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Background: Chronic rhinosinusitis with nasal polyposis (CRSwNP) is an inflammatory disease with a treatment goal of controlling symptoms and limiting disease burden. While endoscopic sinus surgery is effective for removing polyps and aerating sinuses, proper medical management remains necessary for reducing inflammation and limiting polyp recurrence., Objective: This article aims to summarize the literature regarding medical treatment of chronic rhinosinusitis with nasal polyposis, with a specific focus on developments in the past 5 years., Methodology: We conducted a literature review using PubMed to identify studies assessing medical treatment strategies for patients with CRSwNP. Articles focusing on chronic rhinosinusitis without nasal polyposis were excluded unless specifically stated. Surgical treatment and biologic therapies for CRSwNP will be covered in subsequent chapters and are therefore not included., Results: Intranasal saline irrigations and topical steroids are mainstays of CRSwNP treatment in the pre-surgical, post-surgical, and maintenance phases of the disease. Alternative steroid delivery methods and adjunctive treatments with antibiotics, anti-leukotrienes, and other topical therapies have been investigated and may benefit certain patient populations, but convincing evidence does not exist to warrant addition of these treatments to the standard of care for CRSwNP., Conclusions: Topical steroid therapy is clearly effective for CRSwNP, and recent studies demonstrate the safety and efficacy of high-dose nasal steroid rinses. Alternate delivery methods for local steroids may be useful for patients who are not responding to or who are noncompliant with conventional intranasal corticosteroid sprays and rinses. Future studies are needed to clarify if oral or topical antibiotics, oral anti-leukotrienes, or other novel therapies are significantly effective in decreasing symptoms and improving the quality of life in patients with CRSwNP.

Aspirin-exacerbated respiratory disease (AERD) is characterized by abnormal arachidonic acid metabolism leading to chronic rhinosinusitis with nasal polyposis (CRSwNP), asthma, and upper and/or lower respiratory symptoms after ingestion of cyclooxygenase-1 inhibiting nonsteroidal antiinflammatory drugs. Diagnosis is clinical and may involve an aspirin challenge. Inflammatory biomarkers may be useful for diagnosis and treatment monitoring. Conventional medical management for asthma and CRSwNP is often inadequate. Endoscopic sinus surgery followed by continued medical management with or without aspirin desensitization frequently improves symptoms and objective disease measures. Biological agents targeting eosinophilic inflammation are promising alternatives to conventional management., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Identifying effective therapy for recalcitrant chronic rhinosinusitis with nasal polyposis (CRSwNP) is a major challenge; and subtypes such as aspirin-exacerbated respiratory disease (AERD) are even more difficult to treat. Evidence on topical antibiotics use in (CRSwNP) is lacking. Current consensus guidelines recommend against its routine use, but recent reviews show some benefit when managing recalcitrant disease after endoscopic sinus surgery (ESS)., Objective: Evaluate the effect of culture-directed topical antibiotics on sinonasal outcomes in AERD patients with a positive perioperative sinonasal bacterial culture who have undergone ESS., Methods: A retrospective cohort study of AERD patients with positive sinonasal culture, who underwent ESS from 2016 to 2021 was performed. Forty-four patients were identified and stratified based on their postoperative medical treatment. Twenty-six underwent postoperative intranasal corticosteroids (INCS) alone, while eighteen underwent INCS plus a 4-weeks treatment with topical antibiotics. SNOT-22 and Lund-Kennedy score (LKS) were assessed preoperatively and at 4-weeks and 4-6 months after ESS., Results: A statistically significant improvement in the 4-weeks and 4-6 months postoperative SNOT-22 and LKS were noted within both groups (p<0.05). However, only a statistically significant difference was found in the 4-weeks postoperative LKS when comparing between treatment groups (p=0.01) . Our linear regression model demonstrated a relationship between the use of combined therapy with INCS and topical antibiotics and the LKS 4-weeks post ESS (p=0.015)., Conclusion: In AERD patients with a confirmed sinus infection, the combination of culture-directed topical antibiotics and intranasal corticosteroid irrigations in the postoperative period can provide a short-term improvement in endoscopic scores., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Martinez-Paredes, Choby, Marino, Lal, Olomu, Alfakir, Stokken, O’Brien and Donaldson.)

Objectives: Urine leukotriene E4 (uLTE4) is a biomarker of leukotriene synthesis and is elevated in patients with aspirin-exacerbated respiratory disease (AERD). It can also be useful to help delineate aspirin-tolerant chronic rhinosinusitis with nasal polyposis (CRSwNP) patients from AERD patients. The purpose of this study is to determine if uLTE4 biomarker levels are associated with objective and subjective markers of disease severity in patients with CRSwNP., Methods: A retrospective analysis of CRSwNP patients who underwent uLTE4 testing was completed to determine the association of uLTE4 levels to markers of disease severity. uLTE4 levels, as well as presenting subjective (Sinonasal Outcome Test 22 [SNOT22] scores, asthma control test [ACT] scores) and objective data (Lund-Mackay CT score, spirometry and lab values) were collected., Results: Among the 157 CRSwNP patients who met inclusion criteria, uLTE4 levels were associated with history of asthma (P < .001), aspirin sensitivity (P < .001), worse Lund-Mackay CT scores (P = .002) and other objective markers of disease severity including serum IgE (P = .05), presenting blood eosinophil level (P < .001), and the highest recorded eosinophil level (P < .001). In subgroup analysis, associations of uLTE4 to disease markers had stronger correlations in the aspirin sensitive CRSwNP group (R range 0.31-0.52) than the aspirin tolerant CRSwNP group (R range -0.30-0.24). uLTE4 levels were not associated with subjective symptom scores (SNOT22 and ACT scores)., Conclusion: Elevated uLTE4 biomarker levels are associated with worsened objective markers of disease severity in CRSwNP patients but not patient-reported symptom measures., Level of Evidence: 3 Laryngoscope, 131:961-966, 2021., (© 2020 The American Laryngological, Rhinological and Otological Society, Inc. "The Triological Society" and American Laryngological Association (ALA).)

Background: Lymphatic dysfunction is hypothesized to be an underlying factor in the pathophysiology of yellow nail syndrome (YNS) (yellow nails, lymphedema, pleural effusions, and frequently chronic rhinosinusitis [CRS]). It is unclear why some YNS patients develop CRS. We quantified lymphatic and total vasculature of sinonasal mucosa in YNS patients and compared it to controls from CRS patients with (CRSwNP) or without polyps (CRSsNP)., Methods: Immunohistochemistry was performed on archival sinonasal mucosal samples from 5 patients with YNS and 14 controls with antibodies against podoplanin and CD31, markers of lymphatics. Morphometric assessment was performed on digital images using ImageJ software., Results: In YNS, the number of lymphatics/mm 2 ranged from 7 to 18/mm 2 (controls: 6 to 43/mm 2 , p = 0.343), with a mean perimeter between 92 and 201 µm (controls: 42 to 280 µm, p = 0.482). Total vasculature density was higher than lymphatics, ranging between 189 and 1159 vessels/mm 2 , average 669 (controls: 139 to 1467/mm 2 , average 503, p = 0.257) with smaller average perimeter, 40 to 117 µm, mean 64.8 µm (controls: 42 to 92 µm, mean 65.3 µm, p = 0.965). Lymphatics constituted only a small fragment of the total vasculature, ranging from 1.15% to 4.76%, average 2.34% (controls: 0.81% to 10.58%, average 4.88%, p = 0.156). CRSwNP patients had significantly higher lymphatic density (p = 0.011) and ratio of lymphatics to total vasculature (p = 0.045) than patients with YNS or CRSsNP., Conclusion: This is the first histological analysis of sinus mucosa in patients with YNS. Vascular type, density, size, and distribution in the sinonasal mucosa of YNS patients are not statistically significantly different from those of the CRSsNP group. Lymphatic density and ratio to total vasculature is higher in CRSwNP patients., (© 2019 ARS-AAOA, LLC.)