Silent Trichophagia Behind Visible Trichotillomania: A Case Report of a Giant Gastric Trichobezoar in an Adolescent With Intellectual Disability and Anemophobia.

Chronic rhinosinusitis (CRS) is a chronic inflammatory disease that occurs in the mucous membrane of the nasal cavity and sinuses with a duration of more than 12 weeks. Epidemiologic surveys have shown that the overall prevalence of CRS in Chinese people is 8% (), which is higher than that in Brazil, Korea, and Canada (). Its clinical symptoms are mainly manifested as nasal congestion, mucopurulent mucus, dizziness, headache, olfactory dysfunction, and memory loss. The symptoms of the disease directly affect the patient's daily life, resulting in reduced work ability, social activity, and quality of life and increased economic burden. According to a survey in the United States, CRS affects 14-16% of the population, costing about 5.7 billion dollars a year (). In addition, insufficient pulmonary ventilation related to chronic nasal congestion can lead to chronic hypoxia and obstructive sleep apnea syndrome, which may gradually lead to hypertension, diabetes mellitus, and other systemic diseases (). According to the European clinical guidelines (EPOS-2012) and the Chinese clinical guidelines (CPOS-2018), CRS can be classified into chronic rhinosinusitis without nasal polyps (CRSsNP) and chronic rhinosinusitis with nasal polyps (CRSwNP). Patients with CRS are usually first treated with pharmacologic therapy based on nasal glucocorticoids. Those who do not respond to the treatment may undergo functional endoscopic sinus surgery (FESS). However, even after receiving the standardized treatment recommended by the guidelines, there are still a considerable number of patients that do not achieve satisfactory outcomes. International studies have shown that the recurrence rate of CRS patients 12 years after surgery is 20-80% (). Approximately 29% of Chinese CRS patients have difficult-to-treat CRS (DTRS) one year after surgery (). The involvement of multiple immune cells and inflammatory mediators in the pathogenesis makes CRS a highly heterogeneous disease. Depending on the local infiltration of inflammatory cells (eosinophils or neutrophils) and the level of T cell-associated cytokines, CRS can be classified into 5 endotypes (). More than 80% of CRSwNP patients exhibit a predominantly eosinophilic infiltrate, defined as T2 endotype (), with the highest recurrence rate at 3 years after surgery (). The accuracy of the diagnosis, the surgeon's technical skills, and the rationality and standardization of the treatment plan also affect the treatment outcome.