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Adult chronic rhinosinusitis

Abstract

Chronic rhinosinusitis (CRS) occurs in >10% of the adult population in Europe and the USA and can be differentiated into CRS without nasal polyps and CRS with nasal polyps (CRSwNP). Both phenotypes are characterized by a high disease burden and an overlapping spectrum of symptoms, with facial pain and loss of smell being the most differentiating. Great progress has been made in the understanding of CRS pathophysiology: from the epithelium and epithelial–mesenchymal transition to innate and adaptive immunity pathways and, finally, on the role of eosinophils and Staphylococcus aureus in the persistence of disease. Although clinical manifestations and diagnostic tools (including nasal endoscopy and imaging) have undergone major changes over the past few years, management (including pharmacotherapy, surgery and biologics) has experienced enormous progress based on the growing knowledge of key mediators in severe CRSwNP. The introduction of endotyping has led to a differentiation of ‘tailored’ surgical approaches, focusing on the mucosal concept in those with severe CRSwNP and on the identification of patients eligible for extended surgery and possibly biologics in the future.

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Fig. 1: Anatomy of the paranasal sinuses and the nasal passage.
Fig. 2: Relative proportion of allergic rhinitis, asthma and CRS across the lifespan.
Fig. 3: Overview of cellular and molecular changes in epithelium in patients with CRS.
Fig. 4: Type 2 immune response and CRS.
Fig. 5: Possible functions of SAgs in allergy.
Fig. 6: Nasal endoscopy and CT scans to differentiate CRS phenotypes.
Fig. 7: Management algorithm for CRS.
Fig. 8: Patient-specific and surgeon-specific factors impact surgical outcomes.
Fig. 9: PROMs and objective measures of disease severity.

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Authors and Affiliations

Authors

Contributions

Introduction (C.B.); Epidemiology (W.-J.S.); Mechanisms/pathophysiology (R.P.S., B.N.L. and B.M.B.); Diagnosis, screening and prevention (B.M., C.B., C.H. and T.L.); Management (C.H. and R.J.S.); Quality of life (R.J.S.); Outlook (C.B.); Overview of Primer (C.B.).

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Correspondence to Claus Bachert.

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Competing interests

C.B. serves in advisory boards for AstraZeneca, GlaxoSmithKline, Mylan, Novartis and Sanofi-Aventis. R.J.S. has served as a consultant for GlaxoSmithKline, Healthy Humming, Optinose, Sanofi, and Stryker and has received grant support from AstraZeneca, Optinose and Stryker. C.H. has served on advisory boards for AstraZeneca, Olympus, Sanofi and Smith & Nephew. R.P.S. is a consultant for Actobio Therapeutics, Allakos, Aqualung Therapeutics Corp., Astellas Pharm. Inc., AstraZeneca/Medimmune, Aurasense, BioMarck, Celgene Corp., Exicure, Genentech, Genzyme/Sanofi Corp., GlaxoSmithKline, Intersect ENT, Lyra Therapeutics, Merck, Otsuka, and Sanofi and he owns stocks or stock options for Allakos, Aqualung Therapeutics Corp., Aurasense, BioMarck, and Exicure. Furthermore, he owns Allakos Siglec-8 and Siglec-8 ligand related patents; as a result of the Allakos licensing agreement, per Johns Hopkins University policy, he may be entitled to a share of future royalties regarding the sale of Siglec-8 related products, although no such royalties exist at the time of writing. T.L. has served on scientific advisory boards for GlaxoSmithKline, Optinose, Regeneron and Sanofi-Genzyme. B.N.L. serves in advisory boards for GlaxoSmithKline, Novartis, OncoArendi and Argenx. All other authors declare no competing interests.

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Nature Reviews Disease Primers thanks N. Cohen, A. Lane, V. Ramakrishnan, P. Wormald and the other, anonymous, reviewer(s) for their contribution to the peer review of this work.

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Glossary

Hyposmia

Reduced ability to smell.

Anosmia

Loss of smell.

Mucosal concept

The role of prominent immune responses/endotypes in the sinus mucosa, which lead to different phenotypes of chronic rhinosinusitis and related clinical characteristics (asthma comorbidity and disease recurrence).

Acanthosis

Epithelial hyperplasia.

Acantholysis

Epithelial shedding.

Allergens

Proteins with a propensity to induce an adaptive type 2 immune response characterized by specific IgE and type 2 T helper cells.

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Bachert, C., Marple, B., Schlosser, R.J. et al. Adult chronic rhinosinusitis. Nat Rev Dis Primers 6, 86 (2020). https://doi.org/10.1038/s41572-020-00218-1

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