[Expert consensus on the diagnosis and treatment of respiratory diseases exacerbated by nonsteroidal anti-inflammatory drugs （2024, Chengdu）].

Non-steroidal anti-inflammatory drugs-exacerbated respiratory disease （N-ERD） is a chronic respiratory disease characterized by eosinophilic inflammation, featuring chronic rhinosinusitis （CRS）, asthma, and intolerance to cyclooxygenase 1 （COX-1） inhibitors. The use of these medications can lead to an acute worsening of rhinitis and asthma symptoms. This condition has not yet received sufficient attention in China, with a high rate of misdiagnosis and a lack of related research. The Chinese Rhinology Research Group convened a group of leading young experts in otolaryngology from across the country, based on the latest domestic and international evidence-based medical practices to formulate this consensus.The consensus covers the epidemiology, pathogenesis, clinical manifestations, diagnostic methods, and treatment strategies for N-ERD, including pharmacotherapy, surgery, biologic treatments, and desensitization therapy. The goal is to improve recognition of N-ERD, reduce misdiagnosis, and enhance treatment outcomes.

[Modern management of chronic rhinosinusitis]. / Modernes Management der chronischen Rhinosinusitis.

Chronic rhinosinusitis is a common disease. Due to the significant reduction of the quality of life, possible serious complications and economic consequences, a sufficient therapy is essential. With the entry of biologics into the treatment of chronic rhinosinusitis, relevant innovations have emerged in recent years. This article is aimed at providing an up-to-date overview of the conservative and surgical treatment options for chronic rhinosinusitis.

[Current diagnostics and therapy in chronic rhinosinusitis]. / Aktuelle Diagnostik und Therapie der chronischen Rhinosinusitis.

INTRODUCTION: Chronic rhinosinusitis is a prevalent condition with significant implications for both patients and society at large. The diagnostic and treatment approaches are primarily guided by the EPOS2020 guidelines in Europe, which increasingly delve into the molecular -mechanism of the disease and its resulting phenotypes. In recent years, biologics have emerged as a promising option, in particular for cases that are refractory to conventional therapies. However, the management landscape has become more intricate, necessitating consideration and potential concurrent treatment of comorbidities. Moreover, the utilization of biologics is accompanied by substantial costs, warranting personalized assessment for each patient. Hence, the establishment of specialized boards comprising clinicians from diverse disciplines to collaborate on treatment recommendations is imperative.

Does Managing Patients With Chronic Rhinosinusitis Improve Their Depression Score? Prospective Study.

BACKGROUND: To assess the risk of depression in patients with chronic rhinosinusitis (CRS) in a tertiary care center and the effect of treatment on depression scores. METHODS: This prospective cohort study was conducted at King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia, between November 2021 and June 2022 and included adult patients (≥14 years) with CRS. The validated Arabic or English Sinonasal Outcome Test (SNOT-22) and Patient Health Questionnaire-9 (PHQ-9) were used before treatment and 3 to 6 months after surgery and maximal medical treatment. PHQ-9 scores were compared at baseline and follow-up visits. The relationship between changes in SNOT-22 and PHQ-9 scores were assessed using Spearman's correlation and simple linear regression. RESULTS: Overall, 38 participants with a mean ± SD age of 32.7 ± 12 years were enrolled. CRS with nasal polyps (55.26%) was the most frequently seen condition, followed by allergic fungal CRS (31.58%) and CRS without nasal polyps (13.16%). Six patients (15.7%) had PHQ-9 scores ≥10, indicating they had major depressive disorder. PHQ-9 and SNOT-22 scores improved significantly after treatment (3.7 ± 5.8 vs 6.5 ± 6.9 pretreatment, P = .001; 20.7 ± 20.5 vs 45.6 ± 28.9 pretreatment, P < .0001, respectively). Mean ± SD change in PHQ-9 and SNOT-22 scores was -2.7 ± 7 and -24.9 ± 29.8, respectively. SNOT-22 and PHQ-9 scores were positively correlated (r = .522, P < .001). PHQ-9 score change was significantly associated with SNOT-22 score change (ß = .178, 95% confidence interval 0.12-0.23, P < .0001). CONCLUSION: CRS affects the quality of life and psychological well-being of patients. Patient-centered care with maximal medical and surgical treatment help overcome its deleterious consequences.

Clinical effectiveness of focused ultrasound combined with plasma radiofrequency ablation technique in the treatment of persistent strain rhinitis.

Examine the effects of focused ultrasound in combination with plasma radiofrequency ablation technology on the physiological stability and postoperative recovery of persistent strain rhinitis. For a control experiment, 90 patients with persistent strain rhinitis were chosen and split into two groups: the control group (CG) and the experimental group (EG). The CG used conventional radiofrequency ablation technology, while the EG used focused ultrasound technology combined with radiofrequency ablation technology to treat persistent strain rhinitis. Between the EG and the CG, compare and contrast the recovery of nasal symptoms, nasal signs, postoperative discomfort, and postoperative respiratory status. One quarter after surgery, there was a substantial difference in physical sign ratings between the EG and the CG, and a particularly significant difference was seen after six months of treatment. One year following surgery, there was a statistical difference between the EG and the CG in the comparison of effective rates at various intervals, with a P value of .013. At 6 months following surgery, the MTT times in the EG and CG for the comparison of nasal function were 12.63 2.65 and 17.68 2.84, respectively, with statistically significant differences. The difference between the EG and the CG in the MTR comparison is statistically significant. In the comparison of NNO values between the EG and the CG after different treatment times. The nitric oxide value of the EG patients decreased over time, with statistical significance one month after surgery and one year after surgery. It is evident from the comparison of various symptom efficacy rates that the EG has a higher treatment effectiveness rate than the CG, and the total treatment effect difference following surgery has statistical significance. Indicators for PONV, PA, directional ability, respiratory recovery, and olfactory recovery performed better in the EG than in the CG, and the differences were statistically significant. Focused ultrasound and plasma radiofrequency ablation technology have a good therapeutic impact in the treatment of persistent strain rhinitis and can significantly reduce MTT. This technology can effectively improve symptoms such as nasal congestion, nasal flow, and headache in patients, and the therapeutic effect is long-lasting. The hospitalization time after treatment is significantly shortened.

Pädiatrische Rhinologie. / Pädiatrische Rhinologie.

The following review article highlights key topics in pediatric rhinology that are currently the focus in research and at conferences as well as in the interdisciplinary discussion between otorhinolaryngologists and pediatricians. In particular, congenital malformations such as choanal atresia or nasal dermoid cysts are discussed, followed by statements on the current procedures for sinogenic orbital complications as well as on the diagnosis and therapy of chronic rhinosinusitis in children. Furthermore, updates on the role of the ENT specialist in the care for children with cystic fibrosis and primary ciliary dyskinesia are provided.

[Chronic rhinosinusitis with nasal polyposis : A retrospective analysis of therapeutic approaches in 463 patients]. / Chronische Rhinosinusitis mit Polyposis nasi : Retrospektive Analyse des therapeutischen Vorgehens bei 463 Patienten.

BACKGROUND: Chronic rhinosinusitis with nasal polyps (CRSwNP) is a multifactorial inflammatory disease, the treatment of which has undergone significant changes in recent years. In addition to surgical approaches, topical and systemic steroids, and adaptive acetylsalicylic acid (ASA) desensitization, three specific antibodies have complemented the therapeutic portfolio since 2019. METHODS: A retrospective evaluation of all patients who presented as outpatients for the first time due to CRSwNP in 2007 and 2008 (collective A) and 2017 and 2018 (collective B) was performed, up to and including June 2023. RESULTS: The clinical courses of 463 patients (mean age 49.1 years, range 5-82 years; 65.9% male) were included in the analysis. Conservative treatment with nasal corticosteroids started before initial presentation was more frequent in collective B (collective A 43.9% vs. collective B 72.2%). In 278 of the 463 patients (60%; A: 62%, B: 58%), at least one operation on the nasal sinuses had been performed after initial presentation; in 101 of these patients (36.3%) recurrent polyposis (within mean follow-up of 2.4 years) required further treatment. The indication for ASA provocation/desensitization was applied less frequently in collective B, also due to a high discontinuation rate (at least 38%) of the maintenance therapy. Of the total cohort, 16 patients (3.5%; A: n = 8, B: n = 8) were meanwhile switched to antibody therapy at recurrence. CONCLUSION: A step-by-step guideline-orientated approach is recommended in the treatment of CRSwNP. Systemic antibodies as an add-on to nasal corticosteroids are a relatively new therapeutic option for treatment-refractory CRSwNP, which reduces the indication for ASA desensitization, which is associated with a relatively high incidence of side effects and poor compliance.

[Clinical observation of the course of eosinophilic otitis media against the background of biological therapy of chronic polypous rhinosinusitis]. / Klinicheskoe nablyudenie techeniya eozinofil'nogo srednego otita na fone provedeniya biologicheskoi terapii khronicheskogo polipoznogo rinosinusita.

Eosinophilic otitis media (EoOM) is a variant of exudative otitis media characterized by a persistent persistent course, the presence of a very viscous effusion in the tympanic cavity, comorbidally associated with chronic polypous rhinosinusitis and bronchial asthma. The disease is characterized by a persistent progressive course, which can lead to a gradual decrease in hearing up to complete deafness. Conservative treatment methods for EoOM include local and systemic administration of glucocorticosteroids. Encouraging data on the effectiveness of biological therapy have appeared in recent publications. The above clinical observation examines the course of EoOM in a patient who received biological therapy with dupilamab.

Rhinitis Disease Burden and the Impact of Social Determinants of Health.

Social determinants of health (SDHs) have a substantial impact on patient care and outcomes globally, both in low- to middle-income countries and in high-income countries. In the clinic, lack of availability of diagnostic tools, inequities in access to care, and challenges obtaining and adhering to prescribed treatment plans may further compound these issues. This article addresses a case of rhinitis in the context of SDHs and inequities in care that may affect various communities and populations around the world. SDHs may include various aspects of one's financial means, education, access to medical care, environment and living situation, and community factors, each of which could play a role in the rhinitis disease manifestations, diagnosis, and management. Allergic and nonallergic rhinitis are considered from this perspective. Rhinitis epidemiology, disease burden, and risk factors are broadly addressed. Patient evaluation, diagnostic tests, and management options are also reviewed, and issues related to SDHs are noted. Finally, inequities in care, knowledge gaps, and unmet needs are highlighted. It is critical to consider SDHs and care inequities when evaluating and treating patients for rhinitis and other allergic conditions.

Postnasal Drip.

Postnasal drip (PND) is a common symptom encountered when evaluating subjects with sinonasal disease; it may be present without sinonasal disease or as a symptom of laryngopharyngeal reflux. It is postulated that PND stems from dysfunction of normal mucus clearance mechanisms; however, there is no definitive evidence elucidating an exact pathophysiology. Compounding the uncertainties surrounding PND is the lack of an objective assessment tool. Instead, treating physicians must rely on subjective complaints and investigators utilize validated patient-reported outcome instruments, such as the Sino-Nasal Outcome Test, to determine treatment efficacy. This review seeks to discuss the current understanding of PND and evidence regarding effective treatment strategies.

[Difficult-to-treat chronic rhinosinusitis-when the standard treatment is not effective and biologics are not available]. / Schwierig zu behandelnde chronische Rhinosinusitis ­ wenn die Standardtherapie nicht wirkt und Biologika nicht zur Verfügung stehen.

BACKGROUND: In recent years, significant improvements have been made in the treatment options for uncontrolled chronic rhinosinusitis (CRS) refractory to standard medical and surgical therapy. This is the result of a better understanding of the pathophysiology and the resulting development of biologicals for CRS with nasal polyps (CRSwNP). However, biologics are not (yet) available for all patients in Europe. OBJECTIVE: Based on the session "Difficult-to-treat CRS, when biologics are not available" at the 29th Congress of the European Rhinologic Society (ERS) 2023 in Sofia, Bulgaria, the treatment options for uncontrolled CRS with the exclusion of biologics will be discussed. MATERIALS AND METHODS: The content of the presentations "Is there a place for antibiotics?" "Indications for revision surgery," "Novel systemic treatment options," "Novel local treatment options," and "Phototherapy for nasal polyps" are outlined and supported by a review of the literature. RESULTS: Various treatment options are available for managing uncontrolled CRS, even if biologic treatments are unavailable. Treatment options for type­2 (T2) CRS include steroid rinses, repeated short-term oral steroids, steroid-eluting stents, and extended sinus surgery. In the case of nonsteroidal anti-inflammatory drug (NSAID)-exacerbated respiratory disease (NERD), acetylsalicylic acid (ASA) desensitization can be considered. Non-T2 endotypes or CRS without nasal polyps (CRSsNP) may benefit from several weeks of macrolides and xylitol rinses. CONCLUSION: To accurately assess the efficacy of second-line therapies for treatment of difficult-to-treat CRS within an endotype-specific framework, additional controlled clinical trials are needed that take into account the heterogeneity of CRS endotypes.

[Acute and chronic rhinosinusitis age characteristics]. / Vozrastnye osobennosti techeniya ostrogo i khronicheskogo rinosinusita.

Children's and adults' rhinosinusitis are two diseases that have both similarities and differences in anatomy, epidemiology, causes, pathogenesis, diagnosis and treatment. At the same rhinosinusitis is one of the most common in otorhinolaryngology's practice, both in children and adults. The of adults paranasal sinuses (PNS) anatomy differs from children's PNS anatomy. Although ostiomeatal complex occlusion is recognized as a major cause of poor ventilation and drainage of the adult paranasal sinuses, it does not have a strong effect on pediatric rhinosinusitis, but adenoids play a key role. Adenoids are bacteria and biofilms reservoirs that cause chronic refractory rhinosinusitis regardless of pharyngeal tonsil size. The prevalence of chronic rhinosinusitis (CRS) is lower in children than in adults. Diagnosis of children's rhinosinusitis is more difficult because nasal cavity endoscopic examination is performed rarely due to the occasional need of general anesthesia during the procedure. Moreover, it's necessary to take into account prevailing etiological role of viruses in ARS at children's age and chronic adenoiditis often accompanies pediatric CRS, which requires attention prescribing medical therapy as the basis of rhinosinusitis treatment. The DysheLORz based on Pelargonium sidoides roots is highly effective and safe for children's and adults ARS and CRS treatment, both as monotherapy and in combination with topical steroids and antibiotics. This herbal medicine immunomodulatory effect is mediated mainly by stimulating the production of TNF-α, IL-1, IL-12 and IFN-γ. It activates macrophages and improves their phagocytic activity. IL-12, together with TNF-α, enhances NK and cytotoxic CD8+ lymphocytes' activity against infected cells. IL-12 effect on Th1 lymphocytes maturation provides a link between innate and adaptive immunity. This is also increasing MCP-1, IP-10 and MIP-1ß chemokines synthesis and decreasing MIP-1α, ENA-78, GROα and IL-8 production in PNS and nasal mucosa. This leads to decrease of neutrophils chemotaxis to the inflammation site, and decline of serine proteases concentration (neutrophils main enzymes), that increases mucous membrane epithelial barrier permeability, reducing bacterial infections risk. Additionally, Pelargonium sidoides increases epithelial cells beating cilia frequency and inhibits hemagglutinin and neuraminidase present on influenza virus surface. The drug increases antimicrobial peptides production as defensins, human neutrophil peptides (HNP) and bactericidal permeability-increasing protein (BPI), which is also important for rapid inflammation regression in rhinosinusitis. It causes bacterial adhesion to epithelial cells inhibition, phagocytosis stimulation, nitric oxide (NO) release and oxidative burst. The medicine had a direct effect on Streptococcus pneumoniae, Staphylococcus aureus, Neisseria, Moraxella catarrhalis and Haemophilus influenza. Based on these data, it is possible to explain the high effectiveness and safety of the drugs based on Pelargonium sidoides in ENT organs inflammation treatment, for both adults and children over 1 year old.

[Biologic therapy in patients with severe NSAID-exacerbated respiratory disease and previous aspirin desensitization : Results of a multicentric study]. / Biologikatherapie bei schwer erkrankten Patienten mit "NSAID-exacerbated respiratory disease" und stattgehabter ASS­Desaktivierung : Ergebnisse einer multizentrischen Studie.

BACKGROUND: Chronic rhinosinusitis with nasal polyps (CRSwNP) is a type­2 inflammatory disease of the upper airways, with severe impairment of quality of life. Persons affected by NSAID-exacerbated respiratory disease (NERD) usually present with highly dynamic recurrence of polyps and disease despite prior treatment with sinus surgeries, oral corticosteroids, and aspirin desensitization (ATAD). Biologic therapy has fundamentally changed the choice of therapeutic concept; however, limited data exist on subgroups such as NERD patients. The aim of the current article is to report on a multicenter retrospective study on add-on therapy with dupilumab, omalizumab, and mepolizumab in patients with NERD. METHODS: This is a retrospective cohort study of patients (NERD+, status after ATAD) in three reference centers in Germany (Munich, Mainz, Berlin). Subjective and objective parameters were collected at 4, 8, and 12 months after biologic therapy initiation in accordance with current EPOS/EUFOREA (European Position Paper on Rhinosinusitis and Nasal Polyps/European Forum for Research and Education in Allergy and Airway Diseases) guidelines. Biologic agents were chosen depending on availability and patient characteristics. RESULTS: Treatment was commenced in 122 patients meeting the criteria for CRSwNP and NERD. The endoscopic polyp score, SNOT-22 questionnaire score, visual analogue scoring of total symptoms/severity of disease, and sense of smell (psychophysical testing with Sniffin'Sticks/Brief Smell Identification Test, B­SIT; Sensonics, Inc., Haddon Heights, NJ, USA) improved significantly after 4 and 12 months of add-on therapy (p < 0.0001). All three biologic agents significantly improved one or more disease parameter. Adverse events were not life threatening but led to change of biologic agent in 4 cases. Patients rated biologic therapy significantly better than ATAD, with improved long-term disease control. CONCLUSION: Add-on biologic therapy is effective, safe, and widely accepted among CRSwNP + NERD patients. Future studies might allow for personalized algorithms with sequential surgery, ATAD, and/or biologic therapy.

Nonallergic Rhinopathy: A Comprehensive Review of Classification, Diagnosis, and Treatment.

Chronic nonallergic rhinitis syndromes encompass various conditions, of which vasomotor rhinitis is the most common form, representing approximately 80% of patients, also referred to as nonallergic rhinopathy (NAR), nasal hyperreactivity, neurogenic rhinitis, or idiopathic rhinitis. Expert panels have recommended replacing vasomotor rhinitis terminology because it is more descriptive of this condition that is characterized by symptoms triggered by chemical irritants and weather changes through chemosensors, mechanosensors, thermosensors, and/or osmosensors activated through different transient receptor potential calcium ion channels. Elucidating the specific role of transient receptor potential vanilloid 1, triggered by capsaicin, has been an important advancement in better understanding the pathophysiology of NAR because it has now been shown that downregulation of transient receptor potential vanilloid 1 receptors by several therapeutic compounds provides symptomatic relief for this condition. The classification of NAR is further complicated by its association with allergic rhinitis referred to as mixed rhinitis, which involves both immunoglobulin E-mediated and neurogenic mechanistic pathways. Comorbidities associated with NAR, including rhinosinusitis, headaches, asthma, chronic cough, and sleep disturbances, underscore the need for comprehensive management. Treatment options for NAR include environmental interventions, pharmacotherapy, and in refractory cases, surgical options, emphasizing the need for a tailored approach for each patient. Thus, it is extremely important to accurately diagnose NAR because inappropriate therapies lead to poor clinical outcomes and unnecessary health care and economic burdens for these patients. This review provides a comprehensive overview of NAR subtypes, focusing on classification, diagnosis, and treatment approaches for NAR.

The Inflation Reduction Act: Implications for Medicare spending and access to biologic therapies for chronic rhinosinusitis with nasal polyposis and asthma.

KEY POINTS: In 2021, Medicare spending on biologics was $926 million in Part B (FFS) and $1.3 billion in Part D (FFS/MA). Between 2017 and 2021, annual Medicare spending on biologics increased by approximately 200%. Between 2023 and 2025, Medicare Part D OOP costs for biologics will decrease by an estimated 50%-60%.

The Surprising Effect of Priming on SNOT-22 Results.

BACKGROUND: Priming is a psychological phenomenon where subconscious cues in the environment impact our behavioral responses in certain situations. Well studied in the worlds of business, marketing, and even politics, it is unclear how the priming phenomenon impacts patient perception of their own disease state nor how they report that perception using tools like the Sinonasal Outcomes Test (SNOT-22), used to measure that perception in chronic rhinosinusitis. OBJECTIVE: To determine the impact of positive or negative priming on self-reported patient perception of their chronic rhinosinusitis disease using the SNOT-22 disease-specific quality of life instrument. METHODS: Single-blind, randomized, prospective cohort pilot study of 206 consecutive adult patients with a clinical diagnosis of chronic rhinosinusitis presenting to a university rhinology clinic. Patients were randomized to receive "positive priming" (103) or "negative priming" (103) by reading a passage about the positive or negative aspects of chronic sinusitis and its treatment respectively. Patients were then asked to fill out the SNOT-22 and results between the two groups were compared. RESULTS: The negative priming group had a higher median SNOT-22 score of 49 [IQR = 39] compared to the positive priming groups' score of 22 [IQR = 27], p < 0.0001), a difference of nearly three times the minimal clinical impactful difference (MCID). This effect was consistent regardless of age or sex of the patient. Subgroup analysis revealed a greater impact when priming was performed by the senior male attending regardless of patient age or sex (p < 0.001), while priming performed by the younger female research fellow had greater impact on older patients (>59 years, p = 0.001) and female patients (p = 0.003). CONCLUSIONS: Priming impacts how patient's perceive their chronic rhinosinusitis as determined by the SNOT-22. It is imperative that the rhinologist understand this when using this instrument in research applications and in clinical decision-making for patients.