- Email: [email protected]
Treatment of resistant nasal polyps with intranasal Flovent
S200 Abstracts
797
Kimura Disease—What Should an Allergist Know About It?
S. I. Krassilnikova, L. Fisher, T. Craig, S. Chegini; Milton S. Hershey Medical Center, Penn State University, Hershey, PA. BACKGROUND: Kimura disease is a distinct chronic inflammatory condition of unknown etiology that presents with cutaneous nodules in the head and neck region mostly in young oriental males. The nodules consist of eosinophilic infiltrates, fibrous bands and lymphoid follicles with germinal centers. Only a few cases of Kimura disease have been reported in the USA and to date there has been no report of orbital involvement in a Caucasian female. METHOD: We present a 66-year old Caucasian female with unilateral periorbital swelling and proptosis, associated with pruritus of the eyelids. Description of our patient’s clinical course, therapeutic response and differential diagnostic considerations, along with a review of the literature on Kimura disease performed on Medline and PubMed. RESULTS: Fluctuating periorbital swelling and pruritus were present for over 3 years, which were unresponsive to a variety of topical and oral antihistamines. Diplopia developed one year after the onset and was treated surgically after ruling out myasthenia gravis and multiple sclerosis. Swelling slowly progressed and resulted in unilateral proptosis. CT and MRI scans demonstrated progressive periorbital edema, intraorbital softtissue infiltration affecting the extraocular muscles and ocular adnexa, which extended into the periorbital and zygomatic areas. Laboratory evaluation revealed progressive eosinophilia up to 2100/l and elevated IgE at 658. The patient responded to a tapering course of prednisone with marked reduction of proptosis and swelling. CONCLUSION: In a patient with persistent localized swelling and pruritus of head and neck area associated with elevated eosinophil count and IgE level, Kimura disease should be considered in the differential diagnosis.
Relationship Between Clinical Features and Rhinoscopic Appearance in CRS A. Suryadevara1, J. F. Piccirillo2, S. E. Thawley2, M. A. Kramper2, D. L. Hamilos1; 1MGH, Boston, MA, 2Washington University, St. Louis, MO. RATIONALE: To better understand the relationship between clinical features, such as allergic status and prior sinus surgery, and rhinoscopic appearance in CRS. METHODS: Over a two-year period, new patients coming to a University based specialty ENT or Allergy clinic meeting criteria for CRS were enrolled in an outcomes study. Symptoms were recorded and rhinoscopy was performed at entry. The relationship between clinical features and rhinoscopic appearance was analyzed by Chi square analysis. The Allergy clinic subgroup underwent skin testing (n= 47). RESULTS: Of the 126 patients, 33% had prior sinus surgery, 32.5% had polyp/polypoid changes and 40% had a clinical diagnosis of allergic rhinitis (AR). No statistically significant relationship was found between polyp/polypoid phenotype, mucus/purulence or edema and clinical AR. Likewise, no significant relationship was found between these findings and allergic status based on skin testing, with the exception that mucus/purulence was seen more commonly in skin test positive patients (P=0.05). A significant relationship was found between prior sinus surgery and polyp/polypoid phenotype in either the middle meatus/osteomeatal unit (MM/OMU) or sphenoethmoidal recess (P=0.01, 0.001 respectively). No significant relationship was found between prior sinus surgery and the presence of mucus/purulence in the MM/OMU or sphenoethmoidal recess. CONCLUSIONS: Allergic status does not appear to impact greatly on rhinoscopic appearance in CRS. Polyp/polypoid phenotype is more common in patients who had sinus surgery. This may reflect that polyp/polypoid phenotype more commonly leads to surgery. Alternatively, the possibility that surgery modifies the disease process promoting development of this phenotype cannot be excluded.
798
J ALLERGY CLIN IMMUNOL FEBRUARY 2005
799
Treatment of Resistant Nasal Polyps With Intranasal Flovent
C. Monge1, L. Endo1, M. White2, M. Kaliner2; 1Internal Medicine, Washington Hospital Center, Washington DC, DC, 2Institute for Asthma and Allergy, Chevy Chase, MD. RATIONALE: The purpose of our study was to investigate the effect of high dose intranasal Flovent in patients with nasal polyposis that have failed other treatments. The management of intranasal polyposis is complex and there are no established guidelines. This study examined the use of nasal fluticasone (Flovent 220) administered nasally through a baby bottle nipple plus nasal saline irrigation as treatment for nasal polyposis that had failed standard therapy. METHODS: A retrospective chart review of 73 patients with polyps and sinusitis who failed initial therapy was performed. The clinical response to treatment with intranasal Flovent was compared to commercially available nasal CCS. RESULTS: Most patients treated with intranasal Flovent or other nasal CCS were also started on 2-3 weeks of oral CCS (64.4%). Patients treated with nasal Flovent without oral CCS were more likely to have resolution of their polyps than those patients treated with other nasal CCS (p=0.015). The combination of long-term nasal Flovent and short-term oral CCS resolved polyps in 77.4% of patients within an average of 9 months (p=0.0045). There was significant reduction in polyp size within 1-2 months. Polyps in patients given concomitant antibiotic treatment trended toward better outcomes (p= 0.11). Patients with IgG deficiency did just as well as immunocompetent patients with this treatment (p=0.69). CONCLUSIONS: Use of intranasal Flovent with or without a short course of oral CCS plus nasal irrigation is an effective short and long-term management plan for nasal polyposis. Initial treatment with antibiotics may also be useful.
MONDAY
“Baseline” Nasal Symptoms and Secretions Do Not Change Following Acute Sinusitis Despite Standard Treatment and a Nasal Steroid M. Ali, J. N. Baraniuk, K. Petrie; Rheumatology, Immunology and Allergy, Georgetown University Medical Center, Washington, DC. RATIONALE: Our understanding of the natural history of acute sinusitis is incomplete. METHODS: Subjects with acute sinusitis were treated with amoxicillin/clavulanate, pseudoephedrine, oxymetazoline and saline nasal sprays for 1 week, then randomized to receive fluticasone (F; n=12) or vehicle (V; n=12) for 6 weeks. Nasal lavage with 1 ml of saline assessed “baseline” symptoms and secretions. The acute period (Days 1-7) were considered separately from the convalescent period (Days 7-42). RESULTS: F decreased the sensation of drip (rhinorrhea) by 1.2±0.5 cm (p=0.02, paired Student’s t-test; 10cm linear analog scale), while V increased drip by 0.2±0.5 cm. Albumin, a marker of spontaneous vascular permeability, decreased between Day 0 and Day 7. Incremental changes were identical for F (94.8±36.4 g/ml) and V (98.8±49.5 g/ml). Mucin, lysozyme and urea levels did not change between Days 1-7. The convalescent period had no changes in any symptom or secreted analyte for either treatment. CONCLUSIONS: The 1st week of standard therapy was associated with decreased albumin. Nasal steroids had no effect. The mechanism of the vascular permeability is unknown. Decreased drip by Day 7 was the only F-related treatment effect. Vehicle treatment had no effect on any symptom or analyte concentration over the 6 week period. Hypersecretion of glandular products continued unchanged for 6 weeks despite standard or additional topical steroid treatments. Funding: GSK and NIAID RO1 AI42403
800
797
Kimura Disease—What Should an Allergist Know About It?
S. I. Krassilnikova, L. Fisher, T. Craig, S. Chegini; Milton S. Hershey Medical Center, Penn State University, Hershey, PA. BACKGROUND: Kimura disease is a distinct chronic inflammatory condition of unknown etiology that presents with cutaneous nodules in the head and neck region mostly in young oriental males. The nodules consist of eosinophilic infiltrates, fibrous bands and lymphoid follicles with germinal centers. Only a few cases of Kimura disease have been reported in the USA and to date there has been no report of orbital involvement in a Caucasian female. METHOD: We present a 66-year old Caucasian female with unilateral periorbital swelling and proptosis, associated with pruritus of the eyelids. Description of our patient’s clinical course, therapeutic response and differential diagnostic considerations, along with a review of the literature on Kimura disease performed on Medline and PubMed. RESULTS: Fluctuating periorbital swelling and pruritus were present for over 3 years, which were unresponsive to a variety of topical and oral antihistamines. Diplopia developed one year after the onset and was treated surgically after ruling out myasthenia gravis and multiple sclerosis. Swelling slowly progressed and resulted in unilateral proptosis. CT and MRI scans demonstrated progressive periorbital edema, intraorbital softtissue infiltration affecting the extraocular muscles and ocular adnexa, which extended into the periorbital and zygomatic areas. Laboratory evaluation revealed progressive eosinophilia up to 2100/l and elevated IgE at 658. The patient responded to a tapering course of prednisone with marked reduction of proptosis and swelling. CONCLUSION: In a patient with persistent localized swelling and pruritus of head and neck area associated with elevated eosinophil count and IgE level, Kimura disease should be considered in the differential diagnosis.
Relationship Between Clinical Features and Rhinoscopic Appearance in CRS A. Suryadevara1, J. F. Piccirillo2, S. E. Thawley2, M. A. Kramper2, D. L. Hamilos1; 1MGH, Boston, MA, 2Washington University, St. Louis, MO. RATIONALE: To better understand the relationship between clinical features, such as allergic status and prior sinus surgery, and rhinoscopic appearance in CRS. METHODS: Over a two-year period, new patients coming to a University based specialty ENT or Allergy clinic meeting criteria for CRS were enrolled in an outcomes study. Symptoms were recorded and rhinoscopy was performed at entry. The relationship between clinical features and rhinoscopic appearance was analyzed by Chi square analysis. The Allergy clinic subgroup underwent skin testing (n= 47). RESULTS: Of the 126 patients, 33% had prior sinus surgery, 32.5% had polyp/polypoid changes and 40% had a clinical diagnosis of allergic rhinitis (AR). No statistically significant relationship was found between polyp/polypoid phenotype, mucus/purulence or edema and clinical AR. Likewise, no significant relationship was found between these findings and allergic status based on skin testing, with the exception that mucus/purulence was seen more commonly in skin test positive patients (P=0.05). A significant relationship was found between prior sinus surgery and polyp/polypoid phenotype in either the middle meatus/osteomeatal unit (MM/OMU) or sphenoethmoidal recess (P=0.01, 0.001 respectively). No significant relationship was found between prior sinus surgery and the presence of mucus/purulence in the MM/OMU or sphenoethmoidal recess. CONCLUSIONS: Allergic status does not appear to impact greatly on rhinoscopic appearance in CRS. Polyp/polypoid phenotype is more common in patients who had sinus surgery. This may reflect that polyp/polypoid phenotype more commonly leads to surgery. Alternatively, the possibility that surgery modifies the disease process promoting development of this phenotype cannot be excluded.
798
J ALLERGY CLIN IMMUNOL FEBRUARY 2005
799
Treatment of Resistant Nasal Polyps With Intranasal Flovent
C. Monge1, L. Endo1, M. White2, M. Kaliner2; 1Internal Medicine, Washington Hospital Center, Washington DC, DC, 2Institute for Asthma and Allergy, Chevy Chase, MD. RATIONALE: The purpose of our study was to investigate the effect of high dose intranasal Flovent in patients with nasal polyposis that have failed other treatments. The management of intranasal polyposis is complex and there are no established guidelines. This study examined the use of nasal fluticasone (Flovent 220) administered nasally through a baby bottle nipple plus nasal saline irrigation as treatment for nasal polyposis that had failed standard therapy. METHODS: A retrospective chart review of 73 patients with polyps and sinusitis who failed initial therapy was performed. The clinical response to treatment with intranasal Flovent was compared to commercially available nasal CCS. RESULTS: Most patients treated with intranasal Flovent or other nasal CCS were also started on 2-3 weeks of oral CCS (64.4%). Patients treated with nasal Flovent without oral CCS were more likely to have resolution of their polyps than those patients treated with other nasal CCS (p=0.015). The combination of long-term nasal Flovent and short-term oral CCS resolved polyps in 77.4% of patients within an average of 9 months (p=0.0045). There was significant reduction in polyp size within 1-2 months. Polyps in patients given concomitant antibiotic treatment trended toward better outcomes (p= 0.11). Patients with IgG deficiency did just as well as immunocompetent patients with this treatment (p=0.69). CONCLUSIONS: Use of intranasal Flovent with or without a short course of oral CCS plus nasal irrigation is an effective short and long-term management plan for nasal polyposis. Initial treatment with antibiotics may also be useful.
MONDAY
“Baseline” Nasal Symptoms and Secretions Do Not Change Following Acute Sinusitis Despite Standard Treatment and a Nasal Steroid M. Ali, J. N. Baraniuk, K. Petrie; Rheumatology, Immunology and Allergy, Georgetown University Medical Center, Washington, DC. RATIONALE: Our understanding of the natural history of acute sinusitis is incomplete. METHODS: Subjects with acute sinusitis were treated with amoxicillin/clavulanate, pseudoephedrine, oxymetazoline and saline nasal sprays for 1 week, then randomized to receive fluticasone (F; n=12) or vehicle (V; n=12) for 6 weeks. Nasal lavage with 1 ml of saline assessed “baseline” symptoms and secretions. The acute period (Days 1-7) were considered separately from the convalescent period (Days 7-42). RESULTS: F decreased the sensation of drip (rhinorrhea) by 1.2±0.5 cm (p=0.02, paired Student’s t-test; 10cm linear analog scale), while V increased drip by 0.2±0.5 cm. Albumin, a marker of spontaneous vascular permeability, decreased between Day 0 and Day 7. Incremental changes were identical for F (94.8±36.4 g/ml) and V (98.8±49.5 g/ml). Mucin, lysozyme and urea levels did not change between Days 1-7. The convalescent period had no changes in any symptom or secreted analyte for either treatment. CONCLUSIONS: The 1st week of standard therapy was associated with decreased albumin. Nasal steroids had no effect. The mechanism of the vascular permeability is unknown. Decreased drip by Day 7 was the only F-related treatment effect. Vehicle treatment had no effect on any symptom or analyte concentration over the 6 week period. Hypersecretion of glandular products continued unchanged for 6 weeks despite standard or additional topical steroid treatments. Funding: GSK and NIAID RO1 AI42403
800