Perspectives on the etiology of chronic rhinosinusitis

The Role of the Environment and Occupational Exposures in Chronic Rhinosinusitis

PURPOSE OF REVIEW

The purpose of the review is to summarize the current literature and evaluate how different environmental exposures may contribute to the development and course of chronic rhinosinusitis (CRS). The review aims to explore the relationship between host factors and environmental exposures in the pathogenesis of CRS.

RECENT FINDINGS

Recent studies have helped establish the role of air pollutants, tobacco smoke, occupational exposures, and microplastics in the pathogenesis of CRS. These exposures have been shown to cause epithelial dysfunction and promote inflammation through different mechanisms and to different degrees. The pathogenesis of CRS is complex and multifactorial, with environmental exposures playing a key role in its onset and exacerbation. Research indicates that pollutants can damage the sinonasal epithelial barrier and disrupt the microbiome, leading to increased inflammation. A deeper understanding of the mechanisms behind this inflammatory process and its link to environmental exposures could enhance strategies for preventing and treating CRS.

[Modern management of chronic rhinosinusitis]

Chronic rhinosinusitis is a common disease. Due to the significant reduction of the quality of life, possible serious complications and economic consequences, a sufficient therapy is essential. With the entry of biologics into the treatment of chronic rhinosinusitis, relevant innovations have emerged in recent years. This article is aimed at providing an up-to-date overview of the conservative and surgical treatment options for chronic rhinosinusitis.

Improvements after dry needling for craniofacial pain in a patient with chronic rhinosinusitis: a case report

BACKGROUND

Typically treated medically, chronic rhinosinusitis (CRS) is a prevalent condition characterized by multiple craniofacial symptoms, some of which may respond favorably to dry needling intervention.

OBJECTIVE

To describe the outcomes of a patient presenting with craniofacial pain and symptoms consistent with a diagnosis of CRS who was treated with dry needling. Case Description: A 41-year-old male, self-referred to physical therapy with a diagnosis of CRS, with a 20-year history of signs and symptoms associated with CRS, including craniofacial pain and headaches. The patient had been treated with multiple medication regimens over this time, including antihistamines, anti-inflammatories, decongestants, leukotriene inhibitors, and antibiotics; all of which provided only short-term relief. On initial examination, the patient was tender to palpation in multiple muscles of the head, neck, and face. Intervention consisted of dry needling to these muscular tender points once or twice weekly over 2 months.

OUTCOMES

After 2 months of dry needling, the patient demonstrated clinically meaningful improvements in pain and quality of life, which included a decrease in both medication usage and the frequency of sinus infections.

CONCLUSION

Although CRS is generally managed medically, we observed areas of muscular tenderness in this case, which were effectively managed with dry needling. Rehabilitative providers may consider screening CRS patients for muscular impairments that may be modifiable with dry needling. Further research should be performed to determine whether dry needling has a role in the management of CRS.

Prevalence of Risk Factors of Chronic Rhinosinusitis With Nasal Polyps Among the Saudi Population

Background The burden of chronic rhinosinusitis symptoms experienced by Saudi citizens is considered an important factor in getting an overall insight of the problem in the region, therefore our study aimed to determine the prevalence of risk factors of chronic rhinosinusitis with nasal polyps and correlate the risk factors with various sociodemographic parameters among Saudi population. Methods This study analyzed five-year cross-sectional data from 2017-2021. A total of 386 participants were enrolled and subsequently divided into four groups: aged 18-25 years, 26-35 years, 36-45 years, and > 45 years. A study was conducted utilizing non-probability sampling targeting a population of Saudi nationality living in selected regions of Saudi Arabia. Data was collected through an online questionnaire which had been distributed through social media and had been analyzed accordingly using a statistical package for social sciences. Results In this study, 272 (70.5%) participants were female and 114 (29.5%) were male. A total of 374 (96.9%) participants were Saudis while 12 (3.1%) were non-Saudis. Risk factors were compared by age and gender of study participants. Having polyps in the nose (p-value 0.016) and a family history of polyps (p-value 0.049) showed a significant association with the gender of study participants. The frequency of having nasal polyps was significantly higher among male participants, however, having a family history of nasal polyps was significantly higher among female participants. The educational status of study participants showed a significant association with the use of cortisone (p-value 0.032) and having a broken nose (p-value 0.032). Having a family history of nasal polyps showed a significant (p-value 0.017) association with the socioeconomic status of study participants. Conclusion Nasal polyps are more common in males than females, however, having a family history of nasal polyps was significantly higher among female participants.

Insights into the epigenetics of chronic rhinosinusitis with and without nasal polyps: a systematic review

Background

Epigenetics facilitates insights on the impact of host environment on the genesis of chronic rhinosinusitis (CRS) through modulations of host gene expression and activity. Epigenetic mechanisms such as DNA methylation cause reversible but heritable changes in gene expression over generations of progeny, without altering the DNA base-pair sequences. These studies offer a critical understanding of the environment-induced changes that result in host predisposition to disease and may help in developing novel biomarkers and therapeutics. The goal of this systematic review is to summarize the current evidence on epigenetics of CRS with a focus on chronic rhinosinusitis with nasal polyps (CRSwNP) and highlight gaps that merit further research.

Methods

A systematic review of the English language literature was performed to identify investigations related to epigenetic studies in subjects with CRS.

Results

The review identified 65 studies. These have focused on DNA methylation and non-coding RNAs, with only a few on histone deacetylation, alternative polyadenylation, and chromatin accessibility. Studies include those investigating in vivo and in vitro changes or both. Studies also include animal models of CRS. Almost all have been conducted in Asia. The genome-wide studies of DNA methylation found differences in global methylation between CRSwNP and controls, while others specifically found significant differences in methylation of the CpG sites of the thymic stromal lymphopoietin (TSLP), IL-8, and PLAT. In addition, DNA methyltransferase inhibitors and histone deacetylase inhibitors were studied as potential therapeutic agents. Majority of the studies investigating non-coding RNAs focused on micro-RNAs (miRNA) and found differences in global expression of miRNA levels. These studies also revealed some previously known as well as novel targets and pathways such as tumor necrosis factor alpha, TGF beta-1, IL-10, EGR2, aryl hydrocarbon receptor, PI3K/AKT pathway, mucin secretion, and vascular permeability. Overall, the studies have found a dysregulation in pathways/genes involving inflammation, immune regulation, tissue remodeling, structural proteins, mucin secretion, arachidonic acid metabolism, and transcription.

Conclusions

Epigenetic studies in CRS subjects suggest that there is likely a major impact of the environment. However, these are association studies and do not directly imply pathogenesis. Longitudinal studies in geographically and racially diverse population cohorts are necessary to quantify genetic vs. environmental risks for CRSwNP and CRS without nasal polyps and assess heritability risk, as well as develop novel biomarkers and therapeutic agents.

Anti-phospholipid antibodies are elevated and functionally active in chronic rhinosinusitis with nasal polyps

BACKGROUND

Polyps from patients with chronic rhinosinusitis with nasal polyps (CRSwNP) contain increased levels of autoreactive antibodies, B cells and fibrin deposition. Anti-phospholipid antibodies (APA) are autoantibodies known to cause thrombosis but have not been implicated in chronic rhinosinusitis (CRS).

OBJECTIVE

To compare APA levels (anti-cardiolipin, anti-phosphatidylethanolamine (anti-PE), and anti-β2 -glycoprotein (anti-B2GP)) in nasal polyp (NP) tissue with tissue from control and CRS without nasal polyp (CRSsNP) patients, we tested whether NP antibodies affect coagulation, and correlate APAs with anti-dsDNA IgG and markers of coagulation.

METHODS

Patient specimens were assayed for APA IgG, anti-dsDNA IgG and thrombin-anti-thrombin (TaT) complex by ELISA. Antibodies from a subset of specimens were tested for modified activated partial thromboplastin time (aPTT) measured on an optical-mechanical coagulometer.

RESULTS

Anti-cardiolipin IgG in NP was 5-fold higher than control tissue (p < .0001). NP antibodies prolonged aPTT compared to control tissue antibodies at 400 µg/mL (36.7 s vs. 33.8 s, p = .024) and 600 µg/mL (40.9 s vs. 34.7 s, p = .0037). Anti-PE IgG antibodies were increased in NP (p = .027), but anti-B2GP IgG was not significantly higher (p = .084). All APAs correlated with anti-dsDNA IgG levels, which were also elevated (R = .77, .71 and .54, respectively, for anti-cardiolipin, anti-PE, and anti-B2GP; all p < .001), but only anti-cardiolipin (R = .50, p = .0185) and anti-PE (R = 0.45, p = .037) correlated with TaT complex levels.

CONCLUSIONS

APA IgG antibodies are increased in NP and correlate with autoreactive tissue antibodies. NP antibodies have in vitro anti-coagulant activity similar to those observed in anti-phospholipid syndrome, suggesting that they may have pro-coagulant effects in polyp tissue.

Staph’s Toxins IgE Antibodies and Its Relation to the Severity of Allergic Rhinitis

Background

Specific IgE against Staphylococcus can be found in approximately 40% of patients with allergies, also in patients without allergies because they may be sensitized. These antibodies are functional, and they can induce histamine release contributing to chronic pruritus which can worsen disease severity. The objective of this study was to compare levels of specific IgE against S. aureus toxins in those populations.

Methods

A cross-sectional, comparative non-blinded survey was made at the Regional Center for Allergy and Clinical Immunology. Ninety-nine adults between 18 and 70 years of age with allergic rhinitis (AR) and without allergic rhinitis (wAR) were recruited. A clinical history and demographic data, and allergic sensitization patterns to 35 aeroallergens were obtained, and participants were classified according to their severity using the Allergic Rhinitis and Its Impact on Asthma (ARIA) classification. Specific IgE levels were determined using ImmunoCAP™ 100 platform.

Results

The median age (IQR) of the participants was 23 (20–33.7); 56.2% were women. The most frequent comorbidities were asthma and obesity. Of the patients with AR, 46.7% were classified as mild intermittent and 25% as moderate persistent. IgE levels against staph toxins A, B, and TSST were significantly higher in the AR group vs the wAR group [median IQR 0.01 (0.01–0.03) vs. 0.01 (0–0.02), p = 0.01; 0.02 (0.01–0.03) vs. 0.01 (0–0.02), p= 0.02; 0.04 (0.02–0.09) vs. 0.01 (0–0.04), p=0.002, respectably]. A significant difference was found in serum IgE levels against Staph B toxin between severity subgroups.

Conclusion

People with AR have higher IgE levels against staph toxins A, B and TSST than wAR subjects. However, it is not possible declare that the IgE titers were related to disease severity.

Low pH nasal rinse solution enhances mupirocin antimicrobial efficacy

Background: Chronic rhinosinusitis (CRS) is a common condition negatively impacting a patient’s quality of life. It has been hypothesized that bacterial biofilms are involved in the pathogenesis of CRS due to their persistence and difficulty to eradicate with conventional antibiotic therapy. Hence, the topical delivery of antibiotics via nasal rinse solution has gained a lot of attention due to the ability to deliver higher local concentrations, with less systemic absorption and side effects. This study investigates the efficacy of mupirocin dissolved in the 3 most commonly used sinus rinses in Australia Neilmed (isotonic saline), Flo Sinus Care (sodium chloride, sodium bicarbonate, potassium chloride, glucose anhydrous and calcium lactate and Pentahydrate) and FloCRS (sodium chloride, potassium chloride and xylitol). Methods: Planktonic and biofilm cultures of S. aureus (ATCC25923, 2 methicillin-resistant S. aureus (MRSA) (C222 and C263), and 2 methicillin-susceptible S. aureus (MSSS) (C311 and C349) clinical isolates) were treated with mupirocin dissolved in three sinus rinses (Neilmed, Flo Sinus Care and FloCRS with different pH). To establish whether pH was a significant factor in determining antibiotic activity, experiments with Flo CRS were performed both at pH 5.64 and elevated pH 7.7. The minimum inhibitory concentration (MIC) and minimum bactericidal concentration (MBC) were determined for planktonic cells. The biofilm biomass and metabolic activity were assessed by using crystal violet assay and alamarBlue assay respectively. Results: The combination of mupirocin in low pH (pH 5.64) sinus rinse (FloCRS) had the highest efficacy in reducing the growth of S. aureus in both the planktonic and biofilm forms. Mupirocin diluted in FloCRS (pH 5.64) showed a significantly higher reduction in both biomass and metabolic activity than that was observed when mupirocin was diluted in Neilmed, Flo Sinus Care or FloCRS (pH 7.7). Conclusion: The choice of irrigant solution for topical mupirocin delivery appears to be important for antimicrobial activity. The delivery of mupirocin via low pH FloCRS could be useful in eliminating S. aureus biofilms present on the sinus mucosa of patients with CRS.

Acute and Chronic Sinusitis

Based on a review of the most current medical literature, this article outlines the basic concepts and classifications of rhinosinusitis, and delineates best practices for clinical diagnoses and the most up-to-date management strategies. Learning to recognize and differentiate these conditions helps facilitate appropriate and timely diagnoses as well as helping practitioners provide their patients with better counseling and care.

Association of serum vitamin D with Chronic RhinoSinusitis in adults residing at high altitudes

PURPOSE

To evaluate the association of serum vitamin D levels with chronic rhinosinusitis (CRS) in population residing at high altitudes and to assess its correlation with severity of CRS.

METHODS

A prospective case-control study comparing vitamin D in 60 cases (30 with nasal polyposis and 30 without) and 31 controls was carried out. Correlation of vitamin D with severity of disease (Lund Mackay CT/LMS and endoscopic Lund Kennedy scores/LKS) was assessed using Spearman's correlation (r_s). Logistic regression analysis using vitamin D and confounding factors (Age and gender only, as other variables like smoking, bronchial asthma were exclusion criteria) as dependent and CRS (presence/absence) as independent variable, was also conducted.

RESULTS

A significantly lower vitamin D levels were found in CRS (14.60 ± 7.68 ng/ml), CRSwNP (13.70 ± 7.88 ng/ml) and CRSsNP (15.49 ± 7.50 ng/ml), when compared to controls (29.36 ± 7.49 ng/ml). Non allergic cases when compared with controls, showed significantly lower vitamin D levels (13.91 ± 6.78 compared to 29.36 ± 7.49 ng/ml). LMS and LKS in CRS showed a moderate correlation with vitamin D (r_s: - 0.604 for LMS, r_s: - 0.595 for LKS). Logistic regression analysis showed vitamin D levels (Odds-Ratio 0.783) to be an independent predictive factor of CRS.

CONCLUSION

A significantly lower vitamin D level is associated with CRS, irrespective of presence or absence of nasal polyposis in adults residing at high altitudes. Vitamin D is an independent predictive factor for CRS. There is an inverse moderate correlation of severity of CRS with vitamin D.

Effect of nicotine on Staphylococcus aureus biofilm formation and virulence factors

Staphylococcus aureus is a common pathogen in chronic rhinosinusitis (CRS) patients, the pathogenesis of which involves the ability to form biofilms and produce various virulence factors. Tobacco smoke, another risk factor of CRS, facilitates S. aureus biofilm formation; however, the mechanisms involved are unclear. Here, we studied the effect of nicotine on S. aureus biofilm formation and the expression of virulence-related genes. S. aureus strains isolated from CRS patients and a USA300 strain were treated with nicotine or were untreated (control). Nicotine-treated S. aureus strains showed dose-dependent increases in biofilm formation, lower virulence, enhanced initial attachment, increased extracellular DNA release, and a higher autolysis rate, involving dysregulation of the accessory gene regulator (Agr) quorum-sensing system. Consequently, the expression of autolysis-related genes lytN and atlA, and the percentage of dead cells in biofilms was increased. However, the expression of virulence-related genes, including hla, hlb, pvl, nuc, ssp, spa, sigB, coa, and crtN was downregulated and there was reduced bacterial invasion of A549 human alveolar epithelial cells. The results of this study indicate that nicotine treatment enhances S. aureus biofilm formation by promoting initial attachment and extracellular DNA release but inhibits the virulence of this bacterium.

Significance of Nasal Septum Angulation and Its Association with Rhinosinusitis Symptom Scores

OBJECTIVE

The aim of the study was to determine the association of angulation of nasal septum with the severity of rhinosinusitis as measured by symptom score and Visual Analog Score (VAS).

METHOD

The study was performed as a cross sectional study conducted at two different centres in Malaysia. Ninety-eight patients who were diagnosed with rhinosinusitis and fulfilled the selection criteria were assessed as for the symptom score and VAS and the measurement of angulation of nasal septum was performed through a coronal view of CT paranasal sinuses in bone window setting at osteomeatal complex level.

RESULTS

The result obtained from one-way ANOVA test revealed a significant association between category of severity of septal angulation and the symptom score of rhinosinusitis (p=0.025). In addition, the result obtained from one-way ANOVA test also revealed a significant association between category of severity of septal angulation and the VAS of rhinosinusitis (p<0.05).

CONCLUSION

Severity of nasal septum angulation may be significantly associated with severity of rhinosinusitis based on symptom score and VAS. These findings could be used in tailored management of patient with rhinosinusitis especially during functional endoscopic sinus surgery.

Effect of Montelukast, a Cysteinyl Leukotriene Receptor-1 Antagonist, on a Rat Model of Acute Bacterial Sinonasal Inflammation

Aim

This study aimed to investigate montelukast (MONT), a leukotriene receptor antagonist, as a potential treatment protocol and/or supportive therapy against acute bacterial sinonasal inflammation by histopathological and molecular analyses.

Material and Methods

A total of 30 rats were used in the study. The nasal dorsum was sterilized, and gelatin sponges were inserted into the right nasal cavities. The nostrils were then inoculated with Staphylococcus aureus (SA) for rhinosinusitis (RS) induction. Rats were treated once daily for 7 days with an injection of saline, either cefazolin sodium (CEFA) or MONT. Tissue samples were collected for examination.

Results

To evaluate whether CEFA and MONT were able to attenuate the SA-induced nasal inflammation, we analyzed the proinflammatory cytokine levels in the nasal tissue of rats by real-time polymerase chain reaction (PCR). The inflammatory cytokines tumor necrosis factor-α ( P ≤ .05) and interleukin-1α (IL-1α) ( P ≤ .05) increased in the SA-induced group, when compared with the healthy control. MONT treatment significantly reversed these elevations, especially IL-1α messenger RNA expression levels induced by SA. Also, CEFA administration significantly changed the proinflammatory cytokine levels when compared to the SA group, but this effect was not as strong as MONT. Also, histopathological findings supported the beneficial effects of MONT.

Conclusion

This study histopathologically and molecularly showed that MONT significantly ameliorated the SA-associated sinonasal inflammatory reaction, both alone and in combination with CEFA. These results may suggest that MONT may block the inflammatory reaction underlying RS even more significantly by antioxidative or anti-inflammatory effects. This study suggests MONT as a future potential therapeutic agent for RS treatment.

Responses of Well-differentiated Human Sinonasal Epithelial Cells to Allergen Exposure and Environmental Pollution in Chronic Rhinosinusitis

Background

Evidence suggests that intrinsic cell dysfunction leads to dysregulated immune responses to environmental triggers in chronic rhinosinusitis (CRS). Although epidemiological and in vivo studies support this theory, in vitro studies are lacking.

Methods

Epithelial cells from human sinonasal mucosa were cultured using an air–liquid interface culture model producing a well-differentiated phenotype. Specimens were characterized as chronic rhinosinusitis with (CRSwNP) or without (CRSsNP) nasal polyps and healthy control mucosa. Culture wells were exposed to house dust mite (HDM), diesel exhaust particles (DPM), or a combination (HDM + DPM) over 24 hours and responses in the 3 groups compared. Ciliary beat frequency (CBF) and transepithelial electrical resistance (TEER) were measured to assess mucociliary and barrier function, respectively. Interleukin-6 (IL-6) and 33 (IL-33) were measured after 24 hours. Results following challenge testing are expressed as fold change from baseline.

Results

Baseline CBF was lower in CRSsNP compared with control (5.27 ± 0.51 Hz vs 5.88 ± 1.22 Hz, P = .003). HDM significantly reduced CBF and TEER in the CRSwNP group compared with its vehicle (CBF: 0.55 ± 0.25 vs 1.03 ± 0.22, P < .001; TEER: 0.54 [0.13] Ω cm2 vs 0.93 [0.5] Ω cm2, P = .001). In CRSwNP and CRSsNP, HDM induced an increase in IL-6 compared with its vehicle (CRSwNP: 81.11 [67.19] pg/mL vs 3.15 [44.64] pg/mL, P = .016; CRSsNP: 321.46 [182.04] pg/mL vs 21.54 [53.93] pg/mL, P = .004). Results are expressed as median (interquartile range) and in IL-33 in CRswNP (84.04 [69.96] pg/mL vs 16.62 [20.19] pg/mL, P = .025). Exposure to DPM did not affect CBF, TEER, and cytokine release in all groups.

Conclusion

CRSwNP and CRSsNP cells exhibit altered responses particularly to HDM even after they have been removed from their host and cultured in vitro, suggesting an intrinsic cell dysfunction of the upper airway epithelium.

Epithelial physical barrier defects in chronic rhinosinusitis

INTRODUCTION

Chronic rhinosinusitis (CRS) is a common upper airway disease with a prevalence of greater than 10% of the general population. Although the pathogenesis of CRS remains poorly understood, there is growing evidence indicating that epithelial physical barrier defects play an important role in CRS pathogenesis. Areas covered: Epithelial physical barriers are maintained by various intercellular junctions, especially tight junctions (TJs). Recent studies suggest that the expression of TJ molecules and epithelial barrier function in human nasal epithelium are modulated by various internal and external factors. This review summarizes recent advances regarding the structure, function, and regulating mechanisms of the epithelial physical barrier in the context of CRS. Expert opinion: Available data indicate that epithelial physical barrier defects in CRS can result from inhaled allergens, microbial or virus infections, cytokines, hypoxia, or zinc deficiency, among other causes. Several genes/molecules, such as SPINK5, S100A7, S100A8/9, PCDH1, NDRG1, SPRR, and p63 are involved in modulating the physical barrier function in the context of CRS. The exact mechanisms and molecular pathways that lead to these barrier defects, however, require additional study. Additional work is necessary to further explore the epithelial physical barrier function in normal and pathologic sinonasal mucosa.

Activations of group 2 innate lymphoid cells depend on endotypes of chronic rhinosinusitis

OBJECTIVE

Chronic rhinosinusitis (CRS) is a complicated disease with several variants caused by different cellular and molecular mechanisms. The characterization of this heterogeneity supports the definition that the disease consists of many endotypes, such as eosinophilic and neutrophilic CRS, and so on. This study aimed to explore group 2 innate lymphoid cells (ILC2s) in neutrophilic CRS without nasal polyps (CRSsNP) and with nasal polyps (CRSwNP), and evaluate ILC2s across characteristics of the disease.

METHODS

Nasal biopsy samples were obtained from normal subjects or subjects with CRSsNP or CRSwNP during surgery. ILC2s were sorted and purified as CD45+Lin-CD127+CD4-CD8-CRTH2+CD161+ cells through flow cytometry, and were compared among three groups of subjects. Then, these samples were cultured in vitro, and inflammatory factors were assessed in tissue cultures. After that, human recombinant (rm) interleukin (IL)-33 or IL-17 were administered into the cultures, and we again examined relevant inflammatory substances.

RESULTS

ILC2s were upregulated in neutrophilic CRSsNP and CRSwNP patients, and there were no statistical differences between them. Eosinophil cation protein (ECP), myeloperoxidase (MPO), IL-25, IL-33, IL-5, IL-13, interferon (IFN)-γ and IL-17 were increased in the cultures, however, only concentrations of MPO, IFN-γ and IL-17 were enhanced in CRSwNP tissues compared to CRSsNP ones. After administration of rmIL-33, ECP, IL-5 and IL-13 were all increased in tissues from CRSsNP and CRSwNP patients, however, there were no significant differences between them. Finally, we evaluated concentrations of several above inflammatory factors after the treatment of rmIL-17, and found that MPO and IFN-γ were enhanced in these two phenotypes of patients, and were elevated significantly in CRSwNP tissue cultures.

CONCLUSION

These findings show that ILC2s might be inactivated in neutrophilic CRSsNP and CRSwNP based on this pilot study.

The impact of nasal airflow on sinus mucosa: A radiographic review

BACKGROUND

Chronic rhinosinusitis (CRS) is a disease of widespread prevalence and high morbidity. Many suggest that the introduction of toxins and allergens via nasal airflow plays a significant role in the development of CRS. In patients who have undergone total laryngectomy, nasal airflow is disrupted, providing an opportunity to examine the role of nasal airflow in sinonasal pathology.

METHODS

All patients who received a total laryngectomy between 2002 and 2012 with preoperative and postoperative computed tomography (CT) scans were retrospectively reviewed. The Lund-Mackay (LM) score for each sinus was recorded for both scans. The assessment of differences in pre-operative and post-operative LM scores was analyzed utilizing paired t-tests.

RESULTS

56 patients underwent total laryngectomy and had both preoperative and postoperative CT scans. There were no significant differences in the LM scores between pre-operative and post-operative scans within each sinus (frontal sinus, p = 1.0; anterior ethmoid sinus, p = 0.77; posterior ethmoid sinus, p = 0.45; maxillary sinus, p = 0.90; sphenoid sinus, p = 0.63; ostiomeatal complex, p = 0.78) or in the total LM scores (p = 0.97). Furthermore, patients with pre-operative sinonasal mucosal thickening (total LM score > 0) showed no significant change in their total LM score post-operatively (p = 0.13).

CONCLUSION

In total laryngectomy patients, studies demonstrate that a disruption in nasal airflow is correlated to altered sinonasal physiology and decreased subjective symptoms. However, our study shows that the disruption of nasal airflow results in no significant change in radiographic evidence of sinonasal mucosal thickening.

Increased phosphorylation of eNOS in nasal polyps of chronic rhinosinusitis patients can be diminished by 1,8-cineol

INTRODUCTION

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a significant health problem, but the pathogenesis remains unclear to date. Nitric oxide (NO) has known airway modulating functions. Therefore, we investigated nitric oxide production to determine the role of eNOS in nasal polyps, with additional analysis of the effect of the monoterpene oxide 1,8-cineol on the possible regulation of eNOS signaling and thus NO production.

METHODS

We determined eNOS expression, as well as regulatory and effector proteins like NOSTRIN and CASP8, using whole genome microarray, immunohistochemistry and western blot. To evaluate the influence of 1,8-cineol on eNOS signaling, we examined tissue samples of nasal polyps of patients with CRSwNP incubated with 100 μM 1,8-cineol using quantitative real-time PCR, western blot and phosphorylation arrays.

RESULTS

Microarray analysis revealed an increased gene expression of eNOS (1.40-fold) as well as a decreased gene expression of NOSTRIN (0.53-fold) and CASP8 (0.44-fold) in nasal polyps. At the protein level, we detected 2.3-fold higher protein expression of eNOS and significant higher phosphorylation levels of eNOS in nasal polyps (19.7-fold, p ≤ 0.001) compared to inferior turbinates. Additionally, 1,8-cineol did not influence NOSTRIN and CASP8, but decreased the eNOS phosphorylation significantly (p ≤ 0.05).

DISCUSSION

Our study demonstrated for the first time that nasal polyps exhibit an increased phosphorylation of eNOS, which could be important for vascular permeability and the associated edema and elevated inflammation. Additionally, we detected that 1,8-cineol affects the eNOS phosphorylation significantly and thus its activation. This could be important to handle the elevated inflammation and edema formation by regulating the vascular permeability.

Differentially Regulated Host Proteins Associated with Chronic Rhinosinusitis Are Correlated with the Sinonasal Microbiome

The chronic inflammatory nature of chronic rhinosinusitis (CRS) makes it a morbid condition for individuals with the disease and one whose pathogenesis is poorly understood. To date, proteomic approaches have been applied successfully in a handful of CRS studies. In this study we use a multifaceted approach, including proteomics (iTRAQ labeling) and microbiome (bacterial 16S rRNA gene sequencing) analyses of middle meatus swabs, as well as immune cell analysis of the underlying tissue, to investigate the host-microbe interaction in individuals with CRS (n = 10) and healthy controls (n = 9). Of the total 606 proteins identified in this study, seven were significantly (p < 0.05) more abundant and 104 were significantly lower in the CRS cohort compared with healthy controls. The majority of detected proteins (82% of proteins identified) were not significantly correlated with disease status. Elevated levels of blood and immune cell proteins in the CRS cohort, together with significantly higher numbers of B-cells and macrophages in the underlying tissue, confirmed the inflammatory status of CRS individuals. Protein PRRC2C and Ras-related protein (RAB14) (two of the seven elevated proteins) showed the biggest fold difference between the healthy and CRS groups. Validation of the elevated levels of these two proteins in CRS samples was provided by immunohistochemistry. Members of the bacterial community in the two study cohorts were not associated with PRRC2C, however members of the genus Moraxella did correlate with RAB14 (p < 0.0001, rho = -0.95), which is a protein involved in the development of basement membrane. In addition, significant correlations between certain members of the CRS bacterial community and 33 lower abundant proteins in the CRS cohort were identified. Members of the genera Streptococcus, Haemophilus and Veillonella were strongly correlated with CRS and were significantly associated with a number of proteins with varying functions. The results from this study reveal a strong association between the host and microbes in the sinonasal cavity. Proteins identified as associated with CRS could be new targets for drug therapies and biomarkers for assessment of treatment efficacy.

Contemporary Pharmacotherapy for Allergic Rhinitis and Chronic Rhinosinusitis

Chronic rhinosinusitis (CRS) and allergic rhinitis (AR) are chronic conditions causing nasal inflammation. CRS is increasingly recognized as a chronic inflammatory process rather than a chronic infection. Although the primary initiating factors in CRS remain unclear, AR is driven by IgE-mediated hypersensitivity to environmental allergens. Understanding the underlying inflammatory pathways and disease endotypes are driving innovation toward novel pharmacotherapies targeting critical mediators implicated in CRS and AR, including IL-4, IL-13, IL-5, IgE, and epithelial initiators IL-33 and TSLP. Extensive investigations are needed to determine the role, timing, predictive prognostic factors and long-term safety and efficacy of these agents.

Increased expression of the aryl hydrocarbon receptor in allergic nasal mucosa, contributing to chemokine secretion in nasal epithelium

BACKGROUND

Pollutants produced by industrial and traffic-related activities have been linked to allergic responses. These noxious agents induce their effects through the aryl hydrocarbon receptor (AhR).

OBJECTIVE

We analyzed the expression and distribution pattern of AhR in normal and allergic nasal mucosa, and cytokine-driven regulation of its expression. The production levels of chemokine in cultured nasal epithelial cells were evaluated after stimulation with AhR ligand.

METHODS

The expression levels and distribution pattern of AhR in normal, mild, and moderate-severe persistent allergic nasal mucosa were assessed by using real-time polymerase chain reaction, Western blot, and immunohistochemistry. The expression levels of AhR were determined in cultured nasal epithelial cells treated with T-helper 2 cytokines. In cultured epithelial cells stimulated with 2-(10H-indole-30-carbonyl)-thiazole-4-carboxylic acid methyl ester, the expression levels of granulocyte macrophage colony-stimulating factor, thymus and activation regulated chemokine, macrophage inflammatory protein 1 α, monocyte chemotactic protein 1, regulated on activation normal T-cell expressed and secreted, eotaxin, and interleukin 8 were measured with real-time polymerase chain reaction and enzyme-linked immunosorbent assay.

RESULTS

Expression of AhR was observed in normal and allergic nasal mucosa where it is distributed in the epithelial layer, submucosal glands, endothelial cells, and inflammatory cells. Its expression levels are increased in allergic nasal mucosa and upregulated after stimulation with T-helper 2 cytokines. The stimulation with 2-(10H-indole-30-carbonyl)-thiazole-4-carboxylic acid methyl ester resulted in increased production of chemokines in cultured epithelial cells.

CONCLUSION

Analysis of the study results indicated that increased expression levels of AhR may play a role in the pathogenesis of allergic rhinitis, which contributes to chemokine production in nasal mucosa.

Effects of glucocorticoid on the expression and regulation of aquaporin 5 in the paranasal sinus of rats with chronic rhinosinusitis

Aquaporins (AQPs) are water-specific membrane channel proteins that regulate water homeostasis for cells and organisms. AQP5 serves an important role in the maintenance of mucosal water homeostasis, and potentially contributes to mucosal edema and inflammation formation in chronic rhinosinusitis (CRS). The aim of the present study was to explore the expression pattern of AQP5 and the effect of glucocorticoids on AQP5 expression in rats with CRS. The rats were randomly divided into three equal groups, as follows: CRS, dexamethasone (dexa) treatment and control groups. A polyvinyl acetal material containing Staphylococcus aureus was inserted into the left nasal cavity of each rat from the CRS and dexa groups. On the 90th post-operative day, the dexa group received dexamethasone (2 mg/kg/day) via intraperitoneal injection for 7 days. The controls did not receive any treatment. The expression of AQP5 in the sinonasal mucosa was determined using immunohistochemistry and quantitative PCR. The immunoreactivities of AQP5 were primarily noted in the epithelial lining and glandular cells, the vascular endothelium and in the goblet cells in the sinonasal mucosa. The AQP5 mRNA expression level was significantly higher in the dexa group than in the control and CRS groups (P=0.006 and P=0.014, respectively). However, no significant difference was indicated between the CRS and control groups (P=0.760). In conclusion, the current study suggests that glucocorticoids induce AQP5 expression in the sinonasal mucosa of CRS rats, which highlights AQP5 as a potential target in the diagnosis and treatment of CRS.

The impact of total immunoglobulin E levels on outcomes of maximal medical therapy for chronic rhinosinusitis

INTRODUCTION

The goal of this project was to evaluate the impact of immunoglobulin E (IgE) levels on outcomes in patients with chronic rhinosinusitis (CRS) who received maximal medical therapy (MMT).

STUDY DESIGN

Prospective cohort study.

METHODS

Thirty-eight patients who underwent MMT for CRS were assigned to three different cohorts based on their IgE levels: low IgE (<25 IU), moderate (>25 to <149 IU), and high (≥150 IU). The primary outcome evaluated was MMT failure with a surgical recommendation within each IgE cohort. Secondary outcomes included changes in pre- and post-MMT scores for the Rhinosinusitis Disability Index, Chronic Sinusitis Survey, and computed tomography-based Lund-Mackay evaluation. The cohorts were substratified based on the presence of nasal polyps and nasal allergies.

RESULTS

No significant difference was found when MMT failure was compared between the cohorts in terms of quality of life. When substratified based on the presence of nasal polyps and nasal allergies, there was no significant difference between the cohorts. In the high-IgE cohort, all patients regardless of presence of nasal polyps and nasal allergic disease, frequently failed MMT and were recommended for surgery.

CONCLUSIONS

Overall, IgE levels did not seem to have a significant effect on the quality of life or outcomes of MMT in the patients with CRS. However, the presence of nasal allergies regardless of IgE levels seemed to result in more frequent recommendations for surgery after MMT. In the patients with higher-IgE levels (≥150 IU), MMT seemed to fail at high rates with or without the presence of polyps or allergic disease.

Classical complement pathway activation in the nasal tissue of patients with chronic rhinosinusitis

BACKGROUND

Complement plays a major role in inflammatory diseases, but its involvement and mechanisms of activation in patients with chronic rhinosinusitis (CRS) are not known.

OBJECTIVES

After earlier studies discovering autoantibodies in patients with CRS, we sought to investigate the nature, extent, and location of complement activation in nasal tissue of patients with CRS. Specifically, we were interested in whether antibody-mediated activation through the classical pathway was a major mechanism for complement activation in patients with CRS.

METHODS

Nasal tissue was obtained from patients with CRS and control subjects. Tissue homogenates were analyzed for complement activation products (ELISA-C5b-9, C4d, activated C1, and C5a) and major complement-fixing antibodies (Luminex). Tissue sections were stained for C5b-9, C4d, and laminin. Antibodies were purified with protein A/G columns from nasal polyps (NP), matching patient serum, and control serum and assayed for basement membrane binding by means of ELISA.

RESULTS

C5b-9 levels were significantly increased in NP tissue compared with uncinate tissue (UT) of patients with chronic rhinosinusitis with nasal polyps (CRSwNP) and those with chronic rhinosinusitis without nasal polyps (CRSsNP; P < .01). Similarly, C4d levels were increased in NPs compared with UT of patients with CRSwNP, patients with CRSsNP, and control subjects (P < .05). Activated C1 levels were also increased in NP tissue compared with UT of patients with CRSsNP and control subjects (P < .05) and correlated with levels of C5a (P < .01), local immunoglobulins (especially IgM, P < .0001), and anti-double-stranded DNA IgG (P < .05). Immunofluorescence showed that C5b-9 and C4d deposition occurred linearly along the epithelial basement membrane. NP tissue extracts had significantly more anti-basement membrane antibodies than sera from patients with CRSwNP and control subjects (P < .0001).

CONCLUSION

Levels of C5b-9, C4d, and activated C1 were significantly increased locally in NP tissue. C5b-9 and C4d were almost universally deposited linearly along the basement membrane of NP tissue. Furthermore, activated C1 levels were best correlated with local immunoglobulin and C5a levels. Together, these data suggest that the classical pathway plays a major role in complement activation in patients with CRS.

Association between cigarette smoking and interleukin-17A expression in nasal tissues of patients with chronic rhinosinusitis and asthma

Cigarette smoke plays a substantial role in the development of airway inflammatory diseases, including asthma and chronic rhinosinusitis (CRS). Interleukin (IL)-17A might contribute to cigarette smoke-related inflammation of the airway. This study aimed to investigate the association between cigarette smoking and IL-17A expression in the nasal tissues of patients with CRS and asthma.We prospectively recruited 24 patients (13 smokers, 11 nonsmokers) with CRS and asthma and 6 patients with asthma but without CRS (control group) in a tertiary medical center. Nasal mucosa was obtained as part of the nasal surgery. Protein and mRNA levels of IL-17A in the nasal tissues were determined by immunostaining and real-time polymerase chain reaction.The number of unexpected emergency clinic visits for acute asthma attacks were higher among smokers than among nonsmokers. Interleukin-17A protein and mRNA levels in the nasal tissues of smokers were greater compared to those in the nasal tissues of nonsmokers (P = 0.02 both) and control patients (P = 0.05 and 0.04, respectively).Cigarette smoking was associated with an increase in the number of unexpected emergency clinic visits due to acute asthma attack and in the expression of IL-17A in the nasal tissues of patients with airway inflammatory diseases.

Differential short palate, lung, and nasal epithelial clone 1 suppression in eosinophilic and noneosinophilic chronic rhinosinusitis with nasal polyps: implications for pathogenesis and treatment

PURPOSE OF REVIEW

Short palate, lung, and nasal epithelial clone 1 (SPLUNC1) is an epithelium-secreted protein that is involved in innate immunity. A protective role for SPLUNC1 in lower respiratory inflammation and chronic rhinosinusitis (CRS) has recently been recognized.

RECENT FINDINGS

An impaired epithelial immune barrier has been proposed to play a critical role in the pathogenesis of CRS. Recent research has demonstrated that SPLUNC1 is profoundly reduced in polyp tissues of CRS with nasal polyps (CRSwNP) compared with control tissues. Studies investigating the differential expression of SPLUNC1 in eosinophilic and noneosinophilic CRSwNP have been published. Nasal SPLUNC1 expression was inhibited by Th2 cytokines (IL-4 and IL-13) but was stimulated by toll-like receptor (TLR) agonists and glucocorticoids. Decreased SPLUNC1 expression in the sinus mucosa is associated with positive Pseudomonas aeruginosa bacterial colonization and poor surgical outcomes in CRS patients.

SUMMARY

These studies identify the role of SPLUNC1 in sinonasal innate immunity and the pathogenesis of CRS. Defective expression of SPLUNC1 in CRSwNP patients may lead to insufficient maintenance of the epithelial barrier function and enhanced bacterial colonization. The use of SPLUNC1 as a therapeutic target for CRSwNP remains to be determined.

Direct measurement of upper airway inflammation in children with chronic rhinosinusitis: implications for asthma

PURPOSE OF REVIEW

Chronic rhinosinusitis (CRS) is a common heterogenous multifactorial disorder affecting children and adults. The exact mechanism is not completely understood. In this review, we aim to summarize our recent findings regarding etiologies and pathogenesis of CRS in children and review recent studies investigating inflammatory patterns in the upper airways in children and adults with CRS.

RECENT FINDINGS

There are only a few small studies measuring upper airway inflammation in children with CRS. These studies demonstrated more toward eosinophilic and T-cell driven inflammatory pattern. Cytokine patterns in upper airways seem to correlate with asthma symptoms in children with CRS. Adult studies demonstrate eosinophilic and Th-2 (T helper-1) driven inflammation in CRS with nasal polyps and Th-1 (T helper-2) driven inflammation in CRS without nasal polyps.

SUMMARY

Current knowledge about the characteristics of tissue inflammation in upper airways in children with CRS is limited. More studies are needed to better understand the pathogenesis and better define the subgroups of CRS. The findings of such studies will lead to identifying the biological targets to treat this condition.

Is there a future for biologics in the management of chronic rhinosinusitis?

BACKGROUND

Chronic rhinosinusitis (CRS) is a heterogeneous inflammatory condition of the sinonasal mucosa consisting of poorly defined subtypes and characterized by variable clinical manifestations, responses to therapy, and underlying pathophysiologies. In the related disorder of asthma, progress has been made in defining disease subtypes on both clinical and pathophysiologic levels, facilitating the development of targeted biologic pharmacotherapy. The potential role of these drugs for the management of CRS will be reviewed. The objective of this work is to highlight the emerging therapeutic targets in CRS in light of evolving treatment options for asthma and enhanced understandings of the clinical manifestations and pathophysiology of CRS.

METHODS

This article is a review of recent studies regarding current and future advances in biomarker-directed therapies in the medical treatment of CRS.

RESULTS

Various biologic therapies used in the management of asthma have demonstrated clinical promise for CRS, particularly within the CRS with nasal polyposis (CRSwNP) phenotype. Several randomized, double-blind, placebo-controlled studies increasingly support the targeting of immunoglobulin E (IgE) and interleukin (IL)-5 pathways to improve outcome measures in CRSwNP patients. The IL-4/IL-13 pathway and other type 2 inflammatory pathways have also shown potential as targets for CRSwNP, but all pathways require further investigation.

CONCLUSION

Recalcitrant CRS in the United States and Europe is most commonly associated with nasal polyposis and a type 2 cytokine skewing in the tissue, resulting in tissue infiltration of eosinophils, mast cells, and basophils. Targeting biomarkers of the associated type 2 pathways may be a practical treatment option for recalcitrant CRSwNP in the future.

Diagnosis and Management of Rhinosinusitis: Highlights from the 2015 Practice Parameter

Rhinosinusitis is a commonly diagnosed disease in the USA. Rhinosinusitis is classified as acute, recurrent, or chronic (with or without nasal polyps). While acute rhinosinusitis is diagnosed by history and physical examination, chronic rhinosinusitis and recurrent acute rhinosinusitis are diagnosed based on symptoms and the presence of disease on either a sinus CT scan and/or endoscopy. Management of uncomplicated acute rhinosinusitis includes analgesics, saline irrigation, and/or intranasal steroids. Antibiotics and intranasal steroids are recommended for acute bacterial rhinosinusitis. Intranasal and oral steroids with antibiotics are recommended to treat chronic rhinosinusitis although the evidence for antibiotics is weak. Biologics such as omalizumab and mepolizumab are being investigated for the treatment of chronic rhinosinusitis with nasal polyps. Surgery may be indicated in management of refractory chronic rhinosinusitis and rarely for acute bacterial rhinosinusitis. This review discusses highlights of the updated 2014 practice parameter and up-to-date evidence from other literature sources.

Cytokine patterns in nasal secretion of non-atopic patients distinguish between chronic rhinosinusitis with or without nasal polys

BACKGROUND

Being one of the most common nasal diseases, chronic rhinosinusitis (CRS) is subdivided into CRS with nasal polyps (NP) and CRS without nasal polyps (CRSsNP). CRSsNP presents itself with a TH1 milieu and neutrophil infiltration, while NP is characterised by a mixed TH1/TH2 profile and an influx of predominantly eosinophils, plasma cells and mast cells. For the purpose of discovering disease-specific cytokine profiles, the present study compares levels of mediators and cytokines in nasal secretions between CRSsNP, NP, and healthy controls.

METHODS

The study included 45 participants suffering from NP, 48 suffering from CRSsNP and 48 healthy controls. Allergic rhinitis constituted an exclusion criterion. Nasal secretions, sampled using the cotton wool method, were analysed for IL-4, IL-5, IL-10, IL-12, IL-13, IL-17, IL-8, GM-CSF, G-CSF, IFN-γ, MCP-1, MIP-1α, MIP-1β, eotaxin, and RANTES, and for ECP and tryptase, using Bio-Plex Cytokine assay or ELISA, respectively.

RESULTS

Elevated levels of IL-5, IL-17, G-CSF, MCP-1, MIP-1α, MIP-1β, ECP, and tryptase, as well as decreased levels of IL-10, IL-12, IL-13, and IFN-γ were detected in NP. CRSsNP presented increased levels of RANTES and MIP-1β while IL-13 was decreased. No differences between the three groups were found for IL-4, IL-8, GM-CSF, and eotaxin.

CONCLUSIONS

The present work suggests a disequilibrium of TH1 and TH2, together with a down-regulation of regulatory T lymphocytes and up-regulated TH17 in NP. Moreover, elevated levels of diverse mediators represent the activation of various inflammatory cells in this disease entity. The inflammation in CRSsNP, however, is only weakly depicted in nasal secretions. Therefore, cytokines in nasal secretions may provide helpful information for differential diagnosis.

Review: Immunology of sinusitis, trauma, asthma, and sepsis

Background:

This review article is important for allergists/immunologists and otolaryngologists. It discussed chronic rhinosinusitis, epidemiology, pathogenesis, innate adaptive immunology, nuclear factor–kappa B related to inflammation, sepsis, complement, reactive oxygen species, asthma, sinusitis, elderly pathogenesis, oxidative stress, depression, seasonal variation, vitamin D, genetic susceptibility and sepsis, hereditary angioedema related to trauma and stress.

Objective:

The objective of this review is to link chronic rhinosinusitis, epidemiology, innate and adaptive immunology, NF-kappa B related to inflammation, sepsis, complement, reactive oxygen species, asthma and sinusitis.

Methods:

A literature search was conducted from several articles, prospective studies, recent reviews and earlier reports. A synergistic relationship develops between activation of the innate immune system and the loss of organ barrier functions. Many complex factors, such as genetics, physical agents, mediators in the development of organ failure both in asthma, sinusitis, stress, depression and trauma, leading to posttraumatic organ failure. Asthma and sepsis, a common condition encountered in hospital environments remains an important cause of death at intensive care units where allergists/immunologists and otolaryngologists are frequently consulted. The patient's immune surveillance could fail to eliminate the pathogen, allowing it to spread and there is a proinflammatory mediator release with inappropriate activation.

Conclusion:

This review discussed chronic rhinosinusitis, sinusitis related to trauma, the innate and adaptive immunology, NF-kappa B related to inflammation, sepsis, complement, inflammation, reactive oxygen species, asthma pathogenesis, and asthma in the elderly, oxidative stress, depression, seasonal variation and vitamin D, cytokines, genetic susceptibility related to sepsis, hereditary angioedema related to trauma and stress.

Five-year risk of incident disease following a diagnosis of chronic rhinosinusitis

BACKGROUND

Chronic rhinosinusitis (CRS) has a broad range of comorbidities. Due to a lack of longitudinal studies, it is not known whether these comorbidities cause CRS, are promoted by CRS, or share a systemic disease process with CRS.

OBJECTIVE

The objective of this study was to determine the risk of incident disease within 5 years after a new diagnosis of CRS with nasal polyps (CRSwNP) and without nasal polyps (CRSsNP).

METHODS

We conducted a case-control study nested within the longitudinal cohort of primary care patients in the Geisinger Clinic using electronic health record data. We evaluated incident disease over 5 years in newly diagnosed CRSwNP and CRSsNP cases compared to controls using multivariable Cox regression models.

RESULTS

CRSsNP (n = 3612) cases were at greater risk (HR, 95% confidence interval) than controls for incidence of: upper airway diseases, including adenotonsillitis (3.29, 2.41-4.50); lower aerodigestive tract diseases, including asthma (2.69, 2.14-3.38); epithelial conditions, including atopic dermatitis (2.75, 1.23-6.16); and hypertension (1.38, 1.19-1.61). CRSwNP (n = 241) cases were at greater risk for obesity than controls (1.74, 1.08-2.80), but CRSwNP was not associated with other diseases.

CONCLUSION

The risk of other diseases associated with CRS adds to the burden of an already highly burdensome condition, and suggests either that CRS promotes onset of other diseases or is an indicator of systemic disease processes. Different patterns of association with diseases by CRS phenotype may be due to CRSwNP sample size limitations or reflect a different pattern of disease onset by phenotype. These findings have implications for screening guidelines and care of CRS patients.

Different activations of toll-like receptors and antimicrobial peptides in chronic rhinosinusitis with or without nasal polyposis

Both up- and down-regulation of the Toll-like receptors (TLRs) and antimicrobial peptides (AMPs) of the sinonasal mucosa have already been associated with the pathogenesis of chronic rhinosinusitis with (CRSwNP) or without (CRSsNP) nasal polyps. The objective of this study was to determine the expression of all known TLR and several AMP genes and some selected proteins in association with allergy, asthma and aspirin intolerance (ASA) in CRS subgroups. RT-PCR was applied to measure the mRNA expressions of 10 TLRs, four defensins, lysozyme, cathelicidin and lactoferrin (LTF) in sinonasal samples from patients with CRSsNP (n = 19), CRSwNP [ASA(-): 17; ASA(+): 7] and in control subjects (n = 12). Protein expressions were detected with immunohistochemistry (n = 10). Statistical analysis was done with the Kruskal-Wallis ANOVA, Mann-Whitney U, and Student t test. TLR2, TLR5, TLR6, TLR7, TLR8, TLR9, β-defensins 1 and 4, cathelicidin and LTF mRNA expressions were significantly (p < 0.05) increased in CRSwNP, whereas only TLR2 and LTF were up-regulated in CRSsNP compared to controls. There was no statistical difference in respect of allergy, aspirin intolerance and smoking between CRSsNP, ASA(-) and ASA(+) CRSwNP patients. TLR2, TLR3, TLR4, LTF, β defensin 2 and lysozyme protein expressions were found to be elevated in macrophages of CRSwNP samples (p < 0.05). Gene expression analysis showed markedly different expressions in CRSwNP (6 out of 10 TLR and 4 out of 7 AMP genes were up-regulated) compared to CRSsNP (1/10, 1/7). The distinct activation of the innate immunity may support the concept that CRSsNP and CRSwNP are different subtypes of CRS. These findings were found to be independent from allergy, asthma, smoking, aspirin intolerance and systemic steroid application.

Group 2 innate lymphoid cells (ILC2s) are increased in chronic rhinosinusitis with nasal polyps or eosinophilia

BACKGROUND

Chronic rhinosinusitis (CRS) is a heterogeneous disease with an uncertain pathogenesis. Group 2 innate lymphoid cells (ILC2s) represent a recently discovered cell population which has been implicated in driving Th2 inflammation in CRS; however, their relationship with clinical disease characteristics has yet to be investigated.

OBJECTIVE

The aim of this study was to identify ILC2s in sinus mucosa in patients with CRS and controls and compare ILC2s across characteristics of disease.

METHODS

A cross-sectional study of patients with CRS undergoing endoscopic sinus surgery was conducted. Sinus mucosal biopsies were obtained during surgery and control tissue from patients undergoing pituitary tumour resection through transphenoidal approach. ILC2s were identified as CD45(+) Lin(-) CD127(+) CD4(-) CD8(-) CRTH2(CD294)(+) CD161(+) cells in single cell suspensions through flow cytometry. ILC2 frequencies, measured as a percentage of CD45(+) cells, were compared across CRS phenotype, endotype, inflammatory CRS subtype and other disease characteristics including blood eosinophils, serum IgE, asthma status and nasal symptom score.

RESULTS

35 patients (40% female, age 48 ± 17 years) including 13 with eosinophilic CRS (eCRS), 13 with non-eCRS and 9 controls were recruited. ILC2 frequencies were associated with the presence of nasal polyps (P = 0.002) as well as high tissue eosinophilia (P = 0.004) and eosinophil-dominant CRS (P = 0.001) (Mann-Whitney U). They were also associated with increased blood eosinophilia (P = 0.005). There were no significant associations found between ILC2s and serum total IgE and allergic disease. In the CRS with nasal polyps (CRSwNP) population, ILC2s were increased in patients with co-existing asthma (P = 0.03). ILC2s were also correlated with worsening nasal symptom score in CRS (P = 0.04).

CONCLUSION AND CLINICAL RELEVANCE

As ILC2s are elevated in patients with CRSwNP, they may drive nasal polyp formation in CRS. ILC2s are also linked with high tissue and blood eosinophilia and have a potential role in the activation and survival of eosinophils during the Th2 immune response. The association of innate lymphoid cells in CRS provides insights into its pathogenesis.

Risk factors for chronic rhinosinusitis

PURPOSE OF REVIEW

To review the recent literature on risk factors for chronic rhinosinusitis (CRS) with an emphasis on genetic, comorbid diseases and environmental factors associated with CRS. Through identifying potential risk factors for CRS, we aim to glean insights into the underlying pathogenic mechanisms essential for developing effective therapeutic strategies.

RECENT FINDINGS

Recent findings demonstrate that genetics and comorbid medical conditions including airway diseases, gastroesophageal reflux disease, inflammatory and autoimmune diseases, and various demographic and environmental factors are associated with having a CRS diagnosis. Limitations of current studies include variable application of disease definitions, lack of prospective longitudinal studies and a disproportionate focus on tertiary care populations.

SUMMARY

CRS has a broad spectrum of associations ranging from genetics to comorbid diseases and environmental factors. These predisposing factors may provide valuable information for possible designing of therapeutic and preventive interventions. However, to better understand whether these associations cause CRS, further studies are needed to independently replicate findings, establish temporal relationships between exposure and disease onset, evaluate the influence of exposure dose on disease severity, and to understand the biological effects of these risk factors in the context of CRS.

The effect of nasal irrigation formulation on the antimicrobial activity of nasal secretions

BACKGROUND

Saline-based irrigation solutions are evidence-based rhinological treatments; however, the formulation of these solutions could theoretically alter the function of innate antimicrobial peptides. The aim of this study was to determine if the antimicrobial activity of normal human nasal secretions in vivo is altered by commercially available large volume irrigation solutions.

METHODS

Minimally manipulated sinonasal secretions were collected from patients with chronic rhinosinusitis (CRS; n = 10) and normal healthy volunteers (n = 20). In a subset of control patients (n = 10) secretions were collected prior to, and at 1 hour, 6 hours, and 24 hours after nasal irrigation with 4 commercial irrigation solutions. Lysozyme and lactoferrin levels were analyzed and the antimicrobial activity of secretions determined using a radial diffusion assay.

RESULTS

The antimicrobial activity of nasal secretions was reduced in CRS patients compared to healthy volunteers (p < 0.01), but there was no significant difference in antimicrobial peptide concentrations. Isotonic nasal irrigation reduced lysozyme and lactoferrin levels, which returned to baseline levels by 6 hours; in addition to a sustained decrease in antimicrobial activity before returning to baseline at 24 hours. Low-salt solution stimulated peptide secretion by approximately 40% at 6 hours and 24 hours, but produced a transient decrease in antimicrobial activity, returning to baseline levels by 6 hours. Hypertonic solution initially decreased lysozyme and lactoferrin levels but maintained baseline levels of antimicrobial activity and increased peptide secretion by approximately 30% at 24 hours.

CONCLUSION

The formulation of nasal irrigation solutions significantly affects the measured levels and functionality of sinonasal antimicrobial peptides.

Increased expression of the epithelial anion transporter pendrin/SLC26A4 in nasal polyps of patients with chronic rhinosinusitis

BACKGROUND

Chronic rhinosinusitis (CRS) is a multifactorial disease of unknown cause characterized by sinonasal inflammation, increased mucus production, and defective mucociliary clearance. Expression of Pendrin, an epithelial anion transporter, is increased in asthma and chronic obstructive pulmonary disease. Pendrin increases mucus production and regulates mucociliary clearance.

OBJECTIVES

We sought to investigate the expression of pendrin and the mucus-related protein Muc5AC in sinonasal tissues of control subjects and patients with CRS and to evaluate the regulation of pendrin expression in nasal epithelial cells (NECs) in vitro.

METHODS

The expression and distribution of pendrin in sinonasal tissues was analyzed by using real-time PCR, immunoblot analysis, and immunohistochemistry. Differentiated NECs were used to study the regulation of pendrin expression.

RESULTS

Increased pendrin expression was observed in nasal polyp (NP) tissue of patients with CRS. Immunohistochemistry analysis revealed that pendrin was largely restricted to the epithelial layer. Pendrin expression significantly correlated with inflammatory cell markers, suggesting that the factors made by these cells might induce pendrin expression. Furthermore, both pendrin and periostin levels (a biomarker in asthma) correlated with IL-13 levels, suggesting that pendrin can be induced by this cytokine in sinonasal tissues. Expression of the mucus component protein Muc5AC correlated weakly with pendrin expression, indicating that pendrin might modulate mucus production in NPs. In cultured NECs pendrin expression was induced by TH2 cytokines and induced synergistically when TH2 cytokines were combined with IL-17A. Interestingly, human rhinovirus had a potentiating effect on IL-13-induced pendrin expression. Dexamethasone suppressed pendrin expression, suggesting that the therapeutic benefit of dexamethasone in asthmatic patients and those with CRS might involve regulation of pendrin expression.

CONCLUSIONS

TH2-mediated pendrin expression is increased in NPs of patients with CRS and might lead to increased inflammation, mucus production, and decreased mucociliary clearance.

The Etiology and Pathogenesis of Chronic Rhinosinusitis: a Review of Current Hypotheses

Chronic rhinosinusitis (CRS) is a broad clinical syndrome that is characterized by prolonged mucosal inflammation of the nose and paranasal sinuses, and is typically divided into two subtypes based on the presence or absence of nasal polyps. The etiology and pathogenesis of both forms remain areas of active research. Over the last 15 years, a number of hypotheses have been proposed to explain all or part of the clinical CRS spectrum. These hypotheses reflect the concept that CRS results from a dysfunctional interplay between individual host characteristics and factors exogenous to the host. Six broad theories on CRS etiology and pathogenesis are discussed as follows: (1) the "fungal hypothesis," (2) the "superantigen hypothesis," (3) the "biofilm hypothesis," and (4) the "microbiome hypothesis," all of which emphasize key environmental factors, and (5) the "eicosanoid hypothesis" and (6) the "immune barrier hypothesis," which describe specific host factors. These theories are reviewed, and the evidence supporting them is critically appraised.

Steroid-eluting sinus stents for improving symptoms in chronic rhinosinusitis patients undergoing functional endoscopic sinus surgery

BACKGROUND

Functional endoscopic sinus surgery (FESS) has become a well-established approach for treating patients with chronic rhinosinusitis (CRS) refractory to medical management. However, the surgical outcome may be compromised by postoperative inflammation, polyposis and adhesions, which often require subsequent intervention. Bioabsorbable, steroid-eluting sinus stents are inserted into the nose, sinuses or both following surgery to prevent stenosis of the sinus openings during the postoperative healing period. The slow release of corticosteroid aims to decrease mucosal oedema and expedite wound healing. Whether a steroid-eluting stent offers any beneficial effects in terms of improving sinonasal symptoms has not been systematically reviewed.

OBJECTIVES

To assess the safety and efficacy of steroid-eluting sinus stent placement in CRS patients after FESS.

SEARCH METHODS

The Cochrane Ear, Nose and Throat Disorders Group (CENTDG) Trials Search Co-ordinator searched the CENTDG Trials Register; Central Register of Controlled Trials (CENTRAL 2015, Issue 4); PubMed; EMBASE; CINAHL; Web of Science; Clinicaltrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 14 May 2015.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) comparing steroid-eluting sinus stents with non-steroid-eluting sinus stents, nasal packing or no treatment in adult CRS patients undergoing FESS.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by The Cochrane Collaboration.

MAIN RESULTS

We identified no RCTs that met our inclusion criteria. Among the 159 records retrieved using our search strategy, 21 trials had the potential to be included given that they had tested sinus stents, spacers and packing materials for patients with CRS undergoing FESS. However, we excluded these trials from the review because they met some but not all of the inclusion criteria.

AUTHORS' CONCLUSIONS

We are unable to provide evidence to establish whether steroid-eluting sinus stents have potential advantages and disadvantages for patients with CRS undergoing FESS. Future, high-quality RCTs are needed to assess whether or not steroid-eluting sinus stents confer any beneficial effects, over those of surgery alone, when compared to non-steroid sinus stents.

Alternaria-Associated Fungus Ball of Orbit Nose and Paranasal Sinuses: Case Report of a Rare Clinical Entity

Alternaria-associated fungus ball of maxillar, ethmoidal paranasal sinuses, nasal cavity and orbit with bone erosion is extremely rare. Till recently, only two cases of this infection in immune competitive patients have been reported. We are herein describing the case of immune-competent woman who suffered of nasal congestion for 10 years. Patient was treated for tumor-like lesion in right maxillar sinus, where propagation in right nose cavity, right ethmoidal cells and right orbita was present. The organism that was seen in surgical removal of fungal debris by histological study, in using mycological testing, was proven as Alternaria alternata. Combination of surgical intervention and treatment with itraconazole eradicated fungal infection, and the disease was not relapsed in follow-up period of 2 years.

Expression of ligands for Siglec-8 and Siglec-9 in human airways and airway cells

BACKGROUND

Balanced activation and inhibition of the immune system ensures pathogen clearance while avoiding hyperinflammation. Siglecs, sialic acid-binding proteins found on subsets of immune cells, often inhibit inflammation: Siglec-8 on eosinophils and Siglec-9 on neutrophils engage sialoglycan ligands on airways to diminish ongoing inflammation. The identities of human siglec ligands and their expression during inflammation are largely unknown.

OBJECTIVE

The histologic distribution, expression, and molecular characteristics of siglec ligands were explored in healthy and inflamed human upper airways and in a cellular model of airway inflammation.

METHODS

Normal and chronically inflamed upper airway tissues were stained for siglec ligands. The ligands were extracted from normal and inflamed tissues and from human Calu-3 cells for quantitative analysis by means of siglec blotting and isolation by means of siglec capture.

RESULTS

Siglec-8 ligands were expressed on a subpopulation of submucosal gland cells of human inferior turbinate, whereas Siglec-9 ligands were expressed more broadly (submucosal glands, epithelium, and connective tissue); both were significantly upregulated in patients with chronic rhinosinusitis. Human airway (Calu-3) cells expressed Siglec-9 ligands on mucin 5B (MUC5B) under inflammatory control through the nuclear factor κB pathway, and MUC5B carried sialoglycan ligands of Siglec-9 on human upper airway tissue.

CONCLUSION

Inflammation results in upregulation of immune-inhibitory Siglec-8 and Siglec-9 sialoglycan ligands on human airways. Siglec-9 ligands are upregulated through the nuclear factor κB pathway, resulting in their enhanced expression on MUC5B. Siglec sialoglycan ligand expression in inflamed cells and tissues may contribute to the control of airway inflammation.

A retrospective, cross-sectional study reveals that women with CRSwNP have more severe disease than men

Up to 50% of patients with chronic rhinosinusitis (CRS) have comorbid asthma, and we have reported that a subset of CRS patients who have nasal polyps (CRSwNP) have elevated autoantigen-specific antibodies within their nasal polyps (NP). While increases in the prevalence and/or severity of both asthma and autoimmunity in women are well characterized, it is not known whether CRSwNP is more severe or frequent in women than men. We sought to determine whether CRSwNP demonstrated sex-specific differences in frequency and/or severity. Using a retrospectively collected database of tertiary care patients (n = 1393), we evaluated the distribution of sex in patients with CRSwNP with or without comorbid asthma or aspirin hypersensitivity. We further compared the severity of sinus disease between men and women with CRSwNP. Although women comprised 55% of CRS patients without NP (CRSsNP), a significantly smaller proportion of CRSwNP patients were female (38%, P < 0.001). Interestingly, women with CRSwNP were significantly more likely than men to have comorbid asthma (P < 0.001), and 61% of patients with the most severe form of disease (aspirin-exacerbated respiratory disease (CRSwNP plus asthma plus aspirin sensitivity)) were women (P < 0.05). Women with CRSwNP were significantly more likely to have taken oral steroids, and were more likely to have a history of revision surgeries (P < 0.05) compared to men. These data suggest that women with CRSwNP have more severe disease than men in a tertiary care setting. Future studies are needed to elucidate the mechanisms that drive disease severity in men and women, paving the way for the development of personalized treatment strategies for CRSwNP based on sex.

Serum levels of specific IgE to Staphylococcus aureus enterotoxins in patients with chronic rhinosinusitis

The aim of this study was to determine the prevalence of Staphylococcus aureus enterotoxins (SEs) in the serum from patients with chronic rhinosinusitis (CRS) and its involvement in the condition. Thirty CRS patients without nasal polyps (CRSsNP), 40 CRS patients with nasal polyps (CRSwNP), and 30 healthy controls were enrolled in this study. Peripheral blood was obtained and analyzed to measure the serum levels of total IgE, specific IgE to SEA, SEB and SEC, and eosinophil cationic protein (ECP) using ImmunoCAP assays. The positive rate and level of serum specific IgE to SEB, but not to SEA or SEC, were significantly higher in CRSwNP patients compared with the controls (P=0.027 and P=0.021, respectively). No significant differences were found between CRSsNP patients and controls, or between CRSsNP and CRSwNP patients. Serum total IgE was significantly elevated and positively correlated with SEB-specific IgE in the CRSsNP (P<0.001; r=0.393, P=0.032) and CRSwNP (P<0.001; r=0.581, P<0.001) groups. ECP was also significantly increased in the CRSsNP (P=0.002) and CRSwNP (P<0.001) groups, but not correlated with specific IgE to SEs in either CRS group. The results suggest that SEB may play a role in the pathogenesis of CRSwNP.

Clinical predictors of neo-osteogenesis in patients with chronic rhinosinusitis

BACKGROUND

Neo-osteogenesis of the paranasal sinuses is a radiologic finding of unclear clinical significance. Although current evidence suggests that these bony changes represent an inflammatory response rather than an infectious osteitis, bacteria associated with the sinonasal mucosa may induce inflammatory mediators as a mechanism of neo-osteogenesis. The objectives of this study were (1) to determine whether there is an association between bacteria isolated on sinus culture and neo-osteogenesis, and (2) to identify other predictive factors for neo-osteogenesis.

METHODS

Ninety patients undergoing sinus surgery for medically refractory CRS were recruited. Radiologic evidence of neo-osteogenesis was assessed by the Global Osteitis Scoring Scale (GOSS) and mucosal disease severity was assessed by the Lund-Mackay score (LMS). Bacterial culture was obtained endoscopically at the preoperative office visit or during surgery. Multiple and logistic regression models were used to evaluate the association between the types of bacterial species isolated, number of previous surgeries, and severity of neo-osteogenesis.

RESULTS

Thirty of the 90 (33.3%) patients had radiologic evidence of neo-osteogenesis. Pseudomonas aeruginosa was significantly associated with neo-osteogenesis (odds ratio [OR], 3.97; 95% confidence interval [CI], 1.12 to 13.56), whereas Staphylococcus aureus was not. The number of previous surgeries, especially 2 or more previous surgeries, was associated with the extent of neo-osteogenesis (OR, 3.48; 95% CI, 1.14 to 10.51). The LMS was also significantly associated with the extent of neo-osteogenesis.

CONCLUSION

The presence of P. aeruginosa in the sinuses is an independent predictor of neo-osteogenesis, whereas S. aureus is not. The number of previous surgeries and the LMS are also independently associated with the severity of neo-osteogenesis.