Localized immunoglobulin E expression in allergic rhinitis and nasal polyposis. Curr Opin Otolaryngol Head Neck Surg. 2009;17:216-222. [PMID: 19417663 DOI: 10.1097/moo.0b013e32832ad23d]

[Immunoglobulin E in nasal secretions]

Diagnosis of allergic disease is primarily verified by IgE blood serum analysis. Determination in nasal secretions is technically more difficult, particularly due to a low specimen volume and the method of sample collection. Nasal secretions are frequently collected by lavage, which allows qualitative diagnostics, whereas swabs with defined amounts of mucus enable quantitative analyses. In the case of negative skin and serum tests, detection of IgE in nasal mucus combined with nasal provocation testing aids differentiation between local allergic and nonallergic rhinitis.

Evaluation of Serum Levels of Vitamin D3 and IgE in Patients with Chronic and Allergic Sinusitis: A Cross-sectional Study

BACKGROUND

Chronic rhinosinusitis is known as a common problem with inflammatory and allergic causes. Several factors are associated with developing chronic rhinosinusitis, including immunoglobulin E (IgE) production and vitamin D deficiency.

OBJECTIVE

In this study, we investigated the role of IgE and Vitamin D deficiency and differences between patients with chronic, allergic sinusitis and controls.

METHODS

A total of 90 subjects were included in 3 groups (n=30) in this cross-sectional, correlational descriptive study. The subjects were divided into three groups, including control (healthy subjects), chronic sinusitis patients, and allergy patients. A checklist was used to collect the necessary data, including age, gender, and body mass index (BMI). To evaluate serum levels of vitamin D3 and IgE, ELISA kits were used.

RESULTS

The mean vitamin D was 22 g/ml. Fifty-four participants (60%) out of all included people had insufficient vitamin D, 13% had a deficiency, and the high deficiency and insufficiency were in the group of allergic sinusitis. Our results indicated that gender (female) was significantly associated with vitamin D deficiency (p =0.01). Thirty-nine participants (43.3%) out of all studied subjects had high IgE, and the highest level of abnormality of IgE was in the allergic sinusitis group. Furthermore, it was found that gender and IgE were not significantly related. However, IgE was significantly associated with vitamin D deficiency in the allergic sinusitis group.

CONCLUSION

Our findings highlighted that most of the patients with chronic and allergic sinusitis had insufficient vitamin D. A possible association was also found between low vitamin D and IgE levels and the prevalence of allergic sinusitis. This study showed that patients with allergic sinusitis may be more vulnerable to lower serum levels of vitamin D. Therefore, vitamin D supplementation as an adjunctive therapy may be considered in these patients.

A Prospective Analysis of Systemic and Local Aeroallergen Sensitivity in Central Compartment Atopic Disease

OBJECTIVE

To compare systemic allergen sensitivity and local allergen sensitivity in the sinonasal tissue of patients with a recently identified subtype of chronic rhinosinusitis strongly associated with allergy: central compartment atopic disease (CCAD).

STUDY DESIGN

Prospective cohort study.

SETTING

Academic tertiary care rhinology clinic.

METHODS

Fifteen participants with endoscopic and radiographic evidence of CCAD underwent systemic allergy testing with skin testing and measurement of serum specific immunoglobulin E (sIgE) to 15 regionally common aeroallergens. Local allergen sensitivity was determined by measuring sIgE to these same 15 allergens in their sinonasal tissue. sIgE testing was performed by ImmunoCAP assay.

RESULTS

Of the 15 participants, 14 were sensitive to at least 1 allergen locally in the central compartment and systemically on skin or serum testing. Among all participants, 4 were sensitive to allergens on central compartment sIgE testing that they were not sensitive to on skin and serum sIgE testing (range, 1-8 discordant allergens). Comparisons between local and systemic aeroallergen sensitivity results showed statistically significant correlations (P < .05) ranging from weak to strong.

CONCLUSION

Systemic allergy testing is recommended in the initial workup for CCAD. Local allergen sensitivities may be present in a subset of patients with CCAD. Further study of the clinical significance of these sensitivities should be undertaken in CCAD, with evaluation of the role of medical therapies and allergen immunotherapy in the treatment of CCAD.

A comparison of central compartment atopic disease and lateral dominant nasal polyps

BACKGROUND

The characteristics and surgical outcomes of central compartment atopic disease (CCAD) vary by region and race. Therefore, we aimed to identify the risk factors, symptom severity, and prognosis of CCAD in the Asian population.

METHODS

This case-control study recruited patients diagnosed with chronic rhinosinusitis with nasal polyps who underwent functional endoscopic sinus surgery (FESS) at a tertiary hospital in Taiwan. Patients were classified into CCAD and lateral-dominant nasal polyp (LDNP) groups based on endoscopic and computed tomography imaging findings. The demographic data, symptom severity scores, and surgical outcomes of the 2 groups were analyzed.

RESULTS

Our study included 442 patients (CCAD group: n = 51; LDNP group: n = 391). We found that CCAD was strongly related to both asthma (9.8% vs 3.5%, p = 0.04) and allergic rhinitis symptoms (43.3% vs 26.6%, p = 0.01). Higher eosinophil counts were detected in blood serum (5.8% vs 2.8%, p < 0.01) and histopathologic profiles (57.0 vs 17.3, p < 0.01) among patients with CCAD. Improvements in 22-item Sino-Nasal Outcome Test (SNOT-22) score and mucociliary clearance time (MCT) after surgical intervention revealed that the CCAD group had a better response to FESS (SNOT-22 score: -31.82 vs -22.66, p < 0.01; MCT: -233.06 vs -191.93 seconds, p = 0.03). The revision FESS rate was not different between the 2 groups.

CONCLUSION

Polyps originating from the central compartment were found to be related to asthma and allergic rhinitis in Taiwanese patients. A higher eosinophil count was suggested in both serum and local nasal tissue from patients with CCAD. FESS serves as an effective treatment for symptom relief in patients with CCAD.

The Role of Allergic Rhinitis in Chronic Rhinosinusitis

This literature review collates and summarizes recent literature to explore the relationship between chronic rhinosinusitis (CRS) and allergy. The relationship between CRS and allergy is not fully understood. However, current evidence suggests a relationship between allergy and specific endotypes of CRS with nasal polyposis, including allergic fungal rhinosinusitis and central compartment atopic disease. Specific endotypes of CRS with nasal polyps seem to have an association with allergy. More evidence is necessary to better characterize this relationship. Level of evidence: 5.

Chronic Rhinosinusitis: Does Allergy Play a Role?

A few chronic rhinosinusitis (CRS) variants have demonstrated a strong association with environmental allergy, including allergic fungal rhinosinusitis (AFRS) and central compartment atopic disease (CCAD). However, the overall relationship between CRS and allergy remains poorly defined. The goal of this review is to evaluate the relationship between CRS and allergy with a focus on specific CRS variants.

Molecular patterns in the isotype-specific antibody responses to the major cedar aeroallergen Jun a 1

Most studies of the immune responses in allergic rhinitis have focused on IgE antibodies to mixtures of allergenic proteins. Based on our previous studies of the major mountain cedar allergen Jun a 1, we sought to describe a broader assessment of the humoral immune responses to a single, dominant allergen, in three groups of allergic subjects, all of whom had similarly exposures to the whole cedar pollen. The major outcomes of this study was that, with the onset of allergic rhinitis symptoms, and after treatment with immunotherapy, serum IgE and IgG (but not IgA) antibodies to Jun a 1 increased. Interestingly, both IgE and IgG4 antibodies to the Jun a 1 allergen were strongly focused on its conformation epitopes. These IgG antibodies to conformationalstructures may be a useful marker of the therapeutic response to immunotherapy.

Central compartment atopic disease

BACKGROUND

Isolated polypoid changes of the middle turbinate were recently reported as having a high association with inhalant allergy. A more advanced manifestation of this association may present as polypoid changes of the entire central sinonasal compartment (i.e., the middle and superior turbinates, and the posterosuperior nasal septum), while the lateral sinus mucosa remains relatively normal.

OBJECTIVE

To introduce and describe this newly recognized variant of chronic rhinosinusitis (CRS), termed central compartment atopic disease (CCAD).

METHODS

A case series of 15 patients from two institutions who presented with sinonasal symptoms and demonstrated central compartment polypoid mucosal changes on computed tomography (CT). The endoscopic appearance of central compartment edema was assessed. Allergy status was determined by skin or serum in vitro testing.

RESULTS

The mean ± standard deviation patient age was 42.4 ± 14.8 years, and 47% of the patients were women. All 15 patients had a diagnosis of allergic rhinitis symptomatically, and those who underwent allergy assessment (14/15) tested positive. All the patients had central compartment polypoid edema on endoscopy and central nasal soft-tissue thickening with peripheral clearing on CT. Even with more severe sinus disease, a central focus of inflammatory change existed.

CONCLUSION

CCAD may represent a local inhalant allergy process that affects the central nasal structures of ethmoid origin. Although inhalant allergy changes mainly appear within the nasal cavity, medial-to-lateral progression to involve the sinuses can occur as a simple obstructive phenomenon. This is a pattern of CRS distinct from the more diffuse sinonasal inflammatory disease and likely requires allergy management as a core component.

Role of local allergic inflammation and Staphylococcus aureus enterotoxins in Chinese patients with chronic rhinosinusitis with nasal polyps

Objective:

To investigate the role of local allergic inflammation and Staphylococcus aureus enterotoxins in chronic rhinosinusitis with nasal polyps.

Methods:

This study included 36 patients with chronic rhinosinusitis with nasal polyps and 18 controls. Total immunoglobulin E, eosinophil cationic protein, staphylococcal enterotoxin types A and B specific immunoglobulin E, staphylococcal enterotoxin types A and B, and myeloperoxidase levels were determined.

Results:

Four patients with chronic rhinosinusitis with nasal polyps had a local allergy. All chronic rhinosinusitis with nasal polyps patients tested negative for staphylococcal enterotoxin types A and B specific immunoglobulin E. The chronic rhinosinusitis with nasal polyps group had significantly elevated staphylococcal enterotoxin types A and B levels in the supernatant. Fourteen patients belonged to the eosinophilic chronic rhinosinusitis with nasal polyps group and the others were characterised as having non-eosinophilic chronic rhinosinusitis with nasal polyps.

Conclusion:

Local allergy may play a role in chronic rhinosinusitis with nasal polyps, independent of staphylococcal enterotoxin superantigens. Staphylococcal enterotoxins may be important in the pathogenesis of chronic rhinosinusitis with nasal polyps; however, their roles as superantigens were not confirmed in this study. In Chinese subjects, chronic rhinosinusitis with nasal polyps usually manifests as a neutrophilic inflammation.

Polypoid Change of the Middle Turbinate and Paranasal Sinus Polyposis Are Distinct Entities

Objectives

Polypoid change of the middle turbinate (PCMT) is a finding on intranasal examination whose significance is not well understood. We present a comparison of the clinical characteristics of PCMT with paranasal sinus polyposis (PSP), a common condition with potentially similar appearance.

Study Design

Parallel case series.

Setting

Tertiary rhinology clinic.

Subjects and Methods

Data were prospectively compiled from consecutive patients during a 12-month period with either PSP arising from the middle meatus or PCMT limited to the middle turbinate as identified on nasal endoscopy. Recorded data included comorbidities, the 22-item Sinonasal Outcome Test (SNOT-22), Nasal Obstruction Symptom Evaluation (NOSE), Lund-Mackay score from computed tomography (CT) imaging, and total eosinophil levels.

Results

Of 593 patients, 23 (3.9%) had PCMT and 44 (7.4%) had PSP. The PSP group was predominantly male (75% vs 52%, P < .001) with an older mean age (53.4 vs 35.4 years, P < .0001). PCMT was more often associated with allergic rhinitis (83% vs 34%, P < .001), whereas PCMT was rarely associated with chronic rhinosinusitis (10% vs 100%, P < .0001). Mean eosinophil count (7.1 vs 3.1, P = .096) was not significantly different between groups, whereas mean Lund-Mackay score was higher in PSP (14.9 vs 2.8, P < .0008). Mean NOSE score was greater in PSP (65.3 vs 46.8, P = .025), whereas SNOT-22 score was comparable between groups (40.6 vs 34.6, P = .29).

Conclusion

PCMT is a unique physical finding with clinical associations that distinguish it from PSP. PCMT has greater association with allergic rhinitis than chronic rhinosinusitis, and both PCMT and PSP are associated with impaired quality of life.

Non-allergic rhinitis in children: Epidemiological aspects, pathological features, diagnostic methodology and clinical management

Chronic rhinitis is a very common disease, as the prevalence in the general population resulted to be 40%. Allergic rhinitis has been considered to be the most frequent form of chronic rhinitis, as non-allergic rhinitis has been estimated to account for 25%. However, several evidences suggested that non-allergic rhinitis have been underrated, especially in children. In pediatrics, the diagnostic definition of non-allergic rhinitis has been often limited to the exclusion of an allergic sensitization. Actually, local allergic rhinitis has been often misdiagnosed as well as mixed rhinitis has not been recognized in most cases. Nasal cytology is a diagnostic procedure being suitable for routine clinical practice with children and could be a very useful tool to characterize and diagnose non-allergic rhinitis, providing important clues for epidemiological analysis and clinical management.

Characterization of immunoglobulin E plasma cells that are elevated in the upper airway mucosa of nonatopic patients with chronic rhinosinusitis without nasal polyps

BACKGROUND

The immunologic mechanisms driving inflammation in the upper airways of patients with chronic rhinosinusitis (CRS) are poorly understood. Previous studies have shown that B cells and immunoglobulin E (IgE) levels are elevated in the nasal tissue of patients with atopic chronic rhinosinusitis without nasal polyps (CRSsNP). However, less is known regarding B cell subsets and IgE-producing plasmablasts in nonatopic CRSsNP patients.

METHODS

Human blood and ethmoid sinus mucosa samples were analyzed from control (n = 6) and nonatopic CRSsNP (n = 11) patients. Tissue samples were evaluated using high-dimensional flow cytometry.

RESULTS

A population of IgE antibody secreting cells is significantly increased in situ within inflamed nasal tissue of nonatopic CRSsNP subjects when compared to control nasal tissue and the circulating peripheral blood (p < 0.05). This IgE plasma cell population displays ∼90% cell surface Ig lambda light chain, is mitotically active (Ki-67(+)), and displays intracellular IgE expression. The predominant B cell population expressing IgE are plasmablasts (CD38(high), CD138(-)) not typically found in the blood or peripheral tissue of these patients.

CONCLUSION

The nasal mucosa from nonatopic CRSsNP patients demonstrate a significant regional spike in resident in situ IgE plasmablast cells not seen in control nasal tissue or peripheral blood from the same patient. The restricted expression of Ig lambda light chain in this mitotically active IgE plasmablast population supports the hypothesis of aberrant B cell proliferation in the context of CRS. These findings suggest the presence of a unique regional immune microenvironment for B cell priming and/or selection within chronically inflamed airway tissues.

Omalizumab for severe asthma: efficacy beyond the atopic patient?

Several years ago, omalizumab became commercially available for the treatment of severe asthma. It remains the only monoclonal antibody to be marketed for this purpose. Since then, many studies have been published endorsing its efficacy and effectiveness. Concomitantly, evidence of an overlap between atopic and non-atopic severe asthma has emerged. However, there also appears to be some disagreement regarding the value of omalizumab in the management of non-atopic disease, as some studies have failed to show any benefit in these patients. The recent literature has also sought to identify appropriate prognostic biomarkers for the use of omalizumab, other than immunoglobulin (IgE) levels. This article briefly summarizes the evolution of asthma treatment, the pathophysiology of the condition, and the method of action of omalizumab. The author describes the controlled and uncontrolled studies (also named "real-life studies") published in adult and pediatric populations in different countries and expresses his view on the current place of the drug in the management of severe allergic asthma. He offers a personal perspective on the recent evidence for the use of omalizumab in non-atopic patients, highlighting the implications for current clinical practice and the gaps in our knowledge. The author justifies his belief that omalizumab is not only an IgE-blocking drug and should be considered as a disease-modifying therapy because of its multiple effects on different biologic pathways. Finally, some areas for future research are indicated.

Distinct inflammatory profiles in atopic and nonatopic patients with chronic rhinosinustis accompanied by nasal polyps in Western china

PURPOSE

The role of systemic sensitization in the pathophysiology of chronic rhinosinusitis with nasal polyps (CRSwNP) remains elusive. This study sought to characterize the pattern of cytokines in polyp tissues from atopic and nonatopic patients with CRSwNP.

METHODS

Atopic and nonatopic polyp and normal tissues were collected from 70 CRSwNP patients and 26 control subjects, respectively. The distribution of inflammatory cells (eosinophils, neutrophils, mast cells, etc.) were examined using immunohistochemistry, the mRNA levels of the transcription factors GATA-3, T-bet, RORc, and FOXP3 were determined using quantitative real-time polymerase chain reaction. The levels of inflammatory mediators (IFN-γ, IL-5, IL-17A, etc.) in tissue homogenates were measured using enzyme-linked immunosorbent assay (ELISA). Moreover, the levels of inflammatory mediators in the supernatant of anti-IgE stimulated polyp tissues were measured using ELISA.

RESULTS

Atopic CRSwNP patients were characterized by increased eosinophil accumulation, enhanced eosinophilic inflammation (elevated IL-5, ECP, and total IgE), and significantly increased GATA-3 mRNA levels (P<0.05), whereas both atopic and non-atopic CRSwNP patients showed decreased FOXP3 mRNA expression (P<0.05). After addition of anti-IgE stimulation, atopic CRSwNP patients produced more IL-5, IL-2, IL-10, IL-17A, and PGD2 in the supernatant of stimulated polyp tissues than nonatopic CRSwNP patients did.

CONCLUSIONS

Atopic and nonatopic CRSwNP patients may possess the patterns of inflammatory response in polyp tissues.

Association of IL1β and IL4 gene polymorphisms with nasal polyps in a Polish population

Imbalance between proinflammatory and anti-inflammatory cytokines may regulate the inflammatory reaction in the nasal polyps. Polymorphisms in the regulatory regions of the cytokines genes may influence their expression. The aim of this study was to investigate the relationship between an IL-1β and IL-4 promoter polymorphisms and nasal polyps. The C-511T promoter polymorphism of the IL-1β gene and C-590T promoter polymorphism of the IL-4 gene were genotyped by polymerase chain reaction-restriction fragment length polymorphism analysis in 208 Polish patients with nasal polyps and 200 healthy Polish subjects. The risk of susceptibility to NP was significantly higher in patients with NP who had -511 T/T genotype of IL1β than in controls (OR 3.07; 95 % CI 1.18-7.99). No statistically significant differences were found between NP patients and the control group with regard to genotype distribution and allele frequencies of C/T polymorphism of IL4 gene. Our study demonstrated that the TT genotype for C-511T mutation associated with the risk of developing NP in a Polish population.

Expression of matrix metalloproteinase 2 and 9 and tissue inhibitor of metalloproteinase 1 in nonrecurrent vs recurrent nasal polyps

BACKGROUND

Matrix metalloproteinases (MMPs) 2 and 9 are a group of Zn2+-dependent endopeptidases to remodel the extracellular matrix. The association of these 2 endopeptidases with the development of morphologic changes in nasal polyps was previously described.

OBJECTIVE

To determine whether MMP-2, MMP-9, and tissue inhibitor of MMP-1 (TIMP-1) play a role in the recurrence of nasal polyps.

METHODS

To compare MMP-2, MMP-9, and TIMP-1 expression in recurrent vs nonrecurrent polyps, nasal polyps (NPs) and recurrent nasal polyps (RNPs) were obtained from 15 NP patients with chronic rhinosinusitis (CRS) undergoing endoscopic sinus surgery (ESS) and 15 RNP patients with CRS undergoing revision ESS. Fifteen specimens of inferior turbinate mucosa from patients undergoing nasal septal surgery were used as control. Through real-time polymerase chain reaction and immunohistochemistry, MMP-2, MMP-9, and TIMP-1 expressions were measured among controls, NP patients, and RNP patients.

RESULTS

Expression of MMP-9 messenger RNA in the NP patients was significantly higher than in the controls. In addition, expression of MMP-9 messenger RNA in the RNP patents was significantly increased compared with NP patients. With immunohistochemistry, a more increased expression of MMP-9 was observed in NP patients than controls. Expression of MMP-9 in RNP patients was also significantly high compared with NP patients, particularly in stroma.

CONCLUSION

Expression of MMP-9 is increased in NP patients, and it is so more in the mucosa of RNP patients. Increased expression of MMP-9 is particularly found in the stoma of RNP patients, and it may contribute to the recurrence of NP.

Update on the management of chronic rhinosinusitis

Chronic rhinosinusitis (CRS) is a common disorder characterized by mucosal inflammation of the nose and paranasal sinuses with sinonasal symptoms persisting for greater than 12 weeks. The etiology of CRS is incompletely understood. Current understanding supports inflammation, rather than infection, as the dominant etiologic factor. CRS significantly impacts patients' quality of life and health care expenditure. There is no standard management of CRS. Treatment strategies differ based on divergent etiologies of the various CRS subclasses. Both systemic and topical agents are used. These interventions differ in CRS with nasal polyposis (CRSwNP), CRS without nasal polyposis (CRSsNP) and specific situations such as allergic fungal rhinosinusitis or aspirin-exacerbated respiratory disease. Antibiotics are the most commonly prescribed medication for CRS, but their role in management is not strongly supported by high-level studies. This paper provides a succinct review of the evidence supporting or refuting common therapeutic agents in the management of CRS. Novel and emerging strategies will also be discussed.

Ubiquitin E3 ligase TNFIAP3 mediates endosome/lysosome fusion in nasal epithelial cells

The nasal epithelial barrier dysfunction is associated with the pathogenesis of nasal allergy; the causative factors are to be further elucidated. Ubiquitin E3 ligase TNFIAP3 (TNFIAP3, in short) plays a role in the maintenance of the homeostasis in the body. This study aims to elucidate the role of TNFIAP3 in the degradation of endocytic substances in nasal epithelial cells. The nasal epithelial cell line, RPMI 2650 cells (RPC), was cultured into monolayers in transwells. The endocytosis of staphylococcal enterotoxin B (SEB) by RPC monolayers was assessed by enzyme-linked immunoassay. The endocytosis of SEB-triggered endosome/lysosome fusion was observed by immunocytochemistry. The results showed that RPC monolayers expressed TNFIAP3 upon the endocytosis of SEB. Deficiency of TNFIAP3 resulted in abundant SEBs being transported to the basal chambers of transwells via the intracellular pathway. In the TNFIAP3-sufficient RPC, SEB-carrying endosomes fused with lysosomes were observed. The TNFIAP3-deficient RPC showed few SEB-carrying endosomes fused with lysosomes. In summary, TNFIAP3 plays an important role in tethering endosomes to lysosomes in RPC.

Differences in airway inflammation according to atopic status in patients with chronic rhinitis

Background

Chronic rhinitis is a heterogeneous group of diseases that cause nasal inflammation. And the nose may be a window into the lung in the concept of "one airway one disease."

Objective

This study was conducted to evaluate differences between the different forms of chronic rhinitis in terms of lower airway inflammation.

Methods

Patients that attended the allergy clinic and presented with moderate/severe persistent rhinitis symptoms for more than 1 year were enrolled. The patients with chronic rhinitis were classified into two groups (house dust mites [HDM]-sensitive allergic rhinitis [AR] or non-allergic rhinitis [NAR]) according to the presence of atopy, and additionally according to nasal polyposis and airway hyperresponsiveness, respectively. Medical records were reviewed and the mRNA expression levels of IL-5, IFN-γ, TGF-β1, IL-17A, and IL-25 were evaluated in induced sputum samples in each group.

Results

Induced sputum samples of 53 patients were evaluated. Patients with NAR were significantly older than patients with HDM-sensitive AR (p < 0.05). Nasal polyposis was more prevalent in NAR patients than in HDM-sensitive AR patients (10.2% vs. 62.5%, p < 0.001). The expression levels of IL-17A mRNA were higher in NAR patients, regardless of the presence of airway hyperresponsiveness (p = 0.005).

Conclusion

These results suggest that patients with different forms of chronic rhinitis could have different inflammatory environments in their lower airway and NAR patients might have bronchial inflammation related to the elevated levels of IL-17A compared to HDM-sensitive AR patients.

Nasal polyposis in patients with asthma and allergic rhinitis

OBJECTIVE

This study aimed to determine the prevalence of nasal polyps in patients with allergic rhinitis and with asthma, and also to assess the impact of this condition on these disorders.

STUDY DESIGN

Cross-sectional study.

METHODS

The presence of nasal polyps was assessed by rhinoscopy and endoscopic examination.

RESULTS

Nasal polyps were detected in 60 out of 250 patients (24 per cent) with documented asthma or allergic rhinitis. There was a statistically significant correlation between asthma severity and nasal polyposis prevalence (p = 0.007), but not between allergic rhinitis severity and nasal polyposis prevalence (p = 0.081). The prevalence of nasal polyps increased significantly with increasing patient age and rhinitis or asthma duration.

CONCLUSION

The prevalence of nasal polyps in patients with allergic rhinitis or asthma was higher than previously reported. Given this high prevalence of nasal polyposis, nasal examination and concomitant treatment of this disorder are recommended.

Nasal endoscopy in children with suspected allergic rhinitis

OBJECTIVES/HYPOTHESIS

Ear, nose, and throat assessment may be frequently requested for children with allergic rhinitis (AR). Nasal endoscopy allows a thorough evaluation of the nose. The aim of the study was to investigate whether there are endoscopic signs predictive for AR diagnosis in a cohort of children with suspected AR.

STUDY DESIGN

Cohort of observational study.

METHODS

There were 176 children (99 males; mean age, 7.5 years) studied. Clinical visit, nasal endoscopy, and skin prick test were performed in all patients. Nasal endoscopic signs were pale turbinates, middle turbinate contact, and inferior turbinate contact. The AR diagnosis was made when nasal symptom history was concordant with sensitization.

RESULTS

AR was diagnosed in 141 children. Inferior and middle turbinate contact were reliable predictive factors for AR (odds ratio 5.38 and 3.42, respectively), whereas pale turbinates did not predict it.

CONCLUSIONS

This study suggests that nasal endoscopy may reveal signs predictive for AR diagnosis in children.

The Role of IgE Production in the Pathophysiology of Rhinitis and Rhinosinusitis

A multitude of potential etiologies exist for rhinitis and rhinosinusitis. These sinonasal disorders are heterogeneous entities that are best understood by evaluating the causative factors in each individual patient. More precise diagnosis permits accurate and effective treatment. The association of allergy with sinonasal symptoms has been described for decades; however, the specific relationship between allergy, rhinitis, and rhinosinusitis is complex. Considering allergy in terms of a systemic atopic disorder, along with a local inflammatory process mediated by IgE production in sinonasal tissues, is helpful in unveiling the complex connection between allergy, rhinitis, and rhinosinusitis. This article reviews recent literature regarding local IgE and sinonasal inflammatory conditions.

CD23-dependent transcytosis of IgE and immune complex across the polarized human respiratory epithelial cells

IgE-mediated allergic inflammation occurs when allergens cross-link IgE on the surface of immune cells, thereby triggering the release of inflammatory mediators as well as enhancing Ag presentations. IgE is frequently present in airway secretions, and its level can be enhanced in human patients with allergic rhinitis and bronchial asthma. However, it remains completely unknown how IgE appears in the airway secretions. In this study, we show that CD23 (FcεRII) is constitutively expressed in established or primary human airway epithelial cells, and its expression is significantly upregulated when airway epithelial cells were subjected to IL-4 stimulation. In a transcytosis assay, human IgE or IgE-derived immune complex (IC) was transported across a polarized Calu-3 monolayer. Exposure of the Calu-3 monolayer to IL-4 stimulation also enhanced the transcytosis of either human IgE or the IC. A CD23-specific Ab or soluble CD23 significantly reduced the efficiency of IgE or IC transcytosis, suggesting a specific receptor-mediated transport by CD23. Transcytosis of both IgE and the IC was further verified in primary human airway epithelial cell monolayers. Furthermore, the transcytosed Ag-IgE complexes were competent in inducing degranulation of the cultured human mast cells. Because airway epithelial cells are the first cell layer to come into contact with inhaled allergens, our study implies CD23-mediated IgE transcytosis in human airway epithelial cells may play a critical role in initiating and contributing to the perpetuation of airway allergic inflammation.

Local and systemic IgE in the evaluation and treatment of allergy

Traditional descriptions of type I hypersensitivity and its manifestations center on systemic immunoglobulin E (IgE)-mediated reactions to inciting antigens. Hence, many current diagnostic and therapeutic measures are based on systemic skin testing for allergy, systemic pharmacotherapy, and immunotherapy. Recent developments in rhinology and pulmonology, particularly in defining the phenomenon of local IgE production in various airway inflammatory conditions, have an impact on both medical and surgical diagnosis and management of these conditions. This review includes a discussion of allergy as a systemic disease, current systemic diagnostic and management strategies for allergy, and local IgE presence and synthesis in the upper and lower airways.

Local production of IgE in the respiratory mucosa and the concept of entopy: does allergy exist in nonallergic rhinitis?

OBJECTIVE

To review research regarding locally produced IgE and its impact on patients with chronic rhinitis.

DATA SOURCES

PubMed search with the following keywords: entopy, local IgE, nonallergic rhinitis, idiopathic rhinitis, vasomotor rhinitis, and allergic rhinitis.

STUDY SELECTION

Articles were selected based on their relevance to entopy and locally produced IgE and its clinical effect and relationship to idiopathic rhinitis (IR).

RESULTS

Local IgE has been found in a variety of tissues, including nasal and bronchial mucosa. IgE is produced in these local tissues and not simply the product of migration to the tissue from regional lymphoid tissue or blood. Local IgE has been identified in most of both atopic and nonatopic asthmatic patients and allergic rhinitis patients. Up to 40% of patients with IR and a positive nasal provocation test result have evidence of locally produced IgE, which has been coined entopy. Although patients with allergic rhinitis and IR show similar inflammatory patterns with increased activated mast cells, eosinophils, and T-cell subsets in some studies, other studies on IR patients are conflicting with regard to both inflammation and allergen-specific nasal provocation test results.

CONCLUSION

The concept of local allergy in IR patients is both intriguing and controversial. Studies have reported conflicting results, and currently there is no single best test to evaluate for entopy. It is known that there are a large number of IR patients for whom current treatment regimens are suboptimal. Therefore, further research elucidating the mechanisms of IR and the concept of localized IgE are needed to optimally diagnose this condition and treat this group of patients.

Perspectives on the etiology of chronic rhinosinusitis

PURPOSE OF REVIEW

This article reviews recent insights surrounding the etiology and pathogenesis of chronic rhinosinusitis. In particular, we highlight the increasing recognition of host-mediated mechanisms in driving mucosal inflammation.

RECENT FINDINGS

Published differences between epithelium from patients with chronic rhinosinusitis and normal controls can be classified into several broad categories. Alterations are reported in the various components of the epithelial innate immune system including epithelial-expressed pattern-recognition receptors (PRRs) and the levels of antimicrobial innate immune effector molecules. Other studies demonstrate differences in the proteins involved in maintaining epithelial barrier integrity. Finally, recent studies show in chronic rhinosinusitis that epithelial-derived cytokines, chemokines and inducible surface proteins are involved in recruiting and activating cells of the adaptive immune system.

CONCLUSION

The sinonasal epithelium provides a mechanical and innate immune barrier to a diverse array of environmental agents. This barrier also plays a key role in regulating the acquired mucosal immune response in the nose. Recent studies suggest that defects in this barrier may foster development of chronic sinonasal inflammation in response to environmental agents, and pathogenic or commensal organisms. The ability to dissect and analyze defects in the inflammatory response in rhinosinusitis may help identify novel targets for drug development.