Not all congestion-producing chronic rhinosinusitis infections are the same

Not all congestion-producing, ear-popping, runny-nosed, headachy chronic rhinosinusitis infections are the same, researchers have found.

Rather, this problem that afflicts some 30 million Americans annually has four severity classifications that could help guide treatment today and help find better treatments in the future, says the lead author on the study published in the November issue of The Laryngoscope.

“The way we have been reporting on chronic sinusitis is we lump it all together so we are comparing apples to oranges,” says Dr. Stilianos E. Kountakis, otolaryngologist and vice chair of the Medical College of Georgia Department of Otolaryngology-Head and Neck Surgery. “We treat one patient one way and get this outcome, and we treat a similar patient the same way and get another outcome. Using clinical parameters alone does not really predict well what is going to happen to the patient.”

Researchers decided to factor in some basic science as they took a retrospective look at 55 patients who had surgery for their disease at the University of Virginia at Charlottesville, where Dr. Kountakis was previously on faculty. The studies included clinical parameters, such as preoperative computerized tomography scans and endoscopic exams as well as patient reports of their symptoms based on the Sino-Nasal Outcome Test, or SNOT.

But researchers also looked at the expression of a gene known to contribute to sino-nasal inflammation as well as other indicators of inflammation, including aspirin sensitivity and allergies. Typically, pathology studies completed after surgery indicate whether the patient had polyps, growths that can obstruct sinus passages that are believed to result from the body trying to repair an injured sinus lining. These studies also looked at levels of eosinophils, little exterminator-like cells found in the nose that contain bubbles with toxins that can kill fungi and parasites as they enter. Despite their noble task, when too many of these cells are activated, eosinophils contribute to inflammation and help support polyps.

Not surprisingly, researchers found that patients with both polyps and high levels of eosinophils had the worst disease. The other three categories include patients with polyps without eosinophils, patients without polyps who had eosinophils and patients with neither.

“Our analysis showed that disease severity correlated with the presence or absence of polyps (clinical objective parameter) and the presence or absence of sinus tissue eosinophilia (histologic marker),” the researchers write. “All other parameters did not incrementally contribute to this correlation with disease severity.”

Dr. Kountakis already has worked with Dr. Richard B. Hessler, chief of the MCG Section of Anatomic Pathology, to include eosinophil levels on pathology reports for sinusitis patients at MCG Medical Center, a step that could also be taken by other hospitals.

The ability to better categorize this common condition is a good first step in more targeted treatment; for example, patients with higher levels of eosinophils may benefit from more anti-inflammatory agents over longer periods, Dr. Kountakis says.

To simplify categorization, the researchers already are working on a “fingerprint of inflammation” that could be obtained from a simple blood test. “Then, as we design studies to look for still better treatments, we can use this information to compare apples to apples,” says Dr. Kountakis.