A substantial neutrophilic inflammation as regular part of severe type 2 chronic rhinosinusitis with nasal polyps.

BACKGROUND: Chronic rhinosinusitis with nasal polyps (CRSwNP) is generally associated with severe type 2 immune reactions in the white population. However, recent findings suggest an additional role for neutrophils in severe type 2 inflammation. OBJECTIVE: This study aimed to characterize the neutrophilic inflammation in CRSwNP and its relation to eosinophilic inflammation in severe type 2 immune reactions. METHODS: The presence and activation of neutrophils and eosinophils was analyzed in CRS without NP and CRSwNP by measuring cell and activation markers via immunohistochemistry, immunofluorescence, Luminex assay, ELISA, UniCAP, fluorescence-activated cell sorting, and PCR. Differential neutrophil migration was assessed via Boyden-chamber assay and neutrophil survival was analyzed via flow cytometry. RESULTS: Both CRS without NP and CRSwNP displayed variable degrees of eosinophilic and neutrophilic inflammation, with a profound neutrophilic infiltration and activation in type 2 CRSwNP, associated with eosinophil extracellular traps cell death and Charcot-Leyden crystals, but independent of IL-17. Neutrophil extracellular traps cell death in CRSwNP was associated with bacterial colonization, however, neutrophils were less prone to undergo neutrophil extracellular traps cell death in the tissue of patients with severe type 2 CRSwNP. Neutrophils did not show increased migration nor survival in the CRSwNP environment in vitro. CONCLUSIONS: This study demonstrated a severe neutrophilic inflammation associated with severe eosinophilic type 2 inflammatory CRSwNP, the role of which needs further study.

EUFOREA expert board meeting on uncontrolled severe chronic rhinosinusitis with nasal polyps (CRSwNP) and biologics: Definitions and management.

Uncontrolled severe chronic rhinosinusitis with nasal polyps (CRSwNP) is the most bothersome phenotype of chronic rhinosinusitis; it is typically characterized by a type 2 inflammatory reaction and by comorbidities, including asthma, nonsteroidal anti-inflammatory drug-exacerbated respiratory disease, and allergies. Here, the European Forum for Research and Education in Allergy and Airway Diseases proposes structured definitions to enable communication between clinicians and provides a practical algorithm to define type 2 inflammation in CRSwNP in daily clinical practice. A rational approach for the treatment of uncontrolled severe CRSwNP is discussed; it consists of evaluating the perspective and risks of surgery and efficacy and adverse events of biologics on the basis of currently available data. Further, possible combinations of surgery and biologics are discussed, and a rationale is provided. Here, it is of importance to adequately counsel the patient about both approaches to enable a decision-making process with an informed patient. Criteria for the selection of a biologic drug are provided, as several biologics for uncontrolled severe CRSwNP will be available in many countries within a short time. Further, suggestions for monitoring of the drug effects that support recognition of responders to the therapy and, subsequently, the decision regarding continuation or discontinuation of the biologic are proposed.

Contemporary Classification of Chronic Rhinosinusitis Beyond Polyps vs No Polyps: A Review.

Importance: Chronic rhinosinusitis (CRS) is a broadly defined process that has previously been used to describe many different sinonasal pathologic conditions from odontogenic sinusitis and allergic fungal sinusitis to the more contemporary definition of broad inflammatory airway conditions. Previous classification systems have dichotomized these conditions into CRS with nasal polyps and CRS without nasal polyps. However, clinicians are learning more about the inflammatory subtypes of CRS, which can lead to improved delivery and effectiveness of treatment. Observations: In clinical practice, treatment decisions are often based on observable findings, clinical history, presumed disease, and molecular pathophysiologic characteristics. A proposed classification system is simple and practical. It proposes that the functional anatomical compartments involved create the first level of separation into local and diffuse CRS, which are usually unilateral or bilateral in distribution. Diffuse does not imply "pansinusitis" but simply that the disease is not confined to a known functional anatomical unit. This classification takes into account whether local anatomical factors are associated with pathogenesis. Then the inflammatory endotype dominance is separated into a type 2 skewed inflammation, as this has both causal and treatment implications. The non-type 2 CRS encompasses everything else that is not yet known about inflammation and may change over time. The phenotypes or clinical examples are CRS entities that have been described and how they align with this system. Conclusions and Relevance: Although research continues to further define the subtypes of CRS into phenotypes and endotypes, the proposed classification system of primary CRS by anatomical distribution and endotype dominance allows for a pathway forward.

A classification of chronic rhinosinusitis with nasal polyps based on structured histopathology.

AIMS: In chronic rhinosinusitis with nasal polyps (CRSwNP), tools based on objective evidence, such as histopathology, are needed to assist clinical decision-making. The main aim of this exploratory investigation was to determine whether structured histopathology could be used to classify CRSwNP in homogeneous histological clusters. METHODS AND RESULTS: A cohort of 135 CRSwNP patients was assessed, on the basis of clinicopathological features: allergic fungal rhinosinusitis (17 patients); non-steroidal anti-inflammatory drug-exacerbated respiratory disease (19 patients); intrinsic asthma (18 patients); extrinsic asthma (21 patients); allergy (21 patients); histologically eosinophilic (22 patients); and histologically non-eosinophilic (17 patients). For structured histopathology, we considered: the degree of inflammation; eosinophil count; eosinophil aggregates; neutrophil infiltration; goblet cell hyperplasia; basement membrane thickening; fibrosis; hyperplastic/papillary changes; squamous metaplasia; mucosal ulceration; and subepithelial oedema. Cluster analysis identified four distinct sets of cases. On discriminant analysis, the global error rate was 1.48%, and the stratified error rates were 4.34%, 0%, 0%, and 0% for clusters 1, 2, 3 and 4, respectively. Cluster 1 was characterised by infrequent fibrosis (<4.5% of cases). Cluster 2 mainly featured neutrophil infiltration in 100% of cases, hyperplastic/papillary changes in 70% of cases, and fibrosis in 65% of cases. Cluster 3 showed fibrosis in 100% of cases. Cluster 4 showed hyperplastic/papillary changes in 100% of cases, and fibrosis in 92% of cases. CONCLUSIONS: This study shows that cluster analysis can identify different histotypes among CRSwNP patients. The next step will be to investigate, in a larger series, the clinical (e.g. prognostic) implications of identifying such homogeneous clusters of patients with CRSwNP on the basis of their structured histopathology.

[Classification of chronic rhinosinusitis with nasal polyps based on eosinophilic inflammation].

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a heterogeneous disorder characterized by chronic sinonasal mucosal inflammation. CRSwNP can be subdivided into two types based on eosinophilic inflammation: eosinophilic CRSwNP (Eos CRSwNP) and non-eosinophilic CRSwNP (Non-Eos CRSwNP). Eos CRSwNP and Non-Eos CRSwNP demonstrate distinct clinical manifestations, treatment outcomes, and cellular and immunopathologic characteristics. However, currently, there is no unified and generally accepted standard to define the Eos CRSwNP. The aim of this review is to compare the advantages and disadvantages of current methods used to classify Eos CRSwNP, in order to lay foundation for further study.

Revision endoscopic sinus surgery rates by chronic rhinosinusitis subtype.

BACKGROUND: Revision surgery rates following endoscopic sinus surgery (ESS) range between 7% and 50% and are influenced by many factors. This study investigates ESS outcomes for chronic rhinosinusitis (CRS) subtypes. METHODS: Retrospective review of adult CRS patients undergoing ESS with a single surgeon (2010-2015) was conducted. Outcomes were analyzed by CRS subtypes. RESULTS: ESS was performed in 424 CRS patients (CRS with nasal polyps [CRSwNP], n = 170; CRS without polyps [CRSsNP], n = 254). Most patients (309; 72.9%) could not be specifically subtyped; 115 (27.1%) were subtyped as follows: aspirin-exacerbated respiratory disease (AERD), n = 47 (11.1%); allergic fungal sinusitis (AFS), n = 39 (9.2%); immunodeficiency, n = 21 (5.0%); granulomatosis with polyangiitis (GPA), n = 5 (1.2%); and eosinophilic granulomatosis with polyangiitis (EGPA), n = 3 (0.7%). All subgroups experienced clinically meaningful reduction in postoperative 22-item Sino-Nasal Outcome Test (SNOT-22) scores. At median follow-up of 28 months (interquartile range [IQR], 10-47 months), 19 patients (4%) underwent revision ESS (CRSwNP, n = 6; CRSsNP, n = 13). Revision ESS rates were 3.5% and 5.1% for CRSwNP and CRSsNP, respectively. Revision ESS rate for subtypes were: AERD 2%; AFS 2%; immunodeficiency 14%; GPA 40%; EGPA 0%; and "all other CRS" 4% at median follow-up duration of 36, 28, 41, 37, 44, and 26 months, respectively. CONCLUSION: All CRS subtypes demonstrated clinically meaningful improvement in postoperative SNOT-22 scores following ESS. Our overall revision ESS rate was 4% (3.5% in CRSwNP). AFS, AERD, and EGPA groups demonstrated low revision rates, while immunodeficiency and GPA patients required more revision surgery. A contemporary understanding of CRSwNP subtypes facilitated surgical and medical strategies in improving outcomes for AERD, AFS, and EGPA patients. CRSsNP subtypes with immunodeficiency and GPA merit further investigation to optimize outcomes.

Refinement of the nasalisation technique for nasal polyposis.

BACKGROUND: Radical ethmoidectomy for nasal polyposis (nasalisation) tends to offer better results than functional ethmoidectomy in terms of recurrence. We have been performing the nasalisation technique since 2004, but late complications such as mucoceles were noted in several patients. We implemented some modifications to the nasalisation technique in order to reduce the complication rate while obtaining a similar recurrence rate. METHODOLOGY AND PRINCIPAL: Retrospective study on the files of patients operated for diffuse nasal polyposis after 24months of follow-up. Group A included 45 patients (90 sides) operated with the classical nasalisation technique, and group B included 74 patients (148 sides) operated with the modified technique. RESULTS: Preoperative endoscopic grading results did not show any significant difference between groups. Recurrence rates at 24months of postoperative follow-up were of 22.2% and of 18.9% for group A and B respectively. This difference was not statistically significant. Complication rates were of 37.8% and 8.8% for Group A and Group B respectively. Complication rate was significantly lower for group B (P=0.002, standard deviation of 0.467). CONCLUSIONS: The modified nasalisation technique offers the same functional results than the classical technique, but with a significant reduction of the late complication rate.

Histopathological classification of refractory chronic rhinosinusitis with nasal polyps.

OBJECTIVE: To delineate the histopathological characteristics of nasal mucosa in refractory chronic rhinosinusitis with nasal polyps (CRSwNP) in order to demonstrate subtypes of nasal polyps and their potential relation with lower airway comorbidity. STUDY DESIGN: Clinical- and pathological-based cross-sectional study Methods: Nasal polyp specimens were prospectively collected from patients with refractory CRSwNP referred to our institution for endoscopic sinus surgery. Oral and topical steroids were stopped 1 month before surgery. The pathological analysis was conducted by 2 independent reviewers with light microscopy on Hematoxylin-Eosin-Saffron stained slides. Each observer fulfilled a standardized protocol with cell count and stromal characterization on the most representative field. Mean grading scores were established. Morphological aspects were compared with the cell distribution and the clinical conditions. RESULTS: Among 36 patients, three subtypes of nasal polyps were depicted: eosinophilic edematous (64%), fibrous (9%) and intermediate with mixed edematous and collagen stromal structure (27%). Basement membrane thickening and seromucous gland hyperplasia were observed in the fibrosis sub-type (p<0.03). Eosinophilic mucosal infiltrate was significantly increased (p=0.026) in patients with concomitant pulmonary disease (n=21). Nasal polyp distribution was not influenced by asthma, allergy, previous surgery and smoking. CONCLUSION: Our 3-subtype classification of refractory CRSwNP in Caucasian population shows a predominant edematous structure whatever the clinical conditions may have been. Eosinophilia as a major factor of adaptive immune response in nasal inflammation is a feature of concomitant pulmonary disease. Further studies concerning mucosal remodelling and outcome assessment after sinus surgery are required to evaluate the impact of our classification on a daily basis.

Differential expression of periostin in the nasal polyp may represent distinct histological features of chronic rhinosinusitis.

OBJECTIVE: Chronic rhinosinusitis (CRS) is thought to be a multifactorial disease, and it is classified into a number of subtypes according to clinicohistological features. Periostin, a 90-kDa secreted protein, was reported to exist in nasal polyps (NPs) associated with CRS. We compared the expression of periostin with the degree of eosinophilic infiltration as well as tissue remodeling. MATERIALS AND METHODS: Tissue samples were collected from 28 patients of CRS with NPs, and clinicohistological features were evaluated. The pattern of periostin expression was assessed immunohistochemically. RESULT: Two patterns of periostin expression was observed in nasal polyps: "diffuse type", in which periostin was expressed throughout the lamina propria starting just below the basement membrane, and "superficial type", in which the protein was detected only in the subepithelial layers between the basement membrane and the nasal gland. The average infiltrated eosinophil count in the diffuse type was significantly higher than that in the superficial type (diffuse type 360.5±393.0 vs. superficial type 8.46±13.81, p=0.001). Tissue remodeling was observed in 17 (85.0%) of the 20 diffuse-type nasal polyps, but only in one (12.5%) of the eight superficial-type nasal polyps (p<0.001). CONCLUSION: At least two distinct patterns of periostin expression were observed in the nasal polyps associated with CRS in accordance with the heterogeneous mechanisms underlying the pathogenesis of CRS with NPs.

[Morphogenesis of the stromal tissue of nasal polyps].

The objective of the present work was to study various stages of morphogenesis of the stromal tissue of nasal polyps. The materials for the investigation were harvested during endoscopic polypotomies in the nose. They were used to obtain the preparations that were stained by the histological and histochemical methods. The immunochemical studies were carried out using monoclonal antibodies against differentiation clusters, such as CD20, CD31, and vascular endothelial growth factor (VEGF). The study has demonstrated that the growth and evolution of the nasal polyps are accompanied by sequential alterations in the morphological structure of their stromal tissue. The results of the investigations were used to develop the original classification of the selected stages of morphogenesis of the stromal tissue of nasal polyps. The following stages were distinguished: edematous one, inflammatory cellular infiltration, fibrous cirrhotic alterations, and vasculogenesis or neoangiogenesis.

Histopathological and clinical analysis of chronic rhinosinusitis by subtype.

BACKGROUND: Chronic rhinosinusitis (CRS) encompasses diverse phenotypic expression. Clinical and histological differences suggest 4 CRS subtypes: eosinophilic CRS with and without nasal polyps (eCRSwNP, eCRSsNP, respectively) and non-eosinophilic CRS with and without nasal polyps (neCRSwNP, neCRSsNP, respectively). The mucosal basement membrane (BM) and cilia are believed to play roles in CRS pathogenesis by impacting mucociliary clearance and immune barriers. This study aimed to identify clinical, surgical, and histopathological subtype differences to further elucidate disease mechanisms. METHODS: Ethmoid tissue from 33 adult CRS patients and 7 controls was obtained during endoscopic sinus or other sinonasal surgery (controls) and analyzed by light and transmission electron microscopy for BM thickness and presence of cilia. CRS patients were categorized into the 4 subtypes, and 22-item Sinonasal Outcome Test (SNOT-22) score, endoscopy, computed tomography (CT), and surgical data were compared and analyzed for association with histopathology measures. RESULTS: CRS subtypes could be distinguished by CT score and surgical data, with eCRSwNP patients exhibiting greatest disease severity. Whereas eosinophilia was associated with absence of cilia, nasal polyposis showed no association with surgical or histopathological measures. No significant difference in BM thickness was found between controls and CRS subtypes, but distinctions were found regarding cilia, which were less common in eosinophilic subgroups compared to controls and neCRSsNP patients. CONCLUSION: CRS subtypes exhibit some differentiating histopathological and surgical features. The absence of cilia appears to have an important role in the eosinophilic subgroups. Further histologic evaluation is warranted to evaluate for possible subtype-specific treatment targets or prognostic markers.

Efficacy of systemic steroid treatment in sinonasal polyposis.

AIM: Nasal polyposis is an inflammatory disease of unknown origin. Systemic steroid treatment is effective not only in decreasing polyp size but also in controlling mucosal inflammation. We evaluated the efficacy of mean-term systemic corticosteroid treatment in nasal polyposis clinically and radiologically. METHODS: Seventy-five patients with nasal polyposis were included in this study. Patients were treated with methylprednisolone for 20 days. Clinical response was evaluated by nasal symptom scores and changes in polyp size; disease extent was assessed by paranasal sinus tomography. Nasal symptom score, polyp size, and disease extent were reevaluated after therapy. RESULTS: Twenty-one (28%) of 75 patients were female, and 54 (72%) were male. The mean age was 41.63 ± 11.04 with a range of 17 to 80 years. As shown radiologically, 26.7% (n = 20) of patients completely healed, and 41.3% (n = 31) partially healed, whereas there was no improvement in 32% (n = 24). There was a statistically significant improvement in radiological assessment (P < 0.01). The sense of smell showed the greatest improvement (56.98%). The least-improved symptoms were facial pain and headache (37.74%). There was a statistically significant decrease in polyp grade (P < 0.01). CONCLUSIONS: Systemic steroid treatment caused a decrease in all nasal symptoms and polyp size and improved paranasal computed tomography results. In addition, it shortened the duration of surgery and improved the quality of the procedure. Systemic steroid treatment also contributed to the prevention of recurrence.

Subclassification of chronic rhinosinusitis.

OBJECTIVES/HYPOTHESIS: There are variants of chronic rhinosinusitis (CRS). Therefore, the objectives of this study were to phenotype the subclasses of CRS as well as characterize their polyps with histology and cellular-intracellular biomarkers. STUDY DESIGN: Prospective case-control study. METHODS: Demographic data, quality-of-life (QoL) questionnaires, nasal endoscopy (NE), and computed tomography (CT) scores were obtained. CRS was divided into seven subclasses: aspirin-exacerbated respiratory disease (AERD), asthmatic sinusitis with and without allergy, nonasthmatic sinusitis with and without allergy, allergic fungal sinusitis (AFS), and cystic fibrosis (CF). Histopathologic and immunohistochemistry of nasal polyps were recorded. CD3, CD4, CD8, CD19, CD45, and CD56 data were collected. Interleukin (IL)4, IL5, IL13, IL17, and interferon (IFN)-γ were measured. RESULTS: Eight-four subjects were in this study. Two QoL questionnaires were inadequate at distinguishing the control group from CRS. NE and CT were able to differentiate between the control group and all CRS subclasses (P<.01). Asthmatic sinusitis, AERD, and AFS had high NE and CT scores, nasal polyps, eosinophils, mast cell, and hypercellularity. Asthmatic sinusitis, nonasthmatic sinusitis, and AERD had higher CD4 cells than control group (P<.05). Even though asthmatic sinusitis and AFS are mediated by Th2, AFS had differing levels of Th2 cytokines. Each nonasthmatic sinusitis had purulence and low CT score. Each nonasthmatic sinusitis had higher CD4 cells and IFN-γ than control (P<.05). CF is associated with purulence, high CT score, high polymorphonuclear leukocytes, high plasma cells, and high mast cells. CONCLUSIONS: Well-characterized and distinct groups of CRS have been defined for targeted treatment and research studies.

A novel sinonasal endoscopy scoring system: the discharge, inflammation, and polyps/edema (DIP) score.

BACKGROUND: There is an increasing need for a validated grading system to assess sinusitis severity as observed on endoscopic examination. Existing endoscopy scales have limitations in complexity, validation, and/or applicability. We present a novel and straightforward endoscopic scoring system measuring discharge, inflammation, and polyps/edema (DIP). The aim of this study is to determine correlation of the DIP score with existing sinus endoscopy scoring systems, and to determine interrater and test-retest reliability. METHODS: This retrospective cohort includes a total of 29 patients who underwent functional endoscopic sinus surgery (FESS) for chronic rhinosinusitis. Sinus endoscopy videos were scored in a random and blinded fashion by 3 rhinologists (S.D.P., A.N.G., A.H.M.) using the Lund-Kennedy Endoscopic Score (LKES), the Perioperative Sinus Endoscopy (POSE) score, and the DIP score. Pearson correlation coefficients, interrater reliability and test-retest reliability were determined. RESULTS: The results of this study show that the DIP score correlates well (p < 0.0001) with the existing LKES and POSE (Pearson correlation coefficients of 0.78 and 0.90, respectively). The interrater reliability intraclass correlation coefficient (ICC) is highest for the DIP score (0.87), followed by the POSE score (0.84) and the LKES (0.78). Test-retest reliability ICC is highest for the DIP score (0.78), followed by the POSE score (0.59) and the LKES (0.53). CONCLUSION: The DIP score is a novel and straightforward endoscopic sinus scoring system that shows substantial test-retest and interrater reliability in the post-FESS population. It also demonstrates a high correlation with existing scoring parameters (LKES and POSE).

Identification of chronic rhinosinusitis phenotypes using cluster analysis.

BACKGROUND: The pathophysiology of chronic rhinosinusitis (CRS) is not fully understood. In Europe and the United States, major subsets of CRS classification are based on the presence or absence of polyps. Although nasal polyps (NPs) are a critical factor, many other factors also contribute to the pathogenesis of CRS. The aim of this study was to investigate diverse CRS phenotypes using cluster analysis. METHODS: This was a multicenter study examining clinical data from CRS patients treated at five hospitals. The study design was a retrospective analysis of prospectively collected data. Complete data were available for 425/496 patients. Data were subjected to k-means cluster analysis in an attempt to identify the different phenotypes involved in CRS. RESULTS: CRS was divided into four clusters. Cluster 1 (n = 180) and cluster 2 (n = 129) comprised patients with low peripheral eosinophil and mucosal eosinophil counts. However, polyp scores in cluster 2 were higher than cluster 1. Cluster 3 (n = 50) comprised patients with very high mucosal eosinophil counts but low polyp and symptom scores. Finally, subjects in cluster 4 (n = 66) showed severe polyposis. Polyp score and mucosal eosinophil count were the strongest predictors of clustering by discriminant analysis. CONCLUSION: The results of this study identified distinct clinical CRS phenotypes. CRS was classified into four phenotypes based on NPs and mucosal eosinophil counts. Cutoff points for these factors were identified by tree analysis. Additional studies are needed to establish clinical significance of the phenotypes.

Chronic rhinosinusitis: epidemiology and medical management.

Chronic rhinosinusitis (CRS) affects 12.5% of the US population. On epidemiologic grounds, some association has been found between CRS prevalence and air pollution, active cigarette smoking, secondhand smoke exposure, perennial allergic rhinitis, and gastroesophageal reflux. The majority of pediatric and adult patients with CRS are immune competent. Data on genetic associations with CRS are still sparse. Current consensus definitions subclassify CRS into CRS without nasal polyposis (CRSsNP), CRS with nasal polyposis (CRSwNP), and allergic fungal rhinosinusitis (AFRS). Evaluation and medical management of CRS has been the subject of several recent consensus reports. The highest level of evidence for treatment for CRSsNP exists for saline lavage, intranasal steroids, and long-term macrolide antibiotics. The highest level of evidence for treatment of CRSwNP exists for intranasal steroids, systemic glucocorticoids, and topical steroid irrigations. Aspirin desensitization is beneficial for patients with aspirin-intolerant CRSwNP. Sinus surgery followed by use of systemic steroids is recommended for AFRS. Other modalities of treatment, such as antibiotics for patients with purulent infection and antifungal drugs for patients with AFRS, are potentially useful despite a lack of evidence from controlled treatment trials. The various modalities of medical treatment are reviewed in the context of recent consensus documents and the author's personal experience.

Cystic fibrosis and endoscopic sinus surgery: Relationship between nasal polyposis and likelihood of revision endoscopic sinus surgery in patients with cystic fibrosis.

OBJECTIVES: To observe the extent of nasal polyposis endoscopically in a cystic fibrosis population before the first surgical intervention and to grade the extent using a modified Malm scale, to observe patients prospectively and record the need for revision endoscopic sinus surgery (ESS), and to compare this among the individual polyp grading groupings. DESIGN: Retrospective medical record review of data collected prospectively. SETTING: Tertiary care hospital. PATIENTS: Forty-nine consecutive patients with a clinical preoperative diagnosis of cystic fibrosis and sinusitis. MAIN OUTCOME MEASURES: Using a modified Malm scale, the extent of polyps was prospectively graded into 3 groups before the first surgical intervention. The number of patients needing revision ESS and the mean time to revision ESS were compared among the 3 groups. RESULTS: Forty-nine consecutive patients underwent ESS between 1992 and 2007. We used a 3-stage system for extent of polyposis: 16 patients were noted to have no polyps (grade A), 14 had mild polyposis (grade B), and 19 had extensive polyposis (grade C). During the study, 14 patients required revision surgery: 3 with mild polyps and 11 with extensive polyps. Mean time to revision surgery was 39.7 months for those with grade B and 23.8 months for those with grade C. In the overall statistical analysis, the rate of revision ESS was significantly different among the 3 groups (P < .001). In pairwise comparisons, there were significant differences between those with grades A and C (P < .001) and between those with grades B and C (P = .04) and a trend toward significance between those with grades A and B (P = .052). There were no complications from ESS. CONCLUSION: Preoperative grading of nasal polyposis in patients with cystic fibrosis can help assess the future likelihood of revision ESS.