Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia.
St Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Sydney, Australia.
JAMA Otolaryngol Head Neck Surg. 2021 Apr 1;147(4):360-367. doi: 10.1001/jamaoto.2020.5286.
Eosinophilic chronic rhinosinusitis (eCRS), contemporarily classified as diffuse type 2 dominant chronic rhinosinusitis (CRS), is characterized by eosinophil-dominant mucosal inflammation. Contemporary management of eCRS as an inflammatory airway condition is multimodal with corticosteroid irrigations after the surgical creation of a neosinus cavity.
To assess long-term treatment outcomes in patients with primary diffuse type 2 CRS or eCRS receiving multimodal treatment.
DESIGN, SETTING, AND PARTICIPANTS: A prospective cohort study of patients seen in a tertiary rhinology practice recruited from May 2010 to November 2018 was conducted. Follow-up duration was 12 months or more following endoscopic sinus surgery (ESS) with a neosinus cavity formed. Data analysis was performed from August to November 2020. Consecutive adult (≥18 years) patients diagnosed with primary diffuse type 2 dominant CRS or eCRS based on the European Position Paper on Rhinosinusitis and Nasal Polyps 2020 criteria were included. Type 2 inflammation was defined as more than 10 eosinophils per high-power field obtained from sinus mucosal biopsy and managed with neosinus cavity ESS and ongoing corticosteroid irrigations. Exclusion criteria were less than 12 months of follow-up and secondary CRS.
Endoscopic sinus surgery with complete removal of intersinus bony partitions to create a neosinus cavity. Nasal irrigation (240 mL) with betamethasone, 1 mg, or budesonide, 1 mg, daily for 3 to 6 months after ESS and tapered to an as-needed basis (minimum, 2-3 per week).
Poor control was defined as polyp recurrence (polyp growth in >1 sinus area on a single side), use of long-term systemic therapy (biologic therapy or ≥3 consecutive months of oral corticosteroids), and revision surgery involving polypectomy. The disease in patients with no poor control criteria was defined as well controlled, and the disease in those with 1 or more criteria was considered poorly controlled. Maintenance medical therapy use and patient-reported outcomes based on the 22-item Sinonasal Outcomes Test for preoperative and last follow-up were collected.
Of the 222 participants recruited with primary diffuse type 2 dominant CRS or eCRS and minimum of year of follow-up, 126 were men (56.8%). Mean (SD) age was 54.8 (13.6) years, and median (SD) follow-up was 2.2 (2.2) years. Of the 222 patients, 195 (87.8%) had well-controlled disease, 16 (7.2%) had polyp recurrence, 7 (3.2%) continued to receive long-term oral corticosteroid therapy, 5 (2.3%) received biologic therapy, and 8 (3.6%) underwent a revision polypectomy. Clinically meaningful change on the 22-item Sinonasal Outcomes Test and the nasal subdomain score was maintained at the last follow-up in 134 patients (67.0%). Poor disease control was not associated with poor adherence to irrigation use.
The findings of this cohort study suggest that long-term disease control and reduction in symptom burden in patients with primary diffuse type 2 CRS or eCRS might be achieved when managed as an inflammatory disorder. Maintenance corticosteroid irrigations in the population examined appeared to be successfully self-tapered to disease activity.
嗜酸性慢性鼻鼻窦炎（eCRS），目前被归类为弥漫型 2 型优势慢性鼻鼻窦炎（CRS），其特征是嗜酸性粒细胞主导的黏膜炎症。eCRS 作为一种炎症性气道疾病的现代治疗方法是多模式的，在新鼻窦腔形成后，使用皮质类固醇冲洗。
评估接受多模式治疗的原发性弥漫型 2 型 CRS 或 eCRS 患者的长期治疗结果。
设计、地点和参与者：对 2010 年 5 月至 2018 年 11 月期间在一家三级鼻科诊所就诊的患者进行了前瞻性队列研究。内镜鼻窦手术（ESS）后随访时间为 12 个月或更长时间，形成了新鼻窦腔。数据分析于 2020 年 8 月至 11 月进行。连续的成年（≥18 岁）患者根据 2020 年欧洲鼻-鼻窦炎和鼻息肉立场文件的标准被诊断为原发性弥漫型 2 型优势 CRS 或 eCRS。2 型炎症定义为从鼻窦黏膜活检中获得的每高倍镜视野超过 10 个嗜酸性粒细胞，并通过新鼻窦腔 ESS 和持续的皮质类固醇冲洗进行管理。排除标准为随访时间少于 12 个月和继发性 CRS。
ESS 完全切除窦间骨分隔以形成新鼻窦腔。鼻腔冲洗（240 毫升），每天使用倍他米松 1 毫克或布地奈德 1 毫克，ESS 后持续 3 至 6 个月，然后逐渐减少至按需使用（最低 2-3 次/周）。
控制不佳定义为息肉复发（单侧>1 个鼻窦区域的息肉生长）、长期全身治疗（生物治疗或连续 3 个月以上口服皮质类固醇）和涉及息肉切除术的修正手术。没有不良控制标准的患者定义为病情控制良好，有 1 个或多个标准的患者定义为病情控制不佳。收集术前和最后随访时基于 22 项鼻-鼻窦结局测试的维持性药物治疗使用和患者报告的结果。
在 222 名患有原发性弥漫型 2 型优势 CRS 或 eCRS 并至少随访 1 年的患者中，有 126 名男性（56.8%）。平均（标准差）年龄为 54.8（13.6）岁，中位（标准差）随访时间为 2.2（2.2）年。在 222 名患者中，195 名（87.8%）患者的病情得到良好控制，16 名（7.2%）患者出现息肉复发，7 名（3.2%）患者继续接受长期口服皮质类固醇治疗，5 名（2.3%）患者接受生物治疗，8 名（3.6%）患者接受修正性息肉切除术。在最后一次随访中，134 名患者（67.0%）的 22 项鼻-鼻窦结局测试和鼻腔亚域评分的临床显著改善得以维持。不良疾病控制与冲洗使用的不良依从性无关。
本队列研究的结果表明，当作为一种炎症性疾病进行治疗时，原发性弥漫型 2 型 CRS 或 eCRS 患者的长期疾病控制和减轻症状负担可能会实现。在研究人群中，皮质类固醇冲洗的维持似乎成功地根据疾病活动进行了自我减量。
