Chronic Rhinosinusitis with Nasal Polyps in Older Adults: Clinical Presentation, Pathophysiology, and Comorbidity
Purpose of Review
Chronic rhinosinusitis and nasal polyps (CRSwNP) is a common condition that significantly affects patients’ life. This work aims to provide an up-to-date overview of CRSwNP in older adults, focusing on its aging-related clinical presentations, pathophysiology, and comorbidity associations including asthma.
Recent large population-based studies using nasal endoscopy have shown that CRSwNP is a mostly late-onset disease. Age-related changes in physiologic functions, including nasal epithelial barrier dysfunction, may underlie the incidence and different clinical presentations of CRSwNP in older adults. However, there is still a paucity of evidence on the effect of aging on phenotypes and endotypes of CRSwNP. Meanwhile, late-onset asthma is a major comorbid condition in patients with CRSwNP; they frequently present with type 2 inflammatory signatures that are refractory to conventional treatments when they are comorbid. However, as they are more commonly non-atopic, causative factors other than classical atopic sensitization, such as Staphylococcus aureus specific IgE sensitization, are suggested to drive the type 2 inflammation. There are additional comorbidity associations in older patients with CRSwNP, including those with chronic otitis media and head and neck malignancy.
Age is a major determinant for the incidence and clinical presentations of CRSwNP. Given the heterogeneity in phenotypes and endotypes, longitudinal investigations are warranted to elucidate the effects of aging on CRSwNP.
KeywordsChronic rhinosinusitis Nasal polyps Asthma Comorbidity Aging
This work was financially supported by the National Research Foundation of Korea (NRF) grant, funded by the Korean Government (NRF-2018R1D1A1B07049440).
Compliance with Ethical Standards
Conflict of Interest
Woo-Jung Song reports grants from MSD and Astra Zeneca, outside the submitted work. Ji-Hyang Lee, Ha-Kyeong Won, and Claus Bachert declare no conflicts of interest relevant to this manuscript.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 3.Vennik J, Eyles C, Thomas M, Hopkins C, Little P, Blackshaw H, et al. Chronic rhinosinusitis: a qualitative study of patient views and experiences of current management in primary and secondary care. BMJ Open. 2019;9(4):e022644. https://doi.org/10.1136/bmjopen-2018-022644.CrossRefPubMedPubMedCentralGoogle Scholar
- 5.Abdalla S, Alreefy H, Hopkins C. Prevalence of sinonasal outcome test (SNOT-22) symptoms in patients undergoing surgery for chronic rhinosinusitis in the England and Wales national prospective audit. Clin Otolaryngol. 2012;37(4):276–82. https://doi.org/10.1111/j.1749-4486.2012.02527.x.CrossRefPubMedGoogle Scholar
- 7.• Won HK, Kim YC, Kang MG, Park HK, Lee SE, Kim MH, et al. Age-related prevalence of chronic rhinosinusitis and nasal polyps and their relationships with asthma onset. Ann Allergy Asthma Immunol. 2018;120(4):389–94. https://doi.org/10.1016/j.anai.2018.02.005 Comment: Showing the associations between CRSwNP and asthma onset age in a general adult population. CrossRefPubMedGoogle Scholar
- 12.• Ahn J-C, Kim J-W, Lee CH, Rhee C-S. Prevalence and risk factors of chronic rhinosinusitus, allergic rhinitis, and nasal septal deviation: results of the Korean National Health and Nutrition Survey 2008-2012. JAMA Otolaryngol Head Neck Surg. 2016;142(2):162–7 Comment: Reporting risk factors for CRSwNP in a general adult population. CrossRefPubMedGoogle Scholar
- 14.Khan A, Vandeplas G, Huynh TMT, Joish VN, Mannent L, Tomassen P, et al. The Global Allergy and Asthma European Network (GALEN) rhinosinusitis cohort: a large European cross-sectional study of chronic rhinosinusitis patients with and without nasal polyps. Rhinology. 2019;57(1):32–42.CrossRefPubMedGoogle Scholar
- 19.Greisner WA III, Settipane GA, editors. Hereditary factor for nasal polyps. Allergy Asthma Proc. 1996;17(5):283–6.Google Scholar
- 25.• Cho SH, Kim DW, Lee SH, Kolliputi N, Hong SJ, Suh L, et al. Age-related increased prevalence of asthma and nasal polyps in chronic rhinosinusitis and its association with altered IL-6 trans-signaling. Am J Respir Cell Mol Biol. 2015;53(5):601–6. https://doi.org/10.1165/rcmb.2015-0207RC Comment: Suggesting a potential role of nasal epithelial dysfunction in the pathogenesis of CRSwNP in older adults. CrossRefPubMedPubMedCentralGoogle Scholar
- 32.• Tomassen P, Vandeplas G, Van Zele T, Cardell LO, Arebro J, Olze H, et al. Inflammatory endotypes of chronic rhinosinusitis based on cluster analysis of biomarkers. J Allergy Clin Immunol. 2016;137(5):1449–56 e4. https://doi.org/10.1016/j.jaci.2015.12.1324 Comment: A comprehensive cluster analysis showing distinct inflammatory endotypes of CRS and their clinical relevance. CrossRefGoogle Scholar
- 33.• Wang X, Zhang N, Bo M, Holtappels G, Zheng M, Lou H, et al. Diversity of TH cytokine profiles in patients with chronic rhinosinusitis: a multicenter study in Europe, Asia, and Oceania. J Allergy Clin Immunol. 2016;138(5):1344–53 Comment: Reporting a wide geographical variation in immunological phenotypes of CRS. CrossRefPubMedGoogle Scholar
- 34.Jiang WX, Cao PP, Li ZY, Zhai GT, Liao B, Lu X, et al. A retrospective study of changes of histopathology of nasal polyps in adult Chinese in Central China. Rhinology. 2019. https://doi.org/10.4193/Rhin18.070.
- 38.• Kim DW, Kim D-K, Jo A, Jin HR, Eun KM, Mo J-H, et al. Age-related decline of neutrophilic inflammation is associated with better postoperative prognosis in non-eosinophilic nasal polyps. PLoS One. 2016;11(2):e0148442 Comment: Reporting the correlations of age with immunologic and clinical parameters in patients with non-eosinophilic CRSwNP. CrossRefPubMedPubMedCentralGoogle Scholar
- 39.•• Morse JC, Li P, Ely KA, Shilts MH, Wannemuehler TJ, Huang LC, et al. Chronic rhinosinusitis in elderly patients is associated with an exaggerated neutrophilic proinflammatory response to pathogenic bacteria. J Allergy Clin Immunol. 2019;143(3):990–1002.e6. https://doi.org/10.1016/j.jaci.2018.10.056 Comment: Showing the correlations of age with immunologic and microbiologic parameters in patients with CRS. CrossRefPubMedGoogle Scholar
- 46.• Song WJ, Sintobin I, Sohn KH, Kang MG, Park HK, Jo EJ, et al. Staphylococcal enterotoxin IgE sensitization in late-onset severe eosinophilic asthma in the elderly. Clin Exp Allergy. 2016;46(3):411–21. https://doi.org/10.1111/cea.12652 Comment: Reporting the close associations between CRSwNP and severe eosinophilic asthma in older adults. CrossRefPubMedGoogle Scholar
- 47.• Tomassen P, Jarvis D, Newson R, Van Ree R, Forsberg B, Howarth P, et al. Staphylococcus aureus enterotoxin-specific IgE is associated with asthma in the general population: a GA 2 LEN study. Allergy. 2013;68(10):1289–97 Comment: First report on the associations between S. aureus enterotoxin IgE sensitization and asthma in a general population. CrossRefPubMedGoogle Scholar
- 48.• Song WJ, Chang YS, Lim MK, Yun EH, Kim SH, Kang HR, et al. Staphylococcal enterotoxin sensitization in a community-based population: a potential role in adult-onset asthma. Clin Exp Allergy. 2014;44(4):553–62 Comment: Reporting the association between S. aureus enterotoxin IgE sensitization and late-onset asthma in a general population. CrossRefPubMedGoogle Scholar
- 49.Sintobin I, Siroux V, Holtappels G, Pison C, Nadif R, Bousquet J, et al. Sensitisation to staphylococcal enterotoxins and asthma severity: a longitudinal study in the EGEA cohort. Eur Respir J. 2019:1900198. https://doi.org/10.1183/13993003.00198-2019.
- 53.Hayes SH, Biggs TC, Goldie SP, Harries PG, Walls AF, Allan RN, et al. Staphylococcus aureus internalisation in mast cells in nasal polyps-Characterisation of interactions and potential mechanisms. J Allergy Clin Immunol. 2019. https://doi.org/10.1016/j.jaci.2019.06.013.
- 55.• Teufelberger AR, Nordengrün M, Braun H, Maes T, De Grove K, Holtappels G, et al. The IL-33/ST2 axis is crucial in type 2 airway responses induced by Staphylococcus aureus–derived serine protease–like protein D. J Allergy Clin Immunol. 2018;141(2):549–59. e7 Comment: Revealing mechanistic pathways of S. aureus –derived serine protease-like protein D in type 2 airway inflammation. CrossRefPubMedGoogle Scholar
- 56.•• Stentzel S, Teufelberger A, Nordengrün M, Kolata J, Schmidt F, Van Crombruggen K, et al. Staphylococcal serine protease–like proteins are pacemakers of allergic airway reactions to Staphylococcus aureus. J Allergy Clin Immunol. 2017;139(2):492–500. e8 Comment: Revealing novel S. aureus secreted proteins with pro-allergic functions in the airways. CrossRefPubMedGoogle Scholar
- 59.• Hong S-N, Lee WH, Lee SH, Rhee C-S, Lee CH, Kim J-W. Chronic rhinosinusitis with nasal polyps is associated with chronic otitis media in the elderly. Eur Arch Otorhinolaryngol. 2017;274(3):1463–70 Comment: Reporting the associations between chronic otitis media and CRSwNP in older adults. CrossRefPubMedGoogle Scholar
- 61.Wu EL, Riley CA, Hsieh MC, Marino MJ, Wu XC, McCoul ED, editors. Chronic sinonasal tract inflammation as a precursor to nasopharyngeal carcinoma and sinonasal malignancy in the United States. Int Forum Allergy Rhinol. 2017;7(8):786–93.Google Scholar
- 62.• Kim HJ, Ahn HS, Kang T, Bachert C, Song WJ. Nasal polyps and future risk of head and neck cancer: a nationwide population-based cohort study. J Allergy Clin Immunol. 2019. https://doi.org/10.1016/j.jaci.2019.06.024 Comment: A large population-based cohort study showing the associations between head and neck cancer and CRSwNP in older adults.