International Rhinologic Society Rhinology 0300-0729 57 1 2019 February 1 30685779 More papers, more issues 1 1 EN W.J. Fokkens Department of Otorhinolaryngology, Amsterdam University Medical Centres Location AMC, The Netherlands 1871 10.4193/Rhin19.401

International Rhinologic Society Rhinology 0300-0729 57 1 2019 February 1 30052696 The clinical implications of computerised fluid dynamic modelling in rhinology 2 9 EN S.H.P. Leite Department of Surgery, The University of Auckland, Auckland, New Zealand R. Jain Department of Surgery, The University of Auckland, Auckland, New Zealand R.G. Douglas Department of Surgery, The University of Auckland, Auckland, New Zealand 1828 10.4193/Rhin18.035 BACKGROUND: The nose is a dynamic organ and is the first point of contact between inhaled air and mucosal surfaces. Within the nasal cavity, there are changes of air flow and pressure occurring during the respiratory cycle, as well as exchanges of heat and humidity, and important immune responses to inhaled antigens and allergens. METHODOLOGY: This review is a summary for rhinologists covering what is known about airflow within the nose and sinuses and the impact of pathology and treatments on the physical environment of the nasal cavity. The review will concentrate largely on the significant contribution that computational fluid dynamics has had on this field. RESULTS: The complex anatomical structure of the nasal cavity provides an aerodynamic environment that guides the airflow throughout the nasal cavities. However, anatomical or inflammatory changes can modify the air flow, heat and humidity exchanges, with negative consequences on nasal physiology. Restoration of normal airflow is a key goal to achieve success in the treatment of nasal diseases. CONCLUSIONS: Computational fluid dynamics is a method of analysis originating from engineering which has been adapted for rhinology. Although still an expensive and laborious technique, it may become a viable diagnostic tool in the future for studying nasal physiology.

International Rhinologic Society Rhinology 0300-0729 57 1 2019 February 1 30219822 Local specific Immunoglobulin E among patients with nonallergic rhinitis: a systematic review 10 20 EN Aneeza W. Hamizan Rhinology and Skull Base Research Group, St Vincents Centre for Applied Medical Research, University of New South Wales, Sydney, Australia; Department of Otolaryngology and Head & Neck Surgery, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia Janet Rimmer St Vincents Clinic, St Vincents Hospital, Sydney, Australia; The Woolcock Institute, Sydney University, Sydney, Australia Salina Husain Department of Otolaryngology and Head & Neck Surgery, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia Raquel Alvarado Rhinology and Skull Base Research Group, St Vincents Centre for Applied Medical Research, University of New South Wales, Sydney, Australia Jessica Tatersall Rhinology and Skull Base Research Group, St Vincents Centre for Applied Medical Research, University of New South Wales, Sydney, Australia William Sewell St Vincents Clinical School, University of New South Wales Sydney, Australia; Garvan Institute, Sydney, Australia Larry Kalish Sydney Medical school, University of Sydney, Sydney, Australia; Department of Otolaryngology, Head and Neck Surgery, Concord General Hospital, University of Sydney Richard J. Harvey Rhinology and Skull Base Research Group, St Vincents Centre for Applied Medical Research, University of New South Wales, Sydney, Australia; Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia 1841 10.4193/Rhin18.074 Background: Allergen specific immunoglobulin can be present in the nasal mucosa of patients with non-allergic rhinitis (NAR). This condition is defined as local allergic rhinitis. However, the reported presence of nasal specific immunoglobulin E (nspIgE) among NAR is variable. The aim of this review was to summarize the studies which reported the presence of nspIgE among patients diagnosed as NAR. Methods: Embase (1947- ) and Medline (1946-) were searched until 6th June 2017. A search strategy was utilized to identify studies on nspIgE among patients with NAR. The target population was patients with symptoms of rhinitis, but negative systemic allergen sensitization. Studies with original data on detectable nspIgE among the NAR population were included. Meta-analysis of single proportions as a weighted probability %(95%CI) was performed. Heterogeneity was explored amongst studies. Results: A search strategy returned 2286 studies and 21 were included. These studies involved 648 participants with NAR. NspIgE was detected using either; 1. nasal secretions, 2. epithelial mucosa sampling, 3. tissue biopsies or 4. In-situ tests. Metaanalysis was performed on studies with nasal secretions. The weighted proportion of detectable nspIgE in nasal secretions within patients with NAR was 10.2 (7.4-13.4) %. Population definitions partly explained variability. Detection of nspIgE was lower in patients without a history suggestive of allergy compared to those with a positive allergic history (0 (0-3.1) % v 19.8 (14.5-25.6) %, p<0.01). Conclusion: NAR with positive allergy history suggests presence of nspIgE. These patients warrant further allergology evaluation to confirm localized nasal allergy, as they benefit from allergy therapy such as immunotherapy.

International Rhinologic Society Rhinology 0300-0729 57 1 2019 February 1 30221643 Fibrin tissue adhesive versus nasal packing in endoscopic nasal surgery: a systematic review and meta-analysis 21 31 EN James G. Coey Faculty of Biology, Medicine and Health, The University of Manchester, United Kingdom Paula J. Whittaker Faculty of Biology, Medicine and Health, The University of Manchester, United Kingdom Greg Williams Faculty of Biology, Medicine and Health, The University of Manchester, United Kingdom Umar H. Ikram Faculty of Biology, Medicine and Health, The University of Manchester, United Kingdom Oliver J. R. Page Faculty of Biology, Medicine and Health, The University of Manchester, United Kingdom 1842 10.4193/Rhin18.112 BACKGROUND: It has been proposed that fibrin tissue adhesive (FTA) can act as an effective alternative to nasal packing in managing the postoperative symptoms of endoscopic nasal surgery. METHODOLOGY: MEDLINE, Embase, Cochrane Library, The Cumulative Index to Nursing and Allied Health Literature and ClinicalTrials.gov were searched for randomised controlled trials comparing FTA with nasal packing in endoscopic nasal surgery. The primary outcome of interest was bleeding; secondary outcomes included pain, nasal obstruction, infection, adhesions and the formation of granulation tissue. All trials underwent a risk of bias assessment, and a meta-analysis was performed using a random effects model. RESULTS: 315 studies were found, of which four were eligible for inclusion (n = 152). Bleeding was reported in all, with the meta-analysis favouring the packing group, although this was not significant. Nasal obstruction and granulation severity were significantly lower in the FTA group, however, no difference was noted for the outcomes of pain, infection or adhesions. CONCLUSION: Our results indicate minor advantages for using FTA over nasal packing. Unfortunately, the included studies show significant heterogeneity and risk of bias. Based on the available evidence, clinicians must balance the higher cost of FTA against the limited advantages for the patient.

International Rhinologic Society Rhinology 0300-0729 57 1 2019 February 1 The Global Allergy and Asthma European Network (GALEN rhinosinusitis cohort: a large European cross-sectional study of chronic rhinosinusitis patients with and without nasal polyps 32 42 EN A. Khan Sanofi, Chilly Mazarin, France G. Vandeplas Ghent University, Ghent, Belgium T.M.T. Huynh Sanofi, Chilly Mazarin, France V.N. Joish Regeneron Pharmaceuticals, Inc., Tarrytown, NY, USA L. Mannent Sanofi, Chilly Mazarin, France P. Tomassen Ghent University, Ghent, Belgium T. Van Zele Ghent University, Ghent, Belgium L.O. Cardell Karolinska Institutet, Stockholm, Sweden J. Arebro Karolinska Institutet, Stockholm, Sweden H. Olze Charite-Universitatsmedizin, Berlin, Germany U. Foerster-Ruhrmann Charite-Universitatsmedizin, Berlin, Germany M.L. Kowalski Medical University of Lodz, Lodz, Poland A. Olszewska-Ziaber Medical University of Lodz, Lodz, Poland G. Holtappels Ghent University, Ghent, Belgium N. De Ruyck Ghent University, Ghent, Belgium C. van Drunen Academic Medical Center, Amsterdam, the Netherlands J. Mullol Hospital Clinic - IDIBAPS and Universitat de Barcelona, Barcelona, Spain P.W. Hellings University Hospitals Leuven, Leuven, Belgium V. Hox University Hospitals Leuven, Leuven, Belgium E. Toskala Temple University School of Medicine, Philadelphia, PA, USA G. Scadding Royal National Throat, Nose and Ear Hospital, London, UK V.J. Lund Royal National Throat, Nose and Ear Hospital, London, UK W.J. Fokkens Academic Medical Center, Amsterdam, the Netherlands C. Bachert Ghent University, Ghent, Belgium 1816 10.4193/Rhin17.255 BACKGROUND: Chronic rhinosinusitis (CRS) is a common yet under-recognised chronic inflammatory disease of the nose and paranasal sinuses that is classified according to the presence (CRSwNP) or absence (CRSsNP) of nasal polyps. METHODS: This paper reports the methodology and descriptive results of the Global Allergy and Asthma European Network (GALEN) rhinosinusitis cohort. We established a large CRS cohort within the GALEN consortium (European FP6 research initiative) to identify inflammatory endotypes, the natural disease course, and its impact on health-related quality of life (HRQoL). Detailed information on the impact of CRS on HRQoL, comorbidity incidence, objective disease measures, and medical and surgical treatments were collected. RESULTS: This multicentre cross-sectional case-control study recruited 935 adults (869 eligible for analysis: 237 CRSsNP; 445 CRSwNP; 187 controls [reference group]). Comorbidities such as asthma, allergy, eczema, food allergy, urticaria, and chronic obstructive pulmonary disease were significantly more frequent in CRS patients. Nasal corticosteroids, antibiotics, and oral corticosteroids were the most common treatments. Significantly more CRSwNP patients reported previous sinonasal surgery. CONCLUSIONS: This study provides detailed information that facilitates studying CRS and its main phenotypes. However, patient distribution of this study does not necessarily reflect disease distribution in the general population.

International Rhinologic Society Rhinology 0300-0729 57 1 2019 February 1 Epidemiology of chronic rhinosinusitis in Bushehr, southwestern region of Iran: a GA2LEN study 43 48 EN A. Ostovar Osteoporosis Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran W.J. Fokkens Department of Otorhinolaryngology, Academic Medical Center, Amsterdam, the Netherlands K. Vahdat Department of Infectious Diseases, The Persian Gulf Tropical Medicine Research Center, The Persian Gulf Biomedical Sciences Research Institute, Bushehr University of Medical Sciences, Bushehr, Iran A. Raeisi Department of Infectious Diseases, The Persian Gulf Tropical Medicine Research Center, The Persian Gulf Biomedical Sciences Research Institute, Bushehr University of Medical Sciences, Bushehr, Iran A. Mallahzadeh Department of ENT, The Persian Gulf Tropical Medicine Research Center, The Persian Gulf Biomedical Sciences Research Institute, Bushehr University of Medical Sciences, Bushehr, Iran S. Farrokhi Department of Immunology and Allergy, The Persian Gulf Tropical Medicine Research Center, The Persian Gulf Biomedical Research Institute, Bushehr University of Medical Sciences, Bushehr, Iran 1820 10.4193/Rhin18.061 BACKGROUND: Population-based studies using the European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS) criteria for the assessment of the chronic rhinosinusitis (CRS) prevalence play important roles in the development and promotion of public health policies. METHODS: A multistage, stratified cluster, random sampling method was used to select the study participants from individuals living in Bushehr, which is in the southwestern part of Iran. The standardized Global Allergy and Asthma European Network (GA2LEN) questionnaire was completed by 5,201 participants, and the CRS prevalence were compared among different groups of related factors using chi-squared tests. RESULTS: The overall CRS prevalence was 28.4% based on the EPOS criteria, while the self-reported physician-diagnosed CRS prevalence was 20.0%. There was no gender difference; however, CRS was more prevalent in smokers, individuals aged 25 - 34 years old, non-educated persons, and healthcare workers. CRS was also associated with asthma and allergic rhinitis. CONCLUSIONS: The present study showed that the CRS prevalence in Iran was relatively high. These results support the idea that CRS is a major public health problem in Iran.

International Rhinologic Society Rhinology 0300-0729 57 1 2019 February 1 30052697 Rhinology future trends: 2017 EUFOREA debate on allergic rhinitis 49 56 EN G. Scadding The Royal National Throat Nose and Ear Hospital, Grays Inn Road, London, UK J. Bousquet MACVIA-France and Foundation FMC VIA-LR, Montpellier, France C. Bachert Ghent University Hospital, Belgium W.J. Fokkens Department of Otorhinolaryngology, Academic Medical Centre, Amsterdam, The Netherlands P.W. Hellings Clinical Division of Otorhinolaryngology, Head and Neck Surgery, University Hospitals Leuven, Leuven, Belgium E. Prokopakis Department of Otorhinolaryngology, University of Crete School of Medicine, Heraklion, Greece O. Pfaar Department of Otorhinolaryngology, Head and Neck Surgery, Universitatsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany D. Price Centre of Academic Primary Care, University of Aberdeen, Aberdeen, UK 1826 10.4193/Rhin18.076 The 2nd Rhinology Future Debate, organized by EUFOREA (European Forum for Research and Education in Allergy and Airways diseases) was held in Brussels in December 2017. One of these debates addressed the position of MP-AzeFlu in allergic rhinitis (AR) treatment. The current article summarizes this debate; reviewing recent data, and exploring how this has been interpreted by experts and incorporated into AR management guidelines and a clinical decision support system (CDSS). The Allergic Rhinitis & its Impact on Asthma (ARIA) guideline position MP-AzeFlu firstline for the treatment of AR, and in preference to intranasal corticosteroids (INSs) during the first 2 weeks of treatment. The AR CDSS recommends MP-AzeFlu as one of the firstline treatments for patients with a visual analogue scale (VAS) score lower than 5/10 cm, and in preference (along with INS) for those with a VAS score equal or higher than5/10 cm. Panellists agreed that AR management should be kept as simple as possible, with some preferring a one treatment fits all approach, while others preferred a step-up approach. The need to change the AR management mentality was acknowledged, accepting that most patients use their medication as needed and use multiple treatments; AR medications are needed which have a very fast onset of action and which target breakthrough symptoms. Panellists agreed that MP-AzeFlu has a role to play here, since it has a 5 minute onset-of-action, provides clinically-relevant symptom relief in 15 mins and AR control in less than 3 days, targets nasal hyper-reactivity (NHR) which likely contributes to uncontrolled AR and breakthrough symptoms, and provides more effective AR symptom relief than INS monotherapy or INS + oral antihistamine. Finally, experts considered it likely that MP-AzeFlu should have a greater impact on asthma control than INS in co-morbid patients, but clinical data is required to back up existing pharmacoeconomic evidence. The next Rhinology Future Debate will be in held in Brussels in Dec 2019.

International Rhinologic Society Rhinology 0300-0729 57 1 2019 February 1 Impact of cigarette smoke and IL-17A activation on asthmatic patients with chronic rhinosinusitis 57 66 EN Chien-Chia Huang Division of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan; Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taiwan Ta-Jen Lee Division of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan; Department of Otolaryngology, Xiamen Chang Gung Hospital, Xiamen, China Chi-Che Huang Division of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan; Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taiwan Po-Hung Chang Division of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan; Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taiwan Chia-Hsiang Fu Division of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan; Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taiwan Pei-Wen Wu Division of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan; Department of Otolaryngologyâ€"Head and Neck Surgery, Chang Gung Memorial Hospital and Chang Gung University, Keelung, Taiwa Chun-Hua Wang Department of Thoracic Medicine, Chang Gung Memorial Hospital and Medicine of College, Chang Gung University, Taoyuan, Taiwan 1865 10.4193/Rhin18.131 Background: Cigarette smoke have adverse effects in the control of asthma and chronic rhinosinusitis (CRS). Interleukin (IL)-17A, the signature cytokine of helper T 17 cells and group 3 innate lymphoid cells (ILC3), has been reported to link with resistance to therapy in airway inflammation. This study aimed to investigate the impact of cigarette smoking and IL-17A activation on the clinical outcomes of asthmatic patients with chronic rhinosinusitis. Methods: 33 patients with CRS and asthma, including 15 smokers and 18 non-smokers, and 7 asthmatic patients without CRS and smoking were prospectively recruited. The Sino-Nasal Outcome Test-22 and Asthma Control Test were used to evaluate sinonasal symptoms and the level of asthma control, respectively. Real-time PCR and immunostaining were applied to evaluate the expression levels of IL-17A and associated immunological factors on surgically-obtained nasal tissues. Results: Nasal surgery improved both sinonasal symptoms and asthma control. Compared to non-smokers, smokers showed poorer improvement in asthma control. The expression of IL-17A, IL-22, aryl hydrocarbon receptor (AhR), and ILC3 was increased in the nasal tissues of smokers with asthma and CRS. The expression of IL-17A mRNA was correlated with that of AhR and with positive nuclear AhR-AhR nuclear translocator staining cells, and that of cyclooxygenase-2 enzyme (COX-2). ILC3 cells were associated with IL-17A, IL-22, AhR, and COX-2 mRNA expression. Conclusions: Cigarette smoking was related to lesser improvement in asthma control after nasal surgery and to IL-17A activation in the nasal tissues of patients with inflammatory airways.

International Rhinologic Society Rhinology 0300-0729 57 1 2019 February 1 30688945 Histopathology of ethmoid mucosa versus polyp tissue in diagnosing eosinophilic mucin rhinosinusitis 67 72 EN Wanrawee Thaitrakool Department of Otolaryngology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Endoscopic Nasal and Sinus Surgery Excellence Center, King Chulalongkorn Memorial Hospital, Bangkok, Thailand Narittee Sukswai Department of Pathology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand Somboon Keelawat Department of Pathology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand Supinda Chusakul Department of Otolaryngology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Endoscopic Nasal and Sinus Surgery Excellence Center, King Chulalongkorn Memorial Hospital, Bangkok, Thailand Jesada Kanjanaumporn Department of Otolaryngology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Endoscopic Nasal and Sinus Surgery Excellence Center, King Chulalongkorn Memorial Hospital, Bangkok, Thailand Songklot Aeumjaturapat Department of Otolaryngology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Endoscopic Nasal and Sinus Surgery Excellence Center, King Chulalongkorn Memorial Hospital, Bangkok, Thailand Kornkiat Snidvongs Department of Otolaryngology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Endoscopic Nasal and Sinus Surgery Excellence Center, King Chulalongkorn Memorial Hospital, Bangkok, Thailand 1858 10.4193/Rhin18.068 BACKGROUND: This study aims to compare histopathology of nasal polyp and ethmoid mucosa for diagnosing eosinophilic mucin rhinosinusitis (EMRS). METHODOLOGY: Patients with chronic rhinosinusitis with polyps (CRSwNP) were enrolled. Using eosinophilic mucin as a reference, histopathology of polyp apex, polyp pedicle and ethmoid mucosa was compared for density of tissue eosinophil and sensitivity for diagnosing EMRS. Associations with asthma were assessed for each site. RESULTS: Thirty patients with CRSwNP were enrolled. When polyp apex, polyp pedicle and ethmoid mucosa were assessed for tissue eosinophilia, consistent results were reported in 16 patients (53%). Median tissue eosinophil was greater in polyp apex (58, IQR: 7-100) than ethmoid mucosa (10, IQR: 2-21), but not different from polyp pedicle (22, IQR: 1-96). Sensitivity for diagnosing EMRS were 100% (95%CI: 47.8 - 100) for polyp apex, 60% (95%CI: 14.7 - 94.7) for polyp pedicle, 80% (95%CI: 28.4 â€" 99.5) for ethmoid mucosa. Associations with asthma were significant for polyp pedicle, and ethmoid mucosa but not polyp apex. CONCLUSION: Density of tissue eosinophil was greater in nasal polyp than in ethmoid mucosa. Histopathology of polyp apex had good sensitivity for diagnosing EMRS. Polyp pedicle and ethmoid mucosal eosinophilia associated with asthma.

International Rhinologic Society Rhinology 0300-0729 57 1 2019 February 1 30534644 Eustachian Tube dysfunction in chronic rhinosinusitis: pre and post-operative results following endoscopic sinus surgery, a prospective study 73 77 EN Philippe F. D. Bowles ENT Department, Ipswich Hospital NHS Trust, Ipswich, United Kingdom Satish Agrawal ENT Department, Ipswich Hospital NHS Trust, Ipswich, United Kingdom Mahmoud A. Salam ENT Department, Ipswich Hospital NHS Trust, Ipswich, United Kingdom 1859 10.4193/Rhin18.208 BACKGROUND: Prospective study investigating the incidence of concurrent Eustachian Tube dysfunction (ETD) in patients with CRS refractory to medical therapy, and the effect of Endoscopic Sinus Surgery (ESS) on ETD in this patient group. METHODS: Prospective study of 57 CRS patients. Outcome measures were SNOT-22 and ETDQ-7 questionnaires, tympanometry and Valsalva manoeuvre recorded pre-operatively and at 3 and 9 months post ESS. RESULTS: There was a moderate positive correlation between pre-operative ETDQ-7 and SNOT 22 scores (r equals 0.5715, p less than 0.0001). 68% of patients recorded positive ETDQ-7 scores pre-operatively, mean equals 20.6 (SD plus or minus 10.34). Mean ETDQ-7 scores were significantly lower at 3 months; mean equals 11.4 (SD plus or minus 5.65) (P less than 0.0001) and 9 months mean equals 11.4 (SD plus or minus 6.15) (P less than 0.0001) following ESS. Type A tympanograms increased form 76.6% pre-operatively, to 94.5% at 3 months and 96% at 9 months. Reported positive Valsalva increased from 38% pre-operatively to 96% at 3 and 9 months. Mean ETDQ-7 scores were higher in the CRSwNP group; 24.34 (SD plus or minus 9.2) compared to the CRSsNP group; 18.11 (SD plus or minus 10.3), (p equals 0.6101). 16 patients in the cohort had existing diagnoses of asthma, of which 4 had documented aspirin sensitivity. The mean pre-operative SNOT-22 score in this overall subgroup was 64.81 (SD equals plus or mins 20.13) compared with 49.07 (SD equals plus or minus 21.37) in non-asthmatic patients (p equals 0.0168). Conclusions: We found a high incidence of concurrent ETD symptoms in patients with severe CRS, which improve following ESS. Further research is required to better understand the association between CRS and ETD in order to provide effective treatments.