The Journal of Laryngology & Otology

February 2002, Vol. 116, pp. 112115

Some risk factors for refractory chronic sinusitis: an

immunohistochemical and electron microscopic study
Samy Elwany, M.D., Mohamed Bassyouni, M.D., Fikry Morad, M.D.

Abstract
The goal of the present work was to investigate possible risk factors for the poor response of some cases of
chronic sinusitis to endoscopic sinus surgery in spite of the precision of the surgical technique. Eleven
adult patients who were scheduled for revision endoscopic sinus surgery underwent a complete allergy
workup. At the time of surgery, a tiny biopsy was taken from the maxillary sinus mucosa close to the
middle turbinate. The specimens were processed for histochemical and transmission electron microscopic
examination.
Six patients (55 per cent) proved to be allergic. Their sinus mucosa showed eosinophilic inltration (6.1
cells/mm 2), and mast cell degranulation. This proves that allergens can reach the sinus mucosa and have a
direct impact on it. Another three patients (27 per cent) were non-allergic but exhibited mucosal
eosinophilia (5.0 cells/mm2), and two of them showed mast cell degranulation. These patients were
diagnosed as having nonallergic rhinosinusitis with eosinophilia (NARSE). The nasal mucosa of the
remaining two patients did not reveal any characteristic pathological ndings, and no pathologic diagnosis
could be established for them. None of the patients showed electron microscopic evidence of purulent
inammatory changes, and the bacterial cultures recovered normal respiratory ora in nine patients (82
per cent).
The present research spotlights the importance of allergy and nonallergic eosinophilic inltration of the
mucosa as possible risk factors that may degrade the results of endoscopic sinus procedures and discusses
some pertinent pathological and clinical aspects.
Key words: Paranasal Sinuses; Sinusitis; Surgical Procedures, Operative; Treatment Failure

Introduction
Some stubborn cases of chronic sinusitis respond
poorly to different treatment modalities including
well-performed endoscopic sinus procedures. The
aetiology of chronic sinusitis is multifactorial and
ranges from anatomical abnormalities, to atopy,
ciliary dysfunction, immune deciencies, as well as
1
several other factors. Some of these factors may be
subtle or hidden and may be the underlying cause
behind the refractoriness of some patients.
The goal of the present study is to investigate
some of the possible causes of the poor response of
some patients with chronic sinusitis to endoscopic
sinus procedures in spite of the surgical technique.

The mean age was 34.3 years, with a range of 2149

years. Two patients scheduled for transantral maxillary artery ligation were used as a control.
All patients were instructed to stop medical
treatment three days before surgery. None of the
patients had nasal polyps. All of them gave informed
consents after the nature of the research has been
fully explained to them. The Committee on Ethics
and Research approved the protocol of the study.
All patients underwent a complete allergy workup
with in vitro serum micro-ELISA testing. Testing of
serum was performed for specic IgE for a battery of
15 allergens. The numerical data were expressed in
standard IgE units (SIU). A value below 40 SIU was
3
regarded as negative atopy. The student t test was
used to compare different means. Statistical signicance was regarded as p< 0.05. The group sizes,
however, are so small that statistical comparison may
be meaningless as there may not be enough subjects
to detect a difference.

Materials and methods

The study population consisted of 11 adult patients
with the diagnosis of chronic sinusitis, as dened by
the International Conference on Sinus Diseases, 2
who were scheduled for revision endoscopic sinus
surgery. These were nine males and two females.

From the Departments of Otolaryngology and Medical Laboratories, Saqr Hospital (United Arab Emirates), and Alexandria
Medical School (Alexandria, Egypt).
Accepted for publication: 29 August 2001.
112

some risk factors for refractory chronic sinusitis: an immunohistochemical and electron microscopic study

At the time of surgery, endoscopic-guided cultures

were obtained from the maxillary sinuses and
processed for routine bacteriological examination.
A ne-cupped forceps was then used to take a tiny
2 mm2 biopsy of the maxillary sinus mucosa close to
the middle meatal window. The biopsies were
processed for light microscopy (haematoxylin and
eosin stain), immunohistochemistry, and transmission electron microscopy.
Tissue preparation for immunohistochemistry
The biopsy specimens were placed in OCT
(ornithine carbamolytransferase) medium, snap frozen in liquid nitrogen-cooled isopentane, and stored
at 2 808 C. Cryostat sections were cut at 6 m m and
maintained at 2 238 C until used.
Eosinophils were identied by a monoclonal
antibody to major basic protein (MBP). Slides were
developed with fast red substrate for alkaline
phosphatase. A negative control slide was always
included. The number of positive cells was counted
with an Olympus microscope with an eyepiece
graticule at X200 magnication. The graticule was
oriented beneath the basement membrane. At least
three sections and six elds were counted for each
patient. The results were expressed as the mean
number of cells per square millimeter. Cell counts
were compared between patient groups with the
Mann-Whitney U test. Statistical signicance was
regarded as p< 0.05. This was performed using the
SAS software.
Tissue preparation for electron microscopy
The specimens were prepared for transmission
electron microscopy by use of a previously described
technique.4
Results
Allergy workup
Six patients were allergic and tested positive to at
least four allergens by in vitro tests. The other ve
patients were non-allergic and did not test positive to

113

any allergen. The mean serum IgE level of the

allergic group was 51.0 SIU (Table I). This was
signicantly higher than the control group (3.2 SIU)
as well as the non-allergic group (5.5 SIU).
MBP expression in the mucosa (Figure 1a and b)
There was essentially no expression of MBP in
biopsy specimens from two patients as well as from
the control group. Their mean expression of MBP
was, therefore, zero. The mean expression of MBP in
patients with proved allergy was 6.1 cell/mm2. The
mean expression of MBP in the remaining three
patients was 5.0 cells/mm2. There was no signicant
difference between this mean and that of the allergic
patients. These three patients were diagnosed as
having NARSE according to the description of
Moneret-Vautrin et al.5 The mean expression of
MBP in the overall patient group was 4.7 cells/mm2,
and this was not signicantly different from that of
the allergic group.
Transmission electron microscopy
Biopsy specimens taken from the maxillary sinus
showed more than two eosinophils/section in all
allergic patients as well as patients with NARSE.
The eosinophils (Figure 1(c)) exhibited the specic
granules with the characteristics crystalloid core that
contains the MBP.
Degranulated mast cells (Figure 1(d)) were seen in
the mucosa of all allergic patients as well as in two
patients with NARSE.
A summary of the patients data is shown in Table
I. In two nonallergic patients, (No. 1 and 7), no
characteristic immunohistochemical or pathological
features were observed, and no pathologic diagnosis
could be established for them. There were no
purulent inammatory changes in the mucosa of
any of the patients. The bacterial cultures recovered
normal respiratory ora in nine patients (82 per
cent). One patient (No. 1) grew Haemophilus
inuenzae, and another patient (No. 11) grew
Moxarella catarrhalis.

TABLE I
patients data
Patient no.
1
2
3
4
5
6
7
8
9
10
11
C1
C2

Positive
allergens (No.)

Serum IgE
(SIU)

0
9
0
4
0
7
0
6
5
0
9
0
0

6.1
51
4.4
44
6.8
48
2.9
50
51
7.5
62
2.8
3.6

Atopy

MBP
Cells/mm2

2
1
2
1
2
1
2
1
1
2
1
2
2

C1 and C2 are control subjects.

Patients number 2, 4, 6, 8, 9 and 11 are allergic.
Patients number 3, 5 and 10 have non-allergic rhinosinusitis with eosinophilia.

0
6
5
5
4
6
0
8
4
6
8
0
0

Eosinophils

Degranulated
mast cells

2
1

1
1

1
1

1
1

1
2

2
1

1
1

1
1

1
1
2

1
2

114

s. elwany, m. bassyouni, f. morad

(a)

(b)

(c)

(d)

Fig. 1
(A) A high power histological section demonstrating positive staining for MBP (arrow) in the maxillary sinus mucosa of a patient
with chronic rhinosinusitis. (3 200). (B) A high power histological section demonstrating negative staining for MBP in a control
patient. (3 200). (C) A transmission electron micrograph showing an eosinophil with the characteristic bilobed nucleus (N), and the
specific granules (*). Some granules show the electro-lucent crystalloids in the center. (3 22 000). (D) A transmission electron
micrograph showing a degranulated mast cell. Many granules (arrow) are seen well outside the cell membrane. (3 18 000).

Discussion
The study sought to nd a pathological explanation
for the poor response of some cases of chronic
sinusitis to properly performed endoscopic procedures. The study showed two possible culprits:
allergy and NARSE. There was no pathological or
bacteriological evidence of purulent inammation.
There is circumstantial evidence supporting
allergy as a risk factor for sinusitis.1,69 However,
how allergic disease can lead to sinusitis is still
1,9
unclear. In subjects with local predisposing factors,
such as anatomical defects, it is conceivable that the
associated nasal mucosal inammation could induce
obstruction of the sinus ostia. In subjects without
obvious predisposing factors, different mechanisms
should exist.
In the effector phase of allergic reactions, several
chemical mediators, such as histamine and leukotrienes, are released from mast cells. These
mediators stimulate target tissues resulting in mucosal swelling and exessive discharge. The mast cells
also release chemo-attractants that attract other
inammatory cells, notably esoinophils, into the
local tissues. The eosinophils release other media-

tors, such as MBP and the eosinophil cationic protein

(ECP), that have toxic effects on the epithelial
cells. 10,11 Hismatsu et al.11 found that inltration of
the respiratory mucosa with eosinophils renders it
primed and more vulnerable to noxious stimuli than
is the mucosa of normal individuals.
The present study showed that the allergens could
reach the mucosa of the maxillary sinus and initiate
intense allergic reaction in the sinus mucosa at least
in the area surrounding the middle meatal window.
This agrees with the study of Davis et al.12 who found
that the presence of allergy is the most important
variable in predicting the closure of a middle meatal
antrostomy with subsequent persistence of inammatory changes within the maxillary sinus.
The term non-allergic rhinitis with eosinophilia
was used to describe non-atopic inltration of the
nasal mucosa eosinophils.13,14 In our cases it is
rhinosinusitis rather than rhinitis. The reason why
eosinophil move to the nasal or sinus mucosa, in the
absence of an allergic reaction, is still under
investigation. Rowe-Jones et al.15,16 stressed that
eosinophils do play a key role in the pathogenesis of
nasal polyposis. Denburg et al.,17 however, found
that the presence of eosinophilia in the tissues of

some risk factors for refractory chronic sinusitis: an immunohistochemical and electron microscopic study

nasal polyps does not appear to depend on the

presence of allergy or IgE-mediated hypersensitivity,
but is related to the up regulation of certain
cytokines that specically attract eosinophilic precursors from the microvasculature. Togias and
colleagues18 demonstrated that nasal challenge with
cold, dry air induces release of histamine and other
mediators suggesting a mast cell-mediated mechanism of action resembling allergen challenge in atopic
patients. Other every day non-immunological stimuli, such as smoke, perfumes, and chemical
irritants, are likely to have a similar effect. Following
the creation of a wide middle meatal window, these
stimuli can reach the sinus mucosa especially in the
area around the widened window.
It is known that eosinophils are preferentially
attracted by histamine released from mast cells. The
eosinophilic granules contain a histaminase enzyme
that inactivates histamine, and other enzymes that
neutralize leukotrienes and some other mediators
produced by the degranulated mast cells.10 The
eosinophils, on the other hand, can release a number
of cytotoxic agents that may damage the epithelial
cells and the ciliary structures.19 So it seems that
eosinophils, as is the case in allergic rhinosinusitis,
can exert both an effector as well as a protector role,
with the end result depending upon the nal balance
between both roles.
It is clear now that there are many common
pathological aspects between allergic rhinosinusitis
and NARSE. Symptoms of NARSE are, more or
less, similar to those of its allergic perennial counterpart. However, they show a limited response to
antihistamines although they respond very well to
corticosteroids. 5 The major difference between both
conditions is the lack of an IgE-mediated reaction in
NARSE. This facilitates differentiating both conditions on clinical grounds. On the other hand, it is
easy to miss the diagnosis of NARSE, as probably its
only diagnostic clue, apart from negative atopy tests,
is the detection of eosinophils in nasal smears. In this
context, the use of a proper nasal mucosal collecting
device is a must. These devices are designed to
collect optimum specimens with little or no discomfort to the patient. Usually they yield uniform
mucosal samples with 100 to 1000 times more cells
than any other method.
The clinical implication of our ndings is that
patients with allergic rhinosinusitis or NARSE are
less likely to respond favourably to endoscopic sinus
procedures unless we can diagnose and control the
primary condition medically. Failure to recognize
and manage either of these conditions may result in
unsatisfactory results and ineffective surgery.
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Address for correspondence:
Samy Elway, M.D.,
PO Box 3114,
Ras Al-Khaima,
United Arab Emirates.
Fax: 1 971(7) 2222760
E-mail: elwany@emirates.net.ae
Dr S. Elwany takes responsibility for the integrity of the
content of the paper.
Competing interests: None declared