Q:

1/4/2013
Is there any new data on the use of immunotherapy in patient with nasal polyps and resulting nasal congestion, but no other symptoms of rhinitis? The patient has sensitivity to multiple pollens, and indoor allergens on skin testing. The European Position Paper on rhinosinusitis and nasal polyps in 2012 does not address this.

A:

Thank you for your inquiry.

We have dealt with this issue previously on our website, and I have copied for you below our response to a similar inquiry. I have used bold-faced type to point out the portion of this inquiry that deals with your question. As you can see, there is a dearth of literature dealing with this issue, and no strong evidence, to my knowledge, documenting the efficacy of allergen immunotherapy in the treatment of nasal polyps.

Thank you again for your inquiry and we hope this response is helpful to you.

Allergen immunotherapy for a patient with hypereosinophilic syndrome, rhinitis symptoms, and nasal polyps
Question posted 6/8/2012:
I have a 50 year old male with diagnosis of hypereosiniphilic syndrome. Elevated eosinophils and an IgE of 18,000. Negative for the gene mutation so gleevac will not help. He is on prednisone and hydroxyurea. He has nasal polyps, and recurrent sinus infections. He has elevations in allergen specific IgE and allergen skin tests. He has recurrent nasal symptoms. The question is will he benefit from allergen immunotherapy? I realize that allergen immunotherapy will not help the underlying HES.

Answer:
Thank you for your inquiry.

The indication for allergen immunotherapy in your patient would of course be for the management of his rhinitis symptoms. Since I am sure you are familiar with the data regarding the effect of immunotherapy on allergic rhinitis, I will not reiterate the role of immunotherapy in this condition. However, I feel that your question is related to the role of immunotherapy specifically when nasal polyps are present and in the context of your patient with hypereosinophilia.

I think one of the best ways to approach this is to look at the role of immunotherapy in the treatment of nasal polyps. Although there is mention in the literature of immunotherapy being indicated to prevent the recurrence of nasal polyps after surgery and rhinitis symptoms in patients with nasal polyps, there is actually a dearth of literature to confirm the effectiveness of immunotherapy in patients with nasal polyps and concomitant allergic sensitivity. In fact, the European guidelines classify the effectiveness of immunotherapy in nasal polyps as Class D (no evidence available to support its use).

The full reference for this article is: Fokkens W, et al. EAACI Position Paper on Rhinosinusitis and Nasal Polyps (Executive Summary). Allergy 2005 (May); 60(5):583-601.

In addition, the British guidelines (abstract copied below) for the treatment of nasal polyps do not mention immunotherapy as a documented treatment modality. Thus, I am afraid there is very little literature to support the use of immunotherapy in patients with nasal polyps, which I sense is the dominant feature in your patient.

I would also like to mention parenthetically that the history in your patient is suggestive of Churg-Strauss (allergic granulomatous vasculitis). I feel you have probably already looked at this possibility, but I wanted to mention it nonetheless. The presence of marked hypereosinophilia and nasal polyps can be a presenting feature of Churg-Strauss. There are two abstracts, copied below, referring to this for your interest.

In summary, there is very little evidence-based literature to support the use of allergen immunotherapy in the context of the patient you have described, and these symptoms are suggestive for Churg-Strauss syndrome.

Thank you again for your inquiry and we hope this response is helpful to you.

Clin Exp Allergy. 2008 Feb;38(2):260-75. Epub 2007 Dec 20.
BSACI guidelines for the management of rhinosinusitis and nasal polyposis.
Scadding GK, Durham SR, Mirakian R, Jones NS, Drake-Lee AB, Ryan D, Dixon TA, Huber PA, Nasser SM; British Society for Allergy and Clinical Immunology.
Source
The Royal National Throat Nose & Ear Hospital, Gray's Inn Road, London, UK.
Abstract
This guidance for the management of patients with rhinosinusitis and nasal polyposis has been prepared by the Standards of Care Committee (SOCC) of the British Society for Allergy and Clinical Immunology (BSACI). The recommendations are based on evidence and expert opinion and are evidence graded. These guidelines are for the benefit of both adult physicians and paediatricians treating allergic conditions. Rhinosinusitis implies inflammation of the nose and sinuses which may or may not have an infective component and includes nasal polyposis. Acute rhinosinusitis lasts up to 12 weeks and resolves completely. Chronic rhinosinusitis persists over 12 weeks and may involve acute exacerbations. Rhinosinusitis is common, affecting around 15% of the population and causes significant reduction in quality of life. The diagnosis is based largely on symptoms with confirmation by nasendoscopy. Computerized tomography scans and magnetic resonance imaging are abnormal in approximately one third of the population so are not recommended for routine diagnosis but should be reserved for those with acute complications, diagnostic uncertainty or failed medical therapy. Underlying conditions such as immune deficiency, Wegener's granulomatosis, Churg-Strauss syndrome, aspirin hypersensitivity and allergic fungal sinusitis may present as rhinosinusitis. There are few good quality trials in this area but the available evidence suggests that treatment is primarily medical, involving douching, corticosteroids, antibiotics, anti-leukotrienes, and anti-histamines. Endoscopic sinus surgery should be considered for complications, anatomical variations causing local obstruction, allergic fungal disease or patients who remain very symptomatic despite medical treatment. Further well conducted trials in clearly defined patient groups are needed to improve management.

Acta Otolaryngol. 2006 May;126(5):503-9.
Ear, nose and throat manifestations of Churg-Strauss syndrome.
Bacciu A, Bacciu S, Mercante G, Ingegnoli F, Grasselli C, Vaglio A, Pasanisi E, Vincenti V, Garini G, Ronda N, Ferri T, Corradi D, Buzio C.
Source
Department of Otolaryngology, University of Parma, Italy.
Abstract
Conclusion: Ear, nose and throat (ENT) involvement is common in Churg-Strauss syndrome (CSS), usually manifesting as allergic rhinitis and chronic rhinosinusitis with or without polyps. Otolaryngologists may play a pivotal role in making an early diagnosis of this disease.
Objectives: CSS is a systemic vasculitic disorder that affects small to medium-sized blood vessels. Although the cause of CSS remains unknown, tissue damage seems more likely to be mediated by activated eosinophils. Patients affected by CSS frequently have ENT manifestations, which are often present at the time of disease onset and may represent relevant clues for the diagnosis. Thus, our objective was to present the ENT manifestations at the onset, at the diagnosis and at some point during the course of the disease in a series of patients with CSS collected at a single center.
Materials and Methods: Twenty-eight patients with CSS, as defined according to the 1990 American College of Rheumatology classification criteria, were identified. Twenty-one (75%) of these patients had ENT involvement. We evaluated the clinical course, laboratory data, histologic findings, treatment and outcomes.
Results: Of the 21 patients, 13 (61.9%) had ENT involvement at asthma onset and 8 (38%) at diagnosis or during follow-up. The most common ENT manifestations were allergic rhinitis in 9 (42.8%) patients and nasal polyposis in 16 (76.1%). Three (14.2%) patients developed chronic rhinosinusitis without polyps, three (14.2%) had nasal crusting, one (4.7%) serous otitis media, one (4.7%) purulent otitis media, two (9.5%) progressive sensorineural hearing loss, and one (4.7%) unilateral facial palsy. Corticosteroid therapy associated with immunosuppressive drugs usually yielded improvement or stabilization.

Laryngoscope. 2008 Feb;118(2):325-9.
Nasal polyposis in Churg-Strauss syndrome.
Bacciu A, Buzio C, Giordano D, Pasanisi E, Vincenti V, Mercante G, Grasselli C, Bacciu S.
Source
Department of Otolaryngology, University of Parma, Parma, Italy.
Abstract
Objectives: Churg-Strauss syndrome (CSS) is a systemic vasculitic disorder of unknown etiology that affects small-to-medium-size blood vessels. Patients affected by CSS frequently show ear, nose, and throat manifestations, which are often present at the time of disease onset. The purpose of this study was to determine the frequency of nasal polyposis in a series of 29 patients with CSS and to correlate the nasal findings to the total health situation of these patients.
Study Design: Retrospective analysis.
Setting: Department of Otolaryngology and Department of Clinical Medicine, Nephrology and Health Science, University of Parma.
Methods: Twenty-nine patients with CSS were identified. Of the 29 patients, 17 (58.6%) had nasal polyposis and were enrolled in this study. The nasal polyps were graded according to the Lund and Mackay endoscopic and radiological classifications.
Results: At diagnosis, endoscopic intranasal evaluation identified nasal polyposis of grade 3 in nine cases (52.9%), grade 2 in six cases (35.2%), and grade 1 in the remaining case (5.8%). After corticosteroid and immunosuppressive therapy, clinical remission was achieved in 14 patients (82.3%), whereas 3 patients experienced a relapse. Posttreatment endoscopic evaluation showed a permanent disappearance (grade 0) of nasal polyps in eight patients (47%). The other nine patients (52.92%) were found to have a small polyp situated in the middle meatus (grade 1).
Conclusions: Nasal polyposis in patients with CSS may represent the initial phase of the syndrome, though patients often have concurrent pulmonary disease. Corticosteroid therapy either alone or combined with immunosuppressive drugs usually yielded improvement or stabilization.

Sincerely,
Phil Lieberman, M.D.

AAAAI - American Academy of Allergy Asthma & Immunology