Search Results (77)

Introduction: Obstructive sleep apnea syndrome (OSAS) is caused by anatomical and non-anatomical factors which lead to upper airway (UA) obstruction during sleep. Intrinsic UA collapse is the most frequent determinant of OSA. In the era of personalized medicine, adopting a tailored diagnostic approach is essential to rule out secondary causes of UA collapse, particularly those stemming from extrinsic anatomical factors. Although being rarely considered in the differential diagnosis, space-occupying lesions of deep cervical spaces such as the parapharyngeal space (PPS) may be responsible for airway obstruction and lead to OSAS. Objective: This study aimed to present an atypical case of OSAS caused by extrinsic PPS compression, outlining the relevance of modern personalized medicine in the diagnostic and therapeutic protocols, and to enhance understanding through a comprehensive literature review. Methods: A 60-year-old female presented with sleep-disordered complaints and was diagnosed with severe OSAS after polysomnography. At physical examination, a swelling of the right posterior oropharyngeal mucosa was noticed. Imaging confirmed the suspicion of a PPS tumor, and transcervical resection was planned. Case presentation was adherent to the CARE checklist. A comprehensive literature review was conducted using the most reliable scientific databases. Results: Surgery was uneventful, and the patient made a full recovery. The histopathology report was consistent with the diagnosis of pleomorphic adenoma. Postoperative outcomes showed marked improvement in polysomnographic parameters and symptom burden. Conclusions: Parapharyngeal space tumors are a rare, often overlooked cause of OSA. This case highlights the role of a personalized head and neck assessment in OSA patients, particularly in identifying structural causes and offering definitive surgical management when indicated. Full article

Background: Chronic rhinosinusitis with nasal polyps (CRSwNP) is a chronic upper airway disease that may involve different inflammatory endotypes, although in Western populations it is most commonly associated with type 2 inflammation. CRSwNP has a significant impact on the patient’s quality of life. The recommended appropriate medical therapy is effective in controlling CRSwNP symptoms in many patients; however, a subset continues to exhibit persistent type 2 inflammation, evidenced by recurrent nasal polyps, elevated eosinophil counts, or the need for systemic corticosteroids or surgery. Monoclonal antibodies have recently become a novel and personalized treatment that can help refractory patients restore disease control. Objective: The present study aims to evaluate the effectiveness of mepolizumab in real-world settings in a diverse patient population, focusing on assessing the impact of this therapy on patient-reported outcomes after six months of treatment. Methods: This is a multicenter, observational study of CRSwNP patients treated with mepolizumab carried out in five hospitals located in Spain. Adult patients with a diagnosis of uncontrolled CRSwNP were included in the study. The change in the nasal polyp score (NPS) was the main clinical endpoint. Changes in the Sinonasal Outcome Test (SNOT-22), nasal congestion and smell impairment visual analogue scale scores, and blood and nasal polyp tissue eosinophil counts were among other endpoints included. Results: In total, 47 patients were included, and 91% were asthmatic. The nasal polyp score (0–8) was reduced significantly in the cohort (mean change: −2.56, p < 0.0001). The mean SNOT-22 score improved 25.29 points. Nasal congestion (−3.57, p < 0.0001) and smell impairment (−4.0, p < 0.0001) visual analog scale scores (0–10) showed a significant improvement. Blood and tissue eosinophil median counts showed significant reductions versus baseline of 86% and 26%, respectively. Among those patients with asthma, the asthma control test score achieved a median value of 24 points. Conclusions: This study provides real-world evidence supporting the effectiveness of mepolizumab in managing CRSwNP in patients with features suggestive of type 2 inflammation. The observed improvements in patient-reported outcomes, nasal polyp burden, and asthma control suggest that mepolizumab may be a valuable therapeutic option for this patient population. Full article

Background/Objectives: Obstructive sleep apnea is a prevalent, yet often underdiagnosed, condition characterized by recurrent upper airway obstruction during sleep, leading to significant perioperative risks in surgical patients. This systematic review aims to evaluate the incidence and impact of objectively diagnosed obstructive sleep apnea on postoperative outcomes across various surgical specialties—including bariatric, orthopedic, cardiac, and otorhinolaryngologic surgeries—and to assess the effectiveness of preoperative screening and perioperative management strategies. Methods: A comprehensive literature search of PubMed was conducted for studies published between January 2013 and December 2024, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Included studies involved adult surgical patients with OSA confirmed by polysomnography or respiratory polygraphy. Studies were assessed for methodological quality using the Oxford Centre for Evidence-Based Medicine Levels of Evidence framework. Results: The findings consistently indicated that obstructive sleep apnea significantly increases the risk of postoperative complications, such as respiratory depression, atrial fibrillation, acute kidney injury, delirium, and prolonged hospital stay. Continuous positive airway pressure therapy demonstrated a protective effect in bariatric and cardiac surgeries, though its effectiveness in orthopedic and otorhinolaryngologic contexts was inconsistent, largely due to adherence variability and limited implementation. Preoperative screening tools such as the STOP-BANG questionnaire were widely used, but their utility depended on integration with confirmatory diagnostics. Conclusions: Obstructive sleep apnea represents a significant, modifiable risk factor in surgical populations. Preoperative identification and risk-adapted perioperative management, including CPAP therapy and multimodal analgesia, may substantially reduce postoperative morbidity. However, further randomized trials and cost-effectiveness studies are needed to optimize care pathways and ensure consistent implementation across surgical disciplines. Full article

Background: Snoring is a common symptom within the spectrum of sleep-disordered breathing, often occurring independently or in association with obstructive sleep apnea syndrome (OSAS). Despite its prevalence, treatment strategies remain variable and lack standardization, particularly regarding surgical interventions. This review aims to evaluate and summarize the outcomes of soft palate and pharyngeal surgeries for adult snoring based on recent literature. Methods: A systematic review was conducted using the PubMed database, identifying studies published between 2014 and 2024 that involved adult patients undergoing upper airway surgery for snoring. Inclusion criteria required pre- and postoperative snoring assessment using the Visual Analog Scale (VAS). Studies were categorized by surgical technique (anterior vs. lateral/circumferential), anesthesia type, presence of tonsillectomy, BMI, OSAS severity (based on AHI), and use of Drug-Induced Sleep Endoscopy (DISE). Descriptive analysis was performed on the changes in VAS scores. Results: A total of 43 studies involving 2713 patients were included, with 18 eligible for quantitative analysis (716 patients). Across all patients, mean VAS scores improved from 7.29 to 3.50 (ΔVAS 3.79). Both anterior and lateral/circumferential techniques yielded significant symptom reduction (ΔVAS 4.12 and 3.68, respectively). General anesthesia showed slightly better outcomes than local anesthesia. Notably, tonsillectomy was associated with greater symptom improvement (ΔVAS 5.17 vs. 4.49). Patients with lower BMI and milder OSAS showed higher baseline VAS but similar improvements. Limited objective measures and heterogeneity in surgical protocols were key limitations. Conclusions: Surgical interventions for snoring provide subjective symptom relief regardless of surgical approach or OSAS severity. Tonsillectomy may enhance outcomes. Future efforts should prioritize standardized, objective outcome measures and personalized treatment planning, potentially incorporating DISE and wearable acoustic technologies. Full article

Objectives: This review summarizes current evidence on robotic-assisted upper airway and neck surgery in pediatric patients, highlighting clinical indications, outcomes, limitations, and areas for future research. Methods: A systematic review was conducted in accordance with PRISMA guidelines, including studies on robotic surgery for pediatric patients (≤18 years) with upper airway conditions and cervical pathologies. Data on study characteristics, patient demographics, surgical details, outcomes, and robotic system advantages or limitations were extracted. Results: Twenty studies met inclusion criteria, comprising 104 pediatric patients who underwent 110 robotic procedures, mostly transoral robotic surgery (TORS) for base of tongue, laryngeal, and cervical pathologies. The Da Vinci Si was the most used system. The mean operative time was ~74 min, with minimal blood loss and no intra/post operative tracheostomies. Reported advantages included enhanced visualization, precision, and reduced morbidity. Limitations involved size mismatches, limited working space, and high costs. Follow-up (mean 11.4 months) revealed no recurrences, confirming feasibility and safety in selected pediatric cases. Conclusions: Robotic-assisted surgery appears to be a feasible and safe option for managing pediatric upper airway and neck conditions, offering promising functional and aesthetic outcomes with low complication rates. However, its use is currently limited by anatomical constraints, high costs, and the need for surgeon training. Long-term prospective studies with larger cohorts are needed to confirm its efficacy and define its role compared to traditional techniques. Full article

Background: This preliminary case series aimed to evaluate the clinical and morphometric outcomes of maxillomandibular advancement (MMA) surgery in patients with severe obstructive sleep apnea (OSA) using virtual surgical planning (VSP), patient-specific cutting guides, and customized titanium plates. Primary outcomes included changes in the Apnea–Hypopnea Index (AHI), airway dimensions, surgical accuracy, and quality of life. Methods: In this preliminary case series, six patients with severe OSA underwent MMA surgery planned using three-dimensional VSP, and executed with the aid of CAD-/CAM-generated surgical guides and patient-specific osteosynthesis. Clinical variables included AHI, Epworth Sleepiness Scale (ESS), and computed tomography-based airway morphometry. Surgical accuracy was assessed by comparing planned and achieved skeletal movements. Statistical analysis was performed using Wilcoxon signed-rank tests and Spearman’s correlation. Results: The mean preoperative AHI decreased significantly from 48.8 ± 23.6 to 12.4 ± 10.0 (p = 0.035), and ESS scores improved from 14.5 ± 4.6 to 7.8 ± 2.1 (p = 0.029). Mean airway area increased significantly from 51.8 ± 9.0 mm² to 91.8 ± 26.6 mm² (p = 0.035). A strong but non-significant correlation was observed between airway gain and ESS improvement (p = 0.754, p = 0.084). No patients required CPAP at 6-month follow-up, and all were asymptomatic. The anteroposterior accuracy of skeletal movements was high: 82.6% for the maxilla and 85.8% for the pogonion, with mean absolute errors of 1.25 mm and 1.95 mm, respectively. Vertical accuracy was lower, particularly in the chin region, where error analysis showed greater variability. No statistically significant differences were found between planned and achieved movements in any vector. Conclusions: MMA surgery performed with VSP, cutting guides, and customized titanium plates offers a highly effective, safe, and precise treatment modality for selected OSA patients. This approach leads to a significant reduction in AHI, expansion of the upper airway, and improvement in patient-reported daytime functioning. High accuracy in skeletal repositioning—particularly in anteroposterior vectors—supports the reliability and reproducibility of digitally guided orthognathic surgery. These findings reinforce the role of technologically assisted MMA as a definitive treatment for severe OSA. Full article

Background/Objectives: Upper airway patency is a key pathophysiological factor in obstructive sleep apnea (OSA). Research has primarily focused on the role of the genioglossus muscle in maintaining airway patency in OSA. However, hypoglossal nerve stimulation (HNS) therapy, which activates the genioglossus muscle, has been associated with poor outcomes in patients with lateral oropharyngeal collapse. The stylopharyngeus muscle is an upper airway dilator muscle that supports the lateral pharyngeal wall. Its role in maintaining upper airway patency and its effect on normal respiratory airflow is unclear. We hypothesize that bilateral transection of the stylopharyngeus muscles disrupts normal breathing. Currently, no animal model depicting lateral pharyngeal collapse has been reported. This study aims to introduce a novel rodent model with bilateral transection of the stylopharyngeus muscles to examine its effect on respiratory airflow and tracing. Methods: Adult male Sprague Dawley rats were divided into two groups: (1) bilateral stylopharyngeus muscle transection (n = 4) and (2) sham surgery (n = 2). Under anesthesia, the stylopharyngeus muscle was transected bilaterally in the transection group, while only exposure of the muscle was performed in the sham group. Respiratory airflow was measured using whole-body plethysmography before and after surgery, and airflow tracings were analyzed. Results: Significant alterations in respiratory airflow and tracings, particularly a flattening in inspiratory flow and sharp expiratory peaks, were observed on the first post-operative day in the transection group. The flattening of the inspiratory flow persisted over 3 days. No significant changes were noted in the sham group. Conclusions: Bilateral stylopharyngeus muscle transection alters normal airflow in a conscious rodent model, supporting the hypothesis that stylopharyngeus muscle plays a vital role in shaping respiratory airflow. The flattening of the inspiratory airflow is an indication of flow limitations through the upper airway patency due to the loss of stylopharyngeus function. Full article

Background and Objectives: The main objectives of our study were to assess sexual dimorphism and to compare the facial height, as well as the anteroposterior width of the upper airway, within adult Caucasians diagnosed with skeletal Class I and skeletal Class III malocclusion, based on a number of angular and linear cephalometric parameters. Materials and Methods: One hundred lateral cephalograms were selected from orthodontic adult Caucasian patients from western Romania. Several angular parameters (SNA, SNB, ANB, FMA, Y–FH, Ba–S–PNS and NL–ML angles) and linear parameters (total, upper and lower anterior facial height—TAFH, UAFH, LAFH; total posterior facial height—TPFH) were analysed for each case. The upper airway width parameters included the width of the nasopharynx, as well as the upper, middle and lower pharyngeal airway width (UPAW, MPAW and LPAW). Results: Distinct sexual dimorphism was observed regarding the vertical cephalometric parameters within both Class I and Class III groups, with males exhibiting significantly larger facial height parameters, while females demonstrated larger nasopharyngeal depth angles (Ba–S–PNS). The Y–FH angle had significantly higher values in Class I than in Class III subjects, regardless of sex. Upper airway dimensions showed sexual dimorphism specifically in Class III subjects, with females exhibiting larger UPAW values than males. The inter-class comparisons showed larger values for LPAW, especially in females. Correlation analyses revealed no statistically significant relationships between the vertical and the upper airway parameters in Class I subjects. UPAW showed a tendency to decrease in Class III subjects as TAFH and LAFH increased. Ba–S–PNS showed consistent negative correlations with the vertical dimensions in both groups. Conclusions: These findings suggest that skeletal Class I and Class III malocclusions exhibit not only different sagittal relationships, but also distinctive, sex-related vertical skeletal patterns within each group, and therefore it would be advised that male and female patients should be diagnosed and treated according to separate protocols. In our population, Class III males are more likely to require orthognathic surgery, in addition to orthodontic treatment, with a more reserved prognosis and they might have a higher risk of OSA or other respiratory disorders in comparison with Class III females. Full article

Nasal cytology is a non-invasive, affordable, and easily executable technique commonly used in research to study rhinitis and, to a lesser extent, chronic rhinosinusitis. It is particularly useful for the differential diagnosis of non-allergic rhinitis and for phenotyping chronic rhinosinusitis. Allergic rhinitis, asthma, and aspirin intolerance are frequent comorbidities of chronic rhinosinusitis. A diagnostic system has been proposed to assess the severity of chronic rhinosinusitis (clinical-cytological grading), incorporating nasal cytology and comorbidity observation. This score correlates with the recurrence risk of chronic rhinosinusitis with nasal polyposis. Specifically, a higher grade is often linked to asthma, aspirin intolerance, a recurrent disease requiring surgery, and a mixed cell phenotype (eosinophilic and mast cell). Although nasal cytology has been shown to be able to replace bronchial analysis with acceptable precision due to its technical characteristics, its use in diseases affecting both upper and lower airways remains limited. The main limitation of this technique is its lack of standardization, which currently hinders its widespread clinical adoption despite its increasing familiarity among allergists and otolaryngologists. In the context of the unitary airways hypothesis, nasal cytology could also provide valuable insights for managing lower airway diseases like chronic obstructive pulmonary disease and obstructive sleep apnea syndrome, which significantly impact quality of life and healthcare costs. This review aims to provide an overview of nasal cytology, highlighting its limitations and potential applications in chronic respiratory diseases. Full article

Class III patients have classically been managed through monomaxillary techniques, mainly involving mandibular setback movements. More recently, according to the upper incisor to soft tissue plane (UI-STP) or Barcelona Line (BL) planning protocol, bimaxillary procedures for upper maxilla advancement and reduced mandibular setback have been recommended in order to secure better aesthetic outcomes and avoid upper airway constriction. The present study describes the jaw movements in the sagittal plane performed in class III patients subjected to bimaxillary surgery following the BL protocol. A retrospective evaluation was performed on 124 class III patients subjected to bimaxillary surgery. All subjects underwent upper maxilla advancement. A total of 112 patients received mandible advancement movement (90.3%), nine received mandibular setback (7.25%), and the mandible underwent no movement along the sagittal dimension in the three remaining patients (2.4%). Mandibular advancement was significantly the most frequent treatment option. The presented results suggest that when the BL planning protocol is used as an aesthetic and functional reference, class III occlusion appears mostly related to maxillary sagittal hypoplasia instead of mandible hyperplasia, so bimaxillary advancement surgery should be considered as one of the first-choice procedures for the treatment of these patients. Full article

Background and Objectives: Obstructive sleep apnea is an extremely diffuse pathology that, if left untreated, can lead to very serious cardiovascular consequences. The primary goal of treatment is to maintain airflow in the upper airway tract, which can be obtained thanks to orthognathic surgery such as maxillo-mandibular advancement (MMA). This procedure increases the volume of the posterior airway space (PAS)—a parameter considered fundamental in OSA physiology. However, the correlation between the degree of advancement, the volume increase, and the clinical improvement in OSA is not yet clear, even in patients who undergo virtual surgical planning. Aiming to test the correlation of these parameters and the role of PAS volume changes, we present our pre- and post-operative volumetric analysis of the PAS using cone beam computed tomography (CBCT) following CAD/CAM-assisted maxillomandibular advancement. Materials and Methods: We collected information from patients who underwent MMA for moderate or severe OSA, planned virtually with custom-made devices, between 2020 and 2022 at the Maxillofacial Surgery and Odontostomatology Unit of the Policlinico Hospital in Milan. The degree of mandibular advancement (pogonion antero-posterior advancement) was noted. All patients underwent pre- and post-operative CBCT and pre- and post-operative polysomnography to measure the Apnea–Hypopnea Index (AHI) parameters. Both exams were performed within six months before and after surgery. The surgeries were planned virtually along with the production of custom-made devices (cutting guides and mandibular osteosynthesis plates). Volumetric analysis of the PAS was performed pre- and post-CBCT images using medical segmentation software (Mimics, Materialise, Mimcs 26.0). Results: Ten patients (nine men and one woman) with a mean age of 51 years were included in this study. The mean pogonion advancement was 14.5 mm, ranging from 13.8 to 15.6. The mean pre-surgical AHI was 52.31 events/h, while the mean post-surgical AHI was 5.94 events/h (SD 5.34). The improvement in AHI was statistically significant (Wilcoxon matched-pairs signed-rank test, p value 0.004). The mean pre-surgical PAS volume was 8933 mm³, while the mean post-surgical volume was 10,609 mm³. In 8 out of 10 patients, the volume increased, with a mean increase of 2640 mm³ (max. 5183, min. 951), corresponding to a percentage increase variation ranging from 78% to 6%. In two patients, the volume decreased by 1591 (−16%) and 2767 mm³ (−31%), respectively. The difference between pre- and post-operative results was not statistically significant (paired t-test, p value 0.033). Conclusions: The results obtained confirm the efficacy of virtually planned MMA performed with custom-made devices in OSA therapy. However, they also show that PAS volume should not be used as a comprehensive parameter for OSA treatment evaluation because it does not always have a positive correlation with advancement and AHI. Full article

Background/Objectives: Virtual preoperative anaesthetic assessments can significantly reduce healthcare costs and improve patient convenience. The challenge with virtual consults is often the airway assessments, which screen for potentially difficult airways (PDAs). The objective of this pilot study was to determine the reliability of standard airway screening tests for detecting PDAs when conducted virtually. Methods: An observational longitudinal study was conducted between July 2021 and April 2022 at a tertiary hospital in Singapore. We compared the Mallampati score (MS), upper lip bite test (ULBT), thyromental distance, mouth opening test, and neck movements in 94 patients, first during virtual assessments before surgery and subsequently at face-to-face preoperative assessments (gold standard) on the day of surgery by the same team of anaesthesiology trainees. Goodman and Kruskal’s gamma coefficient measured concordance between virtual and face-to-face assessment results. Logistic regression (LR) identified virtual predictors of PDAs in clinical practice. AUROC values informed tool performance. Results: LR showed that elevated virtual MS, virtual ULBT, and body mass index (BMI) were potential predictors of clinical PDAs. Termed the “MBBS”, this collective score showed good performance with a sensitivity of 95% and an AUROC of 0.79. Importantly, all screening tests performed poorly in virtual assessments when applied individually (sensitivity < 50%). Conclusions: In this pilot study, BMI combined with MS and ULBT could reliably detect PDAs during virtual airway assessments. The data herein support further large multi-centre studies to validate the MBBS for clinical use. Full article

Pycnodysostosis (PDS) is an autosomal recessive form of osteosclerotic skeletal dysplasia characterized by craniofacial anomalies, a high-arched palate, and a narrowed pharyngeal space due to mandibular and maxillary deficiencies. These structural anomalies in the upper airway predispose PDS patients to obstructive sleep apnea (OSA). OSA can be managed in PDS patients using either a conservative (non-surgical and multidisciplinary) approach or surgical interventions. Given the craniofacial anomalies associated with PDS, orthodontic treatment aims to address the maxillary transverse deficit and retrognathia. Currently, there is no evidence regarding the impact of orthodontic therapy on OSA levels among PDS patients. This study reports the long-term morphological and functional changes in the upper airway of a PDS patient following adenotonsillectomy and uvulopalatoplasty at an early age (3.6 years) and orthodontic camouflage in late mixed dentition (10 years). Polysomnographies (PSGs), nuclear magnetic resonance (NMR), and lateral cephalograms taken before and after ENT surgery and orthodontic treatment were analyzed. Lateral X-rays were evaluated for changes in the posterior airway space (PAS), while polysomnographies provided the apnea–hypopnea index (AHI). The NMR scans were segmented to measure the perimeter and radius of the upper airway. The findings of this study indicate that improvements following uvulopalatoplasty (UPP) were partial and temporary. Nonetheless, orthodontic therapy and the use of elastics did not appear to influence the PAS or AHI. Future studies with larger cohorts are needed to evaluate the long-term effectiveness of the UPP procedure. This study was conducted in accordance with the CARE guidelines. Full article

We are pleased to introduce the abstracts of the XXIII National Congress of the Italian Society of Thoracic Endoscopy (SIET), which will be held in Florence from 17 to 19 October 2024. The principal objectives of SIET are to (1) Promote research and innovation in the fields of thoracic surgery and endoscopy, facilitating the development and implementation of innovative techniques and technologies; (2) Provide education and training for surgeons, endoscopists, pulmonologists and other related specialties; and (3) Facilitate the exchange of knowledge with the aim of creating a cohesive and active scientific community. The Congress will address the integration of traditional surgical and endoscopic techniques with emerging technologies, with the goal of promoting innovation and education among professionals. The theme of integration will be explored throughout the programme, with a particular focus on the collaborative efforts of different medical specialties to improve patient outcomes. This event will host a multidisciplinary cohort comprising thoracic surgeons, endoscopists, pulmonologists, oncologists, pathologists, radiologists and anaesthetists, who will assume a pivotal role in the multidisciplinary sessions of the scientific programme. The Congress will include several core areas of expertise, including lung cancer, interventional endoscopy, pathology, and upper airway reconstruction. Emphasis will be placed on both the theoretical aspects of these subjects and their practical applications in patient care. The theme of integration will be explored throughout the programme, with particular attention on the impact of recent technological developments in the fields of thoracic surgery and endoscopy. Additionally, the Congress will examine the contributions of allied health professionals, including nurses, physiotherapists, and speech pathologists, to patient care. Full article

Chronic rhinosinusitis with and without nasal polyps (CRSwNP and CRSsNP, respectively) is a chronic inflammatory disease affecting almost 5 to 12% of the population and exhibiting high recurrence rates after functional endoscopic sinus surgery (FESS). TGFβ1-related pathways contribute to tissue remodelling, which is one of the key aspects of CRS pathogenesis. Additionally, adenosine signalling participates in inflammatory processes, and CNPase was shown to elevate adenosine levels by metabolizing cyclic monophosphates. Thus, the aim of this study was to assess the expression levels of Smad2, pSmad3, TGFβ1, and CNPase protein via immunohistochemistry in sinus epithelial tissues from patients with CRSwNP (n = 20), CRSsNP (n = 23), and non-CRS patients (n = 8). The expression of Smad2, pSmad3, TGFβ1, and CNPase was observed in the sinus epithelium and subepithelial area of all three groups of patients, and their expression correlated with several clinical symptoms of CRS. Smad2 expression was increased in CRSsNP patients compared to CRSwNP patients and controls (p = 0.001 and p < 0.001, respectively), pSmad3 expression was elevated in CRSwNP patients compared to controls (p = 0.007), TGFβ1 expression was elevated in CRSwNP patients compared to controls (p = 0.009), and CNPase was decreased in CRSsNP patients compared to controls (p = 0.03). To the best of our knowledge, we are the first to demonstrate CNPase expression in the upper airway epithelium of CRSwNP, CRSsNP, and non-CRS patients and point out a putative synergy between CNPase and TGFβ1/Smad signalling in CRS pathogenesis that emerges as a novel still undiscovered aspect of CRS pathogenesis; further studies are needed to explore its function in the course of the chronic inflammation of the upper airways. Full article