Imaging in Sinonasal Disorders

Computed tomography (CT) is the “working horse” in sinonasal imaging and should always be the first choice. Magnetic resonance imaging (MRI) is complementary to CT when complications to rhinosinusitis or neoplasm are suspected. Imaging of the paranasal sinuses is common due to stuffy nose. In order to correct interpretation, proper imaging technique as well as knowledge of bony anatomy and variants and mucosal incidental findings are of outmost importance. Acute rhinosinusitis is very common and does not need imaging unless complications are suspected. In chronic rhinosinusitis, a CT examination is needed to find the cause and site of the mucociliary obstruction and to rule out other causes as odontogenic and fungal sinusitis and neoplasms

Integrating phenotypes and endotypes in chronic rhinosinusitis: a combined clinical and experimental approach.

Chronic rhinosinusitis (CRS) represents a hot and debated topic in rhinology because of its high prevalence, heterogeneity of clinical manifestations and unpredictability of disease course. The quite recent dichotomic classification of CRS with and without nasal polyps has proved to be too simplistic to fully explain CRS manifestations and the underlying pathogenetic mechanisms. Being either the same phenotype expression of substantially different pathogenic mechanisms or different phenotypes the expression of the same mechanism, a one-size-fit-all therapeutic approach turned out to be insufficient in a non-negligible proportion of patients. Moreover, considering the attempt of giving a classification cut at a biomolecular level, a diagnostic and prognostic approach exclusively limited to subjective and objective clinical parameters is inevitably failing in many ways. However, to date no other more effective markers are available to monitor the trend of the disease. The fact of dealing with an apparently very frequent pathology responsible for a strong discomfort on the QoL and a substantial economic impact requires a diagnostic and therapeutic appropriateness for an adequate allocation of resources within the standards of precision medicine. The development of systems for a uniform archiving and sharing of the experiences of each rhinological center would enhance the efforts of the scientific community in defining integrated and targeted care pathways. The present thesis reports the results and the practical implications of three different experimental studies about the implementation of data storage and sharing systems, methods of analysis of therapeutic outcomes and inflammatory biomarkers in CRS

European Position Paper on Rhinosinusitis and Nasal Polyps 2020

The European Position Paper on Rhinosinusitis and Nasal Polyps 2020 is the update of similar evidence based position papers published in 2005 and 2007 and 2012. The core objective of the EPOS2020 guideline is to provide revised, up-to-date and clear evidence-based recommendations and integrated care pathways in ARS and CRS. EPOS2020 provides an update on the literature published and studies undertaken in the eight years since the EPOS2012 position paper was published and addresses areas not extensively covered in EPOS2012 such as paediatric CRS and sinus surgery. EPOS2020 also involves new stakeholders, including pharmacists and patients, and addresses new target users who have become more involved in the management and treatment of rhinosinusitis since the publication of the last EPOS document, including pharmacists, nurses, specialised care givers and indeed patients themselves, who employ increasing self-management of their condition using over the counter treatments. The document provides suggestions for future research in this area and offers updated guidance for definitions and outcome measurements in research in different settings. EPOS2020 contains chapters on definitions and classification where we have defined a large number of terms and indicated preferred terms. A new classification of CRS into primary and secondary CRS and further division into localized and diffuse disease, based on anatomic distribution is proposed. There are extensive chapters on epidemiology and predisposing factors, inflammatory mechanisms, (differential) diagnosis of facial pain, allergic rhinitis, genetics, cystic fibrosis, aspirin exacerbated respiratory disease, immunodeficiencies, allergic fungal rhinosinusitis and the relationship between upper and lower airways. The chapters on paediatric acute and chronic rhinosinusitis are totally rewritten. All available evidence for the management of acute rhinosinusitis and chronic rhinosinusitis with or without nasal polyps in adults and children is systematically reviewed and integrated care pathways based on the evidence are proposed. Despite considerable increases in the amount of quality publications in recent years, a large number of practical clinical questions remain. It was agreed that the best way to address these was to conduct a Delphi exercise. The results have been integrated into the respective sections. Last but not least, advice for patients and pharmacists and a new list of research needs are included.Peer reviewe

European position paper on rhinosinusitis and nasal polyps 2020

The European Position Paper on Rhinosinusitis and Nasal Polyps 2020 is the update of similar evidence based position papers published in 2005 and 2007 and 2012. The core objective of the EPOS2020 guideline is to provide revised, up-to-date and clear evidence-based recommendations and integrated care pathways in ARS and CRS. EPOS2020 provides an update on the literature published and studies undertaken in the eight years since the EPOS2012 position paper was published and addresses areas not extensively covered in EPOS2012 such as paediatric CRS and sinus surgery. EPOS2020 also involves new stakeholders, including pharmacists and patients, and addresses new target users who have become more involved in the management and treatment of rhinosinusitis since the publication of the last EPOS document, including pharmacists, nurses, specialised care givers and indeed patients themselves, who employ increasing self-management of their condition using over the counter treatments. The document provides suggestions for future research in this area and offers updated guidance for definitions and outcome measurements in research in different settings. EPOS2020 contains chapters on definitions and classification where we have defined a large number of terms and indicated preferred terms. A new classification of CRS into primary and secondary CRS and further division into localized and diffuse disease, based on anatomic distribution is proposed. There are extensive chapters on epidemiology and predisposing factors, inflammatory mechanisms, (differential) diagnosis of facial pain, allergic rhinitis, genetics, cystic fibrosis, aspirin exacerbated respiratory disease, immunodeficiencies, allergic fungal rhinosinusitis and the relationship between upper and lower airways. The chapters on paediatric acute and chronic rhinosinusitis are totally rewritten. All available evidence for the management of acute rhinosinusitis and chronic rhinosinusitis with or without nasal polyps in adults and children is systematically reviewed and integrated care pathways based on the evidence are proposed. Despite considerable increases in the amount of quality publications in recent years, a large number of practical clinical questions remain. It was agreed that the best way to address these was to conduct a Delphi exercise . The results have been integrated into the respective sections. Last but not least, advice for patients and pharmacists and a new list of research needs are included

European Position Paper on Rhinosinusitis and Nasal Polyps 2020

The European Position Paper on Rhinosinusitis and Nasal Polyps 2020 is the update of similar evidence based position papers published in 2005 and 2007 and 2012. The core objective of the EPOS2020 guideline is to provide revised, up-to-date and clear evidence-based recommendations and integrated care pathways in ARS and CRS. EPOS2020 provides an update on the literature published and studies undertaken in the eight years since the EPOS2012 position paper was published and addresses areas not extensively covered in EPOS2012 such as paediatric CRS and sinus surgery. EPOS2020 also involves new stakeholders, including pharmacists and patients, and addresses new target users who have become more involved in the management and treatment of rhinosinusitis since the publication of the last EPOS document, including pharmacists, nurses, specialised care givers and indeed patients themselves, who employ increasing self-management of their condition using over the counter treatments. The document provides suggestions for future research in this area and offers updated guidance for definitions and outcome measurements in research in different settings. EPOS2020 contains chapters on definitions and classification where we have defined a large number of terms and indicated preferred terms. A new classification of CRS into primary and secondary CRS and further division into localized and diffuse disease, based on anatomic distribution is proposed. There are extensive chapters on epidemiology and predisposing factors, inflammatory mechanisms, (differential) diagnosis of facial pain, allergic rhinitis, genetics, cystic fibrosis, aspirin exacerbated respiratory disease, immunodeficiencies, allergic fungal rhinosinusitis and the relationship between upper and lower airways. The chapters on paediatric acute and chronic rhinosinusitis are totally rewritten. All available evidence for the management of acute rhinosinusitis and chronic rhinosinusitis with or without nasal polyps in adults and children is systematically reviewed and integrated care pathways based on the evidence are proposed. Despite considerable increases in the amount of quality publications in recent years, a large number of practical clinical questions remain. It was agreed that the best way to address these was to conduct a Delphi exercise . The results have been integrated into the respective sections. Last but not least, advice for patients and pharmacists and a new list of research needs are included. The full document can be downloaded for free on the website of this journal: http://www.rhinologyjournal.com

The diagnosis, assessment and outcomes of primary systemic vasculitis

We have created definitions for ultrasonographic abnormalities of Giant Cell Arteritis. The ‘halo’ sign is a ‘homogenous, hypoechoic wall thickening, well delineated towards the luminal side, visible both in longitudinal and transverse planes, most commonly concentric in transverse scans.’ At the superficial temporal artery, the interobserver reliability in acquired and dynamic images has a k = 0.87 and 0.60 respectively; the intraobserver reliability in acquired images and live exercises has a k = 0.88 and 0.71 respectively. Ultrasonography is more reliable (k = 0.8) than temporal artery biopsy (k = 0.4) when compared against physician verified diagnosis at 100-week follow-up. Ultrasonography of 25 patients may be enough for service validation if audited against biopsy and long-term outcomes. Activity and Damage form the twin sides of vasculitis assessment. We have validated the Birmingham Vasculitis Activity Score v3 in two separate studies with convergent validity against treatment decision (r = 0.54) and excellent interobserver reliability (ICC = 0.996). A new Combined Damage Assessment index had lower interobserver (ICC = 0.78) and intraobserver reliability (ICC = 0.87) vs the Vasculitis Damage Index (ICC = 0.94 and 0.92 respectively). Granulomatosis with Polyangiitis, Microscopic Polyangiitis and Eosinophilic Granulomatosis with Polyangiitis have remission rates of 30%-93%, 75%-89% and 81%-91% respectively. The 5-year survival is 74%-91%, 45%-76% and 60%-97% respectively. At diagnosis, the quality of life as measured by the Short Form – 36 is worse than normative data. Older age and neurologic involvement at baseline are associated with lower physical composite scores. My work has resulted in improvements in the diagnosis of Giant Cell Arteritis, assessment of primary systemic vasculitis and understanding outcomes in Antineutrophil Cytoplasm Antibody associated vasculitis. They have also informed the research agenda for further developments in the field

Diagnostic tools in Rhinology EAACI position paper

This EAACI Task Force document aims at providing the readers with a comprehensive and complete overview of the currently available tools for diagnosis of nasal and sino-nasal disease. We have tried to logically order the different important issues related to history taking, clinical examination and additional investigative tools for evaluation of the severity of sinonasal disease into a consensus document. A panel of European experts in the field of Rhinology has contributed to this consensus document on Diagnostic Tools in Rhinology

International Consensus Statement on Allergy and Rhinology: Rhinosinusitis

BACKGROUND: The body of knowledge regarding rhinosinusitis (RS) continues to expand, with rapid growth in number of publications yet substantial variability in the quality of those presentations. In an effort to both consolidate and critically appraise this information, rhinologic experts from around the world have produced the International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR:RS). This executive summary consolidates the findings of the ICAR:RS document. METHODS: ICAR:RS presents over 140 topics in the forms of evidence-based reviews with recommendations (EBRRs) and evidence-based reviews (EBR). The structured recommendations of the EBRR sections are summarized in this executive summary. RESULTS: This summary compiles the EBRRs regarding medical and surgical management of acute RS (ARS) and chronic RS with and without nasal polyps (CRSwNP and CRSsNP). CONCLUSION: This ICAR:RS Executive Summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS

International Consensus Statement on Rhinology and Allergy: Rhinosinusitis

Background: The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR‐RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR‐RS‐2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence‐based findings of the document. Methods: ICAR‐RS presents over 180 topics in the forms of evidence‐based reviews with recommendations (EBRRs), evidence‐based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary. Results: ICAR‐RS‐2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence‐based management algorithm is provided. Conclusion: This ICAR‐RS‐2021 executive summary provides a compilation of the evidence‐based recommendations for medical and surgical treatment of the most common forms of RS

The role of epithelial cells and fibroblasts in the pathogenesis of chronic rhinosinusitis

PhD ThesisChronic rhinosinusitis without nasal polyps (CRSsNP) is a heterogeneous condition with common symptoms, clinical and radiological findings. CRSsNP is typified by inflammation of the sinonasal epithelium and development of fibrosis, yet its precise pathophysiology remains elusive. Recently stromal cells have been shown to act like immune effector cells in orchestrating chronic inflammation. Histological analysis of tissue biopsies from patients with CRSsNP demonstrates recruitment of circulating inflammatory cells, though the precise role of structural cells such as epithelial and fibroblast cells in CRSsNP remains to be discovered. Aims 1. (a) Recruit phenotyped cohorts of control & CRSsNP participants. (b) Characterise recruited CRSsNP participants’ tissue samples and isolated epithelial & fibroblast cells. 2. Assay the sinonasal environment to determine any association between, infection, inflammation and remodelling. 3. Identify clusters of genes differentially expressed in CRSsNP & control participants. Methods Cohorts of healthy control and CRSsNP participants were recruited. Matched tissue biopsy, epithelial and fibroblast cells were harvested together with clinical, radiological, microbiological and mucosal swab data. Tissue and cellular samples were characterised to confirm their identity and disease status. The sinonasal environment was characterised from mucosal swabs and analysed for a range of 40 human disease biomarkers. Transcriptome analysis was performed using microarrays and RNA sequencing with downstream bioinformatics investigation of the data. Results 47 age and sex matched CRSsNP and control participants were recruited, differing significantly in symptom and radiological scores. Histological analysis of tissue biopsy specimens was consistent with CRSsNP and control samples. Matched epithelial and fibroblast cells were generated. Assay of the sinonasal microenvironment identified 13 discriminant mediators separating CRSsNP samples from controls using a novel, non-invasive technique. Transcriptomics identified 239 differentially expressed genes in CRSsNP tissue biopsy samples. Cellular samples differed significantly from their matched tissue biopsies. Conclusions This thesis characterises a cohort of tightly defined CRSsNP patients and healthy controls to investigate the potential role of epithelial and fibroblast cells in CRSsNP. Transcriptomics has demonstrated clusters of genes upregulated in CRSsNP, however changes were not consistent in matched cellular samples questioning the validity of cellular models in CRSsNP. Additionally, a straightforward, non-invasive measure of the CRSsNP cytokine profile has been demonstrated. The mediators identified in these assays could potentially be developed as biomarkers of sinonasal inflammation as an adjunct in patient management.Wellcome Trus