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to the macrolides.
4
These two research study findings
are consistent. Macrolides do not affect T helper 2 (Th2)-
mediated inflammation seen in patients with allergic
asthma or high serum IgE. Rather, macrolides target
Th1 inflammation by decreasing interleukin (IL)6 and
IL8 production.
5
Therefore, patients with an infection-
based inflammation are more likely to have a response
to macrolides, because these patients are more likely to
have a Th1-mediated inflammation.
By definition, all CRS cases have sinonasal inflam-
mation. The question is what type of inflammation is it?
Currently, CRS is divided into CRS with polyp and CRS
without polyp. In general, CRS with polyp is thought to
be a Th2-mediated process, whereas CRS without polyp
is mediated by Th1 process. However, this division of
CRS is too simplistic and does not account for any possi-
ble difference that may exist for CRS with polyp. Also,
the definition of CRS with polyp is not clearly defined.
What criteria determine the definition of a nasal polyp
in CRS? In other words, when does nasal mucosal swel-
ling become a polyp? There is no clearly delineated size
of a nasal mucosal engorgement defining a nasal polyp.
Two factors that have enormous impact on the devel-
opment of CRS, especially in CRS with polyp, are allergy
and asthma.
6
Therefore, using asthma and allergy, CRS
was divided into different categories. The objectives of
this study were to characterize the phenotype and the
nasal polyp and understand the inflammatory pathway
for each CRS subclass that has been defined. By charac-
terizing the phenotype and pathway of nasal polyps
formation for the various types of CRS, well-characterized
and distinct groups of CRS can be described. By dividing
CRS into specific distinguished entities, targeted medical
and surgical treatment can be developed for each CRS
subclass to improve efficacy of treatment. Also by delin-
eating specific CRS entities, bench and clinical research
results and outcomes may become more coherent.
MATERIALS AND METHODS
Study Group
Institutional review board approval was obtained for this
prospective case-control study evaluating CRS. A total of seven
subclasses of CRS and a control group were used in the study.
The study groups for CRS were aspirin triad or aspirin exacer-
bated respiratory disease (AERD), asthmatic sinusitis with
allergy (AScA), asthmatic sinusitis without allergy (ASsA), non-
asthmatic sinusitis with allergy (NAScA), nonasthmatic
sinusitis without allergy (NASsA), allergic fungal sinusitis
(AFS), and cystic fibrosis (CF). Both AScA and ASsA will be
defined as asthmatic sinusitis. Both NAScA and NASsA will be
defined as nonasthmatic sinusitis. The CRS study group defini-
tion is described in Table I. The control group did not have any
clinical, endoscopic, or radiographic evidence of CRS and pre-
sented for cerebrospinal fluid (CSF) leakage.
Phenotype
During the initial office visit, CRS patients completed two
quality-of-life (QoL) questionnaires: the Rhinosinusitis Disabil-
ity Index (RSDI) and the Chronic Sinusitis Survey (CSS).
Demographic data, nasal endoscopy (NE), and computed tomog-
raphy (CT) findings during the initial visits were documented.
NE findings were recorded and scored according to a nasal NE
score sheet (Fig. 1). The CT scans during the initial visit were
scored based on the Lund-Mackay scoring system.
Data were collected and organized into the database.
Fisher exact probability test was used to evaluate gender differ-
ences between CRS subclasses. Using SAS Statistical Software
TABLE I.
Definition of the CRS Subclasses.
CRS Subclass
History
Atopy
Asthma
AERD
Positive aspirin sensitivity
6
1
AFS
Positive fungal stain in eosinophilic mucin
1
6
AScA
Positive pulmonary function test and allergy test (in vitro or in vivo)
1
1
ASsA
Positive pulmonary function test and negative history or allergy test
2
1
NAScA
No history of asthma and positive allergy (in vitro or in vivo)
2
1
NASsA
No history of asthma or allergy
2
2
CF
Positive sweat test or gene test
6
6
AERD
5
aspirin exacerbated respiratory disease also known as aspirin triad; AFS
5
allergic fungal sinusitis; AScA
5
asthmatic sinusitis with allergy; ASsA-
asthmatic sinusitis without allergy; CF
5
cystic fibrosis; CRS
5
chronic rhinosinusitis; NAScA
5
nonasthmatic sinusitis with allergy; NASsA
5
nonasthmatic sinusitis
without allergy.
Fig. 1. The Nasal Endoscopy Findings Scoring system rates posi-
tive findings on nasal endoscopy. A total score is calculated on a
scale of 0 to 8 possible points.
Han: Subclassification of Chronic Sinusitis
Laryngoscope
123: March
2013
48