Renata Ribeiro de Mendonça Pilan

ICON: chronic rhinosinusitis

Chronic rhinosinusitis (CRS) is a public health problem that has a significant socio-economic impact. Moreover, the complexity of this disease due to its heterogeneous nature based on the underlying pathophysiology - leading to different disease variants - further complicates our understanding and directions for the most appropriate targeted treatment strategies. Several International/national guidelines/position papers and/or consensus documents are available that present the current knowledge and treatment strategies for CRS. Yet there are many challenges to the management of CRS especially in the case of the more severe and refractory forms of disease. Therefore, the International Collaboration in Asthma, Allergy and Immunology (iCAALL), a collaboration between EAACI, AAAAI, ACAAI, and WAO, has decided to propose an International Consensus (ICON) on Chronic Rhinosinusitis. The purpose of this ICON on CRS is to highlight the key common messages from the existing guidelines, the differences in recommendations as well as the gaps in our current knowledge of CRS, thus providing a concise reference. In this document we discuss the definition of the disease, its relevance, pharmacoeconomics, pathophysiology, phenotypes and endotypes, genetics and risk factors, natural history and co-morbidities as well as clinical manifestations and treatment options in both adults and children comprising pharmacotherapy, surgical interventions and more recent biological approaches. Finally, we have also highlighted the unmet needs that wait to be addressed through future research.

Prevalence of chronic rhinosinusitis in Sao Paulo

BACKGROUND Glucocorticoids (GCs) are considered drugs of choice for treating nasal polyps (NPs). However, a subset of patients shows a limited clinical response even to high doses of GCs. Altered expression of glucocorticoid receptors (GRs), namely GR-alpha; and GR-beta;, is a potential mechanism underlying GC insensitivity. GCs modulate the expression of several cytokines, including transforming growth factor-beta (TGF-beta), which may contribute to cellular proliferation in NPs. The study investigates some biomolecular features of GC-resistant NPs, and examines possible differences from normal mucosa (NM). METHODOLOGY Radioligand binding assay (binding) was used to determine GR-alpha; binding capacity; Western blotting was used to evaluate GR-alpha;, GR-beta;, and TGF-beta; expression and GR-alpha; subcellular distribution. NPs were sampled in 32 patients during ethmoidectomy; NM was taken from 15 healthy patients during rhinoplasty. RESULTS GR-alpha; was present in NPs and NM, with lower affinity for the ligand in NPs. GR-alpha; was prevalent in the cytosol of NPs that were GR-alpha-negative to the binding assay. GR-beta was expressed in NPs and absent in the majority of NM. TGF-beta1 expression was higher in NPs than in NM. CONCLUSIONS GR-beta and TGF-beta1 might be involved in NP pathogenesis, but their role in modulating GC sensitivity is still unclear.INTRODUCTION Studies designed to investigate chronic rhinosinusitis (CRS) epidemiology play an important role to assess population`s distribution and risk factors to result in the development and promotion of public health policies. METHOD This study design is a survey carried out with a complex two-stage cluster sampling plan. Personal interviews were carried out with 2,003 individuals. The questionnaire included the epidemiological criteria for CRS. Demographic data, history of physician-diagnosed respiratory diseases (asthma, sinusitis, rhinitis), smoking, family income, educational attainment, and household characteristics were also evaluated. RESULTS The overall response rate was 93.9% of the households. Mean age was 39.8 +- 21 years; 45.33% were male. The overall prevalence of CRS in the city of Sao Paulo was 5.51%. We found a significant association between diagnosis of CRS and diagnosis of asthma and CRS and diagnosis of rhinitis and a significant association between presence of CRS and belonging to the low-income subgroup. CONCLUSION The municipality of Sao Paulo has an urban population of 11 million. According to the present study, the prevalence of CRS is 5.51%, which represents more than 500,000 individuals affected by this condition in the city.

Cross-cultural adaptation and validation of a quality of life questionnaire: the Nasal Obstruction Symptom Evaluation questionnaire.

BACKGROUND The Nasal Obstruction Symptom Evaluation (NOSE) instrument is a disease-specific questionnaire for assessing the outcome of an intervention in nasal obstruction in trials. This instrument is only available in the English language and cross-culturally valid questionnaires are very important for all research, including nasal obstruction. The aim of the current study was to reproduce the cross-cultural adaptation process for the NOSE questionnaire in the Portuguese language (NOSE-p). METHODOLOGY/PRINCIPAL Cross-cultural adaptation and validation of the instrument were divided into two stages. Stage 1 involved four bilingual professionals, an expert committee and the author of the original instrument. In Stage 2, the NOSE-p was tested on 33 patients undergoing septoplasty for internal consistency, test-retest reliability, construct validity, discriminant validity, criterion validity, and response sensitivity. RESULTS The cross-cultural adaptation process was completed and the NOSE-p was demonstrated to be a valid instrument with satisfactory construct validity. It showed an adequate internal consistency reliability and adequate test-retest reliability. It could discriminate between patients with and without nasal obstruction and it has a high response sensitivity to change. CONCLUSIONS The cross-cultural adaptation and validation process demonstrated to be valid and the NOSE-p proved to be applicable in Brazil.

Avaliação da qualidade de vida após septoplastia em pacientes com obstrução nasal

UNLABELLED Nasal obstruction is a common complaint in the population. When caused by a deviated nasal septum, septoplasty is the procedure of choice for treating these patients. NOSE is a tool for assessing the disease-specific quality of life related to nasal obstruction. AIM To assess the impact of septoplasty on patients with nasal obstruction secondary to deviated nasal septum based on the disease-specific quality-of-life questionnaire. DESIGN Prospective. METHODS Patients undergoing septoplasty with/without turbinectomy after no clinical improvement with medical treatment were assessed by the NOSE questionnaire before and 3 months after surgery. We evaluated the surgical improvement based on total score, the magnitude of the surgery in the disease-specific quality of life and the correlation between the preoperative score and postoperatively improvement. RESULTS Fourty-six patients were included in the study. There was a statistically significant improvement in the preoperative NOSE score (md = 75, IQR = 26) and after three months (md = 10, IQR = 20) (p < 0.001.T-Wilcoxon). The standardized response mean was 3.07. We found a strong correlation between the preoperative score in the NOSE questionnaire and improvements in the postoperative period (r = -0.789, p < 0.001, Spearman). No difference was found in improvement scores by gender. (p = 0.668, U-Mann-Whitney). CONCLUSION Septoplasty resulted in a statistically significant improvement in the disease-specific QOL questionnaire.

Cross-Cultural Adaptation and Validation of SNOT-20 in Portuguese

Introduction. Chronic rhinosinusitis is a highly prevalent disease, so it is necessary to create valid instruments to assess the quality of life of these patients. The SNOT-20 questionnaire was developed for this purpose as a specific test to evaluate the quality of life related to chronic rhinosinusitis. It was validated in the English language, and it has been used in most studies on this subject. Currently, there is no validated instrument for assessing this disease in Portuguese. Objective. Cross-cultural adaptation and validation of SNOT-20 in Portuguese. Patients and Methods. The SNOT-20 questionnaire underwent a meticulous process of cross-cultural adaptation and was evaluated by assessing its sensitivity, reliability, and validity. Results. The process resulted in an intelligible version of the questionnaire, the SNOT-20p. Internal consistency (Cronbachs alpha = 0.91, P < .001), reliability testing-retesting (r = 0.994, P < .001), content validity, validity of discrimination of patients without chronic rhinosinusitis (U = 44, P < .0001) and assessment of sensitivity to change (SRM = 1.53 and 1.09) were evaluated. Conclusion. We conducted a successful process of cross-cultural adaptation and validation of the SNOT-20 questionnaire into Portuguese.

Antibiotic use in post- adenotonsillectomy morbidity: a randomized prospective study

UNLABELLED Tonsillectomy with or without adenoidectomy still is one of the most commonly performed surgical procedures in the world, mostly in the pediatric population. AIM to study the impact of amoxicillin for 7 days in post-adenotonsillectomy recovery, comparing results with a control group. STUDY TYPE prospective, randomized, controlled study with 120 patients. PATIENTS AND METHODS the patients were randomized according to surgery time to receive 7 days of amoxicillin associated with pain killers, or analgesic alone. During the first week of postoperative, we assessed the level of pain, oral intake acceptance, nausea and vomits, fever and return to daily activities. RESULTS It was only in the fourth post-operative day that the group receiving antibiotic agents showed a statistically significant difference as far as pain is concerned. There was no difference between the two groups for other data analyzed. CONCLUSION considering the results from our study and reviewing the literature on the use of antibiotic agents, we agree that there is no improvement in patient recovery after adenotonsillectomy with the use of amoxicillin for 7 days in the postoperative.

Assessment of quality of life after endoscopic sinus surgery for chronic rhinosinusitis

UNLABELLED Chronic rhinosinusitis is a disease of undefined etiology that significantly impacts the quality of life of its patients. Various studies carried out in countries other than Brazil have shown endoscopic sinus surgery as an effective means of treating this condition. OBJECTIVE This study aims to analyze, with the aid of SNOT-20, the association between endoscopic sinus surgery and disease-specific quality of life of Brazilian patients treated for chronic rhinosinusitis accompanied or not by nasal polyps. MATERIALS AND METHODS This prospective study enrolled patients submitted to endoscopic sinus surgery after drug therapy failed to improve their symptoms. They were assessed based on questionnaire SNOT-20p before and 12 months after surgery. Improvement on total scores and on the five items deemed more important by each patient were assessed. The study also looked into the correlation between preoperative scores and postoperative improvement and if there were any gender-related improvement differences. RESULTS Forty-three patients aged 44 (19), md (IQR), 65% of whom (26/43) were males. Statistically significant improvement was seen on SNOT-20 and SNOT-20(5+) and a correlation was established between preoperative scores and postoperative improved scores (p<0.001). No gender-related differences were observed in quality of life. CONCLUSION Endoscopic sinus surgery in patients with chronic rhinosinusitis is associated with statistically significant improvements in disease-specific quality of life.

Avaliação da antibioticoterapia na morbidade pós-adenotonsilectomia: estudo prospectivo randomizado

Tonsillectomy with or without adenoidectomy still is one of the most commonly performed surgical procedures in the world, mostly in the pediatric population. AIM: to study the impact of amoxicillin for 7 days in post-adenotonsillectomy recovery, comparing results with a control group. Study type: prospective, randomized, controlled study with 120 patients. PATIENTS AND METHODS: the patients were randomized according to surgery time to receive 7 days of amoxicillin associated with pain killers, or analgesic alone. During the first week of postoperative, we assessed the level of pain, oral intake acceptance, nausea and vomits, fever and return to daily activities. RESULTS: It was only in the fourth post-operative day that the group receiving antibiotic agents showed a statistically significant difference as far as pain is concerned. There was no difference between the two groups for other data analyzed. CONCLUSION: considering the results from our study and reviewing the literature on the use of antibiotic agents, we agree that there is no improvement in patient recovery after adenotonsillectomy with the use of amoxicillin for 7 days in the postoperative.

Perfuração do septo nasal: etiologia e diagnóstico

INTRODUCTION: The nasal septum perforation is an occasional finding of rhinoscopy and most patients are asymptomatic. However, there are several possible etiologies of this condition, making necessary a thorough investigation. OBJECTIVE: To review the literature the main causes of septal perforation and describe the diagnostic tests currently used. Method: A systematic literature review of journals indexed identifiable until December 2008. FINAL COMMENTS: The main causes are the traumatic / iatrogenic nasal drug use, exposure to toxic gases, inflammatory and infectious diseases and neoplasms. The diagnosis is based on detailed medical history, focusing on occupation and origin of the patient, observation of the characteristics of mucosal injury on biopsy and collection of additional tests such as ANCA, guided by the main suspect.

Doxycycline for Recurrent Chronic Rhinosinusitis with Nasal Polyps

Objectives: Evaluate factors related to improvement after doxycycline treatment for patients with recurrent chronic rhinosinusitis with nasal polyps. Methods: We conducted an open label study from 2012 to 2013 on 32 patients with difficult-to-treat chronic rhinosinusitis with nasal polyps uncontrolled after endoscopic sinus surgery and long-term low-dose clarithromycin treatment. Patients received doxycycline 100mg per day for 12 weeks after a three-month wash-out period. The main outcome measure was a meaningful improvement in SNOT-20 (>0.80). Other outcome measures were the SNOT-20, NOSE, and Lund-Kennedy scores. The following parameters were analyzed: asthma, rhinitis, DREA, and blood testing before treatment for C3, C4, IgG, IgA, IgE, IgM, ANCA, and blood eosinophil count. Results: 53.1% (17/32) of patients showed a clinically significant improvement in SNOT-20 (>0.8) score after treatment. The patients also showed a statistically significant improvement in SNOT-20 (p<0.001), Lund-Kennedy (p<0.001), and NOSE (p<0.004) scores. Presence of asthma (p<0.001), AERD (p<0.008), increased level of blood eosinophil count, and increased serum IgE (p<0.018) were factors associated with a worse prognosis after treatment. Conclusions: Our group of patients showed a positive result after treatment with doxycycline, especially in patients without asthma, DREA, andincreased serum levels of IgE and eosinophil counts.