Terapia anti interleukina 5 para la rinosinusitis crónica con pólipos / Anti-interleukin 5 therapy for chronic rhinosinusitis with polyps

Resumen INTRODUCCIÓN: La rinosinusitis crónica es la inflamación de la mucosa nasosinusal de duración superior a 12 semanas. Se distinguen dos formas clínicas: rinosinusitis crónica con pólipos y sin pólipos. Los pacientes con rinosinusitis crónica con pólipos presentan niveles elevados de interleukina 5, la cual promueve la diferenciación y supervivencia de eosinófilos, por lo que se ha propuesto minimizar su circulación como una nueva estrategia de tratamiento. Sin embargo, no hay claridad respecto a su real efectividad. MÉTODOS: Para responder esta pregunta utilizamos Epistemonikos, la mayor base de datos de revisiones sistemáticas en salud, la cual es mantenida mediante búsquedas en múltiples fuentes de información, incluyendo MEDLINE, EMBASE, Cochrane, entre otras. Extrajimos los datos desde las revisiones identificadas, reanalizamos los datos de los estudios primarios, realizamos un metanálisis y preparamos una tabla de resumen de los resultados utilizando el método GRADE. RESULTADOS Y CONCLUSIONES: Identificamos tres revisiones sistemáticas que en conjunto incluyeron tres estudios primarios, todos correspondientes a ensayos aleatorizados. Concluimos que los inhibidores de interleukina 5 podrían disminuir el puntaje de pólipos nasales. Si bien podrían asociarse a efectos adversos, estos serían poco frecuentes y de baja severidad. Sin embargo, la certeza de la evidencia es baja.

Abstract INTRODUCTION: Chronic rhinosinusitis is the inflammation of sinonasal mucosa lasting longer than 12 weeks. Two clinical forms are distinguished: chronic rhinosinusitis with polyps and without polyps. Patients with chronic rhinosinusitis with polyps exhibit high levels of interleukin 5, which promotes differentiation and survival of eosinophils. So, minimizing their circulation has been proposed as a new treatment strategy. However, there is no clarity regarding its real effectiveness. METHODS: To answer this question we used Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data of primary studies, conducted a meta-analysis and generated a summary of findings table using the GRADE approach. RESULTS AND CONCLUSIONS: We identified three systematic reviews included three primary studies overall, all corresponding to randomized trials. We concluded inhibitors of interleukin 5 might decrease nasal polyps score. Although they might be associated with adverse effects, these would be infrequent and of low severity. However, the certainty of the evidence is low.

Omalizumab para la rinosinusitis crónica / Omalizumab for chronic rhinosinusitis

Resumen INTRODUCCIÓN: La rinosinusitis crónica es una enfermedad inflamatoria crónica de alta prevalencia que compromete la mucosa de la cavidad nasal y senos paranasales. La inmunoglobulina E es un mediador inflamatorio que juega un rol etiopatogénico en esta condición, por lo que se ha planteado que omalizumab, un anticuerpo monoclonal anti-inmunoglobulina E, podría constituir una alternativa de tratamiento. MÉTODOS: Realizamos una búsqueda en Epistemonikos, la mayor base de datos de revisiones sistemáticas en salud, la cual es mantenida mediante el cribado de múltiples fuentes de información, incluyendo MEDLINE, EMBASE, Cochrane, entre otras. Extrajimos los datos desde las revisiones identificadas, analizamos los datos de los estudios primarios, realizamos un metanálisis y preparamos una tabla de resumen de los resultados utilizando el método GRADE. RESULTADOS Y CONCLUSIONES: Identificamos cinco revisiones sistemáticas que en conjunto incluyeron cinco estudios primarios, de los cuales dos corresponden a ensayos controlados aleatorizados. Concluimos que en pacientes con rinosinusitis crónica, no está claro si omalizumab lleva a una mejoría en la escala de pólipos nasales, la calidad de vida, el bienestar general o los síntomas nasales porque la certeza de la evidencia es muy baja. Por otra parte, el uso de omalizumab probablemente se asocia a efectos adversos frecuentes.

Abstract INTRODUCTION: Chronic rhinosinusitis is a high prevalence chronic inflammatory disease that involves nasal mucosa and paranasal sinuses. Immunoglobulin E is an inflammatory mediator that plays an etiopathogenic role in this condition, so omalizumab, an anti-immunoglobulin E monoclonal antibody, might be a therapeutic alternative. METHODS: We searched in Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data of primary studies, conducted a meta-analysis and generated a summary of findings table using the GRADE approach. RESULTS AND CONCLUSIONS: We identified five systematic reviews that included five primary studies overall, of which two correspond to randomized trials. We concluded it is not clear whether omalizumab leads to an improvement in the nasal polyps scale, quality of life, general well-being or nasal symptoms in patients with chronic rhinosinusitis, because the certainty of the evidence is very low. On the other hand, omalizumab is probably associated with frequent adverse effects.

Distinct characteristics of nasal polyps with and without eosinophilia / Diferenças nas características de pólipos nasais com e sem eosinofilia

Abstract Introduction Eosinophilic and noneosinophilic Nasal polyps (NPs) are different subtypes of NPs and require different treatment methods. Objective To compare the histologic characteristics, mRNA and protein expression between Nasal Polyps with and without eosinophilia. Methods NPs tissues were obtained from eighty-six NPs patients during surgery. Eosinophilic and noneosinophilic NPs were distinguished according to immunochemical results of the specimen. The histological, mRNA and protein expression features were compared between the two groups. Results In eosinophilic NPs, we observed a significantly higher GATA-3, IL-5, IL-4, IL-13 mRNA and protein expression. In noneosinophilic NPs, IL-17, IL-23 and RORc mRNA and protein expression were increased. Immunohistochemistry tests showed, more mast cells and less neutrophils in eosinophilic NPs compared with noneosinophilic NPs. Eosinophilic NPs patient presented more severe symptom scores when compared to noneosinophilic NPs. Conclusion We demonstrate for the first time that Th2 is the predominant reaction in eosinophilic NPs while Th17 is the predominant reaction in noneosinophilic NPs. Our study may provide new treatment strategy for NPs.

Resumo Introdução Pólipos nasais (PNs) eosinofílicos e não eosinofílicos são diferentes subtipos de PNs e requerem diferentes métodos de tratamento. Objetivo Comparar as características histológicas e a expressão de mRNAs e proteínas entre PNs com e sem eosinofilia. Método Amostras de PNs foram obtidos de 86 pacientes durante a cirurgia. PNs eosinofílicos e não eosinofílicos foram diferenciados segundo os resultados imunoistoquímicos de cada amostra. As características histológicas e de expressão de mRNAs e de proteínas foram comparadas entre os dois grupos. Resultados Em PNs eosinofílicos, observamos uma expressão significativamente maior dos mRNAs e proteínas GATA-3, IL-5, IL-4 e IL-13. Nos PNs não eosinofílicos, aumentou a expressão dos mRNAs e das proteínas IL-17, IL-23 e RORc. Nos testes imunoistoquímicos, observamos maior número de mastócitos e menor número de neutrófilos nos PNs eosinofílicos, em comparação com PNs não eosinofílicos. Os pacientes com PNs eosinofílicos obtiveram escores de sintomas mais graves vs. PNs não eosinofílicos. Conclusão Demonstramos, pela primeira vez, uma reação Th2 predominante em PNs eosinofílicos e uma reação Th17 predominante em PNs não eosinofílicos. Nosso estudo pode proporcionar novas estratégias terapêuticas para a rinossinusite crônica.

The role of aspirin desensitization in patients with aspirin-exacerbated respiratory disease (AERD) / O papel da dessensibilização à aspirina em pacientes portadores de doença respiratória exacerbada por aspirina (DREA)

ABSTRACT INTRODUCTION: Aspirin-exacerbated respiratory disease (AERD) consists of a classic tetrad: moderate/severe asthma, chronic rhinosinusitis, nasal polyps, and intolerance to aspirin or other nonsteroidal anti-inflammatory drugs. Clinical control with drugs, surgery, and desensitization are treatment options. OBJECTIVE: To evaluate the efficacy and tolerability of aspirin desensitization in patients with AERD. METHODS: Periodic symptom assessment and endoscopy in patients with AERD undergoing surgery who were desensitized. RESULTS: Seventeen patients were desensitized. Eight patients completed the desensitization and were followed for a minimum of a one-year period (mean 3.1 years). These patients showed improvement in all symptoms. Moreover, surgical reassessment was not indicated in any of these patients and there was a decrease in costs with medication and procedures. Eight patients did not complete desensitization, mainly due to procedure intolerance and uncontrolled asthma, whereas another patient was lost to follow-up. CONCLUSION: Aspirin desensitization, when tolerated, was effective in patients with AERD and with poor clinical/surgical response.

Resumo Introdução: A doença respiratória exacerbada por aspirina é composta pela tétrade clássica: asma moderada/grave, rinossinusite crônica, pólipos nasais e intolerância à aspirina ou outro anti-inflamatório não esteroide. Controle clínico com medicamentos, cirurgias e dessensibilização são opções de tratamento. Objetivo: Avaliar a eficácia e tolerabilidade da dessensibilização à aspirina em pacientes com doença exacerbada por aspirina. Método: Avaliação periódica dos sintomas e exame endoscópico em pacientes com doença respiratória exacerbada por aspirina submetidos à cirurgia e dessensibilizados. Resultados: Dezessete pacientes foram dessensibilizados, dos quais oito pacientes completaram a dessensibilização e foram acompanhados pelo tempo mínimo de 1 ano (média de 3,1 anos). Todos referiram melhora de todos os sintomas; não houve nenhuma indicação de reabordagem cirúrgica, e houve redução de gastos com medicações e procedimentos. Outros oito pacientes não completaram a dessensibilização, principalmente por intolerância ao procedimento e descontrole da asma, enquanto outro paciente perdeu o seguimento. Conclusão: A dessensibilização à aspirina, quando tolerada, mostrou-se eficaz nos pacientes com doença respiratória exacerbada por aspirina com resposta clínica/cirúrgica insatisfatória.

[Streptococcus super antigen in polyp tissue of patients with nasal polyposis and chronic rhinosinusitis in comparison to normal population]

Nasal polyp [NP] is a benign mucosal mass located in both sinuses and nares which is mostly seen in association with cystic fibrosis, asthma or oversensitivity to aspirin. The prominent histological feature of NP is inflammatory cell infiltration with eosinophil predominance. Superantigens role in causing NP complications is already proven. Superantigens, which are mostly originated from Streptococci and Staphylococci, activate T cells strongly and increase the process of production and release of cytokines, and secretion of IgE from B cells, which in turn directly affects proinflammatory cells such as eosinophils, both in their tissues infiltration and functions. The samples are collected from patients referring to ENT clinic in Rasoul Akram training Hospital in Tehran after thorough clinical and paraclinical examinations. For control group the samples collected from patients undergoing rhinoplasty. All the samples kept frozen and sent to immunology lab. The DNA of the excised tissues extracted and amplified by using the superantigens specific primers and PCR product detected by gel electrophoresis. The date analyzed by using mean and SD and CHI[2] analytical tools. Fifteen healthy individuals, 25 patients with rhinosinusitis and 24 with polyposis entered this trial. Group A Streptococcus toxin detection was significantly more frequent in those with nasal polyp and rhinosinusitis compared to healthy individuals [P=0.001 and 0.005, respectively], but the results were almost the same for those with nasal polyp and rhinosinusitis [P=0.4]. Streptococci may play an important role in induction or clinical exacerbation of polyposis and group A Streptococcus pyogenes exotoxin [SPEs] with superantigenic effects may have a crucial role in etiology and pathogenesis of polyps with or without rhinosinusitis. It is postulated that, T cells polyclonal activation by SPEs may cause recruitment of inflammatory cells in nasal mucosa. These inflammatory cells include IgE producing B cells leading to allergic and inflammatory reactions in NP.

Cirugía endoscópica en niños y adolescentes con rinosinusitis: perfil inmunológico y bacteriológico / Endoscopic sinus surgery in children and adolescent with rhino sinusitis: immunologic and bacteriologic profile

Introducción: La rinosinusitis, corresponde a un grupo de desórdenes que se caracteriza por la inflamación de la mucosa tanto de cavidades paranasales (CPN) como de fosas nasales. Está determinada por factores del huésped y ambientales que interactúan causando un estado inflamatorio persistente que produce remodelación de la mucosa. Entre éstos se destacan la alergia y otras alteraciones inmunológicas junto con la colonización por agentes infecciosos. Objetivo: Determinar las características demográficas, clínicas, inmunológicas y agentes infecciosos involucrados en la rinosinusitis crónica (RSC) y rinosinusitis aguda (RSA) recurrente de niños y adolescentes sometidos a cirugía endoscópica funcional (CEF). Establecer las posibles asociaciones de estas características con la necesidad de reoperación y la recurrencia de la enfermedad. Material y método: Estudio retrospectivo observacional en que se evalúan 28 niños y adolescentes sometidos a CEF en el servicio de ORL de Clínica Las Condes durante los años 2000 a 2009. Todos los pacientes contaban con estudio inmunológico y test cutáneo preoperatorio más biopsia de mucosa de CPN y cultivos intraoperatorios de secreción de CPN. Los análisis estadísticos se realizaron con test de Anova para los análisis descriptivos y para el análisis de grupos el test de Fisher. Considerando como significativo un p <0,05. Resultados: Se analizaron 28 pacientes; el 89,2 por ciento tuvo test cutáneo positivo y biopsia inflamatoria crónica eosinofílica (53,6(0) por ciento). El 17 por ciento presentó algún tipo de deficiencia inmunológica. Se obtuvo cultivos positivos intraoperatorios en el 71 por ciento de las muestras, en su mayoría agentes aeróbicos (57,1 por ciento), con 14,2 por ciento de anaerobios y sin presencia de hongos. Veinte y siete pacientes tuvieron seguimiento posoperatorio de 5 años. Cuatro de ellos (14 por ciento) debió ser reoperado...

Introduction: Rhino sinusitis is a group of disorders characterized by inflammation of the mucosa of both sinuses and nostrils. It is determined by environmental and host factors that interact causing a persistent inflammatory condition that causes remodeling of the mucosa. Chief among these are allergy and other immune disorders with colonization by infectious agents. Aim: To determine the demographic, clinical, immunologic and infectious agents involved in chronic Rhino sinusitis (CRS) and Recurrent Acute Rhino sinusitis (RAR) in children and adolescents undergoing functional endoscopic sinus surgery (FESS). Establish the possible associations of these characteristics with the need for re operation and recurrence of the disease. Material and method: Retrospective observational study that evaluated 28 children and adolescents involved in the ENT department at Clínica Las Condes, Santiago, Chile during the years 2000 to 2009. All study patients had preoperative Prick test, immune workout and intraoperative Para nasal mucosal biopsy and cultures of Para nasal secretion. Statistical analysis was performed using ANOVA test for descriptive analysis and cluster analysis with Fisher Exact test. Results were considered significant with p <0.05 Results: We analyzed 28 patients, 89.2 percent had positive Prick test and 53.6 percent showed biopsy with eosinophilic inflammatory disease. 17 percent had some type of immune deficiency. Positive intraoperative cultures were obtained in 71 percent of the samples, mostly aerobic agents (57.1 percent), with 14.2 percent anaerobes and negatives cultures for fungi. Twenty seven patients had postoperative follow-up of 5 years. Four of them (14 percent) had to be re-operated. During the monitoring period, 22 percent developed RAR. It was considered a poor surgical outcome the need for re-operation or recurrence of RAR. We couldn't find association of variables with a poor outcome after surgery...

Microbiology of rhinosinusitis in immunosupressed patients from the university hospital / Microbiologia das rinossinusites nos imunossuprimidos do hospital de clínicas

Immunosuppressed patients are often susceptible to upper airway infections, especially those of the paranasal sinuses. These can sometimes jeopardize treatment success and even lead to a fatal outcome. OBJECTIVE: To study the paranasal microbiology of immunosuppressed patients with clinical evidence of rhinosinusitis, and compare it with that from immunocompetent patients. MATERIAL AND METHOD: Retrospective study, in which 42 immunosuppressed and 16 immunocompetent patients were selected. All had clinically evident acute or recurrent rhinosinusitis and were submitted to ethmoidal or sphenoid sinusectomy or maxillary sinus puncture to gather material for microbiological cultures. RESULTS: There were 92 percent positive cultures, and 21 percent were negative. Of the positive cultures, 38 percent were bacterial, with P. aeruginosa being the most frequent agent; 64 percent were fungal, which occurred in the most immunocompromised patients. In the immunocompetent group, there were 62. 5 percent positive cultures and 37. 5 percent negative ones. All the positive ones were bacterial, with no fungi. CONCLUSIONS: Transplant recipients were prone to develop bacterial rhinosinusitis by Gram positive and Gram negative agents, the most common of the latter being Pseudomonas aeruginosa. Fungal infections occurred in the severely immunosuppressed, and it was absent in immunocompetent patients.

Os pacientes imunossuprimidos têm maior risco de infecções de vias aéreas superiores, principalmente seios paranasais. Estas podem ter evolução fatal ou impedir a recuperação e o tratamento das doenças iniciais. OBJETIVO: Verificar a microbiologia dos seios paranasais dos pacientes imunossuprimidos com rinossinusite, em nosso serviço, e comparar com a microbiologia de pacientes imunocompetentes. MATERIAL E MÉTODO: Estudo retrospectivo, no qual foram selecionados 42 pacientes imunossuprimidos e 16 pacientes imunocompetentes. Todos tinham diagnóstico de rinossinusite aguda ou recorrente e foram submetidos à punção de seio maxilar ou sinusectomia etmoidal ou esfenoidal para coleta de secreção para cultura. RESULTADOS: Obteve-se 92 por cento de cultura positiva e 21 por cento negativa nos imunossuprimidos. Dos positivos, 38 por cento foram bacterianos e 64 por cento, fúngicos, sendo a bactéria mais frequente a P. aeruginosa. Os fungos apareceram nos pacientes com imunossupressão grave. Nos imunocompetentes, obteve-se cultura positiva em 62,5 por cento dos pacientes, e negativa em 37,5 por cento deles, com 100 por cento de positividade para bactérias e ausência de fungos. CONCLUSÃO: Pacientes imunossuprimidos adquirem rinossinusites por bactérias Gram positivas, Gram negativas das mais diversas espécies, sendo Pseudomonas aeruginosa a mais frequente. As infecções fúngicas são mais frequentes em pacientes imunossuprimidos graves e ausentes em imunocompetentes.

Patogenia e inmunoterapia en la sinusitis alérgica fúngica (SAF) / Pathogeny and immunotherapy of allergic fungal sinusitis

Allergic fungal sinusitis is an atopic condition close related to fungus allergens that initiate a chronic inflammation dependent of the IgE system and LTCD4-TH2 cells whose cytokines and chemokines induced the clinical symptoms. Specific immunotherapy is recommended to avoid the recurrences and to improve the benefits of the surgical procedures of the affected sinuses. We suggest that Bipolaris sp Drechslera sp extracts must be included in the skin testing of the atopic patients suffering rhinosinusal symptoms as well as those who reveal intense response to fungal allergens in general.

Immunologic Factors in Patients with Chronic Polypoid Sinusitis

Background: Nasal polyposis is the benign protrusion of soft tissue into the nasal cavity; with multifactorial origin. This study is designed to examine the suggested role of IgE and CD and CD lymphocytes in the pathogenesis of 4 8 nasal polyposis. Method: Blood samples were taken from 32 patients with chronic polypoid sinusitis and 32 controls. CD and CD 4 8 total lymphocyte count were determined by flow cytometry and the level of serum IgE was measured by ELISA. Nasal discharge samples were also collected for determining IgE level in both patients and controls during surgery. Results: In 68.8of patients a history of allergy was present. The level of nasal discharge IgE was significantly higher (p0.001) in patients compared to controls; but the difference between serum IgE levels was not significant (p 0.05). CD concentration and blood lymphocytes were 8 significantly higher (p0.001) in the patients group; while CD concentration was significantly lower (p0.001) in 4 them. Finally; CD /CD ratio was significantly lower 4 8 (p0.001) in the patients group. Conclusion: This study suggests that a change in the amount of CD and CD lymphocytes and an increased 4 8 level of local IgE contribute to nasal polyposis; but the results should be confirmed in more extensive studies including cytokine analyses. Such increasing insights in the patho physiology of nasal polyposis open perspectives for new pharmacological treatment options; with immunologic factors as potential targets.of patients a history of allergy was present. The level of nasal discharge IgE was significantly higher (p0.001) in patients compared to controls; but the difference between serum IgE levels was not significant (p 0.05). CD concentration and blood lymphocytes were 8 significantly higher (p0.001) in the patients group; while CD concentration was significantly lower (p0.001) in 4 them. Finally; CD /CD ratio was significantly lower 4 8 (p0.001) in the patients group. Conclusion: This study suggests that a change in the amount of CD and CD lymphocytes and an increased 4 8 level of local IgE contribute to nasal polyposis; but the results should be confirmed in more extensive studies including cytokine analyses. Such increasing insights in the patho physiology of nasal polyposis open perspectives for new pharmacological treatment options; with immunologic factors as potential targets

Allergic fungal sinusitis

Allergic fungal sinusitis is the commonest form of fungal sinusitis which is analogous to allergic bronchopulmonary aspergillosis in many aspects. Once looked upon as a rare disease which now seems to be increasing in incidence either due to better diagnostic criteria or due to genuine increase in the number of cases. We report a case presented as allergic fungal sinusitis with infratemporal extension and expansion with bone resorption into intracranial region in an asthmatic teenager who was treated successfully with a combination of surgery and medical interventions

Immunological evidence supporting the use of extracts from Boehmeria jamaicensis Urb for treating the common cold and sinus infections

Mixed lymphocyte responses assays were conducted at 25.0 and 250.0 microg/mL of the crude ethanolic extract of Boehmeria jamaicensis Urb (coded as BJE) using peripheral lymphocytes obtained from individuals suffering from the common cold after four days of infection and from healthy individuals (without the common cold infection). At a concentration of 25 ug/mL, gamma interferon (IFN-gamma) was increased by 24.03 fold and interleukin 4 (IL-4) by 1.71 fold for the cells obtained from individuals with the common cold (Group A). The extract suppressed IFN-gamma by 8.3% while IL-4 was stimulated by 9.90 fold from peripheral lymphocytes obtained from healthy individuals (Group B). Gamma interferon was suppressed at 250 microg/mL while IL-4 was elevated by 1.86 fold for cells obtained from individuals suffering from the common cold (Group A). In conclusion, BJE could have implications for the treatment of the common cold.

Ensayos de reacci¨®n linfocitaria mixta fueron realizados a 25.0 y 250.0 ¦Ìg/mL de extracto etan¨®lico crudo de Boehmeria jamaicensis Urb (codificado como BJE), usando linfocitos perif¨¦ricos obtenidos de individuos con catarro com¨²n luego de cuatro d¨ªas de infecci¨®n, y de individuos sanos (sin la infecci¨®n del catarro com¨²n). Se hall¨® que el interfer¨®n-gamma (IFN-¦Ã) aument¨® en 24.03 veces, y la interleucina 4 (IL-4) en 1.71 veces para las c¨¦lulas obtenidas de individuos con catarro com¨²n, a 25¦Ìg/mL. El extracto inhibi¨® IFN-¦Ã en un 8.3 % en tanto que el IL-4 fue estimulado en 9.90 veces a partirde los linfocitos perif¨¦ricos obtenidos de individuos sanos. El gamma-interfer¨®n fue inhibido a 250 ¦Ìg/mL, mientras que la IL-4 se elev¨® en 1.86 veces para las c¨¦lulas obtenidas de individuos que sufren de catarro com¨²n.

Rinite, sinusite e asma: indissociáveis? / Rhinitis, Sinusitis and Asthma: hard to dissociate?

Este estudo tem como objetivo rever a literatura ressaltando aspectos epidemiológicos e fisiopatológicos relacionados à abordagem unificada de rinossinusite alérgica e da asma, com as respectivas implicações terapêuticas. O levantamento bibliográfico foi realizado a partir das informações disponibilizadas pelas bases de dados Medline, MD Consult, Highwire, Medscape, LILACS e por pesquisa direta, dos últimos trinta anos, utilizando-se os termos allergic rhinitis e asthma. Foram selecionados 55 artigos originais em revisão não sistemática abordando a questão da associação clínica entre rinossinusite alérgica e asma. Verifica-se que nos últimos anos, com o uso de medicamentos tópicos, para as vias aéreas superiores ou para as vias aéreas inferiores, a abordagem terapêutica tem sido distinta. Entretanto, inúmeros inquéritos epidemiológicos, estudos de imunopatologia e clínicos demonstram a inter-relação entre asma e rinossinusite alérgica evidenciados por: i) a rinite alérgica encontra-se associada à asma e constitui-se em fator de risco independente para o seu aparecimento; ii)as características imunopatológicas da rinite alérgica e da asma são semelhantes; iii)a rinite alérgica e a asma são manifestações de uma enfermidade sistêmica; iv)o controle da rinite favorece o controle da asma. A estreita associação entre a rinite alérgica e a asma requer a integração das abordagens diagnóstica, terapêutica e profilática dessas enfermidades. Opções terapêuticas que permitam o controle simultâneo de ambas oferecem vantagens relacionadas ao custo e à tolerabilidade.

The objective of this study was to review the literature and to discuss epidemiological and physiopathological aspects and therapeutical implications of an unified approach to allergic rhinosinusitis and asthma. The bibliographic survey was based on the information provided by the following databases: Medline, MD Consult, Highwire, Medscape, LILACS and through direct search over thirty years, using the terms allergic rhinitis and asthma. Fifty-five original articles were selected in the no systematically review addressing the issue of clinical association between allergic rhinusinusitis and asthma. It is noteworthy that in the late years, with the use of specific topical medications for the lower airways or else, to the upper airways, the therapeutical approach has been distinct. However, numerous epidemiological surveys, immunopatological and clinical studies demonstrate the inter-relationship between asthma and allergic rhinossinusitis, characterized by: i) allergic rhinitis is associated to asthma and constitute an independent risk factor for its occurrence; ii) the immunopathological characteristics of allergic rhinitis and asthma are similar; iii) allergic rhinitis and asthma are manifestations of a systemic disease; iv) control of rhinitis favors asthma control. taking into consideration the close inter-relationship between allergic rhinitis and asthma, the approach to diagnosis, treatment and prophylaxis of these illnesses should be integrated. Therapeutical options that allow for the simultaneous control of asthma and allergic rhinitis offer advantages related both to costs and tolerability.

Rol de los superantígenos en la etiopatogenia de la rinosinusitis crónica poliposa / Role of the superantigens in the etiopathogeny of chronic polypous rinosinusitis

La Rinosinusitis Crónica es un problema de salud frecuente. La patogénesis, fisiopatología e inmunobiología de esta patología, que durante mucho tiempo ha sido poco clara y desconocida en muchos aspectos, está comenzando a ser revelada. Recientemente se ha sugerido que en la etiopatogenia de la RSC intervendrían una diversidad de factores como los biofilms, hongos, alergia, infecciones bacterianas, y más recientemente, los superantígenos (SAg). Estudios demuestran que Stapylococcus Aureus , es la bacteria más frecuentemente aislada del mucus adyacente a los pólipos nasales. La producción de exotoxinas de éste y otros microorganismos, son capaces de actuar como superantígenos, uniéndose a los receptores de linfocitos T, produciendo activación y expansión de clones de éstos, con la consecuente liberación de citoquinas, que atraerían células inflamatorias principalmente eosinófilos, fundamentales en la patogenia de la Rinosinusitis Crónica Poliposa. En base a la información recopilada y presentada en esta revisión, podemos apreciar que el concepto de superantígenos no es algo abstracto, por el contrario, varios investigadores han demostrado su rol en la génesis y perpetuación de diversas enfermedades. Los hallazgos realizados recientemente nos muestran la relación que existiría con la rinosinusitis crónica, lo que hace plantearnos nuevas hipótesis, áreas de investigación e interrogantes a dilucidar.

The role of cytokines in rhinosinusitis

Since the last decade, new insights into inflammatory processes have become possible by investigating the pattern of cytokines in acute and chronic sinus diseases. This review aims to update and discuss the findings of in vitro and in vivo studies concerning the role of cytokines in sinusitis and nasal polyposis. The proinflammatory cytokines interleukin-1beta, interleukin-6 and the neutrophil-chemoattractant interleukin-8 may play a major role in acute sinusitis, as shown in viral and allergic rhinitis. In chronic sinusitis interleukin-3 dominates the cytokine profiles, giving support to a variety of inflammatory cells. Interleukin-5 is a key protein in the pathogenesis of nasal polyposis. Activation and survival of eosinophils in nasal polyps are thought to be regulated by interleukin-5. Further investigation of cytokine expression patterns in inflammatory sinus diseases will lead to a better understanding of their pathogenesis and to a development of new therapeutic modality.

The role of cytokines in rhinosinusitis

Since the last decade, new insights into inflammatory processes have become possible by investigating the pattern of cytokines in acute and chronic sinus diseases. This review aims to update and discuss the findings of in vitro and in vivo studies concerning the role of cytokines in sinusitis and nasal polyposis. The proinflammatory cytokines interleukin-1beta, interleukin-6 and the neutrophil-chemoattractant interleukin-8 may play a major role in acute sinusitis, as shown in viral and allergic rhinitis. In chronic sinusitis interleukin-3 dominates the cytokine profiles, giving support to a variety of inflammatory cells. Interleukin-5 is a key protein in the pathogenesis of nasal polyposis. Activation and survival of eosinophils in nasal polyps are thought to be regulated by interleukin-5. Further investigation of cytokine expression patterns in inflammatory sinus diseases will lead to a better understanding of their pathogenesis and to a development of new therapeutic modality.

Estudio del niño con obstrucción recurrente de las vías respiratorias superiores / The study of the children wiht recurrent upper airway obstruction

Antecedentes. La indagación sistémica de la obstrucción recurrente de las vías respiratorias superiores en niños debe basarse en una historia clínica completa, el uso adecuado de los estudios de laboratorio, y procedimientos diagnósticos que ayuden a identificar las causas más comunes de obstrucción y su interrelación con otras afecciones como: alergia nasal, rinosinusitis y adenoiditis con o sin hipertrofia significativa. Objetivo. Proponer un protocolo de estudio del paciente con obstrucción recurrente de las vías respiratorias utilizado en el Instituto Privado de Alergia, Inmunología y Vías Respiratorias. Material y método. Se estudió en forma prospectiva una cohorte de 117 pacientes en edad pediátrica, con manifestaciones clínicas de obstrucción recurrente de las vías respiratorias superiores. Resultados. El 75 por ciento de los pacientes estudiados tuvieron un patrón histológico sugerente de alergia nasal e infección interecurrente siguiendo el método descrito por A. Jalowayski con el uso de Thinoprobe. Se comprobó que el uso de la radiología convencional para el diagnóstico de hipertrofia-hiperplasia del tejido adenoideo es útil y orienta al diagnóstico primario en 75 por ciento de los pacientes. Conclusiones. El procedimiento endoscópico de las vías aéreas superiores es la prueba más sensible y específica para valorar la situación real del tejido adenoideo y su relación con la cavidad nasal

Manifestaciones otorrinolaringológicas de los pacientes con inmunodeficiencias primarias / Otolaringol symptoms chronic in patients with deficiencies congenital primary

Objetivo. Determinar el flujograma para el diagnóstico oportuno de las inmunodeficiencias congénitas primarias, basado en las manifestaciones otorrinolaringológicas crónicas recurrentes de difícil control, con o sin enfermedades sistémicas asociadas. Material y método. Estudio retrospectivo, descriptivo y observacional que incluyó a pacientes con diagnóstico de inmunodeficiencia primaria conocida. Se revisaron los expedientes clínicos para conocer su evolución y tratamiento médico-quirúrgico. Resultados. Se encontraron 10 pacientes con diagnóstico de algunas inmunodeficiencias primarias; esto se hizo con base en los síntomas infecciosos otorrinolaringológicos crónicos recurrentes de díficil control; fueron seis hombres y cuatro mujeres entre los cuatro y 36 años de edad. Se encontraron las siguientes inmunodeficiencias: una de hiper IgM, tres por IgG, tres comunes variables, un déficit con C3 del complemento, dos de IgA más atopia. Conclusiones. La sinusitis crónica o recurrente y la otitis media crónica o recurrente pueden ser las únicas manifestaciones de un paciente con inmunodeficiencia primaria. La evaluación inmunológica debe incluir, por lo menos: biometría hemática completa con diferencial, niveles séricos de inmunoglobulinas, al igual que subclases de IgG, C4 y C3 del complemento, respuesta a inmunización con proteínas (difteria y tétanos), y antígenos polisacáridos (pneumovax)

Actividad fagocítica de polimorfonucleares en pacientes con hipersensibilidad a la aspirina, asma y pólipos nasales / Phagocytic function in patients with aspirine sensitive asthma and hypertrophy rhinosinusitis with nasal polyps

La eficiencia de la función fagocítica depende de la óptima actividad de cada estadio del proceso fagocítico. Los pacientes con hipersensibilidad a la aspirina, asma, rinosinusitis hipertrófica con pólipos nasales ®triada de la aspirina¼ (pacientes ASA) tienen indicios de defectos en la fagocitosis. Se estudiaron 34 pacientes ASA y 34 sujetos sanos. Las células polimorfonucleares, quimioluminiscencia (CL) de los pacientes ASA se estudiaron in vitro. La actividad fagocítica se midió con la técnica de quimioluminiscencia. No se encontraron diferencias estadísticas con la prueba de U de Mann Whitney (p=NS). No hubo diferencias en la capacidad fagocítica de polimorfonucleares de pacientes ASA y controles sanos. A pesar de los avances de las ciencias básicas, la causa y patogenesis de los pólipos nasales no se ha aclarado, particularmente la tinosinusitis, asma intrínseca y la intolerancia a farmacos no esteroides

Repercusión de las infecciones respiratorias en el asma y procedimientos terapéuticos / Repercution of the breathing infections in asthma and terapeutic proceedings

Con el propósito de evaluar la importancia de las infecciones respiratorias en el asma se hace una revisión epidemiológica de las infecciones respiratorias virales que afectan más a los niños y de las bacterianas con un menor grado de afección. Se hace una revisión de las sinusitis que tienen mayor repercusión en los adultos; además, se revisa la implicación que puede tener Chlamydia pneumoniae en niños y adultos y la demostración de que ésta exacerba los cuadros de asma. Por otro lado, se presentan las aplicaciones terapéuticas para controlar la hiperreactividad bronquial relacionada con estas infecciones que provocan asma