Diagnosis and Comorbidities

While the etiology of chronic rhinosinusitis with nasal polyps (CRSwNP) is not completely understood, the presence of persistent symptoms such as nasal congestion, loss of smell, and rhinorrhea for >3 months is the basis for diagnosing it.1,2 Postnasal drip is also frequent, whereas facial congestion and pain tend to be more variable. Notably, severe symptoms do not occur at the same intensity throughout the disease spectrum.2

Of note, the above are subjective findings that are neither sensitive nor specific for CRSwNP alone. Indeed, they also are used to characterize patients who have chronic rhinosinusitis without nasal polyps (CRSsNP). In addition to the subjective assessment described above, there must be objective evidence of sinonasal inflammation and nasal polyps on a sinus computed tomography (CT) scan and/or nasal endoscopy.3

The classification of CRS based on phenotype refers to clinical manifestations, whereas the classification based on endotype refers to the critical underlying pathophysiological mechanisms. Compared with CRSsNP, CRSwNP is clinically more challenging since it tends to be more severe, recurrent, and associated with other comorbidities. Additionally, in some groups of patients, the disease is unresponsive to currently established treatments.1,4-6

Comorbidities
CRSwNP is often associated with other medical conditions that can influence disease severity. Data have suggested that patients with CRSwNP have a significantly higher prevalence of acute rhinosinusitis, allergic rhinitis, chronic rhinitis, asthma, gastroesophageal reflux disease, and sleep apnea.3,7

Notably, CRSwNP and asthma share similar features of inflammation and remodeling, including high eosinophil counts, type 2 inflammation, and similar inflammatory mediators.8 Patients with CRSwNP and comorbid asthma—with or without nonsteroidal anti-inflammatory drug (NSAID)-exacerbated respiratory disease—also have more severe disease, which is characterized by3,9:

  • High nasal polyp scores
  • Recurrence of nasal polyps after surgery
  • Frequent systemic corticosteroid dependence
  • Poor asthma control
  • High costs and use of healthcare resources

Treatment of CRS has been shown to decreases asthma severity.8,9

References

  1. Fokkens WJ, Lund VJ, Hopkins C, et al. European position paper on rhinosinusitis and nasal polyps 2020. Rhinology. 2020;58(suppl S29):1-464.
  2. Bachert C, Bhattacharyya N, Desrosiers M, Khan AH. Burden of disease in chronic rhinosinusitis with nasal polyps. J Asthma Allergy. 2021;14:127-134.
  3. Stevens WS, Schleimer RP, Kern RC. Chronic rhinosinusitis with nasal polyps. J Allergy Clin Immunol Pract. 2016;4:565-572.
  4. DeConde AS, Smith TL. Classification of chronic rhinosinusitis—working toward personalized diagnosis. Otolaryngol Clin North Am. 2017;50:1-12.
  5. Baguley C, Brownlow A, Yeung K, et al. The fate of chronic rhinosinusitis sufferers after maximal medical therapy. Int Forum Allergy Rhinol. 2014;4:525-532.
  6. Hull BP, Chandra RK. Refractory chronic rhinosinusitis with nasal polyposis. Otolaryngol Clin North Am. 2017;50:61-81.
  7. Tan BK, Chandra RK, Pollak J, et al. Incidence and associated premorbid diagnoses of patients with chronic rhinosinusitis. J Allergy Clin Immunol. 2013;131:1350-1360.
  8. Orlandi RR, Kingdom TT, Hwang PH, et al. International consensus statement on allergy and rhinology: rhinosinusitis. Int Forum Allergy Rhinol. 2016;6(suppl 1):S22-S209.
  9. Bachert C, Han JK, Desrosiers M, et al. Efficacy and safety of dupilumab in patients with severe chronic rhinosinusitis with nasal polyps (LIBERTY NP SINUS-24 and LIBERTY NP SINUS-52): results from two multicentre, randomised, double-blind, placebo-controlled, parallel-group phase 3 trials. Lancet. 2019;394:1638-1650.

Scientific Council

Neil M. Bressler, MD

James P. Gills Professor of Ophthalmology
Professor of Ophthalmology, Johns Hopkins University School of Medicine
Wilmer Eye Institute, Johns Hopkins Medicine
Baltimore, MD

A. Paul Chous, MA, OD, FAAO

Specializing in Diabetes Eye Care & Education, Chous Eye Care Associates
Adjunct Professor of Optometry, Western University of Health Sciences
AOA Representative, National Diabetes Education Program
Tacoma, WA

Steven Ferrucci, OD, FAAO

Chief of Optometry, Sepulveda VA Medical Center
Professor, Southern California College of Optometry at Marshall B. Ketchum University
Sepulveda, CA

Julia A. Haller, MD

Ophthalmologist-in-Chief
Wills Eye Hospital
Philadelphia, PA

Allen C. Ho, MD, FACS

Director, Retina Research
Wills Eye Hospital
Professor and Chair of the Department of Ophthalmology
Thomas Jefferson University Hospitals
Philadelphia, PA

Charles C. Wykoff, MD, PhD

Director of Research, Retina Consultants of Houston
Associate Professor of Clinical Ophthalmology
Blanton Eye Institute & Houston Methodist Hospital
Houston, TX

Copyright © 2020 | CLEAR Initiative | All Rights Reserved | Website by Divigner

CLEAR Initiative

Chronic rhinosinusitis with nasal polyplosis (CRSwNP) is a chronic inflammatory disease of the nasal mucosa and paranasal sinuses that is associated with significant morbidity and reduced quality of life.

The pathophysiology of CRSwNP is associated with local and systemic inflammation, with ongoing symptoms of nasal congestion, rhinorrhea, and loss of smell. These symptoms result in a significant burden on patients.

As one of the most common medical conditions in the US, CRSwNP has a predominately type 2 inflammatory endotype. It is typically treated with medical management consisting of inhaled corticosteroids, oral corticosteroid bursts, and saline irrigation. Leukotriene antagonists and antibiotics are also used, and if medical management fails, surgical intervention is typically chosen. Additionally, biologics that target type 2 inflammation are now available. These have been or will be approved for use in these patients.

Our CLEAR program is an online tool that aims to provide clinicians and patients with up-to-date information on the presentation, prognosis, pathophysiology, and treatment strategies for individuals with CRSwNP. Our goal is to provide information that empowers clinicians and patients to speak openly about treatment decisions and improve the standard of care for patients with this challenging disease.

Thank you for visiting our website. We invite you to explore the Clinician Toolkit and Patient Toolkit links as well as our pages on CME events, a poster portal to create your own poster, links to animated videos, and much more!

This activity is provided by Med Learning Group. This activity is co-provided by Ultimate Medical Academy/Complete Conference Management (CCM).
This activity is supported by an independent medical education grant from Regeneron Pharmaceuticals, Inc. and Sanofi.

Copyright © 2019 | CLEAR Initiative | All Rights Reserved | Website by Divigner

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