Analysis of nasal secretion culture results in diabetic patients with chronic rhinosinusitis and factors influencing postoperative recurrence

Abstract

BACKGROUND

In diabetic patients, persistent hyperglycemia creates an optimal environment for the proliferation of pathogenic bacteria, resulting in severe complications. Consequently, chronic rhinosinusitis (CRS) complicated by diabetes is highly prevalent in clinical settings.

AIM

To analyze the results of nasal secretion cultures in diabetic patients with CRS and identify the factors influencing postoperative recurrence.

METHODS

A retrospective analysis was conducted on the clinical data of 203 diabetic patients with CRS with nasal polyps who underwent the Messerklinger technique at Qingdao Hiser Hospital Affiliated of Qingdao University between January 2021 and January 2023. Preoperative nasal secretions were cultured to determine the types and distribution of pathogenic bacteria and assess antimicrobial susceptibility. Based on a one-year follow-up, patients were categorized into recurrence and nonrecurrence groups to analyze differences in their clinical data. Univariate and multivariate analyses were used to identify factors influencing postoperative recurrence.

RESULTS

Pathogens were detected in 153 of the 203 nasal secretion specimens collected from diabetic patients with CRS. A total of 134 pathogenic bacteria strains were isolated and identified, including 81 strains (60.4%) of gram-positive bacteria and 53 strains (39.6%) of gram-negative bacteria. Gram-positive bacteria exhibited relatively high resistance to penicillin G and erythromycin, while remaining highly sensitive to vancomycin, gentamicin, and rifampicin. Gram-negative bacteria demonstrated relatively high resistance to cefazolin and gentamicin, but showed high sensitivity to imipenem, meropenem, cefepime, and ceftazidime. Univariate analysis revealed statistically significant differences between the recurrence and nonrecurrence groups in fasting blood glucose levels, smoking history, Lund-Mackay scores, visual analog scale (VAS) scores, nasal septum deviation, allergic rhinitis, bronchial asthma, postoperative infection, long-term use of nasal decongestants, and adherence to medical prescriptions. Multivariate regression analysis identified fasting blood glucose levels and VAS-measured nasal symptom severity scores as independent factors influencing postoperative recurrence.

CONCLUSION

In CRS patients with nasal polyps (CRSwNP), the detection rate of nasal pathogens is relatively high, and most of the isolated bacteria exhibit antimicrobial resistance. Additionally, the blood glucose level of patients with CRS combined with CRSwNP is a risk factor for postoperative recurrence.

Key Words: Diabetes; Chronic rhinosinusitis; Nasal secretions; Pathogen; Postoperative recurrence

Core Tip: Chronic rhinosinusitis (CRS) is a common clinical condition in patients with diabetes, and is associated with environmental factors and reduced host immunity. It not only impairs normal nasal function but may also cause the spread of infection to intracranial tissues, worsening the patient’s condition. Therefore, timely surgical intervention is essential. This study examined the nasal secretion culture results in diabetic patients with CRS and identified key factors influencing postoperative recurrence.

INTRODUCTION

Chronic rhinosinusitis (CRS) is one of the most prevalent chronic inflammatory diseases, affecting approximately 10% of the global population[1]. It is a heterogeneous condition characterized by persistent inflammation of the upper respiratory tract and paranasal sinuses lasting at least 12 weeks, often leading to significant impairment in quality of life[2,3]. The upper respiratory tract plays a vital role in filtering and conditioning inhaled air before it enters the lower respiratory system. The anterior nares, or nasal vestibule, is a relatively dry environment lined with squamous epithelial cells and equipped with sebaceous glands and vibrissae, which remove large particulate matter from the inhaled air[4]. Smaller particles, including bacteria and hydrophilic aerosolized compounds, are trapped by a mucus layer that covers the nasal mucosa and paranasal sinuses. The ciliary function of the nasal mucosa serves as a crucial host defense mechanism for clearing these inhaled particles. Impaired mucociliary clearance-a hallmark of CRS-may contribute to bacterial colonization and the perpetuation of local inflammation[5,6].

Diabetes is a highly prevalent chronic disease in clinical settings. It is well established that the disease results from impaired and insufficient insulin secretion, ultimately leading to a chronic metabolic disorder characterized by persistent hyperglycemia[7,8]. Due to prolonged hyperglycemia and metabolic dysregulation, patients with diabetes typically exhibit compromised immunity, rendering them more susceptible to pathogenic infections. Moreover, a chronic hyperglycemic environment supports the growth and survival of pathogenic microorganisms, further increasing their susceptibility to disease development[9]. Several studies have reported that the cooccurrence of CRS in patients with diabetes is relatively common and that its development is significantly associated with both environmental factors and impaired host immunity[10].

In addition to antibacterial agents, CRS treatment involves surgical intervention[11,12]. However, the abuse of antibiotics has led to the emergence of antimicrobial resistance in various pathogenic bacteria[13-15], thereby reducing treatment efficacy and significantly impacting patient health. Patients with diabetes, in particular, often exhibit weakened stress responses, impaired immune defenses, reduced surgical tolerance, and pathophysiological disturbances, such as water-electrolyte imbalance, posing challenges for intraoperative anesthesia, surgical procedures, and postoperative care. Although numerous studies have confirmed that the advent of endoscopic sinus surgery has markedly improved therapeutic outcomes in CRS, recurrence rates remain relatively high[16]. Ample research suggests that postoperative recurrence in CRS is driven by the interplay of multiple contributing factors[17]. Therefore, this study retrospectively analyzed the surgical management of diabetic patients with CRS, examining the types, distribution, and antimicrobial susceptibility patterns of preoperative nasal secretions, as well as the factors influencing postoperative recurrence, with the aim to provide some references for effective clinical nursing.

MATERIALS AND METHODS

Research subjects

A retrospective analysis was performed on the clinical data of 203 patients with diabetes who underwent surgery for CRS with nasal polyps (CRSwNP) at Qingdao Hiser Hospital Affiliated of Qingdao University, between January 2021 and January 2023. The inclusion criteria were as follows: (1) Patients met the relevant diagnostic criteria outlined in the "Guidelines for Diagnosis and Treatment of CRS", confirmed through surgical and pathological findings; the diagnostic criteria for diabetes were also met; (2) Patients underwent successful surgery at our hospital and had no prior history of endoscopic sinus surgery; (3) Patients underwent pathogen identification and culturing prior to the surgery and had no history of antibiotic use within two weeks prior to the identification; and (4) Complete clinical records and follow-up data were available, and the patient completed a one-year follow-up. The exclusion criteria were as follows: (1) Usage of antibiotics within two weeks before pathogen identification; (2) Presence of nasal or sinus tumors or congenital immunodeficiency disorders; (3) Presence of fungal sinusitis; (4) Presence of genetic or metabolic diseases; and (5) Presence of incomplete clinical or follow-up data.

Diagnostic criteria

The diagnostic criteria for diabetes: Diagnosis was based on a fasting blood glucose level ≥ 7.0 mmol/L or a 2-hour postprandial blood glucose level ≥ 11.10 mmol/L, accompanied by typical hyperglycemia symptoms. Diagnostic criteria for CRS: Presence of clinical symptoms such as nasal congestion, purulent nasal discharge, headache, and olfactory impairment persisting for more than three months; Evidence of lesions in the upper nasal cavity, including turbinate edema, hypertrophy, or nasal polyps; Signs of congestion or ethmoid bulla edema observed via nasal endoscopy; Presence of diffuse mucosal thickening on computed tomography (CT) or plain sinus films, including mucosal thickening > 5 mm or opacity in multiple sinuses.

Culture medium identification and antimicrobial susceptibility testing of pathogenic bacteria

Nasal endoscopy was performed on each patient. Under direct visualization, a sterile swab was used to collect secretions from the sinuses or sinus ostia. The swab was then placed into a sterile test tube and immediately sent for laboratory analysis. The specimens were inoculated onto agar plates and incubated at a constant temperature of 35 °C for 18-24 hours. The isolation of bacterial strains was conducted in strict accordance with the “National Clinical Laboratory Operating Protocols”. A fully automated bacterial identification system was used to identify the strains, and the types and distributions of pathogenic bacteria in nasal secretions were recorded. Antimicrobial susceptibility testing was performed using the Kirby-Bauer disc diffusion method. Susceptibility results were interpreted as susceptible, intermediate, or resistant according to the standards established by the Clinical and Laboratory Standards Institute, United States.

Surgical approaches

All patients underwent routine fasting blood glucose and urine glucose testing prior to nasal endoscopy and received coordinated care with endocrinologists to manage glycemic levels using either oral hypoglycemic drugs or insulin. Surgery was scheduled once glycemic levels were was stabilized to < 7.0 mmol/L. Given that the surgery required general anesthesia, insulin therapy was transitioned to short-acting agents three days before the surgery. On the day of surgery or during the early postoperative period, rapid-acting insulin was administered, with dosages adjusted according to blood and urine glucose test results. Additionally, patients received preoperative treatments beginning three days prior, including anti-inflammatory therapy and nasal glucocorticoid sprays.

Surgical intervention

All surgeries were performed under general anesthesia using the Messerklinger technique. Following the resection of nasal polyps and the uncinate process, the ethmoid bulla was exposed. The ethmoid, frontal, and sphenoid sinuses were opened, and the natural ostium of the maxillary sinus was enlarged to allow for the removal of diseased tissues. In cases in which a deviated nasal septum or significant polypoid changes in the middle turbinate impeded sinus drainage, septoplasty and partial resection of the middle turbinate were performed. Care was taken throughout the procedure to minimize damage to the normal sinus mucosa. Postoperatively, following the removal of nasal packing, the nasal cavity was irrigated with 0.9% sodium chloride solution at 35 °C. Nasal glucocorticoids were administered as spray therapy for 24 weeks.

Patient data collection

A one-year postoperative follow-up was performed, and patients were grouped according to recurrence status. If symptoms of recurrence were identified during reexamination or follow-up within one-year, immediate endoscopic or sinus CT reexamination was performed. Cases with confirmed recurrence were classified into the recurrence group, and their follow-up was immediately terminated. The most recent test results were used as the final data for analysis. The recurrence group included patients with uncontrolled conditions, defined by the absence of symptom resolution or significant improvement, no significant differences in clinical scores compared with baseline, and an insignificant decrease in the total Lund-Mackay score. Postoperative endoscopic examination revealed mucosal congestion and edema, polyp formation or connective tissue hyperplasia, extensive adhesions, sinus ostium stenosis or atresia, and the presence of viscous or mucopurulent secretions. The nonrecurrence group comprised patients with either fully or partially controlled conditions.

General patient data were collected, including age, sex, body mass index, duration of diabetes, fasting blood glucose level, smoking history, alcohol consumption history, Lund-Mackay CT score of the sinuses, and subjective pain score (assessed using the VAS). CT scoring was performed for the bilateral maxillary sinuses, anterior and posterior ethmoid sinuses, sphenoid sinus, frontal sinus, and ostiomeatal complex. A score of 0 indicated no sinus shadow, 1 indicated partial shadow, and 2 indicated complete shadow. For the ostiomeatal complex, 0 indicated no shadow and 2 indicated the presence of a shadow. The total score was 0-24, with higher scores indicating worse conditions. Surgical-related data included operation duration and the amount of intraoperative blood loss. Information regarding allergic rhinitis, bronchial asthma, history of middle turbinectomy, postoperative infection, and long-term use of nasal decongestants was also collected. Postoperative patient-related factors included mental state (assessed using the Hamilton Anxiety Scale, with scores > 7 indicating the presence of anxiety) and adherence to prescribed medications.

Statistical analysis

Data were analyzed using SPSS 25.0. Categorical variables were expressed as counts and percentages, and comparisons between groups were performed using the χ² test. Continuous variables, assumed to follow a normal distribution, were expressed as mean ± SD and compared using t-test. Variables that showed statistically significant differences in the univariate analysis were further assessed in the multivariate logistic regression analysis to identify independent risk factors associated with recurrence after nasal endoscopic surgery. A P value < 0.05 was considered statistically significant.

RESULTS

Analysis of pathogenic bacteria

Bacteriological examination detected pathogenic bacteria in 153 of the 203 nasal secretion samples from diabetic patients with CRS, yielding a positive rate of 75.4%. A total of 134 aerobic bacterial strains were isolated and identified. Of these, 81 strains (60.4%) were gram-positive, predominantly Staphylococcus epidermidis, S. aureus, and S. hominis. The remaining 53 strains (39.6%) were gram-negative, primarily Enterobacter aerogenes, Klebsiella pneumoniae, and Escherichia coli. Table 1 shows the distribution of isolated pathogenic bacteria.

Table 1 Distribution and composition ratio of pathogenic bacteria.

Pathogenic bacteria	Number of strains	Composition ratio (%)
Gram-positive bacteria	81	60.4
Staphylococcus epidermidis	35	26.1
Staphylococcus aureus	24	17.9
Staphylococca hominis	8	6.0
Streptococcus pneumoniae	6	4.5
Staphylococcus saprophyticus	5	3.7
Staphylococcus haemolyticus	3	2.2
Gram-negative bacteria	53	39.6
Enterobacter aerogenes	16	11.9
Klebsiella pneumoniae	11	8.2
Escherichia coli	10	7.5
Enterobacter cloacae	8	6.0
Pseudomonas aeruginosa	6	4.5
Proteus mirabilis	2	1.5

Antimicrobial susceptibility of gram-positive bacteria

Gram-positive bacteria exhibited resistance rates of 86.4% to penicillin G and 75.3% to erythromycin. Their susceptibilities to vancomycin, gentamicin, rifampicin, levofloxacin, and tetracycline were 97.5%, 71.6%, 69.1%, 66.7%, and 63.0%, respectively (Table 2).

Table 2 Antimicrobial susceptibility test results of 81 strains of Gram-positive bacteria.

Drug	Resistant		Intermediate		Susceptible
	Number of bacterial strains	Resistance rate	Number of bacterial strains	Resistance rate	Number of bacterial strains	Susceptibility rate
Penicillin G	70	86.4	0	0	11	13.6
Erythromycin	61	75.3	0	0	20	24.7
Chloramphenicol	35	43.2	4	4.9	42	51.9
Vancomycin	0	0.0	2	2.5	79	97.5
Ciprofloxacin	30	37.0	15	18.5	36	44.5
Tetracycline	29	35.8	1	1.2	51	63.0
Gentamycin	20	24.7	3	3.7	58	71.6
Levofloxacin	18	22.2	9	11.1	54	66.7
Rifampicin	25	30.9	0	0	56	69.1
Sulfamethoxazole/trimethoprim	26	32.1	11	13.6	44	54.3

Antimicrobial susceptibility of gram-negative bacteria

Gram-negative bacteria exhibited resistance rates of 94.3% to cefazolin, 69.8% to gentamicin, and 50.9% to ampicillin. Their susceptibilities to imipenem, meropenem, cefepime, ceftazidime, and amikacin were 100.0%, 94.3%, 92.4%, 92.4%, and 88.7%, respectively (Table 3).

Table 3 Susceptibility test results of 53 strains of Gram-negative bacteria.

Drug	Resistant		Intermediate		Susceptible
	Number of bacterial strains	Resistance rate	Number of bacterial strains	Resistance rate	Number of bacterial strains	Susceptibility rate
Cefazolin	50	94.3	3	5.7	0	0
Cefepime	3	5.7	1	1.9	49	92.4
Ceftazidime	2	3.8	2	3.8	49	92.4
Cefoperazone	4	7.5	8	15.1	41	77.4
Gentamycin	37	69.8	3	5.7	13	24.5
Ampicillin	27	50.9	2	3.8	24	45.3
Amikacin	6	11.3	0	0.0	47	88.7
Imipenem	0	0.0	0	0.0	53	100.0
Aztreonam	21	39.6	4	7.5	28	52.9
Meropenem	3	5.7	0	0.0	50	94.3
Piperacillin	22	41.5	0	0.0	31	58.5

Univariate analysis of postoperative recurrence

Univariate statistical analysis revealed that fasting blood glucose level, smoking history, Lund-Mackay score, VAS-measured nasal symptom severity scores, nasal septum deviation, allergic rhinitis, bronchial asthma, postoperative infection, long-term use of nasal decongestants, and adherence to prescribed medications differed significantly between patients with and without recurrence (P < 0.05; Table 4).

Table 4 Comparison of clinical data between recurrence and non-recurrence groups.

	Recurrence group (n = 40)	Non-recurrence group (n = 163)	χ2/t	P value
Gender			0.774	0.379
Male	22	77
Female	18	86
Age	46.93 ± 7.78	44.32 ± 10.16	1.516	0.131
Body mass index (kg/m2)	23.39 ± 2.34	23.41 ± 2.20	0.052	0.958
Course of diabetes (year)	6.57 ± 0.31	6.46 ± 0.47	1.337	0.183
Preoperative glycated hemoglobin level (%)	8.62 ± 1.75	8.37 ± 0.89	1.268	0.206
Fasting blood glucose level (mmol/L)	11.05 ± 1.87	8.22 ± 0.67	15.73	< 0.0001
Smoking history			8.988	0.003
With	28	71
Without	12	92
Alcohol consumption history			0.029	0.866
With	21	88
Without	19	75
Lund-Mackay score	18.15 ± 3.53	10.02 ± 3.34	13.65	< 0.0001
VAS-measured nasal symptom severity score	6.95 ± 0.85	5.11 ± 0.66	14.94	< 0.0001
Surgery site			0.065	0.799
Left	22	86
Right	18	77
Operation time (min)	61.48 ± 5.89	62.72 ± 7.44	0.979	0.329
Intraoperative blood loss (mL)	46.40 ± 4.98	47.31 ± 5.32	0.984	0.326
Nasal septum deviation			7.086	0.008
With	29	80
Without	11	83
Allergic rhinitis			5.588	0.018
With	25	68
Without	15	95
Bronchial asthma			8.783	0.003
With	22	49
Without	18	114
Middle turbinectomy			0.447	0.504
With	16	56
Without	24	107
Postoperative infection			10.481	0.001
With	17	30
Without	23	133
Long-term use of nasal decongestants			5.580	0.018
With	26	72
Without	14	91
Anxiety			1.697	0.193
With	23	75
Without	17	88
Compliance with medical prescriptions			13.961	0.0002
With	15	113
Without	25	50

VAS: Visual analog scale.

Multivariate analysis of postoperative recurrence

Multivariate logistic regression was performed on the variables with statistically significant differences in the univariate analysis. The results identified fasting blood glucose level and VAS-measured nasal symptom severity score as independent factors influencing postoperative recurrence (Table 5).

Table 5 Logistic regression analysis of postoperative recurrence.

Variable	Assignment	β	SE	Wald	P value	HR	95%CI
Constant	-	-54.679	20.107	7.395	0.007	0.000	-
Fasting blood glucose	Continuous variable	2.269	0.977	5.391	0.020	9.673	1.424-65.681
Smoking history	1 = with, 0 = without	0.720	1.758	0.168	0.682	2.055	0.066-64.405
Lund-Mackay score	Continuous variable	1.163	0.830	1.965	0.161	3.201	0.629-16.281
VAS-measured nasal symptom severity score	Continuous variable	3.033	1.187	6.534	0.011	20.761	2.029-212.469
Nasal septum deviation	1 = companion, 0 = no companion	3.235	3.090	1.096	0.295	25.401	0.059-10847.845
Allergic rhinitis	1 = with, 0 = without	-2.240	2.686	0.695	0.404	0.106	0.001-20.592
Bronchial asthma	1 = with, 0 = without	-1.807	2.640	0.468	0.494	0.164	0.001-29.013
Postoperative infection	1 = with, 0 = without	-0.139	2.104	0.004	0.948	0.871	0.014-53.838
Long-term use of nasal decongestants	1 = with, 0 = without	-1.839	2.511	0.536	0.464	0.159	0.001-21.818
Compliance with medical prescriptions	1 = with, 0 = without	-1.128	2.506	0.203	0.652	0.324	0.001-29.013

VAS: Visual analog scale.

DISCUSSION

The prevalence of CRS is associated with multiple factors, among which aerobic bacterial infection remains a major contributor[18]. The nasal cavity is a primary colonization site for opportunistic pathogenic bacteria, which can be transmitted via sneezing, hand-to-nose contact, or respiration. This facilitates cross-infection and disease transmission. In infected patients, obstruction of paranasal sinus ventilation leads to secretion accumulation, creating a favorable environment for bacterial survival and proliferation. When host immunity is compromised, infections are more likely to develop. Patients with diabetes, on account of long-standing hyperglycemia, experience metabolic disturbances and impaired immune defense, increasing susceptibility to bacterial infections. Compared with nondiabetic individuals, patients with diabetes complicated by CRS are significantly more prone to complications such as nasal polyps and gastro-esophageal reflux[19]. Furthermore, the widespread use of antibiotics in clinical practice exerts selective pressure on bacterial populations, thereby shifting pathogen profiles and increasing drug resistance. This has led to a continuous rise in multidrug-resistant strains and a worsening antimicrobial resistance crisis, thereby posing significant challenges to clinical management.

In this study, nasal secretions from patients with diabetes complicated by CRS were cultured and analyzed. A total of 134 strains of pathogenic bacteria were isolated, including 81 g-positive strains (60.4%) and 53 g-negative strains (39.6%). Gram-positive bacteria exhibited high resistance to penicillin G and erythromycin, but showed high sensitivity to vancomycin, gentamicin, and rifampicin. In contrast, gram-negative bacteria exhibited high resistance to cefazolin and gentamicin, while remaining highly sensitive to imipenem, meropenem, cefepime, and ceftazidime. These findings suggest that the identified pathogens are the primary bacterial colonizers of the nasal cavity and can cause infection when host immunity is compromised, consistent with the findings of Tsou et al[20]. Diabetic infections are typically polymicrobial in nature[21], with S. aureus frequently implicated in skin and soft tissue infections in patients with diabetes[22]. An increasing body of evidence suggests that the immunopathogenesis of CRS may be partially attributable to alterations in host microbiota, including reduced bacterial diversity, increased colonization of proinflammatory pathogens (e.g., S. aureus and Pseudomonas aeruginosa), and loss of beneficial bacteria (e.g., Lactobacillus, Dolosigranulum, and Citrobacter), which may play immunoprotective roles[23]. Additionally, long-term or repeated antibiotic use in refractory and difficult-to-treat CRS cases increases the risk of significant antimicrobial resistance[24]. Consequently, when administering antibacterial therapy, clinicians should strictly adhere to evidence-based prescribing principles. Empirical or indiscriminate use of antibiotics should be avoided randomly. Instead, by understanding the drug resistance and types of pathogenic bacteria and treating them in accordance with their characteristics and the results of drug susceptibility tests, treatment efficacy can be effectively enhanced, and the occurrence of resistant strains can be minimized. The treatment of patients with diabetes using glucocorticoids should be avoided to prevent disease exacerbation.

Although functional endoscopic sinus surgery (FESS) can relieve the clinical symptoms and nasal inflammation associated with CRS, recurrence occurs in > 30% of patients within eight years postoperatively[25]. Vlaminck et al[26] reported an overall recurrence rate exceeding 15% five years after FESS. Given the high rate of postoperative recurrence, preoperative identification of patients at increased risk is essential for guiding treatment selection and enhancing personalized treatment. In this study, patients were followed up and grouped based on recurrence status. The analysis of clinical data revealed significant differences between the recurrence and nonrecurrence groups in terms of fasting blood glucose levels, smoking history, Lund-Mackay scores, VAS-measured nasal symptom severity scores, nasal septum deviation, allergic rhinitis, bronchial asthma, postoperative infection, long-term use of nasal decongestants, and adherence to prescribed medications. Further multivariate regression analysis identified fasting blood glucose level and VAS-measured nasal symptom severity score as independent factors influencing postoperative recurrence. This finding aligns with that of Luo et al[27], whose three-year follow-up study on postoperative CRS patients found that elevated fasting blood glucose levels significantly influenced postoperative recurrence, and a history of type 2 diabetes was an independent risk factor. Additionally, a large-scale national clinical cohort study confirmed significant associations among diabetes, CRS, nasal polyps, and olfactory dysfunction in patients with CRS[28]. In patients with diabetes, underlying metabolic dysfunctions adversely affect immune function and stress responses. If a large-area wound occurs while blood glucose levels are poorly controlled, healing and postoperative recovery may be delayed[29]. Animal and human studies of diabetes have revealed changes in respiratory epithelial cells[30]. These studies have also shown that hyperglycemia impairs immune function by disrupting microcirculation and reducing the delivery of nutrients and oxygen to tissues[31,32]. These changes increase the susceptibility of individuals with diabetes to infections. Both diabetes and insulin resistance are associated with low-grade tissue inflammation induced by oxidative stress, proinflammatory cytokines, and adipocytokines. Insulin indirectly binds to and activates the insulin-like growth factor-1 receptor, thereby inhibiting apoptosis and promoting cell proliferation[33]. These mechanisms may contribute to the increased incidence of CRSwNP in patients with diabetes. Furthermore, in poorly controlled diabetes, persistent hyperglycemia decreases vasodilation and activates protein kinase C, impairing polymorphonuclear cell function, including neutrophil migration, chemotaxis, and phagocytosis. Such metabolic abnormalities also increase the risk of postoperative recurrence[34].

Additionally, VAS-measured nasal symptom severity score was found to be a significant factor influencing postoperative recurrence. The VAS is a widely used psychometric tool in rhinology that subjectively quantifies the severity of patients’ symptoms[35]. In allergic rhinitis, the VAS correlates strongly with disease severity, asthma grading, and the Rhino conjunctivitis Quality of Life Questionnaire[36]. In CRS, the total VAS-measured nasal symptom severity score is typically used to classify disease burden as mild, moderate, or severe. VAS-measured nasal symptom severity has been shown to be valuable for assessing disease severity, monitoring progression, guiding treatment decisions, and evaluating disease burden[37].

CONCLUSION

In conclusion, the detection rate of pathogenic bacteria in nasal secretions is relatively high in patients with diabetes complicated by CRS, and most of these bacteria exhibit drug resistance. Consequently, in clinical practice, it is crucial to strengthen the monitoring of bacterial pathogens and their resistance profiles and to understand their distribution patterns, thereby ensuring the rational use of antibacterial agents. Moreover, the blood glucose level of patients with CRS combined with CRSwNP is a risk factor for postoperative recurrence. Thus, controlling blood glucose levels in patients with diabetes complicated by CRS with CRSwNP is essential. The degree of disease control can also be effectively assessed using the VAS-measured nasal symptom severity score.