Real-World Evaluation of Asthma Severity Following Endoscopic Sinus Surgery in Chronic Rhinosinusitis Patients.

Objective: This study aimed to evaluate the impact of endoscopic sinus surgery (ESS) on asthma severity up to 12 months after surgical intervention. Study Design: Retrospective cohort. Setting: Tertiary care center. Methods: Patients with a history of asthma and Chronic Rhinosinusitis (CRS) who underwent ESS between 2013 and 2023 were included. Asthma severity was assessed according to current Global Initiative for Asthma (GINA) guidelines, classifying patients into mild, moderate, and severe based on medication requirements. Asthma severity was evaluated up to 3 months prior to ESS and 1-year post-ESS. Patients with aspirin-exacerbated respiratory disease (AERD) were excluded. Statistical analysis was performed using McNemar test and Wilcoxon signed-rank test to assess differences in asthma severity, medication doses, and number of medications. Results: Sixty-five patients were included, of which 44 (67.7%) had CRS with nasal polyps (CRSwNP) and 21 (32.3%) had CRS without nasal polyps (CRSsNP). No significant differences were found in asthma severity pre- and post-ESS (P = .175). Similarly, no differences were found in ICS doses (P = .999), total number of prescribed medications (P = .157) or presence of exacerbations before and after ESS (P = .078). However, a significant increase in time from last rescue inhaler use was noted after ESS, increasing from a median of 6.71 to 23.1 weeks (P = .004). Conclusion: This study is the first to assess the impact of ESS on asthma severity in a real-world setting. Our findings suggest that ESS does not impact asthma severity classification. However, it might provide relief of asthma symptoms in the early postoperative period.

The impact of cadaveric donor transplant on the development of chronic rhinosinusitis and recalcitrant disease.

KEY POINTS: The study found a higher incidence of chronic rhinosinusitis (CRS) and recalcitrant CRS in cadaveric organ transplant recipients compared to those receiving living donor transplants. Recipients of cadaveric transplants were 1.32 times more likely to develop CRS and 1.68 times more likely to develop medically recalcitrant CRS. Living kidney transplants significantly reduced the risk of developing CRS (OR = 0.12) and recalcitrant CRS (OR = 0.11), highlighting a potentially protective effect against these conditions. In contrast, cadaveric liver transplants were associated with an increased risk of CRS and medically recalcitrant CRS. Kaplan-Meier survival analysis indicated a significant difference in time to CRS onset between cadaveric and living donor transplants. Median time to CRS onset was longer for living donor recipients (21.1 months) compared to cadaveric recipients (15.6 months). This study underscores the need for transplant teams and otolaryngologist to consider donor type during transplant follow-up due to differing risks of CRS development.

Predictors for Development of Chronic Rhinosinusitis in Transplant Recipients.

OBJECTIVES: Studies suggest that transplant patients are at a higher risk of developing chronic rhinosinusitis (CRS). However, there is a dearth of studies describing the factors that may be linked to the development of CRS in this population. Our objective is to identify the risk factors associated with the development of CRS in transplant recipients. STUDY DESIGN: Retrospective cohort. SETTING: Tertiary care center. METHODS: This cohort included 3347 transplant recipients seen between 2017 and 2022. Of these, 2128 patients met the inclusion criteria and were grouped according to whether they were diagnosed with CRS during the post-transplant period. The analysis included both univariate and multivariate analysis to ascertain the odds ratio (OR) and predictive factors. RESULTS: Of the 2128 patients, 649/2128 (30.4%) had CRS. CRS patients had an increased prevalence of previous endoscopic sinus surgery, allergic rhinitis, and recurrent acute rhinosinusitis in the pre-transplant period compared to the non-CRS group. According to the multivariate analysis, patients with primary immunodeficiency and additional transplant were 1.9 and 3.1 times more likely to develop CRS during the posttransplant period (95% CI: 1.3-2.6, p < .0001), (95% CI: 1.3 -7.3, p = .01), respectively. Sirolimus use was also associated with the development of CRS (OR = 1.4, 95% CI: 1.1-1.9, p = .01). CONCLUSION: This study is the largest cohort aimed at determining the predictive factors associated with the development of CRS. Patients with pretransplant rhinologic conditions, hematologic deficiencies, and the utilization of specific immunosuppressants were found to have a higher likelihood of developing CRS following transplantation.

Incidence of perioperative hypersensitivity reactions: A single-center, prospective, US cohort experience.

Background: A previous study, using administrative data, reported an incidence of perioperative anaphylaxis (POA) of 1:6537 procedures in the United States. Objective: We sought to determine the incidence of POA in a prospective US cohort. Methods: Adult participants undergoing a procedure at a single tertiary care center were studied prospectively between April 2018 and January 2022. Subinvestigators recorded vital signs and skin checks preoperatively, 15 minutes into induction, and hourly thereafter until 1 hour into the postoperative period. If participants developed an adverse reaction, additional variables were documented: causal agent(s) exposure, type of nonallergic adverse reaction, Sixth National Audit Project severity score, evidence of mast cell activation by serum acute and baseline tryptase pairing, Allergy consult, and causal agent identification. Results: Among 939 procedures (mean age, 59.25 ± 14.78 years; 58% females; 87% White), there were 12 (1.3%) cases with an identified adverse reaction. Nine cases were classified as nonhypersensitivity adverse reactions (1%) and 3 as possible hypersensitivity reactions (0.3%); 1 case was classified as suspected perioperative hypersensitivity and 2 as POA (0.2%). Both POA cases were males, had previous procedures, had evidence of mast cell activation, had a Sixth National Audit Project score of 3, and were referred to Allergy for further evaluation. There were 9 participants who developed a nonhypersensitivity adverse reaction: relative overdose of anesthetic (n = 6), transient rash (n = 2), and isolated bronchospasm (n = 1). All transient rashes were observed during undraping protocol. Conclusions: In our prospective study, the incidence of POA is 1:470 procedures. Our study suggests that the incidence of POA may be higher than previously reported.

Risk Factors for Recalcitrant Chronic Rhinosinusitis in Non-Solid and Solid Transplant Recipients.

OBJECTIVES: Transplant patients are high risk for surgery due to their immunocompromised state. There is a paucity of evidence concerning the differences in incidence of chronic rhinosinusitis (CRS) in solid versus non-solid organ transplant. Our aim is to analyze the difference in incidence of CRS requiring endoscopic sinus surgery (ESS) between non-solid and solid transplant populations and determine if certain risk factors are associated with increased incidence of recalcitrant CRS in non-solid versus solid transplants. STUDY DESIGN: Retrospective cohort. SETTING: Multisite tertiary academic center. METHODS: This is a retrospective chart review of 1303 transplant recipients who were seen in our rhinologic clinic for CRS between 2017 and 2022. A total of 224 patients underwent ESS and were further analyzed for risk factors associated with recalcitrant disease requiring sinus surgery. Subgroup analysis based on solid and non-solid organ transplant was performed. RESULTS: Of the 224 patients in the study, 171/224 (76.3%) had solid transplants while 53/224 (23.6%) had non-solid transplants. 17.19% of all transplant recipients required ESS. The incidence of ESS in non-solid transplants was 28.2% versus 57% in solid transplant. The risk of recalcitrant CRS in solid transplant recipients was almost 1.78 times greater than those with non-solid organ transplant (95% CI, 1.27-2.54, p = 0.0005). Individual factors such as certain immunotherapy drugs, pancytopenia, and rejection appear to correlate with the risk of ESS in both non-solid and solid organ transplant. CONCLUSION: Risk of ESS was greater in the solid transplant recipients compared to those who received non-solid organ transplant.

Spontaneous Combined Lung and Bowel Herniation Due to Uncontrolled Asthma.

Spontaneous lung and bowel hernias are infrequent structural defects secondary to conditions that usually follow bouts of excessive straining. These two conditions have been individually well documented in the literature; however, there are seldom reports of this combination of defects. Here, we describe the case of a 69-year-old man diagnosed with combined spontaneous lung and colon herniation following an episode of severe coughing due to uncontrolled asthma. Early recognition and prompt treatment should be warranted to prevent complications.

Relationship Between Alcohol Intolerance and Aspirin-Exacerbated Respiratory Disease (AERD): Systematic Review.

OBJECTIVE: Previous studies have suggested that patients with aspirin-exacerbated respiratory disease (AERD) have a high likelihood of alcohol intolerance. The purpose of this systematic review is to identify if there is sufficient evidence to confirm this correlation and the impact of medical therapy on subsequent alcohol tolerance. DATA SOURCES: PubMed, EMBASE, SCOPUS, EBSCO, Google Scholar, Cochrane Library, and Grey literature. We also performed snowballing on the identified observational studies (OS) for additional data. REVIEW METHODS: A systematic review was conducted from 1968 to 2022 to identify those studies describing AERD symptomatology triggered by alcohol intake. The primary outcome was to analyze the current literature for the association between alcohol intolerance and AERD symptoms. The secondary outcome looked for improvement in alcohol tolerance after aspirin desensitization or biological therapy. RESULTS: A total of 775 studies were identified and 40 abstracts were evaluated. From these, 5 studies met the inclusion criteria. Of the 5 manuscripts, there was 1 case-control, 2 cohort, and 2 cross-sectional studies. A total of 522 participants with AERD and a history of alcohol consumption were included, with 52.8% reporting at least 1 sinopulmonary exacerbation after alcohol intake. One of 3 studies noted improvement in alcohol tolerance after medical therapy with aspirin desensitization. CONCLUSION: The current literature suggests that patients with AERD have a high risk of alcohol intolerance. Additionally, aspirin desensitization may improve alcohol tolerance in this patient population.

Risk Factors for Recalcitrant Chronic Rhinosinusitis in Organ Transplant Recipients.

OBJECTIVE: Studies suggest that transplant patients are at risk for chronic rhinosinusitis (CRS). However, there is limited information in the literature regarding frequency and reasons for failure of adequate medical therapy. We aim to determine the risk factors associated with the development of medically recalcitrant CRS requiring endoscopic sinus surgery (ESS). STUDY DESIGN: Retrospective cohort. SETTING: Mayo Clinic. METHODS: This is a retrospective chart review of 925 transplant recipients seen at Mayo Clinic between 2017 and 2022. INCLUSION CRITERIA: (1) a rhinologic consultation after transplant and (2) clinical diagnosis of CRS. A total of 549 patients met the inclusion criteria and were divided based on the need for ESS versus successful treatment with medical therapy. Univariate and logistic regression analyses were performed to identify risk factors and predictive variables related to failure of medical therapy. RESULTS: Of the 549 patients, 201/549 (37%) had medically recalcitrant disease requiring ESS, while 348/549 (63%) were successfully treated with medical therapy Based on logistic regression, patients with recurrent acute rhinosinusitis in the pretransplant period were 8.68 more likely to have a recalcitrant disease (95% confidence interval, 3.72-20.28, p < 0.0001). Some of the largest determinants of medical therapy failure in the posttransplant period were CRS with nasal polyps, odontogenic CRS, and noninvasive fungal sinusitis. The presence of neutropenia, aplastic anemia, and living transplant were also associated with medically recalcitrant CRS requiring ESS. CONCLUSION: Our predictive model identifies with high accuracy the patients who may be at risk of developing recalcitrant CRS in the organ transplant population.

Bosutinib-Induced Stevens-Johnson Syndrome and Evidence of Tolerance to a Structurally Dissimilar Tyrosine Kinase Inhibitor.

Bosutinib is a breakpoint cluster region-Abelson gene (BCR-ABL) tyrosine kinase inhibitor (TKI) used for the treatment of chronic myeloid leukemia (CML). Patients on TKIs may develop severe cutaneous adverse reactions (SCARs). A 73-year-old female with CML treated with a second-generation TKI (bosutinib) was evaluated after developing fever and a maculopapular exanthema with skin-peeling affecting her lips, oral mucosa, and genitals 10 days after starting the medication. She required hospitalization, bosutinib discontinuation, and management with intravenous corticosteroids and antibiotics. Patch testing was contraindicated due to the severity of the reaction. The patient was subsequently challenged with first-generation TKI along with careful observation without any adverse reactions. She has not reported any adverse reactions while on therapy in the last two years. In patients who have suffered from SCARs, the suspected triggers must be avoided in all instances. In some cases, the underlying condition limits the use of alternative agents, but low-concentration patch testing may help guide alternative therapies within the same medication group. There appears to be a low cross-reactivity among generational TKIs, and our patient benefited from treatment with a structurally dissimilar alternative TKI for her CML.

Delayed Vesicular Urticarial Dermatosis Due to Apixaban.

Cutaneous adverse drug reactions (cADR) are delayed hypersensitivity reactions that are T-cell mediated. Novel oral anticoagulants, including Factor Xa inhibitors, are increasingly used as therapeutic or prophylactic management of thrombosis and atrial fibrillation. We introduce the case of a 78-year-old woman with no known allergies and a history of atrial fibrillation who was started on apixaban for cerebrovascular accident prophylaxis. Approximately nine days after starting apixaban, she developed a vesicular-urticated erythematous rash initially located on her right upper extremity, progressing to her face. She was evaluated after two weeks for the persistence of symptoms and improved with hydroxyzine and prednisone. Subsequently, she was advised to discontinue and evade all Factor Xa inhibitors, including apixaban, and was switched to warfarin. Naranjo score scale was 5-6. The patient declined skin biopsy and drug challenge. After a month of discontinuation of systemic steroids, patch testing was performed with apixaban, rivaroxaban, and edoxaban, with a negative result. Since this episode, the patient has not had a recurrence of the rash. As far as we know, this is the first case report of a non-severe cADR to apixaban. Even though there are no standardized protocols for diagnosing drug reactions to Factor Xa inhibitors, patch testing at increasing non-irritant concentrations with re-challenge of alternative agents and the suspected offending agent, if possible, should be included in the evaluation of a cADR.