Exploration of Asthma & Allergy

Special Issue Topic

Update on Chronic RhinoSinusitis

Submission Deadline: September 30, 2024

Guest Editor

Prof. Ludger Klimek E-Mail

Head and Chairman Center for Rhinology and Allergology, Wiesbaden, Germany

Research Keywords: Allergic rhinitis, allergen immunotherapy, ASA intolerance / N-ERD syndrome, chronic rhinosinusitis / CRSwNP, epithelial immunology

About the Special Issue

Chronic rhinosinusitis (CRS) is a common chronic disease in Europe, the Americas and Asia with prevalences of 7% to 16%. CRSwNP is a subtype of CRS that accounts for the majority of health care costs with a prevalence of approximately 4% in the adult population and is associated with significantly impaired health-related quality of life. In CRSwNP, recurrence is common despite adequate drug and surgical treatment.
Drug treatment of CRSwNP targets the underlying inflammation and includes topical intranasal corticosteroids, short-term systemic corticosteroids (SCS) and others like e.g. leucotrien-antagonists, nasal lavage and antibiotics. Sinus surgery is an option for patients whose symptoms persist despite appropriate drug treatment but patients with severe CRSwNP have a recurrence rate of ca. 40% within three years, even when multimodal treatment methods have been used and of up to 80% within 12 years. Therefore, additional treatment options are needed and modern biologicals like Dupilumab, Mepolizumab and Omalizumab are authorized for severe CRSwNP. Biologic therapy targets type 2 inflammation that is found in approximately 80% of patients with CRSwNP in Europe and is associated more often with comorbid asthma. Aspirin-exacerbated airway disease (AERD or N-ERD) patients are more likely to require sinus surgery, have high corticosteroid use, and are more likely to experience long-term recurrence. Advances in the understanding of the immunologic processes involved in type 1, 2 and 3-inﬂammation will lead to new opportunities for disease control and monoclonal antibodies targeting other immunological players will soon become available.
International recommendations exist for the indication and in-label therapy of CRSwNP with biologics and will be further developed for monitoring the course and efficacy of therapy as well as for reviewing the duration and possible termination of therapy considering pharmacoeconomic aspects, taking into account the high cost of biologics.

Keywords: Chronic rhinosinusitis, biologic therapy, biologicals, asthma

Call for Papers

Published Articles

Open Access

Review

A mini-update on chronic rhinosinusitis
Chronic rhinosinusitis (CRS) is an inflammatory disorder of the paranasal sinuses and the nasal cavity lasting longer than 12 weeks. This disease is a common clinical syndrome with significant monet [...] Read more.

Chronic rhinosinusitis (CRS) is an inflammatory disorder of the paranasal sinuses and the nasal cavity lasting longer than 12 weeks. This disease is a common clinical syndrome with significant monetary burden due to the high costs of medical visits, diagnostic tests, medications, and surgical therapies. CRS without nasal polyposis (CRSsNP) is the most common subtype of CRS, accounting for about 70% of all patients. Other subtypes include CRS with nasal polyposis (CRSwNP) and allergic fungal rhinosinusitis (AFRS). CRSwNP has the worldwide prevalence of 2% to 4% and is often accompanied by type 2 inflammation and asthma as a comorbid condition. Pediatric chronic sinusitis is distinct from adult chronic sinusitis and is currently considered an infectious process, characterized by persistent inflammation representing an exaggerated immune response to an external stimulus. The medical and surgical management of CRS has been remarkably modified in the past two decades. The aim of this study was to present an update on CRS based on the recent years’ literature.

Sepideh Darougar ... Pantea Bozorg Savoji

Published: September 19, 2024 Explor Asthma Allergy. 2024;2:473–484
DOI: https://doi.org/10.37349/eaa.2024.00059

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Chronic rhinosinusitis (CRS) is an inflammatory disorder of the paranasal sinuses and the nasal cavity lasting longer than 12 weeks. This disease is a common clinical syndrome with significant monetary burden due to the high costs of medical visits, diagnostic tests, medications, and surgical therapies. CRS without nasal polyposis (CRSsNP) is the most common subtype of CRS, accounting for about 70% of all patients. Other subtypes include CRS with nasal polyposis (CRSwNP) and allergic fungal rhinosinusitis (AFRS). CRSwNP has the worldwide prevalence of 2% to 4% and is often accompanied by type 2 inflammation and asthma as a comorbid condition. Pediatric chronic sinusitis is distinct from adult chronic sinusitis and is currently considered an infectious process, characterized by persistent inflammation representing an exaggerated immune response to an external stimulus. The medical and surgical management of CRS has been remarkably modified in the past two decades. The aim of this study was to present an update on CRS based on the recent years’ literature.

Open Access

Original Article

Dupilumab improved objective and patient-reported outcomes in patients with chronic rhinosinusitis with nasal polyps and complete nasal obstruction
Aim: The impact of complete bilateral nasal obstruction [nasal polyp score (NPS) = 8/8] on treatment outcomes in chronic rhinosinusitis with nasal polyps (CRSwNP) is unclear. This post hoc analys [...] Read more.

Aim:

The impact of complete bilateral nasal obstruction [nasal polyp score (NPS) = 8/8] on treatment outcomes in chronic rhinosinusitis with nasal polyps (CRSwNP) is unclear. This post hoc analysis assessed disease burden and dupilumab efficacy in patients with severe CRSwNP and baseline NPS = 8 in SINUS-24/-52 (NCT02912468/NCT02898454).

Methods:

Efficacy outcomes assessed: NPS, peak nasal inspiratory flow (PNIF), Lund-Mackay computed tomography (LMK-CT), nasal congestion/obstruction (NC), loss of smell (LoS), rhinosinusitis visual analog scale (rhino-VAS), University of Pennsylvania Smell Identification Test (UPSIT), 22-item Sinonasal Outcome Test (SNOT-22) in patients receiving dupilumab 300 mg or placebo every 2 weeks. Responder analyses evaluated clinically meaningful improvements [≥ 1 (NPS, NC, LoS); ≥ 5 (LMK-CT); ≥ 8 (UPSIT); ≥ 8.9 (SNOT-22); ≥ 20 L/min (PNIF)].

Results:

Ninety-eight patients were included [59% prior NP surgery, 84% systemic corticosteroids (SCS) use in the previous 2 years, 60% coexisting asthma, 91% anosmic, 97% impaired nasal airflow]. Least squares (LS) mean differences [dupilumab vs. placebo (95% CI)] in change from baseline at week (W) 24: NPS, −2.04 (−2.67, −1.40); PNIF, 65.9 (39.4, 92.4) L/min; LMK-CT, −4.97 (−6.50, −3.44); NC, −1.30 (−1.72, −0.89); LoS, −0.96 (−1.39, −0.54); Rhino-VAS, −3.37 (−4.67, −2.07); UPSIT, 8.55 (4.91, 12.20); SNOT-22, −25.3 (−34.1, −16.4) (all P < 0.0001). For all outcomes, significantly greater proportions of dupilumab vs. placebo patients achieved clinically meaningful improvements at W24. Fewer dupilumab vs. placebo patients required SCS and/or surgery through W24 (11.8% vs. 36.7%; P = 0.0005). Efficacy outcomes were similar at W52 (SINUS-52; n = 39) with P values vs. placebo of < 0.0001 for NPS and NC; 0.0002 for LMK-CT; 0.0031 for LoS; 0.0014 for rhino-VAS; 0.0013 for UPSIT; 0.0012 for SNOT-22.

Conclusions:

In patients with CRSwNP with complete bilateral nasal obstruction, dupilumab treatment resulted in clinically significant improvements in NPS, LMK-CT, PNIF, symptoms, and health-related quality of life.

Martin Wagenmann ... Juby A. Jacob-Nara

Published: July 30, 2024 Explor Asthma Allergy. 2024;2:363–372
DOI: https://doi.org/10.37349/eaa.2024.00051

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Aim:

The impact of complete bilateral nasal obstruction [nasal polyp score (NPS) = 8/8] on treatment outcomes in chronic rhinosinusitis with nasal polyps (CRSwNP) is unclear. This post hoc analysis assessed disease burden and dupilumab efficacy in patients with severe CRSwNP and baseline NPS = 8 in SINUS-24/-52 (NCT02912468/NCT02898454).

Methods:

Efficacy outcomes assessed: NPS, peak nasal inspiratory flow (PNIF), Lund-Mackay computed tomography (LMK-CT), nasal congestion/obstruction (NC), loss of smell (LoS), rhinosinusitis visual analog scale (rhino-VAS), University of Pennsylvania Smell Identification Test (UPSIT), 22-item Sinonasal Outcome Test (SNOT-22) in patients receiving dupilumab 300 mg or placebo every 2 weeks. Responder analyses evaluated clinically meaningful improvements [≥ 1 (NPS, NC, LoS); ≥ 5 (LMK-CT); ≥ 8 (UPSIT); ≥ 8.9 (SNOT-22); ≥ 20 L/min (PNIF)].

Results:

Ninety-eight patients were included [59% prior NP surgery, 84% systemic corticosteroids (SCS) use in the previous 2 years, 60% coexisting asthma, 91% anosmic, 97% impaired nasal airflow]. Least squares (LS) mean differences [dupilumab vs. placebo (95% CI)] in change from baseline at week (W) 24: NPS, −2.04 (−2.67, −1.40); PNIF, 65.9 (39.4, 92.4) L/min; LMK-CT, −4.97 (−6.50, −3.44); NC, −1.30 (−1.72, −0.89); LoS, −0.96 (−1.39, −0.54); Rhino-VAS, −3.37 (−4.67, −2.07); UPSIT, 8.55 (4.91, 12.20); SNOT-22, −25.3 (−34.1, −16.4) (all P < 0.0001). For all outcomes, significantly greater proportions of dupilumab vs. placebo patients achieved clinically meaningful improvements at W24. Fewer dupilumab vs. placebo patients required SCS and/or surgery through W24 (11.8% vs. 36.7%; P = 0.0005). Efficacy outcomes were similar at W52 (SINUS-52; n = 39) with P values vs. placebo of < 0.0001 for NPS and NC; 0.0002 for LMK-CT; 0.0031 for LoS; 0.0014 for rhino-VAS; 0.0013 for UPSIT; 0.0012 for SNOT-22.

Conclusions:

In patients with CRSwNP with complete bilateral nasal obstruction, dupilumab treatment resulted in clinically significant improvements in NPS, LMK-CT, PNIF, symptoms, and health-related quality of life.

Open Access

Original Article

Relation of sinonasal anatomic variants with the frequency, pain severity and time off work in patients with migraine
Aim: Chronic migraine (CM) is a condition characterized by attacks of severe headaches leading to an increase in time off work, decrease in work productivity and in physical functioning. The aim [...] Read more.

Aim:

Chronic migraine (CM) is a condition characterized by attacks of severe headaches leading to an increase in time off work, decrease in work productivity and in physical functioning. The aim of this study was to investigate the role of sinus anatomic variants (SAV) on the evolution of migraine from episodic to chronic form.

Methods:

Two hundred and seven migraineurs [110 with episodic migraine (EM) and 97 with CM] with no evidence of nasal septal deviation with a contact point on the lateral nasal wall were evaluated for endoscopic, radiologic and anatomic variant (AV) abnormalities using Lund-Kennedy endoscopy (LKES) and Lund-Mackay radiology scores (LMRS). Headache day frequency, duration, severity and lost time at work were compared with regard to the presence of any AV and concha bullosa (CB) as well.

Results:

There was a very significant difference between EM and CM patients with regard to overall SAV and endoscopy scores. However, no significant difference was seen between the groups with regard to radiology scores and headache pain severity. The presence of one AV increased headache day frequency, severity and days off work in all patients. CB was found to worsen headache severity and lost time at work in all patients.

Conclusions:

Patients with CM have more SAV and worse endoscopy scores than patients with EM. The presence of any of the AVs increases headache day frequency, pain severity and days off work in migraineurs.

Ayşegül Verim ... Tuğba Çelik

Published: June 06, 2024 Explor Asthma Allergy. 2024;2:195–204
DOI: https://doi.org/10.37349/eaa.2024.00040

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Aim:

Chronic migraine (CM) is a condition characterized by attacks of severe headaches leading to an increase in time off work, decrease in work productivity and in physical functioning. The aim of this study was to investigate the role of sinus anatomic variants (SAV) on the evolution of migraine from episodic to chronic form.

Methods:

Two hundred and seven migraineurs [110 with episodic migraine (EM) and 97 with CM] with no evidence of nasal septal deviation with a contact point on the lateral nasal wall were evaluated for endoscopic, radiologic and anatomic variant (AV) abnormalities using Lund-Kennedy endoscopy (LKES) and Lund-Mackay radiology scores (LMRS). Headache day frequency, duration, severity and lost time at work were compared with regard to the presence of any AV and concha bullosa (CB) as well.

Results:

There was a very significant difference between EM and CM patients with regard to overall SAV and endoscopy scores. However, no significant difference was seen between the groups with regard to radiology scores and headache pain severity. The presence of one AV increased headache day frequency, severity and days off work in all patients. CB was found to worsen headache severity and lost time at work in all patients.

Conclusions:

Patients with CM have more SAV and worse endoscopy scores than patients with EM. The presence of any of the AVs increases headache day frequency, pain severity and days off work in migraineurs.

Open Access

Review

Evaluation of ongoing mepolizumab treatment in chronic rhinosinusitis with nasal polyps
Chronic rhinosinusitis with nasal polyps (CRSwNP) is a multifactorial inflammatory disease of the mucous membranes of the nose and paranasal sinuses. Eosinophilic inflammation is described as a comm [...] Read more.

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a multifactorial inflammatory disease of the mucous membranes of the nose and paranasal sinuses. Eosinophilic inflammation is described as a common endotype. The anti-interleukin-5 (IL-5) antibody mepolizumab was approved in November 2021 as an add-on therapy to intranasal glucocorticosteroids for the treatment of adults with severe CRSwNP when systemic glucocorticosteroids or surgery do not provide adequate disease control. While national and international recommendations exist for the use of mepolizumab in CRSwNP, therapy monitoring and follow-up documentation are required, and therapy discontinuation has not been adequately established yet. In this paper, recommendations for monitoring the course and efficacy of therapy as well as for reviewing the duration and possible termination of therapy are provided. For this purpose, a literature search was performed to analyze previous data on the treatment of CRSwNP with mepolizumab and to determine the available evidence by searching MEDLINE, PubMed, and the national and international trial and guideline registries and the Cochrane Library. Human studies published in the period up to and including October 2022 were considered. Based on the international literature and previous experience, recommendations for follow-up, adherence to therapy intervals and possible therapy breaks, as well as termination of therapy when using mepolizumab for the indication CRSwNP in the German health care system are given by an expert panel on the basis of a documentation sheet.

Ludger Klimek ... Claus Bachert

Published: February 22, 2024 Explor Asthma Allergy. 2024;2:33–48
DOI: https://doi.org/10.37349/eaa.2024.00027

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Chronic rhinosinusitis with nasal polyps (CRSwNP) is a multifactorial inflammatory disease of the mucous membranes of the nose and paranasal sinuses. Eosinophilic inflammation is described as a common endotype. The anti-interleukin-5 (IL-5) antibody mepolizumab was approved in November 2021 as an add-on therapy to intranasal glucocorticosteroids for the treatment of adults with severe CRSwNP when systemic glucocorticosteroids or surgery do not provide adequate disease control. While national and international recommendations exist for the use of mepolizumab in CRSwNP, therapy monitoring and follow-up documentation are required, and therapy discontinuation has not been adequately established yet. In this paper, recommendations for monitoring the course and efficacy of therapy as well as for reviewing the duration and possible termination of therapy are provided. For this purpose, a literature search was performed to analyze previous data on the treatment of CRSwNP with mepolizumab and to determine the available evidence by searching MEDLINE, PubMed, and the national and international trial and guideline registries and the Cochrane Library. Human studies published in the period up to and including October 2022 were considered. Based on the international literature and previous experience, recommendations for follow-up, adherence to therapy intervals and possible therapy breaks, as well as termination of therapy when using mepolizumab for the indication CRSwNP in the German health care system are given by an expert panel on the basis of a documentation sheet.

Guest Editor

About the Special Issue

Call for Papers

Published Articles

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