When it comes to chronic rhinosinusitis (CR), gone are the days of limiting classification according to whether there are polyps or no polyps. “It’s a complex group of conditions that present with different phenotypes,” said Prof. Richard Harvey, from Sydney ENT and Program Head at UNSW and Macquarie Clinical Schools in an interview with the limbic. “For the treating physician, the challenge is working out which type is in the patient in front of you, as their phenotype should drive the treatment pathway,”¹ he explained, adding that there are at least three defined phenotypes that can be used to guide treatment decisions.

Understanding which type of CR you are dealing with requires going further than just the clinical history and presumed disease. Molecular and observable findings provide clues to help classify the condition more precisely, which has the potential to improve the prognosis. As Prof. Harvey explained, “There are treatments for some populations that may seem futile and do little to change the clinical course.”

“There’s typically three groups of patients I encounter most frequently in my practice,” said Prof. Harvey.

“The hay fever sufferer”

“These patients are often younger, in their late teens or early 30s and may have had childhood onset asthma.¹ They would describe themselves as persistent hay fever sufferers and on examination you’d find central thickening in the airway and sinus cavity with degenerative changes.^3,4 In essence, this group have a severe inhalant allergy with elevated immunoglobulin E (IgE) driven by elevated T_H2 cytokine elevation.¹ They are often responsive to corticosteroid therapy, although in some cases they may require immunomodulatory therapy.¹ Surgery may be helpful to reconstruct the sinuses, but won’t fix the problem on its own,” he explained. “This is classified as central compartment atopic disease (CCAD).”

“The adult who never recovered from that infection”

“The second group is those without a history of sinus disease.¹ Patients are typically in their 30s to 50s, these patients suddenly present with an acute onset nasal congestion with loss of smell and adult-onset asthma.¹ They have elevated eosinophils, but not so high, which can make diagnosis a challenge. Tissue eosinophilia is currently the best prognostic marker for this group of patients.⁵ The disconnect is further exacerbated by these patients responding well to systemic corticosteroid therapy but limited effect of nasal sprays.¹ Patients may report a return of smell in response to treatment.¹ To really treat the affected area, corticosteroid irrigation is required,”⁶ noted Prof. Harvey. “Of course, no one wants to take systemic corticosteroids for longer than necessary, which has sparked much research and debate about the topical delivery of these treatments to the sinuses,” he said. Merely applying treatment via the nostrils does not imply delivery of the drug into the sinus.⁷ Patients with this phenotype typically respond poorly to surgical excision alone, instead requiring systemic therapy following sinus surgery.^8,9

“The non-inflammatory inflammation”

The third group, Prof. Harvey explained, has no evidence of type 2 inflammation (eosinophilic) at all.¹ “They tend to be an older population (over 50 years), have broader airway inflammation that does not respond well to corticosteroid therapy.¹ They tend to be an unstable group from the outset. Their asthma may be poorly controlled despite maximum therapy. We do surgery and find an absence of tissue squamous metaplasia. Some evidence suggests these patients may respond to long-term, low-dose macrolide therapy,” he said.¹⁰

“The diagnosis and management of CR is an evolving art. One that requires close examination and understanding of the upper and lower airway situation. In most cases, treatment involves surgical and non-surgical approaches to observe and treat the condition,” concluded Prof. Harvey.

Disclosure

This article was sponsored by Novartis. Any views expressed in the article are those of the expert alone and do not necessarily reflect the views of the sponsor. Before prescribing, please review the Xolair product information via the TGA website. Treatment decisions based on these data are the responsibility of the prescribing physician.

References:

1. Grayson JW, et al.J Otolaryngol Head Neck Surg. 2019;48(1):23.
2. Grayson JW, et al. JAMA Otolaryngol Head Neck Surg. 2020;146(9):831-838.
3. DelGaudio JM, et al. Am J Rhinol Allergy. 2017;31(4):228-234.
4. Hamizan, et al. The Laryngoscope 128:2015-2021.
5. Snidvongs K, et al. International Forum of Allergy & Rhinology 2012;2: 376-385.
6. Harvey RJ, et al. Int Forum Allergy Rhinol. 2018;8(4):461-470.
7. Snidvongs K, et al. Am J Rhinol Allergy. 2013;27(3):221-33.
8. Ho J, et al. Curr Opin Allergy Clin Immunol. 2020;20(1):23-29.
9. Ho J, et al. Rhinology. 2021;59(1):59-65.
10. Oakley GM, et al. Rhinology. 2018;56(2):111-117.