Wound healing in endoscopic sinus surgery: Phase 1 clinical trial evaluating the role of Chitogel with adjuvants.

OBJECTIVES: This study aimed to determine the safety and efficacy of Chitogel, with and without Deferiprone (Def) and Gallium Protoporphyrin (GaPP), as a promoter of wound healing to improve surgical outcomes after endoscopic sinus susgery. DESIGN: A double-blinded, randomised control human clinical trial was conducted in patients undergoing ESS as a treatment for chronic rhinosinusitis. Participants underwent functional ESS or FESS with drill out as required and were randomised to receive test product Chitogel, Chitogel in combination with Def or Def-GaPP versus no packing (control). SETTING: Ostial stenosis and persistent inflammation are the main reasons for revision endoscopic sinus surgery (ESS). Post-operative (PO) dressings can improve PO wound healing and patient outcomes after ESS. PARTICIPANTS: Eighty two patients were included in this study with 79 patients completing the study with 40 undergoing full house FESS and 39 FESS plus frontal drillout. MAIN OUTCOME MEASURES: Patients were followed up at 2, 6 and 12 weeks PO, and outcome scores such as SNOT-22, VAS and LKS, pre and post-surgery (12 weeks) were compared. RESULTS: Seventy nine patients completed the study, there was a significant reduction in SNOT-22 score and improvement of VAS at 12 weeks in patients treated with Chitogel compared to control (p < .05). In those patients, the mean ostium area for the Chitogel and the Chitogel + Def + GaPP groups was higher across all three sinuses compared to the no-treatment control group, without statistical significance. Sphenoid sinus ostium was significantly more patent in patients treated with Chitogel compared to the control at the 12-week time point (p < .05). CONCLUSION: Chitogel as a PO dressing after ESS results in the best patient-reported symptom scores and objective measurements. The combination of Def and GaPP to Chitogel though proving safe, had no effect on the ostium patency or mucosal healing.

Allergic fungal rhinosinusitis presented as a unilateral nasal mass: A first case report from Thailand and literature review.

Background: Allergic fungal rhinosinusitis (AFRS) is a relatively new inflammatory sinonasal disease. Prevalence of the disease is reported to be highly different across Asia. Case presentation: A 23-year-old Thai male came to our hospital with left-sided nasal obstruction. Endoscopic examination found a mass originated from the left sphenoethmoidal recess. Incisional biopsy result of the mass indicated an inflammatory process and high level of serum specific IgE to several aeroallergens was found. Based on the biopsy results and other investigations, the diagnosis of AFRS was made and the patient was treated successfully with endoscopic sinus surgery and postoperative systemic/topical steroids. Discussion: While AFRS is quite common in some regions, the disease is rarely encountered in Thailand and can be presented as a unilateral lesion, mimicking a tumor mass, which could lead to an incorrect diagnosis and inappropriate treatment. Conclusion: Even though AFRS is rarely reported in our country, it still can be found and might be recognized falsely as a neoplastic process. High level of awareness of the disease features could help to minimize inappropriate disease management.

Endotyping of Chronic Rhinosinusitis With and Without Polyp Using Transcription Factor Analysis.

Inflammation of the nose and paranasal sinus or rhinosinusitis (RS) is a significant global health problem that is both very common and very costly to treat. Previous reports reveal variability in histology and mechanism of inflammation in patients with chronic rhinosinusitis with and without polyp (CRScNP and CRSsNP, respectively). There are various methods and hypothesis that try to explain this variability. Accordingly, the aim of this study was to investigate the incidence of each type of sinonasal inflammation among patients diagnosed with CRScNP or CRSsNP using transcription factor analysis (TFA). This study included mucosa specimens from nose/paranasal sinuses from patients with chronic rhinitis (CR), CRSsNP, or CRScNP that were obtained at the Department of Otorhinolaryngology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand during the June 2009 to May 2012 study period. TFA was employed to measure the following transcription factors: T-box transcription factor (T-bet) for Th1, GATA binding protein 3 (GATA-3) for Th2, retinoic acid-related orphan receptor C (RORC) for Th17, and forkhead box P3 (FOXP3) for Treg. Forty-one subjects (22 males, 19 females) were enrolled, with a mean age of 45.93 ± 13 years. Twenty-six patients were diagnosed with CRScNP, 7 with CRSsNP, and 8 with CR (controls). The majority of CRScNP specimens (76.9%) had eosinophil count greater than 100 cells/high-power field (HPF). Mean eosinophil count was 930.08 ± 1,399 cells/HPF (range: 17-5,570). Th2 transcription factor (GATA-3) was statistically significantly higher in the CRScNP group than in the CRS and control groups (p < 0.001); whereas, Treg transcription factor (FOXP3) was statistically significantly lower in the CRScNP group than in the CRSsNP and control groups (p < 0.001). The transcription factors for Th1 and Th17 (T-bet and RORC, respectively) were not significantly different among the three groups. The result of transcription factor analysis revealed hyperfunction of Th2 in patients with CRScNP, which might result in hypereosinophilic infliltration in the polyps. One explanation for this finding is the decreased activity of Treg. Although environment-host interaction is the most probable hypothesis, the etiology of aberrant adaptive immunity needs to be elucidated.

Reliability and validity study of Sino-nasal outcome test 22 (Thai version) in chronic rhinosinusitis.

BACKGROUND: Chronic rhinosinusitis (CRS) is one of common health conditions that affects patients' health-related quality of life. Our purpose is to assess the reliability and validity of Thai-version of Sino-Nasal Outcome Test 22 in chronic rhinosinusitis. METHODS: Permission for translation of SNOT-22 from English language to Thai language was obtained from the developer. The translation process was done based on the international standard of translation method. A total of 80 subjects were recruited into the study and divided into two groups comprising of 50 patients with chronic rhinosinusitis and 30 healthy volunteers. Cronbach's α and Intraclass correlation coefficient were evaluated for its reliability. Validity test was evaluated against VAS score, SF-36 (Thai version) questionnaire and CT scan (based on Lund-Mackay score). Responsiveness was assessed between pre-operative and post-operative scores in 34 patients. RESULTS: The Thai version of SNOT-22 showed good reliability according to high value of Cronbach's α coefficient (r = 0.929) and intraclass correlation coefficient (r = 0.935). It also showed good validity by its ability to differential the patients with chronic rhinosinusitis from normal (p < 0.001), and different severity of symptoms (p < 0.05). In addition, the SNOT-22 Thai version also showed good responsiveness when compared between pre-operative and post-operative scores (p < 0.001) and also well-performed in effect size calculation (1.37). CONCLUSION: We demonstrated that Thai -version of SNOT-22 has good reliability and validity, suitable for evaluation of chronic rhinosinusitis symptoms together with severity of the disease and response to treatment. TRIAL REGISTRATION: Thai clinical trials registry TCTR20170320003. Date of registration 20/03/2017 (retrospectively registered).

Enhanced susceptibility of nasal polyp tissues to avian and human influenza viruses.

BACKGROUND: Influenza viruses bind and infect respiratory epithelial cells through sialic acid on cell surface. Differential preference to sialic acid types contributes to host- and tissue-tropism of avian and seasonal influenza viruses. Although the highly pathogenic avian influenza virus H5N1 can infect and cause severe diseases in humans, it is not efficient in infecting human upper respiratory tract. This is because of the scarcity of its receptor, α2,3-linked sialic acid, in human upper airway. Expression of sialic acid can be influenced by various factors including inflammatory process. Allergic rhinitis and nasal polyp are common inflammatory conditions of nasal mucosa and may affect expression of the sialic acid and susceptibility to influenza infection. METHODOLOGY/PRINCIPAL FINDING: To test this hypothesis, we detected α2,3- and α2,6-linked sialic acid in human nasal polyp and normal nasal mucosal tissues by lectin staining and infected explants of those tissues with avian influenza viruses H5N1 and seasonal influenza viruses. We show here that mucosal surface of nasal polyp expressed higher level of α2,3- and α2,6-linked sialic acid than normal nasal mucosa. Accordingly, both H5N1 avian influenza viruses and seasonal influenza viruses replicated more efficiently in nasal polyp tissues explants. CONCLUSIONS/SIGNIFICANCE: Our data suggest a role of nasal inflammatory conditions in susceptibility to influenza infection, especially by avian influenza viruses, which is generally inefficient in infecting human upper airway. The increased receptor expression may contribute to increased susceptibility in some individuals. This may contribute to the gradual adaptation of the virus to human population.