What are the most effective treatments, how to recognize serious cases and why it can make your life miserable

sinusitis (or, more correctly, rhinosinusitis) is an inflammation of the paranasal sinuses – cavities located in the thickness of the bones of the face, communicating with the nasal passages. It can range in severity from a cold or short-term viral rhinosinusitis to chronic forms that can seriously impair the quality of life of those who suffer from it.

“The most serious cases of chronic rhinosinusitis are associated with nasal polyps (polyposis),” explains Giandomenico MaggioreHead of the Department of Endoscopic Surgery of the Paranasal Sinuses and Skull Base, Careggi University Hospital Florence -. The consequences are changes in the sense of smell (up to complete loss) and taste, constant nasal discharge, facial pain, even aesthetic deformations of the root of the nose. “In addition, patients suffer from nighttime breathing problems such as snoring and apnea, and in some cases, mucus clogs the ears, causing hearing loss.”

In patients with chronic sinusitis, these typical “winter” problems (for example, runny nose) are not associated with the cold season, but occur throughout the year.

There is also a special subcategory from a clinical point of view, namely patients with chronic rhinosinusitis, nasal polyposis and inflammation type 2 associated with asthma and allergies to NSAIDs (non-steroidal anti-inflammatory drugs).

Thus, these are people suffering from multiple pathologies (comorbidities). “In these cases, the symptoms are particularly severe,” Maggiore emphasizes, “and it is important to intervene as soon as possible with treatment, which may include nasal lavage, topical cortisone (nasal sprays, aerosols) or systemic endoscopic surgery and monoclonal antibodies.”

“However, there are some limitations: drugs with cortisone, especially systemic ones, must be taken for a short time, since there is a risk of side effects, surgery may be unsuccessful (due to the risk of relapses) and, finally, monoclonal antibodies are very expensive. medications that are only reimbursed for a small percentage of patients with severe forms. “They have a precise action: they act on interleukins (in particular interleukins 4, 5, 13), which are mediators of inflammation,” he adds.

Since sinusitis with polyposis is usually combined with asthma (the latter is not always serious, it can be mild or moderate in severity) it is necessary that the observation of the patient be multidisciplinary (otolaryngologist, immunoallergist, pulmonologist).

“In our Center we see about 300 adults a year, of whom about thirty meet the criteria for the prescription of monoclonal antibodies,” explains Giandomenico Maggiore, “many of them are patients who have been wandering for several years in search of a cure. diagnosis, without the connection of various pathologies with each other. That’s why I say a multidisciplinary approach is needed and when making a diagnosis, the first thing to look at is whether the immune system, the famous type 2 inflammation, is involved.

“A simple blood test measures levels of eosinophils, a certain type of white blood cell, and IgE (immunoglobulin E) antibodies. In the department that I coordinate, we also do a biopsy of the polyp tissue to evaluate the presence of eosinophils, which are responsible for the inflammation in that particular location,” he explains.

“In addition to blood tests, to make a diagnosis videoendoscopy , to assess the size of the polyps and in what anatomical areas they are located, as well as computed tomography of the paranasal sinuses without a contrast agent, continues the expert. At this point, the patient is assigned a disease severity score.”

Then comes the time to choose therapy. ” endoscopic surgery (Fess, functional endoscopic sinus surgery ) uses miniature instruments and an optical device to accurately view the operating area: the goal is to eliminate polyposis and thus ventilate the nasal passages. If the operation is carried out in a reference center, it can be decisive even for 10-15 years, but it is important to trust the hands of a professional. Relapses of polyposis often occur, especially in patients with grade 2 inflammation, bronchial asthma and intolerance to NSAIDs. In this case, the administration monoclonal antibody (every two weeks), a therapy that has been available for a couple of years. However, there are many patients who have to undergo multiple surgeries due to relapses,” says Maggiore.

“In Italy Medical agency has approved three monoclonal antibodies against polyposis, but they are only reimbursed under strict criteria and in accordance with precise recommendations: they are intended for patients who have already undergone various operations and whose quality of life is seriously impaired by the disease, continues Maggiore – . Those taking them undergo periodic monitoring (to check the real effectiveness of therapy in each individual case), and the therapeutic plan must be updated every year. The current tendency is to alternate classical pharmacological therapy (topical and oral cortisone, nasal irrigations, antibiotics) with surgery and monoclonal antibodies, but further research is needed to reach definitive conclusions: the immune response of an individual patient may change over time, and this necessary. It is necessary to understand how long remission lasts after stopping treatment with monoclonal drugs. We know that in the case of asthma, symptoms reappear several months after treatment ends; instead, we need to know what happens to polyposis.