Samantha M. Mucha

Nasal challenge with allergen leads to maxillary sinus inflammation

BACKGROUND Allergic rhinitis and chronic rhinosinusitis are both characterized by chronic inflammation. OBJECTIVE We sought to investigate the effect of nasal allergen challenge on the maxillary sinus and study the effect of premedication with loratadine. METHODS We performed a double blind, crossover, randomized, placebo-controlled study in 20 allergic subjects out of season. After treatment with either placebo or loratadine (10 mg PO daily) for 1 week, a catheter was inserted into one maxillary sinus and used to lavage the cavity. The subjects then underwent nasal challenge with diluent for the allergen extract, followed by 3 concentrations of grass or ragweed. Nasal and ipsilateral sinus lavages were performed after each challenge and then hourly for 8 hours. Sneezes and symptoms were recorded, and the lavage specimens were evaluated for eosinophils and levels of eosinophil cationic protein, albumin, and histamine. Eleven of the subjects underwent a similar challenge with lactated Ringers solution. RESULTS Compared with the lactated Ringers solution challenge, allergen challenge resulted in significant increases in most early- and late-phase nasal parameters. Allergen challenge of the nose also led to a significant increase compared with control values in maxillary sinus eosinophils and the levels of albumin, eosinophil cationic protein, and histamine during the late response. Loratadine resulted in significant inhibition of the nasal early response compared with that seen with placebo (P < .05). CONCLUSION These findings suggest that a neural reflex or systemic allergic inflammation is responsible for the sinus inflammatory response and that this inflammatory response might play a role in the development of rhinosinusitis in allergic subjects.

Evidence of Maxillary Sinus Inflammation in Seasonal Allergic Rhinitis

Objective. Allergic rhinitis has been frequently associated with both acute and chronic sinusitis. Previous studies have shown an influx of eosinophils into the maxillary sinus after nasal challenge with allergen. The objective of this study was to determine, in humans, if the development of seasonal allergic inflammation, secondary to natural allergen exposure, leads to similar inflammation within the maxillary sinus. Study Design. Prospective, longitudinal study. Setting. Academic medical center and research laboratory. Subjects and Methods. Eighteen subjects were evaluated in and out of the ragweed allergy season using subjective measures (nasal symptoms, quality of life), nasal secretory response to methacholine challenge, and evaluation of biomarkers in nasal and sinus lavages. Results. The subjects became symptomatic during the season and reported worse quality of life and increased nasal reactivity to methacholine. The total number of eosinophils obtained by nasal lavage during the season (median= 35,691) was significantly higher compared with out of season (median = 2811, P ≤ .02). Similarly, there were significantly more eosinophils, albeit to a lesser magnitude, in the maxillary sinus during the season (median = 4248) compared with the out-of-season samples (median = 370, P ≤ .02). Conclusion. The authors provide evidence that natural exposure to pollen during an individual’s allergy season leads to both nasal and sinus inflammation, strengthening the association between allergic rhinitis and sinusitis. The mechanism of this inflammatory response needs to be elucidated.

Delayed maxillary sinusitis after orbital floor repair

A 20-year-old white male presented to the otolaryngology clinic 11 months after sustaining a nasal fracture and right orbital floor fracture while water skiing. The injury was treated near the time of injury with a closed reduction of the nasal fracture and open reduction of the orbital floor fracture using a polyglycolic/polylactic acid mesh plate (Lactosorb; Walter Lorenz Surgical, Jacksonville, FL) and titanium screws using a transconjunctival approach. Three weeks prior to presentation, he developed right periorbital edema, centered on the infraorbital rim, resulting in approximately 50% eye closure with associated headache. He had no other sinonasal symptoms and no history of allergic rhinitis or sinusitis. He reported breathing easily through both nasal cavities. The patient complained of pain in the right periorbital area and was treated in the emergency department with Augmentin and discharged. At the clinic visit, anterior rhinoscopy showed a mild left septal deviation and a small septal spur on the right. Fiberoptic endoscopy revealed clear osteomeatal units (OMU) bilaterally. A minimal step off was palpated at the right medial infraorbital rim, with no cosmetic deformity. He had decreased sensation in the distribution of the right maxillary nerve. The eye motion and vision were normal. His face was nontender. A sinus CT scan done 1 week prior to presentation showed an inferiorly displaced right orbital floor with an intraorbital abscess with associated inflammation and an inferiorly displaced orbital floor (Figs 1 and 2). The right maxillary sinus was completely opacified with evidence of OMU obstruction. There was minimal mucosal thickening in the left maxillary sinus and the remaining sinuses were clear. The patient was taken to the operating room electively for an endoscopic right maxillary antrostomy and anterior ethmoidectomy. After removing a sclerotic uncinate pro-