Nasal polyposis

Endotypes of chronic rhinosinusitis: Relationships to disease phenotypes, pathogenesis, clinical findings, and treatment approaches

Chronic rhinosinusitis (CRS) is a common clinical syndrome that produces significant morbidity and costs to our health system. The study of CRS has progressed from an era focused on phenotype to include endotype-based information. Phenotypic classification has identified clinical heterogeneity in CRS based on endoscopically observed features such as presence of nasal polyps, presence of comorbid or systemic diseases, and timing of disease onset. More recently, laboratory-based findings have established CRS endotype based upon specific mechanisms or molecular biomarkers. Understanding the basis of widespread heterogeneity in the manifestations of CRS is advanced by findings that the three main endotypes, Type 1, 2, and 3, orchestrate the expression of three distinct large sets of genes. The development and use of improved methods of endotyping disease in the clinic are ushering in an expansion of the use of biological therapies targeting Type 2 inflammation now and perhaps other inflammatory endotypes in the near future. The purpose of this review is to discuss the phenotypic and endotypic heterogeneity of CRS from the perspective of advancing the understanding of the pathogenesis and improvement of treatment approaches and outcomes.

Blood Eosinophilia and Nasal Polyps

In a controlled prospective study, patients who had nasal polypectomy were compared with patients who required other nasal surgery. Patients with and without asthma were identified. Both polyposis and asthma were independently associated with increased blood absolute eosinophil counts. Absolute eosinophil counts were: neither disease 0.199 × 106 cell/mL ± 0.025, polyposis alone 0.249 × 106 cell/mL ± 0.017, asthma alone 0.318 × 106 cell/mL ± 0.092, and both 0.375 × 106 cell/mL ± 0.076. In contrast, we were unable to show a difference between polyp patients and the controls in the serum IgE concentration or allergy skin test reactivity. Atopy was not a predictive factor for asthma in polyp patients. We conclude that nasal polyposis, like asthma, is highly associated with eosinophilia.

Protein Biochip Array of Adhesion Molecule Expression in Peripheral Blood of Patients with Nasal Polyposis

Nasal polyposis is a chronic non-infectious inflammatory disease of the nasal and paranasal cavity mucosa of unknown multifactorial origin in which inflammatory cells, and in particular eosinophils, seem to play a pivotal role. Eosinophil migration from the bloodstream to nasal polyps is considered to be specific and is a complex process involving several different molecules such as ICAM-1, VCAM-1, and L-, P- and E-selectins. The aim of this study was to investigate, using a protein biochip array technology, the concentrations of these molecules in the peripheral blood of a group of patients affected by nasal polyposis. Patients exhibited a significantly higher expression of VCAM-1, E-selectin, and L-selectin compared to healthy controls, and Spearman's rank correlation test limited to the molecules with significant between-group differences demonstrated a significant correlation between VCAM-1 and E-selectin, VCAM-1 and L-selectin, and E-selectin and L-selectin. The results of this investigation are in line with those coming from various imunohistochemical analyses, and seem to confirm the role of inflammation in the pathogenesis of nasal polyposis. These molecules may also represent novel therapeutic targets in the treatment of nasal polyps, and may allow the selection of pharmacological prophylactics that would allow effective inhibition of the inflammation induced by a given allergen.

Intranasal corticosteroids for nasal polyposis : biological rationale, efficacy, and safety

Nasal polyposis, occurring in about 2% of the general population, is the ultimate form of inflammation of the upper airways. For unknown reasons, polyps develop preferentially in subtypes of inflammatory diseases and are associated with perennial non-allergic rhinitis, asthma, intolerance of aspirin (acetylsalicylic acid)/NSAIDs, allergic fungal rhinosinusitis, cystic fibrosis, and primary ciliary dyskinesia. In contrast to common beliefs, IgE-mediated allergy does not seem to play an etiological role in nasal polyposis.The polyps originate from the mucosa around the clefts of the lateral nasal wall, especially in the region of the ostiomeatal complex. The factors that determine the localization of the disease to a few square centimeters of the airways are not known.Polyps are edematous bags covered by respiratory epithelium and contain very few nerves, blood vessels, and glands that have undergone cystic degeneration. They contain degranulated mast cells, have a very high concentration of histamine, and are characteristically infiltrated by eosinophils. These cells accumulate due to the release of proinflammatory cytokines (in particular, interleukin-5).Nasal polyposis is preceded by a prolonged history of rhinitis accompanied by severe and persistent nasal blockage; typically, the sense of smell is seriously impaired when polyps develop. The diagnosis is based on anterior rhinoscopy or, preferably, endoscopy.Nasal polyposis is medically treatable. Surgical treatment is carried out when medication fails. Intranasal corticosteroids reduce rhinitis symptoms, improve nasal breathing, reduce the size of polyps, and prevent, in part, their recurrence, but this treatment has little effect on the sense of smell. Intranasal corticosteroids can, as basic long-term therapy, be used alone in mild cases or together with systemic corticosteroids and/or surgery in severe cases. Systemic corticosteroids administered for 2-3 weeks have a beneficial effect on all observed symptoms and pathology, including the sense of smell. When nasal blockage is a problem in spite of medical treatment, surgery is recommended. Simple polypectomy can be performed, but endoscopic surgery is recommended in more severe and persistent cases.

Hyaluronan synthases and hyaluronidases in nasal polyps

Nasal polyps (NPs) are benign lesions of nasal and paranasal sinuses mucosa affecting 1-4 % of all adults. Nasal polyposis affects the quality of patient's life as it causes nasal obstruction, postnasal drainage, purulent nasal discharge, hyposmia or anosmia, chronic sinusitis, facial pain and snoring. Without treatment, the disease can alter the craniofacial skeleton in cases of extended growth of polyps. The development of NPs is caused by the hyperplasia of nasal or paranasal sinuses mucosa, and edema of extracellular matrix. This is usually the result of high concentration of high molecular mass hyaluronan (HA) which is either overproduced or accumulated from blood supply. The size of HA presents high diversity and, especially in pathologic conditions, chains of low molecular mass can be observed. In NPs, chains of about 200 kDa have been identified and considered to be responsible for the inflammation. The purpose of the present study was the investigation, in NPs and normal nasal mucosa (NM), of the expression of the wild-type and alternatively spliced forms of hyaluronidases, their immunolocalization, and the expression of HA synthases to examine the isoform(s) responsible for the increased amounts of HA in NPs. Hyaluronidases' presence was examined on mRNA (RT-PCR analysis) and protein (immunohistochemistry) levels. Hyaluronan synthases' presence was examined on mRNA levels. Hyaluronidases were localized in the cytoplasm of epithelial and inflammatory cells, as well as in the matrix. On mRNA level, it was found that hyal-1-wt was decreased in NPs compared to NM and hyal-1-v3, -v4 and -v5 were substantially increased. Moreover, HAS2 and HAS3 were the only hyaluronan synthases detected, the expression of which was almost similar in NPs and NM. Overall, the results of the present study support that hyaluronidases are the main enzymes responsible for the decreased size of hyaluronan observed in NPs; thus they behave as inflammatory agents. Therefore, they could be a potential target for the design of a more advanced treatment for nasal polyposis.

Infection and HLA-G molecules in nasal polyposis

Sinonasal polyposis (SNP) is a chronic inflammatory pathology with an unclear aetiopathogenesis. Human papillomavirus (HPV) infection is one candidate for the development of SNP for its epithelial cell trophism, hyperproliferative effect, and the induction of immune-modulatory molecules as HLA-G. We enrolled 10 patients with SNP without concomitant allergic diseases (SNP-WoAD), 10 patients with SNP and suffering from allergic diseases (SNP-WAD), and 10 control subjects who underwent rhinoplasty. We analyzed the presence of high- and low-risk HPV DNA and the expression of membrane HLA-G (mHLA-G) and IL-10 receptor (IL-10R) and of soluble HLA-G (sHLA-G) and IL-10 by polyp epithelial cells. The results showed the presence of HPV-11 in 50% of SNP-WoAD patients (OR:5.5), all characterized by a relapsing disease. HPV-11 infection was absent in nonrelapsing SNP-WoAD patients, in SNP-WAD patients and in controls, supporting the hypothesis that HPV-11 increases risk of relapsing disease. HPV-11 positive SNP-WoAD patients presented with mHLA-G and IL-10R on epithelial cells from nasal polyps and showed secretion of sHLA-G and IL-10 in culture supernatants. No HLA-G expression was observed in HPV negative polyps. These data highlight new aspects of polyposis aetiopathogenesis and suggest HPV-11 and HLA-G/IL-10 presence as prognostic markers in the follow-up of SNP-WoAD.

Eosinophils and mast cells: a comparison of nasal mucosa histology and cytology to markers in nasal discharge in patients with chronic sino-nasal diseases

Allergic rhinitis (AR), nasal polyps (NP) as well as chronic rhinosinusitis (CRS) are all known to be associated with eosinophilic infiltration and elevated numbers of mast cells (MC) within the mucosa. Both cell types and their markers eosinophilic cationic protein (ECP) and tryptase are utilized in the diagnosis and management of chronic sino-nasal diseases. Mucosal cytology samples were gathered by cytobrush, histological samples were obtained from the inferior turbinate. In both sample sets, the number of eosinophils and MC was determined. Their corresponding markers ECP and tryptase were quantified from nasal discharge. Patients were grouped with reference to their main diagnosis: AR (n = 34), NP (n = 25), CRS (n = 27) and controls (n = 34). Eosinophil counts from cytobrush and ECP levels were significantly elevated in NP compared to all other groups-31- and 13-fold over control, respectively. However, histologic review did not reveal any difference in eosinophil count among groups. Tryptase was significantly elevated threefold in AR versus CRS and controls. No correlation to cytological and histological MC counts could be found. ECP levels in nasal discharge as well as eosinophil counts can provide useful information with regard to the diagnosis. Likewise, tryptase concentrations can do. The presented data show that the measurement of markers in nasal discharge is superior in differentiating among diagnosis groups. Given that the collection of nasal secretions is more comfortable for patients than the more invasive techniques, we recommend first line ECP and tryptase testing performed on nasal secretions.

Expression of the cysteinyl leukotriene 1 receptor and glucocorticoid receptor-β in nasal polyps

The objective of this study was to analyze the expression of cysteinyl leukotriene 1 (CysLT1) receptor and glucocorticoid receptors (GRs) in nasal polyps, and to evaluate the relationship between the expression of CysLT1 receptors and that of GRs. Nasal polyps were taken from 32 patients of chronic rhinosinusitis with nasal polyposis. Samples of middle turbinate from seven healthy subjects were used as controls. Specimens were immunohistochemically stained for CysLT1 receptor, GR-α and GR-β receptor, and were quantified in the unit area of the tissues. Numbers of CysLT1 receptor-positive cells were much increased in nasal polyps than in middle turbinate (281 ± 67 vs. 157 ± 85 cells/mm(2), P = .01). There was no significant difference in the numbers of GR-α positive cells between nasal polyps and normal turbinate mucosa. GR-β positive cells were increased in nasal polyps as compared to normal turbinate mucosa (36 ± 8 vs. 19 ± 7 cells/mm(2), P = .03). A significant relationship was found between the expression of CysLT1 receptor and GR-β in nasal polyps (R = .525, P = .04), whereas there was no significant relationship between the expression of CysLT1 receptor and GR-α in nasal polyps. Our study shows that CysLT1 receptor expression predominates on GR-β over-expressed polyps. This may suggest the additional effect of CysLT1 receptor antagonist for the treatment of nasal polyposis resistant to steroid alone.

Human papillomavirus infection in nasal polyps in a Chinese population

In order to determine the prevalence and genotype distribution of human papillomavirus (HPV) infection in patients with nasal polyps, a total of 204 patients with nasal polyps and 36 healthy controls were recruited for this study. Genomic DNA was extracted from paraffin-embedded tissue sections. HPV DNA genotyping was achieved by a flow-through hybridization and gene-chip method. HPV-positive infection was identified in 82 of 204 (40.2 %) patients, while HPV DNA was not found in healthy controls (P<0.05). Genotyping analysis showed that low-risk HPV genotype 11 was the most prevalent type of HPV in nasal polyps (45.28 %). Both single and multiple HPV genotype infections were found in these HPV-positive cases, although most (74.39 %) were infected with a single genotype. In addition, there was no correlation between HPV infection or HPV subtypes and the clinicopathological characteristics of patients, such as age, gender, number of surgery and disease course. The data from our study clearly demonstrated that HPV infection was associated with nasal polyps. Both high-risk HPV and low-risk HPV (LR-HPV) genotypes were identified in nasal polyp tissues, and LR-HPV-11 was the most prevalent type. Future research will explore the association of HPV infection with the development and progression of nasal polyps.

Eosinophilic allergic polyp: a clinically oriented concept of nasal polyp

OBJECTIVE

Tissue eosinophilia is a hallmark of nasal polyposis. However, there is no universally accepted definition for eosinophilic nasal polyp. The aims of this study were to histologically analyze the inflammatory cell population in the nasal polyp and propose the concept of eosinophilic allergic polyp (EAP), a simple and objective concept that would be clinically and practically valuable.

STUDY DESIGN

A cohort study with histological analysis of tissue sections and chart review.

SETTING

A tertiary university hospital.

SUBJECTS AND METHODS

Nasal polyp tissues were harvested during routine endoscopic sinus surgery from a cohort of 118 patients. Total number of inflammatory cells, including eosinophils, was counted. The presence of allergy and asthma was assessed, which was then correlated with the histologic findings. To determine a criterion for EAP, a receiver operating characteristic curve was used to identify the best cutoff point, which was further validated by comparing the eosinophil proportion in each group with reference to the clinical parameters.

RESULTS

Eosinophil accounted for an average of 18.7% of all inflammatory cells. The proportion of nasal polyps with at least 1 or more eosinophil infiltration accounted for 90.7% of all nasal polyps. When the concept of EAP was applied, a tissue eosinophil count of 11% was found to be significant and clinically most useful. Using this criterion, the proportion of EAP among nasal polyps was 62.7%.

CONCLUSION

The authors suggest a tissue eosinophil proportion of more than 11% as a criterion for EAP, a clinically useful concept of nasal polyp that bears good correlation with asthma and allergy.

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.

[Immunocytochemical detection of caspase 3 in various diseases of human nasal mucosa]

BACKGROUND

Inflammatory processes play a central role in the pathogenesis of chronic rhinosinusitis (CRS), however, the impact of apoptosis in CRS in unclear. The aim of this study was a comparison of caspase 3 activity, a key enzyme in the apoptosis cascade, in samples of nasal tissue from patients with different types of rhinosinusitis.

MATERIAL AND METHODS

Immunohistochemical analyses were carried out to detect caspase 3 in samples of nasal tissue from patients with CRS and nasal polyps (NP), allergic rhinitis (AR), rhinitis medicamentosa (RM) and atrophic rhinitis.

RESULTS

Evidence of increased apoptosis was found in the epithelium, submucosal glands and blood vessels in NP samples. Samples of RM showed strong caspase 3 activity in the endothelial cells and the lamina muscularis of blood vessels. In atrophic rhinitis the epithelium and subepithelial glands showed increased caspase 3 activity. In samples of patients with allergic rhinitis caspase 3 activity could not be detected.

CONCLUSIONS

Activated apoptosis seems to play an important role in the pathogenesis of different types of rhinosinusitis. Further investigations on the induction of caspase 3 are necessary for the development of new therapeutic strategies to influence the regulation of apoptosis.

Long-term study of fluticasone propionate aqueous nasal spray in acute and maintenance therapy of nasal polyposis

BACKGROUND

Topical steroids are first-line medication to control nasal polyposis (NP), a disease with long-term clinical course.

OBJECTIVE

The aim of this study was to evaluate the efficacy and safety of fluticasone propionate aqueous nasal spray (FPANS) 200 microg twice a day (bd) after 1 month of treatment, and to compare FPANS 200 microg bd and FPANS 200 microg once a day (od) in maintenance and long-term treatment.

METHODS

Double-blind, placebo-controlled, 8-month study with three treatment periods (1-month acute period followed with 1-month maintenance period and 6-month follow-up period) was carried out. Group 1 received FPANS 200 microg bd, during acute, maintenance and follow-up periods, Group 2 received FPANS 200 microg bd during acute period and FPANS 200 microg od during maintenance and follow-up periods, and Group 3 received placebo during acute and maintenance periods and FPANS 200 microg bd during follow-up period. Endpoints were change from baseline in clinic peak nasal inspiratory flow (PNIF), domiciliary evening PNIF, intensity of symptoms and polyposis grade.

RESULTS

After acute period and maintenance periods, FPANS 200 microg bd was significantly more effective than placebo on all endpoints and more effective than FPANS 200 microg od after 1-month maintenance period on clinic PNIF, evening PNIF, obstruction, percentage of days with no sense of smell and percentage of nights with no disturbances. The two doses were similar on other endpoints. After the 6-month follow-up period, there was no difference between the two doses of FPANS at all efficacy endpoints. The safety profile of FPANS did not highlight any new or unanticipated adverse events.

CONCLUSION

The study demonstrated the efficacy of FPANS 200 microg bd in acute treatment and FPANS 200 microg od as a sufficient dose to maintain a long-term efficacy in the treatment for NP.

The Effect of High-dose Topical Corticosteroid Therapy on Prevention of Recurrent Nasal Polyps after Revision Endoscopic Sinus Surgery

Background

Topical corticosteroid spray is widely used after endoscopic sinus surgery (ESS) to reduce the recurrence of polyposis. However, it has not always shown satisfactory results in clinical practice. We compared the effects of topical spray and high-dose topical steroid gauze packing on the prevention of recurrent nasal polyps after ESS.

Methods

We selected 32 patients with recurrent nasal polyps after ESS. In group 1, 18 patients were treated with topical steroid spray and in group 2,14 patients were treated with triamcinolone acetonide–soaked (40 mg) gauze packing once a week for 2 months after revision ESS. We observed the recurrence of polyps between the two groups for 12 months.

Results

Polyps recurred in 8 of 18 patients in group 1 compared with 1 of 14 patients in group 2 (p = 0.044).

Conclusion

High-dose topical corticosteroid therapy may be more effective than low-dose topical therapy in preventing recurrent nasal polyps.

Nasal polyp diseases in allergic and nonallergic patients and steroid therapy

OBJECTIVE

To investigate widespread disease causes, cellular-structural differences, and steroid response of nasal polyps (NPs).

METHOD

Study group consisted of NPs, allergic-NPs, NPs with steroid therapy (ST), antrochoanal polyp (ACP), and controls. We investigated stromal eosinophil, mast cell, CD4+ and CD8+ cell counts and presence of squamous metaplasia, Ki-67 expression, intraepithelial eosinophils-mast cells, epithelial damage, edema, fibrosis, hyalinization, polymorphonuclear leukocyte, and glandular hyperplasia.

RESULTS

In allergic-NPs, intraepithelial eosinophils and epithelial damage CD4+ were significantly higher than NPs and also, eosinophils, mast cells, intraepithelial eosinophils, and epithelial damage were significantly higher than ACP. Only stromal eosinophilic infiltration was significantly higher in NPs than ACP. There was significant increased glandular hyperplasia and decreased intraepithelial eosinophils, mast cells, CD4+ cells, squamous metaplasia, and epithelial damage with ST in allergic-NPs. There were no significant differences with ST in NPs.

CONCLUSION

NPs in allergic and nonallergic patients may differ in their histology and in their histologic responses to ST.

EBM RATING

B-3b.

Influence of allergy on the symptoms and treatment of nasal polyposis

CONCLUSION

Allergy does not modify the symptoms of nasal polyposis, either initially or after a 1-year medical treatment.

OBJECTIVES

To assess the role of allergy in the symptoms and treatment of patients presenting with the diagnosis of nasal polyposis.

PATIENTS AND METHODS

Two simultaneous studies were carried out. In the first study, 180 consecutive patients with nasal polyposis (60% males, mean age = 48.4 years) were analyzed to detect whether the severity of their symptoms correlated with the presence of positive allergic tests. In the second study, 74 consecutive patients (57.5% males, mean age = 48.3 years) were analyzed to detect whether the results of a 1-year medical treatment of nasal polyposis were influenced by the presence of positive allergic tests (Phadiatop). Five nasal criteria were scored: nasal obstruction, anterior and posterior rhinorrhea, facial pain, and the loss of sense of smell. The frequency of asthma was evaluated. Treatment of nasal polyposis consisted of washing of the nasal cavities, steroid spray, and oral steroid administration. The amount of steroid consumption (prednisolone and beclomethasone) was studied.

RESULTS

In the first study, mean scores of nasal symptoms did not differ between the two groups of patients with and without allergy. The prevalence of asthma (p = 0.03) was higher in the group with than without allergy. In the second study, decrease of all nasal symptoms was not statistically different in the two groups. Cumulative consumption of prednisolone and beclomethasone between baseline and year 1 were similar in the two groups.

Endothelial and epithelial expression of eotaxin-2 (CCL24) in nasal polyps

BACKGROUND

Nasal polyposis is mostly associated with eosinophilia of mucosal tissue. This points to the implication of CC chemokines in nasal eosinophilia. Recently the CC chemokine eotaxin-2 (CCL24) was identified. This study was initiated to localize the cellular source, analyze expression of mRNA, and quantify protein synthesis of CCL24.

METHODS

Specimens of nasal inferior turbinates from controls and polypous tissue from patients suffering from chronic polypous sinusitis were collected. Furthermore, fibroblasts and epithelial cells were cultured. CCL24 protein was analyzed by immunohistochemistry and ELISA, expression of mRNA by SQ-RT-PCR.

RESULTS

CCL24 was observed in endothelial and epithelial cells. Specimens from patients expressed significantly (>2fold) more CCL24 mRNA than controls. Fibroblasts and unstimulated cells did not express CCL24 mRNA. Upon stimulation with TNF-alpha, INF-gamma, IL-4, or costimulation with TNF-alpha and INF-gamma CCL24 mRNA was significantly enhanced (3.2-19.6%). In controls, fibroblast, and unstimulated cells CCL24 protein was below detection limit. Most polyps comprised significant amounts of CCL24 (mean 0.24 ng/mg). TNF-alpha, INF-gamma or IL-4 induced CCL24 protein (0.1-0.3 ng/ml) in epithelial cells. Costimulation with TNF-alpha and IL-4 (0.1-30 and 1-30 ng/ml, respectively) synergistically induced synthesis of CCL24 protein (0.18-0.31 ng/ml).

CONCLUSION

In nasal polyps endothelial and epithelial cells are obviously the main source of CCL24, which was shown for transcription (mRNA) and production (protein) levels and was associated with diseases. Results gave evidence of CLL24- directed migration of cells from inside (the bloodstream) to the epithelial side (mucosa) in eosinophilic inflammatory diseases, e.g. nasal polyposis.

Ultrastructural investigation of epithelial damage in asthmatic and non-asthmatic nasal polyps

Nasal polyposis is a poorly understood chronic inflammatory disease often associated with asthma. As nasal polyps and asthma both are associated with massive eosinophil infiltration, they may share a common pathophysiological mechanism. Many genetic and autoimmune diseases may result from altered expression or function of cell adhesion molecules such as desmosomes. A transmission electron microscopical study was carried out on tissue from 15 patients suffering from nasal polyps, to investigate if there are changes in desmosomes in nasal polyps from asthmatic and/or allergic patients versus non-asthmatic versus non-allergic patients. In allergic patients the damage to columnar cells was more extensive than in non-allergic patients. Massive infiltration of eosinophils was observed in epithelium and connective tissue in all groups. No significant difference in thickness of the basal lamina was found between any of the groups. All patients had dilated capillaries in the connective tissue. The intercellular space between the epithelial cells was smallest in the asthmatic non-allergic group. The relative length of columnar cell or basal cell desmosomes was reduced in patients with asthma or allergy, compared to non-allergic, non-asthmatic patients. Hence, there appears to be a weakness in the desmosomes in asthmatics and allergics. Epithelial shedding may play an important role in the pathophysiological process of a multifactorial disease such as asthma.

Airway inflammation in nasal polyposis: immunopathological aspects of relation to asthma

BACKGROUND

Nasal polyposis (NP) is a chronic inflammatory disorder of the upper respiratory tract, which is often coexist with asthma. However, the pathogenesis of especially in patients with NP is still a matter of debate.

OBJECTIVE

To better understand the immunopathologic mechanism involved in this relationship, we investigated the inflammatory cell profiles in bronchial and nasal tissues of patients with NP alone and with concomitant asthma.

METHODS

Seventeen patients with NP (six male, 11 female, age range: 19-63, mean age: 38.29+/-13.27 years) were selected for the study. Subjects were divided into two groups based on the presence of asthma or bronchial hyper-responsiveness (BHR). NP without BHR (Group 1) (n=8), NP and asthma or BHR (Group 2) (n=9). All patients underwent atopy evaluation including detailed history, skin prick test (SPT), total and specific IgE determination in sera. None of the subjects had taken inhaled, nasal or oral corticosteroids for at least 1 month before the study. Respiratory symptoms of asthmatic patients were controlled with only short acting beta(2)-agonist inhaler drugs as needed. NP tissue, nasal and bronchial mucosa biopsies were taken from all patients using fiberoptic endoscopy. CD3, CD8, CD16, CD68, AA1 (mast cell tryptase), human leucocyte antigen-DR (HLA-DR) and eosinophil peroxidase (EPO) expressing cells in specimens were determined by immunohistochemical methods. Positively staining inflammatory cell types were counted. Subepithelial lamina propria and periglandular areas were separately evaluated.

RESULTS

No significant difference was found in polyp tissue, nasal and bronchial CD3(+), CD8(+), CD16(+), CD68(+), AA1(+), HLA-DR(+) and EPO(+) positive cells between groups. There were significantly higher numbers of CD8(+), CD16(+), HLA-DR(+), EPO(+) cells in the polyp tissue and nasal mucosa vs. the bronchial mucosa in all groups (P<0.05). However, CD8(+) cells were significantly increased in the polyp tissue and bronchial mucosa of patients with NP alone when compared with the patients with both asthma and NP (P<0.05). CD3(+), CD68(+) and CD16(+) cell counts were tended to be higher within the nasal polyp tissue of patients with isolated NP compared with counts within nasal and bronchial mucosa of patients with NP and asthma. Also, patients with isolated NP showed more HLA-DR(+) cells in the nasal polyp tissue and nasal mucosa than those of patients with NP and asthma. Immunoreactivity for EPO(+) eosinophils within the nasal and bronchial mucosa was more prominent in patients with NP and asthma compared with patients with NP alone. The number of EPO(+) eosinophils within the polyp tissue, nasal and bronchial mucosa was higher in the skin prick test negative (SPT -ve) group than the SPT positive (SPT +ve) ones.

CONCLUSIONS

Our results demonstrate that infiltration of inflammatory cells in the nasal and the lower airways do not remarkably differ between patients with NP alone who has no evidence of BHR and asthmatic patients with NP. However, patients with SPT-ve NP reveal more intense eosinophilic inflammation in the entire respiratory mucosa.

Functional promoter polymorphism in the TBX21 gene associated with aspirin-induced asthma

Asthma is a phenotypically heterogeneous disorder with many etiologic factors and clinical characteristics. T-bet, a Th1-specific transcription factor of T-box family, has been found to control interferon-gamma (IFN-gamma) expression in T cells. Mice lacking the T-bet gene (tbx21) demonstrate multiple physiological and inflammatory features reminiscent of human asthma. In order to examine whether polymorphisms in the candidate gene, TBX21, located on chromosome 17q21.32, are related to the risk of human asthma phenotypes, we have searched for genetic variations in the human TBX21 gene and identified 24 single nucleotide polymorphisms (SNPs), including five novel SNPs, by direct sequencing in Japanese subjects. Among asthma phenotypes, a promoter -1993T-->C SNP, which is in linkage disequilibrium with a synonymous coding 390A-->G SNP in exon 1, is significantly associated with a risk of aspirin-induced asthma (AIA; P = 0.004, P(c) = 0.016). This association has also been confirmed in additional independent samples of asthma with nasal polyposis (P = 0.008), regardless of aspirin hypersensitivity. Furthermore, our data indicate that the -1993T-->C substitution increases the affinity of a particular nuclear protein to the binding site of TBX21 covering the -1993 position, resulting in increased transcriptional activity of the TBX21 gene. Thus, in addition to the antigen-driven excess Th2 response, increased T-bet (and subsequent IFN-gamma) production in human airways of individuals with the -1993T-->C polymorphism could contribute to the development of certain asthma-related phenotypes, such as AIA.

Non-specific bronchial hyperresponsiveness is a risk factor for steroid insensitivity in nasal polyposis

OBJECTIVE

Management of nasal polyposis should be primarily medical. Resorting to intranasal ethmoidectomy should not be envisaged before a trial of dual steroid therapy. Nevertheless, no risk factor for steroid insensitivity in patients with nasal polyposis is actually defined. The aim of this study is to evaluate whether the presence of asthma and/or non-specific bronchial hyperresponsiveness (BHR) can be considered a risk factor for steroid insensitivity.

MATERIAL AND METHODS

This study focused on the evaluation of a dual modality, topical and systemic, over a follow-up period of 3 years. A total of 55 subjects with and 45 subjects without BHR were treated according to a standardized therapeutic protocol combining short-term oral administration of prednisolone and a daily intranasal spray of beclomethasone.

RESULTS

Over the follow-up period of 3 years, this dual modality proved to be successful in 93.4% of subjects without BHR and without aspirin idiosyncrasy, in 82.2% of subjects with BHR and without aspirin idiosyncrasy and in 60% of subjects with BHR and aspirin idiosyncrasy. The percentage of patients who underwent surgery after the failure of medical treatment was significantly larger in patients with than without BHR (p < 0.05) and in patients with than without aspirin idiosyncrasy (p < 0.02).

CONCLUSION

The presence of BHR and/or aspirin idiosyncrasy can be considered a major risk factor for steroid insensitivity in patients with nasal polyposis.

Superantigens and nasal polyps

Nasal polyps represent an often severe T-cell-orchestrated eosinophilic upper airway disease with currently unknown pathogenesis, often associated with lower airway disease, such as asthma. Superantigens, predominantly derived from Staphylococcus aureus, are potent activators of T cells, induce the synthesis of IgE in B cells, and have direct effects on pro-inflammatory cells, such as eosinophils. IgE antibodies to S. aureus enterotoxins have been described in polyp tissue, linked to a local polyclonal IgE production and an aggravation of eosinophilic inflammation. Furthermore, such IgE antibodies have also been described in the sera of patients with asthma, and linked to severity of disease and steroid insensitivity. This review summarizes our current understanding of the possible role of S. aureus enterotoxins in chronic severe airway disease, such as nasal polyposis.

Transcription and translation of the chemokines RANTES and MCP-1 in nasal polyps and mucosa in allergic and non-allergic rhinopathies

The pathogenetic findings of rhinopathies show an increase in infiltrating cells including eosinophils. RANTES is a beta chemokine in which the cysteines are adjacent (C-C), and it attracts and activates eosinophil. We hypothesize that RANTES is locally produced within the nasal polyp microenvironment and is responsible for the inflammatory cell recruitment present in nasal polyposis. To test this hypothesis, we evaluated nasal polyps and mucosa from allergic and control, non-allergic patients for RANTES content. The relative levels of RANTES and MCP-1 protein in tissue homogenates were quantified using enzyme-linked immunosorbent assay technology, and quantitative reverse transcriptase-polymerase chain reaction (RT-PCR) tests for RANTES and MCP-1 mRNA expression were performed. The results indicate that RANTES expression and production increase in nasal mucosa (septal and turbinate portions) of allergic patients compared to the same mucosa in non-allergic patients. In allergic patients, RANTES levels of nasal polyp homogenates were nearly 12-fold higher than the RANTES levels in mucosa homogenate. In this study, we hypothesize that the particular anatomic structure and physiologic function of the turbinates are more involved in the pathogenesis of rhinitis and may undergo polypoid degeneration in allergic rhinitis than any other anatomical structure of the nose. Our data suggest that RANTES is more involved than MCP-1 in recruiting inflammatory cells in rhinological disease and may reflect the degree of local inflammation as consequence of the specific chemoattractant properties of RANTES. The level of RANTES in nasal polyps could be important in the development of the pathological state.

The IL1A genotype is associated with nasal polyposis in asthmatic adults

BACKGROUND

Nasal polyposis (NP) is a chronic inflammatory disease often found coexisting with asthma. As this disorder tends to cluster in families, a genetic predisposition has been suggested. Interleukin-1 (IL-1) has been proposed to play a role in the pathogenesis of NP.

METHODS

We analysed the single G-to-T base exchange polymorphism in exon 5 at +4845 of the gene encoding IL-1alpha (IL1A) and the C-to-T base exchange polymorphism at -511 of the gene encoding IL-1beta (IL1B) in a population-based sample of adult asthma patients (n = 245). The data were assessed for correlation with data on history of NP and other phenotype-related characteristics.

RESULTS

The prevalence of NP in our study group was 14.3%. The distribution of the IL1A genotype differed significantly between asthmatics with and without NP (P = 0.005). The risk of NP was markedly increased in allele G homozygous subjects (OR = 2.73; 95%CI = 1.40-5.32). In the case of IL1B we found no significant associations. Asthmatics with NP had more symptoms than others, but lung function and blood eosinophil counts were similar.

CONCLUSIONS

Our study demonstrates an association of IL1A with NP inasthmatic patients and addresses the role of IL-1alpha as an inflammatory modulator in the pathogenesis of this disease.

IL-1 induced chemokine production through the association of Syk with TNF receptor-associated factor-6 in nasal fibroblast lines

The fibroblasts stimulated by cytokines released the chemokine and recruited the infiltrating cells, including eosinophils, that play a key role in the pathogenesis of airway disease. We established the human fibroblast lines showing high Syk expression and the lines showing low Syk expression from pieces of nasal polyp. IL-1 induces the interaction of TNFR-associated factor (TRAF) 6 with IL-1R-associated kinase, which is rapidly recruited to the IL-1R after IL-1 induction, whereas TRAF2 participates in TNF-alpha-signaling. In the present study, we found that Syk played a different role in IL-1- and TNF-alpha-induced chemokine production through a signaling complex involving Syk and TRAF6. Overexpression of wild-type Syk by gene transfer enhanced RANTES production from nasal fibroblasts stimulated with IL-1. The decrease of Syk expression by the administration of Syk antisense inhibited RANTES production in response to IL-1. However, the change of Syk expression did not affect RANTES production by TNF-alpha stimulation. We concluded that Syk is required for the IL-1-induced chemokine production through the association with TRAF-6 in fibroblasts of nasal polyps.

Cell and cytokine profiles in nasal secretions from patients with nasal polyposis: effects of topical steroids and surgical treatment

BACKGROUND

Nasal polyposis (NP), a chronic inflammatory disease of the paranasal sinus mucosa, is frequently associated with asthma. Previous reports showed that surgical treatment for nasal polyps may influence asthma evolution. We hypothesized that sinus surgery may alter the cytokine network in nasal secretions.

METHODS

We evaluated the characteristics (cells and mediators) of nasal lavages in nine patients with untreated NP (group A), 17 patients treated with topical steroids (group B), 21 patients treated by nasal surgery endonasal ethmoidectomy associated with topical steroids (group C), and 12 healthy subjects (controls).

RESULTS

Percentages of both eosinophils and neutrophils were higher in NP patients than in controls. Percentages of eosinophils and interleukin-5 (IL-5) level were higher in group A than in group C and controls. There was a positive correlation between IL-5 and eosinophils. In marked contrast, IL-8, IL-10, and IL-1beta levels were significantly higher in group C than in groups A and B and controls; TNF-alpha concentration was significantly lower in group C than in groups A and B and controls; and there was a negative correlation between IL-10 and TNF-alpha. The percentage of eosinophils was higher in asthmatic patients with NP than in nonasthmatic patients. In addition, in group C, asthmatic patients also had a significantly higher level of IL-10 than nonasthmatic patients.

CONCLUSIONS

Our study demonstrates that percentages of eosinophils and neutrophils, and IL-5 level were increased in nasal secretions from untreated patients with NP. Topical steroid treatment is associated with a decrease of inflammatory cells and mediators. In marked contrast, nasal surgery is associated with marked changes, in cytokine profile in nasal secretions, that are clearly different from those of controls and topical steroid-treated NP patients.

Total and specific IgE in nasal polyps is related to local eosinophilic inflammation

BACKGROUND

Nasal polyps (NPs) are characterized by eosinophilic inflammation and often coexist with asthma. However, the role of atopy and IgE in NP pathogenesis is unclear.

OBJECTIVE

We sought to determine whether there is an association between total and specific IgE to a variety of allergens in polyp and nonpolyp tissue and markers of eosinophilic inflammation or skin test results.

METHODS

Homogenates were prepared from nasal tissue of 20 patients with NPs and 20 patients without NPs and analyzed for concentrations of IL-5, IL-4, eotaxin, leukotriene (LT) C4/D4/E4, sCD23, and histamine (ELISA). Eosinophil cationic protein (ECP), tryptase, and total and specific IgE for inhalant allergens and Staphylococcus aureus enterotoxins were measured (ImmunoCAP).

RESULTS

The concentrations of total IgE, IL-5, eotaxin, ECP, LTC4/D4/E4, and sCD23 were significantly higher in NP tissue compared with nonpolyp tissue. Total IgE was significantly correlated to IL-5, ECP, LTC4/D4/E4, and sCD23 and to the number of eosinophils in NPs. On the basis of the presence of specific IgE antibodies in tissue, 3 NP groups were defined. NP group 1 demonstrated no measurable specific IgE, and NP group 2 selected specific IgE. The third group demonstrated a multiclonal specific IgE, including IgE to S aureus enterotoxins, a high total IgE level, and a high prevalence of asthma.

CONCLUSIONS

These studies suggest that there is an association between increased levels of total IgE, specific IgE, and eosinophilic inflammation in NPs, which may be of relevance in the pathophysiology of nasal polyposis. Similarly, the presence of specific IgE to staphylococcal enterotoxins A and B also points to a possible role of bacterial superantigens.

Protein-tyrosine kinase Syk expressed in human nasal fibroblasts and its effect on RANTES production

Fibroblasts, a rich source of chemokines, interact with eosinophils and play a key role in the pathogenesis of airway disease. RANTES is produced by fibroblasts to attract and activate eosinophils. LPS is known to induce RANTES and cause protein tyrosine phosphorylation. Nonreceptor protein tyrosine kinase Syk is widely expressed and an important role in intracellular signal transduction in hemopoietic cells. In the present study, we examined whether Syk was expressed in a number of primary human nasal polyp tissue-derived fibroblast lines and whether it played some role in cellular function. Syk proteins were expressed in human nasal fibroblasts, but the expression level varied. There were positive correlations between the level of Syk expression and RANTES production induced by LPS. Overexpression of wild-type Syk by gene transfer enhanced RANTES production from nasal fibroblasts stimulated with LPS. The decrease of Syk expression by the administration of Syk antisense inhibited RANTES production. These results suggest that Syk expression affects RANTES production in fibroblasts of nasal polyps.

Macrolide treatment decreased the size of nasal polyps and IL-8 levels in nasal lavage

Recently, epidemiologic and experimental studies have been reported that long-term macrolides are effective for the treatment of chronic airway inflammatory diseases including diffuse panbronchiolitis, chronic rhinosinusitis, and cystic fibrosis (Jaffe A, Francis J, Rosenthal M, et al. Long-term azithromycin may improve lung function in children with cystic fibrosis. Lancet 351:420, 1998), and that macrolides can directly reduce the production of IL-8 by nasal epithelial cells (Suzuki H, Shimomura A, Ikeda K, et al. Inhibitory effect of macrolides on interleukin-8 secretion from cultured human nasal epithelial cells. Laryngoscope 107:1661-1666, 1997). In this study we administered macrolides with 14-membered rings to patients with nasal polyps due to chronic rhinosinusitis for at least 3 months and measured the IL-8 level in nasal lavage from those patients. The IL-8 levels in nasal lavage from patients with nasal polyps were reduced during macrolide treatment. There was significant correlation between decreased IL-8 levels in nasal lavage and the clinical effect of macrolides on the size of the nasal polyps. In the group whose polyps were reduced in size, the IL-8 levels dramatically decreased from 231.2 pg/mL to 44.0 pg/mL (p < 0.05), and were significantly higher before macrolide treatment than those in the group whose polyps showed no change (p < 0.005). This reduction in IL-8 may be an important aspect of the effect of macrolide treatment on nasal polyps in chronic rhinosinusitis.

Capsaicin significantly reduces sinonasal polyps

Some reports indicate that topical nasal treatment with capsaicin, which is usually effective in reducing symptoms of vasomotor rhinitis, may also reduce symptoms in patients with nasal polyps. The aim of this study was to investigate the effect of topical capsaicin treatment in severe sinonasal polyposis. Nine non-allergic, non-asthmatic patients with diffuse eosinophilic nasal polyposis were subjected to topical capsaicin treatment: for 3 consecutive days 0.5 ml 30 micromol/l capsaicin solution and on days 4 and 5 100 micromol/l capsaicin solution was sprayed into each nostril. Coronary computed tomography (CT) images were made shortly before treatment. Baseline nasal lavages and a questionnaire containing subjective symptoms and nasal endosocpy were taken just prior to the first application. Nasal lavages were performed prior to and after the last treatment and over 4 weeks, endoscopy and subjective scores at each weekly visit, and correspondent CT scans 4 weeks after the treatment. CT images were analysed by computer, calculating the nose sinuses air volume (NSAV) from the surface of aerated parts of nasal and sinus cavities for each slice per patient prior to and after treatment. Statistical analysis was performed comparing NSAV, subjective scores, endoscopy scores and eosinophil cationic protein (ECP) levels in nasal lavages prior to and after treatment. Topical treatment with capsaicin significantly increased NSAV and very significantly improved subjective and endoscopy scores, but did not significantly alter ECP levels in nasal lavages.

Inflammatory cells in nasal mucosa and nasal polyps

OBJECTIVE

Since some controversy exists concerning the frequency of inflammatory cells in nasal polyps, we have compared the frequency of tissue inflammatory cells (lymphocytes, neutrophils, eosinophils and plasma cells) including 11 kinds of lymphocyte subsets in the same specimens of nasal mucosa and nasal polyps.

METHODS

Histopathological observations and flow cytometric analyses were performed on eight mucosal specimens of the inferior turbinates of patients with nasal polyps and on 13 polyp specimens.

RESULTS

Nasal polyps contained significantly more eosinophils, neutrophils and plasma cells than nasal mucosa, and EG2+ cells (activated eosinophils) were significantly more frequent in nasal polyps than in nasal mucosa. Flow cytometric analysis showed that there were no significant differences in the frequencies of lymphocytes and lymphocyte subsets (CD1+, CD2+, CD3+, CD5+, CD7+, CD4+, CD8+, CD10+, CD19+, CD20+ and HLA-DR+ cells) including CD4/8 ratios between nasal mucosa and polyps, though, both nasal mucosa and polyps contained significantly more lymphocytes than eosinophils, neutrophils or plasma cells. The T cell lineage (CD2+, CD3+, CD5+ and CD7+ cells) was found in high frequency and B cell lineage (CD10+, CD19+ and CD20+ cells) in low frequency in both nasal mucosa and polyps. The frequency of HLA-DR+ cells (most of which were activated T cells) was not significantly different between nasal mucosa and nasal polyps.

CONCLUSION

Histopathological and flow cytometric analyses were performed on the composition of inflammatory cells in nasal mucosa of the inferior turbinates and in polyps from the same patients. The elevated numbers of activated eosinophils, neutrophils and plasma cells in nasal polyps compared with nasal mucosa suggest that inflammatory processes play important roles in the pathophysiology of nasal polyps. The frequencies of lymphocytes and lymphocyte subsets were not significantly different between these two tissues.

Cytokines in nasal polyposis, acute and chronic sinusitis

Cytokines are potent biologic factors involved in the regulation of inflammation, immune defense, and wound healing. Recently, growing interest has developed in the role of cytokines in chronic sinusitis and nasal polyposis. In the present study, we investigated the cytokine profile of different types of rhinosinusitis in order to evaluate whether a specific form of rhinosinusitis is associated with the expression of a certain cytokine profile. Sinus mucosa from patients with acute sinusitis (n = 10), chronic sinusitis (n = 7), antrochoanal polyp (n = 10), nasal polyps (n = 8) and controls of turbinate mucosa (n = 7) were sampled. The cytokine protein content (IL-1 beta, IL-3, IL-4, IL-5, IL-6, IL-8, IL-13, GM-CSF, interferon-gamma) of tissue homogenates was measured using ELISA technique. In acute sinusitis, the synthesis of proinflammatory cytokines and of the neutrophil chemokine IL-8 and IL-3 appeared to be upregulated. Chronic sinusitis mucosa demonstrated no significantly increased concentrations of the measured cytokines. In bilateral nasal polyposis, but not in antrochoanal polyps, the eosinophil related cytokine IL-5 was strongly upregulated. From these findings, it appears that specific cytokine patterns are found in different forms of sinusitis, and that IL-5 may represent the most important cytokine responsible for tissue eosinophilia in nasal polyposis.

Interleukin-3 interleukin-5, and granulocyte-macrophage colony-stimulating factor expression in nasal polyps

PURPOSE

Nasal polyps (NP) are grape-like clusters of chronically inflamed tissue. Little is known about the underlying cells and cytokines involved in nasal polyposis. For the present study, we hypothesize that elevated tissue levels of interleukin-3 (IL-3), interleukin-5 (IL-5), and granulocyte-macrophage colony-stimulation factor (GM-CSF) contribute to eosinophil recruitment and activation in NP.

MATERIALS AND METHODS

To begin to test this hypothesis, we evaluated IL-3, IL-5, and GM-CSF levels and distributions in nasal polyp specimens obtained intraoperatively from 13 patients and two normal controls. For these studies, nasal polyp levels were determined by enzyme-linked immunosorbent assay (ELISA), and IL-3, IL-5, and GM-CSF distribution was determined by immunohistochemistry.

RESULTS

Immunohistochemical staining of the NP indicated that in all 13 patient samples, IL-3, IL-5, and GM-CSF were associated with infiltrating cells, primarily eosinophils, in the NP. Quantitation of IL-3, IL-5, and GM-CSF in NP tissue homogenates indicated that IL-3, IL-5, and GM-CSF levels were evaluated in the NP tissues when compared with control tissues. Additionally, elevation of individual cytokines correlated with previous polypectomy (IL-3), steroid use (IL-3, IL-5, and GM-CSF), asthma (IL-5), and age (GM-CSF).

CONCLUSION

These data support our hypothesis that IL-3, IL-5, and GM-CSF are likely to play a key role in eosinophil recruitment/activation and NP formation and support recently advanced theories that cytokines play a key role in the pathogenesis of this disease.

Fluticasone propionate aqueous nasal spray in the treatment of nasal polyposis

BACKGROUND

Topical glucocorticoids are the medical treatment of choice in a majority of patients suffering from nasal polyposis. Fluticasone propionate is a fluorinated steroid reported to be highly effective when used topically in the nose for seasonal and perennial allergic and nonallergic rhinitis.

OBJECTIVES

To evaluate the efficacy and tolerability of intranasal fluticasone propionate in the treatment of long-standing polyposis.

METHODS

Fifty-five patients with long-standing nasal polyposis were treated over a 26-week period with fluticasone propionate aqueous nasal spray 200 micrograms bid, beclomethasone dipropionate aqueous nasal spray 200 micrograms bid or placebo, administered intranasally in an aqueous spray in a double-blind, placebo-controlled parallel-group design at a single center. The primary efficacy endpoint was the physicians' assessment of symptoms and polyp score. Peak nasal inspiratory flow was performed twice daily and on every visit to evaluate the effect of the corticosteroids on nasal air flow.

RESULTS

A significant difference in the primary efficacy endpoint between fluticasone propionate aqueous nasal spray and beclomethasone dipropionate aqueous nasal spray compared with placebo was seen after 14 weeks of treatment. This was further verified by the peak nasal inspiratory flow results. There was some evidence of earlier onset in the fluticasone propionate aqueous nasal spray group compared with the beclomethasone dipropionate aqueous nasal spray group after 4 weeks in terms of the primary efficacy endpoint. From the daily record cards patients receiving fluticasone propionate aqueous nasal spray had a significantly higher percentage of days on which they required no rescue medication (P < .009) and a higher percentage of days with an overall nasal blockage score on waking of < 2 (P < .013) when compared with placebo-treated patients. No other statistically significant results were found between the two active compounds.

CONCLUSION

Fluticasone propionate aqueous nasal spray 200 micrograms bid and beclomethasone dipropionate aqueous nasal spray 200 micrograms bid are effective in treating the symptoms of nasal polyps, with some evidence that fluticasone propionate aqueous nasal spray has a faster onset of action and is tolerated at least as well as beclomethasone dipropionate aqueous nasal spray at the same dose.

The link between the nose and lung, perennial rhinitis and asthma--is it the same disease?

Perennial rhinitis and asthma are clinical syndromes representing a range of overlapping pathologies; accurate classification should therefore precede any comparison. Although the sinonasal cavities, trachea and bronchi have a common respiratory mucosa, there are also anatomical differences. For example, the nose has a capacitance vessel network and the lower airways possess smooth muscle, both of which are responsive to neurohumoral influences. The prevalence of rhinitis and asthma has increased over the last three decades. Rhinitis occurs in around 75% of allergic asthmatics while 20% of perennial allergic rhinitics develop asthma. Eosinophils, and their associated proteins and cytokines, may play a central role in both perennial rhinitis and asthma with and without atopy. The characteristic pathology of asthma can be summarized as a chronic, desquamating, eosinophilic bronchitis. Non-allergic rhinitis with eosinophilia is recognized, but without consistent evidence of epithelial damage. Eosinophils are also present in rhinosinusitis with polyposis, particularly in patients with aspirin sensitivity, in whom asthma also often occurs. Increased mast cell activation and mediator release is evident in both perennial rhinitis and asthma following allergen challenge. The importance of mast cells in non-atopic asthma and polyposis is also recognized. Adhesion molecules may also be upregulated, with an increased number and activation of TH2 lymphocytes. However, allergen-resultant T-cell activation may be less marked in the nose than in the lung. Autonomic imbalance also plays a role in both conditions via changes in neural tone to effector tissues, release of neuropeptides, and interplay with cellular recruitment. Pharmacological manipulation of rhinitis and asthma also illustrates the pathological similarities and differences.

A survey to determine the extent of previous symptoms and surgery on patients presenting with nasal polyps

The aim of our study was to investigate the prevalence of surgery on the nose prior to first time diagnosis of nasal polyps. We interviewed 60 patients who presented to the ENT Department at the Royal South Hants Hospital Southampton and were diagnosed as suffering from nasal polyps for the first time. Patients who suffered from cystic fibrosis or known primary ciliary dyskinesia were excluded. The average length of time of nasal blockage as the main symptom prior to the diagnosis of nasal polyps was less than two years. Out of the 60 patients six (10 per cent) had had previous nasal surgery. Out of these six patients, only four patients had a previous procedure on the nose that could be considered to be related to the later diagnosis of nasal polyps. Only one patient had had radiological investigation of his sinuses in the past. We conclude that polypoid nasal disease is a de novo diagnosis with a relatively short history in the majority of patients and not preceded by a long history of ENT investigations nor surgery on the nose.

Nasal polyps: medical or surgical management?

Nasal polyposis is considered to be a non-IgE-mediated inflammatory condition of the nose and sinuses, often associated with chronic non-allergic rhinitis, aspirin intolerance and non-allergic asthma. The aetiology of nasal polyposis is unknown. The main symptoms are nasal obstruction and disturbance of the sense of smell. Occlusion of the nasal passage by a few large polyps could be treated by simple polypectomy to help the patient breathe through the nose. Polypectomy per se does not worsen asthma. Other surgical procedures can be performed, depending on the degree of the disease. The aim of surgery is to restore the physiological properties of the nose by making the nose as free from polyps as possible, and to allow drainage of infected sinuses. Complementary medical treatment of polyposis is always necessary, as surgery cannot treat the inflammatory component of the mucosal disease. In this respect, topical corticosteroids have long been the drugs of choice to reduce the size of polyps, to prevent recurrence after surgery, and are often the main treatment for the disease in many patients. Fluticasone propionate has now been shown to be at least as effective as beclomethasone dipropionate as a medical tool in the management of polyposis. Short-term treatment with systemic corticosteroids is an alternative method of inducing remission and controlling nasal polyps. However, in most patients with nasal polyps, treatment consists of both medical and surgical management.

Effects of corticosteroid therapy in non-allergic rhinosinusitis

Corticosteroids have a multifactorial effect initiated by their binding to a specific cytoplasmic glucocorticoid receptor. At the cellular level there is a reduction in the number of antigen-presenting cells, in the number and activation and T cells, in the number of epithelial mast cells, and in the number and activation of eosinophils. Steroids have a proven effect on symptoms and signs in non-allergic rhinosinusitis with eosinophilia and in nasal polyposis. Topically applied drugs, studied in many controlled trials, reduce rhinitis symptoms, improved nasal breathing, reduce the size of polyps and their recurrence, but have a poor effect on the sense of smell and no direct effect on sinus pathology. Systemic steroids, less well studied, appear to have an effect on all types of symptoms and pathology, the sense of smell included. A short course of systemic steroids is as effective as polypectomy with a snare. Individualized management of nasal polyposis and non-allergic rhinosinusitis with eosinophilia may consist of long-term topical steroids, short-term systemic steroids, or surgery, in various combinations.

Noradrenergic innervation of nasal polyps and polypoid mucosae

In order to study the sympathetic innervation of nasal polyps and polypoid mucosae, the glyoxylic catecholaminergic histofluorescence method was employed in the examination of specimens taken from patients who had nasal disorders with polyps or polypoid mucosae. One percent neutral red was used as a counterstain. Abundant sympathetic fibers were present around the vessels of the pedicle of nasal polyps. However, no sympathetic innervation was found in the body and apex of the polyps. In the microscopical views of polypoid formations, there were no obvious differences between non-diseased nasal mucosa and polypoid mucosa in the distribution of sympathetic innervation. Based on these results, the following conclusions were drawn: (1) The loss of the sympathetic innervation was suggested to an important role in the pathogenesis of nasal polyps. (2) During polypectomy, the polyp had better be removed along with the pedicle for there is abundant sympathetic innervation and it will result in reduced bleeding.

Efficacy of topical corticosteroid powder for nasal polyps: a double-blind, placebo-controlled study of budesonide

Budesonide has been used for a number of years as a topical nasal corticosteroid in the treatment of nasal allergy and nasal polyps. Recently, a new device for powder insufflation where no constituents or preservatives are included has been developed (Rhinocort Turbuhaler, Astra Draco AB, Sweden). The present investigation was designed in order to study the efficacy of topical budesonide powder as the only treatment of nasal polyps. A total of 126 patients entered the study. The medical history and clinical recordings included symptoms and signs, a semiquantitative test of smell and measurement of nasal expiratory peak flow index. Medication was either 200 or 400 micrograms of budesonide powder b.i.d. or placebo. After 1 month an overall assessment of treatment efficacy was made to determine whether the treatment had been a success or a failure. The results showed a statistically significant improvement of symptoms and signs in the actively treated groups. The increase in expiratory peak flow index was about 60% in the actively treated groups as opposed to 16% in the placebo group. The overall assessment of treatment efficacy showed success in about 82% of actively treated patients as opposed to about 43% in the placebo group. It is concluded that budesonide powder is useful in the treatment of nasal polyps.