JAK2 Phosphorylation Signals and Their Associated Cytokines Involved in Chronic Rhinosinusitis with Nasal Polyps and Correlated with Disease Severity

Janus kinase 2 (JAK2) is a member of the JAK family that transduces cytokine-mediated signals via the JAKs/STATs (signal transducer and activator of transcription proteins) pathway, which plays an important role in many inflammatory diseases. This study investigates the association of p-JAK2 and JAK2-associated cytokines from nasal polyp (NP) tissue with disease severity, and evaluates the p-JAK2-mediated STATs in chronic rhinosinusitis (CRS) with NP. Sixty-one CRSwNP patients with nasal polyps undergoing endoscopic sinus surgery were enrolled, while the turbinate tissues from 26 nasal obstruction patients were examined as the control group. Elevated levels of p-JAK2 were detected in CRSwNP, and significantly correlated with scores of disease severity (LMK-CT, TPS, and SNOT-22). Expressions of the JAK2-associated cytokines, such as IL-5, IL-6, IL-13, G-CSF, and IFN-γ were significantly higher in CRSwNP than in the controls, while the levels of IL-5, IL-6, IL-13, or G-CSF had positive correlation with scores of disease severity. Moreover, markedly increased expression of p-STAT3 in CRSwNP was observed relative to the control. Taken together, these data showed that the JAK2-associated cytokines including IL-6 and G-CSF may stimulate JAK2 phosphorylation to activate p-STAT3, indicating an association with disease severity and supporting its development of JAK2 inhibitor as a potential therapeutic agent for CRS.

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Expression of Matrix Metalloproteinases and Their Tissue Inhibitors in Chronic Rhinosinusitis With Nasal Polyps: Etiopathogenesis and Recurrence

Ear Nose & Throat Journal ◽

10.1177/0145561319896635 ◽

2020 ◽

pp. 014556131989663

Author(s):

Germano Guerra ◽

Domenico Testa ◽

Francesco Antonio Salzano ◽

Domenico Tafuri ◽

Eleonora Hay ◽

...

Keyword(s):

Allergic Rhinitis ◽

Matrix Metalloproteinases ◽

Chronic Rhinosinusitis ◽

Nasal Polyps ◽

Polymerase Chain Reaction Analysis ◽

Sinus Surgery ◽

Control Group ◽

Nonallergic Rhinitis ◽

Tissue Inhibitors ◽

Immunologic Diseases

Chronic rhinosinusitis with nasal polyps is a multifactorial disease of the nasal and paranasal sinus mucosa and it includes, as comorbidities, anatomic and morphologic alterations, allergic rhinitis, and immunologic diseases. We investigated matrix metalloproteinases (MMP-2, MMP-7, and MMP-9) and their tissue inhibitors (TIMP-1 and TIMP-2) concentration in different etiopathogenetical groups of patients with nasal polyposis (NP) in relation to recurrence after sinonasal surgery. The study group consisted of 45 patients with NP (those with allergic rhinitis, nonallergic rhinitis and asthma or nonallergic rhinitis, and obstruction of osteomeatal complex [OMC]) who underwent endonasal sinus surgery. We also collected 10 patients who underwent septoplasty as control. Immunohistochemistry of nasal mucosa fragments, Western blotting, and polymerase chain reaction analysis showed increased MMPs levels (MMP-9 more than MMP-2 and MMP-7) and decreased tissue inhibitors of MMPs levels (TIMP-1 less than TIMP-2), in patients with chronic rhinosinusitis with nasal polyps compared with control group, in particular in patients with nonallergic rhinitis and asthma compared to those with allergic rhinitis and nonallergic rhinitis and obstruction of OMC. We observed a higher risk of recurrence in patients with nonallergic rhinitis and asthma than in those with allergic rhinitis and nonallergic rhinitis and obstruction of OMC after 36 months from surgery. In this research, we evaluated pathogenesis of NP related to MMPs and their inhibitors concentrations in polypoid tissue.

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“In-Office Balloon Sinus Ostial Dilation with Concurrent Antiplatelet and Anticoagulant Therapy for Chronic Rhinosinusitis without Nasal Polyps”

Annals of Otology Rhinology & Laryngology ◽

10.1177/0003489419887195 ◽

2019 ◽

Vol 129 (3) ◽

pp. 280-286

Author(s):

Thomas S. Higgins ◽

Bülent Öcal ◽

Ridwan Adams ◽

Arthur W. Wu

Keyword(s):

Antiplatelet Therapy ◽

Chronic Rhinosinusitis ◽

Anticoagulant Therapy ◽

Endoscopic Sinus Surgery ◽

Nasal Polyps ◽

Sinus Surgery ◽

Bleeding Events ◽

Safe Alternative ◽

Systemic Complications ◽

Snot 22

Objective: Functional endoscopic sinus surgery (FESS) and balloon sinus ostial dilation (BSD) are well-recognized minimally invasive surgical treatments for chronic rhinosinusitis without nasal polyps (CRSsNP) refractory symptoms to medical therapy. Patients on antiplatelet and anticoagulant therapies (AAT) usually are recommended to discontinue their medications around the period of endoscopic sinus surgery. The goal of this study is to assess the clinical experience of BSD in CRSsNP patients with concurrent anticoagulant or antiplatelet therapy. Methods: A review of prospectively-collected clinical data from October 2012 to March 2017 were used to perform a cohort study of subjects with CRSsNP who met criteria for surgical intervention while on antiplatelet and anticoagulant therapy. Data were collected on demographics, details of the procedures, type of AAT used, pre- and postoperative 22-item Sino-Nasal Outcome Test (SNOT-22) scores, and complications. Results: Thirty-five patients underwent in-office BSD while on antiplatelet and/or anticoagulant therapy. The mean difference in pre- and postoperative SNOT-22 scores of 9.9 (SD 14.4, P < .001) was both statistically significant and exceeded the minimal clinically important difference of 8.9. Absorbable nasal packing was used for persistent bleeding immediately post-procedure in two patients. Intraoperative bleeding was associated with aspirin 325 mg and warfarin. FESS was required for further management of chronic sinusitis in four patients after anticoagulant/antiplatelet therapy could be discontinued. There were no systemic complications. None of the patients experienced significant bleeding events postoperatively after leaving the office. Conclusion: In-office BSD appears to be a safe alternative to endoscopic sinus surgery in select patients who cannot discontinue antiplatelet and anticoagulant therapy. Levels of Evidence: IV

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Nucleotide-Binding Oligomerization Domain-Like Receptor 3 Inflammasome Inhibition by MCC950 Reduces the Lipopolysaccharide-Induced Interleukin-1β in Cultured Dispersed Nasal Polyp Cells

Korean Journal of Otorhinolaryngology - Head and Neck Surgery ◽

10.3342/kjorl-hns.2019.00738 ◽

2020 ◽

Vol 63 (5) ◽

pp. 206-215

Author(s):

Soo Kyoung Park ◽

Rui-Ning Han ◽

Jun Xu ◽

Sun Hee Yeon ◽

Sung Bok Lee ◽

...

Keyword(s):

Chronic Rhinosinusitis ◽

Nasal Polyp ◽

Nlrp3 Inflammasome ◽

Nasal Polyps ◽

Inflammatory Diseases ◽

Nucleotide Binding ◽

Enzyme Linked Immunosorbent Assay ◽

Control Group ◽

Western Blot Assay ◽

Oligomerization Domain

Background and Objectives The nucleotide-binding oligomerization domain-like receptor (NLRP) 3 is known as a member of the NLR family, and it has been confirmed that the NLRP3 inflammasome is associated with various diseases such as asthma, inflammatory bowel disease, metabolic disorders and multiple sclerosis, as well as other auto-immune and auto-inflammatory diseases. However, the role of NLRP3 in chronic rhinosinusitis with nasal polyps (CRSwNP) has not yet been explored.Subjects and Method Forty-four specimens of nasal polyps and 25 specimens of uncinate processes were collected from patients with chronic rhinosinusitis with nasal polyps, and 25 specimens of uncinate tissues were collected from patients who underwent other rhino-surgeries. The western blot assay was employed to analyze the expression of NLRP3; interleukin (IL)-1β and IL-17A were detected using immunohistochemistry and real-time polymerase chain reaction. The production of lipopolysaccharide (LPS) induced IL-1β and IL-17A with or without the NLRP3 inflammasome inhibitor (MCC950) was measured using an enzyme linked immunosorbent assay in cultured dispersed nasal polyp cells.Results NLRP3 showed a high level of expression in nasal polyps than in the control group (p<0.01). The expression of IL-1β and IL-17A was significantly higher in nasal polyps in the CRSwNP group than in the control group (p<0.05). LPS-induced production of IL-1β was significantly suppressed by treatment with the NLRP3 inflammasome inhibitor (p<0.05).Conclusion The NLRP3 inflammasome plays an essential role in the pathogenesis of CRSwNP, and thus MCC950 can be considered a prospective therapeutic for NLRP3 inflammasome-mediated inflammation in nasal polyps. Our data provide new evidence that IL-17A is involved in inflammasome-associated inflammation in nasal polyps.

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Efficacy of Dexamethasone Versus Fluticasone Nasal Sprays in Postoperative Patients With Chronic Rhinosinusitis With Nasal Polyps

American Journal of Rhinology and Allergy ◽

10.1177/1945892419841355 ◽

2019 ◽

Vol 33 (5) ◽

pp. 478-482 ◽

Cited By ~ 1

Author(s):

Kristin A. Seiberling ◽

Stephanie C. Kidd ◽

Grace H. Kim ◽

Christopher A. Church

Keyword(s):

Chronic Rhinosinusitis ◽

Nasal Polyps ◽

Standard Dose ◽

Controlled Trial ◽

Sinus Surgery ◽

Double Blind ◽

Nasal Sprays ◽

Significant Difference ◽

Nasal Steroid ◽

Snot 22

Background Topical nasal steroids are commonly prescribed to patients with chronic rhinosinusitis with nasal polyposis (CRSwNP) following endoscopic sinus surgery (ESS). They are found to be effective in improving symptoms and quality of life as well as reducing the incidence of nasal polyps recurrence. Objective We sought to determine whether a higher concentration of topical nasal steroid spray is more effective than the standard nasal steroid spray in controlling symptoms and preventing recurrence of polyps in patients with CRSwNP who underwent ESS. Method A double-blind randomized controlled trial was performed on patients with CRSwNP after ESS. Patients were randomized into 2 treatment groups: one received topical nasal dexamethasone 0.032% and the other, fluticasone proprionate. The 22-item Sino-Nasal Outcome Test (SNOT-22) and Lund-Kennedy nasal endoscopy scores were measured at the initiation of topical nasal steroid treatment and then at approximately 4-, 8-, and 12-week intervals. Results Thirty-nine patients were enrolled in the study. Eighteen patients continued using the medications prescribed to them for the duration of the study. There were 8 patients in the dexamethasone group and 10 patients in the fluticasone group. Both groups saw significant improvements in postoperative SNOT-22 and Lund-Kenney scores over time. There was no significant difference in improvement between the groups. Conclusion There is no significant increased benefit in using a higher dose nasal steroid spray compared to the standard dose nasal steroid spray after ESS.

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Mycoplasma pneumoniaeandChlamydophila pneumoniae: a comparative study in patients with nasal polyposis and healthy controls

The Journal of Laryngology & Otology ◽

10.1017/s0022215115001590 ◽

2015 ◽

Vol 129 (9) ◽

pp. 865-869 ◽

Cited By ~ 1

Author(s):

D G Ioannidis ◽

V A Lachanas ◽

Z Florou ◽

J G Bizakis ◽

E Petinaki ◽

...

Keyword(s):

Polymerase Chain Reaction ◽

Real Time ◽

Chronic Rhinosinusitis ◽

Nasal Polyps ◽

Inferior Turbinate ◽

Sinus Surgery ◽

Control Group ◽

Chain Reaction ◽

Tissue Samples ◽

Polymerase Chain

AbstractIntroduction:The role played byMycoplasma pneumoniaeandChlamydophila pneumoniaein the pathogenesis of chronic rhinosinusitis with nasal polyps has been the object of ongoing debate. We used real-time polymerase chain reaction to investigate the prevalence of both microorganisms in the nasal tissue samples of patients and controls.Methods:We extracted DNA from nasal polyp samples obtained during functional endoscopic sinus surgery and the inferior turbinate samples of controls undergoing septoplasty. We used the highly sensitive real-time polymerase chain reaction to detect the presence ofM pneumoniaeandC pneumoniaeDNA.Results:Patients with chronic rhinosinusitis with nasal polyps consisted of 62 individuals (39 men; mean age 51 years); the control group consisted of 24 individuals (13 men; mean age 45 years). All samples from both groups were negative forM pneumoniaeandC pneumoniaeDNA.Conclusion:We have demonstrated that the likelihood ofM pneumoniaeandC pneumoniaeacting as an ongoing inflammatory stimulus in chronic rhinosinusitis with nasal polyps is slim.

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Chronic Rhinosinusitis without Nasal Polyps in Asian Patients Shows Mixed Inflammatory Patterns and Neutrophil-Related Disease Severity

Mediators of Inflammation ◽

10.1155/2019/7138643 ◽

2019 ◽

Vol 2019 ◽

pp. 1-9 ◽

Cited By ~ 2

Author(s):

Dae Woo Kim ◽

Kyoung Mi Eun ◽

Eun Youn Roh ◽

Sue Shin ◽

Dong-Kyu Kim

Keyword(s):

Immune Response ◽

Chronic Rhinosinusitis ◽

Inflammatory Mediators ◽

Nasal Polyps ◽

Uncinate Process ◽

Sinus Surgery ◽

Individual Treatment ◽

Control Group ◽

Disease Extent ◽

Asian Patients

Chronic rhinosinusitis (CRS) shows heterogeneous immunologic features. Western studies revealed that CRS without nasal polyps (CRSsNP) showed a predominantly type 1 immune response and CRS with nasal polyps (CRSwNP) was characterized by type 2 immune response; however, the detailed immunologic profile of CRSsNP in Asian patients has not been thoroughly investigated. Therefore, we investigated the inflammatory endotypes of CRSsNP in Asian patients. Patients with CRSsNP (N=57), patients with CRSwNP (N=13), and a control group (N=10), who underwent endoscopic sinus surgery, were enrolled; uncinate process (UP) tissues were harvested from all patients. Homogenates were prepared from the UP of each group, and immunologic profiles were analyzed, including major cytokines (32 inflammatory mediators). When comparing the UPs between groups, CRSsNP patients showed higher levels of Th2 cytokines (IL-4 and IL-13), eosinophilic chemokines (CCL-11 and CCL-24), ECP, and total IgE expression than control subjects. In addition, several neutrophilic markers (IL-1α, IL-6, IL-8, CXCL-1, CXCL-2, and MPO), IL-17A, IL-22, and TNF-α were dominant in CRSsNP patients. Among these inflammatory mediators, IL-17A showed higher expression levels in CRSsNP patients than in the control group and CRSwNP patients. However, IFN-γ expression was not significantly elevated in CRSsNP patients. The levels of neutrophil-associated cytokines were well correlated with each other; of which, CXCL2, IL-8, and MMP-9/TIMP-1 levels were significantly correlated with disease extent (r=0.338, r=0.317, and r=0.424, respectively). However, the levels of eosinophil-associated cytokines showed little correlation with each other and were not correlated with disease extent. Our study revealed that Asian CRSsNP patients showed a mixed (types 2 and 17) immune response, but neutrophil-related markers were dominant and associated with disease extent. Knowledge of this immunologic feature may help clinicians make better individual treatment decisions for Asian CRSsNP patients.

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TIM-3–Expressing Mast Cells Are Present in Chronic Rhinosinusitis with Nasal Polyps

Otolaryngology ◽

10.1177/0194599818774560 ◽

2018 ◽

Vol 159 (3) ◽

pp. 581-586 ◽

Cited By ~ 2

Author(s):

Erica Corredera ◽

Binh L. Phong ◽

John A. Moore ◽

Lawrence P. Kane ◽

Stella E. Lee

Keyword(s):

Mast Cell ◽

Mast Cells ◽

Chronic Rhinosinusitis ◽

Disease Severity ◽

Nasal Polyp ◽

Nasal Polyps ◽

Staging System ◽

Sinus Surgery ◽

Epithelial Layer ◽

Polyp Tissue

Objectives To identify whether TIM-3 expression is present in the mast cell population within nasal polyps and to determine its correlation with clinical severity in patients with chronic rhinosinusitis with nasal polyposis. Study Design Basic science, translational study. Setting Nasal polyp tissue collected from patients seen at a tertiary care hospital (2015-2016). Subjects and Methods Nasal polyp tissue obtained during functional endoscopic sinus surgery (n = 24) was enzymatically digested into epithelial and stromal fractions. Viable mast cells expressing TIM-3 were identified using flow cytometry for the following: CD45, Live/Dead, c-kit, FcεR1, TIM-3. Disease severity was assessed using the Sino-Nasal Outcome Test, Lund-Mackay staging system, Lund-Kennedy staging system, and complete blood counts. Results Mast cells were found in both the epithelial and stromal layers of polyps, with a greater %TIM-3+ mast cells in the epithelial layer compared with that of the stromal layer ( P = .001). As the percentage of mast cells increased, there was a comparative worsening in endoscopic severity after comparing pre- and postoperative LK scores (ρ = −0.455, P = .029). In a subgroup of patients with concomitant asthma, increased epithelial %TIM-3+ mast cells also correlated with worsening endoscopic appearance postoperatively (ρ = 0.866, P = .001, n = 11). Oral corticosteroid treatment did not change the viability of mast cells nor their influence on the increased postoperative endoscopic disease severity (ρ = −0.544, P = .020, n = 18). Conclusion Viable mast cells were found to be present in polyps with increased TIM-3 expression at the epithelial layer. This suggests that TIM-3 may play a role in chronic inflammation in CRSwNP via mast cell activation.

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Effect of Functional Endoscopic Sinus Surgery on Gustatory Function in Patients With Chronic Rhinosinusitis

Ear Nose & Throat Journal ◽

10.1177/01455613211015754 ◽

2021 ◽

pp. 014556132110157

Author(s):

Rong-San Jiang ◽

Kai-Hsiang Shih ◽

Kai-Li Liang

Keyword(s):

Chronic Rhinosinusitis ◽

Endoscopic Sinus Surgery ◽

Nasal Polyps ◽

Detection Threshold ◽

Functional Endoscopic Sinus Surgery ◽

Olfactory Function ◽

Sinus Surgery ◽

Testing Procedures ◽

Gustatory Function ◽

Snot 22

Objectives: In this study, we investigated the effect of functional endoscopic sinus surgery (FESS) on gustatory function in patients with chronic rhinosinusitis (CRS). Methods: Forty-three patients with CRS who underwent FESS were included in this study. Prior to FESS and 3 months after surgery, the severity of rhinosinusitis was assessed using the Taiwanese version of the 22-item SNOT (SNOT-22), endoscopic examination, and acoustic rhinometry. The olfactory function was evaluated using the phenylethyl alcohol odor detection threshold test and the traditional Chinese version of the University of Pennsylvania Smell Identification Test, and the gustatory function was evaluated using the whole mouth suprathreshold taste test (WMTT) and the taste quad test (TQT). Subgroup analyses were performed based on CRS phenotypes and endotypes. Results: The SNOT-22 significantly improved 3 months after FESS for all patients with CRS. The endoscopic score and olfactory function significantly improved in patients with eosinophilic CRS and in patients with nasal polyps (CRSwNP). The WMTT sweet and bitter scores were significantly lower after FESS in CRSwNP, but the TQT sweet score was significantly higher in patients without nasal polyps. In addition, patients with noneosinophilic CRS had significantly decreased WMTT and salty scores 3 months after FESS. Conclusion: Our results showed that the effect of FESS on gustatory function of patients with CRS was different with the different testing procedures, the association with nasal polyps, and the underlying inflammatory patterns.

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CD4+ and CD8+ T cells infiltration of the polyp tissue in a series of Greek patients with chronic rhinosinusitis with nasal polyps

European Journal of Inflammation ◽

10.1177/20587392211028733 ◽

2021 ◽

Vol 19 ◽

pp. 205873922110287

Author(s):

Spyridon Gougousis ◽

Kalliopi Domvri ◽

Konstantinos Porpodis ◽

Ioanna Besli ◽

Petros Karkos ◽

...

Keyword(s):

T Cells ◽

Chronic Rhinosinusitis ◽

Clinical Characteristics ◽

Nasal Polyps ◽

Sinus Surgery ◽

Blood Eosinophil ◽

Absolute Count ◽

Tissue Samples ◽

Severity Of The Disease ◽

Snot 22

Chronic rhinosinusitis (CRS) presents with two basic phenotypes, CRS with (CRSwNP) or without nasal polyps (CRSsNP). The present study’s objective was to evaluate the clinical characteristics in a Greek population of CRSwNP patients and their relation to the frequency of CD4+ and CD8+ T cells as well as the CD4+/CD8+ ratio as prognostic biomarkers. Thirty-three adult CRSwNP patients were recruited at the ENT Department of “G. Papanikolaou” General Hospital of Thessaloniki. Tissue samples from nasal polyps were collected during functional endoscopic sinus surgery. Hadley’s nasal endoscopy scores, preoperative Lund-Mackay CT scores, and 22-item Sinonasal Outcome Test, were recorded for each patient. The presence of CD4+ and CD8+ lymphocytes was evaluated in tissue sections by immunohistochemistry. Blood eosinophil and neutrophil counts were also included in the analysis. All data were analyzed with SPSS (version 21.0). Twenty-one males and 12 females were included in the analysis with mean age of 49.5 ± 14.5. LMS ( P < 0.001, r = 0.961) and HES ( P = 0.001, r = 0.54) were both positively correlated with SNOT 22. Hadley’s endoscopic score was also positively correlated with Lund-Mackay CT score ( P < 0.001, r = 0.674). Absolute count and percentage of eosinophils were positively correlated with LMS ( P = 0.003, r = 0.513, P = 0.002, r = 0.527 respectively) and HES ( P < 0.001, r = 0.622, P = 0.004, r = 0.497 respectively). Ιn a subgroup analysis, CRSwNP patients with blood eosinophils >5%, LMS and SNOT 22 were negatively correlated to CD4+ cells ( P = 0.029 r = −0.654, P = 0.043, r = −0.618, respectively). In CRSwNP patients with CD4+/CD8+ ratio <0.3, CD8+ T cells were positively correlated with the absolute count and percentage of eosinophils ( P = 0.042, r = 0.684, P = 0.036, r = 0.699 respectively). In this study, we recognized the potential importance of nasal CD8+ T cells in the pathophysiology of CRSwNP patients, also characterized by eosinophil accumulation. Furthermore, the patients’ clinical characteristics were also positively correlated with the eosinophilic inflammation and the severity of the disease.

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Defining appropriateness criteria for endoscopic sinus surgery during management of uncomplicated adult chronic rhinosinusitis: a RAND/UCLA appropriateness study

Rhinology Journal ◽

10.4193/rhino16.023 ◽

2016 ◽

Vol 54 (2) ◽

pp. 117-128

Author(s):

Luke Rudmik ◽

Zachary M. Soler ◽

Claire Hopkins ◽

Rodney J. Schlosser ◽

Anju Peters ◽

...

Keyword(s):

Chronic Rhinosinusitis ◽

Treatment Option ◽

Endoscopic Sinus Surgery ◽

Nasal Polyps ◽

Adult Patients ◽

Sinus Surgery ◽

Intranasal Corticosteroid ◽

Appropriateness Criteria ◽

Short Course ◽

Snot 22

Introduction: Appropriate indications for endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) are currently poorly defined. The lack of clear surgical indications for ESS likely contributes to the large geographic variation in surgical rates and contributes to reduced quality of care. The objective of this study was to define appropriateness criteria for ESS during management of adult patients with uncomplicated CRS. Methods: The RAND/UCLA appropriateness methodology was performed. An international, multi-disciplinary panel of 10 experts in CRS was formed and completed two rounds of a modified Delphi ranking process along with a face-to-face meeting. Results: A total of 624 clinical scenarios were ranked, 312 scenarios each for CRS with and CRS without nasal polyps. For adult patients with uncomplicated CRS with nasal polyps, ESS can be appropriately offered when the CT Lund-Mackay score is ≥ 1 and there has been a minimum trial of a topical intranasal corticosteroid plus a short-course of systemic corticosteroid with a post-treatment total SNOT-22 score ≥ 20. For adult patients with uncomplicated CRS without nasal polyps, ESS can be appropriately offered when the CT Lund-Mackay score is ≥ 1 and there has been a minimum trial of a topical intranasal corticosteroid plus either a short-course of a broad spectrum/culture-directed systemic antibiotic or the use of a prolonged course of systemic low-dose anti-inflammatory antibiotic with a post-treatment total SNOT-22 score ≥ 20. Conclusion: This study has developed and reported of list of appropriateness criteria to offer ESS as a treatment option during management of uncomplicated adult CRS. The extent or technique of ESS was not addressed in this study and will depend on surgeon and patient factors. Furthermore, these criteria are the minimal threshold to make ESS a treatment option and do not imply that all patients meeting these criteria require surgery. The decision to perform ESS should be made after an informed patient makes a preference-sensitive decision to proceed with surgery. Applying these appropriateness criteria for ESS may optimize patient selection, reduce the incidence of unwarranted surgery, and assist clinicians in providing high quality, patient-centered care to patients with CRS.

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