Management Of Chronic Rhinosinusitis Research Articles

Can computational fluid dynamic models help us in the treatment of chronic rhinosinusitis.

The aim of this study was to review the recent literature (January 2017-July 2020) on computational fluid dynamics (CFD) studies relating to chronic rhinosinusitis (CRS), including airflow within the pre and postoperative sinonasal cavity, virtual surgery, topical drug and saline delivery (sprays, nebulizers and rinses) and olfaction. Novel CFD-specific parameters (heat flux and wall shear stress) are highly correlated with patient perception of nasal patency. Increased ostial size markedly improves sinus ventilation and drug delivery. New virtual surgery tools allow surgeons to optimize interventions. Sinus deposition of nasal sprays is more effective with smaller, low-inertia particles, outside of the range produced by many commercially available products. Saline irrigation effectiveness is improved using greater volume, with liquid entering sinuses via 'flooding' of ostia rather than direct jet entry. CFD has provided new insights into sinonasal airflow, air-conditioning function, the nasal cycle, novel measures of nasal patency and the impact of polyps and sinus surgery on olfaction. The deposition efficiency of topical medications on sinus mucosa can be markedly improved through parametric CFD experiments by optimising nasal spray particle size and velocity, nozzle angle and insertion location, while saline irrigation effectiveness can be optimized by modelling squeeze bottle volume and head position. More sophisticated CFD models (inhalation and exhalation, spray particle and saline irrigation) will increasingly provide translational benefits in the clinical management of CRS.

Chronic rhinosinusitis and endoscopic sinus surgery in children admitted for pulmonary exacerbations of cystic fibrosis

ObjectiveNon-surgical management of chronic rhinosinusitis (CRS) in children with cystic fibrosis (CF) has been increasing over the last decade. This study examines inpatient children with pulmonary exacerbation of CF who were also diagnosed with CRS and underwent endoscopic sinus surgery (ESS). Study designWe used the 2003 to 2016 Kids Inpatient Database to perform a cross-sectional analysis of inpatients (ages 0–21 years) diagnosed with CF and CRS in the United States from 2003 to 2016. Demographics and CF-associated comorbidities were recorded and rates of CRS and ESS in children with CF were examined. Results49,110 children were included in the study. A total of 9334 (19%) were diagnosed with CRS. The average age was 13 (SD 5.9) years; the majority were female (56%), and White (67%). The prevalence of CRS increased from 2003 to 2016 (14%–23%, p < 0.001) while the rate of ESS decreased (20%–11%, p < .001). Patients with CRS that underwent ESS more commonly had CF-associated comorbidities including GI manifestations (15%–25%, p < .001) and liver disease (15%–30%, p < .001). ConclusionThe diagnosis of CRS in children with CF hospitalized for pulmonary exacerbation has increased while ESS has decreased in the last decade. Patients with CRS that underwent ESS more commonly had CF-associated comorbidities. Studies to determine whether children with CF-associated comorbidities are more likely to benefit from ESS are needed.

Operative and postoperative outcomes in elderly patients undergoing endoscopic sinus surgery.

Chronic rhinosinusitis (CRS) is increasingly common in the elderly population (≥ 65years old). Compared to their younger counterparts, differences exist in the etiology of CRS and outcomes of Endoscopic Sinus Surgery (ESS) for elderly patients. The aim of this study is to determine if differences in surgical outcomes are present between these two patient populations to facilitate patient pre-operative counseling by their healthcare providers. Retrospective chart review conducted at a single tertiary care center for patients undergoing ESS between June 2014 and June 2019. Patients were classified into two cohorts (adult and elderly) based on age (< 65 and ≥ 65years old). Demographics, surgical, and postoperative variables were extracted from our institution's electronic medical records. ANOVA and t-test analysis were performed to determine the presence of significant differences between the two cohorts. SNOT-22 scores were used to determine QOL improvements. Compared to the adult cohort, elderly patients had significant QOL improvement after surgical treatment (p = 0.001), but had a similar successful response to treatment (p = 0.74). Elderly patients had no difference in the incidence of operative/perioperative complications (p = 0.89) or intraoperative or postoperative bleeding (p = 0.301, p = 0.62), but had an increased incidence of postoperative infection (p = 0.000). ESS remains an effective treatment modality for the management of CRS, and a safe practice for elderly patients despite the increase in complexity of their medical comorbidities and polypharmacy. QOL improvements are significant, though patient counseling should take into account that improvements may not be as pronounced as in younger patients.

P507 CHRONIC RHINOSINUSITIS WITH NASAL POLYPS: AS ASSESSMENT OF CURRENT CLINICAL PRACTICES

This study’s objective was to assess current clinical practices of allergists related to management of chronic rhinosinusitis with nasal polyps (CRSwNP).

Managing chronic rhinosinusitis in severe asthma.

Over half of all patients with severe asthma have chronic rhinosinusitis (CRS). Although distinct and specialized in function and form, the upper and lower airways share similar and inter-related pathophysiologic mechanisms. The severity of CRS particularly in patients with nasal polyps can correlate with that of asthma and vice versa. The purpose of this review is to elucidate the relationship between these conditions and summarize key elements in the management of these patients. Several advances have been made in the evaluation and treatment of patients with CRS and asthma. Further understanding of inflammatory endotypes common to both CRS and severe asthma hopefully will provide appropriate and effective treatments and improve patient outcomes. CRS significantly impairs quality of life, and therapies are targeted toward improving patient symptoms, and hopefully in the future, treating the underlying immune dysfunction. Management of CRS and severe asthma requires a multidisciplinary approach. Further real-world studies are necessary to determine the best treatment algorithm for these patients.

Efficacy of corticosteroid solution administration via Mygind's position for the management of chronic rhinosinusitis with nasal polyps.

ObjectiveTo investigate whether direct steroid application via Mygind's position improved objective and subjective measures of chronic rhinosinusitis with nasal polyposis (CRSwNP).MethodsA retrospective chart review was performed on patients seen by the senior author in a Rhinology Clinic of a tertiary academic center over a 2 year period. Patients whose only change in medical regimen was initiation of corticosteroid administration via Mygind's position were included for this analysis. The main subjective and objective outcome measures were Sino‐nasal Outcome Test‐22 (SNOT‐22) and endoscopy scores, respectively. Patient scores before and after the change in treatment were compared and analyzed using Student's t test and Wilcoxon signed‐rank test.ResultsTwenty‐two patients were identified for inclusion. There was a statistically significant decrease in overall nasal endoscopy scores for both the right (P = .001) and left (P = .001) sides. A statistically significant and clinically meaningful decrease in total SNOT‐22 scores (12.7 points, P = .008) was also seen. Intolerance to the regimen was observed in 5/48 patients reviewed for inclusion (10.4%), with issues including neck pain, burning, pressure, and thrush.ConclusionThe direct application of topical corticosteroids, specifically via Mygind's position, may improve both objective exam findings and clinical symptomatology in patients with CRSwNP compared to indirect application. Intolerance to the regimen can be observed.Level of Evidence4—Case series (with or without comparison).

Oral Corticosteroid Regimens in the Management of Chronic Rhinosinusitis.

Oral corticosteroids are often used in the medical management of chronic rhinosinusitis (CRS) with and without polyps. The purpose of our study is to review the literature for studies reporting the dosage of oral corticosteroids as part of the appropriate medical management prior to, immediately before, and after surgical intervention. We reviewed the literature for oral corticosteroid regimens given to patients with CRS from March 2012 to September 2018. Studies that did not disclose the exact doses of the regimen were excluded from our analysis. Our search resulted in 7 articles with 4 studies of Level of Evidence (LOE) 1b, 2 studies with LOE III, and 1 study with LOE IV. The daily doses varied from 15 mg to 1 mg/kg, and with total doses ranging from 150 to 352 mg. In addition, several studies gave the same regimen to both subtypes of CRS. There was no mention of side effects in most of the studies. There is a wide variation in the steroid doses given to patients with CRS and prospective or randomized controlled trials are needed to provide better improved evidence.

Guidance for contemporary use of biologics in management of chronic rhinosinusitis with nasal polyps: discussion from a National Institutes of Health-sponsored workshop.

Biologic medications are emerging as options for treating chronic rhinosinusitis with nasal polyps (CRSwNP). Several questions remain regarding patient selection, indications, clinical efficacy, and cost effectiveness. In November 2019, a group of physicians and scientists gathered to consider strategies for future studies regarding biologics. During the discussion, gaps in knowledge highlighted a need for a consensus on the present day use of biologics in polyp patients. The goal of this guideline is to propose recommendations for the current use of biologics in CRSwNP as new evidence continues to emerge and inform practice. We suggest that physicians evaluate patients on an individual basis and closely monitor for improvement due to the high cost and unknown long-term effects of biologics.

Randomized clinical trial to evaluate mometasone lavage vs spray for patients with chronic rhinosinusitis without nasal polyps who have not undergone sinus surgery.

There is no consensus regarding the best route of intranasal delivery of corticosteroids in the treatment of chronic rhinosinusitis (CRS). The study objective of this work was to compare the impact of mometasone furoate nasal spray (MFNS) vs mometasone nasal irrigation in the management of CRS patients who have not undergone sinus surgery. A double-blind, placebo-controlled, randomized clinical trial was conducted in adults with CRS. Individuals with nasal polyps and/or history of sinus surgery were excluded. Patients were randomized to receive 8 weeks of either MFNS or mometasone nasal irrigation. The primary outcome measure was change in the 22-item Sino-Nasal Outcome Test (SNOT-22) score between the 2 groups. Secondary outcome measures included patient global response to treatment and Lund-Kennedy endoscopy scores. A total of 43 participants completed the study (n = 22, MFNS; n = 21,mometasone nasal irrigation). Fourteen (64%) participants in the MFNS group and 17 (81%) in the mometasone lavage group had a clinically meaningful improvement in SNOT-22 scores with a proportion difference of 17% (95% confidence interval [CI], -9% to 44%). The least-squares (LS) mean difference between the 2 groups for SNOT-22 was -8.6 (95% CI, -17.7 to 0.58; p = 0.07), whereas the LS mean difference between the 2 groups for Lund-Kennedy endoscopy scores was 0.16 (95% CI, -0.84 to 1.15; p = 0.75). No adverse events were associated with the study. Both MFNS and mometasone nasal irrigations are beneficial in symptom management of CRS. Our study suggests that patients who perform mometasone lavage do better in a clinically meaningful way, but our results are not definitive and further studies are warranted.

Corrigendum to "Efficacy of lianhuaqingwen granules in the management of chronic rhinosinusitis without nasal polyps" [Am. J. Otolaryngol. 2020 Jan - Feb;41(1):102311

Corrigendum to "Efficacy of lianhuaqingwen granules in the management of chronic rhinosinusitis without nasal polyps" [Am. J. Otolaryngol. 2020 Jan - Feb;41(1):102311

Phenotypes of Chronic Rhinosinusitis

Chronic rhinosinusitis (CRS) is a complex heterogeneous disease with different phenotypes and endotypes. Recent advances in our understanding of the pathogenetic mechanisms of CRS endotypes have led to the introduction of effective biologic agents for CRS management. Traditionally, CRS phenotypes have been divided into with or without nasal polyps depending on the presence of polyps. Although this classification does not reflect the various endotypes that are recently emerging, it is simple and easily recognized by clinicians. Other phenotypes of CRS are fungal rhinosinusitis (including invasive and noninvasive subtypes), infectious rhinosinusitis, aspirin-exacerbated respiratory disease, cystic fibrosis, pediatric CRS, and CRS associated with systemic diseases. This article reviews the diagnostic approaches and up-to-date treatment strategies for each CRS phenotype with the hope that a better understanding of endotypes will result in a more scientific understanding of phenotypes and precise, personalized treatments.

Concordance of self-reported practice patterns of American Rhinologic Society members with the International Consensus Statement of Allergy and Rhinology: Rhinosinusitis.

The 2016 International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR:RS) is a collaborative distillation of available research and consensus recommendations for the management for chronic rhinosinusitis (CRS). However, implementation of the ICAR:RS recommendations in the reality of clinical practice is not clearly defined. An anonymous, web-based survey of the American Rhinologic Society membership was performed in October, 2018. Respondents were asked about the frequency that they recommended the various treatments reviewed in ICAR:RS in the context of medical management for CRS. A 7-point Likert-type scale assessed the frequency of treatment patterns. A total of 140 members completed the survey (response rate 11.9%). Seventy-two (51.4%) were in practice for 0 to 15 years, 61 (43.6%) completed a rhinology fellowship, and 73 (52.1%) worked in private practice. Disparate treatment patterns were reported for each of the therapies assessed for CRS, including those that were "recommended" or "recommended against" in ICAR:RS. Members with <15 years of experience were more likely to use nasal saline irrigation. Fellowship-trained respondents reported a greater likelihood of using nasal saline irrigation and aspirin desensitization (for patients with aspirin-exacerbated respiratory disease). Practitioners in academic medicine were more likely to utilize aspirin desensitization than those in private practice. Surgeons performing >100 sinus surgeries per year were more likely to use topical antibiotics. The range of reported treatment patterns identified in this study despite the availability of the ICAR:RS recommendations may suggest the need for improved standardization of CRS management.

A Comparative Study in the Management of Chronic Rhinosinusitis by Nasal Douching with Hypertonic Saline vs Isotonic Saline.

Chronic rhinosinusitis is one of the most commonly diagnosed medical conditions affecting all age groups. Hypertonic saline solution and isotonic saline solution are used in management of chronic rhinosinusitis. In this study we compare the effectiveness of isotonic saline and hypertonic saline in alleviation of symptoms and clinical outcome of patients with chronic rhinosinusitis. In our study 60 patients diagnosed with chronic rhinosinusitis are divided into two groups; Group A treated with isotonic saline and Group B with 3.5% hypertonic saline for a period of 6weeks. The symptoms were evaluated using SNOT-20 score before and after treatment. It was found that hypertonic saline solution is more efficacious than isotonic saline solution in the treatment of patients with chronic rhinosinusitis.

Persistence of Sinonasal Disease Despite Mepolizumab

The treatment paradigm for the management of chronic rhinosinusitis with nasal polyposis (CRSwNP) is currently undergoing a rapid evolution with the development of monoclonal antibody therapies targeted at type 2 inflammatory pathways. The use of these biologic therapies in asthmatic patients, and more recently, patients with CRSwNP has produced promising results, especially for patients with severe disease. Many questions regarding the appropriate timing of these medications, whether or not these new treatment strategies should be used as a monotherapy or in conjunction with traditional therapies such as sinus surgery, the role of appropriate phenotyping, and identification of biomarkers, remain unanswered. We herein present a case of a patient with severe eosinophilic asthma and comorbid CRSwNP who failed to achieve control of his respiratory symptomology and ultimately progressed to sinus surgery despite treatment with an anti-interleukin 5 monoclonal antibody therapy (mepolizumab). Consideration is given to the mechanistic underpinnings of the reported patient's failure. This case highlights the need for further understanding of the optimal usage of these novel therapeutics in the management of CRSwNP and in the need to better understand the pathophysiology of CRSwNP.

Quality-of-life and olfaction changes observed with short-term medical management of chronic rhinosinusitis.

Patients with chronic rhinosinusitis (CRS) commonly experience both reduced quality of life (QOL) and olfactory dysfunction (OD). Literature on the impacts of appropriate medical therapy (AMT) for CRS on QOL and OD is limited, and the focused design of these studies may limit their applicability to usual clinical practice. Adults with symptomatic CRS were prospectively enrolled (November 2016 to October 2018) into an observational, multi-institutional study. Individualized AMT was initiated using standard practice according to evidence-based guidelines. Endoscopy examination (Lund-Kennedy), olfactory function (Sniffin' Sticks) testing, and QOL survey responses (22-item Sino-Nasal Outcome Test [SNOT-22], Questionnaire of Olfactory Disorders-Negative Statements [QOD-NS]) were obtained at enrollment and follow-up. Baseline measures demonstrated heterogeneity of QOL and OD. After an average of 7.8 weeks, within-subject median SNOT-22 total improved by 39.5% (n = 39, p < 0.001) relative to baseline, including 50% (p = 0.014) improvement for item #21, "Sense of smell/taste." QOD-NS improvement was also statistically significant (p = 0.044). Sniffin' Sticks score relative improvement of 10.9% (n = 33, p = 0.109) was not statistically significant and lacked correlation with SNOT-22 total scores (R = -0.247, p = 0.165) or QOD-NS total scores (R = -0.016, p = 0.930), but correlated moderately with endoscopy score (R = -0.436, p = 0.018). Participants with varied impacts of CRS, treated with individualized short-term AMT, demonstrated significant improvements in CRS- and olfactory-specific QOL measures, without corresponding improvement in clinically measured olfactory function. Olfactory function changes moderately correlated with endoscopy score changes, but lacked an association with QOL measurements.

What is the evidence for fluticasone exhalation delivery system in chronic rhinosinusitis?

The aim of this article is to review the current literature regarding a novel method of topically delivering nasal steroids, namely exhalation delivery system-fluticasone (EDS-FLU), for the treatment of chronic rhinosinusitis (CRS). Recent Food and Drug Administration approval of EDS-FLU and increasing evidence surrounding its efficacy and safety has led to an additional tool for the treatment of chronic rhinosinusitis. Compared with placebo, EDS-FLU has demonstrated significant improvements in patients' sinonasal symptoms and overall inflammatory control as well as quality of life measures. Additionally, using EDS-FLU can lead to polyp grade improvement and polyp elimination in patients with chronic rhinosinusitis with polyps. Furthermore, compared with controls, patients who received EDS-FLU were less likely to meet predefined surgical criteria at the conclusion of the study. EDS-FLU has demonstrated significant improvement in managing symptoms and polyps in CRS. Receiving EDS-FLU was associated with a significant reduction in the proportion of patients meeting surgical criteria. Further studies are warranted to evaluate the long-term outcomes of EDS-FLU, especially as compared with steroid sprays and topical steroid irrigations, in management of CRS.

Latest developments on topical therapies in chronic rhinosinusitis.

Topical therapies play an important role in the management of chronic rhinosinusitis (CRS). A detailed literature review was undertaken to appraise recent evidence surrounding current topical therapies and novel treatments used in the setting of recalcitrant CRS. Effective sinus surgery aids in the delivery of topical therapies. Budesonide nasal rinses delivered by saline irrigation offer clinical and symptomatic improvements pre and postoperatively with a well-proven safety profile. Topical steroids may additionally offer direct antibacterial effects as per in-vitro testing. Topical antibiotics are not recommended in routine practice; however, they may be of benefit for short-term eradication therapy. Novel treatments are under keen investigation and include bacteriophage, colloidal silver and manuka honey. The evidence base for these treatments is not robust enough to recommend their routine use at present. Topical steroids delivered in conjunction with saline nasal irrigation offer the best combination of treatments in CRS and should be considered a standard of care. Wide surgical access and aggressive surgical debridement of polyposis facilitates the delivery of steroid irrigations to sinonasal mucosa and is associated with improved long-term outcomes following endoscopic sinus surgery. The use of novel treatments remains within the research setting alone.

Update on long-term outcomes for chronic rhinosinusitis in cystic fibrosis.

This article reviews the existing body of literature regarding long-term outcomes of various treatments for chronic rhinosinusitis (CRS) in the cystic fibrosis population. The management of CRS in cystic fibrosis involves a multitude of medical and surgical therapies. Despite their high usage amongst clinicians, corticosteroids and antibiotics currently have little outcome data supporting their use. There is emerging evidence demonstrating beneficial outcomes for DNAse mucolytics and molecular modulators of cystic fibrosis transmembrane conductor regulator (CFTR). Endoscopic sinus surgery (ESS) improves sinonasal outcomes in cystic fibrosis CRS; however, the benefit on pulmonary outcomes remains unclear. Successful management of CRS in cystic fibrosis requires multimodal and multidisciplinary care. The long-term outcome data is variable for different treatment modalities. There is recent evidence supporting the role of DNAse mucolytics, CFTR-targeting therapies, and ESS in management of cystic fibrosis CRS.

Use of mucosal eosinophil count as a guide in the management of chronic rhinosinusitis.

Chronic rhinosinusitis (CRS) is a local inflammatory process driven by eosinophils. Mucosal eosinophil count (MEC) has previously been demonstrated to be a reliable indicator of disease severity. We aim to evaluate use of MEC in guiding medical management of CRS after functional endoscopic sinus surgery (FESS). We retrospectively reviewed patients with CRS who underwent FESS from 2004 to 2017. Tissue MEC per high-power field (HPF) was determined by pathologic examination. MECs were compared by polyp status, postoperative medication requirements, and revision surgery. Patients received normal saline (NS) nasal irrigations with additional treatment as needed for disease control: 1-drug therapy (1-DT) intranasal steroid spray (ISS), 2-drug therapy (2-DT) ISS plus budesonide nasal irrigations (BNI) or leukotriene receptor antagonist (LRA), or 3-drug therapy (3-DT) ISS plus BNI and LRA. Correlations between MEC and 22-item Sino-Nasal Outcome Test (SNOT-22), preoperative computed tomography (CT), and nasal endoscopy scores were evaluated. A total of 156 patients were included. Fifty-seven were managed with 1-DT, 35 with 2-DT, and 62 with 3-DT. Across all patients, mean postoperative 6-month and 1-year SNOT-22 (18.1 ± 17.0, 18.1 ± 20.2, respectively) and nasal endoscopy (3.6 ± 3.8, 3.6 ± 4.1, respectively) scores were significantly lower than preoperative scores (37.4 ± 22.8, 6.5 ± 4, respectively). With increasing MEC, odds of requiring 2-DT (odds ratio [OR] = 1.1, p = 0.0002), 3-DT (OR = 1.12, p < 0.0001), and revision surgery (OR = 1.11, p < 0.0001) were significantly increased. Preoperative endoscopy (ρ = 0.44, p < 0.0001) and CT scores (ρ = 0.51, p < 0.0001) and postoperative 6-month (ρ = 0.55, p < 0.0001) and 1-year (ρ = 0.4, p < 0.0001) endoscopy scores demonstrated good correlation with MEC. MEC correlates with objective clinical disease severity and may guide aggressiveness of management for the individual patient.

Development of bacterial resistance during treatment with topical gentamicin for chronic rhinosinusitis in patients with cystic fibrosis and primary ciliary dyskinesis. Retrospective case series.

The management of chronic rhinosinusitis (CRS) in patients with cystic fibrosis (CF) and primary ciliary dyskinesia (PCD) is still a challenge. At our institution we have used gentamycin nasal spray, extemporaneously produced, for prophylactic treatment of moderate-to-severe CRS. The aim of this study was to investigate the gentamycin susceptibility of bacteria in sputum samples in CF and PCD patients treated for CRS. Patients with CF and PCD who were prescribed gentamycin nasal spray for CRS and had sputum bacterial cultures taken pre-treatment and followed-up at least once after ≥6 months were retrospectively included. Microbiological data were descriptively analysed in terms of bacterial species and resistance to gentamycin. A case series of 17 CF and 12 PCD patients passed the inclusion criteria. Of those cases, three (18%) CF patients and one (8%) PCD patient developed resistance to gentamycin during treatment with gentamycin nasal spray. In all four cases, the resistant bacterial isolates were &lt;i&gt;P. aeruginosa&lt;/i&gt;. Additionally, two CF patients already had &lt;i&gt;P. aeruginosa &lt;/i&gt; isolates resistant to gentamycin in the pre-treatment culture. In further two CF patients, the multi-resistant &lt;i&gt;Burgdorferi cepacia &lt;/i&gt;complex, including gentamycin resistance, was identified. &lt;i&gt;P. aeruginosa &lt;/i&gt; and &lt;i&gt;S. aureus &lt;/i&gt; in CF and &lt;i&gt;P. aeruginosa&lt;/i&gt; and &lt;i&gt;H. influenza &lt;/i&gt; in PCD were the predominant bacterial species. The study showed that there was moderate incidence of gentamycin resistance in CF and PCD patients at our institution. However, further prospective studies are needed to confirm the outcomes.