Editorial: Advances in the diagnosis and treatment of patients with chronic rhinosinusitis and allergy

With each new year, we witness numerous advancements in our understanding of chronic rhinosinusitis and welcome novel treatments to improve outcomes in our patients. This January edition of the American Journal of Rhinology and Allergy includes a variety of original research and review articles that answer important questions and provide insight into the pathophysiology and treatment of chronic rhinosinusitis (CRS), allergic rhinitis, and sinonasal tumors. Intranasal corticosteroids are one of the most commonly used treatment options for patients with nasal polyps, rhinosinusitis, and allergic rhinitis. Verkerk et al1 leads off this issue of the AJRA with an insightful systematic review that investigates the theoretical risk of mucosal atrophy after long-term use of intranasal steroids. This study found no histologic evidence of deleterious effects of corticosteroids on human nasal mucosa. As it is important to discuss side effects with any treatment option, this research provides clinicians with useful information. Rezende et al2 examines the effectiveness of topical mometasone furoate on sinonasal symptoms and adenoid hypertrophy. The authors concluded that topical mometasone not only improved nasal obstruction, snoring, and apnea, but it also significantly reduced adenoid tissue in the nasopharynx. This issue of the AJRA has three articles that provide insight into the role of microbiology in sinus health and disease. While much of the current literature focuses on the contribution of bacteria and fungi in sinus disease, Lima et al3 reinforces the importance of viruses in rhinosinusitis. The authors identify seasonal variations in viral prevalence in sinonasal secretions and mucosal samples from patients with CRS. Interestingly, respiratory viruses were detected in almost half of patients in this study with or without sinonasal symptoms, which underscores the possibility of asymptomatic infection. Two articles focus on the important role of Staphylococcus aureus in CRS. In an in vitro study, Cantero et al4 demonstrates that S. aureus biofilms induce apoptosis and an inflammatory immune response on normal sinonasal mucosal explants due to direct effects of both the bacteria and biofilm matrix. In a second article, Gitomer et al5 investigate and discuss the potential contribution of S. aureus small colony variants in recalcitrant CRS. Despite our efforts, the pathophysiology of CRS has yet to be fully elucidated. Inflammation of the sinonasal mucosa is the common histologic and clinical finding in CRS, but the causes of the inflammation are multifactorial. Articles by Chao et al6 and Lin et al7 in this issue investigate the cytokine profile of CRS. IL-21 is a protein expressed in activated CD4 T cells and has potent regulatory effects on the immune system. Chao6 evaluated serum samples from CRS patients and normal controls and found that serum IL-21 levels correlated well with disease severity in patients. Lin et al7 found that IL-9 and its receptor were overexpressed in nasal explant cultures from patients with CRS. Their findings suggest that IL-9 binging to its receptor may induce mucosal epithelial cell growth, epithelial cell proliferation, and inflammatory cell infiltration in CRS. Patients with aspirin-exacerbated respiratory disease (AERD) often have severe sino-pulmonary disease despite aggressive surgical and medical therapy. Articles by Steinke and Borish8 and Ta and Simon9 in this issue of the AJRA discuss the pathophysiology of AERD and provide a critical review of the available treatment options including the use of aspirin desensitization. We et al10 offer interesting national epidemiologic data on the prevalence, risk factors, and comorbidities associated with nasal polyps in a large South Korean study population. The authors report a 2.5% national prevalence of nasal polyps, with an increasing prevalence associated with age. Multivariate analysis identified a variety of other risk factors for nasal polyps including male sex, low education level, and asthma. Chang et al11 provide insight into a potential novel therapeutic agent for eosinophilic rhinosinusitis. Utilizing a mouse model, the authors found that topical cyclosporine might represent an effective drug for the management of patients with nasal polyps. Both CRS with and without nasal polyps are both known to profoundly impact quality of life. Olfactory dysfunction is a common symptom which drives patients to be evaluated by a specialist. Kim et al12 investigate the radiographic and clinical factors which might predict olfaction outcomes after endoscopic sinus surgery (ESS). The authors found that 42% of patients demonstrated improvement in smell after ESS, but many had persistent hyposmia despite surgical intervention. In an article by Chung et al,13 the authors explore a potential association between CRS and dementia. After evaluating thousands of patients in a national database, the authors identified a statistically significant increase in rates of dementia in patients with CRS compared to age and sex-matched controls. These findings underscore not only the local sinonasal symptoms of untreated CRS, but also the potential systemic effects of untreated chronic disease. Complementary and alternative medicine has become a popular treatment option for many patients with rhinitis and rhinosinusitis. It is important that clinicians are aware of its use and potential benefits. Feng et al14 performed a systematic review and meta-analysis of acupuncture for the treatment of allergic rhinitis. The authors found that acupuncture was safe and resulted in significant improvements in nasal symptoms and quality of life. Macdonald et al15 performed a multicenter study investigating the use of sinus irrigation versus saline spray after endoscopic sinus surgery. The authors found that both options were effective in reducing postoperative sinonasal outcomes, including symptoms and endoscopic scores. Surgeons seek to continually improve outcomes and safety for their patients. This issue contains two articles focusing on improving quality after surgery. Endoscopic dacryocystorhinostomy (DCR) is an increasingly popular method of treating patients with epiphora due to nasolacrimal duct obstruction. Use of lacrimal stents and duration of stent placement is still controversial. In a randomized trial, Okuyucu et al16 found that silicone and Prolene stents demonstrated good and equivalent success rates compared to otologic T-tubes. Gode et al17 evaluated the use of ultrasound elastography after inferior turbinate reduction surgery using radiogrequency ablation and submucosal bipolar diathermy to evaluate potential differences in the two techniques. The authors found that both radio frequency ablation and submucosal bipolar diathermy of the inferior turbinates were effective in inducing scar tissue fibrosis of inferior turbinates by ultrasound. Gras-Cabrerizo et al18 reviewed their experience treating sinonasal mucosal melanoma. The authors also compared three difJeffrey D. Suh, M.D., F.A.C.S.