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Patel ZM, Holbrook EH, Turner JH, Adappa ND, Albers MW, Altundag A, Appenzeller S, Costanzo RM, Croy I, Davis GE, Dehgani-Mobaraki P, Doty RL, Duffy VB, Goldstein BJ, Gudis DA, Haehner A, Higgins TS, Hopkins C, Huart C, Hummel T, Jitaroon K, Kern RC, Khanwalkar AR, Kobayashi M, Kondo K, Lane AP, Lechner M, Leopold DA, Levy JM, Marmura MJ, Mclelland L, Miwa T, Moberg PJ, Mueller CA, Nigwekar SU, O'Brien EK, Paunescu TG, Pellegrino R, Philpott C, Pinto JM, Reiter ER, Roalf DR, Rowan NR, Schlosser RJ, Schwob J, Seiden AM, Smith TL, Soler ZM, Sowerby L, Tan BK, Thamboo A, Wrobel B, Yan CH. International consensus statement on allergy and rhinology: Olfaction. Int Forum Allergy Rhinol 2022; 12:327-680. [PMID: 35373533 DOI: 10.1002/alr.22929] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 01/01/2021] [Accepted: 11/19/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND The literature regarding clinical olfaction, olfactory loss, and olfactory dysfunction has expanded rapidly over the past two decades, with an exponential rise in the past year. There is substantial variability in the quality of this literature and a need to consolidate and critically review the evidence. It is with that aim that we have gathered experts from around the world to produce this International Consensus on Allergy and Rhinology: Olfaction (ICAR:O). METHODS Using previously described methodology, specific topics were developed relating to olfaction. Each topic was assigned a literature review, evidence-based review, or evidence-based review with recommendations format as dictated by available evidence and scope within the ICAR:O document. Following iterative reviews of each topic, the ICAR:O document was integrated and reviewed by all authors for final consensus. RESULTS The ICAR:O document reviews nearly 100 separate topics within the realm of olfaction, including diagnosis, epidemiology, disease burden, diagnosis, testing, etiology, treatment, and associated pathologies. CONCLUSION This critical review of the existing clinical olfaction literature provides much needed insight and clarity into the evaluation, diagnosis, and treatment of patients with olfactory dysfunction, while also clearly delineating gaps in our knowledge and evidence base that we should investigate further.
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Affiliation(s)
- Zara M Patel
- Otolaryngology, Stanford University School of Medicine, Stanford, California, USA
| | - Eric H Holbrook
- Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - Justin H Turner
- Otolaryngology, Vanderbilt School of Medicine, Nashville, Tennessee, USA
| | - Nithin D Adappa
- Otolaryngology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mark W Albers
- Neurology, Harvard Medical School, Boston, Massachusetts, USA
| | - Aytug Altundag
- Otolaryngology, Biruni University School of Medicine, İstanbul, Turkey
| | - Simone Appenzeller
- Rheumatology, School of Medical Sciences, University of Campinas, São Paulo, Brazil
| | - Richard M Costanzo
- Physiology and Biophysics and Otolaryngology, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Ilona Croy
- Psychology and Psychosomatic Medicine, TU Dresden, Dresden, Germany
| | - Greg E Davis
- Otolaryngology, Proliance Surgeons, Seattle and Puyallup, Washington, USA
| | - Puya Dehgani-Mobaraki
- Associazione Naso Sano, Umbria Regional Registry of Volunteer Activities, Corciano, Italy
| | - Richard L Doty
- Smell and Taste Center, Otolaryngology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Valerie B Duffy
- Allied Health Sciences, University of Connecticut, Storrs, Connecticut, USA
| | | | - David A Gudis
- Otolaryngology, Columbia University Irving Medical Center, New York, USA
| | - Antje Haehner
- Smell and Taste, Otolaryngology, TU Dresden, Dresden, Germany
| | - Thomas S Higgins
- Otolaryngology, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Claire Hopkins
- Otolaryngology, Guy's and St. Thomas' Hospitals, London Bridge Hospital, London, UK
| | - Caroline Huart
- Otorhinolaryngology, Cliniques universitaires Saint-Luc, Institute of Neuroscience, Université catholgique de Louvain, Brussels, Belgium
| | - Thomas Hummel
- Smell and Taste, Otolaryngology, TU Dresden, Dresden, Germany
| | | | - Robert C Kern
- Otolaryngology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Ashoke R Khanwalkar
- Otolaryngology, Stanford University School of Medicine, Stanford, California, USA
| | - Masayoshi Kobayashi
- Otorhinolaryngology-Head and Neck Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - Kenji Kondo
- Otolaryngology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Andrew P Lane
- Otolaryngology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Matt Lechner
- Otolaryngology, Barts Health and University College London, London, UK
| | - Donald A Leopold
- Otolaryngology, University of Vermont Medical Center, Burlington, Vermont, USA
| | - Joshua M Levy
- Otolaryngology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Michael J Marmura
- Neurology Thomas Jefferson University School of Medicine, Philadelphia, Pennsylvania, USA
| | - Lisha Mclelland
- Otolaryngology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Takaki Miwa
- Otolaryngology, Kanazawa Medical University, Ishikawa, Japan
| | - Paul J Moberg
- Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | | | - Sagar U Nigwekar
- Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Erin K O'Brien
- Otolaryngology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Teodor G Paunescu
- Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Carl Philpott
- Otolaryngology, University of East Anglia, Norwich, UK
| | - Jayant M Pinto
- Otolaryngology, University of Chicago, Chicago, Illinois, USA
| | - Evan R Reiter
- Otolaryngology, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - David R Roalf
- Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Nicholas R Rowan
- Otolaryngology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Rodney J Schlosser
- Otolaryngology, Medical University of South Carolina, Mt Pleasant, South Carolina, USA
| | - James Schwob
- Biomedical Sciences, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Allen M Seiden
- Otolaryngology, University of Cincinnati School of Medicine, Cincinnati, Ohio, USA
| | - Timothy L Smith
- Otolaryngology, Oregon Health and Sciences University, Portland, Oregon, USA
| | - Zachary M Soler
- Otolaryngology, Medical University of South Carolina, Mt Pleasant, South Carolina, USA
| | - Leigh Sowerby
- Otolaryngology, University of Western Ontario, London, Ontario, Canada
| | - Bruce K Tan
- Otolaryngology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Andrew Thamboo
- Otolaryngology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Bozena Wrobel
- Otolaryngology, Keck School of Medicine, USC, Los Angeles, California, USA
| | - Carol H Yan
- Otolaryngology, School of Medicine, UCSD, La Jolla, California, USA
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2
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Talat R, Gengler I, Phillips KM, Caradonna DS, Gray ST, Sedaghat AR. Chronic Rhinosinusitis Outcomes of Patients With Aspirin-Exacerbated Respiratory Disease Treated With Budesonide Irrigations: A Case Series. Ann Otol Rhinol Laryngol 2021; 131:1130-1136. [PMID: 34775833 DOI: 10.1177/00034894211054948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Pathophysiology-targeting treatments exist for aspirin-exacerbated respiratory disease (AERD) through aspirin desensitization and biologics, such as dupilumab. With increasing attention paid to these treatments, which may be associated with significant side effects and/or cost, there is little description of chronic rhinosinusitis with nasal polyps (CRSwNP) response to treatment with intranasal corticosteroids and saline irrigations in AERD. OBJECTIVE To determine the effect of intranasal budesonide irrigations for the treatment of CRSwNP in AERD. METHODS This is an observational study of 14 AERD patients presenting to a rhinology clinic for CRS who were treated with twice daily high volume, low pressure irrigations with 240 mL of saline to which a 0.5 mg/2 mL respule of budesonide was added. All participants completed a 22-item Sinonasal Outcome Test (SNOT-22) at enrollment and at follow up 1 to 6 months later. Polyp scores were also calculated at each time point. RESULTS SNOT-22 scores ranged from 26 to 98 (median: 40.5) at enrollment and 3 to 85 (median: 38.5) at follow-up. Polyp scores ranged from 2 to 6 (median: 4) at enrollment at 0 to 6 (median: 2) at follow-up. Over the treatment period, change in SNOT-22 score ranged from -38 to 16 (median: -18) and change in polyp score ranged from -2 to 0 (median: -0.5). Approximately 57% of participants experienced at least 1 minimal clinically important difference in SNOT-22 score and 21% of participants had a SNOT-22 score <20 at follow-up. CONCLUSION Medical management with intranasal corticosteroids and saline irrigations alone leads to significant improvement in sinonasal symptomatology in a subset of AERD.
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Affiliation(s)
- Rehab Talat
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Isabelle Gengler
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Katie M Phillips
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - David S Caradonna
- Department of Otolaryngology, Harvard Medical School, Boston, MA, USA.,Division of Otolaryngology, Boston, MA, USA
| | - Stacey T Gray
- Department of Otolaryngology, Harvard Medical School, Boston, MA, USA.,Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, MA, USA
| | - Ahmad R Sedaghat
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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3
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Orlandi RR, Kingdom TT, Smith TL, Bleier B, DeConde A, Luong AU, Poetker DM, Soler Z, Welch KC, Wise SK, Adappa N, Alt JA, Anselmo-Lima WT, Bachert C, Baroody FM, Batra PS, Bernal-Sprekelsen M, Beswick D, Bhattacharyya N, Chandra RK, Chang EH, Chiu A, Chowdhury N, Citardi MJ, Cohen NA, Conley DB, DelGaudio J, Desrosiers M, Douglas R, Eloy JA, Fokkens WJ, Gray ST, Gudis DA, Hamilos DL, Han JK, Harvey R, Hellings P, Holbrook EH, Hopkins C, Hwang P, Javer AR, Jiang RS, Kennedy D, Kern R, Laidlaw T, Lal D, Lane A, Lee HM, Lee JT, Levy JM, Lin SY, Lund V, McMains KC, Metson R, Mullol J, Naclerio R, Oakley G, Otori N, Palmer JN, Parikh SR, Passali D, Patel Z, Peters A, Philpott C, Psaltis AJ, Ramakrishnan VR, Ramanathan M, Roh HJ, Rudmik L, Sacks R, Schlosser RJ, Sedaghat AR, Senior BA, Sindwani R, Smith K, Snidvongs K, Stewart M, Suh JD, Tan BK, Turner JH, van Drunen CM, Voegels R, Wang DY, Woodworth BA, Wormald PJ, Wright ED, Yan C, Zhang L, Zhou B. International consensus statement on allergy and rhinology: rhinosinusitis 2021. Int Forum Allergy Rhinol 2021; 11:213-739. [PMID: 33236525 DOI: 10.1002/alr.22741] [Citation(s) in RCA: 408] [Impact Index Per Article: 136.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 11/09/2020] [Indexed: 02/06/2023]
Abstract
I. EXECUTIVE SUMMARY BACKGROUND: The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR-RS-2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence-based findings of the document. METHODS ICAR-RS presents over 180 topics in the forms of evidence-based reviews with recommendations (EBRRs), evidence-based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary. RESULTS ICAR-RS-2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence-based management algorithm is provided. CONCLUSION This ICAR-RS-2021 executive summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS.
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Affiliation(s)
| | | | | | | | | | - Amber U Luong
- University of Texas Medical School at Houston, Houston, TX
| | | | - Zachary Soler
- Medical University of South Carolina, Charleston, SC
| | - Kevin C Welch
- Feinberg School of Medicine, Northwestern University, Chicago, IL
| | | | | | | | | | - Claus Bachert
- Ghent University, Ghent, Belgium.,Karolinska Institute, Stockholm, Sweden.,Sun Yatsen University, Gangzhou, China
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - David A Gudis
- Columbia University Irving Medical Center, New York, NY
| | - Daniel L Hamilos
- Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | | | - Richard Harvey
- University of New South Wales and Macquarie University, Sydney, New South Wales, Australia
| | | | | | | | | | - Amin R Javer
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | | | | | | | | | | | | | | | | | - Valerie Lund
- Royal National Throat Nose and Ear Hospital, UCLH, London, UK
| | - Kevin C McMains
- Uniformed Services University of Health Sciences, San Antonio, TX
| | | | - Joaquim Mullol
- IDIBAPS Hospital Clinic, University of Barcelona, Barcelona, Spain
| | | | | | | | | | | | | | | | | | | | - Alkis J Psaltis
- University of Adelaide, Adelaide, South Australia, Australia
| | | | | | | | - Luke Rudmik
- University of Calgary, Calgary, Alberta, Canada
| | - Raymond Sacks
- University of New South Wales, Sydney, New South Wales, Australia
| | | | | | | | | | | | | | | | | | | | | | | | | | - De Yun Wang
- National University of Singapore, Singapore, Singapore
| | | | | | | | - Carol Yan
- University of California San Diego, La Jolla, CA
| | - Luo Zhang
- Capital Medical University, Beijing, China
| | - Bing Zhou
- Capital Medical University, Beijing, China
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4
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Ceylan SM, Kanmaz MA, Disikirik I, Karadeniz PG. Peak nasal inspiratory airflow measurements for assessing laryngopharyngeal reflux treatment. Clin Otolaryngol 2021; 46:796-801. [PMID: 33580555 DOI: 10.1111/coa.13737] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 12/08/2020] [Accepted: 01/31/2021] [Indexed: 12/18/2022]
Abstract
OBJECTIVES To evaluate the effect of laryngopharyngeal reflux (LPR) and antireflux treatment on peak nasal inspiratory airflow (PNIF). DESIGN Prospective observational study was conducted. SETTING Tertiary otorhinolaryngology clinic. PARTICIPANTS Adults with LPR and healthy controls. MAIN OUTCOME MEASURES PNIF measurements were performed on 60 patients who applied with complaints suggestive of LPR having higher Reflux Symptom Index (RSI) (>13) and Reflux Finding Scores (RFS) scores (>7). Proton pump inhibitor (PPI) treatment was started and PNIF measurements were repeated two months later. A total of 100 patients without any history of LPR and sinonasal disease were included in the study. RESULTS A statistically significant increase was observed in PNIF values after proton pump inhibitor treatment. The mean PNIF values of the LPR patients were 133.83 ± 27.99 L/min and 149.92 ± 23.23 L/min before and after treatment, respectively. The mean PNIF value in the control group was 145.0 ± 25.92 L/min. PNIF values were significantly lower in the LPR relative to the control group (P < .05). CONCLUSION Laryngopharyngeal reflux decreases PNIF. This negative effect on PNIF disappears after antireflux medication. The results of the study indicate that PNIF measurements may be an appropriate method for clinical diagnosis of LPR and evaluation of treatment results.
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Affiliation(s)
- Seyit M Ceylan
- Department of Otorhinolaryngology, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey
| | - Mahmut A Kanmaz
- Department of Otorhinolaryngology, SANKO University, Gaziantep, Turkey
| | - Ilyas Disikirik
- Department of Physical Therapy and Rehabilitation, SANKO University, Gaziantep, Turkey
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5
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Dominas C, Gadkaree S, Maxfield AZ, Gray ST, Bergmark RW. Aspirin-exacerbated respiratory disease: A review. Laryngoscope Investig Otolaryngol 2020; 5:360-367. [PMID: 32596477 PMCID: PMC7314471 DOI: 10.1002/lio2.387] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 03/09/2020] [Accepted: 03/16/2020] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES Aspirin-exacerbated respiratory disease (AERD) is a chronic respiratory condition characterized by a triad of symptoms: asthma, chronic rhinosinusitis with nasal polyposis, and a respiratory reaction to aspirin and other cyclooxygenase-1 inhibitors, also known as nonsteroidal anti-inflammatory drugs. The objective of this review is to provide otolaryngologists with an overview of the pathophysiology, diagnosis, and treatment of this under-recognized condition. DATA SOURCES AND METHODS Foundational papers on AERD were reviewed, focusing on the clinical otolaryngology and allergy/immunology literature and other high impact journals or trials. RESULTS AERD results from increased production of pro-inflammatory leukotrienes and a decrease in production of anti-inflammatory prostaglandins associated with the dysregulation of multiple enzymes influencing eicosanoid metabolism. Diagnosis hinges on a high index of suspicion, careful history, and confirmatory testing for all three elements. Treatments include endoscopic sinus surgery; topical, inhaled, or oral corticosteroids; aspirin desensitization; leukotriene modifying drugs; and the new class of biologics such as dupilumab. CONCLUSION AERD is an under-recognized disease associated with substantial patient-reported morbidity. We expect rapid progress in the pathophysiological understanding of this disease and available treatments in the coming decades. LEVEL OF EVIDENCE 5.
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Affiliation(s)
- Christine Dominas
- Division of Otolaryngology‐Head and Neck SurgeryBrigham and Women's HospitalBostonMassachusettsUSA
| | - Shekhar Gadkaree
- Division of Otolaryngology‐Head and Neck SurgeryBrigham and Women's HospitalBostonMassachusettsUSA
- Department of Otolaryngology‐Head and Neck SurgeryHarvard Medical SchoolBostonMassachusettsUSA
- Department of Otolaryngology‐Head and Neck SurgeryMassachusetts Eye and Ear InfirmaryBostonMassachusettsUSA
| | - Alice Z. Maxfield
- Division of Otolaryngology‐Head and Neck SurgeryBrigham and Women's HospitalBostonMassachusettsUSA
- Department of Otolaryngology‐Head and Neck SurgeryHarvard Medical SchoolBostonMassachusettsUSA
| | - Stacey T. Gray
- Department of Otolaryngology‐Head and Neck SurgeryHarvard Medical SchoolBostonMassachusettsUSA
- Department of Otolaryngology‐Head and Neck SurgeryMassachusetts Eye and Ear InfirmaryBostonMassachusettsUSA
| | - Regan W. Bergmark
- Division of Otolaryngology‐Head and Neck SurgeryBrigham and Women's HospitalBostonMassachusettsUSA
- Department of Otolaryngology‐Head and Neck SurgeryHarvard Medical SchoolBostonMassachusettsUSA
- Center for Surgery and Public HealthBrigham and Women's HospitalBostonMassachusettsUSA
- Patient Reported Outcomes, Value and Experience (PROVE) CenterBrigham and Women's HospitalBostonMassachusettsUSA
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6
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Cho SH, Ledford D, Lockey RF. Medical Management Strategies in Acute and Chronic Rhinosinusitis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:1559-1564. [PMID: 32142965 DOI: 10.1016/j.jaip.2020.02.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 02/19/2020] [Accepted: 02/20/2020] [Indexed: 02/08/2023]
Abstract
Chronic rhinosinusitis, historically, has been considered to be caused by upper airway anatomical abnormalities. However, today that concept has changed, for it is now recognized as an inflammatory disorder of the nasal and sinus mucosa. Acute rhinosinusitis is usually caused by a viral infection, whereas chronic rhinosinusitis is a persistent and heterogeneous inflammatory disorder with increased expression of type 1, 2, or 17 cytokines in the nasal and sinus mucosa, similar to that which occurs in asthma. Exacerbations are caused by aeroallergens in the allergic individual and irritants, pollutants, and viral/bacterial infections in all subjects. It may be categorized by phenotypes, examples of which include chronic rhinosinusitis with nasal polyps or chronic rhinosinusitis without nasal polyps. Defined endotypes are based on underlying pathophysiological mechanisms. Knowledge of chronic rhinosinusitis endotypes will optimize management by employing targeted medical therapies. Understanding that rhinosinusitis is a heterogeneous inflammatory disease has led to the identification of a variety of different predisposing conditions, new medical treatment options, and the concept that rhinosinusitis is primarily a medical problem.
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Affiliation(s)
- Seong H Cho
- Division of Allergy-Immunology, Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, Fla
| | - Dennis Ledford
- Division of Allergy-Immunology, Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, Fla
| | - Richard F Lockey
- Division of Allergy-Immunology, Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, Fla.
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7
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Sedaghat AR. A graduated approach to management of chronic rhinosinusitis in aspirin-exacerbated respiratory disease in the era of precision medicine. Ann Allergy Asthma Immunol 2020; 123:325-326. [PMID: 31586536 DOI: 10.1016/j.anai.2019.07.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 07/31/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Ahmad R Sedaghat
- Department of Otolaryngology-Head & Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio.
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8
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Li KL, Lee AY, Abuzeid WM. Aspirin Exacerbated Respiratory Disease: Epidemiology, Pathophysiology, and Management. Med Sci (Basel) 2019; 7:E45. [PMID: 30884882 PMCID: PMC6473909 DOI: 10.3390/medsci7030045] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Revised: 03/11/2019] [Accepted: 03/11/2019] [Indexed: 11/17/2022] Open
Abstract
The correlation between aspirin sensitivity, asthma, and nasal polyposis was recognized in the early 20th century. Today, this classic triad of symptoms, eponymously named Samter's Triad, is known as aspirin exacerbated respiratory disease (AERD). Aspirin exacerbated respiratory disease affects approximately 0.3⁻0.9% of the general population in the USA and approximately 7% of asthmatic patients. The management of AERD is challenging as no single modality has proven to have high rates of symptom control. Consequently, disease management typically involves a multimodality approach across both medical and surgical disciplines. This review describes the epidemiology of AERD and the current state-of-the-art as it relates to the underlying pathophysiologic mechanisms of this disease process. A significant proportion of the review is focused on the appropriate diagnostic workup for AERD patients including the utility of aspirin provocation testing. The spectrum of medical treatments, including aspirin desensitization and recently introduced immunotherapies, are discussed in detail. Furthermore, surgical approaches to disease control, including advanced endoscopic techniques, are reviewed and treatment outcomes presented.
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Affiliation(s)
- Kevin L Li
- Department of Otorhinolaryngology: Head and Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY 10467, USA.
| | - Andrew Y Lee
- Department of Otorhinolaryngology: Head and Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY 10467, USA.
| | - Waleed M Abuzeid
- Department of Otorhinolaryngology: Head and Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY 10467, USA.
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9
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Kim SD, Cho KS. Samter's Triad: State of the Art. Clin Exp Otorhinolaryngol 2018; 11:71-80. [PMID: 29642688 PMCID: PMC5951071 DOI: 10.21053/ceo.2017.01606] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 01/13/2018] [Accepted: 01/14/2018] [Indexed: 01/01/2023] Open
Abstract
Samter’s triad (ST) is a well-known disease characterized by the triad of bronchial asthma, nasal polyps, and aspirin intolerance. Over the past few years, a rapid development in the knowledge of the pathogenesis and clinical characteristics of ST has happened. The aim of this paper is to review the recent investigations on the pathophysiological mechanisms and genetic background, diagnosis, and different therapeutic options of ST to advance our understanding of the mechanism and the therapeutic control of ST. As concern for ST increase, more application of aspirin desensitization will be required to manage this disease successfully. There is also a need for continued research efforts in pathophysiology, treatment, and possible prevention.
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Affiliation(s)
- Sung-Dong Kim
- Department of Otorhinolaryngology-Head and Neck Surgery and Biomedical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Kyu-Sup Cho
- Department of Otorhinolaryngology-Head and Neck Surgery and Biomedical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
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10
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Rodríguez-Jiménez JC, Moreno-Paz FJ, Terán LM, Guaní-Guerra E. Aspirin exacerbated respiratory disease: Current topics and trends. Respir Med 2018; 135:62-75. [PMID: 29414455 DOI: 10.1016/j.rmed.2018.01.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 12/22/2017] [Accepted: 01/08/2018] [Indexed: 12/21/2022]
Abstract
Aspirin-exacerbated respiratory disease is a chronic and treatment-resistant disease, characterized by the presence of eosinophilic rhinosinusitis, nasal polyposis, bronchial asthma, and nonsteroidal anti-inflammatory drugs hypersensitivity. Alterations in arachidonic acid metabolism may induce an imbalance between pro-inflammatory and anti-inflammatory substances, expressed as an overproduction of cysteinyl leukotrienes and an underproduction of prostaglandin E2. Although eosinophils play a key role, recent studies have shown the importance of other cells and molecules in the development of the disease like mast cells, basophils, lymphocytes, platelets, neutrophils, macrophages, epithelial respiratory cells, IL-33 and thymic stromal lymphopoietin, making each of them promissory diagnostic and treatment targets. In this review, we summarize the most important clinical aspects of the disease, including the current topics about diagnosis and treatment, like provocation challenges and aspirin desensitization. We also discuss recent findings in the pathogenesis of the disease, as well as future trends in diagnosis and treatment, including monoclonal antibodies and a low salicylate diet as a treatment option.
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Affiliation(s)
| | | | - Luis Manuel Terán
- Department of Immunogenetics, National Institute of Respiratory Diseases (INER), Mexico City, Mexico
| | - Eduardo Guaní-Guerra
- Department of Medicine, University of Guanajuato, León, Guanajuato, Mexico; Department of Immunology, Hospital Regional de Alta Especialidad del Bajío, León, Guanajuato, Mexico.
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11
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Management of Respiratory Symptoms Induced by Non-Steroidal Anti-Inflammatory Drugs. CURRENT TREATMENT OPTIONS IN ALLERGY 2017. [DOI: 10.1007/s40521-017-0129-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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12
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Cook KA, Stevenson DD. Current complications and treatment of aspirin-exacerbated respiratory disease. Expert Rev Respir Med 2016; 10:1305-1316. [PMID: 27817219 DOI: 10.1080/17476348.2016.1258306] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Aspirin-exacerbated respiratory disease is defined by the clinical tetrad of aspirin sensitivity, nasal polyps, asthma, and chronic rhinosinusitis. Patients experience acute upper and lower airway reactions with exposure to aspirin and other cyclooxygenase-1 inhibiting medications. However, airway inflammation and disease progression occur even in the absence of exposure to these medications, often leading to aggressive polyp formation and need for systemic corticosteroids to treat exacerbations in asthma and rhinosinusitis. Areas covered: This review focuses on the direct and indirect complications of aspirin-exacerbated respiratory disease. Current and potential management strategies are discussed with emphasis on aspirin desensitization. Expert commentary: Aspirin desensitization remains the gold standard of treatment. Demonstrated benefits of desensitization include improved symptom scores, reduction in use of systemic corticosteroids, slowing of polyp regrowth, and tolerance of aspirin and other NSAIDs for various therapeutic purposes. Continued investigation into the pathogenic mechanisms of AERD is likely to yield new diagnostic and therapeutic approaches.
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Affiliation(s)
- Kevin A Cook
- a Division of Allergy, Asthma and Immunology , Scripps Clinic , San Diego , CA , USA
| | - Donald D Stevenson
- a Division of Allergy, Asthma and Immunology , Scripps Clinic , San Diego , CA , USA
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13
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Kennedy JL, Stoner AN, Borish L. Aspirin-exacerbated respiratory disease: Prevalence, diagnosis, treatment, and considerations for the future. Am J Rhinol Allergy 2016; 30:407-413. [PMID: 28124651 PMCID: PMC5108840 DOI: 10.2500/ajra.2016.30.4370] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Aspirin-exacerbated respiratory disease (AERD) is a late onset condition characterized by the Samter triad (aspirin sensitivity [as well as sensitivity to any nonselective cyclooxygenase inhibitor], nasal polyps, asthma) and additional features, including eosinophilic chronic rhinosinusitis, hypereosinophilia, anosmia, frequent absence of atopy, and, intolerance to ingestion of red wine and other alcoholic beverages. The diagnosis is rare, and, because of this, it is also often missed by physicians. However, it is highly overexpressed in patients with severe asthma (and severe chronic rhinosinusitis with nasal polyps), which makes its recognition essential. For this review, we considered mechanisms involved in the pathogenesis of this disease and discussed the clinical symptoms of AERD. We also discussed the role of aspirin desensitization in the treatment of AERD. Also, we considered medications (e.g, leukotriene modifiers) and surgical interventions that have a role in the treatment of AERD.
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Affiliation(s)
- Joshua L. Kennedy
- From the Department of Pediatrics
- Department of Internal Medicine
- Arkansas Children's Research Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | | | - Larry Borish
- Department of Medicine
- Department of Microbiology, and
- Carter Immunology Center, University of Virginia Health Systems, Charlottesville, Virginia
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Chong LY, Head K, Hopkins C, Philpott C, Schilder AGM, Burton MJ. Intranasal steroids versus placebo or no intervention for chronic rhinosinusitis. Cochrane Database Syst Rev 2016; 4:CD011996. [PMID: 27115217 PMCID: PMC9393647 DOI: 10.1002/14651858.cd011996.pub2] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND This review is one of six looking at the primary medical management options for patients with chronic rhinosinusitis.Chronic rhinosinusitis is common and is characterised by inflammation of the lining of the nose and paranasal sinuses leading to nasal blockage, rhinorrhoea, facial pressure/pain and loss of sense of smell. The condition can occur with or without nasal polyps. The use of topical (intranasal) corticosteroids has been widely advocated for the treatment of chronic rhinosinusitis given the belief that inflammation is a major component of this condition. OBJECTIVES To assess the effects of intranasal corticosteroids in people with chronic rhinosinusitis. SEARCH METHODS The Cochrane ENT Information Specialist searched the Cochrane ENT Trials Register; Central Register of Controlled Trials (CENTRAL 2015, Issue 8); MEDLINE; EMBASE; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 11 August 2015. SELECTION CRITERIA Randomised controlled trials (RCTs) with a follow-up period of at least three months comparing intranasal corticosteroids (e.g. beclomethasone dipropionate, triamcinolone acetonide, flunisolide, budesonide) against placebo or no treatment in patients with chronic rhinosinusitis. DATA COLLECTION AND ANALYSIS We used the standard methodological procedures expected by Cochrane. Our primary outcomes were disease-specific health-related quality of life (HRQL), patient-reported disease severity and the commonest adverse event - epistaxis. Secondary outcomes included general HRQL, endoscopic nasal polyp score, computerised tomography (CT) scan score and the adverse events of local irritation or other systemic adverse events. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics. MAIN RESULTS We included 18 RCTs with a total of 2738 participants. Fourteen studies had participants with nasal polyps and four studies had participants without nasal polyps. Only one study was conducted in children. Intranasal corticosteroids versus placebo or no intervention Only one study (20 adult participants without polyps) measured our primary outcome disease-specific HRQL using the Rhinosinusitis Outcome Measures-31 (RSOM-31). They reported no significant difference (numerical data not available) (very low quality evidence).Our second primary outcome, disease severity , was measured using the Chronic Sinusitis Survey in a second study (134 participants without polyps), which found no important difference (mean difference (MD) 2.84, 95% confidence interval (CI) -5.02 to 10.70; scale 0 to 100). Another study (chronic rhinosinusitis with nasal polyps) reported an increased chance of improvement in the intranasal corticosteroids group (RR 2.78, 95% CI 1.76 to 4.40; 109 participants). The quality of the evidence was low.Six studies provided data on at least two of the individual symptoms used in the EPOS 2012 criteria to define chronic rhinosinusitis (nasal blockage, rhinorrhoea, loss of sense of smell and facial pain/pressure). When all four symptoms in the EPOS criteria were available on a scale of 0 to 3 (higher = more severe symptoms), the average MD in change from baseline was -0.26 (95% CI -0.37 to -0.15; 243 participants; two studies; low quality evidence). Although there were more studies and participants when only nasal blockage and rhinorrhoea were considered (MD -0.31, 95% CI -0.38 to -0.24; 1702 participants; six studies), the MD was almost identical to when loss of sense of smell was also considered (1345 participants, four studies; moderate quality evidence).When considering the results for the individual symptoms, benefit was shown in the intranasal corticosteroids group. The effect size was larger for nasal blockage (MD -0.40, 95% CI -0.52 to -0.29; 1702 participants; six studies) than for rhinorrhoea (MD -0.25, 95% CI -0.33 to -0.17; 1702 participants; six studies) or loss of sense of smell (MD -0.19, 95% CI -0.28 to -0.11; 1345 participants; four studies). There was heterogeneity in the analysis for facial pain/pressure (MD -0.27, 95% CI -0.56 to 0.02; 243 participants; two studies). The quality of the evidence was moderate for nasal blockage, rhinorrhoea and loss of sense of smell, but low for facial pain/pressure.There was an increased risk of epistaxis with intranasal corticosteroids (risk ratio (RR) 2.74, 95% CI 1.88 to 4.00; 2508 participants; 13 studies; high quality evidence).Considering our secondary outcome, general HRQL, one study (134 participants without polyps) measured this using the SF-36 and reported a statistically significant benefit only on the general health subscale. The quality of the evidence was very low.It is unclear whether there is a difference in the risk of local irritation (RR 0.94, 95% CI 0.53 to 1.64; 2124 participants; 11 studies) (low quality evidence).None of the studies treated or followed up patients long enough to provide meaningful data on the risk of osteoporosis or stunted growth (children). Other comparisons We identified no other studies that compared intranasal corticosteroids plus co-intervention A versus placebo plus co-intervention A. AUTHORS' CONCLUSIONS Most of the evidence available was from studies in patients with chronic rhinosinusitis with nasal polyps. There is little information about quality of life (very low quality evidence). For disease severity, there seems to be improvement for all symptoms (low quality evidence), a moderate-sized benefit for nasal blockage and a small benefit for rhinorrhoea (moderate quality evidence). The risk of epistaxis is increased (high quality evidence), but these data included all levels of severity; small streaks of blood may not be a major concern for patients. It is unclear whether there is a difference in the risk of local irritation (low quality evidence).
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Affiliation(s)
| | | | - Claire Hopkins
- Guy's HospitalENT DepartmentGerat Maze PondLondonUKSE1 9RT
| | - Carl Philpott
- Norwich Medical School, University of East AngliaDepartment of MedicineNorwichUKNR4 7TJ
| | - Anne GM Schilder
- Faculty of Brain Sciences, University College LondonevidENT, Ear Institute330 Grays Inn RoadLondonUKWC1X 8DA
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Snidvongs K, Kalish L, Sacks R, Craig JC, Harvey RJ. WITHDRAWN: Topical steroid for chronic rhinosinusitis without polyps. Cochrane Database Syst Rev 2016; 4:CD009274. [PMID: 27111710 PMCID: PMC10644006 DOI: 10.1002/14651858.cd009274.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Review withdrawn from Issue 4, 2016. Replaced by new reviews 'Intranasal steroids versus placebo or no intervention for chronic rhinosinusitis' (Chong 2016a) and 'Different types of intranasal steroids for chronic rhinosinusitis' (Chong 2016b). The editorial group responsible for this previously published document have withdrawn it from publication.
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Affiliation(s)
- Kornkiat Snidvongs
- Chulalongkorn UniversityDepartment of Otolaryngology, Faculty of MedicineBangkokThailand
| | - Larry Kalish
- Sydney Sinus and Allergy CentreSuite 206203‐233 New South Head RoadEdgecliffNSWAustralia2027
| | - Raymond Sacks
- Macquarie UniversityAustralian School of Advanced MedicineSydneyAustralia
- University of SydneySydneyAustralia
- Concord General HospitalDepartment of Otolaryngology, Head and Neck SurgerySydneyAustralia
| | - Jonathan C Craig
- The University of SydneySydney School of Public HealthEdward Ford Building A27SydneyNSWAustralia2006
| | - Richard J Harvey
- Macquarie UniversityAustralian School of Advanced MedicineSydneyAustralia
- St Vincent's HospitalDepartment of Otolaryngology, Head and Neck SurgeryDarlinghurstSydneyAustralia
- University of New South WalesSydneyAustralia
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16
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Kalish L, Snidvongs K, Sivasubramaniam R, Cope D, Harvey RJ. WITHDRAWN: Topical steroids for nasal polyps. Cochrane Database Syst Rev 2016; 4:CD006549. [PMID: 27111709 PMCID: PMC10653020 DOI: 10.1002/14651858.cd006549.pub3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Review withdrawn from Issue 4, 2016. Replaced by new reviews 'Intranasal steroids versus placebo or no intervention for chronic rhinosinusitis' (Chong 2016a) and 'Different types of intranasal steroids for chronic rhinosinusitis' (Chong 2016b). The editorial group responsible for this previously published document have withdrawn it from publication.
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Affiliation(s)
- Larry Kalish
- Sydney Sinus and Allergy CentreSuite 206203‐233 New South Head RoadEdgecliffNSWAustralia2027
- Concord HospitalENT DepartmentConcordAustralia
| | - Kornkiat Snidvongs
- Chulalongkorn UniversityDepartment of Otolaryngology, Faculty of MedicineBangkokThailand
| | | | - Daron Cope
- Concord HospitalENT DepartmentConcordAustralia
| | - Richard J Harvey
- Macquarie UniversityAustralian School of Advanced MedicineSydneyAustralia
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17
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Orlandi RR, Kingdom TT, Hwang PH, Smith TL, Alt JA, Baroody FM, Batra PS, Bernal-Sprekelsen M, Bhattacharyya N, Chandra RK, Chiu A, Citardi MJ, Cohen NA, DelGaudio J, Desrosiers M, Dhong HJ, Douglas R, Ferguson B, Fokkens WJ, Georgalas C, Goldberg A, Gosepath J, Hamilos DL, Han JK, Harvey R, Hellings P, Hopkins C, Jankowski R, Javer AR, Kern R, Kountakis S, Kowalski ML, Lane A, Lanza DC, Lebowitz R, Lee HM, Lin SY, Lund V, Luong A, Mann W, Marple BF, McMains KC, Metson R, Naclerio R, Nayak JV, Otori N, Palmer JN, Parikh SR, Passali D, Peters A, Piccirillo J, Poetker DM, Psaltis AJ, Ramadan HH, Ramakrishnan VR, Riechelmann H, Roh HJ, Rudmik L, Sacks R, Schlosser RJ, Senior BA, Sindwani R, Stankiewicz JA, Stewart M, Tan BK, Toskala E, Voegels R, Wang DY, Weitzel EK, Wise S, Woodworth BA, Wormald PJ, Wright ED, Zhou B, Kennedy DW. International Consensus Statement on Allergy and Rhinology: Rhinosinusitis. Int Forum Allergy Rhinol 2016; 6 Suppl 1:S22-209. [DOI: 10.1002/alr.21695] [Citation(s) in RCA: 333] [Impact Index Per Article: 41.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Revised: 11/13/2015] [Accepted: 11/16/2015] [Indexed: 02/06/2023]
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Valerie Lund
- Royal National Throat Nose and Ear Hospital; London UK
| | - Amber Luong
- University of Texas Medical School at Houston
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18
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Simon RA, Dazy KM, Waldram JD. Aspirin-exacerbated respiratory disease: characteristics and management strategies. Expert Rev Clin Immunol 2015; 11:805-17. [PMID: 25936612 DOI: 10.1586/1744666x.2015.1039940] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Aspirin-exacerbated respiratory disease is a clinical entity comprising chronic rhinosinusitis with nasal polyposis, asthma and intolerance to COX-1 inhibiting drugs. The pathogenesis is not completely understood at this point, but abnormal arachidonic acid metabolism is a key feature in this syndrome. The diagnosis is confirmed only by direct drug challenge. Aspirin desensitization followed by daily aspirin therapy is a useful treatment option in these patients. In this review article are discussed the important characteristics and treatment of aspirin-exacerbated respiratory disease.
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Affiliation(s)
- Ronald A Simon
- Scripps Clinic, Division of Allergy, Asthma and Immunology, 3811 Valley Centre Drive, San Diego, CA 92130, USA
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19
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Snidvongs K, Kalish L, Sacks R, Sivasubramaniam R, Cope D, Harvey RJ. Sinus surgery and delivery method influence the effectiveness of topical corticosteroids for chronic rhinosinusitis: systematic review and meta-analysis. Am J Rhinol Allergy 2013; 27:221-33. [PMID: 23710959 DOI: 10.2500/ajra.2013.27.3880] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Published randomized controlled trials (RCTs) on the efficacy of intranasal corticosteroid (INCS) in chronic rhinosinusitis (CRS) use either nasal delivery (nasal drop or nasal spray) or sinus delivery (sinus catheter or sinus irrigation) in patients with or without sinus surgery. This influences topical drug delivery and distribution. The effect of these factors on the published results of RCTs is assessed. This systematic review explores the strength of evidence supporting the influence of sinus surgery and delivery methods on the effectiveness of topical steroids in studies for CRS with meta-analyses. METHODS A systematic review was conducted of RCTs comparing INCS with either placebo or no intervention for treating CRS. Data were extracted for meta-analysis and subgroup analyses by sinus surgery status and topical delivery methods. RESULTS Forty-eight studies (3961 patients) met the inclusion criteria. INCS improved overall symptoms (standardized mean difference [SMD], -0.49; p < 0.00001) and the proportion of responders (risk ratio [RR], 0.59; p < 0.00001) compared with placebo. It decreased nasal polyp size with a greater proportion of responders (RR, 0.48; p < 0.00001) and prevented polyp recurrence (RR, 0.59; p = 0.0004) compared with placebo. Reduction of polyp size was greater in patients with sinus surgery (RR, 0.31; 95% confidence interval [CI], 0.20, 0.48) than those without (RR, 0.61; 95% CI, 0.46, 0.81; p = 0.009). Greater symptom improvement occurred when sinus delivery methods (SMD, -1.32; 95% CI, -2.26, -0.38) were compared with nasal delivery methods (SMD, -0.38; 95% CI, -0.55, -0.22; p < 0.00001). CONCLUSION INCS is effective for CRS. Prior sinus surgery and direct sinus delivery enhance the effectiveness of INCS in CRS.
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Affiliation(s)
- Kornkiat Snidvongs
- Australian School of Advanced Medicine, Macquarie University, Sydney, Australia.
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20
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Piromchai P, Kasemsiri P, Laohasiriwong S, Thanaviratananich S. Chronic rhinosinusitis and emerging treatment options. Int J Gen Med 2013; 6:453-64. [PMID: 23785241 PMCID: PMC3682850 DOI: 10.2147/ijgm.s29977] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
This review describes the epidemiology and various treatments in chronic rhinosinusitis (CRS) with nasal polyps (CRSwNP) and CRS without nasal polyps (CRSsNP). Evidence for short-term use of systemic corticosteroids has been shown to be favorable in CRSwNP, but still limited in CRSsNP. Topical corticosteroids improve symptom scores in both CRS subgroups. The role of microbes in CRS is still controversial. Culture-directed antibiotics are recommended for CRSsNP with exacerbation. Long-term use of low dosage antibiotics is recommended for CRSsNP for their anti-inflammatory effects. Other emerging treatment options are also discussed.
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Affiliation(s)
- Patorn Piromchai
- Department of Otorhinolaryngology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand ; Department of Otolaryngology, Royal Victorian Eye and Ear Hospital/University of Melbourne, East Melbourne, Australia
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21
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Wei CC, Adappa ND, Cohen NA. Use of topical nasal therapies in the management of Chronic rhinosinusitis. Laryngoscope 2013; 123:2347-59. [DOI: 10.1002/lary.24066] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2012] [Revised: 01/10/2013] [Accepted: 01/31/2013] [Indexed: 11/10/2022]
Affiliation(s)
- Calvin C. Wei
- Department of Otolaryngology-Head and Neck Surgery; St. Luke's-Roosevelt Hospital; New York; New York
| | - Nithin D. Adappa
- Department of Otorhinolaryngology-Head and Neck Surgery; University of Pennsylvania School of Medicine; Hospital of the University of Pennsylvania; Philadelphia; Pennsylvania; U.S.A
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22
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Shikani AH, Kourelis K, Rohayem Z, Basaraba RJ, Leid JG. Topical gel therapy for sinonasal polyposis in Samter's triad: preliminary report. Ann Otol Rhinol Laryngol 2013. [PMID: 23193904 DOI: 10.1177/000348941212101104] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Rhinosinusitis and polyposis are difficult to treat in patients with Samter's triad; they commonly recur despite sinus surgery, antibiotics, and/or nasal steroids. The present study assesses the efficacy of a multimodal regimen that includes topical corticosteroids and antibiotics delivered through a hydroxyethyl cellulose gel and by nebulization. METHODS Eleven patients with Samter's triad who had polyposis and rhinosinusitis that recurred despite endoscopic sinus surgery were treated with a 6-week course of multimodal topical therapy consisting of a hydroxyethyl cellulose gel that releases corticosteroids and antibiotics, topical nebulization of corticosteroids and antibiotics, saline solution rinses, and sinus debridement. Clinical outcomes were evaluated by Lund-Kennedy endoscopic and symptom scores. Histologic assessment was evaluated by hematoxylin and eosin staining before and after treatment. RESULTS Both Lund-Kennedy symptom and endoscopic scores showed.a progressive and statistically significant decline throughout the course of treatment, reaching at 6 weeks 42% of the pretreatment values (p = 0.005) for the Lund-Kennedy symptom score and 34% (p = 0.002) for the endoscopic score, respectively; however, the significance of the improvement was lost with time. CONCLUSIONS Topical gel therapy improves clinical symptoms, endoscopic findings, and sinus membrane histologic features in patients with refractory Samter's triad, but the improvement is transient, suggesting that a longer therapeutic period might be needed.
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Affiliation(s)
- Alan H Shikani
- Division of Rhinology, Dept of Otolaryngology-Head and Neck Surgery, Union Memorial Hospital, 201 E University Pkwy, Baltimore, MD 21218, USA
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23
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Ramakrishnan JB, Kingdom TT, Ramakrishnan VR. Allergic rhinitis and chronic rhinosinusitis: their impact on lower airways. Immunol Allergy Clin North Am 2012; 33:45-60. [PMID: 23337064 DOI: 10.1016/j.iac.2012.10.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Anatomy, pathophysiology, epidemiology, and disease characteristics link the upper and lower airways. Nonspecific symptoms such as cough, congestion, shortness of breath, and recurrent infection may be related to the upper airway, lower airway, or both. Patients with the most severe disease often exhibit symptoms and findings of inflammation at both sites. Recent literature suggests that medical treatment and, when appropriate, surgical therapy directed at the upper airway can yield improvements in the lower airway. An understanding of the diagnosis and management of diseases at both sites will afford patients the best possible outcomes.
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Abstract
BACKGROUND Chronic rhinosinusitis with nasal polyps (CRSwNP) represents inflammatory changes throughout the nose and sinuses from a group of disorders which all lead to swelling and overgrowth of the nasal mucosa. Topical corticosteroids have been the most widely used treatment, with each clinician using different regimes, at different doses, in different settings and with or without sinus surgery. CRSwNP requires ongoing medical management to prevent recurrence. OBJECTIVES To assess the effects of topical corticosteroids on CRSwNP and to analyse various subgroups, including patients who had sinus surgery immediately prior to the delivery of the corticosteroids, surgery any time prior to the topical corticosteroids or patients who had never had previous surgery. Also to assess the most effective dose and delivery methods for topical corticosteroids. SEARCH METHODS We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the search was 10 April 2012. SELECTION CRITERIA Randomised controlled trials studying topical corticosteroids for patients with CRSwNP. DATA COLLECTION AND ANALYSIS At least two authors reviewed the search results and selected trials meeting the eligibility criteria, obtaining full texts and contacting authors. We documented our justification for the exclusion of studies. At least two authors extracted data using a pre-determined, standardised data form. MAIN RESULTS Forty studies (3624 patients) met the inclusion criteria. The trials were at low (21 trials), medium (13 trials) and high (six trials) risk of bias. The primary outcomes were sino-nasal symptoms, polyp size and polyp recurrence after surgery. When compared to placebo, topical corticosteroids improved overall symptom scores (standardised mean difference (SMD) -0.46; 95% confidence interval (CI) -0.65 to -0.27, P < 0.00001; seven trials, n = 445) and had a higher proportion of patients whose symptoms improved (responders) (risk ratio (RR) 1.71; 95% CI 1.29 to 2.26, P = 0.0002; four trials, n = 234). Topical corticosteroids also decreased the polyp score (SMD -0.73; 95% CI -1.00 to -0.46, P < 0.00001; three trials, n = 237) and had a greater proportion of patients with a reduction in polyp size (responders) (RR 2.09; 95% CI 1.65 to 2.64, P < 0.00001; eight trials, n = 785) when compared to placebo. Topical corticosteroids also prevented polyp recurrence after surgery (RR 0.59; 95% CI 0.45 to 0.79, P = 0.0004; six trials, n = 437). Subgroup analyses by sinus surgery status revealed a greater benefit in reduction of polyp score when topical steroid was administered any time after sinus surgery (SMD -1.19; 95% CI -1.54 to -0.83) compared to patients who had never had surgery (SMD -0.13; 95% CI -0.53 to 0.28, P < 0.00001). There was no difference between groups in terms of adverse events. AUTHORS' CONCLUSIONS Topical corticosteroids are a beneficial treatment for CRSwNP and the adverse effects are minor, with benefits outweighing the risks. They improve symptoms, reduce polyp size and prevent polyp recurrence after surgery. Patients having sinus surgery may have a greater response to topical corticosteroids but further research is required.
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Affiliation(s)
- Larry Kalish
- Sydney Sinus and Allergy Centre, Suite 206, 203-233 New South Head Road, Edgecliff, NSW, Australia, 2027
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25
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Abstract
AbstractAspirin (ASA)-sensitive asthma is characterised by a typical sequence of symptoms, including intense eosinophilic inflammation of nasal and bronchial tissues. It is more commonly found in non-atopic, middle-aged female asthmatic patients with chronic rhino-sinusitis and/or nasal polyps. The lysine-aspirin bronchoprovocation test has become a widely used diagnostic test. When ASA-sensitive asthma is confirmed, complete avoidance of ASA/non-steroidal anti-inflammatory agents (NSAIDs) is crucial in preventing life-threatening adverse reactions. The basic principle of pharmacotherapy is step-wise treatment based upon anti-inflammatory therapy. Corticosteroids are the mainstay of therapy and anti-leukotriene agents may be indicated for treatment of the underlying disease.ASA desensitisation may reduce inflammatory mucosal disease symptoms,particularly in the nasal passage.
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Affiliation(s)
- H S Park
- Department of Allergy and Clinical Immunology, Ajou University Schoolof Medicine, Suwon, Korea.
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26
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Moebus RG, Han JK. Immunomodulatory treatments for aspirin exacerbated respiratory disease. Am J Rhinol Allergy 2012; 26:134-40. [PMID: 22487291 DOI: 10.2500/ajra.2012.26.3748] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Aspirin triad is a subclass of chronic sinusitis characterized by nasal polyposis, nonallergic induced asthma, and aspirin sensitivity. Also known as Samter's triad or aspirin-exacerbated respiratory disease, aspirin triad commonly affects the adult population and is seldom found in pediatric patients. METHODS This rhinosinusitis has multiple layers of pathological process, but the ultimate predicament is caused by cysteinyl leukotrienes (cysLTs). RESULTS Pharmacotherapies include oral steroid, lipoxygenase inhibitor, and cysLT receptor inhibitor drugs, which can provide some relief for these patients. CONCLUSION Immunomodulation via aspirin desensitization is considered when pharmacotherapy has failed. When aspirin triad is unmanageable with medical treatment alone, endoscopic sinus surgery with polypectomy can alleviate the patient's symptoms, allowing for a better response to postoperative medical management such as topical medication as well as delivery of topical medications.
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Affiliation(s)
- Rachel G Moebus
- Department of Otolaryngology and Head and Neck Surgery, Eastern Virginia Medical School, Norfolk, Virginia 23507, USA
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Snidvongs K, Kalish L, Sacks R, Craig JC, Harvey RJ. Topical steroid for chronic rhinosinusitis without polyps. Cochrane Database Syst Rev 2011:CD009274. [PMID: 21833974 DOI: 10.1002/14651858.cd009274] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Topical corticosteroid is used as part of a comprehensive medical treatment for chronic rhinosinusitis (CRS) without polyps. Nevertheless, there is insufficient evidence to show a clear overall benefit. Trials studying the efficacy of topical corticosteroid use various delivery methods in patients who have or have not had sinus surgery, which directly impacts on topical delivery and distribution. OBJECTIVES To assess the effects of topical steroid in patients with CRS without nasal polyps and perform a meta-analysis of symptom improvement data, including subgroup analysis by sinus surgery status and topical delivery methods. SEARCH STRATEGY We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ISRCTN and additional sources for published and unpublished trials. The date of the most recent search was 9 July 2010. SELECTION CRITERIA All randomised trials in which a topically administered corticosteroid was compared with either a placebo, no treatment or alternative topically administered corticosteroid for the treatment of CRS without polyps in patients of any age. DATA COLLECTION AND ANALYSIS Two authors reviewed the search results and selected trials meeting the eligibility criteria, obtaining full texts and contacting authors where necessary. We documented our justification for the exclusion of studies. Two authors extracted data using a pre-determined standardised data form. MAIN RESULTS Ten studies (590 patients) met the inclusion criteria. The trials were of low (six trials) and medium (four trials) risk of bias. The primary outcome was sino-nasal symptoms. When compared to placebo, topical steroid improved symptom scores (standardised mean difference -0.37; 95% confidence interval (CI) -0.60 to -0.13, P = 0.002; five trials, n = 286) and had a greater proportion of responders (risk ratio 1.69; 95% CI 1.21 to 2.37, P = 0.002; four trials, n = 263). With a limited number of studies, the subgroup analyses of patients who had received sinus surgery versus those who had not was not significant (P = 0.35). Subgroup analyses by topical delivery method revealed more benefit when steroid was administered directly to the sinuses than with simple nasal delivery (P = 0.04). There were no differences between groups for quality of life and adverse events. AUTHORS' CONCLUSIONS Topical steroid is a beneficial treatment for CRS without polyps and the adverse effects are minor. It may be included in a comprehensive treatment of CRS without polyps. Direct delivery of steroid to the sinuses may bring more beneficial effect. Further studies comparing different topical drug delivery methods to the sinuses, with appropriate treatment duration (longer than 12 weeks), are required.
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Affiliation(s)
- Kornkiat Snidvongs
- Australian School of Advanced Medicine, Macquarie University, Sydney, NSW, Australia
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Management of nasal polyps in 'aspirin sensitive asthma' triad. Curr Opin Otolaryngol Head Neck Surg 2011; 19:6-10. [PMID: 21124222 DOI: 10.1097/moo.0b013e328341e273] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Aspirin-sensitive asthma (ASA) triad is a challenging picture presenting to both the otolaryngologist and the respiratory physicians. Patients present with severe nasal polyposis with a high propensity to recur despite the modality of treatment - medical or surgical. They also often have poorly controlled severe adult onset asthma. We reviewed the scientific literature, focusing on the outcomes of these treatment modalities in the management of nasal polyposis in ASA triad. RECENT FINDINGS Although initial work described by Widal on the subject continues, in the last decade a number of prospective and retrospective studies on outcomes after aspirin desensitization as well as surgery have been reported. The extent of surgery has also been addressed in some of these studies. Medical as well as surgical treatments have a role but there has been increasing evidence to support the role of aspirin desensitization in achieving long-term control of this condition. SUMMARY Overall, with the limitation of data, it appears more is better in patients with ASA and nasal polyposis. There is a lack of level 1 evidence in the proposed treatment modalities. Questions on extent of surgery and dosage as well as length of aspirin desensitization require further research with minimally biased controlled studies.
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Takeda K, Takeno S, Hirakawa K, Ishino T. Expression and distribution of glucocorticoid receptor isoforms in eosinophilic chronic rhinosinusitis. Auris Nasus Larynx 2010; 37:700-7. [PMID: 20488636 DOI: 10.1016/j.anl.2010.03.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2009] [Revised: 02/25/2010] [Accepted: 03/11/2010] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Patients with eosinophilic chronic rhinosinusitis (ECRS) show a high percentage of eosinophilic infiltration in the paranasal sinus mucosa. It is well documented that topical steroids have a beneficial effect in ECRS with nasal polyposis. We investigated mucosal distribution and cellular localization of glucocorticoid receptor (GR) isoform expression in human paranasal sinuses in relation to the clinical characteristics of eosinophilic chronic rhinosinusitis (ECRS) patients. METHODS Mucosal specimens were obtained from 20 sinusitis patients by endoscopic sinus surgery (ESS). Quantitative fluorescence immunohistochemical analysis was employed to examine the degree of glucocorticoid receptor (GR) isoform expression in sinus mucosa specimens. An RT-PCR procedure was performed to determine the relative quantities of mRNA for the human GRalpha and GRbeta genes. RESULTS Patients in the ECRS group showed significant increases in peripheral blood eosinophils as compared to the non-ECRS group (16.98% vs. 2.31%). Positive immunoreactivity of GRbeta expression was predominantly found to be positive in inflammatory cells. The absolute number of GRbeta-positive cells in the ECRS group was increased in comparison with that in the non-ECRS group. The difference was statistically significant both in the maxillary (179.7 cells/mm(2) vs. 82.5 cells/mm(2)) and ethmoid sinus (302.0 cells/mm(2) vs. 61.5 cells/mm(2)) mucosa. The GRbeta/GRalpha cell ratio in the ECRS group was elevated when compared with that in the non-ECRS group both in the maxillary and the ethmoid sinus mucosa, with the latter difference being significant. CONCLUSIONS The presence of high peripheral eosinophilia indicates a high likelihood of ECRS disease. Our results support the association of GRbeta expression with ECRS. The expression of GRbeta immunoreactivity, an endogenous inhibitor of steroid action previously associated with steroid insensitivity, may be one of major contributing factors in ECRS.
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Affiliation(s)
- Kazumasa Takeda
- Department of Otolaryngology, Head and Neck Surgery, Division of Clinical Medical Science, Programs for Applied Biomedicine, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan.
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Abstract
Topical drug delivery for sinonasal disorders is influenced by a variety of factors. Macroscopically (or anatomically), the ability of the drug to reach the appropriate region of the paranasal system is paramount. Delivery techniques, surgical state of the sinus cavity, delivery device, and fluid dynamics (volume, pressure, position) have a significant impact on the delivery of topical therapies to the sinus mucosa. Once topical therapeutics actually reach the desired site, factors within the local microenvironment heavily influence local drug delivery. The presence and composition of the mucus blanket, mucociliary clearance, direct mucin-drug binding, and the permeability of pharmaceutical compounds will all impact drug delivery. In addition, the general therapeutic goal of topical management may lie between the potentially competing actions of mechanical lavage and pharmaceutical intervention. Techniques for the mechanical removal of mucus, antigen, and inflammatory products may not be the most efficient approach for pharmaceutical delivery. This article reviews the evolving concepts in local drug therapy, both for the factors that influence anatomic distribution within the sinonasal system and those that affect mucosal absorption.
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Affiliation(s)
- Richard J Harvey
- Rhinology and Skull Base Surgery, Department of Otolaryngology/Skull Base Surgery, St Vincent's Hospital, 354 Victoria Street, Darlinghurst, Sydney, NSW 2010, Australia.
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Kalish LH, Arendts G, Sacks R, Craig JC. Topical Steroids in Chronic Rhinosinusitis Without Polyps: A Systematic Review and Meta-Analysis. Otolaryngol Head Neck Surg 2009; 141:674-83. [DOI: 10.1016/j.otohns.2009.08.006] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2009] [Revised: 07/12/2009] [Accepted: 08/06/2009] [Indexed: 11/26/2022]
Abstract
OBJECTIVE: To evaluate whether topical steroids provide symptomatic relief in patients with chronic rhinosinusitis without polyps. DATA SOURCES: MEDLINE, EMBASE, and Cochrane CENTRAL databases. REVIEW METHODS: Systematic review and meta-analysis was performed of the articles identified by two independent reviewers of all randomized controlled trials that had evaluated intranasal corticosteroids in patients with chronic rhinosinusitis (CRS) without polyps. The quality of included studies was evaluated, and results synthesized using standard random-effects meta-analytical methods. RESULTS: Of 424 potential studies, only nine randomized trials involving 657 patients in total were eligible. Quality of design and reporting was suboptimal, with only one trial adhering to accepted standards for reporting. Five trials combined outcome measures and reported on overall response of CRS without polyps to topical steroids. The summary estimate for overall response to treatment showed no significant benefit and substantial variability among studies (5 trials: RR 0.75, 95% CI 0.50–1.10, P = 0.14, χ2 = 13.78, I 2 = 66.2%). Total symptom score was reported in three trials with a standardized mean difference favoring topical steroids (RR 0.63, 95% CI 0.16–1.09, P = 0.009), with no evidence of heterogeneity (χ2 = 3.03, P = 0.22). Although the data were limited, there were no reports of increased adverse effects with topical steroids. CONCLUSION: There is insufficient evidence to demonstrate a clear overall benefit for topical steroids in CRS without polyps; however, their use appears safe and may show some symptomatic benefit. A class effect among different topical steroids cannot be assumed, and further trials are required.
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Affiliation(s)
- Larry H. Kalish
- Department of Otorhinolaryngology, Concord Repatriation Hospital, Sydney, New South Wales, Australia
| | - Glenn Arendts
- Centre for Clinical Research in Emergency Medicine, Western Australia Institute for Medical Research, Perth, Western Australia, Australia
| | - Raymond Sacks
- Department of Otorhinolaryngology, Concord Repatriation Hospital, Sydney, New South Wales, Australia
| | - Jonathan C. Craig
- School of Public Health, University of Sydney, Sydney, New South Wales, Australia
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The clinical effectiveness of aspirin desensitization in chronic rhinosinusitis. Curr Allergy Asthma Rep 2008; 8:245-52. [PMID: 18589844 DOI: 10.1007/s11882-008-0041-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Aspirin-exacerbated respiratory disease (AERD) is a chronic inflammatory disease characterized by chronic rhinosinusitis, nasal polyposis, asthma, and airway reactivity to aspirin and other nonsteroidal antiinflammatory drugs (NSAIDs). For patients who have inadequately controlled rhinosinusitis and/or asthma despite treatment with topical corticosteroids and leukotriene-modifying drugs, aspirin desensitization is an important therapeutic option. This review examines the evidence supporting the effectiveness of aspirin desensitization for the treatment of chronic rhinosinusitis in patients with AERD. Practical aspects of conducting safe aspirin desensitization procedures and optimizing therapeutic benefits are also reviewed. When conducted in accordance with current guidelines, aspirin desensitization is a safe procedure that allows patients with AERD who have an indication for aspirin or other NSAIDs to safely ingest these medications. There is now strong evidence that aspirin desensitization and daily aspirin therapy is effective for treatment of the chronic inflammatory disease of the upper airway and lower airways in AERD.
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Nathan RA, Eccles R, Howarth PH, Steinsvåg SK, Togias A. Objective monitoring of nasal patency and nasal physiology in rhinitis. J Allergy Clin Immunol 2007; 115:S442-59. [PMID: 15746882 PMCID: PMC7112320 DOI: 10.1016/j.jaci.2004.12.015] [Citation(s) in RCA: 104] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/30/2022]
Abstract
Nasal obstruction can be monitored objectively by measurement of nasal airflow, as evaluated by nasal peak flow, or as airways resistance/conductance as evaluated by rhinomanometry. Peak flow can be measured during inspiration or expiration. Of these measurements, nasal inspiratory peak flow is the best validated technique for home monitoring in clinical trials. The equipment is portable, relatively inexpensive, and simple to use. One disadvantage, however, is that nasal inspiratory peak flow is influenced by lower airway as well as upper airway function. Rhinomanometry is a more sensitive technique that is specific for nasal measurements. The equipment, however, requires an operator, is more expensive, and is not portable. Thus, it is applicable only for clinic visit measures in clinical trials. Measurements require patient cooperation and coordination, and not all can achieve repeatable results. Thus, this objective measure is best suited to laboratory challenge studies involving smaller numbers of selected volunteers. A nonphysiological measure of nasal patency is acoustic rhinometry. This sonic echo technique measures internal nasal luminal volume and the minimum cross-sectional area. The derivation of these measures from the reflected sound waves requires complex mathematical transformation and makes several theoretical assumptions. Despite this, however, such measures correlate well with the nasal physiological measures, and the nasal volume measures have been shown to relate well to results obtained by imaging techniques such as computed tomography scanning or magnetic resonance imaging. Like rhinomanometry, acoustic rhinometry is not suitable for home monitoring and can be applied only to clinic visit measures or for laboratory nasal challenge monitoring. It has advantages in being easy to use, in requiring little patient cooperation, and in providing repeatable results. In addition to nasal obstruction, allergic rhinitis is recognized to be associated with impaired mucociliary clearance and altered nasal responsiveness. Measures exist for the monitoring of these aspects of nasal dysfunction. Although measures of mucociliary clearance are simple to perform, they have a poor record of reproducibility. Their incorporation into clinical trials is thus questionable, although positive outcomes from therapeutic intervention have been reported. Measures of nasal responsiveness are at present largely confined to research studies investigating disease mechanisms in allergic and nonallergic rhinitis. The techniques are insufficiently standardized to be applied to multicenter clinical trials but could be used in limited-center studies to gain insight into the regulatory effects of different therapeutic modalities.
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MESH Headings
- Humans
- Monitoring, Immunologic/methods
- Nasal Mucosa/immunology
- Nasal Mucosa/pathology
- Nasal Obstruction/immunology
- Nasal Obstruction/pathology
- Rhinitis, Allergic, Perennial/immunology
- Rhinitis, Allergic, Perennial/pathology
- Rhinitis, Allergic, Seasonal/immunology
- Rhinitis, Allergic, Seasonal/pathology
- Rhinomanometry
- Rhinometry, Acoustic
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Affiliation(s)
- Robert A Nathan
- Asthma and Allergy Associates, 2709 North Tejon, Colorado Springs, CO 80907, USA.
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Szczeklik A, Sanak M. The broken balance in aspirin hypersensitivity. Eur J Pharmacol 2006; 533:145-55. [PMID: 16457808 DOI: 10.1016/j.ejphar.2005.12.053] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/13/2005] [Indexed: 10/25/2022]
Abstract
Aspirin was introduced into medicine over a century ago and has become the most popular drug in the world. Although the first hypersensitivity reaction was described soon after aspirin had been marketed, only recently a phenomenon of cysteinyl leukotriene overproduction brought new insights on a balance between pro- and anti-inflammatory mediators derived from arachidonic acid. We describe the most common clinical presentations of aspirin hypersensitivity, i.e. aspirin-induced asthma, rhinosinusitis and aspirin-induced urticaria. We also present their biochemical background. Despite relatively high incidence of these reactions, aspirin hypersensitivity remains underdiagnosed worldwide. Acute reactions of aspirin hypersensitivity are elicited via cyclooxygenase inhibition by non-steroid anti-inflammatory drugs. Coxibs, selective inhibitors of cyclooxygenase-2 isoenzyme, do not precipitate symptoms in susceptible patients. Though hypersensitivity correlates with cyclooxygenase-1 inhibition, diminished tissue expression was described only for cyclooxygenase-2. Aspirin-induced asthma and aspirin-induced urticaria, in a substantial part of the patients, are driven by a release of mediators from activated mast cells. These cells in physiological conditions are under inhibitory control of prostaglandin E2. The origin of aspirin hypersensitivity remains unknown, but accumulating data from genetic studies strongly suggest that environmental factor, possibly a common viral infection, can trigger the disease in susceptible subjects.
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Affiliation(s)
- Andrzej Szczeklik
- Department of Medicine, Jagiellonian University School of Medicine, Skawinska 8, 31-066 Krakow, Poland.
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Lee JY, Stevenson DD. Role of aspirin and other nonsteroidal anti-inflammatory drugs in aspirin-exacerbated respiratory disease. Expert Rev Clin Immunol 2006; 2:75-86. [DOI: 10.1586/1744666x.2.1.75] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Simon RA. Treatment of patients with respiratory reactions to aspirin and nonsteroidal anti-inflammatory drugs. Curr Allergy Asthma Rep 2004; 4:139-43. [PMID: 14769263 DOI: 10.1007/s11882-004-0059-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Aspirin exacerbated respiratory disease (AERD) is an adult onset condition manifested as asthma, rhinosinusitis/nasal polyps, and sensitivity to aspirin and other cyclooxygenase-1 (Cox-1)-inhibitor nonsteroidal anti-inflammatory drugs (NSAIDs). There is no cross-sensitivity to highly selective Cox-2 inhibitors.
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Affiliation(s)
- Ronald A Simon
- Division of Allergy, Asthma and Immunology, Scripps Clinic, 10666 North Torrey Pines Road, 205W, La Jolla, CA 92037, USA.
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Szczeklik A, Sanak M, Nizankowska-Mogilnicka E, Kiełbasa B. Aspirin intolerance and the cyclooxygenase-leukotriene pathways. Curr Opin Pulm Med 2004; 10:51-6. [PMID: 14749606 DOI: 10.1097/00063198-200401000-00009] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW In up to 10% of patients with bronchial asthma, aspirin and other nonsteroidal antiinflammatory drugs precipitate asthmatic attacks. This is a hallmark of a distinct clinical syndrome that develops according to a characteristic sequence of symptoms. Here we discuss its clinical picture and management as related to the abnormalities in arachidonic acid transformations. RECENT FINDINGS At the biochemical level, the characteristic feature is profound alteration in eicosanoid biosynthesis and metabolism. Major advances in the molecular biology of eicosanoids, exemplified by the cloning of cysteinyl-leukotriene receptors and discovery of a whole family of cyclooxygenase enzymes, offer new insights into mechanisms operating in aspirin-induced asthma. Clinical interest has been enhanced by the introduction into therapy of highly specific cyclooxygenase-2 inhibitors and antileukotriene drugs. SUMMARY Recent studies have improved our understanding of mechanisms operating in asthma and unvieled the role of eicosanoid mediators in pulmonary disease.
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Affiliation(s)
- Andrew Szczeklik
- Department of Medicine, Jagiellonian University School of Medicine, Kraków, Poland.
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Szczeklik A, Stevenson DD. Aspirin-induced asthma: advances in pathogenesis, diagnosis, and management. J Allergy Clin Immunol 2003; 111:913-21; quiz 922. [PMID: 12743549 DOI: 10.1067/mai.2003.1487] [Citation(s) in RCA: 356] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
In some asthmatic individuals, aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) that inhibit cyclooxygen-ase 1 (COX-1) exacerbate the condition. This distinct clinical syndrome, called aspirin-induced asthma (AIA), is characterized by an eosinophilic rhinosinusitis, nasal polyposis, aspirin sensitivity, and asthma. There is no in vitro test for the disorder, and diagnosis can be established only by provocation challenges with aspirin or NSAIDs. Recent major advances in the molecular biology of eicosanoids, exemplified by the cloning of 2 cysteinyl leukotriene receptors and the discovery of a whole family of cyclooxygenase enzymes, offer new insights into mechanisms operating in AIA. The disease runs a protracted course even if COX-1 inhibitors are avoided, and the course is often severe, many patients requiring systemic corticosteroids to control their sinusitis and asthma. Aspirin and NSAIDs should be avoided, but highly specific COX-2 inhibitors, known as coxibs, are well tolerated and can be safely used. Aspirin desensitization, followed by daily aspirin treatment, is a valuable therapeutic option in most patients with AIA, particularly those with recurrent nasal polyposis or overdependence on systemic corticosteroids.
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Affiliation(s)
- Andrew Szczeklik
- Department of Medicine, Jagellonian University School of Medicine, Krakow, Poland
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Fahrenholz JM. Natural history and clinical features of aspirin-exacerbated respiratory disease. Clin Rev Allergy Immunol 2003; 24:113-24. [PMID: 12668892 DOI: 10.1385/criai:24:2:113] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Aspirin-exacerbated respiratory disease (AERD) is a clinical syndrome characterized by chronic rhinosinusitis, nasal polyposis, asthma and precipitation of asthma, and rhinitis attacks after ingestion of aspirin (ASA) and most other nonsteroidal antiinflammatory drugs (NSAIDs). Although precipitation of asthma attacks by ingestion of ASA and other NSAIDs is considered a hallmark of the syndrome, the respiratory mucosal inflammatory disease process begins and continues in the absence of ongoing or even intermittent exposure to ASA or NSAIDs. The typical patient with AERD is an adult who develops refractory chronic rhinitis in the third or fourth decade of life. The chronic rhinitis evolves into chronic eosinophilic rhinosinusitis with associated nasal polyposis. Anosmia appears in most patients. CT of the sinuses most often demonstrates pansinusitis and patients often undergo multiple sinus operations resulting in only limited temporary benefit. During the evolution of the sinus disease persistent asthma develops. Finally, if patients are exposed to ASA or NSAIDs acute respiratory reactions begin to occur. Despite subsequent avoidance of ASA and other NSAIDs, the respiratory mucosal inflammatory disease persists, often requiring systemic corticosteroids for control of both upper- and lower-respiratory tract symptoms. Adequate control of asthma can often only be accomplished with the simultaneous control of the associated rhinosinusitis. With few exceptions, once AERD develops it remains for the remainder of the patient s life.
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Abstract
Avoidance of ASA and other NSAIDs prevents the reactions and careful attention to clinical history along with patient education are important. However, blanket advice to avoid all NSAIDs is no longer reasonable. Except for AERD and chronic urticaria, cross-reactivity with other NSAIDs does not occur. A physician can definitively prove this by giving the patient another NSAID in their office and observing no reaction. Furthermore, for patients with AERD and chronic urticaria, they can be given the new selective COX-2 inhibitors (rofecoxib and celecoxib) without any cross-reactivity. All AERD patients can be desensitized to ASA and treated with ASA indefinitely. However, ASA desensitization in chronic urticaria is not possible. Underlying mild and moderate AERD responds well to topical and systemic corticosteroids and leukotriene modifiers. However, the severe forms of the disease should be desensitized to ASA and treated with this drug on a long term basis. In the future, new drugs that prevent eosinophil activation and chemotaxis or enhance eosinophil apoptosis are likely to be useful. Specific blockers of the second cystLT receptor would also be useful. Ultimately as the genetics of these heterogeneous disorders are unraveled, gene substitution therapy may be the ultimate answer.
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Affiliation(s)
- Ronald A Simon
- Divison of Allergy, Asthma, and Immunology, The Scripps Clinic and Research Institute, La Jolla, CA 92037, USA.
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Berges-Gimeno MP, Simon RA, Stevenson DD. Long-term treatment with aspirin desensitization in asthmatic patients with aspirin-exacerbated respiratory disease. J Allergy Clin Immunol 2003; 111:180-6. [PMID: 12532116 DOI: 10.1067/mai.2003.7] [Citation(s) in RCA: 232] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Aspirin desensitization treatment is an option to decrease disease activity and reduce the need for systemic corticosteroids in patients with aspirin-exacerbated respiratory disease (AERD). OBJECTIVE This study was designed to determine whether the clinical courses of patients with AERD improved as early as 6 months after starting aspirin desensitization and to compare this with follow-up evaluations after at least a year. METHODS Between 1995 and 2000, 172 patients with AERD were admitted to our General Clinical Research Center, were desensitized to and treated with aspirin, were discharged to their home communities, and participated in follow-up interviews and written assessments of their clinical courses. RESULTS By the first 6 months of aspirin treatment, there were significant reductions in sinus infections and numbers of short courses of prednisone and improvements in sense of smell and general assessment of nasal-sinus and asthma symptoms (P <.0001). These results persisted for 1 to 5 years (P <.0001). Mean prednisone doses decreased from 10.8 mg/d to 8.1 and 3.6 mg/d at 6 months and greater than 1 year, respectively. Of the 172 patients, 24 (14%) discontinued aspirin treatment because of side effects, and 115 (67%) responded to aspirin treatment. After eliminating those who discontinued aspirin treatment because of side effects, the improvement rate was 115 (78%) of 148 patients. Of the 126 patients who completed a year or more of aspirin treatment, 110 (87%) experienced improvement. CONCLUSION Aspirin desensitization followed by daily aspirin is efficacious by at least the first 6 months of treatment and continues to be effective for up to 5 years of follow-up.
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Affiliation(s)
- M Pilar Berges-Gimeno
- Scripps Research Institute and Scripps Clinic and Scripps Research Institute, La Jolla, Calif 92037, USA
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Abstract
The incidence of asthma is increasing throughout the world, which presents both public health and economic concerns. It is widely recognized that in some adult patients with asthma, aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) that inhibit cyclooxygenase (COX)-1 exacerbate the condition. This is a distinct clinical syndrome called aspirin-induced asthma (AIA). The disease develops according to a characteristic pattern of symptoms. Persistent eosinophilic rhinosinusitis precedes development of nasal polyposis, aspirin hypersensitivity, and asthma. There is no in vitro test, and diagnosis can only be established by provocation tests with aspirin. At the biochemical level, AIA is characterized by a chronic overproduction of cysteinyl leukotrienes. The key enzyme, leukotriene C4 synthase, is overexpressed in bronchi, and its messenger RNA is upregulated in peripheral blood eosinophils. This can be partly related to the genetic polymorphism of the enzyme. The disease runs a protracted course, even if COX-1 inhibitors are avoided. The course of AIA is often severe, and at least half of the patients need systemic corticosteroids to control their asthma. To prevent life-threatening reactions, patients with AIA should avoid aspirin and other analgesics that inhibit COX-1. The incidence of cross-sensitivity to paracetamol in AIA patients is low and, when a reaction does occur, the symptoms experienced are shorter and milder than if the reactions were evoked by an NSAID. Rapidly growing evidence indicates that highly specific COX-2 inhibitors, known as coxibs, are well tolerated and can be safely used by AIA patients.
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Affiliation(s)
- Andrew Szczeklik
- Department of Medicine, Jagellonian University School of Medicine, Cracow, Poland.
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Hellgren J, Torén K, Balder B, Palmqvist M, Löwhagen O, Karlsson G. Increased nasal mucosal swelling in subjects with asthma. Clin Exp Allergy 2002; 32:64-9. [PMID: 12002739 DOI: 10.1046/j.0022-0477.2001.01253.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The objective of this study was to evaluate nasal mucosal swelling with acoustic rhinometry in subjects with asthma and in healthy controls. METHODS We examined 184 individuals with asthma and compared with 156 randomly selected controls outside the pollen season, where 144 subjects in the asthma group and 80 controls had a previous history of non-infectious rhinitis (NIR). Nasal mucosal swelling was assessed with acoustic rhinometry before and after nasal decongestion with oxymetazoline and was analysed for the crosssectional area (4cm from the nostril) and the volume between 3.3 and 4cm from the nostril. Symptom scores for nasal blockage, secretion, itching and sneezing were assessed on a 0-10 visual analogue scale as well as peak nasal inspiratory flow and spirometry. RESULTS Before decongestion there was a decrease in the cross-sectional area at 4 cm (1.32 cm2 vs. 1.59 cm2, mean left + right P = 0.04) and in the volume (1.70 vs. 1.91 cm3 P = 0.03) in the asthma group compared with healthy controls. After decongestion there were no significant differences in cross-sectional area at 4cm (1.66 vs. 1.73cm2 P=0.32) or volume (2.12 vs. 2.24cm3 P=0.32). Combined nasal symptom scores were higher in the asthma group (1.8 vs. 0.8, P=0.0001) and peak nasal inspiratory flow was lower (119 vs. 124 L/min, P = 0.38) than the healthy controls. FEV1 (% predicted) was also lower in asthma group (84 vs. 93% P < 0.0001). CONCLUSION We have been able to demonstrate an increased nasal mucosal swelling in a population sample of persons with asthma compared to healthy controls. These data support previous reports of a generalized airway inflammation in patients with asthma and suggest that acoustic rhinometry can be used to monitor the nasal mucosal swelling in these patients.
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Affiliation(s)
- J Hellgren
- Department of Oto-Rhino-Laryngology, Head and Neck Surgery, Sahlgrenska University Hospital, Göteborg, Sweden.
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Bousquet J, Van Cauwenberge P, Khaltaev N. Allergic rhinitis and its impact on asthma. J Allergy Clin Immunol 2001; 108:S147-334. [PMID: 11707753 DOI: 10.1067/mai.2001.118891] [Citation(s) in RCA: 2094] [Impact Index Per Article: 91.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- J Bousquet
- Department of Allergy and Respiratory Diseases, University Hospital and INSERM, Montpellier, France
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Affiliation(s)
- L T Vaszar
- Stanford University School of Medicine, Division of Pulmonary & Critical Care Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA
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Szczeklik A, Nizankowska E, Sanak M, Swierczynska M. Aspirin-induced rhinitis and asthma. Curr Opin Allergy Clin Immunol 2001. [DOI: 10.1097/00130832-200102000-00006] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
PURPOSE The paper describes the clinical characteristics of patients with aspirin-induced asthma and/or urticaria, angioedema, shock, the results of the challenge tests and the evolution of this disease. MAIN POINT The authors present the different arguments supporting the physiopathological mechanisms from genetics to the inhibition of cyclooxugenase or the leukotriene hypothesis. PROSPECTIVES Finally, they recall the methodology to be used for a good clinical practice on this controversial field of research.
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Affiliation(s)
- A Pradalier
- Service de médecine interne IV, centre d'allergie de l'Ouest parisien, hôpital Louis-Mourier, Colombes, France
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