Prognosis and prediction of response to surgery in allergic patients with chronic sinusitis

Endoscopic sinus surgery for chronic rhinosinusitis: 22-item Sino-Nasal Outcome Test 5-year results

BACKGROUND

Currently, limited data exist as to long-term disease-specific outcomes after endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS). In this report, we present outcomes data collected over 5 years in a large prospective cohort of patients who underwent surgical treatment for CRS.

METHODS

Patients who completed the 22-item Sino-Nasal Outcome Test (SNOT-22) before ESS were asked to complete the same survey at yearly intervals for 5 years thereafter. The impact of patients' demographics and clinical characteristics on clinical outcome was measured using mixed effects modeling for univariate and multivariable analysis. Multivariable logistic regression threshold analyses were also performed.

RESULTS

Among the 925 patients enrolled in the study, the SNOT-22 was completed after ESS by 641 patients (69.3%) at 1 year and 338 patients (36.5%) at 5 years. The mean preoperative SNOT-22 score of 48.5 (standard error [SE], 0.69) improved at all subsequent yearly time-points, including 5 years (mean, 25.8; SE, 1.08; p < 0.0001). SNOT-22 scores over time were impacted by nasal polyps (p < 0.001), environmental allergies (p = 0.010), diabetes (p = 0.032), and preoperative Lund-Mackay score (p < 0.001).

CONCLUSION

Endoscopic sinus surgery appears to be effective at improving the quality of life of patients with CRS for both the short and long term. The successful outcome of such surgery, however, is influenced by a variety of clinical factors, which should be taken into account by clinicians who are considering surgical treatment of CRS for select patients.

Impact of sinus surgery on type 2 airway and systemic inflammation in asthma

Objective: Asthma is frequently associated with chronic rhinosinusitis with nasal polyps (CRSwNP). Although endoscopic sinus surgery (ESS) improves asthma control in CRSwNP patients with asthma, the mechanism that underlies the response to surgical treatment is still unclear. We evaluated the relevance of changes in asthma control and changes in airway/systemic inflammation in eosinophilic CRSwNP patients with not well controlled asthma who underwent ESS.Methods: We prospectively assessed changes in the asthma control questionnaire (ACQ) score, blood eosinophil counts (B-Eos), forced expiratory volume in 1 s (FEV₁), and fraction of exhaled nitric oxide (FeNO) levels at 1-week before and 8 and 52 weeks after ESS.Results: Twenty-five subjects were analyzed. The ACQ score, B-Eos, and FeNO decreased, and FEV₁ increased significantly after ESS. In the period from baseline to 52 weeks after ESS, changes in ACQ were significantly correlated with the changes in blood eosinophil counts (r = 0.58, p<.01) and FeNO (r = 0.45, p<.05). Ten subjects (40%) showed consistently improved asthma control at 52-weeks after ESS. In the remaining subjects, although the ACQ score temporarily improved at 8-weeks after ESS, but eventually deteriorated at 52-weeks. Higher levels of total immunoglobulin E were associated with long-term improved asthma control after ESS.Conclusions: In eosinophilic CRSwNP patients with asthma, sinus surgery impacts asthma control through the suppression of airway/systemic type 2 inflammation. The present study reinforced the common pathophysiology of type 2 inflammation between the upper and lower airways.

Personalized Medicine in Chronic Rhinosinusitis: Phenotypes, Endotypes, and Biomarkers

Chronic rhinosinusitis (CRS) is a heterogeneous disease process with a complex underlying cause. Improved understanding of CRS pathophysiology has facilitated new approaches to management of the patient with CRS that rely on targeting patient-specific characteristics and individual inflammatory pathways. A more personalized approach to care will ultimately incorporate a combination of phenotypic and endotypic classification systems to guide treatment. This review summarizes current evidence with respect to CRS phenotypes and endotypes, as well as the identification of potential biomarkers with potential to guide current and future treatment algorithms.

Expression of Interleukin-5, Interleukin-8, and Interleukin-10 mRNA in the Osteomeatal Complex in Nasal Polyposis

Background

Several cytokines are expressed in chronic sinusitis with and without underlying allergy. Their local production and regulation in the osteomeatal complex, the key area of paranasal sinuses, still is not fully understood. This study was performed to investigate differences of cytokine messenger RNA (mRNA) expression between the medial and the lateral part of the middle turbinate and anterior ethmoid mucosa of allergic and nonallergic patients.

Methods

Using the LightCycler system for real-time reverse-transcription polymerase chain reaction, we investigated the content of interleukin (IL)-5, IL-8, and IL-10 mRNA in tissue samples from middle turbinates and anterior ethmoids of 18 patients with chronic sinusitis and nasal polyps. Inferior turbinate mucosa of six control subjects without sinusitis and allergy served as control.

Results

IL-5 mRNA was detectable in 32 (60%) of 54 samples (two of six controls) in significant different amounts between the various locations (p ≤ 0.001). Anterior ethmoid mucosa (0.96 ± 0.99) expressed the highest amount of IL-5 mRNA followed by the lateral (0.37 ± 0.54) and the medial portion of the middle turbinate (0.12 ± 0.29) with no difference between allergic and nonallergic subgroups. IL-8 was detected in significant higher amounts in all three origins with no significant difference in concentrations between the examined locations as compared with controls. Patients expressed either IL-5 or IL-8 or both cytokine mRNA. IL-10 was expressed in all three specimens from five of eight allergic patients. All five individuals with clinical symptoms of allergy at the time of operation expressed IL-10 in at least one specimen.

Conclusions

IL-5 cytokine expression in the osteomeatal complex is linked to the presence of nasal polyps, whereas IL-8 is up-regulated without distinct correlation to nasal polyps. IL-10 expression was detectable in five of eight allergic patients.

Chronic Panrhinosinusitis Without Nasal Polyps: Long-Term Outcome after Functional Endoscopic Sinus Surgery

OBJECTIVE: The goal of this study was to evaluate the long-term outcome after functional endoscopic sinus surgery (FESS) for chronic panrhinosinusitis without nasal polyps by using symptom scoring and an endoscopic outcome evaluation.

STUDY DESIGN: Seventy-seven patients with chronic panrhinosinusitis without nasal polyps (Kennedy computed tomography (CT) scan stages I to III) were followed up for at least 3 years after FESS. Preoperative evaluation included a CT scan and an immunoallergologic evaluation. Three years after FESS, all patients were interviewed and scored endoscopically.

RESULTS: Ninety-two percent of the patients showed a marked global improvement after FESS. The endoscopic control showed normal findings in 54% of all ethmoidal cavities. The postoperative endoscopic score correlated significantly with the subjective satisfaction ratings ( P < 0.001). The preoperative CT staging proposed by Kennedy was predictive for necessity of revision surgery in 15% of the patients.

CONCLUSIONS: Our data suggest that FESS for chronic panrhinosinusitis without nasal polyps has a good long-term outcome on subjective symptoms and endoscopic findings.

SIGNIFICANCE: According to this study, subjective improvement correlates significantly with the post-operative endoscopic findings in the ethmoidal cavities of patients with chronic panrhinosinusitis without polyps at a long-term follow-up.

Clinical Examination of Tissue Eosinophilia in Patients with Chronic Rhinosinusitis and Nasal Polyposis

OBJECTIVE

(1) Describe clinical and histopathologic findings in patients with chronic rhinosinusitis with nasal polyps (CRSwNP). (2) Determine if tissue and serum eosinophilia predicts disease severity in CRSwNP.

STUDY DESIGN

Case series with chart review.

SETTING

Academic hospital specializing in respiratory and allergic disease.

SUBJECTS

Patients with CRSwNP treated from 2008 to 2010.

METHODS

Clinical data were collected; sinus computed tomography (CT) scans were scored according to the Lund-Mackay system; and surgical specimens were evaluated for degree of tissue eosinophilia. Statistical analysis was performed to compare eosinophilia with indicators of disease severity.

RESULTS

Seventy CRSwNP patients were included, with a mean Lund-Mackay score of 16.7; 62.1% of patients had severe asthma, and 62.9% were aspirin sensitive. Elevated tissue eosinophil level did not correlate with medication usage, olfactory symptoms, or Lund-Mackay scores, nor did it correlate with presence of asthma or aspirin-sensitivity (P = .09). Patients with mild asthma had significantly more tissue eosinophils versus patients with severe asthma, possibly because of the high amount of chronic corticosteroid use in severe asthmatics. There was no correlation between tissue and serum eosinophil counts (P = .97), but there was a significant positive correlation between CT score and peripheral eosinophil level (P < .05).

CONCLUSIONS

Higher serum eosinophil levels may indicate more extensive mucosal disease as measured on CT scan. Neither serum nor tissue eosinophilia predicted disease severity in our retrospective analysis of CRSwNP patients, and serum eosinophil level did not serve as a marker of tissue eosinophilia.

Gram-negative bacterial carriage in chronic rhinosinusitis with nasal polyposis is not associated with more severe inflammation

BACKGROUND

We have previously demonstrated that persistent symptoms following functional endoscopic sinus surgery for chronic rhinosinusitis (CRS) is associated with Gram-negative bacterial carriage. Mechanisms for this remain unknown. We wished to determine whether Gram-negative carriage in patients with CRS with nasal polyposis is associated with a more severe inflammatory phenomenon.

METHODS

Three hundred and thirty-seven patients with CRS with nasal polyposis (CRSwNP) previously phenotyped for genetic association studies with questionnaire, serum biomarkers, and endoscopically-obtained swab cultures were studied. These were separated according to the presence (wGN) or absence (sGN) of Gram-negative bacterial carriage; demographic parameters and available serum biomarkers (complete blood count [CBC], total immunoglobulin E [IgE]) were then compared. Subgroup analysis for Pseudomonas aeruginosa (GNwPa) and non-Pseudomonas Gram-negative bacteria (GNsPs) was performed in order to explore potentially differential roles of these bacteria.

RESULTS

Gram-negative bacterial carriage was not associated with a difference in demographic parameters or serum biomarkers. However, P. aeruginosa carriage was associated with a higher self-reported incidence of asthma (GNwPa 79%, sGN 57%; p = 0.048). Interestingly, serum IgE was increased in the non-Pseudomonas Gram-negative population (GNsPs: 338 IU/mL, sGN: 195 IU/mL; p = 0.026).

CONCLUSION

CRSwNP patients colonized with Gram-negative bacteria have a similar pattern of inflammation as assessed by serum biomarkers to those colonized with Gram-positive ones. Gram-negative bacteria may contribute to development of a T helper 2 (Th2) phenotype via other mechanisms, possibly via Toll-like receptor 4 (TLR4)-mediated interleukin 33 (IL-33) production. Differences in phenotype associated with Pseudomonas species carriage suggest a different behavior than other Gram-negative bacteria, supporting their importance as disease modifiers in CRSwNP.

Medical treatment of allergy in children with recurrent or chronic sinusitis

Background:

Diagnosis and treatment of chronic and recurrent sinusitis in children is of potential importance and many factors can havean influence on it. This study assessed the chronic and recurrent sinusitis and affecting factors, as well as the role of allergy in its course and treatment in children.

Materials and Methods:

A total of 106 children with the diagnosis of chronic or recurrent sinusitis, referred to specialty clinics of otolaryngology and allergy of Tabriz Children Educational-Medical centres since 2010 to 2012, were enrolled. The history and physicalexamination findings were recorded for all patients and allergy Prick test was done for all. Response to treatment was evaluated during the follow-up visits.

Results:

The mean age of studied patients was 6.5 ± 2.9 years. Of all the patients, 54 (50.9%) were male and 52 (49.1%) were female. Skin Prick test was positive in 69.8%. Response to treatment was seen in 86.8% of the patients while 7.5% did not have any favourable outcome. Anti-allergic treatment caused better outcomes in patients with positive Skin Prick test than those with negative results.

Conclusion:

The prevalence of allergic disease in children with chronic or recurrent sinusitis is considerable and anti-allergic treatments can result infavourable therapeutic outcomes in children with sinusitis, especially with positive skin prick test results.

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.

The role of platelet-derived growth factor in the pathogenesis of sinonasal polyps: immunohistochemical assessment in epithelial, subepithelial and deep layers of the mucosa

OBJECTIVES

The aim of this study is to investigate the role of platelet-derived growth factor (PDGF) in the pathogenesis of sinonasal polyps.

METHODS

Study group (groups 1-3) consisted of nasal polyp samples of patients with sinonasal polyps and the control group consisted of inferior turbinate samples of patients without nasal polyp. In group 1, 14 specimens from ethmoid sinus; in group 2, 10 specimens from nasal cavity; in group 3, 10 specimens from maxillary sinus; and in group 4 (control), 9 specimens from inferior turbinate were included. By immunohistochemical staining technique, the PDGF positivity index (PI) in mucosal layers and in the inflammatory cells were assessed at the epithelium (EP), subepithelial layer of lamina propria (SE), and deep paraglandular layer of the mucosa (D).

RESULTS

Polymorphonuclear cell (PMNC)-percentage (%) values of ethmoid and maxillary sinus, and the PDGF PI from all cells of ethmoid sinus and nasal cavity were significantly higher than those of the control group. As mononuclear cell-% (MNC-%) increased, the PDGF_EP_basal PI, PDGF_SE_endothelial PI, and PDGF_D_endothelial PI decreased. As PMNC-PDGF PI increased, the PDGF_D_perivascular PI decreased and PDGF_D_endothelial PI increased. As PDGF-MNC PI increased, the PDGF_EP_apical PI, PDGF_SE_endothelial PI, and PDGF_D_endothelial PI decreased. As PDGF-all cells (PMNCs, MNCs, and fibroblasts) PI increased, the PDGF_EP_basal PI and PDGF_D_endothelial PI decreased, and the PDGF_D_perivascular PI increased.

CONCLUSION

We concluded that the PDGF systems play important roles in polyp pathogenesis. Fibroblast-derived PDGF may be more important than MNC-derived PDGF in polyp developing process. Increased perivascular-PDGF-PI in deep layers of the mucosa may result in sinonasal polyp formation by causing an increase in vascular permeability and extracellular edema, and thus promoting migration of inflammatory cells to extracellular area. Tissue oxygenization may be important for the initiation of PDGF release system. Because of this reason, nasal obstruction should be medically treated earlier, and, if necessary, by surgical approaches.

Correlation analysis of prognostic and pathological features of patients with chronic sinusitis and nasal polyps following endoscopic surgery

The aim of this study was to evaluate the therapeutic value of pathological indicators to predict the efficacy of endoscopic sinus surgery (ESS) in patients with chronic rhinosinusitis (CRS) with nasal polyps. A total of 53 patients with CRS with nasal polyps, who had undergone endoscopic surgery at least one year before, were surveyed for their clinical symptoms. Surgical specimen biopsies were consulted and related pathological indicators were measured. The association between the main symptoms of CRS with nasal polyps following ESS and pathological indicators were statistically analyzed. The main symptoms of patients with CRS with nasal polyps following ESS were nasal congestion, thick nasal discharge, rhinorrhea or sneezing. Goblet cells are associated with the symptoms of sneezing and thick nasal discharge, pathological gland formation is associated with dizziness, and the degree of tissue edema is associated with post-nasal discharge (P<0.05). Pathological indicators aid the prediction of the efficacy of nasal ESS in patients with CRS with nasal polyps.

Meticulous endoscopic sinus surgery to prevent recurrence of massive nasal polyposis

OBJECTIVE

To evaluate the effect of meticulous endoscopic surgery, including opening of all involved sinus cells, on the subsequent symptoms and endoscopic findings of patients with massive nasal polyposis.

STUDY DESIGN AND METHOD

One hundred patients with massive nasal polyposis resistant to medical treatment were selected. We documented each patient's demographic data, associated diseases, endoscopic findings, Lund-Mackay score and Sino-Nasal Outcome Test 22 (SNOT22) symptom score. All patients were followed up for at least two years to evaluate any recurrence.

RESULTS

Of the 100 patients, 20 per cent had a history of asthma and 27 per cent had undergone previous surgery. All underwent endoscopic sinus surgery. After two years of follow up, 8 per cent had recurrence requiring surgery. Recurrence was significantly associated with a history of asthma (p < 0.001) and the histopathological presence of eosinophilia (p = 0.014).

CONCLUSION

Meticulous endoscopic opening of all involved sinus cells can be a safe and effective means of controlling massive nasal polyposis, with an acceptable recurrence rate.

Clinical characteristics and expression of thymic stromal lymphopoetin in eosinophilic and non-eosinophilic chronic rhinosinusitis

OBJECTIVE

To evaluate the differences in clinical features and expression of cytokine thymic stromal lymphopoetin (TSLP) and its receptors in patients with eosinophilic and non-eosinophilic chronic rhinosinusitis (ECRS and NECRS).

METHOD

36 ECRS patients and 50 NECRS patients were evaluated for symptoms, nasal sinus computed tomography scanning, nasal endoscopy, skin prick test (SPT) positivity, and total IgE. Expression of TSLP and receptors in ethmoid sinus mucosa from the ECRS and NECRS groups were investigated by using immunohistochemical staining.

RESULTS

ECRS patients demonstrated significantly higher scores of cough and hyposmia. 66.7% of ECRS patients also demonstrated nasal polyps, compared to 50% of NECRS patients, with significantly higher polyp endoscopy scores. 80.6% of ECRS patients demonstrated SPT positivity, compared to 14% of NECRS patients. The overall expression of TSLP, TSLP receptors and IL-7R was significantly greater in eosinophils in the mucosa of ECRS patients than in NECRS patients. The expression of TSLP and receptors in SPT-positive ECRS patients was significantly greater than in SPT-negative patients, with a significant correlation noted between the expression of TSLP and nasal polyp scores.

CONCLUSION

The clinical manifestations of ECRS are likely to be influenced by atopic status of an individual and TSLP-mediated eosinophil infiltration of the rhinosinusoidal mucosa.

Frontline evaluation and treatment of patients with sinus disease: how otolaryngologists can help primary care providers manage patients with sinusitis

PURPOSE OF REVIEW

Sinus disease impacts millions of Americans every year, with significant associated costs on the healthcare system. Primary care physicians (PCPs) are at the frontline of treatment for patients with sinus disease. Patients would be well served by improved collaboration between PCPs and consulting otolaryngologists.

RECENT FINDINGS

Recent years have seen the adoption of new criteria for the diagnosis of sinus disease; however, this remains an often-times difficult diagnosis to make.

SUMMARY

The management of sinus disease is a major challenge for PCPs who often manage the majority of patients presenting with sinusitis and related conditions. In this article, it is suggested that patients would be well served by close-working relationships between their PCPs and otolaryngologists.

Comparison of efficacy of mometasone furoate versus clarithromycin in the treatment of chronic rhinosinusitis without nasal polyps in Chinese adults

BACKGROUND

Although both nasal steroids and macrolide antibiotics have been recommended for the treatment of chronic rhinosinusitis without nasal polyps (CRSsNPs), whether there is any difference in their clinical efficacy remains unexplored. In addition, few studies have investigated their clinical efficacy in a Chinese population living in China, who present distinct inflammatory patterns compared with white patients in western countries. This study compares the efficacy of mometasone furoate and clarithromycin treatment in CRSsNP in Chinese adults in a preliminary prospective, open-label, randomized trial.

METHODS

Forty-three CRSsNP patients were randomized to receive mometasone furoate nasal spray at 200 μg (n = 21) or clarithromycin tablet at 250 mg (n = 22) once daily for 12 weeks. Patients were assessed before the treatment and after 4, 8, and 12 weeks after treatment. Subjective symptoms were scored on a visual analog scale. Endoscopy physical findings were scored according to Lanza-Kennedy scoring system. Moreover, smoking and atopic status and coexistence of allergic rhinitis (AR) and asthma were recorded.

RESULTS

Before the treatment, no significant difference in symptoms and nasal endoscopic physical findings were found between mometasone furoate and clarithromycin group. As early as 4 weeks after dosing, a significant reduction of total symptom scores, nasal obstruction, headache, rhinorrhea and overall burden scores, and mucosal swelling and nasal discharge scores were observed in both groups. No significant difference in symptom or endoscopic scores was observed between these two groups at any posttreatment observation time point. The coexistence of AR was correlated with lower scores of mucosal edema and nasal secretion in the mometasone furoate group after 12-week treatment.

CONCLUSION

Mometasone furoate and clarithromycin show a comparable clinical effect for CRSsNPs in Chinese adults. Mometasone furoate is more effective in improving edema and secretion for CRSsNP patients with concomitant AR.

Negative impact of occupational exposure on surgical outcome in patients with rhinosinusitis

BACKGROUND

Chronic rhinosinusitis (CRS) is a frequent condition that is treated by functional endoscopic sinus surgery (FESS) when medical treatment fails. Endogenous as well as exogenous factors may be responsible for persisting symptoms after FESS. The role of occupational exposures on success of FESS has never been investigated.

METHODS

In this case-control study, we tested the hypothesis that the outcome of FESS procedures is related to exposures at work. Questionnaires were sent to 890 patients who had undergone one or more FESS procedures and to 182 controls. Three independent experts assessed blindly the reported work exposures to inhaled agents. The relationship between exposure and the number of FESS procedures was analyzed.

RESULTS

Relevant occupational exposure was reported by 25% of all responding patients undergoing FESS (n = 467) and 12% of controls (n = 69). The prevalence of occupational exposures increased linearly with the number of FESS procedures from 21% in those who had one FESS to 44% in those who had four or more FESS (χ(2)  = 12.74, P < 0.001). Logistic regression analysis with adjustments for potential confounders, including smoking, atopy, and asthma, confirmed that the odds ratio (OR) for reporting occupational exposures was significantly higher in those needing more than one FESS (OR = 1.64) or more than two FESS (OR = 1.97). These results were mainly driven by exposure to low molecular weight agents.

CONCLUSION

Exposure at work appears to be a risk factor for the occurrence of CRS and for its recurrence or persistence, as evidenced by the need for revision surgery.

Evidence of Association of Interleukin-1 Receptor-Like 1 Gene Polymorphisms with Chronic Rhinosinusitis

Background

Chronic rhinosinusitis (CRS) is a common complex respiratory disease, with a potential genetic component to its development. The protein encoded by the Interleukin-1 receptor-like 1 (IL1RL1) gene is an important effector molecule of T-helper type 2 responses and may potentially be involved in the persistent inflammatory process observed in CRS. We investigated whether certain polymorphisms in the IL1RL1 gene are differentially present in patients with surgery-unresponsive CRS and in control subjects.

Methods

DNA extracted from an existing population of 206 adult patients with surgery-unresponsive CRS and 196 postal-code-matched controls was used. A set of 15 tagging single nucleotide polymorphisms (SNPs) was selected from the HapMap data set and genotyped. DNA sequencing was performed in a subgroup of 15 CRS patients.

Results

Statistically significant allelic associations with CRS were noted for 5 SNPs (rs10204137, p = 0.04; rs10208293, p = 0.03; rs13431828, p = 0.008; rs2160203, p = 0.03, and rs4988957, p = 0.03). The analysis showed a consistent significant protective effect against CRS for all the SNPs, yielding an odds ratio (OR) ranging from 0.56 to 0.72. The loci rs13431828 showed the highest association with CRS (p = 0.008; OR = 0.56; 95% CI, 0.36–0.86). A subanalysis revealed that the observed associations were stronger among patients with more severe disease. Sequencing identified five additional known nonsynonymous coding SNPs in linkage disequilibrium with genotyped SNPs.

Conclusion

Pending replication of these results, this study suggests that polymorphisms within the IL1RL1 gene may be associated with CRS, conferring a protective effect, particularly among those with severe disease.

Mucosal eosinophils and l-selectin ligands are associated with invasive and noninvasive sinus surgery outcomes

BACKGROUND

Chronic rhinosinusitis (CRS) is characterized by persistent inflammation of the nasal and paranasal mucosa with numerous emigrated leukocytes. L-Selectin on leukocytes and its endothelial glycosylated ligands initiate leukocyte infiltration into inflamed tissues. Endoscopic sinus surgery (ESS) is the major approach for restoring sinus physiology after failure of conservative therapy; however, the effect of enlarging the maxillary sinus ostium is still unknown. Here, we compared two histological markers of local inflammation, the number of mucosal eosinophils, and the expression of endothelial L-selectin ligands, with clinical outcomes after enlarging or saving the maxillary sinus ostium.

METHODS

Twenty-three patients with CRS underwent uncinectomy on one side and additional middle meatal antrostomy on the other side. Maxillary sinus mucosa biopsy specimens from these patients and nine healthy subjects were taken for immunohistochemical evaluations of the number of mucosal eosinophils and endothelial L-Selectin ligands. Also, symptoms and mucociliary clearance were measured.

RESULTS

The postoperative reduction of the endothelial L-Selectin ligands was independent of the operation technique. There was a correlation between postoperative number of mucosal eosinophils and symptom score, which was also independent of the surgical technique. The postoperative decrease of mucosal eosinophils, as well as the correlation of the intraoperative eosinophils with the postoperative symptom score, was found only on antrostomy side.

CONCLUSION

ESS decreases the expression of endothelial L-Selectin ligands, which might lead to decreased eosinophil traffic into maxillary sinus mucosa, putatively more when enlarging the maxillary sinus ostium. Both intra- and postoperative low number of eosinophils seem to be indicators of good subjective recovery.

The comparison of histopathological characteristics of polyps in asthmatic and nonasthmatic patients

INTRODUCTION

Considering the different clinical aspects of polyps in asthmatic and nonasthmatic patients, we aimed to explore their histopathological characteristics.

MATERIAL AND METHODS

Twenty-five asthmatic patients and 25 nonasthmatic patients with polypoid chronic rhinosinusitis (29 male, 21 female; mean age 41.3 +/- 13.27; range 15-78 years) were enrolled in the study to be compared on the basis of histopathological characteristics. They were compared according to the following seven light microscopic findings: basement membrane thickness, goblet cell hyperplasia, subepithelial edema, submucous gland formation, eosinophilic infiltration, lymphocytic infiltration, and polymorphonuclear infiltration.

RESULTS

Basement membrane thickening, goblet cell hyperplasia, and eosinophilic and lymphocytic infiltration were more prominent in the asthmatic compared with the nonasthmatic group (P < 0.05), whereas polymorphonuclear infiltration was more prominent in nonasthmatics (P < 0.05). No statistically significant differences were found between the two groups with regard to submucosal gland hyperplasia or subepithelial edema.

CONCLUSION

Asthmatic patients present histopathological characteristics of a marked chronic inflammatory reaction, which might explain the negative effect on chronic rhinosinusitis outcome and the severity of the disease in this group.

Clinical significance of eosinophilic cationic protein levels in nasal secretions of patients with nasal polyposis

Nasal polyps are characterized by eosinophilic infiltration, and frequently coexist with asthma, aspirin intolerance and allergy. Eosinophilic cationic protein (ECP) is a specific eosinophil granule protein released upon activation of eosinophils. We investigated the ECP levels in nasal secretions of patients with nasal polyposis (NP) in order to correlate them with disease severity and associated diseases and to compare ECP levels between patients with and without recurrence of NP after surgical treatment. A total of 78 patients who had surgery for NP were followed up for a minimum of 18 months. The presence of asthma, allergies or aspirin intolerance was noted. Nasal secretions were obtained 1 day before the surgery and during the follow-up period after surgery. Immunoassays were used to quantify ECP in nasal secretions and serum and interleukin (IL)-5 in nasal secretions. ECP levels in nasal secretions were higher in patients with asthma or aspirin intolerance than in patients without asthma or aspirin intolerance, while no significant differences were found between allergic and non-allergic patients. ECP levels in nasal secretions correlated significantly with IL-5 levels in nasal secretions, the degree of tissue eosinophilia and computed tomographic (CT) scores. In total, 30 patients (38%) developed recurrent NP during the follow-up period. Preoperative ECP and IL-5 levels in nasal secretions were significantly higher in patients with recurrence compared to patients without recurrence. During the follow-up period, patients without recurrence demonstrated a significant reduction in the ECP levels in nasal secretions, whereas there was no significant reduction in the ECP levels of patients with recurrence. The results of this study provide evidence that ECP levels in nasal secretions of patients with NP correlate with the presence of asthma or aspirin intolerance and severity of NP determined by CT scores.

Correlation of histopathology and symptoms in allergic and non-allergic patients with chronic rhinosinusitis

The aim of this study was to estimate and compare some histopathologic predictors of efficacy of endoscopic sinus surgery (ESS) in allergic and non-allergic patients with chronic rhinosinusitis (CRS). Symptomatology was rated in 50 allergic and 50 non-allergic patients prior to as well as 12 and 24 months after surgery. Specimens taken during the procedure were scored for goblet cells, subepithelial thickening, mast cells and eosinophils. The correlation between histopathology and symptoms was evaluated. Goblet cells and subepithelial thickening were the best predictors in both groups of patients. These parameters are significant global outcome predictors for allergic, but not for non-allergic patients. It is concluded that certain histopathologic parameters in CRS correlate with certain symptoms. Certain histopathologic changes are predictable for persistence of some bothersome symptoms after ESS. Pathologic evaluation might give prediction of response to ESS in allergic and non-allegic patients with CRS.

Risk of respiratory distress in the patients who were applied nasal packing at the end of nasal surgery

OBJECTIVE

This prospective study investigated the risk of respiratory distress in the patients who were applied nasal packing at the end of nasal surgery; and effects of nasal packing on consciousness level while the patients were awake or asleep, measured by Bispectral Index (BIS).

METHODS

The study group consisted of 15 adult patients (10 male, 5 female), who were applied nasal packing at the end of nasal surgery. The control group consisted of 15 adult patients (10 male, 5 female), who received general anesthesia for various reasons. In the study and control groups, BIS index, respiratory rate, peripheral oxygen saturation, pulse per minute and blood pressure were measured at seven different times.

RESULTS

There was no statistically significant difference between BIS indexes of the study and control groups. In the fourth hour after sleep (AS-4h), respiratory rate of the study group was significantly lower than that of the control group. In the fourth hour after the anesthesia (AA-4h), oxygen saturation value of the study group was lower than that of the control group.

CONCLUSION

We conclude that in patients who are applied nasal packing at the end of nasal surgery; at AA-4h and AS-4h times, there may be risk of decrease in the oxygen saturation and respiratory rate parameters, respectively. Therefore, it is necessary to monitor non-invasive respiratory parameters and to give enriched oxygen by an oral catheter.

Nasal and sinus endoscopy for medical management of resistant rhinosinusitis, including postsurgical patients

Nasal endoscopy has been practiced by allergists since the early 1980s; however, allergists in general have not embraced endoscopic evaluation of patients with sinus disease, either before or after surgery. Allergists are in a unique position to render medical (as opposed to surgical) care of patients with sinusitis. There has been a growing realization that endoscopy is a valuable procedure for the evaluation and medical treatment of patients with difficult sinusitis. This has resulted in the need for a resource to allow allergists to understand the nature of endoscopic findings in patients with sinusitis, either preoperatively or postoperatively. This article introduces the findings at endoscopy that are common in patients with sinusitis, including those that may be seen after surgery. The findings include perforation of the septum, retained secretions, small surgical ostium caused by postoperative ostial stenosis, previous Caldwell Luc procedure, recirculation of mucus, hyperplastic nasal disease, synechiae, recurrent disease in previously unaffected sinuses, empty nose syndrome, frontal sinus disease, dental disease, and other, more complicated entities.

Impact of nasal polyps on quality of life of chronic sinusitis patients

OBJECTIVE

To study the significance of nasal polyps on the symptoms of chronic rhinosinusitis (CRS) and their influence on surgical outcomes.

METHODS

Retrospective analysis of prospectively collected data comparing two groups of patients diagnosed with CRS with and without polyps who underwent surgery with a minimum of 3 month follow up period. Subjective scoring was performed using the Sino-nasal Outcome Test (SNOT-20) questionnaire. Computed tomography (CT) scans were compared using the Lund-Mackay scoring system. Endoscopic findings were graded according to Lanza and Kennedy staging system. The two groups were analyzed for the need of revision surgery.

RESULTS

30 patients underwent surgical management of CRS over a period of one year. 20 were male, 10 were female and the average age was 26 years (range 15-55years). Polyps were present in 15 patients with CRS while, the other 15 did not have polyps. The average CT score was 10.13 for the polyp group and 9.79 for patients without polyp.The Polyp group SNOT-20 preoperative scores averaged 20.27 with improvement to 3.80 at 2 weeks, 2.67 at 1 month and 2.93 at 3 months (86.21% improvement p=0.001). Non-polyp group SNOT-20 scores were 18.80 preoperatively with improvement to 4.67 at 2 weeks, 3.40 at 1 month and 3.27 at 3 months (81.83% improvement). Preop diagnostic endoscopy on polyp group was 5.27 which improved to 2.13 in 2 weeks, 1.33 in 1 month and 1.53 in 3 months (73% improvement). In the non polyp group it was 4.53 pre-operatively which improved to 1.20 in 2 weeks, 0.93 in 1 month and to 1.13 in 3months (69% improvement). 6 patients required revision surgery (20%), 3 (10%) belonging to polyp group and 3 (10%) who did not have polyps.

CONCLUSION

Nasal Polyp has a significant negative impact on the patients with CRS. Patients with polyps have higher symptom scores, worse objective findings compared with patients without polyp, but patients with polyp show more improvement after surgical intervention and need for revision surgery is equal in both groups.

The relationship between rhinosinusitis and asthma sinusitis

Chronic sinusitis comprises numerous disorders characterized by inflammation, mucous gland hyperplasia, and remodeling. Chronic hyperplastic eosinophilic sinusitis (CHES) is characterized by unrestrained proliferation of eosinophils, Th2-like lymphocytes, fibroblasts, goblet cells, and mast cells. The pathology of CHES is similar to that of asthma, and it is frequently diagnosed in association with asthma. It has been reported that exacerbations of CHES occur temporally with worsening of asthma; however, in the absence of well-controlled studies, this linkage remains unproven. In this article, the potential mechanisms linking these two diseases are examined.

Histopathologic parameters as predictors of response to endoscopic sinus surgery in nonallergic patients with chronic rhinosinusitis

OBJECTIVE

To estimate the predictable value of histopathologic parameters in chronic rhinosinusitis (CRS) for response to endoscopic sinus surgery (ESS).

STUDY DESIGN

Symptomatology was rated in 100 patients prior to as well as 12 and 24 months after surgery. Specimens taken during the procedure were examined and scored for goblet cells, subepithelial thickening, mast cells, and eosinophils. Multiple regression analysis was performed to predict the total score of subjective symptoms before treatment by histopathologic parameters. The correlation between histopathologic parameters and postoperative symptoms was then evaluated.

RESULTS

Goblet cells were the best predictor correlating with 5 symptoms. Subepithelial thickening correlated with 4 symptoms. Mast cell infiltration correlated with 3 symptoms. Eosinophilic infiltration correlated with only one symptom (P<0.05).

CONCLUSION

Certain histopathologic parameters in CRS are predictive of favorable response to ESS.

SIGNIFICANCE

Pathologic evaluation may help the ENT surgeon to predict the persistence of certain CRS symptoms after ESS, even in patients at low risk for surgical failure.

EBM RATING

C-4.

Pathophysiological classification of chronic rhinosinusitis

Background

Recent consensus statements demonstrate the breadth of the chronic rhinosinusitis (CRS) differential diagnosis. However, the classification and mechanisms of different CRS phenotypes remains problematic.

Method

Statistical patterns of subjective and objective findings were assessed by retrospective chart review.

Results

CRS patients were readily divided into those with (50/99) and without (49/99) polyposis. Aspirin sensitivity was limited to 17/50 polyp subjects. They had peripheral blood eosinophilia and small airways obstruction. Allergy skin tests were positive in 71% of the remaining polyp subjects. IgE was<10 IU/ml in 8/38 polyp and 20/45 nonpolyp subjects (p = 0.015, Fisher's Exact test). CT scans of the CRS without polyp group showed sinus mucosal thickening (probable glandular hypertrophy) in 28/49, and nasal osteomeatal disease in 21/49. Immunoglobulin isotype deficiencies were more prevalent in nonpolyp than polyp subjects (p < 0.05).

Conclusion

CRS subjects were retrospectively classified in to 4 categories using the algorithm of (1) polyp vs. nonpolyp disease, (2) aspirin sensitivity in polyposis, and (3) sinus mucosal thickening vs. nasal osteomeatal disease (CT scan extent of disease) for nonpolypoid subjects. We propose that the pathogenic mechanisms responsible for polyposis, aspirin sensitivity, humoral immunodeficiency, glandular hypertrophy, eosinophilia and atopy are primary mechanisms underlying these CRS phenotypes. The influence of microbial disease and other factors remain to be examined in this framework. We predict that future clinical studies and treatment decisions will be more logical when these interactive disease mechanisms are used to stratify CRS patients.

Alternative medical treatment strategies for chronic hyperplastic eosinophilic sinusitis

PURPOSE OF REVIEW

Chronic rhinosinusitis (CRS) is one of the most common chronic illnesses in the United States. Although CRS has been viewed traditionally as an infectious disease, treatment focused on antibiotics and surgery has not infrequently provided disappointing results.

RECENT FINDINGS

Recently much of CRS has been shown to be an eosinophilic inflammatory disease and new anti-inflammatory treatments are being studied.

SUMMARY

This review discusses medical management for chronic hyperplastic eosinophilic sinusitis, including antifungal treatment, low-dose macrolide treatment, antilipid mediator therapy, and new immune-modifying treatments.

Antigen stimulation of TH2 cells augments acute bacterial sinusitis in mice

BACKGROUND

Previously, we showed that an ongoing nasal allergic response augmented bacterial sinusitis in mice. In those experiments mice were sensitized to ovalbumin (OVA) by means of intraperitoneal injections of OVA-alum and then exposed to OVA intranasally before being infected with Streptococcus pneumoniae.

OBJECTIVE

We sought to study the importance of TH2 cells and to eliminate potential alum effects.

METHODS

In this study we sensitized mice by adoptively transferring OVA-specific TH2- or TH1-skewed cells.

RESULTS

TH2 passive sensitization followed by intranasal OVA showed a robust local eosinophilic response (5-fold increase) compared with that seen in mice with only TH2 passive sensitization alone (P <.001). Mice with TH2 passive sensitization and intranasal OVA exposure followed by infection showed an increase in the number of recovered S pneumoniae (P <.05) and an increase in sinus inflammation compared with that seen in those with infection alone (P <.01). In contrast, mice passively sensitized with TH1 followed by intranasal OVA exposure and infection showed no significant increase in the recovery of S pneumoniae and sinus inflammation compared with those with infection alone.

CONCLUSIONS

These data support the importance of antigen-stimulated TH2 cells in the augmented response to infection in allergic mice. Whether the increased infection is related to the direct effect of TH2 cells and their cytokines or subsequent recruitment of other cells, such as eosinophils, will be determined in further studies.

Refractory chronic rhinosinusitis: pathophysiology and management of chronic rhinosinusitis persisting after endoscopic sinus surgery

Refractory chronic rhinosinusitis (RCRS) is defined as persistence of signs and symptoms of chronic rhinosinusitis, despite technically adequate endoscopic sinus surgery. Rather than a simple, prolonged bout of acute sinusitis, it instead appears to be secondary to an interaction of a susceptible host with the outside environment. Inflammatory responses to colonizing bacteria appear to be responsible for a significant portion of the pathophysiology. Reduction of bacterial load and inflammation of the mucosa play an important role in controlling the disease. Novel treatment strategies, with an emphasis on topical therapies, seem to offer optimal management. In this review, current concepts on the pathophysiology and current therapies available for RCRS are outlined. A practical management strategy based on the author's personal experience draws upon these concepts, and is detailed in this review of an unusual topic.

Role of allergy in rhinosinusitis

PURPOSE OF REVIEW

Allergic rhinitis and rhinosinusitis are common diseases occurring in both children and adults that consume enormous amounts of health care dollars. In addition to its own costs, allergic rhinitis is considered a major predisposing factor for the development of rhinosinusitis. Whereas many authors suggest a clinical association between these two diseases, the mechanism of how allergic rhinitis predisposes to rhinosinusitis or affects the course of rhinosinusitis remains unclear.

RECENT FINDINGS

Limited progress has been made in understanding the pathophysiologic mechanism involved in the interaction. Progress in immunologic technique emphasizes the importance of inflammatory cells, especially eosinophils, mast cells, and T lymphocytes, and their mediators. Some authors have proposed a role for neurogenic pathways, whereas others have focused on systemic involvement. Little progress has been made in intervention studies that support the importance of allergic rhinitis in altering the course of acute or chronic rhinosinusitis.

SUMMARY

This paper reviews the limited new literature available to update knowledge that supports the association of allergic rhinitis with rhinosinusitis, mechanisms potentially underlying the association, and implications of this knowledge for therapy.

Relationships between atopy and bacterial infections

Atopy in its most common forms (asthma, allergic rhinitis, and atopic dermatitis) has a significant impact on society in terms of health care costs and quality of life. Aside from having significant morbidity from these diseases, patients with atopy have also been noted to have a high incidence of comorbidities, including bacterial infections such as otitis media and sinusitis. In this paper, current evidence is reviewed that supports the close associations among allergic rhinitis and the two commonly diagnosed bacterial diseases, otitis media and sinusitis.

Cysteinyl leukotriene expression in chronic hyperplastic sinusitis-nasal polyposis: importance to eosinophilia and asthma

BACKGROUND

Chronic hyperplastic eosinophilic sinusitis (CHS) results from the unregulated proliferation of eosinophils, T(H)2-like lymphocytes, goblet cells, mast cells, and fibroblasts and is present in most patients with asthma. The frequent coexpression of these disorders and their shared pathophysiology suggests that these are similar disorders affecting the upper and lower airways.

OBJECTIVE

We evaluated the expression of cysteinyl leukotrienes (CysLTs) in sinus tissue from subjects with CHS compared with that seen in healthy sinus tissue.

METHODS

Nasal polyp and sinus tissue was evaluated from 58 individuals undergoing elective functional endoscopic sinus surgery. The diagnosis of CHS was demonstrated through the presence of eosinophilia and activated (EG2(+)) eosinophils, as determined by means of tissue immunohistochemistry. Data were compared with those from both nasal polyp tissue without eosinophilic inflammation and healthy control sinus tissue obtained from the sinus ostiomeatal complex at the time of surgery for unrelated disorders. CysLTs were quantified by means of ELISA in lipid-extracted tissue. Activation of the metabolic pathway leading to CysLT synthesis was demonstrated by ribonuclease protection. Subjects were genotyped for leukotriene C(4) (LTC(4)) synthase C-to-A promoter polymorphism.

RESULTS

CysLT concentrations were significantly higher in tissue obtained from subjects with CHS (776.7 +/- 201.9 pg/g tissue) compared with that seen in healthy sinus tissue (355.7 +/- 101.6 pg/g tissue, P <.03). CysLT concentrations within noneosinophilic nasal polyps (328.0 +/- 116.4 pg/g tissue) were similar to those in control tissue. The presence of CysLTs in CHS was associated with increased expression of LTC(4) synthase mRNA. The C-to-A promoter polymorphism was associated with trends toward the increased presence of CHS and CysLTs.

CONCLUSIONS

CHS is characterized by the increased presence of CysLTs when compared with concentrations seen in tissue from patients with chronic inflammatory sinusitis or healthy sinus tissue. These studies support the use of LT modifiers as anti-inflammatory agents that might have clinical benefit in patients with these disorders.

Sinusitis update

PURPOSE OF REVIEW

Rhinosinusitis affects more than 10% of the US population. It results in high health care expenditure as well as decreased productivity through lost days of school or work. This review includes recent findings in diagnostics and pathophysiology, as well as recent advances in treatment.

RECENT FINDINGS

Parameters used in the diagnosis of rhinosinusitis include patient symptomatology, physical and endoscopic findings, computed tomography scan scores, and culture results. There has been poor correlation between patient symptoms and computed tomography scan scores, but middle meatal cultures have been shown to correlate well with ethmoid sinus cultures obtained from chronic rhinosinusitis patients. Chronic inflammation with a predominance of eosinophils and T lymphocytes in the tissues is being recognized as a hallmark of chronic rhinosinusitis, especially in patients with asthma or allergic rhinitis. Th2 cytokines are prominent in sinus tissues of patients with chronic rhinosinusitis and allergic rhinitis. While antibiotics are used with greater frequency in the treatment of acute and chronic rhinosinusitis, adjuvant therapies, such as intranasal steroids, might affect patient symptoms and curb disease recurrence.

SUMMARY

Clinical symptoms are important in making the diagnosis of rhinosinusitis and should be supported by objective findings on nasal endoscopy and, if necessary, computed tomography scans. The mainstay of treatment remains antibiotics, with a potential role for decongestants and intranasal steroids. The presence of chronic inflammation with a Th2 cytokine predominance in sinus tissues should be kept in mind, especially in patients with coexistent morbidities such as allergic rhinitis and asthma.

Intrasinus administration of topical budesonide to allergic patients with chronic rhinosinusitis following surgery

OBJECTIVE

Whether instillation into the maxillary sinus of topical budesonide affected the immune response and improved allergic patients with chronic rhinosinusitis that had persistence of symptoms despite appropriate surgical intervention was assessed.

STUDY DESIGN

Double-blind placebo-controlled.

METHODS

Twenty-six patients with allergy to house dust mites who had previously had surgery and who had persistent symptoms of disabling rhinorrhea or pressure-pain resistant to oral antibiotics and intranasal corticosteroids were recruited. During the double-blind study, patients instilled 256 microg budesonide daily or placebo through an intubation device (maxillary antrum sinusotomy tube) into one of the maxillary sinuses for 3 weeks before clinical assessment and a second biopsy.

RESULTS

We found an improvement in the symptom scores in 11 of the 13 patients who received budesonide; we also found a decrease in CD-3 (P = .02) and eosinophils (P = .002), and a decrease in the density of cells expressing interleukin4 (P = .0001) and interleukin-5 messenger RNA (P = .006) after treatment.

CONCLUSION

Topical budesonide delivered through a maxillary antrum sinusotomy tube can control chronic rhinosinusitis that persists after surgery.