Reversibility of reduced mucociliary clearance in chronic sinusitis

Treatment for sialorrhea (excessive saliva) in people with motor neuron disease/amyotrophic lateral sclerosis

BACKGROUND

Motor neuron disease (MND), also known as amyotrophic lateral sclerosis (ALS), is a progressive neurodegenerative condition that may cause dysphagia, as well as limb weakness, dysarthria, emotional lability, and respiratory failure. Since normal salivary production is 0.5 L to 1.5 L daily, loss of salivary clearance due to dysphagia leads to salivary pooling and sialorrhea, often resulting in distress and inconvenience to people with MND. This is an update of a review first published in 2011.

OBJECTIVES

To assess the effects of treatments for sialorrhea in MND, including medications, radiotherapy and surgery.

SEARCH METHODS

On 27 August 2021, we searched the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, Embase, AMED, CINAHL, ClinicalTrials.gov and the WHO ICTRP. We checked the bibliographies of the identified randomized trials and contacted trial authors as needed. We contacted known experts in the field to identify further published and unpublished papers.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and quasi-RCTs, including cross-over trials, on any intervention for sialorrhea and related symptoms, compared with each other, placebo or no intervention, in people with ALS/MND.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We identified four RCTs involving 110 participants with MND who were described as having intractable sialorrhea or bulbar dysfunction. A well-designed study of botulinum toxin B compared to placebo injected into the parotid and submandibular glands of 20 participants showed that botulinum toxin B may produce participant-reported improvement in sialorrhea, but the confidence interval (CI) was also consistent with no effect. Six of nine participants in the botulinum group and two of nine participants in the placebo group reported improvement (risk ratio (RR) 3.00, 95% CI 0.81 to 11.08; 1 RCT; 18 participants; low-certainty evidence). An objective measure indicated that botulinum toxin B probably reduced saliva production (in mL/5 min) at eight weeks compared to placebo (MD -0.50, 95% CI -1.07 to 0.07; 18 participants, moderate-certainty evidence). Botulinum toxin B may have little to no effect on quality of life, measured on the Schedule for Evaluation of Individual Quality of Life direct weighting scale (SEIQoL-DW; 0-100, higher values indicate better quality of life) (MD -2.50, 95% CI -17.34 to 12.34; 1 RCT; 17 participants; low-certainty evidence). The rate of adverse events may be similar with botulinum toxin B and placebo (20 participants; low-certainty evidence). Trialists did not consider any serious events to be related to treatment. A randomized pilot study of botulinum toxin A or radiotherapy in 20 participants, which was at high risk of bias, provided very low-certainty evidence on the primary outcome of the Drool Rating Scale (DRS; range 8 to 39 points, higher scores indicate worse drooling) at 12 weeks (effect size -4.8, 95% CI -10.59 to 0.92; P = 0.09; 1 RCT; 16 participants). Quality of life was not measured. Evidence for adverse events, measured immediately after treatment (RR 7.00, 95% CI 1.04 to 46.95; 20 participants), and after four weeks (when two people in each group had viscous saliva) was also very uncertain. A phase 2, randomized, placebo-controlled cross-over study of 20 mg dextromethorphan hydrobromide and 10 mg quinidine sulfate (DMQ) found that DMQ may produce a participant-reported improvement in sialorrhea, indicated by a slight improvement (decrease) in mean scores for the primary outcome, the Center for Neurologic Study Bulbar Function Scale (CNS-BFS). Mean total CNS-BFS (range 21 (no symptoms) to 112 (maximum symptoms)) was 53.45 (standard error (SE) 1.07) for the DMQ treatment period and 59.31 (SE 1.10) for the placebo period (mean difference) MD -5.85, 95% CI -8.77 to -2.93) with a slight decrease in the CNS-BFS sialorrhea subscale score (range 7 (no symptoms) to 35 (maximum symptoms)) compared to placebo (MD -1.52, 95% CI -2.52 to -0.52) (1 RCT; 60 participants; moderate-certainty evidence). The trial did not report an objective measure of saliva production or measure quality of life. The study was at an unclear risk of bias. Adverse events were similar to other trials of DMQ, and may occur at a similar rate as placebo (moderate-certainty evidence, 60 participants), with the most common side effects being constipation, diarrhea, nausea, and dizziness. Nausea and diarrhea on DMQ treatment resulted in one withdrawal. A randomized, double-blind, placebo-controlled cross-over study of scopolamine (hyoscine), administered using a skin patch, involved 10 randomized participants, of whom eight provided efficacy data. The participants were unrepresentative of clinic cohorts under routine clinical care as they had feeding tubes and tracheostomy ventilation, and the study was at high risk of bias. The trial provided very low-certainty evidence on sialorrhea in the short term (7 days' treatment, measured on the Amyotrophic Lateral Scelerosis Functional Rating Scale-Revised (ALSFRS-R) saliva item (P = 0.572)), and the amount of saliva production in the short term, as indicated by the weight of a cotton roll (P = 0.674), or daily oral suction volume (P = 0.69). Quality of life was not measured. Adverse events evidence was also very uncertain. One person treated with scopolamine had a dry mouth and one died of aspiration pneumonia considered unrelated to treatment.

AUTHORS' CONCLUSIONS

There is some low-certainty or moderate-certainty evidence for the use of botulinum toxin B injections to salivary glands and moderate-certainty evidence for the use of oral dextromethorphan with quinidine (DMQ) for the treatment of sialorrhea in MND. Evidence on radiotherapy versus botulinum toxin A injections, and scopolamine patches is too uncertain for any conclusions to be drawn. Further research is required on treatments for sialorrhea. Data are needed on the problem of sialorrhea in MND and its measurement, both by participant self-report measures and objective tests. These will allow the development of better RCTs.

Reversibility of mucociliary clearance and olfaction impairment following endoscopic sinus surgery: a prospective observational study

OBJECTIVE

Chronic rhinosinusitis is associated with altered mucociliary clearance and olfaction. The study aimed to analyse the reversibility of impairment and endoscopic factors predicting changes in mucociliary clearance and olfactory parameters.

METHODS

This prospective study included patients undergoing functional endoscopic sinus surgery for medically refractory chronic rhinosinusitis. Pre- and post-operative measurements of mucociliary clearance, olfactory thresholds, and identification scores were recorded.

RESULTS

Of the 96 patients, 65.6 per cent had polyposis and 80.2 per cent underwent primary surgery. Improvements in mucociliary clearance and olfaction scores were seen in all patients, with greater reversibility of impairment in patients with polyposis and in those who underwent revision surgery. The presence of polyps correlated significantly with changes in mucociliary clearance and olfaction.

CONCLUSION

The study highlights improvements in mucociliary clearance, olfactory thresholds and identification scores after functional endoscopic sinus surgery in chronic rhinosinusitis with or without nasal polyposis, as well as for primary and revision surgeries. Adequate post-operative care and prevention of polyps recurrence help to improve mucociliary clearance and olfaction scores.

Enhancement of ciliary beat amplitude by carbocisteine in ciliated human nasal epithelial cells

OBJECTIVE

Carbocisteine (CCis), a mucoactive agent, is used to improve the symptoms of sinonasal diseases. However, the effect of CCis on nasal ciliary beating remains uncertain. We examined the effects of CCis on ciliary beat distance (CBD, an index of amplitude), and ciliary beat frequency (CBF) in ciliated human nasal epithelial cells (cHNECs) in primary culture.

METHODS

The cHNECs were prepared from the nasal tissue resected from patients required surgery for chronic sinusitis (CS) or allergic rhinitis (AR). CBD and CBF were measured using videomicroscopy equipped with a high-speed camera.

RESULTS

CCis increased CBD by 30%, but not CBF, and decreased intracellular Cl^- concentration ([Cl^- ]_i ) in cHNECs. The CCis' actions were mimicked by the Cl^- -free NO₃ ^- solution. In contrast, prior treatment of NPPB (20 μM) or CFTR(inh)-172 (1 μM), which increased [Cl^- ]_i by 20%, decreased CBF by 10% and CBD by 25% and inhibited the CCis' actions. However, prior treatment of T16Ainh-A01 (10 μM) did not inhibit the CCis' actions, although it decreased [Cl^- ]_i by 10% and CBD by 15%. Thus, CCis stimulates Cl^- channels including cystic fibrosis transmembrane conductance regulator (CFTR). Moreover, CCis enhanced the transport of microbeads driven by the beating cilia in cHNECs. The CCis actions were similar in cHNECs from both types of pateints.

CONCLUSION

CCis increased CBD by 30% in cHNECs via an [Cl^- ]_i decrease stimulated by activation of Cl^- channels, including CFTR. CCis may stimulate nasal mucociliary clearance by increasing CBD in patients contracting CS or AR.

LEVEL OF EVIDENCE

NA. Laryngoscope, 130:E289-E297, 2020.

Mucociliary Clearance of the Maxillary Sinuses in Patients with Recurrent or Chronic Sinusitis

This is one of the first human studies of maxillary sinus mucociliary activity using human serum albumin labelled with 99m-technetium (99mTc-HSA) as a tracer in patients suffering from recurrent or chronic maxillary sinusitis. The tracer was injected into both maxillary sinuses through small sinus irrigation catheters. Nasal endoscopy and computed tomography were performed in all patients shortly before the injection. The clearance rates of four case report patients with different endoscopic and radiographic findings showed great individual variation. The technique proved to have viability for clinical use when evaluating sinusitis treatment options and results.

Rheologic Properties of Nasal Mucus from Patients with Chronic Sinusitis

The rheologic properties of nasal mucus from the patients with chronic sinusitis was determined by the oscillating sphere magnetic rheometer. The increase in the elastic modulus (G’) and the decrease in the dynamic viscosity (η’) of mucoid and mucopurulent nasal mucus indicate that both types of nasal mucus possess the network of transient cross-links between macromolecules. The G’ and the η’ of 12 mucopurulent nasal mucus was significantly high compared with those of 13 mucoid mucus (p < 0.01), and those of mucopurulent mucus were out of the optimal range for mucociliary transport. Results suggest that abnormally high viscoelasticity of nasal mucus is one of the causes of reduced nasal mucociliary clearance in chronic sinusitis.

Comparison between the use of saline and seawater for nasal obstruction in children under 2 years of age with acute upper respiratory infection

BACKGROUND/AIM

The effectiveness of isotonic and hypertonic saline solutions used to open the nasal passage and improve clinical symptoms was compared in children under 2 years of age admitted with the common cold.

MATERIALS AND METHODS

The study was performed as a randomized, prospective, and double-blind study. The study included 109 children. The children using saline (0.9%) and seawater (2.3%) as nasal drops (the patient group) and the control group (in which nasal drops were not administered) were compared. Seventy-four patients received nasal drops from package A (seawater) in single days and from package B (physiological saline) in double days.

RESULTS

The mean age of the patients was 9.0 ± 3.9 months and the numbers of boys and girls were 65 (59.6%) and 44 (40.4%), respectively. There was no significant difference between Groups A and B in terms of nasal congestion (P > 0.05). However, a significant difference was found between the control group and Groups A and B (P < 0.05).

CONCLUSION

Relief was seen in nasal congestion, weakness, sleep quality, and nutrition with the use of both saline and seawater in children with the common cold. Seawater or saline drops may be added to standard treatment protocols.

Comparison by objective parameters in patients with chronic rhinosinusitis managed medically and surgically (with and without powered instruments)

Objective:

To compare mucociliary clearance time and quality of life in patients who underwent sinus surgery using conventional and powered instruments, and in patients who were treated nonsurgically.

Methods:

A total of 151 patients with chronic rhinosinusitis were included. Fifty-four patients were treated conservatively, 48 patients were managed surgically by using conventional instruments and 49 patients were managed by using a microdebrider. Kupferberg nasal endoscopy grades, 20-item Sino-Nasal Outcome Test scores, Lund-Mackay scores, and mucociliary clearance time were analyzed.

Results:

On comparison among the groups, it was found that there was a significant difference between group A (nonsurgically treated) compared with group B (surgery by conventional means) or group C (surgery with microdebrider) in nasal endoscopic grades, Lund-Mackay scores, 20-item Sino-Nasal Outcome Test scores, and mucociliary clearance time. However, in comparison between groups B and C, there was no statistically significant difference.

Conclusion:

Mucociliary clearance time tended to recover after starting treatment for chronic rhinosinusitis both after conservative treatment and after surgical treatment. Surgery provided better improvement in different objective scores in chronic rhinosinusitis. There exists no statistical difference in parameters independent of the instrument used for surgery.

Genetic variation in genes encoding airway epithelial potassium channels is associated with chronic rhinosinusitis in a pediatric population

Background

Apical potassium channels regulate ion transport in airway epithelial cells and influence air surface liquid (ASL) hydration and mucociliary clearance (MCC). We sought to identify whether genetic variation within genes encoding airway potassium channels is associated with chronic rhinosinusitis (CRS).

Methods

Single nucleotide polymorphism (SNP) genotypes for selected potassium channels were derived from data generated on the Illumnia HumanHap550 BeadChip or Illumina Human610-Quad BeadChip for 828 unrelated individuals diagnosed with CRS and 5,083 unrelated healthy controls from the Children's Hospital of Philadelphia (CHOP). Statistical analysis was performed with set-based tests using PLINK, and corrected for multiple testing.

Results

Set-based case control analysis revealed the gene KCNMA1 was associated with CRS in our Caucasian subset of the cohort (598 CRS cases and 3,489 controls; p = 0.022, based on 10,000 permutations). In addition there was borderline evidence that the gene KCNQ5 (p = 0.0704) was associated with the trait in our African American subset of the cohort (230 CRS cases and 1,594 controls). In addition to the top significant SNPs rs2917454 and rs6907229, imputation analysis uncovered additional genetic variants in KCNMA1 and in KCNQ5 that were associated with CRS.

Conclusions

We have implicated two airway epithelial potassium channels as novel susceptibility loci in contributing to the pathogenesis of CRS.

Treatment for sialorrhea (excessive saliva) in people with motor neuron disease/amyotrophic lateral sclerosis

BACKGROUND

Motor neuron disease (MND), also known as amyotrophic lateral sclerosis, is a progressive, neurodegenerative condition which may cause dysphagia, as well as limb weakness, dysarthria, emotional lability and respiratory failure. Since normal salivary production is 0.5 to 1.5 litres daily, loss of salivary clearance due to dysphagia leads to salivary pooling and sialorrhea, often resulting in distress and inconvenience to patients.

OBJECTIVES

To systematically review evidence on treatment of sialorrhea in MND, including medications, radiotherapy and surgery.

SEARCH STRATEGY

We searched the Cochrane Neuromuscular Disease Group Specialized Register (1 October 2010), the Cochrane Central Register of Controlled Trials )(CENTRAL) (The Cochrane Library issue 3, 2010), MEDLINE (January 1966 to September 2010), EMBASE (January 1980 to September 2010), AMED (1985 to September 2010) and CINAHL Plus (January 1937 September 2010). All bibliographies of the identified randomized trials were reviewed and authors contacted as needed. Known experts in the field were contacted to identify further published and unpublished papers.

SELECTION CRITERIA

We included randomized and quasi-randomised controlled studies on any intervention for sialorrhea and related symptoms, in people with MND.

DATA COLLECTION AND ANALYSIS

Review authors summarised data independently in a customised data collection form and confirmed data presented in Cochrane Review Manager software.

MAIN RESULTS

Only one randomized controlled trial was identified. This was a well designed study of botulinum toxin B injected into parotid and submandibular glands of 20 patients, which showed positive results for four weeks (Jackson 2009). There was low risk of bias in the study and no significant adverse events reported.

AUTHORS' CONCLUSIONS

There is some evidence for use of botulinum toxin injections to salivary glands for the treatment of sialorrhea in MND. Further research is required on this important symptom. Data are needed on the problem of sialorrhea in MND and its measurement, both by patient self report measures and objective tests. These will allow the development of better randomized controlled trials.

Innate immunity

Innate immunity is an exciting area of research in rhinology because emerging evidence suggests that abnormal local immune responses, rather than pathogen-specific adaptive immunity, may play a more important role in the pathogenesis of chronic rhinosinusitis (CRS). This article reviews important recent research regarding the innate immune system and CRS, with particular focus on the role of pattern recognition receptors, antimicrobial peptides and biofilms, epithelial ciliary function, cystic fibrosis, and cigarette smoking, and on areas for future research and therapy.

Inhibitory effects of carbocisteine on type A seasonal influenza virus infection in human airway epithelial cells

Type A human seasonal influenza (FluA) virus infection causes exacerbations of bronchial asthma and chronic obstructive pulmonary disease (COPD). l-carbocisteine, a mucolytic agent, reduces the frequency of common colds and exacerbations in COPD. However, the inhibitory effects of l-carbocisteine on FluA virus infection are uncertain. We studied the effects of l-carbocisteine on FluA virus infection in airway epithelial cells. Human tracheal epithelial cells were pretreated with l-carbocisteine and infected with FluA virus (H(3)N(2)). Viral titers in supernatant fluids, RNA of FluA virus in the cells, and concentrations of proinflammatory cytokines in supernatant fluids, including IL-6, increased with time after infection. l-carbocisteine reduced viral titers in supernatant fluids, RNA of FluA virus in the cells, the susceptibility to FluA virus infection, and concentrations of cytokines induced by virus infection. The epithelial cells expressed sialic acid with an alpha2,6-linkage (SAalpha2,6Gal), a receptor for human influenza virus on the cells, and l-carbocisteine reduced the expression of SAalpha2,6Gal. l-carbocisteine reduced the number of acidic endosomes from which FluA viral RNA enters into the cytoplasm and reduced the fluorescence intensity from acidic endosomes. Furthermore, l-carbocisteine reduced NF-kappaB proteins including p50 and p65 in the nuclear extracts of the cells. These findings suggest that l-carbocisteine may inhibit FluA virus infection, partly through the reduced expression of the receptor for human influenza virus in the human airway epithelial cells via the inhibition of NF-kappaB and through increasing pH in endosomes. l-carbocisteine may reduce airway inflammation in influenza virus infection.

Carbocisteine inhibits oxidant-induced apoptosis in cultured human airway epithelial cells

BACKGROUND AND OBJECTIVE

Increased oxidant levels have been associated with exacerbations of COPD, and L-carbocisteine, a mucolytic agent, reduces the frequency of exacerbations. The mechanisms underlying the inhibitory effects of L-carbocisteine on oxidant-induced COPD exacerbations were examined in an in vitro study of human airway epithelial cells.

METHODS

In order to examine the antioxidant effects of L-carbocisteine, human tracheal epithelial cells were treated with L-carbocisteine and exposed to hydrogen peroxide (H(2)O(2)). Cell apoptosis was assessed using a cell death detection ELISA, and the pathways leading to cell apoptosis were examined by measurement of caspase-3 and caspase-9 by western blot analysis with fluorescent detection.

RESULTS

The proportion of apoptotic cells in human tracheal epithelium was increased in a concentration- and time-dependent manner, following exposure to H(2)O(2). Treatment with L-carbocisteine reduced the proportion of apoptotic cells. In contrast, H(2)O(2) did not increase the concentration of LDH in supernatants of epithelial cells. Exposure to H(2)O(2) activated caspase-3 and caspase-9, and L-carbocisteine inhibited the H(2)O(2)-induced activation of these caspases. L-carbocisteine activated Akt phosphorylation, which modulates caspase activation, and the inhibitors of Akt, LY294002 and wortmannin, significantly reversed the inhibitory effects of L-carbocisteine on H(2)O(2)-induced cell apoptosis.

CONCLUSIONS

These findings suggest that in human airway epithelium, L-carbocisteine may inhibit cell damage induced by H(2)O(2) through the activation of Akt phosphorylation. L-carbocisteine may have antioxidant effects, as well as mucolytic activity, in inflamed airways.

Effect of endoscopic sinus surgery on irradiation-induced rhinosinusitis in patients with nasopharyngeal carcinoma

OBJECTIVES

We evaluated the effect of endoscopic sinus surgery on irradiation-induced rhinosinusitis of the maxillary-sinus mucosa among patients with nasopharyngeal carcinoma (NPC).

DESIGN

Surgical outcomes were evaluated by changes to the ultrastructure of the antral mucosa and nasomucociliary clearance.

METHODS

Twenty-one NPC patients with irradiation-induced chronic sinusitis were enrolled in the study, along with five controls. Specimens were taken from 42 maxillary sinuses during surgery and 1 year after surgery. Saccharin transit time was measured before the initial surgery and 1 year after surgery.

RESULTS

In the postoperative cases, we found a decrease in the number of the submucosal gland openings (P < 0.05), the cilia in the antral mucosa regenerated (P < 0.05), and the saccharin transit time reduced (P < 0.05); the number of goblet cells did not change.

CONCLUSION

Endoscopic sinus surgery is an effective treatment for irradiation-induced rhinosinusitis in NPC patients, improving ventilation and drainage of the paranasal sinuses, and facilitating regeneration of the sinus mucosa.

Impact of isotonic and hypertonic saline solutions on mucociliary activity in various nasal pathologies: clinical study

OBJECTIVE

To investigate the impact of nasal irrigation with isotonic or hypertonic sodium chloride solution on mucociliary clearance time in patients with allergic rhinitis, acute sinusitis and chronic sinusitis.

PATIENTS AND METHODS

Mucociliary clearance time was measured using the saccharine clearance test on 132 adults before and after 10 days' application of intranasal isotonic or hypertonic saline. Patient numbers were as follows: controls, 45; allergic rhinitis, 21; acute sinusitis, 24; and chronic sinusitis, 42. The results before and after irrigation were compared using the Wilcoxon t-test.

RESULTS

Before application of saline solutions, mucociliary clearance times in the three patient treatment groups were found to be significantly delayed, compared with the control group. Irrigation with hypertonic saline restored impaired mucociliary clearance in chronic sinusitis patients (p < 0.05), while isotonic saline improved mucociliary clearance times significantly in allergic rhinitis and acute sinusitis patients (p < 0.05).

CONCLUSION

Nasal irrigation with isotonic or hypertonic saline can improve mucociliary clearance time in various nasal pathologies. However, these solutions should be selectively prescribed rather than used based on anecdotal evidence. Further studies should be conducted to develop a protocol for standardised use of saline solution irrigation in various nasal pathologies.

Effect of carbocisteine on acute exacerbation of chronic obstructive pulmonary disease (PEACE Study): a randomised placebo-controlled study

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is characterised by airflow limitation, and has many components including mucus hypersecretion, oxidative stress, and airway inflammation. We aimed to assess whether carbocisteine, a mucolytic agent with anti-inflammatory and antioxidation activities, could reduce the yearly exacerbation rate in patients with COPD.

METHODS

We did a randomised, double-blind, placebo-controlled study of 709 patients from 22 centres in China. Participants were eligible if they were diagnosed as having COPD with a postbronchodilator forced expiratory volume in 1 s (FEV(1)) to forced vital capacity (FVC) ratio (FEV(1)/FVC) of less than 0.7 and an FEV(1) between 25% and 79% of the predicted value, were aged between 40 and 80 years, had a history of at least two COPD exacerbations within the previous 2 years, and had remained clinically stable for over 4 weeks before the study. Patients were randomly assigned to receive 1500 mg carbocisteine or placebo per day for a year. The primary endpoint was exacerbation rate over 1 year, and analysis was by intention to treat. This trial is registered with the Japan Clinical Trials Registry (http://umin.ac.jp/ctr/index/htm) number UMIN-CRT C000000233.

FINDINGS

354 patients were assigned to the carbocisteine group and 355 to the placebo group. Numbers of exacerbations per patient per year declined significantly in the carbocisteine group compared with the placebo group (1.01 [SE 0.06] vs 1.35 [SE 0.06]), risk ratio 0.75 (95% CI 0.62-0.92, p=0.004). Non-significant interactions were found between the preventive effects and COPD severity, smoking, as well as concomitant use of inhaled corticosteroids. Carbocisteine was well tolerated.

INTERPRETATION

Mucolytics, such as carbocisteine, should be recognised as a worthwhile treatment for prevention of exacerbations in Chinese patients with COPD.

Lysozyme levels in the nasal secretions of patients with perennial allergic rhinitis and recurrent sinusitis

BACKGROUND

The association of perennial allergic rhinitis (PAR) with recurrent sinusitis (RS) is well recognized. Anatomic abnormalities at the osteomeatal complex or ciliary dysfunction may play a significant role in some patients. However, for most patients with allergy, the determinants of RS are unknown.

OBJECTIVE

To determine whether altered concentrations of antimicrobial peptides and proteins, such as lysozyme, lactoferrin, human beta-defensin-2 (HBD-2), and human neutrophil peptides 1 to 3 (HNP-1 to 3), contribute to the development of RS in patients with PAR.

METHODS

Nasal secretions were collected by vacuum aspiration from 15 individuals with PAR+RS, 16 with PAR alone, and 16 controls. Lysozyme and lactoferrin levels were determined in nasal secretions by using quantitative enzyme-linked immunosorbent assay, and HBD-2 and HNP-1 to 3 levels were determined in nasal secretions by using semiquantitative Western blot analysis. Eosinophil-derived neurotoxin (EDN) levels were measured by using enzyme-linked immunosorbent assay as a marker of nasal eosinophilia in all 3 groups.

RESULTS

Levels of EDN were elevated significantly in patients with PAR+RS compared with controls. Lysozyme levels were decreased significantly in patients with PAR+RS compared with PAR alone or controls. Mean lysozyme levels were significantly lower in patients with EDN levels greater than 1,000 ng/mL vs those with levels of 1,000 ng/mL or less in the PAR+RS group. There were no statistically significant differences in lactoferrin, HBD-2, and HNP-1 to 3 levels among the 3 groups.

CONCLUSIONS

The presence of eosinophils and their products and reduced lysozyme concentrations may be critical factors that predispose the airways of patients with PAR to RS.

Cytokine profile in paranasal effusions in patients with chronic sinusitis using the YAMIK sinus catheter with and without betamethasone

Recently, the YAMIK sinus catheter (YAMIK) has been reported to be a useful therapeutic device in the treatment of sinusitis. The present study was conducted to compare its delivery of either a normal saline (NS) or a betamethasone solution (0.4 mg/ml) into the paranasal sinuses of 25 patients (39 sides) with chronic sinusitis. The following parameters were evaluated: (1) subjective nasal clinical symptoms (nasal discharge, nasal obstruction, postnasal drip and headache), (2) X-ray photographs (ethmoid and maxillary sinuses) and (3) cytokine levels (IL-1beta, IL-8 and TNF-alpha) by enzyme-linked immunosorbent assay. The total nasal symptom scores significantly decreased after the first therapy, and the total X-ray photograph scores significantly decreased after therapy with either NS or the betamethasone solution. In both NS and betamethasone patients, the levels of IL-1beta and IL-8 had significantly decreased by the 3rd and 2nd weeks after therapy, respectively. In contrast, the TNF-alpha level decreased after the first therapy with betamethasone solution and remained unchanged after therapy with NS. These findings suggest that evacuation of the pathological effusions in sinuses may exert a beneficial effect by reducing the levels of IL-1beta and IL-8, and we speculate that removal of pathological effusions from the sinuses may provide treatment through different mechanisms than those that occur in treatment with betamethasone.

Effects of bacterial toxins on air-exposed cultured human respiratory sinus epithelium

The present study was designed to investigate the effects of the bacterial toxins lipopolysaccharide (LPS) and lipoteichoic acid (LTA) on air-exposed cultured human respiratory sinus epithelium. The morphological changes, proliferation, and differentiation of sphenoid sinus mucosa were examined after incubation with different LPS or LTA concentrations. Air-exposed cultured sinus mucosa differentiated from pseudostratified respiratory epithelium to squamous ciliated epithelium with few goblet cells. High concentrations of bacterial toxins induced a significant increase in mucus production and a decrease in ciliated cells. Ki67 immunostaining showed an increased cell proliferation after incubation with moderate levels of LPS or LTA. High concentrations of bacterial toxins, on the other hand, induced a decreased proliferation. Involucrin expression was clearly altered by incubation with high levels of bacterial toxins, indicating an increased degree of terminal differentiation. These results indicate that the bacterial toxins LPS and LTA both induce comparable dose-dependent morphological changes in sinus epithelium.

Mucoactive medications and airway disease

Airway mucociliary clearance depends on the properties and volume of secreted mucus, ciliary function and mucociliary interactions. In chronic airway diseases, mucus viscoelasticity is higher than the optimal values for mucociliary clearance. The mucous glycoproteins (MGs) are produced by goblet and submucosal gland cells and are the most important determinant of the viscoelasticity of normal respiratory mucus, although with chronic infection and inflammation neutrophil-derived DNA and F-actin assume an important role. The quantities and structures of MGs mainly determine the rheological properties of mucus. Mucolytic agents, such as the thiols with free sulphydryl groups (classic mucolytics) and proteolytic enzymes (peptide mucolytics) change the conformation of mucus and lead to the reduction of viscoelasticity. Mucoregulatory medications such as glucocorticoids and macrolide antibiotics may decrease the hypersecretion of MGs.

The nose and paranasal sinuses physiology and anatomy

The paranasal sinuses and nose are much more than two cavities behind a projection on the centre of the face. They humidify, filter, warm, and sense what we breathe. The anatomy and physiology interact forming a dynamic system. The anatomy, airflow, nasal resistance, its turbulence, the nasal cycle - a process by which the turbinates or cushions lining the nose alternatively swell and congest from side to side, can all potentially influence the nasal delivery of drugs. Along with these factors mucus rheology and mucociliary clearance influence the removal of substances delivered to the nose. The health of the nose and its immunological response to what is inhaled, be it pollutants, allergens, drugs or vaccines, all need to be considered. It is a fascinating sensor for the body, not only detecting the potentially harmful substances such as smoke, but its psychosexual aspects have far reaching implications and the olfactory pathway has potential as a pathway for the delivery of drugs.

Submucous turbinectomy decreases not only nasal stiffness but also sneezing and rhinorrhea in patients with perennial allergic rhinitis

BACKGROUND

Turbinate surgery, in which mucous epithelium is resected, has often been used for patients with perennial allergic rhinitis, since the mucous epithelium is the principal site for immunoglobulin (Ig)E-mediated allergic reactions and chronic inflammation.

OBJECTIVE

To assess the effect of submucous turbinectomy on allergic rhinitis.

METHODS

Sixty patients with severe perennial allergic rhinitis underwent submucous turbinectomy and were followed-up for 1 year. Nasal symptoms were evaluated with a standard symptom score. Rhinometry was used to evaluate nasal congestion, and nasal provocation tests in vivo were performed to evaluate allergic reactions. In 16 cases, biopsies from the nose were also available for immunohistochemical analysis. These examinations were performed before and after submucous turbinectomy.

RESULTS

The mean total nasal symptom score (7.2 +/- 1.7, mean +/- SD before surgery) was significantly reduced after surgery (1.2 +/- 1.4, P < 0.0001), and the effect of the surgery on nasal symptoms continued for at least 12 months (1.9 +/- 1.8, P < 0.0001). Submucous turbinectomy reduced both nasal discharge and sneezing, as well as nasal stiffness. Histopathological examination following surgery revealed that the lamina propria was occupied by fibrous tissues, and that the number of vessels, nasal glands, eosinophils and infiltrating IgE+ cells decreased in the turbinate. There were no significant differences in the levels of either house dust mite-specific or non-specific IgE in the serum between before and after surgery.

CONCLUSION

Submucous turbinectomy preserving the ciliary epithelium is a powerful strategy for improving nasal symptoms induced by allergic reaction via the reduction in the number of allergy-related cells in the nose.

Evaluation and treatment of allergic fungal sinusitis. I. Demographics and diagnosis

BACKGROUND

Few cases of allergic fungal sinusitis have been systematically evaluated to conclusively confirm working clinical, histopathologic, and serologic diagnostic criteria.

OBJECTIVES

The objective of this study was to describe 67 consecutive cases of allergic fungal sinusitis, the largest number of cases yet published.

METHODS

Cases from 1 practice over 8 years were evaluated with a consistent protocol, including skin testing, serum chemistries and serologies, and surgical specimen analysis.

RESULTS

All patients were atopic (100 %) and had nasal polyposis (100%). They tended to be young (33.3+/-13.1 years, mean +/-SEM), immunocompetent (92 %; remaining 8 % with low quantitative immunoglobulin but normal function), have slight female preponderance (58%), have a history of hypertrophic rhinosinusitis (100%), report nasal cast production (75%), and have developed their disease in the southwestern United States. Bipolaris spicifera was the most prevalent fungus involved (67%). Total serum IgE (mean 668 IU/mL) and fungal-specific IgG were generally elevated, whereas fungal-specific precipitins and specific IgE were generally negative despite positive fungal-specific immediate hypersensitivity skin tests.

CONCLUSIONS

Patients with allergic fungal sinusitis tend to have elevated total serum IgE and fungal-specific IgG at diagnosis but not fungal-specific IgE or precipitins. Histopathologic criteria for allergic fungal sinusitis diagnosis are discussed. The southwestern United States appears to be a "hot spot" for the disease, particularly caused by B spicifera.

Improvement of mucosal pathology of the sinuses after exposure to sulfur dioxide by nebulization of S-carboxymethylcysteine

Since s-carboxymethylcysteine (S-CMC) can directly enhance the ciliary activity in the maxillary sinus mucosa of patients with chronic sinusitis in the absence of significant organic changes of ciliated cells, the nebulization therapy using this medicine might be more effective in the treatment of chronic sinusitis than oral administration of the medicine. The safety of using 0.5-10% of S-SMC as a medicine for nebulization has been experimentally established. The present study was designed to experimentally examine the effectiveness of nebulization using 0.5-10% of S-CMC solution in the treatment of experimental chronic sinusitis in rabbits recurrently exposed to 20 ppm of sulfur dioxide. Thirty-three healthy rabbits were used; 3 of them were used as controls. The remaining 30 were exposed to 20 ppm of sulfur dioxide for 4 h a day for 4 successive weeks. Twelve animals were not treated with any medication during the post-exposure period, and sacrificed at 24 h or 15 days after completion of the final exposure to sulfur dioxide. The remaining 18 animals were treated with nebulization using 10%, 5% or 0.5% of S-CMC solution for 20 min a day for 14 successive days after the final exposure to sulfur dioxide, and they were sacrificed at 24 h after the final nebulization using S-CMC. At the time of sacrifice, the ciliary activity and the morphology of the sinus mucosa were observed to assess the effectiveness of S-CMC nebulization. In the animals sacrificed 24 h after the final exposure, the mucosa of the sinus demonstrated marked epithelial cell injuries, and the ciliary activity was extremely reduced. Complete recovery of the epithelium and the ciliary activity was not recognized in the animals sacrificed 15 days after completion of the exposure. By contrast, epithelial recovery was more accelerated in the animals treated with S-CMC nebulization during the 14 days after the exposure. In the animals treated with 0.5% of S-CMC, the ciliary activity was inferior to that of the control animals, and the epithelial repair was not complete. In the animals treated with 10% of S-CMC, however, ciliary activity and epithelial morphology were completely recovered. In conclusion, our study suggests that clinical application of 10% of S-CMC nebulization may provide otolaryngologists with a new tool in the treatment of sinus diseases such as chronic sinusitis.

Endonasal sinus surgery improves mucociliary transport in severe chronic sinusitis

A total of 22 patients with extensive chronic sinusitis were examined before and 7.2 +/- 1.1 months after microscopic endonasal sinus surgery. Pre- and postoperative nasal mucociliary transport was measured using a modified saccharine test and ciliary beat frequency of nasal respiratory cells using video interference contrast microscopy. In patients suffering from chronic sinusitis, nasal ciliary beat frequency was significantly lower (8.0 +/- 1.8 Hz) than in normals (9.5 +/- 1.7 Hz p < 0.02). Following endonasal sinus surgery, ciliary beat frequency in patients with chronic sinusitis remained reduced (8.3 +/- 1.2 Hz). Nasal mucociliary transport time was significantly (p < 0.05) longer (20.9 +/- 9.4 minutes) in patients with chronic sinusitis than in normals (14.9 +/- 8.4 minutes). Nasal mucociliary transport improved significantly (p < 0.05) to 13.8 +/- 8.4 minutes in 17 of 22 patients without recurrent sinusitis and remained prolonged (20.6 +/- 7.7 minutes) in 5 of 22 patients with recurrent disease. These data suggest that ciliary beat frequency of nasal respiratory cells and nasal mucus transport are impaired in patients suffering from chronic sinusitis. After microscopic endonasal sinus surgery, impaired mucociliary transport is improved, and ciliary beat frequency remains lower than in normals.

Scanning electron microscopy findings of human respiratory cilia in chronic sinusitis and in recurrent respiratory infections

Acute and chronic infections cause morphological changes in the respiratory mucosa. The ultrastructure of human respiratory mucosa was studied by scanning electron microscopy from the maxillary sinuses of 28 patients, with chronic sinusitis, from middle turbinates of 60 patients, with recurrent respiratory infections, and from healthy sphenoidal sinuses of 31 patients. A loss of ciliated cells and an increasing number of nonciliated columnar cells with microvilli were seen in 62 per cent of the maxillary sinus mucosa. Ciliary disorientation was seen in 81 per cent of the chronically infected sinus mucosa and eight per cent in the healthy sphenoidal sinuses. Also metaplasia and extrusion of epithelial cells were prominent in chronic infections. Compound cilia were seen in 52 per cent of the samples from patients with chronic sinusitis and in 31 per cent of the healthy sphenoidal sinuses. Short cilia were often seen in infected mucosa indicating ciliogenesis.

Abnormal nasal glandular secretion in recurrent sinusitis

Recurrent sinusitis (RS) is a very common clinical problem for which no underlying cause can generally be ascertained. We examined nasal mucosal responses in 14 patients with RS to determine if a relative deficiency in secretion of glandular antimicrobial factors might play a role. Twenty-four subjects with no history of sinusitis were studied concurrently as normal control (NC) subjects. RS was defined by two or more episodes of acute sinusitis per year for 2 or more years. After provocation with 25 mg of methacholine or 1 mg of histamine, nasal washings were analyzed for total proteins: the plasma protein albumin, IgG, and nonsecretory IgA (nsIgA), and the glandular proteins secretory IgA (sIgA), lactoferrin (LFN), and lysozyme (LZM). Although baseline secretions in patients with RS were relatively enriched with LFN and LZM as compared to that of secretions in NC subjects, patients with RS had a blunted cholinergic response with decreased secretion of albumin, IgG, nsIgA, sIgA, and LZM. Histamine responses were equivalent in both patients with RS and NC subjects. After 4 to 12 months of medical treatment, the abnormal cholinergic responses improved on repeat methacholine challenge in all eight subjects with RS rechallenged. Thus, patients with RS have a reversible reduction in nasal mucosal secretory responses to cholinergic stimulation. Since glandular secretions are rich in antimicrobial factors, such as LFN, LZM, and sIgA, it appears possible that the inability to secrete glandular proteins normally may predispose to recurrent infections.

Functional and morphological pathology of the nasal mucosa after x-ray irradiation

In our present study we examined the pathology of the nasal mucociliary system after x-ray irradiation in an animal model namely the rabbit. A reduced ciliary activity was observed immediately after the irradiation and did not show any recovery during our observation. No ciliary activity was seen in the nasal mucosa 8 weeks after the irradiation. Morphologically, hypersecretion of goblet cells was observed immediately after irradiation. Cytoplasmic vacuolation and nuclear pyknosis of ciliated cells started after irradiation, and sloughing of ciliated cells was observed for up to 3 weeks. Epithelial metaplasia started from 4 weeks, and no cilia were seen in the nasal mucosa and the surface of the epithelium was covered with flat squamous cells. Our present study shows that x-ray irradiation has serious influence on the function and structure of the nasal mucociliary system and that recovery from degeneration due to x-ray irradiation cannot be expected within several weeks.

Influence of intraoperative antroscopy on surgical treatment of the maxillary antrum

Antroscopy is being used with increasing frequency but its optimum role in clinical practice is still being clarified. One hundred antroscopies were carried out intraoperatively on 50 consecutive patients admitted for non-urgent, intranasal and/or paranasal sinus surgery. A specific surgical procedure had been planned on 28 individual maxillary antra. In the remaining 72 antra, no such procedure was planned. As a result of the antroscopic findings, the surgical procedure was changed in 16% of the total sinuses. In 10% a more extensive, and in 6% a less extensive procedure was carried out than had been envisaged prior to antroscopy. It is concluded that intraoperative antroscopy is extremely helpful in selecting the appropriate procedure, if any, to carry out on the maxillary antrum.

Reversibility of reduced ciliary activity on adenoids of patients with otitis media with effusion following culture

We have studied the ciliary activity of the pharyngeal epithelium on adenoids obtained from patients with recurrent otitis media with effusion to assess indirectly the ciliary activity in the Eustachian tube. In conclusion, the following has been speculated from the present study: (1) middle ear effusions depress the ciliary activity; and (2) recovery of the reduced ciliary activity can be achieved in an effusion-free environment inasmuch as the ciliated cells have not undergone organic changes. Prompt elimination of the effusion, if present, is of critical importance for the recuperation of tubotympanic drainage, because a positive therapeutic effect resulting from elimination of the effusion can only be possible in early phase of the disease, before irreversible morphological lesions have occurred.

The effect of Mucodyne on nasal clearance in healthy adults

A randomized double-blind cross-over trial in healthy young adults compared the effect of S-carboxymethylcysteine (2.25 g per day for 7 days) against placebo on nasal mucociliary clearance. The clearance rate of a radio-labelled aqueous test spray was measured by gamma scintigraphy. Analysis of the data revealed no significant effect of the drug compared to placebo.