Effect of systemic steroids on humming nasal nitric oxide in chronic rhinosinusitis with nasal polyposis

Systemic corticosteroids in treatment of chronic rhinosinusitis-A systematic review

Purpose

When first-line chronic rhinosinusitis (CRS) treatment fails, patients can either be treated with oral or injected systemic corticosteroids. Although the EPOS and international guidelines for CRS do not mention injected corticosteroids, it is commonly used by ear, nose, and throat specialists. While the risks of systemic corticosteroids, in general, are known, the pros and cons of injected and oral corticosteroids (OCS) in CRS treatment are unclear.

Methods

A systematic review of studies that report the effects and/or side effects of injected and oral corticosteroids in the treatment of CRS was made according to the PRISMA guidelines.

Results

Altogether, 48 studies were included, only five studies reported on injected corticosteroids, and five attended with side effects. Three studies found beneficial effects of OCS perioperatively on sinus surgery, while four articles found no effect. Nineteen articles reported that OCS resulted in an improvement in symptoms. Two articles presented a longer-lasting effect of injected corticosteroids than OCS. Three studies reported adverse side effects of systemic corticosteroids, while two studies showed no adverse side effects. One study showed less adrenal suppression after injected corticosteroids compared to OCS. The evidence is not strong but shows a positive effect of systemic corticosteroids that lasts longer with injections.

Conclusion

Although systemic corticosteroids are widely used to treat CRS, there is a lack of studies comparing the OCS and injected corticosteroids. The evidence is sparse, however, injected steroids show longer effects with fewer side effects. An RCT study is needed to compare OCS and injected corticosteroids.

The Diagnostic and Prognostic Role of Biomarkers in Chronic Rhinosinusitis

Chronic rhinosinusitis (CRS) refers to an inflammatory disease of the sinonasal mucosa, with a significant economic burden and impact on quality of life. The diagnosis of CRS is conventionally made on careful history and physical examination, including nasoendoscopic assessment which requires technical expertise. There has been increasing interest in using biomarkers in the non-invasive diagnosis and prognostication of CRS, tailored to the disease inflammatory endotype. Potential biomarkers currently being studied can be isolated from peripheral blood, exhaled nasal gases or nasal secretions, as well as sinonasal tissue. In particular, various biomarkers have revolutionized the way in which CRS is managed, revealing new inflammatory pathways where novel therapeutic drugs are employed to curb the inflammatory process, which may be different from one patient to the next. Biomarkers that have been extensively studied in CRS, such as eosinophil count, IgE, and IL-5, have been associated with a T_H2 inflammatory endotype which correlates with an eosinophilic CRSwNP phenotype that predicts a poorer prognosis, tends to recur after conventional surgical treatment, but responds to glucocorticoid treatment. Newer biomarkers that demonstrate potential, such as nasal nitric oxide, can support a diagnosis of CRS with or without nasal polyps, especially when invasive tests such as nasoendoscopy are unavailable. Other biomarkers such as periostin can be used to monitor disease course after treatment of CRS. With a personalized treatment plan, the management of CRS can be individualized, optimizing treatment efficiency and reducing adverse outcomes. As such, this review aims to compile and summarize the existing literature regarding the utility of biomarkers in CRS in terms of diagnosis and prognostication, and also makes recommendations for further studies to fill current knowledge gaps.

Nasal nitric oxide flux from the paranasal sinuses

PURPOSE OF REVIEW

Upper airway nitric oxide (NO) is physiologically important in airway regulation and defense, and can be modulated by various airway inflammatory conditions, including allergic rhinitis and chronic rhinosinusitis - with and without polyposis. Paranasal sinuses serve as a NO 'reservoir', with concentrations typically exceeding those measured in lower airway (fractional exhaled NO or FeNO) by a few orders of magnitude. However, the dynamics of NO flux between the paranasal sinuses and main nasal airway, which are critical to respiratory NO emission, are poorly understood.

RECENT FINDINGS

Historically, NO emissions were thought to be contributed mostly by the maxillary sinuses (the largest sinuses) and active air movement (convection). However, recent anatomically-accurate computational modeling studies based on patients' CT scans showed that the ethmoid sinuses and diffusive transport dominate the process.

SUMMARY

These new findings may have a substantial impact on our view of nasal NO emission mechanisms and sinus physiopathology in general.

Correlation of polyp grading scales with patient symptom scores and olfaction in chronic rhinosinusitis: a systematic review and meta-analysis

BACKGROUND

Various nasal polyp (NP) scoring systems have been proposed and used in the literature. However, no single system has been identified as superior. Correlations between NP scoring systems and patient symptoms, quality of life (QOL) or olfaction vary widely.

METHODS

A systematic search of PubMed, CINAHL, Scopus, and Cochrane Library was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guideline. Any study examining endoscopy scores and symptom, QOL or olfaction measures in cross sectional manner or after therapeutic intervention were included.

RESULTS

This review identified 55 studies for a pooled meta-analysis of Lund-Kennedy (LK-NP) polyp scores (N = 6), Meltzer scores (N = 6), Nasal polyp scores (NPS; N = 19), Total polyp score (TPS; N=8) Lilholdt scores (N = 8), Olfactory cleft endoscopy score (OCES; N =4), Discharge, inflammation, polyp/edema score (DIP; N = 2), and Perioperative sinus endoscopy score (POSE; N = 2). Meta-regression assessed correlations between NP grading systems and SNOT-22, nasal congestion scores, total nasal symptom scores (TNSS), and Smell Identification Test-40 (SIT40). None of the NP grading systems correlated significantly with any symptom, QOL or olfactory metric. In intervention studies of surgery or monoclonal antibody treatment, changes in NPS scores did not correlate with any patient reported outcome measure (PROM) or olfactory outcomes.

CONCLUSION

Current NP endoscopic scoring systems are not associated with PROMs such as SNOT-22, nasal congestion scores, and TNSS as well as objective measures of olfaction. NP grading systems with improved clinical utility are needed.

The Choice of Biologics in Patients with Severe Chronic Rhinosinusitis with Nasal Polyps

Patients with severe chronic rhinosinusitis with nasal polyps represent an unmet clinical need in terms of recurrent disease despite current medical and surgical therapy. Targeting type 2 inflammatory cytokines (IL4/5/13) appears to be a promising therapeutic approach for such patients akin to what has already been seen in severe asthma. An indirect comparison from phase 3 placebo-controlled trials has shown relative improvements in the coprimary end point of nasal polyp score (NPS) ranging from a 15% reduction (-0.8 units) with mepolizumab, 18% with omalizumab (-1.14 units), and 35% (-2.06 units) with dupilumab. This trend was mirrored by relative improvements in health status with the 22-item Sinonasal Outcome Test score showing a 21% reduction (-13.7 units) with mepolizumab, 27% (-16.1 units) with omalizumab, and 43% (-21.1 units) with dupilumab, all exceeding the minimal clinically important difference of 8.9 units. All biologics improved the coprimary end point of nasal airway blockage and also reduced the need for rescue medical and/or surgical polypectomy. We advocate performing real-life studies looking at the response to biologics in patients who are at increased risk for disease recurrence, including initial optimal medical and surgical polyp clearance before commencing biologics.

Effects of the inverse alpha-agonist doxazosin in allergic rhinitis

BACKGROUND

We examined the paradoxical hypothesis that the alpha-receptor inverse agonist doxazosin might produce beneficial effects in allergic rhinitis.

OBJECTIVES

To evaluate single and chronic dosing effects of doxazosin on nasal airflow and symptoms in allergic rhinitis.

METHODS

Fifteen patients randomized to receive 3-5 weeks of oral doxazosin 4 mg daily or placebo in crossover fashion. Measurements were taken at baseline and after first and last doses.

RESULTS

There was a fall in peak nasal inspiratory flow (PNIF) between baseline vs. first dose of doxazosin: mean difference -19 L/min (95% CI -35 to -2) P = 0.03, with recovery between first and last doses: 21 L/min (95% CI 7-34) P = 0.006. Nasal visual analogue scale (VAS) and blockage scores were worse between baseline vs. first dose of doxazosin: mean difference VAS -10 mm (95% CI -18 to -2) P = 0.02, blockage -0.7 (95% CI -1.3 to -0.1) P = 0.02, with recovery between first and last doses: VAS 15 mm (95% CI 4-25) P = 0.009, blockage 1.1 (95% CI 0.5-1.6) P = 0.001. The oxymetazoline dose-response for PNIF was blunted after single vs chronic dosing with doxazosin: mean difference -17 L/min (95% CI -30 to -4) P = 0.01. Heart rate and diastolic blood pressure showed the same pattern. There was a significant difference between doxazosin and placebo for nasal blockage score and heart rate after single but not chronic dosing.

CONCLUSIONS

There was a disconnect between single and chronic dosing effects of doxazosin for nasal symptoms, oxymetazoline response and cardiovascular outcomes, in turn suggesting alpha-1 receptor up-regulation.

Oral corticosteroids in the management of chronic rhinosinusitis with and without nasal polyps: Risks and benefits

BACKGROUND

Oral steroids are synthetic mimics of adrenal cortex hormones and are considered a staple in the management of chronic rhinosinusitis due to their anti-inflammatory effects. Despite their common use, many providers are not familiar with the potential risks of the drugs.

METHODS

Literature review.

RESULTS

An overview of the existing data on the risks of oral steroids is presented as well as a review of the malpractice lawsuits with regard to oral steroid use and a discussion of the data that support the use of oral steroids in patients with chronic rhinosinusitis with and those without nasal polyps.

CONCLUSION

It is essential for providers to be aware of the potential complications of a medication, the medical jurisprudence of the drugs, and the data that support their use.

Endogenous Production of Hydrogen Sulfide in Human Sinus Mucosa and its Expression Levels are Altered in Patients with Chronic Rhinosinusitis with and without Nasal Polyps

Background

Chronic rhinosinusitis with nasal polyps (CRSwNPs) or CRS without nasal polyps (CRSsNPs) is characterized by persistent inflammation of sinonasal mucosa. No one causative factor fully explains for the pathological manifestations of CRS. Endogenous hydrogen sulfide (H2S) has been shown to participate in inflammatory diseases, functioning as an inflammatory mediator in various organs. We analyzed the contents and synthesis activity of H2S, the expression and distribution pattern of H2S-generating enzymes, cystathione β-synthase (CBS), and cystathione γ-lyase (CSE) in CRSwNPs and CRSsNPs. The effects of H2S on the expression of CRS-relevant cytokines and the effects of cytokines on the expression of CBS and CSE were assessed in an in vitro experiment.

Methods

The contents and synthesis activity of H2S and the expression and distribution pattern of CBS and CSE in sinus mucosa were evaluated using spectrophotometry, real-time polymerase chain reaction, Western blot, and immunohistochemistry. Cultured epithelial cells were used to elucidate the effects of H2S donor, sodium hydrosulfide (NaHS), on the expression of CRS-relevant cytokines and the effects of cytokines on H2S-generating enzymes expression.

Results

The contents and synthesis activity of H2S were increased in CRSwNPs and CRSsNPs. CBS and CSE were localized to the superficial epithelium and submucosal glands, but CSE was also found in vascular endothelium. N S induced increased expression of IL-4, IL-5, interferon γ, and TNF-α. CBS and CSE expression in cultured cells was up-regulated by CRS-relevant cytokines.

Conclusion

H2S levels are increased in CRS, contributing to increased production of cytokines. These results suggest that H2S may function as inflammatory mediator in CRS.

Exhaled nasal nitric oxide during humming: potential clinical tool in sinonasal disease?

The use of nasal nitric oxide (nNO) in sinonasal disease has recently been advocated as a potential tool to explore upper inflammatory airway disease. However, it is currently hampered by some factors including the wide range of measurement methods, the presence of various confounding factors and the heterogeneity of the study population. The contribution of nasal airway and paranasal sinuses communicating with the nose through the ostia represents the main confounding factor. There is accumulating evidence that nasal humming (which is the production of a tone without opening the lips or forming words) during nNO measurement increases nNO levels due to a rapid gas exchange in the paranasal sinuses. The aim of this review is to discuss the basic concepts and clinical applications of nNO assessment during humming, which represents a simple and noninvasive method to approach sinonasal disease.

Sensitivity of impulse oscillometry and spirometry in beta-blocker induced bronchoconstriction and beta-agonist bronchodilatation in asthma

BACKGROUND

Impulse oscillometry (IOS) provides an alternative method of assessing pulmonary function to conventional spirometry.

OBJECTIVE

To compare the sensitivities of IOS and spirometry in assessing bronchoconstriction to propranolol and bronchodilation with salbutamol.

METHODS

A post-hoc analysis of a randomized placebo-controlled crossover study was performed. Patients with mild-to-moderate persistent stable asthma taking 1,000 μg/day or less beclomethasone dipropionate equivalent received 10 or 20 mg of oral propranolol followed by histamine challenge, with recovery to nebulized salbutamol (5 mg). Spirometry and IOS were measured before and 2 hours after beta-blocker, post histamine, and 20 minutes post-salbutamol. Pre versus post percent change (95%CI) values were compared, and standardized response means (SRM) were calculated to assess the "signal to noise" of each test.

RESULTS

Thirteen participants (mean age, 34 years) completed the protocol. Eleven participants received 20 mg of propranolol; 2 received 10 mg, because this dose caused more than 10% decrease in forced expiratory volume in 1 second (FEV(1)) on the test-dose algorithm. All IOS indices (R5, R5-R20, AX, RF) showed significant worsening of airways resistance or reactance to propranolol. FEV(1) but not FEF25-75 showed significant deterioration after beta-blocker (mean percent change, 4.6% and 6.2%). The magnitude of change was consistently higher for parameters of IOS, with the largest change being observed with R5 and RF (mean percent change, 30.8% and 39.4%). The SRMs for IOS outcomes were better than for spirometry. All measures of lung function showed significant bronchodilator response, with the best SRMs seen in R5 and RF.

CONCLUSION

IOS is a more sensitive response outcome than spirometry with respect to bronchoconstriction to oral propranolol and bronchodilatation after salbutamol in patients with mild to moderate asthma.

Pilot evaluation of the nasal nitric oxide response to humming as an index of osteomeatal patency

BACKGROUND

Paranasal sinuses are reservoirs for nitric oxide (NO), and humming facilitates nasal diffusion of NO. The nasal NO response to humming has previously been shown to be blunted with chronic sinusitis and nasal polyposis. We hypothesized that the nasal NO response to humming will be proportional to radiographic osteomeatal patency when comparing allergic rhinitis (AR) patients (without chronic sinusitis) with normal controls.

METHODS

Nonsmoking subjects completed questionnaires and skin-prick testing. Subjects underwent sinus CT scanning, followed by exhaled (oral) and nasal NO sampling (with and without humming). Humming-to-quiet (H/Q) nasal NO ratios were calculated. Three-dimensional reconstructions were used to trace the osteomeatal complex (OMC) and measure minimum cross-sectional area. Lund-Mackay scores were also documented.

RESULTS

A total of 33 subjects (22 women; mean age, 35.5 years) completed the study. Seventeen AR patients (5 IAR and 12 PAR) participated, as did 16 nonallergic controls. Among controls, quiet nasal NO levels--corrected for fractional exhaled NO--rose significantly with OMC area and fell significantly with Lund-Mackay scores (p < 0.05). However, we observed no proportionality between H/Q ratio and radiographic OMC patency.

CONCLUSION

Analysis of nasal NO samples taken under quiet conditions from normal controls was consistent with the paranasal sinuses acting as a reservoir of nasal NO and with OMC patency acting as a significant factor in NO diffusion. However, our results did not support a relationship between the nasal NO response to humming and radiographic OMC patency in a sample excluding subjects with severe rhinosinusitis.

Scientific rationale for the use of alpha-adrenergic agonists and glucocorticoids in the therapy of pediatric stridor

Purpose. The most common pharmacological therapies used in the treatment of stridor in children are glucocorticosteroids (GC) and alpha-adrenergic (αAR) agonists. Despite the long-standing reported efficacy of these medications, there is a paucity of data relating to their actual mechanisms of action in the upper airway. Summary. There is compelling scientific evidence supporting the use of αAR-agonists and GCs in pediatric stridor. αAR signaling and GCs regulate the vasomotor tone in the upper airway mucosa. The latter translates into better airflow dynamics, as delineated by human and nonhuman upper airway physiological models. In turn, clinical trials have demonstrated that GCs and the nonselective αAR agonist, epinephrine, improve respiratory distress scores and reduce the need for further medical care in children with stridor. Future research is needed to investigate the role of selective αAR agonists and the potential synergism of GCs and αAR-signaling in the treatment of upper airway obstruction and stridor.

The links between chronic rhinosinusitis and asthma

PURPOSE OF REVIEW

Chronic rhinosinusitis (CRS) and asthma are two leading causes of morbidity with many shared clinical features. Their relationship has initially been linked by the atopic pathway. However, understanding of the true pathophysiology of each of these conditions is still under investigation.

RECENT FINDINGS

Recent studies have described new common pathogens, such as fungi and Staphylococcus aureus, as well as disease biomarkers such as nitric oxide and interleukin (IL)-17A, involved in both asthma and CRS pathophysiology. These new discoveries offer insight into understanding these upper and lower airway diseases and may potentially affect treatment management. In the following review, we intend to provide an overview of the recent developments in the relevant areas of research within the past year.

SUMMARY

Reactions to fungal stimuli and superantigens, as well as biomarkers such as nitric oxide and IL-17A, may play a role in the pathogenesis of asthma and CRS and may explain their historic relationship.

Structural organization and cellular localization of tuftelin-interacting protein 11 (TFIP11)

Tuftelin-interacting protein (TFIP11) was first identified in a yeast two-hybrid screening as a protein interacting with tuftelin. The ubiquitous expression of TFIP11 suggested that it might have other functions in non-dental tissues. TFIP11 contains a G-patch, a protein domain believed to be involved in RNA binding. Using a green fluorescence protein tag, TFIP11 was found to locate in a novel subnuclear structure that we refer to as the TFIP body. An in vivo splicing assay demonstrated that TFIP11 is a novel splicing factor. TFIP11 diffuses from the TFIP body following RNase A treatment, suggesting that the retention of TFIP11 is RNA dependent. RNA polymerase II inhibitor (-amanitin and actinomycin D) treatment causes enlargement in size and decrease in number of TFIP bodies, suggesting that TFIP bodies perform a storage function rather than an active splicing function. The TFIP body may therefore represent a new subnuclear storage compartment for splicing components.