Evaluation of Diffuse Type 2 Dominant or Eosinophilic Chronic Rhinosinusitis With Corticosteroid Irrigation After Surgical Neosinus Cavity Formation

Abstract

IMPORTANCE Eosinophilic chronic rhinosinusitis (eCRS), contemporarily classified as diffuse type 2 dominant chronic rhinosinusitis (CRS), is characterized by eosinophil-dominant mucosal inflammation. Contemporary management of eCRS as an inflammatory airway condition is multimodal with corticosteroid irrigations after the surgical creation of a neosinus cavity.OBJECTIVES To assess long-term treatment outcomes in patients with primary diffuse type 2 CRS or eCRS receiving multimodal treatment. DESIGN, SETTING, AND PARTICIPANTSA prospective cohort study of patients seen in a tertiary rhinology practice recruited from May 2010 to November 2018 was conducted. Follow-up duration was 12 months or more following endoscopic sinus surgery (ESS) with a neosinus cavity formed. Data analysis was performed from August to November 2020. Consecutive adult (Ն18 years) patients diagnosed with primary diffuse type 2 dominant CRS or eCRS based on the European Position Paper on Rhinosinusitis and Nasal Polyps 2020 criteria were included. Type 2 inflammation was defined as more than 10 eosinophils per high-power field obtained from sinus mucosal biopsy and managed with neosinus cavity ESS and ongoing corticosteroid irrigations. Exclusion criteria were less than 12 months of follow-up and secondary CRS.INTERVENTIONS Endoscopic sinus surgery with complete removal of intersinus bony partitions to create a neosinus cavity. Nasal irrigation (240 mL) with betamethasone, 1 mg, or budesonide, 1 mg, daily for 3 to 6 months after ESS and tapered to an as-needed basis (minimum, 2-3 per week). MAIN OUTCOMES AND MEASURESPoor control was defined as polyp recurrence (polyp growth in >1 sinus area on a single side), use of long-term systemic therapy (biologic therapy or Ն3 consecutive months of oral corticosteroids), and revision surgery involving polypectomy. The disease in patients with no poor control criteria was defined as well controlled, and the disease in those with 1 or more criteria was considered poorly controlled. Maintenance medical therapy use and patient-reported outcomes based on the 22-item Sinonasal Outcomes Test for preoperative and last follow-up were collected. RESULTSOf the 222 participants recruited with primary diffuse type 2 dominant CRS or eCRS and minimum of year of follow-up, 126 were men (56.8%). Mean (SD) age was 54.8 (13.6) years, and median (SD) follow-up was 2.2 (2.2) years. Of the 222 patients, 195 (87.8%) had well-controlled disease, 16 (7.2%) had polyp recurrence, 7 (3.2%) continued to receive long-term oral corticosteroid therapy, 5 (2.3%) received biologic therapy, and 8 (3.6%) underwent a revision polypectomy. Clinically meaningful change on the 22-item Sinonasal Outcomes Test and the nasal subdomain score was maintained at the last follow-up in 134 patients (67.0%). Poor disease control was not associated with poor adherence to irrigation use. CONCLUSIONS AND RELEVANCEThe findings of this cohort study suggest that long-term disease control and reduction in symptom burden in patients with primary diffuse type 2 ...

Relationship of Lesion Location to Postoperative Steroid Use in Eosinophilic Chronic Rhinosinusitis

“…ECRS is associated with a high postoperative recurrence rate of 7.2%-20% at 12 months after ESS. 3,11,12 Although biologics have become popular as a treatment for recurrence, systemic steroids are currently often administered first for subjective exacerbation of symptoms that occur postoperatively. Steroid use is a treatment for postoperative recurrence and may also influence subsequent treatment strategies, including the indication for biologic agents.…”

Comparison of Sinonasal Histopathological Changes in Biological Treatment of Eosinophilic Chronic Rhinosinusitis

“…Patients underwent endoscopic sinus surgery as part of management of their eCRS. 16 This study was limited to patients with disease sub-optimally controlled clinically and symptomatically to warrant operative management. In patients with eCRS, multimodal therapy with surgery, topical medication irrigations and systemic medications (corticosteroids, biologics) has been shown to be successful in most patients to control disease and reduce symptoms.…”

“…In patients with eCRS, multimodal therapy with surgery, topical medication irrigations and systemic medications (corticosteroids, biologics) has been shown to be successful in most patients to control disease and reduce symptoms. 16 The objective for surgery was to provide a wide-open suitable cavity to maximise the postoperative delivery of corticosteroids to the sinonasal mucosa. Operations included revision polypectomy in patients who had recurrent disease/polyposis despite a previously adequately widened sinonasal cavity, to more extensive sinus surgery including Lothrop procedure.…”

“…All patients had a neo-sinus cavity created as part of management of their severe eCRS as described in Li et al 16 Representative sinonasal mucosal tissue biopsy from the ethmoid sinus was obtained intraoperatively and placed in formalin. These were then processed with standard hematoxylin and eosin (H&E) staining and assessed by pathologists blinded to the clinical data.…”

Preliminary application of a 3D-printed track-guided precise drug delivery device for the sinuses after endoscopic sinus surgery

“…10,11 Some studies have reported good results using corticosteroid irrigation, but the irrigation method causes discomfort to patients, and corticosteroids are inconvenient to carry. 12 Therefore, improving the existing drug delivery method for nasal spray hormones and achieving the precise application of glucocorticoids to local sinus lesions have become a focus of CRS treatment research.…”