International Rhinologic Society Rhinology 0300-0729 64 2 2026 4 1 41707022 Targeting outcomes with precision 145 145 EN M.B. Soyka Swiss Institute of Allergy and Asthma Research, University of Zurich, Davos, Davos Platz, Switzerland 3430 10.4193/Rhin26.902 Sir William Osler once said "Treat the patient, not the disease", already touching on the principles of precision or personalised medicine, realising that the one-size-fits all approach does not work. Obviously, the same is true in rhinology. We strive to achieve better results by tailoring diagnostics and therapy to the individual patterns of diseases and patients’ requirements.

International Rhinologic Society Rhinology 0300-0729 64 2 2026 4 1 41313596 Olfactory dysfunction in CHARGE syndrome: a systematic review of prevalence, assessment methods, and clinical correlates 146 160 EN G.M. Spencer Queen’s University School of Medicine, Kingston, Ontario, Canada K. Karim Queen’s University School of Medicine, Kingston, Ontario, Canada P. Coyle Department of ENT, Royal National ENT and Eastman Dental Hospitals, University College London Hospitals NHS Foundation Trust, London, UK E.K. Bhargava Department of ENT, Sheffield Children’s Hospital, Sheffield, UK;Faculty of Health, University of Sheffield, Sheffield, UK K.L. Whitcroft Department of ENT, Sheffield Children’s Hospital, Sheffield, UK 3391 10.4193/Rhin25.391 BACKGROUND: Olfactory dysfunction (OD) is an underrecognized feature of CHARGE syndrome (CS), often associated with CHD7 mutations and structural anomalies of the olfactory system. This systematic review examines the burden, assessment methods, and clinical correlates of OD in CS. METHODOLOGY: A systematic review was conducted in accordance with PRISMA guidelines and registered with PROSPERO (CRD420251040500). A comprehensive search of six databases up to May 2025 was performed. Two independent reviewers screened, extracted data, and assessed study quality. A narrative synthesis was performed. RESULTS: From 1,643 records, 16 studies met inclusion criteria. Most were retrospective cohort studies and employed clinical diagnostic criteria for CS, with a subset reporting CHD7 mutation data. OD was most frequently identified radiologically. Psychophysical testing and self/parent reports were less common. Neurodevelopmental delays, feeding/swallowing issues, and reduced quality of life were reported in association with OD, but causal relationships remain unclear. CONCLUSIONS: OD is highly prevalent in CS, often exceeding 80%, yet remains underrecognized. Radiologic imaging and electrophysiological techniques may be alternatives when psychophysical testing is not feasible. Future research should focus on validating paediatric-specific and developmentally appropriate olfactory assessments and integrating olfaction into quality-of-life frameworks. OD should be considered for inclusion in revised CHARGE diagnostic criteria.

International Rhinologic Society Rhinology 0300-0729 64 2 2026 4 1 41486776 High-dose steroid nasal spray is better than nasal irrigation in nonoperated chronic rhinosinusitis: a randomized clinical trial 161 170 EN G.R. Lima Luz-Matsumoto inology Sector, Department of Otorhinolaryngology and Head and Neck Surgery, Federal University of São Paulo - Paulista School of Medicine, São Paulo, state of São Paulo, Brazil E. Cabernite Marchetti inology Sector, Department of Otorhinolaryngology and Head and Neck Surgery, Federal University of São Paulo - Paulista School of Medicine, São Paulo, state of São Paulo, Brazil L. Lobato Gregorio inology Sector, Department of Otorhinolaryngology and Head and Neck Surgery, Federal University of São Paulo - Paulista School of Medicine, São Paulo, state of São Paulo, Brazil F. Mesquita Callegari Department of Pathology, Federal University of São Paulo - Paulista School of Medicine, São Paulo, state of São Paulo, Brazil E. Macoto Kosugi Rhinology Sector, Department of Otorhinolaryngology and Head and Neck Surgery, Federal University of São Paulo - Paulista School of Medicine, São Paulo, state of São Paulo, Brazil 3398 10.4193/Rhin24.532 BACKGROUND: To compare the efficacy of high-dose nasal steroid administered via high-volume irrigation versus spray delivery in patients with chronic rhinosinusitis (CRS) who have not undergone previous sinonasal surgery. METHODOLOGY: A double-blind randomized clinical trial was conducted. The study comprised two groups receiving 1,000 μg/day of nasal budesonide through two distinct methods over a 3-month period: irrigation and spray delivery. Patients with severe CRS who had never undergone surgery and were on the waiting list for surgery in a public health service were included. Primary outcomes included changes in quality-of-life scores and secondary outcomes included changes in clinical control questionnaire results and nasal endoscopy findings. Assessments were conducted on the total sample, CRS with nasal polyps (CRSwNP), CRS without nasal polyps (CRSsNP), and according to the newly defined phenotypes of diffuse primary CRS (central compartment atopic disease [CCAD], eosinophilic chronic rhinosinusitis [eCRS] and non-eosinophilic CRS [neCRS]). RESULTS: Sixth-seven patients completed the study, with 34 in the Irrigation Group and 33 in the Spray Group. The Spray Group demonstrated superior efficacy in improving endoscopic outcomes across the total sample, particularly among CRSwNP and CCAD. No treatment demonstrated superiority in improving the SNOT-22 score. Furthermore, the Spray Group revealed greater efficacy in reducing the number of uncontrolled patients, as evaluated by the clinical control questionnaire, both in the total sample and CRSwNP. CONCLUSIONS: High-dose steroid nasal spray outperformed high-volume steroid nasal irrigation in improving nasal endoscopy outcomes across the total sample, especially in CRSwNP and CCAD.

International Rhinologic Society Rhinology 0300-0729 64 2 2026 4 1 41486788 Real-world epidemiological outcomes of biologic therapy for chronic rhinosinusitis with nasal polyps: a big data analysis 171 178 EN E. Zloczower Department of Otolaryngology, Head and Neck Surgery, Kaplan Medical Center, Rehovot, Israel;Faculty of Medicine, Hebrew University of Jerusalem, Israel G.G. Nyquist Department of Otolaryngology and Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, United States A. Bebin Department of Otolaryngology, Head and Neck Surgery, Kaplan Medical Center, Rehovot, Israel Y. Lahav Department of Otolaryngology, Head and Neck Surgery, Kaplan Medical Center, Rehovot, Israel;Faculty of Medicine, Hebrew University of Jerusalem, Israel M. Warman Department of Otolaryngology, Head and Neck Surgery, Kaplan Medical Center, Rehovot, Israel;Faculty of Medicine, Hebrew University of Jerusalem, Israel 3404 10.4193/Rhin25.393 BACKGROUND: Biologic therapy has emerged as a key treatment for chronic rhinosinusitis with nasal polyps (CRSwNP), particularly in refractory cases, but its effect on healthcare utilization is not well established. METHODOLOGY: We conducted a retrospective big-data analysis using the Clalit Health Services database, identifying all CRSwNP patients treated with dupilumab or mepolizumab following endoscopic sinus surgery (ESS) between 2010â€"2024. We assessed antibiotic and systemic steroid use, visits to clinics, emergency rooms (ER), hospitalizations, and repeat ESS before and after biologic initiation. RESULTS: Among 861 patients (54.2% on dupilumab, 45.8% on mepolizumab), 62% had asthma. Median therapy duration was 25 months. Mean follow-up was 130 ± 78 months before treatment and 43 ± 42 months after. Biologics significantly reduced antibiotic and systemic steroid use, as well as community clinic, hospitalization, and revision ESS rates. Serum eosinophils declined from 520 ± 440 to 430 ± 460 cells/μL. CONCLUSIONS: Post-ESS biologic therapy in CRSwNP patients is associated with reduced healthcare utilization and systemic medication use, highlighting its positive impact on disease burden and healthcare efficiency.

International Rhinologic Society Rhinology 0300-0729 64 2 2026 4 1 41347785 Association between allergic rhinitis and attention deficit hyperactivity disorder symptoms in pediatric patients: the impact of seasonal variability 179 187 EN A. Sogut Ankara Bilkent City Hospital, Department of Pediatrics, Ankara, Türkiye A. Selmanoglu Ankara Bilkent City Hospital, Department of Pediatric Allergy/Immunology, Ankara, Türkiye C. Genis Ankara Bilkent City Hospital, Department of Pediatric Allergy/Immunology, Ankara, Türkiye Z.S. Emeksiz University of Health Sciences, Ankara Bilkent City Hospital, Department of Pediatric Allergy/Immunology, Ankara, Türkiye E. Cop University of Health Sciences, Ankara Bilkent City Hospital, Department of Child and Adolescent Psychiatry, Ankara, Türkiye E.D. Mısırlıoglu University of Health Sciences, Ankara Bilkent City Hospital, Department of Pediatric Allergy/Immunology, Ankara, Türkiye 3393 10.4193/Rhin25.185 BACKROUND: Allergic rhinitis (AR) patients may experience attention deficits (AD), concentration impairment, and learning difficulties. This study aimed to compare AD hyperactivity disorder (ADHD) symptoms in grass pollenâ€"allergic AR patients and controls and to assess their seasonal variation. METHODOLOGY: The study included children aged 6â€"12 with AR who presented to Ankara Bilkent City Hospital between April 15 and June 15 in 2022 and 2023. The Visual Analog Scale (VAS) was used to assess disease severity, and the Conners Parent Rating Scale (CPRS) was employed to evaluate ADHD symptoms. For comparison, the CPRS was also administered to an age-matched control group consisting of children without known allergies or chronic diseases. RESULTS: The study included 146 AR patients (8.9±1.7 years) and 150 controls (9.0±1.8 years). During the grass pollen season, AR patients showed increased rates of AD, hyperactivity, and school absenteeism, along with a decline in academic performance. Compared to the control group, AR patients exhibited significantly higher AD, hyperactivity, and total CPRS scores. Logistic regression analysis identified male sex, high nasal VAS score, and snoring as independent risk factors for AD, while a high ocular VAS score was an independent risk factor for hyperactivity. CONCLUSIONS: Exacerbation of AR symptoms during the grass pollen season leads to a significant increase in ADHD symptoms and a decline in academic performance. Regular monitoring and symptom control in AR patients are crucial for maintaining academic and social success.

International Rhinologic Society Rhinology 0300-0729 64 2 2026 4 1 41574697 Decoding the neural basis of olfactory dysfunction: a multimodal MRI study in CRS-OD 188 196 EN C. Zhang Department of Radiology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, P.R. China Q. Wang Department of Radiology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, P.R. China C. Jiang Department of Radiology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, P.R. China Z. Tian The first clinical medical college of Xuzhou Medical University, Xuzhou, Jiangsu, China J. Sha Department of Radiology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, P.R. China X. Wang Department of Radiology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, P.R. China W. Zhou Department of Radiology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, P.R. China T. Cui Department of Radiology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, P.R. China Y. Zang Department of Otolaryngology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, P.R. China K. Xu Department of Radiology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, P.R. China 3425 10.4193/Rhin25.096 BACKGROUND: Chronic rhinosinusitis with olfactory dysfunction (CRS-OD) affects both peripheral and central olfactory pathways. Persistent olfactory loss may induce neuroplastic changes in brain regions involved in olfactory processing. We hypothesized that CRS-OD is associated with gray matter atrophy in olfactory-related regions, accompanied by alterations in global functional connectivity as a manifestation of compensatory or maladaptive reorganization. To test this, we performed voxel-based morphometry (VBM) to identify gray matter differences, followed by seed-based functional connectivity (FC) analysis using the altered regions. METHODOLOGY: We prospectively recruited 23 CRS-OD patients and 23 healthy controls (HCs). All patients presented with persistent olfactory dysfunction lasting 6 to 240 months. All participants underwent MRI scanning at the same time point. Olfactory function was assessed in CRS-OD patients using the Threshold-Discrimination-Identification (TDI) test, the Questionnaire of Olfactory Disorders (QOD), and the Olfactory-Evoked Cognitive Score (OECS). MRI analyses included VBM, FC, and olfactory bulb volume on DRIVen Equilibrium turbo spin echo (TSE) images. RESULTS: CRS-OD patients exhibited significantly reduced olfactory bulb (OB) volumes compared to HCs and gray matter atrophy in the inferior frontal orbital gyrus, parahippocampal gyrus, hippocampus, thalamus, and putamen. FC analysis revealed decreased connectivity in sensory-integration networks and increased FC in the superior occipital gyrus, suggesting compensatory reorganization. CONCLUSIONS: CRS-OD is characterized by OB atrophy, gray matter atrophy, and disrupted FC, reflecting both peripheral and central neural alterations. Multimodal MRI may provide new insights into CRS-OD pathophysiology, warranting further longitudinal studies.

International Rhinologic Society Rhinology 0300-0729 64 2 2026 4 1 41191403 Distinct inflammatory features and nasal TH2 cell profiles in allergic patients with chronic rhinosinusitis 197 205 EN H. Bae Yonsei University College of Medicine, Seoul, Republic of Korea G. Kim The Graduate School, Yonsei University College of Medicine, Seoul, Republic of Korea;Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul, Republic of Korea S. Lee The Graduate School, Yonsei University College of Medicine, Seoul, Republic of Korea;Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul, Republic of Korea M-S. Koo The Graduate School, Yonsei University College of Medicine, Seoul, Republic of Korea;Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul, Republic of Korea H-J. Cho Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul, Republic of Korea;The Airway Mucus Institute, Yonsei University College of Medicine, Severance Hospital, Seoul, Republic of Korea C-H. Kim Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul, Republic of Korea;The Airway Mucus Institute, Yonsei University College of Medicine, Severance Hospital, Seoul, Republic of Korea M-S. Rha Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul, Republic of Korea;The Airway Mucus Institute, Yonsei University College of Medicine, Severance Hospital, Seoul, Republic of Korea 3381 10.4193/Rhin25.195 BACKGROUND: Various factors affect the immunopathogenesis of chronic rhinosinusitis (CRS). Although the relationship between allergies and CRS has attracted considerable attention, it remains controversial. Notably, little is known about whether the clinical characteristics and immunological profiles differ based on allergic sensitization status among patients with CRS. METHODOLOGY: This study included 209 patients with CRS with nasal polyps (CRSwNP) who underwent endoscopic sinus surgery, and their nasal polyp tissues were obtained. Patients were divided into two groups according to allergic sensitization status: "allergic" and "non-allergic" groups. The clinical characteristics and immunological profiles were compared between the two groups. Ex vivo phenotypes of nasal CD4+ T cells were analyzed using flow cytometry. RESULTS: Compared to the non-allergic group, the allergic group exhibited a significantly higher prevalence of comorbid asthma, serum total IgE levels, SNOT-22 scores, JESREC scores, blood/ tissue eosinophil counts, the proportion of eosinophilic histologic type, and lower gustatory function test scores. Additionally, the frequencies of nasal T helper 2 (TH2) and proallergic TH2 (TH2A) cells were significantly higher in the allergic group than in both the non-allergic and the control groups, and these frequencies were significantly correlated with eosinophilic inflammation. CONCLUSIONS: Our study demonstrates that allergic sensitization is closely associated with eosinophilic inflammation, as indicated by elevated levels of blood/tissue eosinophils and nasal TH2A cells, and by worse symptom scores in CRSwNP. Given the distinct immunological features of allergic patients, considering allergic sensitization within nasal tissue when managing CRSwNP is crucial.

International Rhinologic Society Rhinology 0300-0729 64 2 2026 4 1 41247318 Profiling nasal trigeminal sensitivity to predict outcomes after nasal obstruction surgery 206 214 EN M. Saro-Buendia Departamento de Otorrinolaringologia, Hospital Universitario y Politecnico La Fe, Valencia, Spain;Departamento de Cirugia, Facultat de Medicina i Odontologia, Universitat de Valencia, Valencia, Spain M. Mata Departamento de Patologia, Facultat de Medicina i Odontologia, Universitat de Valencia, Valencia, Spain;INCLIVA Biomedical Research Institute, Valencia, Spain;CIBER de Bioingenieria, Biomateriales y Nanomedicina, Instituto de Salud Carlos III, Madrid, Spain A. Garcia-Pinero Departamento de Otorrinolaringologia, Hospital Universitario y Politecnico La Fe, Valencia, Spain;Departamento de Cirugia, Facultat de Medicina i Odontologia, Universitat de Valencia, Valencia, Spain L. Milian Departamento de Patologia, Facultat de Medicina i Odontologia, Universitat de Valencia, Valencia, Spain;INCLIVA Biomedical Research Institute, Valencia, Spain P. Suarez-Urquiza Departamento de Microbiologia, Hospital Universitario y Politecnico La Fe, Valencia, Spain M. Armengot-Carceller Departamento de Otorrinolaringologia, Hospital Universitario y Politecnico La Fe, Valencia, Spain;Departamento de Cirugia, Facultat de Medicina i Odontologia, Universitat de Valencia, Valencia, Spain;Instituto de Investigacion Sanitaria (IIS) La Fe, Valencia, Spain;BMCG, Instituto de Investigacion Sanitaria La Fe, CIBERES, Valencia, Spain 3384 10.4193/Rhin25.306 BACKGROUND: Predicting symptom improvement after nasal airway obstruction surgery remains difficult, as objective airflow metrics correlate poorly with patient-reported outcomes. Since trigeminal afferents are key in sensing nasal airflow, this study evaluated whether individual differences in nasal chemosensory functionâ€"particularly trigeminal sensitivityâ€"are associated with subjective airflow perception and predict outcomes in patients undergoing surgery for nasal obstruction. METHODOLOGY: A prospective cohort study was conducted in 43 participants (32 patients with nasal airway obstruction scheduled for surgery, 11 healthy controls). Trigeminal sensitivity was assessed using measures including the menthol lateralisation detection thresholds, TRPV1/TRPM8 gene expression, and the trigeminal subtest of the Barcelona Smell Test-24. Olfactory and gustatory function were also evaluated. Nasal obstruction perception was measured pre- and postoperatively using the NOSE-e questionnaire and a visual analogue scale. Patients were followed for a mean of 10.9 months. RESULTS: Trigeminal sensitivity did not differ significantly between patients and controls. However, baseline trigeminal Barcelona Smell Test-24 scores correlated with greater improvement in NOSE-e scores and satisfaction. Patients with NOSE-e improvement >6 points had lower baseline trigeminal scores than those with lesser gains. No other baseline chemosensory measures were correlated with postoperative outcomes. CONCLUSIONS: Trigeminal sensitivityâ€"particularly as assessed by the Barcelona Smell Test-24 testâ€"may serve as a predictor of both symptom improvement and overall satisfaction after surgery for nasal airway obstruction, underscoring the importance of sensory processing in shaping patient-perceived surgical outcomes.

International Rhinologic Society Rhinology 0300-0729 64 2 2026 4 1 41358581 Magnetic resonance imaging in gustatory disorders: diagnostic usefulness with a cost analysis 215 223 EN S-L. Hool Department of Otorhinolaryngology, Head and Neck Surgery, lnselspital, Bern University Hospital, and University of Bern, Bern, Switzerland H. Friedrich Department of Otorhinolaryngology, Head and Neck Surgery, lnselspital, Bern University Hospital, and University of Bern, Bern, Switzerland B.N. Landis Rhinology-Olfactology Unit, Department of Otorhinolaryngology, Head and Neck Surgery, University Hospitals of Geneva, Geneva, Switzerland M. Pastore-Wapp Neurocenter, Luzerner Kantonsspital, Luzern, Switzerland M-D. Caversaccio Department of Otorhinolaryngology, Head and Neck Surgery, lnselspital, Bern University Hospital, and University of Bern, Bern, Switzerland F. Wagner Department of Otorhinolaryngology, Head and Neck Surgery, lnselspital, Bern University Hospital, and University of Bern, Bern, Switzerland;Department of Diagnostic and Interventional Neuroradiology, lnselspital, Bern University Hospital, and University of Bern, Bern, Switzerland;Department of Diagnostic and Interventional Neuroradiology, Cantonal Hospital Aarau, Aarau, Switzerland S. Negoias Department of Otorhinolaryngology, Head and Neck Surgery, lnselspital, Bern University Hospital, and University of Bern, Bern, Switzerland;Department of Otorhinolaryngology, Head and Neck Surgery, Basel University Hospital, Basel, Switzerland 3394 10.4193/Rhin25.153 OBJECTIVE: Beyond patient history, clinical examination and psychophysical gustatory testing, no standardized guidelines exist for the diagnosis of unclear taste disorders, especially regarding imaging. We therefore aimed to investigate the frequency of use of magnetic resonance imaging (MRI), the findings, and the cost and benefits in a large cohort of patients with taste disorders presenting at a tertiary referral centre over a period of 10 years. METHODOLOGY: We retrospectively reviewed clinical records of all patients with gustatory disorders presenting at our tertiary smell and taste clinic between 2010 and 2019 who received an MRI. A board-certified neuroradiologist, specialized in head and neck imaging, reviewed all MRIs. MRI findings were classified according to their relevance to the taste disorder. A cost-benefit analysis was performed. RESULTS: Of the 125 patients with taste complaints, 70 underwent MRI. Imaging data were retrievable for 65 patients, representing 52% of the total cohort. Pathological findings were observed in 54 patients; 46 had incidentalomas not related to the initial complaint. Findings potentially related to the gustatory complaint (treatable in 6 cases, not treatable in 2 cases) were seen in only 8 MR scans. The imaging findings matched the clinical findings in only 4 cases, and these were therefore classified as clearly related to the complaint. The total cost of all the MRIs performed was 55,034.89 CHF. The estimated costs per finding attributable to a taste disorder were 13,758.72 CHF. CONCLUSIONS: In this selected cohort of patients with isolated taste disorders, MRI rarely revealed findings clearly attributable to the complaint. While incidentalomas were frequent, clinically relevant abnormalities were uncommon. These results suggest that MRI should be reserved for select cases, and its routine use critically evaluated. Further prospective studies are needed to better define when MRI is warranted in the diagnosis of unclear isolated taste disorders.

International Rhinologic Society Rhinology 0300-0729 64 2 2026 4 1 41486802 Integration of transcriptomic data identifies CD163 as a key link between chronic rhinosinusitis with nasal polyps and COVID-19 224 236 EN B. Yang Department of Otorhinolaryngology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China J-Q. Zhang Department of Otorhinolaryngology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China Y. Yuan Department of Otorhinolaryngology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China M. Gu Department of Otorhinolaryngology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China C. Hong Department of Otorhinolaryngology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China C-Y. Qiu Department of Otorhinolaryngology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China X-Y. Zou Department of Otorhinolaryngology, The Fourth Affiliated Hospital of Nanjing Medical University, Nanjing, China M-P. Lu Department of Otorhinolaryngology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China L. Cheng Department of Otorhinolaryngology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China;Department of Allergology 3408 10.4193/Rhin24.462 BACKGROUND: Emerging evidence has highlighted a potential link between chronic rhinosinusitis with nasal polyps (CRSwNP) and coronavirus disease 2019 (COVID-19). However, the exact mechanism driving this association is not well understood. We aimed to explore the biological pathways and differentially expressed genes (DEGs) involved in CRSwNP and COVID-19 by performing bioinformatic analyses. METHODS: Data from the GEO database was analyzed using the "limma" package to identify DEGs. Techniques like weighted gene co-expression network analysis (WGCNA), protein-protein interaction (PPI) networks, and machine learning were employed to pinpoint key genes. Single-sample gene set enrichment analysis (ssGSEA) was used to assess immune cell infiltration. Key gene expression in macrophages was verified using single-cell analysis and immunofluorescence. Genetranscription factor-microRNA (gene-TF-miRNA) regulatory networks were constructed via NetworkAnalyst. Potential therapeutic agents were identified through DGIdb. Nasal polyps and control nasal tissues were surgically obtained for validation purposes. RESULTS: The findings revealed 19 co-DEGs common to both CRSwNP and COVID-19, which were enriched in pathways related to inflammation and the immune response. Among these genes, CD163 was identified as the key gene. The infiltration of CD163+ macrophages was substantially greater in the nasal tissues of CRSwNP and COVID-19 patients than in those of control subjects. Fluticasone was determined to be a promising drug that targets CD163. CONCLUSION: This study highlights CD163 as a promising diagnostic marker for CRSwNP and COVID-19, suggesting that targeting CD163 may be pivotal in the management of these conditions.

International Rhinologic Society Rhinology 0300-0729 64 2 2026 4 1 41486815 Treatment escalation and sustained disease control in chronic rhinosinusitis: a retrospective surgical cohort study 237 247 EN M. Clari-Comes Department of Otolaryngology, Head and Neck Surgery, Alava University Hospital, Alava, Spain;PhD Program in Medicine and Surgery, University of the Basque Country (UPV/EHU), Bizkaia, Spain D. Martin-Jimenez Department of Otolaryngology, Head and Neck Surgery, Alava University Hospital, Alava, Spain;PhD Program in Medicine and Surgery, University of the Basque Country (UPV/EHU), Bizkaia, Spain;Rhinology Unit, Department of Otolaryngology, Head and Neck Surgery, Virgen Macarena University Hospital, Seville, Spain R. Moreno-Luna Rhinology Unit, Department of Otolaryngology, Head and Neck Surgery, Virgen Macarena University Hospital, Seville, Spain M. Gonzalez-Garcia Rhinology Unit, Department of Otolaryngology, Head and Neck Surgery, Virgen Macarena University Hospital, Seville, Spain A. Cuvillo Rhinology and Asthma Unit, Department of Otolaryngology, Jerez University Hospital, Jerez, Spain I. Alobid Rhinology and Skull Base Unit, Department of Otorhinolaryngology, Hospital Clinic, Universitat de Barcelona, IDIBAPS, CIBERES, Barcelona, Spain S. Sanchez- Gomez Rhinology Unit, Department of Otolaryngology, Head and Neck Surgery, Virgen Macarena University Hospital, Seville, Spain 3410 10.4193/Rhin25.301 BACKGROUND: The impact of endoscopic sinus surgery (ESS) extent on long-term disease control and therapeutic escalation in chronic rhinosinusitis with nasal polyps (CRSwNP) remains unclear. This study aims to evaluate the clinical applicability of endoscopy-based criteria for therapeutic escalation and to determine the impact of surgical extent on the risk and timing of treatment intensification. METHODS: A retrospective cohort study with 3-year follow-up was conducted. CRSwNP patients who underwent ESS were included and classified according to Lamella Ostium Extent Mucosa (LOEM) system (t1â€"t4). Baseline characteristics and disease severity measures were assessed. Therapeutic escalation was defined by endoscopic criteria. Predictors of escalation and the effect of ESS extent on escalation timing across clinical phenotypes were analyzed using multivariate logistic regression, Kaplan-Meier curves and Cox regressions. RESULTS: In the overall sample (n=172), patients who required escalation showed higher SNOT-22 scores and poorer olfactory function. More extensive ESS (LOEM t3â€"t4) was associated with significantly reduced escalation risk and prolonged disease control. Post hoc analyses confirmed significant pairwise differences favoring extensive (t3â€"t4) over limited (t1â€"t2) surgery. Subgroup analyses demonstrated greater benefits in older subjects, atopic patients, revision surgeries and patients with eosinophils >300cells/μL. Higher baseline SNOT-22 scores remained an independent predictor of escalation after ESS. CONCLUSIONS: Surgical extent appears to influence both escalation risk and timing. More extensive ESS may provide more sustained control, particularly in revision cases and biomarker-defined subgroups, supporting its integration into personalized algorithms.

International Rhinologic Society Rhinology 0300-0729 64 2 2026 4 1 41486826 Integrated omics-based analysis reveals distinct microbial-metabolite interaction networks in eosinophilic and non-eosinophilic chronic rhinosinusitis with nasal polyps in a Chinese population 248 258 EN H. Zhang Department of Otolaryngology, The Second Qilu Hospital of Shandong University, Jinan, Shandong, China X. Zi Department of Otolaryngology, The Second Qilu Hospital of Shandong University, Jinan, Shandong, China X. Li Department of Allergy, The First Affiliated Hospital of Shandong First Medical University, Shandong Provincial Qianfoshan Hospital, Shandong Institute of Respiratory Diseases, Jinan, China T. Gao Department of Allergy, The First Affiliated Hospital of Shandong First Medical University, Shandong Provincial Qianfoshan Hospital, Shandong Institute of Respiratory Diseases, Jinan, China H. Zhang Department of Otolaryngology, The Second Qilu Hospital of Shandong University, Jinan, Shandong, China H. Zhang Department of Otolaryngology, The Second Qilu Hospital of Shandong University, Jinan, Shandong, China X. Liang Department of Otolaryngology, The Second Qilu Hospital of Shandong University, Jinan, Shandong, China L. Zhi Department of Allergy, The First Affiliated Hospital of Shandong First Medical University, Shandong Provincial Qianfoshan Hospital, Shandong Institute of Respiratory Diseases, Jinan, China P. Jin Department of Otolaryngology, The Second Qilu Hospital of Shandong University, Jinan, Shandong, China 3417 10.4193/Rhin25.166 Background: Chronic rhinosinusitis with nasal polyps (CRSwNP) is a heterogeneous inflammatory condition often classified into eosinophilic (Eos) and non-eosinophilic (nonEos) subtypes. While microbial dysbiosis and metabolic disturbance are known contributors to CRSwNP, the interplay between sinonasal microbiota and local metabolic activity remains unclear. Methods: We conducted 16S rRNA gene sequencing and untargeted metabolomics on sinonasal swabs and tissue samples from patients with Eos-CRSwNP (n = 14), nonEos CRSwNP (n = 7), and healthy controls (n = 14). Microbial diversity, taxonomic differences, and metabolic alterations were analyzed. Spearman correlation and network modeling were used to explore phenotype-specific microbiotaâ€"metabolite interactions and pathway enrichment. Results: Eos CRSwNP was characterized by reduced microbial diversity and increased abundance of Staphylococcus and Corynebacterium, along with elevated levels of fumaric acid, linoleic acid, and arachidonic acidâ€"metabolites linked to oxidative stress and lipid-mediated inflammation. In contrast, nonEos-CRSwNP exhibited greater microbial richness, with enrichment of Streptococcus, Anaerococcus, and Clostridium XlVa, and metabolic shifts in amino acid and nitrogen metabolism, including increased glutamine, taurine, and ethanolamine phosphate. Correlation analysis revealed phenotype-specific networks connecting core microbial genera and metabolites, suggesting distinct inflammatory microenvironments between subtypes. Conclusion: Our integrated multi-omics analysis highlights divergent microbial and metabolic signatures in Eos and nonEos CRSwNP. These findings offer mechanistic insights into subtype-specific disease processes and may guide the future development of targeted diagnostic and therapeutic strategies.

International Rhinologic Society Rhinology 0300-0729 64 2 2026 4 1 41486781 Choanal atresia repair in Germany â€" a comprehensive investigation of the current state of care 259 267 EN M-S. Yilmaz Topcuoglu Department of Otorhinolaryngology, University Hospital Heidelberg, Heidelberg, Germany P.J. Schuler Department of Otorhinolaryngology, University Hospital Heidelberg, Heidelberg, Germany J.H. Westhoff Department I, Center for Pediatric and Adolescent Medicine, Medical Faculty Heidelberg, Heidelberg University, University Hospital Heidelberg, Heidelberg, Germany O. Sommerburg Division of Pediatric Pulmonology, Allergy and Cystic Fibrosis Center, Department III, Center for Pediatric and Adolescent Medicine, University Hospital Heidelberg, Member of the German Center for Lung Research (DZL), University Hospital Heidelberg, Heidelberg, Germany L. Wucherpfennig Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany;Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), Heidelberg, Germany;Department of Diagnostic and Interventional Radiology with Nuclear Medicine, Thoraxklinik at University Hospital Heidelberg, Heidelberg, Germany I. Baumann Department of Otorhinolaryngology, University Hospital Heidelberg, Heidelberg, Germany 3402 10.4193/Rhin25.318 BACKGROUND: There is often a discrepancy between official recommendations and actual clinical practice on repair of congenital choanal atresia (CA). The objective of this study was to evaluate the current state of care for CA patients in Germany. METHODS: An online survey was conducted in which 108 German ENT departments were consulted on various aspects of CA management, including preoperative diagnosis, surgical procedures, and postoperative care.RESULTS: 65% of the ENT departments only perform CA repairs at over 3 years of age. Flexible nasal endoscopy (69%), hearing tests (41%), and computed tomography (52%) were preoperative diagnosis tools. Posterior vomer was resected in 56% of the ENT departments. Scar- (60%), granulation tissue (38%), and insufficient vomer resections (21%) caused recurrences. Stents were used by 38%. CONCLUSIONS: Elective unilateral CA repair should be performed in time to minimise symptoms. Preoperative hearing tests should be introduced as routine to identify CA patients with hearing problems. The utilisation of preoperative computed tomography should be discussed individually. Only just over half of the participating ENT departments resected posterior vomer parts. This is a significant starting point with the potential to improve the recurrence rates of this patient cohort. Stent use is still quite common iin Germany. This should be changed in the future.

International Rhinologic Society Rhinology 0300-0729 64 2 2026 4 1 41486790 Discrepancy between self-reported and actual topical steroid use in CRS-patients with nasal polyps 268 270 EN C. Haase Department of Otorhinolaryngologyâ€"Head and Neck Surgery and Audiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark K.E.J. HÃ¥kansson Department of Otorhinolaryngologyâ€"Head and Neck Surgery and Audiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark K. Aanes Department of Otorhinolaryngologyâ€"Head and Neck Surgery and Audiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark;Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark C.S. Ulrik Department of Respiratory Medicine, Copenhagen University Hospital - Hvidovre, Hvidovre, Denmark;Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark B.A. Esbensen Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Centre for Head and Orthopedics, Rigshospitalet, Glostrup, Denmark;Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark R. Horne University College London, BMA House, UCL School of Pharmacy Tavistock Square, London, United Kingdom V. Backer Department of Otorhinolaryngologyâ€"Head and Neck Surgery and Audiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark;Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark 3403 10.4193/Rhin25.385 Topical corticosteroids are standard therapy in chronic rhinosinusitis with nasal polyps (CRSwNP) and asthma, administered as nasal corticosteroids (NCS) and inhaled corticosteroid (ICS). Suboptimal adherence is associated with impaired health-related quality of life.

International Rhinologic Society Rhinology 0300-0729 64 2 2026 4 1 41494634 Prevalence of ear complaints in patients with severe chronic rhinosinusitis with nasal polyps 271 273 EN H.B.E. Elzinga Department of Otorhinolaryngology, Head and Neck Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands J.J. Otten Department of Otorhinolaryngology, Head and Neck Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands R.J.L. van der Lans Department of Otorhinolaryngology, Head and Neck Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands P. Merkus Department of Otorhinolaryngology, Head and Neck Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands E. van Spronsen Department of Otorhinolaryngology, Head and Neck Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands W.J. Fokkens Department of Otorhinolaryngology, Head and Neck Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands PolyREG Consortium S. Reitsma Department of Otorhinolaryngology, Head and Neck Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands 3399 10.4193/Rhin25.524 Patients with chronic rhinosinusitis (CRS) commonly have ear complaints (ECs). Reported prevalences in CRS-patients vary up to 61%, and even higher (82%) in patients with nasal polyps (CRSwNP) with an indication for surgery. These data, however, are not based on validated otologic surveys. Instead, the ear-related questions of the SinoNasal Outcome Test 22-items (SNOT-22) (5) are used. ECs are often overlooked as CRSwNP patients present primarily with nasal complaints, despite the impact on quality of life of this co-morbidity. With the advent of biological therapy for severe uncontrolled CRSwNP, comorbidities are increasingly appreciated including the rare but debilitating eosinophilic otitis media (EOM). This study investigates ECs, evaluated by otologic questionnaires, in a severe uncontrolled CRSwNP population. It also investigates the use of single SNOT-22 ear items as proxy for relevant ECs.

International Rhinologic Society Rhinology 0300-0729 64 2 2026 4 1 41486775 From ESS to L-ESS waste in the operating room 274 275 EN M.C. Eggink Amsterdam Rhinology Team (ART), Department of Otorhinolaryngology and Head/Neck surgery, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, the Netherlands;Young Otolaryngologists of the International Federation of Otorhinolaryngological Societies (YO-IFOS) Sustainability Committee: "Young Otorhinolaryngologists for Sustainability" L.B.L. Benoist Amsterdam Rhinology Team (ART), Department of Otorhinolaryngology and Head/Neck surgery, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, the Netherlands N.H. Sperna Weiland Department of Anaesthetics, Amsterdam University Medical Centre, the Netherlands S. Reitsma Amsterdam Rhinology Team (ART), Department of Otorhinolaryngology and Head/Neck surgery, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, the Netherlands 3401 10.4193/Rhin25.145 The detrimental effects of climate change on global health are becoming increasingly evident, also within rhinology. Climate change has been shown to cause a longer and more intense pollen season, while the prevalence of allergic rhinitis is expected to rise due to de novo sensitizations caused by the migration of plants. Chronic rhinosinusitis patients will be affected by increasing air pollution as well as changes in spread of potent pathogens and vectors associated with upper airway infections. Meanwhile, healthcare is an evident contributor to climate change. Operating rooms (ORs) have been identified as carbon hotspots due to their high energy consumption and the use of anaesthetic gases with high Global Warming Potential. Also, ORs have been estimated to generate up to 33% of all hospital waste.

International Rhinologic Society Rhinology 0300-0729 64 2 2026 4 1 41081468 Regional disparities in cost-effectiveness of biologics for CRSwNP warrant tailored treatment strategies 276 277 EN M. Xian Department of Otolaryngology Head and Neck Surgery, Beijing TongRen Hospital, Capital Medical University, Beijing, China C. Wang Department of Otolaryngology Head and Neck Surgery, Beijing TongRen Hospital, Capital Medical University, Beijing, China;Beijing Key Laboratory of Nasal Diseases, Beijing Institute of Otolaryngology, Beijing, China L. Zhang Department of Otolaryngology Head and Neck Surgery, Beijing TongRen Hospital, Capital Medical University, Beijing, China;Beijing Key Laboratory of Nasal Diseases, Beijing Institute of Otolaryngology, Beijing, China 3368 10.4193/Rhin25.291 We read with great interest the recent study by Fieux et al. (1), which developed an evaluation model based on clinical practices, public health insurance, and private insurance systems in France. Through rigorous cost-effectiveness analysis, the authors concluded that initiating biologic therapy in patients with chronic rhinosinusitis with nasal polyps (CRSwNP) without previous endoscopic sinus surgery (ESS) imposes excessive economic burdens. This finding aligns with the current guideline regarding the indications for biological treatment in CRSwNP, which reserves biologics primarily for patients with prior ESS history.

International Rhinologic Society Rhinology 0300-0729 64 2 2026 4 1 41486827 Regional disparities in cost-effectiveness of biologics for CRSwNP should not modify the strategy 278 280 EN M. Fieux Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Service d’ORL, d’otoneurochirurgie et de chirurgie cervico-faciale, Pierre Bénite, France;Université de Lyon, Université Lyon 1, Lyon, France;UMR 5305, Laboratoire de Biologie Tissulaire et d'Ingénierie Thérapeutique, Institut de Biologie et Chimie des Protéines, CNRS/Université Claude Bernard Lyon 1, Lyon, France F. Carsuzaa Service ORL, Chirurgie Cervico-Maxillo-Faciale et Audiophonologie, Centre Hospitalier Universitaire de Poitiers, Poitiers, France;Laboratoire Inflammation Tissus Epithéliaux et Cytokines (LITEC), UR15560, Université de Poitiers, Poitiers, France M. Chang Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, United States P.H. Hwang Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, United States Z.M. Patel Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, United States S. Tringali Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Service d’ORL, d’otoneurochirurgie et de chirurgie cervico-faciale, Pierre Bénite, France;Université de Lyon, Université Lyon 1, Lyon, France;UMR 5305, Laboratoire de Biologie Tissulaire et d'Ingénierie Thérapeutique, Institut de Biologie et Chimie des Protéines, CNRS/Université Claude Bernard Lyon 1, Lyon, France V. Favier Departement de ORL, chirurgie cervico faciale et maxillo-faciale, Hospital Gui de Chauliac, CHU de Montpellier, Montpellier, France;Research-team ICAR, Laboratory of Computer Science, Robotics and Microelectronics of Montpellier (LIRMM), Univ. Montpellier, French National Centre for Scientific Research (CNRS), Montpellier, France J. Margier Hospices Civils de Lyon, Pole de Sante Publique, Service d'Evaluation Economique en Sante, Research on Healthcare; Performance (RESHAPE), INSERM U1290, Universite Claude Bernard Lyon 1, Lyon, France 3395 10.4193/Rhin25.548 Chronic rhinosinusitis with nasal polyps (CRSwNP) represents a significant burden on the healthcare system. Xian et al. discussed several aspects of our economic model, based on French pricing, that may impact the cost-effectiveness of biologics . Briefly, they outlined the regional disparities in the cost of biologics, the potential better outcomes of biologics in real-world evidence, and the recurrence rate after endoscopic sinus surgery (ESS). We think that these aspects may be further discussed.

International Rhinologic Society Rhinology 0300-0729 64 2 2026 4 1 41487045 Association of autoimmune diseases with chronic rhinosinusitis in general practices in Germany 281 284 EN D.U. Seidel Department of Otorhinolaryngology, Facial Plastic Surgery, Klinikum Oberberg, Gummersbach, Germany S. Bode Department of Otorhinolaryngology, Facial Plastic Surgery, Klinikum Oberberg, Gummersbach, Germany K. Kostev Epidemiology, IQVIA, Frankfurt am Main, Germany 3411 10.4193/Rhin25.241 Several population-based studies have reported increased prevalence of autoimmune diseases (AID) in patients with chronic rhinosinusitis (CRS). Large-scale datasets from Taiwan demonstrated associations between CRS and conditions such as rheumatoid arthritis, ankylosing spondylitis, polymyositis, psoriasis, Sjogren's syndrome, and systemic lupus erythematosus (SLE). However, sex-specific patterns have not been investigated.

International Rhinologic Society Rhinology 0300-0729 64 2 2026 4 1 41486819 Critical appraisal of methodological rigor in a systematic review on post-COVID-19 vaccination-associated olfactory dysfunction 285 286 EN T. Gupta Department of ENT and Head-Neck Surgery, Uttar Pradesh University of Medical Sciences, Saifai, India J.K. Verma Department of ENT and Head-Neck Surgery, Uttar Pradesh University of Medical Sciences, Saifai, India 3405 10.4193/Rhin25.440 We read with keen interest the article by Kawabata et al. titled "Olfactory disorder after COVID-19 vaccination" which explores 16 cases of olfactory dysfunction temporally associated with vaccination. The paper addresses an important and under-recognized topic; however, several methodological aspects warrant clarification to aid accurate interpretation. First, the inclusion of five institutional cases within a review otherwise presented as PRISMA-compliant raises questions regarding methodological consistency. Under PRISMA, all included studies should be identified through transparent and reproducible database searches. Clarifying whether institutional data were processed separately from literature-derived cases would strengthen transparency and avoid confusion about the evidence level.

International Rhinologic Society Rhinology 0300-0729 64 2 2026 4 1 41574598 Response to the letter "Critical appraisal of methodological rigor in a systematic review on post-COVID-19 vaccination-associated olfactory dysfunction" 287 288 EN M. Kawabata Department of Otorhinolaryngology, The Jikei University School of Medicine, Tokyo, Japan E. Mori Department of Otorhinolaryngology, The Jikei University School of Medicine, Tokyo, Japan N. Yanagi Department of Otorhinolaryngology, The Jikei University School of Medicine, Tokyo, Japan M. Tei Department of Otorhinolaryngology, The Jikei University School of Medicine, Tokyo, Japan N. Otori Department of Otorhinolaryngology, The Jikei University School of Medicine, Tokyo, Japan 3422 10.4193/Rhin25.684 We appreciate the thoughtful comments by Dr. Gupta et al. regarding our systematic review. Their commitment to this rare but emerging clinical topic is welcome, and we would like to address the methodological points raised.