Neuropeptides

Inflammatory mediators in nasal secretions of patients with nasal polyposis with and without aspirin sensitivity

BACKGROUND

The aim of this cross-sectional study was to compare the levels of inflammatory mediators in nasal secretions in patients with aspirin-exacerbated respiratory disease (AERD) and in those with nasal polyposis (NP) without aspirin-sensitivity and to correlate nasal fluid mediator concentrations with clinical parameters of the disease.

METHODS

A total of 30 patients with AERD, 30 chronic rhinosinusitis (CRS) with NP patients without aspirin sensitivity (CRSwNP), and 30 control subjects without inflammation of the nasal mucosa (C), selected for surgical treatment entered the study. The total nasal symptom score (TNSS), endoscopic score (ES), and Lund-Mackay score (LMS), were evaluated. The concentrations of eosinophil cationic protein (ECP), tryptase, heat shock protein 70 (HSP70), substance P and Clara cell protein 16 (CC16) were determined in nasal secretions.

RESULTS

Higher concentrations of ECP, tryptase, and HSP70 were measured in the AERD patients than in the CRSwNP patients and the C group (p < .001; p < .001, respectively for all mediators). However, levels of CC16 were higher in the C group than in the AERD and CRSwNP groups (p < .001; p < .001, respectively). A positive correlation between the TNSS and CC16 and a negative one between CC16 and tryptase levels were found in the C group. The CRSwNP group showed positive correlations between ECP, HSP70, and tryptase and negative correlations between substance P, ES, and LMS, as well as between CC16 and tryptase levels. In the AERD group, we found a positive correlation between HSP70 and ECP levels and a negative correlation between the TNSS and CC16 concentration.

CONCLUSION

The obtained results indicate the increased production of mediators of eosinophil and mast cell function, and the decreased production of biomarker of respiratory epithelial function in AERD patients. Clinical and biochemical parameters correlate in different ways in the AERD and CRSwNP patients.

Different levels of mucus inflammatory mediators in nasal polyposis with and without aeroallergen sensitivity

Objectives

Biomarker levels in nasal secretions can reflect the inflammatory status of nasal mucosa and evolution of sinus disease. The aim of this study was to evaluate the relationship between local inflammatory mediator production and clinical characteristics of patients with nasal polyposis (NP).

Methods

Thirty-one nonaeroallergen sensitized patients with NP (NANP), 29 aeroallergen sensitized patients with NP (ANP), and 30 subjects without inflammation of nasal mucosa as controls (C) entered this prospective, cross-sectional study. Clinical parameters (symptoms, endoscopic, and radiological findings) were assessed. The concentrations of heat shock protein 70 (HSP70), eosinophil cationic protein (ECP), tryptase, substance P and Clara cell protein 16 (CC16) were measured in the nasal secretion samples of all participants by ELISA method.

Results

Our results showed higher concentrations of HSP70, ECP, and tryptase in ANP than in NANP and C (p < .001 for all markers). On the other hand, levels of CC16 were significantly higher in C than in NANP and ANP groups (p < .001; p < .001, respectively). We found positive correlations between HSP70, ECP, tryptase, and substance P levels and nasal symptom score in patients with NP. Also, HSP70, ECP, tryptase, and substance P showed different levels of positive correlation among themselves, with HSP70 showing highest positive correlation with ECP. Finally, relatively strong negative correlations were found between the levels of CC16 and nasal symptoms, as well as between the CC16 levels and levels of other four mediators in nasal fluid.

Conclusion

HSP70, ECP, tryptase, and substance P might play a role in the pathogenesis of NP. The results suggest that chronic inflammation in NP involves a self-sustaining local release of HSP70, ECP, and tryptase, independent of aeroallergen stimulation of the mucosal layer, although the production of these mediators is higher in aeroallergen sensitized NP patients.

Effects of Cetirizine on Substance P Release in Patients with Perennial Allergic Rhinitis

To evaluate the effect of cetirizine hydrochloride on substance P release in allergic rhinitis, we performed a single-blind placebo-controlled study of 14 patients with perennial allergic rhinitis (7 treated with cetirizine and 7 with placebo). After an initial nasal allergen challenge with lavages, the subjects received treatment with placebo or cetirizine hydrochloride (10 mg by mouth daily) for 1 week, followed by the second nasal allergen challenge with lavages. The levels of albumin, histamine, and substance P in nasal lavages before and after allergen challenge were quantified by enzyme-linked immunosorbent assay. Pretreatment of subjects with cetirizine reduced the level of substance P induced by antigen challenge, but did not significantly reduce levels of histamine. These results suggest that cetirizine may reduce nasal neurogenic inflammation by modulating the release of substance P in allergic rhinitis.

Physiology and pathophysiology of respiratory mucosa of the nose and the paranasal sinuses

In this review, anatomy and physiology of the respiratory mucosa of nose and paranasal sinuses are summarized under the aspect of its clinical significance. Basics of endonasal cleaning including mucociliary clearance and nasal reflexes, as well as defence mechanisms are explained. Physiological wound healing, aspects of endonasal topical medical therapy and typical diagnostic procedures to evaluate the respiratory functions are presented. Finally, the pathophysiologies of different subtypes of non-allergic rhinitis are outlined together with treatment recommendations.

Capsaicin treatment of idiopathic rhinitis: the new panacea?

The management of patients with perennial nonallergic or idiopathic rhinitis is difficult. Diagnosis and treatment are hampered by several factors. First, the diagnosis is made by exclusion of other nasal diseases. As a consequence, idiopathic rhinitis is not defined according to clear-cut criteria. A commonly accepted phenotype of idiopathic rhinitis does not exist. Second, the pathophysiology of idiopathic rhinitis is not yet fully elucidated. In contrast with allergic rhinitis, inflammation does not appear to play an important role in idiopathic rhinitis. Recent studies indicate a neural dysregulation of the nasal mucosa. Additionally, the available therapeutic arsenal comprising both pharmacotherapy and surgery is at best partially efficacious in these patients. The efficacy of repeated capsaicin application has been established in several randomized controlled trials. This treatment modality may be the first step to more specific and better treatment options for patients with idiopathic rhinitis that is unresponsive to standard treatment.

Idiopathic rhinitis, the ongoing quest

The term rhinitis in daily practice is used for nasal dysfunction causing symptoms-like nasal itching, sneezing, rhinorrhea and or nasal blockage. Chronic rhinitis can roughly be classified into allergic, infectious or nonallergic/noninfectious. When allergy, mechanical obstruction and infections have been excluded as the cause of rhinitis, a number of poorly defined nasal conditions of partly unknown aetiology and pathophysiology remain. The differential diagnosis of nonallergic noninfectious rhinitis is extensive. Although the percentage of patients with nonallergic noninfectious rhinitis with a known cause has increased the last decades, still about 50% of the patients with nonallergic noninfectious rhinitis has to be classified as suffering from idiopathic rhinitis (IR), or rather e causa ignota. Specific immunological, clinical and sometimes radiological and functional tests are required to distinguish known causes. Research to the underlying pathophysiology of IR has moved from autonomic neural dysbalans to inflammatory disorders (local allergy), the nonadrenergic noncholinergic (NANC) sensory peptidergic neural system and central neural hyperaesthesia, still without solid ground or proof. This review summarizes the currently known causes for nonallergic noninfectious rhinitis and possible treatments. Also possible pathophysiological mechanisms of IR are discussed.

Chlorine inhalation produces nasal airflow limitation in allergic rhinitic subjects without evidence of neuropeptide release

BACKGROUND

Seasonal allergic rhinitic (SAR) subjects are more physiologically reactive to airborne irritants than non-rhinitic (NR) subjects; however the mechanism underlying this difference is unclear.

OBJECTIVE

We sought to determine whether irritant-induced nasal airflow limitation involves neuropeptide release into nasal lining fluid, and if so, whether such release occurs differentially by rhinitic status.

METHODS

Eight SAR and 8 NR subjects were exposed to 1.0 ppm chlorine and filtered air in random order during separate visits; exposures were via nasal mask and lasted 15 min. Rhinomanometry was performed before, immediately post-, and 15 min post-exposure. Following a minimum of 2 weeks' time, exposures and symptom reporting were repeated with nasal lavage pre- and post-exposure. Neuropeptides (substance P, cacitonin gene-related protein, vasoactive intestinal peptide, and neuropeptide Y) as well as markers of plasma leakage (albumin and urea) and glandular secretion (lysozyme and 7F10-mucin) were measured using standard methods.

RESULTS

Cl(2) provocation significantly increased nasal airway resistance in SAR but not NR subjects (p<0.05). Neuropeptide levels in nasal lavage fluid, on the other hand, were unaffected, with the exception of a paradoxical increase in vasoactive intestinal peptide in non-rhinitic controls post-Cl(2) provocation.

CONCLUSIONS

Irritant-induced nasal airflow limitation is more pronounced among SAR than NR subjects. We could not, however, demonstrate a role for neuropeptide release in the nasal congestive response of SAR subjects.

Prevention of otitis media caused by viral upper respiratory tract infection: vaccines, antivirals, and other approaches

Otitis media (OM) imposes significant morbidity on the pediatric age group and a large financial burden on the general population. Because standard medical treatments are not highly efficacious in resolving the accompanying middle ear (ME) inflammation, a goal of current research is OM prevention. Past studies show that new episodes of OM are usually a complication of viral upper respiratory infection (vURI), and therefore, a rational approach to achieving that goal is to develop intervention strategies that target vURI-associated OM. However, past experiences with antibiotics show that, in the absence of well-defined treatment protocols that maximize expected efficacy, the adoption of prophylactic or active treatments for OM can have negative consequences for the patient and for the general population. In this review, we discuss the hypothesized mechanisms by which a vURI is translated into an acute OM episode and describe different strategies for aborting that process. Limitations to deployment of each strategy are outlined.

Human nasal allergen provocation for determination of true allergic rhinitis: methods for clinicians

The nasal provocation test (NPT) could be more extensively used in the diagnosis of allergic rhinitis by practicing physicians. However, the procedure has not been standardized, and has mainly been utilized for scientific purposes in the US. This review illustrates a wide variety of techniques and approaches to dosing and concentration of allergen extracts, and delivery systems. It also outlines the lack of a unified outcomes-evaluation system, including clinical symptom scores and nasal patency measurements, in different countries. NPT is a safe, simple, and useful method when conducted with the consideration of indications and contraindications. Standardized NPT has the potential to become a more frequently used additional clinical test in the diagnosis of allergic rhinitis.

Intrasinus administration of topical budesonide to allergic patients with chronic rhinosinusitis following surgery

OBJECTIVE

Whether instillation into the maxillary sinus of topical budesonide affected the immune response and improved allergic patients with chronic rhinosinusitis that had persistence of symptoms despite appropriate surgical intervention was assessed.

STUDY DESIGN

Double-blind placebo-controlled.

METHODS

Twenty-six patients with allergy to house dust mites who had previously had surgery and who had persistent symptoms of disabling rhinorrhea or pressure-pain resistant to oral antibiotics and intranasal corticosteroids were recruited. During the double-blind study, patients instilled 256 microg budesonide daily or placebo through an intubation device (maxillary antrum sinusotomy tube) into one of the maxillary sinuses for 3 weeks before clinical assessment and a second biopsy.

RESULTS

We found an improvement in the symptom scores in 11 of the 13 patients who received budesonide; we also found a decrease in CD-3 (P = .02) and eosinophils (P = .002), and a decrease in the density of cells expressing interleukin4 (P = .0001) and interleukin-5 messenger RNA (P = .006) after treatment.

CONCLUSION

Topical budesonide delivered through a maxillary antrum sinusotomy tube can control chronic rhinosinusitis that persists after surgery.

Thoughts on the pathophysiology of nonallergic rhinitis

Nonallergic noninfectious rhinitis is a diagnosis by exclusion, meaning that a number of poorly defined nasal conditions that have in common allergy and infection as a cause of the rhinitis have been excluded. The etiology of some subgroups of nonallergic noninfectious rhinitis, like nonallergic rhinitis with eosinophilia (NARES) and drug-induced rhinitis, are quite well defined, but in the majority of the patients, the etiology and pathophysiology are unknown. These patients are classified as idiopathic rhinitis patients. A careful determination of the intensity of the symptoms combined with modern diagnostic tools enables us to discriminate idiopathic rhinitis patients from normal controls. This review discusses the possible pathophysicologic mechanisms of nonallergic noninfectious rhinitis, with emphasis on idiopathic rhinitis.

Nasal provocation testing: a review

OBJECTIVE

This review focuses on the uses of nasal provocation testing (NPT) for scientific investigations of the mechanisms of allergic and nonallergic rhinitis. It also describes the use of NPT as a diagnostic tool in clinical practice. The indications, contraindications, advantages, and limitations of different techniques for evaluation of nasal responses are reviewed. The paper familiarizes investigators with particulars of different nasal delivery systems, provocation agents, nasal patency measurements, secretion collection, and nasal lavage techniques.

DATA SOURCES

Relevant publications obtained from a literature review.

STUDY SELECTION

Relevant publications on the topics of NPT, allergic, and nonallergic rhinitis were critically evaluated.

RESULTS AND CONCLUSIONS

To date, NPT has been used primarily as a research tool for the investigation of allergic and nonallergic rhinitis with a wide variety of techniques depending on the specific scientific purposes. NPT will continue to provide useful information about the pathogenesis of airway diseases. Standardized nasal provocation testing has the potential to become a more frequently used clinical test in the diagnosis of allergic and occupational rhinitis and for determination of the appropriate and focused therapy.

Nasal hyperosmolar challenge with a dry powder of mannitol in patients with allergic rhinitis. Evidence for epithelial cell involvement

BACKGROUND

The responses to airway hyperosmolar challenges probably involve various inflammatory mediators. However, it is not fully understood which cell type/types are the source of these mediators. Potential cell types include mast cell, epithelial cell and the sensory c-fibre nerve cell.

OBJECTIVE

To clarify which cell types are involved with the mediator response to hyperosmolarity in the human airway.

METHODS

Ten healthy subjects, 11 patients with nonactive allergic rhinitis, and nine with active allergic rhinitis were challenged intranasally with mannitol powder, and with sham provocation, on separate days. Symptoms were assessed by visual analogue scales and nasal patency by measuring the nasal peak inspiratory flow (nPIF). Nasal lavage fluid levels of alpha(2)-macroglobulin (an index of plasma extravasation), substance P (an index of sensory nerve cell activation), tryptase (an index of mast cell activation) and 15-hydroxyeicosatetraenoic acid (15-HETE, an index of epithelial cell activation) were analysed.

RESULTS

Immediate, although transient burning was the most prominent symptom in all groups whereas only the patients with active rhinitis experienced a fall in nPIF. Mannitol significantly increased the nasal lavage fluid 15-HETE levels in the allergic patients (P < 0.01 vs the sham challenge), but not in the healthy subjects. The increase in 15-HETE correlated with nasal symptoms for itching (r(s) = 0.65, P = 0.019) and burning (r(s) = 0.72, P = 0.009). Detectable levels of tryptase was found only in five allergic subjects. Lavage levels of substance P and alpha(2)-macroglobulin did not not change.

CONCLUSION

Epithelial cell seems to be involved with the mediator response to airway hyperosmolar challenge. The roles of sensory c-fibre nerve cell and mast cell remained less clear.

Ultracytochemical localization of the NADPH-d activity in the human nasal respiratory mucosa in vasomotor rhinitis

OBJECTIVES

Description of the ultrastructural localization of nitric oxide synthase in the blood vessels of the nasal respiratory mucosa in patients with vasomotor rhinitis.

STUDY DESIGN

This research was conducted on seven patients--men and women, ages 20 to 45 years--suffering from vasomotor rhinitis and who had undergone surgical therapy for reduction of the inferior turbinates.

METHODS

To study the ultrastructural localization of nitric oxide synthase, NADPH-diaphorase cytochemistry was employed. Samples of the nasal mucosa were obtained from inferior turbinates.

RESULTS

The endothelial cells of the arterioles, capillaries, venules and cavernous sinuses revealed a distribution of the enzymatic activity similar to that found in unaffected subjects. A strong enzymatic activity was recognized in the smooth muscle cells of the cavernous sinuses. The smooth muscle cells of arterioles and venules were generally found to be negative to enzymatic reaction.

CONCLUSIONS

This study suggests that the vascular disorders of the vasomotor rhinitis depend, at least in part, from nitric oxide synthase induction in the smooth muscle cells of the cavernous sinuses.