Endotype evaluation of Hispanic/Latinx-American patients with chronic rhinosinusitis with nasal polyps

KEY POINTS

Hispanic-American patients with chronic rhinosinusitis with nasal polyps have a comparable level of tissue eosinophilia compared to their Caucasian counterparts in the United States. Mixed inflammation involving both neutrophils and eosinophils is more common in this population compared to Caucasians. Findings from this study may indicate that Hispanic-American patients have a unique endotype or endotypes that deserves further investigation.

Clinical Efficacy of Topical Nasal Pomegranate Fruit Extract for Chronic Rhinitis and Chronic Rhinosinusitis

Objective: To evaluate the clinical efficacy of topical nasal Pomegranate Fruit Extract (PFE) for Chronic Rhinitis (CR), Chronic Rhinosinusitis with Nasal Polyposis (CRSwNP), and Chronic Rhinosinusitis without Nasal Polyposis (CRSsNP). Methods: Prospective, double-blinded, randomized study including 111 consecutive patients, between April 2012 and January 2017, afflicted by CRSwNP, CRSsNP, and CR. Patients from each group were randomly assigned to either PFE treatment or placebo twice daily for 30 days. Therapeutic efficacy was assessed by Ear Nose and Throat, blood and tomographic examinations, and the SNOT-20 questionnaire. Results: CR patients treated with PFE suffered significantly less from thick nasal discharge, difficulty falling asleep, reduced productivity, reduced concentration, and sadness (P = .004, P = .02, P = .03, P = .007 and P = .02, respectively). Conclusions: Topical nasal PFE was found to have some benefits for CR patients, however, not for CRS with or without Nasal Polyposis.

The chronic rhinosinusitis with nasal polyp patient journey in the United States and Europe

In this letter to the editor, we present questionnaire-based data assessing the patient journey of adults with moderate-severe Chronic Rhinosinusitis with Nasal Polyps (CRSwNP) in the USA and five European countries. These data highlight how long and difficult the patient journey with CRSwNP can be and how improved disease awareness among physicians could lead to more timely diagnosis and treatment, and hence improved management of patients.

Evaluation of Anatomical Variations Associated with Chronic Rhinosinusitis by Computed Tomography of Paranasal Sinuses

BACKGROUND

Chronic rhinosinusitis (CRS) is a syndrome with multifactorial aetiology. Amongst which, anatomical variations studied by computed tomography of paranasal sinuses (CT PNS) had a high incidence which varied between 64.0% and 99.8%10. Due to such high incidence, this study is undertaken to assess the various anatomical variations and their significant association in CRS.

METHOD

A prospective observational study was conducted in 70 CRS patients and were subjected to CT PNS. CT PNS is studied to know the various anatomical variations & other CT findings causing CRS and then findings noted down, tabulated and statistical analysis done.

RESULTS

All 70 CRS patients evaluated by CT PNS had one or more anatomical variations along with other findings like fungal sinusitis in 6 patients, dentigerous cyst and inverted papilloma in 1 case each. The anatomical variations observed in our study were septal deviation(62.8%), concha bullosa(52.8%), agger nasi(51.4%), pneumatized crista galli(47.1%), hyperpneumatized bulla(40%), suprabullar cells(37%), septal spur(34.3%), paradoxically curved middle turbinate(34.2%), supra orbital cells(32.8%), haller cells(31.4%), septal pneumatization(17.1%), pneumatized uncinate(13%), interfrontal septal pneumatization(13%), maxillary septations(10%), maxillary sinus hypoplasia(7.1%), frontal hypoplasia(5.7%), uncinate attached to lamina papyracea(40%), uncinate to middle turbinate(11%), uncinate to skull base(7.9%), free uncinate(41%), frontal cells type 1;2;3;4 (36%);(30%);(20%);(38.5%), onodi cells(27.1%), pneumatized anterior clinoid process(18.5%), lateral recess(15.7%), sphenoid septations attached to optic nerve(10%) and carotid(2.8%), pneumatized superior turbinate(1.4%), Sellar; Pre sellar; Post sellar sphenoid(42.8%);(5.7%);(51.4%). In our study only anatomical variations around the maxillary & Frontal sinus showed significant association with CRS.

CONCLUSION

Anatomical variations around the anterior group of sinuses have a significant association with CRS.

Cost-effectiveness analysis of biologics for the treatment of chronic rhinosinusitis with nasal polyps in Canada

BACKGROUND

Dupilumab, omalizumab, and mepolizumab are the three biologics currently approved for use in CRSwNP in Canada. Despite evidence of efficacy, their cost-effectiveness, which is a key factor influencing prescribing patterns, has not yet been compared to each other.

METHODS

A cost-effectiveness model using quality-adjusted life years (QALYs) was constructed using a Decision Tree Markov analysis. A third-party healthcare payer perspective and a 10-year time horizon was used. A willingness-to-pay (WTP) threshold of 50,000 Canadian dollars (CAD) per QALY was used to determine cost-effectiveness. Dupilumab, omalizumab, and mepolizumab were each compared to each other.

RESULTS

Omalizumab was the most cost-effective biologic using current estimates of cost and efficacy in CRSwNP. Using omalizumab as a baseline, dupilumab had an ICER of $235,305/QALY. Mepolizumab was dominated by omalizumab and dupilumab at the current drug prices and estimates of efficacy. Sensitivity analyses determined that when increasing the WTP threshold to $150,000/QALY, dupilumab became cost-effective compared to omalizumab in 22.5% of simulation scenarios. Additionally, altering dosing frequency had a significant effect on cost-effectiveness.

CONCLUSION

When comparing the relative cost-effectiveness of biologics in recalcitrant CRSwNP, omalizumab currently appears to be the most cost-effective option. Future reductions in drug prices, adjustments to currently approved dosing regimens, better patient selection, and improvements in sinus surgery outcomes will challenge the current cost-effectiveness models and necessitate reassessment as treatments for CRSwNP continue to evolve.

Use of peripheral blood eosinophils to guide post-operative glucocorticoid therapy in patients with chronic rhinosinusitis with nasal polyps: a randomised, controlled trial

OBJECTIVE

This study aimed to explore the utility of the eosinophil percentage in peripheral blood for guiding post-operative glucocorticoid therapy in patients with chronic rhinosinusitis with nasal polyps.

METHODS

Forty-four patients with chronic rhinosinusitis with nasal polyps underwent functional endoscopic sinus surgery and were randomly divided into two groups. Patients in the standard treatment group used oral and nasal spray glucocorticoids. In the biomarker treatment group, patients with peripheral blood eosinophil percentage values less than 3.05 per cent did not receive glucocorticoid treatment, whereas patients with values 3.05 per cent or above were part of the standard treatment group. Visual Analogue Scale, Sino-Nasal Outcome Test-22 scores, endoscopic Lund-Kennedy scores, eosinophils, interleukin-5 and eosinophil cationic protein in peripheral blood, and nasal secretions were measured.

RESULTS

After functional endoscopic sinus surgery, the Visual Analogue Scale, Sino-Nasal Outcome Test-22 and Lund-Kennedy scores were significantly reduced in both groups; there were no significant differences in those indicators between the groups during the three follow-up visits.

CONCLUSION

Peripheral blood eosinophil percentage offers a potential biomarker to guide post-operative glucocorticoid therapy in patients with chronic rhinosinusitis with nasal polyps.

Efficacy of Submucosal Diathermy of Inferior Turbinate in Patients with Chronic Rhinosinusitis Undergoing Functional Endoscopic Sinus Surgery

Aim

To assess the efficacy of submucosal diathermy (SMD) in Chronic rhinosinusitis and inferior turbinate hypertrophy undergoing Functional Endoscopic Sinus Surgery.

Materials and Methods

We conducted a Randomized Prospective study in patients undergoing Functional Endoscopic Sinus surgery for Chronic Rhinosinusitis in a tertiary care centre in South India for a period of 2 years. Patients were divided into two groups, Group A underwent FESS and Group B underwent FESS with SMD. The outcome was evaluated using nasal endoscopy score (NES), modified SNOT score and Modified Lund Kennedy scores.

Results

A total of 80 patients were included in this study.40 patients were allotted in each group. Male: Female ratio was 48:32. The age distribution ranged from 19 to 44 years with a mean of 29.55 ± 6.90 yrs. Mean NES scores, Modified SNOT and Modified Lund -kennedy scores were estimated pre-operatively and during 1st, 2nd and 3rd month of post-operative periods. The mean pre-operative sores were comparable in both the groups except NES score, which was higher in group B. Both the groups showed significant improvement in post-operative period. Inter group comparison showed significant difference in all scores with group B having better results when compared to group A.

Conclusion

This study proves that FESS combined with SMD improves the postoperative clinical outcomes when compared with FESS without turbinate reduction. We conclude that SMD is a simple, mucosal preserving technique with almost no complications and can be safely done along with FESS to improve the outcomes .

Roles of Anatomical Abnormalities in Localized and Diffuse Chronic Rhinosinusitis

Background

This study aimed to examine the roles of anatomical variation in localized and diffuse chronic rhinosinusitis [LCRS and DCRS]) .

Methods

A database was analyzed retrospectively on patients hospitalized in the Department of Otorhinolaryngology of our university hospital from 2017 to 2020. A total of 281 patients were included and divided into three categories: patients with LCRS, patients with DCRS, and a normal control group. The frequency of anatomical variation, the demographic information, disease type (with or without polyps), symptom visual analogue scale (VAS) scores and Lund-Mackay (L-M) scores were calculated and compared.

Results

Anatomical variants were observed more frequently in LCRS than DCRS (P < 0.05). The frequency of variation was higher in the LCRSwNP group than the DCRSwNP group (P < 0.05), and higher in the LCRSsNP group than the DCRSsNP group (P < 0.05). The L-M scores for patients with DCRS with nasal polyps were significantly higher (14.96 ± 6.15) than those of patients with DCRS without nasal polyps (6.80 ± 5.00) and also significantly higher (3.78 ± 2.07) than those of patients with LCRS with nasal polyps (2.63 ± 1.12; P < 0.05). A poor correlation was observed between the severity of symptoms and the performance of CT scans in CRS (R = 0.29, P < 0.01).

Conclusion

Anatomical variants were common in CRS, and possibly correlated with LCRS but not with DCRS. The frequency of anatomical variation is not associated with the occurrence of polyps. CT could reflect the severity of disease symptoms to some extent.

The negative impact of chronic rhinosinusitis on the health-related quality of life among adult patients with cystic fibrosis

BACKGROUND

With improved survival in cystic fibrosis (CF) patients, it is crucial to evaluate the impact of chronic co-morbidities such as chronic rhinosinusitis (CRS). The objectives were 1) To determine the prevalence of CRS with a large series of CF patients 2) To evaluate the impact of CRS on the Health-Related Quality of Life (HRQoL) of CF patients and 3) To compare CRS-specific, CF-specific and general HRQoL instruments.

METHODS

Consecutive CF patients from the Toronto Adult Cystic Fibrosis Centre were recruited between March 2018 and January 2020. Participants completed the 22-Item Nasal Outcome Test (SNOT-22), Cystic Fibrosis Questionnaire-Revised for adolescents and adults over 14 years of age (CFQ-R), Cystic Fibrosis Quality of Life Evaluative Self-administered Test (CF-QUEST) and the 36-Item Short Form Survey (SF-36). HRQoL scores were correlated using Spearman's correlation coefficients.

RESULTS

Out of 195 patients eligible for analysis, the prevalence of CRS with positive endoscopic findings was 42.6% (95% confidence interval: 35.5-49.8%). CRS patients reported significantly lower HRQoL with higher SNOT-22 scores and lower scores in the respiratory domain of CFQ-R and physical health domains of CF-QUEST and SF-36. The physical (ρ= -0.63) and mental (ρ= -0.66) domains of SF-36 and CF-QUEST (ρ= -0.76) had a strong correlation with SNOT-22. Higher scores of SNOT-22 nasal subdomains correlated with lower scores of SF-36, CFQ-R and CF-QUEST.

CONCLUSION

CRS is a prevalent co-morbidity of CF patients, which significantly reduces HRQoL. SNOT-22, CFQ-R, CF-QUEST and SF-36 were strongly correlated. Severity of sinonasal symptoms have a strong correlation with HRQoL in CF patients.

Improving predictability of IgE-high type 2 chronic sinusitis with nasal polyps in the biologic era

BACKGROUND

Chronic rhinosinusitis (CRS) is an inflammatory disease that may require biological therapy. Omalizumab is an anti-IgE biologic that was recently approved by the FDA and Health Canada for use in severe CRS with nasal polyps (CRSwNP) recalcitrant to intranasal corticosteroids. Dosing is based on weight and pre-treatment serum IgE, with elevated levels of the latter being an indication for biologic treatment according to EPOS and EUFOREA guidelines. The goal of this study was to identify variables that predict IgE-high type 2 inflammation and serve as indicators for biologic treatment in CRS.

METHODS

Patients ≥ 19 yo diagnosed with CRS undergoing functional endoscopic sinus surgery were included retrospectively. Demographics, past medical history, preoperative blood work, Lund-Mackay (LM), Lund Kennedy (LK), and SNOT-22 scores were extracted. Descriptive statistics and binary logistic regression analyses were conducted. Model superiority was based on Nagelkerke R2 scores and receiver operating characteristic curves.

RESULTS

Sixty-five patients, average age 49.96 ± 13.59 years, were included. Sixty-one binary logistic regression models for elevated serum IgE were created. Among the top 3 models, the best model had sensitivity, specificity, positive predictive value and negative predictive values of 82.1, 69.2, 80.0, and 72.0. All performance measures except sensitivity exceeded the Canadian Biologics Guideline model. Serum eosinophils ≥ 300 cell/uL, CRSwNP and LM ≥ 17 increased the odds of elevated IgE.

CONCLUSIONS

IgE-high type-2 inflammation can be predicted by a model that includes eosinophil ≥ 300 cell/uL, CRSwNP, LM ≥ 17, asthma diagnosis and SNOT-22 ≥ 40. Patients meeting these parameters have a high pretest probability for elevated IgE and would benefit from IgE serology to determine qualification for omalizumab. This could reduce unwarranted IgE serology in patients with CRSwNP but also target a patient population for further workup that will lead to optimization of resource allocation and improve healthcare equity in rural and remote areas within Canada.

Identifying barriers to care for complex airway disease and multidisciplinary solutions to optimize therapy in Canada

Background

Complex airway disease such as Chronic Rhinosinusitis with Asthma or Aspirin Exacerbated Respiratory Disease requires a multidisciplinary approach to management and treatment. Many centers in the USA have created collaborative multidisciplinary clinics to support the management of these patients; however, similar structures do not appear to exist in Canada.

Methods

This mixed methods study used a combination of structured interviews and a cross-sectional national survey. Interviewees included members of the Canadian Rhinology Working Group and survey participants were a combination of academic and community Rhinologists, Respirologists and Allergists. All participation was voluntary and selection criteria was based on their involvement in treating complex airway disease. Our objective was to identify the current state of diagnosis and treatment of complex airway patients in Canada between Rhinology, Respirology and Allergy and understand the barriers, challenges and propose solutions to establishing a multidisciplinary airway clinic in Canada.

Results

Four Rhinologists participated in qualitative interviews and a convenience sample of 42 specialists through our known network responded to our quantitative survey. From our survey, 54.8% believed multidisciplinary clinics were necessary in the management of complex airway disease, providing better outcomes and cost-savings (69%, 45.2%). Most specialties agreed that history, physical, pulmonary function and skin prick testing was important for diagnosis (92.9%, 92.9%, 88.1%). If clinicians were to participate in a multidisciplinary clinic, they would be willing to forego an average of 14.2% of their mean daily income for that clinic. The ideal clinic location was split between a neutral shared location vs. a Rhinology clinic space (38.1%, 45.2%).

Conclusions

Complex airway diseases are currently managed in subspecialty silos resulting in fragmented care. Our study highlights gaps in management, areas for improvement and support for establishing multidisciplinary complex airway disease clinics in Canada to better treat this population.

Is there a Role for Antibiotics in the Treatment of Chronic Rhinosinusitis?

Rhinosinusitis is one of the most common reasons for adult outpatient antibiotic prescriptions, though there is little clinical evidence to support this practice, especially for chronic rhinosinusitis. Despite considerable research, the etiology of chronic rhinosinusitis, including the pathogenic role of microbes, remains poorly understood. Rigorous studies of the efficacy of antibiotic treatment of chronic sinusitis are surprisingly few in number and the results are somewhat conflicting. This article will review the rationales for and against the treatment of chronic rhinosinusitis with antibiotics, based on current evidence and understanding of pathophysiology, and will also summarize the current guidelines.

Healthcare utilization for sinusitis after pneumococcal vaccination in patients with low antibody titers

BACKGROUND

Pneumococcal antibody deficiency has been the subject of limited study in chronic rhinosinusitis (CRS) and has not been studied in recurrent acute rhinosinusitis (RARS). The 23-valent pneumococcal polysaccharide vaccine (PPSV23) is considered for patients with non-protective Streptococcus pneumoniae titers. We hypothesized that both RARS and CRS patients with deficient S. pneumoniae titers and subsequent PPSV23 vaccination would have reduced healthcare encounters for sinusitis and fewer prescriptions for antibiotics or steroids.

METHODS

A retrospective cohort study was performed of patient encounters between January 2011 and December 2019. All patients included were ≥18 and ≤65 years old with a diagnosis of CRS or RARS and pneumococcal titer data. Patients with immunodeficiency and comorbid conditions requiring PPSV23 vaccination prior to the age of 65 were excluded.

RESULTS

A total of 938 patients were included. Non-protective antibody titers were present in 75.8% of CRS and 74.8% of RARS patients. 306 patients with deficient antibody titers received the PPSV23 vaccine. 89% of CRS and 90.1% of RARS patients had protective responses. Among 217 patients with continuous data from 2 years before through 2 years after PPSV23 vaccination, a decrease in the number of encounter diagnoses of CRS (p<0.0001) and RARS (p = 0.0006) was observed. Decreases in the frequency of antibiotic (p = 0.002) and corticosteroid (p = 0.04) prescriptions were also appreciated.

CONCLUSIONS

Most patients with CRS and RARS have non-protective antibody titers. PPSV23 administration significantly decreases healthcare utilization. This article is protected by copyright. All rights reserved.

Outcomes of Dupilumab Treatment versus Endoscopic Sinus Surgery for Chronic Rhinosinusitis with Nasal Polyps

BACKGROUND

Outside of the SINUS-24 and SINUS-52 trials, there is limited data on the efficacy of dupilumab in patients with chronic rhinosinusitis with nasal polyps (CRSwNP). The objective was to compare dupilumab to functional endoscopic sinus surgery (FESS) in CRSwNP patients by assessing the change in nasal polyp and SNOT-22 scores post-intervention.

METHODS

A retrospective matched cohort study compared 54 CRSwNP patients treated with dupilumab to 54 CRSwNP patients who underwent FESS with both cohorts treated with topical corticosteroids. The primary endpoints were change in NPS and change in overall SNOT-22 score. Secondary endpoints were change in SNOT-22 domain scores and change in SNOT-22 olfaction score.

RESULTS

FESS patients had a greater improvement in NPS (5.18 ± 2.01) compared to dupilumab patients (4.27 ± 1.98, p=0.02). There was no significant difference in terms of the change in overall SNOT-22 score. Dupilumab patients had greater improvement in the extra-nasal rhinologic SNOT-22 domain scores (4.87 ± 3.91) compared to FESS patients (2.93 ± 4.32, p=0.02). There was a greater improvement in the SNOT-22 olfaction scores for dupilumab patients (2.35 ± 2.17) compared to FESS patients (1.48 ± 2.24, p=0.04). Dupilumab patients were followed on average for 12.20 months and FESS patients for 17.90 months.

CONCLUSIONS

Overall, both therapies are effective at reducing symptoms in patients with CRSwNP by SNOT-22. Dupilumab patients reported improved olfaction and decreased cough, post-nasal drainage, and thick nasal drainage as compared to FESS patients while FESS patients had a greater reduction in polyp burden. This article is protected by copyright. All rights reserved.

Economic Evaluation of Dupilumab versus Endoscopic Sinus Surgery for the Treatment of Chronic Rhinosinusitis with Nasal Polyps

BACKGROUND

Dupilumab is a novel monoclonal antibody that recently received FDA approval for the treatment of chronic rhinosinusitis with nasal polyps (CRSwNP). Endoscopic sinus surgery (ESS) has been the mainstay of treatment for patients refractory to initial medical therapy. Data comparing the cost-effectiveness of these treatments is scarce. The objective of this study is to compare the cost-effectiveness of dupilumab and ESS treatment for patients with CRSwNP refractory to medical therapy.

METHODS

A cohort-style Markov decision tree economic evaluation with 10-year time horizon was performed. The two comparative treatment strategies were dupilumab therapy or ESS followed by postoperative maintenance therapy. Patients with response to treatment continued with either maintenance or dupilumab therapy; patients with no response underwent ESS. The primary outcome measure was incremental cost per quality-adjusted life year (QALY) calculated from sino-nasal outcome test (SNOT-22) scores. Sensitivity analyses were performed including discounting scenarios and a probabilistic sensitivity analysis.

RESULTS

The dupilumab strategy cost $195,164 and produced 1.779 QALYs. The ESS strategy cost $20,549 and produced 1.526 QALYs. This implies an incremental cost of $691,691 for dupilumab for every one-unit increase in QALY compared with ESS. Probability sensitivity analysis indicated that ESS was more cost-effective than dupilumab in all iterations.

CONCLUSIONS

While dupilumab and ESS may demonstrate similar clinical effectiveness, ESS remains the most cost-effective treatment option and should remain standard of care for CRSwNP patients refractory to medical therapy. This article is protected by copyright. All rights reserved.

Risk Model Establishment of Endoscopic Sinus Surgery for Patients with Chronic Rhinosinusitis: a Multicenter Study in Korea

BACKGROUND

Endoscopic sinus surgery (ESS) is the mainstay treatment for refractory chronic rhinosinusitis (CRS). Since various factors may contribute to the surgical outcome, it is challenging for physicians to predict surgical outcomes. The aim of study was to analyze the prognostic factors of postoperative outcomes and to establish the prediction model with the risk factors that impact the postoperative outcomes.

METHODS

Medical records of CRS patients who underwent ESS at 9 institutions in 2005, 2010, and 2016 were retrospectively reviewed. We classified the patients into 2 groups based on postoperative objective endoscopic outcomes. Demographics, nose-specific symptoms, olfactory function, eosinophil counts in blood (EoB) and nasal tissue (EoT), and Lund-Mackay CT score (LMS) were collected. Univariate and multivariate analyses were performed and established a prediction equation for postoperative endoscopic objective outcomes.

RESULTS

In total (n = 1,249), 27.0% were not satisfied under postoperative endoscopic examination. Of 10 variables, LMS (> 5), sinus dominancy (maxillary sinus and ethmoid sinus), EoB (> 210), and EoT (> 100) were statistically significant in univariate analysis (P < 0.05, all). In multivariate analysis, EoT (> 100) and LMS (> 5) were significantly associated with poor postoperative outcome. Furthermore, 5 significant variables were employed to establish the risk model of postoperative outcomes and P (the value of prediction probability) = 1 / (1 + exp [-0.392 + 1.088 × EoT (> 100) + 0.123 × mean LMS (> 5) - 0.366 × sinus dominancy (maxillary) + 0.064 × sinus dominancy (similar) + 0.200 × EoB (4%) + 0.344 × EoB (> 210)] was developed.

CONCLUSION

Tissue eosinophil count and radiographic severity predispose to a poorer outcome of ESS and the risk model established may be helpful to predict postoperative outcomes of ESS.

Canadian Rhinology Working Group consensus statement: biologic therapies for chronic rhinosinusitis

BACKGROUND

Recent evidence suggests that biologic therapy with targeted activity within the Type 2 inflammatory pathway can improve the clinical signs and symptoms of chronic rhinosinusitis with nasal polyposis (CRSwNP). There remains a population in CRSwNP that despite medical therapy and endoscopic sinus surgery have persistent signs and symptoms of disease. Therefore, biologics, monoclonal antibody agents, could be beneficial therapeutic treatments for these patients. There have been eight randomized, double-blind, placebo-controlled trails performed for CRSwNP targeted components of the Type 2 inflammatory pathway, notably interleukin (IL)-4, IL-5 and IL-13, IL-5R, IL-33, and immunoglobulin (Ig)E. However, there are no formal recommendations for the optimal use of biologics in managing Chronic Rhinosinusitis (CRS) within the Canadian health care environment.

METHODS

A Delphi Method process was utilized involving three rounds of questionnaires in which the first two were completed individually online and the third was discussed on a virtual platform with all the panelists. 17 fellowship trained rhinologists across Canada evaluated the 28 original statements on a scale of 1-10 and provided comments. A rating within 1-3 indicated disagreement, 8-10 demonstrated agreement and 4-7 represented being neutral towards a statement. All ratings were quantitively reviewed by mean, median, mode, range and standard deviation. Consensus was defined by removing the highest and lowest of the scores and using the "3 point relaxed system".

RESULTS

After three rounds, a total of 11 statements achieved consensus. This white paper only contains the final agreed upon statements and clear rationale and support for the statements regarding the use of biologics in patients with CRS.

CONCLUSION

This white paper provides guidance to Canadian physicians on the use of biologic therapy for the management of patients with CRS, but the medical and surgical regimen should ultimately be individualized to the patient. As more biologics become available and additional trials are published we will provide updated versions of this white paper every few years.

Crosstalk Between Mucosal Inflammation and Bone Metabolism in Chronic Rhinosinusitis

Chronic rhinosinusitis (CRS) is a multifactorial and highly heterogeneous upper airway disease that affects approximately 12% of the general population. There is increasing evidence supporting the impact of osteitis on the pathophysiology of CRS. Osteitis is frequently observed in patients with CRS, and is associated with severe sinonasal inflammation and recalcitrant cases. The overlying inflammatory sinonasal mucosa plays a critical role in the initiation of osteitis; however, the underlying molecular mechanisms and functional significance remain unclear. Increasingly many studies have suggested that immune cells play a crucial role in the bone remodeling process in CRS. The purpose of this review is to summarize the current state of knowledge regarding the specific role of sinonasal inflammation in bone remodeling in CRS patients.

Neutrophils as a Protagonist and Target in Chronic Rhinosinusitis

Neutrophils have traditionally been acknowledged as the first immune cells that are recruited to inflamed tissues during acute inflammation. By contrast, their importance in the context of chronic inflammation has been studied in less depth. Neutrophils can be recruited and are largely present in the nasal mucosa of patients with chronic rhinosinusitis (CRS) both in Asians and in Caucasians. Increased infiltration of neutrophils in patients with CRS has been linked to poor corticosteroid response and disease prognosis. Meanwhile, tissue neutrophils may possess specific phenotypic features distinguishing them from resting blood counterparts and are endowed with particular functions, such as cytokines and chemokines production, thus may contribute to the pathogenesis of CRS. This review aims to summarize our current understanding of the pathophysiologic mechanisms of CRS, with a focus on the roles of neutrophils. We discuss recruitment, function, and regulation of neutrophils in CRS and outline the potential therapeutic strategies targeting neutrophils.

Treatment Outcomes in Chronic Rhinosinusitis Refractory to Maximal Medical Therapy: A Prospective Observational Study Under Real-World Conditions

This investigation explored the outcomes of 4 standardized treatments in patients with refractory chronic rhinosinusitis (CRS), despite recent maximal medical therapy (MMT). In a prospective observational study, we compared continued nasal steroids and irrigation (cNSI), repeated MMT (rMMT), pulsed nasal steroid inhalation (PSI), and endoscopic sinus surgery (ESS). Between November 2015 and March 2016, patients with symptomatic CRS despite having received MMT during the year prior to symptom reoccurrence were offered 1 of 4 standardized treatments. Reflecting real-world conditions, patients selected their treatment option following physician counseling. Sino-Nasal Outcome Test-22 (SNOT-22) scores were obtained before treatment, at the end of treatment, and at 2 months and 1 year following treatment. The mean (± standard deviation [SD]) duration since last MMT was 144 (±36 days). Of the 130 patients, 52 selected cNSI, 16 PSI, 19 rMMT, and 43 ESS. Mean SNOT-22 scores before treatment did not significantly differ between treatments (P = .99). Overall, SNOT-22 scores decreased from 38 ± 2 before treatment to 20 ± 2 after 1 year (P < .001), with a higher reduction for patients having CRS with nasal polyps than for those without nasal polyps (35 ± 2 to 15 ± 2 vs 41 ± 3 to 25 ± 4, respectively; both P < .001). Overall, no difference between the 3 medical treatments was observed (all P > .2). Post-treatment scores following ESS (19 ± 2) were significantly lower than for each of the 3 medical treatments (cNSI 26 ± 2, P = .004; PSI 27 ± 3, P = .026; rMMT 28 ± 3, P = .008). At 1 year following ESS, 26 of 31 patients were asymptomatic and did not require additional systemic steroids, compared to 25 of 50 patients following medical treatment (P = .002). The investigated standardized treatments significantly improved SNOT-22 scores in patients with refractory CRS under real-world conditions. Both patients having CRS with and those without nasal polyps showed significant improvement in SNOT-22 scores, although a less profound effect was found among the latter group. Patients who selected ESS were less symptomatic during the first follow-up year than patients who selected medical treatment alone. Patients with refractory CRS did not benefit from an additional course of MMT in comparison to those who were treated only with cNSI.

Levels of total IgA and IgA subclasses in the serum of chronic rhinosinusitis patients

Background: Different inflammatory mechanisms take part in the immunopathogenesis of chronic rhinosinusitis (CRS). Immunoglobulin (Ig) A is the first-line defense in the airway tracts and other mucosal sites, but little is reported regarding its serum level in CRS patients. The purpose of current study is to determine the serum levels of total IgA, and its subclasses (IgA1, and IgA2) in CRS with nasal polyps (CRSwNP), CRS without nasal polyps (CRSsNP), and control groups.

Methods: In this case-control study the serum levels of total IgA and IgA subclasses were determined by Nephelometry and ELISA methods, respectively. The difference of the median concentrations was analyzed with the Kruskal-Wallis test. Collected data were analyzed using SPSS and presented by GraphPad Prism software.

Results: A total of 10 CRSwNP patient, 10 CRSsNP patients and 10 healthy controls participated in our study. The mean age of the groups were 38.2±12.6, 25.6±10.54, and 30.1±9.5, respectively. The concentrations of total IgA were 156(120-165), 165 (149-173), and 172 (152.8-184.3) mg/dl, respectively. The concentrations of IgA1 were 107 (77.9-169.9), 156.1(112.8-175.6), and 130.4 (118.8- 175.2) mg/dl, respectively. The concentrations of IgA2 were 26.11 (18.41-38.11), 26.96 (15.48-38.39), and 23.2 (18.42-31.78) mg/dl, respectively. There was no significant difference in total IgA (p=0.120), IgA1 (p=0.397) and IgA2 (p=0.925) serum levels among three groups.

Conclusion: Our study showed there is no difference in total IgA and IgA subclasses in the serum of CRS patients in comparison to healthy controls.

Symptom control in chronic rhinosinusitis is an independent predictor of productivity loss

AIMS

Sinonasal symptoms cause significant productivity losses in patients with chronic rhinosinusitis (CRS). Patient-perceived CRS symptom control is a longitudinal measure of CRS symptomatology and is directly associated with general health-related quality of life (QOL) in patients with CRS. The aim of this study was to better understand the relationship between symptom control and productivity loss in CRS.

MATERIALS AND METHODS

Prospective cross-sectional cohort study of 200 patients with CRS. Patients categorized their CRS symptom control as "Not at all", "A little", "Somewhat", "Very", and "Completely". Lost productivity was assessed by determining the number of work and/or school days missed in the last 3 months due to CRS symptoms. Sinonasal symptom severity was measured using the 22-item Sinonasal Outcomes Test (SNOT-22). Associations were sought between lost productivity and patient-perceived CRS symptom control.

OBJECTIVE

To determine the association between patient-perceived longitudinal symptom control and productivity in patients with CRS.

RESULTS

A total of 200 participants (48% male, 52% female), with a mean age of 52 years (Standard Deviation [SD]: 16) were enrolled. The mean SNOT-22 score of participants was 33.5 (SD: 22.4). Participants missed a mean of 3 days (SD: 10) of work or school due to CRS. CRS symptom control classified as "not at all" was associated with 11 days of lost productivity due to CRS on univariate analysis (β=11.16, 95% CI: 5.39-16.94, P<0.001) and 8 days of lost productivity on multivariate analysis (β=8.02, 95% CI: 1.92-14.13, P=0.011). None of the other categories of patient-reported CRS symptom control were associated with lost productivity due to CRS.

CONCLUSIONS

Patient-perceived control of CRS symptoms, an important metric previously shown to be significantly associated with QOL in CRS patients, is independently associated with lost productivity. These results motivate longitudinal studies to determine if improvement of CRS symptom control may reduce losses in productivity.

Impact and Modulations of Peripheral and Edaphic B Cell Subpopulations in Chronic Rhinosinusitis With Nasal Polyposis

Objectives

The pathophysiological mechanisms of chronic rhinosinusitis with nasal polyposis (CRSwNP) still are discussed controversially. Regulatory B cells (B_reg) are responsible for the suppression of T cell activity: deficiencies for B_reg have been demonstrated to contribute to autoimmune disorders, e.g., systemic lupus erythematosus. In order to evaluate the influence of B cell subpopulations, especially B_reg, on the etiology of this disease, the aim of this study was to characterize subpopulations of peripheral and edaphic B cells in CRSwNP.

Methods

Polypoid tissue and blood samples were collected from 10 patients undergoing paranasal sinus surgery and lymphocytes were analyzed by multicolor flow cytometry.

Results

There was a significantly lower frequency of B cells in nasal polyps compared to peripheral blood mononuclear cells (PBMC) in patients with CRSwNP. Mature resting B cells were the main population within B cells in PBMC, and memory B cells in nasal polyps. Remarkably, B_reg and mature B cells significantly decreased in nasal polyps compared to PBMC. Memory B cells significantly increased and represented the main subpopulation in nasal polyps in patients with CRSwNP.

Conclusion

In this study a detailed contemporary characterization of B cell subpopulations in patients with CRSwNP is presented. The influence of edaphic B cells could play a key role in the maintenance of this chronic infectious disease.

Clinical implications of microbial biofilms in chronic rhinosinusitis and orbital cellulitis

Background

Discovery of sessile mode of microbial existence (Biofilm state) focussed much interest, during the recent years, on the study of biofilms in many recurring and chronic infections. However, the exact role of microbial biofilms in chronic rhinosinusitis and orbital cellulitis were not elucidated earlier. The purpose of the present study was to look for the adherent property and biofilm producing ability of the clinical isolates in chronic rhinosinusitis and orbital cellulitis, and to look for the effects of antimicrobial agents on these biofilms by colorimetric assay and ultrastructural analysis.

Methods

Organisms were isolated and identified from various clinical samples in patients with chronic sinusitis and orbital cellulitis. Antimicrobial sensitivity testing was carried out by the standard protocol. Biofilms were developed; quantified and antimicrobial drug perfusion through the biofilm model was evaluated by the earlier devised procedure. Electronmicroscopic study of the biofilm was performed by the recommended technique.

Results

Of the total of 70 clinical samples processed, 48 i.e. 68.5 % grew bacteria and 13 i.e.(18.6 %) fungi. Staphylococcus aureus (20), S epidermidis (16) and Pseudomonas aeruginosa (6) accounted for the majority of the bacterial isolates. Aspergillus flavus (8), however was the commonest amongst the fungi. A total of 40 bacteria and 8 fungi could be tested for biofilm production. Eighteen (45 %) of the 40 bacterial isolates and 4(50 %) out of the 8 A flavus isolates were found to be biofilm producers. In vitro adherence testing revealed that majority i.e. 16 (88.8 %) of the 18 biofilm positive bacteria were adherent to artificial surfaces. Antimicrobial drug perfusion through the biofilm model was poor. Antimicrobial treatment was totally ineffective against strong biofilm producers, whose electron microscopic picture was quite similar to that observed for biofilm producers without any antimicrobial pre-treatment.

Conclusions

Filamentous fungi, like bacteria were capable of forming biofilms, which could be one of the important virulence factors in determining the pathogenic potential of these organisms in causing chronic rhinosinusitis and orbital cellulitis.

The Lung Function Impairment in Non-Atopic Patients With Chronic Rhinosinusitis and Its Correlation Analysis

Objectives

Chronic rhinosinusitis (CRS) is common disease in otorhinolaryngology and will lead to lower airway abnormality. However, the only lung function in CRS patients and associated factors have not been much studied.

Methods

One hundred patients with CRS with nasal polyps (CRSwNP group), 40 patients with CRS without nasal polyps (CRSsNP group), and 100 patients without CRS were enrolled. The difference in lung function was compared. Meanwhile, CRSwNP and CRSsNP group were required to undergo a bronchial provocation or dilation test. Additionally, subjective and objective outcomes were measured by the visual analogue scale (VAS), 20-item Sino-Nasal Outcome Test (SNOT-20), Lund-Mackay score, Lund-Kennedy endoscopic score. The correlation and regression methods were used to analyze the relationship between their lung function and the above parameters.

Results

The forced expiratory volume in 1 second (FEV₁) and forced expiratory flow between 25% and 75% of forced vital capacity (FEF_25-75) of CRSwNP group were significantly lower than other groups (P<0.05). On peak expiratory flow, there was no difference between three groups. In CRSwNP group, FEV₁ was negatively correlated with peripheral blood eosinophil count (PBEC) and duration of disease (r=–0.348, P=0.013 and r=–0.344, P=0.014, respectively), FEF_25-75 negatively with VAS, SNOT-20 (r=–0.490, P=0.028 and r=–0.478, P=0.033, respectively) in CRSsNP group. The incidence of positive bronchial provocation and dilation test was lower in CRSwNP group (10% and 0%, respectively), with both 0% in CRSsNP group. The multiple linear regression analysis indicated that change ratio of FEV₁ before and after bronchial provocation or dilation test were correlated with PBEC in CRSwNP group (β=0.403, P=0.006).

Conclusion

CRS leading to impaired maximum ventilation and small airway is associated with the existence of nasal polyp. Lung function impairments can be reflected by PBEC, duration, VAS, and SNOT-20. In CRSwNP patients, PBEC is independent predictor of FEV₁ change ratio.

Schizophyllum commune: an emergent or misdiagnosed fungal pathogen in rhinology?

Schizophyllum commune is a common basidiomycete fungus that is rarely involved in human disease. The medical records of patients operated on for fungal rhinosinusitis (FRS) in two University Hospitals between 2012 and 2014 were reviewed. Within the two-year survey, six female, and notably no male, patients were diagnosed with S. commune rhinosinusitis. Mean age was 44.6 years at diagnosis (30 to 68 years). Mean time between onset of symptoms and diagnosis was 8.5 months (2 to 12 months). All six patients were immunocompetent and had no particular host factor for FRS. S. commune was identified using MALDI-TOF mass spectrometry and identifications were confirmed via DNA sequence analysis. Chronic invasive fungal rhinosinusitis was diagnosed in three of our six patients. Based on histological findings, antifungal treatment was delivered in association with surgery. The basidiomycete fungus S. commune is an emerging cause of rhinosinusitis probably as a direct consequence of the recent technological progress in fungal identification methods (DNA sequencing and MALDI-TOF mass spectrometry).

Cost efficient workup and management of patients with chronic rhinosinusitis - challenges and unmet needs

Chronic rhinosinusitis (CRS) is a common disease, estimated to occur in 12-16% of the United States population. This prevalence creates a significant health burden with an estimated 15 million ambulatory visits for the condition annually. Consequently, practice guidelines have been designed to assist both the primary care provider and specialist in establishing a CRS diagnosis and prescribing effective treatment for CRS. The guidelines for CRS diagnosis have evolved since the United States Rhinosinusitis Task Force first published its symptom-based guidelines in 1997. Contemporary practice guidelines still require 12 weeks of appropriate symptoms, but now include corroboration of objective sinonasal inflammation demonstrated on physical exam, imaging, or endoscopy to arrive at a CRS diagnosis. While these diagnostic criteria are seemingly straightforward and are regarded as the gold standard for the diagnosis, the appropriate timing of imaging and endoscopy remain unspecified and continue to present challenges for both primary care and specialty providers. These considerations have to be measured by the direct and indirect costs of the diagnostic workup including office visits, CT scanning, endoscopy, as well as the potential for overuse of treatment modalities such as antibiotics and steroid medications. The goal of this review is to update the primary care provider and otolaryngologist on current evidence regarding the diagnosis and treatment of chronic rhinosinusitis, including the costs and timing of endoscopy and imaging.

Treatment and outcomes of chronic rhinosinusitis in children with primary ciliary dyskinesia: where is the evidence? A qualitative systematic review

BACKGROUND

Consensus on treatment of chronic rhinosinusitis (CRS) in children with primary ciliary dyskinesia (PCD) is limited. We sought to synthesize the best available evidence pertaining to treatment and outcomes of CRS in children with PCD.

METHODS

This work is a systematic review of PubMed and EMBASE for studies pertaining to treatment and outcomes of CRS in children with PCD in a 20-year period. Two reviewers independently extracted information on study design, setting, medical or surgical therapy for CRS, and treatment outcomes.

RESULTS

Twelve studies from 8 countries were included for analysis: (3 retrospective cohorts, 2 prospective cohorts, 2 cross-sectional, 1 case series, and 4 case reports). The number of patients with PCD ranged from 1 to 78. Medical treatment included oral antibiotics, intranasal steroids, and oral steroids. Surgical treatment was mentioned in 8 studies, with endoscopic sinus surgery (ESS) described in 3 of 8. Outcome measures were rarely defined but included the 20-item Sino-Nasal Outcome Test (SNOT-20) questionnaire (1/12), symptom questionnaire (1/12), decreased recurrent pneumonia (1/12), and subjective report of CRS symptoms. No randomized, controlled, or long-term prospective cohort studies were identified, and no study employed a disease-specific, pediatric-validated instrument to measure outcomes of therapy.

CONCLUSION

There is a paucity of evidence pertaining to CRS treatment or outcomes in children with PCD. Given the rare prevalence of PCD and the insufficient evidence pertaining to treatment effectiveness for CRS, we propose an international, multicenter database to prospectively track data pertaining to diagnosis, treatment, and outcomes of CRS for children with PCD. This effort would encourage implementation of validated and standardized outcome measures.

Atopic profile of patients failing medical therapy for chronic rhinosinusitis

BACKGROUND

Chronic rhinosinusitis (CRS) is an inflammatory condition of the nasal airway and paranasal sinuses that can broadly be classified into CRS with nasal polyps (CRSwNP) and CRS without nasal polyps (CRSsNP). The relationship between CRS and atopy to inhalant allergens remains unclear. We sought to examine the presence of atopy in patients failing medical therapy for both types of CRS. The objective of this research was to analyze the frequency and distribution of allergen sensitivity in patients failing medical therapy for CRSwNP and CRSsNP in comparison to rhinitis patients without CRS and the general population.

METHODS

A prospectively collected database of 334 consecutive CRS patients who had surgery after failing maximal medical therapy was queried to identify those who met inclusion criteria: a sinus computed tomography (CT), an endoscopy consistent with CRS, and skin-prick testing with 24 common inhalant allergens in 8 classes at our institution (n = 125). Additionally, data from these CRS patients were compared to a group of 50 patients diagnosed with rhinitis who had similar symptoms but radiologically normal CT scans, as well as published normative population skin-prick testing data obtained from the National Health and Nutrition Examination Study III (NHANES III). The relationship between atopy, as assessed by the frequency of skin test positivity, and radiological disease severity, was assessed for several allergen classes in CRSwNP, CRSsNP and rhinitis patients.

RESULTS

One or more positive skin results were observed in 103 of 125 (82.4%) CRS patients who underwent surgery--a prevalence significantly higher than that found in the NHANES III study (p < 0.05) but not different from the rhinitis control group (36/50, 72.0%). The most prevalent positive skin test results were to dust mites and ragweed in CRSwNP, CRSsNP, and rhinitis patients. Comparing these 3 patient groups, there were no significant differences in the rates of positive skin-test results to any single allergen. However, the median number of skin test–positive results was higher in CRSwNP patients compared to CRSsNP and rhinitis patients. Consistent with other studies, we found that CRSwNP patients were more likely to be male and have concurrent asthma.

CONCLUSION

In our series of patients failing medical therapy for CRS, we found higher rates of atopy compared with the general population but not compared with rhinitis patients. CRSwNP patients with medically refractory sinusitis were more likely to have multiple positive skin tests and asthma as compared to the general population or patients with either CRSsNP or rhinitis. Host barrier dysfunction may play a role in enabling multisensitization.