The European Position Paper on Rhinosinusitis and Nasal Polyps 2020 is the update of similar evidence based position papers published in 2005 and 2007 and 2012. The core objective of the EPOS2020 guideline is to provide revised, up-to-date and clear evidence-based recommendations and integrated care pathways in ARS and CRS. EPOS2020 provides an update on the literature published and studies undertaken in the eight years since the EPOS2012 position paper was published and addresses areas not extensively covered in EPOS2012 such as paediatric CRS and sinus surgery. EPOS2020 also involves new stakeholders, including pharmacists and patients, and addresses new target users who have become more involved in the management and treatment of rhinosinusitis since the publication of the last EPOS document, including pharmacists, nurses, specialised care givers and indeed patients themselves, who employ increasing self-management of their condition using over the counter treatments. The document provides suggestions for future research in this area and offers updated guidance for definitions and outcome measurements in research in different settings. EPOS2020 contains chapters on definitions and classification where we have defined a large number of terms and indicated preferred terms. A new classification of CRS into primary and secondary CRS and further division into localized and diffuse disease, based on anatomic distribution is proposed. There are extensive chapters on epidemiology and predisposing factors, inflammatory mechanisms, (differential) diagnosis of facial pain, allergic rhinitis, genetics, cystic fibrosis, aspirin exacerbated respiratory disease, immunodeficiencies, allergic fungal rhinosinusitis and the relationship between upper and lower airways. The chapters on paediatric acute and chronic rhinosinusitis are totally rewritten. All available evidence for the management of acute rhinosinusitis and chronic rhinosinusitis with or without nasal polyps in adults and children is systematically reviewed and integrated care pathways based on the evidence are proposed. Despite considerable increases in the amount of quality publications in recent years, a large number of practical clinical questions remain. It was agreed that the best way to address these was to conduct a Delphi exercise . The results have been integrated into the respective sections. Last but not least, advice for patients and pharmacists and a new list of research needs are included. The full document can be downloaded for free on the website of this journal: http://www.rhinologyjournal.com.

/pdf/european-position-paper-on-rhinosinusitis-and-nasal-polyps-mj734vsl7p.pdf

European Position Paper on Rhinosinusitis and Nasal Polyps 2020

ObjectiveThis update of a 2007 guideline from the American Academy of Otolaryngology—Head and Neck Surgery Foundation provides evidence-based recommendations to manage adult rhinosinusitis, defined as symptomatic inflammation of the paranasal sinuses and nasal cavity. Changes from the prior guideline include a consumer added to the update group, evidence from 42 new systematic reviews, enhanced information on patient education and counseling, a new algorithm to clarify action statement relationships, expanded opportunities for watchful waiting (without antibiotic therapy) as initial therapy of acute bacterial rhinosinusitis (ABRS), and 3 new recommendations for managing chronic rhinosinusitis (CRS).PurposeThe purpose of this multidisciplinary guideline is to identify quality improvement opportunities in managing adult rhinosinusitis and to create explicit and actionable recommendations to implement these opportunities in clinical practice. Specifically, the goals are to improve diagnostic accuracy for adu...

/pdf/clinical-practice-guideline-update-adult-sinusitis-2ljjii9vlh.pdf

Clinical Practice Guideline (Update) Adult Sinusitis

The airways of patients with cystic fibrosis (CF) are nearly always infected with many different microorganisms. This environment offers warm, humid and nutrient-rich conditions, but is also stressful owing to frequent antibiotic therapy and the host immune response. Pseudomonas aeruginosa is commonly isolated from the airways of patients with CF, where it most often establishes chronic infections that usually persist for the rest of the lives of the patients. This bacterium is a major cause of mortality and morbidity and has therefore been studied intensely. Here, we discuss how P. aeruginosa evolves from a state of early, recurrent intermittent colonization of the airways of patients with CF to a chronic infection state, and how this process offers opportunities to study bacterial evolution in natural environments. We believe that such studies are valuable not only for our understanding of bacterial evolution but also for the future development of new therapeutic strategies to treat severe chronic infections.

Adaptation of Pseudomonas aeruginosa to the cystic fibrosis airway: an evolutionary perspective

SUMMARY A select group of microorganisms inhabit the airways of individuals with cystic fibrosis. Once established within the pulmonary environment in these patients, many of these microbes adapt by altering aspects of their structure and physiology. Some of these microbes and adaptations are associated with more rapid deterioration in lung function and overall clinical status, whereas others appear to have little effect. Here we review current evidence supporting or refuting a role for the different microbes and their adaptations in contributing to poor clinical outcomes in cystic fibrosis.

Clinical Significance of Microbial Infection and Adaptation in Cystic Fibrosis

https://www.thelancet.com/pdfs/journals/lanres/PIIS2213-2600(16)00023-0.pdf

Progress in Therapies for Cystic Fibrosis

Rationale: Lower airway (LAW) infection with Pseudomonas aeruginosa (P.a.) and Staphylococcus aureus (S.a.) is the leading cause of morbidity in Cystic Fibrosis (CF). The upper airways (UAW) were shown to be a gateway for acquisition and reservoir of opportunistic bacteria. Therefore, tools for UAW-assessment within CF-routine care require evaluation. Objectives: Aims of the study were non-invasive assessment of UAW and LAW microbial colonization and genotyping of P.a. and S.a. strains from both segments. Methods: 182 CF-patients were evaluated (age 0.4-68yrs, median 17yrs). LAW specimens were preferably sampled as expectorated sputum and UAW specimens by nasal lavage. P.a. and S.a.-isolates were typed in informative single nucleotide polymorphisms (SNPs) or by spa typing, respectively. Results: Of the typable S.a. and P.a. isolates from concomitant UAW- and LAW-positive specimens, 31 of 36 patients were carrying identical S.a. spa types and 23 of 24 patients identical P.a. SNP-genotypes in both compartments. Detection of S.a. or P.a. in LAW specimens was associated with a 15- or 88-fold higher likelihood to also identify S.a. or P.a. in a UAW specimen from the same patient. Conclusions: The presence of the same genotypes in UAW and LAW suggests a role of UAW as a reservoir of S.a. and P.a. in CF. Nasal lavage appears to be suitable for non-invasive UAW-sampling but further longitudinal analyses and comparison with invasive methods are required. While UAW bacterial colonization is typically not assessed in regular CF-care, our data challenge the need to discuss diagnostic and therapeutic standards for this airway compartment.

https://thorax.bmj.com/content/thoraxjnl/64/6/535.full.pdf

Manfred Käding

Papers

Concordant genotype of upper and lower airways P aeruginosa and S aureus isolates in cystic fibrosis

Effects of ivacaftor on severely ill patients with cystic fibrosis carrying a G551D mutation.

Prevalence of CF-related chronic rhinosinusitis – results from a multicentre interdisciplinary study