Nasal nitric oxide is a useful biomarker for acute unilateral maxillary sinusitis in pediatric allergic rhinitis: A prospective observational cohort study

Yung-Sung Wen; Ching-Yuang Lin; Kuender D Yang; Chih-Hsing Hung; Yu-Jun Chang; Yi-Giien Tsai

doi:10.1016/j.waojou.2019.100027

Nasal nitric oxide is a useful biomarker for acute unilateral maxillary sinusitis in pediatric allergic rhinitis: A prospective observational cohort study

World Allergy Organ J. 2019 May 17;12(4):100027. doi: 10.1016/j.waojou.2019.100027. eCollection 2019.

Authors

Yung-Sung Wen^{1

2

3}, Ching-Yuang Lin⁴, Kuender D Yang⁵, Chih-Hsing Hung⁶, Yu-Jun Chang⁷, Yi-Giien Tsai^{3

6

8}

Affiliations

¹ Department of Otorhinolaryngology, Head and Neck Surgery, Changhua Christian Hospital, Changhua, Taiwan.
² Department of Otorhinolaryngology, Head and Neck Surgery, Yunlin Christian Hospital, Xiluo, Taiwan.
³ School of Medicine, Chung Shan Medical University, Taichung, Taiwan.
⁴ Clinical Immunological Center and College of Medicine, China Medical University Hospital, Taiwan.
⁵ Departments of Pediatrics, Mackay Memorial Hospital, and Institute of Biomedical Sciences, Mackay Medical College, Taipei, Taiwan.
⁶ School of Medicine, Kaohsiung Medical University, Taiwan.
⁷ Epidemiology and Biostatistics Center, Changhua Christian Hospital, Changhua, Taiwan.
⁸ Department of Pediatrics, Changhua Christian Children Hospital, Changhua, Taiwan.

Abstract

Background: Nasal nitric oxide (nNO) could be a biomarker for nasal passage inflammation and sinus ostial patency. We have aimed to investigate the nNO concentration and the effect of antibiotic therapy in children with perennial allergic rhinitis (PAR) children with/without acute bacterial sinusitis.

Methods: We enrolled a cohort of 90 and 31 children with PAR, without and with acute unilateral maxillary sinusitis, and 79 normal children. Acute bacterial maxillary sinusitis was diagnosed based on clinical signs and symptoms, radiographic examination and nasal fibroendoscopy. Rhinitis control assessment test (RCAT), rhinomanometry, nNO and fractional exhaled NO (FENO) measurements were performed before and 2 weeks after antibiotic therapy.

Results: We found significantly higher mean nNO levels, FENO values, and total nasal resistance in children with PAR than in normal children (p < 0.05). Acute unilateral maxillary sinusitis was associated with lower lesion-side nNO levels, higher FENO values, total nasal resistance, and poor RCAT scores (p < 0.05). In multivariate analysis, age, IgE, and acute maxillary sinusitis were significant factors influencing nNO levels in children with PAR. The lesion-side nNO levels, FENO values, total nasal resistance, and RCAT scores were reversed after antibiotic therapy (p < 0.05). The lesion-side nNO levels were significantly correlated to nasal obstructive scores (r = 0.59, p < 0.05) and expiratory nasal resistance (r = -0.54, p < 0.05) in the acute maxillary sinusitis. A cut-off nNO value of 538 ppb showed 100% sensitivity and 94.9% specificity, to predict PAR from normal children. An nNO value of 462 ppb showed 100% sensitivity and 100% specificity to discriminate between the lesion-side and the unaffected sinus-side in PAR children with acute unilateral maxillary sinusitis.

Conclusions: We conclude that the obstruction of NO from the sinus into the nasal passage is the likely explanation for the decreased lesion-side nNO levels in acute unilateral maxillary sinusitis. nNO is a non-invasive biomarker with high sensitivity to diagnose and monitor treatment responses of PAR patients with acute rhinosinusitis. Both nNO and FENO levels return to baseline following antibiotic therapy, supporting the "one airway one disease" concept.

Keywords: ARIA, Allergic rhinitis and its impact on asthma; Der f, Dermatophagoides farinae; Der p, Dermatophagoides pteronyssinus; FENO, Fractional Exhaled NO; NO, Nitric oxide; RCAT, Rhinitis control assessment test; nNO, Nasal nitric oxide.