Discussion
Chronic rhinosinusitis is a group of multifactorial diseases, associated
with asthma, allergy, high tissue eosinophil ratio, and
blood
eosinophil counts. CRS is generally treated by pharmacotherapy or by
FESS. 9 In this study, we evaluated CRS patients who
had an average follow-up time of 1 year after undergoing
FESS.
Effective interpretation of clinical characteristics in CRS is very
important, as it plays a deciding role in predicting the possibility of
postoperative uncontrolled disease in these patients.
Patients
at a higher risk for revisional surgery, personalized treatments, or
targeted therapies should also be directed to disease control.
Asthma
In 2012, a multicenter study conducted by the Global Allergy and Asthma
Network of Excellence (GA(2) LEN) showed that asthma was associated with
CRS in all age groups, irrespective of gender and smoking behavior.10 Our group previously reported that EESS (Extensive
endoscopic sinus surgery) improved the surgery outcomes in asthma.11 In a 12-year study, asthma was identified as the
only factor that increased the chance of recurrence in patients with
either CRSwNP or CRSsNP(Chronic rhinosinusitis without nasal polyps).7,12 Our current study also showed that asthma was the
important factor for disease control after surgery, as demonstrated in
univariate and multivariate
analysis. In the training cohort,
the AUC of the asthma models was 0.665 (0.593-0.737). However, CRS with
or without asthma is an indisputable element
affecting its prognosis.
Allergy
The causal relationship between allergy and CRS is still debatable,
however, the risks of CRSwNP are higher in patients with co-existing
allergy and asthma conditions 10 A
population-based study reported the AR higher prevalence, before the
diagnosis of CRSsNP or CRSwNP in comparison with patients without CRS.13 A multicenter cross-sectional study in
China reported that many occupational factors are
significantly
associated with the CRS 14 ,
especially exposure to dust or smoke,
coal cooking fumes, chemical gases (such as isocyanides), cleaning
agents and hair-care products lead to increased risk.15Allergic asthma and rhinitis caused by inhaled allergens, are mainly
elicited by a TH2-dominated immune response associated with increased
serum IgE levels. 16 Allergy rhinitis with
high IgE expression may also affect the disease control of CRSwNP after
the surgery. Recently, a randomized phase 3 trials reported that
Omalizumab (IgE antibody) significantly improved the clinical,
endoscopic, and patient-reported outcomes in refractory CRSwNP17 . Therefore, allergic rhinitis was also
considered in the prediction model. In our study, the AUC in the
training cohort for the AR model was 0.595 (0.52.8-0.66.2), and it also
affected the disease control to a certain extent.
System and local eosinophil
The EPOS2020 and several studies reported the cutoff points for EOS in
blood and tissue. We classified the
cohort subjects by using 0.3\(\times\)10^9 /L as a cutoff value for
blood EOS counts and 10% for polyp tissue EOS percentages.2 The cutoff point of 10% tissue EOS has been
extensively used for differentiating the eosinophilic CRS.18 Lou et al. and Nakayama et al. have also
demonstrated a strong correlation between polyp recurrence and tissue
EOS numbers. 19 20 Blood EOS can
also reflect the prognosis of chronic sinusitis, but its sensitivity is
low as compared to the tissue EOS.21,22 Our group has
reported that the tissue and blood
eosinophilia has an additive effect in predicting the risk of poor
disease control after at least 1 year of FESS. 23 This
study further demonstrated using multivariate analysis, that the tissue
eosinophilia ratio was an independent factor, affecting the disease
control after surgery. The analysis revealed that the number of
eosinophils in tissues had no significant effect on CRS disease control.
However, EPOS 2020 suggests that tissue eosinophils can be considered as
nasal polyps eosinophils in case the tissue eosinophils count was more
than 10 24. In many pieces of literature, tissue
eosinophils ratio was still higher than 10% as the cutoff value to
predict the prognosis of chronic sinusitis nasal polyps.22 Therefore, we only included TER in our Nomogram
prediction model.
So far, few studies have focused on the various combination factors
among AS, PBEC, TER, AR, and disease control.
Interestingly,
in our study, the combination of AS, AR, TER, PBEC significantly
increased the odds ratio for predicting the possibility of uncontrolled
and partly controlled disease. To the best of our knowledge, this
observation has not been reported in the literature. Therefore, as the
potential predictors, we included allergy, asthma, TER, and blood EOS
counts, among the various demographic factors in our nomograms. For a
long, these factors have been recognized to have a significant impact on
the disease control of Chronic rhinosinusitis.
This study also had some limitations due to the small cohort size. In
addition, childhood-onset, or adult-onset asthma in CRSwNP were not
confirmed. Further, we could not evaluate the relationship between the
prognosis of disease the childhood or adult-onset asthma.