SEARCH

SEARCH BY CITATION

Keywords:

  • cypress pollen;
  • intermittent allergic rhinitis;
  • leucotriene C4;
  • nasal provocation test;
  • sinus tomodensitometry;
  • sinusitis

Abstract

  1. Top of page
  2. Abstract
  3. Material and methods
  4. Patient characteristics
  5. Cypress pollen extract
  6. Nasal provocation tests
  7. Nasal lavage and titration of mediators in nasal secretion
  8. Tomodensitometry of the paranasal sinuses
  9. Design of the study and statistical methods
  10. Results
  11. Sinus CT-scan analysis
  12. Clinical observations
  13. Mediator levels in nasal lavages
  14. Discussion
  15. Acknowledgments
  16. References

Background:  Involvement of paranasal sinuses has been suggested in allergic rhinitis but not clearly demonstrated.

Aims:  To investigate the relationship between intermittent allergic rhinitis and computerized tomography (CT).

Methods:  Twenty patients with intermittent rhinitis and sensitized to cypress pollens underwent unilateral nasal provocation tests (NPTs) using increasing concentrations of cypress pollens out of the pollen season. Sinus CT-scans were carried out just before a NPT and 24 h later. Nasal lavage was carried out just before a NPT, 30 min after a positive challenge and again 24 h later. Leucotriene C4/D4, intracellular adhesion molecule-1 and eosinophil cationic protein were measured in nasal secretions.

Results:  Thirteen patients (65%) showed an alteration in their CT-scans after allergen challenge. Ten of them showed sinus changes controlateral to their allergenic provocation. Radiological changes mainly affected the osteomeatal complex and the ethmoid sinuses. Pre-existing abnormalities (13 of 20 cases) mainly concerned the maxillary sinuses. There was no correlation between CT-scan abnormalities and levels of mediators released in nasal secretions.

Conclusions:  We have shown that nasal allergen challenge can produce radiological changes in the paranasal sinuses. This mainly concerned the ethmoid sinuses.

Abbreviations:
ECP

eosinophil cationic protein

LTC4

leucotriene C4

NPT

nasal provocation test

The relationship between the nose and the sinuses has been established in viral inflammation (1). In this study, 27 of 31 subjects with computerized tomography (CT)-scans 2–3 days after a common cold had abnormalities of one or both maxillary-sinus cavities and 24 had occlusion of the ethmoid infundibulum. In this context, it is usual to consider rhinosinusitis in the same entity. In allergic rhinitics, sinus involvement when they are exposed to allergens was not proven until 1990 (2). Using standard radiography, the authors found that after an allergen nasal provocation test (NPT), the maxillary sinuses were modified. During the pollen season an involvement of sinuses has been suggested using CT-scans (3). Moreover, in a large paediatric survey, allergic rhinitis was the number one risk factor of physician-diagnosed sinusitis in 8-year-old children (4). Finally, amongst the risk factors of severe chronic sinusitis, proved by extensive CT-scan abnormalities and resistance to medical treatment leading to ENT surgery, elevated specific immunoglobulin E and allergic rhinitis have been demonstrated (5).

Obviously, sinus X rays are insufficient for the diagnosis of sinusitis, in particular for ethmoid sinuses (6, 7). Moreover, no study has ever put together an homogeneous population of patients suffering from intermittent allergic rhinoconjunctivitis and sensitized to the same aeroallergen in order to evaluate the sinus CT-scan changes 24 h after allergen NPT.

This is why we have designed a prospective study with the following specific aims: first, using CT-scans we attempted to demonstrate, that NPTs with cypress allergen can induce nasal and sinus CT-scan abnormalities, and to specify the site of sinus involvement. Secondly, we analysed whether there was a link between the CT-scan changes that take place 24 h after a specific NPT and the level in the nasal lavages of some of the mediators of the allergic inflammation.

For this purpose, 20 patients, allergic to cypress pollen and suffering from intermittent rhinoconjunctivitis, underwent NPTs outside of the pollen season.

Patient characteristics

  1. Top of page
  2. Abstract
  3. Material and methods
  4. Patient characteristics
  5. Cypress pollen extract
  6. Nasal provocation tests
  7. Nasal lavage and titration of mediators in nasal secretion
  8. Tomodensitometry of the paranasal sinuses
  9. Design of the study and statistical methods
  10. Results
  11. Sinus CT-scan analysis
  12. Clinical observations
  13. Mediator levels in nasal lavages
  14. Discussion
  15. Acknowledgments
  16. References

Twenty patients aged between 17 and 47 years (10 men and 10 women) entered the study. For at least 2 years, all of the patients had been suffering from intermittent rhinoconjunctivitis between January and March during the peak of the cypress pollen season. Although some patients were sensitized to other allergens, they did not have persistent rhinitis as defined by allergic rhinitis and its impact on asthma (6). They had a positive skin prick test with cypress pollen extract, as described elsewhere (8, 9), a positive Basotest® (Beckton Dickinson, Pont'de Claix, France) to cypress pollen (8) and anti-Cupressus sempervirens serum immunoglobulin (Ig)E levels (Pharmacia, Uppsala, Sweden). None of the patients showed signs of asthma, and their spirometric values were normal. None of these patients had had any previous ENT surgery. Five nonallergic subjects who did not suffer from rhinitis were used as a control group. All subjects underwent anterior rhinoscopy to exclude any anatomical cause of nasal obstruction, including nasal polyposis.

Patients were informed and had given their written consent.

Cypress pollen extract

  1. Top of page
  2. Abstract
  3. Material and methods
  4. Patient characteristics
  5. Cypress pollen extract
  6. Nasal provocation tests
  7. Nasal lavage and titration of mediators in nasal secretion
  8. Tomodensitometry of the paranasal sinuses
  9. Design of the study and statistical methods
  10. Results
  11. Sinus CT-scan analysis
  12. Clinical observations
  13. Mediator levels in nasal lavages
  14. Discussion
  15. Acknowledgments
  16. References

The cypress pollen extract was not standardized because it seems that the amount of proteins released by C. sempervirens, the major cypress tree of the Montpellier area, is insufficient for a reproducible standardization. As it is of paramount importance to use reproducible materials for nasal challenge, we used lyophilized vials from the same batch (Stallergènes SA, Antony, France). Nonstandardized extracts of cypress pollen (C. sempervirens) (1 : 10 weight-by-volume) were prepared according to the proposals of the Allergen Subcommittee of the International Union of Immunology Societies (previously described) (8, 9). The same extract was lyophilized in different batches, which were reconstituted each test day.

Nasal provocation tests

  1. Top of page
  2. Abstract
  3. Material and methods
  4. Patient characteristics
  5. Cypress pollen extract
  6. Nasal provocation tests
  7. Nasal lavage and titration of mediators in nasal secretion
  8. Tomodensitometry of the paranasal sinuses
  9. Design of the study and statistical methods
  10. Results
  11. Sinus CT-scan analysis
  12. Clinical observations
  13. Mediator levels in nasal lavages
  14. Discussion
  15. Acknowledgments
  16. References

We used a method previously described in detail (8, 9). Briefly, a new vial of the lyophilized cypress pollen extract was reconstituted every test day and five threefold increasing concentrations of the extract (1.2–100 IR) were insufflated into the right nostril using a pump. This was repeated every 15 min until a cumulative symptom score of at least seven was obtained (10).

Nasal lavage and titration of mediators in nasal secretion

  1. Top of page
  2. Abstract
  3. Material and methods
  4. Patient characteristics
  5. Cypress pollen extract
  6. Nasal provocation tests
  7. Nasal lavage and titration of mediators in nasal secretion
  8. Tomodensitometry of the paranasal sinuses
  9. Design of the study and statistical methods
  10. Results
  11. Sinus CT-scan analysis
  12. Clinical observations
  13. Mediator levels in nasal lavages
  14. Discussion
  15. Acknowledgments
  16. References

Nasal lavage and the measurement of mediators were carried out as previously described in detail (10). Mediators were measured before challenge, 30 min after a positive challenge and again 24 h later. Eosinophil cationic protein (ECP) was titrated by a double antibody radioimmunoassay (Pharmacia Diagnostics AB, Uppsala, Sweden). Levels under 2 μg/l are undetectable. The leucotriene C4 (LTC4)/D4 was assayed by enzyme immunoassay using a commercially available kit (Stallergénes). Soluble intracellular adhesion molecule (ICAM)-1 was measured using a commercially available enzyme-linked immunosorbent assay kit (Genzyme, Cambridge, MA). The limit of detection is 0.5 ng/ml.

Tomodensitometry of the paranasal sinuses

  1. Top of page
  2. Abstract
  3. Material and methods
  4. Patient characteristics
  5. Cypress pollen extract
  6. Nasal provocation tests
  7. Nasal lavage and titration of mediators in nasal secretion
  8. Tomodensitometry of the paranasal sinuses
  9. Design of the study and statistical methods
  10. Results
  11. Sinus CT-scan analysis
  12. Clinical observations
  13. Mediator levels in nasal lavages
  14. Discussion
  15. Acknowledgments
  16. References

Paranasal sinuses were analysed before NPTs and 24 h after using 18–22 coronal planes in contiguous 3 mm slides without injection of radiocontrast media. Two examiners blindly analysed each sinus CT-scan and a semi-quantitative score was established using two methods previously described (11, 12). This method accounts for (i) right and left osteomeatal complexes (from 0, normal to 2, blocked) (11) and (ii) abnormal surface area of the sinus mucosa (from 0, normal to 4, 100% involved for each of the seven sinus areas: frontal, maxillary, ethmoid left and right and sphenoid) (12). The maximal total score is 32.

Design of the study and statistical methods

  1. Top of page
  2. Abstract
  3. Material and methods
  4. Patient characteristics
  5. Cypress pollen extract
  6. Nasal provocation tests
  7. Nasal lavage and titration of mediators in nasal secretion
  8. Tomodensitometry of the paranasal sinuses
  9. Design of the study and statistical methods
  10. Results
  11. Sinus CT-scan analysis
  12. Clinical observations
  13. Mediator levels in nasal lavages
  14. Discussion
  15. Acknowledgments
  16. References

In this prospective study, two sinus CT-scans were carried out before and 24 h after a unilateral NPT using an extract of cypress pollen. This study took place during the summer, well out of the cypress pollen season and when the patients were showing no other symptoms and had stopped all treatment for at least 1 month.

Results are expressed in medians and 25–75th percentiles. All statistical comparisons were performed using nonparametric tests. The Mann–Whitney U-test was used for unpaired data and the Wilcoxon signed rank test for paired data.

Sinus CT-scan analysis

  1. Top of page
  2. Abstract
  3. Material and methods
  4. Patient characteristics
  5. Cypress pollen extract
  6. Nasal provocation tests
  7. Nasal lavage and titration of mediators in nasal secretion
  8. Tomodensitometry of the paranasal sinuses
  9. Design of the study and statistical methods
  10. Results
  11. Sinus CT-scan analysis
  12. Clinical observations
  13. Mediator levels in nasal lavages
  14. Discussion
  15. Acknowledgments
  16. References

Using a control group of three patients with intermittent rhinitis who were not sensitized to cypress pollen, we first proved that NPTs do not induce CT-scan changes after 24 h (data not shown). Moreover, none of the five controls had CT-scan changes after cypress pollen NPTs.

All the patients had a positive NPT with cypress pollens. Sinus CT-scan changes 24 h after a specific NPT enabled us to divide our 20 patients into two groups: seven patients did not show any visible changes and made up group I, whereas six patients developed abnormalities of the sinus cavities and seven others showed a worsening of pre-existing abnormalities. These 13 patients (65% of the cases) made up group II (Table 1).

Table 1.  Patients’ characteristics: Group I refers to the rhinitic patients showing no CT-scan change 24 h after cypress pollen nasal provocation test and Group II to those showing CT-scan changes
 Group IGroup II
  1. * Median (25–75th percentiles).

  2. † P < 0.05.

  3. CT, computerized tomography; M, male; F, female; IgE, immunoglobulin E; ECP, eosinophil cationic protein; LTC4, leucotriene C4; ICAM, intracellular adhesion molecule.

Sinus CT-scan changes at 24 hoursnoyes
Number of patients713
Sex ratio M/F1/69/4
Age (years)*†39 (38–46)25 (23–33)
Monosensitized to cypress pollen1/73/13
Blood eosinophilia (%)*†3.2 (2.5–4.2)1.8 (1.3–2.7)
Total serum IgE (kU/l)*120 (79–292)140 (73–291)
Detectable ECP at baseline0/74/13
Detectable soluble ICAM-1 at baseline0/72/13
Basal LTC4 (pg/ml)*8.9 (8.0–9.9)9.5 (7.4–11.9)

Radiological abnormalities already existed in 13 of the 20 cases, in six of seven in group I and in seven of 13 in group II. Before the NPT, the maxillary sinuses were affected the most often (10 of 13), followed by the ethmoid (five of 13) and the frontal sinuses (two of 13). Only one of 13 cases presented abnormalities of the sphenoid sinus. The CT-scan scores ranged from 1 to 27 [6 (2–21)], with no difference between group I and group II.

After the NPT, sinus CT-scan changes (group II) concerned the osteomeatal complex 12 times of 13. The osteomeatal complex was constantly affected in the patients who did not show any pre-existing CT-scan abnormalities (Table 2), and in three cases, this was the only abnormality. The changes were observed mainly in the anterior ethmoid sinus (eight of 13). Changes took place three times in the maxillary sinuses and in these three cases, pre-existing abnormalities were present and worsened. The frontal sinuses were never involved. The controlateral sinuses were involved in 10 of 13 patients (four of seven with pre-existing lesions and six of six without) and concerned mainly the anterior ethmoid sinus (Table 2). The CT-scan scores after a NPT ranged from 2 to 31, with a clear difference between the group with pre-existing sinus abnormalities [14 (7–21)] and the group without [6.5 (4–9), P < 0.01].

Table 2.  Localization of sinus CT-scan changes and some clinical patterns of the patients showing CT-scan changes 24 h after cypress pollen nasal provocation test (group II)
 Pre-existing sinus abnormalitiesNo pre-existing sinus abnormalities
  1. * Median (25–75th percentiles).

  2. † P < 0.01.

  3. CT, computerized tomography; M, male; F, female; NPT, nasal provocation test.

Number of patients 7/13 6/13
Age (years)*23 (21–32)26 (24–38)
Sex ratio M/F 5/2 4/2
Total CT-scan score†14 (7–21) 6.5 (4–9)
Ipsilateral sinus involvement
 Osteomeatal complex 6/7 6/6
 Ethmoid 5/7 3/6
 Maxillary 3/7 0/6
 Sphenoid 1/7 0/6
 Frontal 0/7 0/6
Controlateral sinus involvement 4/7 6/6
Bilateral nasal obstruction 4/7 1/6
Pain after NPT
  Headache 2/7 1/6
  Ear pain 0/7 0/6

Clinical observations

  1. Top of page
  2. Abstract
  3. Material and methods
  4. Patient characteristics
  5. Cypress pollen extract
  6. Nasal provocation tests
  7. Nasal lavage and titration of mediators in nasal secretion
  8. Tomodensitometry of the paranasal sinuses
  9. Design of the study and statistical methods
  10. Results
  11. Sinus CT-scan analysis
  12. Clinical observations
  13. Mediator levels in nasal lavages
  14. Discussion
  15. Acknowledgments
  16. References

The symptomatic clinical score of 7 was reached with different concentrations depending on the patient's group. Patients with sinus CT-scan changes after a NPT (group II) reacted to lower allergen concentrations. In group I, five of the seven patients reached this score with concentrations >33.3 IR as opposed to seven of 13 in group II. Control subjects did not react at all, even after the maximal 100 IR concentration.

In group I, two of seven patients ended up with complete nasal obstruction of both nostrils after the NPT as opposed to five of 13 in group II. Among these five patients from group II, four had pre-existing CT-scan abnormalities (Table 2).

Three patients suffered from a headache 24 h after the NPT. All were in group II and showed sinus CT-scan changes of the ethmoid sinus (Table 2).

Mediator levels in nasal lavages

  1. Top of page
  2. Abstract
  3. Material and methods
  4. Patient characteristics
  5. Cypress pollen extract
  6. Nasal provocation tests
  7. Nasal lavage and titration of mediators in nasal secretion
  8. Tomodensitometry of the paranasal sinuses
  9. Design of the study and statistical methods
  10. Results
  11. Sinus CT-scan analysis
  12. Clinical observations
  13. Mediator levels in nasal lavages
  14. Discussion
  15. Acknowledgments
  16. References

Peripheral blood eosinophil counts were greater in patients from group I [3.2% (2.5–4.2)] as opposed to patients from group II [1.8% (1.3–2.7)] (P < 0.05, Table 1). Serum total IgE levels were similar in both groups (Table 1). These two biological abnormalities were in fact associated with the existence of pre-existing CT-scan abnormalities where blood eosinophils [2.8 (1.9–5.1)%] and total IgE [234 (114–470) kU/l] were greater as compared with patients for whom sinus CT-scans prior to NPT were normal [blood eosinophils 1.4 (0.8–2.8)%, total IgE 90 (54–116) kU/l; P < 0.05].

Before NPTs, the ECP and soluble ICAM-1 levels in nasal lavages were detected in only four and two patients of group II respectively (Table 1). After the NPT, the detection of ECP and ICAM-1 was too inconsistent to enable any analysis (data not shown). The LTC4/D4 was the only measurable mediator in the three nasal lavages of each patient (Fig. 1). There were no significant differences between groups I and II in LTC4/D4 levels at the three time periods. At peak symptomatic reaction, LTC4/D4 levels in both groups increased significantly as compared with levels before NPT (P < 0.03 and <0.002 in groups I and II respectively). In patients with pre-existing sinusitis, the LTC4/D4 levels differed significantly (P < 0.01) only at peak symptomatic reaction, with a greater level [32 (11–78) pg/ml] as compared with the one in patients for whom sinus CT-scans prior to NPT were normal [16.3 (13.8–32.5) pg/ml].

image

Figure 1. Leucotriene C4 levels (median, 25–75th percentiles) in the nasal lavages before [prenasal provocation test (NPT)], 30 min after a positive challenge (peak-NPT) and 24 h (24h-NPT) after cypress pollen NPT in rhinitic patients showing no computerized tomography (CT)-scan change 24 h after NPT (group I, n = 7) or showing CT-scan changes (group II, n = 13). *P < 0.03 from pre-NPT values; **P < 0.002 from pre-NPT-values; †P < 0.04 from peak-NPT; +P > 0.05 from pre-NPT values.

Download figure to PowerPoint

Discussion

  1. Top of page
  2. Abstract
  3. Material and methods
  4. Patient characteristics
  5. Cypress pollen extract
  6. Nasal provocation tests
  7. Nasal lavage and titration of mediators in nasal secretion
  8. Tomodensitometry of the paranasal sinuses
  9. Design of the study and statistical methods
  10. Results
  11. Sinus CT-scan analysis
  12. Clinical observations
  13. Mediator levels in nasal lavages
  14. Discussion
  15. Acknowledgments
  16. References

In the present study, we have been able to detect ‘radiological sinusitis’ (six patients) or a worsening of pre-existing ‘radiological sinusitis’ (seven patients) in two-thirds of our patients 24 h after a cypress pollen NPT. This study suggests that nasal allergen challenge results in new or worsening abnormalities on CT-scans. However, changes on CT-scan of mucosal thickening does not necessary mean that patients have sinusitis. Moreover, in our series, radiological sinus changes were not constant (13 of 20): seven of 20 cases did not show any changes after an allergen NPT. They were older, had more frequent pre-existing radiological abnormalities (six of seven), more frequent hypereosinophilia and an increase in total serum IgE levels. In 40 persistent rhinitis patients, one study has already used sinus CT-scans to show an increased frequency of sinusitis when compared with 30 control subjects (13). Another prospective study (3) involved 10 rhinitis patients sensitized to ragweed during the pollen season. A sinus CT-scan showed that six of these patients had a thickening of the mucosa of the ethmoid sinus. In five of these patients who underwent a second CT-scan, this did not disappear after treatment with beclomethasone, although the patients did feel better. The authors concluded that sinus involvement did not participate to the symptoms and/or that the sinus inflammation may not be intense enough (3). The CT-scan findings in patients with chronic rhinosinusitis remain consistent over time (14). However, there may be nonspecific mucosal CT-scan abnormalities in 17–42% asymptomatic patients scanned during nonsinus evaluations (including head injuries, seizures and intraorbital diseases) (15–18). Therefore, having a CT-scan before and after an NPT was mandatory. Moreover, the clinical relevance of CT-scan findings is not straightforward (3).

The radiological changes observed after a NPT concerned more often (eight of 13) the anterior ethmoid sinus and the osteomeatal complex (12 of 13). After 24 h, we also observed three isolated cases of osteomeatal complex abnormalities. On the contrary, the pre-existing radiological abnormalities in the 12 patients (six in each group) involved the maxillary sinuses (10 of 13 cases) more so than the ethmoid sinuses (five of 13). This seems to confirm the main pathophysiological role of the ethmoid sinuses as regards the maxillary sinuses in the late-phase reaction following allergen challenge. It also confirms that a late-phase allergic reaction in the ethmoidal sinuses is associated with a more severe clinical expression. The ethmoid sinuses may be anatomically the first exposed elements when there is a change in allergenic exposure. On the contrary, repeated allergenic exposures may provoke a progressive extension of radiological changes towards other sinuses.

One of the possible drawbacks of our study is that we used allergen extracts in a soluble form whereas natural exposure is by pollen grains. Thus, it may be postulated that the allergen in solution can enter the sinus cavities whereas pollen grains are unable to do so (19). However, as there has been a bilateral sinus involvement in many patients and NPTs were performed on a single nostril, one can rule out this drawback. Patients were challenged with a different dose of allergen based on rhinitis symptoms and patients with sinus CT-scan changes after NPT reacted to lower allergen concentrations. Another option would have been to give all subjects one fixed (high) dose. This may have given better comparisons between the subjects.

In 10 of 13 cases (77%), the radiological changes were bilateral. One likely mechanism of controlateral changes is the nociceptive nerve axone reflex. C-fibres, present in ethmoid sinus but not in maxillary sinuses (20–22), might be stimulated by the local release of histamine (and also of bradykinin and serotonin). Their stimulation then leads to a nociceptive nerve axone reflex responsible for the release of acetylcholine (leading to mucosecretion via the M3 receptors), nitric oxide, substance P and vasoactive intestinal peptide (vasodilatation) (23) but also of histamine (24) and prostaglandin D2 (25). These last notions are yet to be confirmed. Finally, connections to several superior nervous centres are responsible for coughing and sneezing (23, 26). Another hypothesis is the bilateral recruitment, from the bone-marrow, of circulating inflammatory cells, following unilateral stimulation. Other potential mechanisms of the controlateral sinus involvement are less credible. Direct contact with the controlateral sinus mucosa and the allergens via the back of the nostrils is impossible and a regional diffusion of the mediators is anatomically unlikely because of the separation of the right and left nostrils. The role of the dysfunction of the osteomeatal complex gives rise to controversy (27). In our series, isolated osteomeatal complex involvement is found in only three of 13 cases and can be absent at the same time as the presence of radiological changes in ethmoid sinus.

The analysis of the biological markers is in accordance with radiological findings. In the two groups, blood eosinophilia, as well as high total IgE levels were associated with pre-existing radiological abnormalities. This supports recent results which found several risk factors of extensive sinusitis, including higher serum total IgE levels (5, 28) and blood eosinophilia (28). The increase of LTC4 in both patient groups confirms the role of this mediator in the inflammation of intermittent rhinitis. An increased production of LTC4 in nasal lavage has already been observed in subjects presenting with intermittent allergic rhinitis because of ragweed, these levels regaining a normal value after the pollen season (29). The role of LTC4 in the inflammation of intermittent allergic rhinitis is also highlighted by clinical trials showing a superior efficacy in the association of montelukast and loratadine as compared with one of these medications alone (30), and an equal efficacy of this association when compared with inhaled glucocorticosteroids (31).

To conclude, this study seems to differentiate two sub-populations of intermittent rhinitis patients. The first concerns patients without changes after allergen NPT and frequent pre-existing maxillary sinusitis. The second concerns younger patients, reacting with a lower threshold of positive allergen NPTs. After 24 h, these patients show predominant radiological changes in the ethmoidal sinuses whose frequent bilateral character could constitute an indirect experimental proof of the participation of parasympathetic nervous reflexes in intermittent allergic rhinitis. Future therapeutic trials with antileucotrienes or nasal glucocorticosteroids would strengthen these notions using the same patient group design. One other interesting question would be about how long the changes that occur on a CT-scan last and the effects of repeated allergenic exposures on symptoms and prognosis of the disease.

Acknowledgments

  1. Top of page
  2. Abstract
  3. Material and methods
  4. Patient characteristics
  5. Cypress pollen extract
  6. Nasal provocation tests
  7. Nasal lavage and titration of mediators in nasal secretion
  8. Tomodensitometry of the paranasal sinuses
  9. Design of the study and statistical methods
  10. Results
  11. Sinus CT-scan analysis
  12. Clinical observations
  13. Mediator levels in nasal lavages
  14. Discussion
  15. Acknowledgments
  16. References

The authors would like to thank Ms Catherine Devautour, Dr Patricia Bayart-Meyer Zu Reckendorf and Alison Campbell for technical assistance, Anna Bedbrook for manuscript revision and Professor Jean-Michel Klossek (ENT department, University Hospital of Poitiers) for fruitfull discussions.

References

  1. Top of page
  2. Abstract
  3. Material and methods
  4. Patient characteristics
  5. Cypress pollen extract
  6. Nasal provocation tests
  7. Nasal lavage and titration of mediators in nasal secretion
  8. Tomodensitometry of the paranasal sinuses
  9. Design of the study and statistical methods
  10. Results
  11. Sinus CT-scan analysis
  12. Clinical observations
  13. Mediator levels in nasal lavages
  14. Discussion
  15. Acknowledgments
  16. References
  • 1
    Gwaltney JM, Phillips CD, Miller RD, Riker DK. Computed tomographic study of the common cold. N Engl J Med 1994;330: 2530.
  • 2
    Pelikan Z, Pelikan-Filipek M. Role of nasal allergy in chronic maxillary sinusitis. Diagnostic value of nasal challenge with allergen. J Allergy Clin Immunol 1990;86: 484491.
  • 3
    Naclerio RM, DeTineo ML, Baroody FM. Ragweed allergic rhinitis and the paranasal sinuses. A computed tomographic study. Arch Otolaryngol Head Neck Surg 1997;123: 193196.
  • 4
    Lombardi E, Stein RT, Wright AL, Morgan WJ, Martinez FD. The relation between physician-diagnosed sinusitis, asthma, and skin test reactivity to allergens in 8-year-old children. Pediatr Pulmonol 1996;22: 141146.
  • 5
    Baroody FM, Suh S-H, Naclerio RM. Total IgE serum levels correlate with sinus mucosal thickness on computerized tomography scans. J Allergy Clin Immunol 1997;100: 563568.
  • 6
    Bousquet J, van Cauwenberge P, Khaltaev N and the WHO panel. Allergic rhinitis and its impact on asthma. ARIA. In collaboration with the World Health Organization. J Allergy Clin Immunol 2001;108: S147S334.
  • 7
    Kaliner MA, Osguthorpe JD, Fireman P, Anon J, Georgitio J, Davis ML et al. Sinusitis: bench to bedside. J Allergy Clin Immunol 1997;99: S829S848.
  • 8
    Paris-Kohler A, Demoly P, Persi L, Lebel B, Bousquet J, Arnoux B. In vitro diagnosis of cypress pollen allergy by using cytofluorimetric analysis of basophils (Basotest). J Allergy Clin Immunol 2000;105: 339345.
  • 9
    Demoly P, Persi L, Dhivert H, Delire M, Bousquet J. Immunotherapy with KLH-conjugated decapeptide vaccine in cypress pollen allergy. Clin Exp Allergy 2002;32: 10711076.
  • 10
    Lebel B, Bousquet J, Morel A, Chanal I, Godard P, Michel FB. Correlation between symptoms and the threshold for release of mediators in nasal secretions during nasal challenge with grass-pollen grains. J Allergy Clin Immunol 1988;82: 869877.
  • 11
    Lund V, Mackay IS. Staging in rhinosinusitus. Rhinology 1993;31: 183184.
  • 12
    Zinreich SJ, Kennedy DW, Rosenbaum AE, Gayler BW, Kumar AJ, Stammberger H. Paranasal sinuses: CT imaging requirements for endoscopic surgery. Radiology 1987;163: 769775.
  • 13
    Berrettini S, Carabelli A, Sellari-Franceschini S, Bruschiru L, Abruzze A, Quartieri F et al. Perennial allergic rhinitis and chronic sinusitis: correlation with rhinologic risk factors. Allergy 1999;54: 242248.
  • 14
    Bhattacharyya N. Test–retest reliability of computed tomography in the assessment of chronic rhinosinusitis. Laryngoscope 1999;109: 10551058.
  • 15
    Havas TE, Motbey JA, Gullane PJ. Prevalence of incidental abnormalities on computed tomographic scans of the paranasal sinuses. Arch Otolaryngol Head Neck Surg 1988;114: 856859.
  • 16
    Lloyd GA. CT of the paranasal sinuses: study of a control series in relation to endoscopic sinus surgery. J Laryngol Otol 1990;104: 477481.
  • 17
    Bolger WE, Butzin CA, Parsons DS. Paranasal sinus bony anatomic variations and mucosal abnormalities: CT analysis for endoscopic sinus surgery. Laryngoscope 1991;101: 5664.
  • 18
    Jones NS, Strobl A, Holland I. A study of the CT findings in 100 patients with rhinosinusitis and 100 controls. Clin Otolaryngol 1997;22: 4751.
  • 19
    Adkins TN, Goodgold HM, Hendershott L, Slavin RG. Does inhaled pollen enter the sinus cavities? Ann Allergy Asthma Immunol 1998;81: 181184.
  • 20
    Baroody FM, Gungor A, DeTineo M, Haney L, Blair C, Naclerio RM. Comparison of the response to histamine challenge of the nose and the maxillary sinus: effect of loratadine. J Appl Physiol 1999;87: 10381047.
  • 21
    Baroody FM, Ford S, Proud D, Kagey-Sobotka A, Lichtenstein L, Naclerio RM. Relationship between histamine and physiological changes during the early response to nasal antigen provocation. J Appl Physiol 1999;86: 659668.
  • 22
    Tai CF, Baraniuk JN. Upper airway neurogenic mechanisms. Curr Opin Allergy Clin Immunol 2002;2: 1119.
  • 23
    Mosimann BL, White MV, Hohman RJ, Goldrich MS, Kaulbach HC, Kaliner MA. Substance P, calcitonin gene-related peptide, and vasoactive intestinal peptide increase in nasal secretions after allergen challenge in atopic patients. J Allergy Clin Immunol 1993;92: 95104.
  • 24
    Wagenmann M, Baroody FM, Cheng CC, Kagey-Sobotka A, Lichtenstein LM, Naclerio RM. Bilateral increases in histamine after unilateral nasal allergen challenge. Am J Respir Crit Care Med 1997;155: 426431.
  • 25
    Wagenmann M, Baroody FM, Desrosiers M, Hubbard WC, Ford S, Lichtenstein LM et al. Unilateral nasal allergen challenge leads to bilateral release of prostaglandin D2. Clin Exp Allergy 1996;26: 371378.
  • 26
    Undem BJ, Kajekar R, Hunter DD, Myers AC. Neural integration and allergic disease. J Allergy Clin Immunol 2000;106: S213S220.
  • 27
    Melen I, Ivarsson A, Schrewelius C. Ostial function in allergic rhinitis. Acta Otolaryngol Suppl 1992;492: 8285.
  • 28
    Hoover GE, Newman LJ, Platts-Mills TAE, Phillips CD, Gross CW, Wheatley LM et al. Chronic sinusitis: risk factors for extensive disease. J Allergy Clin Immunol 1997;100: 185191.
  • 29
    Volovitz B, Osur SL, Bernstein JM, Ogra PL. Leukotriene C4 release in upper respiratory mucosa during natural exposure to ragweed in ragweed-sensitive children. J Allergy Clin Immunol 1988;82: 414418.
  • 30
    Meltzer EO, Malmstrom K, Lu S, Prenner BM, Wei LX, Weinstein SF et al. Concomitant montelukast and loratadine as treatment for seasonal allergic rhinitis: a randomized, placebo-controlled clinical trial. J Allergy Clin Immunol 2000;105: 917922.
  • 31
    Wilson AM, Orr LC, Sims EJ, Lipworth BJ. Effects of monotherapy with intra-nasal corticosteroid or combined oral histamine and leukotriene receptor antagonists in seasonal allergic rhinitis. Clin Exp Allergy 2001;31: 6168.