Endoscopic sinus surgery and aspirin desensitization improve otologic-specific SNOT-22 scores

ObjectiveThere are few studies evaluating the impact of Aspirin-exacerbated respiratory disease (AERD) treatment on otologic symptoms. The aim of this study is to evaluate the effects of endoscopic sinus surgery (ESS) and aspirin desensitization (AD) on otologic symptoms in subjects with AERD.MethodsRetrospective chart review of adult patients diagnosed with AERD at our tertiary Care Academic Medical Center - Otorhinolaryngology Department. Charts of adult patients diagnosed with AERD who underwent ESS and ASA desensitization at our institution's AERD Center from 2016 to 2019 were reviewed. Sino-Nasal Outcomes Test 22-item survey (SNOT-22) scores were evaluated for patients at various time points including: pre-surgery, post-surgery/pre-aspirin desensitization, and various times post-desensitization up to >12 months. Within the SNOT-22, otologic-specific subdomain scores were evaluated at similar time points. Patients on immunomodulatory medications other than corticosteroids were excluded from analysis.ResultsSNOT-22 scores were analyzed for 121 patients. There was a significant improvement in overall SNOT scores from pre-surgery (44.62) to post surgery/pre-desensitization (23.34) (P < 0.0005). Similarly, SNOT-22 otologic-specific scores also improved after surgery prior to desensitization (3.19–2.04) (P = 0.005). Following AD, the improvement in the overall SNOT-22 continued to improve for up to 12 months (P < 0.005). While the otologic-specific SNOT-22 scores remained stable after surgery and ASA desensitization.ConclusionESS and AD reduce otologic-specific SNOT-22 scores and parallel trends in overall SNOT-22 scores. The effect of treatment is durable over the course of 12 months. Future work should aim to correlate otologic SNOT-22 scores with objective otologic data.     

Aspirin-exacerbated respiratory disease: Update on medical management

Aspirin-exacerbated respiratory disease (AERD) is frequently diagnosed in patients with severe type 2 airway inflammation presenting with nasal polyps and severe asthma. It has been associated with a recalcitrant course with high medical and surgical requirements. The advent of recent biological and other targeted treatments show promise in the medical management of patient with AERD. The goal of complete disease control where patients no longer require recurrent surgical procedures, systemic corticosteroid exposure and may live with a stable and relatively normal quality of life is now within reach. Further work is necessary to identify biomarkers predictive of treatment response.     

Systematic review of outcomes for endoscopic sinus surgery and subsequent aspirin desensitization in aspirin-exacerbated respiratory disease

ObjectiveTo review and evaluate outcomes of patients with aspirin-exacerbated respiratory disease (AERD) following endoscopic sinus surgery and subsequent aspirin desensitization.MethodsElectronic searches of OVID MEDLINE (1948 to September 10, 2019), EMBASE (1980 to September 10, 2019), and PubMed were performed on September 10, 2019. A systematic review of the literature was performed using the 2009 PRISMA guidelines. Studies with both preoperative and postoperative data for patients with AERD who underwent sinus surgery and aspirin desensitization were considered appropriate for inclusion. Publications were written in English and included patients aged 18 years or older.ResultsSix studies met inclusion criteria for this systematic review. The primary outcome measure was change in symptom profile measured by patient-reported quality of life scores. The results demonstrate statistically significant improvement in symptoms following endoscopic sinus surgery, with sustained improvement following aspirin desensitization. Revision surgery rates were significantly lower in patients maintained on aspirin therapy.ConclusionThis review suggests that surgery followed by aspirin desensitization results in improvement in both subjective and objective outcome measures. The adjunctive use of aspirin desensitization allows for long-term stability in symptom scores. Recurrence of polyps and worsening symptoms requiring revision surgery occurs when aspirin maintenance therapy is interrupted.     

Olfactory outcomes in the management of aspirin exacerbated respiratory disease related chronic rhinosinusitis

Patients with aspirin exacerbated respiratory disease (AERD) experience a severe and recalcitrant form of chronic rhinosinusitis with nasal polyposis (CRSwNP) and asthma, which are exacerbated by aspirin/NSAID ingestion. As compared with aspirin-tolerant CRSwNP, patients with AERD experience more severe olfactory dysfunction, which is one of the key contributors to the observed decrease in quality of life (QOL) in this disease. The objective of this paper is to review the published olfactory outcomes observed with various treatment modalities.     

Comparative outcomes of endoscopic sinus surgery in patients with chronic sinusitis and nasal polyps

This study was carried out to compare the outcomes of endoscopic sinus surgery in patients with chronic sinusitis without nasal polyps (CRS) and those with nasal polyps (NP). We also sought to determine the correlation between preoperative computed tomography (CT) findings and postoperative endoscopy and symptom score improvement. Data were collected from two groups of patients diagnosed as CRS with and without nasal polyps that underwent functional endoscopic sinus surgery with a 1-year postoperative follow up. Preoperative symptoms, CT scores, and endoscopic scores were recorded. Postoperative symptom and endoscopic scores were recorded at 1, 6, and 12 months. Assessment of symptoms was performed subjectively using visual analogue scoring (VAS). CT scan findings were scored using the Lund–Mackay system. Endoscopic examination findings were scored according to the staging system proposed by Lanza and Kennedy. The correlations between the CT score, endoscopic scores and VAS scores were calculated. There was a statistically significant correlation between the preoperative CT, symptom, and endoscopic scores. Postoperative symptom and endoscopic scores also showed a significant correlation. Total CT scores of the CRS group were significantly lower than the scores of the NP group. Also preoperative endoscopy and symptom scores were statistically lower in CRS group compared to NP group. Endoscopy total scores and symptom total scores of both groups were significantly decreased at postoperative 12th month. Statistically significant difference was observed between the preoperative and postoperative symptom and endoscopy scores. The patients with polyps had higher symptom scores and worse objective findings compared to the patients with CRS. In all patients groups, objective and subjective scores seemed to correlate well preoperatively and postoperatively. These data suggest that endoscopic sinus surgery provides significant symptomatic relief and endoscopic healing in patients with CRS and NP.     

Comparison of subjective and objective assessment of glucocorticoid response in nasal polyps: a preliminary study

Background: Glucocorticoids (GC) therapeutic response in patients with chronic rhinosinusitis with nasal polyps (CRSwNP) varies markedly.

Aims/Objectives: To compare the utility between subjective and objective assessment of GC sensitivity in reflecting the impact of GC on systemic and local eosinophilia in CRSwNP patients.

Material and methods: Twenty-six patients with CRSwNP were enrolled. All patients were given 30?mg of prednisone once daily for 7 days and subsequently classified into subjectively GC-sensitive and -insensitive subgroup or objectively GC-sensitive and -insensitive subgroup. The numbers of eosinophils and neutrophils in blood and polyp tissues were compared between GC-sensitive and GC-insensitive subgroup.

Results: 17/26 (65.4%) patients were subjectively and 8/26 (30.8%) patients objectively sensitive to GC treatment. The absolute number and percentage of eosinophils in blood were decreased both in GC-sensitive and -insensitive subjects after GC treatment. In addition, a significant reduction in tissue eosinophil percentage was only observed in objectively GC-sensitive subjects after GC treatment. Furthermore, the change of tissue eosinophil percentage in objectively GC-sensitive subjects was significantly higher than that in objectively GC-insensitive subjects.

Conclusions and significance: Objective assessment may better reflect oral GC response in tissue eosinophilic inflammation than subjective assessment in patients with CRSwNP.     

Nasal polyposis pathophysiology: Endotype and phenotype open issues

Purpose

Endotyping chronic rhinosinusitis with nasal polyps (CRSwNP) poses a challenge for rhinologists nowadays. Phenotyping CRSwNP proved inappropriate as an approach to their classification because of their common clinical features. Endotyping, being based on the pathogenic mechanism, provides a precise picture more appropriate for use in clinical practice. Patients' treatment and follow-up can thus be tailored to cope with the degree of aggressiveness of a specific CRSwNP endotype.The aim of this study was to analyze the available information about the main currently accepted endotypes of CRSwNP; furthermore, we reported and commented evidence regarding some clinical conditions associated with nasal polyposis which could be related with new endotypes.

The importance of timely diagnosis of aspirin-exacerbated respiratory disease for patient health and safety

BackgroudAspirin-exacerbated respiratory disease (AERD) is a difficult-to-treat syndrome where timely diagnosis and initiation of disease-specific therapies are pertinent to improved patient outcomes.ObjectiveTo characterize the most common timeline for development of the clinical triad [asthma, nasal polyposis, and reactions to nonsteroidal anti-inflammatory drugs (NSAIDs)], identify barriers to prompt diagnosis of AERD, and describe indications for an aspirin challenge to facilitate accurate diagnosis.MethodsSix hundred ninety-seven patients with diagnosed AERD and history of at least one sinus surgery to remove nasal polyps were identified in the Brigham and Women's Hospital AERD registry. Patient reported age at disease onset of asthma, nasal polyposis, and age of first NSAID reaction were obtained from 2013 to 2019 at enrollment.ResultsOf the 697 patients identified, diagnosis of asthma preceded diagnosis of nasal polyposis and first NSAID reaction, although there was considerable variability between patients.ConclusionsPrompt diagnosis of AERD is important for patient and provider education and improved care of this difficult-to-treat population of patients. Consider diagnostic aspirin challenge in patients without historical reactions to NSAIDs who have an otherwise compatible clinical history, specifically in patients who take daily low-dose aspirin, leukotriene modifiers, avoid NSAIDs, or who are severely symptomatic at baseline where it would be difficult to identify an acute worsening of symptoms.     

儿童鼻窦炎与哮喘:统一气道疾病

鼻窦炎和哮喘是儿童常见的异质性疾病,发病因素多样。慢性鼻窦炎可能是哮喘的危险因素,二者之间存在强关联性。上下气道炎症常伴发,具有共同的病理机制。对此,“统一气道疾病”的理论得到广泛认可。对于哮喘患者,特别是严重哮喘,常伴有鼻窦炎,是影响儿童哮喘严重程度和临床控制的主要合并症之一。对一种疾病的治疗可能会影响另一种疾病的控制,而深入理解病理生理学机制将有助于更好地进行疾病管理。本文从儿童鼻窦炎和哮喘的疾病特征、发病机制、药物治疗以及生物制剂治疗等方面进行讨论。     

Objective screening for olfactory and gustatory dysfunction during the COVID‐19 pandemic: A prospective study in healthcare workers using self‐administered testing

BackgroundSmell and taste loss are highly prevalent symptoms in coronavirus disease 2019 (COVID‐19), although few studies have employed objective measures to quantify these symptoms, especially dysgeusia. Reports of unrecognized anosmia in COVID‐19 patients suggests that self‐reported measures are insufficient for capturing patients with chemosensory dysfunction.ObjectivesThe purpose of this study was to quantify the impact of recent COVID‐19 infection on chemosensory function and demonstrate the use of at‐home objective smell and taste testing in an at‐risk population of healthcare workers.MethodsTwo hundred and fifty healthcare workers were screened for possible loss of smell and taste using online surveys. Self‐administered smell and taste tests were mailed to respondents meeting criteria for elevated risk of infection, and one‐month follow‐up surveys were completed.ResultsAmong subjects with prior SARS‐CoV‐2 infection, 73% reported symptoms of olfactory and/or gustatory dysfunction. Self‐reported smell and taste loss were both strong predictors of COVID‐19 positivity. Subjects with evidence of recent SARS‐CoV‐2 infection (<45 days) had significantly lower olfactory scores but equivalent gustatory scores compared to other subjects. There was a time‐dependent increase in smell scores but not in taste scores among subjects with prior infection and chemosensory symptoms. The overall infection rate was 4.4%, with 2.5% reported by PCR swab.ConclusionHealthcare workers with recent SARS‐CoV‐2 infection had reduced olfaction and normal gustation on self‐administered objective testing compared to those without infection. Rates of infection and chemosensory symptoms in our cohort of healthcare workers reflect those of the general public.