Atopy in chronic rhinosinusitis: impact on quality of life outcomes.

BACKGROUND: Chronic rhinosinusitis (CRS), in particular with nasal polyps (CRSwNP), has been linked with skewed T-helper 2 and immunoglobulin E (IgE)-mediated allergic responses. The role of atopy in CRS, however, remains unclear. Correlations between immunological allergic markers and patient-reported outcomes measures (PROMs) were investigated. METHODS: A cross-sectional study of adult patients with CRS undergoing endoscopic sinus surgery was conducted. Immunological allergic markers included automated immunoassay testing for serum-specific IgE to common allergens (house dust mite, grass, mold, animal epithelia) and total IgE. PROMs were assessed using the 22-item Sino-Nasal Outcome Test (SNOT-22). Patients were defined as atopic based on either a positive specific IgE or elevated total IgE (>160 kU/L). RESULTS: A total of 446 patients (45.7% female, age 49.05 ± 14.96 years) were recruited, of which 42.8% had asthma, 51.6% had CRSwNP, and 63.0% had eosinophilic CRS. Positive allergen sensitization was detected in 52.9% patients. Total IgE levels were elevated in 28.0% with mean IgE level of 161 ± 269 kU/L. Atopy was associated with younger age at the time of surgery, CRSwNP, asthma, and eosinophilic CRS (eCRS). Atopy was also associated with increased severity in nasal symptom score (13.1 ± 6.4 vs 11.9 ± 6.0, p = 0.04), as well as worse scores in the loss of smell/taste (χ2 (1) = 5.97, p = 0.02) and need to blow nose (χ2 (1) = 4.26, p = 0.04) questions in the CRS population. In the CRSwNP population, there was no significant association between atopy and PROMs. CONCLUSION: Comorbid atopy in CRS is associated with additional symptom burden, reflected mainly within the nasal symptom quality of life markers. Atopy assessment in CRS is important to ensure appropriate and successful treatment of the disease.

The role of atopy in corneal graft survival in keratoconus.

PURPOSE: To compare the prevalence of endothelial rejection episodes and the probability of graft survival after initial and repeat penetrating keratoplasty (PK) in patients with keratoconus with and without atopy. METHODS: A retrospective review was conducted of all patients receiving PK for keratoconus at the University of Texas Southwestern Medical Center at Dallas from 1988 to 2009. Inclusion criteria involved those with both an International Classification of Diseases-9 code for keratoconus and a Current Procedural Terminology code for PK based on a computer database search. Patients younger than 18 years were excluded. These records were then reviewed for a history of atopic disorders. The main outcome measures included the prevalence of endothelial rejection episodes and the probability of graft survival. The probability of corneal graft survival in patients with and without a history of atopy was compared using the Kaplan-Meier method. RESULTS: There were 168 grafts in 122 patients. There were 66 (39.2%) and 102 (60.8%) grafts with and without a history of atopy, respectively. Bilateral first grafts were required in 32 patients, 14 and 18 patients with and without a history of atopy, respectively. The atopic and nonatopic groups had no significant differences with respect to age, preexisting ocular conditions, concomitant surgical procedures, and length of follow-up. Men received first grafts significantly more frequently than women in the nonatopic group (P = 0.029); however, there was no sex difference in repeat grafts. There were no significant differences in the prevalence of endothelial rejection episodes after the first (P = 0.716), second (P > 0.999), and third or further grafts (P > 0.999). Graft survival between the atopic and nonatopic groups did not differ significantly in the first (P = 0.881), second (P = 0.752), or third or further graft (P = 0.157). Among first grafts in the atopic group, no statistically significant difference in survival existed among patients analyzed with different manifestations of atopy (P = 0.061). One episode of allograft endothelial rejection created a statistically significant difference in ultimate graft survival probability in both the atopic (P = 0.003) and nonatopic (P = 0.002) groups. CONCLUSIONS: Among patients with keratoconus receiving PK, there is no statistically significant difference in the prevalence of endothelial graft rejection episodes or probability of graft survival between patients with and without a clinical history of atopy.

Impact of repeated surgical procedures on the incidence and prevalence of latex allergy: a prospective study of 1263 children.

Assessment with questionnaire, skin tests, and immunoglobulin E measurements showed 6 (0.5%) of 1263 children having elective surgery had latex allergy; 50 (4%) others were latex-sensitized. Any previous operation increased the odds of latex sensitization by 13 times; multiple operations had a less marked effect. All children having surgery may need primary prophylaxis for latex.

Prognosis and prediction of response to surgery in allergic patients with chronic sinusitis.

BACKGROUND: Chronic rhinosinusitis (CRS) occurs frequently in patients with atopy, but little is known of the prognosis after surgery and of factors that may predict a poor outcome. OBJECTIVE: Our purpose was to assess the long-term prognosis in atopic patients with CRS who undergo surgery and whether certain immune markers could predict a worse prognosis in this setting. METHODS: Fifteen patients with diffuse involvement of the sinuses on computed tomographic (CT) scan but without nasal polyposis underwent ethmoidectomy with middle meatotomy for CRS when it was clinically indicated. All patients had a biopsy of the inferior turbinate and of the most inflamed areas of the maxillary and ethmoid sinuses at the time of surgery. Follow-up was performed by video endoscopy and by assessment of 2 chronic sinusitis questionnaires at 0, 6, and 24 months postoperatively. The number of lymphocyte subsets (CD3, CD4, CD8), mast cells and eosinophils, and cells expressing IL-4 and IL-5 messenger RNA (mRNA) in all 3 biopsy sites at the time of surgery were compared with the clinical response after surgery. RESULTS: Seven patients had persistent improvement after surgery, with a decrease in pain, rhinorrhea, or nasal obstruction and a decrease in the need for medication. Eight patients were unchanged or worsened after surgery with disabling rhinorrhea and repeated sinusitis. We found no difference in the number of inflammatory cells, lymphocyte subsets, or IL-4 mRNA-positive cells in the sinus mucosa between responders and nonresponders. However, an increased number of cells expressing IL-5 mRNA was found in the ethmoid sinus at the time of surgery in patients who did not respond to the surgical intervention (P =.007). CONCLUSION: More than 50% of patients with perennial rhinitis and CRS do not improve after surgery, a response that may be predicted by more cells expressing IL-5 mRNA in the ethmoid sinuses. The increased number of cells expressing IL-5 mRNA may have the potential to be used as a marker for prediction of the response to surgery. The worsening of symptoms in some patients with CRS after sinus surgery could be a result of the disturbance of the anatomy of the sinuses and exposure to the environmental allergens.

Treatment of allergic fungal sinusitis: a comparison trial of postoperative immunotherapy with specific fungal antigens.

OBJECTIVE: To determine the effect of immunotherapy (IT) with fungal antigens on clinical outcome in patients with allergic fungal sinusitis (AFS). STUDY DESIGN: Prospective case control. METHODS: In this comparison study, 22 patients meeting the diagnostic criteria of allergic fungal sinusitis (AFS) were evaluated after a mean of 33 months' therapy. All received similar treatment consisting of endoscopic sinus surgery, corticosteroids, and antibiotics as needed for complicating purulent sinusitis. Eleven patients received postoperative immunotherapy (IT) with fungal and nonfungal antigens to which sensitivity had been demonstrated, while the remaining 11 received no immunotherapy. RESULTS: The effect of IT was to significantly improve patient outcome as assessed objectively by an AFS endoscopic mucosal staging system (P < .001) and a sinusitis-specific quality-of-life scale, the Chronic Sinusitis Survey (P = .002). In addition, IT was shown to reduce reliance on systemic (P < .001) and topical nasal (P = .043) corticosteroid therapy to control disease. Follow-up was similar in the two groups and was not a determinant of differences in outcome (P = .7). CONCLUSIONS: Results from this study indicate that specific IT with fungal antigens improves patient outcome in AFS.

Demonstration of the high-affinity IgE receptor (Fc epsilon RI) on Langerhans' cells of diseased nasal mucosa.

Langerhans' cells in the skin have recently been shown to bind IgE molecules via the high-affinity IgE receptor (Fc epsilon RI). Using two highly specific antibodies against the antibody-binding alpha-chain of this receptor, 29C6 and 6F7, we demonstrate by immunohistochemistry and immunoelectron microscopy that Langerhans' cells of diseased nasal mucosa can express the Fc epsilon RI. Tissue sections from hyperplastic nasal conchae and nasal polyps of atopic and nonatopic patients have shown no basic differences in epithelial Fc epsilon RI-bearing cells. Only a few cells expressed the low-affinity IgE receptor (Fc epsilon RII) (Tü1 antibody) in some sections. These findings suggest that Langerhans' cells play an important role in the induction of transepithelial IgE-mediated allergy and in the mediation of inflammation of the nasal mucosa via their Fc epsilon RI.

Mycotic sinusitis.

In recent years, Extramucosal Fungal Sinusitis (EFS) in immunocompetent hosts have aroused increasing interest from both clinicians and pathologists. Histopathologically, they are characterized by the presence of fungal hyphae in the lumen of the sinus with no tissue invasion. They include two different entities: the mycetoma and the atopical fungal sinusitis (AFS). The mycetoma is the most frequent and best recognized form of EFS. The clinical picture is that of a unilateral symptomatic chronic sinusitis, often painful, unresponsive to appropriate medical treatment. CT scanning is very evocative in most cases. Definitive diagnosis requires histological and bacteriological examinations of the sinus contents. Surgery is the treatment of choice. Additional antifungal therapy is not indicated unless there is fungal tissue invasion. AFS is a distinct form of EFS. It typically occurs in an atopic patient with a long story of either chronic sinusitis or recalcitrant nasal polyposis recurring after adequate medical treatment or previous sinus surgery. Histopathologically, the pathognomonic pattern shows an "allergic mucin" and scanty fragmented fungal hyphae. Culture is the only way to identify the causative agent. Management should include wide radical sinus surgery combined with long-term nasal steroids. In spite of proper medico-surgical management, the prognosis remains variable and recurrences frequently arise.

[Effect of splenectomy on the dynamics of allergic symptoms and the level of IgE in the complex treatment of children with liver cirrhosis]. / Vliianie splenektomii na dinamiku allergicheskikh simptomov i uroven' IgE pri kompleksnom lechenii detei s tsirrozom pecheni.

Overall 21 children suffering from active liver cirrhosis were examined for the dynamics of allergic symptoms and IgE before and after splenectomy. The IgE level was measured 2-4 weeks, 3-11 months and 1-5 years after splenectomy. All the children received glucocorticosteroid therapy followed by the administration of maintenance therapy. It has been shown that splenectomy as one of the pathogenetic forms of therapy of active liver cirrhosis produces a decrease in blood IgE and in the incidence of allergic manifestations in addition to the clinical effect and amelioration of liver function.