Chronic rhinosinusitis: epidemiology and medical management

Chronic rhinosinusitis (CRS) affects 12.5% of the US population. On epidemiologic grounds, some association has been found between CRS prevalence and air pollution, active cigarette smoking, secondhand smoke exposure, perennial allergic rhinitis, and gastroesophageal reflux. The majority of pediatric and adult patients with CRS are immune competent. Data on genetic associations with CRS are still sparse. Current consensus definitions subclassify CRS into CRS without nasal polyposis (CRSsNP), CRS with nasal polyposis (CRSwNP), and allergic fungal rhinosinusitis (AFRS). Evaluation and medical management of CRS has been the subject of several recent consensus reports. The highest level of evidence for treatment for CRSsNP exists for saline lavage, intranasal steroids, and long-term macrolide antibiotics. The highest level of evidence for treatment of CRSwNP exists for intranasal steroids, systemic glucocorticoids, and topical steroid irrigations. Aspirin desensitization is beneficial for patients with aspirin-intolerant CRSwNP. Sinus surgery followed by use of systemic steroids is recommended for AFRS. Other modalities of treatment, such as antibiotics for patients with purulent infection and antifungal drugs for patients with AFRS, are potentially useful despite a lack of evidence from controlled treatment trials. The various modalities of medical treatment are reviewed in the context of recent consensus documents and the author's personal experience.     

United airways: the impact of chronic rhinosinusitis and nasal polyps in bronchiectasic patient's quality of life

Background: The nose and the bronchi belong, in anatomical and physiopathological terms, to the concept of united airways. Associations between upper and lower airways diseases have been demonstrated in allergic rhinitis and asthma, nasal polyposis (NP) and asthma, chronic rhinosinusitis (CRS) and chronic obstructive pulmonary disease, and more recently CRS/NP and bronchiectasis (BQ). Objective: To evaluate the impact of CRS on quality of life (QoL) of patients with BQ, and to correlate these findings with the pulmonary status, nasal symptoms, and general health status. Methods: In a prospective study, patients with BQ (n = 80) were evaluated for CRS and NP using EP³OS criteria, and severity of BQ using chest high resolution computed tomography (HRCT)‐scan. Quality of life was assessed in all patients by using specific [Sinonasal Outcome Test‐20 (SNOT‐20), St George Respiratory Questionnaire (SGRQ)], and generic (Short Form‐36; SF‐36) questionnaires. Results: Using SNOT‐20, patients with CRS had worse QoL (2.1 ± 0.1; P < 0.001) than patients without CRS (0.4 ± 0.06). Using SGRQ total score, patients with CRS had worse QoL (43.7 ± 2.2; P < 0.001) than patients without CRS (24.7 ± 2.5). Using SF‐36, patients with CRS had worse QoL, both in the physical summary (64 ± 3.4; P < 0.05) and the mental summary (65.5 ± 4.7; P < 0.05), than patients without CRS (physical summary [PS]: 76.2 ± 3.3; mental summary [MS]: 78.3 ± 5.3, respectively). Sinonasal Outcome Test‐20 was correlated with SGRQ total score (r = 0.72; P < 0.01), and SF‐36 physical summary (r = ?0.63; P < 0.01). St George Respiratory Questionnaire was correlated with SF‐36 on physical summary (r = ?0.58; P < 0.05) and with forced expiratory volume in 1 s (r = ?0.41; P < 0.05). Conclusion: These results suggested that CRS, measured by both specific and generic questionnaires, has a considerable impact on the QoL of patients with BQ.     

Antibiotic-Dependent Relationships Between the Nasal Microbiome and Secreted Proteome in Nasal Polyps

PurposeChronic rhinosinusitis (CRS) is a heterogeneous chronic inflammatory condition of the paranasal sinuses and nasal passages. Although antibiotics are used to reduce inflammation or to treat an episode of acute rhinosinusitis, their effects on the nasal environment and host response in CRS is unclear.MethodsWe analyzed the effects of antibiotics on the nasal microbiome and secreted proteome in CRS using multi-omic analysis. Nasal secretions were collected from 29 controls, 30 CRS patients without nasal polyps (NP), and 40 CRS patients with NP. A total of 99 subjects were divided into 2 groups that included subjects who had taken antibiotics 3 months prior to sampling and those who had not. We performed 16S ribosomal DNA sequence analyses and Orbitrap mass spectrometry-based proteomic analyses. Spearman correlation was used to assess the correlations between the nasal microbiome and secreted proteome.ResultsThe associations between the nasal microbiome and secreted proteome were noted in subjects who had used antibiotics. Antibiotics could have stronger effects on their associations in patients with CRS with NP than in those without. It remains unknown whether these holistic changes caused by antibiotics are beneficial or harmful to CRS, however, the associations could be differentially affected by disease severity.ConclusionThese findings provide new insight into the nasal environment and the host response in CRS.     

Important research questions in allergy and related diseases: 3-chronic rhinosinusitis and nasal polyposis – a GA2LEN study

Chronic rhinosinusitis is one of the most common health care challenges, with significant direct medical costs and severe impact on lower airway disease and general health outcomes. The diagnosis of chronic rhinosinusitis (CRS) currently is based on clinical signs, nasal endoscopy and CT scanning, and therapeutic recommendations are focussing on 2 classes of drugs, corticosteroids and antibiotics. A better understanding of the pathogenesis and the factors amplifying mucosal inflammation therefore seems to be crucial for the development of new diagnostic and therapeutic tools. In an effort to extend knowledge in this area, the WP 2.7.2 of the GA²LEN network of excellence currently collects data and samples of 1000 CRS patients and 250 control subjects. The main objective of this project is to characterize patients with upper airway disease on the basis of clinical parameters, infectious agents, inflammatory mechanisms and remodeling processes. This collaborative research will result in better knowledge on patient phenotypes, pathomechanisms, and subtypes in chronic rhinosinusitis. This review summarizes the state of the art on chronic rhinosinusitis and nasal polyposis in different aspects of the disease. It defines potential gaps in the current research, and points to future research perspectives and targets.     

Chronic Rhinosinusitis and the Coagulation System

Chronic rhinosinusitis (CRS) is one of the most common chronic diseases in adults and severely affects quality of life in patients. Although various etiologic and pathogenic mechanisms of CRS have been proposed, the causes of CRS remain uncertain. Abnormalities in the coagulation cascade may play an etiologic role in many diseases, such as asthma and other inflammatory conditions. While studies on the relationship between asthma and dysregulated coagulation have been reported, the role of the coagulation system in the pathogenesis of CRS has only been considered following recent reports. Excessive fibrin deposition is seen in nasal polyp (NP) tissue from patients with chronic rhinosinusitis with nasal polyp (CRSwNP) and is associated with activation of thrombin, reduction of tissue plasminogen activator (t-PA) and upregulation of coagulation factor XIII-A (FXIII-A), all events that can contribute to fibrin deposition and crosslinking. These findings were reproduced in a murine model of NP that was recently established. Elucidation of the mechanisms of fibrin deposition may enhance our understanding of tissue remodeling in the pathophysiology of NP and provide new targets for the treatment of CRSwNP.     

Allergic vs nonallergic rhinitis: which is more predisposing to chronic rhinosinusitis?

BACKGROUND: The impact of allergy on chronic rhinosinusitis (CRS) is controversial. OBJECTIVE: To evaluate whether a history of CRS is more prevalent in patients with allergic rhinitis than in those with nonallergic persistent rhinitis. METHODS: A total of 115 patients (78 females; mean age, 31.9 years; age range, 14-64 years) with persistent rhinitis were included in the study. A 7-point analog scale was used to report the severity of individual and global CRS symptoms and to determine the impact of rhinosinusitis symptoms on quality of life. The allergic status of the patients was evaluated using skin prick tests for common inhalant allergens, and asthma was evaluated by means of history, physical examination, and respiratory function tests. Rhinoscopy and paranasal sinus computed tomography were used to determine CRS. RESULTS: Asthma and CRS were not significantly different in allergic and nonallergic patients. Nasal polyps were found equally in both groups (8 patients). However, mean Lund-Mackay staging scores, postnasal drainage, dental pain, and global CRS scores were significantly higher in patients with nonallergic rhinitis (P = .045, P = .001, P = .02, and P = .01, respectively). No significant correlations, except for dental pain (correlation coefficient, 0.250; P = .008), were found between Lund-Mackay scores and CRS symptoms. In rhinoscopy, the only conspicuous difference was nasal purulence in allergic patients (P = .002). CONCLUSION: Allergic and nonallergic rhinitis may contribute similarly to the development of CRS.     

Amphotericin B nasal lavages: not a solution for patients with chronic rhinosinusitis

BACKGROUND: Chronic rhinosinusitis (CRS) is one of the most common chronic diseases. Recently, it has been suggested that an exaggerated immune response to fungi is crucial in the pathogenesis of the disease. On the basis of this hypothesis, intranasal treatment with amphotericin B should benefit patients with CRS. Data from 2 uncontrolled and 2 controlled trials are conflicting, however. OBJECTIVE: To clarify the role of intranasal antifungal drugs in the treatment of CRS, we conducted a large, double-blind, placebo-controlled, multicenter study comparing the effectiveness of amphotericin B nasal lavages with placebo. METHODS: A total of 116 randomly selected patients with CRS were instructed to instill 25 mL amphotericin B (100 microg/mL) or placebo to each nostril twice daily for 3 months. Primary outcomes included a reduction in total visual analog scale (VAS) score and nasal endoscopy score. Secondary outcome measures included peak nasal inspiratory flow, polyp score, quality of life (Short Form-36, Rhinosinusitis Outcome Measure-31), and individual VAS scores. RESULTS: Analysis was based on intention to treat and involved all patients randomly assigned. Mean VAS scores, Short Form-36 and Rhinosinusitis Outcome Measure-31 data, peak nasal inspiratory flow values, nasal endoscopy scores, and polyp scores were similar in both treatment groups at the time of randomization, and no significant differences were observed after 13 weeks of treatment. CONCLUSION: Amphotericin B nasal lavages in the described dosing and time schedule do not reduce clinical signs and symptoms in patients with CRS. CLINICAL IMPLICATIONS: Amphotericin B nasal lavages in the described dosing and time schedule are ineffective and therefore not advised in the treatment of patients with CRS.     

Nasal biomarker profiles in acute and chronic rhinosinusitis

BACKGROUND: Clinical manifestations of rhinosinusitis include acute rhinosinusitis, chronic rhinosinusitis (CRS) with nasal polyps and CRS without polyps. OBJECTIVE: Possible mechanisms defining these three forms of rhinosinusitis should be investigated assessing biomarker profiles in nasal secretions. METHODS: Fifteen cytokines, three cellular activation markers and total IgE were determined in nasal secretions of seven patients with acute rhinosinusitis, 12 patients with CRS without polyps, 13 patients with CRS with polyps and six healthy controls. Principal component analysis was used to extract relevant factors. RESULTS: Irrespective of the clinical manifestation, all biomarkers assessed were increased in patients with rhinosinusitis when compared with controls (P<0.001). Principal component analysis allowed the extraction of three factors explaining 83% of data variance. The general inflammatory activation was mainly reflected by the first factor. The second factor differentiated acute from CRS. This factor correlated with IL-12, which is involved in pathogen-related immune activation by antigen-presenting cells. It was also positively correlated with IL-4, IL-10 and IL-13, which play an important role in the resolution of infections. The third factor differentiated CRS with polyps from CRS without polyps (P=0.001). It represented IL-5 and nasal IgE (nIgE), whereas eosinophil cationic protein and tryptase were not specific for CRS with polyps. CONCLUSION: In mucosal infection, numerous inflammatory mediators are activated. Simple correlations of few biomarkers with a specific disease process bear the risk of overestimating a possibly unspecific effect. To assess biomarker profiles, more complex analytic tools may be more appropriate to delineate mechanisms underlying mucosal disease. Using principal component analysis, it was found that high nIgE and IL-5 levels are specific for CRS with nasal polyps.     

The role of ubiquitous airborne fungi in chronic rhinosinusitis

Chronic rhinosinusitis (CRS) is a confusing disease for both allergists and otorhinolaryngologists, partly because of its poorly understood pathophysiology and partly because of its limited treatment options. Several recent reports have provided evidence for a better understanding of the etiology and the relationship of CRS to airborne fungi-especially to Alternaria. First, the development of novel methods enables detection of certain fungi in mucus from the nasal and paranasal sinus cavities. Second, a non-IgE-mediated immunological mechanism for reactivity of patients with CRS to certain common fungi has been described. Third, these fungi are surrounded by eosinophils in vivo, suggesting that they are targeted by eosinophils. Finally, the preliminary results of studies using antifungal agents to treat patients with CRS are promising. Overall, these recent discoveries provide a logical mechanism for the pathophysiology of CRS, and they also suggest promising avenues for treatment of CRS with antifungal agents.     

Role of imbalance of eicosanoid pathways and staphylococcal superantigens in chronic rhinosinusitis

Chronic rhinosinusitis (CRS) is a multifactorial disease of the upper airways with a high prevalence (approximately 11%) in the general population. Different immune and inflammatory mechanisms are involved in its pathogenesis. Alterations in the arachidonic acid pathway (leading to an imbalanced production of eicosanoids) have been linked to the pathophysiology of different diseases especially nasal polyposis, asthma, and aspirin‐exacerbated respiratory disease. Furthermore, viral and bacterial infections have been identified as important factors amplifying the pro‐inflammatory reactions in these pathologies. This review summarizes the impact of an imbalance in the eicosanoid pathway and the effect of Staphylococcus aureus enterotoxins on the regulation of the pro‐inflammatory network in CRS and their translation into disease severity.     

Nasal hyperreactivity in rhinitis: A diagnostic and therapeutic challenge

Although nasal hyperreactivity (NHR) is a common feature in patients suffering from allergic and nonallergic rhinitis, it is widely neglected during history taking, underdiagnosed in the majority of patients with rhinitis and rhinosinusitis, not considered as an outcome parameter in clinical trials on novel treatments for rhinitis and rhinosinusitis, and no target for routine treatment. In contrast to the simple nature of diagnosing NHR by a history of nasal symptoms induced by nonspecific exogenous and/or endogenous triggers, quantification is hardly performed in routine clinic given the lack of a simple tool for its diagnosis. So far, limited efforts have been invested into gaining better insight in the underlying pathophysiology of NHR, helping us to explain why some patients with inflammation develop NHR and others not. Of note, environmental and microbial factors have been reported to influence NHR, contributing to the complex nature of understanding the development of NHR. As a consequence of the neglect of NHR as a key clinical feature of rhinitis and chronic rhinosinusitis (CRS), patients with NHR might be suboptimally controlled and/or dissatisfied with current treatment. We here aim to provide a comprehensive overview of current knowledge on the pathophysiology, and the available tools to diagnose and treat NHR.     

Highlights in the advances of chronic rhinosinusitis

Chronic rhinosinusitis (CRS) is a complex upper airway inflammatory disease with a broad spectrum of clinical variants. As our understanding of the disease pathophysiology evolves, so too does our philosophy towards the approach and management of CRS. Endotyping is gaining favour over phenotype-based classifications, owing to its potential in prognosticating disease severity and delivering precision treatment. Endotyping is especially useful in challenging CRS with nasal polyposis cases, for whom novel treatment options such as biologicals are now available. The latest European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS2020) reflects these changes with updated rhinosinusitis classifications and new integrated care pathways. With the coronavirus disease 2019 (COVID-19) pandemic, physicians and rhinologists have to balance the responsibility of managing their patients’ upper airway while adequately protecting themselves from droplet and aerosol transmission. This review summarises the key updates from EPOS2020, endotype-based classification and biomarkers. The role of biologicals in CRS and the lessons we can draw from their use in severe asthma will be examined. Finally, the principles of CRS management during COVID-19 will also be discussed.     

The accuracy of symptom-based definition of chronic rhinosinusitis

OBJECTIVE: Currently, the diagnosis of chronic rhinosinusitis (CRS) is a symptom-based definition. This study aims to study, verify and evaluate the predictive value of the symptom-based definition of CRS and compare this with objective tests. METHODS: Seven hundred and sixty-eight adults, who were referred from primary care centers as patients who met the definition of CRS, were enrolled in the study. The patients were divided into two groups according to their allergic status. The patients were subjected to nasal endoscopy and computed tomography (CT) on the same day. RESULTS: The results showed 73.15% of the nonallergic patients with symptom-based diagnosed CRS and 65.34% of the allergic patients with symptom-based diagnosed CRS had no CT and endoscopic pathology (Endoscopic score 0 + CT score 0). Nasal discharge was the most common major symptom in all patients from both groups who had pathologic endoscopic and/or CT scan scores. CONCLUSIONS: It is well established that symptoms are very important in the diagnosis of CRS. However, two major symptoms are insufficient for diagnosis. Therefore, endoscopy and CT have important differential diagnostic roles. Our study showed that in patients with three major symptoms, CT pathology may be sufficient for definitive diagnosis. However, in patients with two major symptoms such as nasal discharge and/or low grade nasal polyposis, endoscopy becomes considerably more important due to inspective findings. If no endoscopic findings are found, the importance of the CT scans is increased.     

How should nasal symptoms be investigated in asthma? A comparison of radiologic and endoscopic findings

BACKGROUND: To improve asthma control, the management of rhinosinusitis often leads the physician to perform sinonasal imaging and/or nasal endoscopy, but their respective contributions are still insufficiently understood. OBJECTIVE: To evaluate the potential contribution of a symptoms questionnaire, sinus radiography (SR) and computed tomography (CT) scan to the diagnosis of nasal diseases in asthmatic patients when compared with ENT examination. METHODS: A total of 124 patients completed a questionnaire on nasal symptoms administered by the chest physician. Then, they underwent ENT examination. On the same day, SR and CT scans were performed independently. RESULTS: Patients (80.3%) had nasal symptoms during the month preceding the consultation. The ENT examination was normal in 8.1% (n = 10) and revealed rhinitis in 57.3% (n = 71), rhinosinusitis in 14.5% (n = 18) and nasal polyposis in 20.2% (n = 25). For rhinitis, the negative predictive value of bilateral nasal obstruction was 87.8%. Both SR and CT had low sensitivity and specificity. For rhinosinusitis, the negative predictive value of nasal symptoms varied from 85.4 to 95.2%. Sinus CT was at least as accurate as SR for the diagnosis of rhinosinusitis. In a multivariate analysis, only the CT scan (score > or =12) appeared to be significantly associated with the diagnosis of nasal polyposis. CONCLUSION: In asthmatic patients, physicians need to enquire systematically about the existence of nasal symptoms by using this simple questionnaire which is sensitive for rhinitis, and has good negative predictive value for excluding rhinosinusitis and nasal polyposis.     

Nasal polyposis and its impact on quality of life: comparison between the effects of medical and surgical treatments

BACKGROUND: Nasal polyposis (NP) is not a life-threatening disorder but may have a great impact on the quality of life (QoL). The objective of this study: (i) to investigate the health burden incurred by NP compared with the Spanish general population using the Short Form-36 Health Survey (SF-36) questionnaire; (ii) to compare the QoL outcome after medical or surgical treatment; and (iii) to assess and compare the effect of medical and surgical treatment on nasal symptoms. METHODS: About 109 patients with nasal polyps were included. Fifty-three patients were randomly allocated to receive oral prednisone for 2 weeks and 56 to undergo endoscopic sinus surgery. All patients administered intranasal budesonide for 12 months. Patients were evaluated for nasal symptoms, polyp size, and QoL. RESULTS: In comparison with the Spanish general population, patients with NP had worse scores on all SF-36 domains except for physical functioning. Nonasthmatic patients with NP had better QoL than asthmatic patients with NP on role physical functioning, body pain, and vitality (P <0.05). At 6 and 12 months, a significant improvement on all of SF-36 domains was observed after both medical and surgical treatment reaching the levels of general population (P <0.05). Nasal symptoms and polyp size improved after both medical and surgical treatment at 6 and 12 months (P <0.05). CONCLUSION: These results suggest that NP has considerable impact on a patient's QoL and that both medical and surgical treatment led to similar effects in improving QoL.     

Thermotherapy: a novel possible treatment strategy of chronic rhinosinusitis based on the chilblain-like alteration in the early pathophysiology

Chronic rhinosinusitis (CRS) is one of the most common inflammatory diseases affecting large number of patients globally. The pathogenesis of CRS is still unclear and the treatment is unsatisfied. Clinical data provide the evidence that the chilblain-like alteration occurs in the early pathophysiology of CRS. We hypothesize that thermotherapy may offer a novel possible treatment strategy of chronic rhinosinusitis. In this article, we discuss the possibility of the chilblain-like alteration in the early pathophysiology and a therapeutic role of thermotherapy.     

Treatment of chronic rhinosinusitis with intranasal amphotericin B: a randomized, placebo-controlled, double-blind pilot trial

BACKGROUND: Chronic rhinosinusitis (CRS) is one of the most common chronic diseases. Its etiology is unknown, and there is a paucity of effective medical treatments. OBJECTIVE: We tested the hypothesis that intranasal antifungal treatment improves the objective computed tomography (CT) findings (inflammatory mucosal thickening), nasal endoscopy stages, and symptoms of CRS. METHODS: A randomized, placebo-controlled, double-blind, single-center trial used amphotericin B to treat 30 randomly selected patients with CRS. Patients were instructed to instill 20 mL amphotericin B (250 mug/mL) or placebo to each nostril twice daily for 6 months. The primary outcome was a quantitative reduction in inflammatory mucosal thickening on CT scans of a standardized coronal cut. Secondary outcome measures were endoscopic scores, patient symptom scores, and levels of intranasal inflammatory mediators. RESULTS: Twenty-four patients completed the 6 months of treatment. Patients receiving amphotericin B achieved a relative reduction in the percentage of mucosal thickening on CT scans (n = 10; -8.8%) compared with placebo (n = 14; +2.5%; P = .030). Likewise, the changes in the endoscopic scores improved in the amphotericin B group compared with placebo ( P = .038). Between-group comparisons of the changes in the intranasal mucus levels of eosinophil-derived neurotoxin showed a reduction in the amphotericin B group and an increase in the placebo group ( P = .046); levels of IL-5 showed similar tendencies ( P = .082). CONCLUSION: Intranasal amphotericin B reduced inflammatory mucosal thickening on both CT scan and nasal endoscopy and decreased the levels of intranasal markers for eosinophilic inflammation in patients with CRS.     

Improvement of clinical and immunopathologic parameters in asthmatic children treated for concomitant chronic rhinosinusitis.

BACKGROUND: Chronic rhinosinusitis is frequently associated with asthma. A Th2 cytokine pattern has been recently reported in chronic rhinosinusitis in asthmatic children. OBJECTIVE: To evaluate the effects of treating concomitant chronic rhinosinusitis on respiratory symptoms and function and immunopathological parameters in asthmatic children. METHODS: Eighteen children with moderate asthma (age range, 5 to 12 years) poorly controlled by high doses of inhaled corticosteroids and chronic rhinosinusitis were evaluated for symptoms, spirometry, and inflammation at baseline, after treatment, and 1 month after suspension of treatment. All of the children were treated with a combination of amoxicillin and clavulanate (20 mg/kg twice daily) and fluticasone propionate aqueous nasal spray (100 microg/d) for 14 days. A short course of oral corticosteroids was also prescribed (deflazacort, 1 mg/kg daily for 2 days, 0.5 mg/kg daily for 4 days, and 0.25 mg/kg daily for 4 days). Rhinosinusal lavage for cytokine measurements and a nasal scraping for cytologic analysis were performed in all patients before and after medical treatment. RESULTS: A negative endoscopy result was demonstrated in 15 children after treatment. Symptoms and respiratory function significantly improved after treatment and 1 month later; 8 children had intermittent asthma and 10 had mild asthma. A significant reduction of inflammatory cell numbers was detected in all asthmatic children. Interleukin 4 levels significantly decreased (P < 0.001), whereas interferon-y levels increased (P < 0.001). CONCLUSION: Treatment of chronic rhinosinusitis is able to improve symptoms and respiratory function in asthmatic children, reducing inflammatory cells and reversing the cytokine pattern from a Th2 toward a Th1 profile.     

Clinical outcomes after endoscopic sinus surgery

PURPOSE OF REVIEW: Chronic rhinosinusitis continues to present diagnostic and therapeutic challenges for clinicians. Recently, attention has been focused on reliable and valid measures of outcomes for many sinonasal diseases. As a significant fraction of patients with chronic rhinosinusitis will come to endoscopic sinus surgery, there has been a dedicated focus on determining objective clinical outcomes after medical and surgical treatment for CRS. This has been aided by validated instruments for measuring both symptom outcomes and quality of life after endoscopic sinus surgery. RECENT FINDINGS: Recent studies have demonstrated that endoscopic sinus surgery provides statistically and clinically significant improvements in most sinonasal symptoms. These benefits are maintained more than 1 year after surgery. In addition, the significant adverse effects of chronic rhinosinusitis on quality of life can be reversed with appropriate endoscopic sinus surgery. Certain sub-populations do not fare as well with endoscopic sinus surgery, however; adjunctive medical management is required to maintain symptomatic and quality-of-life improvements for patients with nasal polyposis. Unfortunately, paranasal sinus computed tomography scan findings do not predict symptomatic or quality-of-life improvements after endoscopic sinus surgery. SUMMARY: With reliable objective evidence of the health benefits of endoscopic sinus surgery, patients should be considered for such surgery after failure of medical management. Further work is required to characterize outcomes for sub-populations, and to stage and select patients who will derive appropriate benefit from endoscopic sinus surgery.     

Differentiation of chronic sinus diseases by measurement of inflammatory mediators

Background:  Chronic rhinosinusitis (CRS) clinically is a heterogeneous group of sinus diseases, which may cover different disease entities, or may represent a disease continuum. Studying inflammatory cells and mediators in clearly defined disease subgroups may lead to a better differentiation of chronic sinus diseases.
Methods:  Sinonasal mucosal tissue from 10 nasal polyp (NP) patients, 13 cystic fibrosis patients (CF-NP), eight CRS subjects without polyps, and nine control patients were stained for CD3, CD25, CD68, CD20, myeloperoxidase (MPO), CD138 and tissue homogenates were assayed for eotaxin, interleukin (IL)-1 β , IL-2sR α , IL-5, interferon (IFN)- γ , IL-8, transforming growth factor (TGF)- β 1, tumor necrosis factor- α , and MPO by enzyme-linked immunosorbent assay or UNICAP system.
Results:  Nasal polyp and CF-NP showed increased numbers and activation of T cells, while only NP displayed an increase in plasma cells. Nasal polyp had significantly higher levels of eosinophilic markers [eosinophils, eotaxin, and eosinophil cationic protein (ECP)] compared with CRS, controls and CF-NP. Chronic rhinosinusitis was characterized by a Th1 polarization with high levels of IFN- γ and TGF- β , while NP showed a Th2 polarization with high IL-5 and immunoglobulin (Ig) E concentrations. Nasal polyp and CF-NP were discriminated by edema from CRS and controls, with CF-NP displaying a very prominent neutrophilic inflammation.
Conclusion:  Based on cellular and mediator profiles, we suggest that CRS, NP, and CF-NP are distinct disease entities within the group of chronic sinus diseases.