People with cystic fibrosis are often also affected by chronic rhinosinusitis, which can negatively impact their quality of life and can lead to bacterial seeding of the lower airways, an increased risk of bacterial infections and pulmonary exacerbations, and poor respiratory health. The introduction of highly effective CFTR modulator therapies, including elexacaftor/tezacaftor/ivacaftor (ETI) therapy, in the clinical practice has transformed the treatment landscape of patients with cystic fibrosis and has been shown to improve pulmonary health and to alleviate but not fully resolve chronic rhinosinusitis symptoms. Despite therapeutic advances, a subset of patients with cystic fibrosis and chronic rhinosinusitis still need to consider endoscopic sinus surgery. However, the prioritization of rhinologic symptoms in patients with cystic fibrosis and areas that influence chronic rhinosinusitis treatment choices, including the choice of endoscopic sinus surgery, have not been sufficiently studied.
At the 2024 American Rhinologic Society (ARS) meeting at the COSM, Christina Liu, MS from the University of California, Los Angeles presented data from a study that investigated symptom prioritization for the treatment of chronic rhinosinusitis in patients with cystic fibrosis.
The data were collected in a prospective observational study that included patients with comorbid cystic fibrosis and chronic rhinosinusitis enrolled at eight centers during the period 2019 to 2023. The study participants had failed initial medical therapy for chronic rhinosinusitis, and, at their first study visit, elected to undergo endoscopic sinus surgery or to continue medical therapy. The 22-item Sino-Nasal Outcome Test (SNOT-22) survey and a modified SNOT-22 instrument, which assessed the relative importance of symptoms, were employed. The importance rankings for individual symptoms and means of SNOT-22 symptom importance subdomains were compared between two sets of patient subgroups. The first subdivision was between patients who pursued endoscopic sinus surgery and those who chose continuing medical management, whereas the second subdivision was between patients who were on ETI therapy and those who were not on ETI therapy.
The study involved 69 participants with comorbid cystic fibrosis and chronic rhinosinusitis. Among the total study population, the highest chronic rhinosinusitis symptom priorities were nasal congestion (69.6% important), post-nasal discharge (46.4% important), facial pain (43.3% important), waking up tired (39.1% important), and fatigue (37.7% important).
Twenty-three patients chose endoscopic sinus surgery, whereas 49 patients chose continuing medical management. Those who elected endoscopic sinus surgery prioritized sleep (median score 19.0 versus 4.5, p < 0.0001) and psychological dysfunction symptoms (median score 17.0 versus 7.0, p < 0.01) in comparison to those who pursued continuing medical management.
Thirty-five patients were on ETI therapy, whereas 34 were not. There were no significant differences in the SNOT-22 total symptom importance scores between these two groups. However, among those who were not on ETI therapy, there was a trend toward prioritizing sleep symptoms compared to those who were on ETI therapy (median score 13.0 versus 6.0, p = 0.055).
Overall, nasal congestion and post-nasal discharge were the most common priorities in patients with comorbid cystic fibrosis and chronic rhinosinusitis. Patients who chose endoscopic sinus surgery prioritized sleep and psychological symptoms, suggesting that these symptoms should be included in preoperative discussions. In addition, sleep improvement was a priority for patients who were not on ETI therapy compared to those who were on ETI therapy, implying the presence of specific therapeutic needs and disease impact in this patient population. The findings of the study provide insight into the priorities of people with cystic fibrosis with regards to the treatment of comorbid chronic rhinosinusitis symptoms. They should be taken into consideration during patient counseling and can help to improve patient satisfaction.