Matthew W. Ryan

Asthma and the unified airway

Inflammatory processes of the upper and lower airway commonly co-exist. Patients with upper respiratory illnesses such as allergic rhinitis and acute and chronic rhinosinusitis often present to both otolaryngologists and primary care physicians for treatment of their symptoms of nasal and sinus disease. These patients often have concurrent lower respiratory illnesses such as asthma that may be contributing to their overall symptoms and quality of life. Unfortunately, asthma frequently remains undiagnosed in this population. It was the objective of this paper to examine the relationship between upper respiratory illnesses such as rhinitis and rhinosinusitis and lower respiratory illnesses such as asthma, and to provide a framework for primary care and specialty physicians to approach these illnesses as a spectrum of inflammatory disease. The present manuscript was developed by a multidisciplinary workgroup sponsored by the American Academy of Otolaryngic Allergy. Health care providers in various specialties contributed to the manuscript through preparation of written materials and through participation in a panel discussion held in August 2006. Each author was tasked with reviewing a specific content area and preparing a written summary for inclusion in this final document. Respiratory inflammation commonly affects both the upper and lower respiratory tracts, often concurrently. Physicians who are treating patients with symptoms of allergic rhinitis and rhinosinusitis must be vigilant to the presence of asthma among these patients. Appropriate diagnostic methods should be used to identify individuals with concurrent respiratory illnesses, and comprehensive treatment should be instituted to reduce symptoms and improve quality of life.

The effect of saline solutions on nasal patency and mucociliary clearance in rhinosinusitis patients.

Objective To compare the effect of two saline nasal sprays on nasal patency and mucociliary clearance in patients with rhinosinusitis. Study Design Randomized double-blind trial. Subjects and Methods Eighty patients with rhinosinusitis at a tertiary care academic center had nasal patency and mucociliary clearance measured. Each patient was then treated with either physiological or hypertonic saline. Nasal patency and mucociliary clearance measurements were repeated after treatment. Subjective evaluation was also performed. Results Both solutions improved saccharine clearance times (P < 0.0001). Buffered physiological saline significantly affected nasal airway patency (P = 0.006). Both solutions improved symptoms of nasal stuffiness (P < 0.0001) and nasal obstruction (P < 0.0001). Buffered hypertonic saline caused increased nasal burning/irritation compared with buffered physiological saline (P < 0.0001). Conclusions Buffered physiological and buffered hypertonic saline nasal sprays both improve mucociliary clearance, which is beneficial for treatment of rhinosinusitis. Additionally, buffered physiological saline improves nasal airway patency, whereas buffered hypertonic saline has no effect. Both solutions provide symptomatic relief, but buffered hypertonic saline is more irritating.

Effects of Buffered Saline Solution on Nasal Mucociliary Clearance and Nasal Airway Patency

OBJECTIVE: To compare the effects of buffered hypertonic and buffered normal saline nasal spray on mucociliary clearance and nasal airway patency. STUDY DESIGN AND SETTING: Double-blind trial with subjects acting as their own controls. Tertiary care academic medical center. RESULTS: Buffered hypertonic saline and buffered normal saline both improved saccharine clearance times (P < 0.0001 for buffered hypertonic and P = 0.002 for buffered normal saline). Buffered hypertonic saline improved saccharine clearance times more than buffered normal saline (39.6% vs 24.1%, P = 0.007). Neither buffered hypertonic nor buffered normal saline significantly affected nasal airway patency. CONCLUSIONS: Both buffered hypertonic and buffered normal saline nasal spray significantly improved saccharine clearance times without affecting nasal airway patency. Buffered hypertonic saline affected saccharine clearance times to a greater degree than buffered normal saline. CLINICAL SIGNIFICANCE: Buffered hypertonic and buffered normal saline sprays both improve mucociliary clearance and should therefore be beneficial in conditions such as rhinitis and sinusitis, which are associated with disruption of mucociliary clearance. However, these sprays do not appear to affect the nasal airway. Patients may therefore benefit from other treatments for “nasal congestion.” EBM rating: B-2.

Allergic fungal rhinosinusitis: diagnosis and management.

Purpose of reviewThe proper diagnosis and treatment of allergic fungal rhinosinusitis remain controversial. We discuss recent additions to the literature regarding diagnosis and treatment of this condition. Recent findingsThere is considerable overlap in the clinical features of allergic fungal rhinosinusitis and other forms of eosinophilic mucin chronic rhinosinusitis. Type 1 hypersensitivity and characteristic computed tomographic findings may have predictive value for a final diagnosis of allergic fungal rhinosinusitis, patients with which are more likely to have bony erosion than patients with other forms of chronic rhinosinusitis. The decreases in orbital volume associated with expansive allergic fungal rhinosinusitis disease may spontaneously improve after successful treatment. Most patients have detectable fungal-specific IgE in their so-called allergic mucin. Elevated levels of fungal-specific IgG3 are a consistent finding in patients with allergic fungal rhinosinusitis and eosinophilic mucin chronic rhinosinusitis. Antifungal treatment is still considered a treatment option, but further study is needed. SummaryType 1 hypersensitivity to fungal antigens helps to distinguish allergic fungal rhinosinusitis from other forms of eosinophilic mucin chronic rhinosinusitis. Bony erosion and orbital expansion giving rise to proptosis are prominent features of allergic fungal rhinosinusitis. Advances in medical treatment will require prospective and controlled trials.

Balloon catheter technology in rhinology: Reviewing the Evidence

Balloon catheter technology (BCT) for management of paranasal sinus inflammatory disease was introduced to otolaryngology in 2005. Since its introduction, BCT has been a subject of considerable controversy with proponents for and against adoption of the technology. Balloon procedures have been promoted as a less invasive alternative to endoscopic sinus surgery that results in reduced pain and quicker recovery. The technology and its promotion have generated significant press coverage and interest by the lay public looking for new solutions for sinonasal problems. Over time, alternate balloon devices have been advocated for operating room and office‐based sinus ostia dilatation. This contemporary review will evaluate the existing evidence on the available balloon devices. The frank strengths and weaknesses of the peer‐reviewed literature will be highlighted. The potential complications unique to balloon catheters and radiation exposure from fluoroscopy will also be discussed. Laryngoscope, 2011

Diseases associated with chronic rhinosinusitis: what is the significance?

Purpose of reviewTo discuss the systemic conditions that may impact the incidence, severity, prognosis, or treatment approach in patients with chronic rhinosinusitis. Recent findingsPatients with allergic rhinitis do not necessarily have more severe chronic rhinosinusitis as assessed by symptom scores, nasal endoscopy, or computed tomography staging. However, at least in pediatric patients with chronic rhinosinusitis who undergo surgery, consideration of allergy and allergy treatment appears to improve surgical results. Patients with aspirin sensitivity have a more severe disease, but benefit from surgical treatment to the same degree as non-aspirin-sensitive patients with chronic rhinosinusitis. Surgical treatment of polypoid rhinosinusitis in cystic fibrosis patients improves symptoms, and aggressive surgical opening of sinus cavities may provide long-lasting benefit, though polyps will regrow in most patients, and many will require repeat surgery. Rhinosinusitis is among the most common infectious complications of humoral immunodeficiency, and humoral immunodeficiency is not uncommon in patients with refractory chronic rhinosinusitis. Patients with granulomatous disease causing rhinosinusitis, such as Wegeners granulomatosis, appear to suffer from a symptom burden that is equivalent to the broader population of chronic rhinosinusitis patients. SummarySystemic disease conditions influence the incidence, treatment, and severity of chronic rhinosinusitis. Specific diagnosis of these contributing conditions will facilitate appropriate treatment.

Asthma and Rhinitis: Comorbidities

The connection between asthma and rhinitis is not a new discovery. Significant progress has been made in understanding the relationship of these two conditions, however, and the implications of the asthma-rhinitis link make it increasingly important. Patients who have asthma and rhinitis tend to have more severe disease with higher treatment costs. Treatment of rhinitis may improve asthma control, and early treatment of allergies may prevent the development of asthma. This article more fully explores the epidemiologic, pathophysiologic, and clinical relationships between asthma and rhinitis.

Executive Summary: Asthma and the Unified Airway

Asthma is a common comorbid disorder that will be seen by otolaryngologists in their treatment of patients with rhinitis, rhinosinusitis, and otitis media. Among otolaryngologists, however, a diagnosis of asthma is infrequently considered in this patient population. Otolaryngologists, however, may be in an important position to recognize this potential diagnosis and provide treatment or appropriate referral. To further develop this relationship among upper and lower airway inflammation, and to provide important information to otolaryngologists regarding this relationship, a multidisciplinary workgroup was impaneled by the American Academy of Otolaryngic Allergy in August 2006. The full report of this meeting is published separately as a Supplement to Otolaryngology-Head and Neck Surgery. This Executive Summary provides a brief synopsis of that document, with a focus on comorbid respiratory inflammation for otolaryngologists. In the treatment of their patients with allergic rhinitis and rhinosinusitis, otolaryngologists must be aware of the possible presence of asthma so that appropriate treatment and/or referral can be initiated. The impact of this practice will allow more comprehensive treatment of patients with upper and lower airway disease, and will improve patient symptoms, function, and quality of life.

Human IgA-inducing protein from dendritic cells induces IgA production by naive IgD+ B cells.

Over the last several years, there has been a great deal of progress in characterizing the role of dendritic cells (DCs) in the activation and modulation of B cells. DC-secreted chemokines can induce B cell trafficking to the lymph nodes. DC-produced survival factors such as B cell-activating factor of the TNF family and a proliferation-inducing ligand have been shown to be essential for B cell maturation, but have also been implicated in class-switch recombination and B cell lymphoma survival. Recently added to this list of DC-derived factors effecting B cells is IgA-inducing protein (IGIP). In this study, we characterize production of IGIP by human DCs, and examine its capacity to induce IgA class switching and differentiation of naive B cells in vitro. Monocyte-derived DCs were cultured in vitro with TLR agonists (TLR3, 4, 5, and 9) and other factors, including CD40 ligand, GM-CSF, and IL-4 as well as the neuropeptide vasoactive intestinal peptide. Under in vitro stimulation with vasoactive intestinal peptide and CD40L, IGIP mRNA expression could be up-regulated as much as 35-fold above nonstimulated samples within 12–48 h. Naive B cells cultured with exogenous recombinant human IGIP produced IgA in greater quantities than nonstimulated controls. Finally, we demonstrate that IGIP stimulation drives the production of μ-α switch circles from IgM+IgD+ naive human B cells, indicating its role as an IgA switch factor.

Allergic fungal rhinosinusitis.

Allergic fungal rhinosinusitis is a phenotype of chronic rhinosinusitis with nasal polyposis, characterized by type 1 hypersensitivity to fungi, eosinophilic mucin with fungal hyphae in sinus secretions, and propensity for mucocele formation and bone erosion. Although its differentiation from other forms of chronic polypoid rhinosinusitis with eosinophilic mucin is sometimes problematic, type 1 hypersensitivity is a component of the disease process. Medical and surgical management can be augmented by immunotherapy directed toward the patients specific allergen sensitivities. The primary rationale for immunotherapy is to control the allergic diathesis that may be contributing to the patients chronic sinus inflammation.