Publications by authors named "Devyani Lal"

74 Publications

"Black fungus": a perspective on the coronavirus disease 2019 (COVID-19)-associated rhino-orbital mucormycosis epidemic in India.

Int Forum Allergy Rhinol 2021 08 29;11(8):1278-1279. Epub 2021 Jun 29.

Department of Otorhinolaryngology-Head and Neck Surgery, Mayo Clinic, Phoenix, Arizona, USA.

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http://dx.doi.org/10.1002/alr.22855DOI Listing
August 2021

Urine Leukotriene E4: Implications as a Biomarker in Chronic Rhinosinusitis.

Otolaryngol Head Neck Surg 2021 May 11:1945998211011060. Epub 2021 May 11.

Department of Otolaryngology-Head & Neck Surgery, Mayo Clinic, Scottsdale, Arizona, USA.

Objective: To provide a comprehensive state-of-the-art review of the emerging role of urine leukotriene E4 (uLTE4) as a biomarker in the diagnosis of chronic rhinosinusitis (CRS), aspirin-exacerbated respiratory disease (AERD), and asthma.

Data Sources: Ovid MEDLINE(R), Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus.

Review Methods: A state-of-the-art review was performed investigating the role of uLTE4 as a diagnostic biomarker, predictor of disease severity, and potential marker of selected therapeutic efficacy.

Conclusions: uLTE4 has been shown to be a reliable and clinically relevant biomarker for CRS, AERD, and asthma. uLTE4 is helpful in ongoing efforts to better endotype patients with CRS and to predict disease severity.

Implications For Practice: Aside from being a diagnostic biomarker, uLTE4 is also able to differentiate aspirin-tolerant patients from patients with AERD and has been associated with objective disease severity in patients with CRS with nasal polyposis. uLTE4 levels have also been shown to predict response to medical therapy, particularly leukotriene-modifying agents.
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http://dx.doi.org/10.1177/01945998211011060DOI Listing
May 2021

Gender and authorship trends in rhinology, allergy, and skull-base literature from 2008 to 2018.

Int Forum Allergy Rhinol 2021 Mar 16. Epub 2021 Mar 16.

Department of Otolaryngology-Head and Neck Surgery, Emory University Atlanta, Atlanta, Georgia, USA.

Background: A recent analysis suggested potential narrowing of the gender gap in research productivity in the field of rhinology. This analysis did not, however, provide insight into how the genders are represented in the rhinologic literature. This study aimed to evaluate 11 years of literature to evaluate for gender differences in authorship position, collaborations, category and content of research, citations, and funding to gain perspective on how gender and authorship has changed over time.

Methods: Authorship data for all articles on rhinologic subject matter published between January 1, 2008 and December 31, 2018 in four otolaryngology journals was collected. The gender of authors was determined by protocol. Category and content of research and funding status/source were additionally obtained.

Results: Data were collected from 2666 articles. Gender of 14,510 authors was determined. Female authors accounted for 23% of the overall authors and male authors accounted for 77%. Female first authorship increased significantly over time, but there was no change in female senior authorship. The percentage of female authors steadily increased over time, whereas male authorship decreased slightly. Mixed gender teams were shown to be increasing in frequency. Women published more than expected in basic science and allergy and less than expected in skull base. On funded studies, women were significantly underrepresented as senior authors.

Conclusion: This study represents the first assessment of gender differences in the rhinology literature. Areas where female representation can improve include senior authorship, increased involvement in skull base publications, and increased funding.
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http://dx.doi.org/10.1002/alr.22793DOI Listing
March 2021

Benefits of biologic therapy administered for asthma on co-existent chronic rhinosinusitis: A real-world study.

Int Forum Allergy Rhinol 2021 Aug 1;11(8):1152-1161. Epub 2021 Feb 1.

Department of Otorhinolaryngology, Mayo Clinic, Phoenix, AZ.

Background: Asthma and some chronic rhinosinusitis (CRS) subtypes are mediated by similar pathophysiologic mechanisms. The purpose of this study was to evaluate the effects of biologic therapy for asthma on co-existent CRS in the "real-world" setting.

Methods: A review of electronic health records (2016-2019) at Mayo Clinic was conducted to identify asthma patients treated with biologics who had co-existent CRS. Matched-pair analyses compared pretherapy and posttherapy Lund-Mackay computed tomography (CT) scores and 22-item Sino-Nasal Outcome Test (SNOT-22) scores. Performance of endoscopic sinus surgery (ESS) after initiating biologics was studied.

Results: We identified 247 patients who received anti-asthma biologic therapy and had co-existent CRS. Of these, 181 patients (73.3%) had CRS with nasal polyposis (CRSwNP) and 66 (26.7%) had CRS without nasal polyposis (CRSsNP). The biologics utilized were omalizumab (51.0%), mepolizumab (46.6%), benralizumab (10.5%), reslizumab (1.6%), and dupilumab (2.4%). Anti-interleukin-5 (anti-IL-5) intervention was associated with significant improvement in CT scores (CRS overall, CRSwNP subgroup, CRSsNP subgroup) and SNOT-22 scores (CRS overall, CRSwNP subgroup). Patients on omalizumab had a decrease in CT scores, but not SNOT-22 scores. ESS was performed in 206 patients (84.1%); 55 (22.3%) underwent surgery post-biologic intervention (anti-IL-5: 16.5%; omalizumab 27.8% of patients).

Conclusion: Anti-IL-5 agents were associated with improved CT and SNOT-22 scores in the overall CRS group and in CRSwNP subgroup; CRSsNP patients showed improved CT scores only. Omalizumab improved CT but not SNOT-22 scores. ESS was performed in 22% of patients after initiating biologics. These real-world results may influence future trial designs and clinical applications of biologics for CRS. ©2021 ARSAAOA, LLC.
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http://dx.doi.org/10.1002/alr.22774DOI Listing
August 2021

Outcomes of Septal Perforation Repair With Concurrent Endoscopic Sinus Surgery.

Otolaryngol Head Neck Surg 2021 Jan 26:194599820982912. Epub 2021 Jan 26.

Department of Otolaryngology Head and Neck Surgery, Mayo Clinic Arizona, Phoenix, Arizona, USA.

Objective: This study reviews a cohort of patients in whom septal perforation repair was performed concurrently with endoscopic sinus surgery. We present an endonasal perforation repair technique using bilateral mucosal flaps with an autogenous interposition graft. Intraoperative and postoperative management of the combined surgical patient is discussed and perforation closure outcomes are reported.

Study Design: Case series.

Setting: Tertiary care center.

Methods: In this institutional review board-approved retrospective chart review, adult patients who underwent concurrent bilateral mucosal flap septal perforation repair and endoscopic sinus surgery from March 1992 to March 2020 were identified. Data on demographics, clinical presentations, perforation size, surgical techniques, and outcomes were extracted and analyzed for patients with a minimum of 3 months of follow-up.

Results: Fifty-six patients met study inclusion criteria. Nasal obstruction/congestion was the most frequent symptom reported (80.4%), followed by crusting and epistaxis. Mean perforation size measured at the time of surgery was 14.7 (range, 3-41) mm in length by 9.3 (range, 2-23) mm in height. Temporalis fascia was the most frequent (57.9%) interposition graft material used. Complete perforation closure at the time of the last follow-up was noted in 51 (91.1%) patients. Only 1 failure was noted in the last 48 attempted repairs.

Conclusion: Patients with a perforated septum may have coexistent chronic sinusitis. The feasibility of attempting concurrent sinus surgery and perforation repair has been questioned. Our review demonstrates a high perforation closure rate when a bilateral mucosal flap procedure is performed after sinus surgery is performed at the same setting.
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http://dx.doi.org/10.1177/0194599820982912DOI Listing
January 2021

Microbiology, Histopathology, and Radiographic Findings in Silent Sinus Syndrome.

Am J Rhinol Allergy 2021 Jan 19:1945892421989161. Epub 2021 Jan 19.

Department of Otorhinolaryngology/Head and Neck Surgery, Mayo Clinic, Phoenix, Arizona.

Background: The histopathology and microbiology associated with silent sinus syndrome (SSS) have not been well described.

Objective: This study details the histopathological and microbiological characteristics in addition to radiographic findings of SSS in comparison to those of chronic maxillary sinusitis (CRS).

Methods: 42 patients diagnosed with SSS at Mayo Clinic Hospital in Arizona were identified. Paranasal computed tomography scans of the 42 SSS patients as well as 42 matched CRS patients were analyzed in order to assess differences in the prevalence of septal spurs/deviation. 20 of the SSS patients and 19 of the matched CRS patients also had histopathology and microbiology reports, which were compiled and summarized. Additionally, 19 SSS and 19 matched CRS patients were contacted via phone survey for a more complete patient history regarding maxillary dental disease/surgery.

Results: SSS patients have a significantly higher prevalence of septal spurs/deviation than CRS patients. The microbiomes of SSS patients more closely resemble those of healthy controls than those of CRS patients. Analysis of the histopathology of SSS reveals chronic, non-specific inflammation similar to that seen in non-eosinophilic CRS without polyps. SSS patients were significantly more likely to have a history of maxillary dental disease requiring surgery.

Conclusion: These data support the hypothesis that the pathogenesis of SSS is more likely due to anatomical/mechanical factors than inflammatory/microbiological factors.
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http://dx.doi.org/10.1177/1945892421989161DOI Listing
January 2021

International consensus statement on allergy and rhinology: rhinosinusitis 2021.

Int Forum Allergy Rhinol 2021 Mar;11(3):213-739

Rutgers New Jersey Medical School, Newark, NJ.

I.

Executive Summary: 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.
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http://dx.doi.org/10.1002/alr.22741DOI Listing
March 2021

Leveraging Advanced Practice Providers in an Otolaryngology Practice.

Otolaryngol Head Neck Surg 2021 05 17;164(5):959-963. Epub 2020 Nov 17.

Department of Otolaryngology Head-Neck Surgery, Mayo Clinic, Phoenix, Arizona, USA.

Objective: Advanced practice providers (APPs) may see patients independently or assist in "collaborative" clinics in otolaryngology practices. Our goal was to redesign the collaborative physician-APP clinic model to increase patient access, maintain financial sustainability, and optimize patient and staff experience.

Methods: The study was performed in a tertiary care academic rhinology clinic seeing adult patients. The DMAIC framework (define, measure, analyze, improve, control) was used to develop the new model. The process shift between old and new models was analyzed by utilizing a statistical process control chart. Patient and staff surveys were tracked.

Results: The collaborative physician-APP model was redesigned into 2 parallel and independently run ("concurrent") physician and APP clinics. Patient access increased by 38.9% from a mean of 17.9 patients per collaborative clinic (n = 15 days, 269 patients) to 29.3 patients per concurrent clinic (n = 12 days, 352 patients). Medicare reimbursement rate modeling showed the collaborative clinic to operate at a loss of $1341.51 per day, while the concurrent clinic model operated at a $1309.88 gain (200% positive change). Patient and staff experience tracked positively.

Discussion: Otolaryngology clinics can become overwhelmed by the volume of empaneled established patients. Traditional collaborative physician-APP clinics see the same panel of patients together. However, these can be successfully redesigned to a concurrent model. Concurrent clinics improve patient access and provider satisfaction while maintaining patient satisfaction and fiscal performance.

Implications For Practice: Leveraging an experienced APP to run a parallel and independent clinic alongside the physician (concurrent clinic model) may improve patient access, financial metrics, and patient/staff experience.
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http://dx.doi.org/10.1177/0194599820972924DOI Listing
May 2021

Intranasal Corticosteroid Therapy: Systematic Review and Meta-analysis of Reported Safety and Adverse Effects in Children.

Otolaryngol Head Neck Surg 2020 Dec 14;163(6):1087-1096. Epub 2020 Jul 14.

Department of Otolaryngology-Head & Neck Surgery, Mayo Clinic, Phoenix, Arizona, USA.

Objectives: To address concerns related to the safety profile of both Food and Drug Administration (FDA)-approved and non-FDA-approved intranasal corticosteroid (INCS) use in the pediatric population.

Data Source: Systematic review of MEDLINE, PubMed, and EMBASE databases using comprehensive search strategy, including all INCS formulations and adverse events. The study design was developed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Additional sources were identified from study references of relevant articles.

Review Methods: A structured literature search was conducted. Extracted data included age, population size, study design, drug (dosage, route, and frequency), presence of hypothalamic-pituitary-adrenal (HPA) axis suppression, ocular symptoms, and growth velocity adverse events.

Results: A total of 33 studies met inclusion criteria. The studies included use of INCS as nasal sprays and drops. There were no persistent abnormalities noted in cortisol level or intraocular pressure change. Growth velocity reduction was reported in 3 of 10 randomized trials. Meta-analysis of epistaxis and headache showed no significant difference in the incidence of headache or epistaxis when FDA-approved INCSs were compared to placebo, with a relative risk of 1.12 (95% CI, 0.77-1.63; = .56) and 0.84 (95% CI, 0.60-1.18; = .32), respectively. Meta-analysis was not performed for growth velocity, HPA axis suppression, and ocular change.

Conclusions: INCSs in FDA-approved routes of administration are generally safe to use in the pediatric population. Use of non-FDA-approved INCS drops may increase risk of iatrogenic Cushing's syndrome. Growth velocity reduction, HPA axis suppression, and visual changes due to INCS are uncommon.
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http://dx.doi.org/10.1177/0194599820931454DOI Listing
December 2020

Intranasal Corticosteroid Therapy: Systematic Review and Meta-analysis of Reported Safety and Adverse Effects in Adults.

Otolaryngol Head Neck Surg 2020 Dec 16;163(6):1097-1108. Epub 2020 Jun 16.

Department of Otolaryngology Head & Neck Surgery, Mayo Clinic in Arizona, Phoenix, Arizona, USA.

Objectives: To address concerns related to the safety profile of both Food and Drug Administration (FDA)-approved and non-FDA-approved intranasal corticosteroid (INCS) use in the adult population.

Data Source: Systematic review of MEDLINE, PubMed, and EMBASE databases using a comprehensive search strategy including all INCS formulations and adverse events. The study design was developed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Additional sources were identified from study references of relevant articles.

Review Methods: A structured literature search was conducted. Each study was graded for level of evidence using the Oxford Centre for Evidence-Based Medicine. Extracted data included population size, study design, drug (dosage, route, and frequency), presence of hypothalamus pituitary axis suppression, ocular symptoms, and treatment-related adverse events.

Results: A total of 60 studies met inclusion criteria. The studies included use of INCS as metered nasal sprays, drops, injections, aerosols, and irrigations. There were no persistent abnormalities in cortisol level or intraocular pressure change. Meta-analysis of epistaxis showed a significantly increased risk in the FDA-approved treatment group in comparison with control (risk ratio 1.56; 95% confidence interval, 1.13-2.14; = .007).

Conclusions: Overall, it appears that the use of both FDA and published non-FDA application of INCS are safe in the adult population. Meta-analysis demonstrated an increased risk of epistaxis in patients using INCS compared with placebo. Otherwise, there was no significant difference between in adults in the treatment group and placebo group. As an important caveat, the interpretation of safety of nonstandard INCS is restricted to delivery methods and dosages published in the literature.
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http://dx.doi.org/10.1177/0194599820931455DOI Listing
December 2020

Rhinologic Practice Special Considerations During COVID-19: Visit Planning, Personal Protective Equipment, Testing, and Environmental Controls.

Otolaryngol Head Neck Surg 2020 10 2;163(4):676-681. Epub 2020 Jun 2.

Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic Arizona, Phoenix, Arizona, USA.

As rhinologists return to practice amid SARS-CoV-2, special considerations are warranted given the unique features of their subspecialty. Rhinologist manipulation of nasal tissue, proximity, and frequent aerosol-generating procedures (AGPs) create high risk for infection transmission. There are 4 areas of special consideration to mitigate risk: (1) previsit planning for risk stratification/mitigation, (2) appropriate personal protective equipment, (3) preprocedural testing, and (4) environmental controls. During previsit planning, risk factors of the patient and procedures are considered. High-risk AGPs are identified by duration, proximity, manipulation of high-viral load tissue, and use of powered instrumentation. Appropriate personal protective equipment includes selection of respiratory and eye protection. COVID-19 testing can screen for asymptomatic carriers prior to high-risk procedures; however, alternative testing methods are required in rhinologic patients not eligible for nasopharyngeal testing due to nasal obstruction or skull base defects. Last, AGPs in rhinologic practices require considerations of room air handling and environmental controls.
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http://dx.doi.org/10.1177/0194599820933169DOI Listing
October 2020

Machine learning of biomarkers and clinical observation to predict eosinophilic chronic rhinosinusitis: a pilot study.

Int Forum Allergy Rhinol 2021 Jan 7;11(1):8-15. Epub 2020 Jul 7.

Department of Otorhinolaryngology, Mayo Clinic, Phoenix, AZ.

Background: Subtyping chronic rhinosinusitis (CRS) by tissue eosinophilia has prognostic and therapeutic implications, and is difficult to predict using peripheral eosinophil counts or polyp status alone. The objective of this study was to test machine learning for prediction of eosinophilic CRS (eCRS).

Methods: Input variables were defined as peripheral eosinophil count, urinary leukotriene E4 (uLTE4) level, and polyp status. The output was diagnosis of eCRS, defined as tissue eosinophil count >10 per high-power field. Patients undergoing surgery for CRS were retrospectively reviewed for complete datasets. Univariate analysis was performed for each input as a predictor of eCRS. Logistic regression and artificial neural network (ANN) machine learning models were developed using random and surgeon-specific training/test datasets.

Results: A total of 80 patients met inclusion criteria. In univariate analysis, area under the receiver operator characteristic curve (AUC) for peripheral eosinophil count and uLTE4 were 0.738 (95% confidence interval [CI], 0.616 to 0.840) and 0.728 (95% CI, 0.605 to 0.822), respectively. Presence of polyps was 94.1% sensitive, but 51.7% specific. Logistic regression models using random and surgeon specific datasets resulted in AUC of 0.882 (95% CI, 0.665 to 0.970) and 0.945 (95% CI, 0.755 to 0.995), respectively. ANN models resulted in AUC of 0.918 (95% CI, 0.756 to 0.975) and 0.956 (95% CI, 0.828 to 0.999) using random and surgeon-specific datasets, respectively. Model comparison of logistic regression and ANN was not statistically different. All machine learning models had AUC greater than univariate analyses (all p < 0.003).

Conclusion: Machine learning of 3 clinical inputs has the potential to predict eCRS with high sensitivity and specificity in this patient population. Prospective investigation using larger and more diverse populations is warranted.
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http://dx.doi.org/10.1002/alr.22632DOI Listing
January 2021

The neurotrophic potential of human platelet lysate substitution for fetal bovine serum in glial induction culture medium.

Neurosci Lett 2020 06 5;730:135025. Epub 2020 May 5.

Head and Neck Regenerative Medicine Program, Center for Regenerative Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; Department of Otolaryngology - Head and Neck Surgery, Mayo Clinic, Phoenix, AZ 85054, USA. Electronic address:

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http://dx.doi.org/10.1016/j.neulet.2020.135025DOI Listing
June 2020

Association of cough with asthma in chronic rhinosinusitis patients.

Laryngoscope Investig Otolaryngol 2020 Apr 11;5(2):200-204. Epub 2020 Mar 11.

Department of Otorhinolaryngology Mayo Clinic Phoenix Arizona USA.

Objective: To determine whether the complaint of cough in chronic rhinosinusitis (CRS) patients is associated with asthma and if there is a potential predictive value for asthma diagnosis.

Method: Consecutive patients presenting for initial evaluation at a tertiary rhinology clinic who were diagnosed with CRS were considered for inclusion in a cross-sectional study. The presence and severity of cough was determined using the 22-item Sinonasal Outcome Test (SNOT-22). Subgroup analysis included asthma diagnosis confirmed by pulmonary function testing (PFT) in our institution, and for chronic rhinosinusitis patients with (CRSwNP) and without nasal polyps (CRSsNP).

Results: The total study population included 297 patients with a diagnosis of CRS, with 63.9% of patients reporting cough. Physician-confirmed diagnosis of asthma was made in 38.7% of patients, and confirmed in 69.6% by PFT. Cough was more frequently reported by CRS patients diagnosed with asthma (relative risk [RR] = 1.60, 95% confidence interval [CI], 1.13-2.25), with sensitivity of 73.9% (95% CI, 65.0%-81.1%). This remained significant in the CRSsNP subgroup (RR = 2.65, 95% CI, 1.32-5.30), with sensitivity of 83.3% (95% CI, 70.4%-91.3%) and specificity of 41.2% (95% CI, 33.2%-49.8%). Cough was not associated with asthma in CRSwNP patients (RR = 1.26, 95% CI, 0.89-1.79). Cough severity had poor predication for asthma diagnosis (AUC = 0.60, 95% CI, 0.54-0.65).

Conclusions: Complaint of cough is associated with diagnosis of asthma in CRS patients. In CRSsNP, complaint of cough was sensitive for asthma diagnosis, although specificity was low. Cough in CRS patients can be multifactorial and asthma may be an important diagnostic consideration.

Level Of Evidence: 4.
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http://dx.doi.org/10.1002/lio2.373DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7178445PMC
April 2020

Surgical Outcomes with Midline versus Lateral Approaches for Cranial Base Chordomas: A Systematic Review and Meta-Analysis.

World Neurosurg 2020 08 14;140:378-388.e2. Epub 2020 Apr 14.

Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona, USA; Department of Otolaryngology, Mayo Clinic, Phoenix, Arizona, USA; Department of Radiology, Mayo Clinic, Phoenix, Arizona, USA; Precision Neuro-therapeutics Innovation Laboratory, Mayo Clinic, Phoenix, Arizona, USA; Neurosurgery Simulation and Innovation Laboratory, Mayo Clinic, Phoenix, Arizona, USA. Electronic address:

Background: Cranial base chordomas are complex lesions centered on the clivus that surgically can be approached from either a midline or a lateral corridor.

Objective: To compare the surgical outcomes from midline versus lateral approaches by conducting a meta-analysis of the literature.

Methods: Studies were identified between 2000 and 2018. The primary outcome was gross total resection (GTR) rate. The secondary outcomes were recurrence rate and rates of cerebrospinal fluid (CSF) leak and new cranial nerve palsy. Odds ratios were calculated with a random-effect model using studies describing both approaches. An indirect (proportion) meta-analysis was performed pooling studies describing either of the approaches. Individual patient data were analyzed for differences in GTR or recurrence rate with different tumor extensions.

Results: Thirty-three studies were found suitable for indirect meta-analysis and 10 studies for direct meta-analysis. The overall odds of GTR with a midline approach compared with a lateral approach was 0.83 (95% confidence interval [CI], -0.43 to 1.62). The odds ratios for recurrence, CSF leak, and new cranial nerve palsy were 0.82 (95% CI, 0.26-2.56), 1.49 (95% CI, 0.14-15.5), and 0.14 (95% CI, 0.04-0.56), respectively. With individual patient data analysis, no statistically significant difference was observed in GTR or recurrence rates between the 2 approaches with different tumor extensions.

Conclusions: The meta-analysis did not show any significant difference in GTR or recurrence rates between the midline versus lateral approaches. Tumor extension to different compartments did not affect the GTR or recurrence rates with either approach. In terms of complications, CSF leak rate was higher in midline approaches and cranial nerve palsy was higher in lateral approaches.
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http://dx.doi.org/10.1016/j.wneu.2020.03.192DOI Listing
August 2020

The Rationale for Multidisciplinary Management of Chronic Rhinosinusitis with Nasal Polyposis.

J Allergy Clin Immunol Pract 2020 05 12;8(5):1565-1566. Epub 2020 Mar 12.

Division of Allergy, Asthma, and Clinical Immunology, Mayo Clinic, Scottsdale, AZ. Electronic address:

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http://dx.doi.org/10.1016/j.jaip.2020.03.001DOI Listing
May 2020

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

Laryngoscope Investig Otolaryngol 2020 Feb 7;5(1):5-10. Epub 2020 Feb 7.

Department of Otorhinolaryngology - Head & Neck Surgery Mayo Clinic Phoenix Arizona.

Objective: The histopathological characteristics of primary vs recurrent nasal polyps in patients with chronic rhinosinusitis with nasal polyps (CRSwNP) have not been studied comprehensively. Identification of these features may be helpful for prognostication, postoperative management, and consideration of novel eosinophil-targeting biologic therapy. This study investigates the histopathological differences in primary vs recurrent CRSwNP tissue.

Methods: Patients undergoing endoscopic sinus surgery for CRSwNP were included if all 13 histopathological and mucin characteristics on a standardized report were available. Histopathology parameters were compared in surgical tissue and mucin from primary vs recurrent CRSwNP.

Results: Complete structured histopathology reports were available for 96 patients (39 primary polyps and 57 recurrent polyps). Compared to primary polyp tissue, recurrent CRSwNP mucin was significantly more likely to feature eosinophil aggregates (57.9% vs 35.9%; = .047). Tissue eosinophilia (using a threshold >10 per high power field [HPF]) was not significantly different in primary and recurrent CRSwNP tissue. Other histopathologic parameters and clinical characteristics were similar.

Conclusion: Eosinophil aggregates on histopathology are significantly more likely to be present in recurrent CRSwNP. In the limited series, tissue eosinophilia (>10 per HPF) was not significantly different in primary and recurrent CRSwNP. Therefore, in addition to the study of tissue eosinophilia levels, Rhinologic surgeons should also direct attention to CRSwNP mucin. Mucin eosinophilic aggregates are an independent marker of severe inflammation that is associated more likely with recurrent vs primary polyposis. Further study of this marker may help determine its role of choice of postoperative medical therapies, including anti-eosinophilic biologics.

Level Of Evidence: 4.
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http://dx.doi.org/10.1002/lio2.358DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7042647PMC
February 2020

Inflammatory cell predominance and patterns in chronic rhinosinusitis with and without nasal polyposis patients.

Laryngoscope Investig Otolaryngol 2019 Dec 13;4(6):573-577. Epub 2019 Nov 13.

Department of Otorhinolaryngology Mayo Clinic Phoenix Arizona.

Objectives: There is interest in identifying chronic rhinosinusitis (CRS) endotypes that align pathophysiology with clinical observation and outcomes. CRS with polyps (CRSwNP) has classically been studied with reference to tissue eosinophilia, but the role of other cellular infiltrates remains uncharacterized. No particular tissue prognosticators have been described for CRS without nasal polyps (CRSsNP). Predominance of leukocytes seen in surgical tissue may be useful for differentiating CRS subtypes, severity of inflammation, and outcomes.

Methods: Structured histopathology reports were examined for 277 patients undergoing endoscopic sinus surgery for CRSwNP (n = 115), CRSsNP (n = 141), and recurrent acute rhinosinusitis (RARS, n = 21). Inflammatory predominance was examined for associations with nasal polyposis, asthma, allergic rhinitis, aspirin exacerbated respiratory disease (AERD), immune deficiency, preoperative Lund-Mackay score, and outcome (SNOT-22 score change).

Results: In order of frequency, the prevalence of predominant inflammatory patterns accounting for 93.5% of CRS patients were: lymphoplasmocytic (n = 111), lymphocytic (n = 74), eosinophilic (n = 50), and lymphoplasmocytic with eosinophilic (n = 24). Eosinophilic predominance was 97.4% specific for nasal polyps (95% confidence interval [CI], 93.4%-99.3%), although sensitivity was 43.4% (95% CI, 33.8%-53.4%). The absence of eosinophilic predominance was 100% sensitive for RARS (95% CI, 82.4%-100%), however specificity was 30.8% (95% CI 25.1%-37.1%). There were no significant differences in preoperative SNOT-22 scores or change postoperatively.

Conclusions: Eosinophilic inflammatory predominance was predictive for nasal polyps and against RARS. Nevertheless, the majority of CRSwNP patients had a different inflammatory predominance, demonstrating heterogeneity in CRS, even among patients with nasal polyps. Symptomatic outcomes were not associated with inflammatory predominance through 12 months follow up.

Level Of Evidence: 4.
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http://dx.doi.org/10.1002/lio2.328DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6929577PMC
December 2019

A structured histopathology-based analysis of surgical outcomes in chronic rhinosinusitis with and without nasal polyps.

Laryngoscope Investig Otolaryngol 2019 Oct 21;4(5):497-503. Epub 2019 Aug 21.

Department of Otorhinolaryngology Mayo Clinic Phoenix Arizona U.S.A.

Objectives: Structured histopathology reporting has been recently described for detailing immunopathological characteristics of chronic rhinosinusitis (CRS), and can be utilized for subtyping CRS and personalizing management. This study scrutinized elements of structured histopathology to identify characteristics that prognosticate outcomes following endoscopic sinus surgery (ESS) for CRS patients with nasal polyps (CRSwNP) and without nasal polyps (CRSsNP).

Methods: Outcomes following ESS were measured using the patient-reported 22-item sinonasal outcome test (SNOT-22). Changes in total SNOT-22 scores at 6 and 12 months postoperatively were analyzed. Thirteen parameters reported in structured histopathology of sinus surgical tissue were studied for association with outcomes postsurgery. The overall cohort of all CRS patients was studied, along with subgroup analyses of CRSwNP and CRSsNP patients.

Results: In the entire CRS cohort (n = 171), eosinophil count >10 per high power field (HPF) was associated with greater improvement in SNOT-22 scores at 6 months post-ESS ( = .039). At 12 months follow-up, no histopathological characteristic was associated with change in total SNOT-22 score. In the CRSwNP (n = 66) subgroup, the presence of fibrosis ( = .006) and eosinophil count ≤10 per HPF ( = .025) were associated with less favorable changes in SNOT-22 scores at 12 months follow-up. Fibrosis remained statistically significant in multivariable analysis ( = .007).

Conclusions: At 6 months post-ESS, tissue eosinophilia is associated with significantly higher improvement in SNOT-22 scores, but this difference is diluted by 12 months. Fibrosis was associated with less favorable outcomes in SNOT-22 scores for CRSwNP patients at 12 months and may be a prognosticator for poorer long-term outcomes.

Level Of Evidence: 4.
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http://dx.doi.org/10.1002/lio2.303DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6793607PMC
October 2019

Imaging characteristics and clinical outcomes of biphenotypic sinonasal sarcoma.

Laryngoscope Investig Otolaryngol 2019 Oct 6;4(5):484-488. Epub 2019 Sep 6.

Department of Radiology Mayo Clinic Phoenix Arizona U.S.A.

Objectives: Biphenotypic sinonasal sarcoma (BSS) is a new, rare tumor characterized by concomitant neural and myogenic differentiation. The aim of this study is to describe the imaging characteristics and clinical outcomes of this neoplasm.

Methods: A retrospective review of BSS patients surgically treated within a tertiary academic health care system was performed. Imaging characteristics and clinical outcomes were reviewed.

Results: Five patients underwent surgical resection of BSS tumors. Negative surgical margins were achieved in four (80%) patients. There were no deaths but two (40%) patients developed local recurrences during the postoperative follow-up period (median follow-up 31.4 months). Review of imaging characteristics revealed a median tumor size of 3.8 cm in greatest dimension. All tumors were unilateral and centered within the nasoethmoidal region. In all cases, the tumors extended to the nasal septum, lamina papyracea, and anterior skull base with variable degrees of erosion through these structures. On CT, involved bony structures demonstrated mixed lytic and sclerotic pattern, with definitive hyperostotic bone identified in four (80%) cases. On MRI, tumors were isointense-to-mixed iso/hypointense on both T1- and T2-weighted sequences with one tumor demonstrating mixed T2 hyperintensity. All cases demonstrated gadolinium contrast enhancement.

Conclusions: BSS is a locally aggressive tumor with a low risk of regional or distant metastases but has a significant rate of recurrence even with adequate resection. Despite its rarity, BSS should be considered in the differential diagnosis when imaging demonstrates a unilateral nasoethmoidal mass that is predominantly isointense to cerebral gray matter on T2-weighted MRI and is hyperostotic on CT.

Level Of Evidence: 4.
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http://dx.doi.org/10.1002/lio2.305DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6793931PMC
October 2019

ICAR: endoscopic skull-base surgery.

Int Forum Allergy Rhinol 2019 07;9(S3):S145-S365

University of Pennsylvania, Philadelphia, PA.

Background: Endoscopic skull-base surgery (ESBS) is employed in the management of diverse skull-base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull-base surgery have produced the International Consensus Statement on Endoscopic Skull-Base Surgery (ICAR:ESBS).

Methods: Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence-based review or evidence-based review with recommendations format. Subsequently, each topic was written and then reviewed by skull-base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus.

Results: The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull-base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated.

Conclusion: A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence-based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull-base community to embrace these opportunities and collaboratively address these shortcomings.
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http://dx.doi.org/10.1002/alr.22326DOI Listing
July 2019

Evaluating narrative operative reports for endoscopic sinus surgery in a residency training program.

Laryngoscope Investig Otolaryngol 2019 Jun 23;4(3):279-284. Epub 2019 Apr 23.

Department of Otorhinolaryngology Mayo Clinic Phoenix Arizona U.S.A.

Objective: The narrative operative report (NR) bears testimony to critical elements of patient care. Residents' NRs also provide insights into their comprehension of the procedure. NR documentation is an informal element of surgical residency training but data regarding quality of such training are scant. We aim to evaluate the NR within a residency training program.

Methods: The quality of NRs for endoscopic sinus surgery (ESS) was evaluated through a retrospective analysis of 90 NRs for ESS. Thirty-four elements that the attending surgeon regards as "critical" variables, or quality indicators (QIs), that should be documented, were studied to evaluate quality. A "performance metric (PM)," defined as the average percent of QIs dictated/total word count, was determined. Subgroup analysis by the level of training was additionally performed.

Results: Surgical indications, procedural steps, and immediate postoperative findings were accurately documented in 71%, 84%, and 82% of patients, respectively. The attending surgeon had the highest proportion of included key elements (89% ± 6.2%) followed by junior residents (87% ± 5.7%) and then senior residents (80% ± 14%) ( = .008). The attending surgeon also demonstrated the highest PM, followed by senior and then junior residents ( < .0001).

Conclusions: The quality of NRs was found to be high overall, but not "perfect" for either the attending or trainee surgeon. The PM among residents was expectedly lower than the attending surgeon. We propose that a synoptic reporting system that ensures inclusion of key elements may be helpful in training residents (and attendings) in creating comprehensive and efficient NRs.

Level Of Evidence: 3.
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http://dx.doi.org/10.1002/lio2.264DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6580071PMC
June 2019

Clinical Consensus Statement: Balloon Dilation of the Eustachian Tube.

Otolaryngol Head Neck Surg 2019 07 4;161(1):6-17. Epub 2019 Jun 4.

16 American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA.

Objective: To develop a clinical consensus statement on the use of balloon dilation of the eustachian tube (BDET).

Methods: An expert panel of otolaryngologists was assembled with nominated representatives of general otolaryngology and relevant subspecialty societies. The target population was adults 18 years or older who are candidates for BDET because of obstructive eustachian tube dysfunction (OETD) in 1 or both ears for 3 months or longer that significantly affects quality of life or functional health status. A modified Delphi method was used to distill expert opinion into clinical statements that met a standardized definition of consensus.

Results: After 3 iterative Delphi method surveys, 28 statements met the predefined criteria for consensus, while 28 statements did not. The clinical statements were grouped into 3 categories for the purposes of presentation and discussion: (1) patient criteria, (2) perioperative considerations, and (3) outcomes.

Conclusion: This panel reached consensus on several statements that clarify diagnosis and perioperative management of OETD. Lack of consensus on other statements likely reflects knowledge gaps regarding the role of BDET in managing OETD. Expert panel consensus may provide helpful information for the otolaryngologist considering the use of BDET for the management of patients with OETD.
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http://dx.doi.org/10.1177/0194599819848423DOI Listing
July 2019

Eosinophil peroxidase, GATA3, and T-bet as tissue biomarkers in chronic rhinosinusitis.

J Allergy Clin Immunol 2019 06 8;143(6):2284-2287.e6. Epub 2019 Feb 8.

Department of Otolaryngology, Mayo Clinic, Phoenix, Ariz; Division of Allergy, Asthma, and Clinical Immunology, Mayo Clinic, Scottsdale, Ariz; Division of Pulmonology, Phoenix Children's Hospital, Phoenix, Ariz. Electronic address:

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http://dx.doi.org/10.1016/j.jaci.2019.01.038DOI Listing
June 2019

Submental flap for reconstruction of anterior skull base, orbital, and high facial defects.

Am J Otolaryngol 2019 Mar - Apr;40(2):218-223. Epub 2018 Nov 22.

Purpose: Large anterior skull base, orbital, and high facial defects can present a challenging reconstructive problem. Limited data exists in the literature on the use of a submental flap for reconstructing such defects. We aimed to describe the feasibility, success, and advantages of using variations of the submental flap for reconstruction of anterior skull base, orbital, and high facial defects.

Materials & Methods: Outcomes measured included flap method, flap survival, flap size, reconstructive site complications, donor site complications, and length of hospital stay.

Results: Nine patients were identified that underwent submental flap reconstruction of anterior skull base, orbital, or high facial soft tissue defects. There were 5 pedicled, 2 hybridized, and 2 free submental flap reconstructions. Flap survival was 100%. One flap required leech therapy for early post-operative venous congestion. Average flap skin paddle size was 63.7 cm. Average length of hospital stay was 7.3 days. No complications from the donor site were reported.

Conclusions: Different variations on the submental flap are viable options for reconstruction of high defects in the head and neck. Such flaps have a number of unique qualities that are suitable for reconstruction of anterior skull base, orbital, and high facial defects.
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http://dx.doi.org/10.1016/j.amjoto.2018.11.008DOI Listing
June 2019

Revision endoscopic sinus surgery rates by chronic rhinosinusitis subtype.

Int Forum Allergy Rhinol 2018 09 31;8(9):1047-1051. Epub 2018 May 31.

Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic in Arizona, Phoenix, AZ.

Background: Revision surgery rates following endoscopic sinus surgery (ESS) range between 7% and 50% and are influenced by many factors. This study investigates ESS outcomes for chronic rhinosinusitis (CRS) subtypes.

Methods: Retrospective review of adult CRS patients undergoing ESS with a single surgeon (2010-2015) was conducted. Outcomes were analyzed by CRS subtypes.

Results: ESS was performed in 424 CRS patients (CRS with nasal polyps [CRSwNP], n = 170; CRS without polyps [CRSsNP], n = 254). Most patients (309; 72.9%) could not be specifically subtyped; 115 (27.1%) were subtyped as follows: aspirin-exacerbated respiratory disease (AERD), n = 47 (11.1%); allergic fungal sinusitis (AFS), n = 39 (9.2%); immunodeficiency, n = 21 (5.0%); granulomatosis with polyangiitis (GPA), n = 5 (1.2%); and eosinophilic granulomatosis with polyangiitis (EGPA), n = 3 (0.7%). All subgroups experienced clinically meaningful reduction in postoperative 22-item Sino-Nasal Outcome Test (SNOT-22) scores. At median follow-up of 28 months (interquartile range [IQR], 10-47 months), 19 patients (4%) underwent revision ESS (CRSwNP, n = 6; CRSsNP, n = 13). Revision ESS rates were 3.5% and 5.1% for CRSwNP and CRSsNP, respectively. Revision ESS rate for subtypes were: AERD 2%; AFS 2%; immunodeficiency 14%; GPA 40%; EGPA 0%; and "all other CRS" 4% at median follow-up duration of 36, 28, 41, 37, 44, and 26 months, respectively.

Conclusion: All CRS subtypes demonstrated clinically meaningful improvement in postoperative SNOT-22 scores following ESS. Our overall revision ESS rate was 4% (3.5% in CRSwNP). AFS, AERD, and EGPA groups demonstrated low revision rates, while immunodeficiency and GPA patients required more revision surgery. A contemporary understanding of CRSwNP subtypes facilitated surgical and medical strategies in improving outcomes for AERD, AFS, and EGPA patients. CRSsNP subtypes with immunodeficiency and GPA merit further investigation to optimize outcomes.
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http://dx.doi.org/10.1002/alr.22146DOI Listing
September 2018

A Cross-sectional Survey of the North American Skull Base Society on Vestibular Schwannoma, Part 2: Perioperative Practice Patterns of Vestibular Schwannoma in North America.

J Neurol Surg B Skull Base 2018 Jun 3;79(3):297-301. Epub 2017 Nov 3.

Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic School of Medicine, Rochester, Minnesota, United States.

 Perioperative care of vestibular schwannoma (VS) patients is extremely variable across surgeons and institutions making practice patterns difficult to standardize. No data currently exist detailing this practice variability.  The North American Skull Base Society membership was electronically surveyed regarding perioperative care of surgically operated VS patients.  There were 87 respondents to the survey. Surgical positioning, surgical approach utilized, and perioperative medical adjuncts are quite variable. However, of those performing retrosigmoid approaches, 49% perform this in the supine position, while 33% use a park-bench position with only 2% using the sitting position. In those performing translabyrinthine approaches, 86% perform this in supine position. Although the use of neuromonitoring appears to be standard of care (98%), other than the seventh nerve, there is substantial variability between respondents regarding monitoring of additional cranial nerves. Postoperative antibiotics are used by 65%, postoperative steroids 81%, and postoperative chemical deep vein thrombosis prophylaxis in 68% of survey respondents.  Although the perioperative adjuncts to VS surgery are variable, there does appear to be a trend in common practice. Therefore, making surgeons aware of these trends may lead to standardized practice or alternatively trials of these variances to instruct which truly improve patient outcomes.
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http://dx.doi.org/10.1055/s-0037-1607976DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5951703PMC
June 2018

A Cross-sectional Survey of the North American Skull Base Society: Current Practice Patterns of Vestibular Schwannoma Evaluation and Management in North America.

J Neurol Surg B Skull Base 2018 Jun 3;79(3):289-296. Epub 2017 Nov 3.

Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic School of Medicine, Rochester, Minnesota, United States.

 Very few studies have examined vestibular schwannoma (VS) management trends across centers and between providers. The objective of this study is to examine current practice trends, variance in treatment philosophies, and nuanced or controversial aspects of VS care across North America.  This is a cross-sectional survey of North American Skull Base Society (NASBS) members who report regular involvement in VS care.  A total of 57 completed surveys were returned. Most respondents claimed to have over 20 years of experience and the majority reported working in an academic practice with an affiliated otolaryngology and/or neurosurgery residency program. Sixty-three percent of respondents claimed to evaluate VS patients in clinic with both an otolaryngologist and neurosurgeon involved. Eighty-six percent of respondents claimed to operate on VS with both an otolaryngologist and neurosurgeon involved, while only 18% of neurosurgeons and 9% of otolaryngologists performed surgery alone. There was a wide range in the number of cases evaluated at each center annually. Similarly, there was wide variation in the number of patients treated with microsurgery and radiation at each center. Additional details regarding management preferences for microsurgery, stereotactic radiosurgery, stereotactic radiotherapy, and conservative observation are presented.  VS management practices vary between providers and centers. Overall, most centers employ a multidisciplinary approach to management with collaboration between otolaryngology and neurosurgery. Overall, survey responses concur with previous studies suggesting a shift toward conservatism in management.
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http://dx.doi.org/10.1055/s-0037-1607319DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5951692PMC
June 2018

Recent advances in biologic therapy of asthma and the role in therapy of chronic rhinosinusitis.

F1000Res 2018 29;7:412. Epub 2018 Mar 29.

Department of Otolaryngology-Head & Neck Surgery, Mayo Clinic, Arizona, USA.

Great strides have been made in the last five years in understanding the pathology of chronic rhinosinusitis (CRS). CRS is now accepted to be the end-stage manifestation of inflammation resultant from various pathogenetic mechanisms. This has resulted in increasing recognition of distinct CRS endotypes. Such endotypes encompass a cluster of patients with similar pathogenic mechanisms that may have common therapeutic targets and responsiveness to interventions. The elucidation of mechanisms leading to the development of chronic upper (sino-nasal) airway inflammation has to some extent paralleled investigations of aberrant pathways operant in asthma. In this review, we focus on recent developments in understanding the innate immune pathways as well as adaptive (late) immune responses in CRS and asthma and their implication as potentially modifiable targets in CRS. Specific biologic therapy (that is, monoclonal antibodies targeting cytokines, cytokine receptors, or specific key molecules targeting inflammation) is an exciting proposition for the future of medical management of CRS. As of the writing of this article, the agents described are not approved for use in CRS; many have partial approval for use in asthma or are considered experimental.
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http://dx.doi.org/10.12688/f1000research.13170.1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5883390PMC
March 2018
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