The role of allergy in chronic rhinosinusitis

The management of paediatric rhinosinusitis

Paediatric rhinosinusitis (PDRS) is commonly used as a synonym for rhinitis within healthcare. Although they may share common symptoms, the pathophysiology does differ; PDRS is the inflammation of the nasal mucosa in addition to the sinuses whereas rhinitis is the inflammation of just nasal mucosa. This review provides a comprehensive overview of the epidemiology, pathophysiology, symptoms, diagnosis and management of PDRS. There is a greater emphasis on the diagnosis and management of PDRS within this review due to a lack of clear guidelines, which can lead to the common misconception that PDRS can be treated indifferently to rhinitis and other upper respiratory conditions. PDRS has detrimental effects on children's current health, long-term health into adulthood and education. Therefore, having a comprehensive guide of PDRS would provide a greater understanding of the condition as well as improved diagnosis and management. This article primarily focuses on the position of Europe and the United Kingdom; however, the recommendations can be applied to other countries as the causes and treatments would not differ significantly.

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.

Role of antibiotics in sinusitis

PURPOSE OF REVIEW

Sinusitis is a leading reason for outpatient antibiotic use, but symptoms are nonspecific. We review potential methods that might enhance the ability to appropriately prescribe antibiotics.

RECENT FINDINGS

The evidence base for antibiotic use in acute rhinosinusitis is strongest in studies with stringent entry criteria. In less restrictive studies antibiotics and placebo perform equally. Bacteria from nasopharyngeal swabs in adults correlate with sinus cultures. A recent study showed that antibiotics shortened the duration of acute rhinosinusitis (ARS) symptoms in children. Tellingly, over 2000 children with symptoms were screened to enroll less than 10% who fulfilled the study's stringent criteria. In chronic rhinosinusitis (CRS), two grade 1 studies on efficacy of long-term macrolide therapy showed conflicting results. Odontogenic sinusitis is underappreciated and frequently fails to grow on culture because of presumed difficulty in growing anaerobes.

SUMMARY

There is currently no grade 1 evidence to support antibiotic use in CRS; however, studies to date have not been conducted in patients with isolated purulent sinusitis. Future use of cultures to direct antibiotic therapy, such as nasopharyngeal swabs in adults with ARS or endoscopically guided cultures, may aid in targeting antibiotic therapy more effectively.

Functional endoscopic balloon dilation of sinus ostia for chronic rhinosinusitis

BACKGROUND

Dilation of sinus ostia using a high-pressure balloon has been introduced as a treatment for chronic rhinosinusitis (CRS) refractory to medical treatment. The efficacy of this technology, however, has not been systematically reviewed.

OBJECTIVES

To assess the effectiveness of balloon sinus ostial dilation as a treatment for patients suffering with CRS refractory to medical treatment.

SEARCH STRATEGY

We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; CENTRAL; PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ISRCTN and additional sources for published and unpublished trials. The date of the most recent search was 20 December 2010.

SELECTION CRITERIA

Randomised controlled trials in patients of any age with rhinosinusitis lasting longer than 12 weeks who have failed a prolonged course of medical treatment. Studies compared either balloon sinus ostial dilation or a hybrid procedure (balloon dilation in conjunction with functional endoscopic sinus surgery (FESS)) versus conventional surgery (e.g. FESS) or a waiting list control.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies for inclusion, extracted data and assessed risk of bias.

MAIN RESULTS

One study (34 patients) met our inclusion criteria although it was not yet a peer reviewed publication. The study randomised patients with chronic frontal sinusitis who had failed a prolonged course of medical treatment into two groups: balloon dilatation of the frontal recess (plus conventional FESS of other involved sinuses) versus conventional FESS (Draf type 1/2a procedures on the frontal sinuses). At 12 months follow up there was no statistically significant difference in radiological resolution of frontal sinuses between the two groups. The percentages of directly observed patent frontal recesses at 12 months were 75% in the balloon dilation group versus 63% in the FESS-only group. The authors state that this was statistically significant but details of the analysis were not presented. Indeed the study as a whole suffers from a bias in the way its outcome measures were reported.No major complications were reported. Three patients in the FESS-only group required further revision frontal sinus surgery compared to one in the balloon dilation group, although synechiae were more common in the latter.

AUTHORS' CONCLUSIONS

At present there is no convincing evidence supporting the use of endoscopic balloon sinus ostial dilation compared to conventional surgical modalities in the management of CRS refractory to medical treatment. With the escalating use of balloon sinuplasty, there is an urgent need for more randomised controlled trials to determine its efficacy over conventional surgical treatment modalities.

The effect of endoscopic sinus surgery on bacterial biofilms in chronic rhinosinusitis

OBJECTIVE

To determine whether or not endoscopic sinus surgery (ESS) alters bacterial biofilms in patients with chronic rhinosinusitis (CRS) after three months of follow-up.

STUDY DESIGN

Prospective study.

SETTING

Department of Otorhinolaryngology-Head and Neck Surgery, University of Queensland.

SUBJECTS AND METHODS

Participants with CRS from the Princess Alexandra Hospital Department of Otorhinolaryngology-Head and Neck Surgery and from Logan Hospital were enrolled in the study (2008-2009). The total number of patients was 28, and the age range was 18 to 65 years. All patients underwent pre- and post-ESS questionnaires, endoscopic scoring, and nasal swabs for bacterial culture. Crystal violet staining was used to assess biofilm formation on a 96-well culture plaque.

RESULTS

ESS resulted in a statistically significant improvement in quality-of-life, subjective, and objective outcome measures after three months. A significant reduction was observed in biofilm density before and after ESS (2.63 versus 1.3, P = 0.043). No correlations between the reduction of bacterial biofilms with any of the subjective, objective, and quality-of-life outcomes were seen in our study.

CONCLUSION

ESS was shown to be capable of reducing the prevalence of bacterial biofilms but did not eliminate them entirely. There was no correlation between altered biofilm formation and improved outcome measures in individual patients.

Allergic vs nonallergic rhinitis: which is more predisposing to chronic rhinosinusitis?

BACKGROUND

The impact of allergy on chronic rhinosinusitis (CRS) is controversial.

OBJECTIVE

To evaluate whether a history of CRS is more prevalent in patients with allergic rhinitis than in those with nonallergic persistent rhinitis.

METHODS

A total of 115 patients (78 females; mean age, 31.9 years; age range, 14-64 years) with persistent rhinitis were included in the study. A 7-point analog scale was used to report the severity of individual and global CRS symptoms and to determine the impact of rhinosinusitis symptoms on quality of life. The allergic status of the patients was evaluated using skin prick tests for common inhalant allergens, and asthma was evaluated by means of history, physical examination, and respiratory function tests. Rhinoscopy and paranasal sinus computed tomography were used to determine CRS.

RESULTS

Asthma and CRS were not significantly different in allergic and nonallergic patients. Nasal polyps were found equally in both groups (8 patients). However, mean Lund-Mackay staging scores, postnasal drainage, dental pain, and global CRS scores were significantly higher in patients with nonallergic rhinitis (P = .045, P = .001, P = .02, and P = .01, respectively). No significant correlations, except for dental pain (correlation coefficient, 0.250; P = .008), were found between Lund-Mackay scores and CRS symptoms. In rhinoscopy, the only conspicuous difference was nasal purulence in allergic patients (P = .002).

CONCLUSION

Allergic and nonallergic rhinitis may contribute similarly to the development of CRS.

Cyclooxygenases and the pathogenesis of chronic rhinosinusitis and nasal polyposis

Cyclooxygenase (COX) enzymes catalyze the rate-limiting steps in prostaglandin synthesis. Prostaglandins have an important role in several physiological processes such as maintenance of gastrointestinal integrity and pathological processes such as inflammation and neoplasia. Several mechanisms have been proposed for the development of chronic rhinosinusitis, but the common final pathway seems to be an integrated process involving the mucosal epithelium, matrix, and inflammatory cells and mediators. Upper and lower airway pathologies coexist and share common etiopathogenic mechanisms, and nasal polyposis is often associated with asthma and aspirin sensitivity. The cellular source of COX activity in acute and chronic inflammation, as in chronic rhinosinusitis, is poorly understood. COX theory postulated that inhibition of COX broke down biochemical reactions that lead to the development of asthma attacks. This article focuses on COX in the pathogenesis of chronic rhinosinusitis and nasal polyposis.

Allergic rhinitis and rhinosinusitis

A relationship between allergic rhinitis and acute and chronic rhinosinusitis has been postulated for many years. Epidemiologic evidence suggests that such a relationship is likely. In addition, evidence of a common pathophysiologic mechanism linking these diseases is compelling and continues to evolve. Although a clear and definitive causal relationship remains to be elucidated, an increasing number of studies support the plausibility of this link. The current paradigm of the "unified airway" and evidence to support this model further strengthen this link. This article reviews the literature relating allergic rhinitis and acute and chronic rhinosinusitis.

Imaging techniques in the diagnosis and management of rhinosinusitis in children

Sinusitis in children is a common problem. The diagnosis of both acute and chronic rhinosinusitis in the pediatric population, should be made first of all clinically, and not on the basis of imaging findings alone. Plain radiography may be used as a screening method for various pathological conditions of sinuses, but computed tomography (CT) remains the study of choice for the imaging evaluation of acute and chronic rhinosinusitis. In acute sinusitis, CT is indicated in patients with symptoms persisting after 10 days of appropriate therapy and in patients with suspected complications (especially in the brain and in the orbit). In addition to CT scanning, magnetic resonance (MR) imaging of the sinuses, orbits, and brain should be performed whenever extensive or multiple complications of sinusitis are suspected. In chronic sinusitis, CT scanning is the 'gold standard' for the diagnosis and the management, because it also provides an anatomic road map, when surgery is required. Nuclear medicine studies and ultrasound are rarely indicated in acute and chronic rhinosinusitis.

The role of sinus disease in asthma

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Allergy and Chronic Rhinosinusitis

The association between chronic rhinosinusitis (CRS) and allergy of the upper respiratory system has been discussed for many years,but much of this discussion has been anecdotal. Although epidemiologic evidence supports the increased prevalence of CRS among patients who have allergic rhinitis, and treatment of upper airway inflammation and allergy has been shown to decrease morbidity in patients who have CRS, but pathophysiologic mechanisms linking the two disease states have not been well elucidated. This article examines data supporting the link between upper airway allergic disease and CRS. It proposes a frame work for the treatment of CRS, with consideration of managing the allergic inflammation commonly noted in this disease. Finally, it discusses avenues for potential future research in evaluating the comorbidities of allergic inflammation and CRS.

Endothelial L-selectin ligands in sinus mucosa during chronic maxillary rhinosinusitis

RATIONALE

Chronic rhinosinusitis 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 organ-specific leukocyte infiltration into inflamed tissues.

OBJECTIVES

The purpose of this study was to evaluate the endothelial expression of functionally active endothelial L-selectin ligands, sulfated sialyl Lewis x, in maxillary sinus mucosa from patients with chronic rhinosinusitis and from normal control subjects.

METHODS

Maxillary sinus mucosa specimens (116) were obtained surgically and immunohistochemically stained with monoclonal antibodies detecting sialyl Lewis x or sulfated extended core 1 lactosamines. The severity of the inflammation was determined by intraoperative endoscopic findings, computed tomography scans, and histopathologic assessment of the specimens.

MEASUREMENTS AND MAIN RESULTS

The percentage of vessels expressing endothelial sulfated sialyl Lewis x epitopes increased during chronic rhinosinusitis compared with uninflamed control tissue, especially in patients with additional allergic rhinitis, and decreased in specimens from aspirin-intolerant patients with preoperative oral corticosteroid treatment. In addition, the expression level of endothelial sulfated sialyl Lewis x epitopes and the number of mucosal eosinophils correlated with the severity of the inflammation, and decreased in specimens taken 9 months postoperatively compared with intraoperative samples, especially in patients with intranasal corticosteroid treatment.

CONCLUSIONS

Our results suggest that functionally active L-selectin ligands might guide leukocyte traffic into maxillary sinus mucosa preferentially in patients with severe findings of chronic maxillary rhinosinusitis, thus leading to aggravation of the inflammation.

Inflammatory sinonasal disease

Inflammation of the nose and sinuses is a clinical problem frequently encountered in the practice of otolaryngology. The most common of these inflammatory illnesses are allergic rhinitis and acute and chronic rhinosinusitis. The recognition of inflammatory sinonasal diseases and an understanding of their pathophysiology are essential to successful management of these common illnesses.

Intravenous antibiotics for chronic rhinosinusitis: are they effective?

PURPOSE OF REVIEW

Antibiotics have been used commonly in chronic rhinosinusitis, often because chronic rhinosinusitis has features of a prolonged bacterial sinusitis, including abnormal CT findings and positive bacterial cultures. The advent of peripherally inserted central catheters has enabled outpatient parenteral antibiotic therapy to become a convenient means of delivering potent antibiotics for various conditions when oral antibiotics may not be effective or appropriate. Chronic rhinosinusitis has been included as a condition that may benefit from outpatient parenteral antibiotic therapy; however, there are few studies that document its success and, furthermore, chronic rhinosinusitis may not always be an infectious process.

RECENT FINDINGS

Three recent uncontrolled retrospective studies examined outpatient parenteral antibiotic therapy in chronic rhinosinusitis. In one series outpatient parenteral antibiotic therapy was used as an adjunct to sinus surgery, in another it was used as an alternative to sinus surgery in the pediatric population, and in the third it was used as temporary resolution for adult patients who had failed other therapies including sinus surgery. Short-term success rates were reported in the range of 29 to 89%, but relapse rates were as high as 89%. Complication rates in theses studies ranged from 14 to 26%, including medication reactions and intravenous line problems.

SUMMARY

The role of outpatient parenteral antibiotic therapy in the treatment of chronic rhinosinusitis has not been universally established. Although outpatient parenteral antibiotic therapy may have a role in avoiding sinus surgery in select pediatric populations, the contribution to a lasting resolution in adult patients is less clear and there are possible complications. Recognizing subsets of chronic rhinosinusitis patients for whom outpatient parenteral antibiotic therapy is appropriate will be the challenge for the future.