- Email: [email protected]
Computed tomographic study of the paranasal sinuses in allergic rhinitis
1130 Leipziget al.
J ALLERGYCLINIMMUNOL DECEMBER 1996
REFERENCES 1. Israili ZH, Hall WD. Cough and angioneurotic edema associated with angiotensin-converting enzyme inhibitor therapy. Ann Intern Med 1992;117:234-42. 2. Dicpinigaitis PV, Dobkin JB. Effect of angiotensin-converting enzyme inhibition on bronchial responsiveness. J Clin Pharmacol 1996;36:361-4. 3. Acker CG, Greenberg A. Angioedema induced by the angiotensin II blocker losartan [letter]. N Engl J Med 1995;333:1572. 4. Package insert. Cozaar (losartan). West Point (PA): Merck & Co., Inc., April 1995.
5. Timmermans PBMWM, Wong PC, Chiu AT, Herblin WF, Benfield P, Carini DJ, et al. Angiotensin II receptors and angiotensin II receptor antagonists. Pharmacol Rev 1993;45: 205-51. 6. Entzeroth M, HadamovskyS. Angiotensin II receptors in the rat lung are of the A II-1 subtype. Eur J Pharmacol 1991;206:237-41. 7. Millar EA, Nally JE, Thomson NC. Angiotensin II potentiates methacholine-induced bronchoconstriction in human airwayboth in vitro and in vivo. Eur Respir J 1995;8:1838-41.
Computed tomographic study of the paranasal sinuses in allergic rhinitis Jeffrey R. Leipzig, MD, David S. Martin, MD, John F. Eisenbeis, MD, and Raymond G. Slavin, MD St. Louis, Mo. In recent years, there has b e e n m u c h interest in the relationship b e t w e e n allergic rhinitis and sinusitis. O n e aspect of sinus disease that still remains undefined is the role of allergic inflamm a t i o n on the sinus mucosa. Clinically, patients can report congestion and discomfort localized to the sinuses during periods of s y m p t o m a t i c allergic rhinitis. O u r g r o u p previously r e p o r t e d that i n f l a m m a t i o n of the sinuses could be detected on single p h o t o n emission c o m p u t e r i z e d t o m o g r a p h y in p u r e allergic rhinitis. 1 T h e ability to d e m o n s t r a t e allergic sinusitis with c o m p u t e d t o m o g r a p h i c (CT) scans during periods o f symptomatic allergic rhinitis would have i m p o r t a n t t h e r a p e u t i c implications. A recent study d e m o n strated a n u m b e r of significant changes in the sinus cavities on C T scan in patients with viral u p p e r respiratory tract infections. 2 T o d e t e r m i n e w h e t h e r allergic rhinitis results in sinus inflamm a t i o n that could be d e t e c t e d by CT scan, we studied adults by using limited CT scans during episodes of s y m p t o m a t i c allergic rhinitis.
METHODS Limited coronal CT scans of the nasal passages, osteomeatal complex, and paranasal sinuses were obFrom the Departments of Internal Medicine, Radiology, and Otolaryngology-Head and Neck Surgery, Saint Louis University School of Medicine. Reprint requests: Raymond G. Slavin, Division of Allergy and Immunology, St. Louis University School of Medicine, 1402 South Grand Blvd., St. Louis, MO 63104. J Allergy Clin Immunol 1996;98:1130-1. Copyright 9 1996 by Mosby-Year Book, Inc. 0091-6749/96 $5.00 + 0 1/54/77596
Abbreviation used
CT:
Computed tomographic
tained for nine atopic subjects before the pollen seasons and when subjects were experiencing symptoms during documented pollen seasons. Subjects were enrolled during successive ragweed and tree or grass pollen seasons in St. Louis between 1994 and 1996. Patients were determined to be allergic by history, physical examination, and allergy skin testing. All CT scans were read in a blinded fashion by a radiologist. All participants signed an informed consent statement, which had been approved by the institutional review board.
RESULTS During the pollen season, all nine patients had symptoms of allergic rhinitis including sneezing, nasal pruritus, rhinorrhea, and nasal congestion. All had markedly swollen, pale nasal turbinates on physical examination. None demonstrated any clinical symptoms of sinusitis. There were several minor incidental findings noted on preseasonal baseline CT scans. One patient had a small (1 m m ) maxillary retention cyst, which remained unchanged as shown on the seasonal CT scan. Another patient had paradoxical turbinates. Septal deviation was identified in five of nine subjects. In six of nine subjects (67%), both the preseasonal and seasonal CT scans demonstrated normal osteomeatal complex and normal lining of the paranasal sinus mucosa. The seasonal CT scans
J ALLERGYCLIN IMMUNOL
Malo et al.
1131
VOLUME 98, NUMBER 6, PART 1
of these six subjects were unchanged from the normal baseline preseasonal CT scans. Two subjects were found to have changes on CT during the study. The most significant finding was bilateral infundibular occlusion, which was observed on the seasonal CT scan in these subjects (Table I). One subject whose preseasonal CT scan was normal, in addition to bilateral infundibular occlusion, also demonstrated several minimal abnormalities in all four paranasal sinuses on the seasonal CT scan. This patient's seasonal CT scan showed a 3 mm thickening of the right frontal sinus, 2 to 3 mm thickening of the right ethmoidal sinus, and a 1 mm thickening of the left ethmoidal sinus. The second patient with bilateral infundibular occlusion on seasonal CT scan had a preseasonal CT scan that demonstrated a large leftsided septal deviation with resultant occlusion of the ipsilateral infundibulum. The patient also had bilateral ethmoidal opacification, a 3 mm thickening on the left maxillary sinus, a 2 mm thickening of the sphenoidal sinus, and 1 to 2 mm thickening of the right frontal sinus as shown on the preseasonal CT scan. This same patient's seasonal CT scan demonstrated bilateral infundibular occlusion with a new 3 mm thickening of the right maxillary sinus, along with the same findings seen on the preseasonal CT scan. In one subject minimal mucosal changes were noted in the sinuses on preseasonal and seasonal CT scans. This patient's series of CT scans demonstrated a normal osteomeatal complex with normal lining of frontal and sphenoidal sinuses; however, the ethmoidal sinuses revealed 1 to 2 mm thickening, and maxillary sinuses showed 3 mm of mucosal thickening. These findings remained essentially unchanged during periods of symptomatic allergic rhinitis. DISCUSSION
In contrast to a recent report indicating that viral upper respiratory tract infections resulted in development of occlusion of the infundibulum in 77% of subjects and in development of abnormalities of one or both maxillary sinuses in 87% of subjects, as determined by CT scan, 2 our study of patients with symptomatic allergic rhinitis demonstrated infrequent and minimal changes in the sinuses during natural seasonal exposure. Only two of nine (22%) patients with symptomatic allergic rhinitis demonstrated any significant interval changes on sinus CT scans. These two patients had bilateral infundibular occlusion and minimal sinus mucosal thickening. Contrary to our previous work on allergic inflammation of the paranasal sinuses, which demonstrated
TABLE I. CT f i n d i n g s in n i n e a d u l t s w i t h allergic rhinitis
Site
Nasal passages Septal deviation Engorged turbinates Thickened nasal wall Osteomeatal complex Infraorbital cells Right Left Concha bullosa Right Left Infundibular occlusion Right Left
No. of patients (%)
5/9 (55%) 2/9 (22%)* 0/9
2/9 (22%) 2/9 (22%) 3/9 (33%) 4/9 (43%) 2/9 (22%)* 2/9 (22%)*
*Abnormalitynot present in baseline CT scan study.
increased blood flow on single photon emisssion CT scan, 1 the presence of allergic inflammation of the sinuses cannot be reliably verified by limited coronal CT scan of the sinuses in patients with symptomatic allergic rhinitis. With radiographic imaging, one could only speculate as to the exact pathophysiology occurring within the paranasal sinuses; however, if allergic T m cytokine profiles for IL-4 and IL-5 were obtained from the paranasal sinuses during a patient's most symptomatic period, one might be able to demonstrate markers of an allergic reaction in the microenvironment. The incidental findings noted on CT scan in this study were no greater than those of previous studies? This study, though limited in size, suggests a different radiographic appearance on limited CT scans between allergic rhinitis and viral upper respiratory tract infections, which has not been reported in the literature to date. In summary, we were unable to demonstrate any sinus inflammation that could be detected by limited computerized tomography in patients with symptomatic allergic rhinitis. REFERENCES
1. Slavin RG, ZillioxAP, Samuels LD. Is there such an entity as allergic sinusitis? [abstract]. J Allergy Clin Immunol 1988;81:284. 2. GwaltneyJM, Phillips CD, Miller RD, Riker DK. Computed tomographic study of the common cold. N Engl J Med 1994;330:25-30. 3. Calhoun KH, Waggenspack GA, Simpson B, Hokanson JA, Bailey BJ. CT evaluation of the paranasal sinuses in symptomatic and asymptomatic populations. Otolaryngol Head Neck Surg 1991;104:480-3.
J ALLERGYCLINIMMUNOL DECEMBER 1996
REFERENCES 1. Israili ZH, Hall WD. Cough and angioneurotic edema associated with angiotensin-converting enzyme inhibitor therapy. Ann Intern Med 1992;117:234-42. 2. Dicpinigaitis PV, Dobkin JB. Effect of angiotensin-converting enzyme inhibition on bronchial responsiveness. J Clin Pharmacol 1996;36:361-4. 3. Acker CG, Greenberg A. Angioedema induced by the angiotensin II blocker losartan [letter]. N Engl J Med 1995;333:1572. 4. Package insert. Cozaar (losartan). West Point (PA): Merck & Co., Inc., April 1995.
5. Timmermans PBMWM, Wong PC, Chiu AT, Herblin WF, Benfield P, Carini DJ, et al. Angiotensin II receptors and angiotensin II receptor antagonists. Pharmacol Rev 1993;45: 205-51. 6. Entzeroth M, HadamovskyS. Angiotensin II receptors in the rat lung are of the A II-1 subtype. Eur J Pharmacol 1991;206:237-41. 7. Millar EA, Nally JE, Thomson NC. Angiotensin II potentiates methacholine-induced bronchoconstriction in human airwayboth in vitro and in vivo. Eur Respir J 1995;8:1838-41.
Computed tomographic study of the paranasal sinuses in allergic rhinitis Jeffrey R. Leipzig, MD, David S. Martin, MD, John F. Eisenbeis, MD, and Raymond G. Slavin, MD St. Louis, Mo. In recent years, there has b e e n m u c h interest in the relationship b e t w e e n allergic rhinitis and sinusitis. O n e aspect of sinus disease that still remains undefined is the role of allergic inflamm a t i o n on the sinus mucosa. Clinically, patients can report congestion and discomfort localized to the sinuses during periods of s y m p t o m a t i c allergic rhinitis. O u r g r o u p previously r e p o r t e d that i n f l a m m a t i o n of the sinuses could be detected on single p h o t o n emission c o m p u t e r i z e d t o m o g r a p h y in p u r e allergic rhinitis. 1 T h e ability to d e m o n s t r a t e allergic sinusitis with c o m p u t e d t o m o g r a p h i c (CT) scans during periods o f symptomatic allergic rhinitis would have i m p o r t a n t t h e r a p e u t i c implications. A recent study d e m o n strated a n u m b e r of significant changes in the sinus cavities on C T scan in patients with viral u p p e r respiratory tract infections. 2 T o d e t e r m i n e w h e t h e r allergic rhinitis results in sinus inflamm a t i o n that could be d e t e c t e d by CT scan, we studied adults by using limited CT scans during episodes of s y m p t o m a t i c allergic rhinitis.
METHODS Limited coronal CT scans of the nasal passages, osteomeatal complex, and paranasal sinuses were obFrom the Departments of Internal Medicine, Radiology, and Otolaryngology-Head and Neck Surgery, Saint Louis University School of Medicine. Reprint requests: Raymond G. Slavin, Division of Allergy and Immunology, St. Louis University School of Medicine, 1402 South Grand Blvd., St. Louis, MO 63104. J Allergy Clin Immunol 1996;98:1130-1. Copyright 9 1996 by Mosby-Year Book, Inc. 0091-6749/96 $5.00 + 0 1/54/77596
Abbreviation used
CT:
Computed tomographic
tained for nine atopic subjects before the pollen seasons and when subjects were experiencing symptoms during documented pollen seasons. Subjects were enrolled during successive ragweed and tree or grass pollen seasons in St. Louis between 1994 and 1996. Patients were determined to be allergic by history, physical examination, and allergy skin testing. All CT scans were read in a blinded fashion by a radiologist. All participants signed an informed consent statement, which had been approved by the institutional review board.
RESULTS During the pollen season, all nine patients had symptoms of allergic rhinitis including sneezing, nasal pruritus, rhinorrhea, and nasal congestion. All had markedly swollen, pale nasal turbinates on physical examination. None demonstrated any clinical symptoms of sinusitis. There were several minor incidental findings noted on preseasonal baseline CT scans. One patient had a small (1 m m ) maxillary retention cyst, which remained unchanged as shown on the seasonal CT scan. Another patient had paradoxical turbinates. Septal deviation was identified in five of nine subjects. In six of nine subjects (67%), both the preseasonal and seasonal CT scans demonstrated normal osteomeatal complex and normal lining of the paranasal sinus mucosa. The seasonal CT scans
J ALLERGYCLIN IMMUNOL
Malo et al.
1131
VOLUME 98, NUMBER 6, PART 1
of these six subjects were unchanged from the normal baseline preseasonal CT scans. Two subjects were found to have changes on CT during the study. The most significant finding was bilateral infundibular occlusion, which was observed on the seasonal CT scan in these subjects (Table I). One subject whose preseasonal CT scan was normal, in addition to bilateral infundibular occlusion, also demonstrated several minimal abnormalities in all four paranasal sinuses on the seasonal CT scan. This patient's seasonal CT scan showed a 3 mm thickening of the right frontal sinus, 2 to 3 mm thickening of the right ethmoidal sinus, and a 1 mm thickening of the left ethmoidal sinus. The second patient with bilateral infundibular occlusion on seasonal CT scan had a preseasonal CT scan that demonstrated a large leftsided septal deviation with resultant occlusion of the ipsilateral infundibulum. The patient also had bilateral ethmoidal opacification, a 3 mm thickening on the left maxillary sinus, a 2 mm thickening of the sphenoidal sinus, and 1 to 2 mm thickening of the right frontal sinus as shown on the preseasonal CT scan. This same patient's seasonal CT scan demonstrated bilateral infundibular occlusion with a new 3 mm thickening of the right maxillary sinus, along with the same findings seen on the preseasonal CT scan. In one subject minimal mucosal changes were noted in the sinuses on preseasonal and seasonal CT scans. This patient's series of CT scans demonstrated a normal osteomeatal complex with normal lining of frontal and sphenoidal sinuses; however, the ethmoidal sinuses revealed 1 to 2 mm thickening, and maxillary sinuses showed 3 mm of mucosal thickening. These findings remained essentially unchanged during periods of symptomatic allergic rhinitis. DISCUSSION
In contrast to a recent report indicating that viral upper respiratory tract infections resulted in development of occlusion of the infundibulum in 77% of subjects and in development of abnormalities of one or both maxillary sinuses in 87% of subjects, as determined by CT scan, 2 our study of patients with symptomatic allergic rhinitis demonstrated infrequent and minimal changes in the sinuses during natural seasonal exposure. Only two of nine (22%) patients with symptomatic allergic rhinitis demonstrated any significant interval changes on sinus CT scans. These two patients had bilateral infundibular occlusion and minimal sinus mucosal thickening. Contrary to our previous work on allergic inflammation of the paranasal sinuses, which demonstrated
TABLE I. CT f i n d i n g s in n i n e a d u l t s w i t h allergic rhinitis
Site
Nasal passages Septal deviation Engorged turbinates Thickened nasal wall Osteomeatal complex Infraorbital cells Right Left Concha bullosa Right Left Infundibular occlusion Right Left
No. of patients (%)
5/9 (55%) 2/9 (22%)* 0/9
2/9 (22%) 2/9 (22%) 3/9 (33%) 4/9 (43%) 2/9 (22%)* 2/9 (22%)*
*Abnormalitynot present in baseline CT scan study.
increased blood flow on single photon emisssion CT scan, 1 the presence of allergic inflammation of the sinuses cannot be reliably verified by limited coronal CT scan of the sinuses in patients with symptomatic allergic rhinitis. With radiographic imaging, one could only speculate as to the exact pathophysiology occurring within the paranasal sinuses; however, if allergic T m cytokine profiles for IL-4 and IL-5 were obtained from the paranasal sinuses during a patient's most symptomatic period, one might be able to demonstrate markers of an allergic reaction in the microenvironment. The incidental findings noted on CT scan in this study were no greater than those of previous studies? This study, though limited in size, suggests a different radiographic appearance on limited CT scans between allergic rhinitis and viral upper respiratory tract infections, which has not been reported in the literature to date. In summary, we were unable to demonstrate any sinus inflammation that could be detected by limited computerized tomography in patients with symptomatic allergic rhinitis. REFERENCES
1. Slavin RG, ZillioxAP, Samuels LD. Is there such an entity as allergic sinusitis? [abstract]. J Allergy Clin Immunol 1988;81:284. 2. GwaltneyJM, Phillips CD, Miller RD, Riker DK. Computed tomographic study of the common cold. N Engl J Med 1994;330:25-30. 3. Calhoun KH, Waggenspack GA, Simpson B, Hokanson JA, Bailey BJ. CT evaluation of the paranasal sinuses in symptomatic and asymptomatic populations. Otolaryngol Head Neck Surg 1991;104:480-3.