Nobuyoshi Otori

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.

International Consensus Statement on Allergy and Rhinology: Rhinosinusitis

Isam Alobid, MD, PhD1, Nithin D. Adappa, MD2, Henry P. Barham, MD3, Thiago Bezerra, MD4, Nadieska Caballero, MD5, Eugene G. Chang, MD6, Gaurav Chawdhary, MD7, Philip Chen, MD8, John P. Dahl, MD, PhD9, Anthony Del Signore, MD10, Carrie Flanagan, MD11, Daniel N. Frank, PhD12, Kai Fruth, MD, PhD13, Anne Getz, MD14, Samuel Greig, MD15, Elisa A. Illing, MD16, David W. Jang, MD17, Yong Gi Jung, MD18, Sammy Khalili, MD, MSc19, Cristobal Langdon, MD20, Kent Lam, MD21, Stella Lee, MD22, Seth Lieberman, MD23, Patricia Loftus, MD24, Luis Macias‐Valle, MD25, R. Peter Manes, MD26, Jill Mazza, MD27, Leandra Mfuna, MD28, David Morrissey, MD29, Sue Jean Mun, MD30, Jonathan B. Overdevest, MD, PhD31, Jayant M. Pinto, MD32, Jain Ravi, MD33, Douglas Reh, MD34, Peta L. Sacks, MD35, Michael H. Saste, MD36, John Schneider, MD, MA37, Ahmad R. Sedaghat, MD, PhD38, Zachary M. Soler, MD39, Neville Teo, MD40, Kota Wada, MD41, Kevin Welch, MD42, Troy D. Woodard, MD43, Alan Workman44, Yi Chen Zhao, MD45, David Zopf, MD46

Saccharin test of maxillary sinus mucociliary function after endoscopic sinus surgery.

Objectives: To determine the usefulness of the saccharin time (ST) test for evaluating the mucociliary function of the maxillary sinus after endoscopic sinus surgery (ESS) for chronic sinusitis.

Correlation between the Prostaglandin D2 E2 Ratio in Nasal Polyps and the Recalcitrant Pathophysiology of Chronic Rhinosinusitis Associated with Bronchial Asthma

BACKGROUND The prevalence of patients with chronic rhinosinusitis (CRS) refractory to traditional therapy appears to be on the increase. In these cases, CRS tends to be associated with bronchial asthma (BA), especially, aspirin-intolerant asthma (AIA). On the other hand, arachidonic acid metabolites have been extensively investigated in the pathogenesis of BA. We sought to assess the role of prostaglandin D2 (PGD2) and prostaglandin E2 (PGE2) in the recalcitrant pathophysiology of CRS. METHODS Samples were prepared from the nasal polyps and mucosa of 40 patients undergoing endoscopic sinus surgery (ESS) at our hospital. The nasal polyp specimens obtained from the patients with CRS were divided into three groups, as follows: the CRS-AIA group, consisting of specimens obtained from patients with CRS complicated by AIA, the CRS-ATA group, consisting of specimens obtained from patients with CRS associated with aspirin-tolerant asthma (ATA), and the CRS-NA group, consisting of specimens obtained from CRS patients without BA. PGD2 and PGE2 were extracted from the specimens and quantified. RESULTS The concentrations of PGD2 were significantly higher in the nasal polyps of the CRS-ATA group. The concentrations of PGE2 were lowest in the nasal polyps of the CRS-AIA group. The PGD2/PGE2 ratio was highest in the CRS-AIA group. CONCLUSIONS It has previously been reported that CRS complicated by AIA is most likely to be characterized by repeated remissions and relapses, and is thus the most intractable. We may therefore say that the PGD2/PGE2 ratio reflects the intractable nature of CRS.

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.

Histopathological features of nasal polyps with asthma association: an immunohistochemical study.

Background Myofibroblasts are related to airway remodeling and may play an important role in the pathogenesis of the histological features of nasal polyps associated with asthma. The aim of this study was to analyze and compare the eosinophilic cationic protein, transforming growth factor (TGF) β, and myofibroblasts in the nasal polyps of patients with chronic sinusitis associated with and without asthma. Methods Nasal polyp samples were obtained during endoscopic sinus surgery and were classified into asthma and nonasthma groups. Immunohistochemistry was performed using antibodies against activated eosinophils, TGF-β, and myofibroblasts. Results The asthma group showed an increased number of activated eosinophils, TGF-β, and myofibroblasts compared with the nonasthma and control groups. We found no correlation of asthma and aspirin intolerance with the immunohistochemical findings. Conclusion The increased number of myofibroblasts in the nasal polyps of the asthma group may be responsible for the extracellular matrix accumulation, polyp formation, and polyp recurrence.

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.