Clarithromycin and prednisolone inhibit cytokine production in chronic rhinosinusitis

Bioabsorbable dressing impregnated with betamethasone and ciprofloxacin after endoscopic sinus surgery: A randomized, double-blind, placebo-controlled study

BACKGROUND

In addition to its hemostatic and stabilization role, biodegradable nasal packing can be used as a carrier for drugs after functional endoscopic sinus surgery (FESS). The aim of this study was to compare the influence of biodegradable synthetic polyurethane foam (NasoPore) soaked with ciprofloxacin, or betamethasone, or both to the same foam soaked with saline after FESS.

METHODS

120 adults with chronic rhinosinusitis, with and without polyps, directed for bilateral full-house FESS were enrolled for the study. The patients were randomized and blinded into 3 groups, depending on the type of postoperative procedure applied. Thus, NasoPore soaked with antibiotic was provided to the first group; in the second group, the steroid was used; and the combination of both, in the third group. In each case, the aforementioned procedure was administered on one side of the nose, while NasoPore was soaked in saline on the other, at the end of the surgery, respectively. The patients were requested to complete a questionnaire during their postoperative visits at 2, 10, 30, 90, and 180 days, scoring the level of complaints on the VAS scale, separately for each side. The evaluation of the healing process was performed at each visit using rigid endoscopy and subsequently rated on numerical scales.

RESULTS

Decreased mucosal edema and secretion; reduced Lund-Kennedy score; and favorable influences on facial pressure, nasal blockage, and smell were most evidently seen in the group receiving the antibioticsteroid combination.

CONCLUSIONS

The application of biodegradable nasal packing with betamethasone and ciprofloxacin in sino-nasal surgery has positive effects not only on the healing process but also impacts patient's comfort. To optimize it, however, further research is needed.

Association Between Smoking and Chronic Rhinosinusitis: A Systematic Review and Meta-Analysis

OBJECTIVE

Chronic rhinosinusitis (CRS) is a prevalent inflammatory disease of the upper airway. The impact of smoking on CRS has not been clearly established. We aim to clarify the association between first-hand cigarette smoking and the prevalence and prognoses of CRS.

REVIEW METHODS

PubMed, Embase, SCOPUS, and Cochrane Library were searched from inception until May 15, 2022. Three blinded reviewers selected relevant studies, extracted data, and evaluated study bias following a PROSPERO-registered protocol (CRD42022345585). We used random-effects meta-analyses to pool the prevalence of smoking in CRS, association between smoking status and CRS, and association of smoking with quality of life (QOL) before and after functional endoscopic sinus surgery (FESS). We also performed descriptive analyses of olfactory function, CT scores, and endoscopy scores before and after FESS.

RESULTS

We included 23 cross-sectional studies, 19 cohort studies, two case-control studies, and one prospective clinical trial. The pooled prevalence of ever-smokers was 40% (95% CI = 0.30-0.51) and 33% (95% CI = 0.25-0.43) in patients with and without CRS. Compared to never-smokers, active smokers and past smokers had 1.35 (95% CI = 1.18-1.55) and 1.23 (95% CI = 1.17-1.29) higher odds of having CRS. Among patients with CRS, non-smokers reported higher initial QOL than smokers (standardized mean difference [SMD] = 0.23, 95% CI = 0.11-0.35), although post-FESS QOL was similar (SMD = 0.10, 95% CI = -0.30-0.51). Descriptive analysis found no significant correlations between smoking and post-FESS olfactory function and endoscopy scores.

CONCLUSIONS

Cigarette smoking is associated with higher prevalence and odds of CRS. Clinicians should be aware that smoking predisposes to CRS, but does not negatively impact the rhinologic outcomes of FESS. Laryngoscope, 134:2513-2524, 2024.

The Mechanism of Action and Clinical Efficacy of Low-Dose Long-Term Macrolide Therapy in Chronic Rhinosinusitis

Various chronic inflammatory airway diseases can be treated with low-dose, long-term (LDLT) macrolide therapy. LDLT macrolides can be one of the therapeutic options for chronic rhinosinusitis (CRS) due to their immunomodulatory and anti-inflammatory actions. Currently, various immunomodulatory mechanisms of the LDLT macrolide treatment have been reported, as well as their antimicrobial properties. Several mechanisms have already been identified in CRS, including reduced cytokines such as interleukin (IL)-8, IL-6, IL-1β, tumor necrosis factor-α, transforming growth factor-β, inhibition of neutrophil recruitment, decreased mucus secretion, and increased mucociliary transport. Although some evidence of effectiveness for CRS has been published, the efficacy of this therapy has been inconsistent across clinical studies. LDLT macrolides are generally believed to act on the non-type 2 inflammatory endotype of CRS. However, the effectiveness of LDLT macrolide treatment in CRS is still controversial. Here, we reviewed the immunological mechanisms related to CRS in LDLT macrolide therapy and the treatment effects according to the clinical situation of CRS.

Therapeutic Strategies to Prevent the Recurrence of Nasal Polyps after Surgical Treatment: An Update and In Vitro Study on Growth Inhibition of Fibroblasts

Chronic rhinosinusitis with nasal polyps (CRSwNP) is the most bothersome phenotype of chronic rhinosinusitis, which is typically characterized by a Type 2 inflammatory reaction, comorbidities and high rates of nasal polyp recurrence, causing severe impact on quality of life. Nasal polyp recurrence rates, defined as the number of patients undergoing revision endoscopic sinus surgery, are 20% within a 5 year period after surgery. The cornerstone of CRSwNP management consists of anti-inflammatory treatment with local corticosteroids. We performed a literature review regarding the therapeutic strategies used to prevent nasal polyp recurrence after surgical treatment. Finally, we report an in vitro study evaluating the efficacy of lysine-acetylsalicylic acid and other non-steroidal anti-inflammatory drugs (ketoprofen and diclofenac) on the proliferation of fibroblasts, obtained from nasal polyp tissue samples. Our study demonstrates that diclofenac, even more so than lysine-acetylsalicylic acid, significantly inhibits fibroblast proliferation and could be considered a valid therapeutic strategy in preventing CRSwNP recurrence.

The Role of Steroids for Pediatric Orbital Cellulitis - Review of the Controversy

Orbital cellulitis in the pediatric population is treated primarily with antibiotic therapy. This leaves the inflammatory component unchecked. Corticosteroid therapy has been used to accelerate recovery and decrease the long-term morbidity in other infectious conditions. Its use has also been proposed for pediatric orbital cellulitis. The aim of this manuscript is to conduct a literature review to summarize existing evidence and understand ongoing controversies. Overall, prior investigations on corticosteroid therapy for pediatric orbital cellulitis are limited by their study design and sample sizes. One of the most discussed potential benefits is that adjuvant steroid therapy for pediatric orbital cellulitis is associated with shorter hospitalization without major infectious complications. However, decreased hospitalization length is an imperfect metric, especially without standardized criteria for hospital discharge. Future studies are warranted to better guide the use of adjuvant steroid therapy and to optimize its potential in the management of pediatric orbital cellulitis.

Clarithromycin prevents preterm birth and neonatal mortality by dampening alarmin-induced maternal–fetal inflammation in mice

Background

One of every four preterm neonates is born to a woman with sterile intra-amniotic inflammation (inflammatory process induced by alarmins); yet, this clinical condition still lacks treatment. Herein, we utilized an established murine model of sterile intra-amniotic inflammation induced by the alarmin high-mobility group box-1 (HMGB1) to evaluate whether treatment with clarithromycin prevents preterm birth and adverse neonatal outcomes by dampening maternal and fetal inflammatory responses.

Methods

Pregnant mice were intra-amniotically injected with HMGB1 under ultrasound guidance and treated with clarithromycin or vehicle control, and pregnancy and neonatal outcomes were recorded (n = 15 dams each). Additionally, amniotic fluid, placenta, uterine decidua, cervix, and fetal tissues were collected prior to preterm birth for determination of the inflammatory status (n = 7–8 dams each).

Results

Clarithromycin extended the gestational length, reduced the rate of preterm birth, and improved neonatal mortality induced by HMGB1. Clarithromycin prevented preterm birth by interfering with the common cascade of parturition as evidenced by dysregulated expression of contractility-associated proteins and inflammatory mediators in the intra-uterine tissues. Notably, clarithromycin improved neonatal survival by dampening inflammation in the placenta as well as in the fetal lung, intestine, liver, and spleen.

Conclusions

Clarithromycin prevents preterm birth and improves neonatal survival in an animal model of sterile intra-amniotic inflammation, demonstrating the potential utility of this macrolide for treating women with this clinical condition, which currently lacks a therapeutic intervention.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04764-2.

Injectable and Self-Healing Hydrogel with Anti-Bacterial and Anti-Inflammatory Properties for Acute Bacterial Rhinosinusitis with Micro Invasive Treatment

Systemic antibiotic therapy is the main treatment for acute bacterial rhinosinusitis (ABRS). However, this treatment often causes side effects of dizziness, diarrhea, and drug resistance. In this study, a new polyethylene glycol hydrogel (PEG-H) treatment model is developed to achieve sustained release of drugs at the locality while avoiding those adverse effects. The PEG-H is composed of 4-arm-PEG-SH and silver ions through a high affinity and dynamic reversible coordination bond between the thiol and silver ion. In the initial test, PEG-H is loaded with Clarithromycin (CAM-Lips@Hydrogel) or Clarithromycin and Budesonide liposomes (CAM+BUD-Lips@Hydrogel). The results show that PEG-H maintains the characteristics of self-healing, biodegradability, moderate swelling rate, injectibility and sustained drug release. In in vivo studies, the hydrogel is injected into the maxillary sinus of ABRS rabbit models. In both a single or combined load, the hydrogel not only plays an effective role as an anti-bacterial, but also inhibits inflammatory response of local sinus mucosa. In addition, no other side effects are observed in the ABRS rabbit model through behavioral observation and drug sensitivity tests. Therefore, the injectable self-healing hydrogel with anti-bacterial and anti-inflammatory properties provides a new micro invasive therapeutic method for the clinical treatment of ABRS.

Effectiveness of endoscopic versus external surgical approaches in the treatment of orbital complications of rhinosinusitis: a systematic review protocol

OBJECTIVE

This review aims to investigate and compare the effectiveness of endoscopic drainage techniques against external drainage techniques for the treatment of orbital and subperiosteal abscesses as a complication of rhinosinusitis.

INTRODUCTION

Transnasal endoscopic drainage and external drainage techniques have been used in the management of subperiosteal orbital abscesses secondary to rhinosinusitis. Each of these approaches has its own advantages and disadvantages, with extensive literature describing each technique separately. However, there is a lack of guidance in the studies on assessing and comparing the safety, effectiveness and suitability of these techniques. This review aims to compare the effectiveness of these techniques based on measuring outcomes in the literature such as: length of postoperative hospital stay, rate of revision surgery and complication rates.

INCLUSION CRITERIA

Eligible studies will include people of all ages diagnosed with subperiosteal abscess, orbital abscess or cavernous sinus thrombosis (Chandler stages III-V) secondary to rhinosinusitis disease, who have also undergone drainage via either an endoscopic approach, external approach or combined surgical approach.

METHODS

A comprehensive search of both published and unpublished literature will be performed to uncover studies meeting the inclusion criteria. Reference lists of studies included in final analyses will also be manually searched and subject matter experts contacted to investigate other sources of literature. Two reviewers will screen studies and a third reviewer will resolve disagreements. Studies will, where possible, be pooled in statistical meta-analysis with heterogeneity of data being assessed using the standard Chi-squared and I tests.

Interleukin-4, Interleukin-8 and E-selectin Levels in Intranasal Polyposis Patients with and without Allergy: A Comparative Study

Intranasal polyposis is a chronic inflammatory upper airway disease with unknown aetiology. Interleukin (IL)-4 and IL-8 play very significant roles in allergic events and infectious inflammation, respectively. In contrast, E-selectin is important in the initiation and organization of inflammation. In this study, levels of IL-4, IL-8 and E-selectin were measured in nasal mucosa specimens of intranasal polyposis patients with and without allergic rhinitis, and healthy controls. Healthy controls had significantly higher IL-4 levels than allergic patients and non-allergic patients; IL-4 levels were similar in allergic and non-allergic patients. Allergic and non-allergic patients had significantly higher IL-8 levels than healthy controls; IL-8 levels were comparable in allergic and non-allergic patients. E-selectin levels were similar in all groups. The infection-based theory, represented by IL-8, seems to be more likely than the allergy-based theory, represented by IL-4, for the pathogenesis of nasal polyposis.

C-Reactive Protein As a Marker for Initiating Steroid Treatment in Children With Orbital Cellulitis

PURPOSE

To determine both the benefit of systemic steroids in pediatric patients with orbital cellulitis and to assess the usefulness of C-reactive protein (CRP) levels as a marker for starting steroids.

METHODS

Prospective, comparative interventional study. Pediatric patients aged 1 to 18 years admitted to a tertiary care children's hospital with a diagnosis of orbital cellulitis from October 2012 to March 2014 were included in the study. All patients were treated with intravenous antibiotics, and patients with subperiosteal abscess who met previously published criteria for surgical decompression underwent combined transorbital drainage and/or endoscopic sinus surgery. CRP was measured daily as a biomarker of inflammation, and when below 4 mg/dl, patients were started on oral prednisone 1 mg/kg per day for 7 days. Patients whose families did not consent to steroid treatment served as the control group. Patients were followed after discharge until symptoms resolved and all medications were discontinued.

RESULTS

Thirty-one children were diagnosed with orbital cellulitis during the study period. Of these 31 children, 24 received oral steroids (77%) and 7 did not (23%). There were 19 males and 5 females in the steroid group with an average age of 8.1 years, and 6 males and 1 female in the nonsteroid group with an average age of 7.1 years (p = 0.618). Thirteen patients (54%) in the steroid group and 2 patients (29%) in the nonsteroid group underwent sinus surgery with or without orbitotomy (p = 0.394). The average CRP at the onset of steroid treatment was 2.8 mg/dl (range: 0.5-4). Patients who received oral steroids were admitted for an average of 3.96 days. In comparison, patients who did not receive steroids were admitted for an average of 7.17 days (p < 0.05). Once CRP was ≤4 mg/dl, patients treated with steroids remained in the hospital for another 1.1 days, while patients who did not receive steroids remained hospitalized for another 4.9 days (p < 0.01). In the steroid group, 2 families reported increased hyperactivity in their children while on steroids. There was 1 case in each group of recurrence of symptoms after discharge from the hospital. Average follow-up time was 2.4 months in the steroid group and 2 months in the nonsteroid group (p = 0.996). At last visit, all patients returned to their baseline ophthalmic examination. There were no cases of vision loss or permanent ocular disability in either group.

CONCLUSIONS

Our results give further evidence of the safety and benefit of systemic steroids in children with orbital cellulitis. Futhermore, this is the first study to suggest a standardized starting point (CRP ≤ 4 mg/dl) and dosing schedule (oral prednisone 1 mg/kg for 7 days) for children with orbital cellulitis. Patients who received systemic steroids after CRP dropped below 4 mg/dl were discharged from the hospital earlier than patients who did not receive systemic steroids.

Macrolides increase the expression of 11β-hydroxysteroid dehydrogenase 1 in human sinonasal epithelium, contributing to glucocorticoid activation in sinonasal mucosa

BACKGROUND AND PURPOSE

The anti-inflammatory and immunomodulatory effects of macrolides include the ability to decrease mucus secretion and inhibit inflammatory mediators in chronic rhinosinusitis. Nevertheless, their mechanisms of action remain to be determined. Here we have investigated the effects of macrolide antibiotics (clarithromycin, azithromycin and josamycin; representating the 14-, 15- and 16-membered macrolides) on endogenous steroids in human sinonasal epithelial cells and mouse nasal mucosa.

EXPERIMENTAL APPROACH

The effects of macrolides on the expression of steroid-converting enzymes [11β-hydroxysteroid dehydrogenase (11β-HSD1 and 11β-HSD2)], steroid-synthesizing enzymes (3β-HSD, CYP21, CYP11B1 and CYP11A1) and cortisol levels were assessed in cultured human epithelial cells. In control and adrenalectomized mice , these enzymes and corticosterone levels were evaluated in nasal mucosa and serum after administration of macrolides.

KEY RESULTS

The expression levels of 3β-HSD, CYP21, 11β-HSD1 and CYP11B1 increased in human epithelial cells treated with clarithromycin and azithromycin, whereas the expression levels of 11β-HSD2 and CYP11A1 were not affected. Josamycin had no effects on the expression of these enzymes. Cortisol levels increased in epithelial cells treated with clarithromycin or azithromycin. The expression of 3β-HSD, CYP11A1, CYP21, CYP11B1 and 11β-HSD1 was upregulated in nasal mucosa of mice treated with clarithromycin or azithromycin, but not in adrenalectomized mice.

CONCLUSIONS AND IMPLICATIONS

This study provides evidence that 14- and 15-membered macrolide antibiotics may affect the expression of steroid-synthesizing and steroid-converting enzymes in human sinonasal epithelial cells and mouse nasal mucosa, increasing the endogenous cortisol levels in sinonasal mucosa.

Airway Inflammation in Chronic Rhinosinusitis with Nasal Polyps and Asthma: The United Airways Concept Further Supported

Background

It has been established that patients with chronic rhinosinusitis with nasal polyps (CRSwNP) often have co-existing asthma.

Objective

We aimed to test two hypotheses: (i) upper and lower airway inflammation in CRSwNP is uniform in agreement with the united airways concept; and (ii) bronchial inflammation exists in all CRSwNP patients irrespective of clinical asthma status.

Methods

We collected biopsies from nasal polyps, inferior turbinates and bronchi of 27 CRSwNP patients and 6 controls. All participants were evaluated for lower airway disease according to international guidelines. Inflammatory cytokines were investigated using a Th1/Th2 assay including 14 chemokines and cytokines; tissue concentrations were normalized according to tissue weight and total protein concentration. Individual cytokines and multivariate inflammatory profiles were compared between biopsy sites and between patients and controls.

Results

We found significantly higher concentrations of Th2 cytokines in nasal polyps compared to inferior turbinate and bronchial biopsies. In addition, we showed that the inflammatory profile of nasal polyps and bronchial biopsies correlated significantly (p<0.01). From the Th2 cytokines measured, IL-13 was significantly increased in bronchial biopsies from CRSwNP patients with, but not without asthma.

Conclusion

Our findings support the united airways concept; however, we did not find evidence for subclinical bronchial inflammation in CRSwNP patients without asthma. Finally, this study indicates for the first time that nasal polyps potentially play an important role in the airway inflammation rather than being a secondary phenomenon.

Clarithromycin and dexamethasone show similar anti-inflammatory effects on distinct phenotypic chronic rhinosinusitis: an explant model study

BACKGROUND

Phenotype of chronic rhinosinusitis (CRS) may be an important determining factor of the efficacy of anti-inflammatory treatments. Although both glucocorticoids and macrolide antibiotics have been recommended for the treatment of CRS, whether they have different anti-inflammatory functions for distinct phenotypic CRS has not been completely understood. The aim of this study is to compare the anti-inflammatory effects of clarithromycin and dexamethasone on sinonasal mucosal explants from different phenotypic CRS ex vivo.

METHODS

Ethmoid mucosal tissues from CRSsNP patients (n = 15), and polyp tissues from eosinophilic (n = 13) and non-eosinophilic (n = 12) CRSwNP patients were cultured in an ex vivo explant model with or without dexamethasone or clarithromycin treatment for 24 h. After culture, the production and/or expression of anti-inflammatory molecules, epithelial-derived cytokines, pro-inflammatory cytokines, T helper (Th)1, Th2 and Th17 cytokines, chemokines, dendritic cell relevant markers, pattern recognition receptors (PRRs), and tissue remodeling factors were detected in tissue explants or culture supernatants by RT-PCR or ELISA, respectively.

RESULTS

We found that both clarithromycin and dexamethasone up-regulated the production of anti-inflammatory mediators (Clara cell 10-kDa protein and interleukin (IL)-10), whereas down-regulated the production of Th2 response and eosinophilia promoting molecules (thymic stromal lymphopoietin, IL-25, IL-33, CD80, CD86, OX40 ligand, programmed cell death ligand 1, CCL17, CCL22, CCL11, CCL5, IL-5, IL-13, and eosinophilic cationic protein) and Th1 response and neutrophilia promoting molecules (CXCL8, CXCL5, CXCL10, CXCL9, interferon-γ, and IL-12), from sinonasal mucosa from distinct phenotypic CRS. In contrast, they had no effect on IL-17A production. The expression of PRRs (Toll-like receptors and melanoma differentiation-associated gene 5) was induced, and the production of tissue remodeling factors (transforming growth factor-β1, epidermal growth factor, basic fibroblast growth factor, platelet derived growth factor, vascular endothelial growth factor, and matrix metalloproteinase 9) was suppressed, in different phenotypic CRS by dexamethasone and clarithromycin in comparable extent.

CONCLUSIONS

Out of our expectation, our explant model study discovered herein that glucocorticoids and macrolides likely exerted similar regulatory actions on CRS and most of their effects did not vary by the phenotypes of CRS.

Efficacy and safety of long-term antibiotics (macrolides) for the treatment of chronic rhinosinusitis

Long-term treatment of airway inflammation/infection with macrolide antibiotics has now been in use for almost 30 years. Whereas the beneficial clinical effect in cystic fibrosis and COPD have been backed up by randomized controlled trials, the evidence from the upper airways is not as strong. We have identified 22 open studies in chronic rhinosinusitis, with and without polyps, but only 2 randomized controlled trials. Of the controlled trials, the one including CRS patients just without polyps, showed a significant effect in sino-nasal outcome test, saccharine transit time, nasal endoscopy, and IL-8 levels in lavage fluid after 12 weeks of roxithromycin, whereas, in the other RCT with a mixed study group of CRS patients with and without polyps, 12 weeks of azithromycin showed no effect compared to placebo. Concerns regarding the risk of macrolides to induce arrhythmia have been raised. Recent FDA guidelines changes has recommended caution in patients with risk factors such as long QT syndrome, bradycardia, hypokalemia, or hypomagnesemia. Ototoxicity is another concern. Long-term macrolide antibiotics in the treatment of CRS patients is still a viable option in a select group of patients.

Efficacy of Chinese Herbal Medicine Compared with a Macrolide in the Treatment of Chronic Rhinosinusitis without Nasal Polyps

Background

This study was designed to examine the efficacy of Chinese herbal medicine (CHM) in the treatment of chronic rhinosinusitis (CRS) without nasal polyps.

Methods

Patients with CRS without nasal polyps were enrolled in the study. Before treatment, they were evaluated by the Taiwanese version of the 20-item Sino-Nasal Outcome Test (TWSNOT-20), nasal endoscopy, saccharin test, and bacterial culture. Then, they were randomized to take CHM (Tsang-Erh-San extract granules and Houttuynia extract powder) or erythromycin for 8 weeks. After treatment, they were evaluated again by the TWSNOT-20, nasal endoscopy, saccharin test, and bacterial culture.

Results

Fifty-three patients completed the study with 26 in the CHM group and 27 in the erythromycin group. In both the CHM and the erythromycin groups, TWSNOT-20 scores significantly decreased after treatment, but the decrease was not significantly different between the two groups. However, the saccharin transit times were shortened in more patients in the CHM group than in patients in the erythromycin group.

Conclusion

Our results showed CHM had an efficacy similar to that of macrolides in the treatment of CRS without nasal polyps. However, a placebo effect remained possible in both treatment groups.

State of the art treatment of nasal polyposis

BACKGROUND

Nasal polyposis represents the end point of multiple inflammatory pathways and controversy continues as to the exact roles of medical and surgical approaches in the management of nasal polyposis.

METHODS

A combination of both is often required to manage polyps adequately with surgery and intranasal steroids remaining the mainstay of therapy.

RESULTS

Fortunately, new technological advances are making surgery safer and more efficient. In the postoperative period, debridement is effective in reducing the formation of adhesions, and topical medications may play a beneficial role in preventing polyp reformation.

CONCLUSION

Additional investigations into the optimal perioperative medical management is needed to ensure optimal surgical outcomes.

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.

Prospective observational study of chronic rhinosinusitis: environmental triggers and antibiotic implications

BACKGROUND

A prolonged course of antibiotic therapy is often initiated for chronic rhinosinusitis (CRS) based on symptomatology. We examined differences in clinical manifestations and underlying conditions in patients with symptoms typical for CRS. CT scan abnormality of the sinuses was the gold standard for diagnosis of CRS.

METHODS

We performed a prospective observational study of 125 adults with classic symptoms of CRS undergoing nasal endoscopy and sinus CT.

RESULTS

The patients were classified into 2 groups: (1) those with radiographic evidence of sinusitis by CT (Sx + CT) (75) and (2) those with normal CT scans of the sinus (Sx - CT) (50). Decreased smell was significantly more common in Sx + CT than in Sx - CT patients, (P = .003). Paradoxically, headache, facial pain, and sleep disturbance occurred significantly more frequently in patients with Sx - CT than in patients with Sx + CT (P < .05). The absence of mucopurulence on endoscopy proved to be highly specific for Sx - CT patients (100%). On the other hand, sensitivity was low; only 24% of Sx + CT patients demonstrated mucopurulence by endoscopy. Improvement in response to antibiotics was similar between both CRS categories.

CONCLUSIONS

Most symptoms considered to be typical for CRS proved to be nonspecific. Interestingly, symptoms that were more severe were significantly more likely to occur in younger patients who were Sx - CT. The efficacy of antibiotic therapy was uncertain. We suggest that objective evidence of mucopurulence assessed by endoscopy or CT should be obtained if antibiotics are to be given for prolonged duration. We recommend a moratorium for the widespread practice of a prolonged course of empiric antibiotics in patients with presumed CRS.

Lack of efficacy of long-term, low-dose azithromycin in chronic rhinosinusitis: a randomized controlled trial

BACKGROUND

In persistent chronic rhinosinusitis (CRS), conventional treatment is often insufficient. Long-term, low-dose administration of macrolides has been suggested as a treatment option. The MACS (Macrolides in chronic rhinosinusitis) study is a randomized placebo-controlled trial evaluating the efficacy of azithromycin (AZM) in CRS.

METHODS

We describe a group of patients with recalcitrant CRS with and without nasal polyps unresponsive to optimal medical and (in 92% also) surgical treatment. Patients were treated with AZM or placebo. AZM was given for 3 days at 500 mg during the first week, followed by 500 mg per week for the next 11 weeks. Patients were monitored until 3 months post-therapy. The assessments included Sino-Nasal Outcome Test-22 (SNOT-22), a Patient Response Rating Scale, Visual Analogue Scale (VAS), Short Form-36 (SF-36), rigid nasal endoscopy, peak nasal inspiratory flow (PNIF), Sniffin' Sticks smell tests and endoscopically guided middle meatus cultures.

RESULTS

Sixty patients with a median age of 49 years were included. Fifty per cent had asthma and 58% had undergone revision sinus surgery. In the SNOT-22, Patient Response Rating Scale, VAS scores and SF-36, no significant difference between the AZM and the placebo groups was demonstrated. Nasal endoscopic findings, PNIF results, smell tests and microbiology showed no relevant significant differences between the groups either.

CONCLUSION

At the investigated dose of AZM over 3 months, no significant benefit was found over placebo. Possible reasons could be disease severity in the investigated group, under-dosage of AZM and under-powering of the study. Therefore, more research is urgently required.

Management of preseptal and orbital cellulitis

Orbital cellulitis describes an infection involving the soft tissues posterior to the orbital septum, including the fat and muscle within the bony orbit. This condition may be associated with severe sight and life-threatening complications. Despite significant advances in antimicrobial therapies and diagnostic technologies, the management of orbital cellulitis often remains challenging, and rapid diagnosis and prompt initiation of therapy are important in minimizing complications and optimizing outcomes. This review summarizes the distinctive characteristics of preseptal and orbital cellulitis, with a focus on anatomic considerations, predisposing conditions, approaches to evaluation, and management strategies.

Systemic therapies in managing sinonasal inflammation

Chronic rhinosinusitis (CRS) is a condition characterized by persistent inflammation due to intrinsic mucosal hypersensitivity or persistent infection. Proper medical treatment with antibiotic, leukotriene modifiers, oral corticosteroids, or even aspirin desensitization for the sinus inflammation can prevent the need for surgical intervention. The key to delineating the specific medical application is to determine the cause of the sinus mucosa dysfunction and its specific inflammatory pathway. Such targeted antiinflammatory medical therapy will lead to improved efficacy in the management of CRS. Even if surgical intervention is required, postoperative medical treatment is essential to minimizing the intrinsic mucosal inflammation and therefore preventing revision endoscopic procedures.

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

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

Anti-inflammatory effects of macrolides: applications in chronic rhinosinusitis

The anti-inflammatory effects of macrolides are significant. The clinical impact on diffuse panbronchiolitis (DPB) has improved 10-year survival from 12% to more than 90% for these patients. The immunomodulatory activity of macrolides has been a source of mechanistic research as well as clinical research in non-DPB inflammatory airway disease. Suppression of neutrophilic inflammation of the airways has been demonstrated as the most robust immunomodulatory response from 14- and 15-membered ring macrolides. The inhibition of transcription factors, mainly nuclear factor-kB and activator protein 1, from alterations in intracellular cell signaling drives this mechanism. The suppression of interleukin-8 to a range of endogenous and exogenous challenges characterizes the alterations to cytokine production. The inflammatory mechanisms of chronic rhinosinusitis (CRS) have been a major non-DPB focus. Macrolides have been trialed in more than 14 prospective trials and are the focus of numerous research projects. Evidence for a strong clinical effect in CRS is mounting, but results may be tempered by researchers' inability to characterize the disease process. Eosinophilic dominated CRS is unlikely to respond, based on current research understanding and data from clinical trials. This article discusses the current concepts of macrolides and their application in the management of CRS.

Clarithromycin inhibits rhinovirus-induced bacterial adhesions to nasal epithelial cells

OBJECTIVES/HYPOTHESIS

We investigated the inhibitory effects of clarithromycin (CM) on the rhinovirus (RV)-induced expression of fibronectin (Fn) and carcinoembryonic antigen-related cell adhesion molecules (CEACAMs), which act as major receptors for Staphylococcus aureus and Haemophilus influenzae, respectively. We further investigated the effects of CM on secondary S. aureus and H. influenzae adhesions to RV-infected primary human nasal epithelial cells (HNECs).

METHODS

Cells were pretreated with 10 microM CM 24 hours before RV-16 infection and for 48 hours thereafter. The expression levels of Fn and CEACAMs were assayed by reverse transcriptase-polymerase chain reaction and Western blotting. Bacterial adhesion to cells was assessed by confocal microscopy and the fluorescence intensity of adherent bacteria was analyzed using Image-Pro Plus 5.1 (Media Cybernetics, Bethesda, MD).

RESULTS

Clarithromycin significantly inhibited the RV-induced gene and protein expression of Fn and CEACAMs in HNECs. Compared with RV-infected cells, CM treatment significantly reduced the adhesion levels of S. aureus and H. influenzae in RV-infected HNECs to the levels seen in noninfected control cells.

CONCLUSIONS

These findings indicate that CM has the potential to prevent secondary bacterial infections in RV-infected HNECs by inhibiting the expression of Fn and CEACAM, thereby interfering with bacterial adhesion.

Pharmacokinetics and anti-inflammatory pharmacodynamics of prednisolone in cynomolgus monkey

The purpose was to investigate whether the pharmacokinetics and pharmacodynamics of prednisolone in the non-human primate was an appropriate surrogate for man. After single intravenous doses of 0.03, 0.3, and 3 mg kg(-1), prednisolone demonstrated a dose-dependent clearance and volume of distribution. When corrected for concentration-dependent protein binding, the free clearance was linear at the tested dose levels. The protein binding-corrected volume of distribution was similar across doses. The serum half-life was estimated as being between 2 and 4 h. Prednisolone exhibits near complete inhibition of the cytokines TNF-alpha, IL-1beta, IL-6 and IL-8 with very similar IC50 estimates from 0.09 to 0.16 microg ml(-1) (from 0.24 to 0.44 microM). The monkey demonstrated a similar pharmacokinetics-pharmacodynamics profile of prednisolone when compared with man (from the literature).

Antibiotics for the allergist: part 2

OBJECTIVE

To review antibiotic use and selection for disorders commonly seen in allergy practice.

DATA SOURCES

MEDLINE searches were performed cross-referencing antibiotic, antimicrobial, management, and treatment with multiple disorders commonly seen in allergy practice. References of the chosen articles were also examined.

STUDY SELECTION

Articles were selected based on their relevance to the subject matter.

RESULTS

A large body of research is available relevant to both conventional and novel uses of antibiotics. The use of antibiotics is in question for some disorders, whereas novel approaches to therapy with macrolide antibiotics are areas of active investigation. Meanwhile, patterns of microbial resistance continue to evolve.

CONCLUSION

For decades, antibiotics have been traditional first-line treatment for many disorders. Currently, this paradigm appears to be shifting as periods of observation come into favor and nonbacterial causes of inflammation are under greater scrutiny. Nonetheless, appropriate antibiotic selection often remains a key element in the treatment of these disorders. Knowledge of the relevant microbiology is an inherent requirement in selecting antibiotic therapies and necessitates awareness of current trends in bacterial resistance.

Effects of long-term clarithromycin treatment on lavage-fluid markers of inflammation in chronic rhinosinusitis

Macrolides can be clinically effective in chronic rhinosinusitis (CRS). However, little is known about how these drugs affect pathophysiological features of CRS in vivo. In the present study, patients with CRS were subjected to long-term treatment with clarithromycin. Nasal lavages with and without histamine (40 and 400 microg ml(-1)) were carried out prior to and late into the treatment period. Histamine was included as a tool to produce plasma exudation, a process known to move free cellular products from the mucosal tissue into the airway lumen thereby enriching nasal surface liquids with such products. Interleukin-8 (IL-8), myeloperoxidase (MPO), eosinophil cationic protein (ECP), alpha(2)-macroglobulin and fucose were monitored as indices of pro-inflammatory cytokine production, neutrophil and eosinophil granulocyte activities, plasma exudation and mucinous secretion, respectively. Clarithromycin reduced the lavage fluid levels of IL-8 at the low-dose histamine observation (P<0.001). There was a trend towards reduced MPO by the treatment, whereas ECP was significantly reduced at the low-dose histamine observation (P<0.05). alpha(2)-Macroglobulin was reduced by clarithromycin (saline lavages) (P = 0.05), whereas fucose was unaffected. The exudative responsiveness to high-dose histamine was significantly reduced by the treatment (P<0.05). Furthermore, significantly lower levels of fucose were observed at the low-dose histamine observation (P<0.01). We conclude that long-term clarithromycin treatment likely exerts an anti-inflammatory effect in CRS.

Anti-inflammatory effects of ciprofloxacin in S. aureus Newman induced nasal inflammation in vitro

Objectives

Chronic rhinosinusitis (CRS) is a chronic inflammatory disease of the nasal mucosa. Recent studies suggest that S. aureus enterotoxins may play an etiologic role in the development of CRS. Apart from surgery and repeated courses of steroids, macrolide antibiotics have been reported to exert anti-inflammatory effects in CRS. Similar effects have been reported for fluoroquinolones on various cell types. Since these effects have poorly been characterized in CRS, we examined anti-inflammatory effects of ciprofloxacin on human nasal epithelial cells (HNECs).

Methods

Inflammation was induced in HNECs cultured from nasal turbinate mucosa with supernatants of S. aureus Newman for 12 hours. Subsequently, HNECs were coincubated with S. aureus Newman and ciprofloxacin (1.5 × 10^-5 M), clarithromycin (10^-6 M) or prednisolone (10^-5 M) for another 12 hours. IL-8 synthesis was quantified after 12 and 24 hours by ELISA.

Results

Stimulation with S. aureus Newman supernatants was associated with an increase of IL-8 synthesis after 12 hours in all experiments. During the second 12 hours, IL-8 synthesis decreased and this effect was independent from any stimulus or inhibitor. However, coincubation of HNECs with ciprofloxacin was associated with a more extensive decrease of IL-8 synthesis. Similarly, addition of clarithromycin was associated with a reduction of IL-8 synthesis although this effect was not significant. Coincubation with prednisolone resulted in a significant reduction of IL-8 levels.

Conclusion

Ciprofloxacin exerts anti-inflammatory effects in S. aureus Newman driven nasal inflammation. Inhibitory effects were comparable to those of prednisolone and clarithromycin.

Role of matrix metalloproteinases in chronic rhinosinusitis

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Fungal allergens induce cathelicidin LL-37 expression in chronic rhinosinusitis patients in a nasal explant model

BACKGROUND

Fungus is thought to play an important role in some subgroups of chronic rhinosinusitis (CRS) patients with eosinophilic mucus (EMCRS). The cathelicidin LL-37 is an important innate defense peptide with antimicrobial activity but its responses in CRS and EMCRS patients have not been established. We investigated the innate immune responses of LL-37 in nasal tissue from CRS and EMCRS patients to fungal allergen challenge.

METHODS

The levels of LL-37 produced by nasal tissue and secreted in response to fungal allergen challenge were determined by a nasal tissue explant in vitro model. LL-37 mRNA and protein levels were quantified by real-time reverse-transcriptase-polymerase chain reaction and immunoassay methods.

RESULTS

LL-37 mRNA expression in CRS, but not EMCRS patients, is significantly upregulated by Aspergillus (mean fourfold increase) and Alternaria (mean sixfold increase) extracts in a dose-response manner (p < 0.001). LL-37 peptide levels in the nasal tissue from CRS patients are increased in response to Alternaria (p < 0.05). In contrast, with EMCRS patients, the expression of LL-37 peptide in nasal tissue is increased with Aspergillus (p < 0.001) but is reduced with Alternaria. We also observed a trend where levels of secreted LL-37 were decreased with higher doses of Alternaria and Aspergillus extracts.

CONCLUSION

LL-37 is significantly up-regulated at the mRNA and protein level in CRS patients in response to fungal allergens. However, EMCRS patients do not show increased LL-37 at either the mRNA or the protein level in response to Alternaria.

Effects of macrolides on antigen presentation and cytokine production by dendritic cells and T lymphocytes

Macrolides are effective therapeutic agents for chronic respiratory tract diseases, such as chronic sinusitis, sinobronchial syndrome and diffuse panbronchiolitis. Although only limited information is available about their mechanisms, suppression of various inflammatory cytokines (IL-8, etc.) and some transcription factors has been reported to be involved. Non-typeable Haemophilus influenzae (NTHI) is one of the most important pathogens of the respiratory tract. P6 is one of the outer membrane proteins of NTHI and the target antigen of protective antibodies. To analyze the influence of macrolides on human dendritic cells (DCs), we treated DCs with macrolides and used them as antigen-presenting cells (APCs). Clarithromycin, roxithromycin and prednisolone suppressed the in vitro proliferative response of CD4+ T cells to P6 and also the production of cytokines. As a control, we also cultured DCs alone and exposed them to the medicament, while conversely culturing T cells without adding any drugs to the cultures. The results showed similar tendencies for suppression of immune responses. These findings suggest that macrolides suppress the antigen-specific immune responses of DCs in vitro.

Surfactant Protein D Expression in Chronic Rhinosinusitis Patients and Immune Responses In Vitro to Aspergillus and Alternaria in a Nasal Explant Model

OBJECTIVES/HYPOTHESIS

Common fungi have been implicated in the pathogenesis of chronic rhinosinusitis (CRS) with eosinophilic mucus (EMCRS). Surfactant protein (SP)-D plays an important role in the immune response to Aspergillus fumigatus in the lungs. We sought to determine whether SP-D is expressed in nasal mucosa and investigated the response of SP-D in vitro to fungal allergens.

STUDY DESIGN AND METHODS

1) Nasal biopsies from 59 CRS and EMCRS patients, stratified into allergic fungal sinusitis (AFS), nonallergic fungal eosinophilic sinusitis (NAFES), and nonallergic nonfungal eosinophilic sinusitis (NANFES) were studied by quantitative reverse-transcriptase polymerase chain reaction (qRT-PCR), immunostaining and enzyme-linked immunosorbent assay (ELISA). 2) Nasal tissue from three CRS and three NANFES patients was cultured with fungal allergens in a nasal explant in vitro model for 24 hours at increasing concentrations and mRNA SP-D secreted SP-D protein levels in response to the fungi determined by qRT-PCR and ELISA.

RESULTS

Staining for SP-D was detected in the submucosal glands from the nasal biopsies in all patient groups except for AFS. By ELISA, SP-D was undetectable in AFS and decreased in NAFES, NANFES, and CRS compared with controls. CRS patients in vitro cultured with Aspergillus and Alternaria allergens in a nasal tissue explant model induced up-regulation of SP-D by qRT-PCR. In contrast, NANFES nasal tissue explants cultured with Aspergillus allergens induced down-regulation of SP-D.

CONCLUSIONS

We report for the first time the expression of SP-D in both diseased and normal nasal mucosa. SP-D expression in CRS patients is up-regulated by fungal allergens in an in vitro model. These results may provide potential novel therapy for treatment of CRS.

Macrolide immunomodulatory effects and symptom resolution in acute exacerbation of chronic bronchitis and acute maxillary sinusitis: a focus on clarithromycin

Bacterial respiratory tract infections are common in the primary care setting and patients often seek the assistance of a healthcare professional in order to achieve resolution of their symptoms. Antibiotic agents that offer rapid symptom relief, in addition to excellent bacteriological and clinical cure, are highly desired. Macrolides have proven to be highly effective in treating acute bacterial exacerbations of chronic bronchitis and acute maxillary sinusitis. In addition, immunomodulatory effects that may contribute to symptom resolution have been reported. This article reviews current literature on symptom resolution in acute bacterial exacerbations of chronic bronchitis and acute maxillary sinusitis, with a focus on clarithromycin, and explores the potential mechanisms that may contribute to this action.

A double-blind, randomized, placebo-controlled trial of macrolide in the treatment of chronic rhinosinusitis

OBJECTIVES

The antiinflammatory effect of macrolide antibiotics has been well-established, as has their role in the treatment of certain disorders of chronic airway inflammation. Several studies have suggested that long-term, low-dose macrolides may be efficacious in the treatment of chronic rhinosinusitis; however, these studies have lacked a control group. To date, this effect has not been tested in a randomized, placebo-controlled study.

METHOD

The authors conducted a double-blind, randomized, placebo-controlled clinical trial on 64 patients with chronic rhinosinusitis. Subjects received either 150 mg roxithromycin daily for 3 months or placebo. Outcome measures included the Sinonasal Outcome Test-20 (SNOT-20), measurements of peak nasal inspiratory flow, saccharine transit time, olfactory function, nasal endoscopic scoring, and nasal lavage assays for interleukin-8, fucose, and a2-macroglobulin.

RESULTS

There were statistically significant improvements in SNOT-20 score, nasal endoscopy, saccharine transit time, and IL-8 levels in lavage fluid (P<.05) in the macrolide group. A correlation was noted between improved outcome measures and low IgE levels. No significant improvements were noted for olfactory function, peak nasal inspiratory flow, or lavage levels for fucose and a2-macroglobulin. No improvement in any outcome was noted in the placebo-treated patients.

CONCLUSION

These findings suggest that macrolides may have a beneficial role in the treatment of chronic rhinosinusitis, particularly in patients with low levels of IgE, and supports the in vitro evidence of their antiinflammatory activity. Additional studies are required to assess their place in clinical practice.

Effect of corticosteroids in the acute management of pediatric orbital cellulitis with subperiosteal abscess

PURPOSE

To determine the effect of intravenous corticosteroids in the acute management of pediatric orbital cellulitis with subperiosteal abscess.

METHODS

The inpatient records of all patients treated for orbital cellulitis with subperiosteal orbital abscess between January 2001 and August 2003 were reviewed. The use of corticosteroids, length of hospital stay, need for surgical drainage, treatment course, and clinical outcomes were reviewed. A t test and Fisher exact test analysis were calculated to evaluate statistical significance.

RESULTS

Twelve patients received intravenous corticosteroids and 11 patients did not receive corticosteroids. All patients had complete resolution of their abscess without complications. Length of hospitalization between the patients treated with and without intravenous corticosteroids was not significantly different (p = 0.26). Four of 12 patients treated with intravenous corticosteroids underwent orbitotomy for drainage of the abscess, and 6 of 11 patients treated without intravenous corticosteroids underwent surgical drainage (p = 0.20). Two of 12 patients treated with corticosteroids received intravenous antibiotics after discharge, whereas 7 of 11 in the group not treated with corticosteroids received intravenous antibiotics after discharge (p = 0.03).

CONCLUSIONS

The use of intravenous corticosteroids does not appear to adversely affect clinical outcomes and may be beneficial in the treatment of pediatric orbital cellulitis with subperiosteal abscess. Review of our data suggests that a prospective, randomized trial is warranted to further clarify the role of corticosteroids in the acute management of pediatric orbital cellulitis with subperiosteal abscess.

Anti-inflammatory effects of macrolide antibiotics in the treatment of chronic rhinosinusitis

Apart from their obvious antibiotic effects, the macrolides have some potentially useful immunomodulatory properties. Which pathway dominates the clinical effect is debatable. Favoring the anti-inflammatory effects are the substantial in vitro data and serum concentrations well below minimal inhibitory concentrations for several pathogens. Furthermore, tissue reparative effects are seen in diffuse panbronchiolitis regardless of the presence of P. aeruginosa, a pathogen not sensitive to macrolide antibiotics. Clinical studies support the view that prolonged treatment is likely to be beneficial in most patients who have CRS. The evidence concerning CRS is still weak because placebo-controlled trials are missing. One should remember, however, the general lack of placebo-controlled trials even in the "more established" medical management of CRS. The concern for an increasing incidence of macrolide-resistant bacterial strains must be taken seriously. Therefore the authors advocate repeated nasal cultures during macrolide therapy. It is hoped that the future will bring larger, prospective, randomized, controlled trials that will investigate the efficacy and safety of macrolides in CRS.

Treatment of chronic rhinosinusitis with low-dose, long-term macrolide antibiotics: an evolving paradigm

The 14-membered and 15-membered ring macrolide antibiotics express immunomodulatory effects in chronic respiratory disorders in humans that are distinct from their antimicrobial properties. These drugs downregulate the excessive immune and inflammatory responses observed in these conditions while promoting tissue repair. To this end, chronic rhinosinusitis is characterized by mucosal inflammation of nasal and sinus mucosa for more than 3 months and accounts for significant health care resource allocation due to difficulties in treatment. Clinical efficacy of macrolide antibiotics as biologic response modifiers in patients with chronic rhinosinusitis is suggested by compelling basic research and small, uncontrolled clinical studies. Hence, long-term, prospective double-blind placebo-controlled clinical studies are indicated to establish the utility of these drugs in the treatment of patients with chronic rhinosinusitis.

Potential New Avenues of Treatment for Chronic Rhinosinusitis: an Anti-inflammatory Approach

Chronic rhinosinusitis is a complex disease process, one that is characterized by much more than just infection. Until its pathophysiology is understood fully, truly definitive therapy may remain elusive. As this underlying inflammatory process begins to unravel, however, new avenues of therapy will begin to emerge. This article discusses some of these new therapies and provides some clues as to where future avenues may go.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.