Webinars, along with YouTube lectures, are the 21st century version of television; your audio and camera are disabled, and you can dress, and come and go as you please. In the past, physician grand rounds started with a patient being brought or wheeled in. The patient, before an audience of about 100 physicians and medical students, was asked a few questions, and then whisked out the door. It seemed a bit demeaning and impersonal to the patient. I had once listened to a webinar on Amyotrophic Lateral Sclerosis (ALS, or “Lou Gehrig’s Disease”). Listening to the difficulties that patients had living and accommodating to this awful disease was very instructive. Questions from the audience were directed both to the physicians and the patients. This approach is much better and more illuminating. On to the topic at hand.
The webinar I recently listened to also included a patient who gave a discussion and sat through the entire lecture. The topic of the webinar was on the diagnosis and treatment of chronic rhinosinusitis without nasal polyps (CRSsNP- the “s” stands for sans). 80% of all patients with chronic sinusitis have this subtype. This webinar started with a patient describing her issues with CRSsNP, followed by a discussion by a physician of the current medical science.
Rhinosinusitis can represent infection, as in acute sinusitis, or inflammation, as in chronic sinusitis.
Acute rhinosinusitis can be bacterial in origin, but is much more common to be of a viral cause. Acute bacterial sinusitis is seen with patients who have symptoms for at least 10 days, and who typically have one sided facial pain. Despite this fact, many, if not most patients with a simple upper respiratory infection are needlessly given antibiotics. At best, this is not helpful. At worst, patients can have adverse reactions to the antibiotics, and lend to the development of antibiotic resistant bugs.
Chronic rhinosinusitis occurs when patients have symptoms of nasal blockage, facial pain, and purulent mucus for 3 months or longer. One type, chronic rhinosinusitis with nasal polyps (CRSwNP) is associated with loss of smell, and the visualization of benign growths known as polyps. Unlike CRSsNP, CRSwNP is very amenable to treatment with steroids and antibiotics, which shrink the polyps, clear bacterial infections and help with drainage. CRSsNP, on the other hand, is much more difficult to treat. Antibiotics and steroids frequently do not help.
This gets me to the topic of inflammation (not the kind discussed on social media). There are 2 major types of immunity: Type 1 and Type 2.
Type 1 immunity is directed against infectious diseases. The major white cell involved is the neutrophil, and treatment with steroids is not generally effective.
Type 2 immunity is directed against auto-immune diseases and allergy. With allergic inflammation, the eosinophil is the major kind of white blood cell involved. With other causes, such as inflammatory bowel disease and rheumatoid arthritis, the lymphocyte is the predominant white blood cell. Steroids can treat both. Biologic therapies are now widely used to treat Type 1 diseases.
I am simplifying here. Many diseases have type 1 and type 2 immune responses. The other thing to note is that, in the vaccine and antibiotic era, there is a phenomenon known as immune deviation in which type 1 immunity is tamped down, with the result that type 2 immunity gets more prominent. This is associated with the greater incidence of autoimmune and allergic diseases in developed societies.
CRSsNP, as a type 1 disease, is very difficult to treat. Steroids are only minimally effective, antibiotics don’t work, and biologic therapies used to treat allergies and the Type 2 CRSwNP do not help. Nasal washes and nasal steroids do help somewhat. Surgery, using endoscopic techniques do help, although incompletely. As the patient stated in the webinar, she is miserable and frustrated.
Future research into biologics may yet yield a therapeutic answer to CRSsNP. We shall see.
References:
https://www.ncbi.nlm.nih.gov/books/NBK547701/
https://allergyasthmanetwork.org/chronic-sinus-conditions/chronic-rhinosinusitis/
https://www.sciencedirect.com/science/article/pii/S1323893014000586
No posts
Comments
Nothing yet. Say the first thing.
Sign in to join the conversation.