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Background: Minimally invasive temperature-controlled radiofrequency (TCRF) ablation of the posterior nasal nerve (PNN) demonstrated a significant larger treatment effect on the symptom burden of chronic rhinitis patients than a sham control (no energy delivery) at the 3-month primary endpoint of this trial., Methods: Two-year posttreatment outcomes for patients treated in a prospective, multicenter, patient-blinded randomized controlled trial were determined by combining the index active treatment-arm and index control-arm crossover patients into a single group (after the primary endpoint) to evaluate the treatment effect durability and long-term effects on concomitant chronic rhinitis medication usage., Results: The mean baseline reflective total nasal symptom score (rTNSS) was 8.2 (95% confidence interval [CI], 7.9-8.6; N = 104). At 2 years (N = 79), the mean change in rTNSS was -5.3 (95% CI, -5.8 to -4.8; p < 0.001; 64.6% improvement). The 2-year responder rate (≥30% improvement in rTNSS) was 87.3% (95% CI, 78.0-93.8). All four components of the rTNSS (rhinorrhea, congestion, sneezing, and nasal itching) showed significant improvement over baseline, with rhinorrhea and congestion showing the most improvement. Postnasal drip and cough symptoms were also significantly improved. At 2 years, 81.0% (95% CI, 70.6-89.0) reported a minimal clinically important difference of ≥0.4-point improvement in the mini-rhinoconjunctivitis quality of life questionnaire score. Of 56 patients using chronic rhinitis medications at baseline, 25 of 56 (44.6%) either stopped all medication use (7/56 [12.5%]) or stopped/decreased (18/56 [32.1%]) use of ≥1 medication class at 2 years. No serious adverse events related to the device/procedure were reported over 2 years. To determine the potential effect of patients who left the trial over 2 years on the responder rate, the responder statuses of the 14 patients with follow-up data who were lost to follow-up/withdrew/died were imputed by the last observation carried forward and the responder statuses of all nine patients who had an additional nasal procedure were imputed to nonresponder, resulting in a 2-year responder rate of 79.4% (95% CI, 70.3-86.8)., Conclusion: TCRF ablation of the PNN is safe and resulted in a significant and sustained reduction in chronic rhinitis symptom burden through 2 years and a substantial reduction in concomitant medication burden., (© 2024 The Authors. International Forum of Allergy & Rhinology published by Wiley Periodicals LLC on behalf of American Academy of Otolaryngic Allergy and American Rhinologic Society.)

Background: Adult and elderly patients with chronic rhinosinusitis (CRS) undergo similar therapeutic management. Few studies have undertaken sinonasal tissue-level comparisons of these groups. This study examines histopathological differences between adults (>18, <65 years) and the elderly (≥65 years) with CRS, with the goal of optimizing medical management., Methods: In a retrospective cohort analysis, demographic factors, comorbidities, and a structured histopathological report of 13 variables were compared across adult and elderly patients with CRS who underwent functional endoscopic sinus surgery. These cohorts of adult and elderly patients included patients with and without nasal polyps (NP)., Results: Three hundred adult (158 aCRSsNP, 142 aCRSwNP) and 77 elderly (38 eCRSsNP, 39 eCRSwNP) patients were analyzed. Mean age of the adult cohort was 44.4 ± 12.4 years, while that of the elderly cohort was 71.9 ± 5.9 years ( P   <   .001 ). Significantly more adults compared to elderly individuals demonstrated a positive atopic status (79.7% vs 64.0%, P   =   .004 ). Elderly patients exhibited higher rates of comorbid diabetes mellitus than adult patients (21.6% vs 10.3%, P   =   .009 ). Adults exhibited more tissue eosinophilia (43.4% vs 28.6%, P   =   .012 ) and presence of eosinophil aggregates (25.0% vs 14.3%, P   =   .029 ) compared to elderly patients, regardless of NP status. Conversely, the elderly demonstrated significantly more fungal elements (11.7% vs 3.0%, P   =   .004 ), and trended toward increased overall inflammation (63.6% vs 55.3%, P   =   .118 ) and tissue neutrophilia (35.1% vs 27.3%, P   =   .117 ), compared to adults., Conclusion: Sinonasal tissue of adult and elderly patients with CRS demonstrates clear histopathological differences. Patient comorbidities, in addition to histopathological characterizations, may provide further context for management optimization., Level of Evidence: 2., Short Summary: Sinonasal tissue samples from adult and elderly patients with CRS demonstrate clear histopathological differences. These patient populations also exhibit unique comorbidities. These distinctions have the potential to inform and optimize management of this condition.

Objective: To explore how diabetes mellitus impacts chronic rhinosinusitis clinically and on structured histopathology to provide insights on new potential chronic rhinosinusitis endotypes., Study Design: Retrospective cohort study., Setting: Tertiary academic center., Methods: A retrospective study of chronic rhinosinusitis patients who underwent functional endoscopic sinus surgery from 2015 to 2020 was performed. Structured 13-variable histopathology reports were generated from intraoperative sinonasal specimens. These variables were compared against demographic factors, comorbidities, culture data, and preoperative Lund-Mackay and SNOT-22 scores using logistic regression., Results: There were 411 patients, including 52 diabetics. Diabetes was associated with higher mean body mass index (34.9 vs 29.2; p < .001), age (57.8 vs 48.0; p < .001), and Gram-negative (40.2% vs 22.7%; p < .030) and coagulase-negative Staphylococcus (49.0% vs 28.5%; p = .008) culture rates. Black (23.1% vs 18.7%) and Hispanic (23.1% vs 8.6%) races were more common with diabetes (p = .026). Gender, smoking, polyp status, and Lund-Mackay and SNOT-22 scores did not differ between groups. Diabetics had more fungal elements (13.5% vs 3.3%, p = .018); no other histopathological differences were seen. When controlling for demographic variables and comorbidities, diabetes independently predicted the presence of fungal elements (HR 4.38, p = .018)., Conclusion: Diabetic chronic rhinosinusitis patients demonstrated increased fungal elements on structured histopathology. Other histopathological features were unaffected by diabetes. These findings may have important implications on the medical and surgical management of diabetic chronic rhinosinusitis patients in which early fungal disease assessment is paramount., (© 2023 American Academy of Otolaryngology-Head and Neck Surgery Foundation.)

Background: Adult and pediatric patients with chronic rhinosinusitis (CRS) may have differing philosophies in therapeutic management. Few studies have examined sinonasal tissue-level comparisons of these groups. This study examines histopathologic differences between children and adults with CRS, with the goal of understanding disease pathogenesis and optimizing medical management for both populations., Methods: In a retrospective cohort of CRS patients who underwent functional endoscopic sinus surgery (FESS), demographic factors, pertinent comorbidities, and a structured histopathologic report of 13 variables were compared across pediatric and adult CRS patients with and without nasal polyps (pCRSwNP, pCRSsNP, aCRSwNP, aCRSsNP, respectively)., Results: A total of 378 adult (181 aCRSsNP, 197 aCRSwNP) and 50 pediatric (28 pCRSsNP, 22 pCRSwNP) patients were analyzed. Significantly more children compared with adults had a comorbid asthma diagnosis (64.5% vs. 37.2%, p = 0.003). Adults with CRS exhibited significantly more tissue neutrophilia (28.9% vs. 12.0%, p = 0.006), basement membrane thickening (70.3% vs. 44.0%, p < 0.001), subepithelial edema (61% vs. 30.0%, p < 0.001), squamous metaplasia (22.0% vs. 4.0%, p < 0.001), and eosinophil aggregates (22.8% vs. 4.0%, p < 0.001) than children with CRS. The majority (66.5%) of adult CRS patients exhibited a lymphoplasmacytic-predominant inflammatory background, whereas the majority (57.8%) of children with CRS exhibited a lymphocyte-predominant inflammatory background., Conclusions: Sinonasal tissue of adult and pediatric CRS patients demonstrates clear histopathologic differences. Our findings provide insight into differing pathophysiology, which may enable optimization of targeted therapies for patients in each of these unique clinical groups., (© 2022 ARS-AAOA, LLC.)

Background: Medically refractory chronic rhinosinusitis (CRS) is often treated with functional endoscopic sinus surgery (FESS) and high-volume steroid nasal irrigation. While budesonide is the most common steroid irrigation for this indication, mometasone has a superior pharmacokinetic profile, which may allow dose escalation. The safety and efficacy of mometasone at higher concentrations than previously used in treating CRS have not been explored., Methods: Patients were recruited from a tertiary level clinic between June 2018 and December 2019. Inclusion criteria included adults (>18 years); CRS diagnosis; previous FESS; pre-treatment morning cortisol within normal range; minimum of twice daily high-volume sinonasal mometasone irrigations (total dose of 4 mg) for 12 weeks; and post-treatment morning cortisol measured within 2 weeks following the study period. Patients with potential for endogenous or exogenous disruption of the HPA axis were excluded., Results: 14 patients were enrolled in this prospective cohort study. In all but one patient, pre- and post-treatment morning cortisol levels were not significantly different and were within normal limits (6.7-25.4 μg/dL). Following an uninterrupted 12-week treatment course, no evidence of HPA axis suppression was found (P = 0.915). The single patient who was found to have a low (1.3 μg/dL) post-treatment morning serum cortisol level reportedly received an intraarticular steroid shot several days prior to the blood draw. She remained asymptomatic and her rechecked serum cortisol was within normal limits at 12.3 μg/dL., Conclusions: High-volume 2 mg twice daily sinonasal mometasone irrigations did not cause HPA axis suppression in a representative sample of patients with refractory CRS post-FESS with normal baseline cortisol levels., (© 2021 ARS-AAOA, LLC.)

Background: Ambient air pollution is well known to cause inflammatory change in respiratory epithelium and is associated with exacerbations of inflammatory conditions such as asthma and chronic obstructive pulmonary disease. However, limited work has been done on the impact of air pollution on pathogenesis of chronic rhinosinusitis and there are no reports in the literature of how pollutant exposure may impact sinonasal histopathology in patients with chronic rhinosinusitis., Objective: This study aims to identify associations between certain histopathologic characteristics seen in sinus tissue of patients with chronic rhinosinusitis (CRS) and levels of particulate air pollution (PM 2.5 ) and ground-level ozone in their place of residence., Methods: A structured histopathology report was created to characterize the tissues of CRS patients undergoing sinus surgery. An estimate for each patient's exposure to air pollutants including small particulate matter (PM 2.5 ) and ground-level ozone was obtained using the Environmental Protection Agency's (EPA) Environmental Justice Screening and Mapping Tool (EJSCREEN). Mean pollutant exposures for patients whose tissues exhibited varying histopathologic features were compared using logistic regression models., Results: Data from 291 CRS patients were analyzed. Higher degree of inflammation was significantly associated with increased ozone exposure (p = 0.031). Amongst the patients with CRSwNP (n=131), presence of eosinophilic aggregates (p = 0.018) and Charcot-Leyden crystals (p = 0.036) was associated with increased ozone exposure., Conclusion: Exposure to ambient air pollutants may contribute to pathogenesis of CRS. Increasing ozone exposure was linked to both higher tissue inflammation and presence of eosinophilic aggregates and Charcot-Leyden crystals in CRSwNP patients.

Background: Atopy has a strong association with chronic rhinosinusitis (CRS)., Objective: To understand whether patients with atopy and CRS can be defined by markers of tissue histopathology, systemic biomarkers, and clinical factors, which may guide their response to new pharmacologic agents., Methods: In a retrospective cohort of CRS patients who underwent functional endoscopic sinus surgery, a structured histopathology report consisting of 12 variables, comorbid conditions, preoperative total serum IgE levels, and preoperative modified Lund-Kennedy endoscopic and sinonasal outcome test (SNOT-22) scores were compared between atopic CRS (aCRS) and non-aCRS control patients in a multivariable model., Results: A total of 380 CRS patients were enrolled, 286 of whom had comorbid atopy (aCRS). Compared with non-aCRS, aCRS patients had significantly higher preoperative total SNOT-22 scores (40.45 ± 22.68 vs 29.70 ± 20.68, P = .015) and symptom-specific SNOT-22 scores in all domains except psychological dysfunction. Relative to non-aCRS, aCRS patients had increased tissue eosinophilia (P < .0001), eosinophil aggregates (P < .0001), Charcot-Leyden crystals (P < .04), fibrosis (P < .02), total serum IgE levels (P < .04), polyploid disease (P < .001), and a prevalence of comorbid asthma (P < .0001) and aspirin exacerbated respiratory disease (AERD) (P < .003). Patients with aCRS demonstrated increased tissue eosinophilia compared with non-aCRS patients even after controlling for polypoid disease, asthma, and AERD., Conclusion: In the context of CRS, atopy appears to be a specific predictor of CRS severity linked to specific histopathologic variables, including enhanced eosinophilic aggregates. Moving forward, allergic status may be a useful way to identify an atopic endotype of CRS patients. Furthermore, after surgery, patients are often maintained on intranasal corticosteroids. In patients whose disease is unresponsive to steroids, we may look to atopic status to identify another management therapy. Atopic CRS patients, irrespective of polyp and asthmatic status, could be optimal candidates for biologic agents such as T-helper cell, eosinophil, and/or IgE-targeted therapies., (Copyright © 2021 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Background: Structured histopathology reporting is increasingly being utilized in rhinology to characterize endotypes in chronic rhinosinusitis and guide management decisions after sinus surgery., Objective: The goal of this investigation is to evaluate inter-observer agreement in structured histopathology reporting., Methods: Two experienced head and neck pathologists independently compiled structured histopathology reports for tissue samples collected during functional endoscopic sinus surgery. Cohen's standard kappa (κ) coefficients were calculated for each histopathologic variable to assess inter-pathologist agreement., Results: A total of 92 cases were analyzed. Substantial inter-pathologist agreement was reached on tissue eosinophil count (κ = 0.64, P  < .001), the presence of eosinophil aggregates (κ = 0.62, P  < .001), and the presence of fungal elements (κ = 0.74, P  < .001). There was moderate agreement on the degree of inflammation (κ = 0.56, P  < .001) and the presence of squamous metaplasia (κ = 0.46, P  < .001). There was fair agreement on the presence of neutrophil infiltrates (κ = 0.33, P  < .001), the presence of hyperplastic changes (κ = 0.40, P  < .001), and the presence of fibrosis (κ = 0.24, P  = .022). There was only slight agreement on the degree of subepithelial edema (κ = 0.20, P  = .008). The κ coefficients for basement membrane thickening and mucosal ulceration were not statistically significant., Conclusion: High inter-pathologist agreement was demonstrated for several salient histopathologic variables, including tissue eosinophil count and the presence of eosinophil aggregates. However, refining the definitions of certain histopathologic variables may improve the reproducibility of structured histopathology reporting.

Background: Smoking status has been established as a known irritant of the upper and lower respiratory tracts, leading to inflammation throughout the respiratory system. Tobacco smoking is one comorbidity encountered among chronic rhinosinusitis (CRS) patients. The histopathologic features of CRS and comorbid smoking status have yet to be determined by structured histopathology and may have important implications on disease management., Methods: Retrospective study of structured histopathology reports analyzing sinus tissue removed during functional endoscopic sinus surgery. Histopathology variables were compared among patients with CRS who were reported as never smokers, former smokers, or current smokers., Results: A total of 285 CRS patients were included: 173 never smokers, 85 former smokers, and 27 current smokers. When compared with former smokers, current smokers demonstrated increased basement membrane thickening (88.9% vs 67.1%, P <.020). Compared with never smokers, former and current smokers collectively demonstrated increased hyperplastic changes (14.3% vs 6.9%, P  < .035), increased squamous metaplasia (26.8% vs 17.3%, P  < .040), and trends toward increased basement membrane thickening (72.3% vs 65.3%, P  < .124) and increased fibrosis (47.3% vs 40.5%, P  < .154)., Conclusion: Smoking status may influence histopathologic tissue-level changes in CRS disease. Interestingly, former and current smokers maintained few differences in histopathology. However, former and current smokers collectively demonstrated increased chronic inflammatory changes compared with never smokers. These findings suggest that the timing of smoking exposure has limited effect on the tissue level, rather exposure overall influences inflammatory change. These findings may have important implications on medical and surgical management of CRS disease and comorbid smoking status.

Objective: This study explored the impact of laryngopharyngeal reflux (LPR) on quality-of-life outcomes captured by Sino-Nasal Outcome Test (SNOT-22) and Reflux Symptom Index (RSI) in patients with chronic rhinosinusitis (CRS) and patients with symptoms of LPR., Methods: In a retrospective chart review, SNOT-22 and RSI scores were analyzed in patients seen at a tertiary care center with CRS, LPR, or both CRS and LPR. SNOT-22 items were grouped into sleep, nasal, otologic, and emotional symptom subdomains., Results: A total of 138 patients (36 with CRS alone, 60 with LPR alone, and 42 with both CRS and LPR) were included. Compared to patients with CRS alone, those with CRS and LPR (CRS+LPR) had higher SNOT-22 total (50.54 ± 19.53 vs 35.31 ± 20.20, P < .001), sleep (19.61 ± 9.31 vs 14.42 ± 10.34, P < .022), nasal (17.38 ± 7.49 vs 11.11 ± 8.52, P < .001), otologic subdomains (9.17 ± 5.07 vs 5.53 ± 5.14, P < .002), and RSI (22.06 ± 9.42 vs 10.75 ± 8.43, P < .003). Patients with LPR alone had higher RSI compared to those with CRS (18.48 ± 9.77 vs 10.75 ± 8.43, P < .037). RSI and SNOT-22 scores were positively correlated irrespective of patient group (R = 0.289, P = .003)., Conclusion: Compared to patients with CRS or LPR alone, those with CRS+LPR demonstrated higher RSI and total and subdomain SNOT-22 scores. Patients with LPR alone had elevated SNOT-22 despite absent endoscopic evidence of sinusitis.

Background: Posterior nasal nerve (PNN) cryoablation has shown promise in improving rhinorrhea due to allergic and nonallergic rhinitis (NAR). Early case series have shown meaningful clinical improvement in 75-80% of patients, but variables predicting PNN cryoablation success have not been studied. The purpose of this study was to evaluate whether disease features and ipratropium nasal spray response predicted rhinorrhea response after PNN cryoablation., Methods: A multi-institutional retrospective case-control study of 55 patients who underwent PNN cryoablation for bilateral rhinorrhea due to allergic, nonallergic, or mixed rhinitis was conducted at 3 tertiary medical centers. Patients received a 1-month trial of ipratropium spray. Runny Nose Scores (RNSs) of 0-5 from the 22-item Sino-Nasal Outcome Test were collected prospectively, before and after PNN cryoablation., Results: The mean age of subjects was 55.3 years and 54.6% were women. Mean follow-up was 170 days. NAR comprised 62% of patients. Of the 48 patients who trialed ipratropium spray, 33 (69%) had some response and 15 (31%) had no response. Mean overall preprocedural RNS was 4.2 ± 1.0. After PNN cryoablation, there was a ≥1-point decrease in RNS in 39 patients (71%). Only ipratropium spray (INS) response predicted cryoablation success. For ipratropium spray responders, 28 of 33 (85%) had improved RNS after cryoablation, whereas 5 of 15 (33%) nonresponders improved (p = 0.001)., Conclusion: In chronic rhinitis patients, rhinorrhea response to ipratropium was predictive of rhinorrhea improvement after PNN cryoablation. This study has important implications for preoperative counseling and guiding patient expectations when considering PNN cryoablation., (© 2020 ARS-AAOA, LLC.)

Background: Prior studies have demonstrated associations between serum eosinophilia and chronic rhinosinusitis (CRS) pathogenesis. However, the association of serum eosinophilia with histopathology profiling in CRS has not been fully delineated and may help better characterize CRS disease burden prior to surgery., Methods: A structured histopathology report of 13 variables was utilized to analyze sinus tissue removed during functional endoscopic sinus surgery (FESS). Complete blood count (CBC) with differential was drawn within 4 weeks prior to FESS. Serum eosinophilia was defined as >6.0% (>0.60 th/μL). Histopathology variables were compared among patients., Results: A total of 177 CRS patients (37 with serum eosinophilia and 140 with normal serum eosinophilia) were analyzed. Compared to CRS patients with normal serum eosinophil counts, CRS patients with serum eosinophilia demonstrated increased polypoid disease (67.6% vs 35.0%, P  < .001), eosinophil aggregates (45.9% vs 20.7%, P  = .003), and eosinophils per high-power field (>5/HPF) (67.6% vs 40.7%, P  = .003)., Conclusion: CRS patients with serum eosinophilia demonstrated severe disease burden on histopathology with high levels of polypoid disease and tissue eosinophilia. However, a considerable number of patients without serum eosinophilia demonstrated eosinophilic disease on histopathology, indicating that preoperative serum eosinophilia alone could not be reliably used to predict eosinophilic CRS., Level of Evidence: 4.

Purpose of Review: To review the recent literature describing the association between chronic rhinosinusitis and its effects on sleep quality., Recent Findings: Chronic rhinosinusitis (CRS) causes significantly worse sleep by both subjective and objective measures. CRS is also strongly associated with obstructive sleep apnea. Treating CRS surgically improves subjective sleep scores., Summary: CRS worsens sleep quality both subjectively and objectively. Sleep quality is improved after endoscopic sinus surgery.

Background: Chronic rhinosinusitis (CRS) is a frequently observed condition in patients with immunodeficiency secondary to tumor necrosis factor alpha inhibitors (TNFαis). The histologic features of CRS caused by TNFαis have yet to be determined and may have important implications in understanding the pathophysiology of the disease process., Methods: A structured histopathology report was used to analyze sinus tissue removed during functional endoscopic sinus surgery (FESS). These structured histopathology variables were compared among patients with CRS on TNFαi (CRSαi), CRS without nasal polyps (CRSsNP) patients, and CRS with nasal polyps (CRSwNP) patients., Results: Eighteen CRSαi, 91 CRSwNP, and 113 CRSsNP patients undergoing FESS were analyzed. Compared to CRSsNP, CRSαi patients exhibited increased mucosal ulceration (16.7% vs 0.9%, p < 0.008), increased fibrosis (100% vs 34.5%, p < 0.001), and increased presence of Charcot-Leiden crystals (16.7% vs 0%, p < 0.002). Compared to CRSwNP, CRSαi patients demonstrated increased fibrosis (100% vs 54.9%, p < 0.001), decreased presence of subepithelial edema (44.4% vs 69.2% p < 0.043), decreased eosinophil aggregates (22.2% vs 47.3% p < 0.042), and fewer eosinophils per high-power field (44.4% vs 73.6%, p < 0.017)., Conclusion: CRSαi exhibits structured histopathology more similar to CRSsNP. In the appropriate clinical context, it may be reasonable that the medical regimen for these patients be focused on a more antineutrophilic, macrolide-based approach. This study provides insight into the inflammatory environment of patients with CRSαi and may have implications for disease management., (© 2019 ARS-AAOA, LLC.)

Objectives: Functional endoscopic sinus surgery (FESS) is a standard treatment modality for patients with chronic rhinosinusitis (CRS) who have failed appropriate medical therapy. However, FESS entails modification of the upper airway tract that may alter phonatory resonance and produce voice changes. The effects of FESS on postoperative voice characteristics in patients with CRS have yet to be quantitatively assessed., Methods: Patients with severe CRS who underwent FESS at a tertiary care referral center between May and October 2017 were prospectively enrolled. The Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) and the Voice Handicap Index (VHI) were used to quantitatively evaluate voice characteristics and quality of life, respectively. Preoperative and postoperative CAPE-V and VHI scores were compared with postoperative scores for each patient. Sino-Nasal Outcome Test (SNOT-22) scores were also obtained to assess changes in patient symptoms., Results: 18 CRS patients undergoing FESS were enrolled. The average preoperative Lund-Mackay score was 14, indicating baseline severe CRS. Postoperative assessments demonstrated a statistically significant decrease in CAPE-V (45-27, p = .005) and VHI (10-4.7, p < .001) scores. These correlated with a statistically significant decrease in SNOT-22 scores (42-13, p < .001)., Conclusions: Patients with CRS experience a significant improvement in voice characteristics and vocal quality of life following FESS. Furthermore, this appears to correlate with a significant decrease in self-reported disease severity. These findings may augment the discussion of potential benefits of FESS to a new potential domain for voice quality.

Background: Recently, there has been mounting evidence suggesting the efficacy of steroid-eluting stents (SES) for management of chronic rhinosinusitis after endoscopic sinus surgery (ESS). This meta-analysis serves to evaluate the efficacy of SES in improving postoperative outcomes after ESS., Methods: A systematic literature search was performed of PubMed for articles published between 1985 and 2018. The outcome variables were reported at, on average, 30 days postintervention., Results: Seven of the 76 published studies, all of which were industry-sponsored, were included for a collective cohort of 444 SES and 444 control sinuses. In patients who received SES vs controls, collective odds ratios (ORs) for postoperative need for intervention, surgery, and oral steroid were 0.45 (95% confidence interval [CI], 0.33-0.62; p < 0.001), 0.30 (95% CI, 0.18-0.52; p < 0.001), and 0.58 (95% CI, 0.40-0.84; p = 0.004), respectively. In addition, collective ORs for frontal sinus ostia (FSO) patency, moderate-to-severe adhesion/scarring, and increase in polyp score were 2.53 (95% CI, 1.61-3.97; p < 0.001), 0.28 (95% CI, 0.13-0.59; p < 0.001), and 0.42 (95% CI, 0.25-0.74; p = 0.002), respectively. Collective mean differences for FSO/ethmoid inflammation and FSO diameter were -10.86 mm (p < 0.001) and +1.34 mm (p < 0.001), respectively., Conclusion: Aggregate evidence suggests that SES can improve ESS outcomes by reducing rates of postoperative intervention and recurrent polyposis and inflammation, while promoting FSO patency. All included and analyzed studies were industry-sponsored and ruling-out publication bias was not possible. Future independent and nonsponsored studies to further evaluate SES's long-term efficacy are warranted., (© 2019 ARS-AAOA, LLC.)

Background: Chronic rhinosinusitis (CRS) is an inflammatory disease process characterized by different phenotypes and histopathology profiles. Race and access to care have been implicated in CRS disease severity. Structural histopathology reporting may aid in delineating the inflammatory burden responsible for this effect., Methods: A structured histopathology report of 14 variables was utilized to assess sinus tissue removed during functional endoscopic sinus surgery (FESS). Histopathology variables and 22-item Sino-Nasal Outcome Test (SNOT-22) scores were compared by race (Black, White, Latino, and Asian) and insurance status (Medicare, Medicaid, and private insurance)., Results: A total of 201 CRS patients (124 White, 38 Black, 28 Latino, and 9 Asian) undergoing FESS were included. Black patients demonstrated increased SNOT-22 scores (50.74 ± 20.32 vs 41.47 ± 22.75, p < 0.022) and number of eosinophils per high-power field (>5/HPF) (60.5% vs 44.8%, p < 0.05). White patients demonstrated decreased eosinophil aggregates (22.6% vs 35.1%, p < 0.039) and eosinophils/HPF (<5/HPF) (42.7% vs 55.8%, p < 0.048). Medicaid patients showed increased SNOT-22 score (55.50 ± 24.46 vs 41.39 ± 21.74, p < 0.003), polypoid disease (61.5% vs 42.3%, p < 0.05), subepithelial edema (80.8% vs 53.1%, p < 0.006), hyperplastic/papillary changes (23.1% vs 8.0%, p < 0.028), fibrosis (61.5% vs 38.5%, p < 0.036), eosinophil aggregates (46.2% vs 24.6%, p < 0.022), and eosinophils/HPF (>5/HPF) (65.4% vs 45.1%, p < 0.043). When controlling for insurance status, Black race was no longer associated with increased SNOT-22 (p < 0.104) or eosinophils/HPF (>5/HPF) (p < 0.183)., Conclusion: Black and Medicaid patients demonstrated more severe disease by histopathology and SNOT-22 scores. These findings were no longer significant among Black patients after adjusting for insurance status, suggesting that the prevailing factor influencing worse disease may be access to care., (© 2019 ARS-AAOA, LLC.)

Purpose of Review: New research in the pathogenesis of chronic rhinosinusitis has shed light on an emerging classification system based on endotypes, which help to explain the individualized mechanism of disease in patients suffering from chronic rhinosinusitis with and without nasal polyps. The purpose of this review is to advocate the use of structured histopathologic analysis in the diagnosis and management of patients affected by chronic rhinosinusitis with and without polyps., Recent Findings: Numerous studies have demonstrated the role of inflammation in chronic rhinosinusitis and the ensuing histopatholgic changes. Few studies have implemented structured histopathologic analysis to guide diagnosis and treatment. Individualized therapy including biotherapeutics and comprehensive surgery has shown to improve outcomes in patients with refractory disease., Summary: Structured histopathologic analysis can provide helpful information on the endotype of chronic rhinosinusitis. Routine use in clinical practice should be standardized especially in cases of chronic rhinosinusitis refractory to medical therapy and/or surgery.

Background: Chronic rhinosinusitis (CRS) is an inflammatory disease process with several different phenotypes. Recent data has shown that CRS phenotypes maintain distinct nasal microbiota that may predict surgical outcomes. Nasal microbiota and structured histopathologic reporting have the potential to further differentiate subtypes and provide additional insight into the pathophysiology of CRS., Methods: Sinus swabs collected during functional endoscopic sinus surgery (FESS) were studied by polymerase chain reaction analysis of 16S ribosomal RNA. A structured histopathology report of 13 variables was utilized to analyze sinus tissue removed during FESS. Histopathology variables and relative abundance of nasal microbiota were compared among CRS patients., Results: A total of 51 CRS patients who underwent FESS were included. Relative abundance of the Firmicutes phylum in nasal microbiota of CRS patients was associated with presence of neutrophilic infiltrate (27.47 ± 44.75 vs 9.21 ± 11.84, p < 0.029), presence of mucosal ulceration (47.67 ± 45.52 vs 13.27 ± 26.48, p < 0.041), presence of squamous metaplasia (5562.70 ± 2715.66 vs 3563.73 ± 2580.84, p < 0.035), and absence of Charcot-Leyden crystals (5423.00 ± 3320.57 vs 679.94 ± 1653.66, p < 0.001). Relative abundance of the Bacteroidetes phylum in nasal microbiota of CRS patients was associated with increased severity of inflammatory degree (p < 0.004) and presence of mucosal ulceration (p < 0.004)., Conclusion: Distinct histopathologic features of CRS are associated with relative abundance of nasal microbiota phyla, specifically Firmicutes and Bacteroidetes. These findings contribute to the growing body of literature on microbiota in sinonasal disease and may have important implications for understanding pathophysiologic mechanisms of CRS subtypes and disease management., (© 2018 ARS-AAOA, LLC.)

Background: Chronic rhinosinusitis (CRS) is a frequently observed condition in patients with immunodeficiency secondary to immunosuppressive medications. The histologic features of CRS among patients undergoing immunosuppressive treatment have yet to be determined and may have important implications on understanding the pathophysiology of the disease process., Methods: A structured histopathology report was utilized to analyze sinus tissue removed during functional endoscopic sinus surgery (FESS). Histopathology variables, Lund-Mackay score (LMS), and sinonasal outcome test 22 scores were compared among patients with CRS on immunosuppressive therapy (CRSi), CRS without nasal polyps (CRSsNP) patients, and CRS with nasal polyps (CRSwNP) patients., Results: Fifteen CRSi, 36 CRSwNP, and 56 CRSsNP patients undergoing FESS were analyzed. Compared to CRSsNP, CRSi patients exhibited a trend toward increased moderate-severe inflammation (66.7% vs 42.1%, P < .080), increased neutrophil infiltrate (40.0% vs 24.6%, P < .192), and decreased fibrosis (26.7% vs 43.9%, P < .182). Compared to CRSwNP, CRSi patients demonstrated decreased fibrosis (26.7% vs 66.7%, P < .010), decreased eosinophil aggregates (13.3% vs 44.4%, P < .032), and a trend toward fewer eosinophils per high-power field (46.7% vs 66.7%, P < .154). CRSi cases had significantly lower mean LMS (8.20 ± 4.30 vs 12.78 ± 6.56, P < .017) compared to CRSwNP., Conclusion: CRSi patients exhibit histopathology and disease severity more similar to CRSsNP with trends toward increased neutrophilia and reduced fibrosis. In the appropriate clinical context, discontinuing or changing a patient's immunosuppressive regimen may be a valid treatment option in patients with CRSi. This study provides initial insight into understanding the propensity for chronic sinusitis in patients undergoing immunosuppressive treatment which may have implications on disease management.

Introduction: Chronic rhinosinusitis (CRS) is a commonly seen persistent inflammatory disease process affecting the paranasal sinuses with extensively reported economic implications. Despite an elusive pathophysiologic mechanism underlying this disease process, treatment outcomes are encouraging with the employment of an array of medical and surgical therapies. Areas covered: The goal of this paper is to provide a comprehensive, up to date analysis of the literature concerning the medical management of CRS by summarizing the evidence in support of traditional medical therapies for the management of CRS in addition to highlighting novel medical therapies currently under investigation. Expert opinion: The current staples of medical therapy for CRS based on the strength of available evidence include topical and oral corticosteroids, oral antibiotics and topical saline. The introduction of immunomodulatory therapies ('Biologics') for the treatment of CRS shows promise but have yet to be employed in a widespread fashion due to the need for additional research to better elucidate their role.

Background: Pseudomonas aeruginosa is a gram-negative bacterium frequently implicated in recalcitrant sinonasal infections, especially in immunocompromised hosts. We report 6 cases of rapidly progressive pseudomonal acute rhinosinusitis producing tissue necrosis and, in certain cases, cranial nerve palsies., Methods: Retrospective review of 6 patients with aggressive necrotizing sinonasal infections treated at 4 tertiary academic medical centers with sinonasal cultures growing P. aeruginosa in the absence of other pathology., Results: A total of 6 patients were identified. In all cases, there was tissue necrosis that appeared to mimic an invasive process such as mucormycosis, prompting urgent surgical intervention. Pathologic analysis revealed fibropurulent exudates in backgrounds of positive P. aeruginosa cultures without evidence of invasive fungal organisms or malignancy. Four of the 6 patients presented with cranial nerve palsies, with 3 patients having vision changes and 3 complaining of trigeminal neuropathy. Four of 6 patients improved clinically over time after surgery and antibiotic therapy; 1 remains in follow-up without complete improvement and 1 has succumbed to other causes., Conclusion: P. aeruginosa is a tenacious organism that is frequently associated with severe, recalcitrant sinonasal infections. We report the first case series of necrotizing sinonasal infections caused by this organism, and illustrate that, in rare cases, P. aeruginosa may mimic and behave like life-threatening conditions such as fulminant invasive fungal sinusitis or malignancy., (© 2017 ARS-AAOA, LLC.)

Background: Chronic rhinosinusitis (CRS) is commonly classified into CRS with nasal polyps (CRSwNP) and CRS without nasal polyps (CRSsNP). Structured histopathologic reporting has the potential to identify salient histologic markers to differentiate subtypes and provide insights into pathophysiologic mechanisms in CRS., Methods: A structured histopathology report of 13 variables was prospectively employed to analyze ethmoid sinus tissue removed during endoscopic sinus surgery for 99 patients, including 43 CRSsNP and 56 CRSwNP. These variables were compared in association with presence of nasal polyps, radiographic computed tomography scores (Lund-Mackay Score [LMS]), subjective symptoms scores (SNOT-22), duration of CRS, comorbid asthma, and atopy., Results: Overall inflammation did not differentiate between CRSsNP and CRSwNP (p < 0.26). Compared to CRSsNP, CRSwNP had statistically significant increase in basement membrane thickening (76.8% vs 48.8%, p < 0.004), subepithelial edema (19.6% vs 2.3%, p < 0.01), fibrosis (58.9% vs 27.9%, p < 0.002), hyperplastic/papillary changes (12.5% vs 0.0%, p < 0.016), eosinophilia (41.1% vs 18.6%, p < 0.047), and eosinophilic aggregates (30.4% vs 11.6%, p < 0.022). Higher LMS was associated with increased eosinophilia (p < 0.001), eosinophil aggregates (p < 0.000), inflammation (p < 0.023), basement membrane thickening (p < 0.037), hyperplastic/papillary changes (p < 0.040) and fibrosis (p < 0.000). SNOT-22 scores were not associated with any histologic parameters., Conclusion: Significant histopathologic differences were evident in patients with CRSwNP and CRSsNP. No single feature reliably differentiated between the 2 subtypes, underscoring the heterogeneity of CRS and limitation of this phenotypic classification system. Eosinophilic aggregates were associated with significantly worse disease, possibly signifying a unique subtype. Further studies are needed to understand the relationship of histopathologic features to disease outcome., (© 2017 ARS-AAOA, LLC.)

Background: Retromaxillary air cells (RMC) are posterior ethmoid cells that separate the maxillary and ethmoid sinuses. The clinical significance of these cells in contributing to revision functional endoscopic sinus surgery (FESS) is unknown., Objectives: To investigate the prevalence, anatomic dimensions, and radiographic characteristics of RMC in patients with recalcitrant chronic rhinosinusitis after previous FESS., Methods: A retrospective review of patients who underwent revision FESS at a tertiary medical center between January 1, 2012, and December 31, 2014. Computed tomographies of patients who underwent revision FESS, including posterior ethmoidectomies, were reviewed. Each side of the scan was assessed for residual RMCs. The radiographic dimensions and Lund-Mackay (LM) scores of these cells were recorded., Results: Sixty-nine patients who underwent revision FESS were identified. The median age of the patient population was 51 years (range, 21-79 years). Forty-two percent of the patients had nasal polyps. The mean number of previous FESS was 2 (range, 1-10). Incompletely dissected RMCs were identified in 101 of 138 analyzed sides (73%), despite documented previous posterior ethmoidectomies. Sixty-five percent of RMCs had an LM score of ≥1; RMCs of patients with polyps were more likely to have an LM score of 2 (p = 0.049). There was a significant correlation between the number of previous FESS procedures and whether the RMCs had been dissected (p = 0.010). There also was a significant correlation between RMC height and the number of previous FESS procedures (p = 0.015)., Conclusion: RMCs seemed to often be undissected during primary FESS and, thus, were commonly encountered in revision FESS. The majority of analyzed cells in this cohort demonstrated an LM score of ≥1, which indicated that these cells frequently harbor residual diseased mucosa that may contribute to the need for revision surgery.

Chronic sinusitis is a burdensome disease that has substantial individual and societal impact. Although great advances in medical and surgical therapies have been made, some patients continue to have recalcitrant infections. Microbial biofilms have been implicated as a cause of recalcitrant chronic sinusitis, and recent studies have tried to better understand the pathogenesis of chronic sinusitis as it relates to microbial biofilms. Here, we provide an overview of biofilms in chronic sinusitis with emphasis on pathogenesis, treatment, and future directions. In addition, recent evidence is presented, elucidating the role of bitter taste receptors as a possible key factor leading to biofilm formation.

Chronic rhinosinusitis (CRS) is an epidemiologically important, chronic inflammatory disease process affecting the paranasal sinuses with significant and extensively reported economic implications. Despite an elusive pathophysiologic mechanism underlying this disease process, treatment outcomes are encouraging with the employment of an array of medical and surgical therapies. The goal of this paper is to provide a comprehensive, up to date analysis of the literature concerning the medical management of CRS by highlighting the most recent evidence based recommendations addressing this ongoing field of research.