Sinus mucosal IL-8 gene expression in chronic rhinosinusitis

Current Insight into Treatment of Chronic Rhinosinusitis: Phenotypes, Endotypes and Implications for Targeted Therapeutics

Chronic rhinosinusitis (CRS) is characterized by persistent locoregional mucosal inflammation of the paranasal sinuses and upper airway that has substantial associated health care costs¹. Personalized approaches to care that incorporate use of molecular biomarkers, phenotypes and inflammatory endotypes is a major focus of research at this time, and the concurrent rise of targeted therapeutics and biologic therapies has the potential to rapidly advance care and improve outcomes. Recent findings suggest that improved understanding of CRS phenotypic and endotypic heterogeneity, and incorporation of these characteristics into clinical care pathways, may facilitate more effective selection of surgical and/or therapeutic interventions². Ultimately, these personalized approaches have the potential to target specific inflammatory pathways, increase efficacy, reduce costs, and limit side effects. This review summarizes recent advances in the identification and characterization of CRS phenotypes, endotypes, and biomarkers and reviews potential implications for targeted therapeutics.

Eupatoriopicrin Inhibits Pro-inflammatory Functions of Neutrophils via Suppression of IL-8 and TNF-alpha Production and p38 and ERK 1/2 MAP Kinases

During chronic inflammation, neutrophils acting locally as effector cells not only activate antibacterial defense but also promote the inflammatory response. Interleukin 8 (IL-8), the main cytokine produced by activated neutrophils, positively correlates with the severity of respiratory tract diseases. By screening European plants traditionally used for treating respiratory tract diseases, we found that extracts of aerial parts of Eupatorium cannabinum inhibit IL-8 release from neutrophils. Using bioassay-guided fractionation, we identified five sesquiterpene lactones, eupatoriopicrin (1), 5'-deoxyeupatoriopicrin (2), hiyodorilactone A (3), 3-hydroxy-5'- O-acetyleupatoriopicrin = hiyodorilactone D (4), and hiyodorilactone B (5), that efficiently (IC₅₀ < 1 μM) inhibited IL-8 and TNF-α release in lipopolysaccharide (LPS)-stimulated human neutrophils. Moreover, all these sesquiterpene lactones suppressed the adhesion of human neutrophils to an endothelial monolayer by downregulating the expression of the β2 integrin CD11b/CD18 on the neutrophil surface. Furthermore, eupatoriopicrin efficiently suppressed LPS-induced phosphorylation of p38 MAPK and ERK and attenuated neutrophil infiltration in the thioglycolate-induced peritonitis model in mice. Altogether, these results demonstrate the potential of the sesquiterpene lactone eupatoriopicrin as a lead substance for targeting inflammation.

Inflammatory immune response in rabbits with Staphylococcus aureus biofilm-associated sinusitis

Background

Staphylococcus aureus is the most commonly isolated bacterium from patients with surgically recalcitrant chronic rhinosinusitis (CRS). Understanding the immune responses to S aureus biofilms will provide insights into how the host response may be manipulated by therapeutic agents to improve the chances of successfully preventing and treating these infections. In this study, we investigated the inflammatory immune response in a rabbit model of S aureus biofilm–related sinusitis by analyzing the levels of some major inflammatory cytokines.

Methods

Eighteen New Zealand white rabbits were randomly divided into 3 groups: a blank‐control group; a negative‐control group; and a model group. Four weeks after the biofilm‐associated sinusitis models were established, the sinus mucosa was harvested and examined using hematoxylin‐eosin (H&E) staining, scanning electron microscopy (SEM), reverse transcription polymerase chain reaction (RT‐PCR), and western blotting. The expression levels of inflammatory cytokines were analyzed statistically.

Results

Interleukin (IL)‐1β, IL‐8, and tumor necrosis factor (TNF)‐α expression levels were significantly higher in the model group than in the blank‐control group (p < 0.05); mRNA levels were increased by 1600%, 230%, and 130%, respectively, and the protein levels were increased by 180%, 100%, and 100%, respectively. In contrast, IL‐4 and IL‐5 mRNA levels were reduced by 44% and 70%, respectively, compared with the blank‐control group (p < 0.05).

Conclusion

S aureus biofilms in the rabbit maxillary sinus mucosa were associated with increased IL‐1β, IL‐8, and TNF‐α expression, and decreased IL‐4 and IL‐5 expression.

LL-37 causes cell death of human nasal epithelial cells, which is inhibited with a synthetic glycosaminoglycan

LL-37 is an immune peptide that regulates innate and adaptive immune responses in the upper airways. Elevated levels of LL-37 have been linked to cell death and inflammatory diseases, such as chronic rhinosinusitis (CRS). Glycosaminoglycans (GAGs) are polysaccharides that are found on respiratory epithelial cells and serve important roles in mucosal surface repair. Recent findings suggest that a synthetic glycosaminoglycan (GM-0111) can protect against LL-37-induced sinonasal mucosal inflammation and cell death in a murine model of acute RS. Herein, we elucidated the mechanisms by which LL-37 causes sinonasal inflammation and how GM-0111 can prevent these mechanisms. When challenged with LL-37, human nasal epithelial cells (HNEpCs) and mouse macrophages (J774.2) demonstrated increased release of adenosine triphosphate (ATP) and interleukin (IL)-6 and -8, as well as cell death and lysis. These cellular responses were all blocked dose-dependently by pre-treatment with GM-0111. We identified that LL-37-induced cell death is associated with caspase-1 and -8 activation, but not activation of caspase-3/7. These responses were again blocked by GM-0111. Our data suggest that LL-37 causes cellular death of HNEpCs and macrophages through the pro-inflammatory necrotic and/or pyroptotic pathways rather than apoptosis, and that a GM-0111 is capable of inhibiting these pro-inflammatory cellular events.

Pulmonary function in patients with eosinophilic chronic rhinosinusitis

OBJECTIVE

There is a close relationship between upper and lower respiratory tract diseases. Chronic rhinosinusitis patients frequently have lung diseases including asthma and chronic obstructive pulmonary disease. Eosinophilic chronic rhinosinusitis is considered a refractory and intractable subtype of chronic rhinosinusitis. However, there has been no report on pulmonary function in patients with eosinophilic chronic rhinosinusitis. The purpose of this study is to examine the pulmonary function in eosinophilic chronic rhinosinusitis patients and non-eosinophilic chronic rhinosinusitis patients, and evaluate clinical factors associated with the pulmonary function of these patients.

METHODS

Pulmonary function was measured in 53 patients with eosinophilic chronic rhinosinusitis with asthma, 58 patients with eosinophilic chronic rhinosinusitis without asthma, and 30 patients with non-eosinophilic chronic rhinosinusitis. The diagnosis of chronic rhinosinusitis was based on the definition in the European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS) 2012. Eosinophilic chronic rhinosinusitis was diagnosed based on the Japanese Epidemiological Survey of Refractory Eosinophilic Chronic Rhinosinusitis (JESREC) scoring system. The relationship between pulmonary function and clinical parameters was assessed. These parameters included radiographic severity of chronic rhinosinusitis, peripheral blood eosinophil percentage, serum total immunoglobulin E level, and eosinophilic infiltration in nasal polyps.

RESULTS

The pulmonary function of the patients with eosinophilic chronic rhinosinusitis was significantly affected. The eosinophilic chronic rhinosinusitis patients had more peripheral airway obstruction as compared to the patients with non-eosinophilic chronic rhinosinusitis.

CONCLUSION

Our findings indicated latent obstructive lung function changes in the eosinophilic chronic rhinosinusitis patients. The patients with eosinophilic chronic rhinosinusitis should be carefully monitored in order to detect lung diseases.

Superoxide dismutase reduces the inflammatory response to Aspergillus and Alternaria in human sinonasal epithelial cells derived from patients with chronic rhinosinusitis

BACKGROUND

Aspergillus fumigatus and Alternaria alternata are ubiquitous environmental fungal allergens that can exacerbate airway inflammation and contribute to the disease process in patients with chronic rhinosinusitis (CRS). These antigens have been shown to induce human sinonasal epithelial cells (HSNECs) to promote a proinflammatory response, but what is unclear is a means by which to reduce these effects. Inhaled pathogens can induce HSNECs to produce reactive oxygen species (ROS) that trigger cytokine production.

OBJECTIVE

This study aimed to determine whether the free radical scavenger superoxide dismutase (SOD) could reduce HSNEC-derived inflammation, as measured by interleukin (IL)-6 and IL-8 production, in response to Aspergillus or Alternaria exposure.

METHODS

Sinus tissue explants were collected at the time of surgery from control patients (n = 7) and patients with CRS with nasal polyps (CRSwNP) (n = 9). HSNECs were cultured from the explants and treated with Aspergillus, Alternaria, and SOD for 24 hours. Cell supernatants and lysates were collected, and IL-6 and IL-8 concentrations were measured using enzyme-linked immunosorbent assay.

RESULTS

In control and CRSwNP HSNECs, Aspergillus and Alternaria both increased cytokine production (p < 0.05), as measured by IL-6 and IL-8 concentration. SOD treatment reduced the inflammatory response to fungal antigen exposure from CRSwNP HSNECs but not control HSNECs. In CRSwNP patients, SOD significantly decreased IL-6 and IL-8 production after Alternaria exposure and IL-8 after Aspergillus exposure (p < 0.05).

CONCLUSIONS

When HSNECs from CRSwNP patients are treated with SOD concurrently with Aspergillus or Alternaria, SOD treatment decreases the fungal antigen-induced inflammatory response. The ability to attenuate inflammation induced by common fungal allergens with SOD treatment could provide a novel therapeutic or preventative approach for patients with CRS or other allergic inflammatory airway diseases.

Histopathological evaluation of chronic rhinosinusitis: a critical review

BACKGROUND

Chronic rhinosinusitis (CRS) consists of a constellation of symptoms, including facial pressure/pain, hyposmia, rhinorrhea, and nasal congestion. On histopathological evaluation, the disease can be divided into pathophysiologically distinct subgroups. This study systematically reviews the literature regarding the unique histopathological findings of the various subtypes of CRS to determine the potential diagnostic value of performing tissue analysis of CRS specimens beyond routine hematoxylin and eosin (H&E) staining.

METHODS

A PubMed search was untaken to identify articles that evaluated the histopathological features of CRS. Six hundred fifty-four relevant articles were identified and after application of specific exclusion criteria, 71 articles were further reviewed in detail.

RESULTS

All articles included analysis of tissue samples from in-office biopsies or intraoperative specimens of patients who underwent sinus surgery. CRS was often further divided into subgroups and compared with each other and with a control group. The subgroups included CRS with and without nasal polyps, asthmatic and nonasthmatic patients, and with and without eosinophilia. Distinct inflammatory mediators were found for the different subgroups. Twenty-eight articles evaluated these inflammatory markers for their potential value as prognostic indicators.

CONCLUSION

CRS is a heterogeneous disease based on its histopathological findings. Information that is obtainable from light microscopy, but typically goes unreported, can serve as valuable prognostic indictors. However, routine H&E staining is suboptimal in distinguishing among the various subgroups of CRS. Assessment of specific inflammatory mediators in sinus mucosa specimens may help provide prognostic information and guide more tailored treatment for the individual patient.

Prostaglandin E2 Induces IL-6 and IL-8 Production by the EP Receptors/Akt/NF-κB Pathways in Nasal Polyp-Derived Fibroblasts

Purpose

Interleukin 6 (IL-6) and IL-8 participate in the pathogenesis of chronic rhinosinusitis with nasal polyps, and their levels are increased by prostaglandin E2 (PGE2) in different cell types. The purposes of this study were to determine whether PGE2 has any effect on the increase in the levels of IL-6 and IL-8 in nasal polyp-derived fibroblasts (NPDFs) and subsequently investigate the possible mechanism of this effect.

Methods

Different concentrations of PGE2 were used to stimulate NPDFs at different time intervals. NPDFs were treated with agonists and antagonists of E prostanoid (EP) receptors. To determine the signaling pathway for the expression of PGE2-induced IL-6 and IL-8, PGE2 was treated with Akt and NF-κB inhibitors in NPDFs. Reverse transcription-polymerase chain reaction for IL-6 and IL-8 mRNAs was performed. IL-6 and IL-8 levels were measured byenzyme-linked immunosorbent assay (ELISA). The activation of Akt and NF-κB was evaluated by western blot analysis.

Results

PGE2 significantly increased the mRNA and protein expression levels of IL-6 and IL-8 in NPDFs. The EP2 and EP4 agonists and antagonists induced and inhibited IL-6 expression. However, the EP4 agonist and antagonist were only observed to induce and inhibit IL-8 expression level. The Akt and NF-κB inhibitors significantly blocked PGE2-induced expression of IL-6 and IL-8.

Conclusions

PGE2 increases IL-6 expression via EP2 and EP4 receptors, and IL-8 expression via the EP4 receptor in NPDFs. It also activates the Akt and NF-κB signal pathways for the production of IL-6 and IL-8 in NPDFs. These results suggest that signaling pathway for IL-6 and IL-8 expression induced by PGE2 might be a useful therapeutic target for the treatment of nasal polyposis.

Resveratrol has salutary effects on mucociliary transport and inflammation in sinonasal epithelium

OBJECTIVE/HYPOTHESIS

Therapeutic agents that enhance mucociliary transport (via stimulation of transepithelial Cl- secretion) and inhibit inflammation could provide considerable advantages over conventional treatments for chronic rhinosinusitis (CRS). The objectives of the present study were to investigate whether the polyphenolic compound resveratrol promotes transepithelial Cl- transport and inhibits KC/IL-8 secretion in sinonasal epithelium.

STUDY DESIGN

In vitro and in vivo study.

METHODS

Transepithelial Cl- transport was investigated in primary murine nasal septal (MNSE) and human sinonasal epithelial (HSNE) cultures. In vivo activity was also measured using the murine nasal potential difference assay. CFTR R-domain phosphorylation and cAMP levels were examined as a test of cAMP/PKA-dependent activation. In vitro LPS-induced KC/IL-8 secretion was quantified and compared to a panel of intranasal steroids.

RESULTS

Resveratrol(100 μM) significantly increased CFTR-mediated Cl- transport (change in short-circuit current, ΔI(SC) ) in both MNSE (13.51 ± 0.77 vs. 4.4 ± 0.66 [control]; P < .05) and HSNE (12.28 ± 1.08 vs. 0.69 ± 0.32 [control]; P < .05). Cl- secretion across in vivo murine nasal epithelium was also enhanced (-4 ± 1.8 vs. -0.8 ± 1.7mV [control], P < .05). There was no increase in cellular cAMP or CFTR R-domain phosphorylation detected. Resveratrol also significantly inhibited KC/IL-8 secretion in a dose-dependent fashion (pg/mL) in MNSE (181 ± 39[100 μM) vs. 94 ± 16 [200 μM] vs. 16 ± 22 [500 μM] vs. 1195 ± 355 [LPS control]; P < .001). The compound robustly abrogated KC/IL-8 secretion when compared to ciclesonide (765 ± 139), triamcinolone (561 ± 124), and budesonide (742 ± 428), but had similar activity to fluticasone proprionate (65 ± 47). Similar effects were demonstrated in HSNE (975 ± 244 [100 μM] vs. 1825 ± 144 [LPS control]; P < .001) with inhibition comparable to fluticasone proprionate (785 ± 277).

CONCLUSIONS

These in vitro and in vivo findings indicate resveratrol is a potent Cl- secretagogue and anti-inflammatory agent. Future clinical trials for CRS are warranted.

Induction of interleukin-8 from nasal epithelial cells during bacterial infection: the role of IL-8 for neutrophil recruitment in chronic rhinosinusitis

Objectives. The aim of this study was to elucidate the role of IL-8 for neutrophil recruitment in nonallergic CRS patients. Methods. After coculture of Streptococcus pneumoniae (SP) with the mucosal epithelial cells (MECs) from non-CRS patients, at three different SP/MEC (1/1, 10/1, 100/1) ratios, the expression of IL-8 mRNA and the concentration of IL-8 were measured by RT-PCR and ELISA. The expression of CD11b/CD18 on neutrophils and E-selectin/ICAM-1 on endothelial cells and the adherence between neutrophils and human umbilical vascular endothelial cells (HUVECs) were determined by flow cytometric analysis, ELISA, and RIA, respectively. Results. IL-8 concentration and IL-8 mRNA expression continued to increase from 3 hours after incubation in SP number-dependent manner. The expression of CD11b/CD18 on neutrophils and E-selectin/ICAM-1 on HUVECs, and the adherence between neutrophils and HUVECs were significantly increased in 10 SP/MEC-CM, and the increments were significantly blocked by anti-IL-8 antibody. Conclusion. MEC and IL-8 are major factors for neutrophil recruitment in nonallergic CRS.

Vitamin D derivatives: calcitriol and tacalcitol inhibits interleukin-6 and interleukin-8 expression in human nasal polyp fibroblast cultures

PURPOSE

Biologically active vitamin D3 (VD) derivatives possess modulatory activities on immunological and inflammatory responses which can be reflected by altered levels of pro-inflammatory chemokines. Nasal polyposis (NP), defined as a chronic inflammatory process of upper respiratory system, could be influenced by VD derivatives. The purpose of this study was to investigate the influence of 1alpha,25-dihydroxyvitamin D3 (calcitriol) and 1alpha,24(R)-dihydroxyvitamin D3 (tacalcitol) on the secretion of IL-6 and IL-8 by fibroblasts derived from NP.

MATERIAL AND METHODS

The study involved 12 fibroblast cultures derived from NP samples obtained from surgically treated patients. Measurements were performed on the polyp cells after the 6-9 passages. Culture stimulation involved treatment with tacalcitol and calcitriol at a defined strength (from 10(-7)M to 10(-4)M). IL-6 and IL-8 concentrations were estimated with ELISA.

RESULTS

Treatment with calcitriol or tacalcitol inhibits the synthesis of both IL-6 and IL-8 compared to the control group. The dose dependence of this effect has been confirmed. VD derivatives influence was marked at higher concentrations. Significant interleukin decrease was observed at 10(-5) and 10(-4) for calcitriol and 10-4 in the case of tacalcitol.

CONCLUSIONS

The present study demonstrates that calcitriol and tacalcitol are capable of affecting pro-inflammatory cytokine (IL-6 and IL-8) levels in NP cultures. Our data imply a potential therapeutical application of topical VD derivates in NP and warrant further investigation.

Expression profiling of inflammatory mediators in pediatric sinus mucosa

OBJECTIVE

To evaluate gene expression by microarray analyses of inflammatory mediators in the sinus mucosa of children with and without chronic rhinosinusitis (CRS).

DESIGN

Prospective molecular genetics analysis.

SETTING

Children's National Medical Center, Washington, DC.

SUBJECTS

Eleven patients with CRS who underwent endoscopic sinus surgery and 10 control children who underwent craniofacial resection or neurosurgical procedures.

MAIN OUTCOME MEASURES

Gene expression levels of sinus tissue from 6 patients with CRS and 6 controls and messenger RNA expression levels of upregulated inflammatory/immune response genes, as well as cytokines of interest, determined by quantitative reverse transcription-polymerase chain reaction.

RESULTS

Gene expression using the Plier algorithm yielded the most consistent grouping of samples: 96 genes were significantly upregulated more than 2-fold, and 123 genes were downregulated by at least 50% in the CRS sinus tissues compared with controls (P < .05). GeneSpring analysis demonstrated significant changes in several ontology categories in the CRS samples, including inflammatory/immune response genes. The chemokines CXCL13 and CXCL5, serum amyloid A, serpin B4, and defensin beta1 were highly upregulated (> or =5-fold). Increased expression of these genes was validated by quantitative reverse transcription-polymerase chain reaction in an independent set of tissues. Expression levels of interleukins 5, 6, and 8 were similar in both cohorts; these results were validated by reverse transcription-polymerase chain reaction.

CONCLUSIONS

Microarray analyses of sinus mucosa in children with CRS showed an increased expression of inflammatory genes involved in innate and adaptive immune systems. This technology can be successfully used to identify genes implicated in the pathogenesis of pediatric CRS.

Role of matrix metalloproteinases in chronic rhinosinusitis

PURPOSE OF REVIEW

In this review, we discuss the role of matrix metalloproteinases and the potential therapeutic inhibition of metalloproteinases in chronic rhinosinusitis. Metalloproteinases control tissue remodelling along with several other physiologic processes. Failures may cause extracellular matrix deposition and sustained inflammation, which are common features in chronic rhinosinusitis.

RECENT FINDINGS

Metalloproteinases are rarely studied in chronic rhinosinusitis. Upregulation of certain metalloproteinases (gelatinases, collagenases and matrilysin) is described in the literature. The results are partly controversial, suggesting that metalloproteinases are implicated in the destructive processes in the disease pathogenesis, but also demonstrate that they may exert an anti-inflammatory function in chronic rhinosinusitis. The imbalance between metalloproteinases and the tissue inhibitor of metalloproteinases is proposed to be crucial in the extracellular matrix deposition in asthma, and it may also lead to pathologic tissue remodelling in chronic rhinosinusitis.

SUMMARY

Metalloproteinases are implicated in the chronic respiratory-tract diseases, but little is known about their detailed functions in disease pathogenesis. Metalloproteinases may serve as tools in evaluating prognosis and provide a target for novel therapies, highlighting the need for better understanding of metalloproteinase functions in chronic rhinosinusitis.

Drug management in chronic rhinosinusitis: identification of the needs

Chronic rhinosinusitis (CRS) is a group of multifactorial diseases characterized by inflammation of the mucosa of the nose and paranasal sinuses with a history of at least 12 weeks of persistent symptoms despite maximal medical therapy. The precise role played by infection and immunoglobin E (IgE)-mediated hypersensitivity remains unclear. Diagnosis of CRS is based upon medical history, nasal endoscopy and computed tomography scan of the sinuses. The CRS with polyps visible in the middle meatus must be distinguished from the CRS without polyps. Based on the current knowledge about the pathogenesis of CRS, it is admitted that an optimal medical treatment must consider all favorizing factors and control efficaciously the inflammation process. In case of failure of medical treatment, endoscopic sinus surgery should be proposed. However, some well-validated data and scientific evidences are missing, even for the most frequently used medications. After a review of the actual definitions and classifications, a short description of the current knowledge about pathogenesis of CRS is provided in order to justify the actual therapeutic rationales and identify the needs for an effective treatment of CRS.

Inflammatory pathway gene expression in chronic rhinosinusitis

BACKGROUND

The main objective in this preliminary experiment was to compare gene expression in the sinus mucosa of patients with chronic hyperplastic rhinosinusitis (CRS) against normal subjects, using gene microarray technology. The specific aim was to examine alterations in inflammatory mediator expression in patients with CRS. We performed a prospective experimental study.

METHODS

Total RNA samples were obtained from the sinus mucosa biopsies of 14 patients with chronic hyperplastic sinusitis and 4 normal controls, using the Affymetrix recommended protocol. The data for 22,000 genes on the GeneChip U133A were generated from 18 hybridizations. Affymetrix GeneChip 5.0 was used as the image acquisition software for the U133A chips. Data normalization, log transformation, statistical analysis, and pattern study were performed with GeneSpring software. Comparison between patients with CRS and normal controls were performed using the Welch t-test, with log transformed data.

RESULTS

There were a total of 1283 genes scored as differentially expressed between groups. The value of p, the probability of a false positive, was set to <0.05. Hierarchical clustering was applied to study coexpression patterns of the 1283 significant genes. The inflammatory pathway was overlaid with the differential expressed gene list. Four genes involved in the inflammatory pathway, interleukin (IL)-6, IL-12A, IL-13, and tumor necrosis factor (TNF) alpha (2) were consistently overexpressed in patients with hyperplastic CRS.

CONCLUSION

There is overexpression of four major genes of the inflammatory pathway (IL-6, IL-12A, IL-13, and TNF-alpha (2)) in patients with CRS compared with the normal population. Defining gene expression profiles may help elucidate new key factors in the pathogenesis of CRS and perhaps aid in the development of new therapeutic modalities.

Factors contributing to nasal allergic late phase eosinophilia

OBJECTIVE

This study focused on factors contributing to eosinophilia after intranasal allergen challenge.

METHODS

Nasal secretions of 13 allergic individuals were gained over a period of 8 hours after nasal allergen challenge. Early and late phase reactions were determined by acoustic rhinometry and changes of volume and total protein in nasal secretions. Eosinophilia was demonstrated by nasal eosinophilic cationic protein. Interleukin (IL)-5; the chemokines IL-8, monocyte chemotactic protein (MCP)-1 and MCP-3, and eotaxin; soluble vascular cell adhesion molecule 1 (sVCAM-1); and the leukotriene C4 (LTC4) were analyzed by enzyme-linked immunosorbent assay for their suggested impacts on tissue eosinophilia.

RESULTS

By means of rhinometry, we observed in 69% an alternating type of late phase response, followed by a bilateral (15%) or unilateral (8%) type. A biphasic kinetic could be demonstrated by changes in nasal volume and total protein of nasal secretions, reflecting the early and late phase responses. A typical late phase kinetic was observed for IL-5, MCP-1, eotaxin, sVCAM-1, and LTC4. Interleukin 8 was characteristic for early phase reaction but increased in late phase as well. We could not detect any MCP-3 in our samples.

CONCLUSIONS

Our data point to a relevant role of the T(H)2 cytokine IL-5; of the chemokines IL-8, MCP-1, and eotaxin; of the adhesion molecule sVCAM-1; and of the leukotriene LTC4 for the allergic late phase eosinophilia.

In vivo relationship between collagenase-2 and interleukin-8 but not tumour necrosis factor-alpha in chronic rhinosinusitis with nasal polyposis

BACKGROUND

The characteristic feature of chronic rhinosinusitis with nasal polyposis (CRSwNP) is eosinophilic inflammation of the sinus mucosa; a type of inflammation also seen in asthmatic airways. Similar histopathologic findings of airway remodelling are present in both diseases. Remodelling is tightly controlled by matrix metalloproteinases (MMP). Increase of collagenase-2 (MMP-8) expression in the bronchial epithelial cells has been described in asthmatic patients, but it has not been studied in CRSwNP.

METHODS

The concentrations and degree of activation of MMP-8 were analysed by immunofluorometric assay and Western blotting, respectively, in sinus mucus samples from CRSwNP patients and in nasal lavages from healthy controls in relation to inductive cytokines interleukin-8 (IL-8) and tumour necrosis factor-alpha (TNF-alpha).

RESULTS

Significantly elevated levels of MMP-8 and IL-8 but not TNF-alpha were found in CRSwNP patients relative to controls. In particular, the activation of mesenchymal-type MMP-8 but not polymorphonuclear-type MMP-8 was associated with elevated IL-8 levels.

CONCLUSIONS

The IL-8 and MMP-8 seemingly form an inductive cytokine-proteinase cascade in CRSwNP pathogenesis. Together they provide a target for novel therapies and a diagnostic tool for monitoring CRSwNP treatment.

Pharmacologic management of chronic rhinosinusitis, alone or with nasal polyposis

Patients with chronic rhinosinusitis (CRS) and chronic rhinosinusitis with nasal polyposis (CRSwNP) commonly present with nasal obstruction, nasal discharge, facial pressure/pain, and hyposmia of prolonged duration. Recent evidence suggests that, despite clinical similarities, CRS and CRSwNP are distinct entities with separate inflammatory pathways and cytokine profiles. Antibiotics and nasal steroids are the mainstay of treatment in CRS, whereas combination systemic and nasal steroids are the foundation of CRSwNP management. Allergy therapy may play a significant role in CRS, whereas antileukotriene therapy has demonstrated promise in CRSwNP. Although prolonged medical therapy is usually necessary with both disorders, surgery may also be required to relieve refractory symptoms, and to improve sinus aeration and nasal access for topical therapy.

Rhinosinusitis: establishing definitions for clinical research and patient care

Background

There is a need for more research on all forms of rhinosinusitis. Progress in this area has been hampered by a lack of consensus definitions and the limited number of published clinical trials.

Objectives

To develop consensus definitions for rhinosinusitis and outline strategies useful in clinical trials.

Methods

Five national societies, The American Academy of Allergy, Asthma and Immunology; The American Academy of Otolaryngic Allergy; The American Academy of Otolaryngology Head and Neck Surgery; The American College of Allergy, Asthma and Immunology; and the American Rhinologic Society formed an expert panel from multiple disciplines. Over two days, the panel developed definitions for rhinosinusitis and outlined strategies for design of clinical trials.

Results

Committee members agreed to adopt the term “rhinosinusitis” and reached consensus on definitions and strategies for clinical research on acute presumed bacterial rhinosinusitis, chronic rhinosinusitis without polyposis, chronic rhinosinusitis with polyposis, and classic allergic fungal rhinosinusitis. Symptom and objective criteria, measures for monitoring research progress, and use of symptom scoring tools, quality-of-life instruments, radiologic studies, and rhinoscopic assessment were outlined for each condition.

Conclusion

The recommendations from this conference should improve accuracy of clinical diagnosis and serve as a starting point for design of rhinosinusitis clinical trials.

Rhinosinusitis: Establishing definitions for clinical research and patient care

Background

There is a need for more research on all forms of rhinosinusitis. Progress in this area has been hampered by a lack of consensus definitions and the limited number of published clinical trials.

Objectives

To develop consensus definitions for rhinosinusitis and outline strategies useful in clinical trials.

Study design

Five national societies, The American Academy of Allergy, Asthma and Immunology; The American Academy of Otolaryngic Allergy; The American Academy of Otolaryngology Head and Neck Surgery; The American College of Allergy, Asthma and Immunology; and the American Rhinologic Society formed an expert panel from multiple disciplines. Over two days, the panel developed definitions for rhinosinusitis and outlined strategies for design of clinical trials.

Results

Committee members agreed to adopt the term “rhinosinusitis” and reached consensus on definitions and strategies for clinical research on acute presumed bacterial rhinosinusitis, chronic rhinosinusitis without polyposis, chronic rhinosinusitis with polyposis, and classic allergic fungal rhinosinusitis. Symptom and objective criteria, measures for monitoring research progress, and use of symptom scoring tools, quality-of-life instruments, radiologic studies, and rhinoscopic assessment were outlined for each condition.

Conclusions

The recommendations from this conference should improve accuracy of clinical diagnosis and serve as a starting point for design of rhinosinusitis clinical trials.

Surgical rhinology: recent advances and future directions

The discipline of rhinology is poised on the cusp of explosive growth in its cumulative body of knowledge. Advances in surgical technique, applied technology, and basic science over the past 2 decades have yielded significant benefits to both practitioner and patient. The future holds great promise for continued technical innovation, acquisition of new knowledge,and advances in the science of rhinology.

Allergy and the contemporary rhinologist

Recently, an expanded view of inflammatory disease of the nose and paranasal sinuses, an improved understanding of the functional anatomy of this region, and the development of more sophisticated methods for examining inflammation have led to subtle changes in the field of rhinology. Careful review of the literature suggests that a number of disparate disease processes may serve as cofactors leading to the ultimate development of inflammatory nasal/paranasal sinus disease. Evaluation of cellular infiltrates and inflammatory mediators associated with various forms of rhinologic disease reveals significant overlap among many diseases that were previously thought to be separate disease processes. Further, epidemiologic studies suggest that diseases such as allergic rhinitis may be associated with the development of various forms of rhinosinusitis, and its treatment may impact the ultimate treatment for these diseases. It is becoming increasingly apparent that the contemporary rhinologist can no longer rely simply on either technical surgical skills or cognitive nonsurgical skills alone to treat these patients. Instead, to be most effective, rhinologists must synthesize diagnostic and treatment plans, using all aspects of this field of medicine.

Cytokine profile in paranasal effusions in patients with chronic sinusitis using the YAMIK sinus catheter with and without betamethasone

Recently, the YAMIK sinus catheter (YAMIK) has been reported to be a useful therapeutic device in the treatment of sinusitis. The present study was conducted to compare its delivery of either a normal saline (NS) or a betamethasone solution (0.4 mg/ml) into the paranasal sinuses of 25 patients (39 sides) with chronic sinusitis. The following parameters were evaluated: (1) subjective nasal clinical symptoms (nasal discharge, nasal obstruction, postnasal drip and headache), (2) X-ray photographs (ethmoid and maxillary sinuses) and (3) cytokine levels (IL-1beta, IL-8 and TNF-alpha) by enzyme-linked immunosorbent assay. The total nasal symptom scores significantly decreased after the first therapy, and the total X-ray photograph scores significantly decreased after therapy with either NS or the betamethasone solution. In both NS and betamethasone patients, the levels of IL-1beta and IL-8 had significantly decreased by the 3rd and 2nd weeks after therapy, respectively. In contrast, the TNF-alpha level decreased after the first therapy with betamethasone solution and remained unchanged after therapy with NS. These findings suggest that evacuation of the pathological effusions in sinuses may exert a beneficial effect by reducing the levels of IL-1beta and IL-8, and we speculate that removal of pathological effusions from the sinuses may provide treatment through different mechanisms than those that occur in treatment with betamethasone.

The role of nuclear factor-kappa B in interleukin-8 expression by human adenoidal fibroblasts

OBJECTIVES/HYPOTHESIS

The production of cytokines by adenoids is known to be associated with inflammation of nasopharynx and the pathogenesis of otitis media with effusion. However, the role of adenoids in producing inflammatory cytokines such as interleukin-8 (IL-8) is not yet clear. In the present study, expression of IL-8 in adenoidal fibroblasts was investigated at the level of transcription factors. Further, the effects of clarithromycin, a 14-member ring macrolide, on IL-8 gene expression and nuclear factor-kappa B (NF-kappa B) activation in adenoidal fibroblasts were evaluated.

STUDY DESIGN

In vitro study for the production of inflammatory cytokine from human adenoidal fibroblasts.

METHODS

Adenoidal fibroblasts were incubated with nontypeable Haemophilus influenzae endotoxin or interleukin-1 beta. Then the expression of IL-8 and the influence of NF-kappa B inhibitor and clarithromycin were evaluated. Interleukin-8 protein production was assessed by ELISA, and IL-8 messenger RNA production was measured by Northern blot analysis and reverse transcriptase-polymerase chain reaction. Activation of NF-kappa B and inhibition of its activation were determined by electrophoretic mobility shift assay.

RESULTS

The expression of both IL-8 protein and messenger RNA in adenoidal fibroblasts was enhanced by Haemophilus influenzae endotoxin and interleukin-1 beta and was positively correlated with increases in NF-kappa B activity. Treatment of cells with the NF-kappa B inhibitor N-tosyl-(L)-phenylalanine chloromethyl ketone, as well as with clarithromycin, reduced expression of IL-8 and NF-kappa B activity in a dose-dependent manner.

CONCLUSIONS

Results suggest that adenoidal fibroblasts produce IL-8 in response to endotoxin through NF-kappa B activation. The inhibitory effects of clarithromycin on NF-kappa B activation and IL-8 production in adenoidal fibroblasts might explain, in part, the mechanism of this drug in improving otitis media with effusion.

The primary role in biologic activity of the neutrophil chemokines IL-8 and GRO-alpha in cultured nasal epithelial cells

Primary nasal epithelial cells were investigated for their ability to synthesize and deliver neutrophil chemotactic factors (chemokines) following tumor necrosis factor-alpha (TNF-alpha) induction. The chemokines interleukin8 (IL-8), growth-related oncogene-alpha (GRO-alpha), epithelial cell-derived neutrophil attractant-78 (ENA-78), and granulocyte chemotactic protein-2 (GCP-2) have been detected and characterized and shown to have different potencies in the chemotaxis of neutrophils. Cultures of primary nasal epithelial cells were treated with TNF-alpha in concentrations of 20 and 200 ng/ml for 2, 8, 24, and 72 h. The chemokine protein concentrations in the supernatants of the incubations were determined by the ELISA technique. Chemokine mRNA expression in epithelial cells was also measured using the reverse transcriptase-polymerase chain reaction (RT-PCR). The biologic activity of the chemokines was identified using a three-step high-performance liquid chromatography (HPLC) technique, a bioassay involving measurement of neutrophil chemotaxis in a single Boyden chamber. Both the IL-8 and GRO-alpha proteins and their respective mRNA appear to be induced by TNF-alpha in epithelial cells. The chemotactic responsiveness of both GRO-alpha and IL-8 appears to predominate after 24 h incubation with TNF-alpha. The chemokines GCP-2 and ENA-78 were only weakly induced by TNF-alpha. The neutrophil chemokines IL-8 and GRO-alpha were synthesized in nasal epithelial cell culture induced by TNF-alpha in biologically active concentrations of 0.8 ng/ml and 1.42 ng/ml, respectively. It appears that both the IL-8 and GRO-alpha chemokines may contribute to neutrophil tissue migration in sinusitis, whereas GCP-2 and ENA-78 are of secondary importance to the chemotaxis of neutrophils in this condition.

The role of infection in chronic rhinosinusitis

Chronic rhinosinusitis is a common condition, yet little is understood about its pathogenesis. Chronic infection traditionally has been considered a significant factor in the etiology and manifestations of chronic rhinosinusitis. Bacteria can be recovered in most cases of chronic rhinosinusitis, most commonly consisting of Staphylococcus species, anaerobes, and in some cases, gram-negative bacteria. Increasing trends toward bacterial resistance have been identified in chronic rhinosinusitis. Recently, a potential role for fungal infection has emerged. A knowledge of the microbiology of chronic rhinosinusitis will help guide treatment, but more research is required to understand further the exact role of infection in the pathophysiology of chronic rhinosinusitis.

Fosfomycin nebulizer therapy to chronic sinusitis

OBJECTIVE

effects of Fosfomycin (FOM) nebulizer therapy were studied in patients with chronic sinusitis.

METHODS

about 28 patients with chronic sinusitis were administered 2 ml of FOM sodium (3% w/v) by nebulizer three times per week for 4 weeks. Levels of IL-1 beta, IL-6, IL-8, and TNF-alpha in nasal lavage were also measured before and at the end of treatment.

RESULTS

the overall efficacy of this treatment on the basis of both subjective and objective symptoms, was 'excellent' for 28.6%, 'good' for 10.7%, 'fair' for 39.4%, and yield 'no change' for 21.4% of the patients. Both IL-1 beta and IL-6 concentrations were significantly decreased after treatment. Although the IL-8 level did not significantly decrease, it seems to be related to the overall efficacy. TNF-alpha was not detected in all of the samples.

CONCLUSION

FOM nebulization therapy is highly effective in treatment for chronic sinusitis, and efficacy may be due to an immunomodulatory mechanism, as well as its bactericidal effect.

Chronic sinusitis

Sinusitis is a very common chronic illness with a substantial health care impact. This review focuses on factors contributing to sinusitis pathogenesis and chronicity, including anatomic factors, disturbances in mucociliary clearance, microbial pathogens, and inflammatory factors. A distinction is made between "infectious" and "noninfectious" types of inflammation in chronic sinusitis. The inflammatory characteristics of noninfectious inflammation are reviewed primarily in the context of chronic hyperplastic sinusitis with nasal polyposis. Key features of this type of inflammation include the presence of chronic inflammatory cells, large numbers of eosinophils, and IL-5-producing T lymphocytes. Allergic fungal sinusitis is discussed as a special type of chronic sinusitis. Published studies on the outcomes of medical management are reviewed. Finally, algorithms for medical management of chronic sinusitis and allergic fungal sinusitis are presented.

Changes in nasal leukocytes and epithelial cells associated with topical beclomethasone treatment

BACKGROUND

We had previously observed that changes in nasal cytology were associated with specific clinical patterns in cross-sectional studies of allergy clinic patients. In the present study, we sought to determine whether specific cytologic changes occurred with antiinflammatory therapy in a controlled setting in a prospective manner.

OBJECTIVE

To examine changes in nasal leukocytes and epithelial cells associated with topical beclomethasone treatment in allergic rhinitis patients. Specifically we tested the hypothesis that number of nasal leukocytes relative to epithelial cell numbers are altered by topical beclomethasone treatment.

METHODS

Adult volunteers (n=26) with symptoms consistent with allergic rhinitis and positive aeroallergen skin tests were enrolled for treatment with either beclomethasone or placebo nasal spray. Sprays were allocated in a double-blind manner and were prescribed to be administered over a 2-week period. Baseline quality of life, nasal cytograms, and mucosal physical appearance scores were obtained at baseline and at the end of the treatment period. Changes in various nasal leukocytes and epithelial cell types were analyzed for association with active treatment using bivariate and multivariate analysis.

RESULTS

Total leukocytes showed greater decreases with beclomethasone treatment than with placebo. Total epithelial cells on the other hand showed an increase with active treatment compared with placebo treatment. In multivariate analysis, the changes in both total leukocytes and total epithelial cells showed independent associations with beclomethasone treatment. Combining these two variables into a single leukocyte per epithelial ratio resulted in variable with values showing a significant decreases associated with beclomethasone treatment compared with placebo treatment (P = .03).

CONCLUSIONS

The administration of topical corticosteroids results in decreases in total leukocytes and this decrease is of enhanced significance when adjusted for the quantities of associated epithelial cells. Further investigation relating to the quantities of total nasal leukocytes in inflammatory nasal diseases may be helpful in gauging disease activity and monitoring treatment modalities.