Endotypes of Chronic Rhinosinusitis with Nasal Polyps: Pathology and Possible Therapeutic Implications.

Today, chronic rhinosinusitis (CRS) is a symptomatic disease diagnosed by nasal endoscopy and eventually computed tomography scan, and is treated by pharmacotherapy or, when unsuccessful, by sinus surgery. With the advent of biologics, the diagnostic approach needs to be adjusted to appreciate CRS endotypes, introducing biomarkers, and the therapeutic options will be extended by the application of biologics. Specifically, type 2 immune reactions moved into the focus, similar to asthma, involving innate and adaptive immunity pathways to establish an often severe, persistent disease. The role for endotyping of CRS became evident for biologics, but also turned out to be meaningful for the decision on the selection of pharmacotherapy and the specific surgical approach to choose. Furthermore, considerations on the role of surgery and biologics needed to be elaborated to develop decision-making processes for patients with moderate-to-severe CRS with nasal polyps, with or without comorbid asthma, allowing us to adjust the treatment for patient groups based on endotyping (precision medicine). We here aim to guide the decisions in a rational way based on the current knowledge of the efficacy and complications or side effects of the recently enlarged therapeutic options. Personal experience has been added where knowledge was lacking in this fast moving field.

Clinical presentation of allergic fungal sinusitis in children.

OBJECTIVE: To compare the differences in the clinical and radiographic presentation of allergic fungal sinusitis in children and adults. STUDY DESIGN: Retrospective chart and computed tomography review. METHODS: The settings included a tertiary care children's hospital, adult academic private hospital, and academic affiliated county hospital. All patients with documented allergic fungal sinusitis who underwent computed tomography evaluation and had surgical treatment of their disease from 1988 to 1999 were included in the study. In total, 151 patients aged 5 to 75 years; 44 of these patients were less than or equal to 17 years of age (children) and 107 were greater than 17 years of age (adults). Main outcome measures included 1) the presence of obvious bony facial abnormalities on presentation, 2) bilateral or unilateral sinus disease on presentation, 3) the presence of asymmetrical disease on presentation, 4) the presence of bony extension on computed tomography scan, and 5) type of fungus present. RESULTS: Fifteen of 36 (42%) pediatric patients and 10 of 103 (10%) adult patients had obvious alteration of their facial skeleton (proptosis, telecanthus, or malar flattening) on presentation (P <.05). Proptosis was the most common facial abnormality in both groups and was seen more often in children (8 of 36 [22%]) than in adults (9 of 103 [9%]) (P <.05). Twenty-eight of 40 (70%) pediatric patients and 37 of 100 (37%) adult patients presented with unilateral sinus disease (P <.05). Thirty-five of 40 (88%) pediatric patients and 58 of 100 (58%) adults presented with asymmetrical disease (P <.05). Computed tomography scans showed that 10 of 40 (25%) pediatric patients and 23 of 100 (23%) adult patients had bony erosion with extension of disease into surrounding structures (P >.05). Cultures from both adults and children showed mainly Bipolaris and Curvilaria species in equal amounts (P >.05). Adults had a greater incidence of Aspergillus species. CONCLUSIONS: Presentation in pediatric patients with allergic fungal sinusitis is different from that in adults, with children having obvious abnormalities of their facial skeleton, unilateral sinus disease, and asymmetrical disease more often. Findings on computed tomography scan show an equal amount of bony erosion with extension of disease. The types of fungus cultured in the sinus cavities are similar in both groups.