Recurrent Acute Rhinosinusitis Research Articles

Role of Sinonasal Anatomic Variants in Recurrent Acute Rhinosinusitis.

Prior studies evaluating the role of sinonasal anatomic variants with recurrent acute rhinosinusitis (RARS) are limited by inconsistent results. The goal of this study is to evaluate the association between sinonasal anatomic variants and RARS. A 1:2 retrospective case-control study was conducted using patients presenting to the rhinology clinic from August 2020 to January 2023. A total of 60 patients with RARS were compared to 120 control patients. RARS was diagnosed based on the International Consensus Statement on Allergy and Rhinology criteria of four or more independent episodes of acute rhinosinusitis per year with at least one episode documented by objective findings, with complete resolution of the infection in-between episodes. Sinonasal anatomic variants included nasal septal deviation (NSD), concha bullosa (CB), infraorbital (Haller) cells, nasal septal spur in the middle meatus, and frontal sinus cells (supra-agger, supra-agger frontal, and suprabullar frontal cells). Age was similar in RARS and control patients (47.4 ± 16.5 vs. 49.3 ± 14.5, p = 0.432). Both the RARS group and control group were more likely to be female (78.3% vs. 77.5%, p = 0.899). There was no significant association between NSD and RARS compared to the control group (OR = 0.97, p = 0.916), and no significant association between any of the anatomic variants and RARS [infraorbital cells (OR = 0.64, p = 0.167), CB (OR = 0.84, p = 0.596), spur in the middle meatus (OR = 1.28, p = 0.514), supra-agger (OR = 0.88, p = 0.708), supra-agger frontal cells (OR = 0.97, p = 0.939), or suprabullar frontal cells (OR = 1.13, p = 0.766)]. Our findings suggest no association between nasal septal deviation or any of the anatomic variants studied and RARS. 3 Laryngoscope, 2024.

Association of autoimmune disorders with chronic rhinosinusitis in adults

IntroductionIncreasing evidence suggests that autoimmune disorders and their immunomodulating medications may increase the risk of rhinosinusitis compared to rhinitis. GoalTo investigate the association between autoimmune disorders and rhinosinusitis. MethodsWe performed a case-control study of patients referred to West Virginia University from August 2020 to October 2022 for rhinologic complaints. Rhinosinusitis patients were diagnosed with either chronic rhinosinusitis (CRS) or recurrent acute rhinosinusitis (RARS). These patients were compared to non-rhinosinusitis patients. Patients' characteristics, comorbidities, and type of treatment of autoimmune disorders were reviewed. ResultsThe sample consisted of 527 rhinosinusitis [184 CRS without nasal polyps (CRSsNP), 263 CRS with nasal polyps (CRSwNP) and 80 RARS patients] patients and 564 non-rhinosinusitis patients. Patients with rhinosinusitis were more likely to be older, males, have asthma, and have current and past smoking history (all with p-value < 0.05). Autoimmune disorders, primary antibody deficiency, and immunomodulator agents were more common in rhinosinusitis patients (16.5 % vs 9.4 %, OR = 1.9, p < 0.001; 5.1 % vs 0.5 %, OR = 10.1, p < 0.001; and 3.8 % vs 1.1 %, OR = 3.7, p = 0.003 respectively). Multivariate logistic regression adjusting for confounders showed that autoimmune disorders were strongly associated with rhinosinusitis [OR = 1.6, 95 % CI = 1.10–2.48], whereas the immunomodulators did not reach statistical significance [OR = 2.4, 95 % CI = 0.87–6.47]. Subgroup analysis showed the autoimmune disorders did not significantly differ between CRS and RARS groups [OR = 1.0, 95 % CI = 0.5–2.1], or between the CRSsNP and CRSwNP groups [OR = 0.9, 95 % CI = 0.5–1.7]. ConclusionAutoimmune disorders are associated with rhinosinusitis, both CRS and RARS, independently of other risk factors.

Impact of recurrent acute rhinosinusitis on quality of life.

Quality of life (QoL) in patients with recurrent acute rhinosinusitis (RARS) is understudied. QoL for RARS patients is similar to chronic rhinosinusitis patients, although objective disease severity is lower. QoL of RARS patients is similarly affected during active and inactive infection.

Risk Factors for Recalcitrant Chronic Rhinosinusitis in Organ Transplant Recipients.

Studies suggest that transplant patients are at risk for chronic rhinosinusitis (CRS). However, there is limited information in the literature regarding frequency and reasons for failure of adequate medical therapy. We aim to determine the risk factors associated with the development of medically recalcitrant CRS requiring endoscopic sinus surgery (ESS). Retrospective cohort. Mayo Clinic. This is a retrospective chart review of 925 transplant recipients seen at Mayo Clinic between 2017 and 2022. (1) a rhinologic consultation after transplant and (2) clinical diagnosis of CRS. A total of 549 patients met the inclusion criteria and were divided based on the need for ESS versus successful treatment with medical therapy. Univariate and logistic regression analyses were performed to identify risk factors and predictive variables related to failure of medical therapy. Of the 549 patients, 201/549 (37%) had medically recalcitrant disease requiring ESS, while 348/549 (63%) were successfully treated with medical therapy Based on logistic regression, patients with recurrent acute rhinosinusitis in the pretransplant period were 8.68 more likely to have a recalcitrant disease (95% confidence interval, 3.72-20.28, p < 0.0001). Some of the largest determinants of medical therapy failure in the posttransplant period were CRS with nasal polyps, odontogenic CRS, and noninvasive fungal sinusitis. The presence of neutropenia, aplastic anemia, and living transplant were also associated with medically recalcitrant CRS requiring ESS. Our predictive model identifies with high accuracy the patients who may be at risk of developing recalcitrant CRS in the organ transplant population.

Computed Tomography Grading of Nasal Obstruction Severity in Recurrent Acute Rhinosinusitis Patients

Computed Tomography Grading of Nasal Obstruction Severity in Recurrent Acute Rhinosinusitis Patients

Health-care utilization for sinusitis after pneumococcal vaccination in patients with low antibody titers.

Pneumococcal antibody deficiency has been the subject of limited study in chronic rhinosinusitis (CRS) and has not been studied in recurrent acute rhinosinusitis (RARS). The 23-valent pneumococcal polysaccharide vaccine (PPSV23) is considered for patients with nonprotective Streptococcus pneumoniae titers. We hypothesized that both RARS and CRS patients with deficient S pneumoniae titers and subsequent PPSV23 vaccination would have reduced health-care encounters for sinusitis and fewer prescriptions for antibiotics or steroids. A retrospective cohort study was performed of patient encounters between January 2011 and December 2019. All patients included were ≥18 and ≤65 years old with a diagnosis of CRS or RARS and pneumococcal titer data. Patients with immunodeficiency and comorbid conditions requiring PPSV23 vaccination before 65 years of age were excluded. A total of 938 patients were included in the study. Nonprotective antibody titers were present in 75.8% of CRS and 74.8% of RARS patients. A total of 306 patients with deficient antibody titers received the PPSV23 vaccine. Eighty-nine percent of CRS and 90.1% of RARS patients had protective responses. Among the 217 patients with continuous data from 2 years before through 2 years after PPSV23 vaccination, a decrease in the number of encounter diagnoses of CRS (p<0.0001) and RARS (p=0.0006) was observed. Decreases in the frequency of antibiotic (p=0.002) and corticosteroid (p=0.04) prescriptions were also appreciated. Most patients with CRS and RARS have nonprotective antibody titers. PPSV23 administration significantly decreases health-care utilization.

Endoscopic sinus surgery (ESS) to change quality of life for adults with recurrent rhinosinusitis: study protocol for a randomized controlled trial

BackgroundEndoscopic sinus surgery (ESS) has been used for decades to treat recurrent acute rhinosinusitis episodes (RARS) in adults. RARS results in infectious symptoms, antibiotic courses, sick leaves, and impaired quality of life. Theoretically, the ESS procedure, through improving the drainage of the paranasal sinuses, decreases the symptoms and enhances the quality of life of the RARS patients. Whether this is true has not been reported in a randomized trial yet.MethodsWe conduct a single-center, non-blinded, randomized, 6-month, parallel group superiority clinical study including 80 adult participants referred to surgical treatment for RARS. The participants will either have ESS or conservative medical treatment (control group). The primary outcome will be the difference between the mean disease-specific Sinonasal Outcome Test 22 (quality of life questionnaire) change scores (from baseline to 6 months) of ESS and control group.DiscussionThis study will add significant new information to the effect and harms of ESS procedure in the treatment of adults with RARS.Trial registrationClinicalTrials.govNCT04241016. Registered on 17 January 2020

Effects of the Traditional Mediterranean Diet in Childhood Recurrent Acute Rhinosinusitis

Introduction: There are more and more studies that demonstrate the anti-inflammatory effects of the traditional Mediterranean diet (TMD). The aim of the study was to assess the effects of an intervention with the TMD in patients with recurrent acute and chronic rhinosinusitis. Material and Methods: We performed a pretest–posttest comparison study in 114 patients (56 girls and 58 boys) aged one to five years who had three or more acute rhinosinusitis episodes in the period of 1 year. They were included for a year in the nutritional program “Learning to eat from the Mediterranean”. The anthropometric, clinical, and therapeutic characteristics were studied. Results: All the studied indicators showed a positive and statistically significant evolution. Of the patients, 53.5% did not have any episode of acute rhinosinusitis, and 26.3% had only one, compared to the 3.37 they had on average in the previous year. The use of antibiotics decreased by 87.6%. The degree of satisfaction of the families was very high. The Mediterranean Diet Quality Index (KIDMED) that assesses the quality of the TMD rose from 7.7 to 11 points. Conclusions: The adoption of the TMD could have promising effects in the prevention and treatment of recurrent acute and chronic rhinosinusitis, limiting the pharmacological and surgical intervention in many of these patients.

Outcome of Immunoglobulin Replacement Therapy in Adults With Rhinosinusitis.

To evaluate the outcome of immunoglobulin (IG) replacement therapy in adults with rhinosinusitis and primary humoral immunodeficiency disorders (PID). Retrospective cohort study. Retrospective chart review of adult (18 years and older) patients who were diagnosed with PID and had the diagnosis of recurrent acute rhinosinusitis (RARS) and chronic rhinosinusitis (CRS) and who are on IG replacement therapy. Demographic data, associated conditions, and duration of treatment were reviewed. Number of yearly sinus infections, sinus CT Lund-Mackay (LM) score, and need for functional endoscopic sinus surgery (FESS) were reviewed before and after starting IG therapy. Fifty-eight patients were included. Average age was 52 years (18-79 years). About 74% were female. Thirty patients (51.7%) had common variable immunodeficiency (CVID), 18 (31.1%) had hypogammaglobulinemia, and 10 (17.2%) had specific antibody deficiency (SAD). About 79% of patients had allergic rhinitis and 74% had asthma. Pretreatment LM score was 7.6 (±2.2, range of 0-24) compared to posttreatment score of 3.5 (±1.3, range of 0-16) (P=.01). Eleven patients (19%) had FESS pretreatment compared to only two patients (3.4%) requiring ESS after starting treatment on IG therapy (P=.004). Prior to starting IG therapy, five patients (8.6%) had more than 10 sinus infections per year, 33 patients (56.9%) had 5 to 10 infections, and 20 patients (34.5%) had 1 to 5 infections per year. After starting on IG, 34 patients (58.6%) had no infections reported anymore (P < .001), and 24 patients (41.4%) had only 1 to 5 infections reported per year CONCLUSION: IG therapy is a promising treatment option for recurrent rhinosinusitis in patients with PID. 4 Laryngoscope, 132:732-736, 2022.

Rhinitis, rhinosinusutus and phytotherapy

Acute rhinitis and acute rhinosinusitis (ARS) have viral etiology in the most of cases, and their therapy is aimed at alleviating clinical symptoms and preventing new episodes. The indications for antibiotic therapy are severe bacterial ARS, ARS with complications, and recurrent bacterial ARS. Such a categorical approach is due to the increase of antibiotic resistance, which leads to the popularization of efficient phytotherapy. Modern herbal medical products comply with general recommendation and standards of efficacy, safety and quality, and their effectiveness has been proven in clinical trials along with synthetic drugs. In acute upper respiratory tract infections, herbal medical drugs stimulate the immune system, relieve clinical symptoms, and improve the patient’s quality of life. A significant emphasis in phytotherapy is given to complex drugs synthesized on the basis of phytoneering. One of such remedies is the herbal medicinal product containing the different parts of 5 medicinal herbs: Gentian root (Gentianae radix), Primrose flowers (with calyx) (Primulae flos (cum calycibus)), Common sorrel herb (Rumicis herba), Elder flowers (Sambuci flos) and Vervain herb (Verbenae herba). This herbal medicinal product shows secretolytic, secretomotor, antiinflammatory, antiviral and mild antibacterial farmacological effects. The article provides an analysis of studies in vitro and in vivo proving the anti-inflammatory effect of Sinupret®, its potentiating effect on nasal mucosa mucociliary transport as well as efficacy and safety in patients with rhinosinusitis.

Antibody deficiencies are more common in adult versus pediatric recurrent acute rhinosinusitis

PurposeTo evaluate the frequency and types of humoral immunodeficiencies (HID) in pediatric and adult patients with recurrent (RARS). Patients with HID commonly present with upper respiratory tract infections. Their pathophysiology in children is different than adult counterparts. It is unknown how HID affects those two age groups. Materials and methodsWe performed a retrospective chart review of pediatric (<18 years old) and adult (18 years and older) patients who were evaluated in our pediatric and adult rhinology clinic between July 2010 and December 2020 and had the diagnosis of recurrent (>3 times/year) rhinosinusitis. Patients with cystic fibrosis, Aspirin Exacerbated Respiratory Disease (AERD), and ciliary dyskinesia were excluded. Demographic data and associated conditions were reviewed. Immunologic evaluation included complete blood cell count (CBC) with differential, serum immunoglobulin G, A, and M levels, and baseline and post-vaccination pneumococcal antibody titers. ResultsThere were 135 patients who met the inclusion criteria. 86 patients (63.7%) were children, 49 patients (36.3%) were adults. 46.5% of the pediatric patients and 45% of the adult patients were female. 17.4% of children had abnormal immunologic findings: 8 had hypogammaglobulinemia (p < 0.0001), 2 had specific antibody deficiency (SAD), and 5 had selective IgA deficiency. 32.7% of adults (p < 0.0001) had abnormal immunologic findings: 4 had hypogammaglobulinemia, 11 had SAD (p < 0.0001), and 1 patient had both IgA deficiency and SAD. ConclusionHumoral immunodeficiency, specifically SAD, seems to be more common in adult versus pediatric RARS that is refractory to treatment.

The role of CT and endoscopy in the evaluation of patients referred for intranasal Cryoablation

BackgroundCryoablation (CA) of the posterior nasal nerves has garnered increasing interest as an office-based procedure for chronic rhinitis (CR). Standardized preoperative evaluation, specifically the role of computed tomography (CT) and nasal endoscopy, has yet to be defined. We report a series of patients who underwent CT and endoscopy as part of CR work-up in patients referred for CA. ObjectiveHighlight the importance of both nasal endoscopy and CT scan in the evaluation of CR given significant overlap of symptoms and common occurrence of related sinonasal conditions. MethodsRetrospective analysis of all patients referred to a single tertiary rhinology practice for CA was performed. ResultsFifteen patients were sent for CA by medical allergists. Five patients were deemed CA candidates, and 1 patient received only medical CR treatment. Four patients had evidence of incomplete prior sinus surgery and/or continued chronic rhinosinusitis on endoscopic exam. These 4 patients received a combination of medical and surgical management with either complete resolution or improvement in CR symptoms. In 3 patients, CT confirmed chronic rhinosinusitis that was not apparent on endoscopy, and received a combination of medical and surgical management with symptom improvement. In the last two patients, final diagnoses were nasal valve collapse and recurrent acute rhinosinusitis. ConclusionsReferrals for CA are becoming more common and the optimal preoperative work up remains unclear. In this limited retrospective review, 67% of patients had diagnoses other than CR and thus were not deemed candidates for CA. Both CT and endoscopy are complementary to a detailed history and physical examination and can aid in CA candidate selection.

Diagnostic Criteria of Recurrent Acute Rhinosinusitis: A Systematic Review.

RARS is a challenging clinical phenomenon that affects many patients, and diagnostic criteria for this condition are not fully characterized in the literature. To examine diagnostic criteria for recurrent acute rhinosinusitis (RARS). Systematic review. Cochrane, PubMed (MEDLINE), clinicaltrials.gov, EMBASE, Google Scholar, and Web of Science databases were queried for articles related to RARS dating from 1990 to present, according to PRISMA statement guidelines. Full text articles pertinent to the diagnostic criteria of RARS were included in this review. Inclusion criteria included articles specifically addressing RARS; studies with 3 or more patients; and articles in English. A total of 1022 titles/abstracts potentially related to RARS were identified. Of these, sixty-nine full texts were selected for review, and 22 of these ultimately met inclusion criteria. The level of evidence was generally low. Studies and guidelines have used many different definitions for RARS diagnosis over the years based on symptomatology, physical examination, nasal endoscopy, imaging, and laboratory domains. Clinically important RARS has been defined most commonly as 4 or more discrete episodes of ARS per year, but this frequency is typically based on expert opinion. Additionally, radiologic anatomic associations such as concha bullosa, accessory maxillary os, and narrowed infundibular distance may be associated with RARS. Endoscopic visualization and imaging are sometimes used to confirm the presence of sinus disease during exacerbations of RARS, but there is variability in this practice. The diagnostic definition for RARS has developed over time and is currently based on low level 4 and 5 evidence. Because of the migratory definition of RARS, comparing inter-study results of RARS management remains difficult, and future studies should aim to follow current expert guidelines on diagnostic criteria of RARS.

Clinical Evidence and Biomarkers Linking Allergy and Acute or Chronic Rhinosinusitis in Children: a Systematic Review.

Purpose of the ReviewWe provide a systematic review of experimental and clinical evidences linking allergy to acute, including common cold, and chronic rhinosinusitis in children. Furthermore, we questioned if anti-allergy treatment may prevent the occurrence of rhinosinusitis or improve outcomes of its specific management.Recent FindingsAllergic rhinitis is a common childhood disease in industrialized countries that is responsible for a major impact on quality of life and healthcare resources. Over the years many authors tried to correlate allergy with comorbidities and in particular to the onset of rhinosinusitis including common cold, even though conflicting results are frequently reached. We performed a systematic review in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) process. Our search yielded 7103 that were finally screened. This resulted in 25 publications of which the full texts were assessed and included in a qualitative analysis per different phenotypes of rhinosinusitis.SummaryThe evidence suggests that allergy may lead to overall impairment of mechanical and immunological defense function of the nasal mucosa against viruses and that anti-allergy treatment may significantly decrease the number and severity of upper respiratory tract infections including common colds in children. It was not possible to perform the analysis for allergy and post-viral acute rhinosinusitis, bacterial acute rhinosinusitis, and recurrent acute rhinosinusitis because of paucity and heterogeneity of data. Although there is no definitive proof of causation linking allergy to chronic rhinosinusitis, studies lead to suppose that anti-allergy treatment may improve outcomes of specific CRS treatments.

Outcomes in Treatment of Rhinosinusitis in the Setting of Medication Induced Immunosuppression.

There is no data currently available to direct nuanced treatment for recurrent acute and chronic rhinosinusitis (RARS, CRS) in patients on daily, long term medications that suppress the immune system. This study sought to evaluate the outcomes of different treatment pathways when treating immunosuppressed patients with chronic rhinosinusitis or recurrent acute rhinosinusitis. A retrospective review of patients on immune suppressing medication presenting to a tertiary care center with RARS or CRS between the years 2014-2019 was completed. Patients were categorized into three groups based on treatment: medical management alone (MM), surgery after medical management (SAMM), or upfront surgery (US). Lund-Kennedy scores (LKS) and SNOT-22 scores were evaluated at baseline, 1 month, 3 months and 6 months from presentation. 68 patients met inclusion criteria, with no difference in demographics between groups. Patients who were treated with US and SAMM had significantly higher baseline LKS than those who were treated with MM alone (p = 0.050, p = 0.039). Once this difference was controlled for, there was no significant difference in overall change of LKS between the three groups over time. There was no significant disparity in baseline SNOT-22 scores between the three groups, but patients who underwent US had a significantly higher improvement in SNOT-22 from baseline compared to those undergoing MM alone (p = 0.013). Patients experiencing chronic rhinosinusitis and recurrent acute rhinosinusitis who are taking immunosuppressive medication can significantly improve from both medical and surgical management, but upfront surgical management appears to result in greater disease resolution relative to medical management in those with CRS. More study is needed in the RARS patient population regarding upfront surgery versus medical management.

The Effect of Endoscopic Sinus Surgery on Eustachian Tube Dysfunction Symptoms.

We assessed how eustachian tube dysfunction (ETD) changed with endoscopic sinus surgery (ESS) and identified factors associated with improvement. Retrospective chart review. Academic center. Patients undergoing ESS for chronic rhinosinusitis with and without nasal polyposis (CRSwNP, CRSsNP) or recurrent acute rhinosinusitis (RARS) completed the Eustachian Tube Dysfunction Questionnaire 7 (ETDQ-7) preoperatively and postoperatively at 2 weeks, 6 weeks, 3 months, and 6 months. Included in analyses were demographics, comorbidities, Sinonasal Outcome Test 22 (SNOT-22), radiographic score, endoscopy score, procedure, and medication use. Regression analysis identified factors associated with improvement, defined as ΔETDQ-7 >3.5. In total, 302 patients were studied. ETD prevalence was 68% in CRSsNP, 48% in CRSwNP, and 88% in RARS. Patients with ETD had a mean baseline ETDQ-7 of 25.8 ± 8.0 and improved postoperatively at 2 weeks (19.9 ± 8.1, P < .001), 6 weeks (17.8 ± 9.3, P < .001), 3 months (16.8 ± 8.5, P < .001), and 6 months (16.4 ± 7.9, P < .001). At 6 months, ETD improved in 89% of patients with CRSsNP, 68% with CRSwNP, and 78% with RARS. On multivariate analysis, ETD improvement was associated with higher preoperative ETDQ-7 score (adjusted odds ratio [aOR], 1.12; 95% confidence interval [CI], 1.04-1.22; P = .030), higher preoperative SNOT-22 score (aOR, 1.02; 95% CI, 1.02-1.08; P = .001), higher preoperative SNOT-22 ear subscore (aOR, 1.27; 95% CI, 1.02-1.65; P = .034), posterior ethmoidectomy (aOR, 1.59; 95% CI, 1.22-4.92; P = .025), and postoperative corticosteroid spray use (aOR, 1.57; 95% CI, 1.17-1.66; P = .008). ETD symptoms often improve following ESS. Factors associated with improvement include higher preoperative disease burden, posterior ethmoidectomy, and postoperative corticosteroid spray. 4.

Endoscopic Sinus Surgery in Recurrent Acute Rhinosinusitis

Endoscopic Sinus Surgery in Recurrent Acute Rhinosinusitis

Acute Exacerbations in Recurrent Acute Rhinosinusitis: Differences in Quality of Life and Endoscopy.

Research surrounding outcome differences for patients with recurrent acute rhinosinusitis (RARS) is scarce. This investigation explored quality of life (QOL) and sinonasal attributes in patients during acute episodes (AEs) and in-between AEs of RARS. Retrospective outcomes research. Data from patients with RARS were collected from two academic institutions between 2009 and 2017 using prospective and retrospective methodology. During clinical presentation, subjects were classified as with or without an AEs using guideline definitions of acute bacterial rhinosinusitis (ABRS). Between-group differences in 22-item Sino-Nasal Outcome Test (SNOT-22) survey and Lund-Kennedy (LK) endoscopy scores were assessed. Four hundred twenty-three clinical visits from 202 patients were included. Visits during an AE (168/423, 40%) were associated with significantly worse SNOT-22 total scores compared to between AEs (255/423, 60%; median = 53.0 [interquartile range (IQR) = 24.0] vs. 34.0 [IQR = 29.5]) and all SNOT-22 subdomain scores (all P < .001). LK scores were available for 167 visits, with 56 (34%) completed during an AE. Compared to visits without an AE, endoscopy findings associated with an AE were less frequently normal (LK score = 0, 45% vs. 62%, P = .031) with worse median LK scores (2.0 [IQR = 4.0] vs. 0.0 [IQR = 2.0], P = .005). AEs are associated with significantly worse QOL and mildly worse endoscopic findings. Almost half of visits during AEs had negative endoscopy, identifying a disparity between patient symptoms and objective findings and calling into question alternative or concomitant diagnoses. Diagnostic criteria for ABRS or AEs in RARS do not require objective confirmation of inflammation, presenting a conundrum for clinicians. The potential for overdiagnosis of ABRS and AEs should be considered when determining the risk/benefit ratio of treatments for RARS. 2c Laryngoscope, 2019.

Rate of rhinosinusitis and sinus surgery following a minimally destructive approach to endoscopic transsphenoidal hypophysectomy.

There remains considerable variation in the extent of sinonasal preservation during the approach for endoscopic transsphenoidal hypophysectomy (TSH). We advocate for a minimally destructive approach utilizing turbinate lateralization, small posterior septectomy, no ethmoidectomy, and preservation of nasoseptal flap (NSF) pedicles bilaterally. Due to these factors, this approach may affect the rates of postoperative rhinosinusitis. The objective of this study is to define the rates of postoperative rhinosinusitis in patients undergoing this approach. Single institution, retrospective chart review of patients undergoing TSH from 2005 to 2018. A total of 415 patients were identified and 14% developed an episode of postoperative rhinosinusitis within 3 months. These patients were significantly more likely to have had a history of recurrent acute or chronic rhinosinusitis. Most cases were sphenoethmoidal sinusitis managed with 1 to 2 courses of antibiotics. Of patients with postoperative rhinosinusitis, most did not undergo NSF. Average follow-up was 38 months. Six patients (1.4%) underwent post-TSH functional endoscopic sinus surgery (FESS). Average time from TSH to FESS was 26.3 months. Two of these patients had a history of prior chronic rhinosinusitis without polyposis. Two patients underwent revision TSH for recurrent tumor as the primary indication for surgery at time of FESS. Twenty-two-item Sino-Nasal Outcome Test (SNOT-22) scores generally increased immediately postoperatively, but frequently decreased below preoperative level by the time of last follow-up, regardless of whether patients developed rhinosinusitis. Sinonasal preservation during TSH is associated with a low rate of postoperative rhinosinusitis requiring FESS and excellent long-term patient reported outcomes. We continue to advocate for sinonasal preservation during pituitary surgery.

Inflammatory cell predominance and patterns in chronic rhinosinusitis with and without nasal polyposis patients.

ObjectivesThere is interest in identifying chronic rhinosinusitis (CRS) endotypes that align pathophysiology with clinical observation and outcomes. CRS with polyps (CRSwNP) has classically been studied with reference to tissue eosinophilia, but the role of other cellular infiltrates remains uncharacterized. No particular tissue prognosticators have been described for CRS without nasal polyps (CRSsNP). Predominance of leukocytes seen in surgical tissue may be useful for differentiating CRS subtypes, severity of inflammation, and outcomes.MethodsStructured histopathology reports were examined for 277 patients undergoing endoscopic sinus surgery for CRSwNP (n = 115), CRSsNP (n = 141), and recurrent acute rhinosinusitis (RARS, n = 21). Inflammatory predominance was examined for associations with nasal polyposis, asthma, allergic rhinitis, aspirin exacerbated respiratory disease (AERD), immune deficiency, preoperative Lund‐Mackay score, and outcome (SNOT‐22 score change).ResultsIn order of frequency, the prevalence of predominant inflammatory patterns accounting for 93.5% of CRS patients were: lymphoplasmocytic (n = 111), lymphocytic (n = 74), eosinophilic (n = 50), and lymphoplasmocytic with eosinophilic (n = 24). Eosinophilic predominance was 97.4% specific for nasal polyps (95% confidence interval [CI], 93.4%‐99.3%), although sensitivity was 43.4% (95% CI, 33.8%‐53.4%). The absence of eosinophilic predominance was 100% sensitive for RARS (95% CI, 82.4%‐100%), however specificity was 30.8% (95% CI 25.1%‐37.1%). There were no significant differences in preoperative SNOT‐22 scores or change postoperatively.ConclusionsEosinophilic inflammatory predominance was predictive for nasal polyps and against RARS. Nevertheless, the majority of CRSwNP patients had a different inflammatory predominance, demonstrating heterogeneity in CRS, even among patients with nasal polyps. Symptomatic outcomes were not associated with inflammatory predominance through 12 months follow up.Level of Evidence4.