A role for anti-BP180 autoantibodies in chronic rhinosinusitis

OBJECTIVES/HYPOTHESIS

Chronic Rhinosinusitis (CRS) is accompanied by evidence of a vigorous adaptive immune response, and emerging studies demonstrate that some nasal polyps manifest a polyclonal autoantibody response. We previously found that antibodies against BP180, a component of the hemidesmosome complex and the dominant epitope in autoimmune bullous pemphigoid, were found at elevated levels in nasal polyp tissue. Given the critical role of hemidesmosomes in maintaining epithelial integrity, we sought to investigate the distribution of BP180 in nasal tissue and evaluate for evidence of systemic autoimmunity against this antigen in CRS.

STUDY DESIGN

Case-control experimental study.

METHODS

The expression and distribution of BP180 in cultured nasal epithelial cells and normal nasal tissue were confirmed using real-time polymerase chain reaction (PCR), Western immunoblotting, immunofluorescence and immunohistochemistry. Sera were collected from three groups: control, CRSsNP, and CRSwNP. A commercially available ELISA was utilized to compare anti-BP180 autoantibody levels in sera.

RESULTS

BP180 is expressed in nasal epithelium, but is not confined to the basement membrane as it is in human skin. In cultured nasal epithelial cells, confocal immunofluorescence showed a punctate distribution of BP180 along the basal surface, consistent with its distribution in epithelial keratinocytes. There are significantly higher levels of circulating nonpathologic anti-BP180 autoantibodies in CRS patients compared with normal controls (P <0.05).

CONCLUSIONS

BP180 is more widely expressed in nasal epithelium versus skin, although it appears to play a similar role in the formation of hemidesmosomes along the basement membrane. Further investigations are ongoing to characterize the pathogenicity of the anti-epithelial antibody response in CRS.

Variations in antibiotic prescribing of acute rhinosinusitis in United States ambulatory settings

OBJECTIVE

To identify variations in antibiotic treatment of acute rhinosinusitis (ARS) on a national level.

STUDY DESIGN

Cross-sectional study of a national database.

SETTING

Otolaryngology and primary care ambulatory settings.

SUBJECTS AND METHODS

A nationally representative sample of adult outpatient visits was extracted from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Care Survey data for 2006 to 2009. Antibiotic prescriptions associated with ARS were tabulated. Statistical analyses were conducted to identify variations in antibiotic prescribing by patient and physician characteristics.

RESULTS

Antibiotics were prescribed in 82.3% ± 2.6% of 18.7 million visits for ARS (mean age, 46.2 years; 65.9% female). The ratio of primary care physician (PCP) to otolaryngologist (ENT) ARS visits was 18.6:1. Antibiotic prescription rates were inversely related to increasing age groups of 18 to 39, 40 to 64, and ≥ 65 years (87.8%, 81.2%, and 71.0%, respectively; P = .02). Physicians in general medicine outpatient departments, internal medicine, and family medicine were more likely to prescribe antibiotics compared with ENTs (adjusted odds ratio [OR], 7.9 [95% confidence interval (CI), 3.5-17.8]; 6.9 [2.5-19.2]; and 3.9 [2.0-7.7], respectively). The most commonly prescribed antibiotics were azithromycin, amoxicillin, and amoxicillin/clavulanate acid (27.5%, 15.5%, and 14.6%, respectively). The ENTs selected broad-spectrum antibiotics more often than PCPs (94.3% vs 75.7% of visits with antibiotics were broad-spectrum agents; P = .01).

CONCLUSION

Antibiotics were prescribed frequently despite recent consensus guidelines that discourage antibiotic use in mild cases. Furthermore, antibiotic prescription was more likely for younger patients and in primary care settings. This highlights the need to promote awareness of practice guidelines.

Incidence and associated premorbid diagnoses of patients with chronic rhinosinusitis

BACKGROUND

Chronic rhinosinusitis (CRS) is a prevalent condition with underexplored risk factors.

OBJECTIVES

We sought to determine CRS incidence and evaluate associations with a range of premorbid medical conditions for chronic rhinosinusitis without nasal polyps (CRSsNP) and chronic rhinosinusitis with nasal polyps (CRSwNP) using real-world clinical practice data.

METHODS

Electronic health records data from 446,480 Geisinger Clinic primary care patients were used for a retrospective longitudinal cohort study for data from 2001-2010. By using logistic regression, newly diagnosed CRS cases between 2007 and 2009 were compared with frequency-matched control subjects on premorbid factors in the immediate (0-6 months), intermediate (7-24 months), and entire observed timeframes before diagnosis.

RESULTS

The average incidence of CRS was 83 ± 13 CRSwNP cases per 100,000 person-years and 1048 ± 78 CRSsNP cases per 100,000 person-years. Between 2007 and 2009, 595 patients with incident CRSwNP and 7523 patients with incident CRSsNP were identified and compared with 8118 control subjects. Compared with control subjects and patients with CRSsNP, patients with CRSwNP were older and more likely to be male. Before diagnosis, patients with CRS had a higher prevalence of acute rhinosinusitis, allergic rhinitis, chronic rhinitis, asthma, gastroesophageal reflux disease, adenotonsillitis, sleep apnea, anxiety, and headaches (all P < .001). Patients with CRSsNP had a higher premorbid prevalence of infections of the upper and lower airway, skin/soft tissue, and urinary tract (all P < .001). In the immediate and intermediate timeframes analyzed, patients with CRS had more outpatient encounters and antibiotic prescriptions (P < .001), but guideline-recommended diagnostic testing was performed in a minority of cases.

CONCLUSIONS

Patients who are given a diagnosis of CRS have a higher premorbid prevalence of anxiety, headaches, gastroesophageal reflux disease, sleep apnea, and infections of the respiratory system and some nonrespiratory sites, which results in higher antibiotic, corticosteroid, and health care use. The use of guideline-recommended diagnostic testing for confirmation of CRS remains poor.

Genetics of chronic rhinosinusitis: state of the field and directions forward

The cause of chronic rhinosinusitis (CRS) remains unclear. Study of the genetic susceptibility to CRS might be a valuable strategy to understand the pathogenesis of this burdensome disorder. The purpose of this review is to critically evaluate the current literature regarding the genetics of CRS in a comprehensive fashion. The most promising findings from candidate gene studies include the cystic fibrosis transmembrane conductance regulator gene (CFTR), as well as genes involved in antigen presentation, innate and adaptive immune responses, tissue remodeling, and arachidonic acid metabolism. We also review the few hypothesis-independent genetic studies of CRS (ie, linkage analysis and pooling-based genome-wide association studies). Interpretation of the current literature is limited by challenges with study design, sparse replication, few functional correlates of associated polymorphisms, and inadequate examination of linkage disequilibrium or expression quantitative trait loci for reported associations. Given the relationship of CRS to other airway disorders with well-characterized genetic components (eg, asthma), study of the genetics of CRS deserves increased attention and investment, including the organization of large, detailed, and collaborative studies to advance knowledge of the mechanisms that underlie this disorder.

Increased expression of factor XIII-A in patients with chronic rhinosinusitis with nasal polyps

BACKGROUND

Profound edema or formation of a pseudocyst containing plasma proteins is a prominent characteristic of nasal polyps (NP). However, the mechanisms underlying NP retention of plasma proteins in the submucosa remain unclear. Recently, we reported that impairment of fibrinolysis causes excessive fibrin deposition in NP and this might be involved in the retention of plasma proteins. Although the coagulation cascade plays a critical role in fibrin clot formation at extravascular sites, the expression and role of coagulation factors in NP remain unclear.

OBJECTIVE

The objective of this study was to investigate the expression of coagulation factors in patients with chronic rhinosinusitis (CRS).

METHODS

Sinonasal tissues were collected from patients with CRS and control subjects. We assayed mRNA for factor XIII-A (FXIII-A) by using real-time PCR and measured FXIII-A protein by means of ELISA, immunohistochemistry, and immunofluorescence.

RESULTS

FXIII-A mRNA levels were significantly increased in NP tissue from patients with CRS with NP (P < .001) compared with uncinate tissue from patients with CRS or control subjects. Similarly, FXIII-A protein levels were increased in NP. Immunofluorescence analysis revealed that FXIII-A expression in inflammatory cells and FXIII-A(+) cell numbers were significantly increased in NP. Most FXIII-A staining was observed within CD68(+)/CD163(+) M2 macrophages in NP. Levels of FXIII-A correlated with markers of M2 macrophages, suggesting that M2 macrophages are major FXIIIA-producing cells in NP.

CONCLUSION

Overproduction of FXIII-A by M2 macrophages might contribute to the excessive fibrin deposition in the submucosa of NP, which might contribute to the tissue remodeling and pathogenesis of CRS with NP.

Excessive fibrin deposition in nasal polyps caused by fibrinolytic impairment through reduction of tissue plasminogen activator expression

RATIONALE

Nasal polyps (NPs) are characterized by intense edema or formation of pseudocysts filled with plasma proteins, mainly albumin. However, the mechanisms underlying NP retention of plasma proteins in their submucosa remain unclear.

OBJECTIVES

We hypothesized that formation of a fibrin mesh retains plasma proteins in NPs. We assessed the fibrin deposition and expression of the components of the fibrinolytic system in patients with chronic rhinosinusitis (CRS).

METHODS

We assessed fibrin deposition in nasal tissue from patients with CRS and control subjects by means of immunofluorescence. Fibrinolytic components, d-dimer, and plasminogen activators were measured using ELISA, real-time PCR, and immunohistochemistry. We also performed gene expression and protein quantification analysis in cultured airway epithelial cells.

MEASUREMENTS AND MAIN RESULTS

Immunofluorescence data showed profound fibrin deposition in NP compared with uncinate tissue (UT) from patients with CRS and control subjects. Levels of the cross-linked fibrin cleavage product protein, d-dimer, were significantly decreased in NP compared with UT from patients with CRS and control subjects, suggesting reduced fibrinolysis (P < 0.05). Expression levels of tissue plasminogen activator (t-PA) mRNA and protein were significantly decreased in NP compared with UT from patients with CRS and control subjects (P < 0.01). Immunohistochemistry demonstrated clear reduction of t-PA in NP, primarily in the epithelium and glands. Th2 cytokine-stimulated cultured airway epithelial cells showed down-regulation of t-PA, suggesting a potential Th2 mechanism in NP.

CONCLUSIONS

A Th2-mediated reduction of t-PA might lead to excessive fibrin deposition in the submucosa of NP, which might contribute to the tissue remodeling and pathogenesis of CRS with nasal polyps.

Identifying clinical symptoms for improving the symptomatic diagnosis of chronic rhinosinusitis

BACKGROUND

Current symptom criteria for identifying patients with chronic rhinosinusitis (CRS) has poor specificity. The objective of this study was to test the hypothesis that symptoms drawn from the Task Force on Rhinosinusitis (RSTF) criteria and the International Headache Society (IHS) criteria for primary headaches can differentiate CRS patients from those with CRS-symptoms but no evidence for inflammation (non-CRS).

METHODS

A retrospective cohort study from a total of 140 charts of patients who received a diagnostic computed tomography (CT) scan for CRS symptoms in a tertiary care clinic. The study was conducted in 2 phases: (1) using a retrospective review of otolaryngologist-documented symptoms (ODS) in the medical record; and (2) using patient-reported symptoms (PRS) on a prospectively collected customized review of systems form from a separate cohort. A radiographic gold standard differentiated CRS from non-CRS patients.

RESULTS

Subjects in the CRS and non-CRS group were matched for age and race and almost universally met symptomatic criteria as defined by the RSTF in both study phases. In both study phases, facial pain, but not facial pressure, was negatively predictive for CRS (p < 0.05). Similarly, hyposmia was positively predictive, whereas facial pain of a pulsating quality and photophobia were negatively predictive (p < 0.05), although analysis of PRS was significant only when symptom frequency was considered. Nonetheless, significant overlap exists between the prevalence and frequency of symptoms in both groups.

CONCLUSION

The symptom-based diagnosis of CRS is challenging but symptoms of hyposmia is positively predictive while facial pain, a throbbing quality, headaches and photophobia are negatively predictive and show promise for improving the specificity of CRS diagnosis. Further validation studies are needed.

Antimicrobials and chronic rhinosinusitis with or without polyposis in adults: an evidenced-based review with recommendations

BACKGROUND

Chronic rhinosinusitis (CRS) is characterized by inflammation of the mucosa of the nose and paranasal sinuses. The role of bacterial or fungal infection in CRS is unclear, yet antimicrobials are commonly prescribed for this condition. Published guidelines offer little direction regarding antibiotic strategies for CRS. The purpose of this article is to provide an evidence-based approach to the use of antibacterial and antifungal antibiotics in the management of CRS.

METHODS

A systematic review of the literature was performed following recommendations of the Clinical Practice Guideline Manual, Conference on Guideline Standardization (COGS), and the Appraisal of Guidelines and Research Evaluation (AGREE). Inclusion criteria were: age ≥18 years old, chronic rhinosinusitis with or without polyps, antibiotic treatment as the experimental group, and clearly defined primary clinical endpoint. Studies involving patients with cystic fibrosis or acute invasive fungal sinusitis were excluded.

RESULTS

The review identified and evaluated the literature on 8 classes of antimicrobials for CRS: oral antibacterial antibiotics ≤3 weeks, oral antibacterial antibiotics >3 weeks, macrolide antibiotics, intravenous antibacterial antibiotics, topical antibacterial antibiotics, oral antifungals, intravenous antifungals, and topical antifungals.

CONCLUSION

Based on the available evidence, oral antibacterial antibiotics and prolonged macrolide antibiotics are considered therapeutic options in the treatment of CRS while the use of topical antibacterial antibiotics, intravenous antibacterial antibiotics and oral, topical, or intravenous antifungals would be recommended against. These evidence-based recommendations should not necessarily be applied to all patients with CRS and are not intended to supersede clinical judgment based on individual patient circumstances.

Atopic profile of patients failing medical therapy for chronic rhinosinusitis

BACKGROUND

Chronic rhinosinusitis (CRS) is an inflammatory condition of the nasal airway and paranasal sinuses that can broadly be classified into CRS with nasal polyps (CRSwNP) and CRS without nasal polyps (CRSsNP). The relationship between CRS and atopy to inhalant allergens remains unclear. We sought to examine the presence of atopy in patients failing medical therapy for both types of CRS. The objective of this research was to analyze the frequency and distribution of allergen sensitivity in patients failing medical therapy for CRSwNP and CRSsNP in comparison to rhinitis patients without CRS and the general population.

METHODS

A prospectively collected database of 334 consecutive CRS patients who had surgery after failing maximal medical therapy was queried to identify those who met inclusion criteria: a sinus computed tomography (CT), an endoscopy consistent with CRS, and skin-prick testing with 24 common inhalant allergens in 8 classes at our institution (n = 125). Additionally, data from these CRS patients were compared to a group of 50 patients diagnosed with rhinitis who had similar symptoms but radiologically normal CT scans, as well as published normative population skin-prick testing data obtained from the National Health and Nutrition Examination Study III (NHANES III). The relationship between atopy, as assessed by the frequency of skin test positivity, and radiological disease severity, was assessed for several allergen classes in CRSwNP, CRSsNP and rhinitis patients.

RESULTS

One or more positive skin results were observed in 103 of 125 (82.4%) CRS patients who underwent surgery--a prevalence significantly higher than that found in the NHANES III study (p < 0.05) but not different from the rhinitis control group (36/50, 72.0%). The most prevalent positive skin test results were to dust mites and ragweed in CRSwNP, CRSsNP, and rhinitis patients. Comparing these 3 patient groups, there were no significant differences in the rates of positive skin-test results to any single allergen. However, the median number of skin test–positive results was higher in CRSwNP patients compared to CRSsNP and rhinitis patients. Consistent with other studies, we found that CRSwNP patients were more likely to be male and have concurrent asthma.

CONCLUSION

In our series of patients failing medical therapy for CRS, we found higher rates of atopy compared with the general population but not compared with rhinitis patients. CRSwNP patients with medically refractory sinusitis were more likely to have multiple positive skin tests and asthma as compared to the general population or patients with either CRSsNP or rhinitis. Host barrier dysfunction may play a role in enabling multisensitization.

Osteomeatal complex obstruction is not associated with adjacent sinus disease in chronic rhinosinusitis with polyps

BACKGROUND

It is universally accepted that osteomeatal complex (OMC) disease is linked to the subsequent development of chronic rhinosinusitis without nasal polyps (CRSsNPs) via postobstructive mechanisms. The role of OMC obstruction in the pathogenesis of CRSwNPs is less clear. This study was designed to identify if there is an association between OMC obstruction and inflammation of the adjacent sinuses, when patients are stratified by polyp status. This is a follow-up and expanded series of a previous pilot study from our group.

METHOD

CT scans of 144 patients with CRSsNPs and 123 patients with CRS with nasal polyps (CRSwNPs) were evaluated for each sinus and OMC. Patients had no previous surgeries for NPs. CT scans were obtained after a trial of maximal medical therapy.

RESULTS

Increasing OMC involvement was associated with increasing Lund-Mackay score for both CRSsNPs and CRSwNPs. In CRSsNP patients, OMC status significantly correlated with adjacent sinus status (p << 0.0001). Meanwhile in CRSwNPs, OMC status does not correlate with adjacent sinus status (p = 0.328).

CONCLUSION

OMC obstruction in the setting of CRSwNP may be a barometer of the overall disease process, but in this scenario, paranasal sinus inflammation can not be classified as a postobstructive phenomenon. These findings question the role of minimally invasive procedures in the management of CRSwNPs.

Glandular mast cells with distinct phenotype are highly elevated in chronic rhinosinusitis with nasal polyps

BACKGROUND

Although chronic rhinosinusitis (CRS) with nasal polyps (CRSwNP) is characterized by T(H)2 inflammation, the role of mast cells is poorly understood.

OBJECTIVE

The objective of this study was to investigate the presence, localization, and phenotype of mast cells in patients with CRS.

METHODS

We collected nasal tissue and nasal lavage fluid from patients with CRS and control subjects. We analyzed mRNA for the mast cell proteases tryptase, chymase, and carboxypeptidase A3 by using real-time PCR and measured mast cell protease proteins by using ELISA, immunohistochemistry, and immunofluorescence.

RESULTS

Tryptase mRNA was significantly increased in nasal polyps (NPs) from patients with CRSwNP (P< .001) compared with uncinate tissue from patients with CRS or control subjects. Tryptase protein was also elevated in NPs and in nasal lavage fluids from patients with CRSwNP. Immnohistochemistry showed increased numbers of mast cells in epithelium and glands but not within the lamina propria in NPs. The mast cells detected in the epithelium in NPs were characterized by the expression of tryptase and carboxypeptidase A3 but not chymase. Mast cells expressing all the 3 proteases were abundant within the glandular epithelium of NPs but were not found in normal glandular structures.

CONCLUSIONS

Herein we demonstrated a unique localization of mast cells within the glandular epithelium of NPs and showed that mast cells in NPs have distinct phenotypes that vary by tissue location. Glandular mast cells and the diverse subsets of mast cells detected may contribute to the pathogenesis of CRSwNP.

Tissue-specific effects of allergic rhinitis in mouse nasal epithelia

Allergic rhinitis (AR) can cause significant olfactory loss, but few studies have specifically investigated AR effects on olfactory and nasal respiratory tissues per se. To address this, we used a murine AR protocol employing nasal allergen infusion for both sensitization and challenges. Seven- to 11-week BALB/c mice were bilaterally infused with 1% ovalbumin (OVA) in phosphate-buffered saline (PBS) or PBS alone for 6 or 11 weeks, given single bilateral PBS or OVA infusions 24 h before sacrifice, or left untreated. High OVA-specific IgE serum levels and eosinophil infiltration confirmed AR induction. Olfactory (OE) and respiratory (RE) epithelia showed distinctly different responses, most conspicuously, massive eosinophil infiltration of immediately RE-subjacent lamina propria. In OE, such infiltration was minimal. Significant RE hypertrophy and hyperplasia also occurred, although OE organization was generally maintained and extensive disruption localized despite a 20% reduction in sensory neurons and globose basal cells after 11 weeks OVA. Pronounced Bowman's gland hypertrophy crowded both OE and olfactory nerve bundles. Cellular proliferation was widely distributed in RE but in OE was localized to normally thinner OE and RE-proximal OE, suggesting possible indirect RE influences. Terminal deoxynucleotide transferase (TdT) nick end labeling was greater in OE than RE and, in contrast to other effects, occurred with acute infusions and chronic PBS alone, often unilaterally. Following chronic OVA, AR-related bilateral increases appeared superimposed on those. These findings indicate AR effects on olfactory function may be complex, reflecting various levels of RE/OE responses and interactions.

Establishing a Threshold for Surgery in Recurrent Acute Rhinosinusitis

Objective. Treatment of recurrent acute rhinosinusitis (RARS) has 2 effective modalities: medical therapy with exacerbations or surgery to reduce the frequency and severity of infections. However, it is unclear when one therapy should be recommended over the other. This study seeks to identify a threshold number of infections where the morbidity of surgery is offset by the morbidity of RARS.

Study Design. Health economic breakeven threshold analysis.

Setting. Clinical otolaryngology practice.

Subjects. None.

Methods. A model of productivity was constructed to simulate the first 1 to 3 years after surgery using literature reported rates of medical and surgical response rates, quality of life, and productivity.

Results. Based on lost productivity, the lost time for the postoperative period balances out when patients suffer from 4 episodes per year (range, 1.8-12.8).

Conclusion. Because of possible confusion with upper respiratory tract infections (URTIs), the authors have adopted an approach similar to that adopted by the Rhinosinusitis Task Force (RTF). Given the average number of URTIs suffered by adults annually is 1.4 to 2.3, they suggest adding 2 to the threshold number of episodes similar to the RTF guideline for RARS. From a productivity perspective, surgical intervention may be a viable consideration if patients have suffered from 6 episodes per year. However, the effects of surgery are expected to last longer than the 19 months observed in the literature, implying that the breakeven threshold is likely lower than projected. Discussion with the patient must include a rational consideration of the burden of disease, overall patient quality of life, and risks of surgery.