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In Response to Is Ethmoidal Air Cell Count Relevant in CRS?

Thanks to Professor Satar for his interest in our study on the ethmoidal air cell count in chronic rhinosinusitis (CRS). As correctly stated, the pathogenesis of CRS to the best of our knowledge is multifactorial and most likely has different causes depending on the endotype. Our article by no means tries to state that aircell count is decisive; however, it is obvious that CRS patients have more cells than healthy controls, irrespective of potentially confounding factors. The suggested main factors of CRS pathogenesis including allergies have been discussed controversially over decades, just as anatomic variations. In fact, the percentage of patients with septal deviations or a concha bullosa are not significantly higher in the CRS population than in the healthy community. Recurrent upper airway infections (exacerbations) are rather consequence than cause of CRS. We agree that smoking is a potential risk factor. It is more likely that a genetic background together with exogenous factors leads to chronicity, including epithelial barrier deficiency, defects in the innate and adaptive immune system, and so on. Since this study was designed retrospectively and patients were matched for age only, there are obvious shortcomings. Nevertheless, none of your suggested mechanisms have been proven to affect air-cell counts. Unfortunately, it is impossible to find reliable data on allergic sensitizations in our control group; therefore, this would require a prospective setup. Furthermore, the definition of a relevant septal deviation is very difficult from computed tomography (CT) data only. The rise in air-cell numbers, when multiplying sagittal with axial scans, is due to the three-dimensional structure of the ethmoid and the mathematical model. As discussed, it is nowadays impossible to reliably identify and count a “real” total number of air cells specifically in the opacified group. We do not consider 100 CTs to be a small cohort. Statistically, the smaller the number of patients, the harder it is to obtain significant results. Nevertheless, our data show clear differences. Generally, we obtain CT scans preoperatively under maximal medical treatment. Any nonsurgical treatment would not change the air-cell count, in addition the definition of CRS was not done on the CT scan alone but rather according to the guidelines of the European Position Paper on Rhinosinusitis and Nasal Polyps 2020. We hope to have clarified some of Professor Satar’s concerns, but clearly understand the limitations of our study and its findings.