[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.

Chronic Rhinosinusitis.

Chronic rhinosinusitis (CRS) is an inflammatory disease of the nose and paranasal sinuses, with a prevalence of approximately 1% to 7%. It is defined by the presence of at least two cardinal symptoms (nasal blockage, obstruction, or congestion; anterior or posterior nasal drainage; facial pain or pressure; and hyposmia) for at least three consecutive months, with objective findings on imaging or nasal endoscopy. CRS can result in significant patient costs and lower quality of life due to severe fatigue, depression, and sometimes reduced cognitive function. The condition is categorized as primary or secondary and with or without nasal polyps. Treatment is directed at reducing symptoms, improving mucus clearance, reducing inflammation, enhancing ciliary function, and removing bacteria and biofilms from the nasal mucosa. First-line treatment comprises nasal saline irrigation and intranasal corticosteroids. Acute exacerbation of CRS is common and is defined as a transient worsening of symptoms. The role of oral antibiotics and oral corticosteroids for acute exacerbations is unclear. Optimal maintenance therapy can help alleviate exacerbations. Patients with refractory CRS that is not responsive to first-line treatment and patients with alarm symptoms should be referred to an otolaryngologist for further evaluation and consideration of surgical management. Identifying patients who have CRS with nasal polyps or comorbid conditions such as atopic dermatitis, asthma, or eosinophilic esophagitis is especially important to ensure they are referred to a specialist for consideration of biologic therapy.

[Experience of biological therapy in severe forms of chronic rhinosinusitis with nasal polyps in the conditions of regional healthcare]. / Opyt biologicheskoi terapii pri tyazhelykh formakh khronicheskogo polipoznogo rinosinusita v usloviyakh regional'nogo zdravookhraneniya.

Recurrent chronic rhinosinusitis with nasal polyps (CRSwNP) with a predominant Th2 endotype of inflammation, including associated with bronchial asthma and/or allergic rhinitis, aspirin triad, refers to diseases with an insufficient level of control, despite the use of a wide range of options for conservative and surgical treatment. OBJECTIVE: To analyze our own experience, clinical and organizational features of the application of the method of biological therapy in patients with severe forms of recurrent CRSwNP. MATERIAL AND METHODS: 25 patients with severe and moderate forms of CRSwNP were examined, who, in a round-the-clock hospital (model CSG 36.018) was treated with Dupilumab, in the form of subcutaneous injections of 300 mg/2 ml 1 every two weeks. The diagnosis was confirmed on the basis of anamnestic data, SNOT-22 quality of life questionnaires, visual endoscopic examination, evaluation of CT data (Lund-Mackay scale), laboratory data. The effectiveness of treatment was monitored after 16 weeks, based on endoscopic examination data, evaluation of CT and SNOT-22 data. In 3 observations, a study of pathomorphological material for tissue eosinophilia was performed. RESULTS: The duration of the course of treatment ranged from 10 to 56 weeks. The most striking clinical effect was observed for signs such as sense of smell and nasal breathing (in some cases-after the first injection). The degree of regression of polyps according to CT and endoscopic examination was more prolonged in time, the same dynamics was observed in the level of total IgE. In a number of patients, the phenomenon of eosinophilia growth was observed against the background of treatment (with regression of clinical symptoms). Pathomorphological examination confirmed a high level of tissue eosinophilia as one of the fundamental signs of Th2 inflammation. One patient with concomitant chronic tubar dysfunction had an improvement in hearing. All patients with AD noted a subjective improvement in disease control (a decrease in the frequency and severity of choking attacks). The cancellation (break in treatment) of treatment was accompanied by a gradual return of symptoms in all patients at various times. CONCLUSIONS: Patients who have not achieved an acceptable level of control of CRSwNP,that meets the criteria of Th2 inflammation can be considered as candidates for the use of targeted biological therapy. With strict compliance with the selection criteria, there is a good clinical effect, primarily in relation to nasal symptoms (sense of smell and nasal breathing) and improved control of asthma symptoms.

Rhinosinusitis: clinical-based phenotyping.

Rhinosinusitis (RS) is a common disease and is currently classified into two main types: acute RS (ARS) and chronic RS (CRS), which in turn includes CRS with or without nasal polyps. Different guidelines consider this classification. However, in clinical practice, other phenotypes exist. The current article would propose new clinical-based phenotyping of RS, including the following clinical phenotypes: simple catarrhal RS, Acute RS, acute bacterial RS, severe (complicated) acute RS, chronic RS, and recurrent chronic RS. Treatment strategy should be tailored considering the clinical phenotype and could include phytomedicines, intranasal non-pharmacological remedies, and local bacteriotherapy. In conclusion, RS requires thorough diagnostic work-up, and the therapeutic approach should be mainly based on appropriate management.

Usefulness of bilateral mucoplasty plus reboot surgery in severe type-2 chronic rhinosinusitis with nasal polyps.

BACKGROUND: Although extended endoscopic sinus surgery (ESS) constitutes an alternative approach in patients with Chronic Rhinosinusitis with Nasal Polyps (CRSwNP), the surgical techniques proposed so far do not allow for an optimal control of the disease. This study introduces bilateral mucoplasty as a complementary technique to extended ESS such as reboot surgery, analyzing its benefits in healing and quality of life (QoL). METHODS: Patients diagnosed with severe Type-2 CRSwNP were selected for a prospective cohort study in two surgery groups: reboot surgery plus bilateral mucoplasty versus reboot surgery only. In the first group, an autologous endonasal mucosal graft from the nostril floor was placed bilaterally onto the ethmoidal roof. Endoscopic, radiological and QoL outcomes were compared before and one year after surgery between the two groups using Modified Lund Kennedy (LKM), Meltzer and Lund Mackay (LM) scores, and the Sino-Nasal Outcome Test 22 (SNOT-22). RESULTS: 64 patients with homogeneous baseline characteristics were included: 17 patients underwent a reboot surgery plus a bilateral mucoplasty and 47 a reboot surgery only. LKM, Meltzer and SNOT-22 scores showed significant differences before and after surgery in both groups, with higher improvement in the mucoplasty group. A greater mean improvement of 20.5 ± 6.4 points in SNOT-22 change was associated with bilateral mucoplasty. CONCLUSION: Bilateral mucoplasty plus reboot surgery constitutes a useful surgical resource in Type-2 CRSwNP patients, showing improved endoscopic, radiological and QoL outcomes one year after surgery. Further studies are needed to determine their long-term benefits.

A Comparison of International Guidelines for Rhinosinusitis.

The European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS), latest version EPOS2020, and the International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS), latest version ICAR-RS-2021, assimilate thousands of articles on the topic of rhinosinusitis. Encompassing scores of subtopics and relying on the perspectives of many international experts, EPOS2020 and ICAR-RS-2021 reduce the existing data into consumable formats and create evidence-based recommendations. The approaches and findings are similar in many respects but have significant differences. This clinical commentary, authored by some of the principal authors of these documents, compares and contrasts EPOS2020 and ICAR-RS-2021, examining methodology, diagnostic and treatment recommendations, and each document's emphases. This commentary demonstrates that, through somewhat differing methodologies, the 2 documents arrive at largely similar conclusions. Those who care for patients suffering from rhinosinusitis will find the documents complementary and valuable in their differences as much as in their similarities.

Haemorrhagic nasal polyp mimicking melanoma in an 83-year-old on rivaroxaban.

An 83-year-old woman presented with rapid onset unilateral nasal obstruction after sneezing. She had a history of hypertension and atrial fibrillation, and was on rivaroxaban. Examination revealed a dark red polypoidal lesion completely obstructing the left nostril. She underwent CT and MRI, and proceeded to urgent excision biopsy of the lesion. Intraoperative appearance was in keeping with a haemorrhagic polyp arising from the nasal septum. Histology revealed haematoma within a layer of nasal mucosa. There was no evidence of haemangioma underlying the polyp. Our literature search has identified this case as the first described haemorrhagic polyp of the nasal septum. It is likely that rivaroxaban contributed to the formation of this haemorrhagic polyp, and it is important to differentiate benign haemorrhagic lesions from malignant conditions such as melanoma. Similar cases may become more common in the future as the proportion of the population on anticoagulants increases.

Microscopic endonasal surgery of nasal and paranasal cavities.

OBJECTIVE: To present the experience of our department on microscopic surgery of the nose and sinuses and compare our results with those of other standard approaches. Furthermore we attempt to specify the main indications for the use of the method. METHODS: During the period between January 1990 and December 2002, the prementioned technique was performed in a total of 250 patients. The preoperative evaluation, surgical technique and postoperative management of all patients are described in detail. RESULTS: Most common diagnoses included nasal polyps and chronic rhinosinusitis. The average age of patients was 42 years. Males accounted for 48%. No major postoperative complications were noted. Minor complications such as epistaxis and midfacial pain were observed in 24% of cases. While the majority of patients reported severe symptomatology preoperatively, 91% reported substantial improvement of their clinical condition within 3 months after surgery. CONCLUSION: Microscopic surgery is a technique which can be used alternatively to traditional procedures. It provides an excellent, clear, stereoscopic vision and allows the surgeon to work bimanually. Complications are rare and easily controlled. Our experience favors the use of microscopic technique compared to common endoscopic approaches, especially in cases of nasal polyps and chronic rhinosinusitis.

Ligneous conjunctivitis: a clinicopathological, immunohistochemical, and genetic study including the treatment of two sisters with multiorgan involvement.

Ligneous conjunctivitis (LC) is a rare disease characterized by wood-like pseudomembranes developing on the ocular and extraocular mucosae secondary to plasminogen (PLG) deficiency. In this paper, we report two cases of LC in two sisters of 57 and 62 years of age that presented with recurrent, bilateral pseudomembranes on conjunctiva and a history of consanguinity and deafness. Pseudomembranes showed superficial and/or subepithelial deposits of eosinophilic amorphous hyaline, amyloid-like material with a variable proportion of granulation tissue, and inflammatory cells. The eosinophilic deposits were negative for Congo red stain, immunoreactive for fibrinogen, and consistently negative for amyloid A component, transthyretin, beta(2)-microglobulin, albumin, fibronectin, collagen type IV, vimentin, and cytokeratins. Among inflammatory cells, a percentage of positivity of roughly 60% for lymphocytes T (CD3+) and 40% for lymphocytes B (CD8+), with a relation of cytotoxic/helper (CD8/4) T cells of 3:2, was found. In one case, nasal polyps and recurrent gastric peptic ulcer were also characterized by the same subepithelial hyaline deposits. A novel homozygous point mutation c.1856 C>T was found in exon 15 of the PLG gene in both patients. Amniotic membrane transplantation was done in one case with promising results.

[Bone mineral density after treatment for nasal polyposis]. / Traitement médical de la polypose naso-sinusienne. Effet sur la densité minérale osseuse.

PURPOSE: Medical treatment of nasal polyposis is based on corticotherapy, and the most frequent complication of long-term corticotherapy is corticosteroid-induced osteoporosis. OBJECTIVE: To assess bone mineral density after long-term, high-dose corticosteroid treatment for nasal polyposis. PATIENTS AND METHODS: Bone mineral density at the spine and hip was measured by absorptiometry in 32 patients who had received high doses of corticosteroids for nasal polyposis. None of them had a disease that interfered with bone mineral density RESULTS: Bone mineral density was measured in 32 patients (59% men) aged 49.7 +/- 3.7 years [range: 29 - 74] after corticosteroid therapy for a mean of 5.3 years [range: 2-22 years]. More than 70% of the patients had abnormal bone density (osteopenia or osteoporosis ) at the spine and 44% at the hip. Only eight (25%) patients had normal bone density at both the spine and hip. CONCLUSION: High doses of corticosteroids in the treatment of nasal polyposis affect bone mineral density. Assessment of the benefits and risks of endoscopic sinus surgery must take this iatrogenic risk into account.

Adenocarcinoma of the ethmoid sinuses: a case of two primary tumours.

The authors present a case report of a retired furniture worker who initially presented with a mucin-secreting adenocarcinoma of the right ethmoid sinus. He underwent surgical resection, leaving the nasal septum intact, and topical treatment with 5-fluorouracil. He remained disease free. Three years after his initial presentation he was found to have a left nasal polyp on routine examination. This subsequently proved to be a second primary adenocarcinoma. A review of the literature has not shown any other cases of a second primary adenocarcinoma of the ethmoid sinuses.

Rinitis en la edad infanto-juvenil / Rhinitis in children and adolescent

La rinitis es un síndrome producido por la inflamación de la mucosa de las fosas nasales cuya expresión clínica es la congestión nasal, estornudos e hipersecreción seromucosa; su origen puede ser alérgico o no alérgico.En la rinitis alérgica el mecanismo inmunopatológico está determinado por el tipo I de hipersensibilidad mediada por IgE; los alérgenos más frecuentes son los pneumoalérgenos siendo de menos importancia los trofoalérgenos. Las manifestaciones clínicas pueden tener presentación estacional -principalmente en la temporada de polinización- o perenne, que no presenta variación estacional y tienen síntomas todo el año.En la rinitis no alérgica no existe reacción de hipersensibilidad mediada por IgE y comprende un numeroso grupo de afecciones de origen inflamatorio y no inflamatorio.El tratamiento de la rinitis alérgica consiste en medidas de desalergenización, diversas clases de fármacos y terapéutica de hiposensibilización con vacunas alergénicas.Asociaciones comórbidas (asma, conjuntivitis, sinusitis, otitis...) acompañan con frecuencia a las rinitis alérgicas (AU)

[Angiosarcoma of the nasal septum]. / Angiosarkom des Nasenseptums.

This is a report on a female patient, 37 years old, with a polypous, sessile tumor on the nasal septum covered by smooth mucous membrane. She was treated with local excision. The histological diagnosis was an angiosarcoma, confirmed by immunohistological stain with factor VIII-like antigen, thrombomodulin, and UEA. She currently remains free of the disease 12 months after diagnosis. Angiosarcoma in the head and neck area and especially the localization in the nasal septum are extremely rare. Prognosis, differential diagnosis, metastasis formation, and therapy of this tumor are presented.