Nasal polyps in asthma and rhinitis. A review of 6,037 patients

Why do we not find polyps in the lungs? Bronchial mucosa as a model in the treatment of polyposis

The link between lower and upper airways has been reported since the beginning of 1800 s. They share the same pseudostratified ciliated columnar epithelium lining and the concept of one airway, one disease is quite well widespread. Nasal polyposis and asthma share basically the same inflammatory process: predominant infiltration of eosinophils, mucus cell hyperplasia, edema, thickened basal membrane, polarization for Th2 cell immune response, similar pro-inflammatory mediators are increased, for example cysteinyl leukotrienes. If the lower and upper airways share a lot of common epithelial structural features so why is the edema in the nasal mucosa able to increase so much the size of the mucosa to the point of developing polyps? The article tries to underline some differences between the nasal and the bronchial mucosa that could be implicated in this aberrant change from normal mucosa to polyps. This paper creates the concept that there are no polyps with the features of nasal polyposis disease in the lower airway and through it is developed the hypothesis of the nasal polyps origin could partially lie on the difference between the upper and lower airway histology.

Milk Allergy is Frequent in Patients with Chronic Sinusitis and Nasal Polyposis

Background

Chronic sinusitis and nasal polyps with subsequent nasal blocking, anosmia, and relapsing infections are frequent in the rhinological practice. Often, recurrent disease necessitates repetitive conservative therapy and surgical treatment (functional endoscopic sinus surgery). This study was initiated to scrutinize the relationship of wheat and milk allergies to chronic polypoid sinusitis (CPS) and recurrent disease.

Methods

Blood samples of 50 healthy controls and 50 patients with clinically and radiologically diagnosed CPS and nasal polyposis were screened for common food allergies including wheat and milk allergy. On inclusion into the study, none of the patients reported a symptomatic food allergy.

Results

Fifteen of 100 tested subjects (15%) revealed a previously undiagnosed allergy to inhalant (dust, rye, and pollens) and other food allergens (corn and egg white). Six of 50 patients (12%) with CPS exhibited a wheat allergy, and a milk allergy could be identified in 7 patients (14%). In the control group, seven healthy subjects (14%) showed a wheat allergy and no case of milk allergy could be identified (p = 0.0125).

Conclusion

In contrast to previous studies in other countries presenting a food allergy incidence of ∼75% in patients with nasal polyposis, we could not show such a high incidence. In the group with chronic polyposis 14% of the patients were positive for milk allergy compared with none of the tested healthy subjects, resulting in a strong statistical significance. Therefore, we conclude that cow's milk but not wheat allergy might be a relevant pathogenetic entity in chronic nasal polyps.

Oral steroids for nasal polyps

BACKGROUND

This is an update of a Cochrane Review first published in The Cochrane Library in Issue 1, 2007.Benign nasal polyps are lesions that arise from the mucosa of the nasal cavity or one or more of the nasal sinuses. The presenting symptoms are nasal obstruction, watery anterior rhinorrhoea (excessive nasal secretions) or mucopurulent postnasal drip (or both), hyposmia and anosmia (reduced or absent sense of smell) with a concomitant alteration in taste and infrequently pain over the dorsum of the nose, forehead and cheeks. The main aim of treatment is to relieve these symptoms. The aetiology of polyps is uncertain, therefore treatment options differ, consisting of a combination of medical and surgical management. Medical therapy is mainly in the form of steroids, administered topically or systemically via the oral route.

OBJECTIVES

To assess the effects of oral steroids in patients with multiple nasal polyps.

SEARCH STRATEGY

We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ISRCTN and additional sources for published and unpublished trials. The date of the most recent search was 12 October 2010, following a previous search in April 2006.

SELECTION CRITERIA

Randomised controlled trials and controlled clinical trials comparing oral steroids with no intervention, or placebo, or comparing doses or schedules of oral steroids in patients with multiple nasal polyps.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed study quality. We contacted study authors for additional information.

MAIN RESULTS

Three trials (166 patients) met our inclusion criteria and showed a short-term benefit of a short (two to four-week) course of oral steroids of variable doses and duration when compared to placebo. There was an objective reduction of polyp size and a subjective improvement of nasal symptoms and quality of life. However, due to the moderate to low quality of these trials it was not possible to quantify the overall size of this effect.There was no report of significant adverse effects of treatment with a short course of steroids.

AUTHORS' CONCLUSIONS

The authors found three randomised controlled trials, albeit of moderate to poor quality, that suggest a short-term benefit of oral steroids in patients with multiple nasal polyps. To address the issue more thoroughly well-designed, prospective, randomised controlled trials are still needed.

Physiology and pathophysiology of respiratory mucosa of the nose and the paranasal sinuses

In this review, anatomy and physiology of the respiratory mucosa of nose and paranasal sinuses are summarized under the aspect of its clinical significance. Basics of endonasal cleaning including mucociliary clearance and nasal reflexes, as well as defence mechanisms are explained. Physiological wound healing, aspects of endonasal topical medical therapy and typical diagnostic procedures to evaluate the respiratory functions are presented. Finally, the pathophysiologies of different subtypes of non-allergic rhinitis are outlined together with treatment recommendations.

Evidence-based management of nasal polyposis by intranasal corticosteroids: from the cause to the clinic

BACKGROUND

Nasal polyposis is an inflammatory disorder involving the mucosa of the nose and paranasal sinuses and affecting approximately 2-4% of the general population.

METHODS

A literature search of Medline and Embase was conducted to obtain an overview of the epidemiology, pathophysiology, and current treatment of nasal polyposis, focusing on evidence-based efficacy of intranasal corticosteroids (INSs) as primary and postoperative therapy. Recent research on INSs in nasal polyp treatment, along with notable historic findings, was reviewed.

RESULTS

Nasal polyps are mostly characterized by eosinophil infiltration, a complex inflammation of nasal mucosa, and possibly production of polyclonal IgE. Current treatment modalities include INSs, oral corticosteroids, and surgery; surgery is generally limited to those with an insufficient response to medical treatment. Because of their effects on eosinophil-dominated inflammation, INSs and oral corticosteroids are the primary medical treatment strategies. The very low (≤1%) systemic bioavailability of newer INSs minimizes the systemic adverse effects seen with oral corticosteroids.

CONCLUSION

Based on randomized, controlled trials, guidelines recommend INSs as first-line therapy for nasal polyps and for care after polypectomy. Clinical data suggest INSs are effective in reducing polyp size and relieving nasal symptoms. INS treatment has also reduced nasal polyp recurrence in patients undergoing functional endoscopic sinus surgery. Treatment with these mainstay options has been found to improve quality of life, which, along with symptom improvement, is a key factor in disease treatment.

Local and systemic IgE in the evaluation and treatment of allergy

Traditional descriptions of type I hypersensitivity and its manifestations center on systemic immunoglobulin E (IgE)-mediated reactions to inciting antigens. Hence, many current diagnostic and therapeutic measures are based on systemic skin testing for allergy, systemic pharmacotherapy, and immunotherapy. Recent developments in rhinology and pulmonology, particularly in defining the phenomenon of local IgE production in various airway inflammatory conditions, have an impact on both medical and surgical diagnosis and management of these conditions. This review includes a discussion of allergy as a systemic disease, current systemic diagnostic and management strategies for allergy, and local IgE presence and synthesis in the upper and lower airways.

The role of local steroid injection for nasal polyposis

Sinonasal polyps affect a small but significant percentage of patients with chronic sinusitis. Treatments vary and range from oral and topical medical treatments to surgical removal. Corticosteroids typically have been regarded as the gold standard medical treatment for sinonasal polyps. Delivery of steroids is traditionally via oral or topical means. Over the years, otolaryngologists have also found that intrapolyp injection of corticosteroids is an effective means to treat some patients with sinonasal polyps. This article reviews the prevalence, pathophysiology, and medical treatment options for sinonasal polyps. Focused attention is paid to treatment with steroid injections, including a review of its associated risks and benefits.

Do comorbidities influence objective and subjective recovery rates of nasal polyposis?

OBJECTIVES

To investigate the clinical and laboratory outcomes both objectively and subjectively in nasal polyposis patients with or without comorbidity (CoM; asthma and allergy).

PATIENTS AND METHODS

Thirty-three nasal polyposis patients (13 women and 20 men) were included into the study. Their mean age was 39.23 +/- 9.13 years. CoM(+) and CoM(-) nasal polyposis patients were compared with each other. Evaluations contained endoscopic nasal examination, acoustic rhinometry, rhinomanometry, visual analog scale score of nasal blockage, olfactory function score, respiratory function test, skin prick tests, and paranasal sinus computed tomography.

RESULTS

Recovery was statistically significant in all observed evaluations for endoscopic and radiologic staging, nasal obstruction, and sense of smell compared with the first evaluation in all patients regardless of the subgroups. Although objective measurements of respiratory functions did not show any change, clinical improvement was detected in CoM(+) patients with a decrease of need to their antiasthmatic medical treatment.

CONCLUSIONS

Results of CoM(+) patients led to no statistical difference when compared with CoM(-) subgroup. When applying predefined nasal polyposis treatment protocol, the polyp patients with CoMs do not need close follow-up compared to the patients without CoMs.

Human nasal polyp microenvironments maintained in a viable and functional state as xenografts in NOD-scid IL2rgamma(null) mice

OBJECTIVES

The objective was to develop a model with which to study the cellular and molecular events associated with nasal polyp progression. To accomplish this, we undertook to develop a system in which nondisrupted human nasal polyp tissue could be successfully implanted into severely immunocompromised mice, in which the histopathology of the original nasal polyp tissue, including inflammatory lymphocytes, epithelial and goblet cell hyperplasia, and subepithelial fibrosis, could be preserved for prolonged periods.

METHODS

Small, non-disrupted pieces of human nasal polyp tissues were subcutaneously implanted into NOD-scid IL2rgamma(null) mice. Xenografts at 8 to 12 weeks after implantation were examined histologically and immunohistochemically to identify human inflammatory leukocytes and to determine whether the characteristic histopathologic characteristics of the nasal polyps were maintained for a prolonged period. The xenografts, spleen, lung, liver, and kidneys were examined histologically and immunohistochemically and were evaluated for changes in volume. The sera of these mice were assayed for human cytokines and immunoglobulin.

RESULTS

Xenografts of human nasal polyp tissues were established after their subcutaneous implantation into NOD-scid IL2rgamma(null) mice. The xenografts were maintained in a viable and functional state for up to 3 months, and retained a histopathologic appearance similar to that of the original tissue, with a noticeable increase in goblet cell hyperplasia and marked mucus accumulation in the submucosal glands compared to the original nasal polyp tissue. Inflammatory lymphocytes present in the polyp microenvironment were predominantly human CD8+ T cells with an effector memory phenotype. Human CD4+ T cells, CD138+ plasma cells, and CD68+ macrophages were also observed in the xenografts. Human immunoglobulin and interferon-gamma were detected in the sera of xenograft-bearing mice. The polyp-associated lymphocytes proliferated and were found to migrate from the xenografts to the spleens of the recipient mice, resulting in a significant splenomegaly. A progressive increase in the volume of the xenografts was observed with little or no evidence of mouse cell infiltration into the human leukocyte antigen-positive human tissue. An average twofold increase in polyp volume was found at 3 months after engraftment.

CONCLUSIONS

The use of innate and adaptive immunodeficient NOD-scid mice homozygous for targeted mutations in the interleukin-2 receptor gamma-chain locus NOD-scid IL2rgamma(null) for establishing xenografts of nondisrupted pieces of human nasal polyp tissues represents a significant improvement over the previously reported xenograft model that used partially immunoincompetent CB17-scid mice as tissue recipients. The absence of the interleukin-2 receptor gamma-chain results in complete elimination of natural killer cell development, as well as severe impairments in T and B cell development. These mice, lacking both innate and adaptive immune responses, significantly improve upon the long-term engraftment of human nasal polyp tissues and provide a model with which to study how nasal polyp-associated lymphocytes and their secreted biologically active products contribute to the histopathology and progression of this chronic inflammatory disease.

Aspirin-sensitive respiratory disease

Aspirin-sensitive respiratory disease (ASRD) is a condition characterized by persistent and often severe inflammation of the upper and lower respiratory tracts. Patients develop chronic eosinophilic rhinosinusitis, nasal polyposis, and asthma. The ingestion of aspirin and other cyclooxygenase-1 (COX-1) inhibitors induces exacerbations of airway disease that may be life-threatening. Thus, aspirin sensitivity is a phenotypic marker for the syndrome, yet nearly all affected individuals can be desensitized by the administration of graded doses of aspirin, leading to long-term clinical benefits. Patients with aspirin sensitivity are often able to tolerate selective COX-2 inhibitors. The pathogenesis of ASRD is underpinned by abnormalities in eicosanoid biosynthesis and eicosanoid receptor expression coupled with intense mast cell and eosinophilic infiltration of the entire respiratory tract. This review focuses on the molecular, cellular, and biochemical abnormalities characterizing ASRD and highlights unanswered questions in the literature and potential future areas of investigation.

Localized immunoglobulin E expression in allergic rhinitis and nasal polyposis

PURPOSE OF REVIEW

This article reviews recent literature on local tissue identification of immunoglobulin E (IgE) in various sinonasal inflammatory conditions. Discussions of local IgE expression in allergic and nonallergic rhinitis, atopic and nonatopic sinonasal polyposis, and allergic fungal rhinosinusitis are included.

RECENT FINDINGS

Increased levels of IgE and positive reactivity on nasal allergen provocation tests have been demonstrated in nasal lavage fluid of patients with negative systemic allergy testing. In addition, elevated levels of Alternaria alternata-specific IgE have been identified in nasal polyp patients; this is hypothesized as a contributory factor in the development of nasal polyposis. Further evidence supports the role of local IgE to Staphylococcus aureus superantigens in atopic and nonatopic nasal polyposis. Finally, local IgE specific for a range of antigens has been identified in sinus and inferior turbinate tissue in patients with allergic fungal rhinosinusitis.

SUMMARY

Increased levels of IgE have been identified in sinonasal tissues in allergic and nonallergic rhinitis, atopic and nonatopic sinonasal polyposis, and allergic fungal rhinosinusitis. The ability to identify local tissue IgE in inflammatory sinonasal disease states may have significant diagnostic and therapeutic implications.

Clinical presentation and management of geriatric rhinitis

The population of Americans over 65 years of age is growing at an unprecedented rate. Rhinitis is a common and burdensome complaint in this group, and physicians should be aware of the diagnosis and management of the disease. Geriatric rhinitis is a nasal disorder of older persons that presents with a constellation of nasal symptoms. The etiologies of this condition include both inflammatory diseases and the effects of aging on physiology of the upper airway. Possible causes include allergic rhinitis, nonallergic rhinitis (vasomotor rhinitis and gustatory rhinitis), adverse effects of medications, hormonal changes, postnasal drip syndrome, chronic rhinosinusitis and atrophic rhinitis. Nasal symptoms in the older patient present a clinical challenge because of the physiologic effects of the aging nose, the unusual clinical presentation, the presence of multiple comorbidities and the problem of polypharmacy. A number of therapeutic options exist for this disorder, although definitive studies of effective regimens are needed.

Surgical management of polyps in the treatment of nasal airway obstruction

In addition to their role in chronic rhinosinusitis and nasal congestion, sinonasal polyps are associated with significant nasal obstruction. Effective long-term treatments remain difficult to pinpoint. Management of these polyps is a difficult challenge for the contemporary otolaryngologist. Medical options vary and include topical and oral steroids; macrolide antibiotics; diuretic nasal washes; and intrapolyp steroid injection. Surgical options include polypectomy and functional endoscopic sinus surgery (FESS). In addition, novel treatments for polyps are introduced with some frequency. This article presents an overview of management options for sinonasal polyps, focusing on the indications, efficacy, and complications of the more common interventions.

Is intrinsic asthma synonymous with infection?

Rackemann described the 'intrinsic asthma' population over 50 years ago as a unique subgroup that was characterized by onset of progressive loss of lung function beginning later in life, possibly after a respiratory infection. It has also been associated with a female predominance, aspirin-sensitive bronchospasm, and nasal polyposis. While the aetiology is not understood, we propose that persistent respiratory infections play a central role in the development of intrinsic asthma.

Important research questions in allergy and related diseases: 3-chronic rhinosinusitis and nasal polyposis - a GALEN study

Chronic rhinosinusitis is one of the most common health care challenges, with significant direct medical costs and severe impact on lower airway disease and general health outcomes. The diagnosis of chronic rhinosinusitis (CRS) currently is based on clinical signs, nasal endoscopy and CT scanning, and therapeutic recommendations are focussing on 2 classes of drugs, corticosteroids and antibiotics. A better understanding of the pathogenesis and the factors amplifying mucosal inflammation therefore seems to be crucial for the development of new diagnostic and therapeutic tools. In an effort to extend knowledge in this area, the WP 2.7.2 of the GA(2)LEN network of excellence currently collects data and samples of 1000 CRS patients and 250 control subjects. The main objective of this project is to characterize patients with upper airway disease on the basis of clinical parameters, infectious agents, inflammatory mechanisms and remodeling processes. This collaborative research will result in better knowledge on patient phenotypes, pathomechanisms, and subtypes in chronic rhinosinusitis. This review summarizes the state of the art on chronic rhinosinusitis and nasal polyposis in different aspects of the disease. It defines potential gaps in the current research, and points to future research perspectives and targets.

[Diagnosis, therapy and current research aspects of selected chronic inflammatory diseases with head and neck involvement]

Wegener's granulomatosis, Churg-Strauss syndrome and analgesics intolerance syndrome with polyps demonstrate non-specific manifestations in the head and neck region. These symptoms can often lead to early diagnosis and initiation of the correct therapy. However, symptoms are often ambiguous and many rare differential diagnoses must be borne in mind. This clinical picture presents a challenge for the otorhinolaryngologist, who is commonly the first contacted physician. Diagnostics and therapy have to be carried out in an interdisciplinary approach between rheumatologist, pulmonologist, pathologist, radiologist, ophthalmologist, infection specialist and nephrologist. Despite significant scientific and therapeutic advances, these diseases remain incurable. In recent decades they have lost their life-threatening character (Wegener's granulomatosis) and are now chronically relapsing diseases. Their aetiology, however, is still unclear and treatment leads to a wide spectrum of undesirable effects. Research work is needed to advance diagnostics and therapy in this field. Recent research aspects are presented in this article.

Middle turbinate preservation versus middle turbinate resection in endoscopic surgical treatment of nasal polyposis

CONCLUSION

Relapse in patients affected by nasal polyposis and subjected to endoscopic surgery appears to be a relevant feature. Surgical treatment shows a significant increase in quality of life in all the patients aside from surgical technique used. Our results show a better control of relapse of nasal pathology in patients subjected to more radical surgery (group B) vs patients subjected to conservative surgery on middle turbinate (group A). Allergic patients in group B had a smaller number of relapses during the follow-up period compared with allergic patients in group A and this was statistically significant.

OBJECTIVES

Different endoscopic surgical techniques have been applied for the treatment of nasal polyposis. During ethmoidectomy, some authors prefer to remove the middle turbinate while others preserve this structure. To date, there have been no studies comparing the results, in a homogeneous case series of patients operated exclusively for nasal polyposis, between those whose middle turbinate was resected and those whose middle turbinate was preserved. The aim of our study was to compare results in these two groups of patients.

PATIENTS AND METHODS

A prospective study was performed. Nasal polyposis was studied on the basis of endoscopic examination and all the patients were classified on the basis of CT of paranasal sinuses using the Kennedy CT staging system. In the study group, only subjects affected by nasal polyposis with stage II-III at endoscopic evaluation and a Kennedy score of III-IV, affected by nasal polyposis, and not responsive to medical treatment were recruited. The presence of allergy was evaluated by skin prick test results and that of asthma by spirometric examination. Recurrence rates and quality of life were evaluated in a 3-year follow-up.

RESULTS

In total, 56 patients were selected and all were observed over a 3-year follow-up period. We identified two groups: group A, 34 patients (60.71%) affected by nasal polyposis who underwent endoscopic surgery with the conservation of middle turbinate; group B, 22 patients (39.29%) affected by nasal polyposis who underwent more radical endoscopic sinus surgery. Analyzing the entire study group, during the 3-year follow-up, 20 (35.71%) of the 56 patients had a relapse of nasal polyposis. Analyzing time to relapse curves in the allergic and non-allergic patients, we obtained a p value of 0.0589, i.e. at the limit of statistical significance. The comparison between preoperative and postoperative Cologne test in the whole study group was statistically significant for a symptomatic improvement (p < 0.001). Trends within the two groups were also evaluated: there was a statistically significant difference in behavior upon time to relapse of the patients in group B vs group A (p = 0.0102). The patients in group A developed nasal recurrence more frequently during the follow-up periods. In patients affected by allergy vs patients not affected by allergy in group A, a statistically significant difference was noted (p = 0.0074); the allergic patients developed nasal recurrence more frequently during the follow-up period. We could not find a statistically significant difference between those patients affected by allergy and those not affected by allergy, as regards the number of relapses in patients in group B.

A review of nasal polyposis

Nasal polyps are common, affecting up to four percent of the population. Their etiology remains unclear, but they are known to have associations with allergy, asthma, infection, cystic fibrosis, and aspirin sensitivity. They present with nasal obstruction, anosmia, rhinorrhoea, post nasal drip, and less commonly facial pain. Clinical examination reveals single or multiple grey polypoid masses in the nasal cavity. Computerized tomography allows evaluation of the extent of the disease and is essential if surgical treatment is to be considered. Management of polyposis involves a combination of medical therapy and surgery. There is good evidence for the use of corticosteroids (systemic and topical) both as primary treatment and as postoperative prophylaxis against recurrence. Surgical treatment has been refined significantly over the past twenty years with the advent of endoscopic sinus surgery and, in general, is reserved for cases refractory to medical treatment. Recurrence of the polyposis is common with severe disease recurring in up to ten percent of patients.

Sinonasal pathology in nonallergic asthma and COPD: 'united airway disease' beyond the scope of allergy

BACKGROUND

In contrast to the epidemiological and clinical association between allergic rhinitis and asthma, upper airway inflammation is less characterized in patients with nonatopic asthma and virtually unexplored in chronic obstructive pulmonary disease (COPD). Here, sinonasal pathology is studied in patients with allergic asthma, nonallergic asthma and COPD.

METHODS

Ninety patients with stable bronchial disease were included in the study, of which 35 were diagnosed with allergic asthma, 24 with nonallergic asthma and 31 with COPD. Concurrently, 61 control subjects without pulmonary disease were included and matched for age and smoking habits respectively with the asthma and the COPD group. Sinonasal symptoms were evaluated on a visual analogue scale and rhinosinusitis-related impairment of quality of life was assessed with the sino-nasal outcome test-22 (SNOT-22) questionnaire. Nasal mucosal abnormalities were quantified with nasal endoscopy and nasal secretions collected for measuring inflammatory mediators.

RESULTS

Allergic asthmatics, nonallergic asthmatics and COPD patients reported more nasal symptoms than their respective control subjects, had a higher SNOT-22 score and presented more mucosal abnormalities in the nose. Nasal secretions of both allergic and nonallergic asthmatics contained higher levels of eotaxin, G-CSF, IFN-gamma and MCP-1 than controls. Allergic asthmatics had higher nasal IP-10 levels as well. COPD-patients had higher nasal levels of eotaxin, G-CSF and IFN-gamma than controls.

CONCLUSION

Patients with allergic and nonallergic asthma and COPD show increased nasal symptoms and more nasal inflammation. Hence, our data confirm the 'united airways' concept to be beyond the scope of allergic asthma.

BSACI guidelines for the management of allergic and non-allergic rhinitis

This guidance for the management of patients with allergic and non-allergic rhinitis has been prepared by the Standards of Care Committee (SOCC) of the British Society for Allergy and Clinical Immunology (BSACI). The guideline is based on evidence as well as on expert opinion and is for use by both adult physicians and paediatricians practicing in allergy. The recommendations are evidence graded. During the development of these guidelines, all BSACI members were included in the consultation process using a web-based system. Their comments and suggestions were carefully considered by the SOCC. Where evidence was lacking, consensus was reached by the experts on the committee. Included in this guideline are clinical classification of rhinitis, aetiology, diagnosis, investigations and management including subcutaneous and sublingual immunotherapy. There are also special sections for children, co-morbid associations and pregnancy. Finally, we have made recommendations for potential areas of future research.

BSACI guidelines for the management of rhinosinusitis and nasal polyposis

This guidance for the management of patients with rhinosinusitis and nasal polyposis has been prepared by the Standards of Care Committee (SOCC) of the British Society for Allergy and Clinical Immunology (BSACI). The recommendations are based on evidence and expert opinion and are evidence graded. These guidelines are for the benefit of both adult physicians and paediatricians treating allergic conditions. Rhinosinusitis implies inflammation of the nose and sinuses which may or may not have an infective component and includes nasal polyposis. Acute rhinosinusitis lasts up to 12 weeks and resolves completely. Chronic rhinosinusitis persists over 12 weeks and may involve acute exacerbations. Rhinosinusitis is common, affecting around 15% of the population and causes significant reduction in quality of life. The diagnosis is based largely on symptoms with confirmation by nasendoscopy. Computerized tomography scans and magnetic resonance imaging are abnormal in approximately one third of the population so are not recommended for routine diagnosis but should be reserved for those with acute complications, diagnostic uncertainty or failed medical therapy. Underlying conditions such as immune deficiency, Wegener's granulomatosis, Churg-Strauss syndrome, aspirin hypersensitivity and allergic fungal sinusitis may present as rhinosinusitis. There are few good quality trials in this area but the available evidence suggests that treatment is primarily medical, involving douching, corticosteroids, antibiotics, anti-leukotrienes, and anti-histamines. Endoscopic sinus surgery should be considered for complications, anatomical variations causing local obstruction, allergic fungal disease or patients who remain very symptomatic despite medical treatment. Further well conducted trials in clearly defined patient groups are needed to improve management.

Detection of natural killer T cells in the sinus mucosa from asthmatics with chronic sinusitis

BACKGROUND

Chronic sinusitis (CS) with asthma generally exhibits a high degree of sinus tissue eosinophilia and recurrence often occurs even after surgical therapy. However, the cause has not yet been fully clarified.

AIMS OF THE STUDY

To elucidate the pathogenesis of this refractory disease, we examined the infiltration of natural killer T (NKT) and type 1 helper T (Th1)/type 2 helper T (Th2) cells, and the cytokine expression in the sinus mucosa.

METHODS

Sinus mucosal specimens were obtained surgically from 16 CS patients with nasal polyps. The NKT cells, Th1/Th2 cells and the expression of IL-4, IL-5, IL-13 and IFN-gamma were examined by a polymerase chain reaction or flow cytometry. Nasal mucosal specimens from six other patients with allergic rhinitis (AR) were examined in a similar manner.

RESULTS

The NKT cells were detected to varying degrees in the sinus mucosa from asthmatic CS patients, but neither in the nonasthmatics nor in the nasal mucosa from the patients with AR. The Th2 cells and Th2 cytokines were expressed at significantly higher levels in the sinus mucosa from the CS patients with asthma in comparison to those without asthma. However, the Th1 cell infiltration and IFN-gamma expression were not different between these groups.

CONCLUSION

Natural killer T cells may, therefore, play important roles in the enhanced Th2 cytokine expression and increased infiltration of Th2 cells and eosinophils observed in the sinus mucosa from asthmatic CS patients through MHC-independent mechanisms.

Oral steroids for nasal polyps

BACKGROUND

Benign nasal polyps are lesions that arise from the mucosa of the nasal cavity or one or more of the nasal sinuses. The presenting symptoms of nasal polyps are nasal obstruction, watery anterior rhinorrhoea (excessive nasal secretions) or mucopurulent postnasal drip (or both), hyposmia and anosmia (reduced or absent sense of smell) with a concomitant alteration in taste and infrequently pain over the dorsum of the nose, forehead and cheeks. The main aim of treatment is to relieve these symptoms. Because of their uncertain aetiology treatment options differ, consisting of a combination of medical and surgical management. Medical therapy is mainly in the form of steroids, administered topically or systemically via the oral route.

OBJECTIVES

To assess the effects of oral steroids in patients with multiple nasal polyps.

SEARCH STRATEGY

We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2006), MEDLINE (January 1950 to April 2006), EMBASE (January 1974 to April 2006), CINAHL, LILACS, MEDCARIB, KOREAMED, INDMED, PAKMEDINET, SAMED, PANTELEIMON, ZETOC, Cambridge Scientific Abstracts, mRCT (metaRegister of Clinical Trials), NRR (National Research Register), ISI Web of Science and the reference lists of relevant articles. We also contacted leading experts in the field. The date of the most recent search was April 2006.

SELECTION CRITERIA

Randomised controlled trials and controlled clinical trials comparing oral steroids with no intervention, or placebo, or comparing doses or schedules of oral steroids in patients with multiple nasal polyps.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data and assessed study quality. Study authors were contacted for additional information.

MAIN RESULTS

Only one trial was identified which met the inclusion criteria. This trial showed a significant improvement in quality of life and nasal symptom scores (comprising nasal obstruction and loss of smell scores) and a significant reduction in polyp size after two weeks of treatment with oral steroids compared to no steroid treatment. However the trial was small and of low methodological quality.

AUTHORS' CONCLUSIONS

The authors found one small randomised controlled trial, albeit of poor quality, that suggests a short-term effect of oral steroids in patients with multiple nasal polyps. To address the issue more thoroughly a well designed, prospective randomised controlled trial is needed.

Pathogenesis of chronic rhinosinusitis

Chronic rhinosinusitis (CRS) is a heterogenous disorder and represents a major public health problem. Although insights into the pathophysiology of CRS have largely expanded over the last two decades, the exact etiology and mechanism of persistence is still unrevealed. CRS is a multifactorial disease, and, with variable evidence, impaired ostial patency, mucociliary impairment, allergy, bacterial or fungal infection (or triggering), immunocompromised state, and environmental and genetic factors have been suggested to be associated or risk factors. Pathomechanisms in CRS are better understood currently, allowing us to characterize and differentiate the heterogeneous pathology of chronic sinonasal inflammation based on histopathology, inflammatory pattern, cytokine profile, and remodeling processes. In nasal polyposis (NP), but not CRS without NP, an abundant eosinophilic inflammation and local immunoglobulin E production could be demonstrated, and Staphylococcus-derived superantigens may at least modulate disease severity and expression. These findings question the current assumption that NP is a subgroup of CRS, but suggest that CRS and NP should probably be considered as distinct disease entities.

The relationship between rhinosinusitis and asthma sinusitis

Chronic sinusitis comprises numerous disorders characterized by inflammation, mucous gland hyperplasia, and remodeling. Chronic hyperplastic eosinophilic sinusitis (CHES) is characterized by unrestrained proliferation of eosinophils, Th2-like lymphocytes, fibroblasts, goblet cells, and mast cells. The pathology of CHES is similar to that of asthma, and it is frequently diagnosed in association with asthma. It has been reported that exacerbations of CHES occur temporally with worsening of asthma; however, in the absence of well-controlled studies, this linkage remains unproven. In this article, the potential mechanisms linking these two diseases are examined.

The impact of allergic and nonallergic rhinitis on pediatric sinusitis

There is a great deal of published evidence that there is a relationship between both allergic and nonallergic rhinitis and sinusitis in both pediatric and adult patients. The relationship between rhinitis and sinusitis may involve inflammation in one compartment leading to secondary inflammation in the other compartment, such as in the case of rhinitis leading to obstruction of the osteomeatal complex. The relationship may also involve individual manifestations of a shared process, such as allergic disease. A better understanding of the relationship between rhinitis and sinusitis may significantly influence the treatment of these common and important conditions.

The relationship between atopy and chronic rhinosinusitis

BACKGROUND

The aim of this study was to determine whether atopy influences either clinical and radiological severity or surgical revision rates in patients with chronic rhinosinusitis (CRS).

METHODS

Patients who had been scheduled for endoscopic sinus surgery were classified as having CRS or nasal polyposis. Their atopic status was determined by ImmunoCAP testing. Disease severity was assessed clinically by the Lund symptom and Sino-Nasal Outcome Test 20 (SNOT-20) quality-of-life scores and radiologically by the Lund-Mackay CT score.

RESULTS

One hundred ninety-three consecutive patients with rhinosinusitis were included in the study. The prevalence of atopy in this group was found to be 30%. No association was found between atopic status and Lund symptom scores. Analysis of the SNOT-20 scores indicated that atopic patients had higher sneezing scores (p < 0.03), reduced productivity (p < 0.01), and reduced concentration (p < 0.01). The mean CT score was significantly higher in the atopic patients than in nonatopic patients overall (14.2+/-1.6 versus 12.2+/-1.3; p = 0.05), although within each of the clinical subgroups no statistically significant relationship was observed between a patients' atopic status and their CT scores. The rate of revision surgery was not significantly different between atopic and nonatopic patients.

CONCLUSION

These results suggest that atopic status has minimal impact on the severity of CRS.

Perennial non-infectious rhinitis--an independent risk factor for sleep disturbances in Asthma

AIM OF THE STUDY

To evaluate if perennial non-infectious rhinitis is associated with sleep disturbances in asthma.

MATERIALS AND METHODS

This is a questionnaire based study in a random population sample from Denmark, Estonia, Iceland, Norway and Sweden aged 30-54yr. A total of 1127 individuals reporting asthma from an original random population sample of 16,191 were analysed regarding their quality of sleep in relation to perennial non-infectious rhinitis. Perennial non-infectious rhinitis was defined as having nasal symptoms such as nasal blockage and secretion in the absence of common cold, always. Asthma was defined as both ever having had asthma and having physician diagnosed asthma. Odds ratios (OR) for difficulties inducing sleep, difficulties maintaining sleep, early morning awakenings and daytime sleepiness were calculated in a multiple logistic regression controlling for other risk factors for sleep disturbances such as snoring, wheeze, obesity and smoking.

RESULTS

The response rate was 74%. A total of 189 (17%) of the subjects with asthma reported perennial non-infectious rhinitis. Perennial non-infectious rhinitis was associated with an increased OR for difficulties maintaining sleep (1.6 (95% confidence interval (CI) 1.1-2.3)), early morning awakenings (1.5 (95% CI 1.1-2.2)) and daytime sleepiness (1.8 (95% CI 1.2-2.9)). The result show that perennial non-infectious rhinitis is an independant risk factor for sleep disturbances in asthma.

Rhinitis in the elderly

The effects of aging on the nose include structural, hormonal, mucosal, olfactory, and neural changes. As the US population ages and remains in overall better health, we will have more patients with rhinologic problems related to aging. In this manuscript, we review the available evidence on the structural and physiologic changes of the nose caused by aging, and we briefly describe management of common causes of rhinitis in the elderly.

DQA1 and DQB1 association and nasal polyposis

OBJECTIVE

The aim of this study was to determine the contribution of the human major histocompatibility complex (HLA)-DQA1, -DQB1, and TNFalpha genes with simple nasal polyposis.

STUDY DESIGN AND SETTING

A comparative case-control study with 31 patients and 151 controls was performed. HLA-DQA1, -DQB1, and TNFalpha -238 promoter position loci were typed by polymerase chain reaction (PCR) and sequence specific oligonucleotide probes (SSOPs). TNFalpha -308 promoter position was determined by PCR and digestion with NcoI restriction enzyme.

RESULTS

The allele HLA-DQA1*0201 (P(c) = 0.019) had an etiologic fraction (EF) of 17%, whereas 13% EF was found for the haplotype HLA-DQA1*0201-DQB1*0201 (P = 0.016). Analysis of -DQB1 and TNFalpha promoter did not show significant differences between cases and controls.

CONCLUSIONS

HLA-DQA1*0201-DQB1*0201 haplotype is involved in susceptibility, conferring 5.53 times more risk of developing this disease.

EBM RATING

B-2b.

General and Rhinosinusitis-Related Quality of Life in Patients With Wegener???s Granulomatosis

OBJECTIVES

The objectives of this cross-sectional study were to outline the pattern of sinonasal morbidity and determine its effects on the quality of life (QOL) of patients with Wegener's granulomatosis (WG).

METHODS

The authors conducted a survey of 199 patients with WG, including two validated (QOL) instruments to assess general (SF-36) and rhinosinusitis-specific quality of life (Sinonasal Outcome Test [SNOT-22]).

RESULTS

Patients with WG who have sinonasal involvement reported significantly lower general QOL scores than their unaffected counterparts (P = .000006-0.04) for all SF-36 subsets except for emotional role. WG-related sinonasal morbidity was comparable to the high levels previously demonstrated in the general rhinosinusitis population. A total of 38.2% of all patients with WG reported a nasal symptom as their most troublesome from a list of nasal and constitutional symptoms. Twenty-three percent of all patients with WG rated nasal crusting and 17% rated epistaxis as one of their top three most troublesome symptoms even in the setting of multisystem disease. The inclusion of crusting, bleeding, and nasal deformity in the SNOT scoring significantly increased average scores of patients with WG (P = .024, paired t test).

CONCLUSIONS

Sinonasal involvement impacts significantly on the general QOL of patients with WG and is at least as significant as that of the general rhinosinusitis population. Nasal symptoms that are of particular relevance to this patient group include nasal crusting and epistaxis.

[Relation between rhinosinusitis and bronchiectasis]

The nose and lungs have both histological and functional similarities and differences. Sinonasal and bronchial involvement are associated in many diseases. Cystic fibrosis, primary ciliary dyskinesia, Young's syndrome, and alpha-1 antitrypsin deficiency are diseases in which bronchiectasis and rhinosinusitis are both present. This review considers the diseases in which bronchiectasis occurs along with sinonasal manifestations. We propose examining sinonasal disease from a new perspective by observing it in patients with bronchiectasis.

The role of sinus disease in asthma

PURPOSE OF REVIEW

Some time ago, a link between upper and lower respiratory disease was described, which gave rise to the concept of 'united airways disease'. This concept primarily refers to the well established link between allergic rhinitis and asthma, but it also covers a possible link between sinus disease and asthma (allergic or nonallergic) and other lower airway disease.

RECENT FINDINGS

The current classification of chronic rhinosinusitis (CRS) includes disease without and with nasal polyps, which are considered subgroups of CRS. Different patterns of inflammatory and regulatory cytokines (involving distinguishable T-helper lymphocyte populations) and of remodelling markers, however, were recently described to differentiate nasal polyposis from CRS, yielding two discrete entities. These patterns resemble those of lower airway diseases, such as asthma and chronic obstructive pulmonary disease, and suggest a common aetiological/pathogenetic background. Whereas the link between nasal polyps and asthma is well established (indeed, asthma improves after medical or surgical treatment of sinus disease), that between CRS and lower airway disease is not well understood. Recently, Staphylococcus aureus enterotoxins, acting as superantigens, were identified as a possible link between nasal polyps and asthma, resulting in severe disease manifestations in both upper and lower airways.

SUMMARY

The role played by sinus disease in asthma is only partially understood, largely because of deficits in the clinical classification and in basic knowledge of pathophysiological pathways. Recent research into upper airway and sinus inflammation and remodelling may reveal new perspectives and lead to a classification of sinus disease, which will facilitate appropriate clinical and epidemiological studies.

Fungi in chronic hyperplastic eosinophilic sinusitis: reasonable doubt

Chronic hyperplastic eosinophilic sinusitis (CHES) is a T-helper (Th)2-like, lymphocyteinitiated, eosinophil-rich inflammatory disease. The complex immune interactions required to orchestrate these processes begin with the presentation of antigen by mature dendritic cells to Th lymphocytes that display the appropriate antigen-specific T-cell receptor. The objective of sinus research must be to identify and target that antigen; this will lead to the cure for this condition. This article reviews numerous models that may be responsible for the pathophysiology of this disorder, including putative roles for allergens, bacteria, and bacterial-derived superantigens, as well as recent interest in fungal-derived antigens. Additionally, we speculate that whatever the inciting cause of CHES may be, it is plausible that once initiated, cellular differentiation pathways may lead to the development of an antigen-independent permanent phase. More than one of these may be valid in different subjects and, furthermore, this list almost assuredly does not explain all cases of CHES. The concept that fungal antigens colonizing the sinuses are responsible for CHES represents an intriguing, but unproven, hypothesis. Presently, the case for the fungus remains circumstantial. The case for fungi will be proved only with definitive proof that T-cells within the sinuses are actively responding to fungal antigens present in the sinus and with the further demonstration that removal of those fungal antigens ameliorates the disease.

Allergic rhinitis and its impact on otorhinolaryngology

Allergic rhinitis (AR) is a disease with growing impact on everyday medical practice, as its prevalence has steadily increased during the last decades. Immunoglobulin-E (IgE)-mediated airway inflammation may manifest itself as AR, asthma or both. Allergic inflammation in upper and lower airways is now considered as one airway disease, with manifestation of symptoms in upper, lower or global airway. This insight into allergic inflammation of the whole respiratory tract has consequences for the diagnostic and therapeutic approach of affected patients, as highlighted in the ARIA document. In contrast to asthma, the link between AR and associated conditions in the upper airways like rhinosinusitis, nasal polyps, recurrent viral infections, adenoid hypertrophy, tubal dysfunction, otitis media with effusion and laryngitis remains less explored. It is however of utmost importance to consider the aetiological role of IgE-mediated inflammation of the nasal mucosa in several diseases of the upper respiratory tract, as they represent a large body of patient population seen by the general practitioner as well as the paediatrician, allergologist and otorhinolaryngologist. We here aim at reviewing the current literature on the relationship between AR and conditions in upper airways frequently encountered in everyday clinical practice, and highlight the need for further studies exploring the role of allergic inflammation in the development of these diseases.

A Short Course of Oral Prednisone Followed by Intranasal Budesonide Is an Effective Treatment of Severe Nasal Polyps

BACKGROUND

Nasal polyposis is an inflammatory disease of unknown etiology. This study aimed to evaluate the effect of a short course of oral prednisone followed by intranasal budesonide on nasal symptoms, polyp size, nasal flow, and computed tomography scan.

METHODS

Eighty-four patients with severe nasal polyps were included. After a steroid washout period, patients were randomized into two groups: group A (n = 63) received oral prednisone for 2 weeks and group B (n = 21) did not receive any steroid treatment. Patients from group A received intranasal budesonide for 12 weeks.

RESULTS

Atopy was positive in 36.8% of patients. Blood eosinophilia was higher in asthmatic (7.2 +/- 0.7%, P < .05) than in nonasthmatic (3.0 +/- 0.4%) patients. Asthmatic patients showed higher scores on nasal obstruction and loss of smell than nonasthmatics. Oral steroids caused a significant improvement in all nasal symptoms and improved polyp size (2.1 +/- 0.1, P < .05) and nasal flow (560 +/- 35 cm/s, P < .05) compared with nontreated patients (2.8 +/- 0.1 and 270 +/- 34 cm/s, respectively). Intranasal budesonide maintained the improvement on nasal symptoms, polyp size, and nasal flow. Steroid treatment reduced the computed tomography scan score (15.4 +/- 1, P < .05) compared with before treatment (18.2 +/- 0.8).

CONCLUSION

A short course of oral steroids improved all nasal symptoms, polyp size, and nasal flow, whereas intranasal steroid maintain this effect.

Diffuse mucosal inflammation in nasal polyps and adjacent middle turbinate

BACKGROUND

Nasal polyp (NP) is the most common mass lesion in the nose with unclear etiology and pathogenesis.

OBJECTIVE

To investigate the association of allergy and type of cellular inflammation in Asian patients with NPs.

METHODS

Immunohistochemical staining with a panel of antibodies for CD4+ and CD8+ T cells, B cells, Langerhans' cells, eosinophils, neutrophils, and mast cells were performed in pairs of NP tissue and middle turbinate (MT) biopsies from the same side of 48 patients and MT of controls. Serum total IgE and specific IgE to a panel of common local allergens were tested by the UniCAP (Pharmacia & Upjohn AB, Uppsala, Sweden) system.

RESULTS

Atopy was found in 29.7% of NP patients. Strong correlations of cell scores were evidenced between the paired samples from nasal polyp patients. The cell patterns in nasal polyp mainly showed a combined cell infiltration with significantly higher CD8+ T cell, eosinophil and neutrophil scores, and an inverse median ratio of CD4+/CD8+ T cells as compared with the MT from controls.

CONCLUSION

The similar immunohistochemical pattern of mucosal inflammation in NPs and the paired MT mucosa suggests a diffuse mucosal involvement. This indicates the necessity of anti-inflammatory treatment of changes in the adjacent nasal mucosa in addition to the surgical removal of NPs. Besides the well-recognized eosinophilic inflammation in Caucasian studies, predominant infiltration of T cells, especially CD8+ T cells, could be a key component underlying the pathogeneses of NPs.

[Relation between rhinosinusitis and bronchiectasis]

The nose and lungs have both histological and functional similarities and differences. Sinonasal and bronchial involvement are associated in many diseases. Cystic fibrosis, primary ciliary dyskinesia, Young's syndrome, and alpha-1 antitrypsin deficiency are diseases in which bronchiectasis and rhinosinusitis are both present. This review considers the diseases in which bronchiectasis occurs along with sinonasal manifestations. We propose examining sinonasal disease from a new perspective by observing it in patients with bronchiectasis.

Efficacy of montelukast in the treatment of nasal polyposis

OBJECTIVES

Twenty-four consecutive patients with symptomatic nasal polyposis and nonallergic or perennial rhinitis who were undergoing chronic nasal steroid therapy were prospectively evaluated for response to adjunctive oral montelukast sodium therapy.

METHODS

The patients were undergoing daily intranasal steroid sprays for a minimum of 6 months before being started on montelukast sodium 10 mg by mouth per day for 3 months while intranasal steroids were continued. The patients were given a validated symptom score survey at the start and end of therapy, with a lower score indicating fewer symptoms. The nasal polyps were submitted to biopsy before and after treatment to determine their degree of eosinophilia. Eosinophilia was graded in a blinded fashion by an independent pathologist on a scale of 0 to 3, with 3 being severe. Patients with seasonal allergies were excluded, and the studied patients were treated during the winter season to avoid confounding by potential seasonal allergic responses.

RESULTS

The patients tended to improve on montelukast therapy in terms of their symptom scores and polyp eosinophil counts. The symptoms improved in 17 patients (71%) and remained the same or worsened in 7 patients (29%). The symptom score for the group improved from a pretreatment value of 33.4 (SD, 7.73) to a posttreatment value of 23.3 (SD, 13.73; p < .001). In addition, the eosinophilia score improved from 2.3 (SD, 0.68) to 1.5 (SD, 0.82; p < .01). The improvement was most noticeable in the patients with perennial allergies.

CONCLUSIONS

These results suggest that montelukast appears to be beneficial for some patients with nasal polyposis. Patients with perennial allergies and nasal polyposis seem more likely to respond to the treatment than those with nonallergic nasal polyposis.

Activated eosinophils in nasal polyps: a comparison of asthmatic and non-asthmatic patients

OBJECTIVES

There is a recognized clinical association between nasal polyps and asthma. Nasal polyps and the airways of asthmatic patients demonstrate marked eosinophilia suggesting that this inflammatory cell may have a key role to play in both conditions. The objective of this study was to determine whether nasal polyps from patients with asthma had a greater density of activated eosinophils than patients with no associated respiratory disease.

DESIGN

Archived specimens were retrieved from patients who had undergone nasal polyp surgery and their case notes reviewed. Activated eosinophils were identified using immunohistochemistry for a monoclonal antibody to secreted eosinophil cationic protein (EG2).

SETTING

Teaching hospital otolaryngology unit.

PARTICIPANTS

Consecutive patients who had undergone nasal polyp surgery in 1994 were recruited. The diagnosis of asthma was based on a documented physician diagnosis and appropriate drug treatment. Twenty-four asthmatic and 35 non-asthmatic patients were studied.

MAIN OUTCOME MEASURES

Eosinophil density was measured using a standardized counting technique.

RESULTS

Asthmatic patients were significantly more likely to have had previous polyp surgery (chi-square test: P < 0.05). Areas of intense eosinophilia were identified in all samples. There was a significant greater degree of activated eosinophilia in the asthmatic patients (t-test: P < 0.05).

CONCLUSIONS

We have demonstrated a higher number of previous operations in asthmatic patients, and also a greater degree of activated eosinophilia in asthmatic polyps compared with non-asthmatics. This would suggest that eosinophil activity has a role to play in the pathogenesis of nasal polyps.

Aspirin-sensitive asthma

Aspirin-sensitive asthma is a common and often underdiagnosed disease affecting up to 20% of the adult asthmatic population. It is associated with more severe asthma, requires increased use of inhaled and oral corticosteroids, more presentations to hospital and a risk of life-threatening reactions with aspirin/non-steroid anti-inflammatory drug (NSAID) ingestion. Aspirin-sensitive asthma is often accompanied by severe rhinosinusitis and recurrent nasal polyposis, causing significant impairment of patients' quality of life. The pathogenesis of aspirin-sensitive asthma is complex and involves chronic eosinophilic inflammatory changes, with evidence of increased mast cell activation. The cyclo-oxygenase pathways play a major role in the respiratory reactions that develop after aspirin ingestion. The cysteinyl-leukotrienes have also been shown to play a role in the pathogenesis of aspirin-sensitive asthma. The clinical management of aspirin-sensitive asthma is complicated by the lack of diagnostic testing, other than challenge procedures. Other aspects of management include management of the underlying asthma and avoidance of NSAID in the majority of patients. Other considerations in the management of patients with aspirin-sensitive asthma include the role of leukotriene modifying agents, aspirin desensitization, and the use of other agents, such as roxithromycin. The management of nasal polyposis in patients with aspirin-sensitive asthma often needs to be considered as a separate issue, and requires a team approach.