An open audit of montelukast, a leukotriene receptor antagonist, in nasal polyposis associated with asthma.

BACKGROUND: Nasal polyposis occurs frequently in patients with intrinsic asthma, especially in those who are aspirin sensitive. It can be difficult to treat effectively, even with surgery and regular topical intranasal corticosteroids many patients are still symptomatic. OBJECTIVE: To investigate the response to montelukast, a leukotriene D4 receptor antagonist, as an add-on therapy to topical and inhaled corticosteroids in patients, both aspirin sensitive (AS) and aspirin tolerant (AT), with nasal polyposis and asthma. METHODS: Nasal polyposis symptoms were assessed by visual analogue scales; nasal polyps were assessed by nasendoscopy and via the measurement of nasal volumes by acoustic rhinometry. The nasal airway was assessed by nasal inspiratory peakflow (NIPF). Asthma was monitored using symptom scores and peak expiratory flow measurements. Aspirin sensitivity was assessed by history together with intranasal lysine aspirin challenge. Upper and lower airway nitric oxide measurements were made before and during treatment. RESULTS: Clinical subjective improvement in nasal polyposis occurred in 64% AT (P < 0.01), patients and 50% AS patients (P > 0.05); asthma improvement in 87% AT and 61% AS patients (P < 0.05 for both). Objective changes in peak flow occurred only in AT patients (P < 0.05). Acoustic rhinometry, nasal inspiratory peak flow and nitric oxide levels did not change significantly in any group, however, correlations were seen between nitric oxide levels and polyp scores and between nitric oxide levels and acoustic rhinometry changes. Improvement on montelukast therapy was not associated with any of the following variables: age, sex, skin prick test positivity, disease duration or aspirin sensitivity. (P > 0.05 for all). CONCLUSION: The findings are consistent with a subgroup of nasal polyps/asthma patients in whom leukotriene receptor antagonists are effective. This is not related to aspirin sensitivity. Further placebo-controlled studies need to be undertaken.

Measurement of peak flow in children: a comparison between the low-range mini Wright and the low-range Ferraris pocket peak flow meter.

The new, low-range Ferraris pocket peak flow meter was compared with the well established low-range mini Wright peak flow meter for measuring peak flow rates in children. The peak flow meters were compared by performing three forced expirations using each meter, in 50 children. On average the pocket peak flow meter gave higher readings than the mini Wright, by a mean of 15 l/min. The peak flow rates obtained by the two meters were highly correlated (P < 0.001, r = 0.882 n = 50). In conclusion, the Ferraris pocket peak flow meter is easy and comfortable to use, giving reproducible measurements of peak flow in children.

Intranasal lysine aspirin in recurrent nasal polyposis.

Twenty patients with recurrent nasal polyposis but without any history of aspirin sensitivity were given 2000 micrograms of intranasal lysine aspirin to one nostril and saline to the other once a week for periods of up to 15 months. Two patients had increased nasal obstruction following the initial test doses of lysine aspirin and were excluded from the trial proper. In the remainder symptomatic polyp recurrence was delayed compared with the previous experience while on intranasal steroids, with eight patients remaining symptom free at 15 months compared with an expected number of three (P = < 0.05, chi 2 test). Polyp recurrence was bilateral but there was a tendency for the lysine aspirin treated side to have less polyp tissue as assessed by nasendoscopy and by acoustic rhinometry.

The effect of long-term antibiotic therapy upon ciliary beat frequency in chronic rhinosinusitis.

The mucociliary escalator is the first line of defence of the upper and lower respiratory tracts (Greenstone and Cole, 1985; Sleigh et al., 1988). Failure of mucociliary clearance is associated with chronic or recurrent respiratory tract infection. Ten patients with chronic rhinosinusitis underwent nasal brushings for the assessment of ciliary beat frequency. In two no beating cilia were seen; in the remainder the mean value was 9.3 Hz +/- 2.3; range 6.1-12.8 Hz (n = 8). Following three months continuous oral antibiotic therapy repeat nasal brushings demonstrated increased ciliary beat frequencies in all patients, mean value 13.7 Hz +/- 1.6; range 11.5-16.3 Hz (n = 10); (p < 0.01; paired t-test). Depression of mucociliary clearance can occur secondarily to chronic infection and is improved by prolonged antibiotics.

Effect of short-term treatment with fluticasone propionate nasal spray on the response to nasal allergen challenge.

The aim of the study was to investigate the effect of short-term treatment with fluticasone propionate on the response to nasal allergen challenge in patients with allergic rhinitis. Responses to nasal allergen challenge were assessed subjectively by recording symptom scores on visual analogue scales, and objectively by measuring histamine, PGD2 and LTC4 in nasal lavage and by measuring nasal inspiratory peak flow following challenge. Nasal allergen challenge resulted in an increase in all symptom scores (P < 0.05); an increase in histamine and PGD2 (P < 0.05), and a decrease in nasal inspiratory peak flow at 1 h, 5 h and 7 h following challenge (P < 0.05). The allergen-induced changes in symptom scores, mediator levels and nasal inspiratory peak flow were attenuated by treatment with fluticasone propionate (P < 0.05 for all parameters measured). Post-challenge nasal obstruction was decreased by 45%; sneezing, itching and rhinorrhoea by 73, 78 and 80% respectively in the group as a whole comparing scores whilst on fluticasone propionate with those on no therapy. Fluticasone propionate, 200 micrograms twice daily for 2 weeks is effective in reducing significantly the early and late response to nasal allergen challenge.

Acoustic rhinometry compared with anterior rhinomanometry in the assessment of the response to nasal allergen challenge.

Acoustic rhinometry was used to assess nasal airway patency objectively and was compared with the more established method of anterior rhinomanometry. Ten patients with allergic rhinitis underwent 15 nasal challenges with allergen to which they showed positive skin-prick tests. Responses were assessed by measuring the minimum nasal cross-sectional area (Amin.) using acoustic rhinometry and by measuring nasal airway resistance (NAR) using anterior rhinomanometry. The measurements of Amin. and NAR showed a significant negative correlation. Acoustic rhinometry appears to be superior to anterior rhinomanometry in quantifying the response to nasal allergen challenge and may be particularly useful in patients with initial nasal blockage.

IgG subclass levels in chronic rhinosinusitis.

Sera from seventy-four adult patients with chronic or recurrent rhinosinusitis (mean duration 10.3 years) were tested for levels of total immunoglobulin and IgG subclasses. Fourteen (19%) had low levels of one of the major immunoglobulin classes and 23 (31%) had one or more IgG-subclass deficiencies, i.e. values less than the mean minus 2 standard deviations of a control population sample. Nineteen patients had low IgG3 levels. The group as a whole showed significantly low mean levels of IgG3, 46.9 +/- 19.5 mg/dl compared to 76 +/- 21 mg/dl for the controls, p < 0.0005 (Student's t-test). Since there was no clinical difference between those with and without IgG3 deficiency, there exists the possibility of an underlying immune defect, possibly involving heavy chain switching, in all these patients.

Assessment of nasal obstruction. A comparison between rhinomanometry and nasal inspiratory peak flow.

In several conditions objective assessment of nasal obstruction would be of great value. In this study we have compared two different methods for this purpose. Anterior rhinomanometry is a well established method, which measures nasal airway resistance (NAR). This was compared with nasal inspiratory peak flow (NIPF) measured with a Youlten peak flow meter. The assessments were undertaken in patients with allergic rhinitis, before and after challenge with hyperosmolar saline solution. After challenge there was a fall in NIPF value as a mean of 17.4%, that was mirrored by a rise in NAR of 15.6%. There was also a statistically significant negative linear correlation between these two methods (p less than 0.01). We conclude that NIPF is a cheap, easily performed and quick method suitable for assessing nasal airway patency in e.g. allergics during treatment and during challenge.