Peter Small

Canadian clinical practice guidelines for acute and chronic rhinosinusitis

This document provides healthcare practitioners with information regarding the management of acute rhinosinusitis (ARS) and chronic rhinosinusitis (CRS) to enable them to better meet the needs of this patient population. These guidelines describe controversies in the management of acute bacterial rhinosinusitis (ABRS) and include recommendations that take into account changes in the bacteriologic landscape. Recent guidelines in ABRS have been released by American and European groups as recently as 2007, but these are either limited in their coverage of the subject of CRS, do not follow an evidence-based strategy, or omit relevant stakeholders in guidelines development, and do not address the particulars of the Canadian healthcare environment.Advances in understanding the pathophysiology of CRS, along with the development of appropriate therapeutic strategies, have improved outcomes for patients with CRS. CRS now affects large numbers of patients globally and primary care practitioners are confronted by this disease on a daily basis. Although initially considered a chronic bacterial infection, CRS is now recognized as having multiple distinct components (eg, infection, inflammation), which have led to changes in therapeutic approaches (eg, increased use of corticosteroids). The role of bacteria in the persistence of chronic infections, and the roles of surgical and medical management are evolving. Although evidence is limited, guidance for managing patients with CRS would help practitioners less experienced in this area offer rational care. It is no longer reasonable to manage CRS as a prolonged version of ARS, but rather, specific therapeutic strategies adapted to pathogenesis must be developed and diffused.Guidelines must take into account all available evidence and incorporate these in an unbiased fashion into management recommendations based on the quality of evidence, therapeutic benefit, and risks incurred. This document is focused on readability rather than completeness, yet covers relevant information, offers summaries of areas where considerable evidence exists, and provides recommendations with an assessment of strength of the evidence base and degree of endorsement by the multidisciplinary expert group preparing the document.These guidelines have been copublished in both Allergy, Asthma & Clinical Immunology and the Journal of Otolaryngology-Head and Neck Surgery.

Acute Bacterial Sinusitis in Adults: Management in the Primary Care Setting

Sinus disease is inherently associated with viral upper respiratory tract infections and occurs in 90% of individuals with the common cold. Acute bacterial sinusitis occurs in 0.5 to 2% of these individuals. Although the diagnosis of acute bacterial sinusitis is usually based on physical findings, no one sign or symptom is either sensitive or specific for sinusitis. The predictive power can be significantly improved when all signs and symptoms are combined into a clinical impression. Imaging studies have not been shown to be cost effective in the initial assessment and treatment of patients in the primary care setting. Simple plain films may be indicated to resolve the diagnosis in patients with an equivocal history or to follow patients admitted to hospital with severe sinus disease. The initial management of acute sinusitis should be directed toward the relief of symptoms with a 7-day course of decongestants and mucoevacuents. For patients who fail to improve with symptomatic treatment, a 10-day course of amoxicillin is recommended. Second line antibiotics should be initiated if improvement is not seen within 72 to 96 hours.

Effects of treatment with beclomethasone dipropionate in subpopulations of perennial rhinitis patients

The efficacy and safety of beclomethasone dipropionate (BD), 0.05 mg three times daily, sprayed in each nostril was studied in 39 adult patients with perennial rhinitis in a 12 wk, double-blind, vehicle controlled trial. Parameters of IgE-mediated reactivity, including epicutaneous skin testing, total serum IgE, specific serum IgE, and nasal eosinophilia, were assessed. All adverse reactions, including changes in serum cortisol and nasal and pharyngeal Candida infections, were monitored. Sixty-three percent of BD patients achieved total or substantial control of nasal symptoms compared with 25% of controls (p = 0.04). Eighty-three percent of BD-treated, skin test-positive patients improved, while only 14% of BD nonatopics improved (p less than 0.05). All BD patients with nasal eosinophilia improved compared with 38% without eosinophilia. Adverse reactions were frequent, minor, and equal in both groups. Serum cortisols were stable and no nasal Candida infections were documented. This study demonstrates the efficacy and safety of BD in treatment of perennial rhinitis, particularly in atopic patients with nasal eosinophilia.

Interleukin-4, interleukin-5, and granulocyte-macrophage colony-stimulating factor receptor expression in chronic sinusitis and response to topical steroids☆☆☆★★★♢

Chronic sinusitis and its associated eosinophilic infiltrate are believed to be mediated, at least in part, by the upregulation of Th-2 cytokines, including interleukin-4, interleukin-5, and granulocyte-macrophage colony-stimulating factor (GM-CSF). Interleukin-4 is involved in IgE production and in eosinophil recruitment through upregulation of vascular cell adhesion molecule-1. Interleukin-5 and GM-CSF are involved in eosinophil growth and survival. The aim of this study was to investigate the expression of receptors for these cytokines in the sinus mucosa of subjects with chronic sinusitis. Using the technique of in situ hybridization to detect specific cytokine receptor messenger RNA, we studied the sinus mucosa of subjects with nonallergic chronic sinusitis, subjects with allergic chronic sinusitis, subjects with allergic chronic sinusitis treated with topical steroids, and normal controls. Our data demonstrate higher expression of interleukin-4 receptor in subjects with allergic chronic sinusitis than in controls (p <0.001) and higher expression of interleukin-5 receptor in both subjects with nonallergic chronic sinusitis and subjects with allergic chronic sinusitis than in controls (p <0.001, p <0.001). The expression of interleukin-4 receptor and interleukin-5 receptor was higher in subjects with allergic chronic sinusitis than in subjects with nonallergic chronic sinusitis (p <0.001). GM-CSF receptor expression was also found to be higher in subjects with allergic chronic sinusitis and subjects with nonallergic chronic sinusitis than in controls (p <0.001,p <0.001). In contrast to interleukin-4 receptor and interleukin-5 receptor, however, expression of GM-CSF receptor was higher in subjects with non-allergic chronic sinusitis than in subjects with allergic chronic sinusitis (p <0.001). In subjects with allergic chronic sinusitis treated with topical corticosteroids, the expression of interleukin-4 receptor and interleukin-5 receptor messenger RNA levels was significantly lower than levels in patients with allergic chronic sinusitis who were not taking topical steroids (p <0.001, p <0.001). Steroid treatment had no effect on GM-CSF receptor messenger RNA expression. In conclusion, our data support a role for Th-2 cytokine receptors in the pathophysiology of chronic sinusitis. Further, our data lend support to the theory that differential activation of distinct cytokine pathways mediates inflammation in chronic sinusitis depending on whether there is associated allergy. Finally, treatment with topical corticosteroids has been demonstrated in chronic sinusitis to downregulate receptors for interleukin-4 and interleukin-5.

Th‐2 Type Cytokine Receptors in Allergic Rhinitis and in Response to Topical Steroids

Objectives: Th‐2 type cytokine production (Interleukin‐4 [IL‐4] and interleukin‐5 [IL‐5]) has been demonstrated to play a significant role in the pathophysiology of allergic rhinitis (AR), and the treatment of AR with topical corticosteroids has been shown to reduce the expression of Th‐2 type cytokines in vivo. However, the contribution and expression of Th‐2 type cytokine receptors in AR and their response to corticosteroid treatment remain to be clarified. Objectives of the current study are 1. To examine the expression of the cytokine IL‐4 and IL‐5 receptors (IL‐4R and IL‐5R) in a nasal allergen challenge model and to contrast this with the expression of the receptor for the Th‐1 type cytokine, interferon‐gamma receptor (IFN‐γR), and 2. to examine the effects of pretreatment with topical corticosteroid before allergen challenge on the expression of these same receptors.

Disparities in rate, triggers, and management in pediatric and adult cases of suspected drug‐induced anaphylaxis in Canada

Data is sparse on drug‐induced anaphylaxis (DIA) and there have not been studies assessing the differences in clinical characteristics and management of DIA between adults and children.

28 Effects of azatadine, terfenadine, and astemizole on allergen induced nasal provocation

Fifty-six patients with ragweed seasonal rhinitis were challenged intranasally with ragweed. A clinical score (0-12)--including measurements of rhinomanometry, secretions, and sneezes--was generated. Each patient then received either azatadine (A), terfenadine (T), astemizole (AS), or nothing (control), for 1 week. Repeat challenges revealed changes in clinical score with A 3.6 (P less than .01), AS 3.1 (P less than .02), and T 2.7 (P less than .05). All three antihistamines similarly inhibited the nasal provocation response to ragweed.

Allergic rhinitis in the primary care setting: patient practice reflective

Background Allergic rhinitis (AR) is a multifaceted condition affecting up to 40% of the population. AR leads to nasal symptoms of congestion, rhinorrhea, sneezing, and nasal itching. It is often associated with ocular symptoms of itching/burning, tearing/watering and redness. AR has a negative impact on patients’ quality of life (QoL) due to both nasal and ocular symptoms. Market research showed that Canadian physicians believe only 44% of their seasonal allergic rhinitis (SAR) patients suffer from ocular symptoms. The objective of the program was to better understand the symptom severity and impact on QoL of SAR patients in Canada.