title: Are atopy and eosinophilic bronchial inflammation associated with relapsing forms of chronic rhinosinusitis with nasal polyps?
abstract: BACKGROUND
  The aetiopathogenesis of chronic rhinosinusitis with nasal polyps (CRSwNP) is still unknown. The role of atopy and the concept of united airways in such patients are still a matter of debate. In this pilot study we aimed at evaluating the degree of eosinophilic inflammation and the frequency of atopy in a cohort of CRSwNP patients candidate for Functional Endoscopic Sinus Surgery (FESS) and assessing the association between these factors and relapsing forms of CRSwNP.
  
  
  METHODS
  30 patients (18 men, 12 women) with CRSwNP eligible for FESS were evaluated before and after surgery. Preoperative investigation included: history of previous relapse after FESS, clinical and laboratory allergologic assessment, spirometry, methacholine challenge, blood eosinophilia and determination of the fraction of nitric oxide in exhaled air (FeNO). Nasal fibroendoscopy, spirometry and FeNO determination were also assessed prospectively at 3 and 27 months post-FESS.
  
  
  RESULTS
  18/30 subjects were atopic, 6/18 (33 %) were monosensitized, 16/30 (53 %) were asthmatics and 10/30 (33 %) had non steroidalantinflammatory drugs (NSAIDs) hypersensitivity. Twenty-one patients (70 %) were classified as relapsers, 15/18 (83 %) among atopics, 6/12 (50 %) among non atopics (p = 0.05). Among patients with NSAIDs hypersensitivity, 9/10 (90 %) were relapsers. The median IgE concentration was 161.5 UI/mL in relapsers and 79 UI/mL in non-relapsers (ns). The mean FeNO decreased after FESS (43.1-26.6 ppb) in 84 % of patients, but this effect disappeared over time (FeNO = 37.7 ppb at 27 months). Higher levels of FeNO pre-FESS were detected in atopics, and in particular in relapsing ones (median 51.1 ppb vs 22.1, ns). Higher levels of FeNO pre-FESS were detected in asthmatic patients, especially in those who relapsed (median: 67 vs 64.85 ppb in non-relapsed patients, ns). The Tiffeneau Index (FEV1/FVC) was significantly lower in asthmatic relapsers than in non relapsers asthmatics (94.7 ± 11.1 versus 105 ± 5.9-p = 0.04). Patients with asthma and atopy had a major risk of relapse (p = 0.05).
  
  
  CONCLUSIONS
  In our pilot study, atopy, severe asthma, bronchial inflammation, NSAIDs hypersensitivity and high level of total IgE are possible useful prognostic factors for the proneness to relapse after FESS. The role of allergy in CRSwNP pathogenesis should consequently be given deeper consideration. Allergen specific immunotherapy, combined with anti-IgE therapy, may have an immunomodulatory effect preventing polyps relapse and need to be investigated.
authors.affiliation: Allergy and Clinical Immunology Unit, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy ; Vita-Salute San Raffaele University, Milan, Italy.
authors.forename: Mona-Rita
authors.initials: MR
authors.lastname: Yacoub
authors.affiliation: Allergy and Clinical Immunology Unit, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy ; Vita-Salute San Raffaele University, Milan, Italy.
authors.forename: Matteo
authors.initials: M
authors.lastname: Trimarchi
authors.affiliation: Allergy and Clinical Immunology Unit, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy ; Vita-Salute San Raffaele University, Milan, Italy.
authors.forename: George
authors.initials: G
authors.lastname: Cremona
authors.affiliation: Allergy and Clinical Immunology Unit, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy ; Vita-Salute San Raffaele University, Milan, Italy.
authors.forename: Sara
authors.initials: S
authors.lastname: Dal Farra
authors.affiliation: Allergy and Clinical Immunology Unit, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy ; Vita-Salute San Raffaele University, Milan, Italy.
authors.forename: Giuseppe Alvise
authors.initials: GA
authors.lastname: Ramirez
authors.affiliation: Allergy and Clinical Immunology Unit, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy ; Vita-Salute San Raffaele University, Milan, Italy.
authors.forename: Valentina
authors.initials: V
authors.lastname: Canti
authors.affiliation: Allergy and Clinical Immunology Unit, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy ; Vita-Salute San Raffaele University, Milan, Italy.
authors.forename: Emanuel
authors.initials: E
authors.lastname: Della Torre
authors.affiliation: Allergy and Clinical Immunology Unit, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy ; Vita-Salute San Raffaele University, Milan, Italy.
authors.forename: Mattia
authors.initials: M
authors.lastname: Baldini
authors.affiliation: Allergy and Immunology Unit, Fondazione Salvatore Maugeri, IRCCS, Pavia, Italy.
authors.forename: Patrizia
authors.initials: P
authors.lastname: Pignatti
authors.affiliation: Allergy and Clinical Immunology Unit, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy ; Vita-Salute San Raffaele University, Milan, Italy.
authors.forename: Mario
authors.initials: M
authors.lastname: Bussi
authors.affiliation: Allergy and Clinical Immunology Unit, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy ; Vita-Salute San Raffaele University, Milan, Italy.
authors.forename: Maria Grazia
authors.initials: MG
authors.lastname: Sabbadini
authors.affiliation: Allergy and Clinical Immunology Unit, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy ; Vita-Salute San Raffaele University, Milan, Italy.
authors.forename: Angelo A
authors.initials: AA
authors.lastname: Manfredi
authors.affiliation: Allergy and Clinical Immunology Unit, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy ; Vita-Salute San Raffaele University, Milan, Italy.
authors.forename: Giselda
authors.initials: G
authors.lastname: Colombo
keywords: Atopy; Eosinophils; Nasal polyps; Relapse; Rhinosinusitis