Chronic rhinosinusitis update
By Richard (Wei Chern) Gan

There is still a lack of awareness of chronic rhinosinusitis (CRS) despite its burden, calling for events such as the recent Global Chronic Rhinosinusitis with Nasal Polyps (CRSwNP) Awareness Day. Research findings from recent publications by Backaert et al have shown that visual analogue scores rating the severity of symptoms – such as obstruction, postnasal drip, rhinorrhoea, nasal itch, sneezing, ocular itch, headache, loss of smell, and overall nasal symptom burden – could be used together to differentiate between allergic rhinitis, non-allergic rhinitis and chronic rhinosinusitis. Furthermore, it could even identify overlapping phenotypes. With regards to disease biomarkers, blood eosinophilic count (BEC) in type 2 disease is useful in directing therapy and predicting outcomes. A study by Deng et al showed that tailoring steroid treatment, oral or topical corticosteroid, based on BEC was comparable to standard oral corticosteroid treatment. Total IgE level has limited added value over BEC as a biomarker for type 2 CRS. Tissue / polyp eosinophil count remains a good predictor of recurrence after endoscopic sinus surgery (ESS) and, in the paediatric CRS population, a predictor of revision surgery. There is still debate over cut-offs for tissue / polyp eosinophil count, as well as the best protocol for histopathologic assessment and timing of tissue sampling (during biopsy vs. at the time of surgical treatment). Despite CRS and asthma sharing so much underlying pathophysiology, they are usually managed separately by different specialties. To bridge the gap, a STARR-15 questionnaire, addressing CRS, asthma and allergic rhinitis has been developed. Comorbidities associated with CRS include type 2 disorders like bronchial asthma, eczema, allergies, eosinophilic esophagitis and NSAID intolerance, as well as non-type 2 disorders gastroesophageal reflux and Sjögren’s syndrome. Disease control may be assessed using the seven criteria defined by EPOS, with five symptoms that can be measured using visual analogue scores. SNOT-22 scores are also used. However, studies have shown that the scores tend to underestimate the level of control compared to patient and clinician perceptions. A recent international, multidisciplinary panel of experts and patients identified consensus criteria for assessing CRS disease control. A study of the practice patterns of experienced rhinologists across the world found that nasal endoscopy findings with a total modified Lund-Kennedy score of ≥4 (out of 12) or total Nasal Polyp Score (NPS) of ≥3 (out of eight) would lead to consideration for CRS treatment escalation. The new EPOS classification of CRS is based on localised / diffuse disease, primary / secondary disease and likely endotype. In diffuse CRS, patients respond well to medical treatment but some require ESS, 19% of which require revision surgery. Short-term oral corticosteroids (OCS) form part of the medical treatment but long-term OCS use is not warranted, given possible adverse effects. Treatable traits such as smoking, allergen exposure, comorbidities, occupation and patient-related factors should form part of the evaluation as therapeutic targets. Biologics have been a breakthrough in the treatment of CRS with nasal polyps, with the otorhinolaryngologist needing to consider which patients are eligible and which biologic to use.

Recent advances in chronic rhinosinusitis: pathophysiology, treatments, and outcome measures.
Fokkens WJ, Sedaghat AR, Soyka MB, Reitsma S.
RHINOLOGY
2024;62(6):652–8.