Background Chronic rhinosinusitis (CRS) often coexists with lower respiratory tract diseases, and such cases tend to be more refractory. However, few studies have specifically investigated chest computed tomography (CT) findings in patients with CRS. This study analyzed chest CT findings in patients with CRS and investigated their associations with CRS phenotypes and clinical characteristics. Methods We retrospectively analyzed 278 patients with CRS who underwent preoperative chest CT prior to endoscopic sinus surgery. Patients were stratified based on the presence or absence of abnormal chest CT findings. Clinical parameters related to upper and lower airway inflammation, including CRS phenotypes, were compared between the groups. The prognosis for ECRS was evaluated using the systemic steroid dose as a longitudinal outcome variable in a linear mixed-effects model. Results Among the 278 patients, 174 were diagnosed with eosinophilic CRS (ECRS) and 104 with non-eosinophilic CRS (NECRS). Ground-glass attenuation (GGA) and bronchial wall thickening (BWT) were observed in 35 and 27 patients (12.6 %, 9.7 %), respectively. The frequencies of GGA and BWT were significantly higher in the ECRS group than in the NECRS group. Among patients with ECRS, those with GGA had significantly higher tissue eosinophil counts and Lund–Mackay CT scores, as well as significantly lower olfactory function. Steroid dose reduction was significantly slower in the GGA group. Conclusions The presence of GGA on chest CT in patients with CRS is associated with the CRS phenotype and greater disease severity, suggesting that chest imaging findings could serve as potential indicators of systemic disease burden in CRS.

Allergic fungal rhinosinusitis (AFRS) is a distinct, noninvasive endotype of chronic rhinosinusitis with nasal polyps characterized by type 2 inflammation, eosinophilic mucin-containing fungal elements, and dramatic radiographic findings. Despite extensive sinonasal disease with expansile remodeling that may extend into orbital or intracranial spaces, patients often report disproportionately mild symptoms, contributing to delayed diagnosis. This article presents a representative case of unilateral AFRS in a young, immunocompetent patient and uses it as a framework to review current diagnostic criteria, epidemiologic features, radiographic nuances, and common diagnostic pitfalls. We discuss the evolving understanding of AFRS pathophysiology, including emerging immunologic insights that distinguish AFRS from other eosinophilic chronic rhinosinusitis phenotypes. Management remains centered on early, comprehensive endoscopic sinus surgery for removal of eosinophilic mucin, followed by long-term topical anti-inflammatory therapy. Recent observational studies and a randomized controlled trial suggest a role for type 2-targeted biologics as adjunctive therapy in select patients with refractory disease. Recognition of AFRS as a unique clinical entity is essential to ensure appropriate management, avoid unnecessary medical therapy, and prevent disease-related complications.

The endoscopic endonasal approach has emerged as an effective and minimally invasive technique for the management of tuberculum sellae meningiomas. A 53-year-old woman with progressive visual deterioration due to a tuberculum sellae meningioma extending into the optic canal underwent endoscopic endonasal resection with optic canal decompression. Gross-total removal was achieved using a "French-door" dural opening and angled dissection, resulting in Simpson grade II resection with the preservation of neurovascular structures. Optic canal opening enabled safe tumor removal and significant visual improvement. Reconstruction employed sutured fascia lata grafts and a sphenoid sinus mucosal flap resulted in no postoperative cerebrospinal fluid leakage. The video can be found here: https://stream.cadmore.media/r10.3171/2025.10.FOCVID25151.

BACKGROUND AND OBJECTIVES:To describe technical nuances of optic canal superior wall (OCSW) decompression during the endoscopic endonasal approach (EEA) for tuberculum sellae meningiomas (TSMs), quantify decompression, and evaluate associations with tumor features and outcomes. METHODS:Data of 17 patients who underwent EEA for TSMs were retrospectively reviewed. Postoperative computed tomography was performed to measure the width and anteroposterior length of the OCSW decompression, and an OCSW decompression rate was calculated relative to the interanterior clinoid process distance. Tumor characteristics were scored using the University of California-San Francisco (UCSF) system, and surgical outcomes were assessed based on the extent of resection, postoperative complications, cerebrospinal fluid leakage, Visual Impairment Score (VIS)-based visual change, and intraoperative blood loss. Correlations and a two-predictor logistic regression (tumor size, OCSW decompression) modeled visual improvement. RESULTS:The cohort comprised 11 female and 6 male patients (mean age, 64.6 years). The mean UCSF total score was 4.65 (median, 5; range, 1-6), with mean subscores of 1.71 (size), 1.35 (canal), and 1.59 (arterial encasement). Gross total resection was achieved in 12/17 (70.6%), and VIS improved in 13/17 (76.5%); no visual deterioration occurred. The mean OCSW opening ratio was 93.3% (range, 71.4%-107.8%). OCSW decompression correlated with tumor size score (Spearman ρ = 0.55, P = .022) and total UCSF score (ρ = 0.56, P = .019), but not with extent of resection, cerebrospinal fluid leakage, VIS improvement on univariate testing, or blood loss. In the logistic model, tumor size (odds ratio 2.42, P = .0038) and OCSW decompression (odds ratio 2.04, P = .0092) independently predicted visual improvement (pseudo-R2 = 0.49; goodness-of-fit P = .798). CONCLUSION:Wider OCSW decompression scaled with tumor complexity and, after adjustment for tumor size, independently increased the odds of visual improvement. These data support planned, adequately wide OCSW decompression to secure lateral working space and facilitate safe dissection in EEA for TSMs.

Background:Radical resection of transinfundibular craniopharyngiomas (TCs) while preserving endocrine function remains a major surgical challenge because of their origin within the pituitary stalk. The "vertical infundibular split with subpial excavation" (VISSE) technique in endoscopic endonasal surgery (EES) is an effective approach that may enable gross total resection (GTR) in selected cases while aiming to preserve pituitary stalk integrity and neuroendocrine function. This procedure involves a vertical split of the pia mater of the pituitary stalk at sites with sparse pituitary portal veins, followed by subpial circumferential dissection along the tumor-stalk interface. Methods:We report two patients with TC who underwent EES using the VISSE technique, achieving GTR with pituitary stalk preservation. Case 1 was a 68-year-old woman with an 18-mm solid TC compressing the optic chiasm and involving the pituitary stalk. Case 2 was a 53-year-old man with a 65-mm mixed solid-cystic TC extending toward the frontal lobe. Results:Postoperatively, Case 1 maintained stable endocrine function without replacement therapy, suggesting preservation of both anterior and posterior pituitary function. Case 2 developed permanent diabetes insipidus and growth hormone deficiency, whereas other anterior pituitary axes were preserved. Conclusion:The VISSE technique may enable GTR while preserving pituitary function to varying degrees in selected TC cases.

Epithelial remodeling is a hallmark of host antiviral responses that strengthen barrier defenses against infection. Our current understanding of viral pathophysiology within the nasal epithelium, the initial site of most respiratory viral infections, remains incomplete due to limited understanding of the native tissue architecture and protective epithelial remodeling during immune events. Leveraging coronavirus disease 2019 (COVID-19) as a model, we applied spatial multi-omics on nasal cross-sectional tissues to characterize the immune-epithelial landscape during infection, identifying a coordinated increase in goblet cells and suppressive macrophages associated with elevated IL13 in the immune compartment. Our results further reveal that goblet cell and suppressive macrophage enrichment are spatially linked in proximity to IL13-expressing CD4 T cells, consistent with IL13-driven remodeling in situ . Using a primary human nasal air-liquid interface model, we demonstrate that IL13 alone is sufficient to remodel epithelial composition and morphology, subsequently restricting viral infection by reshaping the apical mucus barrier of the nasal epithelium. Our findings uncover a spatially organized, IL13-driven circuit for immune-epithelial remodeling as a protective barrier against respiratory viral infections.

Postoperative weight gain following endoscopic endonasal surgery (EES) for craniopharyngiomas remains a challenging complication. Thus, in this study, we aimed to identify risk factors for new or worsened obesity following EES and to explore age-related patterns of postoperative weight change. We conducted a retrospective cohort study of 72 patients (26 pediatric and 46 adult) who underwent initial EES for craniopharyngioma at two academic centers. We defined obesity based on body mass index (BMI) in adults and the BMI standard deviation score in pediatric patients. The primary outcome was new or worsened obesity at follow-up. Tumor extension and hypothalamic involvement/damage were assessed using standardized classification systems. Multivariate logistic regression was used to identify independent predictors. New or worsened obesity was observed in 17 patients (23.6

BACKGROUND:Allergic fungal rhinosinusitis (AFRS) is a subtype of chronic rhinosinusitis driven by Types 1 and 3 allergies to fungi. In Japan, it is relatively rare and characterized by prominent eosinophilic infiltration of the sinonasal mucosa, together with eosinophilic mucin containing scattered fungi in the sinus cavity. Eosinophilic chronic rhinosinusitis (eCRS) involves similar eosinophilic infiltration and shares some clinical features with AFRS. However, the clinical differences between eCRS and AFRS remain to be fully elucidated. The aim of this study was to clarify the phenotypes of eCRS and AFRS. METHODS:This multicenter retrospective study enrolled patients with AFRS and eCRS and compared their clinical parameters. A cluster analysis was conducted to determine the phenotypes of the two diseases. RESULTS:AFRS patients had a younger age of onset and exhibited milder computed tomography and nasal polyp scores than eCRS patients. Total IgE was significantly higher in AFRS patients than in eCRS patients, while mucosal eosinophil counts were similar. Olfactory disturbances were significantly less severe in AFRS patients compared with eCRS patients. The cluster analysis revealed three phenotypes for AFRS: one that was distinct and independent from eCRS, representing the more classically described AFRS patients, and more the other two that shared characteristics with eCRS. CONCLUSIONS:AFRS exhibits unique clinical features compared with eCRS. Cluster analysis identified three distinct AFRS phenotypes characterized by CT findings, eosinophilic inflammation, and specific IgE levels against inhaled antigens. These findings underscore the importance of differential diagnosis and personalized treatment strategies for AFRS and eCRS.

Background:Eosinophilic chronic rhinosinusitis (ECRS) is a subgroup of chronic rhinosinusitis with nasal polyps (CRSwNP), which is a disease characterized by eosinophilic infiltration of the sinonasal mucosa. Few studies that reported the effect of dupilumab on CRSwNP focused on a single phenotype of CRSwNP, such as ECRS. Objectives:This study aimed to determine the effectiveness of dupilumab in ECRS with postoperative recurrence. Methods:We retrospectively enrolled 107 patients and assessed the effectiveness of dupilumab by various clinical outcomes. We performed multivariable analysis on nasal polyp score (NPS) and computed tomography score and a meta-analysis of the effect of dupilumab on chronic rhinosinusitis regarding improvement in the NPS. Results:At 12 months of dupilumab treatment, there were 65 patients (60.7%) in the excellent response group and 42 (39.3%) in the moderate response group. Nasal polyps had disappeared in 91 patients (85.9%) at 12 months, and there was improvement in all end points; 104 patients (97.2%) were able to eliminate systemic corticosteroid therapy. In the multivariate analysis, male sex was significantly associated with patients who did not show an improvement to 0 in the NPS and computed tomography score (odds ratios: 7.58 and 2.45; P = .01 and P = .04, respectively). The meta-analysis showed that dupilumab treatment resulted in a trend toward better improvement in the NPS (mean difference = -5.41) than previously reported results. Conclusions:Dupilumab shows effectiveness in treating ECRS and could serve as an alternative therapeutic option to systemic corticosteroids. This effectiveness may be further enhanced by limiting the target population to recurrent ECRS.

OBJECTIVE:Lesions of the ventral craniovertebral junction are difficult to access owing to their deep location and proximity to critical neurovascular and pharyngeal structures. In this study, we aimed to describe the surgical technique and clinical outcomes of the endoscopic endonasal transnasopharyngeal approach for ventral craniovertebral junction lesions and highlight key considerations regarding approach selection, airway management, and occipitocervical stabilization. METHODS:We retrospectively reviewed 7 patients who underwent the endoscopic endonasal transnasopharyngeal approach for ventral craniovertebral junction lesions. The analysis included preoperative planning for surgical access, intraoperative technique, postoperative management, airway and nutritional strategies, and the need for occipitocervical fixation. One representative case is presented to illustrate key technical steps. RESULTS:Of the 7 patients, 6 had neoplastic lesions and 1 had basilar invagination. Despite a relatively large mean lesion size of 39.4 mm, subtotal or greater resection was achieved in 5 of the 6 tumor cases. Occipitocervical fixation was performed in 2 cases. Two patients underwent prophylactic tracheostomy because of anticipated airway compromise. Of the 5 orally intubated cases, 3 were extubated immediately and 2 by postoperative day 2. Oral feeding resumed by day 10 in 6 cases. No postoperative infections or cerebrospinal fluid leakage occurred. One patient experienced transient velopharyngeal insufficiency, which resolved spontaneously. CONCLUSION:The endoscopic endonasal transnasopharyngeal approach is a safe and effective option for ventral craniovertebral junction lesions when appropriately selected. Careful preoperative evaluation and individualized management of airway and spinal stability are essential for favorable outcomes.

Chronic rhinosinusitis (CRS) is a common chronic inflammatory disease of the sinonasal cavity affecting millions worldwide. Its complex pathophysiology remains poorly understood, with emerging evidence implicating interactions between diverse immune and epithelial cells in disease progression. We applied single-cell RNA sequencing (scRNA-seq) and spatial transcriptomics to both dissociated and intact human tissues from individuals with CRS with and without nasal polyps and compared them with controls. We revealed mechanisms of macrophage-eosinophil recruitment, CD4+ and CD8+ T cell dysregulation, and mast cell enrichment. We identified key immune-epithelial interactions in tissue remodeling, particularly involving basal progenitor and tuft cells. A distinct basal cell trajectory was implicated in nasal polyp formation. Orthogonal validation with spatial transcriptomics from >100 individuals with CRS revealed conserved tissue remodeling features. Our study provides insights into CRS pathophysiology, highlighting immune-epithelial interactions as potential therapeutic targets in chronic inflammation, also serving as a resource for dissecting immune disease mechanisms.

Sinonasal mucosal epithelial cells act not only as a physical barrier, but also as dynamic regulators of immune responses through innate and acquired immunity. These cells play a key role in detecting environmental stimuli, such as pathogens, allergens, and pollutants, and in initiating the inflammatory cascade that shapes the overall immune response. By releasing cytokines, such as interleukin (IL)-25 and IL-33, and thymic stromal lymphopoietin, epithelial cells interact with immune cells and promote type 2 inflammation. The pathogenesis of eosinophilic chronic rhinosinusitis (ECRS), which is driven by type 2 inflammation, is heterogeneous. While immune cells have traditionally been considered to be central to the disease pathogenesis, emerging evidence has indicated the critical role of epithelial cells. Furthermore, novel biologics targeting the IL-4/IL-13 signaling pathway have shown potential in alleviating epithelial dysfunction and inflammation. Eosinophilic mucins that accumulate in the sinuses impair mucociliary function, and especially eosinophil extracellular trap cell death (EETosis) stimulate epithelial cells and amplify eosinophilic inflammation. Eosinophilic mucin formation has been shown to significantly increase viscosity through EETosis, and novel biologics targeting the IL-5 signaling pathway hold promise for effectively mitigating this process. To develop targeted interventions, it is important to explore the role of epithelial subpopulations, such as basal cells and tuft cells, in maintaining the balance between tissue repair and chronic inflammation. Single-cell transcriptomics and spatial transcriptomics technologies have provided significant insights into the complexity of epithelial cell-derived inflammation in ECRS. The heterogeneity of the pathogenesis of CRS with nasal polyps and ECRS across patient populations complicates the development of universal therapies, underscoring the need for stratified medicine approaches. Potential future therapeutic strategies include the restoration of epithelial integrity and immune balance by disrupting aberrant crosstalk between epithelial and immune cells, particularly in patients unresponsive to current treatments.

Background: Eosinophilic chronic rhinosinusitis (eCRS) is a type 2 inflammatory disease that frequently recurs after surgery. In recent years, dupilumab has been available for the treatment of refractory chronic rhinosinusitis since 2020 in Japan. Although there are some reports of its usefulness, there are not enough reports of its clinical efficacy for longer than 1 year, especially for olfactory recovery. Methods: Twenty patients with eCRS who had recurrence after surgery and had been receiving dupilumab were enrolled retrospectively. The nasal polyp score (NPS), computed tomography (CT) score, T&T olfactometer, and olfactory cleft opacification on CTwere evaluated at baseline, at an average of 5.1 months later (short term), and at an average of 18.3 months later (long term). Results: At the short-term evaluation, there were significant improvements in the NPS and CT scores (P <.001, P=.008, respectively). The CT score was further improved at the long- term evaluation compared to the short-term evaluation (P =.018) and baseline (P=.008). T&T detection/recognition thresholds and olfactory cleft opacification showed significant improvements only at the long-term evaluation compared to baseline (P =.002, P=.006, and, P=.006, respectively). Conclusion: The NPS remained improved, and the CT score showed further improvement with long-term treatment, whereas olfactory function and olfactory cleft opacification showed significant improvement only after long-term treatment. There was a dissociation between the time to improve in the NPS and CT scores and the time to improve in olfactory function and olfactory cleft opacification. Based on these results, dupilumab should be administered for longer than 1 year, especially for olfactory function.

Respiratory epithelial adenomatoid hamartoma (REAH) is a relatively rare disease that commonly occurs in the olfactory cleft, followed by the posterior nasal septum within the nasal cavity. We herein report a case of REAH on the nasal floor, which is an extremely rare anatomical site for the occurrence of REAH. A 63-year-old man was referred to our department because he had developed right epistaxis. Endoscopic examination revealed a protruding lesion on the floor of the right nasal cavity. The tumor was endoscopically removed and histopathological examination revealed that the tissue was characterized by proliferation of glandular duct structures composed of multiciliated cells and glandular cells, consistent with isolated REAH. No evidence of recurrence was observed endoscopically 14 months after surgery. The findings indicate that REAH can occur in the nasal cavity at sites covered by the respiratory mucosa that have not been previously reported and should be treated with caution.

Background:Chronic rhinosinusitis with nasal polyps (CRSwNP) is a chronic nasal and sinonasal inflammatory disease. Recently, resident memory B (BRM) cells have been identified in the lungs, although not in the sinonasal mucosa. Objective:Our aim was to characterize memory B-cell phenotypes with regard to patients with CRSwNP and identify BRM cells in both normal sinonosal mucosa and samples from patients with CRSwNP. Methods:CD19+ B cells were isolated from patients with CRSwNP and analyzed using flow cytometry and immunohistochemistry. Results:Although BRM cells were found in the normal sinonasal mucosa, their numbers and frequencies tended to be limited. These findings were confirmed on the basis of immunohistochemical analyses indicating an upregulation of CD69/CD45RB in tissue sections from patients with CRSwNP, although not in normal sinonasal mucosa. Accordingly, BRM cells were established to be enriched in the nasal polyps isolated from patients with CRSwNP. Conclusion:Our findings in this study reveal that BRM cells can be detected in normal sinonasal mucosa, although they are significantly enriched in nasal polyps derived from patients with CRSwNP. These findings can contribute to gaining a more comprehensive understanding of the immune reactions associated with CRSwNP and facilitate the identification of potential therapeutic targets, such as anti-B-cell therapy.