Comorbidity has no impact on eosinophil inflammation in the upper airways or on severity of the sinonasal disease in patients with nasal polyps

Predictive Value of Eosinophil Cationic Protein in Nasal Secretions in Eosinophilic Chronic Rhinosinusitis

OBJECTIVES

To investigate the value of secretions Eosinophilic cationic protein (ECP) detection in the diagnosis of endotypes of Chronic rhinosinusitis (CRS) and its correlation with clinical symptoms, so as to provide guidance for the clinical application of EOS and ECP detection in secretions.

METHODS

Patients' nasal secretions and polyps (or middle turbinate for control) were collected and their EOS% and ECP levels were measured. Correlation analysis was performed for EOS% and ECP levels in secretions and tissues, respectively. The correlation between secretions EOS% and ECP and clinical symptom scores (symptomatic visual analog scale (VAS) scores, Lanza-kennedy scores from nasal endoscopy and Lund-Mackay scores from sinus CT) was further analyzed. Receiver operating characteristic curves were used to assess the predictive potential of EOS% and ECP in nasal secretions.

RESULTS

Eosinophilic chronic rhinosinusitis (ECRS) patients had higher concentrations of ECP in nasal secretions than healthy subjects and NECRS (non-eosinophilic CRS) (p < 0.0001;0.0001); EOS% in nasal secretions was higher in ECRS than healthy subjects (p = 0.0055), but the differences between ECRS and NECRS were not statistically significant (p = 0.0999). Correlation analysis showed that tissue EOS% was correlated with ECP concentration and EOS% in nasal secretions (R = 0.5943;0.2815). There was a correlation between EOS% in secretions with a total LM score (R = 0.3131); ECP concentration in secretions with a total LK score (R = 0.3792). To diagnose ECRS, the highest area under the curve (0.8230) was determined for ECP in secretions; the highest area under the curve (0.6635) was determined for EOS% in secretions.

CONCLUSION

Measurement of ECP in nasal secretions is useful for non-invasive diagnosis of ECRS.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:3304-3312, 2023.

Biologics in Otolaryngology: Past, Present, and Future

Biologics have been widely adopted in multiple subspecialties of otolaryngology. This article provides an overview of past, present, and future uses of biologics in otolaryngology with emphasis on allergic rhinitis, chronic rhinosinusitis with polyposis, head and neck squamous cell carcinoma, salivary and skull base tumors, hearing loss, and other otologic disorders.

Non-Reflex Defense Mechanisms of Upper Airway Mucosa: Possible Clinical Application

The sinonasal mucosa has an essential role in defense mechanisms of the upper respiratory tract. The innate immune system presents the primary defense against noxious microorganisms followed by induction of the adaptive immune mechanisms as a consequence of the presence of pathogens. This well-known activation of adaptive immune system in response to presence of the antigen on mucosal surfaces is now broadly applicated in vaccinology research. Prevention of infectious diseases belongs to substantial challenges in maintaining the population health. Non-invasive, easily applicable mucosal vaccination purposes various research opportunities that could be usable in daily practice. However, the existence of multiple limitations such as rapid clearance of vaccine from nasal mucosa by means of mucociliary transport represents a great challenge in development of safe and efficient vaccines. Here we give an updated view on nasal functions with focus on nasal mucosal immunity and its potential application in vaccination in nearly future.

Bidirectional association between asthma and chronic rhinosinusitis: Two longitudinal follow-up studies using a national sample cohort

The aim of this study was to evaluate an epidemiologic association of asthma and chronic rhinosinusitis (CRS) using a national sample cohort of the Korean population. We collected data from the Korean Health Insurance Review and Assessment Service-National Sample Cohort between 2002 and 2013, and two different case-control cohorts were designed (1st: asthmatic patients matched in a 1:1 ratio with 204,119 non-asthmatics as control I, 2nd: CRS patients matched in a 1:4 ratio with 124,020 non-CRS patients as control II). Bidirectional association was examined using Cox proportional hazard models stratified by age, sex, income, and region of residence. Patients with asthma had an increased risk of developing CRS [adjusted hazard ratio (95% confidence interval) = 1.74 (1.67–1.80)], both with nasal polyps [1.55 (1.36–1.78)], without nasal polyps [1.74 (1.67–1.81)]. In the second cohort, patients with CRS had increased risk of developing asthma [1.85 (1.80–1.91)] with similar results for those with and without nasal polyps. The strongest association for risk of CRS was in 20–39 years old men with asthma [2.41 (1.97–2.96)], while the strongest association for increased risk of asthma in those with CRS group was also seen in this same subgroup [2.40 (2.18–2.63)]. CRS and asthma had a bidirectional influence on each other. CRS increased the risk of asthma, and asthma increased the risk of CRS, especially in young men.

Revision surgery rates in chronic rhinosinusitis with nasal polyps: meta-analysis of risk factors

BACKGROUND

Wide variations in revision endoscopic sinus surgery (ESS) rates for chronic rhinosinusitis with nasal polyposis (CRSwNP) have been reported. It is important to understand expected revision rates and factors that impact the need for revision.

METHODS

A literature search was conducted on PubMed, Scopus, and the Cochrane Database of Systematic Reviews. Following PRISMA guidelines, a systematic review and meta-analysis was performed on studies that reported revision surgery data for CRSwNP patients.

RESULTS

Forty-five studies with 34,220 subjects were meta-analyzed, with an overall revision rate of 18.6% (95% confidence interval, 14.1%-23.6%). Studies with extractable follow-up data reported a mean revision rate of 16.2% over a weighted mean follow-up of 89.6 months. Factors associated with increased revision rates included allergic fungal rhinosinusitis (28.7%), aspirin-exacerbated respiratory disease (27.2%), asthma (22.6%), prior polypectomy (26.0%), and publication prior to 2008 (22.7%) (p < 0.05 for all).

CONCLUSION

Although polyps can recur after ESS, reported long-term ESS revision rates are approximately 14% to 24%. Identifying risk factors for revision surgery can help manage patient expectations and determine optimal personalized treatments.

Nasal cytology: Methodology with application to clinical practice and research

Nasal cytology is an easy, cheap, non-invasive and point-of-care method to assess nasal inflammation and disease-specific cellular features. By means of nasal cytology, it is possible to distinguish between different inflammatory patterns that are typically associated with specific diseases (ie, allergic and non-allergic rhinitis). Its use is particularly relevant when other clinical information, such as signs, symptoms, time-course and allergic sensitizations, is not enough to recognize which of the different rhinitis phenotypes is involved; for example, it is only by means of nasal cytology that it is possible to distinguish, among the non-allergic rhinitis, those characterized by eosinophilic (NARES), mast cellular (NARMA), mixed eosinophilic-mast cellular (NARESMA) or neutrophilic (NARNE) inflammation. Despite its clinical usefulness, cheapness, non-invasiveness and easiness, nasal cytology is still underused and this is at least partially due to the fact that, as far as now, there is not a consensus or an official recommendation on its methodological issues. We here review the scientific literature about nasal cytology, giving recommendations on how to perform and interpret nasal cytology.

Nasal Nitric Oxide in Healthy Adults – Reference Values and Affecting Factors

Nitric oxide (NO) is an important endogenous mediator with significant role in the respiratory system. Many endogenous and exogenous factors influence the synthesis of NO and its level is significantly changed during the inflammation. Analysis of nasal nitric oxide (nNO) is not validated so far as the diagnostic method. There is a lack of reference values with possible identification of factors modulating the nNO levels. In healthy adult volunteers (n=141) we studied nasal NO values by NIOX MINO® (Aerocrine, Sweden) according to the recommendations of the ATS & ERS. Gender, age, height, body weight, waist-to-hip ratio, FEV1/FVC, PEF and numbers of leukocytes, eosinophils, basophils and monocytes were studied as potential variables influencing the levels of nNO. The complexity of the results allowed us to create a homogenous group for nasal NO monitoring and these data can be used further as the reference data for given variables. Because of significant correlation between nNO and exhaled NO, our results support the “one airway – one disease” concept. Reference values of nasal NO and emphasis of the individual parameters of tested young healthy population may serve as a starting point in the non-invasive monitoring of the upper airway inflammation.

Role of Eosinophil Granulocytes in Allergic Airway Inflammation Endotypes

Eosinophil granulocytes are intriguing members of the innate immunity system that have been considered important defenders during parasitic diseases as well as culprits during allergy-associated inflammatory diseases. Novel studies have, however, found new homoeostasis-maintaining roles for the cell. Recent clinical trials blocking different Th2 cytokines have uncovered that asthma is heterogeneous entity and forms different characteristic endotypes. Although eosinophils are present in allergic asthma with early onset, the cells may not be essential for the pathology. The cells are, however, likely disease causing in asthma with a late onset, which is often associated with chronic rhinosinusitis. Assessment of eosinophilia, fraction exhaled nitric oxide (FeNO) and periostin are markers that have emerged useful in assessing and monitoring asthma severity and endotype. Current scientific knowledge suggests that eosinophils are recruited by the inflammatory environment, activated by the innate interleukin (IL)-33 and prevented from apoptosis by both lymphocytes and innate immune cells such as type two innate immune cells. Eosinophils contain four specific granule proteins that exhibit an array of toxic and immune-modulatory activates. The granule proteins can be released by different mechanisms. Additionally, eosinophils contain a number of inflammatory cytokines and lipid mediators as well as radical oxygen species that might contribute to the disease both by the recruitment of other cells and the direct damage to supporting cells, leading to exacerbations and tissue fibrosis. This review aimed to outline current knowledge how eosinophils are recruited, activated and mediate damage to tissues and therapies used to control the cells.

Two inflammatory phenotypes of nasal polyps and comorbid asthma

BACKGROUND

Nasal polyps and comorbid asthma (NPCA) is a common united airway disease. However, the inflammatory phenotyes of NPCA are not clear.

OBJECTIVE

To identify inflammatory phenotypes of NPCA.

METHODS

A total of 106 patients diagnosed with NPCA were recruited from rhinologic clinics. A combined method of biopsies from nasal polyps and fractional exhaled nitric oxide (FeNO) was used to explore inflammatory phenotyes of NPCA. Patients were evaluated with respect to clinical, functional, and inflammatory parameters. Clinical outcomes after medical treatment were also assessed.

RESULTS

Two distinct inflammatory phenotypes (eosinophilic [64.15%] and noneosinophilic phenotypes [35.85%]) were identified. Inflammatory patterns of upper and lower airways were consistent in NPCA. Patients with eosinophilic NPCA had a higher nasal polyps recurrence rate than did patients with noneosinophilic NPCA, a more severe asthma phenotype (P < .001), higher exhaled nitric oxide levels (P < .001), higher IgE levels (P < .001), higher Lund-Mackay scores (P < .05), and more blood eosinophilia (P < .001). In addition, eosinophilic NPCA was associated with worse pulmonary function and responded well to an 8-week course of medical treatment based on computed tomographic findings and the ratio of forced expiratory volume in 1 second to forced vital capacity. The total IgE concentration was a marker for eosinophilic NPCA (optimal cutoff, >55.5 kU/L; sensitivity, 86.2%; specificity, 85.4%).

CONCLUSION

Patients with NPCA had 2 inflammatory phenotypes with distinct clinical profiles. Total IgE is a marker of eosinophilic NPCA.

A pilot study of symptom profiles from a polyp vs an eosinophilic-based classification of chronic rhinosinusitis

BACKGROUND

Chronic rhinosinusitis (CRS) is likely a biologically heterogeneous disease process. Current guidelines propose subclassification using polyp status while others propose using mucosal eosinophilia. We hypothesized that appropriate CRS subclassification would increase homogeneity of baseline symptoms, and identify characteristic symptoms of each subtype.

METHODS

A total of 57 CRS patients undergoing surgery prospectively completed a preoperative battery of 73 questions relating to symptoms including the 22-item Sino-Nasal Outcome Test (SNOT-22) and 29-item Patient-Reported Outcomes Measurement Information System (PROMIS-29) general quality of life (QOL) measures. Eosinophilic cationic protein (ECP) levels were determined from ethmoid, uncinate, and polyp tissue homogenates using enzyme-linked immunosorbent assay (ELISA) and normalized to total protein. Patients were classified as eosinophilic (eCRS) or non-eosinophilic (neCRS) using a 95th percentile threshold established from control tissue from 82 patients without CRS. Separate pairwise comparisons were performed on patient-reported symptoms using polyp and eosinophilic status.

RESULTS

Of the 57 patients, 28 had CRS with nasal polyps (CRSwNP); 27 of 57 patients had eCRS (CRSwNP, n = 21; CRS without nasal polyps [CRSsNP], n = 6). CRSwNP patients had increased need to blow nose, frequency of nasal congestion, more severe difficulty breathing through nose, more severe nasal discharge, but less cough (p < 0.05). eCRS patients had more bothersome loss of taste/smell, ear pain, sneezing, severe difficulty breathing through nose, and severe nasal congestion compared to neCRS patients (p < 0.05).

CONCLUSION

Subclassifying CRS with symptoms alone is difficult with neither polyp status nor eosinophilia giving a distinctive clinical symptom profile. However, certain symptoms may help otolaryngologists identify CRS subtypes, which may help guide future treatments. Further validation and evaluation of prognosis following treatment is required to evaluate appropriate means of subclassifying CRS.