Melanie Cole, MS (Host): Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole. And today, we're talking about advances in rhinology and chronic sinusitis with Dr. Kevin Welch. He's a Professor of Otolaryngology Head and Neck Surgery at Northwestern Medicine.

Dr. Welch, thank you so much for joining us today. I'd like you to start with the prevalence of chronic sinusitis in the general population and the importance of treatment. Tell us what you've been seeing in the trends and how it's going right now.

Dr Kevin Welch: Thank you very much for having me. My passion is chronic sinusitis and I've been treating people with chronic sinusitis for over 15 years. Chronic sinusitis is a disease in which the prevalence is difficult to truly assess. You know, it's not something that is assessed regularly when you go to your primary care doctor's office. It's not like a lab or a variable that can be routinely checked and assessed. And that's because primarily the effects it has on people relate to their quality of life. So, it's very hard to assess quality of life in an individual. And among individuals, we all have different tolerances for conditions that affect our quality of life. So, there may be some overreporting in some studies and there may be underreporting in some studies as well.

The other problem with assessing prevalence is that chronic sinusitis is a diagnosis that requires objective findings. And we do that through CT scans or nasal endoscopy or physical examination. And you have to have both symptoms and a physical finding or an objective finding to make that diagnosis. So we don't rely just on symptoms. But if you look at the studies, roughly, if you go only by symptoms, it ranges from about 7% to about 25%. So in some studies, up to a quarter of the population has symptoms of chronic sinusitis.

But if you incorporate those objective findings, like a nasal endoscopy or CAT scan that demonstrate sinusitis. It's a little bit more modest, maybe 2-10% of the population at some point will have it. So, that can be a significant chunk of your patient population. So, I would probably assess my patients for something if it is in some studies found in up to 10% of patients. So, it's something that I think we all should be looking for. It's an important disease to treat, not only because it affects our quality of life, but studies show that it causes fatigue. It will negatively impact sleep and there's some evidence that it may now be a causal factor or at least a related factor in obstructive sleep apnea. It affects our cognition. It's been associated with depression. It's been associated with asthma and allergies. And It affects so many other aspects of our general health. So, it's an important disease to recognize as being out there. And it relates to a lot of diseases that we all consider to be more significant diseases, when in fact chronic sinusitis may be part of that problem or an origin for some of those problems.

It costs a tremendous amount to treat. Each year, about $11 billion is invested in the management of chronic sinusitis. Almost half a million surgeries are done each year for it. And it affects our ability to be present at work, to be functional at work, and a lot of missed work days are due to flares or exacerbations in chronic sinusitis. So, it's out there, it's fairly common, it's measurable in some ways, and it can affect us in many, many different ways. So, it's something all clinicians need to look for.

Melanie Cole, MS: Well, thank you, Dr. Welch, and great points that you made about its association with other diseases as causal relations that we're looking at now, and some of the studies are showing us. I'd like you to speak about some of the standard treatments. As you've said, this is about quality of life, but also more. And speak about what has been the standard of care and what are some of the novel therapeutic approaches or medications for the treatment of chronic sinusitis and things that you've seen that really excite you and have helped your patients.

Dr Kevin Welch: Yeah. So, chronic sinusitis is often mistaken as a singular disease, as a chronic infection that affects the sinuses and the nose; and therefore, we just need to treat it with antibiotics. But chronic sinusitis can also be simply chronic inflammation of the sinuses without any evidence of infection. So, there's no standard treatment. And if you look at the medications we use, none of them is FDA approved for chronic sinusitis. So, it's not like a drug that's approved for hypertension or a drug that's approved for cholesterol. So, we're using nasal steroid sprays. We're using saline sprays or saline rinses like a neti pot. In some cases, we're using antibiotics. In other cases, we're using oral steroids like prednisone. And oftentimes, many people require repeated treatments of those antibiotics and/or oral steroids.

Sinusitis can be a surgical problem, mostly that is in either urgent cases or in cases after repeated courses of antibiotics and steroids. There's no resolution. So, surgery, antibiotics, steroids, sprays, rinses, those are all valid treatments for chronic sinusitis depending on how much it affects an individual's quality of life and depending upon what other conditions are related to or are being caused by chronic sinusitis. So, there quite a number of treatments in our toolboxes that we can use.

As we begin to understand more and more about what may cause sinusitis in a particular individual, whether it's infection or inflammation, as we understand more about the molecular mechanisms or those little chemical signals that occur in our cells that promote sinusitis, there are new drugs on the market which are called biologics. And they're very exciting for many ways, because they can target specific aspects of the immune system, which are known to be involved in the pathogenesis of chronic sinusitis. And unlike some of the other biologics or immune therapies that we have out there, these drugs are very, very specific for a certain type of cytokine or a certain receptor inflammatory cells. So fortunately, if they do work and they don't all work, if they do work, the side effects are relatively few. However, these are likely long-term therapies for individuals because once the drug is removed, the problem tends to come back. So, no matter how you shape it up, patients are going to require some long-term therapy, with or without surgery. But these are exciting because as time moves forward, there'll probably be more and more of these specific immune therapies that might bring much more lasting treatment results for patients who have chronic sinusitis.

Melanie Cole, MS: Well then, along those lines, Dr. Welch, what should providers know about the presence of nasal and sinus polyps and how that affects the treatment regimens you were just discussing?

Dr Kevin Welch: And we used to think that polyps represent a different form of chronic sinusitis, and they may on many levels represent a more severe form of chronic sinusitis, but there are definitely forms of chronic sinusitis that can be as severe or as recalcitrant as sinusitis with polyps, but have no polyps.

As I alluded to earlier, what's really important in chronic sinusitis is more or less what you see under the microscope, so to speak, or what chemical signaling are involved. But when you see polyps, you're already dealing with somebody who has a significant amount of chronic sinusitis, a high degree of inflammation in their sinuses.

The other thing that providers should know about polyps is that in about 40-60% of patients who have sinusitis and polyps, they're very likely to have at least some form of asthma. And that form of asthma can be mistaken because patients may feel like they just have a simple cough or maybe get a little winded when they exercise, and they may attribute that to being out of shape or coughing under random circumstances or just difficulty breathing, but it may actually be asthma. So if patients have chronic sinusitis and polyps, every physician should be immediately thinking there may be some asthma already present. And studies also show that if you don't have asthma, you're at increased risk of developing asthma.

So, polyps shouldn't be just seen as nuisance, as an obstructive problem for the sinuses, but you need to get that investigated. You need to look more deeply into it. And every patient who sees me for polyps, I'm sending to an allergist for allergy management or investigation and either a pulmonologist who is familiar with asthma or an allergist and immunologist who is familiar with asthma, because they go hand in hand. It's a similar inflammatory process in the upper airway or the sinuses and the lower airways. And we find that treatment of one often helps treatment of the other condition. So, it's important to identify and recognize polyps as being potentially a marker for people who have asthma and significant lower airway disease. It also opens up different types of treatments for patients, such as the biologics I mentioned earlier, because many of the biologics not only treat polyps, but also treat forms of asthma and other pulmonary conditions that are strictly inflammatory. So, that's the main thing that every clinician should know when they see a patient with polyps.

Melanie Cole, MS (Host): So informative. Dr. Welch, how does Northwestern Medicine's Sinus and Allergy Center support exceptional rhinologic care. Speak about the multidisciplinary approach for these patients, your team. Tell us about the center.

Dr Kevin Welch: Well, that's exactly it. It's a multidisciplinary operation. And as I mentioned with sinusitis often come allergies and often come problems with asthma. So, at the Sinus Center at Northwestern, we have otolaryngologists and we have leading allergists and immunologists who jointly see patients either at the same clinic day or have a very smooth operation and integration into one of the other clinics. And we look at all aspects of a patient's upper airway and lower airway disease. If allergies are present, they're managed. If asthma is present, it's managed. And if sinus problems are present, they're all managed together by two or three physicians who are working together to maximize the outcomes of the patients. And sometimes we can do this strictly with medications. Sometimes we can do it with injections, sometimes it requires surgery, and sometimes it requires any combination of those different approaches. But it's nice in that we are always collaborating with our partners in other disciplines to really try and find the most optimal way that makes the most sense to every individual patient.

As I said earlier, sometimes the quality of life issues can be very severe for one patient, but not so severe for another patient. And we may be inclined to take a very conservative approach for some patients if they don't have other systemic problems, or we may have to be very aggressive with some patients. And it really just depends on the level of their disease and what we as a group see as the most optimal to treat patients and working with leaders in Otolaryngology who are presidents and past presidents of the American Rhinologic Society and those who make guideline statements or are officers for the American Academy of Allergy, Asthma, and Immunology.

We here at Northwestern participate in a lot of clinical trials. So, I think that presents opportunities to patients as well who have failed other therapies to potentially get involved with investigational therapies for these new drugs that I mentioned earlier or combinations of therapies. There's a lot to be seen in our clinics, and there's a lot of benefit for patients in our multidisciplinary clinics.

Melanie Cole, MS: Thank you, Dr. Welch. As we wrap up, what's on the horizon for Northwestern Medicine's innovative rhinologic care that really excites you? Give us a little blueprint for further research and what you want the key takeaways to be for other providers.

Dr Kevin Welch: I think the basic thing is that we are understanding chronic sinusitis more and more each day. We're understanding the cellular mechanisms, the signaling, the cytokines, the interleukins, what triggers the disease, and all of this is opening doorways for drug investigation as well as avenues for prevention of the condition. I think it's exciting to see the exponential growth in our understanding of the disease in the past five to ten years. And it's only going to get more intense and more interesting as time moves forward as we really identify these molecular mechanisms.

I'm excited about growing technology in the surgical arena. We essentially have equipment now that shows the potential of increasing the safety and efficacy of sinus surgery through navigation, if you will. And then, the drug development, as I mentioned earlier, with these biologics, these immune therapies that are very specific for inflammatory pathways in chronic sinusitis are probably one of the most influential or game-changing treatments that have come about in the last five to ten years. And there are quite a number of drugs on the horizon, which will probably be as good, if not more effective for this disease. So, there's the potential to shift the climate in the next 15 some odd years in which if you have chronic sinusitis with polyps, you may simply need an injection and that might take care of the problem, and that will reduce all of those other associated problems that we mentioned before. And it's exciting to see that this could actually move the needle on how we manage patients with chronic sinusitis.

Melanie Cole, MS: Thank you so much, Dr. Welch, for joining us today and sharing your incredible expertise. And to refer your patient or for more information, please visit our website at breakthroughsforphysicians.nm.org/ent. That concludes this episode of Better Edge, a Northwestern Medicine podcast for physicians. Please remember to subscribe, rate, and review Better Edge on Apple podcasts, Spotify, iHeart, and Pandora. I'm Melanie Cole. Thanks so much for joining us today.