Causal association of gastroesophageal reflux disease with chronic sinusitis and chronic disease of the tonsils and adenoids

BACKGROUND

Exploring bidirectional causal associations between gastroesophageal reflux disease (GERD) and chronic disease of the tonsils and adenoids and chronic sinusitis, respectively.

METHODS

We first conducted a TSMR (two-sample mendelian randomization) study using the results of the inverse variance weighting method as the primary basis and bidirectional MR to rule out reverse causation. Subsequently, MVMR (multivariate MR) analysis was performed to identify phenotypes associated with SNPs and to explore the independent effect of GERD on two outcomes. Finally, we calculated MR-Egger intercepts to assess horizontal polytropy and Cochran's Q statistic to assess heterogeneity and ensure the robustness of the study.

RESULTS

For each standard deviation increase in genetically predicted GERD rate, there was an increased risk of chronic disease of the tonsils and adenoids (OR 1.162, 95% CI 1.036-1.304, P: 1.06E-02) and of developing chronic sinusitis (OR 1.365, 95% CI 1.185-1.572, P: 1.52E-05), and there was no reverse causality. Causality for TSMR was obtained on the basis of IVW (inverse variance weighting) and appeared to be reliable in almost all sensitivity analyses, whereas body mass index may be a potential mediator of causality between GERD and chronic sinusitis.

CONCLUSION

There is a causal association between GERD and chronic disease of the tonsils and adenoids and chronic sinusitis, respectively, and the occurrence of GERD increases the risk of developing chronic disease of the tonsils and adenoids and chronic sinusitis.

Allergy and Asthma Prevalence and Management Across Nasal Polyp Subtypes

Allergy and asthma prevalence vary across different subsets of chronic rhinosinusitis with nasal polyposis. In this article, the authors investigate the management of allergy and asthma within populations of patients with aspirin-exacerbated respiratory disease, allergic fungal rhinosinusitis, and central compartment atopic disease. Topical steroids, nasal rinses, and endoscopic sinus surgery are frequently employed in the management of nasal polyposis. Further, other causes of upper and lower airway inflammation like allergy and asthma should be considered in the overall treatment plan in order to optimize outcomes.

Prevalence of Tonsilloliths in Chronic Rhinosinusitis: A Retrospective CT PNS Study

To determine the prevalence of tonsilloliths in CT PNS (Computed Tomography ParaNasal Sinuses) of patients with and without features of chronic rhinosinusitis. 97 CT PNS of the patients with features of chronic rhinosinusitis were included in the study group, and 124 CT PNS of cases without features of chronic rhinosinusitis were taken as the control group. All 221 CT PNS were then evaluated for the presence of tonsillar calcifications indicative of tonsilloliths and the prevalence of the same in the study and control groups. 97 of the 221 CT PNS evaluated showed features of chronic rhinosinusitis. 60 of these 97 CT PNS showed features of tonsillolith in one or both tonsils. Of these 60 cases, 58 had maxillary sinusitis, and 17 had pansinusitis. Most of the cases had small tonsilloliths (1-3 mm), and only one case had a large tonsillolith (> 6 mm). At the same time, 27 out of the remaining 124 CT PNS without chronic rhinosinusitis showed the presence of tonsilloliths in one or both tonsils. The prevalence of tonsilloliths is significantly higher in patients with chronic rhinosinusitis than in the control group. The presence of tonsilloliths in patients with chronic rhinosinusitis indicates repeated inflammation of the tonsils due to sinusitis. Such chronic inflammation of the mucosa of the pharynx should prompt more aggressive treatment of chronic rhinosinusitis.

Clinical and imaging features of ethmomaxillary sinus compared to Haller's cell

PURPOSE

Understanding the anatomy of the paranasal sinuses and their variations is essential to achieving safe and effective endoscopic sinus surgery. The ethmomaxillary sinus (EMS) is a relatively under-researched anatomical variation. This study investigated the prevalence, clinical features, and effect of EMS on the maxillary sinus in comparison with Haller's cells.

METHODS

Patients who visited the Rhinology Clinic at our hospital for rhinologic symptoms between January 2020 and December 2020. Computed tomography (CT) scans of paranasal sinuses were obtained at 1 mm-section thickness. Using CT scans, we investigated the clinical features of EMS, measured maxillary sinus volume, and analyzed the presence of maxillary sinusitis.

RESULTS

EMS was observed in 26 of the 250 patients (10.4%). The male-to-female ratio was equal. The age ranged from 18 to 83 years (mean age, 56.3). Of the patients with EMS, 65.4% were unilateral and 34.6% were bilateral. The prevalence of Haller's cells was similar to that in EMS (10.8%). In the analysis of patients with unilateral EMS, the EMS side was found to have a significantly reduced maxillary sinus volume compared to the opposite side, whereas the difference was not significant in Haller's cells. There was no significant relationship between EMS or Haller's cells and maxillary sinusitis.

CONCLUSIONS

EMS can significantly affect maxillary sinus volume. Therefore, surgeons should thoroughly review PNS CT scans before paranasal sinus surgery to determine the presence and features of EMS.

Our Experience of Surgically Managing Orbital Complications Due to Chronic Sinusitis: A Case Series

Despite antibiotic treatment applied in Otorhinolaryngology, orbital complications due to chronic rhinosinusitis are considered a threat to the functions of the eyes. If timely intervention is not provided, orbital complications could rapidly progress to optic neuritis or life-threatening intracranial complications. A retrospective study included four patients between the ages of 29-70 years with orbital complications due to chronic sinusitis. Diagnosis was based on history, clinical examination, and imaging. In all cases, treatment was initiated with intravenous antibiotics and steroids. Surgical intervention was performed in all the patients when symptoms failed to resolve after 48 h of intravenous treatment. In our study, we encountered patients with orbital complications which included pre-septal cellulitis (75%) and frontal sinus fistula (25%). Average time of hospital stay was 9.5 days. All patients underwent surgery after 48 h of intravenous treatment and showed resolution of orbital symptoms within 2-6 months post-operatively. No recurrences have been encountered till date. Orbital complications are severe pathologies which require immediate attention and aggressive treatment via endoscopic approach as well as antimicrobial treatment to prevent unwanted threat to life.

Characterizing Adverse Events of Biologic Treatment of T2 Disease: A Disproportionality Analysis of the FDA Adverse Event Reporting System

INTRODUCTION

Over the last 3 years, the FDA has approved dupilumab, omalizumab, and mepolizumab for the treatment of CRSwNP; however, adverse events of these biologics have not been described in post-marketing surveillance trials. By utilizing the FDA Adverse Event Reporting System (FAERS), this study describes and compares biologic-associated adverse events in T2 disease.

METHODS

This case-non-case study assessed disproportionate reporting rates using reporting odds ratios (RORs). RORs and p values for biologic-associated AEs were categorized and compared among dupilumab, omalizumab, and mepolizumab. This analysis included AEs associated with all treatment indications. Relative AE rates and outcomes were calculated.

RESULTS

There were a total of 112,560, 24,428, and 18,741 unique AE reports associated with dupilumab, omalizumab, and mepolizumab, respectively. Omalizumab had the strongest association with anaphylaxis (ROR = 20.80, 95% confidence interval [CI]: 18.58, 23.29). Dupilumab had large relative proportions and positive signals in the ophthalmologic category (7.76%, ROR = 6.20, 95% CI: 6.06, 6.35), such as with blurry vision (ROR = 3.80, CI: 3.52, 4.12) and visual impairment (ROR = 1.98, CI: 1.80, 2.19). Dupilumab was the only biologic associated with injection-site reactions (7.98%, ROR = 8.17, 95% CI: 7.98, 8.37).

DISCUSSION/CONCLUSION

This is the first large-scale comparative analysis of the AE profiles of dupilumab, omalizumab, and mepolizumab. Our data suggest possible relations between dupilumab and ophthalmologic and injection-site AEs. Omalizumab was the only biologic with a positive anaphylaxis signal. This FAERS investigation suggests important AE differences among these biologics.

Allergic fungal rhinosinusitis and eosinophilic mucin chronic rhinosinusitis: Differential diagnostic criteria. A two-center comparative study following STROBE methodology

OBJECTIVES

Allergic fungal rhinosinusitis (AFRS) and eosinophilic mucin chronic rhinosinusitis (EMRS) are two forms of chronic sinusitis distinguished by the presence (AFRS) or absence (EMRS) of fungal elements in sinus mucin. Detection of the fungal elements, however, is complex and it is difficult to say whether EMRS is in fact an entity distinct from AFRS. The aim of the present study, based on a retrospective series of AFRS and EMRS, was to identify the specific clinical and radiological elements distinguishing between the two.

MATERIALS AND METHODS

A 2-center retrospective observational study following STROBE guidelines included patients managed for AFRS or EMRS between 2009 and 2022. Clinical, mycological, pathologic and radiological data were collected. Type of treatment and disease progression were also analyzed. Intergroup comparison used Student's test for mean values of quantitative variables, with calculation of P-values, and Pearson's Chi2 test or Fisher's exact test for categoric variables, with calculation of relative risk and 95% confidence intervals.

RESULTS

The AFRS group comprised 41 patients and the EMRS group 34. Demographic data were comparable between groups. EMRS showed a higher rate of asthma (79.4 vs. 31.4%; P<0.001), more severe nasal symptomatology (rhinorrhea, P=0.01; nasal obstruction, P=0.001), and more frequent bilateral involvement (85.3 vs. 58.5%; P=0.021). AFRS showed more frequent complications (19 vs. 0%; P=0.006). Radiologically, mucin accumulation was greater in AFRS, filling the sinus in 84.2% of cases, versus 26.3% (P<0.001), with more frequent sinus wall erosion (19 vs. 5.8%; P=0.073). The recurrence rate was higher in EMRS: 38.2 vs.21.9% (P=0.087).

CONCLUSION

The present retrospective study found a difference in clinical and radiological presentation between AFRS and EMRS, with EMRS more resembling the presentation of severe nasal polyposis.

Chronic Rhinosinusitis With Nasal Polyposis Treated With Dupilumab: Real-World Use and Outcomes

BACKGROUND

Biologic medications are increasingly incorporated into chronic rhinosinusitis with nasal polyps (CRSwNP) management. However, little is known about prescribing patterns in real-world settings and how this relates to proposed international guidelines and outcomes.

OBJECTIVES

To characterize use patterns of dupilumab for CRSwNP better in relation to proposed guidelines and explore real-world outcomes.

METHODS

We used the TriNetX Web-based tool to identify patients who were prescribed dupilumab for CRSwNP. Patients prescribed dupilumab for a CRSwNP indication were included for analysis. Dupilumab initiation criteria were determined via the European Position Paper on Rhinosinusitis and Nasal Polyps 2020 (EPOS2020).

RESULTS

In total, 121 patients were identified who were prescribed dupilumab for a CRSwNP indication. Of these, 86 (71%) met EPOS2020 indications for biologic initiation and 35 (29%) did not. Overall, patients had significant improvements in the 22-item SinoNasal Outcome Test scores (mean improvement of 24.3 points) and nasal polyp scores (mean improvement of 1.0 point). However, 20 patients (30%) did not show meaningful improvement in the 22-item SinoNasal Outcome Test scores. Twenty-one patients (17%) failed a previous biologic attempt. Therapy was discontinued by six patients (5%) due to side effects, and by six (5%) owing to a lack of efficacy.

CONCLUSIONS

In our experience, patients prescribed dupilumab for CRSwNP frequently may not meet EPOS2020 Guidelines. Over 25% of those who do not meet criteria may not have CRSwNP. Overall, dupilumab use among well-selected patients appears to be safe and effective. Further real-world study of biologic use for CRSwNP will help improve its judicious use and identify populations who benefit most from biologic therapies.

Rhino-Cerebral Aspergillosis in an Immunocompetent Patient

Rhino-cerebral aspergillosis is a rare phenomenon describing a contiguous spread of Aspergillus species from the paranasal sinuses to the intracranial space. In this case report, we describe a case of invasive rhino-cerebral aspergillosis arising in the setting of prolonged intranasal steroid use in an 81-year-old patient with chronic sinusitis. This case report emphasizes the importance of recognizing steroid use as a risk factor for invasive aspergillosis in otherwise immunocompetent individuals.

Dose development in sinonasal imaging over the last decade - a retrospective patient study

BACKGROUND

Computed tomography (CT) has become the primary imaging modality for visualization of the paranasal sinuses. In this retrospective, single center patient study the radiation dose development in the past 12 years in CT imaging of the paranasal sinuses was assessed.

METHODS

The computed tomography dose index (CTDIVol) and dose length product (DLP) of a total of 1246 patients (average age: 41 ± 18 years, 361 females, 885 males) were evaluated, who received imaging of the paranasal sinuses either for chronic sinusitis diagnostic, preoperatively or posttraumatically. Scans were performed on three different CT scanners (Somatom Definition AS, Somatom Definition AS+, Somatom Force, all from Siemens Healthineers) and on one CBCT (Morita) ranging from 2010 to 2022. Reconstruction techniques were filtered back projection and three generations of iterative reconstruction (IRIS, SAFIRE, ADMIRE, all from Siemens Healthineers). Group comparisons were performed using either parametrical (ANOVA) or non-parametrical tests (Kruskal-Wallis Test), where applicable.

RESULTS

Over the past 12 years, there was a 73%, 54%, and 66% CTDIVol reduction and a significant (p < 0.001) 72%, 33%, and 67% DLP reduction in assessing the paranasal sinuses for chronic sinusitis, preoperatively and posttraumatically, respectively.

CONCLUSION

Technological developments in CT imaging, both hardware and software based, have led to a significant reduction in dose exposure in recent years. Particularly in imaging of the paranasal sinuses, the reduction of radiation exposure is of great interest due to the often young patient age and radiation-sensitive organs in the area of radiation exposure.

Ectopic Tooth with Odontogenic Keratocyst in Myasthenia Gravis: A Rare Coexistence

Ectopic tooth in nondentate areas is uncommon. Odontogenic keratocyst arising from impacted tooth in the inferior border of orbit is very rare. This article reports the case of a 22-year-old female with odontogenic keratocyst arising from an impacted left maxillary third molar in the inferior border of the orbit causing symptoms of chronic sinusitis. The patient also had myasthenia gravis which confounded the diagnosis. The cyst was surgically enucleated along with the tooth which relieved the symptoms of the patient.

Maxillary sinus volume and facial asymmetry after unilateral zygomaticomaxillary complex fracture reduction with 2, 3, and 4 fixation points: CBCT-based investigation

PURPOSE

This study aimed to assess the maxillary sinus volume (MSV), Chronic Sinusitis incidence, and asymmetry of the zygomaticomaxillary complex (ZMC) following ZMC fracture surgery with various numbers of fixation points.

MATERIALS AND METHODS

In a prospective non-randomized cohort, 50 adults with unilateral ZMC fractures who treated by open reduction and internal fixation (ORIF) between November 2019 and October 2021 were assigned to accomplish this study. They distributed into three groups as per fixation points (2, 3, or 4 Points). Preoperative (T1), Immediate postoperative (T2), and follow-up (T3) cone beam computed topography were analyzed using the Mimics software. The main measures were MSV and asymmetry indexes (ASI) of six paired bilateral anatomical landmarks (Orbital, Suprajugal, Jugale, Zygon, Maxillozygion 1, and Maxillozygion 2).

RESULTS

MSV decreased significantly on the affected sides postoperatively in 2P and 3P groups, both in T2 and T3. Further, the T2-T3 comparisons showed a significant MSV change (p = 0.001). ASI reduced considerably to clinically tolerated levels (<3 mm) on landmarks near the fixation sites postoperatively. The ASI on the Zygon and Maxillozygion 1 landmarks showed significant changes among the three groups in both T2 and T3. Interestingly, only five cases had reported postoperative sinusitis symptoms.

CONCLUSIONS

Although the MSV was changed among the different fixation point groups, the incidence of chronic sinusitis was uncommon. Bilateral asymmetry affected by number and position of the fixation points, fixation with 4 points provide more symmetry.

Sinus culture differences in patients with radiographic evidence of odontogenic disease

PURPOSE

Odontogenic sinusitis is a well-known entity with a different pathogenesis than chronic rhinosinusitis. Nonspecific symptoms can make diagnosis difficult. This study aims to compare culture results between patients with and without computed tomography findings indicative of possible odontogenic disease.

MATERIALS AND METHODS

This was a retrospective cohort study in which patients undergoing endoscopic sinus surgery for chronic sinusitis over a three-year period at a single institution were reviewed. CT imaging was reviewed for evidence of dental disease, specifically periapical lucency, dehiscence of the floor of the maxillary sinus, oroantral fistula, or foreign body. Culture results were then assessed and compared between groups with CT evidence of a possible odontogenic source to those without.

RESULTS

Overall, 231 patients were evaluated. 92 patients (39.8 %) were found to have evidence of a likely odontogenic source on CT. Cultures were available for 118 of 231 patients (51.1 %). Patients with CT signs of odontogenic disease were significantly more likely to grow Proteus mirabilis (p = 0.018) and Klebsiella pneumoniae (p = 0.037) on culture. Patients without CT signs of odontogenic sources were significantly more likely to grow Pseudomonas aeruginosa (p = 0.009). Of note, patients with CT findings concerning for an odontogenic source were also more likely to grow fungi other than Aspergillus and Mucor species on culture (p = 0.004).

CONCLUSION

Patients with CT findings concerning for an odontogenic source of sinus disease showed differences in culture results that could be important in differentiating pathogenesis of sinus disease.

Pheno-Endotyping Antrochoanal Nasal Polyposis

PURPOSE OF REVIEW

Antrochoanal polyps (ACPs) are benign polypoid lesions arising from the inner wall of the maxillary sinus and extending into the choana. Although the diagnosis and treatment strategies of ACP have changed since this entity was first described, the underlying pathogenic mechanism of APC is poorly understood. This article reviews the current knowledge of the etiology, inflammatory parameters, and microscopic findings of ACP.

RECENT FINDINGS

The inflammatory pattern of ACP appears to center around a neutrophilic inflammation T1-dominant endotype. Apart from the inflammatory component of ACP, at the microscopic level, the presence of tissue remodeling, mostly fibrin deposition and edema, and cysts in the epithelium and lamina propria has been described. Although the origin of this T1-dominant endotype immune response of ACPs is not entirely clear, it could be related to a lymphatic obstruction mechanism. This review serves to define a phenotype of ACP with potential endotypes based on the characteristics of the inflammatory parameters, microscopic findings, and hypotheses about the pathogenesis of ACP.

Identification and validation of ferroptosis-related genes for chronic rhinosinusitis with nasal polyps

PURPOSE

Even though the great progress in the field of chronic rhinosinusitis with nasal polyps (CRSwNP) has been achieved, ferroptosis and its molecular mechanism in CRSwNP remain blank. We are the first to study the relationship between CRSwNP and ferroptosis, aiming to identify ferroptosis-related genes in the process of CRSwNP.

METHODS

Using the GEO database and the FerrDb database, significantly differentially expressed ferroptosis-related genes (DEFGs) were selected between CRSwNP-NP and CRSwNP-IT specimens. Then, the protein-protein interaction (PPI) network of ferroptosis-related genes was constructed. Functional enrichment analyses (GSVA, GO, KEGG, and GeneCodis analyses) were introduced in our study. Besides, based on the GSE136825 data set, DEFGs between CRSwNP-NP and CS-IT specimens were also analyzed. Finally, qRT-PCR was performed to validate the selected ferroptosis-related genes with clinical samples.

RESULTS

31 significantly DEFGs were identified between CRSwNP-NP and CRSwNP-IT specimens. Functional enrichment analyses and the analysis of GeneCodis 4 pointed out that DEFGs may potentially be involved in some related KEGG pathways. 8 DEFGs were selected between CRSwNP-NP and CS-IT specimens. The experimental verification indicated that 4 genes (GPX2, CDO1, CAV1, and TP53) were the important DEFGs of CRSwNP. The Venn diagrams proved that CDO1 and GPX2 were considered as the most important DEFGs genes of CRSwNP, especially GPX2.

CONCLUSIONS

Though a comprehensive bioinformatics analysis and the experimental verification, CDO1 and GPX2 were considered as the important ferroptosis-related genes of CRSwNP, especially GPX2. However, further molecular biological experiments would be still required to uncover the underlying mechanism between ferroptosis and CRSwNP.

Periostin is an aggravating factor and predictive biomarker of eosinophilic chronic rhinosinusitis

BACKGROUND

Patients with eosinophilic chronic rhinosinusitis (ECRS) respond poorly to many treatment modalities. Overproduction of periostin in the nasal mucosa is reported to contribute to polyp formation. This study examined periostin levels in patients with ECRS in comparison with levels in patients with non-ECRS.

METHODS

Fifty-nine patients with chronic rhinosinusitis were grouped into those with ECRS and those with non-ECRS. We compared the relationships between peripheral blood eosinophil level, serum periostin level, histopathological findings, clinical and laboratory findings, nose findings, diagnostic score of the Japanese Epidemiological Survey of Refractory Eosinophilic Chronic Rhinosinusitis Study, and postoperative recurrence of nasal polyps in each group.

RESULTS

In the ECRS group, a positive correlation was found between peripheral blood eosinophil level and serum periostin level (r_s = 0.49, P < 0.01: Spearman's rank correlation coefficient). ROC curve analysis was used to evaluate the serum periostin level that could predict postoperative recurrence of nasal polyps in the ECRS group: the area under the curve (AUC) was 0.95, sensitivity was 92%, and specificity was 100%; the serum periostin cutoff value for postoperative recurrence of nasal polyps was 130 ng/ml. In ROC curve analysis to evaluate peripheral blood eosinophil level, the AUC was 0.73, sensitivity was 69.2%, and specificity was 85.0%; the cutoff value was 8.8%.

CONCLUSIONS

periostin was implicated in the pathophysiology of ECRS. Periostin shown to be a more useful biomarker than eosinophils in ECRS. Periostin was shown to likely be an important biomarker for pathological severity of ECRS and postoperative recurrence of nasal polyps.

A Comparative Study of Interventions of Middle Turbinate Medialization in Endoscopic Sinus Surgery

The shape and position of middle turbinate play an important role in ventilation and drainage of the osteomeatal complex. The preservation of middle turbinate is one of the major goals of functional endoscopic sinus surgery (FESS). Middle turbinate intervention is essential to prevent obliteration of osteomeatal complex. The aim of this prospective study is to postulate which middle turbinate intervention is most effective and compare the results with conventional technique. In this randomized controlled study, 60 patients were included of the age group of 15-60 years who presented to the Otorhinolaryngology OPD of our institute between November 2017 to June 2019 with symptoms of chronic sinusitis with clinical and radiological evidence and who underwent FESS. The patients were divided into three group, Group A-Bolgerization (n = 20), Group B-Vicryl-conchopexy (n = 20) and Group C-No intervention, Control group (n = 20). The patency of middle meatus and the status of middle turbinate (medialized or lateralized or neither of the two) was ascertained postoperatively. Improvement in symptoms was also evaluated. The middle turbinate was medialized in 90% of Group A and 95% of Group B cases. The middle turbinate was neither medialized nor lateralized in 70% of patients in Group C. 70% of the patients in Group A and 80% of patients in Group B had complete improvement in symptoms with no recurrence of sinusitis compared to Group C in which only 50% of the patients had improvement in symptoms due to development of synechiae. Medialization of the middle turbinate should be considered as one of the essential steps of FESS as it helps in improving the surgical outcome.

Real-life effectiveness of dupilumab in patients with mild to moderate bronchial asthma comorbid with CRSwNP

BACKGROUND

Dupilumab, an anti-IL-4α receptor antibody, is a new treatment for severe or refractory asthma. However, real-world evidence on the efficacy of dupilumab in patients with mild to moderate bronchial asthma is lacking.

METHODS

We retrospectively evaluated the effects of dupilumab in 62 patients who received dupilumab for eosinophilic sinusitis comorbid with asthma at a single centre in Japan. Type 2 inflammatory markers, ACT, respiratory function tests, and forced oscillation technique (FOT) were analysed before, three months after, and one year after dupilumab administration, mainly in patients with mild to moderate asthma.

RESULTS

FEV1, %FEV1, %FVC, treatment steps for asthma and ACT improved significantly after three months of dupilumab treatment. FeNO was markedly decreased, whereas IgE and eosinophil counts showed no significant changes. Pre- and post-treatment respiratory resistance (Rrs) and respiratory reactance (Xrs) correlated significantly with FEV1. Improvement in %FEV1 was associated with higher FeNO and higher serum IgE before dupilumab treatment.

CONCLUSION

Dupilumab treatment for sinusitis may improve respiratory functions, asthma symptoms, and asthma treatment reduction, even if the associated bronchial asthma is not severe.

ACR Appropriateness Criteria® Sinonasal Disease: 2021 Update

This article presents guidelines for initial imaging utilization in patients presenting with sinonasal disease, including acute rhinosinusitis without and with suspected orbital and intracranial complications, chronic rhinosinusitis, suspected invasive fungal sinusitis, suspected sinonasal mass, and suspected cerebrospinal fluid leak. CT and MRI are the primary imaging modalities used to evaluate patients with sinonasal disease. Given its detailed depiction of bony anatomy, CT can accurately demonstrate the presence of sinonasal disease, bony erosions, and anatomic variants, and is essential for surgical planning. Given its superior soft tissue contrast, MRI can accurately identify clinically suspected intracranial and intraorbital complications, delineate soft tissue extension of tumor and distinguish mass from obstructed secretions.The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Pre-intervention SNOT-22 scores predict outcomes in aspirin exacerbated respiratory disease

PURPOSE

This study evaluated whether stratified preoperative, pre- aspirin desensitization (AD) sinonasal symptom scores predict postoperative, post-AD outcomes in Aspirin exacerbated respiratory disease (AERD).

MATERIALS AND METHODS

Retrospective chart review of patients with aspirin challenge-proven AERD who underwent endoscopic sinus surgery followed by AD was performed. Preoperative, postoperative/pre-AD, and postoperative/post-AD sinonasal symptom scores were collected (22-item Sino-Nasal Outcomes Test, SNOT-22). A longitudinal linear mixed-effects model was used for data analysis.

RESULTS

Forty-seven patients (59.6% female) aged 48.0 ± 13.2 were included. Average time from surgery to AD was 70.0 ± 52.8 days. Preoperative SNOT-22 scores (n = 47) were divided into tertiles (cutoffs of 36 and 54 indicating mild [22.5 ± 13.7], moderate [44.3 ± 12.2], and severe [72.9 ± 19.7] disease). This corresponded to 12 (25.5%), 18 (38.3%), and 17 (36.2%) subjects being categorized into mild, moderate, and severe tertiles, respectively. Postoperative, pre-AD SNOT-22 in all disease groups decreased and were not significantly different (12.3 ± 13.7, 11.1 ± 12.2, 22.7 ± 19.7; p = 0.074). At short-term post-AD, only the severe group worsened (35.0 ± 20.3, p < 0.001), whereas other groups demonstrated negligible change (9.3 ± 14.3 and 14.4 ± 12.2). At long-term post-AD, all groups redemonstrated convergence in symptom scores (23.7 ± 20.9, 19.4 ± 15.4, and 31.0 ± 27.6, p = 0.304).

CONCLUSION

Preoperative SNOT-22 scores may be used as a predictor of postoperative, post-AD patient-reported outcomes in AERD. Patients with mild and moderate disease may derive benefit from surgery and AD alone, while those with severe disease may require additional interventions (e.g., biologics).

Predictors of sinonasal disease onset, progression, and severity in pediatric cystic fibrosis patients

PURPOSE

Pediatric cystic fibrosis (CF) patients have a variable onset, severity, and progression of sinonasal disease. The objective of this study was to identify genotypic and phenotypic factors associated with CF that are predictive of sinonasal disease, recurrent nasal polyposis, and failure to respond to standard treatment.

METHODS

A retrospective case series was conducted of 30 pediatric patients with CF chronic rhinosinusitis with and without polyps. Patient specific mutations were divided by class and categorized into high risk (Class I-III) and low risk (Class IV-V). Severity of pulmonary and pancreatic manifestations of CF, number of sinus surgeries, nasal polyposis and recurrence, age at presentation to Otolaryngology, and Pediatric Sinonasal Symptom Survey (SN-5)/Sinonasal Outcome Test (SNOT-22) scores were examined.

RESULTS

27/30 patients (90%) had high risk mutations (Class I-III). 21/30 (70.0%) patients had nasal polyposis and 10/30 (33.3%) had recurrent nasal polyposis. Dependence on pancreatic enzymes (23/27, 85.2% vs 0/3, 0.0%, p = 0.009) and worse forced expiratory volumes (FEV1%) (mean 79, SD 15 vs mean 105, SD 12, p = 0.009) were more common in patients with high risk mutations. Insulin-dependence was more common in those with recurrent polyposis (5/10, 50% vs 2/20, 10%, p = 0.026). There was no statistical difference in ages at presentation, first polyps, or sinus surgery, or in polyposis presence, recurrence, or extent of sinus surgery based on high risk vs. low risk classification.

CONCLUSION

CF-related diabetes was associated with nasal polyposis recurrence. Patients with more severe extra-pulmonary manifestations of CF may also be at increased risk of sinonasal disease.

The Choice of Biologics in Patients with Severe Chronic Rhinosinusitis with Nasal Polyps

Patients with severe chronic rhinosinusitis with nasal polyps represent an unmet clinical need in terms of recurrent disease despite current medical and surgical therapy. Targeting type 2 inflammatory cytokines (IL4/5/13) appears to be a promising therapeutic approach for such patients akin to what has already been seen in severe asthma. An indirect comparison from phase 3 placebo-controlled trials has shown relative improvements in the coprimary end point of nasal polyp score (NPS) ranging from a 15% reduction (-0.8 units) with mepolizumab, 18% with omalizumab (-1.14 units), and 35% (-2.06 units) with dupilumab. This trend was mirrored by relative improvements in health status with the 22-item Sinonasal Outcome Test score showing a 21% reduction (-13.7 units) with mepolizumab, 27% (-16.1 units) with omalizumab, and 43% (-21.1 units) with dupilumab, all exceeding the minimal clinically important difference of 8.9 units. All biologics improved the coprimary end point of nasal airway blockage and also reduced the need for rescue medical and/or surgical polypectomy. We advocate performing real-life studies looking at the response to biologics in patients who are at increased risk for disease recurrence, including initial optimal medical and surgical polyp clearance before commencing biologics.

Usefulness of endonasal mucoplasty in the surgical treatment of chronic rhinosinusitis with nasal polyps. Prospective study

Chronic Rhinosinusitis with Nasal Polyps (CRScPN) is a disease with great impact on health. The surgical option using endoscopic nasosinus surgery is the therapeutic alternative when control of the disease is not achieved with medical treatment. Extensive endoscopic approaches are being postulated as a possible best surgical treatment option in certain phenotypes of CRScPN. Endonasal mucoplasty associated with these approaches has been shown to be a complementary technique that improves both healing and mucosal oedema in patients with CRScPN in the short term. The aim of our study was to analyse the results of endonasal mucoplasty associated with a complete ethmoid-sphenoidotomy plus grade III frontal sinusotomy in the treatment of CRScPN in the medium term. For this purpose, a prospective case-control study (10/10) was carried out on patients with CRScPN. In the case group, endonasal mucoplasty in the left nostril was associated with surgery, and the control group was not. The assessment of quality of life at one year after surgery, as measured by the mean difference in SNOT-22 (mean [SD]), in the case group was significantly better than in the control group, (45.9 [19.6]-26.6 [16.05], P = 0.027). The endoscopic improvement in healing and mucosal oedema, measured by the Modified Lund-Kennedy scale, showed relevant improvements, when comparing both pits, but without reaching significance (P = 0.29). Endonasal mucoplasty promotes short-term healing, improving the quality of life in the medium term (one year) of patients treated with extensive endoscopic breast resections.

Diversity of cystic fibrosis chronic rhinosinusitis microbiota correlates with different pathogen dominance

Chronic rhinosinusitis (CRS) affects nearly all individuals with cystic fibrosis (CF) and is thought to serve as a reservoir for microbiota that subsequently colonize the lung. To better understand the microbial ecology of CRS, we generated a 16S rRNA gene sequencing profile of sinus mucus from CF-CRS patients. We show that CF-CRS sinuses harbor bacterial diversity not entirely captured by clinical culture. Culture data consistently identified the dominant organism in most patients, though lower abundance bacteria were not always identified. We also demonstrate that bacterial communities dominated by Staphylococcus spp. were significantly more diverse compared to those dominated by Pseudomonas spp. Diversity was not significantly associated with clinical factors or patient age, however, younger subjects yielded a much wider range of bacterial diversity. These data mirror bacterial community dynamics in the lung and provide additional insight into the role of sinus microbiota in chronic airway disease progression.

Middle turbinate resection is unlikely to cause empty nose syndrome in first year postoperatively

PURPOSE

Empty nose syndrome (ENS) is characterized by nasal dryness, crusting, and paradoxical nasal obstruction most commonly after inferior turbinate resection. ENS has also been reported to occur after middle turbinate resection (MTR), and concern for causing ENS is a possible reason surgeons preserve the MT during endoscopic sinus surgery (ESS). The objective was to determine whether MTR during ESS led to ENS.

MATERIALS AND METHODS

This was a prospective case series of 95 consecutive patients that underwent bilateral subtotal MTR during ESS with either Draf IIB or Draf III frontal sinusotomies, for chronic rhinosinusitis with or without nasal polyps, and frontal sinus inverted papillomas. Demographic data and postoperative Empty Nose Syndrome 6-item Questionnaire (ENS6Q) scores were obtained. Nasal crusting was also documented on last postoperative nasal endoscopy.

RESULTS

Pathologies included chronic rhinosinusitis with nasal polyps (69), without nasal polyps (12), and inverted papillomas (14). Fifty-six patients underwent subtotal MTRs during ESS with Draf IIB, and 39 with Draf III. Mean follow-up was 19.4 months (range 12-49). Mean postoperative ENS6Q score was 2.1. Only 2.1% had ENS6Q scores ≥ 11, and 6.3% had nasal crusting at last follow-up. None of the patients with ENS6Q scores ≥ 11 had nasal crusting at last follow-up. There were no significant differences in outcomes between ages, genders, surgery types, or pathologies.

CONCLUSIONS

Patients who underwent bilateral subtotal MTR during ESS were unlikely to develop ENS by at least 1 year postoperatively, based on patients rarely experiencing ENS6Q scores ≥ 11 or persistent nasal crusting.

Assessment of maxillary sinus lifting procedure in the presence of chronic sinusitis, a retrospective comparative study

INTRODUCTION

Chronic sinusitis can be considered a relative contraindication for sinus lifting procedure. However, its specific effects on bone height, infection and healing have not been as well investigated as its incidence as a post-operative complication.

METHODS

A retrospective comparative investigation was executed to evaluate the impact of chronic sinusitis on sinus lifting procedures regarding bone height, infection, and healing scores. Pre-operative and 6-month postoperative records (CBCT or CT and panoramic radiographs) of 40 patients who underwent sinus lifting procedure with graft and implant placement were split into two sets of 20 patients each; Group A is comprised of a patient with healthy sinus, whereas Group B includes patients with chronic sinusitis (identified as the presence of thickening of Schniederian membrane ≥ 2 mm, mucosal cyst, polyp or fluid level). Records of both groups were assessed for the difference in bone height of alveolar ridge between pre-operative radiograph and after six months postoperatively, and clinical notifications at the postoperative follow-up to report the healing and infection scores.

RESULTS

Statistically, there was non-significant difference in mean bone height gain (p-value > 0.05) in comparison to control group mean bone height (8.84 ± 0.93). Also, there was non-significant variation in mean healing and infection scores.

CONCLUSION

According to the available data, chronic sinusitis presenting as a thickening in the Schneiderian membrane has no significant effect on postoperative bone height, healing, or infection score in patients undergoing sinus augmentation with simultaneous implant placement. Further research is needed to better evaluate the effect of chronic sinusitis and its current status as a relative contraindication for sinus lifting procedure.

Emergency radiologic approach to sinus disease

Sinus disease is commonly encountered, especially in the acute care setting. Imaging can support a diagnosis of sinusitis, help identify an etiology, and delineate intracranial and extracranial complications. Suspicion of complicated rhinosinusitis is an indication for contrast-enhanced computed tomography or magnetic resonance imaging. It is important for radiologists to be familiar with patient risk factors that predispose to uncommon but aggressive forms of sinus disease such as invasive fungal sinusitis. Lastly, many conditions, ranging from benign to malignant, can mimic rhinosinusitis clinically and on imaging. Radiologists can help by recognizing these entities and facilitating appropriate referral and follow-up. This article reviews the breadth of sinus disease commonly encountered in the emergency setting, potential complications, and mimics.

Endoscopic maxillectomy: anatomo-radiological description of the "double" maxillary sinus window

OBJECTIVES/HYPOTHESIS

To present a modified endoscopic medial maxillectomy (MEMM) approach to control maxillary sinus pathologies.

METHODS

MEMM was completed in 13 fresh-frozen specimens. An MEMM includes cutting the nasolacrimal duct, inferior meatus flap, and repositioning the inferior turbinate (IT). The following measurements were obtained: length of IT, height from the nasal floor to valve of Hasner, height of the IT at the level of valve of Hasner, height of the IT at the insertion of the middle turbinate, and distance from the piriform aperture to the posterior wall of maxillary sinus and to the posterior border of palatine bone. Similar measurements were also performed on craniofacial computed tomography (CT) scans (n = 50). The surgical technique was performed in a case series (n = 8).

RESULTS

The mean of the specimens was 82 (range 70-95) years old. The average area of the harvested inferior meatus flap area was 9.6 ± 1.0 cm². In the radiologic study, the mean maximum antrostomy area was 8.8 ± 1.7 cm² and the IT area overlapping the antral window was 5.8 ± 1.1 cm², the area allowing a double window control was 3.1 ± 1.9 cm², the posterior IT insertion length was 0.7 ± 0.4 cm, and the inferior meatus flap covering the inferior meatotomy had an area measuring 6.7 ± 1.7 cm². Eight patients underwent MEMM for various benign conditions showing no recurrence after 26 month follow-up.

CONCLUSION

The proposed modifications of MEMM provide a "double" window maxillary sinus control with access to all maxillary walls and preservation of the IT.

Usefulness of endonasal mucoplasty in the surgical treatment of chronic rhinosinusitis with nasal polyps. Prospective study

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a disease with great impact on health. The surgical option using endoscopic sinus surgery is the therapeutic alternative when control of the disease is not achieved with medical treatment. Extensive endoscopic approaches are being postulated as a possible best surgical treatment option in certain phenotypes of CRSwNP. Endonasal mucoplasty associated with these approaches has been shown to be a complementary technique that improves both healing and mucosal edema in patients with CRSwNP in the short term. The aim of our study was to analyse the results of endonasal mucoplasty associated with a complete ethmoid-sphenoidotomy plus grade III frontal sinusotomy in the treatment of CRSwNP in the medium term. For this purpose, a prospective case-control study (10/10) was carried out on patients with CRSwNP. In the case group, endonasal mucoplasty in the left nostril was associated with surgery, and the control group was not. The assessment of quality of life at one year after surgery, as measured by the mean difference in SNOT-22 (mean [SD]), was significantly better in the case group than in the control group (45.9 [19.6]-26.6 [16.05] P=0.027). The endoscopic improvement in healing and mucosal edema, measured by the Modified Lund-Kennedy scale, showed relevant improvements, when comparing both nostrils, but without reaching significance (P=0.29). Endonasal mucoplasty promotes short-term healing, improving the quality of life in the medium term (one year) of patients treated with extensive endoscopic mucosal resections.

[IgG4-Related Orbitopathy as an Important Differential Diagnosis of Advanced Silent Sinus Syndrome. German version]

Hintergrund

Mit Immunglobulin (Ig)G4 assoziierte Erkrankungen werden als immunvermittelte Erkrankungen klassifiziert. Die Ätiologie dieser Krankheiten ist bisher noch nicht geklärt. Sie manifestieren sich auf verschiedene Weise, und die gleichzeitige Beteiligung mehrerer Organe ist nicht ungewöhnlich.

Kasuistik

Es wird der Fall eines Patienten vorgestellt, der in die Klinik der Autoren überwiesen wurde, nachdem mehrere erfolglose Nasennebenhöhlenoperationen bei ihm durchgeführt worden waren; bei Vorliegen eines Enophthalmus und einer resultierenden Durchwanderungskeratitis bestand die Verdachtsdiagnose eines Silent-Sinus-Syndroms. Der Erhalt der Orbita war nicht mehr möglich. Nach 5 Jahren ohne definitive Diagnose wurde nun die Diagnose einer IgG4-assoziierten Erkrankung gesichert.

Diskussion

IgG4-assoziierte Erkrankungen stellen einen wichtigen Baustein bei der Differenzialdiagnose chronischer fortgeschrittener Erkrankungen der Orbita und der Nasennebenhöhlen dar. Bei unklaren Krankheitszeichen sollte diese Diagnose in Erwägung gezogen werden. Zu den typischen histologischen Befunden gehören ein storiformes Muster der Fibrose, Vaskulopathie und Gewebeinfiltration durch IgG4-Plasmazellen.

Acute effect of ambient air pollution on hospital outpatient cases of chronic sinusitis in Xinxiang, China

Many studies have reported that exposure to ambient air pollution has adverse effects on health. However, there are little researches to explore the relationship between ambient air pollution and chronic sinusitis (CS). From January 1 2015 to December 31 2018, a time-series study were carried out to investigate the acute adverse roles of six criteria ambient air pollutants (fine particulate matter [PM_2.5], inhalable particulate matter [PM₁₀], nitrogen dioxide [NO₂], sulfur dioxide [SO₂], ozone [O₃], and carbon monoxide [CO]) in hospital outpatients with CS in Xinxiang, China. Then, an over-dispersed Poisson generalized additive model was utilized to analyzed the relationships. In total, 183,943 hospital outpatient cases of CS were identified during the study period. We found that a 10 μg/m³ increase in PM_2.5, PM₁₀, SO₂, NO₂, and CO corresponded to 0.48% (95% confidence interval: 0.22-0.74%), 0.33% (0.16-0.50%), 0.88% (0.13-1.62%), 1.98% (1.31-2.64%), and 0.05% (0.03-0.07%) increments, respectively, in CS outpatients on the current day. The young group (<15 years of age) was more susceptible than the adult or elderly groups. These results suggested that outdoor air pollutants might increase CS outpatient, especially among youth in Xinxiang. Precautions and protective measures should be strengthened to reduce the air pollution level in the future.

Appropriate extent of surgery for aspirin-exacerbated respiratory disease

The current literature lacks strong guidelines regarding surgical management of patients with aspirin-exacerbated respiratory disease (AERD), who present with the clinical triad of chronic rhinosinusitis with nasal polyposis (CRSwNP), bronchial asthma, and aspirin/nonsteroidal anti-inflammatory drug intolerance. To further define the effectiveness of sinus surgery in treating AERD patients, this review article discusses current evidence regarding outcomes associated with more extensive surgery, the benefits of frontal sinus surgery on polyposis, and the role of Draf III intervention. Numerous studies suggest that Draf III frontal sinusotomy may be an efficacious early intervention due to increased neo-ostial patency and subsequent distribution of topical therapies. Future studies that further investigate the efficacy and safety of extensive surgery in AERD patients are warranted.

Contribution of Short Chain Fatty Acids to the Growth of Pseudomonas aeruginosa in Rhinosinusitis

Background: Chronic rhinosinusitis (CRS) is characterized by complex bacterial infections with persistent inflammation. Based on our rabbit model of sinusitis, blockage of sinus ostia generated a shift in microbiota to a predominance of mucin degrading microbes (MDM) with acute inflammation at 2 weeks. This was followed by conversion to chronic sinus inflammation at 3 months with a robust increase in pathogenic bacteria (e.g., Pseudomonas). MDMs are known to produce acid metabolites [short chain fatty acids (SCFA)] that have the potential to stimulate pathogen growth by offering a carbon source to non-fermenting sinus pathogens (e.g., Pseudomonas). The objective of this study is to evaluate the concentrations of SCFA within the mucus and its contribution to the growth of P. aeruginosa. Methods: Healthy and sinusitis mucus from the rabbit model were collected and co-cultured with the PAO1 strain of P. aeruginosa for 72 h and colony forming units (CFUs) were determined with the targeted quantification of three SCFAs (acetate, propionate, butyrate). Quantification of SCFAs in healthy and sinusitis mucus from patients with P. aeruginosa was also performed via high performance liquid chromatography. Results: To provide evidence of fermentative activity, SCFAs were quantified within the mucus samples from rabbits with and without sinusitis. Acetate concentrations were significantly greater in sinusitis mucus compared to controls (4.13 ± 0.53 vs. 1.94 ± 0.44 mM, p < 0.01). After 72 h of co-culturing mucus samples with PAO1 in the presence of mucin medium, the blue-green pigment characteristic of Pseudomonas was observed throughout tubes containing sinusitis mucus. CFUs were higher in cultures containing mucus samples from sinusitis (8.4 × 10⁹ ± 4.8 × 10⁷) compared to control (1.4 × 10⁹ ± 2.0 × 10⁷) or no mucus (1.5 × 10⁹ ± 2.1 × 10⁷) (p < 0.0001). To provide evidence of fermentative activity in human CRS with P. aeruginosa, the presence of SCFAs in human mucus was analyzed and all SCFAs were significantly higher in CRS with P. aeruginosa compared to controls (p < 0.05). Conclusion: Given that SCFAs are solely derived from bacterial fermentation, our evidence suggests a critical role for mucin-degrading bacteria in generating carbon-source nutrients for pathogens. MDM may contribute to the development of recalcitrant CRS by degrading mucins, thus providing nutrients for potential pathogens like P. aeruginosa.

A dental implant dislocated in the ethmoidal sinus: A case report

Maxillary sinusitis can represent a rare complication of dental implants of endodontic materials impinging in the maxillary sinuses. The effects of anatomical variants of paranasal sinuses on pathophysiological and clinical manifestations of dental sinusitis are poorly understood. Herein, we present a case of dislocation of a dental implant in the ethmoidal sinus in a 63-years old man with bilateral accessory maxillary orifice. This anatomical variation, by providing an additional way for the drainage of mucus in the maxillary sinus, could have allowed the dislocation of the implant in the ethmoidal sinus without causing mucus stagnation and consequent sinusitis, leading to a unusual clinical presentation. .

Activation of the 15-lipoxygenase pathway in aspirin-exacerbated respiratory disease

BACKGROUND

Aspirin-exacerbated respiratory disease (AERD) is characterized by asthma, chronic rhinosinusitis with nasal polyps (CRSwNP), and an intolerance of medications that inhibit cyclooxygenase-1. Patients with AERD have more severe upper and lower respiratory tract disease than do aspirin-tolerant patients with CRSwNP. A dysregulation in arachidonic acid metabolism is thought to contribute to the enhanced sinonasal inflammation in AERD.

OBJECTIVE

Our aim was to utilize an unbiased approach investigating arachidonic acid metabolic pathways in AERD.

METHODS

Single-cell RNA sequencing (10× Genomics, Pleasanton, Calif) was utilized to compare the transcriptional profile of nasal polyp (NP) cells from patients with AERD and patients with CRSwNP and map differences in the expression of select genes among identified cell types. Findings were confirmed by traditional real-time PCR. Lipid mediators in sinonasal tissue were measured by mass spectrometry. Localization of various proteins within NPs was assessed by immunofluorescence.

RESULTS

The gene encoding for 15-lipooxygenase (15-LO), ALOX15, was significantly elevated in NPs of patients with AERD compared to NPs of patients with CRSwNP (P < .05) or controls (P < .001). ALOX15 was predominantly expressed by epithelial cells. Expression levels significantly correlated with radiographic sinus disease severity (r = 0.56; P < .001) and were associated with asthma. The level of 15-oxo-eicosatetraenoic acid (15-Oxo-ETE), a downstream product of 15-LO, was significantly elevated in NPs from patients with CRSwNP (27.93 pg/mg of tissue) and NPs from patients with AERD (61.03 pg/mg of tissue) compared to inferior turbinate tissue from controls (7.17 pg/mg of tissue [P < .001]). Hydroxyprostaglandin dehydrogenase, an enzyme required for 15-Oxo-ETE synthesis, was predominantly expressed in mast cells and localized near 15-LO⁺ epithelium in NPs from patients with AERD.

CONCLUSIONS

Epithelial and mast cell interactions, leading to the synthesis of 15-Oxo-ETE, may contribute to the dysregulation of arachidonic acid metabolism via the 15-LO pathway and to the enhanced sinonasal disease severity observed in AERD.

IgG4-related orbitopathy as an important differential diagnosis of advanced silent sinus syndrome

BACKGROUND

Immunoglobulin (Ig)G4-related disease is classified as an immune-mediated disease. The etiology of this condition has not been explained to date. Manifestations of the disease are diverse, and simultaneous involvement of multiple organs is not unusual.

CASE REPORT

We report the case of a patient referred to us after multiple unsuccessful paranasal sinus operations who presented with enophthalmos and a resultant migratory keratitis with a suspected diagnosis of silent sinus syndrome. Preservation of the orbit was no longer feasible. After five years without a definitive diagnosis, we ascertained that this was a case of IgG4-related disease.

DISCUSSION

IgG4-related disease represents an important element in the differential diagnosis of chronic advanced diseases of the orbit and paranasal sinuses. The diagnosis should be considered in the case of unclear disease presentations. Typical histological findings include a storiform pattern of fibrosis, vasculopathy, and tissue infiltration by IgG4 plasma cells.

Readmissions following ambulatory pediatric endoscopic sinus surgery

OBJECTIVES/HYPOTHESIS

Endoscopic sinus surgery (ESS) is indicated in select pediatric patients with medically refractory sinus disease. Our objectives were to examine indications and rates of readmission following ambulatory pediatric ESS and identify specific subgroups that may benefit from inpatient admission.

STUDY DESIGN

Retrospective database review.

METHODS

The Pediatric Health Information Systems (PHIS) 2004-2016 database was retrospectively reviewed for patients age <18 years who underwent ambulatory ESS between January 2011 and December 2016 and were readmitted within 30 days postoperatively. Data regarding demographics, extent of surgery, comorbidities, adjunctive procedures, and cost were collected. A multivariable mixed-effects logistic regression model was employed for analysis.

RESULTS

We identified 3,669 unique pediatric ESS cases with 128 readmissions within 30 days (3.5%; 95% confidence interval [CI]: 2.9%-4.1%). Median cost of readmission was $980 (mean, $5,890; standard deviation, $13,421). The most common indication for readmission was epistaxis (17.2%), followed by nausea/abdominal pain (14.1%). Respiratory infection (13.3%) and sinusitis (10.2%) presented a combined readmission rate exceeding that of epistaxis alone. Multivariable analysis indicated age <3 years (odds ratio [OR]: 3.41, 95% CI: 1.96-5.93) and a prior diagnosis of asthma (OR: 2.88, 95% CI: 1.99-4.18) or cystic fibrosis (OR: 1.57, 95% CI: 1.00-2.44) significantly increased the risk of readmission. Extent of ESS and simultaneous adenoidectomy, septoplasty, or turbinate reduction had no significant impact on readmission rates.

CONCLUSIONS

ESS is a relatively safe outpatient surgical procedure in pediatric patients, with an overall readmission rate of 3.5%. Clinicians should consider careful preoperative evaluation of very young patients and those with cystic fibrosis or asthma to optimize perioperative management and determine if postoperative admission is warranted, given their significantly higher readmission rates.

LEVEL OF EVIDENCE

NA Laryngoscope, 129:2681-2686, 2019.

Computed Tomography Findings in Patients with Samter's Triad: An Observational Study

Samter’s Triad is a disorder characterized by chronic rhinosinusitis (CRS) with nasal polyps (NPs), asthma, and intolerance to cyclooxygenase-1 inhibitors. However, there have been no studies investigating the prediction of Samter’s Triad using imaging findings. Therefore, the authors aimed to investigate whether there is a difference in computed tomography (CT) findings between patients who have CRS with NPs and those with Samter’s Triad. Patients were classified into a CRS group and a Samter group. Opacification was measured using data from CT scans by scoring each sinus on a numerical rating scale ranging from 0 to 4. The opacification scores of the ethmoid and frontal sinuses were significantly higher in the Samter’s Triad group. Furthermore, Samter’s Triad was more common in patients who scored ≤ 2 for maxillary opacification (7/16) than in those who scored ≥3 (4/45, p=0.005). Patients with Samter’s Triad exhibited a tendency toward higher opacification scores for the ethmoid and frontal sinuses, with a relatively lower opacification score for the maxillary sinus. These findings could be helpful in distinguishing patients with Samter’s Triad from those who have CRS with NPs, and to plan treatment strategies without having to perform additional laboratory or radiological tests.

Maxillary fungus balls due to Fusarium proliferatum

Fungus ball is the most common form of non-invasive fungal rhinosinusitis. Aspergillusfumigatus (between 44.8% and 75%) and Aspergillusflavus (14%) are the two most common species recovered. However, recent advances in mycological laboratory methods have enhanced the detection and identification of fungi within fungus balls. Fusarium species, sometimes recovered from other forms of fungal rhinosinusitis such as allergic fungal rhinosinusitis or acute invasive fungal rhinosinusitis, are poorly associated with sinonasal fungus ball. Here, we describe two further cases of a fungus ball due to Fusariumproliferatum and provide the first description of this fungal pathogen with a fungus ball of odontogenic origin. These case reports demonstrate that uncommon fungal species such as Fusarium spp. might be underestimated as agents of sinusal cavity fungus ball. Enhanced mycological detection and diagnostic techniques might give rise, in the near future, to the emergence of new or rare fungal species associated with this clinical entity.

Chronic sinusitis-associated antrolith

An antrolith is a calcified mass found in the nasal cavity or sinus, usually maxillary, described in literature as a rare phenomenon. Its presenting symptoms are variable and include symptoms associated with chronic sinusitis. We describe a 66 year old man with chronic sinusitis who presented with facial pain and epistaxis and upon further evaluation was found to have an antrolith of the left maxillary sinus.

Acquired cystic fibrosis transmembrane conductance regulator dysfunction

Sinonasal respiratory epithelium is a highly regulated barrier that employs mucociliary clearance (MCC) as the airways first line of defense. The biological properties of the airway surface liquid (ASL), combined with coordinated ciliary beating, are critical components of the mucociliary apparatus. The ASL volume and viscosity is modulated, in part, by the cystic fibrosis transmembrane conductance regulator (CFTR). The CFTR is an anion transporter of chloride (Cl⁻) and bicarbonate (HCO₃⁻) that is located on the apical surface of respiratory epithelium and exocrine glandular epithelium. Improved understanding of how dysfunction or deficiency of CFTR influences the disease process in both genetically defined cystic fibrosis (CF) and acquired conditions has provided further insight into potential avenues of treatment. This review discusses the latest data regarding acquired CFTR deficiency and use of CFTR specific treatment strategies for CRS and other chronic airway diseases.

Successful long-term, adjunctive use of guaifenesin in a patient with a complex atopic medical history and primary immune deficiency: A case report

We report the case of a 45 year old female patient who suffered from recurrent respiratory infections, asthma, allergies and atopic dermatitis since childhood and multiple autoimmune and chronic respiratory conditions as an adult, who has achieved symptoms remission through a combination of immunotherapy and the daily use of over-the-counter high-dose guaifenesin.

The development of diffuse panbronchiolitis during the treatment with long-term, low-dose clarithromycin for chronic sinusitis

Diffuse panbronchiolitis (DPB) is a progressive inflammatory airway disease characterized by a chronic cough, copious sputum expectation, dyspnea, and chronic sinusitis. Owing to the long-term treatment of low-dose macrolides, the prognosis has been remarkably improved. However, in some cases, patients are refractory to macrolides, and the subsequent treatment strategies are controversial. We herein present a patient with the onset of DPB during treatment with long-term, low-dose clarithromycin (CAM) for chronic sinusitis who was successfully treated by switching to long-term treatment with normal-dose CAM. We should recognize that DPB may develop in patients with chronic sinusitis despite treatment with a long-term, low-dose macrolide. We also propose that increasing the dose of macrolide may be a useful strategy for treating refractory patients.

Chronic Rhinitis Is a High-Risk Comorbidity for 30-Day Hospital Readmission of Patients with Asthma and Chronic Obstructive Pulmonary Disease

BACKGROUND

Early hospital readmissions for asthma and chronic obstructive pulmonary disease (COPD), measured as hospital readmission within 30 days from the last discharge, is a major economic burden to our health care system. The association of this measure with comorbid chronic rhinitis (CR) has not been investigated before despite significant clinical association between CR and asthma or COPD.

OBJECTIVE

To investigate the association of CR with the risk of asthma or COPD-related early hospital readmission rates.

METHODS

This retrospective cohort study was performed using the asthma- and COPD-related hospital encounter and patient comorbidity data between June 15, 2012, and July 19, 2017, from a large hospital care system in Cincinnati, Ohio. Patients (any sex, race or socioeconomic status, and of all ages) with a primary discharge diagnosis of asthma (n = 4754 patients, 10,111 encounters) and COPD (n = 2176 patients, 4748 encounters) based on International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes were included. Relevant comorbidities, including comorbid allergic rhinitis (AR) or nonallergic rhinitis (NAR), in such patients were identified using ICD-10-CM codes. The association between 30-day asthma or COPD-related hospital readmission (1670 such encounters for asthma and 736 for COPD) and comorbid CR in the affected patients were determined using Cox proportional hazards models. Multivariate-adjusted hazard ratios (HRs), adjusted for relevant patient comorbidities, compared 30-day asthma- and COPD-related readmissions of patients with CR with those patients without a CR diagnosis.

RESULTS

Analysis was performed on 4754 patients with asthma and 2176 patients with COPD. The median follow-up period (+interquartile range) for asthma was 980 (+760) days and for COPD was 553 (+827) days. The HRs for 30-day asthma- or COPD-related readmission rates were significantly higher in patients with AR (HR = 4.4 [3.9, 5.0] and 2.4 [1.7, 3.2], respectively) or NAR (HR = 3.7 [2.9, 4.9] and 2.6 [1.8, 3.7], respectively) compared with patients without rhinitis. For asthma, both AR and NAR had higher HRs compared with all other comorbidities analyzed. For COPD, both AR and NAR had HRs to the magnitude as obesity and hypertension.

CONCLUSIONS

Comorbid CR is significantly associated with 30-day asthma- and COPD-related readmissions. These findings are useful for guiding health care professionals to focus on outpatient management of both the upper and lower respiratory tracts to reduce early readmission of patients with asthma and COPD.

16S rRNA gene sequencing reveals site-specific signatures of the upper and lower airways of cystic fibrosis patients

BACKGROUND

Metastasis of upper airway microbiota may have significant implications in the development of chronic lung disease. Here, we compare bacterial communities of matched sinus and lung mucus samples from cystic fibrosis (CF) subjects undergoing endoscopic surgery for treatment of chronic sinusitis.

METHODS

Mucus from one maxillary sinus and expectorated sputum were collected from twelve patients. 16S rRNA gene sequencing was then performed on sample pairs to compare the structure and function of CF airway microbiota.

RESULTS

Bacterial diversity was comparable between airway sites, though sinuses harbored a higher prevalence of dominant microorganisms. Ordination analyses revealed that samples clustered more consistently by airway niche rather than by individual. Finally, predicted metagenomes suggested that anaerobiosis was enriched in the lung.

CONCLUSIONS

Our findings indicate that while the lung may be seeded by individual sinus pathogens, airway microenvironments harbor distinct bacterial communities that should be considered in selecting antimicrobial therapies.

Kartagener's syndrome: a case report

BACKGROUND

Kartagener's syndrome is a subset of primary ciliary dyskinesia, an autosomal recessive inherited disorder characterized by the clinical triad of chronic sinusitis, bronchiectasis, and situs inversus. Abnormal ciliary structure or function leading to impaired ciliary motility is the main pathophysiologic problem in Kartagener's syndrome.

CASE PRESENTATION

A 24-year-old man from Gondar town, North-West Ethiopia, presented to University of Gondar Hospital with recurrent episodes of nasal congestion with itching and paranasal discomfort, and productive cough for more than a decade. Clinical and imaging findings revealed chronic sinusitis, bronchiectasis, dextrocardia, and situs inversus. He was treated with orally administered antibiotics, mucolytic, and chest physiotherapy. He was symptomatically better with the above therapy, and started on a long-term low-dose prophylactic antibiotic.

CONCLUSIONS

Patients with Kartagener's syndrome exist in Ethiopia as cases of chronic recurrent sinopulmonary infections. As there is no easy, reliable non-invasive diagnostic test for Kartagener's syndrome and the correct diagnosis is often delayed by years, it may cause chronic respiratory problems with reduced quality of life. Genetic counseling and fertility issues should be addressed once Kartagener's syndrome is diagnosed.

Recent thymic emigrants, T regulatory cells, and BAFF level in children with X-linked agammaglobulinaemia in association with chronic respiratory disease

BACKGROUND

X-linked agammaglobulinaemia (XLA) is a genetic disorder affecting B cell maturation, which is characterised by a low number of B cells, agammaglobulinaemia and increased susceptibility to a variety of bacterial infections. This study was performed to assess T cell subpopulations in a group of children with XLA in association with chronic respiratory disease (CRD).

METHODS

Numbers of T cell subpopulations (CD3+, CD4+, CD8+, CD3+DR+, naïve, memory, recent thymic emigrants (RTE), regulatory T cells, follicular T helpers) were measured by eight-colour flow cytometry in 22 XLA patients and 50 controls. BAFF level was measured by ELISA.

RESULTS

XLA patients with CRD had a significantly lower percentage of RTE numbers and Tregs, while significantly higher absolute counts of lymphocytes, CD3+, CD8+, CD3+DR+ and CD4+CD45RO+ T cells were detected as compared with healthy controls. In patients with XLA without CRD, the number of follicular T helper cells was altered significantly (percentage and absolute), as compared with healthy controls. Additionally, they had significantly higher counts (percentage and absolute) of CD4+CD45RA+ cells and lower percentage of CD4+CD45RO+ cells in comparison with healthy controls.

CONCLUSIONS

Our study affords new information concerning CRD and T cell subsets that differentiate or are maintained in the absence of B cells in children with XLA. T cell's homeostasis depends on the presence of chronic respiratory disease that may be caused by the delay in diagnosis.

Chronic Rhinosinusitis and Aspirin-Exacerbated Respiratory Disease

Patients with severe asthma and concomitant chronic rhinosinusitis often have severe, refractory upper and lower airway inflammation. This inflammation has been proposed to be similar throughout the upper and lower airways leading to the unified airways concept. This article reviews chronic rhinosinusitis with and without nasal polyps, and the subgroup with aspirin-exacerbated respiratory disease, while focusing on the relationship with asthma. Additionally, diagnosis and treatment with current and newer therapies are discussed.

Orbital pseudotumor as a result of chronic sinusitis in an HIV-positive patient

Orbital inflammatory pseudotumor is an infrequent lesion that may mimic malignancy and may be associated with autoimmune disease. Orbital pseudotumor is in the differential in any patient with an orbital mass, especially in the setting of chronic infection or immunosuppression. This HIV‐positive patient presented with chronic sinusitis and orbital pseudotumor.