Rhinosinusitis pathophysiology
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Dima Nimri, M.D. [2]
Overview
The pathophysiology for both acute and chronic rhinosinusitis involves blockage of the nasal sinuses and inflammation of the nasal sinuses. However, biofilms play a role in the pathogenesis of chronic rhinosinusitis. There are many associated conditions with rhinosinusitis, but most notably are those related to allergy and immunodeficiency.
Pathophysiology
Physiology
Sinuses are made up of frontal, maxillary and anterior ethmoid bones of the face. They are lined with ciliated pseudostratified columnar epithelium with a protective layer of mucosa. The cilia by propelling the inhaled particles into the nose for disposal and the mucosa by trapping the particles, together protect the sinuses from irritants and potential immune reactions.[1]
Pathogenesis
Acute Rhinosinusitis
Pathophysiology of acute rhinosinusitis could be explained by several mechanisms [1]:
- Anatomic variants: Since imaging modalities are not necessary for uncomplicated ARS, there aren’t enough evident regarding the contribution of anatomy to the pathogenesis of ARS. However, several contributing factors have been proposed:
- Anomalies of the unicate and middle turbinate
- Stenosis of the infundibulum
- Recirculation phenomenon
- Infraorbital ethmoid cells
- Nasoseptal deviation
- Allergy: Allergens trigger the recruitment of eosinophils into the maxillary sinus causing inflammation.
- Viruses: Viruses (e.g. Rhinovirus, H1N1), inhibit the mucociliary clearance and local swelling which in turn leads to the blockade of the sinus ostea and subsequent bacterial infection.
- Odontogenic infection: The proximity of maxillary sinus to the teeth roots causes rhinosinusitis in patients with dental maxillary pathology.
Chronic Rhinosinusitis
There are several proposed mechanisms for the pathophysiology of chronic rhinosinusitis [1][2]:
- Fungus: Proteins of the fungus trigger T cell response, causing cytokine storm which in turn leads to recruitment of the eosinophils to mucus. Degranulated eosinophils target the fungi causing collateral tissue damage.
- Bacteria, mostly contribute to the pathogenesis of chronic rhinosinusitis without nasal polyps and are composed of three hypotheses:
- Super antigen: Staphylococcus aureus superantigenic exotoxins bind T cells outside their antigen binding site, bypassing the antigen recognition pathway, thus provoking polyclonal T cell response which in turn leads to cytokine storm.
- Biofilm: Biofilms are composed of bacteria embedded in an extracellular matrix, protecting them from antibiotics.
- Microbiome: It is suggested that external factors could change the normal microbiome of the nasal and sinus mucosa facilitating the growth of pathogens that were normally suppressed by the commensals.
- Host related factors:
- Immune barrier:
- Mechanical barrier: Defect in mucociliary clearance, increased susceptibility to exogenous protease and decreased tight junction proteins of the epithelium causing the formation of a porous barrier contribute to the increased access and transmit time of the foreign materials.
- Innate immune response: Abnormal secretion of the antimicrobials of the mucosa (i.e. defensins, lysozyme, cathelicidins, collectins, lactoferrin, S100s and PLUNC) in response to pathogen recognition receptors (PRR), results in abnormal microbiome, increased exposure to foreign materials and increased compensatory response of the innate and adaptive immune system.
- Anatomic variations: Variations that affect the ostio-meatal complex (i.e. anomalies in the middle turbinate, concha, cells of the infraorbital ethmoid and nasoseptal deviation) or the drainage of the frontal sinus contribute to chronic rhinosinusitis with polyps.
- Immune barrier:
There are limited evidence proposing some other mechanisms involved in the pathogenesis of chronic rhinosinusitis:
- Eicosanoids: Eicosanoids are the product of Arachidonic acid metabolism which function as signaling molecules. Defects in the Eicosanoid pathway causes an increased pro-inflammatory leukotriene and decreased anti-inflammatory prostaglandin resulting in the mucosal inflammation.
- Vitamin D deficiency: Vitamin D has anti-microbial and anti-inflammatory effects. Thus, its deficiency results in increased Th2 and eosinophilic response resulting mostly in chronic rhinosinusitis without polyps.
- Osteitis and neo-osteogenesis: Histopathological changes of the bone including inflammation, fibrosis and new bone formation were observed in harvested ethmoid bones of patients with chronic rhinosinusitis.
- Reflux: Laryngopharyngeal reflux exposes the nasal cavity and sinuses to gastric acid and possible H. Pylori infection causing inflammatory response and defective mucociliary clearance. Also, the reflux triggers the esophagus resulting in stimulation of vagus nerve.
Genetics
Chronic rhinosinusitis is believed to be the result of environmental and genetic factors combined. The role of genetic factors in chronic rhinosinusitis is not yet fully understood.[3] However, in chronic rhinosinusitis with and without nasal polyposis, first and second degree relatives conferred an increased risk to receiving the same diagnosis.[4]
Associated Conditions
- Allergies, such as hay fever[5]
- Asthma[6]
- Nasal Polyposis[7]
- Cilia disorders, such as cystic fibrosis and Kartagener Syndrome[8]
- Wegener's Granulomatosis[9]
- Humoral immunodefiency, such as IgA deficiency and X-linked agammaglobulinemia[9]
Gross Pathology
On gross examination of the sinuses, polyps may appear as transparent and pedunculated masses. In sinusitis, changes include minimal edema and thickening of the mucosa.[10]
Microscopic Pathology
Rhinosinusitis can present with the following microscopic findings;[10]
- Acute Bacterial Sinusitis: Inflammatory infiltrate is dominated by neutrophils.
- Allergic Rhinosinusitis: Inflammatory infiltrate is dominated by eosinophils.
- Chronic Rhinosinusitis: Mixed inflammatory infiltrate of lymphocytes, plasma cells, eosinophils, neutrophils, and macrophages.
References
- ↑ 1.0 1.1 1.2 Orlandi RR, Kingdom TT, Hwang PH, Smith TL, Alt JA, Baroody FM; et al. (2016). "International Consensus Statement on Allergy and Rhinology: Rhinosinusitis". Int Forum Allergy Rhinol. 6 Suppl 1: S22–209. doi:10.1002/alr.21695. PMID 26889651.
- ↑ Lam K, Schleimer R, Kern RC (2015). "The Etiology and Pathogenesis of Chronic Rhinosinusitis: a Review of Current Hypotheses". Curr Allergy Asthma Rep. 15 (7): 41. doi:10.1007/s11882-015-0540-2. PMC 4874491. PMID 26143392.
- ↑ Al-Shemari H, Bossé Y, Hudson TJ, Cabaluna M, Duval M, Lemire M, Vallee-Smedja S, Frenkiel S, Desrosiers M (2008). "Influence of leukotriene gene polymorphisms on chronic rhinosinusitis". BMC Med. Genet. 9: 21. doi:10.1186/1471-2350-9-21. PMC 2292155. PMID 18366797.
- ↑ Oakley GM, Curtin K, Orb Q, Schaefer C, Orlandi RR, Alt JA (2015). "Familial risk of chronic rhinosinusitis with and without nasal polyposis: genetics or environment". Int Forum Allergy Rhinol. 5 (4): 276–82. doi:10.1002/alr.21469. PMID 25677865.
- ↑ Christodoulopoulos P, Cameron L, Durham S, Hamid Q (2000). "Molecular pathology of allergic disease. II: Upper airway disease". J. Allergy Clin. Immunol. 105 (2 Pt 1): 211–23. PMID 10669839.
- ↑ Slavin RG (2008). "The upper and lower airways: the epidemiological and pathophysiological connection". Allergy Asthma Proc. 29 (6): 553–6. doi:10.2500/aap.2008.29.3169. PMID 19173781.
- ↑ Meltzer EO, Hamilos DL (2011). "Rhinosinusitis diagnosis and management for the clinician: a synopsis of recent consensus guidelines". Mayo Clin. Proc. 86 (5): 427–43. doi:10.4065/mcp.2010.0392. PMC 3084646. PMID 21490181.
- ↑ Le C, McCrary HC, Chang E (2016). "Cystic Fibrosis Sinusitis". Adv. Otorhinolaryngol. 79: 29–37. doi:10.1159/000444959. PMID 27466844.
- ↑ 9.0 9.1 Ryan MW (2008). "Diseases associated with chronic rhinosinusitis: what is the significance?". Curr Opin Otolaryngol Head Neck Surg. 16 (3): 231–6. doi:10.1097/MOO.0b013e3282fdc3c5. PMID 18475077.
- ↑ 10.0 10.1 Thompson, Lester D. R. Head and Neck Pathology. Elsevier Health Sciences. p. 3. ISBN 9781437726077.