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.

Allergic and nonallergic rhinitis and skin sensitization to metals: is there a link?

Background. Chromium, Cobalt and Nickel are responsible for contact dermatitis, that is largely prevalent in the general population. They can act also as irritants in the upper and lower respiratory airways. Also rhinitis (allergic and nonallergic) is a high prevalence disorder. Both diseases could share some common inflammatory mechanisms, but the clinical association between skin sensitization to metals and rhinitis was never studied. Objective. We assessed the presence of skin sensitization to metals in subjects with rhinitis. Methods. Patients suffering from rhinitis underwent a standard diagnostic procedure, including skin testing, nasal endoscopy and nasal cytology. Control healthy subjects were also included. None of the patients had skin diseases. All subjects underwent patch test with Chromium, Cobalt and Nickel. Results. None of the 26 controls had positive skin prick test or nasal cytology. The 82 rhinitis patients were subdivided into allergic (group A = 27), nonallergic (group B = 31) and overlapping (group C = 24). The prevalence of positive patch test to metals was 26% in group A, 45% in group B, 42% in group C and 31% in controls. The percentage of patch-positive subjects was significantly different between Group A and B (p = 0.0045; OR: 0.43), Group A and C (p = 0.0186; OR: 0.49), and Group B and controls (p = 0.0360; OR: 1.85). There was a significant difference between groups A + controls and B + C. Conclusion. Even in the absence of skin diseases, the prevalence of sensitization to metals (patch test) is greater in nonallergic and overlapping rhinitis, as compared to allergic rhinitis and controls.

Adjuvant treatment with a symbiotic in patients with inflammatory non-allergic rhinitis

Inflammatory non-allergic rhinitis (INAR) is characterized by the presence of an inflammatory infiltrate and a non-IgE-mediated pathogenesis. This retrospective, controlled, multicentre study investigated whether a symbiotic, containing Lactobacillus acidophilus NCFM, Bifidobacterium lactis, and fructo-oligosaccharides (Pollagen®, Allergy Therapeutics, Italy), prescribed as adjunctive therapy to a standard pharmacological treatment, was able to reduce symptom severity, endoscopic features, and nasal cytology in 93 patients (49 males and 44 females, mean age 36.3±7.1 years) with INAR. The patients were treated with nasal corticosteroid, oral antihistamine, and isotonic saline. At randomization, 52 patients were treated also with symbiotic as adjunctive therapy, whereas the remaining 41 patients served as controls. Treatment lasted for 4 weeks. Patients were visited at baseline, after treatment, and after 4-week follow-up. Adjunctive symbiotic treatment significantly reduced the percentages of patients with symptoms and endoscopic signs, and diminished inflammatory cells. In conclusion, the present study demonstrates that a symbiotic was able, as adjuvant treatment, to significantly improve symptoms, endoscopic feature, and cytology in patients with INAR, and its effect may be long lasting.

Nasal irrigation with Nasir® in children: a preliminary experience on nasal cytology

Allergic rhinitis (AR) and upper airway respiratory infections are frequent in children, and both have a relevant impact on some social aspects, including school attendance and performance, sleep, quality of life (also of the parents), and costs. Saline nasal irrigation is widely employed to reduce nasal congestion and mucopurulent secretion, to stimulate cleansing of the nasal and paranasal cavities, and to induce restoration of mucociliary clearance. The present study evaluated the effects of nasal irrigation on nasal cytology, using the new device Nasir® in 66 children (40 males, 26 females, mean age 7.31±1.7 years, age range 4-17 years) with allergic rhinitis. The patients were treated with nasal irrigation with warm (36°C) Nasir® (250 mL sacs of premixed solution): one sac twice daily for 12 days. Nasal irrigation significantly reduced the neutrophilic infiltrate (baseline median value 2.8±0.7; post treatment value 2±0.5; p less than 0.05). In addition, there was a reduction of eosinophil infiltrate (T0= 3.2±1.1; T1= 2.6±1.2; p= less than 0.05). There was no significant change with regard to bacteria (T0= 2.7±0.9; T1= 2.3±1.02; p= 0.17). In conclusion, this pilot study reports that nasal irrigation with Nasir® might be useful to attenuate upper airway inflammation.

Cartilage ossiculoplasty in cholesteatoma surgery: hearing results and prognostic factors

Cartilage tympanoplasty is an established procedure for tympanic membrane and attic reconstruction. Cartilage has been used as an ossiculoplasty material for many years. The aim of this study was to evaluate hearing results of costal cartilage prostheses in ossicular chain reconstruction procedures in subjects operated on for middle ear cholesteatoma and to determine the presence of prognostic factors. Candidates for this study were patients affected by middle ear cholesteatoma whose ossicular chain was reconstructed with a chondroprosthesis. 67 cases of ossiculoplasty with total (TORP) or partial (PORP) chondroprosthesis were performed between January 2011 and December 2013. Follow-up examination included micro-otoscopy and pure tone audiometry. The guidelines of the Committee on Hearing and Equilibrium of the American Academy of Otolaryngology Head and Neck Surgery were followed and pure-tone average (PTA) was calculated as the mean of 0.5, 1, 2 and 4 kHz thresholds. Statistical analysis was performed with ANOVA tests and regression models. Average air-bone gap (ABG) significantly improved from 39.2 dB HL (SD 9.1 dB HL) to 25.4 dB HL (SD 11 dB HL) (p < 0.001). Linear regression analysis showed that the only prognostic factor was the type of operation (p = 0.02). In fact, patients submitted to ICWT presented better post-operative ABG compared to CWDT. None of the other variables influenced the results. The present study proposes costal cartilage as material of choice when autologous ossicles are not available. The maintenance of the posterior canal wall was the only prognostic factor identified.

Ancillary therapy of intranasal T-LysYal® for patients with allergic, non-allergic, and mixed rhinitis

Allergic rhinitis (AR) is caused by an IgE-mediated inflammatory reaction. Non-allergic rhinitis (NAR) is characterized by a non-IgE-mediated pathogenesis. Frequently, patients have the two disorders associated: such as mixed rhinitis (MR). Hyaluronic acid (HA) is a fundamental component of the human connective tissue. HA may exert anti-inflammatory and immune-modulating activities. Recently, an intranasal HA formulation was 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 89 patients (48 males and 41 females, mean age 36.3±7.1 years) with AR, NAR, and MR. Patients were treated with intranasal T-LysYal® or isotonic saline solution as adjunctive therapy to nasal corticosteroid and oral antihistamine for 4 weeks. 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 conclusion, the present study demonstrates that intranasal T-LysYal® is able, as ancillary therapy, to significantly improve patients with AR, NAR, and MR, and its effect is long lasting.

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.