A Decade of Clinical Advances in Chronic Rhinosinusitis: 2012-2022.

The field of chronic rhinosinusitis (CRS) is constantly evolving. In the past 10 years, key advancements in basic and translational research as well as clinical studies have improved our understanding and management of CRS. Notably, treatment options have expanded to include novel therapeutic drugs, devices, and surgical techniques. Assessments of patient symptoms and their impact on quality of life have become more standardized. Progress has also been made in both determining the true prevalence of CRS and recognizing comorbidities that can impact CRS severity. Practice guidelines have also shifted from expert opinion to more data-driven analyses. This review highlights major clinical advancements made in the field of CRS over the past 10 years as well as identifies current gaps in knowledge that can form the basis for new areas of study over the next decade.

Management of complicated acute sinusitis in the setting of concurrent COVID-19.

PURPOSE: Intraorbital and intracranial complications of acute bacterial rhinosinusitis require timely medical and surgical treatment to prevent the development of long-term neurologic sequelae. The era of Coronavirus Disease-2019 (COVID-19) has complicated the management of complicated acute rhinosinusitis, especially when patients have concurrent acute sinusitis and COVID-19 infection. This case series aims to highlight the clinical course of pediatric patients at a single tertiary pediatric hospital with concurrent complicated bacterial rhinosinusitis and COVID-19. MATERIALS AND METHODS: A search of pediatric patients treated for COVID-19 and complications from acute sinusitis was performed using billing records for the year 2020-2021 at a single pediatric tertiary hospital. Data regarding presentation, management, microbiology, and hospital course was collected for review. RESULTS: A total of 6 patients with complicated bacterial sinusitis in the setting of COVID-19 infection were included. All patients were initially managed with medical therapy, consisting of systemic antibiotics, but 3 of these patients ultimately required surgical intervention. Cultures from the cohort grew Staphylococcus aureus, streptococcus intermedius, streptococcus constellatus or Prevotella species. All patients experienced clinical improvements and were eventually discharged home with oral antibiotics. CONCLUSION: COVID-19 continues to be an unusual disease especially for the pediatric population. Concurrent complicated acute rhinosinusitis and COVID-19 appear to have higher rates of surgical requirement in the pediatric population. COVID-19 safety precautions have influenced management practices for patients with severe bacterial rhinologic infections. While there may be an association between complicated bacterial rhinosinusitis and COVID-19 infection, further research is necessary to determine a true correlation.

SWOT Analysis of Chronic Rhinosinusitis Care Anno 2022.

Chronic rhinosinusitis (CRS) is a prevalent chronic condition with dynamic developments in diagnostic and therapeutic approaches given the recent updated guidelines and novel therapeutic approaches. A critical reflection on clinical practice of CRS care in 2022 is needed, hence providing hints for better care. This review provides an overall evaluation of the current approach of CRS care, including strengths, weaknesses, opportunities, and threat related to the current care pathways in most regions worldwide. Strengths of current CRS care are mainly related to effective treatment options allowing personalized care, with preventive and curative goals included in the current guidelines. However, a large portion of patients with CRS remain uncontrolled given the multiple weaknesses in CRS care, related to several factors such as underdiagnosis, undertreatment, and suboptimal coordination of care among health care providers. The opportunities for better care are ample given the possibility of implementing optimal care following guidelines, including preventive interdisciplinary strategies and patient-oriented treatment plans. In 2022, CRS represents a chronic condition that is subject to a (r)evolution of care with good opportunities for better outcomes and health economic savings.

Chronic Rhinosinusitis and COVID-19.

The COVID-19 pandemic has raised awareness about olfactory dysfunction, although a loss of smell was present in the general population before COVID-19. Chronic rhinosinusitis (CRS) is a common upper airway chronic inflammatory disease that is also one of the most common causes of olfactory dysfunction. It can be classified into different phenotypes (ie, with and without nasal polyps) and endotypes (ie, type 2 and non-type 2 inflammation). However, scientific information regarding CRS within the context of COVID-19 is still scarce. This review focuses on (1) the potential effects of severe acute respiratory syndrome coronavirus 2 infection on CRS symptoms, including a loss of smell, and comorbidities; (2) the pathophysiologic mechanisms involved in the olfactory dysfunction; (3) CRS diagnosis in the context of COVID-19, including telemedicine; (4) the protective hypothesis of CRS in COVID-19; and (5) the efficacy and safety of therapeutic options for CRS within the context of COVID-19.

Emergence of Invasive Fungal Rhinosinusitis in Recently Recovered COVID-19 Patients.

OBJECTIVE: The risk of invasive fungal rhinosinusitis is increased in Coronavirus disease 2019 (COVID-19) because of its direct impact in altering innate immunity and is further exacerbated by widespread use of steroids/antibiotics/monoclonal antibodies. The study aims to describe this recently increased clinical entity in association with COVID-19. METHOD: A prospective, longitudinal study including patients diagnosed with acute invasive fungal rhinosinusitis (AIFRS) who recently recovered from COVID-19 infection or after an asymptomatic carrier state. A single-center, descriptive study investigating demographic details, clinical presentation, radio-pathological aspects, and advocated management. RESULT: A total of 21 patients were included with a mean age of 49.62 years (SD: 14.24). Diabetes mellitus (DM) was the most common underlying disorder (90.48%), and 63.16% of all patients with DM had a recent onset DM, either diagnosed during or after COVID-19 infection. Nineteen patients (90.48%) had recently recovered from active COVID-19 infection, and all had a history of prior steroid treatment (oral/parenteral). Remaining 2 patients were asymptomatic COVID-19 carriers. Surprisingly, 2 patients had no underlying disorder, and 5 (23.81%) recently received the Covishield vaccine. Fungal analysis exhibited Mucor (95.24%) and Aspergillus species (14.29%). Most common sign/symptom was headache and facial/periorbital pain (85.71%), followed by facial/periorbital swelling (61.90%). Disease involvement: sinonasal (100%), orbital (47.62%), pterygopalatine fossa (28.58%), infratemporal fossa (14.29%), intracranial (23.81%), and skin (9.52%). Exclusive endoscopic debridement and combined approach were utilized in 61.90% and 38.10%, respectively. Both liposomal amphotericin B and posaconazole were given in all patients except one. CONCLUSION: A high suspicion of AIFRS should be kept in patients with recent COVID-19 infection who received steroids and presenting with headache, facial pain, and/or facial swelling. Asymptomatic COVID-19 carriers and COVID-19 vaccinated candidates are also observed to develop AIFRS, although the exact immuno-pathogenesis is still unknown. Prompt diagnosis and early management are vital for a favorable outcome.

Invasive Fungal Sinusitis in Post COVID-19 Patients: A New Clinical Entity.

OBJECTIVES: Occurrence of invasive fungal respiratory superinfections in patients with COVID-19 has gained increasing attention in the latest studies. Yet, description of acute invasive fungal sinusitis with its management in those patients is still scarce. This study aims to describe this recently increasing clinical entity in relation to COVID-19 patients. STUDY DESIGN: Longitudinal prospective study. METHODS: Prospective longitudinal study included patients diagnosed with acute invasive fungal rhinosinusitis after a recent COVID-19 infection. Antifungal agents given included amphotericin B, voriconazole, and/or posaconazole. Surgical treatment was restricted to patients with PCR negative results for COVID-19. Endoscopic, open, and combined approaches were utilized to eradicate infection. Follow-up for survived patients was maintained regularly for the first postoperative month. RESULTS: A total of 36 patients with a mean age of 52.92 ± 11.30 years old were included. Most common associated disease was diabetes mellitus (27.8%). Mycological analysis revealed infection with Mucor and Aspergillus species in 77.8% and 30.6% of patients, respectively. Sino-nasal, orbital, cerebral, and palatine involvement was found in 100%, 80.6%, 27.8%, and 33.3% of patients, respectively. The most common reported symptoms and signs are facial pain (75%), facial numbness (66.7%), ophthalmoplegia, and visual loss (63.9%). All patients were treated simultaneously by surgical debridement with antifungal medications except for two patients with PCR-positive swab for COVID-19. These two patients received antifungal therapy alone. Overall survival rate was 63.89% (23/36). CONCLUSION: Clinical suspicion of acute invasive fungal sinusitis among COVID-19 patients and early management with antifungal therapy and surgical debridement is essential for better outcomes and higher survival. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:2652-2658, 2021.

The management of upper airway diseases: an ongoing challenge for the clinician.

Upper airway diseases are widespread in clinical practice. However, some aspects are still debated. The current supplement presents and discusses the most common disorders encountered in daily medical activity. The COVID-19 dramatic pandemic requires an urgent solution. Promising non-pharmacological agents are discussed. Chronic diseases are frequent in childhood, so to know risk factors is useful in their management. Allergic rhinitis and chronic rhinosinusitis should be treated with anti-inflammatory drugs, but complementary compounds should be alternated to preserve health. Empty nose syndrome is a frequent complication of nasal surgery and requires adequate staging and hydrating procedure. Lastly, laryngopharyngeal reflux is an intriguing challenge for the clinician. Alginates represent a safe and effective way to relieve LPR symptoms.

Highlights in the advances of chronic rhinosinusitis.

Chronic rhinosinusitis (CRS) is a complex upper airway inflammatory disease with a broad spectrum of clinical variants. As our understanding of the disease pathophysiology evolves, so too does our philosophy towards the approach and management of CRS. Endotyping is gaining favour over phenotype-based classifications, owing to its potential in prognosticating disease severity and delivering precision treatment. Endotyping is especially useful in challenging CRS with nasal polyposis cases, for whom novel treatment options such as biologicals are now available. The latest European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS2020) reflects these changes with updated rhinosinusitis classifications and new integrated care pathways. With the coronavirus disease 2019 (COVID-19) pandemic, physicians and rhinologists have to balance the responsibility of managing their patients' upper airway while adequately protecting themselves from droplet and aerosol transmission. This review summarises the key updates from EPOS2020, endotype-based classification and biomarkers. The role of biologicals in CRS and the lessons we can draw from their use in severe asthma will be examined. Finally, the principles of CRS management during COVID-19 will also be discussed.

EUFOREA expert board meeting on uncontrolled severe chronic rhinosinusitis with nasal polyps (CRSwNP) and biologics: Definitions and management.

Uncontrolled severe chronic rhinosinusitis with nasal polyps (CRSwNP) is the most bothersome phenotype of chronic rhinosinusitis; it is typically characterized by a type 2 inflammatory reaction and by comorbidities, including asthma, nonsteroidal anti-inflammatory drug-exacerbated respiratory disease, and allergies. Here, the European Forum for Research and Education in Allergy and Airway Diseases proposes structured definitions to enable communication between clinicians and provides a practical algorithm to define type 2 inflammation in CRSwNP in daily clinical practice. A rational approach for the treatment of uncontrolled severe CRSwNP is discussed; it consists of evaluating the perspective and risks of surgery and efficacy and adverse events of biologics on the basis of currently available data. Further, possible combinations of surgery and biologics are discussed, and a rationale is provided. Here, it is of importance to adequately counsel the patient about both approaches to enable a decision-making process with an informed patient. Criteria for the selection of a biologic drug are provided, as several biologics for uncontrolled severe CRSwNP will be available in many countries within a short time. Further, suggestions for monitoring of the drug effects that support recognition of responders to the therapy and, subsequently, the decision regarding continuation or discontinuation of the biologic are proposed.

The toll of noninfected CRS patients to the COVID-19 pandemic.

Social distancing with the aim of avoiding infections and pre-serve critical care capacities during the COVID-19 pandemic has been implemented in Germany according to World Health Organization (WHO) recommendations from early March onwards. Limitations of physical contacts to reduce exposure to SARS-CoV-2 infected individuals were handled strictly, particularly in medical centers dealing with airway diseases, like rhinology and pneumology clinics. Such measures and reluctance to visit out- and inpatient services resulted in a 82% decrease in consultations to the 12 German oto-rhino-laryngological (ORL) centres forming our database during the 50 days following March 09 in 2020 if compared to the same period in 2019. Our data on CRS care underline reports on undertreatment of non-COVID-19 individuals with several different diseases during the current pandemic. We should try to reduce the toll these patients have to pay as much as possible. We established telemedicine, e-Health and artificial intelligence-supported triage for selecting the right patients for onsite-consultations and to advise patients in several demands.

Telemedicine, Patient Satisfaction, and Chronic Rhinosinusitis Care in the Era of COVID-19.

BACKGROUND: Telemedicine has become increasingly popular in the care of rhinologic patients during the COVID-19 pandemic. This change in practice patterns may place patients at risk of a perceived lower-quality exchange with their healthcare provider, which may in turn impact satisfaction. OBJECTIVE: This study compares patient satisfaction scores between in-person clinic visits and telemedicine video visits in patients with chronic rhinosinusitis (CRS). METHODS: Sixty-nine patients with CRS presenting to an academic rhinology clinic between March to April 2020 were retrospectively divided into video visits (VV) and clinic visits (CV) groups based on mandated state quarantine orders on March 19. Patient demographics, disease severity measures, and Patient Satisfaction Questionnaire-18 (PSQ-18) scores were collected and analyzed. Chi square test and Fisher's exact test were performed. RESULTS: There were no significant differences in age (p = 0.81), gender (p = 0.55), CRS phenotype (p = 0.16), and disease severity measures (Sinonasal Outcomes Test-22 (SNOT-22) (p = 0.92); Lund-Mackay score (p = 0.96)) between the video and clinic visit groups. There were no significant differences in PSQ-18 total scores (VV PSQ-18 mean score = 78.1, CV PSQ-18 mean score = 78.4; p = 0.67) or the following subdomain scores between the two groups: general satisfaction (p = 0.73), technical quality (p = 0.62), interpersonal manner (p = 0.41), communication (p = 0.31), financial aspects (p = 0.89), time spent with doctor (p = 0.88), and accessibility and convenience (p = 0.47). CONCLUSION: Patient satisfaction with telemedicine in the COVID-19 pandemic parallels that of traditional in-person visits. Video visits can serve as a viable alternative to clinic visits, while still maintaining high satisfaction.

Management of complicated pediatric rhinosinusitis in the COVID-19 era.

With the ongoing development of the COVID-19 pandemic, research continues to emerge regarding the pathophysiology, characteristics, and treatment considerations for patients with COVID-19. No reports have highlighted the specific challenges posed in the management of pediatric patients with COVID-19 who present with complicated rhinosinusitis. In this report, we discuss our preoperative, intraoperative, and postoperative multidisciplinary treatment strategy for these cases and provide two examples of complicated rhinosinusitis cases in COVID-19 patients, treated with two different approaches. Pearls, insights, and a brief review of the literature are discussed.