Bilateral vs Unilateral Chronic Rhinosinusitis in HIV: Distinct Phenotypes from a Surgical Cohort

Bilateral vs Unilateral Chronic Rhinosinusitis in HIV: Distinct Phenotypes from a Surgical Cohort | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Bilateral vs Unilateral Chronic Rhinosinusitis in HIV: Distinct Phenotypes from a Surgical Cohort Shan Shao, Xinwei Guo, Miao Zhang, Xuejin Dong, Xiangdong Wang, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8417222/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background The European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS) 2020 classification for chronic rhinosinusitis (CRS) lacks validation in people living with HIV (PLWH), a population with a high burden of sinonasal disease. This study aimed to phenotype surgical HIV-associated CRS and compare bilateral versus unilateral disease. Methods This single-center, population-based cohort study included 60 consecutive patients with HIV-associated CRS requiring endoscopic sinus surgery between January 2020 and June 2025 at Beijing You’an Hospital, a national designated center where nearly all HIV-associated CRS surgical cases have been managed in China. Demographic, clinical, laboratory (including eosinophil/neutrophil counts), and radiological (Lund-Mackay score, E/M ratio) factors were analyzed. Univariate and multivariable logistic regression identified associations with bilateral CRS. Results The cohort comprised 60 PLWH (median age 36.0 years; 95.0% male), with bilateral CRS being predominant (78.3%). Univariate analysis revealed significant differences between bilateral and unilateral CRS in eosinophil parameters (both count and percentage: p < 0.001), neutrophil percentage (p = 0.018), Lund-Mackay CT scores (p = 0.007), and the ethmoid-to-maxillary sinus ratio (p = 0.037). On multivariable analysis, bilateral disease remained independently associated with a higher Lund-Mackay CT score (adjusted odds ratio [aOR] = 1.60, 95% CI: 1.02–2.51, p = 0.043) and an elevated blood eosinophil percentage (aOR = 2.27, 95% CI: 1.01–5.14, p = 0.049). Conclusions In PLWH, bilateral CRS is the dominant phenotype. Its association with radiographic severity and a type 2 inflammatory marker supports the use of the EPOS 2020 anatomic classification in this population. Chronic rhinosinusitis HIV EPOS 2020 Bilateral Figures Figure 1 Figure 2 Figure 3 Introduction Chronic rhinosinusitis (CRS) is a common inflammatory disease with a global prevalence of 5.5–28%, posing a substantial burden on healthcare resources and patient quality of life [ 1 – 5 ]. The traditional phenotypic classification of CRS based solely on the presence or absence of nasal polyps is now considered inadequate to reflect the disease's complex heterogeneity in clinical presentation and underlying pathophysiology [ 2 , 6 – 8 ]. The European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS) 2020 has introduced a pivotal, more nuanced framework for classifying CRS [ 2 ]. This system first distinguishes primary from secondary CRS, then further categorizes disease by its anatomic distribution (localized vs. diffuse). For secondary CRS, etiologies are specified, including local, mechanical, inflammatory, and immunological factors. Immunodeficiency is a key etiological factor within this new paradigm. Acquired immunodeficiency syndrome (AIDS), resulting from HIV-mediated depletion of CD4 + T-cells, is a classic secondary immunodeficiency [ 9 ]. Evidence suggests that CRS in the context of such immunodeficiencies may respond poorly to standard therapies, often requiring targeted management of the underlying immune dysfunction for optimal sinus disease control [ 2 , 10 – 17 ]. Despite the success of antiretroviral therapy (ART) in transforming HIV into a chronic condition, CRS remains a highly prevalent comorbidity, affecting up to 68% of people living with HIV (PLWH) [ 16 , 18 – 26 ]. This high disease burden, coupled with the global persistence of HIV as a major public health issue, underscores the critical need to characterize CRS in PLWH through the modern lens of the EPOS2020 criteria [ 27 ]. However, data on the clinical features of CRS in this specific population, classified according to this new framework, are notably scarce. As a designated national center for HIV/AIDS care in China, our institution manages a large surgical cohort of PLWH, including nearly all HIV-associated CRS requiring endoscopic sinus surgery, providing a unique population-level perspective [ 22 ]. Therefore, we conducted a 5-year study to characterize surgical HIV-associated CRS and to evaluate differences between unilateral and bilateral disease in clinical manifestations, peripheral blood indices, and imaging characteristics using the novel EPOS 2020 classification system. Materials and methods Study Design and Population This retrospective surgical cohort was conducted at the Department of Otorhinolaryngology, Head and Neck Surgery of Beijing You’an Hospital, Capital Medical University, a designated center where nearly all surgical HIV-associated CRS in China have been managed. The study included 60 consecutive HIV-associated CRS who underwent endoscopic sinus surgery between January 2020 and June 2025. The study protocol was approved by the Ethics Committee of Beijing You'an Hospital (No. jingyoukelunzi [2025]108). Participants provided written informed consent prior to enrollment. This study was conducted in accordance with the Declaration of Helsinki and reported following the STROBE guideline for observational studies. The diagnosis of CRS was established according to the European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS) 2012 criteria, based on patient history, clinical examination, nasal endoscopy, and computed tomography (CT) findings [ 7 ]. The diagnosis of HIV/AIDS was based on the Guidelines for diagnosis and treatment of HIV/AIDS in China (2005) [ 28 ]. Inclusion and Exclusion Criteria Inclusion criteria were: (1) age ≥ 18 years; (2) a confirmed diagnosis of CRS meeting EPOS 2012 criteria; and (3) documented HIV infection. Exclusion criteria were: (1) diagnosis of acute sinusitis, acute exacerbation of chronic rhinosinusitis, or acute upper respiratory infection within 4 weeks prior to enrollment; (2) presence of benign or malignant tumors of the nose or sinuses; (3) history of sinus surgery within the past 6 months; (4) untreated or inadequately treated chronic infections, including parasitic infection, viral hepatitis, or syphilis; (5) pregnancy or lactation; (6) missing > 50% of key data in medical records. Data Collection Preoperative data were systematically collected from electronic medical records. Demographic and clinical variables included age, sex, smoking history, comorbidities (atopy, asthma, aspirin intolerance), history of prior sinus surgery, disease duration, and major sinonasal symptoms. Laboratory data, obtained 1–2 weeks preoperatively, included complete blood count, total immunoglobulin E (IgE) levels, and allergen-specific IgE testing. HIV-specific variables included viral load, peripheral blood CD4 + T-cell count, and CD8 + T-cell count. Co-infection status with other chronic infectious diseases was also recorded. Radiological assessment was based on preoperative paranasal sinus CT scans. Imaging variables collected included the Lund-Mackay score (LMS) for sinus opacification, the ethmoid-to-maxillary sinus (E/M) ratio [ 4 ]. CRS Classification Surgical HIV-associated CRS was classified sequentially according to the EPOS 2020 guidelines [ 2 ]: Primary Categorization All cases were classified as secondary CRS due to the underlying secondary immunodeficiency (HIV). Anatomic Distribution Secondary CRS was then subcategorized into bilateral or unilateral disease based on CT and endoscopic findings. Etiologic Subclassification Within the bilateral and unilateral subgroups, cases were further reviewed for typical pathologic causes as defined by EPOS 2020. Diagnoses such as odontogenic sinusitis and fungal ball were based on clinical presentation, CT characteristics, and histopathological confirmation [ 2 ]. Cases associated with sinus neoplasms, given their distinct features, were excluded from the final analysis. Cases without an identifiable typical pathologic cause were classified as "unclassified" secondary CRS. Statistical Analysis All statistical analyses were performed using SPSS 26.0 software. Continuous variables were expressed as median with interquartile range. Group comparisons (unilateral vs. bilateral CRS) for continuous variables were made using the independent samples t-test or the Mann-Whitney U test, as appropriate. Categorical variables are presented as frequencies and percentages and were compared using the χ² test or Fisher's exact test. Multivariable logistic regression was used to analyze the associated factors with unilateral/bilateral CRS. A two-sided p < 0.05 was considered statistically significant. Results Classification of Surgical HIV-associated CRS Based on EPOS 2020 Criteria A total of 60 HIV-associated CRS requiring endoscopic sinus surgery were included in the analysis. According to the EPOS 2020 framework, all cases were classified as secondary CRS due to HIV-associated immunodeficiency. Based on anatomic distribution, 13 patients (21.7%) had unilateral disease and 47 (78.3%) had bilateral disease (Fig. 1). Within the unilateral CRS subgroup, specific etiologies were identified in a subset of cases: odontogenic sinusitis (15.4%) and chronic invasive fungal sinusitis (7.7%). In the bilateral CRS subgroup, only 2.1% of cases were attributed to allergic fungal rhinosinusitis (AFRS). Odontogenic sinusitis was exclusively observed in the unilateral group, with a prevalence significantly higher than in the bilateral group (p = 0.04). No coexisting cases of primary ciliary dyskinesia, cystic fibrosis, granulomatosis with polyangiitis, or eosinophilic granulomatosis with polyangiitis were identified in this cohort. Demographic and Clinical Characteristics by Anatomical Distribution Demographic and clinical characteristics of the overall cohort and by disease laterality are summarized in Table 1. No significant differences were observed between the unilateral and bilateral groups regarding age, sex, smoking history, prior sinus surgery, atopy, asthma, or aspirin sensitivity. Virological and immunological status was comparable between groups in terms of HIV duration and CD4 + T-cell counts. The median CD4 + T-cell count for the entire cohort was 575.0 cells/mm³ (IQR 501.0-768.0), with 91.7% of patients having counts > 350 cells/mm³. All patients were receiving antiretroviral therapy at the time of surgery. However, a statistically significant difference was found in HIV viral load between the unilateral and bilateral groups (p = 0.04). Regarding comorbidities, syphilis co-infection was present in 36.7% of all patients, with hepatitis B and C in 5.0% and 3.3%, respectively. No significant differences in co-infection rates were observed between the unilateral and bilateral groups. The most common sinonasal symptoms were nasal blockage (96.7%), purulent rhinorrhea (48.3%), and hyposmia (40.0%). Patients with bilateral CRS had a significantly higher prevalence of nasal blockage and sleep disturbance compared to those with unilateral disease (p = 0.04 and p = 0.03, respectively). Peripheral Blood Indices by Anatomical Distribution Analysis of peripheral blood indices revealed significant differences in eosinophil counts between groups (Fig. 2). Both the absolute count and percentage of peripheral blood eosinophils were significantly higher in the bilateral CRS group compared to the unilateral group (p < 0.001 for both). The neutrophil percentage was lower in the bilateral group and this difference was statistically significant (p = 0.02). Imaging Findings by Anatomical Distribution Preoperative CT imaging findings are summarized in Fig. 3. The Lund-Mackay CT score was significantly higher in the bilateral CRS group compared to the unilateral group (p = 0.007). Similarly, the ethmoid-to-maxillary sinus (E/M) ratio was significantly higher in the bilateral group (p = 0.04). The incidence of nasal septum deviation did not differ significantly between groups. Multivariable Analysis of Factors Associated with Bilateral CRS A multivariable logistic regression model was constructed to identify factors independently associated with bilateral (as opposed to unilateral) CRS (Table 2). To reflect demographic characteristics, infection status of PLWH, disease features of CRS and imaging information, age, CD4 + T-cell count, CD8 + T-cell count, neutrophil percentage, and E/M ratio were included in the multivariable logistic regression model. After adjusting for age, CD4 + T-cell count, CD8 + T-cell count, neutrophil percentage, and E/M ratio, only a higher Lund-Mackay CT score (adjusted odds ratio [aOR], 1.60; 95% CI, 1.02–2.51; p = 0.04) and a higher peripheral blood eosinophil percentage (aOR, 2.27; 95% CI, 1.01–5.14; p = 0.05) emerged as independent risk factors for bilateral disease (Table 2). Discussion To our knowledge, this study represents the first comprehensive characterization of surgical HIV-associated CRS using the standardized EPOS 2020 diagnostic criteria. Conducted at a designated national HIV/AIDS care center in China, our research draws from a large, representative cohort that includes nearly all surgical HIV-associated CRS nationwide, thereby offering a unique population-level perspective. By systematically applying the EPOS 2020 criteria, we identified clear distinctions between unilateral and bilateral CRS in this immunocompromised population—including clinical, radiological, and hematological differences. Notably, bilateral disease was associated with more extensive radiographic involvement and a systemic eosinophilic response, suggesting a potentially distinct endotype of HIV-associated CRS that may underlie its pathophysiology. The epidemiological landscape of surgical HIV-associated CRS, particularly the proportion of secondary causes, remains underexplored[ 29 ]. Our study fills a critical gap by quantifying the anatomical distribution in PLWH: bilateral CRS was predominant (78.3%), while localized disease accounted for 21.7% of cases. This distribution contrasts with a recent Taiwanese study where secondary CRS was primarily attributed to localized etiologies, with immunodeficiency being a rare cause (0.3%)[ 29 ]. This discrepancy underscores significant interregional and interhospital variations in CRS classification and etiology, likely influenced by genetic and environmental factors that affect the prevalence of und30, 31]. Notably, all patients in our cohort were receiving oral ART. Compared to our previous study, recent heightened awareness and adherence to ART treatment in China was evident[ 22 ]. The vast majority (91.7%) had well-preserved immunologic function (CD4 + count > 350 cells/mm³), with a median (IQR) of 575.0 (501.0-768.0) cells/mm³[ 20 ]. This suggests that CRS can manifest across the spectrum of immune recovery in PLWH. While ART effectively suppresses viral replication and restores CD4 + counts, persistent immune activation and senescence may contribute to the unique pathophysiology of HIV-associated CRS, warranting specific clinical attention[ 22 , 32 – 34 ]. A key objective was to compare unilateral and bilateral surgical HIV-associated CRS. Univariate analysis revealed significant differences in HIV viral load, odontogenic causes, symptoms of nasal obstruction and sleep disturbance, peripheral blood eosinophil counts/percentages, neutrophil percentage, and CT scores. After adjusting for covariates in a multivariate model, peripheral blood eosinophil percentage and total CT score emerged as independent predictors for bilateral disease. This hematologic profile—elevated eosinophils and lower neutrophils in bilateral CRS—suggests a potential shift toward type 2 inflammation in bilateral cases, whereas unilateral CRS may be more frequently linked to non-type 2 mechanisms, such as bacterial or odontogenic infections. This aligns with growing evidence on the utility of peripheral blood eosinophils in CRS endotyping [ 35 – 39 ], though the underlying mechanisms in the context of HIV require further elucidation. Radiologically, bilateral CRS was associated with significantly higher Lund-Mackay scores, indicating more extensive sinus involvement. This finding is consistent with some prior reports of more severe radiographic disease in immunocompromised hosts [ 40 ], though direct comparisons are complicated by population heterogeneity, such as a recent study of Molokomme restricted to HIV-negative vs HIV-positive nasal polyps [ 41 ]. Regarding symptomatology, the symptomatology of CRS in PLWH appears largely comparable to that of the immunocompetent population [ 41 ]. Notably, although one study identified a greater frequency of fever and postnasal discharge in AIDS patients, both that study and an independent comparison by Porter et al. concluded that the symptoms and severity of CRS were similar between HIV-infected groups and, critically, between seropositive patients with or without AIDS[ 40 , 42 ]. In our study, nasal obstruction, purulent rhinorrhea, and hyposmia were most common. As expected, nasal blockage and sleep disturbance were significantly more prevalent in the bilateral group—a finding not previously detailed in this specific population. While HIV-infected individuals can present with a broad spectrum of fungal sinusitis, our study intriguingly revealed the incidence of fungal sinusitis in our cohort was lower than that of the general population [ 43 – 50 ]. Notably, no fungal ball was found in our study, which was relatively more prevalent in the immonocompetent host [ 29 , 51 , 52 ]. Although fungi are major contributors to the opportunistic infections that threaten patients with HIV infection, fungal sinusitis has been relatively uncommon in PLWH [ 21 , 53 – 55 ]. Invasive fungal sinusitis is a rare and life-threatening opportunistic infection in PLWH that occurs predominantly in those with low CD4 cell counts, nonsuppressed HIV ribonucleic acid (RNA) levels, and in those not receiving ART [ 47 , 56 ]. The post-ART era has seen a marked decline in invasive fungal sinusitis among PLWH, a trend potentially reflected in our findings and possibly influenced by regional HIV/AIDS policies and host immune factors [ 47 ]. This study has several limitations. Firstly, its single-center, retrospective design inherently risks selection bias and unmeasured confounding. Secondly, the modest sample size, though substantial for this specific population, may limit the generalizability of our findings. Thirdly, the absence of an HIV-negative control group with CRS precludes direct comparisons to determine HIV-specific disease features. Future prospective, multi-center studies with larger, diverse cohorts are needed to validate these findings and further explore the pathophysiological mechanisms of surgical HIV-associated CRS. Conclusion In this cohort of patients with HIV-associated CRS requiring surgery, bilateral disease was the predominant presentation. Bilateral disease was associated with more severe radiographic involvement and a systemic eosinophilic response, suggesting a differing underlying pathophysiology, potentially driven by type 2 (T2) inflammation. In contrast, unilateral disease presented with less radiographic severity and lacked a pronounced systemic inflammatory signature. These findings highlight the clinical relevance of the EPOS 2020 criteria in a comorbid population and underscore the need for phenotype-driven management strategies to optimize therapeutic outcomes in surgical HIV-associated CRS. Declarations Ethics approval and consent to participate The study was approved by the Ethics Committee of Beijing You'an Hospital (No. jingyoukelunzi [2025]108) in accordance with the standards of the Declaration of Helsinki. Participants provided written informed consent prior to enrollment. Consent for publication Not applicable. Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare no competing interests. Funding This work was supported by Young Investigator Grant in Beijing You'an Hospital Affiliated to Capital Medical University (BJYAYY-YN2023-03), China University Industry-University-Research Innovation Fund (2024GR101), National Natural Science Foundation of China (82171110, 82471137) and High Level Public Health Technical Talent Training Plan (Lingjunrencai-01-08). Authors' contributions All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by S.S., X.W.G. and M.Z.. All authors drafted the initial manuscript. All authors critically revised the manuscript for important intellectual content. All authors read and approved the final version of the manuscript. Acknowledgment We are grateful to the individuals who volunteered to contribute to this study. Clinical trial number Not applicable. References Shao S, Zheng M, Wang X, et al. 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Demographic Data and Clinical Characteristics CRS (n=60) Unilateral CRS (n=13) Bilateral CRS (n=47) p value a Demographic information Gender, male, No. (%) 57 (95.0) 12 (92.3) 45 (95.7) 0.53 Age, median (IQR), y 36.0 (31.3 to 47.0) 36.0 (31.0 to 45.0) 36.0 (32.0 to 47.0) 0.99 Smoking, No. (%) 15 (25.0) 3 (23.1) 12 (25.5) 0.99 Infection status Duration of HIV, median (IQR), m 78.0 (36.0 to 120.0) 84.0 (42.0 to 132.0) 72.0 (36.0 to 120.0) 0.74 Detectable HIV viral load b , No. (%) 2 (3.3) 2 (15.4) 0 0.04 a Antiretroviral therapy, No. (%) 60 (100) 13 (100) 47 (100) NA CD4-positive cell count, median (IQR), cells/mm³ 575.0 (501.0 to 768.0) 556.0 (481.0 to 752.0) 588.5 (510.0 to 778.8) 0.63 CD4-positive cell counts classification, No. (%) >350 55 (91.7) 12 (92.3) 43 (91.5) 0.99 250-350 4 (6.7) 1 (7.7) 3 (6.4) <250 1 (1.7) 0 1 (2.1) CD8-positive cell count, median (IQR), cells/mm³ 684.0 (535.0 to 1000.5) 824.0 (653.0 to 1259.0) 652.0 (501.5 to 916.5) 0.15 CD4/CD8, median (IQR), cells/mm³ 0.83 (0.59 to 1.33) 0.77 (0.55 to 0.96) 0.88 (0.63 to 1.35) 0.33 Co-infections Syphilis, No. (%) 22 (36.7) 4 (30.8) 18 (38.3) 0.86 Hepatitis B, No. (%) 3 (5.0) 0 3 (6.4) 0.99 Hepatitis C, No. (%) 2 (3.3) 0 2 (4.3) 0.99 Clinical characteristics Previous sinus surgeries, No. (%) 7 (11.7) 1 (7.7) 6 (12.8) 0.99 Atopy, No. (%) 18 (30.0) 2 (15.4) 16 (34.0) 0.34 Asthma, No. (%) 4 (6.7) 1 (7.7) 3 (6.4) 0.99 Aspirin sensitivity, No. (%) 1 (1.7) 0 1 (2.1) 0.99 Duration of CRS, median (IQR), m 36.0 (4.3 to 60.0) 12.0 (4.0 to 36.0) 36.0 (4.0 to 84.0) 0.13 Odontogenic sinusitis, No. (%) 2 (3.3) 2 (15.4) 0 0.04 a Fungal sinusitis, No. (%) 2 (3.3) 1 (7.7) 1 (2.1) 0.39 Symptomatology Nasal blockage, No. (%) 58 (96.7) 11 (84.6) 47 (100.0) 0.04 a Purulent rhinorrhea, No. (%) 29 (48.3) 9 (69.2) 20 (42.6) 0.09 Postnasal drip, No. (%) 4 (6.7) 1 (7.7) 3 (6.4) 0.99 Hyposmia, No. (%) 24 (40.0) 4 (30.8) 20 (42.6) 0.44 Headache, No. (%) 17 (28.3) 6 (46.2) 11 (23.4) 0.21 Facial pain or pressure, No. (%) 13 (21.7) 2 (15.4) 11 (23.4) 0.81 Sleep disturbance, No. (%) 22 (36.7) 1 (7.7) 21 (44.7) 0.03 a Epistaxis, No. (%) 8 (13.3) 3 (23.1) 5 (10.6) 0.48 Rhinocnesmus, No. (%) 3 (5.0) 1 (7.7) 2 (4.3) 0.53 Sneezing, No. (%) 19 (31.7) 6 (46.2) 13 (27.7) 0.35 Watery rhinorrhea, No. (%) 13 (21.7) 2 (15.4) 11 (23.4) 0.81 Peripheral blood Eosinophil count, median (IQR), 10^9 cells/L 0.13 (0.07 to 0.26) 0.06 (0.04 to 0.09) 0.15 (0.09 to 0.27) <0.001 a Eosinophil percentage, median (IQR) 1.9 (1.0 to 3.6) 0.8 (0.5 to 1.4) 2.6 (1.5 to 4.4) <0.001 a Neutrophil count, median (IQR), 10^9 cells/L 3.28 (2.66 to 4.49) 3.43 (2.78 to 7.86) 3.24 (2.56 to 4.30) 0.12 Neutrophil percentage, median (IQR) 55.4 (49.2 to 62.7) 59.3 (52.9 to 70.3) 53.7 (48.9 to 60.8) 0.02 a Imaging CT score, median (IQR) 7 (4.3 to 11.8) 5.0 (4.0 to 6.0) 9.0 (5.0 to 13.0) 0.007 a E/M ratio, median (IQR) 1 (0.5 to 2.0) 1 (0.5 to 1.3) 1 (1.0 to 2.0) 0.04 a Concha bullosa, No. (%) 23 (38.3) 5 (38.5) 18 (38.3) 0.99 Nasal septum deviation, No. (%) 44 (73.3) 7 (53.8) 37 (78.7) 0.15 Abbreviations: IQR, interquartile range; CRSwNP, chronic rhinosinusitis with nasal polyps; HIV, human immunodeficiency virus; CD4, cluster of differentiation 4; CD8, cluster of differentiation 8; CT, computerized tomography; E/M, ethmoid-to-maxillary sinus. NA, not applicable. a The p value indicated the differences between patients of unilateral CRS and bilateral CRS, and p value less than .05 were considered to indicate statistical significance. b Detectable HIV viral load is shown in the table as ‘HIV viral load more than 40 copies/mL’. Table 2. Multivariate logistic regression analysis of influencing factors in patients with unilateral/bilateral CRS Variable P value aOR 95%CI Age 0.97 1.00 (0.90 to 1.11) CD4-positive cell count 0.54 1.00 (1.00 to 1.00) CD8-positive cell count 0.12 1.00 (1.00 to 1.00) Eosinophil percentage 0.05 a 2.27 (1.01 to 5.14) Neutrophil percentage 0.88 1.00 (0.91 to 1.09) CT score 0.04 a 1.60 (1.02 to 2.51) E/M ratio 0.63 0.67 (0.13 to 3.43) Abbreviations: aOR, adjusted odds ratio; CI, confidence interval; CD4, cluster of differentiation 4; CD8, cluster of differentiation 8; CT, computerized tomography; E/M, ethmoid-to-maxillary sinus. a The p value less than .05 was considered to emerge as independent risk factors for bilateral disease. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 15 Feb, 2026 Reviews received at journal 16 Jan, 2026 Reviews received at journal 12 Jan, 2026 Reviewers agreed at journal 12 Jan, 2026 Reviewers agreed at journal 10 Jan, 2026 Reviewers invited by journal 09 Jan, 2026 Editor assigned by journal 26 Dec, 2025 Submission checks completed at journal 26 Dec, 2025 First submitted to journal 21 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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11:57:21","extension":"xml","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":139744,"visible":true,"origin":"","legend":"","description":"","filename":"e8ec7a5060b84dd1bcd42bc1482ec8a81structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8417222/v1/ba1cd1e09b766d53b577c4e9.xml"},{"id":100400241,"identity":"c9099c2e-3cae-45c2-86ff-1561f9bbf8fb","added_by":"auto","created_at":"2026-01-16 11:58:02","extension":"html","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":155829,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8417222/v1/5aaab6960886d08be7b458e6.html"},{"id":100399387,"identity":"3b48ffe2-e434-4be2-a44f-9151d22c27b3","added_by":"auto","created_at":"2026-01-16 11:56:52","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":47955,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eClassification of CRS in PLWH.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAbbreviations: CRS, chronic rhinosinusitis; PLWH, People Living with HIV; ODS, odontogenic sinusitis; CIFRS, chronic invasive fungal rhinosinusitis; AFRS, allergic fungal rhinosinusitis. Percentages may not sum to 100% due to rounding.\u003c/p\u003e","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8417222/v1/bfac148965a2461a401b6b76.png"},{"id":100399418,"identity":"a3a4f482-018a-401e-9257-29623ca00ee0","added_by":"auto","created_at":"2026-01-16 11:56:56","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":78307,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePeripheral blood indices stratified by anatomical distribution\u003c/strong\u003e. (A) the peripheral blood eosinophil count of unilateral and bilateral groups. (B) the peripheral blood eosinophil percentage of unilateral and bilateral groups. (C) the peripheral blood neutrophil count of unilateral and bilateral groups. (D) the peripheral blood neutrophil percentage of unilateral and bilateral groups. Abbreviations: Eos, eosinophil count; Eos%, eosinophil percentage; Neu, neutrophil count; Neu%, neutrophil percentage. *p \u0026lt; 0.05; ***p \u0026lt; 0.001; ns= not significant.\u003c/p\u003e","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8417222/v1/e00fc85f5e0ee9689ef1639d.png"},{"id":100421447,"identity":"f348ced5-1a8d-4d4e-8b69-16d9e0ca0026","added_by":"auto","created_at":"2026-01-16 13:32:59","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":49572,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eImaging findings stratified by anatomical distribution\u003c/strong\u003e. (A) the CT score of unilateral and bilateral groups. (B) the E/M ratio of unilateral and bilateral groups. Abbreviations: CT, computerized tomography; E/M, ethmoid-to-maxillary sinus. *p \u0026lt; 0.05; **p \u0026lt; 0.01.\u003c/p\u003e","description":"","filename":"Onlinefloatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-8417222/v1/400b0011357947b96ab7de03.png"},{"id":100546393,"identity":"2a1b8ec8-d0df-40d0-a444-a0756704261f","added_by":"auto","created_at":"2026-01-19 08:08:03","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1216586,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8417222/v1/9e43c055-3852-4095-8584-af6fbe9a1723.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Bilateral vs Unilateral Chronic Rhinosinusitis in HIV: Distinct Phenotypes from a Surgical Cohort","fulltext":[{"header":"Introduction","content":"\u003cp\u003eChronic rhinosinusitis (CRS) is a common inflammatory disease with a global prevalence of 5.5\u0026ndash;28%, posing a substantial burden on healthcare resources and patient quality of life [\u003cspan additionalcitationids=\"CR2 CR3 CR4\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The traditional phenotypic classification of CRS based solely on the presence or absence of nasal polyps is now considered inadequate to reflect the disease's complex heterogeneity in clinical presentation and underlying pathophysiology [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS) 2020 has introduced a pivotal, more nuanced framework for classifying CRS [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. This system first distinguishes primary from secondary CRS, then further categorizes disease by its anatomic distribution (localized vs. diffuse). For secondary CRS, etiologies are specified, including local, mechanical, inflammatory, and immunological factors. Immunodeficiency is a key etiological factor within this new paradigm. Acquired immunodeficiency syndrome (AIDS), resulting from HIV-mediated depletion of CD4\u003csup\u003e+\u003c/sup\u003e T-cells, is a classic secondary immunodeficiency [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Evidence suggests that CRS in the context of such immunodeficiencies may respond poorly to standard therapies, often requiring targeted management of the underlying immune dysfunction for optimal sinus disease control [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan additionalcitationids=\"CR11 CR12 CR13 CR14 CR15 CR16\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite the success of antiretroviral therapy (ART) in transforming HIV into a chronic condition, CRS remains a highly prevalent comorbidity, affecting up to 68% of people living with HIV (PLWH) [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan additionalcitationids=\"CR19 CR20 CR21 CR22 CR23 CR24 CR25\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. This high disease burden, coupled with the global persistence of HIV as a major public health issue, underscores the critical need to characterize CRS in PLWH through the modern lens of the EPOS2020 criteria [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. However, data on the clinical features of CRS in this specific population, classified according to this new framework, are notably scarce.\u003c/p\u003e \u003cp\u003eAs a designated national center for HIV/AIDS care in China, our institution manages a large surgical cohort of PLWH, including nearly all HIV-associated CRS requiring endoscopic sinus surgery, providing a unique population-level perspective [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Therefore, we conducted a 5-year study to characterize surgical HIV-associated CRS and to evaluate differences between unilateral and bilateral disease in clinical manifestations, peripheral blood indices, and imaging characteristics using the novel EPOS 2020 classification system.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Population\u003c/h2\u003e \u003cp\u003eThis retrospective surgical cohort was conducted at the Department of Otorhinolaryngology, Head and Neck Surgery of Beijing You\u0026rsquo;an Hospital, Capital Medical University, a designated center where nearly all surgical HIV-associated CRS in China have been managed. The study included 60 consecutive HIV-associated CRS who underwent endoscopic sinus surgery between January 2020 and June 2025. The study protocol was approved by the Ethics Committee of Beijing You'an Hospital (No. jingyoukelunzi [2025]108). Participants provided written informed consent prior to enrollment. This study was conducted in accordance with the Declaration of Helsinki and reported following the STROBE guideline for observational studies.\u003c/p\u003e \u003cp\u003eThe diagnosis of CRS was established according to the European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS) 2012 criteria, based on patient history, clinical examination, nasal endoscopy, and computed tomography (CT) findings [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The diagnosis of HIV/AIDS was based on the Guidelines for diagnosis and treatment of HIV/AIDS in China (2005) [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eInclusion and Exclusion Criteria\u003c/h3\u003e\n\u003cp\u003eInclusion criteria were: (1) age\u0026thinsp;\u0026ge;\u0026thinsp;18 years; (2) a confirmed diagnosis of CRS meeting EPOS 2012 criteria; and (3) documented HIV infection.\u003c/p\u003e \u003cp\u003eExclusion criteria were: (1) diagnosis of acute sinusitis, acute exacerbation of chronic rhinosinusitis, or acute upper respiratory infection within 4 weeks prior to enrollment;\u003c/p\u003e \u003cp\u003e(2) presence of benign or malignant tumors of the nose or sinuses; (3) history of sinus surgery within the past 6 months; (4) untreated or inadequately treated chronic infections, including parasitic infection, viral hepatitis, or syphilis; (5) pregnancy or lactation; (6) missing\u0026thinsp;\u0026gt;\u0026thinsp;50% of key data in medical records.\u003c/p\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003ePreoperative data were systematically collected from electronic medical records. Demographic and clinical variables included age, sex, smoking history, comorbidities (atopy, asthma, aspirin intolerance), history of prior sinus surgery, disease duration, and major sinonasal symptoms.\u003c/p\u003e \u003cp\u003eLaboratory data, obtained 1\u0026ndash;2 weeks preoperatively, included complete blood count, total immunoglobulin E (IgE) levels, and allergen-specific IgE testing. HIV-specific variables included viral load, peripheral blood CD4\u0026thinsp;+\u0026thinsp;T-cell count, and CD8\u0026thinsp;+\u0026thinsp;T-cell count. Co-infection status with other chronic infectious diseases was also recorded.\u003c/p\u003e \u003cp\u003eRadiological assessment was based on preoperative paranasal sinus CT scans. Imaging variables collected included the Lund-Mackay score (LMS) for sinus opacification, the ethmoid-to-maxillary sinus (E/M) ratio [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eCRS Classification\u003c/h3\u003e\n\u003cp\u003eSurgical HIV-associated CRS was classified sequentially according to the EPOS 2020 guidelines [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]:\u003c/p\u003e \u003cp\u003e \u003cstrong\u003ePrimary Categorization\u003c/strong\u003e \u003cp\u003eAll cases were classified as secondary CRS due to the underlying secondary immunodeficiency (HIV).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eAnatomic Distribution\u003c/strong\u003e \u003cp\u003eSecondary CRS was then subcategorized into bilateral or unilateral disease based on CT and endoscopic findings.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eEtiologic Subclassification\u003c/strong\u003e \u003cp\u003eWithin the bilateral and unilateral subgroups, cases were further reviewed for typical pathologic causes as defined by EPOS 2020.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eDiagnoses such as odontogenic sinusitis and fungal ball were based on clinical presentation, CT characteristics, and histopathological confirmation [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Cases associated with sinus neoplasms, given their distinct features, were excluded from the final analysis. Cases without an identifiable typical pathologic cause were classified as \"unclassified\" secondary CRS.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eAll statistical analyses were performed using SPSS 26.0 software. Continuous variables were expressed as median with interquartile range. Group comparisons (unilateral vs. bilateral CRS) for continuous variables were made using the independent samples t-test or the Mann-Whitney U test, as appropriate. Categorical variables are presented as frequencies and percentages and were compared using the χ\u0026sup2; test or Fisher's exact test. Multivariable logistic regression was used to analyze the associated factors with unilateral/bilateral CRS. A two-sided p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\"\u003e\n \u003ch2\u003eClassification of Surgical HIV-associated CRS Based on EPOS 2020 Criteria\u003c/h2\u003e\n \u003cp\u003eA total of 60 HIV-associated CRS requiring endoscopic sinus surgery were included in the analysis. According to the EPOS 2020 framework, all cases were classified as secondary CRS due to HIV-associated immunodeficiency. Based on anatomic distribution, 13 patients (21.7%) had unilateral disease and 47 (78.3%) had bilateral disease (Fig. 1).\u003c/p\u003e\n \u003cp\u003eWithin the unilateral CRS subgroup, specific etiologies were identified in a subset of cases: odontogenic sinusitis (15.4%) and chronic invasive fungal sinusitis (7.7%). In the bilateral CRS subgroup, only 2.1% of cases were attributed to allergic fungal rhinosinusitis (AFRS). Odontogenic sinusitis was exclusively observed in the unilateral group, with a prevalence significantly higher than in the bilateral group (p = 0.04). No coexisting cases of primary ciliary dyskinesia, cystic fibrosis, granulomatosis with polyangiitis, or eosinophilic granulomatosis with polyangiitis were identified in this cohort.\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eDemographic and Clinical Characteristics by Anatomical Distribution\u003c/h3\u003e\n\u003cp\u003eDemographic and clinical characteristics of the overall cohort and by disease laterality are summarized in Table 1. No significant differences were observed between the unilateral and bilateral groups regarding age, sex, smoking history, prior sinus surgery, atopy, asthma, or aspirin sensitivity.\u003c/p\u003e\n\u003cp\u003eVirological and immunological status was comparable between groups in terms of HIV duration and CD4 + T-cell counts. The median CD4 + T-cell count for the entire cohort was 575.0 cells/mm³ (IQR 501.0-768.0), with 91.7% of patients having counts \u0026gt; 350 cells/mm³. All patients were receiving antiretroviral therapy at the time of surgery. However, a statistically significant difference was found in HIV viral load between the unilateral and bilateral groups (p = 0.04).\u003c/p\u003e\n\u003cp\u003eRegarding comorbidities, syphilis co-infection was present in 36.7% of all patients, with hepatitis B and C in 5.0% and 3.3%, respectively. No significant differences in co-infection rates were observed between the unilateral and bilateral groups.\u003c/p\u003e\n\u003cp\u003eThe most common sinonasal symptoms were nasal blockage (96.7%), purulent rhinorrhea (48.3%), and hyposmia (40.0%). Patients with bilateral CRS had a significantly higher prevalence of nasal blockage and sleep disturbance compared to those with unilateral disease (p = 0.04 and p = 0.03, respectively).\u003c/p\u003e\n\u003cdiv id=\"Sec11\"\u003e\n \u003ch2\u003ePeripheral Blood Indices by Anatomical Distribution\u003c/h2\u003e\n \u003cp\u003eAnalysis of peripheral blood indices revealed significant differences in eosinophil counts between groups (Fig. 2). Both the absolute count and percentage of peripheral blood eosinophils were significantly higher in the bilateral CRS group compared to the unilateral group (p \u0026lt; 0.001 for both). The neutrophil percentage was lower in the bilateral group and this difference was statistically significant (p = 0.02).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\"\u003e\n \u003ch2\u003eImaging Findings by Anatomical Distribution\u003c/h2\u003e\n \u003cp\u003ePreoperative CT imaging findings are summarized in Fig. 3. The Lund-Mackay CT score was significantly higher in the bilateral CRS group compared to the unilateral group (p = 0.007). Similarly, the ethmoid-to-maxillary sinus (E/M) ratio was significantly higher in the bilateral group (p = 0.04). The incidence of nasal septum deviation did not differ significantly between groups.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\"\u003e\n \u003ch2\u003eMultivariable Analysis of Factors Associated with Bilateral CRS\u003c/h2\u003e\n \u003cp\u003eA multivariable logistic regression model was constructed to identify factors independently associated with bilateral (as opposed to unilateral) CRS (Table 2). To reflect demographic characteristics, infection status of PLWH, disease features of CRS and imaging information, age, CD4 + T-cell count, CD8 + T-cell count, neutrophil percentage, and E/M ratio were included in the multivariable logistic regression model. After adjusting for age, CD4 + T-cell count, CD8 + T-cell count, neutrophil percentage, and E/M ratio, only a higher Lund-Mackay CT score (adjusted odds ratio [aOR], 1.60; 95% CI, 1.02–2.51; p = 0.04) and a higher peripheral blood eosinophil percentage (aOR, 2.27; 95% CI, 1.01–5.14; p = 0.05) emerged as independent risk factors for bilateral disease (Table 2).\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eTo our knowledge, this study represents the first comprehensive characterization of surgical HIV-associated CRS using the standardized EPOS 2020 diagnostic criteria. Conducted at a designated national HIV/AIDS care center in China, our research draws from a large, representative cohort that includes nearly all surgical HIV-associated CRS nationwide, thereby offering a unique population-level perspective. By systematically applying the EPOS 2020 criteria, we identified clear distinctions between unilateral and bilateral CRS in this immunocompromised population\u0026mdash;including clinical, radiological, and hematological differences. Notably, bilateral disease was associated with more extensive radiographic involvement and a systemic eosinophilic response, suggesting a potentially distinct endotype of HIV-associated CRS that may underlie its pathophysiology.\u003c/p\u003e \u003cp\u003eThe epidemiological landscape of surgical HIV-associated CRS, particularly the proportion of secondary causes, remains underexplored[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Our study fills a critical gap by quantifying the anatomical distribution in PLWH: bilateral CRS was predominant (78.3%), while localized disease accounted for 21.7% of cases. This distribution contrasts with a recent Taiwanese study where secondary CRS was primarily attributed to localized etiologies, with immunodeficiency being a rare cause (0.3%)[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. This discrepancy underscores significant interregional and interhospital variations in CRS classification and etiology, likely influenced by genetic and environmental factors that affect the prevalence of und30, 31].\u003c/p\u003e \u003cp\u003e Notably, all patients in our cohort were receiving oral ART. Compared to our previous study, recent heightened awareness and adherence to ART treatment in China was evident[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The vast majority (91.7%) had well-preserved immunologic function (CD4\u003csup\u003e+\u003c/sup\u003e count\u0026thinsp;\u0026gt;\u0026thinsp;350 cells/mm\u0026sup3;), with a median (IQR) of 575.0 (501.0-768.0) cells/mm\u0026sup3;[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. This suggests that CRS can manifest across the spectrum of immune recovery in PLWH. While ART effectively suppresses viral replication and restores CD4\u003csup\u003e+\u003c/sup\u003e counts, persistent immune activation and senescence may contribute to the unique pathophysiology of HIV-associated CRS, warranting specific clinical attention[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan additionalcitationids=\"CR33\" citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA key objective was to compare unilateral and bilateral surgical HIV-associated CRS. Univariate analysis revealed significant differences in HIV viral load, odontogenic causes, symptoms of nasal obstruction and sleep disturbance, peripheral blood eosinophil counts/percentages, neutrophil percentage, and CT scores. After adjusting for covariates in a multivariate model, peripheral blood eosinophil percentage and total CT score emerged as independent predictors for bilateral disease. This hematologic profile\u0026mdash;elevated eosinophils and lower neutrophils in bilateral CRS\u0026mdash;suggests a potential shift toward type 2 inflammation in bilateral cases, whereas unilateral CRS may be more frequently linked to non-type 2 mechanisms, such as bacterial or odontogenic infections. This aligns with growing evidence on the utility of peripheral blood eosinophils in CRS endotyping [\u003cspan additionalcitationids=\"CR36 CR37 CR38\" citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e], though the underlying mechanisms in the context of HIV require further elucidation.\u003c/p\u003e \u003cp\u003eRadiologically, bilateral CRS was associated with significantly higher Lund-Mackay scores, indicating more extensive sinus involvement. This finding is consistent with some prior reports of more severe radiographic disease in immunocompromised hosts [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e], though direct comparisons are complicated by population heterogeneity, such as a recent study of Molokomme restricted to HIV-negative vs HIV-positive nasal polyps [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRegarding symptomatology, the symptomatology of CRS in PLWH appears largely comparable to that of the immunocompetent population [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Notably, although one study identified a greater frequency of fever and postnasal discharge in AIDS patients, both that study and an independent comparison by Porter et al. concluded that the symptoms and severity of CRS were similar between HIV-infected groups and, critically, between seropositive patients with or without AIDS[\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. In our study, nasal obstruction, purulent rhinorrhea, and hyposmia were most common. As expected, nasal blockage and sleep disturbance were significantly more prevalent in the bilateral group\u0026mdash;a finding not previously detailed in this specific population.\u003c/p\u003e \u003cp\u003eWhile HIV-infected individuals can present with a broad spectrum of fungal sinusitis, our study intriguingly revealed the incidence of fungal sinusitis in our cohort was lower than that of the general population [\u003cspan additionalcitationids=\"CR44 CR45 CR46 CR47 CR48 CR49\" citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. Notably, no fungal ball was found in our study, which was relatively more prevalent in the immonocompetent host [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. Although fungi are major contributors to the opportunistic infections that threaten patients with HIV infection, fungal sinusitis has been relatively uncommon in PLWH [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan additionalcitationids=\"CR54\" citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e]. Invasive fungal sinusitis is a rare and life-threatening opportunistic infection in PLWH that occurs predominantly in those with low CD4 cell counts, nonsuppressed HIV ribonucleic acid (RNA) levels, and in those not receiving ART [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e]. The post-ART era has seen a marked decline in invasive fungal sinusitis among PLWH, a trend potentially reflected in our findings and possibly influenced by regional HIV/AIDS policies and host immune factors [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis study has several limitations. Firstly, its single-center, retrospective design inherently risks selection bias and unmeasured confounding. Secondly, the modest sample size, though substantial for this specific population, may limit the generalizability of our findings. Thirdly, the absence of an HIV-negative control group with CRS precludes direct comparisons to determine HIV-specific disease features. Future prospective, multi-center studies with larger, diverse cohorts are needed to validate these findings and further explore the pathophysiological mechanisms of surgical HIV-associated CRS.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn this cohort of patients with HIV-associated CRS requiring surgery, bilateral disease was the predominant presentation. Bilateral disease was associated with more severe radiographic involvement and a systemic eosinophilic response, suggesting a differing underlying pathophysiology, potentially driven by type 2 (T2) inflammation. In contrast, unilateral disease presented with less radiographic severity and lacked a pronounced systemic inflammatory signature. These findings highlight the clinical relevance of the EPOS 2020 criteria in a comorbid population and underscore the need for phenotype-driven management strategies to optimize therapeutic outcomes in surgical HIV-associated CRS.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Ethics Committee of Beijing You'an Hospital (No. jingyoukelunzi [2025]108) in accordance with the standards of the Declaration of Helsinki. Participants provided written informed consent prior to enrollment.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by Young Investigator Grant in Beijing You'an Hospital Affiliated to Capital Medical University (BJYAYY-YN2023-03), China University Industry-University-Research Innovation Fund (2024GR101), National Natural Science Foundation of China (82171110, 82471137) and High Level Public Health Technical Talent Training Plan (Lingjunrencai-01-08).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by S.S., X.W.G. and M.Z.. All authors drafted the initial manuscript. All authors critically revised the manuscript for important intellectual content. All authors read and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe are grateful to the individuals who volunteered to contribute to this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eShao S, Zheng M, Wang X, et al. Asia-Pacific survey of physicians\u0026rsquo; perceptions and managements of chronic rhinosinusitis. 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Clinicopathologic characteristics of paranasal sinus fungus ball: retrospective, multicenter study in Korea. Eur Arch Otorhinolaryngol. 2020;277(3):761\u0026ndash;765. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00405-019-05738-5\u003c/span\u003e\u003cspan address=\"10.1007/s00405-019-05738-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCostacurta MRR, Orlandini RK, Rocha AC de SD da, et al. Are Candida albicans isolates from people living with HIV more resistant to antifungals? A systematic review and meta-analysis. 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Medicine (Baltimore). 2003;82(1):39\u0026ndash;50. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/00005792-200301000-00004\u003c/span\u003e\u003cspan address=\"10.1097/00005792-200301000-00004\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChin-Hong PV, Sutton DA, Roemer M, Jacobson MA, Aberg JA. Invasive fungal sinusitis and meningitis due to Arthrographis kalrae in a patient with AIDS. J Clin Microbiol. 2001;39(2):804\u0026ndash;807. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1128/JCM.39.2.804-807.2001\u003c/span\u003e\u003cspan address=\"10.1128/JCM.39.2.804-807.2001\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1. Demographic Data and Clinical Characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 31px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCRS (n=60)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUnilateral CRS (n=13)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBilateral CRS (n=47)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep value\u003csup\u003ea\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDemographic information\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 31px;\"\u003e\n \u003cp\u003eGender, male, No. (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e57 (95.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e12 (92.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e45 (95.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.53\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 31px;\"\u003e\n \u003cp\u003eAge, median (IQR), y\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e36.0 (31.3 to 47.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e36.0 (31.0 to 45.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e36.0 (32.0 to 47.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 31px;\"\u003e\n \u003cp\u003eSmoking, No. (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e15 (25.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e3 (23.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e12 (25.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInfection status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 31px;\"\u003e\n \u003cp\u003eDuration of HIV, median (IQR), m\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e78.0 (36.0 to 120.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e84.0 (42.0 to 132.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e72.0 (36.0 to 120.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.74\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 31px;\"\u003e\n \u003cp\u003eDetectable HIV viral load\u003csup\u003eb\u003c/sup\u003e, No. (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e2 (3.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e2 (15.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.04\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 31px;\"\u003e\n \u003cp\u003eAntiretroviral therapy, No. (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e60 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e13 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e47 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 31px;\"\u003e\n \u003cp\u003eCD4-positive cell count, median (IQR), cells/mm\u0026sup3;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e575.0 (501.0 to 768.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e556.0 (481.0 to 752.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e588.5 (510.0 to 778.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.63\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 19px;\"\u003e\n \u003cp\u003eCD4-positive cell counts classification, No. (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e\u0026gt;350\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e55 (91.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e12 (92.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e43 (91.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 8px;\"\u003e\n \u003cp\u003e0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e250-350\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e4 (6.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e1 (7.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e3 (6.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e\u0026lt;250\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e1 (1.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e1 (2.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 31px;\"\u003e\n \u003cp\u003eCD8-positive cell count, median (IQR), cells/mm\u0026sup3;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e684.0 (535.0 to 1000.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e824.0 (653.0 to 1259.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e652.0 (501.5 to 916.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.15\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 31px;\"\u003e\n \u003cp\u003eCD4/CD8, median (IQR), cells/mm\u0026sup3;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e0.83 (0.59 to 1.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e0.77 (0.55 to 0.96)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e0.88 (0.63 to 1.35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.33\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" style=\"width: 100px;\"\u003e\n \u003cp\u003eCo-infections\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 31px;\"\u003e\n \u003cp\u003eSyphilis, No. (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e22 (36.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e4 (30.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e18 (38.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.86\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 31px;\"\u003e\n \u003cp\u003eHepatitis B, No. (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e3 (5.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e3 (6.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 31px;\"\u003e\n \u003cp\u003eHepatitis C, No. (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e2 (3.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e2 (4.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eClinical characteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 31px;\"\u003e\n \u003cp\u003ePrevious sinus surgeries, No. (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e7 (11.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e1 (7.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e6 (12.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 31px;\"\u003e\n \u003cp\u003eAtopy, No. (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e18 (30.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e2 (15.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e16 (34.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.34\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 31px;\"\u003e\n \u003cp\u003eAsthma, No. (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e4 (6.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e1 (7.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e3 (6.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 31px;\"\u003e\n \u003cp\u003eAspirin sensitivity, No. (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e1 (1.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e1 (2.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 31px;\"\u003e\n \u003cp\u003eDuration of CRS, median (IQR), m\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e36.0 (4.3 to 60.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e12.0 (4.0 to 36.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e36.0 (4.0 to 84.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 31px;\"\u003e\n \u003cp\u003eOdontogenic sinusitis, No. (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e2 (3.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e2 (15.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e0\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.04\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 31px;\"\u003e\n \u003cp\u003eFungal sinusitis, No. (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e2 (3.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e1 (7.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e1 (2.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.39\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" style=\"width: 100px;\"\u003e\n \u003cp\u003eSymptomatology\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 31px;\"\u003e\n \u003cp\u003eNasal blockage, No. (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e58 (96.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e11 (84.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e47 (100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.04\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 31px;\"\u003e\n \u003cp\u003ePurulent rhinorrhea, No. (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e29 (48.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e9 (69.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e20 (42.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 31px;\"\u003e\n \u003cp\u003ePostnasal drip, No. (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e4 (6.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e1 (7.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e3 (6.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 31px;\"\u003e\n \u003cp\u003eHyposmia, No. (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e24 (40.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e4 (30.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e20 (42.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.44\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 31px;\"\u003e\n \u003cp\u003eHeadache, No. (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e17 (28.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e6 (46.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e11 (23.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.21\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 31px;\"\u003e\n \u003cp\u003eFacial pain or pressure, No. (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e13 (21.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e2 (15.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e11 (23.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.81\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 31px;\"\u003e\n \u003cp\u003eSleep disturbance, No. (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e22 (36.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e1 (7.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e21 (44.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.03\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 31px;\"\u003e\n \u003cp\u003eEpistaxis, No. (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e8 (13.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e3 (23.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e5 (10.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.48\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 31px;\"\u003e\n \u003cp\u003eRhinocnesmus, No. (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e3 (5.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e1 (7.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e2 (4.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.53\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 31px;\"\u003e\n \u003cp\u003eSneezing, No. (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e19 (31.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e6 (46.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e13 (27.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.35\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 31px;\"\u003e\n \u003cp\u003eWatery rhinorrhea, No. (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e13 (21.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e2 (15.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e11 (23.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.81\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePeripheral blood\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 31px;\"\u003e\n \u003cp\u003eEosinophil count, median (IQR), 10^9 cells/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e0.13 (0.07 to 0.26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e0.06 (0.04 to 0.09)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e0.15 (0.09 to 0.27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 31px;\"\u003e\n \u003cp\u003eEosinophil percentage, median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e1.9 (1.0 to 3.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e0.8 (0.5 to 1.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e2.6 (1.5 to 4.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 31px;\"\u003e\n \u003cp\u003eNeutrophil count, median (IQR), 10^9 cells/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e3.28 (2.66 to 4.49)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e3.43 (2.78 to 7.86)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e3.24 (2.56 to 4.30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 31px;\"\u003e\n \u003cp\u003eNeutrophil percentage, median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e55.4 (49.2 to 62.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e59.3 (52.9 to 70.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e53.7 (48.9 to 60.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.02\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eImaging\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 31px;\"\u003e\n \u003cp\u003eCT score, median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e7 (4.3 to 11.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e5.0 (4.0 to 6.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e9.0 (5.0 to 13.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.007\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 31px;\"\u003e\n \u003cp\u003eE/M ratio, median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e1 (0.5 to 2.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e1 (0.5 to 1.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e1 (1.0 to 2.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.04\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 31px;\"\u003e\n \u003cp\u003eConcha bullosa, No. (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e23 (38.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e5 (38.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e18 (38.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 31px;\"\u003e\n \u003cp\u003eNasal septum deviation, No. (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e44 (73.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e7 (53.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e37 (78.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0.15\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbbreviations: IQR, interquartile range; CRSwNP, chronic rhinosinusitis with nasal polyps;\u0026nbsp;HIV,\u0026nbsp;human immunodeficiency virus;\u0026nbsp;CD4, cluster of differentiation 4; CD8, cluster of differentiation 8; CT, computerized tomography;\u0026nbsp;E/M,\u0026nbsp;ethmoid-to-maxillary sinus. NA, not applicable.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003ea\u003c/sup\u003e The p value indicated the differences between patients of unilateral CRS and bilateral CRS, and p value less than .05 were considered to indicate statistical significance.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003eb\u003c/sup\u003e Detectable HIV viral load is shown in the table as \u0026lsquo;HIV viral load more than 40 copies/mL\u0026rsquo;.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Multivariate logistic regression analysis of influencing factors in patients with unilateral/bilateral CRS\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eaOR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95%CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33px;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e0.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e(0.90 to 1.11)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33px;\"\u003e\n \u003cp\u003eCD4-positive cell count\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e0.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e(1.00 to 1.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33px;\"\u003e\n \u003cp\u003eCD8-positive cell count\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e(1.00 to 1.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33px;\"\u003e\n \u003cp\u003eEosinophil percentage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e0.05\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e2.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e(1.01 to 5.14)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33px;\"\u003e\n \u003cp\u003eNeutrophil percentage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e0.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e(0.91 to 1.09)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33px;\"\u003e\n \u003cp\u003eCT score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e0.04\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e1.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e(1.02 to 2.51)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33px;\"\u003e\n \u003cp\u003eE/M ratio\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e0.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e0.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e(0.13 to 3.43)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbbreviations: aOR, adjusted odds ratio; CI, confidence interval; CD4, cluster of differentiation 4; CD8, cluster of differentiation 8; CT, computerized tomography; E/M, ethmoid-to-maxillary sinus.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003ea\u003c/sup\u003e The p value less than .05 was considered to emerge as independent risk factors for bilateral disease.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-medical-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejmr","sideBox":"Learn more about [European Journal of Medical Research](http://eurjmedres.biomedcentral.com)","snPcode":"40001","submissionUrl":"https://submission.nature.com/new-submission/40001/3","title":"European Journal of Medical Research","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Chronic rhinosinusitis, HIV, EPOS 2020, Bilateral","lastPublishedDoi":"10.21203/rs.3.rs-8417222/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8417222/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS) 2020 classification for chronic rhinosinusitis (CRS) lacks validation in people living with HIV (PLWH), a population with a high burden of sinonasal disease. This study aimed to phenotype surgical HIV-associated CRS and compare bilateral versus unilateral disease.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis single-center, population-based cohort study included 60 consecutive patients with HIV-associated CRS requiring endoscopic sinus surgery between January 2020 and June 2025 at Beijing You\u0026rsquo;an Hospital, a national designated center where nearly all HIV-associated CRS surgical cases have been managed in China. Demographic, clinical, laboratory (including eosinophil/neutrophil counts), and radiological (Lund-Mackay score, E/M ratio) factors were analyzed. Univariate and multivariable logistic regression identified associations with bilateral CRS.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe cohort comprised 60 PLWH (median age 36.0 years; 95.0% male), with bilateral CRS being predominant (78.3%). Univariate analysis revealed significant differences between bilateral and unilateral CRS in eosinophil parameters (both count and percentage: p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), neutrophil percentage (p\u0026thinsp;=\u0026thinsp;0.018), Lund-Mackay CT scores (p\u0026thinsp;=\u0026thinsp;0.007), and the ethmoid-to-maxillary sinus ratio (p\u0026thinsp;=\u0026thinsp;0.037). On multivariable analysis, bilateral disease remained independently associated with a higher Lund-Mackay CT score (adjusted odds ratio [aOR]\u0026thinsp;=\u0026thinsp;1.60, 95% CI: 1.02\u0026ndash;2.51, p\u0026thinsp;=\u0026thinsp;0.043) and an elevated blood eosinophil percentage (aOR\u0026thinsp;=\u0026thinsp;2.27, 95% CI: 1.01\u0026ndash;5.14, p\u0026thinsp;=\u0026thinsp;0.049).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eIn PLWH, bilateral CRS is the dominant phenotype. Its association with radiographic severity and a type 2 inflammatory marker supports the use of the EPOS 2020 anatomic classification in this population.\u003c/p\u003e","manuscriptTitle":"Bilateral vs Unilateral Chronic Rhinosinusitis in HIV: Distinct Phenotypes from a Surgical Cohort","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-16 08:47:42","doi":"10.21203/rs.3.rs-8417222/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-15T20:25:56+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-16T14:26:49+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-13T02:11:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"134799494024974687670603467917259870348","date":"2026-01-13T02:01:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"244086707411734888827768921243145503388","date":"2026-01-10T10:49:01+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-09T12:53:19+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-26T09:56:47+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-26T09:54:48+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Journal of Medical Research","date":"2025-12-21T12:27:36+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-medical-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejmr","sideBox":"Learn more about [European Journal of Medical Research](http://eurjmedres.biomedcentral.com)","snPcode":"40001","submissionUrl":"https://submission.nature.com/new-submission/40001/3","title":"European Journal of Medical Research","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a782892f-d222-4484-a2ad-fc7dd34de9cc","owner":[],"postedDate":"January 16th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-13T14:38:01+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-16 08:47:42","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8417222","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8417222","identity":"rs-8417222","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}