Deconstructing Barriers in Support of the Systemic Management of Chronic Rhinosinusitis With Nasal Polyps

Deconstructing Barriers in Support of the Systemic Management of Chronic Rhinosinusitis With Nasal Polyps

Online Course | Specialties: Otolaryngology
Released: 12/16/2021
Expires: 12/15/2022
Max Credits: 0.5

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William Busse, MD
Emeritus Professor of Medicine
Division of Allergy, Pulmonary, and Critical Care Medicine
University of Wisconsin School of Medicine and Public Health
Madison, WI

Christine Franzese, MD
Professor of Clinical Otolaryngology
Director of Allergy
University of Missouri School of Medicine
Columbia, MO

Activity Planners
Sara Samuel, MSc, MPhil, MS
Clinical Content Manager
Baltimore, MD

Rebecca L. Julian, MS, ELS
Senior Manager, Editorial
Baltimore, MD

Samantha Gordon, MS
Accreditation Manager
Baltimore, MD

Amy Sison
Director of CME
Baltimore, MD

Haifa Kassis, MD
West Roxbury, MA

Learning Objectives
Upon completion, participants should be able to:

  • Discuss the disease burden of CRSwNP and its potential effects on patient quality of life
  • Identify the common underlying pathophysiologic mechanisms involved in CRSwNP and the spectrum of inflammatory diseases
  • Adopt an individualized, interdisciplinary treatment approach for CRSwNP that incorporates current treatment modalities and optimizes outcomes

Target Audience
This activity is intended for otolaryngologists.
Statement of Need
Patients who have chronic rhinosinusitis with nasal polyps (CRSwNP) experience recurring nasal polyps that can greatly reduce their quality of life; however, many clinicians dismiss CRSwNP as simply a “chronic runny nose.” The current standard of care consists of symptomatic relief and surgery if less-invasive steroid treatments are insufficient. However, polyp recurrence after surgery is common; in fact, rates are as high as 50% over the course of 3 years. Recent research has revealed an underlying immunologic cause for CRSwNP, which has informed the development of new and emerging biologic therapies that target type 2 inflammation. Thus, healthcare providers can benefit from education on current evidence regarding CRSwNP and management approaches, as well as best practices for facilitating care coordination.

Providership Statement
Provided by Med-IQ.

Accreditation/Designation Statements
Med-IQ is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Med-IQ designates this enduring material for a maximum of 0.5 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Nurse practitioners, physician assistants, and other healthcare professionals who successfully complete the activity will receive a Statement of Participation indicating the maximum credits available.

Medium/Method of Participation
This is a 0.5-credit CE activity. To receive credit, read the introductory CE material, complete all of the modules, and complete the evaluation, attestation, and post-test, answering at least 70% of the post-test questions correctly.

Initial Release Date: December 16, 2021
Expiration Date: December 15, 2022
Estimated Time to Complete This Activity: 30 minutes

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Drug/Product Usage by Faculty
Off-label/unapproved drug uses or products are mentioned within this activity. 

Disclosure Statement
The content of this activity has been peer reviewed and has been approved for compliance. The faculty and contributors have indicated the following financial relationships, which have been resolved through an established COI resolution process, and have stated that these reported relationships will not have any impact on their ability to give an unbiased presentation.

William Busse, MD
Consulting fees/advisory boards: AstraZeneca, Genentech, GlaxoSmithKline, Novartis Pharmaceuticals Corporation, Regeneron Pharmaceuticals, Inc., Sanofi-aventis U.S. Inc.
Fees received for promotional/non-CE activities: Regeneron Pharmaceuticals, Inc., Sanofi-aventis U.S. Inc.

Christine Franzese, MD
Consulting fees/advisory boards: Genentech, GlaxoSmithKline, Optinose, Regeneron Pharmaceuticals, Inc.
Fees received for promotional/non-CE activities: AstraZeneca, Genentech, GlaxoSmithKline, Optinose, Regeneron Pharmaceuticals, Inc., Sanofi-aventis U.S. Inc.
Contracted research: AstraZeneca, Bellus Health, GlaxoSmithKline, Merck & Co., Inc., Novartis Pharmaceuticals Corporation, Optinose, Regeneron Pharmaceuticals, Inc., Sanofi-aventis U.S. Inc., Shionogi

The writer, peer reviewers, and other activity planners have no financial relationships to disclose.
Statement of Evidence-Based Content
Educational activities that assist physicians in carrying out their professional responsibilities more effectively and efficiently are consistent with the ACCME definition of continuing medical education (CME). As an ACCME-accredited provider of CME, Med-IQ has a policy to review and ensure that all the content and any recommendations, treatments, and manners of practicing medicine in CME activities are scientifically based, valid, and relevant to the practice of medicine. Med-IQ is responsible for validating the content of the CME activities it provides. Specifically, (1) all recommendations addressing the medical care of patients must be based on evidence that is scientifically sound and recognized as such within the profession; (2) all scientific research referred to, reported, or used in CME in support or justification of a patient care recommendation must conform to generally accepted standards of experimental design, data collection, and analysis.

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Complimentary CE
This activity is available free of charge to participants.

Acknowledgment of Commercial Support
This activity is supported by an educational grant from Regeneron Pharmaceuticals, Inc. and Sanofi Genzyme.



Chronic rhinosinusitis (CRS) is a prevalent health condition defined as sinonasal inflammation persisting for more than 12 weeks.1,2 CRS is phenotypically divided into CRS with nasal polyps (CRSwNP) or without nasal polyps (CRSsNP).2 CRSwNP accounts for 25% to 30% of all CRS cases and is estimated to affect up to 4% of the general population.3 The signs and symptoms of CRSwNP include persistent nasal obstruction or blockage, nasal discharge (anterior rhinorrhea or postnasal drip), impaired smell, and facial pain or pressure.2,4,5 Polyps typically develop bilaterally in the nasal cavity.3 Symptoms usually worsen gradually; thus, many patients who present with CRSwNP are middle aged. Although men are affected at higher rates than women, the disease is often more severe in women.5
Available data indicate that a combination of genetic traits and defects acquired by different external and internal factors (eg, allergens, pathogens, cytokines) can result in compromised epithelial barriers, leading to dysregulated chronic inflammation and tissue remodeling in patients with CRSwNP.6-9 In Western populations, CRSwNP involves a predominately type 2 immune response characterized by an infiltration of eosinophils and mast cells, goblet cell hyperplasia, and increased levels of eosinophil cationic protein, eotaxins, total immunoglobulin E (IgE), and interleukin (IL)-5, IL-4, and IL-13.10,11 Less eosinophilic and more neutrophilic inflammation have been reported in Asian patients, suggesting that environmental factors may play a role in the pathogenesis of the disease.12 In addition, patients with CRSwNP show higher rates of airway colonization with Staphylococcus aureus, which can result in biofilm formation and trigger epithelial barrier dysfunction and chronic inflammation.4 Patients with CRS have reduced richness and diversity of the upper respiratory microbiome, which might be a result of antibiotic overuse or reflect the underlying sinonasal inflammation.13 Recent data indicate that reduced microbiome diversity—lower rates of protective microorganisms (eg, Corynebacterium) and higher rates of pathogenic microorganisms (eg, S aureus)—is associated with a higher risk of nasal polyp recurrence after surgery.14
CRSwNP is associated with significant morbidity, impaired health-related quality of life (HRQOL), and substantial economic burden that is often overlooked.15 The detrimental effect of CRSwNP on HRQOL has been reported to be comparable to that of other common chronic illnesses, such as chronic obstructive pulmonary disease, asthma, and diabetes.4 The disease burden is particularly high in patients who need repeated corticosteroid treatments and/or surgeries and in those with comorbid asthma and/or nonsteroidal anti-inflammatory drug–exacerbated respiratory disease (NSAID-ERD).4 CRSwNP is frequently diagnosed in patients who have other type 2 inflammatory diseases, such as asthma (which is present in up to 65% of patients with CRSwNP), allergic rhinitis, and NSAID-ERD. CRSwNP also often coexists with obstructive sleep apnea, gastroesophageal reflux disease, anxiety, and depression.3,4,16 The most common risk factors for developing CRSwNP include asthma, gene polymorphisms, and aging. Other risk factors include smoking, aspirin intolerance, occupational exposure to irritants and pollutants, obesity, family history, higher serum levels of IL-5 or IL-13, and eosinophilia.5

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