Do corticosteroids induce apoptosis in nasal polyp inflammatory cells? In vivo and in vitro studies

Effectiveness of Dupilumab in the Treatment of Patients with Uncontrolled Severe CRSwNP: A "Real-Life" Observational Study in Naïve and Post-Surgical Patients

Background: Chronic rhinosinusitis with nasal polyps (CRSwNP) represents 25−30% of all CRS cases, and in the most severe forms it is associated with a poor quality of life and a high rate of nasal polyps’ recurrence after surgery. Dupilumab has been suggested as a treatment option for severe CRSwNP. Methods: Patients with severe CRSwNP receiving dupilumab from January 2021 were followed up at 1, 3, 6, 9 and 12 months from the first administration and were considered for this study. At baseline and at each follow-up, patients underwent nasal endoscopy and completed the Sinonasal Outcome Test (SNOT)-22, a Visual Analogue Scale (VAS) for smell/nasal obstruction, the Nasal Congestion Score and the Asthma Control Test. Peak nasal inspiratory flow (PNIF), a smell test, nasal cytology and blood eosinophilia were also evaluated. Results: Forty-seven patients were included in the study. Of these, 33 patients had a history of previous surgery (ESS) and had recurrent nasal polyps, while 14 patients were naïve to nasal surgery. Both subjective and objective parameters improved after biological treatment and were correlated with each other (p < 0.05), except for the SNOT-22 and the nasal polyp’s score. No correlations were found between nasal and blood eosinophilia. No differences were observed when comparing the post-surgical and the naïve groups. Conclusions: Dupilumab improves nasal obstruction and the sense of smell and reduces the level of local inflammation in severe CRSwNP patients in a similar way in both naïve and post-surgical patients.

High PI3K/mTOR and low MAPK/JNK activity results in decreased apoptosis and autophagy in nasal polyposis

Introduction

Nasal polyposis is a progressive inflammatory disease that reduces the quality of life. The role of apoptotic and autophagic pathways in nasal polyposis pathogenesis is not yet clearly known.

Objective

In this study we aimed to investigate apoptotic (MAPK/JNK), anti-apoptotic (PI3K/mTOR) and autophagic (LC3) pathways which are related each other in the nasal polyposis tissues.

Methods

Twenty patients with nasal polyps and fifteen patients going through an inferior turbinate reduction were included in this study. Patients with asthma, Samter triad and allergic fungal sinusitis were excluded from the study. The apoptotic and autophagic pathways were investigated in paraffin-embedded nasal tissue sections of 20 NP and 15 samples from inferior turbinate reduction by H&E and immunohistochemistry with h-score. TUNEL method with apoptotic index was used to demonstrate apoptotic cells.

Results

Decreased immunoreactivity of P38 MAPK (p < 0.005) and JNK (p < 0.005) were observed in nasal polyposis compared to material from inferior turbinate reduction. This decrease may indicate a downregulation of apoptosis as demonstrated by decreased TUNEL staining in nasal polyposis (p < 0.005). The PI3K (p < 0.002) and mTOR (p < 0.005) immunoreactivities were increased in nasal polyposis. This increase indicates a downregulation of autophagy as demonstrated by decreased LC3 staining in nasal polyposis (p < 0.001).

Conclusion

Deficient apoptosis and autophagy through MAPK/JNK and PI3K/mTOR pathways may have a role in the pathogenesis of nasal polyposis.

The Effect of Topical Corticosteroid on Basic Fibroblast Growth Factor in Nasal Polyp Tissue

Background

The etiology of nasal polyposis and pathophysiological mechanisms of polyp formation is still poorly understood. Experimental models have suggested that nasal polyp growth requires extracellular matrix formation and is associated with fibroblast proliferation. Intranasal corticosteroids appear to be useful in reducing nasal polypoid lesions and the likelihood of polyp recurrence after surgery. Basic fibroblast growth factor (bFGF) is a potent angiogenesis factor and is mitogenic for a wide range of cell types. We investigated the alteration of bFGF levels in nasal polyp tissue after administration of topical corticosteroid.

Methods

Nasal polyp tissues were obtained from 36 patients with diffuse nasal polyposis before and after topical nasal steroid treatment. As a topical nasal steroid mometasone furoate was given for 4 weeks in a dosage of 200 μg/day. The bFGF levels were measured by competitive enzyme immunoassay method.

Results

The mean levels of tissue bFGF, before and after topical nasal steroid treatment, were 1485 ± 826 ng/mg protein (range, 416–3434 ng/mg) and 1340 ± 749 ng/mg protein (range, 330–3288 ng/mg), respectively. The levels of bFGF in nasal polyps were significantly lower than those before treatment after administration of topical nasal steroid (p = 0.011).

Conclusion

Administration of topical nasal steroid decreases bFGF levels of nasal polyp. It may be suggested that one of the effects in diminishing the size of nasal polyps is by decreasing the bFGF.

Causality Assessment of Olfactory and Gustatory Dysfunction Associated with Intranasal Fluticasone Propionate: Application of the Bradford Hill Criteria

Causality assessment is crucial to post-marketing pharmacovigilance and helps optimize safe and appropriate use of medicines by patients in the real world. Self-reported olfactory and gustatory dysfunction are common in the general population as well as in patients with allergic rhinitis and nasal polyposis. Intranasal corticosteroids, including intranasal fluticasone propionate (INFP), are amongst the most effective drugs indicated in the treatment of allergic rhinitis and nasal polyposis. While intranasal corticosteroids are associated with olfactory and gustatory dysfunction and are currently labeled for these adverse events, causality assessment has not been performed to date. Although there is no single widely accepted method to assess causality in pharmacovigilance, the Bradford Hill criteria offer a robust and comprehensive approach because nine distinct aspects of an observed potential drug–event association are assessed. In this literature-based narrative review, Hill’s criteria were applied to determine causal inference between INFP and olfactory and gustatory dysfunction.

Azithromycin for the treatment of eosinophilic nasal polyposis: Clinical and histologic analysis

Introduction:

Macrolides used as immunomodulators are a promising tool for chronic inflammatory airway diseases. Eosinophilic nasal polyposis (ENP) is still considered a disease that is difficult to control with the currently standardized treatments.

Objectives:

To evaluate prolonged treatment with low-dose azithromycin for ENP based on clinical and histopathologic variables.

Methods:

The present investigation was a self-paired case study of 33 patients with ENP. A comparison was performed between patients before and after treatment with azithromycin for 8 weeks. The patients were subjected to clinical examinations, staging (three-dimensional imaging by endoscopy), application of the questionnaire, and biopsy of nasal polyps at the beginning and at the end of the treatment.

Results:

The treatment yielded a clinical improvement regarding the two variables studied: polyposis staging (69.7%) and questionnaire (57.6%). We did not find significant differences in the inflammatory pattern and in the percentage or absolute number of eosinophils per field between samples obtained before and after the treatment (p > 0.05). There was no difference between the answers obtained from groups with and without asthma and/or aspirin intolerance (p > 0.3). The patients with advanced initial staging exhibited lower subjective improvement index and staging reduction (p = 0.031 and p = 0.012, respectively).

Conclusion:

Based on this study, azithromycin may be considered as another therapeutic option for ENP. However, further studies are necessary to define the real mechanism of action involved.

Intranasal steroids versus placebo or no intervention for chronic rhinosinusitis

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).

WITHDRAWN: Topical steroids for nasal polyps

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.

Evaluation of the improvement of quality of life with Azithromycin in the treatment of eosinophilic nasal polyposis

Introduction

The Sino-Nasal Outcome Test 22 (SNOT-22) is an important tool in assessing the quality of life (QoL) of patients with chronic rhinosinusitis with a validated version in Brazil. The eosinophilic nasal polyposis (ENP) represents most of the cases of nasal polyposis (85–90%) and belongs to the group of chronic rhinosinusitis. It is a chronic inflammatory disease that impacts the QoL of patients, not only causing localized symptoms, but also resulting in a general malaise. The standard treatments (corticosteroids and nasal endoscopic surgery) lead to partial control of symptoms, but relapses are frequent. Macrolide acting as an immunomodulator is a promising tool for more effective control of this disease. Studies are still lacking to assess the real impact on the QoL in patients treated with macrolides.

Objective

To evaluate the improvement of QL, evaluated using SNOT-22, in patients with PNSE treated with immunomodulatory dose azithromycin.

Methods

This is a paired experimental study in patients with ENP. Comparison of pre-treatment and post-treatment with azithromycin was performed. Patients completed the SNOT-22 questionnaire before the start of treatment and returned for evaluation after eight weeks of treatment. Azithromycin was prescribed at a dose of 500 mg, orally, three times a week, for 8 weeks.

Results

SNOT-22 score decreased 20.3 points on average. There was a significant decrease in the SNOT-22 (difference greater than 14 points) in 19 patients (57.6%). There was no significant difference in improvement in SNOT in subgroups with or without asthma/aspirin intolerance.

Conclusion

Azithromycin resulted in significant improvement of QoL, assessed by SNOT-22, in the studied population.

Intranasal Steroids and the Myth of Mucosal Atrophy: A Systematic Review of Original Histological Assessments

Background

Intranasal corticosteroids (INCSs) are well established in the treatment of allergic rhinitis, chronic rhinosinusitis, and nasal polyposis. Although reversible atrophy of keratinized skin is seen with corticosteroids, the respiratory mucosa is histologically very different and but concerns remain among patients and some health-care professionals over local side effects on nasal respiratory mucosa. A systematic review and meta-analysis were performed of the available evidence for nasal mucosal atrophy as an adverse effect of INCSs in patients with sinonasal disease.

Methods

A systematic search of Embase (1974-) and Medline (1946-) databases to September 27, 2013 was performed. Inclusion criteria selected any study where the histopathology of nasal mucosa was assessed in patients with sinonasal disease using intranasally administered corticosteroids with or without a control group.

Results

Twenty-three hundred sixty-four publications were retrieved with a subsequent full text review of 149 publications for 34 articles that met the selection criteria. These articles included 11 randomized controlled trials, 5 cohorts, and 20 case series. Duration of treatment varied from 5 days to 5.5 years. “Mucosal atrophy” as an outcome was reported in 17 studies. The definition of “mucosal atrophy” was highly variable with a definition given in only 10 studies. One hundred thirty-six patients were represented in controlled studies of atrophy with only one study reporting the event in both groups with an odds ratio of “mucosal atrophy” at 0.51 (95% CI, 0.09-3.11; p = 0.47).

Conclusion

The concept of nasal mucosal atrophy is poorly defined and there is no histological evidence for deleterious effects from INCS use on human nasal mucosa.

Dexamethasone Induces Apoptosis of Nasal Polyp-Derived Tissue Cultures Through JNK and p38 MAPK Activation

Objectives

Glucocorticoids, such as dexamethasone (DEX), increase apoptosis in a variety of white cells in nasal polyps and apoptosis is an important factor in the resolution of inflammation. However, the mechanism of glucocorticoids induced apoptosis in nasal polyp remains unclear. In this study the authors evaluated which pathways were engaged in apoptosis induced by DEX in an ex vivo model of nasal polyps.

Methods

Nasal polyp tissues were cultured using an air-liquid interface method. Cultures were maintained in the absence or presence of DEX (10 or 100 µM) for 24 hours. To investigate the involvement of the apoptotic signaling pathways in nasal polyp, such as caspase cascades, Fas-FasL signaling pathway, mitochondrial pathway and p38 mitogen-activated protein kinase (MAPK)/JNK pathway, the authors performed reverse transcription-polymerase chain reaction and Western blotting.

Results

The expression ratios of FasL, activated form of caspase-8, caspase-9, and caspase-3 were significantly higher in DEX-treated polyps (P<0.01). In the Bcl-2 family expression, the anti-apoptotic molecules, Bcl-2 and Bcl-XL decreased, but pro-apoptotic molecules, Bax increased, and Bid and Bad were activated. In the conventional MAPKs, JNK, and the phospho-p38 MAPK were significantly higher, but phospho-extracellular signal-regulated kinase (ERK)1/2 was significantly lower in DEX-treated polyps (P<0.01).

Conclusion

DEX induces apoptosis of nasal polyp via caspase cascades, Fas-FasL signaling pathway, mitochondrial pathway and p38 MAPK/JNK pathway.

Eosinophil apoptosis and clearance in asthma

Asthma is an increasingly common respiratory condition characterized by reversible airway obstruction, bronchial hyper-responsiveness and airway inflammation with a clear unmet need for more effective therapy. Eosinophilic asthma is a phenotype of the condition that features increased blood or sputum eosinophils whose numbers correlate with disease severity. Several lines of evidence are now emerging, which implicate increased persistence of eosinophils in the lungs of patients with asthma as a consequence of inhibition of and defects in the apoptotic process, together with impaired apoptotic cell removal mechanisms. This article will update our knowledge of the mechanisms controlling eosinophil apoptosis and clearance, together with evidence implicating defects in apoptosis and pro-inflammatory cell removal in asthma. Recent developments in novel therapies for asthma that target eosinophil apoptotic and/or clearance pathways will also be discussed.

Topical steroids for nasal polyps

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.

The effects of systemic, topical, and intralesional steroid treatments on apoptosis level of nasal polyps

OBJECTIVE

The purpose of this study was to compare the apoptotic responses to systemic, topical, and intrapolyp injection of glucocorticoid with no treatment in nasal polyps.

STUDY DESIGN

Prospective, randomized controlled study.

SETTING

Tertiary training hospital.

SUBJECTS AND METHODS

The study was performed on 48 patients with nasal polyposis in the Department of Otorhinolaryngology between 2008 and 2009. Patients were assigned to 1 of 4 groups of 12 patients. Group A was treated with oral methylprednisolone 1 mg/kg/d, and the dose was tapered gradually. Group B received 0.3 mL triamcinolone acetonide (40 mg/mL), which was injected into polyp tissue. Group C was treated with topical 55 µg triamcinolone acetonide 2 times daily for 1 month. Group D received no medication. Samples were collected endoscopically after the seventh day for groups A and B, the first month for group C, and the first visit for group D. Apoptotic indexes were determined using the terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling method.

RESULTS

Statistically significant differences in apoptotic index were found between each steroid-medicated group and the control group (P (D-A) = .0001; P (D-B) = .003; P (D-C) = .026) and between groups A and C (P (A-C) = .012). Group B did not differ significantly from either group A or C (P (A-B) = .11; P (B-C) = .75).

CONCLUSIONS

The apoptotic index in nasal polyps treated with systemic, topical, and intrapolyp injection forms of glucocorticoids was higher than that in the control group. Systemic steroid treatment induced the most apoptosis.

Chronic rhinosinusitis with nasal polyps: a proteomic analysis

OBJECTIVES

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a severe subtype of chronic rhinosinusitis that can affect patients despite medical and surgical interventions. The purpose of this study was to utilize the techniques of proteomics to investigate differences in protein abundance within the sinonasal mucosa of patients with CRSwNP compared to healthy controls.

METHODS

In a case-control study at a tertiary-care academic medical center, sinonasal mucosa was harvested from 3 patients with CRSwNP and 3 control patients undergoing transsphenoidal excision of pituitary tumors. Two-dimensional gel electrophoresis was used to identify proteins with elevated or reduced abundance in CRSwNP patients compared to controls. The proteins showing the greatest abundance differences were characterized by mass spectrometry.

RESULTS

More than 300 differentially abundant proteins (p < or = 0.05) were identified. Many of these protein species were involved in the host inflammatory response. Proteins up-regulated in CRSwNP patients included eosinophil lysophospholipase by a ratio (R) of 18.13, RHO-GDP dissociation inhibitor 2 (R = 2.80), and apolipoprotein A-1 (R = 1.73). Down-regulated proteins in CRSwNP patients included catalase (R = -5.87), annexin A1 (R = -6.27), and keratin II-8 (R = -6.73). A detailed analysis of additional protein species is outlined.

CONCLUSIONS

The proteomic approach allows detection of significant differences in protein abundance in CRSwNP and provides unique insight into the pathophysiology of this common disease.

Bax-gene transfer enhances apoptosis by steroid treatment in human nasal fibroblasts

Gene therapy has become a focus not only in the study of cancer but also lifestyle-related diseases. In case of chronic rhinosinusitis with nasal polyps and aspirin-induced asthma, nasal polyps poorly respond to a local administration of steroid. The Bax and Bcl-2 proteins play important roles in the regulation of apoptosis. The treatment of steroid (prednisone) induced apoptosis in the fibroblast. The Bax accelerates apoptosis. Apoptosis is very important in the anti-inflammatory mechanism. In this study, we investigated whether the overexpression of Bax in human fibroblasts influences apoptosis by treatment with a steroid (prednisolone) in vitro. Human nasal fibroblasts were isolated from small pieces of nasal polyp and were transfected with a bax gene-bearing mammalian expression vector. Human nasal fibroblasts were transiently transfected with the expression vector hBaxpcDNA3 (Bax-NF) or native pcDNA3 (Neo-NF). Both transfectants (Bax-NF, Neo-NF) and wild-type-nasal fibroblast (wt-NF) were cultured in conditioning medium and treated with each concentration of prednisolone for 72 h. Prednisolone at a concentration of 10 ng/ml decreased the viability of Bax-NF compared to that of Bax-NF in the absence of prednisolone. The cytotoxicity of prednisolone to Bax-NF was significantly higher than that to Neo-NF or wt-NF (p < 0.01) and the susceptibility of Bax-NF to prednisolone was about 1,000 times that of Neo-NF or wt-NF. We found that the transfer of the exogenous bax gene enhanced the induction of apoptosis by steroid-treatment in human nasal fibroblasts. Therefore, we suggest that exogenous Bax protein expression by gene transfer might be useful for the treatment of nasal polyps. We will further the preclinical study in improving steroids dose and in adopting to transfer bax gene to the nasal polyps by intranasal injection, thus providing a more effective and safer way for the nasal polyps that poorly respond to a local administration of steroids.

Eosinophil survival and apoptosis in health and disease

Eosinophilia is common feature of many disorders, including allergic diseases. There are many factors that influence the production, migration, survival and death of the eosinophil. Apoptosis is the most common form of physiological cell death and a necessary process to maintain but limit cell numbers in humans and other species. It has been directly demonstrated that eosinophil apoptosis is delayed in allergic inflammatory sites, and that this mechanism contributes to the expansion of eosinophil numbers within tissues. Among the proteins known to influence hematopoiesis and survival, expression of the cytokine interleukin-5 appears to be uniquely important and specific for eosinophils. In contrast, eosinophil death can result from withdrawal of survival factors, but also by activation of pro-apoptotic pathways via death factors. Recent observations suggest a role for cell surface death receptors and mitochondria in facilitating eosinophil apoptosis, although the mechanisms that trigger each of these death pathways remain incompletely delineated. Ultimately, the control of eosinophil apoptosis may someday become another therapeutic strategy for treating allergic diseases and other eosinophil-associated disorders.

Surgical management of polyps in the treatment of nasal airway obstruction

In addition to their role in chronic rhinosinusitis and nasal congestion, sinonasal polyps are associated with significant nasal obstruction. Effective long-term treatments remain difficult to pinpoint. Management of these polyps is a difficult challenge for the contemporary otolaryngologist. Medical options vary and include topical and oral steroids; macrolide antibiotics; diuretic nasal washes; and intrapolyp steroid injection. Surgical options include polypectomy and functional endoscopic sinus surgery (FESS). In addition, novel treatments for polyps are introduced with some frequency. This article presents an overview of management options for sinonasal polyps, focusing on the indications, efficacy, and complications of the more common interventions.

The Effect of High-dose Topical Corticosteroid Therapy on Prevention of Recurrent Nasal Polyps after Revision Endoscopic Sinus Surgery

Background

Topical corticosteroid spray is widely used after endoscopic sinus surgery (ESS) to reduce the recurrence of polyposis. However, it has not always shown satisfactory results in clinical practice. We compared the effects of topical spray and high-dose topical steroid gauze packing on the prevention of recurrent nasal polyps after ESS.

Methods

We selected 32 patients with recurrent nasal polyps after ESS. In group 1, 18 patients were treated with topical steroid spray and in group 2,14 patients were treated with triamcinolone acetonide–soaked (40 mg) gauze packing once a week for 2 months after revision ESS. We observed the recurrence of polyps between the two groups for 12 months.

Results

Polyps recurred in 8 of 18 patients in group 1 compared with 1 of 14 patients in group 2 (p = 0.044).

Conclusion

High-dose topical corticosteroid therapy may be more effective than low-dose topical therapy in preventing recurrent nasal polyps.

Organ culture at the air-liquid interface maintains structural and functional integrities of inflammatory and fibrovascular cells of nasal polyps

BACKGROUND

Both inflammatory and fibrovascular cells play an important role in development of nasal polyps (NPs). In this study, we have developed a culture system to maintain structural and functional integrities of submucosal cells in vitro.

METHODS

NP tissue was cultured on a gelatin sponge at air-liquid (AL) interface or was cultured in submerging. Tissues were analyzed for survival, structural integrity, and vascular endothelial growth factor (VEGF) expression.

RESULTS

Most cells of NPs cultured in submerging died within 3 days. In culture at the AL interface, epithelium as well as submucosa kept structural integrity during the culture period. RT-PCR and immunohistochemistry showed that submucosa cells displayed VEGF expression, which is a major inducer of angiogenesis and edema of NPs.

CONCLUSION

Our study is the first demonstration that organ culture of NPs at the AL interface retains integrity of both epithelium and submucosa and this culture method possibly will be used to study the pathogenesis of NPs.

The efficacy and safety of once-daily mometasone furoate nasal spray in nasal polyposis: a randomized, double-blind, placebo-controlled study

CONCLUSION

In subjects with mild-to-moderate nasal polyposis, treatment with mometasone furoate nasal spray (MFNS) 200 microg once daily (QD) significantly decreases nasal congestion, reduces polyp size, and improves quality of life.

OBJECTIVES

To evaluate the efficacy and safety of MFNS, administered QD in the morning, in subjects with mild-to-moderate nasal polyposis.

SUBJECTS AND METHODS

This randomized, double-blind, double-dummy, placebo-controlled clinical trial enrolled subjects with mild-to-moderate nasal polyposis at 12 centers in Denmark, Finland, Norway, and Sweden. Inclusion criteria were: age > or = 18 years, a diagnosis of bilateral nasal polyps, and clinically significant nasal congestion. Following a 2-4-week run-in period, subjects were randomized to receive MFNS 200 microg QD or matching placebo for 16 weeks.

RESULTS

A total of 298 subjects were randomized to treatment. Of those subjects included in the intent-to-treat efficacy analysis (n = 291), a statistically greater proportion of the MFNS group than the placebo group had improvements in investigator-assessed nasal congestion score between baseline and end point (the primary outcome) (74.3% vs 46.8%; p < 0.001). Significant benefits of MFNS were also seen for secondary end points, including polyp size, sense of smell, peak nasal inspiratory flow, therapeutic improvement, and quality-of-life measures. MFNS was well tolerated, with no unusual or unexpected adverse events.

Topical furosemide versus oral steroid in preoperative management of nasal polyposis

The efficacy of topical nasal furosemide treatment has been shown in the protection of nasal polyp recurrence. The aim of the study was to compare the effect of oral steroid, as standard preoperative treatment, and inhaled furosemide, as alternative treatment, for 7 days preoperatively in terms of subjective improvement of nasal symptoms, polyp size reduction, inflammation in the polyp tissue, and intraoperative blood loss. A group of 40 patients with nasal polyposis entered the study and they were randomly allocated to 7-day preoperative treatment with either oral methylprednisolon (1 mg/kg/day) or topical furosemide by inhalation (6.6 mmol/l solution). Subjective scores of rhinosinusitis symptoms, polyp scores at endoscopy, and biopsy of the most superficial polyp were taken at inclusion. All procedures were repeated on day 7. Intraoperative blood loss was estimated (scores 0-10) by the surgeon at the operation. Eosinophils, mastocytes, and oedema were quantified by histomorphometry. Subjective symptoms and endoscopy scores did not differ significantly between the groups after the treatment although improvement of olfaction was insignificantly better in the steroid group. Steroid treatment significantly reduced eosinophil count, with no effect on mastocytes and oedema. Furosemide treatment did not affect inflammatory cells count significantly, but it has significantly reduced oedema in previously unoperated patients. No difference in intraoperative bleeding was observed between the groups.

Intercellular adhesion molecule-1 expression in nasal polyps treated with corticosteroid

PURPOSE

The aim of this study was to compare intracellular adhesion molecule-1 (ICAM-1) expression in nasal polyp cases who were administered topical corticosteroid and in middle turbinates.

MATERIALS AND METHODS

Twenty-four patients with nasal polyps were included in the study group. These patients were treated with 100 microg budesonide in each nostril twice daily for 2 months before the surgery. Twenty-one nonatopic patients with concha bullosa were included in the control group. The specimens were taken from patients undergoing endoscopic surgery.

RESULTS

In polyps, significantly higher mean ICAM-1 intensity scores were found by comparison with the control turbinates.

CONCLUSIONS

Corticosteroid treatment in patients with nasal polyps does not diminish ICAM-1 to that of turbinate tissue. The initiating events in the formation of nasal polyps still occur in these patients despite treatment with the topical nasal steroid.

Effects of glucocorticoids on infiltrating cells and epithelial cells of nasal polyps

Glucocorticoids are known to be effective in the treatment of nasal polyps (NPs). To examine the mechanisms of their effect, we evaluated 1) the ability of glucocorticoids to induce the apoptosis of eosinophils and T lymphocytes in NPs, and 2) the ability of dexamethasone to down-regulate epithelial cell functions that relate to eosinophilic inflammation. In vitro and in vivo, glucocorticoids increased the apoptosis of both eosinophils and T lymphocytes in NPs. Dexamethasone inhibited the production of granulocyte-macrophage colony-stimulating factor (GM-CSF) from both NP epithelial cells that were unstimulated and NP epithelial cells that were stimulated with interleukin-4 or tumor necrosis factor alpha. These results suggest that the clinical efficacy of glucocorticoids on NPs may be due to 1) induction of apoptosis in both eosinophils and T lymphocytes that infiltrate NPs, and 2) down-regulation of epithelial GM-CSF production, which prolongs eosinophil survival.

Occurrence of apoptosis, secondary necrosis, and cytolysis in eosinophilic nasal polyps

The paradigm states that inflammatory cells disappear from airway tissues through apoptosis and phagocytosis. However, cells may also be cleared through primary cytolysis, necrosis secondary to apoptosis, or transepithelial migration. This study examines the occurrence of apoptosis, secondary necrosis, and cytolysis of eosinophils in human nasal polyps in vivo and blood eosinophils in vitro. Eosinophils abounded in subepithelium and in paracellular epithelial pathways. Macrophages commonly occurred but without engulfed eosinophils. Scattered cells, including epithelial cells, were stained by antibody to the caspase cleavage product of poly(ADP-ribose) polymerase. Few cells were apoptotic (stained by terminal deoxy RNase nick end labeling). Of more than 3,000 examined tissue eosinophils, 110 were caspase cleavage positive, but only one was apoptotic. Transmission electron microscopy analysis of more than 500 eosinophils revealed viable and cytolytic eosinophils but not apoptosis, secondary necrosis, or engulfment of eosinophils. Plasma cells but neither epithelial cells nor eosinophils exhibited apoptotic ultrastructural morphology. Eosinophils in vitro exhibited different stages of apoptosis, ending with secondary necrosis distinct from in vivo eosinophil cytolysis. Our results show that the clearance of eosinophils from nasal polyps largely occurs through nonapoptosis pathways, including cytolysis and paraepithelial migration, and they challenge the belief that apoptosis is important for clearance of eosinophils from respiratory tissues.

Eosinophilia in nasal polyposis: its objective quantification and clinical relevance

BACKGROUND

Eosinophilia within nasal polyps is often taken as a criterion for adjuvant medical treatment postoperatively such as topical steroids.

OBJECTIVE

This study was performed in order to validate a new technique for objective quantification of eosinophilia by using laser scanning cytometry (LSC), to compare these results with manual scoring and routine histopathology, and to correlate them with the history of allergy or recurrence.

METHODS

LSC was used for semi-automated analysis of single-cell preparations from representative ethmoidal polyps obtained during routine paranasal sinus surgery (n=41). This microscope-based instrument scans the cells after immobilization of cells on a glass slide and after triple staining of cytokeratin, eosinophilic granula, and DNA. The location of each cell is stored with the fluorescence data. Therefore, the morphology of every cell can be documented by re-staining with haemotoxylin and eosin and re-localization on the slide. Subsequently, slides were subjected to manual scoring. The remaining polyps were analysed by routine histopathology.

RESULTS

Data from LSC and manual scoring showed good correlation (r=0.81, P<0.001), whereas there were discrepancies with histopathology. Eosinophilia scored by LSC and histopathology was neither correlated with the history of allergy nor with recurrence as determined by Fisher's exact test independent of the definition of eosinophilia (> or =2%, > or =3%, or > or =5% of all cells).

CONCLUSION

Scoring eosinophilia by LSC in comparison with histopathology does not contribute to a more reliable basis for adjuvant medical therapy in nasal polyposis. Instead, functional parameters (cytokine production, apoptosis) may serve better.

[Chronic rhinitis--effect of topical administration of corticosteroids on eosinophilic leukocytes]

Clinical manifestation of chronic rhinitis is due to local release of mediators from inflammatory cells. Eosinophil leukocytes are important in pathogenesis of nasal hypersensitivity as well as nasal hyperreactivity [1, 2]. The aim of the study was to follow-up the effect of local corticosteroid treatment on a number of eosinophils in nasal secretion of patients with chronic rhinitis. The study was prospective and controlled. A total number of 88 subjects was included in the study. Patients with chronic rhinitis who were treated with local corticosteroids (63) constituted the experimental group (37 with isolated allergic rhinitis, 10 with isolated nonallergic noninfective hyperreactive rhinitis, 10 with allergic rhinitis associated with nasal polyposis and 6 with nonallergic noninfective hyperreactive rhinitis associated with nasal polyposis). There were 25 patients with chronic rhinitis in the control group (18 with isolated allergic rhinitis, 2 with isolated nonallergic noninfective hyperreactive rhinitis, 3 with allergic rhinitis associated with nasal polyposis, and 2 with nonallergic noninfective, hyperreactive rhinitis associated with nasal polyposis). During the treatment with beclomethasone dipropionate aqueous nasal spray (daily dose was 400 micrograms during 6 weeks for isolated rhinitis and 6 months for associated forms of rhinitis), control examinations were regulary performed. The first control was after one week, the second after six weeks, the third after three months and the fourth after six months. The same control was carried out in the control group of patients who were without therapy. Cytological examination of nasal secretions included brush method of collecting secretions, staining smears with Leishman's stain and light microscopic scrutinising of nasal smear magnified up to 1000 times. The results of the study demonstrated the highly significant decrease in the number of eosinophils after the therapy in patients with isolated allergic rhinitis (x2(FR) = 71,121, DF = 2, p < 0.01), in patients with isolated hyperreactive rhinitis (x2(FR) = 19,050, DF = 2, p < 0.01), in patients with allergic rhinitis associated with nasal polyposis (x2(FR) = 26,730, DF = 3, p < 0.01), as well as in patients with hyperreactive rhinitis associated with nasal polyposis (x2(FR) = 17,000, DF = 3, p < 0.01). There were no significant differences in control group of patients, neither in subgroup with allergic rhinitis (x2(FR) = 2,528, DF = 2, p > 0.05) nor in subgroup with hyperreactive rhinitis associated with nasal polyposis (x2(FR) = 0.250, DF = 2, p > 0.05) (Table 2). Local corticosteroids have the potential to influence the regulation of eosinophil apoptosis. The induction of apoptosis by beclomethasone dipropionate treatment is an efficient way to remove eosinophil leukocytes from inflammatory sites [8]. The locally used corticosteroids in chronic rhinitis reduced significantly the number of eosinophils in nasal secretion. This result proves immunomodulatory effects of these medicaments in the pathogenesis of chronic rhinitis.

Human alveolar epithelial cells engulf apoptotic eosinophils by means of integrin- and phosphatidylserine receptor-dependent mechanisms: a process upregulated by dexamethasone

BACKGROUND

We previously demonstrated receptor-mediated apoptotic-eosinophil engulfment by human small airway epithelial cells, which may represent a potentially important mechanism in the resolution of allergic and asthmatic inflammation.

OBJECTIVE

A549 cells were selected as being representative of alveolar epithelial cells, and their ability to ingest human apoptotic eosinophils was examined in terms of the effects of dexamethasone treatment and the receptor-mediated recognition mechanisms important in this process.

METHODS

A549 epithelial-cell expression of alpha(v)beta3, alpha(v)beta5, CD36, and the phosphatidylserine receptor was established by using immunostaining and flow cytometry, and inhibition assays were examined by using the role of these receptors in apoptotic-eosinophil recognition by resting and dexamethasone-treated A549 epithelial cells. Electron microscopy confirmed engulfment of apoptotic eosinophils, and receptor clustering around apoptotic eosinophils was examined by using immunofluorescent labeling.

RESULTS

A549 epithelial cells recognized and engulfed apoptotic eosinophils but not freshly isolated cells. Dexamethasone enhanced the number of A549 cells ingesting apoptotic eosinophils and dose dependently increased their capacity for ingestion. The tetrapeptide RGDS significantly inhibited apoptotic-eosinophil uptake by A549 cells, indicating a role for integrins in the recognition process. A549 cells expressed alpha(v)beta3, alpha(v)beta5, beta5, CD36, and the phosphatidylserine receptor, and expression of these receptors was not significantly increased after dexamethasone treatment. Engulfment of apoptotic eosinophils by A549 cells involved alpha(v)beta3-, CD36-, alpha(v)beta5-, and phosphatidylserine receptor-mediated recognition mechanisms and was associated with the formation of integrin focal adhesion complexes around apoptotic eosinophils.

CONCLUSIONS

These data further suggest a nonpassive role for airway epithelium in the resolution of eosinophilic inflammation in asthma.

Topical corticosteroids in nasal polyposis

Nasal polyps are the common end-point of a number of conditions characterised by inflammation and are rarely 'curable' in its true sense. After consideration of the underlying aetiology and confirmation of the diagnosis, they are normally managed by a combination of medical and surgical interventions. Of these, topical corticosteroids have proved to be the medical treatment of choice. The objectives of the medical management are to eliminate or reduce the size of polyps, re-establish nasal airway and nasal breathing, improve or restore the sense of smell, and prevent recurrence of nasal polyps. The mechanism of action of corticosteroids may be by a multifactorial effect on various aspects of the inflammatory reaction, the effect being initiated by their binding to a specific cytoplasmic glucocorticoid receptor. At a cellular level, there is a reduction in the number of antigen-presenting cells, in the number and activation of T cells, in the number of mast cells, and in the number and activation of eosinophils. When polyps are large (grade 3) topical medication is difficult to instil in a very blocked nose and surgery or short term systemic corticosteroids may be required. Topical corticosteroids are of use in the primary treatment of nasal polyps when they are of a small or medium size (grades 1 and 2) and in the maintenance of any therapeutic improvement. The efficacy of topical corticosteroids such as betamethasone sodium phosphate nose drops, beclomethasone dipropionate, fluticasone propionate and budesonide nasal sprays in reducing polyp size and rhinitis symptoms has been demonstrated in several randomised, placebo-controlled trials. Beclomethasone dipropionate, flunisolide and budesonide sprays have also been shown to delay the recurrence of polyps after surgery. Placebo-controlled studies of agents that have shown a significant clinical effect in the management of nasal polyposis are reviewed.

Steroid-dependent anosmia

OBJECTIVE

To document the response to steroids in patients remaining anosmic following endoscopic nasal and sinus polypectomy.

STUDY DESIGN

A prospective study of 24 patients with nasal and sinus polyps who were anosmic prior to endoscopic nasal and sinus surgery. Those who remained anosmic after surgery were treated with steroids. Most patients had asthma, allergic rhinitis, or both. A few had aspirin sensitivity.

METHODS

All 24 patients had testing of their sense of smell before and after surgery. Those who remained anosmic postoperatively were first treated with topical nasal and then oral steroids and then tested again.

RESULTS

Twelve of the 24 remained anosmic after surgery and were found to be unresponsive to nasal steroids, but oral steroids were found to restore the sense of smell to normal in most patients. Few patients continued to take the medication for long periods of time mainly because of a fear of side effects. Recent studies have suggested the role of systemic steroids in olfactory secretion, which may explain the mechanism for this response.

CONCLUSION

Patients who remain anosmic after the removal of nasal and sinus polyps can be treated with oral steroids resulting in improvement of their sense of smell. Further research is needed on a molecular level to determine the reason for this and also why oral but not nasal steroids are helpful in these patients.