The presence of eosinophil aggregates correlates with increased postoperative prednisone requirement

Abstract

Objectives/Hypothesis Failure after sinus surgery is multifactorial, but often due to recurrence of inflammatory mucosal disease. Postoperative steroid requirements for controlling mucosal inflammation may provide insight into predicting which patients require more aggressive medical therapy to prevent disease relapse. Study Design Retrospective chart review. Methods A review was performed of patients who underwent functional endoscopic sinus surgery (FESS) for refractory chronic rhinosinusitis (CRS). Sino‐Nasal Outcome Test‐22 scores and cumulative prednisone dose (milligrams) requirements at 1, 3, and 6 months postoperatively were reviewed. A structured histopathology report of 11 variables was accessed to correlate histopathology with postoperative steroid requirements. Results One hundred one patients were reviewed including 42 CRS with nasal polyps and 59 CRS without nasal polyps patients. CRS patients with eosinophilia required greater cumulative steroids to control disease at 1‐, 3‐, and 6‐month postoperative intervals (P < .026, P < .007, P < .013, respectively) compared to patients without eosinophilia. Patients with tissue eosinophil aggregates required the highest cumulative steroids at 1‐, 3‐, and 6‐month postoperative intervals (P < .003, P < .001, P < .001, respectively). When removing patients with eosinophil aggregates from the eosinophilia group, no difference persisted between patients with eosinophilia and those without eosinophilia at all intervals (P = .664, P = .735, P = .800, respectively). No other histopathology variable correlated with postoperative steroid requirement. Conclusions Tissue eosinophil aggregates appear to be the largest driving factor for increased prednisone requirements after sinus surgery to control mucosal disease than mere presence of eosinophils. This key finding may identify patients at high risk for failure after sinus surgery and guide more proactive postoperative management. Level of Evidence 4 Laryngoscope, 129:794–799, 2019

Histopathological characteristics of surgical tissue from primary vs recurrent chronic rhinosinusitis with nasal polyposis patients

“…Eosinophilic aggregates have been reported in patients with CRSwNP in only three prior studies . A study conducted by Kuhar et al posited that the presence of tissue eosinophilic aggregates may be a useful predictor of polyposis and may also indicate a more severe disease process .…”

“…This further supports previous studies' findings that activated eosinophils may play role in more severe (recurrent) CRSwNP and indicate disease that is difficult to treat with standard therapies. A recent study also suggests that tissue eosinophil aggregates were the most substantial driving factor for increased cumulative prednisone doses following sinus surgery . In this study, patients with eosinophilic predominance were more likely to have eosinophil aggregates ( P < .001), although patients with both eosinophilic predominance and eosinophil aggregates were not different between primary and recurrent nasal polyp tissue.…”

“…CRSwNP in only three prior studies. 11,12,19 A study conducted by Kuhar et al posited that the presence of tissue eosinophilic aggregates may be a useful predictor of polyposis and may also indicate a more severe disease process. 12 The current study finds that eosinophil aggregates are more prevalent in recurrent CRSwNP mucin compared to primary disease.…”

Exploring the role of nasal cytology in chronic rhinosinusitis

“…A basic attempt of CRS endotyping is based on the identification of the predominant immune cells in the inflamed sinonasal mucosa; in particular, it is key the distinction between eosinophilic and non-eosinophilic mediated CRS (ECRS and non-ECRS, respectively) 2 . The clinical interest in ECRS arises as it generally shows a poor response to medical and surgical therapies 5 . The therapeutic impact would be significant, as cases with intense eosinophilia would justify higher dosage of steroids and, theoretically, selected biological antagonists of type 2 inflammation 6 .…”

A classification of chronic rhinosinusitis with nasal polyps based on structured histopathology

“…Therefore, there is a need to develop tools to assist clinical decision‐making based on objective evidence, such as histopathology . In routine practice today, histopathology on surgical samples offers limited information on the heterogeneous pathogenic mechanisms underlying different CRSwNP endotypes, but a potential role of structured histopathological profiling for CRSwNP has begun to attract attention . The few, but very intriguing, currently available studies support the concept that histopathology could provide very meaningful information to improve our endotyping capabilities.…”