Chinese Society of Allergy and Chinese Society of Otorhinolaryngology-Head and Neck Surgery Guideline for Chronic Rhinosinusitis

Abstract

The current document is based on a consensus reached by a panel of experts from the Chinese Society of Allergy and the Chinese Society of Otorhinolaryngology-Head and Neck Surgery, Rhinology Group. Chronic rhinosinusitis (CRS) affects approximately 8% of Chinese adults. The inflammatory and remodeling mechanisms of CRS in the Chinese population differ from those observed in the populations of European descent. Recently, precision medicine has been used to treat inflammation by targeting key biomarkers that are involved in the process. However, there are no CRS guidelines or a consensus available from China that can be shared with the international academia. The guidelines presented in this paper cover the epidemiology, economic burden, genetics and epigenetics, mechanisms, phenotypes and endotypes, diagnosis and differential diagnosis, management, and the current status of CRS in China. These guidelines-with a focus on China-will improve the abilities of clinical and medical staff during the treatment of CRS. Additionally, they will help international agencies in improving the verification of CRS endotypes, mapping of eosinophilic shifts, the identification of suitable biomarkers for endotyping, and predicting responses to therapies. In conclusion, these guidelines will help select therapies, such as pharmacotherapy, surgical approaches and innovative biotherapeutics, which are tailored to each of the individual CRS endotypes.

Keywords: China; Chronic, sinusitis; biomarkers; diagnosis; endotypes; epigenesis; guideline; inflammation; management; phenotype.

Fig. 1. Potential mechanisms of immune cells and mediators involved in the pathogenesis of airway diseases.

IL, interleukin; DC, dendritic cell; TSLP, thymic stromal lymphopoietin; BAFF, B-cell activating factor; Ig, immunoglobulin; Th, T helper; CCL23, chemokine (C-C motif) ligand 23; CRSsNP, chronic rhinosinusitis without nasal polyps; CRSwNP, chronic rhinosinusitis with nasal polyps.

Fig. 2. Representative hematoxylin and eosin staining of nasal polyps in 5 inflammatory phenotypes (400× magnification). (A) Cluster 1, the plasma cell-dominant group. (B) Cluster 2, the lymphocyte-dominant group. (C) Cluster 3, the mixed group. (D) Cluster 4, the neutrophil-dominant group. (E) Cluster 5, the eosinophil-dominant group. Plasma cell, green arrow; lymphocyte, black arrow; neutrophil, blue arrow; eosinophil, red arrow.

Fig. 3. Endoscopic view of an uncinectomy. (A) An incision was made with a sickle knife or elevator, along the anterior margin of the UP. (B) The EB was exposed after the removal of the UP, and natural ostium maxillary sinus (↑) can be observed.

NS, nasal septum; MT, middle turbinate; UP, uncinate process; EB, ethmoidal bulla. ^*Upper attachment of UP.

Fig. 4. Endoscopic view of ethmoidectomy (cadaver dissection).

PE, posterior ethmoidal sinus; ST, superior turbinate; MT, middle turbinate. ^*The bottoms of adjacent ethmoidal cells at the same level indicate lamina papyracea.

Fig. 5. Endoscopic image of the cadaver shows that: (A) After partial superior turbinectomy, the ostium of the SS (↑), located medially to the remnant ST (△△△), was well exposed; (B) the SS was opened by a Kerrison punch.

ST, superior turbinate; SS, sphenoidal sinus; PE, posterior ethmoidal sinus. ^*Lamina papyracea.

Fig. 6. Postoperative endoscopy and images demonstrate Draf type frontal sinus surgeries: Draf I, II (a, b) and III. FS (↑).

FS, frontal sinus.

Fig. 7. Postoperative endoscopy. Well-epithelized nasal cavity after nasalization using the Draf III procedure. (A), endoscopic view of bilateral frontal sinuses and ethmoid sinuses. (B), endoscopic view of left ethmoid sinus, sphenoid sinus and maxillary sinus.

FS, frontal sinus; ES, ethmoidal sinus; SS, sphenoidal sinus; MS, maxillary sinus, NS, nasal septum. ^*Middle turbinate.

Fig. 8. Representative images of a preoperative computed tomographic scan (A, B) and 4-year postoperative endoscopic views of the sinuses (C, right nasal cavity; D, left nasal cavity) from a patient with chronic rhinosinusitis and asthma.