Chronic rhinonsinusitis and nasal polyposis: the etiopathogenesis revealed?

Nasal polyps represent a severe eosinophilic inflammation of the upper airways which is characterized by poor impact of therapeutic intervention and frequent recurrences. Based on distinct cytokine, mediator and cell profiles, chronic sinonasal disease in Caucasians can be differentiated into several subgroups such as chronic rhinosinusitis without nasal polyps, chronic rhinosinusitis with nasal polyps, and nasal polyps in cystic fibrosis patients,. In Caucasians, nasal polyps showed a Th2 polarisation with high IL-5 concentrations, while chronic rhinosinusitis without polyps was characterized by a Thl polarisation with high levels of IFN-gamma. In the Caucasian nasal polyps we found that significantly more nasal polyp patients are colonized with S. aureus and that colonization increased in patients with concomitant asthma and aspirin sensitivity. Although there was no major difference in the presence of enterotoxin genes in S. aureus strains derived from nasal polyp or control patients, we found an increased immune response to S. aureus enterotoxins in nasal polyps, which resulted in a more pronounced eosinophilic inflammation and higher total IgE production in those polyps affected. We suggest that S. aureus superantigens amplify the inflammation in about 50% of nasal polyps, resulting in a strong Th2 polarisation, eosinophil activation, and an overproduction of IgG4 and IgE. These findings imply new therapeutic approaches apart from the currently used topical and systemic steroid therapy for nasal polyposis. In three double blind placebo controlled studies it was shown that firstly, oral corticosteroids only led to a short term reduction of polyp size. Secondly that a low dose of doxycycline treatment for 20 days had a sustained clinically relevant effect on polyp size for more than 3 months and thirdly we also showed a significant effect on polyp size by selective antagonizing IL-5 with a monoclonal antibody.

Role of neutrophils in preventing and resolving acute fungal sinusitis

Acute fungal sinusitis (AFS) is a devastating disease of the paranasal sinuses afflicting immunocompromised individuals. Knowledge about this disease is limited to clinical observations because there are no animal models in which to study the pathogenesis of the infection. Our goal was to develop a murine model of AFS and examine the role of neutrophils in host defense within the nasal cavity. Female C57BL/6 mice were depleted of neutrophils using anti-Gr-1 monoclonal antibody from day -1 to day 5 postinfection to initiate a transient neutropenia within the mice. At day 0, Aspergillus fumigatus conidia were administered intranasally. The untreated Aspergillus-exposed group had significant neutrophil recruitment by day 3, but by day 7 the leukocyte numbers had returned to unexposed levels. There was not a significant influx of mononuclear cells at either time point. In contrast, beginning at day 3 postinfection and continuing through day 7, anti-Gr-1-treated mice had increased cellular recruitment consisting of banded neutrophils at day 3 and mature neutrophils at day 7. Hyphal masses developed only in the anti-Gr-1-treated mice (25 to 36%) but only during the period of treatment. When the treatment was discontinued, hyphal masses could no longer be detected in the nasal cavities of these mice. In contrast, cyclophosphamide treatment did not induce neutropenia, and the nasal cavity remained free of hyphal masses. These studies demonstrate the feasibility of using this model to study AFS and implicate neutrophils in protection of the sinuses against acute Aspergillus infection and in clearance of established hyphal masses.

Current issues in the management of acute bacterial sinusitis in children

OBJECTIVE

To review and summarize recent challenges in the microbiology and treatment of acute bacterial sinusitis (ABS), one of the most common infectious diseases in the pediatric community.

METHODS

A review of recent medical literature from 1990 to 2006 was acquired using the National Library of Medicine's PUBMED database.

RESULTS

Multiple mechanisms of penicillin resistance have been identified: porin channel blockage, beta-lactamase production, and changes in penicillin-binding proteins (PBPs). Other factors affecting treatment efficacy include the role of normal nasopharyngeal flora, such as alpha-streptococci. The more widely documented shift in the causative pathogens of acute otitis media (AOM) following the release of the heptavalent pneumococcal conjugate vaccine (PCV7) has also been documented in two studies of ABS in children.

CONCLUSIONS

Treatment of ABS in children is complicated by a number of emerging changes in pathogen resistance patterns. These include beta-lactamase-negative ampicillin resistance (BLNAR) and multi-drug resistance, bacterial interference, and geographic data. These phenomena are likely to impact the treatment of URIs. Appropriate diagnosis and differentiation from viral sinusitis is essential prior to initiating therapy. Clinician education about these emerging issues remains an important strategy in diagnosing and treating ABS in children. This includes an understanding of known patient adherence to antibiotic therapy, such as taste, tolerability, dosing schedule, therapy duration, and patient preference. Clinicians should review judicious ABS treatment approaches that employ agents with documented efficacy against implicated pathogens.

Rhinosinusitis: prevention strategies

Risk factors of recurrent sinusitis involve upper respiratory infections, bacterial load of the adenoids, day care attendance and exposure to tobacco smoke as well as sinonasal abnormalities, including septal deviation, choanal atresia, polyps and hypoplasia of sinuses. Furthermore, several systemic disorders can facilitate the development of chronic sinusitis, such as allergic rhinitis, gastro-esophageal reflux disease (GER), cystic fibrosis, primary ciliary dyskinesia, and immunodeficiency diseases. A clinical practice guideline for the management of sinusitis is available only for the acute disease, but does not include for the management of the chronic form (i.e. chronic/recurrent sinusitis) and even less for the prevention strategies. As several studies indicate that the majority of children respond to sequential medical followed by surgical interventions, when needed, the best prevention of recurrence or chronicity is to properly treat acute sinusitis; in addition, children should be removed from larger and crowded day care whenever possible and should not be exposed to cigarette smoke. If allergic rhinitis co-exists, it can be managed with nasal steroids sprays and anti-histamines, although the long-term results are controversial. In case of chronic sinusitis, the strategy of prevention is to assess and to cure the associated conditions.

[Diseases of the upper respiratory tract]

A great number of agents found in inhaled air, whether in the environment or in the workplace, can cause symptoms and diseases of the upper respiratory tract. Unfortunately, establishing the cause-and-effect relationship between exposure to one of the various types of agents that can provoke such diseases and the diseases themselves is not routine practice among the health professionals involved. A comprehensive list of these agents and their relationships with the effects and onset of such illnesses is available in the literature. Chief among these ills are rhinosinusitis, dysphonia and ulceration/perforation of the nasal septum, as well as tumors in the nasal cavity or paranasal sinuses, all of which can be work related. Although widely available, diagnostic procedures for the investigation of occupational etiology are not yet routinely employed. In general, early identification of, and discontinuation of the contact with, the causal agent can resolve the problem, thereby averting the development of the chronic form of the disease. As with other types of occupational respiratory diseases, prevention and control programs are indispensable in the fight against these illnesses.

Biofilms in ear, nose, and throat infections: how important are they?

BACKGROUND

Biofilms present a new challenging concept in sustaining chronic, common antibiotic-resistant ear, nose, and throat (ENT) infections. They are communities of sessile bacteria embedded in a matrix of extracellular polymeric substances of their own synthesis that adhere to a foreign body or a mucosal surface with impaired host defense. The aim of this paper is to review the literature on ENT diseases that can be attributed to biofilm formation and to discuss options for future treatment.

MATERIALS AND METHODS

Literature review from Medline and database sources. Electronic links and related books were also included.

STUDY SELECTION

Controlled clinical trials, animal models, ex vivo models, laboratory studies, retrospective studies, and systematic reviews.

DATA SYNTHESIS

Biofilm formation is a dynamic five-step process guided by interbacterial communicating systems. Bacteria in biofilms express different genes and have markedly different phenotypes from their planktonic counterparts. Detachment of cells, production of endotoxin, increased resistance to the host immune system, and provision of a niche for the generation of resistant organisms are biofilm processes that could initiate the infection process. Effective prevention and management strategies include interruption of quorum sensing, inhibition of related genes, disruption of the protective extrapolymer matrix, macrolides (clarithromycin and erythromycin), and mechanical debridement of the biofilm-bearing tissues. With regard to medical indwelling devices, surface treatment of fluoroplastic grommets and redesign of cochlear implants could minimize initial microbial colonization.

CONCLUSION

As the role of biofilms in human infection becomes better defined, ENT surgeons should be prepared to deal with their unique and tenacious nature.

Aspirin challenge and desensitization for aspirin-exacerbated respiratory disease: a practice paper

Aspirin desensitization is indicated for patients who have aspirin-exacerbated respiratory disease and whose asthma and/or rhinosinusitis is suboptimally controlled with inhaled corticosteroids and leukotriene-modifying drugs. In this practice paper, the general requirements for aspirin desensitization are presented, the locations where desensitizations can be safely performed are outlined, prechallenge patient preparation is discussed, an oral aspirin challenge protocol is presented, treatment of adverse reactions is reviewed, and maintenance of aspirin desensitization is discussed.

[Using antibiotics in case of influenza]

Acute respiratory bacterial infection is the most common complication of influenza and a leading cause for excess rate of outpatient visits, hospitalization, and death (pneumonia). Influenza promotes bacterial infection as stated by epidemiologic evidence of temporal association between outbreaks or peaks of both influenza and bacterial pneumonia. The bacteria involved are Streptococcus pneumoniae, Haemophilus influenzae, Staphylococcus aureus. However, Gram-negative rods, Klebsiella pneumoniae, Pseudomonas aeruginosa, anaerobes and methicillin resistant S. aureus may be involved in institutionalized elderly patients. Various studies confirm that antibiotics are over-prescribed in patients with influenza or influenza like illness, even in the absence of bacterial infection signs, and in patients without comorbidity. No data has proven the benefice of antibiotic prescription in influenza-infected patients without bacterial infection. Neuraminidase inhibitors may be of interest for the management of influenza infected patients, because they can decrease the risk of bacterial complications and the use of antibiotics.

Indikationen und Nutzen der Pneumokokken-Konjugat-Vakzine

Streptococcus pneumoniae is a leading cause of bacterial pneumonia, meningitis, sinusitis, and acute otitis media in children and adults worldwide. Especially in the age group of < 2 years the incidence of invasive pneumococcal is high. The vulnerability of children to S. pneumoniae can also be demonstrated by the high rate of sequelae (> 20 % in Germany) and the high mortality (7.5 %) in pneumococcal meningitis. A 7-valent pneumococcal conjugate vaccine that was shown to be highly efficacious in preventing invasive pneumococcal disease in infants in the USA was licensed in Europe in 2001. It is expected that broad usage of the vaccine would reduce the incidence of invasive pneumococcal disease and the levels of pneumococcal resistance significantly.

[Risk factors and preventive steps for nasosinusitis after radiotherapy of nasopharyngeal carcinoma]

OBJECTIVE

To study the risk factors and preventive steps of nasosinusitis after radiotherapy of nasopharyngeal carcinoma (NPC).

METHOD

Two hundreds and thirtyone NPC patients were retrospectively analysed.

RESULT

Among 231 NPC patients, 98 patients (42.4%) had nasosinusitis before radiotherapy, 165 patients (66.7%) suffered from nasosinusitis after radiotherapy. The rate of nasosinusitis in NPC patients with high T stage and nasalcavity anatomical aberrance was higher than in others (P = 0.014, CR = 1. 973; P = 0. 034, OR = 2.156), and the rate of nasosinusitis in NPC patients with nasopharynx therapy was low (P = 0.008, OR = 0.675), most patients with nasosinusitis before radiotherapy had not any improve after radiotherapy,and effected the effect of radiotherapy.

CONCLUSION

To reduce nasosinusitis after radiotherapy and improve patients quality of life, we suggest that nasopharyngeal cavity therapy should be carried out during and after irradiation for NPC patients, especially for those patients with high T stage and nasalcavity anatomical aberrance, and for those who had nasosinusitis before radiotherapy.

Acute community-acquired bacterial sinusitis: continuing challenges and current management

Acute sinusitis is one of the most common infections seen in general clinical practice. The most common cause of acute sinusitis is viral; however, many patients receive a prescription for an antibiotic. Such injudicious prescribing habits have a major impact on health care costs, contribute to the increasing prevalence of drug-resistant strains of common respiratory pathogens, and reflect many of the challenges in differentiating viral and bacterial disease. Sinus puncture and culture of the aspirate, the diagnostic reference standard in the research setting, are not appropriate for routine clinical practice. However, certain clinical signs and symptoms that do not improve or that worsen after 7-10 days are currently accepted criteria for diagnosis of bacterial sinusitis. Accurate diagnosis can select patients who would benefit most from antimicrobial use. Antimicrobial agents should be selected on the basis of local resistance patterns, and their spectrum of activity should cover the common bacterial pathogens, including resistant strains.

Fluticasone propionate aqueous nasal spray does not influence the recurrence rate of chronic rhinosinusitis and nasal polyps 1 year after functional endoscopic sinus surgery

BACKGROUND

Local corticosteroids are widely used in the treatment of nasal polyps and chronic rhinosinusitis both before and after nasal surgery. Their efficacy after functional endoscopic sinus surgery (FESS) has not been fully established by placebo-controlled trials.

OBJECTIVE

This double-blind placebo-controlled randomized study was performed in order to investigate whether fluticasone propionate aqueous nasal spray (FPANS) reduces the recurrence rate of nasal polyps and chronic rhinosinusitis during the first year after FESS.

PATIENTS AND METHODS

The trial looked at 162 patients aged 18 years and older requiring FESS for chronic rhinosinusitis or nasal polyps. After FESS combined with peri-operative systemic corticosteroids, patients were randomized and given FPANS 400 microg b.i.d., FPANS 800 microg b.i.d. or placebo b.i.d. for the duration of 1 year. Patients were withdrawn from the trial (but still included in the study for statistical purposes) if there were recurrent or persistent diseases, defined as progressive regrowth of nasal polyps, recurrent signs and symptoms of chronic sinusitis combined with abnormalities on computed tomography scan and persistent complaints for at least 2 months after FESS.

RESULTS

A significant reduction of symptoms was seen after FESS. After 1 year, 46 patients had been withdrawn from the trial because of recurrent diseases and 32 patients because of persistent symptoms. No differences in the number of patients withdrawn because of recurrent or persistent diseases were found between the patients treated with FPANS and patients treated with placebo. We were also unable to find a positive effect of FPANS compared with placebo in several subgroups such as patients with nasal polyps, high score at FESS or no previous sinus surgery.

CONCLUSION

This placebo-controlled study does not show that treatment with FPANS up to 1 year after FESS had a positive effect compared with placebo.

Effects of mould remediation on school teachers' health

The follow-up study of the health of teachers (n = 56) of three mould damage schools were done with self-administered symptom questionnaire before and 1 year after the remediation of school buildings. Technical and microbiological investigations were done parallel at the same time. In the beginning of the study symptoms of allergic rhinitis, sinusitis, conjunctivitis and fatigue were high compared to normal population and 1 year after the intervention a decrease in fatigue (OR = 0.4) and headache (OR = 0.2) was observed. An association between female gender and sinusitis was found before the remediation (OR = 8.1). Age over 40 years was a risk factor for voice problems and more than 10 working years at the same school were associated with increased risk for conjunctivitis (OR = 8.5) and headache (OR = 5.4). Other exposure situations such as mould problems at home and mould exposure during leisure time also have an effect on teachers' health. Significant reduction was found in symptoms of fatigue and headache after the cessation of exposure, while respiratory symptoms need much longer time to relieve after the remediation. Age, female gender, atopy, long-term exposure time and other exposure situations might be the risk factors for prolonged symptoms among mould exposed teachers.

Daily interruption of sedative infusions and complications of critical illness in mechanically ventilated patients

OBJECTIVE

In critically ill patients receiving mechanical ventilation, daily interruption of sedative infusions decreases duration of mechanical ventilation and intensive care unit length of stay. Whether this sedation strategy reduces the incidence of complications commonly associated with critical illness is not known.

DESIGN

Blinded, retrospective chart review.

SETTING

University-based hospital in Chicago, IL.

PATIENTS

One hundred twenty-eight patients receiving mechanical ventilation and continuous infusions of sedative drugs in a medical intensive care unit.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We performed a blinded, retrospective evaluation of the database from our previous trial of 128 patients randomized to daily interruption of sedative infusions vs. sedation as directed by the medical intensive care unit team without this strategy. Seven distinct complications associated with mechanical ventilation and critical illness were identified: a) ventilator-associated pneumonia; b) upper gastrointestinal hemorrhage; c) bacteremia; d) barotrauma; e) venous thromboembolic disease; and f) cholestasis or g) sinusitis requiring surgical intervention. The incidence of complications was evaluated for each patient's hospital course. One hundred twenty-six of 128 charts were available for review. Patients undergoing daily interruption of sedative infusions experienced 13 complications (2.8%) vs. 26 (6.2%) in those subjected to conventional sedation techniques (p =.04).

CONCLUSIONS

Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation reduces intensive care unit length of stay and, in turn, decreases the incidence of complications of critical illness associated with prolonged intubation and mechanical ventilation.

Chronic sinusitis: defective T-cells responding to superantigens, treated by reduction of fungi in the nose and air

In this study, the author used endoscopic sinus photography to study the effects of reduction of fungi in the nose, and in environmental air, on the sinus mucosa of 639 patients diagnosed with chronic rhinosinusitis. Sinus mucosal photographs were taken before and after reduction of fungal load in the nose and air, to determine if there was an optimum environmental air fungal load associated with sinus mucosal recovery to normal appearance. Systemic symptoms associated with fungal exposure, which resolved when fungus was removed from the patient and the environmental air and reappeared with recurrent environmental fungal exposure, are also discussed and are termed systemic fungal symptoms. Interventions consisted of nasal fungal load reduction with normal saline nasal irrigations and antimicrobial nasal sprays, and environmental air fungal load reduction with high-efficiency particulate air (HEPA) filtration in combination with ionizers or evaporation of a solution of botanical extract. Main outcome measures were obtained with environmental air 1-hr gravity-plate fungal colony counts, laser air particle counts, and endoscopic sinus photography. Blood levels of immunoglobulins IgG and IgE for 7 common molds were also determined. After intervention, 94% of patients who used antimicrobial nasal sprays and who reduced their environmental fungal air count to 0-4 colonies per 1-hr agar gravity-plate exposure (n = 365) exhibited normal sinus mucosa by endoscopic exam. Environmental air fungal counts that exceeded 4 colonies resulted in sinus mucosal abnormalities ranging from edema, to pus and/or nasal polyps at higher counts. Neutralization of allergy, and/or surgery, were used as appropriate following implementation of environmental measures. On the basis of these observations, as well as detailed clinical experience and a review of the current literature, the author hypothesizes that the pathogenesis of chronic rhinosinusitis, allergic fungal sinusitis, and systemic fungal symptoms is a genetic defect at the variable beta chain helper T-cell receptor (TCR Vbeta) site which requires the presence of an antigen (fungus). Chronic sinusitis patients who have recurring exposure to environmental air that contains fungal concentrations in excess of 4 colonies per 1-hr agar plate exposure appear to have an increased risk of persistent chronic sinusitis and/or systemic symptoms, regardless of the medical treatment provided.

Rhinosinusitis

History, physical examination, and allergy testing may distinguish the syndromes of rhinitis, classified as allergic, infectious, perennial, nonallergic, and miscellaneous. All may be associated with sinusitis, probably on the basis of obstruction of the osteomeatal complex. Although topical nasal steroids are useful in the treatment of all forms of rhinitis, diagnosis of the offending type in a given patient is necessary for optimal management.

Comparison of the efficacy of IGIV-C, 10% (caprylate/chromatography) and IGIV-SD, 10% as replacement therapy in primary immune deficiency. A randomized double-blind trial

A novel method of large-scale chromatography has been developed to improve recovery and purity of immunoglobulin G (IgG) from pooled plasma. The current study compares safety, toxicity and efficacy of two intravenous immunoglobulin products: a novel formulation, IGIV caprylate/chromatography (IGIV-C; Gamunex, 10%) and a licensed solvent/detergent-treated product, Gamimune N, 10% (IGIV-SD). The study, a randomized, double-blind, parallel group, therapeutic equivalence trial, was conducted at 25 treatment centers in Canada and the United States. Patients (n=172) having confirmed chronic primary immunodeficiency (PID), aged 1-75 years, and receiving IGIV therapy were enrolled. For 9 months, patients were treated with IGIV-C or IGIV-SD in accordance with the patient's individualized treatment regimen utilized before study entry. The primary endpoint was the proportion of patients with >or=1 validated acute sinopulmonary infection during the treatment period. Secondary endpoints included the proportion of patients with all infections, time to first infection, annual infection rates, lung function parameters, infusion-related safety and viral safety. The annual validated infection rate in the IGIV-C group was 0.18 compared to 0.43 in the IGIV-SD group (p=0.023). Nine patients receiving IGIV-C experienced validated infections, compared to 17 patients in IGIV-SD group (p=0.06). Acute sinusitis (validated plus clinically defined) was less frequent in the IGIV-C group (p=0.012). Presence of bronchiectasis did not affect efficacy. Adverse reactions were similar in frequency and severity in both groups. No evidence of viral transmission was observed. IGIV-C appears to be superior to IGIV-SD in preventing validated sinopulmonary infections, especially acute sinusitis, in patients with PID.

Treatment of recurrent chronic hyperplastic sinusitis with nasal polyposis

OBJECTIVE

To demonstrate the long-term efficacy of intranasal furosemide, an inhibitor of the sodium chloride cotransporter channel at the basolateral surface of the respiratory epithelial cell, vs no therapeutic intervention vs intranasal mometasone furoate, a corticosteroid, in preventing relapses of chronic hyperplastic sinusitis with nasal polyposis.

DESIGN

Randomized prospective controlled study. Patients were examined every 6 months during follow-up (range, 1-9 years).

PATIENTS

One hundred seventy patients with bilateral obstructive or minimally obstructive chronic hyperplastic sinusitis with nasal polyposis.

INTERVENTION

All patients were surgically treated in the ENT Department, University of Siena Medical School. One month after surgery, group 1 patients (n = 97) started treatment with intranasal furosemide, group 2 (n = 40) received no therapeutic treatment, and group 3 (n = 33) were treated with mometasone.

MAIN OUTCOME MEASURES

Clinical and instrumental evaluation of postoperative outcomes.

RESULTS

Seventeen (17.5%) of 97 patients in group 1, 12 (30.0%) of 40 patients in group 2, and 8 (24.2%) of 33 patients in group 3 experienced nasal polyposis relapses. We noted a prevalence of early-stage relapse in patients treated with furosemide or mometasone, whereas patients who did not receive any treatment experienced more severe grades of chronic hyperplastic sinusitis with nasal polyposis (P<.005).

CONCLUSION

Use of intranasal furosemide represents a valid therapeutic treatment in the prevention of chronic hyperplastic sinusitis with nasal polyposis.

Medical management in functional endoscopic sinus surgery failures

Functional endoscopic sinus surgery has a high rate of success, ranging from 75 to 95% improvement in symptoms for patients who have medically refractory chronic rhinosinusitis. However, symptom improvement does not necessarily correlate with disease resolution, and even asymptomatic patients may require long-term medical management and endoscopic surveillance if late recurrence is to be avoided. The 5 to 25% percent of patients who continue to have symptoms create a challenge for the rhinologist. Correct diagnosis is the hallmark of successful treatment of this recidivistic population, carried out through history, nasal endoscopy, and radiologic (computed tomography) studies. Particularly in patients with a primary complaint of headache or facial pain, the initial preoperative diagnosis should also be revisited, particularly before further surgical intervention is considered. Once a proper diagnosis is made, management is multifaceted, including topical and systemic medications, and mechanical improvements in the sinus drainage pathways, either through treatments in the office or revision surgery. Therefore, we strongly recommend that chronic rhinosinusitis be viewed as a medical disease in which surgery plays a therapeutic role. Frequently, persistent inflammation slowly settles down over time with appropriate medical management.

[Reduction of acute recurrence in patients with chronic recurrent hypertrophic sinusitis by treatment with a bacterial immunostimulant (Enterococcus faecalis Bacteriae of human origin]

A double-blind, placebo-controlled multicenter study in 157 patients with chronic recurrent sinusitis investigated the occurrence of acute relapses during treatment of patients with a bacterial immunostimulant (3 x 30 drops/day), comprised of cells and autolysate of human Enterococcus faecalis bacteria (Symbioflor 1, n = 78) in comparison to placebo (n = 79). The study included a treatment period of 6 months and a follow-up period of 8 months. Under verum the occurrence of relapses (50 incidents) was about half (56%) the number observed under placebo (90 incidents). In the Kaplan-Meier test the verum preparation emerged as significantly superior (p = 0.045, log rank test) compared to placebo. This superiority of verum was found during the treatment period with 17 vs. 33 relapses (p = 0.019) as well as during the follow-up observation with 33 vs. 57 relapses (p = 0.013). The time interval to the first relapse was clearly longer under verum (513 days) than under placebo (311 days). The relative risk for a relapse under the test preparation compared to placebo was 49.0% during the treatment and 55.8% during the follow-up period. Severity of the acute relapses was comparable in both groups. However, antibiotic therapy was only required in 2 patients treated with verum compared to 6 patients in the placebo group. Both preparations were well tolerated and serious side effects did not occur in either group. No changes in laboratory tests--hematology and clinical chemistry--were observed. Potential immunomodifying effects of the test preparation in view of the significant reduction in relapses were discussed.

Modulation of murine allergic rhinosinusitis by CpG oligodeoxynucleotides

BACKGROUND

Allergic rhinosinusitis is characterized by eosinophilic inflammation of the upper airway, which is induced by TH-2 cytokines. CpG oligodeoxynucleotides (ODN) are known to induce TH-1 and to suppress TH-2 cytokines in a variety of settings, including murine models of asthma.

OBJECTIVE

To examine the effect of CpG ODN in a murine model of upper airway allergic inflammation and to correlate with reduction of its manifestations of sneezing and nasal scratching.

METHODS

BALB/c mice were sensitized using Ovalbumin (Ova) intraperitoneally and challenged with aerosolized Ova. CpG ODN were administered at the time of Ova sensitization. Outcomes measured included nasal symptoms, submucosal eosinophilia in the areas lined by respiratory or olfactory epithelium, and bone marrow eosinophilia. To delineate the mechanism of CpG ODN-induced suppression of eosinophilic inflammation, in vitro experiments were carried out to examine the effect of stimulation with Ova on splenocytes obtained from mice that were treated with CpG or control ODN (or no ODN) in vivo. Supernatant was collected after 72 hours of incubation and cytokines were measured by enzyme linked immunosorbent assay.

RESULTS

CpG ODN administered at the time of Ova sensitization effectively abrogated nasal symptoms and eosinophilic upper airway inflammation compared with mice treated with control ODN or with no ODN. Cytokine data revealed that Ova sensitization suppressed IFN-gamma and induced IL-4 and IL-5 compared with non-sensitized mice. CpG ODN treatment reversed these effects.

CONCLUSION

CpG ODN prevents the development of TH-2-mediated eosinophilic inflammation and symptoms in a murine model of allergic rhinosinusitis.