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.

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 Ringer's solution. RESULTS: Compared with the lactated Ringer's 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.

Comparison of montelukast and pseudoephedrine in the treatment of allergic rhinitis.

OBJECTIVE: To compare montelukast sodium and pseudoephedrine hydrochloride in the treatment of seasonal allergic rhinitis. DESIGN: A 2-week, parallel, randomized, double-blind study with rolling enrollment. SETTING: Tertiary care medical center. PATIENTS: A total of 58 adult subjects with ragweed allergic rhinitis as documented by positive findings on a skin test to ragweed and history of symptoms during previous seasons. INTERVENTIONS: After recording their own baseline nasal symptoms, nasal peak inspiratory flow (NPIF), and diurnal and nocturnal rhinoconjunctivitis quality of life (QOL) scores, subjects were randomized to receive daily morning oral doses of either pseudoephedrine hydrochloride (240 mg) or montelukast sodium (10 mg) for 2 weeks. They recorded their nasal symptoms and NPIF twice daily during this time, and at the end of the study, they completed another QOL questionnaire and 2 tolerability profiles. MAIN OUTCOME MEASURES: Nasal symptoms, NPIF, QOL scores, and tolerability profiles. RESULTS: Both active treatments resulted in significant improvements from baseline in all symptoms of allergic rhinitis as well as in all the domains of the QOL questionnaires. When changes from baseline were compared between treatments, there were no significant differences except in the symptom of nasal congestion, for which pseudoephedrine was more effective than montelukast. Both treatments resulted in a significant increase in NPIF over baseline with no significant difference between treatments. Both drugs were well tolerated with no differences in the tolerability profiles between treatments. CONCLUSIONS: Pseudoephedrine and montelukast are equivalent in improving symptoms and QOL and increasing nasal airflow in patients with seasonal allergic rhinitis. The lack of the usual adverse effects in the pseudoephedrine group is ascribed to morning dosing.

Relationships between atopy and bacterial infections.

Atopy in its most common forms (asthma, allergic rhinitis, and atopic dermatitis) has a significant impact on society in terms of health care costs and quality of life. Aside from having significant morbidity from these diseases, patients with atopy have also been noted to have a high incidence of comorbidities, including bacterial infections such as otitis media and sinusitis. In this paper, current evidence is reviewed that supports the close associations among allergic rhinitis and the two commonly diagnosed bacterial diseases, otitis media and sinusitis.

Sinusitis update.

PURPOSE OF REVIEW: Rhinosinusitis affects more than 10% of the US population. It results in high health care expenditure as well as decreased productivity through lost days of school or work. This review includes recent findings in diagnostics and pathophysiology, as well as recent advances in treatment. RECENT FINDINGS: Parameters used in the diagnosis of rhinosinusitis include patient symptomatology, physical and endoscopic findings, computed tomography scan scores, and culture results. There has been poor correlation between patient symptoms and computed tomography scan scores, but middle meatal cultures have been shown to correlate well with ethmoid sinus cultures obtained from chronic rhinosinusitis patients. Chronic inflammation with a predominance of eosinophils and T lymphocytes in the tissues is being recognized as a hallmark of chronic rhinosinusitis, especially in patients with asthma or allergic rhinitis. Th2 cytokines are prominent in sinus tissues of patients with chronic rhinosinusitis and allergic rhinitis. While antibiotics are used with greater frequency in the treatment of acute and chronic rhinosinusitis, adjuvant therapies, such as intranasal steroids, might affect patient symptoms and curb disease recurrence. SUMMARY: Clinical symptoms are important in making the diagnosis of rhinosinusitis and should be supported by objective findings on nasal endoscopy and, if necessary, computed tomography scans. The mainstay of treatment remains antibiotics, with a potential role for decongestants and intranasal steroids. The presence of chronic inflammation with a Th2 cytokine predominance in sinus tissues should be kept in mind, especially in patients with coexistent morbidities such as allergic rhinitis and asthma.