Comparison of nasal nitric oxide levels between the inferior turbinate surface and the middle meatus in patients with symptomatic allergic rhinitis

Nasal Nitric Oxide as a Biomarker in the Diagnosis and Treatment of Sinonasal Inflammatory Diseases: A Review of the Literature

OBJECTIVE

To critically review the literature on nasal nitric oxide (nNO) and its current clinical and research applicability in the diagnosis and treatment of different sinonasal inflammatory diseases, including acute bacterial rhinosinusitis (ABRS), allergic rhinitis (AR), and chronic rhinosinusitis (CRS).

METHODS

A search of the PubMed database was conducted to include articles on nNO and sinonasal diseases from January 2003 to January 2020. All article titles and abstracts were reviewed to assess their relevance to nNO and ABRS, AR, or CRS. After selection of the manuscripts, full-text reviews were performed to synthesize current understandings of nNO and its applications to the various sinonasal inflammatory diseases.

RESULTS

A total of 79 relevant studies from an initial 559 articles were identified using our focused search and review criteria. nNO has been consistently shown to be decreased in ABRS and CRS, especially in cases with nasal polyps. While AR is associated with elevations in nNO, nNO levels have also been found to be lower in AR cases with higher symptom severity. The obstruction of the paranasal sinuses is speculated to be an important variable in the relationship between nNO and the sinonasal diseases. Treatment of these diseases appears to affect nNO through the reduction of inflammatory disease burden and also mitigation of sinus obstruction.

CONCLUSION

nNO has been of increasing interest to researchers and clinicians over the last decade. The most compelling data for nNO as a clinical tool involve CRS. nNO can be used as a marker of ostiomeatal complex patency. Variations in measurement techniques and technology continue to impede standardized interpretation and implementation of nNO as a biomarker for sinonasal inflammatory diseases.

The Functional Diversity of Nitric Oxide Synthase Isoforms in Human Nose and Paranasal Sinuses: Contrasting Pathophysiological Aspects in Nasal Allergy and Chronic Rhinosinusitis

The human paranasal sinuses are the major source of intrinsic nitric oxide (NO) production in the human airway. NO plays several roles in the maintenance of physiological homeostasis and the regulation of airway inflammation through the expression of three NO synthase (NOS) isoforms. Measuring NO levels can contribute to the diagnosis and assessment of allergic rhinitis (AR) and chronic rhinosinusitis (CRS). In symptomatic AR patients, pro-inflammatory cytokines upregulate the expression of inducible NOS (iNOS) in the inferior turbinate. Excessive amounts of NO cause oxidative damage to cellular components, leading to the deposition of cytotoxic substances. CRS phenotype and endotype classifications have provided insights into modern treatment strategies. Analyses of the production of sinus NO and its metabolites revealed pathobiological diversity that can be exploited for useful biomarkers. Measuring nasal NO based on different NOS activities is a potent tool for specific interventions targeting molecular pathways underlying CRS endotype-specific inflammation. We provide a comprehensive review of the functional diversity of NOS isoforms in the human sinonasal system in relation to these two major nasal disorders' pathologies. The regulatory mechanisms of NOS expression associated with the substrate bioavailability indicate the involvement of both type 1 and type 2 immune responses.

Clinical Efficacy Evaluation of 1-Year Subcutaneous Immunotherapy for Artemisia sieversiana Pollen Allergic Rhinitis by Serum Metabolomics

Subcutaneous immunotherapy is the only treatment that improves the natural progression of allergic rhinitis and maintains long-term outcomes after discontinuation of the drug. Metabolomics is increasingly applied in the study of allergic diseases, including allergic rhinitis. However, little is known about the discovery of metabolites that can evaluate clinical efficacy and possible mechanisms of Artemisia sieversiana pollen subcutaneous immunotherapy. Thirty-three patients with Artemisia sieversiana pollen allergic rhinitis significantly improved after 1-year subcutaneous immunotherapy treatment, while ten patients were ineffective. Pre- and post-treatment serum samples from these patients were analyzed by metabolomics based on the combined detection of liquid chromatography-mass spectrometry and gas chromatography-mass spectrometry. As a result, L-Tyrosine can be a potential biomarker because of its opposite trend in effective patients and ineffective patients. And mechanism of immunotherapy may be closely related to NO and nitric oxide synthase. The discovery of potential biomarkers and metabolic pathways has contributed to the in-depth study of mechanisms of subcutaneous immunotherapy treatment of Artemisia sieversiana pollen allergic rhinitis.

The effect of medical treatment on nasal exhaled nitric oxide (NO) in patients with persistent allergic rhinitis: A randomized control study

PURPOSE

This study aimed to evaluate the role of nasal nitric oxide (NO) in the management of patients with persistent allergic rhinitis (PER).

METHODS

It was a randomized and comparative study. The study subjects were classified as controls (healthy subjects) or patients with PER based on defined criteria. All clinical, functional and biological data were collected for analyzing. Nasal fractional exhaled nitric oxide (FENO) was measured by electroluminescence device. Patients with PER were randomized for treatment with antihistamine (ATH) combined with leukotriene receptor antagonists (LRA) or only with intranasal steroids (INS).

RESULTS

During two years, 501 subjects were included: 234 control subjects and 267 patients with PER. The levels of nasal NO, total IgE, blood eosinophil counts, and apnea-hypopnea index (AHI) in patients with PER were higher than controls (P < 0.001; P < 0.05; P < 0.05; P < 0.01; respectively). There were statistically significant correlations between nasal NO, nasal peak flows, total IgE, and blood eosinophil counts in patients with PER (R = -0.687 and P = 0.0012; R = -0.643 and P = 0.0018; R = 0.432 and P = 0.0024; R = 0.445 and P = 0.002; respectively). After 6 months of treatment, patients treated with INS had greater improvement of clinical symptoms and reduction of nasal NO values than patients treated with ATH + LRA (985 ± 253 vs. 732 ± 298 ppb; P < 0.05).

CONCLUSION

Nasal NO measurement is a useful tool for the follow-up of patients with PER. It also helps clinicians to estimate the level of response to treatment in patients with PER.

Nasal Polyposis: More than a Chronic Inflammatory Disorder-A Disease of Mechanical Dysfunction-The São Paulo Position

Introduction  The importance of our study lies in the fact that we have demonstrated the occurrence of mechanical dysfunction within polypoid tissues, which promotes the development of polyps in the nasal cavity. Objective  To change the paradigm of nasal polyposis (NP). In this new conception, the chronic nasal inflammatory process that occurs in response to allergies, to pollution, to changes in the epithelial barrier, or to other factors is merely the trigger of the development of the disease in individuals with a genetic predisposition to an abnormal tissue remodeling process, which leads to a derangement of the mechanical properties of the nasal mucosa and, consequently, allows it to grow unchecked. Data Synthesis  We propose a fundamentally new approach to intervening in the pathological process of NP, addressing biomechanical properties, fluid dynamics, and the concept of surface tension. Conclusion  The incorporation of biomechanical knowledge into our understanding of NP provides a new perspective to help elucidate the physiology and the pathology of nasal polyps, and new avenues for the treatment and cure of NP.

Fibrotic Tissue and Middle Turbinate Exhibit Similar Mechanical Properties. Is Fibrosis a Solution in Nasal Polyposis?

Introduction Nasal polyposis (NP) is a chronic inflammatory condition of the upper airway characterized by overgrowth of nasal mucosa. Recent studies have shown a mechanical dysfunction in the nasal polyp tissue. Objective This study aims to evaluate the mechanical properties of nasal fibrotic tissue. Method This study was an institutional review board approved translational study in 20 participants (8 patients with NP, 7 patients with nasal synechiae, and 5 subjects without sinus disease (control group). We used Controlled Disc Stimulation equipment to compare the curve Pressure/Volume created during the saline solution infusion. Results The increase of pressure in response to solution injection was lower in the nasal polyp group when compared with control middle turbinate group and fibrotic group. No significant difference was found in the pressure response during solution injection between fibrotic group and control middle turbinate group. Inferior turbinate group showed significant difference when compared with control middle turbinate group. Conclusion The mechanical dysfunction found in the nasal mucosa of patients with NP provides new insight into this condition. These data allow the belief that the fibrosis has a potential role in increasing interstitial hydrostatic pressure and, consequently, mitigating edema formation in NP.

The role of nasal fractional exhaled nitric oxide as an objective parameter independent of nasal airflow resistance in the diagnosis of allergic rhinitis

OBJECTIVE

Patients with allergic rhinitis (AR) show augmented activity of nitric oxide (NO) metabolism, similar to those in bronchial asthma (BA). We hypothesized that measurements of nasal fractional exhaled NO (FeNO) could be used as an objective marker to detect the presence of AR. Our objective was to clarify the influence of nasal airflow resistance (NAR) on nasal FeNO levels through an exhalation maneuver in symptomatic AR patients. We also examined the diagnostic test validity of the mean nasal FeNO level for disease discrimination by means of a receiver operating characteristic (ROC) curve analysis.

METHODS

Fifty-nine untreated perennial AR patients without BA and 60 healthy controls were enrolled in this retrospective cross-sectional study. The subjective symptoms were recorded and the disease severity was classified according to the Japanese guideline for AR. The oral and nasal FeNO measurements were carried out using a handheld electrochemical analyzer according to the ATS/ERS guidelines. NAR was measured using a rhinomanometer by the anterior method.

RESULTS

The patients in the moderate-to-most severe AR group showed significantly higher levels of oral FeNO compared to the controls. The AR patients in both the mild (n=25) and the moderate-to-most severe (n=34) groups showed significantly higher levels of nasal FeNO compared to the controls (44.1ppb, 54.5ppb, and 26.5ppb, respectively). There was no significant difference in total NAR between the AR patients and the controls. The results of our comparison of nasal FeNO and NAR values of the ipsilateral nasal cavity for each individual indicated no significant correlation between the two-paired parameters. The optimal cut-off point of the mean nasal FeNO level was calculated as 38.5ppb (with 71% sensitivity and 86% specificity) to discriminate the presence of AR.

CONCLUSION

Nasal FeNO measurements can be an objective parameter for the diagnosis and classification of perennial AR in Japanese individuals. Nasal FeNO and NAR appear to be two independent measures that can be used to objectively evaluate nasal functions.

Why we should avoid using inferior turbinate tissue as control to Nasal Polyposis studies

CONCLUSION

The authors are aware that inferior turbinate mucosa presents different properties from middle turbinate mucosa and any data generated using inferior turbinate as control in Nasal Polyposis (NP) should be analysed very carefully.

OBJECTIVE

This study aims to compare the mechanical properties of inferior turbinate mucosa vs middle turbinate mucosa.

MATERIALS AND METHODS

The interstitial hydrostatic pressure behaviour was compared during a saline solution infusion between healthy nasal mucosa from inferior turbinate with middle turbinate (four patients).

RESULTS

A significant difference, p = 0.02, was found in the response of interstitial hydrostatic pressure during the saline injection when the inferior turbinate vs middle turbinate was compared.