps (NPs), but their efficacy is reduced by poor patient compliance and impaired access of drug to the sinus mucosa. A corticosteroid‐eluting sinus implant was designed to address these limitations in patients with recurrent polyposis after sinus surgery by delivering 1350 μg of mometasone furoate (MF) directly to the ethmoid sinus mucosa over approximately 90 days.

Methods

A randomized, sham‐controlled, double‐blind trial was undertaken in 300 adults with refractory chronic rhinosinusitis with NPs (CRSwNP), who were candidates for repeat surgery. Eligible patients were randomized (2:1) and underwent in‐office bilateral placement of 2 implants or a sham procedure. All patients used the MF INCS 200 μg once daily. Co‐primary efficacy endpoints were the change from baseline in nasal obstruction/congestion score and bilateral polyp grade, as determined by an independent panel based on centralized, blinded videoendoscopy review.

Results

Patients treated with implants experienced significant reductions in both nasal obstruction/congestion score (p = 0.0074) and bilateral polyp grade (p = 0.0073) compared to controls. At day 90, implants were also associated with significant reductions in 4 of 5 prespecified secondary endpoints compared to control: proportion of patients still indicated for repeat sinus surgery (p = 0.0004), percent ethmoid sinus obstruction (p = 0.0007), nasal obstruction/congestion (p = 0.0248), and decreased sense of smell (p = 0.0470), but not facial pain/pressure (p = 0.9130). One patient experienced an implant‐related serious adverse event (epistaxis).

Conclusion

Significant improvements over a range of subjective and objective endpoints, including a reduction in the need for sinus surgery by 61%, suggest that MF sinus implants may play an important role in management of recurrent NP.

Peak nasal inspiratory flow as outcome for provocation studies in allergen exposure chambers: a GA2LEN study

Background

The GA²LEN chamber has been developed as a novel mobile allergen exposure chamber (AEC) allowing standardized multicenter trials in allergy. Hitherto, subjective nasal symptom scores have been the most often used outcome parameter, but in standardized modern trials objective parameters are preferred. Despite its practicability, the objective parameter peak nasal inspiratory flow (PNIF) has been rarely used for allergy trials in the setting of allergen exposure chambers. This study aims to evaluate PNIF as an outcome parameter for provocation studies in AECs.

Methods

In a randomized controlled blinded setting subjects suffering from allergic rhinitis were exposed to grass pollen, birch pollen, house dust mite and/or placebo in the GA²LEN chamber. Different allergen concentrations were used to evaluate symptom severities. Patients had to perform PNIF before and every 30 min during a challenge using a portable PNIF meter.

Results

86 subjects participated in 203 challenges, altogether. House dust mite provocations caused the greatest reduction in PNIF values, followed by grass pollen and birch pollen. Provocations with every allergen or pollen concentration led to a significant decrease (p < 0.05) in PNIF compared to baseline. Furthermore, positive correlations were obtained between PNIF and peak expiratory flow, height and weight, and inverse correlations between PNIF and total nasal symptom score, nasal congestion score and visual analog scale of overall subjective symptoms.

Conclusion

PNIF is a helpful and feasible tool for conducting provocation trials with allergens, especially grass pollen and house dust mite, in an AEC.

Electronic supplementary material

The online version of this article (doi:10.1186/s13601-017-0169-4) contains supplementary material, which is available to authorized users.

Olfaction in Chronic Rhinosinusitis

Olfactory dysfunction is a frequent complaint in chronic rhinosinusitis patients and has a significant impact on quality of life. Therefore, it is essential that clinicians are aware of the importance of olfactory dysfunction in chronic rhinosinusitis (CRS) patients and know how to deal with it. Notably, the evaluation of olfactory function (i.e., using psychophysical testing) and imagery of olfactory bulb play an important role in the evaluation of patients and give essential information about the "baseline" olfactory function. Because the high impact of olfactory function on quality of life and medical and/or surgical treatment should be proposed to patients. However, it remains difficult to predict the outcome of treatment as well as long-term efficacy. The first section of this review is dedicated to the assessment of olfactory function. Secondly, we will discuss the etiopathology of olfactory dysfunction in CRS with and without nasal polyps. Finally, we will review literature findings about the efficacy of different treatments on olfactory function.

Outcomes in endoscopic sinus surgery: olfaction, nose scale and quality of life in a prospective cohort study

OBJECTIVES

To determine the efficacy of endoscopic sinus surgery (ESS) on olfactory function in chronic rhinosinusitis patients with nasal polyps (CRSwNP) and without nasal polyps (CRSsNP) and to compare the nasal obstruction and symptom evaluation (NOSE) scale before and after surgery.

DESIGN

A prospective cohort study SETTING: Royal National Throat and Nose and Ear Hospital, London UK.

PARTICIPANTS

One hundred and thirteen patients with CRS; 60 CRSwNP and 53 CRSsNP.

OUTCOME MEASUREMENTS

Olfaction was measured using both the University of Pennsylvania Smell Investigation Test (UPSIT) and the 'sense of smell' visual analogue scale (VAS). The NOSE scale, the sinonasal outcome test (SNOT 22) and the Lund-Kennedy (LK) surgeon reported scores were also measured pre- and postoperatively at 6 months.

RESULTS

The UPSIT psychophysical measurement significantly improved following ESS in the CRSwNP subgroup as did the patients perceived VAS sense of smell. However, in the CRSsNP subgroup, the improved VAS and UPSIT measurements were not significant. The NOSE, SNOT 22 and LK scores all improved significantly. The olfactory improvement as measured by the UPSIT correlated to the SNOT-22, but a correlation between the NOSE score and UPSIT was not found.

CONCLUSIONS

Endoscopic sinus surgery significantly improved the patient's perceived and measured sense of smell in the CRSwNP subgroup which is the most surgically responsive CRS subgroup. Additionally, improved olfaction in the CRSwNP subgroup is most likely to improve the patient's quality of life. Endoscopic sinus surgery significantly improved the NOSE scale in both CRS subgroups at 6 months following surgery.

Measuring Nasal Obstruction

The nose and the nasal airway is highly complex with intricate 3-dimensional anatomy, with multiple functions in respiration and filtration of the respired air. Nasal airway obstruction (NAO) is a complex problem with no clearly defined "gold-standard" in measurement. There are 3 tools for the measurement of NAO: patient-derived measurements, physician-observed measurements, and objective measurements. We continue to work towards finding a link between subjective and objective nasal obstruction. The field of evaluation and surgical treatment for NAO has grown tremendously in the past 4-5 decades and will continue to grow as we learn more about the pathophysiology and treatment of nasal obstruction.

Measurements of nasal airflow and patency: a critical review with emphasis on the use of peak nasal inspiratory flow in daily practice

Objective measures can be used to assist the clinician to diagnose and treat nasal obstruction and also to quantify nasal obstruction in research. Objective measurements of nasal obstruction are as important as objective measurements of lung function. peak nasal inspiratory flow (PNIF), acoustic rhinometry (AR) and rhinomanometry (RM), with their specific peculiarity, assess different aspects of nasal obstruction. From the studies available in the literature, it seems that these methods roughly correlate with each other and that all of them can be alternatively utilized very well in research as well as in clinical practice. This review describes the various methods that can be used to measure nasal patency, airflow and resistance, mainly peak nasal inspiratory flow, rhinomanometry and acoustic rhinometry. PNIF has been demonstrated to be reproducible and as good an indication of objective nasal patency as formal rhinomanometry and has the advantage to be cheap, simple and suitable for serial measurements and for home use even in the paediatric population. PNIF normative data are available for children, adults and elderly subjects, and the availability of unilateral PNIF normal values allows evaluation of nasal sides separately. Just as in the lower airways, objective and subjective evaluation gives different information that together optimizes the diagnosis and the treatment of our patients. We argue that PNIF should be used regularly in every outpatient clinic that treats patients with nasal obstruction.

Olfactory-specific quality of life outcomes after endoscopic sinus surgery

BACKGROUND

Olfactory loss is a cardinal symptom of chronic rhinosinusitis (CRS) and affects 40% to 80% of patients. However, common sinus-specific quality-of-life (QOL) instruments include only single questions related to olfaction. Few studies have explored olfactory outcomes after surgery utilizing validated, olfaction-specific QOL questionnaires.

METHODS

Patients with CRS were enrolled from 3 centers across North America into a prospective cohort study. Patients completed the short modified version of the Questionnaire of Olfactory Disorders (QOD-NS) and the 40-item Smell Identification Test (SIT-40) before and at least 6 months after endoscopic sinus surgery (ESS). Multivariate linear regression was used to determine whether specific demographic, comorbidity, or disease severity measures were independently associated with QOD scores at baseline or predicted change after surgery.

RESULTS

A total of 121 patients, equally split between genders, were enrolled with an average age of 47.9 years (range, 18-80 years). Baseline total QOD-NS scores were significantly associated with SIT-40 scores, with a moderate strength of correlation (Rs = 0.400; p < 0.001). The average QOD-NS score improved after ESS (35.7 ± 13.0 vs 39.7 ± 12.2; p = 0.006). Allergy, polyps, and steroid-dependent conditions were found to be independently associated with worse preoperative QOD-NS scores, whereas septal deviation was associated with better QOD-NS scores. Baseline computed tomography (CT) scores were the only variable that significantly predicted change in QOD-NS after surgery.

CONCLUSION

Olfaction-specific QOL is worse in patients with polyps and comorbid allergy. Significant improvements in olfaction-specific QOL are seen after ESS, with the greatest gains seen in those with worse CT scores at baseline.

Efficacy of ESS in chronic rhinosinusitis with and without nasal polyposis: a Danish cohort study

Endoscopic sinus surgery (ESS) for patients with severe chronic rhinosinusitis (CRS) has become a well-established treatment in cases where medical therapy fails. Even though CRS patients are divided into two subgroups, CRS with nasal polyposis (CRSwNP) and CRS without nasal polyposis (CRSsNP), most studies present only results for the total cohort. This prospective cohort study evaluated the efficacy of ESS on both quality of life and olfactory function measures, in a cohort of Danish CRS patients diagnosed according to the EPOS criteria, with results analysed separately for the CRSwNP and CRSsNP subgroups. All 97 CRS patients who underwent ESS over an 18-month trial period were evaluated preoperative by SNOT-22 score, Sniffin' Sticks score, modified Lund-Kennedy endoscopic score and Lund-Mackay CT score. Patient outcomes were reevaluated at clinical follow-up 1 and 6 months postoperative. ESS efficiently and immediately improved quality of life for both CRSwNP and CRSsNP patients, with over 50 % reduction in SNOT-22 score 1 month after surgery, which sustained 6 months postoperative. Olfactory function measured by Sniffin' Sticks score showed overall improvement in both groups. ESS efficiently improved quality of life in both CRSwNP and CRSsNP patients, and surgery lead to an overall improvement in olfactory function. However, a minor proportion of patients experienced deterioration in olfactory function after ESS.

N-butanol olfactory threshold and nasal patency before and after palatal expansion in children. A preliminary study

OBJECTIVES

Olfaction is based on the function of the nasal olfactory receptors. Children can well detect and respond to odors in order to have information about food and environment. Rapid maxillary expansion seems to improve dental class and increase nasal patency correcting oral respiration in children. Nevertheless, there are no studies demonstrating that expansion in pediatric patients could influence olfactory sensitivity. The aim of this study was to evaluate olfactory threshold and nasal patency in children aged from 6 to 12 years before and after rapid maxillary expansion.

METHOD

N-butanol olfactory thresholds, anterior active rhinomanometry, and peak nasal inspiratory flow were measured in 12 children (6-12 years) before (T0), 20 days (T1), and 6 months after rapid maxillary expansion application (T2).

RESULTS

A significant lower olfactory threshold was found comparing T2 and T0 N-butanol olfactory threshold values (p=0.038). Peak nasal inspiratory flow showed a significant improvement both at T1 and T2, with respect to T0 values (p=0.043 and p=0.0001, respectively). T2 nasal resistances showed a trend towards a significant reduction when compared with T1 values (p=0.15).

CONCLUSION

This pilot study suggested that rapid maxillary expansion may lead to improved N-butanol olfactory thresholds, at least 6 months after palatal expansion. Furthermore, rapid maxillary expansion seems to improve peak nasal inspiratory flow values, and finally although with lower sensitivity, reduce nasal resistances as measured by rhinomanometry.

The clinical value of peak nasal inspiratory flow, peak oral inspiratory flow, and the nasal patency index

OBJECTIVES/HYPOTHESIS

The aim of this study was to ascertain the most reliable objective measurement for the assessment of nasal patency by investigating the relationship between peak nasal inspiratory flow, peak oral inspiratory flow, and the nasal patency index in relation to the patient's subjective perception regarding nasal obstruction.

STUDY DESIGN

Prospective cohort study.

METHODS

This study included 131 volunteers of both genders, aged 18 years or older, with or without nasal symptoms, who were able to give informed consent, completed the study protocol, and could speak and write Dutch fluently. Peak nasal inspiratory flow and peak oral inspiratory flow were performed and nasal patency index was computed. The results were evaluated and compared with the subjective perception of nasal passage, using the validated Nasal Obstruction Symptom Evaluation scale and visual analog scale for nasal passage.

RESULTS

Our study showed that peak nasal inspiratory flow, nasal patency index and nasal patency visual analog scale correlate with the Nasal Obstruction Symptom Evaluation scale in contrast to peak oral inspiratory flow. Peak nasal inspiratory flow and nasal patency index also showed significant association with the Nasal Obstruction Symptom Evaluation scale after adjustment for confounders.

CONCLUSIONS

Peak nasal inspiratory flow is the most reliable method for the assessment of nasal patency. It is quick, inexpensive, and easy to perform, and correlates significantly with the subjective feeling of nasal obstruction. There is no clinical need to measure peak oral inspiratory flow or to calculate the nasal patency index in the evaluation of nasal patency.

LEVEL OF EVIDENCE

4

Audit of nasal lysine aspirin therapy in recalcitrant aspirin exacerbated respiratory disease

Background

Aspirin – exacerbated respiratory disease can prove difficult to control. Oral aspirin desensitization is effective, but has adverse effects and may not be cardio-protective at the high doses needed.

Objective

To examine the effectiveness of aspirin administered in lower doses via the nose.

Methods

An audit of 121 patients with aspirin exacerbated respiratory disease (AERD), 105 of whom were treated with intranasal lysine aspirin in gradually increasing doses following positive lysine aspirin challenge.

Results

Treatment was associated with subjective symptomatic improvement or stabilization in 60 of 78 patients at 3 months and 19 of 27 at 12 months. Nasal inspiratory peak flow, olfaction, exhaled and nasal nitric oxide levels were significantly improved (p < 0.05 for all). Patients with positive skin prick tests and those with later onset (>40 years) AERD improved more than non-atopics and those with early onset AERD.

Asthma outcomes over 1 year were assessed by questionnaire in 22 patients on lysine aspirin and in 20 who were positive on challenge but who either refused treatment or took it only briefly (less than or equal to 3 months). There was a significant decrease in emergency visits (p = 0.0182), hospitalization (p = 0.0074) and oral steroid use (p = 0.004) in those on nasal lysine aspirin for a year.

Gastrointestinal side effects occurred in 3.8%, lower than those reported for oral aspirin therapy. Conclusions and Clinical Relevance This form of therapy might reduce the need for expensive monoclonal antibodies in AERD patients.

Long-term Results of Stellate Ganglion Block in Patients with Olfactory Dysfunction

Background

Olfactory dysfunction, including anosmia and hyposmia is difficult to treat. Although the mechanism is not well known, stellate ganglion block (SGB) is used to treat olfactory dysfunction. There are no prior studies on the long-term effects of SGB on olfactory dysfunction. The purpose of this study was to evaluate the continuity of therapeutic effects and patient satisfaction with SGB treatment.

Methods

This was a follow-up study carried out via a telephonic survey. The olfactory function of the patient was evaluated using a visual analog scale (VAS). We checked VAS three times: VAS-I (pre-treatment VAS), VAS-A (post-treatment VAS), and VAS-C (VAS at follow up telephone survey). We divided the subjects into 2 groups according to their responsiveness to SGB: the responsive (R group) and the unresponsive groups (UR group). Patient satisfaction was evaluated using a Likert scale.

Results

Out of the 40 subjects, 37 responded to the telephone survey. In the UR group, there was difference in the olfactory function. However, in the R group, there were significant VAS differences; VAS-I was 9.6 ± 0.7, VAS-A was 5.1 ± 4.2, and VAS-C was 2.7 ± 2.7 (P < 0.05). On the Likert scale, patient satisfaction was as follows: grade 1, 17 patients (45.9%); grade 2, 6 patients (16.2%); grade 3, 6 patients (16.2%); and grade 4, 8 patients (21.6%).

Conclusions

SGB is a safe, long-lasting, and effective therapeutic modality for olfactory dysfunction treatment.

Olfactory improvement after endoscopic sinus surgery

PURPOSE OF REVIEW

Olfactory dysfunction is a common complaint in patients with chronic rhinosinusitis (CRS). The purpose of this article is to review the current evidence on the impact of endoscopic sinus surgery (ESS) on CRS-related olfactory dysfunction.

RECENT FINDINGS

The recent literature suggests that olfactory outcomes after ESS are challenging to predict. Some evidence supports a positive impact of ESS on improving olfactory outcomes in patients with preoperative nasal polyposis and anosmia. However, despite improvements in smell, most of these patients remain with severe hyposmia. One study suggests ESS has no impact on olfactory outcomes.

SUMMARY

CRS-related olfactory dysfunction is a complex clinical scenario and it is challenging to predict improvement following ESS. CRS patients with anosmia and nasal polyposis preoperatively may have a higher likelihood of olfactory improvement following ESS.

Short-time cold dry air exposure: a useful diagnostic tool for nasal hyperresponsiveness

OBJECTIVES/HYPOTHESIS

Demonstration of nasal hyperreactivity (NHR) in allergic and nonallergic rhinitis remains a diagnostic challenge because of the lack of a clinically attractive protocol with high sensitivity and specificity. Our aim was to evaluate the feasibility of a shortened cold dry air (CDA) provocation protocol for the diagnosis of NHR in patients with allergic rhinitis (AR) and idiopathic rhinitis (IR).

STUDY DESIGN

Twelve AR patients, 12 IR patients, and 12 controls were exposed to air at -10°C and <10% humidity for 15 minutes.

METHODS

Nasal symptoms were subjectively evaluated by visual analogue scale (VAS), and nasal obstruction was objectively measured by peak nasal inspiratory flow (PNIF) before and after CDA exposure. NHR was defined as a drop in PNIF larger than 20% from baseline upon CDA challenge.

RESULTS

Nasal CDA exposure induced nasal obstruction in AR and IR patients but not in controls. The VAS for nasal obstruction increased significantly in IR patients (post-CDA: 9.1 cm [6.9, 9.7] vs. pre-CDA: 5.5 cm [5.0, 8.9], P = .004) as well as in AR patients (post-CDA: 5.0 cm [1.3, 6.6] vs. pre-CDA: 0.8 cm [0.0, 1.7], P = .001). PNIF values showed a significant decrease in the AR (post-CDA: 50.0 L/min [37.5, 97.5] vs. pre-CDA: 95.0 L/min [52.5, 127.5], P = .002) and IR (post-CDA: 75.0 L/min [47.5, 102.5] vs. pre-CDA: 100.0 L/min [67.5, 130.0], P = .002) group after CDA provocation, which was not observed in the controls (P = 1.000). The sensitivity and specificity of CDA provocation for diagnosis of NHR were 66.7% and 100%, respectively, for both IR and AR. In contrast to nasal obstruction, rhinorrhea and sneezing were not induced by CDA exposure.

CONCLUSIONS

This study demonstrates that a short nasal CDA exposure is a reliable method for the diagnosis of NHR in rhinitis patients, with a high sensitivity and specificity.