Daiya Asaka

Chronic Rhinosinusitis: Risk Factors for the Recurrence of Chronic Rhinosinusitis Based on 5-Year Follow-Up after Endoscopic Sinus Surgery

Background: Chronic rhinosinusitis (CRS) is one of the most frequent chronic diseases in the US, and little is understood about its pathogenesis. This study was conducted to characterize, retrospectively, the clinical, objective and immunological parameters that accompany recurrence of CRS during long-term follow-up after surgery. Methods: Fifty-six patients with CRS who had undergone endoscopic sinus surgery were followed up for 5 years after the surgery. The CRS parameters chosen were as follows: history of asthma and/or allergic rhinitis, peripheral eosinophilia of at least 520 cells/µl, peripheral eosinophil count, total IgE, presence of polyps, CT score, presence of fungi (positive fungal culture or stain), mucus or mucosal eosinophilia, mucosal eosinophil count, presence of acute infection after surgery, gender and age. Individual correlations and stepwise regression were performed. Results: Patients with a total peripheral eosinophil count of 520/µl or more and those with asthma were likely to experience recurrence of CRS within 5 years after surgery. Furthermore, patients with mucus or mucosal eosinophilia who were diagnosed as having eosinophilic CRS (ECRS) showed a high incidence of recurrence within 5 years. The parameter of mucus or mucosal eosinophilia (diagnosis of ECRS) had a positive predictive value of 85.7%. Conclusions: Surgeons should always examine the inflammatory infiltrate of nasal polyps or the paranasal mucosa, and patients with ECRS require anti-inflammatory medications, such as steroids, for a long time after surgery. Long-term follow-up is also essential.

Novel scoring system and algorithm for classifying chronic rhinosinusitis: the JESREC Study.

Chronic rhinosinusitis (CRS) can be classified into CRS with nasal polyps (CRSwNP) and CRS without nasal polyps (CRSsNP). CRSwNP displays more intense eosinophilic infiltration and the presence of Th2 cytokines. Mucosal eosinophilia is associated with more severe symptoms and often requires multiple surgeries because of recurrence; however, even in eosinophilic CRS (ECRS), clinical course is variable. In this study, we wanted to set objective clinical criteria for the diagnosis of refractory CRS.

Mucosal eosinophilia and recurrence of nasal polyps - new classification of chronic rhinosinusitis.

BACKGROUND Eosinophils and nasal polyps are believed to affect the surgical outcome of chronic rhinosinusitis (CRS). CRS is classified based on the presence of nasal polyps in western countries. The majority of patients with CRS with nasal polyps (CRS with NP) are characterized by predominantly eosinophilic inflammation. However, Asian patients with CRS with NP show characteristics indicative of neutrophilic inflammation. Therefore, are eosinophils or nasal polyps more important for the classification of CRS? METHODS A prospective cohort study conducted from April 2007 to March 2008 classified patients with CRS based on the presence of nasal polyps and mucosal eosinophilia. The recurrence rate of nasal polyps was compared between the groups. Recurrence rate was analysed as a time-dependent variable by the Kaplan-Meier method. RESULTS Eosinophilic inflammation was found in 59.6% of patients with CRS with NP. Patients with mucosal eosinophilia had higher polyp recurrence rate than patients without mucosal eosinophilia, whereas patients with nasal polyps did not have higher polyp recurrence rate than patients without nasal polyps. CONCLUSIONS Presence of mucosal eosinophilia is a more important factor than nasal polyps for classifying CRS in terms of the surgical outcome.

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.

Elevated Levels of Interleukin-33 in the Nasal Secretions of Patients with Allergic Rhinitis

Background: Interleukin (IL)-33, which is a member of the IL-1 family of cytokines, is now recognized as an important contributor to Th2-type immune responses. We examined whether the levels of IL-33 in sera and nasal secretions are upregulated in allergic rhinitis (AR) patients, and we tested for correlations between the IL-33 level and the parameters of atopy and the nasal symptom score. Methods: The study included 24 Japanese cedar pollinosis patients (12 male and 12 female patients with a mean age of 47.7 years) with a history of moderate-to-severe AR, 14 house-dust-mite-sensitized patients with AR (9 male and 5 female patients with a mean age of 42 years) and 8 normal controls. We used Japan Rhinoconjunctivitis Quality-of-Life Questionnaire sheets to evaluate the nasal symptoms. We collected sera and nasal secretions to examine the level of IL-33 protein by ELISA. Results: IL-33 protein was not detected in the serum of any of the subjects. However, the IL-33 level in nasal secretions was significantly elevated in patients with Japanese cedar pollinosis at peak season and in patients with perennial AR compared to Japanese cedar pollinosis patients at preseason and the normal controls. Furthermore, IL-33 in nasal secretions correlated significantly with the total nasal symptom score. Conclusions: Our results suggest that IL-33 in nasal secretions may be related to exacerbation of AR, including that of Japanese cedar pollinosis cases.

Endoscopic medial maxillectomy with preservation of inferior turbinate and nasolacrimal duct.

Background Endoscopic medial maxillectomy (EMM) is a safe and effective procedure for treatment of inverted papilloma (IP) originating from the maxillary sinus. However, EMM usually removes the inferior turbinate and nasolacrimal duct. The inferior turbinate has a critical function in conditioning of the nasal airflow, and resection of the nasolacrimal ducts has a risk of epiphora. We developed a newly derived surgical technique, endoscopic modified medial maxillectomy (EMMM), which enables preservation of the inferior turbinate and nasolacrimal duct. Methods A retrospective case series of six patients with IP and nine patients with mucoceles of the maxillary sinus after a Caldwell-Luc operation, who underwent surgery using the EMMM technique, were reviewed. Results In patients with IP, there were no recurrences for a mean follow-up of 16.7 months. Eight of nine patients with mucoceles of the maxillary sinus showed patency. All patients showed preservation of the inferior turbinate. One patient with mucocele was referred for dacryocystorhinostomy because of epiphora. Conclusion EMMM produces access to the maxillary sinus identically to conventional EMM, despite preservation of the inferior turbinate and nasolacrimal duct.

Risk factors for complications of endoscopic sinus surgery for chronic rhinosinusitis.

Background Patients undergoing endoscopic sinus surgery (ESS) are at risk of complications because of the close proximity of the sinuses to the orbit and anterior skull base. The aim of this study was to evaluate the complications of ESS and to identify patient characteristics that were risk factors for the complications. Methods We conducted a prospective study of 706 patients who underwent ESS for chronic rhinosinusitis. Patients completed preoperative examinations that included computed tomography, endoscopic observation for nasal polyps, and tests for comorbidities including asthma and vascular disease. Perioperative complications were evaluated based on information provided by the surgeons. Multivariate analysis was performed to identify patient characteristics that were risk factors for complications. Results Overall, perioperative complications occurred in 41 patients (5.8%). A major complication, cerebrospinal fluid leakage, occurred in one patient (0.1%). Minor complications occurred in 40 patients (5.7%), with the most common being intraoperative hemorrhage (n = 18). Multivariate analysis indicated that presence of asthma and the total polyp score correlated significantly with the occurrence of complications. Conclusion The risk factors for perioperative complications were asthma and the polyp score. We conclude that the surgeon should confirm whether the patient has lower airway disease, especially asthma, before operating. The surgeon should also determine the grade of nasal polyps.

Evaluation of symptoms and QOL with calcium alginate versus chitin-coated gauze for middle meatus packing after endoscopic sinus surgery

OBJECTIVE Nasal packing is used to control postoperative bleeding and wound healing, and it also exerts a very strong influence on the comfort of the patient. Sorbsan(®) (calcium alginate) is an absorbent packing that shows a potent hemostatic effect and is able to maintain wound surfaces in a moist environment by absorbing and gelling the wound exudate. The aim of this study was to evaluate the early symptoms and QOL with Sorbsan(®) versus Beschitin-F(®) (chitin-coated gauze) for middle meatus packing after endoscopic sinus surgery (ESS). METHODS We performed a cohort study of 40 patients who underwent ESS. Following ESS, the patients were randomly allocated into two groups of 20 patients each who underwent insertion of either Sorbsan(®) or Beschitin-F(®) into the middle meatus. A daily diary was used to record the symptoms and QOL, measured using visual analogue scales, before the ESS and on each day thereafter. Postoperative bleeding and local infection were also recorded. RESULTS The scores for each of the symptoms of nasal pain, headache, nasal bleeding and postnasal drip were statistically significantly lower in the Sorbsan(®) group. The scores for each of the QOL parameters, including the effect on their stay in the hospital and sleep disturbance, were also significantly lower in the Sorbsan(®) group. There were no findings of postoperative hemorrhage or local infection in either group. CONCLUSION Sorbsan(®) packing did not cause any major complications and has the potential to reduce nasal pain and suffering in post ESS patients compared with gauze packing.

Nasal splinting using silicone plates without gauze packing following septoplasty combined with inferior turbinate surgery

OBJECTIVE Nasal packing after septoplasty is uncomfortable and painful for patients. The aim of this study was to determine the efficacy of nasal splinting using silicone plates to prevent complications and decrease the pain after septoplasty compared with the conventional gauze packing. MATERIALS AND METHODS Thirty-five adult patients who had undergone septoplasty were included in this study. The patients were allocated into two groups: Group S, silicone plates were used (13 males, 2 females); and Group G, gauze packing smeared with an antibiotic ointment was used (19 males, 1 female). We evaluated and compared the postoperative pain, pain due to postoperative cleaning, nasal bleeding, postnasal drip, body temperature, effect on stay in the hospital, effect on food intake and sleep disturbance using visual analogue scale (VAS) scores. RESULTS The postoperative pain score in Group S was significantly lower than in Group G on days 1 and 2 after the septoplasty. And the pain due to postoperative cleaning score was significantly lower than in Group G on days 2 and 3 after operation. No statistically significant differences were found between the two groups in regard to nasal bleeding, postnasal drip, body temperature, effect on stay in the hospital, effect on food intake or sleep disturbance. Objective evaluation performed at 4 weeks postoperatively revealed that nasal crusting occurred at a significantly higher incidence in Group G compared with Group S. CONCLUSION The use of silicone plates in lieu of conventional gauze packing decreased post-septoplasty nasal pain and pain due to postoperative cleaning of the nasal cavity. We conclude that nasal splinting using silicone plates after septoplasty is an effective method for managing pain and preventing complications.

Sinus Fungus Ball in the Japanese Population: Clinical and Imaging Characteristics of 104 Cases

Sinus fungus ball is defined as noninvasive chronic fungal rhinosinusitis occurring in immunocompetent patients with regional characteristics. The clinical and imaging characteristics of paranasal sinus fungus ball were retrospectively investigated in 104 Japanese patients. All patients underwent endoscopic sinus surgery. Preoperative computed tomography (CT), magnetic resonance (MR) imaging, age, sex, chief complaint, causative fungus, and clinical outcome were analyzed. Patients were aged from 25 to 79 years (mean 58.8 years). Female predominance was noted (58.7%). Most common symptoms were nasal discharge and facial pain. CT showed high density area in 82.0% of the cases (82/100), whereas T2-weighted MR imaging showed low intensity area in 100% of the cases (32/32). Histological examination showed that most causative agents were Aspergillus species (94.2% (98/104)). Culture test was positive for 16.7% (11/66). Recurrence was found in 3.2% (3/94). Older age and female predominance were consistent with previous reports. MR imaging is recommended to confirm the diagnosis.