Computational fluid dynamic modeling of the effect of dupilumab in the management of anosmia secondary to chronic rhinosinusitis with nasal polyps (CRSwNP).
Chronic rhinosinusitis with nasal polyposis (CRSwNP) is among the most common causes of olfactory loss, potentially mediated by inflammatory sensorineural loss and/or by conductive obstruction of airflow to the olfactory receptor sites. Dupilumab is a monoclonal antibody treatment for severe, inadequately controlled CRSwNP, which often results in significant olfactory improvement compared to placebo.1, 2 Yet the mechanism by which it improves olfaction remains unsettled. Previous studies have implicated the role of interleukin 13 (IL-13) in inducing damage to olfactory epithelium, suggesting a possible sensorineural anti-inflammatory mechanism.3-5 Studies have also shown a significant reduction in polyp burden after dupilumab, suggesting there may be a conductive component, although this mechanism has not been quantitatively confirmed.5 The goal of this study is to use computational fluid dynamic modeling (CFD) to examine the potential conductive mechanism of how dupilumab may alleviate olfactory loss in patients with CRSwNP. Three-dimensional (3D) computational fluid dynamic (CFD) models were constructed using a previously described method6 based on cone beam computed tomography (CT) scans (3D Accuitomo 170; J. Morita USA, Inc.) of one CRSwNP patient (a 33-year-old female) who did not improve symptomatically after multiple surgeries but did with dupilumab (22-item Sino-Nasal Outcome Test [SNOT-22] baseline: 84; 7 weeks postsurgery: 74; 11 months post-dupilumab: 24). Airflow patterns and velocity changes throughout the nasal airway were simulated under restful quasi-steady (15-Pa pressure drop between the nostrils and the nasal pharynx) using CFD software (ANSYS Fluent 19.2; Ansys, Inc., Canonsburg, PA) at the following time points: (1) baseline, where the patient had been experiencing sinus symptoms for 8 years after unsuccessful treatment with budesonide and azelastine nasal sprays, and multiple sinus surgeries at an external hospital; (2) 7 weeks after revision comprehensive sinus surgery in October 2018; and (3) 11 months after starting dupilumab in December 2020, when her symptoms remitted after surgery and a trial of benralizumab was ineffective at symptomatic relief. The numerical method and meshing protocol applied in this study have been previously validated against experimental measurements.6 The baseline CT showed a completely obstructed nasal airway and sinuses, and CFD simulations showed that no air would pass through the nasal airway or the olfactory region, corroborating the patient's symptom of complete anosmia. Postsurgery, CFD modeling demonstrated an improvement in patency of the olfactory cleft, with 0.5% of the total airflow passing through the olfactory region (pink/purple region in Figure 1). This percentage of olfactory flow distribution is further increased to 26.4%, or a 51.8-fold increase post-dupilumab. There was minimal change (∼1%) in overall nasal resistance between the last two time points (postsurgery: 0.0486 Pa/ml/s; post-dupilumab: 0.0480 Pa/ml/s). The non-obstructed olfactory surface area increased from 0.411 cm2 (postsurgery) to 8.525 cm2 (post-dupilumab), or a 20.7-fold increase. This improvement in patent olfactory area and airflow corresponded to a significant improvement in smell identification score (postsurgery: 16 to post-dupilumab: 35). Postsurgery, most airflow occurs in high velocity between the inferior and middle turbinates (Figure 2A,B), whereas a minimal amount, if any, reaches the superior turbinate and olfactory cleft in the model (Figure 1A,B). Post-dupilumab, airflow is more well-distributed throughout the entire nasal cavity, with significantly more velocity of airflow superior to the middle turbinate (Figure 1C,D), suggesting a potential conductive mechanism by which dupilumab aids in olfactory improvement. The patient's Nasal Obstruction Symptom Evaluation (NOSE) score had already improved significantly after surgery (baseline: 80 to postsurgery: 35), with a small additional benefit after starting dupilumab (35 to 30). This trend corresponds well with CFD simulation findings that surgery and dupilumab are likely both efficacious in relieving nasal obstruction (∼1% difference in nasal resistance), whereas dupilumab has a further effect of increasing relative airflow to the olfactory region. Limitations of this study include its design as a case report and its retrospective nature, which limit generalizability. The study also relies on preexisting CT scans that did not necessarily capture optimal time points. However, this study highlights an interesting finding that dupilumab may offer greater relief of congestion specifically in the olfactory region, which may inspire future, more well-powered prospective studies on this topic. The mechanism by which dupilumab improves olfaction in patients with CRSwNP may involve the reduction of regional nasal obstruction in the olfactory cleft, thereby allowing more odorants to reach the olfactory epithelium, in addition to the potential sensorineural recovery described in the literature. The authors have no conflicts of interest to disclose. NIH NIDCD R01 DC013626 and R21 DC017530 to Kai Zhao.
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