Updates on current evidence for biologics in chronic rhinosinusitis Purpose of review The purpose of this review is to present the most important recent developments concerning biologics as a therapeutic option for chronic rhinosinusitis (CRS). Recent findings mAb anti-IL-4 receptor α (Dupilumab) was recently approved by Food and Drug Administration (FDA) for patients with CRSwNP and four other biologics are under investigation, with promising preliminary results. Summary CRS is a disease associated with a significant symptom burden and high-indirect costs. Despite recent advances in combined approaches, persistent symptoms or recurrences are not uncommon. Monoclonal antibodies, used mainly to treat asthma, have recently been shown to have a positive impact on controlling the symptoms of CRS and reducing the need for endoscopic sinus surgery. Dupilumab, mepolizumab, reslizumab, benralizumab and omalizumab are discussed and their mechanism of action, risk and current evidence on efficacy are presented. Preliminary studies show encouraging results with relatively few side effects. Once the high cost of such therapies is addressed, they could prove an important adjuvant therapy for patients with CRS. Large-scale clinical trials designed to evaluate them are called for. Correspondence to Christos C. Georgalas, MD, PhD, MRCS(Ed), DLO(Eng), FRCS (ORL-HNS), Endoscopic Skull Base Athens, Hygeia Hospital, Erythrou Stayrou 4, Maroussi, 15123 Athens, Greece. Tel: +30 210 6867 321; e-mail: cgeorgalas@gmail.com Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

The relationship of chronic rhinosinusitis and depression Purpose of review The aim of this article is to identify and describe the relationship between chronic rhinosinusitis (CRS) and comorbid depression, including the patient factors that may increase the risk of depression. The impact of comorbid depression on quality of life, response to treatment and healthcare utilization will also be assessed. Recent findings CRS is associated with a significantly increased prevalence of depression, where 9–26% of patients with CRS will have physician-diagnosed depression. An additional 40% will have undiagnosed depression that can be identified through screening tools. Patients without polyps are more likely to experience comorbid depression, as are patients with significant sleep dysfunction, olfactory dysfunction, and pain. CRS symptoms do improve with medical and surgical therapy in depressed patients, though baseline and posttreatment scores are worse. A similar degree of benefit from therapy is seen in both depressed and nondepressed patients. CRS treatment does seem to improve depression, whereas the effect of depression specific therapy is unknown. Depressed patients have a significantly larger economic burden because of their increased healthcare utilization and productivity losses. Summary Depression is a highly prevalent and impactful comorbidity in patients with CRS. Increased awareness of this relationship may improve patients’ overall quality of care. Correspondence to Kristine A. Smith, Department of Otolaryngology – Head and Neck Surgery, University of Manitoba, GB421B, 820 Sherbrook Street, Winnipeg, MB, Canada. Tel.: +1 204 787 7174;. e-mail: kristine.smith2012@gmail.com Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

What is the evidence for fluticasone exhalation delivery system in chronic rhinosinusitis? Purpose for review The aim of this article is to review the current literature regarding a novel method of topically delivering nasal steroids, namely exhalation delivery system-fluticasone (EDS-FLU), for the treatment of chronic rhinosinusitis (CRS). Recent findings Recent Food and Drug Administration approval of EDS-FLU and increasing evidence surrounding its efficacy and safety has led to an additional tool for the treatment of chronic rhinosinusitis. Compared with placebo, EDS-FLU has demonstrated significant improvements in patients’ sinonasal symptoms and overall inflammatory control as well as quality of life measures. Additionally, using EDS-FLU can lead to polyp grade improvement and polyp elimination in patients with chronic rhinosinusitis with polyps. Furthermore, compared with controls, patients who received EDS-FLU were less likely to meet predefined surgical criteria at the conclusion of the study. Summary of findings EDS-FLU has demonstrated significant improvement in managing symptoms and polyps in CRS. Receiving EDS-FLU was associated with a significant reduction in the proportion of patients meeting surgical criteria. Further studies are warranted to evaluate the long-term outcomes of EDS-FLU, especially as compared with steroid sprays and topical steroid irrigations, in management of CRS. Correspondence to Edward C. Kuan, MD, MBA, Department of Otolaryngology – Head and Neck Surgery, University of California, Irvine, 101 The City Dr S, Bldg 56, Ste 500, Orange, CA 92868, USA. Tel: +1 714 456 5753; fax: +1 614 456 5747; e-mail: eckuan@uci.edu Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Latest developments on topical therapies in chronic rhinosinusitis Purpose of review Topical therapies play an important role in the management of chronic rhinosinusitis (CRS). A detailed literature review was undertaken to appraise recent evidence surrounding current topical therapies and novel treatments used in the setting of recalcitrant CRS. Recent findings Effective sinus surgery aids in the delivery of topical therapies. Budesonide nasal rinses delivered by saline irrigation offer clinical and symptomatic improvements pre and postoperatively with a well-proven safety profile. Topical steroids may additionally offer direct antibacterial effects as per in-vitro testing. Topical antibiotics are not recommended in routine practice; however, they may be of benefit for short-term eradication therapy. Novel treatments are under keen investigation and include bacteriophage, colloidal silver and manuka honey. The evidence base for these treatments is not robust enough to recommend their routine use at present. Summary Topical steroids delivered in conjunction with saline nasal irrigation offer the best combination of treatments in CRS and should be considered a standard of care. Wide surgical access and aggressive surgical debridement of polyposis facilitates the delivery of steroid irrigations to sinonasal mucosa and is associated with improved long-term outcomes following endoscopic sinus surgery. The use of novel treatments remains within the research setting alone. Correspondence to Alkis J. Psaltis, Department of Surgery – Otolaryngology, Head and Neck Surgery, Adelaide Universities, The Queen Elizabeth Hospital, 28 Woodville Road, Woodville, SA 5011, Australia. E-mail: alkis.psaltis@adelaide.edu.au Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Indications for Eustachian tube dilation Purpose of review Eustachian tube dilation is a controversial surgical procedure because the intended problem for which it is meant to address, obstructive Eustachian tube dysfunction, is a clinical diagnosis without a reliable diagnostic tool to test. In the past 10 years, balloon dilation Eustachian tuboplasty (BDET) has been the most commonly performed Eustachian tube dilation procedure. The present review seeks to identify the patients who may benefit from this procedure and thus propose the indications. Recent findings Two randomized controlled trials for BDET published in the past 2 years showed statistically significant improvement in terms of symptomatic relief based on the ETDQ-7 scores and conversion of abnormal tympanograms (type B and type C) to normal tympanograms (type A). Summary Based on the review of the evidence available so far, the proposed indication for Eustachian tube dilation using BDET is for a patient with ALL of the following: aural fullness greater than 12 weeks; type B or C tympanogram; ETDQ-7 mean score more than 2; and failed medical management including Valsalva maneuver and either 4 weeks of nasal steroids or 1 week of oral steroids. Correspondence to Jin-Keat Siow, MD FAMS FRCSEd MBBS, Department of Otorhinolaryngology, Tan Tock Seng Hospital, 11, Jalan Tan Tock Seng, Singapore 308433. Tel: +6563577742; fax: +6563577749. e-mail: Jin_Keat_Siow@ttsh.com.sg Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Chronic rhinosinusitis and sleep quality Purpose of review To review the recent literature describing the association between chronic rhinosinusitis and its effects on sleep quality. Recent findings Chronic rhinosinusitis (CRS) causes significantly worse sleep by both subjective and objective measures. CRS is also strongly associated with obstructive sleep apnea. Treating CRS surgically improves subjective sleep scores. Summary CRS worsens sleep quality both subjectively and objectively. Sleep quality is improved after endoscopic sinus surgery. Correspondence to Peter Papagiannopoulos, MD, 1611W. Harrison St., Suite 550, Chicago, IL 60612, USA. Tel.: +1-312-942-7182;. fax: +312-942-6225;. e-mail: ppapagiannopoulos@gmail.com Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.