In this video, Jonathan A. Bernstein, MD, speaks about the pathogenesis of chronic rhinosinusitis with and without nasal polyps, the clinical management of chronic rhinosinusitis with and without nasal polyps, and updates of recent chronic rhinosinusitis guidelines. Dr Bernstein also spoke about these topics during his session titled “Updates on Sinusitis Parameter” at ACAAI Annual Scientific Meeting 2022.

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Jonathan A. Bernstein, MD, is a professor of clinical medicine at the University of Cincinnati College of Medicine in the Division of Rheumatology, Allergy and Immunology and Partner of Bernstein Allergy Group and Bernstein Clinical Research Center (Cincinnati, OH).

TRANSCRIPTION:

Dr Jonathan A. Bernstein:

I'm Dr. Jonathan Bernstein, professor of medicine at the University of Cincinnati, and partner of Bernstein Allergy Group and Clinical Research Center. The objectives of this talk were to define the pathogenesis of chronic rhinosinusitis with and without nasal polyps, determine the clinical management of chronic rhinosinusitis with and without nasal polyps, and then describe updates of recent chronic rhinosinusitis guidelines that just came out.

So, we reviewed what is chronic rhinosinusitis? We talked about the pathogenesis. There's type 2 inflammation versus type 1 or type 3 inflammation, which is typically more neutrophilic infiltrates and lower numbers of eosinophils. And of course, most of the patients with chronic rhinosinusitis with nasal polyps are more type 2 inflammation and you see more type 1 or type 3 inflammation in the chronic rhinosinusitis without nasal polyps.

We talked about the differential diagnosis of chronic rhinosinusitis and briefly talked about infectious causes and why patients would get recurrent infections such as biofilms forming is a source of bacteria that can change from a resting state to their planktonic form, resulting in super-infection. And they can be these sources for different antigens or super-antigens and they can promote inflammation in the sinuses.

We also talked about non-eosinophilic sinusitis and how that leads to recurrent chronic sinusitis, and the different effector cells that are involved in this condition. And then we made our way through... In preparation for talking about the guidelines, we talked about what are important outcome themes in patients with chronic rhinosinusitis? And that there's sometimes discordance between what the patient reports and what the practitioner reports. And we talked about validated patient-report outcome measures that are used in clinical studies that could also be used in the practice setting to assess quality of life, to assess response to treatment and so forth. And one of those tools is the SNOT, the SNOT-22, which stands for the sino-nasal outcome test. There are other visual ways of assessing chronic rhino sinusitis using the Lund-Mackay CT scan assessment, and we showed an example of that. And then we also talked about nasal endoscopy, which can be used to grade polyps size.

And then we talked about a little bit about the therapeutic implications in future directions and how there's a need for additional research to understand pathogenesis better of the chronic rhinosinusitis without nasal polyps. They seem to be a little bit more difficult to manage. And so the pathways, which there are a number of pathways and the type 2 inflammatory arm of inflammation, which have been targeted for treatment. And I showed some examples of that. These are essentially drugs that are used for other conditions that have been repurposed for chronic sinusitis, including dupilumab, mepolizumab, omalizumab, and benralizumab.

So, we did then start to review the sinusitis guidelines and what was different in the guideline in that there were probably softer recommendations compared to the 2004. We gave more suggesting recommendations rather than recommend. Recommend is based on stronger evidence whereas suggest is based on weaker evidence. So I think after doing the grade analysis, we were able to show that some of these recommendations were more conditional. And then we talked about PICO questions, which stands for population intervention comparison outcome questions and how these questions were formed, and we had three PICO questions in the guideline. One was look at intranasal corticosteroids, the benefits of using them. One was to look at biologics and one was to look at aspirin therapy after desensitization.

And I reviewed the recommendations. For instance, nasal corticosteroids were recommended over no intranasal corticosteroid for the treatment of chronic rhinosinusitis with nasal polyps. All of these recommendations, however, were conditional recommendations based on low certainty of evidence due to the low number of well-designed, randomized clinical trials that were not biased. Similarly, we talked about the fact that the guidelines have tips for shared decision-making. How to discuss what are the advantages, pros and cons, costs, availability, accessibility, practical implications of delivery. These are all important things to discuss with patients.

We provided nice tables to show how the different studies compared with respect to critical outcomes versus important outcomes and so forth. And these were all originally described by the patient and the panel of experts as which ones were critical, which ones were important, and which ones were less important.

The second question was related to biologics, and the panel suggested biologics rather than no biologics. Again, a conditional recommendation based on moderate certainty of evidence. And again, talked about shared decision-making points. This is something that is discussed in the guidelines and showed a nice table comparing improvement in quality-of-life symptoms, smell, rescue between the different biologics that are approved for chronic rhinosinusitis with nasal polyps.

And then the final question was regarding aspirin-exacerbated respiratory disease and using aspirin therapy after desensitization. And it was recommended that this treatment be used rather than no aspirin therapy. This was a conditional recommendation as well, with a moderate certainty of evidence. And again, we talked about the same kind of shared decision-making. There are increased risks with aspirin in that people have a greater risk of side effects such as bleeding, and this would be worse with older individuals, low birth weight, BMI, things of that nature. And we also talked that biologics may be preferred over aspirin treatment after desensitation in patients who experienced risks of harms with aspirin treatment, and so they may not wish to undergo this treatment.

But again, patients allergic to non-steroidals who require an enset for alternative indications such as cardiovascular disease or arthritis. They may prefer this approach over other options. So this is what we talked about, shared decision-making with the patient. And we show a table, which shows that it is efficacious. It has intermediate benefit in terms of improving quality of life, but it also has significant and most beneficial effects in terms of reducing symptoms, but it does have the most harmful effects in terms regarding adverse effects because this is associated with taking chronic daily aspirin.

So I think that the takeaway points from this lecture was chronic rhinosinusitis, a heterogeneous chronic disease as well defined phenotypes, diagnosis requires a thorough history and physical exam with appropriate confirmatory testing. Patient report outcomes should be used in clinical practice to establish severity and monitor response to treatment. Understanding the pathogenesis of non-eosinophilic and eosinophilic chronic rhinosinusitis has resulted in novel therapies which can improve the clinical outcomes of these challenging conditions. And grade methodology evidence-based guidelines are essential for elucidating best treatment approaches in conjunction with shared decision-making.