Editorial
Expanding our research horizons
T
he incredibly high quality of medical care that mechanisms that underlie the mucosal inflamwe are able to deliver to our patients today is mation seen in chronic rhinosinusitis and also built upon years of effort by physicians, physiciansuggest a possible future target for therapy. scientists, and other medical researchers. Yet, we Although we often think of medical research find that we are often met with significant chalas a process that involves asking a question and lenges in the clinic. There are still many poorly then moving forward to answer it prospectively, understood diseases, countless patients who are difthree retrospective articles this month also reficult to treat, and an array of complications that mind us that there is plenty of valuable knowlmay arise from our well-intended therapies. Thereedge to be gained from retrospective review. fore, as medical practitioners, we all rely on ongoing Work by Møller et al.5 highlighted the importance of further exploration into the pathologic medical research to continuously revolutionize role of upper respiratory tract bacteria in cystic medical knowledge. Furthermore, many of us have fibrosis and primary ciliary dyskinesia, and the had the joy and satisfaction of finding ways to inclear need for strict standardization of collection corporate research, either formally or informally, and analysis techniques. A review of dacryointo our medical careers. The September 2017 edicystorhinostomy clinical research articles by Sation of the American Journal of Rhinology and Allergy niasiaya et al.6 confirmed that endoscopic showcases wonderful examples of how research efTanya M. Laidlaw, M.D. dacryocystorhinostomy should be considered as forts from all angles and at all levels can make an a safe therapeutic approach to treating children impact, and I am honored to serve as this month’s with recalcitrant excessive eye watering due to guest editor. The untiring determination of the labnasolacrimal duct obstruction. A review by Lobo et al.,7 of patients oratory researchers featured here continues to provide much-needed insights into the underlying molecular causes of the diseases that we with sinonasal squamous cell carcinoma from two centers teaches us evaluate. It is clear that the laboratory-based mechanistic discoveries that, although squamous cell carcinoma with and squamous cell then set the stage for clinical investigators to capitalize on those carcinoma without inverted papilloma have generally been considadvances, move them into medical practices, and provide the tools ered to be two distinct diseases, their demographics and outcomes are needed to make profound changes in treatment approaches. quite similar. We must always be guided by our patients’ needs because this will Of equal weight are data gained from patient-reported outcomes. lead us to where the holes in our current standards of care lie. For As sublingual immunotherapy (SLIT) becomes increasingly available patients with sinus disease, anosmia is one of the symptoms that most in the United States, outcome comparisons with the now-traditional severely impacts their quality of life, and it is also a symptom for subcutaneous immunotherapy (SCIT) will be key to their appropriate which we have frustratingly little to offer by way of treatment opapplication. Having gone through the experience of then weekly and tions. Jiang et al.1 showed that 3-month olfactory training with phenyl now monthly injections required for SCIT with my own son, my initial bias was that the at-home and less-painful SLIT therapy would ethyl alcohol in patients with traumatic anosmia could significantly have been vastly preferred by most patients. In fact, Schwanke et al.8 improve the phenyl ethyl alcohol odor threshold levels of their patients, which indicated that this could be recommended as a noninfound, in a SCIT versus SLIT comparative study, that the change in terventional option for these patients. Soyka et al.2 studied patients Rhinoconjunctivitis Quality of Life Questionnaire score was statistically significant after 6 months and 1 year of treatment only in the who underwent skull base surgery for midline lesions by using a participants who received SCIT. They suggested that the lack of nasoseptal flap and found a significant decrease in olfactory function significant improvement in the patients who received SLIT could on the flap donor side. They proposed that it may be wise to have have been due to difficulties in adhering to immunotherapy dosing patients undergo a monorhinal smell test before surgery to prevent schedules or to the small population size studied. In a study by bilateral smell impairment in patients with preexisting single-sided Pecorari et al.,9 they examined differences in subjective and objective hyposmia. Results from a basic science study by Li et al.3 showed that soluble chitosan, a linear polysaccharide made from the chitin shells evaluations of changes in nasal airflow resistance after closed septoof crustaceans, can promote the differentiation of embryonic rat neurhinoplasty. Although the patient-reported symptom of nasal obroepithelial cells. Indeed, because chitosan is already under investistruction subjectively improved after surgery, the objective analysis of gation for other medicinal applications, including hemostasis, this anterior active rhinomanometry did not show any statistically signifstudy could well be an early investigation to suggest its use as an icant improvement, perhaps due to concurrent surgery on the nasal eventual therapy for anosmia. septum and the nasal valve. Another study that provided fascinating scientific insight was by Surgeons will appreciate the very comprehensive and practical Ramakrishnan et al.4 and explores the potential causative mechanisms guidance offered by Carney10 in his How I Do It article in which he that contribute to the epithelial barrier dysfunction seen in chronic described a simple and safe way to perform a Draf III approach to the rhinosinusitis. When looking at uncinate tissue specimens from pafrontal sinus, with advice to help reduce operative time and minimize tients with chronic rhinosinusitis and controls, they found that excomplications. Because my own area of research and clinical interest pression levels of two small proline-rich proteins were increased in is largely focused on patients with aspirin-exacerbated respiratory the mucosal samples from the patients with chronic rhinosinusitis. disease (AERD), the triad of asthma, recurrent eosinophilic nasal Furthermore, pathway analysis indicated that these small proline-rich polyps, and respiratory reactions to aspirin and nonsteroidal antiproteins changes could reflect an end-effect of tumor necrosis factor ␣ inflammatory drugs, I was delighted to find that this month’s edition modulation. Their results both further our understanding of the has two wonderful articles dedicated to this mysterious syndrome.
American Journal of Rhinology & Allergy
281
Our understanding of immunoglobulin G4 (IgG4) related disease continues to evolve, and a case by Johal et al.11 detailed a patient with coexistent IgG4-related sinus disease and AERD. Because the causative trigger is not known for either AERD or IgG4-related disease, this case of overlapping clinical syndromes pushes us to further consider the potential for overlapping mechanistic abnormalities that may underlie both diseases. Finally, White12 lent his expertise regarding the epidemiology of AERD. Although much progress has been made in the field of AERD over the past decade and the enthusiasm that continues to drive further investigation is heartening, the article White12 highlighted the critical need to increase awareness in the medical community to properly identify these patients. As you settle in to read through this month’s edition of the American Journal of Rhinology and Allergy, you will note that this series of articles covers a wide array of relevant disease topics and highlights the importance of expanding our research horizons to appreciate and learn from investigations at all levels, from the bench to the bedside and back!
3.
4.
5.
6.
7.
8.
9.
REFERENCES 1.
2.
282
Jiang RS, Twu CW, and Liang KL. The effect of olfactory training on the odor threshold in patients with traumatic anosmia. Am J Rhinol Allergy 31:317–322, 2017. Soyka MB, Serra C, Regli L, et al. Long-term olfactory outcome after nasoseptal flap reconstructions in midline skull base surgery. Am J Rhinol Allergy 31:334–337, 2017.
10. 11.
12.
Li ST, Young TH, Lin CF, and Huang TW. Promotion of olfactory receptor neuron differentiation of olfactory neuroepithelial cells by using chitosan solution. Am J Rhinol Allergy 31:289–292, 2017. Ramakrishnan VR, Gonzalez JR, Cooper SE, et al. RNA sequencing and pathway analysis identify tumor necrosis factor alpha driven small proline-rich protein dysregulation in chronic rhinosinusitis. Am J Rhinol Allergy 31:283–288, 2017. Møller ME, Alantin MC, Grønhøj C, et al. Sinus bacteriology in patients with cystic fibrosis or primary ciliary dyskinesia: A systematic review. Am J Rhinol Allergy 31:293–298, 2017. Saniasiaya J, Abdullah B, Husain S, et al. Primary endoscopic endonasal dacryocystorhinostomy for pediatric nasolacrimal duct obstruction: A systematic review. Am J Rhinol Allergy 31:328–333, 2017. Lobo BC, D’Anza B, Farlow JL, et al. Outcomes of sinonasal squamous cell carcinoma with and without association of inverted papilloma: A multi-institutional analysis. Am J Rhinol Allergy 31:305– 309, 2017. Schwanke T, Carragee E, Bremberg M, and Reisacher WR. Qualityof-life outcomes in patients who underwent subcutaneous immunotherapy and sublingual immunotherapy in a real-world clinical setting. Am J Rhinol Allergy 31:310–316, 2017. Pecorari G, Riva G, Bianchi FA, et al. The effect of closed septorhinoplasty on nasal functions and on external and internal nasal valves: A prospective study. Am J Rhinol Allergy 31:323–327, 2017. Carney AS. Draf III frontal sinus surgery: “How I do it.” Am J Rhinol Allergy 31:338–340, 2017. Johal K, Welch K, and Peters A. Immunoglobulin G4 sinusitis in association with aspirin-exacerbated respiratory disease. Am J Rhinol Allergy 31:302–304, 2017. White AA. An update on the epidemiology of aspirin-exacerbated respiratory disease. Am J Rhinol Allergy 31:299–301, 2017. e
September–October 2017, Vol. 31, No. 5
Expanding our research horizons
T
he incredibly high quality of medical care that mechanisms that underlie the mucosal inflamwe are able to deliver to our patients today is mation seen in chronic rhinosinusitis and also built upon years of effort by physicians, physiciansuggest a possible future target for therapy. scientists, and other medical researchers. Yet, we Although we often think of medical research find that we are often met with significant chalas a process that involves asking a question and lenges in the clinic. There are still many poorly then moving forward to answer it prospectively, understood diseases, countless patients who are difthree retrospective articles this month also reficult to treat, and an array of complications that mind us that there is plenty of valuable knowlmay arise from our well-intended therapies. Thereedge to be gained from retrospective review. fore, as medical practitioners, we all rely on ongoing Work by Møller et al.5 highlighted the importance of further exploration into the pathologic medical research to continuously revolutionize role of upper respiratory tract bacteria in cystic medical knowledge. Furthermore, many of us have fibrosis and primary ciliary dyskinesia, and the had the joy and satisfaction of finding ways to inclear need for strict standardization of collection corporate research, either formally or informally, and analysis techniques. A review of dacryointo our medical careers. The September 2017 edicystorhinostomy clinical research articles by Sation of the American Journal of Rhinology and Allergy niasiaya et al.6 confirmed that endoscopic showcases wonderful examples of how research efTanya M. Laidlaw, M.D. dacryocystorhinostomy should be considered as forts from all angles and at all levels can make an a safe therapeutic approach to treating children impact, and I am honored to serve as this month’s with recalcitrant excessive eye watering due to guest editor. The untiring determination of the labnasolacrimal duct obstruction. A review by Lobo et al.,7 of patients oratory researchers featured here continues to provide much-needed insights into the underlying molecular causes of the diseases that we with sinonasal squamous cell carcinoma from two centers teaches us evaluate. It is clear that the laboratory-based mechanistic discoveries that, although squamous cell carcinoma with and squamous cell then set the stage for clinical investigators to capitalize on those carcinoma without inverted papilloma have generally been considadvances, move them into medical practices, and provide the tools ered to be two distinct diseases, their demographics and outcomes are needed to make profound changes in treatment approaches. quite similar. We must always be guided by our patients’ needs because this will Of equal weight are data gained from patient-reported outcomes. lead us to where the holes in our current standards of care lie. For As sublingual immunotherapy (SLIT) becomes increasingly available patients with sinus disease, anosmia is one of the symptoms that most in the United States, outcome comparisons with the now-traditional severely impacts their quality of life, and it is also a symptom for subcutaneous immunotherapy (SCIT) will be key to their appropriate which we have frustratingly little to offer by way of treatment opapplication. Having gone through the experience of then weekly and tions. Jiang et al.1 showed that 3-month olfactory training with phenyl now monthly injections required for SCIT with my own son, my initial bias was that the at-home and less-painful SLIT therapy would ethyl alcohol in patients with traumatic anosmia could significantly have been vastly preferred by most patients. In fact, Schwanke et al.8 improve the phenyl ethyl alcohol odor threshold levels of their patients, which indicated that this could be recommended as a noninfound, in a SCIT versus SLIT comparative study, that the change in terventional option for these patients. Soyka et al.2 studied patients Rhinoconjunctivitis Quality of Life Questionnaire score was statistically significant after 6 months and 1 year of treatment only in the who underwent skull base surgery for midline lesions by using a participants who received SCIT. They suggested that the lack of nasoseptal flap and found a significant decrease in olfactory function significant improvement in the patients who received SLIT could on the flap donor side. They proposed that it may be wise to have have been due to difficulties in adhering to immunotherapy dosing patients undergo a monorhinal smell test before surgery to prevent schedules or to the small population size studied. In a study by bilateral smell impairment in patients with preexisting single-sided Pecorari et al.,9 they examined differences in subjective and objective hyposmia. Results from a basic science study by Li et al.3 showed that soluble chitosan, a linear polysaccharide made from the chitin shells evaluations of changes in nasal airflow resistance after closed septoof crustaceans, can promote the differentiation of embryonic rat neurhinoplasty. Although the patient-reported symptom of nasal obroepithelial cells. Indeed, because chitosan is already under investistruction subjectively improved after surgery, the objective analysis of gation for other medicinal applications, including hemostasis, this anterior active rhinomanometry did not show any statistically signifstudy could well be an early investigation to suggest its use as an icant improvement, perhaps due to concurrent surgery on the nasal eventual therapy for anosmia. septum and the nasal valve. Another study that provided fascinating scientific insight was by Surgeons will appreciate the very comprehensive and practical Ramakrishnan et al.4 and explores the potential causative mechanisms guidance offered by Carney10 in his How I Do It article in which he that contribute to the epithelial barrier dysfunction seen in chronic described a simple and safe way to perform a Draf III approach to the rhinosinusitis. When looking at uncinate tissue specimens from pafrontal sinus, with advice to help reduce operative time and minimize tients with chronic rhinosinusitis and controls, they found that excomplications. Because my own area of research and clinical interest pression levels of two small proline-rich proteins were increased in is largely focused on patients with aspirin-exacerbated respiratory the mucosal samples from the patients with chronic rhinosinusitis. disease (AERD), the triad of asthma, recurrent eosinophilic nasal Furthermore, pathway analysis indicated that these small proline-rich polyps, and respiratory reactions to aspirin and nonsteroidal antiproteins changes could reflect an end-effect of tumor necrosis factor ␣ inflammatory drugs, I was delighted to find that this month’s edition modulation. Their results both further our understanding of the has two wonderful articles dedicated to this mysterious syndrome.
American Journal of Rhinology & Allergy
281
Our understanding of immunoglobulin G4 (IgG4) related disease continues to evolve, and a case by Johal et al.11 detailed a patient with coexistent IgG4-related sinus disease and AERD. Because the causative trigger is not known for either AERD or IgG4-related disease, this case of overlapping clinical syndromes pushes us to further consider the potential for overlapping mechanistic abnormalities that may underlie both diseases. Finally, White12 lent his expertise regarding the epidemiology of AERD. Although much progress has been made in the field of AERD over the past decade and the enthusiasm that continues to drive further investigation is heartening, the article White12 highlighted the critical need to increase awareness in the medical community to properly identify these patients. As you settle in to read through this month’s edition of the American Journal of Rhinology and Allergy, you will note that this series of articles covers a wide array of relevant disease topics and highlights the importance of expanding our research horizons to appreciate and learn from investigations at all levels, from the bench to the bedside and back!
3.
4.
5.
6.
7.
8.
9.
REFERENCES 1.
2.
282
Jiang RS, Twu CW, and Liang KL. The effect of olfactory training on the odor threshold in patients with traumatic anosmia. Am J Rhinol Allergy 31:317–322, 2017. Soyka MB, Serra C, Regli L, et al. Long-term olfactory outcome after nasoseptal flap reconstructions in midline skull base surgery. Am J Rhinol Allergy 31:334–337, 2017.
10. 11.
12.
Li ST, Young TH, Lin CF, and Huang TW. Promotion of olfactory receptor neuron differentiation of olfactory neuroepithelial cells by using chitosan solution. Am J Rhinol Allergy 31:289–292, 2017. Ramakrishnan VR, Gonzalez JR, Cooper SE, et al. RNA sequencing and pathway analysis identify tumor necrosis factor alpha driven small proline-rich protein dysregulation in chronic rhinosinusitis. Am J Rhinol Allergy 31:283–288, 2017. Møller ME, Alantin MC, Grønhøj C, et al. Sinus bacteriology in patients with cystic fibrosis or primary ciliary dyskinesia: A systematic review. Am J Rhinol Allergy 31:293–298, 2017. Saniasiaya J, Abdullah B, Husain S, et al. Primary endoscopic endonasal dacryocystorhinostomy for pediatric nasolacrimal duct obstruction: A systematic review. Am J Rhinol Allergy 31:328–333, 2017. Lobo BC, D’Anza B, Farlow JL, et al. Outcomes of sinonasal squamous cell carcinoma with and without association of inverted papilloma: A multi-institutional analysis. Am J Rhinol Allergy 31:305– 309, 2017. Schwanke T, Carragee E, Bremberg M, and Reisacher WR. Qualityof-life outcomes in patients who underwent subcutaneous immunotherapy and sublingual immunotherapy in a real-world clinical setting. Am J Rhinol Allergy 31:310–316, 2017. Pecorari G, Riva G, Bianchi FA, et al. The effect of closed septorhinoplasty on nasal functions and on external and internal nasal valves: A prospective study. Am J Rhinol Allergy 31:323–327, 2017. Carney AS. Draf III frontal sinus surgery: “How I do it.” Am J Rhinol Allergy 31:338–340, 2017. Johal K, Welch K, and Peters A. Immunoglobulin G4 sinusitis in association with aspirin-exacerbated respiratory disease. Am J Rhinol Allergy 31:302–304, 2017. White AA. An update on the epidemiology of aspirin-exacerbated respiratory disease. Am J Rhinol Allergy 31:299–301, 2017. e
September–October 2017, Vol. 31, No. 5
