2018 Section 5 - Rhinology and Allergic Disorders

Lu-Myers et al

Table 2. Differences in Disease Severity between AFRS, CRSwNP, and CRSsNP Patients.

Disease Severity Markers

AFRS (n = 93)

CRS (n = 93)

CRSsNP (n = 32)

CRSwNP (n = 61)

P Value

\ .0001

IgE level, IU/mL, mean (SD)

1030 (1278)

352 (924)

212 (304)

429 (1133)

No. of surgeries before rhinologist care, n (%)

.1

0 1 2 3 4 5 6

44 (48) 22 (24) 15 (17)

44 (47) 18 (19) 17 (18) 12 (13)

14 (44)

30 (49) 12 (20) 14 (23)

6 (19)

3 (9)

6 (6) 0 (0) 1 (1) 3 (3)

8 (25)

4 (6) 1 (2) 0 (0) 0 (0)

2 (2) 0 (0) 0 (0)

1 (3) 0 (0) 0 (0)

No. of surgeries after rhinologist care, n (%)

.4

0 or 1

66 (73) 23 (27) 42 (51) 45 (50) 79 (88) No data 19 (39) 6 (7)

72 (77) 21 (23) 23 (25) 40 (43)

27 (84)

45 (74) 16 (26) 21 (34) 25 (41)

. 2

5 (16)

Budesonide, n (%)

2 (6)

.0001

Asthma, n (%)

15 (47)

.6 .3

Aspirin sensitivity, n (%) Allergic rhinitis, n (%)

8 (9)

1 (3)

7 (12)

\ .0001 \ .0001

57 (61)

16 (50)

41 (67)

. Endpoint 4 on allergen testing, n (%) . Endpoint 4 on RAST testing, n (%)

1 (1)

0 (0) 0 (0) 8 (4)

1 (5)

2 (17)

2 (25)

.3

\ .0001 \ .0001 \ .0001

Lund-Mackay score, mean (SD) No. of CT scans, mean (%)

16 (5)

11.3 (4.2)

13 (4)

3 (1)

1.6 (1)

2 (0.8) 4 (13) 4 (13)

2 (1)

No. of patients undergoing . 3 CT scans (%)

50 (55) 47 (53)

14 (15) 23 (25)

10 (16) 19 (31)

Immunotherapy, n (%)

.0001

Abbreviations: AFRS, allergic fungal rhinosinusitis; CRS, chronic rhinosinusitis; CRSsNP, CRS without nasal polyps; CRSwNP, CRS with nasal polyps; CT, com- puted tomography; IgE, immunoglobulin E; RAST, radioallergosorbent test.

correlation with symptoms, sinus disease on CT, and disease outcome. 6,27-29 Furthermore, the role of IgE-mediated fungal hypersensitivity in the pathogenesis of both CRS and AFRS has been challenged. 30 Further research in this area is needed before the statistically significant differences in allergy-related disease severity markers found here are translated to clinical interpretation and practice. Lund-Mackay scores were found to be highest in AFRS patients and lowest in CRSsNP patients in this study. Correlation between Lund-Mackay scores and symptomatic improvement after FESS has been demonstrated, but the association is neither stable nor strong. 31,32 Even though radiologic measures have an inconsistent relationship with symptoms, the differences in Lund-Mackay scores can still aid clinicians in diagnostic workup, in terms of distinguish- ing AFRS from other subtypes of CRS. In regard to the key question of the linkage between demo- graphics, socioeconomic status, and disease severity, such associations in AFRS patients have been well established by Miller et al, 15 Wise et al, 13 and others. 33,34 In contrast, among the CRS patients studied, derived from the same academic ter- tiary care center and the same providers as the 93 AFRS patients studied in Miller et al, 15 there is no clear association. Several points are important to explain the differences seen in AFRS versus CRS patients in terms of their demographics, socioeconomic status, and disease severity. Starting with genetic predisposition, previous studies have shown a unique

gene expression profile for AFRS that is distinct from normal subjects. 35 In addition, nasal polyposis, which is involved in both AFRS and CRSwNP, has been shown to have characteris- tic transcriptional signatures on genome-wide expression microarrays when compared with normal sinonasal mucosa. 36 Thus, true biological and genetic differences deserve more attention and may help explain the distinctive nature of AFRS compared with other subtypes of CRS. Genetic predisposition is closely connected to socioeco- nomic and environmental exposures. In a study based on national survey database registries of 27,731 patients, Soler et al 10 found significant differences between racial-ethnic groups in insurance status and resources used in terms of referral patterns, specialist visits, and surgical care, disfavor- ing minority patients. In addition, the investigators found underrepresentation of minorities in the surgical cohort (18% vs national average of 35%), which may point to undertreat- ment of minorities due to barriers of income, referral patterns, and other socioeconomic confounders. 10 These barriers also explain results found by Miller et al. 15 In summary, the dif- ferences between the AFRS and CRS patients are multifac- torial and may encompass differing genetic dispositions, histologic and pathophysiologic factors, socioeconomic and environmental exposures, health behaviors, and health care access that all ultimately effect disease severity and outcome. Our study was limited in several aspects. Objective markers of disease severity for CRwNP and CRSsNP are not clearly

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