Despite optimal medical and surgical therapy, many patients suffering from chronic rhinosinusitis (CRS) experience continuous inflammation for which revision surgery can be indicated. The present work was set out to investigate the extent of prior endoscopic sinus surgery (ESS) performed in CRS patients referred to tertiary rhinologic centers for revision surgery in Western countries. A retrospective multicenter study was conducted including patients with any (pheno)type of diffuse CRS, who had undergone at least one prior ESS. All patients had a sinus computed tomography (CT) scan performed before their revision surgery which was used to retrieve the Amsterdam classification of completeness of ESS (ACCESS) scores, which range from 0 (sinuses functionally opened) to 24 (no sinus opening). 114 patients from 6 different centers were included. The median ACCESS score was 12 (7-17). Most patients had only one previous ESS (70/114, 61%), while 24 (21%) had 2 previous surgeries, 13 (11.4%) patients had three, and 7 (6%) patients had four or more. Median ACCESS scores by number of previous ESS were: 13 (6-16) for one prior surgery, 12 (7-18) for two, 10 (8-13) for three, and 6 (3-13) for four or more surgeries. Multivariate linear regression analysis showed small changes in the patient's ACCESS score in relation to their number of previous surgeries. Our study underscores a large heterogeneity in extent of prior ESS among patients referred to tertiary rhinologic centers for diffuse CRS, regardless of the number of previous surgeries.

The efficacy of tezepelumab in chronic rhinosinusitis with nasal polyps (CRSwNP) has been demonstrated in clinical trials, but real-world evidence remains limited. Our study investigated the trend of CRSwNP outcomes in patients prescribed with tezepelumab for severe asthma and the impact of upper airways comorbidity on asthma outcomes over a 6 months follow-up. Data from 5 referral centres for severe asthma and CRSwNP were retrospectively analysed. Patient reported outcomes and objective measures related to nasal (SNOT-22, VAS, nasal polyp score) and bronchial (asthma control test, lung function) evaluation were assessed at baseline, 3 and 6 months after tezepelumab initiation. Tezepelumab significantly and rapidly improved all the nasal outcomes and asthma-related parameters, irrespective of sex, body mass index, prior biologic use, or disease duration. Furthermore, significant reduction of oral corticosteroid use, hospitalizations and exacerbations were also observed. When comparing patients with and without CRSwNP, no differences were observed in term of treatment response. In patients with severe asthma and CRSwNP, tezepelumab demonstrated to induce in the real-life setting an overall rapid and sustained improvement of nasal outcomes, as well as of lung function and clinical parameters in asthma patients regardless of upper airway involvement. Although larger studies are needed, these findings contribute to the positioning of tezepelumab in the real-world clinical practice according to a precision medicine approach.

The COVID-19 pandemic brought attention to post-viral smell distortion, or parosmia, which is defined as a qualitative dysfunction resulting from distorted odor perception in the presence of an odorous medium (1). Very often, qualitative and quantitative alterations occur simultaneously. Patients severely affected by qualitative odor disorders find that their quality of life has deteriorated (2). For quantitative loss from viruses, the role of olfactory training has been emphasized (3), along with high volume steroid nasal irrigations (4), and even injections with platelet-rich plasma (5). However, there has been no high-level evidence demonstrating an effective treatment for qualitative olfactory disorders.

The detrimental effects of climate change on global health are becoming increasingly evident, also within rhinology. Climate change has been shown to cause a longer and more intense pollen season, while the prevalence of allergic rhinitis is expected to rise due to de novo sensitizations caused by the migration of plants (1). Chronic rhinosinusitis patients will be affected by increasing air pollution as well as changes in spread of potent pathogens and vectors associated with upper airway infections (2,3). Meanwhile, healthcare is an evident contributor to climate change (4). Operating rooms (ORs) have been identified as carbon hotspots due to their high energy consumption (5) and the use of anaesthetic gases with high Global Warming Potential (6). Also, ORs have been estimated to generate up to 33% of all hospital waste (7).

Postoperative cerebrospinal fluid (CSF) leak is a significant complication of endoscopic skull base surgery (ESBS) that increases meningitis risk, a serious and potentially life-threatening infection. This study aimed to delineate the risk factors associated with the development of meningitis in patients who experienced postoperative CSF leakage. We reviewed 1,303 ESBS cases for skull base lesion between January 2020 and July 2024 at a single tertiary center. Patient demographics, pathology, intraoperative CSF leak grade, reconstruction techniques, and postoperative CSF leak management strategies-including the use of nasoseptal flaps, fat grafts, and lumbar drains-were collected. Clinical and surgical factors were analyzed among patients with postoperative CSF leak to identify associations with the development of meningitis. Postoperative CSF leak was suspected in 49 patients (3.8%). Among them, 36 (2.8%) underwent repair surgery, while 13 (1.0%) were treated conservatively without surgical confirmation. Meningitis occurred in 21 of these patients. Multivariate analysis revealed that intraoperative CSF leak grade, use of fat grafts, lumbar drain insertion, and delayed CSF leak recognition were significantly associated with meningitis development. Patients with grade 3 intraoperative leaks had 3.21-fold increased odds of developing meningitis compared to grade 0. Tumor pathology, nasoseptal flap viability, and hydroxyapatite use were not significantly associated. The transition from postoperative CSF leak to meningitis is influenced by the severity of intraoperative leakage, reconstructive choices, and the timing of leak detection. Restricting fat grafts and lumbar drains to selected cases and ensuring close postoperative rhinologic surveillance are critical in mitigating infectious complications following ESBS.

Biologic therapy has emerged as a key treatment for chronic rhinosinusitis with nasal polyps (CRSwNP), particularly in refractory cases, but its effect on healthcare utilization is not well established. We conducted a retrospective big-data analysis using the Clalit Health Services database, identifying all CRSwNP patients treated with dupilumab or mepolizumab following endoscopic sinus surgery (ESS) between 2010-2024. We assessed antibiotic and systemic steroid use, visits to clinics, emergency rooms (ER), hospitalizations, and repeat ESS before and after biologic initiation. Among 861 patients (54.2% on dupilumab, 45.8% on mepolizumab), 62% had asthma. Median therapy duration was 25 months. Mean follow-up was 130 ± 78 months before treatment and 43 ± 42 months after. Biologics significantly reduced antibiotic and systemic steroid use, as well as community clinic, hospitalization, and revision ESS rates. Serum eosinophils declined from 520 ± 440 to 430 ± 460 cells/μL. Post-ESS biologic therapy in CRSwNP patients is associated with reduced healthcare utilization and systemic medication use, highlighting its positive impact on disease burden and healthcare efficiency.

We read with keen interest the article by Kawabata et al. titled "Olfactory disorder after COVID-19 vaccination," which explores 16 cases of olfactory dysfunction temporally associated with vaccination (1). The paper addresses an important and under-recognized topic; however, several methodological aspects warrant clarification to aid accurate interpretation. First, the inclusion of five institutional cases within a review otherwise presented as PRISMA-compliant raises questions regarding methodological consistency. Under PRISMA, all included studies should be identified through transparent and reproducible database searches (2). Clarifying whether institutional data were processed separately from literature-derived cases would strengthen transparency and avoid confusion about the evidence level.

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a heterogeneous inflammatory condition often classified into eosinophilic (Eos) and non-eosinophilic (nonEos) subtypes. While microbial dysbiosis and metabolic disturbance are known contributors to CRSwNP, the interplay between sinonasal microbiota and local metabolic activity remains unclear. We conducted 16S rRNA gene sequencing and untargeted metabolomics on sinonasal swabs and tissue samples from patients with Eos-CRSwNP (n = 14), nonEos-CRSwNP (n = 7), and healthy controls (n = 14). Microbial diversity, taxonomic differences, and metabolic alterations were analyzed. Spearman correlation and network modeling were used to explore phenotype-specific microbiota- metabolite interactions and pathway enrichment. Eos-CRSwNP was characterized by reduced microbial diversity and increased abundance of Staphylococcus and Corynebacterium, along with elevated levels of fumaric acid, linoleic acid, and arachidonic acid-metabolites linked to oxidative stress and lipid-mediated inflammation. In contrast, nonEos-CRSwNP exhibited greater microbial richness, with enrichment of Streptococcus, Anaerococcus, and Clostridium XlVa, and metabolic shifts in amino acid and nitrogen metabolism, including increased glutamine, taurine, and ethanolamine phosphate. Correlation analysis revealed phenotype-specific networks connecting core microbial genera and metabolites, suggesting distinct inflammatory microenvironments between subtypes. Our integrated multi-omics analysis highlights divergent microbial and metabolic signatures in Eos and nonEos CRSwNP. These findings offer mechanistic insights into subtype-specific disease processes and may guide the future development of targeted diagnostic and therapeutic strategies.

Biologic therapies targeting type 2 inflammation, such as dupilumab, omalizumab, and mepolizumab, have been developed to manage chronic rhinosinusitis with nasal polyps (CRSwNP), particularly in patients with comorbid asthma or aspirin-exacerbated respiratory disease (AERD). Functional endoscopic sinus surgery (FESS) remains the mainstay of treatment in patients who are refractory to medical therapy (1,2). However, direct comparisons between biologic therapy and FESS are limited. This systematic review and meta-analysis aimed to compare sinonasal outcomes between FESS and biologic therapy in real-world settings.

To compare the efficacy of high-dose nasal steroid administered via high-volume irrigation versus spray delivery in patients with chronic rhinosinusitis (CRS) who have not undergone previous sinonasal surgery. A double-blind randomized clinical trial was conducted. The study comprised two groups receiving 1,000 μg/day of nasal budesonide through two distinct methods over a 3-month period: irrigation and spray delivery. Patients with severe CRS who had never undergone surgery and were on the waiting list for surgery in a public health service were included. Primary outcomes included changes in quality-of-life scores and secondary outcomes included changes in clinical control questionnaire results and nasal endoscopy findings. Assessments were conducted on the total sample, CRS with nasal polyps (CRSwNP), CRS without nasal polyps (CRSsNP), and according to the newly defined phenotypes of diffuse primary CRS (central compartment atopic disease [CCAD], eosinophilic chronic rhinosinusitis [eCRS] and non-eosinophilic CRS [neCRS]). Sixth-seven patients completed the study, with 34 in the Irrigation Group and 33 in the Spray Group. The Spray Group demonstrated superior efficacy in improving endoscopic outcomes across the total sample, particularly among CRSwNP and CCAD. No treatment demonstrated superiority in improving the SNOT-22 score. Furthermore, the Spray Group revealed greater efficacy in reducing the number of uncontrolled patients, as evaluated by the clinical control questionnaire, both in the total sample and CRSwNP. High-dose steroid nasal spray outperformed high-volume steroid nasal irrigation in improving nasal endoscopy outcomes across the total sample, especially in CRSwNP and CCAD.