Significance of eosinophilia in chronic rhinosinusitis

BACKGROUND: The purpose of this study was to investigate the impact of serum eosinophilia in the prognosis of chronic rhinosinusitis (CRS). Eosinophils are now considered to play a major role in the pathogenesis of CRS. To date, no study has evaluated the clinical course of patients with CRS and serum eosinophilia. METHODS: A retrospective chart review of 620 patients who underwent endoscopic sinus surgery, (ESS) for CRS was performed. Thirty-one patients (5%) had elevated serum eosinophil counts and served as the study group. Patient charts of the study group and 34 (5%) controls with normal serum eosinophil counts were reviewed for comorbid diseases including asthma, polyps, and allergic fungal sinusitis. The number of ESSs performed and the postoperative recurrence of multiple sinus infections and need for antibiotics, systemic steroids, and antifungal agents were compared. RESULTS: A higher proportion of patients with serum eosinophilia had a history of asthma, polyp disease, and allergic fungal sinusitis. Postoperatively, the study group had a statistically significant difference (p < 0.05) as compared with controls with respect to postoperative recurrent sinus infections (94% versus 32%) and polyp disease (35% versus 3%). Statistical difference between study and control groups was also found with respect to the postoperative need for antifungal agents (23% versus 3%), multiple courses of antibiotics (84% versus 32%), and revision ESS (84% versus 24%). Although not statistically significant, a higher proportion of the study group required systemic steroids. CONCLUSIONS: CRS patients with serum eosinophilia have a worse prognosis when compared with controls. Patients with eosinophilia should be counseled appropriately, and the physician should be aware of the chronicity of disease.     

Cost analysis in the diagnosis of chronic rhinosinusitis

BACKGROUND: The present treatment regimen for a diagnosis of chronic rhinosinusitis involves a prolonged course of antibiotic therapy along with other adjunctive therapy. The decision to start treatment is made after diagnosis of chronic rhinosinusitis, which is based on subjective symptoms. The working hypothesis of this study is that the diagnosis based on subjective symptoms is inaccurate, leading to inappropriate antibiotic therapy and unnecessary health care expense. METHODS: One hundred patients were evaluated prospectively to determine which patients qualified for this study. Seventy-eight patients satisfied current criteria for a diagnosis of rhinosinusitis. RESULTS: Fifty-three percent (41 patients) of the 78 patients did not have a diagnosis of chronic sinusitis based on same-day computed tomography (CT) scanning. A charge analysis comparing treatment after diagnosis with medical therapy alone and CT scan for failures versus CT scanning with medical treatment for positive scans was performed. Although the most economical method of treatment was initiating medical therapy, it was also the least sensitive and specific in that 52% of patients didn't require the treatment. Endoscopy and/or CT screening with medical therapy were much better at appropriate diagnosis and targeted therapy but charge analysis indicated a much higher cost. CONCLUSION: Presently, the current subjective diagnostic paradigm for chronic rhinosinusitis is most cost-effective but least accurate. Objective evaluations (endoscopy and CT scanning) to aid in diagnosis are more accurate but more costly. Where cost constraints are important, careful considerations of alternatives are important.     

慢性鼻-鼻窦炎鼻息肉组织及外周血嗜酸细胞与临床表现的关系

目的 探讨慢性鼻-鼻窦炎伴鼻息肉(chronic rhinosinusitis with nasal polyps,CRSwNP)患者组织及外周血中嗜酸细胞(eosinophils,Eos)计数的相关性,并研究Eos与鼻窦影像学表现及术后复发的关系.方法 回顾性分析102例确诊为CRSwNP患者的临床资料,对鼻息肉组织进行Eos计数,比较其与外周血Eos的相关性.根据术后1年随访结果,比较复发组与非复发组之间的组织及外周血Eos计数、鼻窦CT Lund-Mackay评分的统计学差异.结果 复发组外周血Eos计数、外周血Eos百分数以及鼻息肉组织Eos计数显著高于非复发组(P=0.032、0.033、0.017),两组的鼻窦CT评分无统计学差异(P=0.089).鼻息肉组织Eos计数与外周血Eos绝对值具有显著相关性(r=0.637,P=0.000);鼻息肉组织Eos计数与外周血Eos百分比也具有显著相关性(r=0.542,P=0.000);外周血Eos计数、Eos百分数、鼻息肉组织Eos计数与术前鼻窦CT评分无显著相关性(P=0.072、0.065、0.695).结论 外周血及鼻息肉组织Eos计数具有显著相关性,并且鼻息肉组织及外周血Eos计数与鼻息肉术后复发相关.     

Adult chronic rhinosinusitis: diagnosis and dilemmas

Chronic rhinosinusitis (CRS) is one of the most frequent otolaryngologic diseases encountered. The diagnosis of CRS is made by a wide variety of practitioners, including primary care physicians,physician extenders, pulmonologists, and otolaryngologists. Therefore, an accurate, efficient, and accessible method of making a CRS diagnosis is required. This article describes the criteria for making a diagnosis and the problems encountered in applying those criteria.     

The accuracy of computed tomography in the diagnosis of chronic rhinosinusitis

OBJECTIVE: To determine the sensitivity, specificity, and diagnostic accuracy of paranasal sinus computed tomography (CT) in the diagnosis of chronic rhinosinusitis (CRS). STUDY DESIGN: Prospective dual cohort study. METHODS: One hundred seventy-one consecutive patients undergoing endoscopic sinus surgery for CRS were evaluated with CT and staged according to the Lund system. Histopathological findings from sinus specimens were reviewed and graded. A second contemporaneous control group of 130 patients undergoing CT of the sinus regions for other reasons but without a diagnosis of CRS was also staged. Sensitivity, specificity, and the receiver-operator characteristic were determined for the sinus CT in the diagnosis of CRS. Positive and negative predictive values were also computed. RESULTS: In the disease-positive group of patients with CRS, the mean Lund score was 9.8 (95% confidence interval, 9.0-10.6). The mean inflammatory grade on histopathological study was 2.3 (range, 0-4). For the control group (without disease), the mean Lund score was 4.3 (95% confidence interval, 3.5-5.0). The AUC for the receiver-operator characteristic was 0.802 (P <.001). Selecting a Lund score cut-off value of greater than 2 as abnormal, the sinus CT exhibited sensitivity and specificity of 94% and 41%, respectively. Increasing the cut-off value to 4 changed the sensitivity and specificity to 85% and 59%, respectively. CONCLUSIONS: The paranasal sinus CT scan exhibits good sensitivity and above-average specificity for the diagnosis of CRS. When added to the history and physical findings, CT may add to the diagnostic accuracy of CRS.     

JESREC score and mucosal eosinophilia can predict endotypes of chronic rhinosinusitis with nasal polyps

Objective

Recently, JESREC score and mucosal eosinophil count have been used to diagnose eosinophilic chronic rhinosinusitis (ECRS) in Japan. However, it remains unknown whether the subtypes of CRS diagnosed by these criteria have different endotypes. In the present study, we investigated whether JESREC score and mucosal eosinophil count were appropriate for classification of CRS subgroups into endotypes.

慢性鼻-鼻窦炎的发病机制及诊疗进展

慢性鼻-鼻窦炎(CRS)是耳鼻咽喉头颈外科的多因素疾病。根据患者症状、鼻内镜检查以及鼻窦CT扫描,CRS的诊断比较明确,但其病理机制却较复杂,治疗方式的选择也不完全一样。临床上应该更多地考虑内在的病理机制类型,采取针对性的治疗方式,以达到最好的治疗效果。     

鼻窦CT在慢性鼻窦炎早期诊断及治疗中的应用

目的探讨慢性鼻窦炎的临床诊断及治疗方法.方法回顾分析39例慢性鼻窦炎术前CT及内窥镜的检查结果,探讨CT诊断、内窥镜诊断与术后病理诊断的关系.结果 CT诊断与临床诊断的符合率为94.9%(37/39),内窥镜诊断与临床诊断的符合率为89.7%(35/39),CT结合内窥镜诊断与术后病理诊断的符合率为100%.所测上颌窦病变CT平均值为30.94Hu.结论鼻窦CT结合内窥镜检查能够准确评估鼻腔鼻窦病变的性质和范围,便于早期诊断和治疗,提高疗效.     

Bacteriology of postradiotherapy chronic rhinosinusitis in nasopharyngeal carcinoma patients and chronic rhinosinusitis

The purpose of this study was to investigate and compare the bacteriology of postradiotherapy chronic rhinosinusitis (postRT-CRS) and chronic rhinosinusitis (CRS) by evaluating the aspiration materials of the maxillary sinus of patients with postRT-CRS and patients with CRS. We collected the secretions of the maxillary sinus from 30 nasopharyngeal carcinoma patients with postRT-CRS and 30 patients with CRS for aerobe/facultative anaerobe bacteria culture. The most common isolates in the postRT-CRS group were Streptocuccus viridans, Staphylococcus aureus and Haemophilus influenzae, while those in the CRS group were Haemophilus influenzae, Pseudomonas aeruginosa and Staphylococcus aureus. Isolated Gram-positive coccus rate in postRT-CRS patients was significantly higher than in CRS patients (62.50% compared with 30.00%, respectively; P < 0.05), and isolated Gram-negative bacilli rate in postRT-CRS patients was significantly lower than in CRS patients (31.25% compared with 70.00%, respectively; P < 0.05). However, the incidence of positive cultures was not significantly different between the postRT-CRS group and the CRS group (P > 0.05). This study found that there were some differences in bacteriology between postRT-CRS and CRS. Gram-positive coccus was the predominant aerobic/facultative anaerobe pathogenic bacterium in patients with postRT-CRS, and Gram-negative bacilli was predominant in CRS patients.     

Local and systemic eosinophilia in patients undergoing endoscopic sinus surgery for chronic rhinosinusitis with and without polyposis

Eosinophils play a key role in the pathophysiology of sinonasal polyposis; their role in chronic rhinosinusitis without polyposis is less clear. To investigate this further, we biopsied diseased sinonasal tissue from 116 patients undergoing endoscopic sinus surgery and normal nasal mucosa from 24 controls. The patients were grouped, according to the nasal endoscopic appearance of their disease, into four clinical groups: chronic rhinosinusitis with no polyps, grade 1 polyps, grade 2 polyps, and grade 3 polyps. We also measured the peripheral blood eosinophil count. Histological analysis of the inflammatory cell content of the biopsies was carried out. The percentage of eosinophils in tissue from each of the clinical groups was significantly higher than that from the controls. There was no significant difference between the percentage of eosinophils in any of the clinical groups, but a trend. Peripheral eosinophil count increased with increasing severity of nasal disease.     

Immunomodulators in chronic rhinosinusitis

ObjectiveTo provide new insight into how chronic rhinosinusitis (CRS) is conceptualized and treated with a focus on immunomodulator therapy.Data sourcesPubmed, Medline, and Embase.MethodsA current review of the evidence is provided for immunomodulators investigated for treatment of CRS with nasal polyps (CRSwNP).ResultsBiologic therapies targeting IgE, IL-4, IL-5, and IL-13 for the treatment of CRSwNP have shown promise and are currently in phase 3 trials. Anti-immunoglobin E (IgE) therapy with omalizumab was assessed in 6 studies, anti-interleukin (IL)-5 therapy in 3 studies (2 mepolizumab, 1 reslizumab) and anti IL-4/IL-13 (dupilumab) therapy in one study. Studied outcomes varied, but the majority of trials identified clinical benefit of therapy over placebo. Other potential targets include thymic stromal lymphopoetin (TSLP), IL-25, IL-33, and sialic acid-binding immunoglobulin-type lectin (Siglec)-8. Small molecule drugs that target the dysregulation of the immune system in CRS are also being investigated for their immunomodulatory effects on inflammation.ConclusionImmunomodulator therapies for CRS currently in development will likely provide another therapeutic option for patients who have severe disease unresponsive to corticosteroids and surgery. Targeted monoclonal antibody therapies have shown encouraging results and phase 3 trials are underway. IL-4/IL-13 inhibition has shown the most promise to date. Further larger, well-designed trials are needed to improve understanding of these molecules and to offer endotype-driven therapies in the management of CRS. None of these therapeutics have shown long-term immunomodulation when discontinued and therefore further investigation into the pathomechanism of disease continues to be needed.     

Osteitis in chronic rhinosinusitis

The presence of inflammation and remodeling within the bone of the paranasal sinuses has been demonstrated in animal and human models of chronic rhinosinusitis. This form of osteitis is present in the underlying bone of affected mucosa and can spread to involve distant sites within the paranasal sinuses. This potential for distant involvement has implications for the medical and surgical management of chronic rhinosinusitis and may contribute to chronic rhinosinusitis refractory to management.     

慢性侵袭性真菌性鼻-鼻窦炎的概念和早期诊断以及治疗

目的　探讨慢性侵袭性真菌性鼻 鼻窦炎 (chronicinvasivefungalrhinosinusitis,CIFRS)的概念、早期诊断与治疗。方法　以最终病理学诊断为依据 ,总结分析 4 8例真菌性鼻 鼻窦炎 (fungalrhinosinusitis,FRS)的病程、临床表现、鼻窦CT、窦内病变特征、窦黏膜表现、组织病理学和真菌学特征、以及 2种治疗方式的疗效。结果　 18例为CIFRS ,早期在病程、临床表现、真菌种类和鼻窦CT特征与非侵袭型真菌性鼻窦炎 (noninvasivefungalrhinosinusitis,NIFRS)相似 ;其中 16例 ( 88 9% )窦内病变为泥石样物 ,15例 ( 83 3% )窦黏膜表现为Ⅲ度以上 ;窦内病变为泥石样物、同时窦黏膜Ⅲ度以上者与病理真菌的符合率为 83 3% ( 15 / 18) ;鼻窦清创术加抗真菌药物治疗治愈率达 81 8%。结论CIFRS进展缓慢 ,临床并非少见 ,早期临床表现缺乏特异性 ,窦内为泥石样物和窦黏膜表现为Ⅲ度以上是其主要鉴别特征 ,早期诊断和鼻窦清创术联合抗真菌药物治疗可望提高治愈率。     

2008年全国慢性鼻-鼻窦炎诊断和治疗专题学术会议纪要

由中华耳鼻咽喉头颈外科杂志编委会和中华医学会耳鼻咽喉头颈外科学分会主办的2008年全国慢性鼻-鼻窦炎诊断和治疗专题学术会议于2008年9月21日-24日在江西南昌举行,到会代表近400人.     

Pediatric chronic rhinosinusitis

PURPOSE OF REVIEW: Pediatric acute and chronic rhinosinusitis are common pediatric ailments averaging six to eight occurrences a year with 0.5-5% of these progressing to acute sinusitis. A yet undefined number of children progress to chronic sinusitis. Significant resources are spent treating children for sinus infections that would otherwise clear on their own. Practice guidelines for chronic sinusitis are needed. RECENT FINDINGS: Good prospective studies are lacking because of the shear numbers of patients that must be enrolled to obtain a homogeneous population for study. This lack of good prospective studies prevents the development of pediatric practice guidelines for medical and surgical management of chronic rhinosinusitis. Most recent studies focus primarily on pathophysiology and medical management. An area of significant knowledge deficit is the role of gastroesophageal reflux disease in chronic sinusitis. There have been no recent significant changes in the medical or surgical management of chronic rhinosinusitis other than the rationale of performing an adenoidectomy prior to endoscopic sinus surgery for eradication of biofilms. SUMMARY: Current therapy for pediatric chronic rhinosinusitis continues to be prolonged courses of antibiotics and if the symptoms persist, staged surgical intervention with initial adenoidectomy followed by partial or anterior ethmoidectomy.     

Pediatric chronic rhinosinusitis

PURPOSE OF REVIEW: Pediatric sinusitis is prevalent, and the debate continues regarding how best to care for these children. Although acute sinusitis is commonly associated with an upper respiratory infection, the focus of this paper is on chronic rhinosinusitis in children. Research is often more difficult in children than adults, so many times one can learn from the adult literature and determine whether there can be application to the childhood population. RECENT FINDINGS: This paper looks at both medical and surgical treatment of chronic rhinosinusitis. "Maximal medical management" is often cited in the literature, but what this should consist of has never been clearly proved in the literature. Alternative medicine approaches as well as irrigation as an adjunct to care are discussed. Biomaterials are also be discussed. Recent outcome data are put in perspective. SUMMARY: Hopefully the reader will find the presentation stimulating. The paper does not promote surgery as a "cure all," and in the end, analysis will hopefully leave the reader more cautious but with a better understanding of this complex disease.