Rhinologic Innovation and Advancement Come in All Forms of Investigation

As I prepare this guest editorial for this month's issue of American Journal of Rhinology and Allergy, I am in awe of the sheer breadth and advances in research, we, as a community publishing. It was not that long ago that we were limited to basic surgical technique and small single institution retrospective studies. Reviewing, this exciting issue, we really get a fantastic appreciation for advances in surgical technique, novel prospective investigations, large database studies, and high-quality basic science work. I really feel that we are in a golden era of innovation in our field, and this journal continues to demonstrate they are in the forefront of innovation.

We were fortunate to see several publications discussing advanced surgical techniques. Li and colleagues evaluated the efficacy of a Denker's approach versus a prelacrimal approach to the pterygopalatine fossa and infratemporal fossa. ¹ Utilizing cadaveric dissection, they found while both approaches can provide access to those areas, the Denker's provides improved freedom of motion ultimately suggesting that this would be the preferred approach for pathology in the pterygopalatine and infratemporal fossa. Similarly, this month's “how I do it” publication by Takaishi demonstrates a novel method of reconstruction of a medial orbital wall fracture. ² Here, Takaishi utilizes the patients nasal tissue, specifically septal cartilage to reconstruct the defect after any bone fragments are removed, and the orbital contents are reduced and avoids using alloplastic implants.

Switching gears to a prospective investigation, we had an excellent study by Esmaeilzdeh et al prospectively identified 66 moderate to severe allergic rhinitis patients and placed them in 3 treatment arms; montelukast and steroid spray, intranasal antihistamine and steroid spray, and intranasal steroid with a placebo tablet. ³ They found that the nasal antihistamine group with steroid spray was the superior outcomes arms in regard to SNOT-22 scores. Conversely, in their investigation, they found montelukast has no improvement over intranasal steroids alone. We also had several excellent retrospective studies published in this issue. Huang and colleagues published a retrospective study of chronic rhinosinusitis patients 55 and old and stratified by the Charlson Comorbidity Index and identified that even with worse medical comorbities, patients still had similar improvement in SNOT-22 scores. ⁴ Interestingly, they also looked at complication rates but this needs to be looked into further. Another study very relevant to sinus surgeons was published by Ritter et al. ⁵ Their group looked at detection and outcomes of invasive fungal rhinosinusitis in immunosuppressed children. They identified in their retrospective cohort that enhanced panfungal polymerase chain reaction and treatment with both novel antifungals and aggressive surgical approaches improved their outcomes in this challenging treatment population.

Moving through this issue of American Journal of Rhinology and Allergy (AJRA), we get the opportunity to see the power of well-performed database studies. Han and colleagues performed a very interesting cross-sectional study of nationwide data in South Korea evaluating the association between the concentration of air pollutants and the prevalence of allergic rhinitis and chronic rhinosinusitis. ⁶ They found the prevalence of allergic rhinitis was significantly associated with the particulate matter but chronic rhinosinusitis was not associated with air pollutant concentrations. Abdelshafy et al performed a systematic review and meta-analysis of the impact of bilastine, a novel oral second-generation H-1 antihistamine for both allergic rhinitis and chronic urticaria. ⁷ They included 9 randomized trials including 3801 participants and found bilastine safely improved total symptoms in hyper histaminic allergic conditions involving nasal symptoms. Another great study by Son et al used a Korean National Health Insurance Service database to investigate whether there is an association between chronic rhinosinusitis and atopic dermatitis. ⁸ Using propensity score matching, the found there is a higher risk of atopic dermatitis in patients with chronic rhinosinusitis. Continuing with systematic reviews, Hura et al investigated both the utility of magnetic resonance imaging (MRI) in diagnosis of idiopathic olfactory dysfunction and to describe MRI findings among mixed olfactory dysfunction etiologies. ⁹ In the covid era, this is a very relevant study. Their review included 33 studies, 4 of which reviewed patients with idiopathic olfactory dysfunction. They found 4.6% of patients had a potential central cause; 42% of studies reported significant correlation between olfactory bulb volume and olfactory outcomes and 18% of studies reported gray matter volume reduction. Finally, Gao et al performed univariate and multivariate analyses on treatment and survival of sinonasal extramedullary plasmacytoma through the National Cancer Database. ¹⁰ They found that patients with this pathology have an overall 5-year survival of 74% with decreased survival associated with the frontal sinus as primary site as well as age greater than 60.

Finally, no issue can be complete without cutting-edge basic science research and this issue is no different. Yang et al evaluated to role of NLRP3, the main receptor activated by pathogen-associated molecular patterns, which has been associated with a variety of inflammatory diseases. ¹¹ Their group looked at a control group as well as chronic rhinosinusitis with and without polyps and investigated the differential expression. They were able to identify that NLRP3 is involved in the pathogenesis of chronic rhinosinusitis. Another interesting area of investigation, He et al evaluated the role of astragalus polysaccharide (APS) in mitigating inflammation in allergic rhinitis. Utilizing a guinea pig model, they found that APS treatment reduced sneezing and rubbing times in the guinea pigs. In addition, a number of inflammatory mediators were suppressed. This study demonstrates that APS may reduce the inflammatory response in allergic rhinitis. ¹² In a similar fashion, Lett and colleagues used a rat sciatic nerve model to evaluate submucosal nerve ablation using radio frequency and cryoablation. ¹³ After utilizing techniques, they evaluated histological section 2 days and a month after treatment. In both treatment arms, they demonstrated a similar axonal disintegration which lead to disruption of electrical signals. This suggested that the methods were effective in nerve ablation. Switching gears to oncology, Chen et al looked at upregulation of HOXA10 in nasopharyngeal carcinoma. ¹⁴ HOXA10 has been previously identified to promote proliferation and invasion in nasopharyngeal carcinoma but further mechanistic details have been lacking. Chen and colleagues identified that CircKIAA0368 upregulates HOXA10 expression and may help identify further therapeutic options. Finally, Wang et al evaluated the role of inflammation in inverted papillomas. ¹⁵ They evaluated a number of patients with unilateral papillomas and contralateral nasal polyps and assessed neutrophil and eosinophil infiltration with immunostaining. Their study demonstrated distinct inflammatory patterns between the inverted papilloma and implied there may be an oncogenic role of neutrophils in the pathogenesis of inverted papillomas.

The current breadth rhinologic investigation is truly impressive. This issue of AJRA highlights this point perfectly. We have an issue that produces a wide variety of research coming in the form of advances in surgical technique, novel prospective investigations, large database studies, and high-quality basic science work. Fortunately, the journal continues to be at the cutting edge of rhinologic literature that is great for educating our readership and providing thought-provoking research that we can all build upon in a variety of ways in our daily lives as surgeons and scientists.