Alternative medical treatment strategies for chronic hyperplastic eosinophilic sinusitis

Sinusitis, Rhinitis, Asthma, and the Single Airway Hypothesis

The one airway, one disease hypothesis proposes that the upper and lower airways share the same physiology and histomorphology. Epidemiological clinical studies support a link between rhinosinusitis and asthma. The relationship can occur in both directions, with nasal allergen challenge leading to inflammatory changes in the lower airway and bronchoprovocation studies of the lower airway leading to inflammatory changes in the upper airway. In addition, both similarities and differences exist in the pathogenesis of nasal polyps and asthma. The mechanism for the connection between the upper and lower airways is a matter of great debate. It has been proposed that inflammatory changes in the lower airway may lead to systemic inflammatory effects that play a role in increased bronchial hyperresponsiveness. Similarly, lower airway inflammatory changes may affect nasal airway patency via systemic effects. Moreover, nasopharyngeal-bronchial reflexes may play a non-immunologic role in the interaction between the lower and upper airways. An example of the connection between the upper and lower airways is found in aspirin-exacerbated respiratory disease whereby leukotrienes play a role in the pathology of chronic rhinosinusitis with polyps and asthma. It is also been observed that the treatment of asthma is hindered by untreated rhinosinusitis.

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.

Leukotriene Inhibitors in Sinusitis

It has been recognized for many years that leukotrienes play an important role in mediating various effects of the allergic reaction. Recent evidence has shown that they play a role in other diseases including chronic sinusitis, particularly those sub-types involving eosinophils. Leukotrienes can be separated into the fairly well characterized cysteinyl leukotrienes and less well characterized leukotriene B(4). Effects of the leukotrienes are mediated through receptors that are expressed on a variety of cell types and can be modulated based on the inflammatory environment present. The pharmaceutical industry has long been interested in blocking leukotriene action and as such, two approaches have been developed that led to drugs approved for treatment of allergic disease. The most widely used class is the cysteinyl type 1 receptor antagonists, which block binding of the cysteinyl leukotrienes to the cell. The second class is an inhibitor of the 5-lipoxygenase enzyme that prevents synthesis of both the cysteinyl leukotrienes and leukotriene B(4). This review will focus on the role that leukotrienes play in chronic sinusitis and consider the rationale for choosing either a leukotriene antagonist or synthesis inhibitor as a treatment option. We will also discuss off-label uses for other medications that might be useful in these diseases as they relate to their ability to modulate leukotriene action.

Mucosal remodeling in chronic rhinosinusitis

BACKGROUND

Despite pathophysiologic similarities, mucosal remodeling is well described in asthma but not chronic rhinosinusitis (CRS).

OBJECTIVE

This study attempts to identify mucosal remodeling in CRS and correlate it with clinical information.

METHODS

Charts and histopathology from 53 CRS patients who underwent functional endoscopic sinus surgery were reviewed. Clinical data and basement membrane (BM) thickness were recorded. BM thickness was graded as 0 (no thickening), 1 (mild thickening), 2 (moderate thickening), or 3 (marked thickening). Control mucosae from ten patients without CRS were analyzed for comparison.

RESULTS

Duration of CRS symptoms positively correlated with BM thickness (p = 0.007). Also, patients with a markedly thickened BM (score of 3) had a significantly greater duration of CRS symptoms (120 months) compared to patients with a thinner BM (score < or =2) (33 months) (p = 0.010). Markedly thickened BM was associated with increased coincidence of asthma (p = 0.019) and aspirin sensitivity (p = 0.003). No correlation was found between BM thickness and preoperative Lund-MacKay score. There was no statistically significant difference between markedly thickened BM and thinner BM with respect to coincidence of polyps, course of preoperative systemic steroids, estimated blood loss at surgery, and number of prior surgeries.

CONCLUSION

Increased BM thickness is correlated with prolonged duration of symptoms and the coincidence of asthma. This may indicate paranasal sinus remodeling akin to that which occurs in the bronchioles of persistent asthmatic sufferers.

Drug management in chronic rhinosinusitis: identification of the needs

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

An immunological approach to chronic and recurrent sinusitis

PURPOSE OF REVIEW

Sinusitis is an illness that is often successfully treated by primary care physicians. Recurrent or chronic rhinosinusitis, however, can be frustrating for patients as well as primary care and subspecialty providers. The present review details the approach to recurrent or chronic sinusitis. We give a broad overview of the workup of chronic rhinosinusitis, focusing on immune deficiency, an often overlooked but clinically important aspect of the sinusitis workup.

RECENT FINDINGS

Immune deficiency is prevalent in patients with recurrent or chronic sinus disease. An immunologic workup, as well as a workup for other chronic treatable diseases, should be undertaken before sinus surgery or in patients who have been unresponsive to surgery. This approach can enhance visualization during surgery, minimize postoperative complications, improve surgical outcomes, and possibly obviate the need for surgery altogether.

SUMMARY

Elucidating the cause of recurrent or refractory sinus disease can be challenging. Allergic disease should be evaluated and treated early in the process. An immunologic evaluation should be performed and uncommon causes of sinus inflammation should be addressed later in the course to reduce inflammation either to avoid surgery or improve surgical outcomes.