Non-surgical management of chronic rhinosinusitis with nasal polyps based on clinical-cytological grading: a precision medicine-based approach

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a common inflammatory disorder that strongly impacts patients' quality of life. CRSwNP is still a challenge for ENT specialists due to its unknown pathogenesis, difficult control and frequent relapse. We tested the hypothesis that a new standardised therapeutic approach based on individual clinical-cytological grading (CCG), may improve control of the disease and prevent the needing for surgery. We analysed 204 patients suffering from bilateral CRSwNP, 145 patients of whom regularly assumed therapy, respecting the planned check-up, and were considered cases; 59 patients were not assuming therapy as indicated and were considered as controls. After five years of standardised treatment, 15 of 145 (10.5%) improved endoscopic staging, 61 of 145 (42%) did not change their endoscopic staging, and 69 of 145 (47.5%) were worse. In the control group, 49 of 59 (83%) were worse by at least two stages (p < 0.05). Patients and controls were stratified basing on clinical and cytological grading as mild, moderate and severe. After patient stratification, in the mild group (n = 27) 92% patients had a constant trend, with no worsening and no need for surgery over a 5-year period, whereas in the mild CCG control group 1 of 59 (1.6%) required surgery (p < 0.05). In moderate GCC (n = 83), 44% of patients did not modify or improve endoscopic staging and 3.6% needed surgery, compared to 13.6% of controls with moderate GCC (p < 0.05). In severe CCG (n = 35), even though no patients achieved significant amelioration of endoscopic grading, 40% of patients were considered as "clinically controlled" and 5.7% of patients underwent surgery, but the percentage was significantly higher (49%) in the control group significant (p = 0.0000). Finally, statistical analyses revealed a clear trend that polyp size increased at a faster rate in the control group than in the treatment group and for each subgroup (low, moderate and severe). The present study suggests a new approach in the management of CRS according to clinical cytological grading that allows defining the grade of CRSwNP severity and to adapt the intensity of treatment. This approach limited the use of systemic corticosteroids to only moderate-severe CRSwNP with a low corticosteroid dosage in comparison with those previously suggested. Our protocol seems to improve the adherence by patients, control of disease and the need for surgery in the long-term.

Intranasal T-LysYal® as adjunctive therapy for patients after functional endoscopic sinus surgery

Functional Endoscopic Sinus Surgery (FESS) is a common day surgery technique for upper airway disorders. Hyaluronic acid (HA) is a fundamental component of the human connective tissue. HA may exert reparative, anti-inflammatory and immune-modulating activities. Recently, a new intranasal HA formulation has been proposed: a supramolecular system containing lysine hyaluronate, thymine and sodium chloride (T-LysYal®). This randomized study investigated whether intranasal T-LysYal® (RinoLysYal®, Farmigea, Italy) was able to reduce symptom severity, endoscopic features, and nasal cytology in 83 patients (49 males and 34 females mean age 45.4±6.2 years) treated with FESS. All patients were treated with isotonic saline solution for 4 weeks, and a sub-group (active group) was also treated with intranasal T-LysYal®. Patients were visited at baseline, after treatment, and after 4-week follow-up. Intranasal T-LysYal® treatment significantly reduced the quote of patients with symptoms, endoscopic features, and inflammatory cells in comparison to isotonic solution. In conclusion, the present study demonstrates that intranasal T-LysYal® is able to significantly improve patients after FESS and its effect is long lasting.

Effect of sodium hyaluronate on mucociliary clearance after functional endoscopic sinus surgery

BACKGROUND

To determine the effect of intranasal sodium hyaluronate on mucociliary clearance time following functional endoscopic sinus surgery in patients with nasal polyposis.

STUDY DESIGN

Randomized, controlled, blinded study.

METHODS

Thirty-six patients with grade II nasal polyposis undergoing functional endoscopic sinus surgery received intranasal sodium hyaluronate 9 mg twice daily or saline for 30 days commencing on the second day after surgery. Ciliary mucous transport time was assessed using charcoal powder and saccharin administered during rhinoscopy. Other outcomes included changes in symptoms, endoscopic appearance of the nasal mucosa, and tolerability.

RESULTS

Patients receiving sodium hyaluronate had a significantly faster mucociliary clearance time at 1 month compared with controls (14.3 +/- 2.5 vs. 23.6 +/- 3.3 minutes; p = 0.000). Furthermore, sodium hyaluronate recipients experienced a lower incidence of rhinorrhea, less nasal obstruction and a lower incidence of exudate on endoscopy than control subjects at 1 month (all p < 0.05). Sodium hyaluronate was well tolerated in patients following functional endoscopic sinus surgery.

CONCLUSION

The use of intranasal sodium hyaluronate in patients undergoing functional endoscopic sinus surgery for nasal polyposis augmented the improvement in mucociliary clearance observed following this procedure and improved several clinical and endoscopic parameters. These data provide encouraging evidence of the beneficial effects of sodium hyaluronate in the care of patients undergoing functional endoscopic sinus surgery with which to continue the development of the product for this indication.

[Bilateral semicircular canal pathology]

The authors report 12 cases of bilateral cupulolithiasis found in 142 subjects diagnosed as having benign paroxysmal positional vertigo. A case history was taken for these patients (4 males, 8 females; average age 28 years) and 10 reported a previous cranial trauma while the remainder did not refer any previous condition of note. All patients had normal cochleovestibular test results and showed no signs of concomitant internal and/or central pathologies. The Hallpike maneuver was able to evoke an intense symmetrical paroxysmal vertigo and this was often accompanied by neurovegetative phenomena while paroxysmal nystagmus always appeared. The patients were treated with a rehabilitative technique: the Brandt-Daroff was preferred as it is better tolerated. Within 15 days all patients had full remission of symptoms and at 6 months after treatment there have been no signs of recurrence. The conclusion is, thus, drawn that while the technical characteristics of the Sémont maneuver make it suitable only for use as rehabilitation in unilateral benign paroxysmal positional vertigo, this experience indicates that the Brandt-Daroff technique is better suited for the bilateral forms of this disorder.

[Muco-ciliary transport in chronic inflammatory pathology of the middle ear]

The Authors have studied the behaviour of nasal mucociliary transport (MCT) in the chronic phlogistic pathology of the middle ear, in subjects suffering from simple and cholesteatomatous otitis. In both groups the duration of MCT was longer than a control group of normal subjects; instead no significant difference was observed either between the two kind of pathologies nor between the two different phases of the otitis (quiescence and breakthrough). The Authors conclude therefore that, in the recurrent phlogistic pathology of the middle ear, the function of MCT must be carefully studied, possibly corrected if damaged, to prevent the evolution in the breakthrough.

[Effect of physical exercise on nasal resistance in normal subjects and in patients with vasomotor rhinopathy]

The study has evaluated the behaviour of the nasal resistances, studied using Anterior Active Rhinomanometry, after physical exercise, in normal subjects and in allergic and non allergic vasomotor rhinopathics. The results, in accordance with the literature, show a reduction of nasal resistances in all subjects, particularly in the rhinopathics, immediately after the effort and a return to the starting values after a rest period of 30 minutes. Among vasomotor patients, only the non-allergic group has shown very significant variations in the resistances, because in these subjects there is almost always an exaltation of the neurovegetative system, which we did not observe in the allergic subjects in the intercritical phase. The effort test is therefore, among the aspecific tests of nasal reactivity useful, perhaps, more to therapy than to diagnostic aims.

[Herpetic vestibular neuronitis: a hypothesis]

Abundant experimental research has shown the potentially damaging effects that the herpes simplex virus (HSV) may have on peripheral or central nervous pathways. Fifty subjects (ages 20-45) with labial herpes virus (HSV-1) and 15 (ages 25-35) with genital herpes virus (HSV-2) were studied through recording spontaneous and optokinetic nystagmus (OKN) and using the eye-tracking-test (ETT) by means of electronystagmography (ENG). Recording was carried out during the first two days after vesicular eruption and seven days later, when cutaneous manifestations had disappeared. Thirty-five of the 50 subjects with HSV-1 showed spontaneous nystagmus, frequently with a vertical component, which in most cases had disappeared by the seventh control day. We recorded qualitative alterations of OKN as well as ETT in 19 patients while in 3 subjects only ETT was abnormal. All the subjects were normal on the seventh control day. At no time did any of the patients with HSV-2 show objective signs involving the peripheral or central vestibular system. Our research shows that HSV infection, especially HSV-1 infection, determines subclinical alterations of the vestibular function, probably due to the involvement of the brainstem. Therefore the virus is to be taken into account in establishing the etiology of "unknown" vertigo.

[Visual inhibition of the ampullar rotational-acceleratory excitation]

We have studied in normal subjects, the monocular and binocular influence on the nystagmus provoked by angular acceleration. The results show that the fixation determines a reduction of all quantitative parameters of the nystagmic response that, in the binocular fixation condition, is nearly 80% and halves with monocular fixation. The data shows activity conditions in a simple summation report of the values of visual input and demonstrate not only that the quality of the visual inhibition is, in normal subjects, perfectly equivalent between the two eyes but also that the stimulations evoked in the two labyrinths, convergent to the equilibrium centres, integrate in a perfectly complementary way. We have to study how this complex and harmonious polysensorial activity deteriorates with pathologic alterations of the visual and ampullar systems.

[Experimental research on vestibular compensation using posturography]

Vestibular compensation is a representation of nervous system plasticity which manifests as a gradual recovery of equilibrium function both in vestibulo-spinal system and vestibulo-oculomotor system. In order to assess whether the vestibular compensation is a homogeneous process among the different reflexes, the Authors have studied two groups of subjects affected by peripheral or central lesion. The development of the vestibular compensation has been evaluated by the rotation and posturographic tests. The results demonstrate a constant correlation between rotation and stabilometric parameters in the patients suffering from peripheral dizziness while there isn't any correlation between acceleratory and posturographic tests in patients affected by central vertigo. These results demonstrate that the compensation develops at the different levels of the balance function in a very different and independent way and that comparison of the rotation and posturographic patterns may be useful to establish the peripheral or central site of the lesions.

[Experimental research on sensitized posturography: importance of the neck reflexes]

In order to assess the influence of the cervical structures on the vestibulo-spinal reflex, and so on the posture, we have studied twenty subjects undergoing stimulation of the neck's proprioceptor structures. Each subject, by means of computerized stabilometric platform, has been submitted to the sensitized test with head retroflexed. In all cases significant variations of the posturographic parameters regarding in a particular way the total tracing length, the ellipse surface and the mean speed have been recorded. The results show that there are in man too stimulations of cervical origin which serve the purpose of maintaining posture; we can't exclude the possibility of the interference of an otolithic stimulation.

[Effect of aging on posture]

In order to assess the postural behaviour of the elderly, we have submitted twenty subjects of more than seventy years old to posturography. In all cases, compared to young people, significant variations of the posturographic parameters regarding in a particular way the total tracing length, the ellipse surface and the mean speed have been recorded. The conclusion is that the values obtained should always be compared with the standard values for each age group.

[Effect of the cervical reflex on the posture of normal subjects. Balance measurement study]

The little we know about the existence and the meaning of the cervical component on the vestibulo-spinal reflex, led us to carry out a study on normal subjects examined by computerized stabilometry with the head turned 75 degrees left and right, in order to check the postural alterations during the stimulation of the neck proprioceptors. The results show a significant increase of the values of the LTT, SE and Vm with the head turned to the left; the increases were not significant with the head turned to the right. The difference is difficult to explain. The results show that in man too the posture is affected by reflex of cervical origin.