Improvement of clinical and immunopathologic parameters in asthmatic children treated for concomitant chronic rhinosinusitis

STAT6 Blockade Abrogates Aspergillus-Induced Eosinophilic Chronic Rhinosinusitis and Asthma, A Model of Unified Airway Disease

Unified airway disease, including concurrent asthma and chronic rhinosinusitis (CRS), is a common, but poorly understood disorder with no curative treatment options. To establish a murine model of chronic unified eosinophilic airway inflammation, mice were challenged with Aspergillus niger, and sinonasal mucosa and lung tissue were evaluated by immunohistochemistry, flow cytometry, and gene expression. Inhalation of A niger conidia resulted in a Th2-biased lung and sinus inflammation that typifies allergic asthma and CRS. Gene network and pathway analysis correlated with human disease with upregulation of not only the JAK-STAT and helper T-cell pathways, but also less expected pathways governing the spliceosome, osteoclast differentiation, and coagulation pathways. Utilizing a specific inhibitor and gene-deficient mice, we demonstrate that STAT6 is required for mycosis-induced sinus inflammation. These findings confirm the relevance of this new model and portend future studies that further extend our understanding of the immunopathologic basis of airway mycosis and unified airway disease.

International consensus statement on allergy and rhinology: rhinosinusitis 2021

I.

EXECUTIVE SUMMARY

BACKGROUND: The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR-RS-2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence-based findings of the document.

METHODS

ICAR-RS presents over 180 topics in the forms of evidence-based reviews with recommendations (EBRRs), evidence-based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary.

RESULTS

ICAR-RS-2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence-based management algorithm is provided.

CONCLUSION

This ICAR-RS-2021 executive summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS.

Fungi in Mucoobstructive Airway Diseases

Asthma, chronic rhinosinusitis, and related incurable allergic afflictions of the upper and lower airways are medically important because of their association with the disabling symptom of dyspnea and, at least for asthma, the potential to cause fatal asphyxiation. Extensive research over the past two decades has uncovered both the physiological basis of airway obstruction in asthma and key governing molecular pathways. Exaggerated airway constriction in response to diverse provocative stimuli, termed airway hyperresponsiveness, is mediated through the cytokines interleukin 4 (IL-4) and IL-13 and the transcription factor signal transducer and activator of transcription 6 (STAT6). Overproduction of mucus has long been known to be an essential second component of airway obstruction and is also mediated in part through the IL-4/IL-13/STAT6 pathway. In this review, we discuss a second major signaling pathway which underlies mucus production that is mediated through proteinase-cleaved fibrinogen signaling through Toll-like receptor 4. Unexpectedly, our analysis of human sputum and paranasal sinus fluid indicates that in most cases of severe allergic airway disease, a unique type of airway fungal infection, termed airway mycosis, is pathogenically linked to these conditions. We further discuss how fungal and endogenous proteinases mediate the fibrinogenolysis that is essential to both Toll-like receptor 4 signaling and fibrin deposition that, together with mucus, contribute to airway obstruction.

Pediatric rhinosinusitis and asthma

Both asthma and rhinosinusitis are complex and heterogeneous diseases and, importantly, they often coexist: these diseases can be concomitant in 35-65% of affected children, according to different studies. Thus, evaluating this comorbidity in the clinical practice should be paramount. In this review, we focused our discussion on the multiple pathophysiological aspects that may link rhinosinusitis and asthma in the pediatric population. Although rhinosinusitis may exacerbate asthma through several mechanisms occurring by contiguity, actually this aspect seems to be only one component of the complex interplay between upper and lower airways. In particular, the onset of an important and persistent Th2-driven inflammatory process dominated by eosinophils presence at one site of the airways, may release into the bloodstream several cytokines; in their turn, those can lead to the stimulation of the bone marrow, which may function as a systemic amplifier of such an eosinophilic inflammation.

Sinus and Upper Airway Surgery in Children

PURPOSE OF REVIEW

Chronic sinus and upper airway disease in children is a common health problem encountered every day. Its pathophysiology is complicated which leads to different treatment options and approaches. We seek to review the current literature and evidence to surgical treatments.

RECENT FINDINGS

Medical treatment with antibiotics and topical nasal sprays continues to be the first-line treatment. Surgical interventions include adenoidectomy, balloon catheter sinuplasty (BCS), and endoscopic sinus surgery (ESS). Each modality has proven to be safe; however, its effectiveness is widely variable. More research with higher level of evidence is needed to help in choosing the right surgical treatment with optimal benefit.

Advances in rhinitis: Models and mechanisms

OBJECTIVE

To summarize studies highlighting recent advances in rhinitis-related research in the past 2 years.

DATA SOURCES

Original research articles were procured and examined from the Rhinitis and Upper Airway Disease section of the 2015 to 2017 Annals of Allergy, Asthma & Immunology issues. Additional original research articles were identified from PubMed and Google Scholar using the following search terms: allergic rhinitis, rhinitis, chronic rhinosinusitis, environmental exposure unit, and nasal allergen challenge. Only research articles published in the past 2 years were procured.

STUDY SELECTIONS

Articles conducting research in allergic rhinitis (AR) or chronic rhinosinusitis or using controlled allergen challenge facilities or the nasal allergen challenge model were selected.

RESULTS

Studies in the past 2 years have focused on using skin prick tests and early-life phenotyping to predict AR development in children. They also have elucidated the role of a subset of CD4⁺ T cells, basophils, and mast cells in non-eosinophilic chronic rhinosinusitis with nasal polyps, a relatively new chronic rhinosinusitis subtype in the Asian population. Several advances have been made in understanding the role of several cytokines and peripheral cell mitochondrial function in AR using controlled allergen challenge facilities and direct nasal allergen challenges.

CONCLUSION

Findings from the recent literature highlight the utility of early-life predictors of AR in possibly targeting high-risk groups for prophylactic interventions. Studies also emphasize the use of controlled allergen challenge facilities and the nasal allergen challenge model as robust experimental models to study AR pathogenesis.

Problem-based learning discussion: Medical treatment of pediatric chronic rhinosinusitis

This problem-based learning case focused on the approach to evaluation and management of a 5-year old girl who was "always sick" with sinus infections. The discussion unfolds in a "real life" scenario, i.e., based on information available to the clinician initially and after the acquisition of laboratory data, and, ultimately, after sinus surgery. Emphasis is placed on the differential diagnosis of the patient's symptoms, discussion of the initial management strategy for chronic rhinosinusitis (CRS), evolution from acute rhinosinusitis to CRS, the prevalence of and differential diagnosis of nasal polyps in children, treatment considerations specific for CRS with nasal polyps, the significance of Pseudomonas aeruginosa sinus infection, the significance of an abnormal sweat chloride test in a young child with nasal polyposis, special considerations in children with CRS who have cystic fibrosis, treatment considerations after endoscopic sinus surgery, and, finally, prognostic factors that impact the outcomes of endoscopic sinus surgery. This problem-based learning case highlights many facets of managing refractory CRS in children.

WITHDRAWN: Topical steroid for chronic rhinosinusitis without polyps

Review withdrawn from Issue 4, 2016. Replaced by new reviews 'Intranasal steroids versus placebo or no intervention for chronic rhinosinusitis' (Chong 2016a) and 'Different types of intranasal steroids for chronic rhinosinusitis' (Chong 2016b).

The editorial group responsible for this previously published document have withdrawn it from publication.

Pediatric Severe Chronic Upper Airway Disease (P-SCUAD)

The term SCUAD (severe chronic upper airway disease) has been previously introduced to describe cases with upper airway disorders and symptoms not adequately controlled despite correct diagnosis and management. It has been so far applied mainly in adults and no specific focus has been given on the pediatric population. When the term SCUAD is considered for children specifically, a series of issues may arise. These issues involve accurate definition, epidemiology, clinical characteristics, pathophysiology, and socioeconomic implications. These issues seem to clearly differentiate adult from pediatric SCUAD. We attempt to shed light on these issues in an effort to provide directions for future guideline development and research. In this context, P-SCUAD (pediatric severe chronic upper airway disease) is hereby introduced.

Severe Chronic Upper Airway Disease (SCUAD) in children. Definition issues and requirements

OBJECTIVES

Upper airway diseases are extremely common, and a significant proportion of patients are not adequately controlled by contemporary treatment algorithms. The term SCUAD (Severe Chronic Upper Airway Disease) has been previously introduced to describe such cases. However, this term has not been adequately focused on children.

METHODS

This study aims to address the necessity of the term, as well as further details specifically for children. For this purpose, a review was performed of the current literature, with specific focus on issues regarding SCUAD in children.

RESULTS

Paediatric SCUAD represents a heterogeneous group of patients and has significant clinical and socioeconomic implications. Relevant literature is generally lacking and questions regarding definition and pathogenesis remain unanswered.

CONCLUSIONS

Accurate definition and acknowledgement of paediatric SCUAD cases may lead to better design of future clinical and molecular research protocols. This may provide improved understanding of the underlying disease processes, more accurate data regarding socioeconomic burden, and, above all, more successful treatment and prevention strategies.

Sinus and adenoid inflammation in children with chronic rhinosinusitis and asthma

BACKGROUND

Chronic rhinosinusitis (CRS) and asthma frequently coexist in children and adults. However, the precise pathophysiologic mechanism of this interaction is still poorly understood, especially in children, owing to the lack of direct measurements of mucosal inflammation in the upper airways.

OBJECTIVE

To determine the pathophysiologic mechanism by analyzing the expression of a large array of inflammatory cytokines and chemokines in the sinus and adenoid tissues surgically removed from pediatric patients with CRS refractory to medical management.

METHODS

Twenty-eight children 2 to 12 years old diagnosed with CRS with or without asthma and 10 controls were included in this prospective, nonrandomized study. Mucosal expression of 40 inflammatory cytokines was measured with a multiplex assay and was normalized to total tissue protein.

RESULTS

Compared with children with CRS and without asthma, children with CRS and asthma had significantly higher sinus levels of tumor necrosis factor-α and adenoid levels of epidermal growth factor, eotaxin, fibroblast growth factor-2, growth-related oncogene, and platelet-derived growth factor-AA.

CONCLUSION

The inflammatory response in the upper airway mucosa of children with asthma and CRS was similar, but more severe, compared with children with CRS without asthma. This observation is consistent with the hypothesis that asthma in these patients is caused or exacerbated by severe upper airway disease and supports the concept that treating sinus disease is paramount in the management of chronic asthma in children using, for the first time, direct measurements of airway inflammation in children.

Association and management of eosinophilic inflammation in upper and lower airways

This review discussed the contribution of eosinophilic upper airway inflammation includes allergic rhinitis (AR) and chronic rhinosinusitis (CRS) to the pathophysiology and course of asthma, the representative counterpart in the lower airway. The presence of concomitant AR can affect the severity of asthma in patients who have both diseases; however, it is still debatable whether the presence of asthma affects the severity of AR. Hypersensitivity, obstruction and/or inflammation in the lower airway can be detected in patients with AR without awareness or diagnosis of asthma, and AR is known as a risk factor for the new onset of wheeze and asthma both in children and adults. Allergen immunotherapy, pharmacotherapy and surgery for AR can contribute to asthma control; however, a clear preventive effect on the new onset of asthma has been demonstrated only for immunotherapy. Pathological similarities such as epithelial shedding are also seen between asthma and CRS, especially eosinophilic CRS. Abnormal sinus findings on computed tomography are seen in the majority of asthmatic patients, and asthmatic patients with CRS show a significant impairment in Quality of Life (QOL) and pulmonary function as compared to those without CRS. Conversely, lower airway inflammation and dysfunction are seen in non-asthmatic patients with CRS. Treatments for CRS that include pharmacotherapy such as anti-leukotrienes, surgery, and aspirin desensitization show a beneficial effect on concomitant asthma. Acting as a gatekeeper of the united airways, the control of inflammation in the nose is crucial for improvement of the QOL of patients with co-existing AR/CRS and asthma.

Diseases of the nose and paranasal sinuses in child

Diseases of the pediatric nose and nasal sinuses as well as neighboring anatomical structures encompass a variety of pathologies, especially of inflammatory nature. Congenital disease, such as malformations and structural deviations of the nasal septum, as well as systemic metabolic pathologies affecting the nose and sinuses, rarely require medical therapy from an Otolaryngologist. The immunological function of the mucosa and genetic factors play a role in the development of disease in the pediatric upper airway tract, especially due to the constantly changing anatomy in this growth phase. Disease description of the nose and nasal sinuses due to mid-facial growth must also take developmental age differences (infant, toddler, preschool, and school age) into account. Epidemiological examinations and evidence based studies are often lacking in the pediatric population. The wide range of inflammatory diseases of the nose and paranasal sinuses, such as the acute and chronic rhinosinusitis, the allergic rhinitis, and adenoid disease, play a role in the susceptibility of a child to infection. The susceptibility to infection depends on the pediatric age structure (infant, young child) and has yet to be well defined. The acute rhinosinusitis in children develops after a viral infection of the upper airways, also referred to as the "common cold" in the literature. It usually spontaneously heals within ten days without any medical therapy. Antibiotic therapy is prudent in complicated episodes of ARS. The antibiotic therapy is reserved for children with complications or associated disease, such as bronchial asthma and/or chronic bronchitis. A chronic rhinosinusitis is defined as the inflammatory change in the nasal mucosa and nasal sinus mucosa, in which the corresponding symptoms persist for over 12 weeks. The indication for CT-imaging of the nasal sinuses is reserved for cases of chronic rhinosinusitis that have been successfully treated with medication. A staged therapeutic concept is followed in CRS based on conservative and surgical methods. Nasal sinus surgery is considered nowadays as effective and safe in children. Based on the assumption that adenoids are a reservoir for bacteria, from which recurrent infections of the nose and nasal sinus originate, the adenoidectomy is still defined as a cleansing procedure in rhinosinusitis. 69.3% of the children had benefit from adenoidectomy. Comorbidities, such as pediatric bronchial asthma, presently play an even more important role in the therapy of rhinosinusitis; therefore, it is often wise to have the support of pediatricians. In western European countries 40% of children presently suffer from allergic rhinitis, in which pronounced nasal obstruction can cause disturbed growth in facial bones. An early therapy with SIT may prevent the development of bronchial asthma and secondary sensitization to other allergens. Therefore, SIT is recommended in treatment of allergic rhinitis whenever, if possible. The assessment of diagnostic tools is for the examiner not often possible due to the lack of evidence. Rhinosurgical approaches are often described in study reports; however, they lack the standard prospective randomized long-term study design required nowadays and can only be evaluated with caution in the literature.

Use of Topical or Systemic Steroids in Children with Upper Respiratory Tract Infection

Steroids have long been used to improve a number of clinical conditions because of their role in reducing inflammatory responses, but their use has always been limited because of their possible long-term side effects. The aim of this review is to establish whether steroids can have a positive effect on the outcome of some pediatric upper respiratory tract infections. We used PubMed to select all of the studies on topical or systemic steroids, and their therapeutic use in children with rhinosinusitis (RS), acute otitis media (AOM), otitis media with effusion (OME), acute pharyngitis (AP), or periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis (PFAPA), published over the last 15 years. Although a generally significant improvement in signs and symptoms has been observed with the use of intranasal steroids in children with RS, it is not clear which molecule should be recommended, how long treatment should be continued, or whether the benefits are limited to allergic children. No high-quality studies on the use of topical or systemic steroids in AOM have been carried out, and the results of studies of OME are controversial. The potential positive effects of steroids in children with AP are too slight to justify their use, and their possible adverse effects (particularly in the case of repeated administration) have not been clearly evaluated. Oral corticosteroids seem to be effective in resolving the symptoms of PFAPA, although they do not prevent future fever cycles. These findings show that further randomised and controlled studies are required in order to approach upper respiratory tract infections correctly and avoid the risks associated with frequent steroid use.

Nasal disease and asthma

The nose plays a primary role within the airways, working as a filter and air-conditioner, together with other important functions. Thus, it is not surprising that nasal diseases are associated with several other comorbidities, including both upper and lower airways, such as bronchial hyperresponsiveness (BHR) and asthma. Several studies have investigated the relationship existing between the upper and the lower airways and new insights are rising. Nevertheless, some uncertainties still remain, mainly because nasal disorders are quite heterogeneous, overlapping (i.e. rhinitis-rhinosinusitis-sinusitis, acute or chronic, allergic or non-allergic) and difficult to diagnose, so that, frequently, many studies don’t differentiate between the various conditions. For this reason, the purpose of this review is to systematically analyze present epidemiological, pathophysiological and clinical data on the relationship between nasal diseases and asthma, splitting up three main conditions: allergic rhinitis, chronic rhinosinusitis and nasal polyposis.

Topical steroid for chronic rhinosinusitis without polyps

BACKGROUND

Topical corticosteroid is used as part of a comprehensive medical treatment for chronic rhinosinusitis (CRS) without polyps. Nevertheless, there is insufficient evidence to show a clear overall benefit. Trials studying the efficacy of topical corticosteroid use various delivery methods in patients who have or have not had sinus surgery, which directly impacts on topical delivery and distribution.

OBJECTIVES

To assess the effects of topical steroid in patients with CRS without nasal polyps and perform a meta-analysis of symptom improvement data, including subgroup analysis by sinus surgery status and topical delivery methods.

SEARCH STRATEGY

We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ISRCTN and additional sources for published and unpublished trials. The date of the most recent search was 9 July 2010.

SELECTION CRITERIA

All randomised trials in which a topically administered corticosteroid was compared with either a placebo, no treatment or alternative topically administered corticosteroid for the treatment of CRS without polyps in patients of any age.

DATA COLLECTION AND ANALYSIS

Two authors reviewed the search results and selected trials meeting the eligibility criteria, obtaining full texts and contacting authors where necessary. We documented our justification for the exclusion of studies. Two authors extracted data using a pre-determined standardised data form.

MAIN RESULTS

Ten studies (590 patients) met the inclusion criteria. The trials were of low (six trials) and medium (four trials) risk of bias. The primary outcome was sino-nasal symptoms. When compared to placebo, topical steroid improved symptom scores (standardised mean difference -0.37; 95% confidence interval (CI) -0.60 to -0.13, P = 0.002; five trials, n = 286) and had a greater proportion of responders (risk ratio 1.69; 95% CI 1.21 to 2.37, P = 0.002; four trials, n = 263). With a limited number of studies, the subgroup analyses of patients who had received sinus surgery versus those who had not was not significant (P = 0.35). Subgroup analyses by topical delivery method revealed more benefit when steroid was administered directly to the sinuses than with simple nasal delivery (P = 0.04). There were no differences between groups for quality of life and adverse events.

AUTHORS' CONCLUSIONS

Topical steroid is a beneficial treatment for CRS without polyps and the adverse effects are minor. It may be included in a comprehensive treatment of CRS without polyps. Direct delivery of steroid to the sinuses may bring more beneficial effect. Further studies comparing different topical drug delivery methods to the sinuses, with appropriate treatment duration (longer than 12 weeks), are required.

Seeking common pathophysiology in asthma, atopy and sinusitis

Asthma and chronic sinusitis are inexplicably common airway diseases that are linked to atopy and allergic inflammation. T helper type 2 (Th2) cells and the associated cytokines are believed to play crucial pathogenic roles in asthma, but the environmental factors that instigate allergic airway disease remain poorly understood. Environmental proteinases are highly allergenic and are candidate inducers of airway Th2 responses. Determining the proteinases and their sources that are relevant to airway disease, however, remains challenging. In this Opinion, we summarize the evidence that implicates fungi as both a relevant source of allergenic proteinases and a potential cause of asthma, atopy and chronic sinusitis through airway infection. Clarification of the extrinsic causes of these processes will markedly improve diagnosis, prognosis and therapy.

Outpatient management of asthma in children age 5-11 years: guidelines for practice

PURPOSE

To increase awareness among nurse practitioners (NPs) regarding diagnostic and treatment guidelines for asthma for the 5-11 year age group recently updated by the National Asthma Education Prevention Program-Expert Panel 3 (NAEPP-EPR3).

DATA SOURCES

NAEPP-EPR3 guidelines for the diagnosis and management of asthma released from the National Heart, Lung, and Blood Institute in August 2007, selected clinical trials, meta-analyses, and clinical reviews.

CONCLUSIONS

Recent research has revealed that children suffering from asthma in the United States are underdiagnosed and their asthma is poorly controlled. Compelling evidence supports that children classified as having persistent asthma following NAEPP-EPR3 guidelines benefit from daily inhaled corticosteroid therapy, yet many are misclassified and undertreated.

IMPLICATIONS FOR PRACTICE

With application of current guidelines from NAEPP-EPR3, NPs can more effectively assess, diagnose, treat, and foster a collaborative self-management plan for children age 5-11 years. These interventions will result in an improved quality of life and decreased health risks for this young population.

Rhinosinusitis in children and asthma severity

PURPOSE OF REVIEW

Rhinosinusitis is a common condition in children. The association between rhinosinusitis and asthma is supported by strong epidemiological and pathogenic evidence. Moreover, a close relationship between sinusitis and asthma severity has also been reported. This study shows the new findings in this strong relationship.

RECENT FINDINGS

The profile of inflammatory cells and inflammatory mediators seen in both conditions bears considerable similarity, especially in both diseases with a relevant role played by eosinophils.

SUMMARY

Severe asthma is uncommon in childhood, but there is compelling evidence showing that the most severe asthma is closely associated to upper respiratory illness, especially rhinosinusitis. Treatment of chronic rhinosinusitis, medical or surgical or both, benefits concomitant asthma and has been shown to reduce the severity of asthma.

[Evaluation of acute bacterial rhinosinusitis in asthma patients based on clinical parameters and imaging studies, together with ear, nose and throat examination]

OBJECTIVE

To evaluate paranasal sinuses in patients with stable or acute asthma in order to determine the prevalence of acute bacterial rhinosinusitis.

METHODS

A cross-sectional study including 30 patients with acute asthma (73% females) treated in the emergency room and 30 patients with stable asthma (80% females) regularly monitored as outpatients. All patients completed a questionnaire on respiratory signs and symptoms and were submitted to ear, nose and throat (ENT) examination, as well as to X-ray and computed tomography (CT) imaging of the sinuses.

RESULTS

Based on the clinical diagnosis, the prevalence of acute bacterial rhinosinusitis was 40% in the patients with acute asthma and 3% in those with stable asthma. The ENT examination findings and the imaging findings in isolation were not useful to confirm the diagnosis.

CONCLUSIONS

In themselves, ENT examination findings, X-ray findings and CT findings were not useful for the diagnosis of acute bacterial rhinosinusitis. Our results provide further evidence that a clinical diagnosis of bacterial rhinosinusitis should be made with caution.

Chronic rhinosinusitis and asthma

Based on considerations of the underlying epidemiology, pathophysiology, histopathology, clinical relationships and treatment outcomes, the links between rhinosinusitis and asthma become evident supporting the unified airway concept.

The future of asthma therapy: integrating clinical and experimental studies

Asthma is one of the most common, and now most heavily investigated, of modern diseases. Research along two fronts, involving experimental models of asthma and human clinical trials, proceeds in parallel, often with investigators unaware of their counterpart's findings. Here, we review the unique immunological insights into asthma pathogenesis and therapy that may be gained from comparison of human clinical trial results and analogous experimental studies. The pitfalls and benefits of animal models of asthma are discussed, and we briefly review ongoing asthma clinical studies that are based on immunological principals. Finally, we use new insights from human and animal studies to construct a refined immunopathologic disease model that may be of use in designing future experimental and therapeutic studies.

Chronic rhinosinusitis and psoriasis: do mutually exclusive systemic Th1 and Th2 disease patterns exist?

CONCLUSION

Our results support the theory that chronic rhinosinusitis (CRS) is a systemic Th alteration, the relevance of which is discussed in detail.

OBJECTIVE

CRS imposes a heavy burden on society; however, a reliable CRS therapy has not been found. Developing a better understanding of this pathology will help us in our search for more effective therapies. One question, which is rarely examined, is the possibility of CRS existing as a systemic immune alteration in Th response. Thus, the goal of this study was to examine the occurrence of CRS, a Th2 pathology, with Th1 pathologies such as psoriasis.

PATIENTS AND METHODS

This study was performed via a retrospective electronic query of our medical center in regards to patients coded with the respective diagnosis.

RESULTS

Analysis of the data showed that occurrence of CRS rarely coincided with the occurrence of psoriasis and other such Th1 pathologies.

The impact of comorbid atopic disease on asthma: clinical expression and treatment

Clinically, asthma and allergic rhinitis involve separate regions of the respiratory tract while representing a common underlying inflammatory syndrome. Much evidence supports an epidemiologic association between the diseases, paranasal sinus involvement in both conditions, and parallel relationship in severity and treatment outcomes. Pathophysiologic mechanisms, including immunoglobulin E (IgE)- mediated inflammation, are also shared. Blocking IgE with the recombinant humanized monoclonal antibody omalizumab demonstrated clinical efficacy in patients with upper and lower airway diseases. IgE blockade, leukotriene modulation, and B-cell depletion therapy have all exhibited success in chronic inflammation, reinforcing and expanding the beneficial role of immunomodulation of global mediators.

Pediatric chronic sinusitis and asthma: a review

Rhinosinusitis and asthma are common conditions associated with significant morbidity and health care costs. Recent studies in adults have suggested that rhinosinusitis and asthma may be manifestations of an inflammatory process within a continuous airway rather than fully separate diseases that only act locally; and, in fact, the presence of upper airway disease may influence lower airway disease. Controlling upper airway infection, inflammation, and symptoms may improve signs and symptoms of asthma. Pediatric studies regarding this matter are few, but the impact of rhinosinusitis and asthma is still immense and significant in children. This article discusses several pediatric studies regarding medical or surgical management of sinusitis and asthma outcome. These studies show that aggressive treatment of sinusitis when present can significantly improve asthma symptoms and quality of life in children, indicating that sinusitis may play an important role in initiating or exacerbating asthma. These findings have important implications for the physician treating a child with chronic asthma.

6: Rhinitis and asthma: united airway disease

United airway disease is characterised by inflammation of the respiratory tract, in which asthma and rhinitis are the upper and lower respiratory tract manifestations, respectively, of the same disease process. Irrespective of cause, the upper and lower respiratory tract manifestations are characterised by a systemic inflammatory response. Patients with rhinitis or asthma should always be assessed for coexistent disease in the reciprocal area. Treatment of upper airway disease can modify the severity of lower airway disease and vice versa. The potential for early treatment of allergic rhinitis to prevent progression to asthma merits further study.

Identifying and managing rhinitis and its subtypes: allergic and nonallergic components--a consensus report and materials from the Respiratory and Allergic Disease Foundation

BACKGROUND

Rhinitis is one of the most common chronic disorders presenting to an internal medicine, pediatric, or family practice clinician. It can greatly impact a patient's quality of life and exerts a tremendous societal burden in terms of both its direct and indirect costs. In practice, in treatment guidelines, and in the literature, discussions of rhinitis as an inflammatory (allergic) disease often eclipse discussions of the nonallergic components, which often contribute to, or are responsible for, a patient's disease. Recommendations for specific diagnostic criteria and treatment options for nonallergic rhinitis are often lacking compared with those addressing allergic rhinitis. Previous guidelines primarily focus on allergic rhinitis and do not provide easy-to-use tools to help primary care practitioners differentiate between, and appropriately treat, the different types of rhinitis. Although it is often difficult and time-consuming clinically to differentiate between the various rhinitis subtypes, this must be done in order to select an appropriate treatment and achieve desirable outcomes.

OBJECTIVE

We sought to develop a useful diagnostic worksheet and treatment algorithm to help clinicians correctly identify rhinitis subtypes and provide the appropriate therapy.

METHODS

An expert multidisciplinary consensus panel, comprising five allergy and immunology specialists and three ear, nose, and throat specialists with expertise in the diagnosis and treatment of rhinitis, was assembled by the Respiratory & Allergic Disease Foundation (RAD) to discuss a practical clinical approach to rhinitis that considers both inflammatory and noninflammatory elements of the disease. During this meeting, the panel discussed current data and treatment recommendations as well as clinical experiences and challenges in treating rhinitis. Materials to help simplify the diagnosis and management of rhinitis were developed as tools to aid the healthcare practitioner.

RESULTS

A rhinitis diagnostic worksheet and treatment algorithm were developed by the authors following the meeting, based on transcripts of the consensus panel's discussions. The diagnostic worksheet can be used to quickly categorize patients as having allergic, nonallergic, or 'mixed' rhinitis using descriptive criteria. Using the treatment algorithm as a guide, the appropriate treatment can then be selected based on the suspected rhinitis subtype.

CONCLUSION

The use of these clinical practice tools may improve the management of rhinitis by helping clinicians to identify both the allergic and nonallergic components of a patient's disease and choose an appropriate treatment.

The role of sinus disease in asthma

PURPOSE OF REVIEW

Some time ago, a link between upper and lower respiratory disease was described, which gave rise to the concept of 'united airways disease'. This concept primarily refers to the well established link between allergic rhinitis and asthma, but it also covers a possible link between sinus disease and asthma (allergic or nonallergic) and other lower airway disease.

RECENT FINDINGS

The current classification of chronic rhinosinusitis (CRS) includes disease without and with nasal polyps, which are considered subgroups of CRS. Different patterns of inflammatory and regulatory cytokines (involving distinguishable T-helper lymphocyte populations) and of remodelling markers, however, were recently described to differentiate nasal polyposis from CRS, yielding two discrete entities. These patterns resemble those of lower airway diseases, such as asthma and chronic obstructive pulmonary disease, and suggest a common aetiological/pathogenetic background. Whereas the link between nasal polyps and asthma is well established (indeed, asthma improves after medical or surgical treatment of sinus disease), that between CRS and lower airway disease is not well understood. Recently, Staphylococcus aureus enterotoxins, acting as superantigens, were identified as a possible link between nasal polyps and asthma, resulting in severe disease manifestations in both upper and lower airways.

SUMMARY

The role played by sinus disease in asthma is only partially understood, largely because of deficits in the clinical classification and in basic knowledge of pathophysiological pathways. Recent research into upper airway and sinus inflammation and remodelling may reveal new perspectives and lead to a classification of sinus disease, which will facilitate appropriate clinical and epidemiological studies.

Is rhinosinusitis a cause of asthma?

There is a great deal of evidence of an association between rhinosinusitis and asthma. However, it is less clear whether rhinosinusitis is a direct trigger for asthma or the two conditions are simply manifestations of a common underlying process. Evidence for a role for rhinosinusitis as a trigger for asthma includes many examples of improvement in asthma once concomitant rhinosinusitis is treated medically or surgically. Possible mechanisms for this relationship include naso-pharyngo-bronchial reflexes, postnasal drip, abnormal breathing, and the local production of inflammatory mediators that trigger pulmonary inflammation via the bone marrow. On the other hand, evidence exists that rhinosinusitis and asthma are manifestations of a common process. For example, there are similarities between the histopathological changes in the epithelium in chronic rhinosinusitis and asthma. The bone marrow may provide the link between the upper and lower airways in creating a common disease. A second possible mechanism for a common disease is response to staphylococcal enterotoxins. Although evidence exists to suggest that rhinosinusitis either triggers asthma or represents a local manifestation of a shared disorder, the key to reconciling this apparent controversy is to consider that rhinosinusitis is not just a single, uniform disease. Current evidence suggests that rhinosinusitis with neither polyps nor eosinophilic inflammation acts as a direct trigger for asthma, whereas rhinosinusitis with both polyps and eosinophilic inflammation shares underlying mechanisms with asthma. Clearly, however, there is considerable overlap between the different, complex mechanisms that link rhinosinusitis to asthma.

A possible link between sinusitis and lower airway hypersensitivity: the role of Staphylococcal enterotoxin B

Background and aims

The prevalence of asthma has been keeping arising with unknown etiology. The cumulative evidence indicates that chronic rhinosinusitis (CRS) closely relates to asthma, but the detailed mechanisms remain unclear. The present study aimed to take insight into the role of Staphylococcus enterotoxin B (SEB) in a possible association between CRS and asthma.

Methods

38 patients with both CRS and asthma underwent functional endoscopic sinus surgery. Serum specific IgE and cytokines, clinical symptoms of CRS and asthma were evaluated before and after the surgery. Peripheral blood mononuclear cells (PBMCs) were separated from the patients and cultured. Th2 response of the cultured PBMCs in the presence or absence of specific antigens and SEB was evaluated.

Results

Besides the improvement of CRS symptoms, amelioration of asthma was also observed in the patients with both CRS and asthma after the sinus surgery. The preoperatively elevated Th2 cytokines, IL-4 and IL-5, normalized postoperatively. Th2 response was generated with separated PBMCs in the presence of specific antigens. SEB was required for maintaining Th2 response in these separated PBMCs.

Conclusion

The present results indicate that a possible link exists between CRS and lower airway hypersensitivity. Sinusitis derived SEB may play a role in sustaining Th2 responses in the low airway hypersensitivity related to sinusitis.

Rhinosinusitis and pediatric asthma

Rhinosinusitis is a common disease in patients of all age groups. Rhinosinusitis arises from a variety of infectious and inflammatory mechanisms. There is ample evidence that rhinosinusitis can directly influence asthma. There is also growing evidence that rhinosinusitis may be associated with asthma as different manifestations of the same disorder. A great deal of future research is required to fully elucidate the different mechanisms whereby rhinosinusitis influences or associates with asthma, but it is clear that rhinosinusitis needs to be considered in patients with severe or refractory asthma.

Correlation of nasal inflammation and nasal airflow with forced expiratory volume in 1 second in patients with perennial allergic rhinitis and asthma

BACKGROUND

Allergic rhinitis and asthma are frequently associated and are characterized by TH2-dependent inflammation. Nasal and bronchial obstruction largely depend on allergic inflammation.

OBJECTIVE

To evaluate the relationships among nasal eosinophil counts, interleukin 4 (IL-4) and interferon-gamma (IFN-gamma) levels, nasal airflow, and forced expiratory volume in 1 second (FEV1) in patients with perennial allergic rhinitis and asthma.

METHODS

Eight men and 7 women (mean +/- SD age, 24.8 +/- 4.7 years) with perennial allergic rhinitis and asthma were evaluated. All 15 patients had a moderate-to-severe grade of nasal obstruction. Total symptom score, rhinomanometry, nasal lavage, nasal scraping, and spirometry were evaluated in all patients. Eosinophils were counted using conventional staining; IL-4 and IFN-gamma levels were measured by immunoassay in fluids recovered from nasal lavage.

RESULTS

Significant positive relationships were demonstrated between eosinophil infiltration and IL-4 levels, nasal airflow and IFN-gamma levels, FEV1 and IFN-gamma levels, and nasal airflow and FEV1 (P < .001 for all). Significant negative relationships were demonstrated between eosinophil infiltration and IFN-gamma levels, IL-4 and IFN-gamma levels, eosinophil infiltration and nasal airflow, IL-4 values and nasal airflow, nasal eosinophil counts and FEV1, and IL-4 values and FEV1 (P < .001 for all).

CONCLUSIONS

There is a close association between TH2 cytokines and eosinophil infiltration in the nose. There is also clear evidence concerning the relationships among eosinophil infiltration, IL-4 and IFN-gamma levels, and nasal airflow. Nasal eosinophil, IL-4, and IFN-gamma levels correlate with FEV1. Finally, nasal airflow is related to FEV1. These findings constitute the first evidence of a relationship between TH2-related nasal inflammation and nasal and bronchial airflow in patients with perennial allergic rhinitis and asthma.

Asthma-related health care resource use among asthmatic children with and without concomitant allergic rhinitis

OBJECTIVE

To determine the incremental effect of allergic rhinitis on health care resource use in children with asthma.

DESIGN

Population-based historical cohort study.

SETTING

Data in a general practice database in the United Kingdom during 1998 to 2001.

PATIENTS

Children 6 to 15 years old with asthma and with >or=1 asthma-related visits to a general practitioner (GP) during a 12-month follow-up period.

MAIN OUTCOME MEASURES

Asthma-related hospitalizations, GP visits, and prescription drug costs during the 12-month follow-up period for patients with and without comorbid allergic rhinitis.

RESULTS

Of 9522 children with asthma, 1879 (19.7%) had allergic rhinitis recorded in the GP medical records. Compared with children with asthma alone, children with comorbid allergic rhinitis experienced more GP visits (4.4 vs 3.4) and more of them were hospitalized for asthma (1.4% vs 0.5%) during the 12-month follow-up period. In multivariable regression analyses, comorbid allergic rhinitis was an independent predictor of hospitalization for asthma (odds ratio: 2.34; 95% confidence interval [CI]: 1.41-3.91) and was associated with increases in the number of asthma-related GP visits (mean increase: 0.53; 95% CI: 0.52-0.54) and asthma drug costs (mean increase pound: 6.7; 95% CI: 6.5-7.0). The association between allergic rhinitis and higher costs of prescriptions for asthma drugs was independent of asthma severity, measured indirectly by the intensity of use of asthma drugs.

CONCLUSIONS

Children with comorbid allergic rhinitis incurred greater prescription drug costs and experienced more GP visits and hospitalizations for asthma than did children with asthma alone. A unified treatment strategy for asthma and allergic rhinitis, as recommended by the Allergic Rhinitis and Its Impact on Asthma initiative, might reduce the costs of treating these conditions.

An update on the asthma-rhinitis link

PURPOSE OF REVIEW

For the present article we collected and reviewed the more relevant experimental results concerning the asthma-rhinitis link in allergic diseases, published since January 2002.

RECENT FINDINGS

During the last 2 years, particular attention has been devoted to the behaviour of the immune response in the two compartments of the airways. The recent experimental data, mainly obtained with specific nasal or bronchial allergen challenges, have confirmed that the link between the nose and the bronchi is bidirectional, and that a systemic cross-talk occurs. Furthermore, the pathogenic role of paranasal sinus infections in respiratory allergy has been better elucidated. It was shown that, in sinusitis, a T helper type 2 polarization exists, which can be reverted by proper therapy. On the other hand, despite the abundant experimental evidence, our view of the united airways is still not complete, and several points need to be developed.

SUMMARY

The new findings on the asthma-rhinitis link have confirmed the current pathogenic view of respiratory allergy. These findings have important implications from a therapeutic point of view, and therefore encourage and promote the search for novel integrated treatment strategies.

Airway function and nasal inflammation in seasonal allergic rhinitis and asthma

BACKGROUND

Allergic rhinitis (AR) and asthma are frequently associated and characterized by a Th2-dependent inflammation. Nasal and bronchial obstruction may be objectively measured.

OBJECTIVE

The aim of this study was to evaluate the relationships among upper and lower airway function and nasal inflammation in subjects with seasonal allergic rhinitis (SAR) and asthma.

METHODS

Twenty out-patients (12 males and eight females, mean age: 23.4+3.6 years) with SAR and asthma were evaluated during the pollen season. All of them showed a moderate-severe grade of nasal obstruction. Total symptom score, rhinomanometry, spirometry, nasal lavage, and nasal scraping were obtained in all subjects. Eosinophils were counted by conventional staining; IL-4 and IFN-gamma were measured by immunoassay on fluids recovered from nasal lavage.

RESULTS

Functional parameters, i.e. nasal airflow and forced expiratory volume in 1 s (FEV(1)), were correlated with nasal eosinophils (R(2)>0.83, P<0.001). Inflammatory parameters, i.e. eosinophils were correlated with immunological parameters, i.e. IL-4 and IFN-gamma levels (R(2)=0.93, P<0.001). Nasal symptoms were correlated with nasal airflow (rho=-0.71, P< or =0.01) and eosinophils (rho=0.72, P<0.01). Nasal airflow was correlated with FEV(1) (r=0.89, P<0.0001).

CONCLUSIONS

This study demonstrates the close connection between Th2 cytokines and eosinophil infiltration in the nose. There is also clear evidence concerning the relationships between eosinophils infiltration and cytokines levels. Nasal eosinophils can be regarded as the most important predictors of upper and lower airway functions. These findings constitute first evidence of a relationship among nasal Th2-related inflammation and nasal and bronchial airflow in patients with SAR and asthma.