10.14639/0392-100X-N1361
Objective. The relationship between chronic rhinosinusitis, asthma and allergic rhinitis is well known, but only recently has the scientific community started to evaluate these as different manifestations of a common pathogenic phenomenon, considering them as a unified airway disease. Methods. Twenty-two patients with chronic rhinosinusitis treated with endoscopic sinus surgery (ESS) were included in the study. Sino-nasal assessment questionnaire (SNAQ) investigating subjective evaluation of sino-nasal state was administered to patients, while objective evaluations included nasal endoscopy, sinonasal CT, skin prick tests, nasal cytology, spirometry, bronchodilator responsiveness testing and sputum eosinophil count. All tests were performed before surgery. Two months after surgery, SNAQ questionnaire, nasal endoscopy, spirometry and bronchodilator responsiveness testing were repeated. Results. All patients had significant improvement of subjective status: mean SNAQ score decreased in all from 99.31 to 16.04. Mean Forced Expiratory Volume in the 1st second (FEV1) significantly improved after surgery from 3.23 to 3.45 L/s. Conclusions. ESS achieved a beneficial effect on upper and lower airway status in patients with chronic rhinosinusitis with or without lower airway diseases.
text/xml
1827-675X
1361
en
Francesco Bussu
http://creativecommons.org/licenses/by-nc-nd/4.0
ACTA Otorhinolaryngologica Italica
FEV1 and endoscopic sinus surgery
A prospective pilot study on the effects of endoscopic sinus surgery on upper and lower airway performance
Text.Serial.Journal
https://www.actaitalica.it/
41
Rhinology
2023-10-18
2021-01-05
2021-12-22
2023-10-18
544-549
1
Francesco Bussu
2021
10.14639/0392-100X-N1361
544
Otolaryngology Division, Sassari University Hospital, Sassari, Italy; Department of Clinical, Surgical and Experimental Medicine, University of Sassari, Italy
1827-675X
FEV1 and endoscopic sinus surgery
549
A prospective pilot study on the effects of endoscopic sinus surgery on upper and lower airway performance
https://www.actaitalica.it/article/download/1361/718
41
ACTA OTORHINOLARYNGOLOGICA ITALICA 2021;41:544-549; doi: 10.14639/0392-100X-N1361




Rhinology


A prospective pilot study on the effects of endoscopic
sinus surgery on upper and lower airway performance
Studio prospettico pilota sugli effetti della ESS sulla performance delle vie aeree
superiori e inferiori
Silvia Atzei1, Andrea Melis1, Laura Maria De Luca1, Maurizio Gaetano Filippo Macciotta2,3, Valentina Scano2,3,
Adriana Pintus4, Francesco Tanda4, Alessandro Giuseppe Fois2,3, Pietro Pirina2,3, Angelo Zinellu5, Paolo Castiglia3,
Davide Rizzo1, Francesco Bussu1,3
1
 Otolaryngology Division, Sassari University Hospital, Sassari, Italy; 2 Unit of Respiratory disease, Sassari University Hospital,
Sassari, Italy; 3 Department of Clinical, Surgical and Experimental Medicine, University of Sassari, Italy; 4 Institute of Histopathology,
Sassari University Hospital, Sassari, Italy; 5 Department of Biomedical Science, University of Sassari, Sassari, Italy


SUMMARY
Objective. The relationship between chronic rhinosinusitis, asthma and allergic rhinitis is
well known, but only recently has the scientific community started to evaluate these as dif-
ferent manifestations of a common pathogenic phenomenon, considering them as a unified
airway disease.
Methods. Twenty-two patients with chronic rhinosinusitis treated with endoscopic sinus
surgery (ESS) were included in the study. Sino-nasal assessment questionnaire (SNAQ)
investigating subjective evaluation of sino-nasal state was administered to patients, while
objective evaluations included nasal endoscopy, sinonasal CT, skin prick tests, nasal cytol-       Received: January 5, 2021
ogy, spirometry, bronchodilator responsiveness testing and sputum eosinophil count. All            Accepted: August 19, 2021
tests were performed before surgery. Two months after surgery, SNAQ questionnaire, nasal
endoscopy, spirometry and bronchodilator responsiveness testing were repeated.
Results. All patients had significant improvement of subjective status: mean SNAQ score            Correspondence
                                                                                                   Davide Rizzo
decreased in all from 99.31 to 16.04. Mean Forced Expiratory Volume in the 1st second
                                                                                                   Otolaryngology Division, Azienda Ospedaliero Uni-
(FEV1) significantly improved after surgery from 3.23 to 3.45 L/s.                                 versitaria, Sassari, Italy, viale san Pietro 47, 07100
Conclusions. ESS achieved a beneficial effect on upper and lower airway status in patients         Sassari, Italy
with chronic rhinosinusitis with or without lower airway diseases.                                 E-mail: davide.rizzo@aousassari.it
KEY WORDS: upper and lower airways, chronic rhinosinusitis and asthma, endoscopic
sinus surgery and lower airways, FEV1 and endoscopic sinus surgery                                 Funding
                                                                                                   None.

RIASSUNTO                                                                                          Conflict of interest
Obiettivo. La relazione tra rinosinusite cronica, asma e rinite allergica è ben nota, ma           The Authors declare no conflict of interest.
solo recentemente la comunità scientifica ha iniziato a considerarle come manifestazioni
differenti di un comune evento patogenetico.                                                         How to cite this article: Atzei S, Melis A, De
Metodi. In questo studio sono stati arruolati 22 pazienti con rinosinusite cronica trattati con      Luca LM, et al. A prospective pilot study on the
chirurgia endoscopica dei seni paranasali (ESS), sottoposti prima dell’intervento chirurgico         effects of endoscopic sinus surgery on upper
a Sino-nasal assesment questionnaire (SNAQ) per valutare la sintomatologia soggettiva, en-           and lower airway performance. Acta Otorhi-
doscopia nasale, TC dei seni paranasali, prick test cutanei, citologia nasale, spirometria con       nolaryngol Ital 2021;41:544-549. https://doi.
valutazione del volume espiratorio massimo nel 1 secondo (FEV1), test di broncoreversibilità e       org/10.14639/0392-100X-N1361
misurazione dell’eosinofilia dell’escreato. A distanza di 2 mesi dall’operazione i pazienti sono
stati nuovamente sottoposti a SNAQ, endoscopia nasale, spirometria e test di broncoreversibilità   © Società Italiana di Otorinolaringoiatria
                                                                                                   e Chirurgia Cervico-Facciale
Risultati. Tutti i pazienti hanno presentato un miglioramento significativo dei parametri
soggettivi (riduzione della media del SNAQ da 99,31 a 16,04), e di quelli oggettivi (media
                                                                                                                  OPEN ACCESS
del FEV1 da 3,23 a 3,45).
Conclusioni. La chirurgia dei seni paranasali ha dimostrato di apportare benefici sia alle         This is an open access article distributed in accordance with
                                                                                                   the CC-BY-NC-ND (Creative Commons Attribution-Non-
alte che alle basse vie aeree in pazienti con rinosinusite cronica, associata o meno a distur-     Commercial-NoDerivatives 4.0 International) license. The
bi delle basse vie aeree.                                                                          article can be used by giving appropriate credit and mentio-
                                                                                                   ning the license, but only for non-commercial purposes and
PAROLE CHIAVE: vie aeree superiori e inferiori, rinosinusite cronica e asma, endoscopic            only in the original version. For further information: https://
sinus surgery e vie aeree inferiori, FEV1 ed endoscopic sinus surgery                              creativecommons.org/licenses/by-nc-nd/4.0/deed.en




544
                                                                                                  Effect of ESS on airway performance




Introduction                                                     Medical history was collected with a particular regards to
                                                                 atopy, upper airway disease and exposure to risk factors
In the last 20 years, emerging pathophysiological evi-
                                                                 (smoke, occupational factors).
dence led to identify obstructive disease of the lungs and
                                                                 The SNAQ was obtained with the help of a physician for
rhinosinusitis as manifestations of a chronic inflammatory
                                                                 all patients pre- and post-operatively to obtain a subjective
respiratory syndrome of the common airways (one-airway
                                                                 score. It was developed in 2002 by Fahmy et al. 4 to dem-
disease hypothesis) 1. Therefore, rhinosinusitis and asthma
                                                                 onstrate the clinical effectiveness of surgery, and includes
are not confined to a specific anatomic site, but should be
                                                                 11 questions on the clinical complaints of patients. The
considered as a disorder of the entire respiratory tract, with
                                                                 score attributed to each question, based on the frequency and
a range of clinical manifestations and relevant diagnostic
                                                                 clinical severity of each symptom, ranges from 0 to 15 and
and therapeutic implications.
                                                                 is weighted by multiplying by 3 the first two scores (blocked
Many studies 2 have analysed allergic status and pulmo-
                                                                 nose, nasal congestion/stuffy nose) and by 2 the third (facial
nary function in patients with chronic rhinosinusitis (CRS)
                                                                 pain/pressure). Other questions focus on runny nose/ante-
scheduled for sinus surgery, but few have studied the ef-
                                                                 rior nasal discharge, postnasal discharge, sneezing, cough,
fects of surgery on the lower airways.
                                                                 reduced/altered smell, headache, earache/ear fullness, lack
Most studies analysed patients with chronic rhinosinusi-
                                                                 of good night’s sleep/tiredness/fatigue. The total score repre-
tis associated with bronchial asthma, but only a very few 3
                                                                 sents the subjective clinical status of each patient.
evaluated patients without any clinical involvement of the
                                                                 Skin prick tests were carried out in order to evaluate the
lower airways. Furthermore, while subjective symptoms
                                                                 presence of early phase IgE reactions. We used Alk-Abellò
were well considered in all studies, assessment of the ob-
                                                                 tests for seasonal allergens (grasses, parietaria, cypress,
jective parameters was limited to nasal endoscopy and
                                                                 birch, cynodon dactylon, artemisia, olive tree) and peren-
sinonasal CT, for the upper airway, and spirometry and
                                                                 nial allergens (dermatophagoides pteronyssinus and fari-
peak expiratory flow, for the lower airway.
                                                                 nae, epithelium of dog and cat, alternaria). We referred to
The aim of the present work is a comprehensive evaluation
of variations of subjective and objective airway parameters      European Academy of Allergy and Clinical Immunology
in patients who underwent surgery for chronic rhinosinusi-       for the assessment and classification of the results 5, homo-
tis with or without lower airway diseases.                       geneously and in continuity with other studies 6.
                                                                 Surgery on patients with allergy to seasonal agents is car-
                                                                 ried out in our institution at least four months before the
Materials and methods                                            peak period of involved allergen(s) so that the postsurgi-
A clinical prospective study was carried out during Sep-         cal course (as well as postsurgical evaluation of the present
tember 2014 - March 2015. We enrolled 22 patients with           work) is not affected by the peak itself.
CRS (with or without nasal polyps) with or without lower         Nasal mucosal specimens were obtained by scraping the
airway disease who were referred to the Department of            middle one-third of inferior turbinate with Rhinoprobes
Otorhinolaryngology of the University Hospital of Sassari.       and stained with May Grunwald-Giemsa. Nasal cytology
All patients underwent endoscopic sinus surgery between          was examined under an optical microscope (Motic BA210)
September 2014 and March 2015. All procedures per-               evaluating the cytopathological findings as recommended
formed were in accordance with the ethical standards of          by the Italian Academy of Nasal Cytology 7. Apart from the
the institutional research committee (Sassari ethical com-       normal cell population, inflammatory cells (lymphocytes,
mittee) and with the 1964 Helsinki declaration and its later     neutrophils, eosinophils, mast cells), bacteria, or fungal hy-
amendments or comparable ethical standards.                      phae/spores were identified.
Exclusion criteria included pathological obesity (body mass      Viral infections, allergic rhinitis, vasomotor rhinitis and over-
index > 40 kg/m2) and important comorbidities (diabetes, im-     lapping forms can be easily identified. According to the pre-
munological diseases, cardiovascular diseases, malignant tu-     dominant cell type, various entities can be defined: eosinophil-
mours).                                                          ic non-allergic rhinitis (NARES), non-allergic rhinitis mast
Before surgery, a standard questionnaire (sino-nasal assess-     cell (NARMA), neutrophilic non-allergic rhinitis (NARNA),
ment questionnaire-SNAQ), nasal endoscopy, sinonasal             and eosinophil-mast cell non-allergic rhinitis (NARESMA).
CT scan, skin prick tests, nasal cytology, spirometry, bron-     Pulmonologists (M.G.F., V.S., A.G.F., P.P.) performed
chial responsiveness testing and sputum eosinophil count         spirometry on a MasterScreen Body plethysmograph JAE-
were performed. Each patient was re-evaluated 2 months           GER®, and registered FEV1 in all patients pre- and post-
after surgery with SNAQ questionnaire, nasal endoscopy,          operatively.
spirometry and bronchodilator responsiveness testing.            In cases of patients showing significant reduction of FEV1



                                                                                                                                545
S. Atzei et al.




compared to the predicted value, a bronchial responsiveness      Table I. Patient data.
test was carried out by performing a new spirometry after 20      Characteristic
minutes following inhalation of 400 μg of salbutamol. If the      Age
FEV1 value increased more than 12% or 200 ml from the pre-          Mean (range)                                         40.1 (24-71)
vious basal value, asthma was diagnosed, otherwise the di-        Sex
agnosis was chronic obstructive pulmonary disease (COPD).           Male                                                  13 (59.1%)
The pulmonary function tests were conducted in observance           Female                                                 9 (40.9%)
with the ATS/ERS guidelines for spirometry testing 8.             BMI
A specimen of induced sputum was collected after pre-               Median (range)                                   26.31 (17.85-40.00)
cautionary inhalation of salbutamol and 20 minutes of iso-        Smoking
tonic solution (0.9% NaCl) nebulization. The conveniently
                                                                    Yes                                                    2 (9.1%)
fixed sputum was analysed at the Department of Pathologic
                                                                    No                                                    20 (90.9%)
Anatomy of the University of Sassari to test the presence of
                                                                  Nasal polyps
inflammatory cells, particularly eosinophils.
Statistical analysis was performed with the collaboration of         CRSwNP                                               18 (81.8%)
the Hygiene Department of the University of Sassari. The             CRS                                                   4 (18.2%)
impact of surgery on numeric parameters (SNAQ score and           Allergy
FEV1) was assessed by paired Student t tests. The influence          Yes                                                  13 (59.1%)
of concomitant lung diseases, nasal cytology, induced spu-           No                                                    9 (40.9%)
tum findings, allergy on SNAQ score and FEV1 improve-             Obstructive bronchial disease
ment was also evaluated. A p value < 0.05 was considered             Asthma                                               6 (27.3%)
statistically significant.                                           Asthma + COPD                                         2 (9.1%)
                                                                     No asthma                                            14 (63.6%)
Results                                                           Nasal cytology
                                                                     Eosinophilia                                         11 (50.0%)
Twenty-two patients who underwent endoscopic sinus sur-              Neutrophilia                                          7 (31.8%)
gery (ESS) were included in the study (descriptive statistics
                                                                     Eosinophilia/neutrophilia                             1 (4.5%)
are reported in Table I).
                                                                     Normal                                                3 (13.7%)
                                                                  Rhinitis phenotype
Preoperative data
                                                                     NARES                                                 2 (9.1%)
Eight patients had obstructive bronchial diseases: seven pa-
                                                                     Allergic rhinitis                                    13 (59.1%)
tients were previously diagnosed with asthma and two with
COPD, while 1 patient was diagnosed with asthma by the               NARNE                                                 5 (22.8%)
tests carried out for this study.                                    NARES/NARNE                                           1 (4.5%)
                                                                     Normal                                                1 (4.5%)
Among the 12 patients showing eosinophils in nasal cytol-
                                                                  Sputum cytology
ogy, atopy was observed in three, while the remaining had
                                                                     Eosinophilia                                         10 (45.5%)
non-allergic rhinitis with eosinophils (NARES) 9.
                                                                     Not assessed                                          2 (9.0%)
Eosinophils were detected in nose smears in five of six pa-
tients with asthma and in both patients with COPD.                   Normal                                               10 (45.5%)
Sputum eosinophilia was observed in 10 patients (45%) in          Preoperative FEV1
the entire group and in four of six patients suffering from          Mean (range)                                      3.23 (2.00-5.00)
asthma.                                                           Postoperative FEV1
                                                                     Mean (range)                                      3.45 (2.04-5.43)
Impact of ESS                                                     Preoperative SNAQ
A significant difference in SNAQ score before and after the          Mean (range)                                      99.31 (62-143)
procedure was observed (p < 0.01 at paired t-test). The mean      Postoperative SNAQ
total SNAQ score was 99.31 before surgery and 16.04 after            Mean (range)                                       16.04 (1-116)
surgery (Fig. 1). Allergic patients showed a slight higher but   BMI: Body Mass Index; CRSwNP: chronic rhinosinusitis with nasal polyps; CRS:
                                                                 chronic rhinosinusitis; COPD: Chronic obstructive pulmonary disease; NARES:
non-significant preoperative and postoperative total mean        Non-allergic Rhinitis with Eosinophilia Syndrome; NARNE: Non-allergic Rhinitis
SNAQ scores compared with non-allergic ones (Fig. 2). No         with neutrophils; FEV1: Forced Expiratory Volume in the 1st second; SNAQ: sino-
significant differences between FEV1 values in allergic and      nasal assessment questionnaire.




546
                                                                                                       Effect of ESS on airway performance




                                                                        nonallergic patients were detected either before or after ESS.
                                                                        The mean FEV1 was 3.23 before surgery and 3.45 after sur-
                                                                        gery. A significant improvement in FEV1 before and after the
                                                                        procedure was observed (p < 0.05 at paired t-test) (Fig. 3).
                                                                        No significant differences in SNAQ score and FEV1 im-
                                                                        provements were detected in relation to allergic and cyto-
                                                                        logical findings.
                                                                        When considering only patients with eosinophils in both
                                                                        nasal and bronchial cytology, improvement of SNAQ score
                                                                        and FEV1 lost statistical significance.

                                                                        Discussion
                                                                        Nowadays interactions between upper and lower airways
                                                                        are not completely clear, even if pathophysiologic events
Figure 1. Mean SNAQ score before and after surgery.                     causing diseases in both districts are similar. Indeed, CRS
                                                                        and obstructive pulmonary diseases share most cell types,
                                                                        mediators of inflammation, cytokines and neurotransmit-
                                                                        ters 10; recently, Samitas et al. 11 revisited the concept of
                                                                        “one airway disease” identifying a common inflammatory
                                                                        remodelling. Such common factors may also explain the
                                                                        increasing prevalence of chronic bronchitis, defined as
                                                                        “mucus-producing cough on most days for a minimum of
                                                                        3 months per year and for at least 2 consecutive years”, in
                                                                        asthmatic and rhinitic patients despite a decrease in smok-
                                                                        ing habit 12. Furthermore, nasal polyposis and asthma seems
                                                                        to share genetic susceptibility factors such as ADRB2 gene
                                                                        polymorphisms 13. The approach to these issues has dras-
                                                                        tically changed in the last decade, and the main focus is
                                                                        clearly moving from clinical features (phenotyping) to
                                                                        pathogenic mechanisms (endotyping).
                                                                        This is a small pilot study with several limitations. Apart
Figure 2. Differences in mean SNAQ score between allergic and non al-   from the low numbers, the follow-up is limited and some
lergic patients.                                                        postoperative data, such as cytology, are not available.
                                                                        Nonetheless, the present study provides some relevant infor-
                                                                        mation: first, even in a small pilot series, it clearly shows
                                                                        the extreme clinical variability of CRS, but at the same time
                                                                        generally confirms the positive impact of ESS not only on
                                                                        the upper, but also on the lower, airways. Although many
                                                                        studies have demonstrated the correlation between the up-
                                                                        per and lower airways 9,14-16, the role of surgery for CRS on
                                                                        the lower airways is still controversial. Furthermore, in most
                                                                        previous studies, few subjective and objective variables were
                                                                        collected 17,18. For example, many studies have specifically
                                                                        evaluated the impact of ESS on control of symptoms in asth-
                                                                        matic patients, with few investigating the effects on pulmo-
                                                                        nary function parameters 19-21; to our knowledge, there are no
                                                                        studies globally evaluating the impact of ESS on pulmonary
                                                                        function in relation with nasal and bronchial cytology and
                                                                        subjective score testing of symptoms.
Figure 3. FEV1 before and after surgery in the totality of patients.    In the present series, not only did the mean total SNAQ



                                                                                                                                     547
S. Atzei et al.




score drastically decrease in all patients after surgery, but               3
                                                                                 Ikeda K, Tanno N, Tamura G, et al. Endoscopic sinus surgery im-
                                                                                 proves pulmonary function in patients with asthma associated with
endoscopic sinus surgery proved to be effective on the lower                     chronic sinusitis. Ann Otol Rhinol Laryngol 1999;108:355-359. htt-
airways with an improvement of objective parameters, and                         ps://doi.org/10.1177/000348949910800407
in particular FEV1. Our results confirm previous data 18,20-22.             4
                                                                                 Fahmy FF, McCombe A, Mckiernan DC. Sino nasal assessment ques-
Previous studies have shown a correlation between blood                          tionnaire, a patient focused, rhinosinusitis specific outcome measure.
                                                                                 Rhinology 2002;40:195-197.
eosinophilia and massive nasal polyposis on the one hand 23                 5
                                                                                 Position paper: Allergen standardization and skin tests. The Euro-
and eosinophils in nasal cytology and asthma on the oth-                         pean Academy of Allergology and Clinical Immunology. Allergy
er 24. In the present small pilot study, almost all asthmatic                    1993;48:48-82.
patients (five of six) showed the presence of eosinophilia                  6
                                                                                 Muñoz del Castillo F, Jurado-Ramos A, Fernández-Conde BL, et al.
                                                                                 Allergenic profile of nasal polyposis. J Investig Allergol Clin Immu-
in both nasal and bronchial specimens and patients with                          nol 2009;19:110-116.
nasal and bronchial eosinophilia seem to benefit less, in                   7
                                                                                 Gelardi M, Fiorella ML, Leo G, et al. Cytology in the diagnosis of
terms of FEV1, from surgery. This may confirm a further                          rhinosinusitis. Pediatr Allergy Immunol 2007;18:50-52. https://doi.
role for both nasal and bronchial cytology in predicting the                     org/10.1111/j.1399-3038.2007.00634.x
outcomes of ESS, at least at the level of the lower airways 25              8
                                                                                 Miller MR, Hankinson J, Brusasco V, et al. Standardisation of spirom-
                                                                                 etry. Eur Respir J 2005;26:319-338. https://doi.org/10.1183/0903193
and may define a group which could benefit from treatment                        6.05.00034805
with novel monoclonal antibodies targeting Type 2 inflam-                   9
                                                                                 Ellis AK, Keith PK. Nonallergic rhinitis with eosinophilia syndrome.
mation 26.                                                                       Curr Allergy Asthma Rep 2006;6:215-220. https://doi.org/10.1007/
Also, based upon this evidence, it can be suggested that,                        s11882-006-0037-0
                                                                            10
                                                                                 American Thoracic Society Workshop. Immunobiology of asth-
even in absence of specific lower airway disorders, all pa-                      ma and rhinitis. Pathogenic factors and therapeutic options. Am J
tients with CRS should undergo a pulmonary medical ex-                           Respir Crit Care Med 1999;160:1778-1787. https://doi.org/10.1164/
amination and cytology in order to predict and better define                     ajrccm.160.5.ats7-99
the results of surgery.                                                     11
                                                                                 Samitas K, Carter A, Kariyawasam HH, et al. Upper and lower air-
                                                                                 way remodelling mechanisms in asthma, allergic rhinitis and chronic
                                                                                 rhinosinusitis: the one airway concept revisited. Allergy 2018;73:993-
Conclusions                                                                      1002. https://doi.org//10.1111/all.13373
                                                                            12
                                                                                 Accordini S, Corsico AG, Cerveri I, et al. Diverging trends of chronic
The present results show that endoscopic sinus surgery                           bronchitis and smoking habits between 1998 and 2010. Respir Res
in CRS patients has a relevant role not only in improv-                          2013;14:16. https://doi.org/10.1186/1465-9921-14-16
ing upper airway function, but also in the management of
                                                                            13
                                                                                 Bussu F, Tiziano FD, Giorgio A, et al. Argl6gly polymorphism of the
                                                                                 beta2-adrenoceptor gene (ADRBeta2) as a susceptibility factor for na-
comorbidities associated with the lower airways. Further-                        sal polyposis. Am J Rhinol 2007;21:378-382. https://doi.org/10.2500/
more, it adds useful evidence that support the “one-airway                       ajr.2007.21.3015
disease” hypothesis 1, which is in agreement with the cur-                  14
                                                                                 Hellings PW, Hens G. Rhinosinusitis and the lower airways. Immunol
                                                                                 Allergy Clin North Am 2009;29:733-740. https://doi.org/10.1016/j.
rent literature. The present data were collected before the                      iac.2009.08.001
end of 2015 and in a small group of patients. In the rapidly                15
                                                                                 Dixon AE. Rhinosinusitis and asthma: the missing link. Curr
evolving world of clinical research in rhinology, the num-                       Opin      Pulm     Med      2009;15:19-24.      https://doi.org/10.1097/
ber of patients should be increased and the data should be                       MCP.0b013e32831da87e
re-evaluated and enriched with increasingly popular scores
                                                                            16
                                                                                 Virchow JC. Asthma, allergic rhinitis, sinusitis. Concept of the ‘uni-
                                                                                 fied respiratory tracts’. HNO 2005;53(Suppl 1):S16-S20. https://doi.
(e.g. SNOT 27, ACT, UPSIT) and information that help in                          org/10.1007/s00106-005-1231-4
defining the endotype (e.g. FeNO, periostin and blood eo-                   17
                                                                                 Nakamura H, Kawasaki M, Higuchi Y, et al. Effects of sinus surgery
sinophils, but also expression of inflammatory cytokines) 28                     on asthma in aspirin triad patients. Acta Otolaryngol 1999;119:592-
                                                                                 598. https://doi.org/10.1080/00016489950180856
and to stratify the results and impact of surgery according                 18
                                                                                 Batra PS, Kern RC, Tripathi A, et al. Outcome analysis of en-
to the endotype.                                                                 doscopic sinus surgery in patients with nasal polyps and
                                                                                 asthma.       Laryngoscope        2003;113:1703-1706.         https://doi.
                                                                                 org/10.1097/00005537-200310000-00008
References                                                                  19
                                                                                 Ohta N, Suzuki Y, Ikeda H, et al. Efficacy of endoscopic sinus sur-
1
    Bousquet J, Khaltaev N, Cruz AA, et al. Allergic Rhinitis and its Im-        gery for eosinophilic chronic rhinosinusitis with asthma. Allergol Int
    pact on Asthma (ARIA) 2008 update (in collaboration with the World           2020;69:144-145. https://doi.org/10.1016/j.alit.2019.08.004
    Health Organization, GA(2)LEN and AllerGen). Allergy 2008;63(Sup-       20
                                                                                 Benninger MS, Holy CE. The impact of endoscopic sinus surgery on
    pl 86):8-160. https://doi.org/10.1111/j.1398-9995.2007.01620.x               health care use in patients with respiratory comorbidities. Otolaryngol
2
    Håkansson K, Thomsen SF, Konge L, et al. A Comparative and de-               Head Neck Surg 2014;151:508-515. https://doi.org/10.1177/0194599
    scriptive study of asthma in chronic rhinosinusitis with nasal pol-          813495815a287
    yps. Am J Rhinol Allergy 2014;28:383-387. https://doi.org/10.2500/      21
                                                                                 Sujatha S, Suja V. Evaluation of quality of life and pattern of im-
    ajra.2014.28.4076                                                            provement of bronchial asthma in chronic rhinosinusitis patients




548
                                                                                                                         Effect of ESS on airway performance




     treated by functional endoscopic sinus surgery. Indian J Otolaryn-         25
                                                                                     Gelardi M, Iannuzzi L, De Giosa M, et al. Non-surgical management of
     gol Head Neck Surg 2019;71:2176-2181. https://doi.org/10.1007/                  chronic rhinosinusitis with nasal polyps based on clinical-cytological
     s12070-019-01586-1                                                              grading: a precision medicine-based approach. Acta Otorhinolaryngol
22
     Vashishta R, Soler ZM, Nguyen SA, et al. A systematic review and                Ital 2017;37:38-45. https://doi.org/10.14639/0392-100X-1417
     meta-analysis of asthma outcomes following endoscopic sinus sur-           26
                                                                                     Bandi F, Gallo S, Preti A, et al. Effects of biological therapies on chron-
     gery for chronic rhinosinusitis. Int Forum Allergy Rhinol 2013;3:788-           ic rhinosinusitis in severe asthmatic patients. Acta Otorhinolaryngol
     794. https://doi.org/10.1002/alr.21182                                          Ital 2020;40:435-443. https://doi.org/10.14639/0392-100X-N0716
23
     Newman LJ, Platts-Mills TA, Phillips CD, et al. Chronic sinusitis.         27
                                                                                     Gallo S, Russo F, Mozzanica F, et al. Prognostic value of the
     Relationship of computed tomographic findings to allergy, asthma,               Sinonasal Outcome Test 22 (SNOT-22) in chronic rhinosinusi-
     and eosinophilia. JAMA 1994;271:363-367. https://doi.org/10.1001/               tis. Acta Otorhinolaryngol Ital 2020;40:113-121. https://doi.
     jama.271.5.363                                                                  org/10.14639/0392-100X-N0364
24
     Harlin SL, Ansel DG, Lane SR, et al. A clinical and pathologic study       28
                                                                                     Fokkens WJ, Lund VJ, Hopkins C, et al. European Position Paper
     of chronic sinusitis: the role of the eosinophil. J Allergy Clin Immunol        on Rhinosinusitis and Nasal Polyps 2020. Rhinology 2020;58(Suppl
     1988;81:867-875. https://doi.org/10.1016/0091-6749(88)90944-x                   S29):1-464. https://doi.org/10.4193/Rhin20.600




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