Academic Year 2015 - 2017

Alcohol -induced hyper -responsiveness in chronic rhinosinusitis with nasal polyps

Eline GABRIELS

Promotor: Prof. Dr. Ph. Gevaert Co-promotor: Dr. E. De Schryver

Dissertation presented in the 2 nd Master year in the programme of MASTER OF MEDICINE IN MEDICINE

Academic Year 2015 - 2017

Alcohol -induced hyper -responsiveness in chronic rhinosinusitis with nasal polyps

Eline GABRIELS

Promotor: Prof. Dr. Ph. Gevaert Co-promotor: Dr. E. De Schryver

Dissertation presented in the 2 nd Master year in the programme of MASTER OF MEDICINE IN MEDICINE

Deze pagina is niet beschikbaar omdat ze persoonsgegevens bevat. Universiteitsbibliotheek Gent, 2021.

This page is not available because it contains personal information. Ghent University, Library, 2021. Foreword

This thesis was written within the context of a Master degree in Medicine at Ghent University.

I wish to thank those without whose help this thesis could not have been accomplished: Prof. Dr. Philippe Gevaert, Dr. Els De Schryver and Lara Derycke for their guidance, assistance and advise; the people who filled in the questionnaires; the patients and controls who participated in the challenge study; the upper airway research laboratory for their research on inflammatory markers.

Furthermore I want to thank my friends and family for their support. In particular Mathias Valcke, who has been on my side throughout the course of this assignment.

I

List of abbreviations

AHR: alcohol hyper-responsiveness

AR: allergic rhinitis

ARIA: allergic Rhinitis and its Impact on Asthma

ATA: aspirin-tolerant asthmatics

CRS: chronic rhinosinusitis

CRSsNP: chronic rhinosinusitis without nasal polyps

CRSwNP: chronic rhinosinusitis with nasal polyps

ECP: eosinophil cationic protein

FESS: functional endoscopic sinus surgery

HR: hyper-responsiveness

IFN γ: Interferon gamma

IgE: immunoglobulin E

IL-17: interleukin 17

IL-5: interleukin 5

INS: intranasal corticosteroids

NERD: NSAID exacerbated respiratory disease

NSAID: Non-steroidal anti-inflammatory drug

SAE-IgE: S. aureus enterotoxin-specific IgE

TNF α: tumor necrosis factor alpha

II

List of figures

Figure 1: Prevalence of alcohol-induced symptoms ...... 23 Figure 2: Causal beverages of alcohol-induced nasal HR ...... 25 Figure 3: Frequency of nasal HR after drinking alcohol ...... 26 Figure 4: Severity of alcohol-induced nasal symptoms ...... 26 Figure 5: Onset of alcohol-induced nasal symptoms ...... 27 Figure 6: Duration of alcohol-induced nasal symptoms ...... 28 Figure 7: Quantity of units needed to elicit nasal symptoms ...... 28 Figure 8: Relation of time of diagnosis to nasal alcohol hyper-responsiveness ...... 29 Figure 9: Correlation between ECP and VAS-score after consuming alcohol ...... 30 Figure 10: The evolution of the mean rhinomanometry scores compared to baseline in CRSwNP patients ...... 35 Figure 11: The evolution of the mean rhinomanometry scores compared to baseline in control subjects ...... 36

III

List of tables

Tabel 1: Characteristics of the study population ...... 20 Tabel 2: Alcohol consumption in our study population ...... 22 Tabel 3: Prevalence of alcohol hyper-responsiveness ...... 24

List of appendices

Appendix 1: Informed Consent ...... VII Appendix 2: Questionnaire for healthy volunteers...... IX Appendix 3: Questionnaire for CRSwNP patients ...... XV Appendix 4: Questionnaire for CRSsNP patients ...... XXII Appendix 5: Questionnaire for AR patients ...... XXVIII Appendix 6: Publication ...... XXXV

IV

Table of contents Foreword ...... I List of abbreviations ...... II List of figures ...... III List of tables ...... IV List of appendices ...... IV 1 Abstract ...... 1 2 Introduction ...... 3 2.1 Chronic rhinosinusitis with nasal polyposis ...... 3 2.1.1 Epidemiology ...... 3 2.1.2 Diagnosis ...... 3 2.1.3 Pathophysiology ...... 4 2.1.4 Comorbidity ...... 5 2.1.5 Treatment ...... 6 2.2 Chronic rhinosinusitis without nasal polyposis ...... 7 2.2.1 Epidemiology ...... 7 2.2.2 Diagnosis ...... 7 2.2.3 Pathophysiology ...... 7 2.2.4 Comorbidity ...... 8 2.2.5 Treatment ...... 8 2.3 Allergic rhinitis ...... 8 2.3.1 Epidemiology ...... 8 2.3.2 Diagnosis ...... 9 2.3.3 Pathophysiology ...... 9 2.3.4 Comorbidity ...... 9 2.3.5 Treatment ...... 10 2.4 Alcohol intolerance in airway disease ...... 11 2.4.1 What is already known? ...... 11 2.4.2 Aim of this study ...... 15 3 Materials and methods ...... 16 3.1 Questionnaires ...... 16 3.2 Research population ...... 16 3.3 Processing of the questionnaires ...... 16 3.4 Correlation with inflammatory markers ...... 17 3.5 Statistical analysis ...... 17

V

4 Results ...... 18 4.1 Demographics and characteristics of our study population ...... 18 4.2 Correlations in healthy subjects? ...... 21 4.3 Alcohol-induced respiratory reactions in upper airway disease ...... 21 4.3.1 Prevalence ...... 21 4.3.2 Characteristics ...... 25 4.4 Inflammatory markers in alcohol hyper-responsiveness in CRSwNP patients ...... 30 5 Discussion ...... 31 5.1 Prevalence ...... 31 5.2 Characteristics ...... 32 5.3 Mechanisms ...... 33 5.4 Clinical implications ...... 33 5.5 Limitations ...... 34 5.6 Provocation study ...... 34 6 Conclusion ...... 37 7 References ...... 38 8 Appendices ...... VII

VI

1 Abstract Background: Alcohol-induced hyper-responsiveness has been studied in chronic airway diseases like asthma and AR but in CRSwNP patients the prevalence and characteristics of these symptoms has not been investigated properly yet. Neither has research focused on nasal alcohol-induced symptoms in this patient group.

Objective: In this study, we want to determine the prevalence of both bronchial and nasal alcohol hyper-responsiveness in patients with CRSwNP, CRSsNP and AR. We will compare these results with the results found in a healthy control group. Furthermore, we want to evaluate characteristics of nasal symptoms in the different groups. We also want to investigate the relation with inflammatory markers in CRSwNP.

Methods: A questionnaire was used to evaluate the prevalence and characteristics of alcohol hyper-responsiveness. We included 534 CRSwNP patients, 198 CRSsNP patients, 369 AR patients and 180 healthy volunteers. In the group of CRSwNP patients, a distinction could be made between NSAID exacerbated respiratory disease, CRSwNP with asthma and CRSwNP without comorbidities. We compared levels of inflammatory markers (ECP, IL-5, IgE, SAE- IgE, IL-17, TNF α and IFN γ) between CRSwNP patients with and without alcohol hyper- responsiveness.

Results: The highest percentage of alcohol hyper-responsiveness was reported by CRSwNP patients with NSAID exacerbated respiratory disease, followed by CRSwNP with asthma, CRSwNP without comorbidities, CRSsNP and AR. Only a few healthy individuals reported symptoms. The percentage of abstainers was correlated with the amount of people suffering from AHR in each group. The ECP-levels were higher in hyper-responsive CRSwNP patients. Characteristics of nasal hyper-responsiveness reactions differed between the different chronic airway diseases and control subjects.

Conclusions: Alcohol hyper-responsiveness is frequent in CRSwNP patients and its prevalence is correlated with the severity of the disease. In other chronic airway diseases AHR is less prevalent and healthy subjects rarely report AHR. Nasal hyper-responsiveness is significantly correlated with the grade of eosinophilic inflammation.

1

Achtergrond: Eerder onderzoek rond alcohol geïnduceerde hyperreactiviteit van de luchtwegen in chronische luchtweginfecties heeft zich vooral gericht op hyperreactiviteit in astma en allergische rhinitis. Rond de prevalentie en karakteristieken in chronische rhino- sinusitis met nasale poliepen is er maar weinig geweten. Verder heeft bestaand onderzoek zich vooral gefocust op symptomen van de lage luchtweg en is er maar weinig bekend over de invloed van alcohol op de neus.

Doel: In deze studie gingen we op zoek naar de prevalentie van zowel bronchiale als nasale symptomen uitgelokt door alcohol in patiënten met CRSwNP, CRSsNP en allergische rhinitis. Deze resultaten werden vergeleken met de resultaten van een gezonde controlegroep. Verder vergeleken we ook de kenmerken van uitgelokte nasale symptomen tussen de verschillende groepen. Binnen de CRSwNP groep bekeken we de relatie met inflammatoire merkers.

Methode: Een vragenlijst werd opgesteld voor elke subgroep in deze studie. Daarin werd er gepeild naar de prevalentie en karakteristieken van alcohol-geïnduceerde symptomen. Er werden 534 CRSwNP patiënten, 198 CRSsNP patiënten, 369 AR patiënten en 180 gezonde vrijwilligers geïncludeerd. Binnen de CRSwNP groep werd er een opdeling gemaakt tussen NERD, CRSwNP patiënten met astma en CRSwNP patiënten zonder comorbiditeiten. Verder bekeken we de aanwezigheid van inflammatoire merkers (ECP, IL-5, IgE, SAE-IgE, IL-17, TNF α en IFN γ) in CRSwNP patiënten.

Resultaten: Het hoogste percentage alcohol hyperreactiviteit werd gerapporteerd door patiënten met NERD, gevolgd door CRSwNP patiënten met astma, CRSwNP patiënten zonder comorbiditeiten, CRSsNP patiënten en AR patiënten. Slechts enkele gezonde personen meldden klachten. Hoe groter het aantal mensen met alcohol hyperreactiviteit in een bepaalde groep, hoe groter het percentage van alcohol onthouders in die groep. Symptomen kwamen meer voor in ernstigere vormen van de ziekte. De gemiddelde hoeveelheid ECP was hoger in CRSwNP patiënten met alcohol hyperreactiviteit. De karakteristieken van de nasale hyperreactiviteit verschilden tussen de verschillende chronische luchtwegaandoeningen en de controlegroep.

Conclusie: Alcohol hyperreactiviteit is een frequent fenomeen in CRSwNP patiënten en komt meer voor in ernstigere vormen van het ziektebeeld. In andere chronische luchtwegaandoeningen is alcohol hyperreactiviteit minder frequent maar het komt er nog steeds meer voor dan in gezonde vrijwilligers. Nasale hyperreactiviteit is significant gecorreleerd met de graad van eosinofiele inflammatie.

2

2 Introduction Clinical expertise learned us that many chronic rhinosinusitis patients with nasal polyps experienced aggravation of their airway symptoms after drinking alcohol. This phenomenon is of unknown significance as little research has been done on the subject. We want to investigate the significance of this problem because it may be of clinical importance to warn patients for the effects of alcohol. Alcohol avoidance may lead to a better disease control and thus a better quality of life. Underlying mechanisms may also enable us to develop new treatment strategies.

Alcohol-induced hyper-responsiveness symptoms have been studied by questionnaires in asthma patients and in a general population. A few challenge tests with red wine were performed in asthmatics. Alcohol has proven to be an asthma exacerbation causing agent but the role in other airway diseases is yet to be determined. In our study, we want to focus on nasal alcohol-induced symptoms in CRSwNP patients. We will compare the characteristics with symptoms in CRSsNP patients, AR patients and healthy subjects. 2.1 Chronic rhinosinusitis with nasal polyposis Chronic rhinosinusitis is a collective term for many different disease entities (1). A major distinction is made between CRS with and without nasal polyps. Both have similar symptoms but their pathophysiology and comorbidities are different (2-4). CRS has a huge financial and economic impact caused by repeated medical visits and lost working days (5).

2.1.1 Epidemiology The prevalence of CRSwNP is approximately 4,2% in a general population (3). Nasal polyps appear at the average age of 42 and are uncommon under the age of 20 (6). The incidence increases with age and they are more frequent in men and asthmatics (5, 6). Studies in diverse parts of the world have suggested that the prevalence and pathophysiology of NP are different worldwide (2). Environmental, genetic and infectious factors influence the development (5). In some studies cigarette smoking was correlated with a higher prevalence of CRSwNP (3).

2.1.2 Diagnosis Chronic rhinosinusitis is defined by the EPOS guidelines as an inflammation of the nose and the paranasal sinuses characterized by at least 2 symptoms of the following 4: nasal congestion, nasal obstruction, facial pain/pressure and reduced smell. 1 symptom should be either nasal congestion or nasal obstruction. When symptoms last more than 12 weeks the diagnosis of CRS can be made. An objective measure of the disease is necessary because

3

symptoms can be nonspecific. Nasal endoscopy is preferred and is also used to make a distinction between CRSsNP and CRSwNP (2, 6). Grape-like semitransparent pedunculated extrusions from the sino-nasal mucosa in the middle meatus are seen in CRSwNP (2, 7).

Patients with CRSwNP have a higher total symptom score and experience other symptoms than CRSsNP patients (8). The main symptom is nasal obstruction (2). Others are purulent nasal discharge, hyposmia, hypoxia, hypercapnia, snoring and sleep disorders. Hyposmia and reduced odor discrimination are more common in CRSwNP than in CRSsNP (9). Olfactory function decreases with increased nasal inflammation.

2.1.3 Pathophysiology Researchers have found different types of inflammation in CRSwNP. In western countries, the inflammation in 80% of the polyps is eosinophilic. In Asia, neutrophilic inflammation is more common although symptoms and remodeling of the nose are the same. Even within a disease subgroup, the inflammatory cell pattern may differ significantly (8). In eosinophilic polyps a robust T-helper 2 response, a decreased T-regulatory function and an abundance of IL-5 was found (6). The Th2 response aggravates the pre-existing inflammation (8). In neutrophilic polyps, especially T-helper 1 and T-helper 17 inflammatory profiles were found (6). CRSwNP may be considered as an immunoglobulin generating disease with an up- regulation of plasma cells, B-cells and the attracting chemokines CXCL12 and CXCL13 (2, 10).

Studies showed a strong association between Staphylococcus aureus superantigens and the eosinophilic inflammation in CRSwNP. The intracellular presence of S. aureus indicates a barrier dysfunction or a defect in the local immune system (3). These superantigens may cause a Th2 cytokine response, eosinophilia and the local production of polyclonal immunoglobulins (2, 3, 8). However, this effect can only be demonstrated in approximately half of the CRSwNP patients. Dixon et al. found a colonization rate of 67% in CRSwNP (11). The prevalence of Staphylococcus is much lower in Asian polyps, indicating that superantigens should be considered as disease modifier in eosinophilic inflammation rather than etiologic agent (3). It’s not completely clear if colonization can’t be considered as a downstream effect of the inflammatory disease mechanism (10).

The tissue changes associated with CRSwNP are presumably secondary to the release of vasoactive mediators and degranulation products of eosinophils, mast cells, neutrophils and macrophages. This gives albumin accumulation, lack of collagen in the extracellular matrix, a

4

thickened basement membrane and edema formation (2, 3, 12). TGF-b is essential in the remodeling process of the airways because it’s responsible for the upregulation of ECM synthesis by attracting and inducing the proliferation of fibroblasts (13).

Local auto-immune responses and defects in the eicosanoid pathway with increased synthesis of pro-inflammatory leukotrienes and decreased synthesis of anti-inflammatory prostaglandins have also been proposed as potential causes of CRSwNP (3). The heritability of the disease is estimated at 13 to 53% (2). Environmentally-determined epigenetic changes may explain why there are geographic differences in inflammation patterns (3). Anatomic deformities like nasal septal deviations, septal perforations and nasal valve dysfunction may aggravate the disease (2, 3). In immunocompetent patients, the role of fungi is very limited (14).

2.1.4 Comorbidity CRSwNP is often linked with other respiratory diseases. For this study, the presence of aspirin sensitivity, allergy and asthma was investigated.

2.1.4.1 Asthma The prevalence of asthma is reported to variate between 26% and 45% in CRSwNP patients, compared to 6% in a general population (3, 8). The severity of asthma is linked with the severity of CRSwNP (2). In patients with both allergic rhinitis and CRS, the highest percentage of asthma was found (3, 13). Airway remodeling is more extensive in the bronchial mucosa than in the nasal mucosa (12, 15). CRSwNP and AR treatment may have a positive effect on asthma control (11, 12).

Asthma comorbidity is more common in some parts of the world than others. When Belgian and Chinese patients with similar symptoms and CT-scans were compared, asthma comorbidity was more common in Belgian patients (8). This suggests that eosinophilic inflammation plays a crucial role in the development of asthma comorbidity (13). Researchers have found that the presence of IL-5, local IgE and SE-IgE antibodies predicts comorbid asthma (2, 8).

2.1.4.2 Allergy The prevalence of allergic rhinitis in patients with CRSwNP has been reported varying from 10% to 64% (3). Atopy is suggested as facilitating factor in the development of nasal polyps and may influence the period of asthma onset (3, 16). A possible explanation for the predisposition to develop polyps in AR is swelling of the nasal mucosa induced by AR which

5

gives obstruction of the drainage and aeration of the sinuses (3, 12). Another possible explanation is that allergens enter the sinuses and start inflammation, or they aggravate the preexisting inflammation (2, 12). However, the role of allergy in CRSwNP is questioned. Ragweed-allergic subjects with polyps didn’t experience an increase in symptoms or markers of inflammation after ragweed exposure (17). Also, symptoms reported by CRSwNP patients with AR are the same as symptoms reported by CRSwNP patients without AR (18).

2.1.4.3 Aspirin-intolerance Aspirin-intolerance is frequently seen in combination with CRSwNP and asthma, this is called NSAID exacerbated respiratory disease (NERD). The prevalence of NERD varies from 0,3 to 0,9% in the general population, from 10 to 20% in an asthmatic population and from 8 to 26% in patients with CRSwNP (6, 19, 20). In about half of the patients with NERD, rhinitis is the first symptom to occur around the age of 30 (19, 20). Female patients have a higher risk to develop aspirin-intolerance (6, 21).

It usually takes about 6 years to develop all the elements of NERD. CRSwNP and asthma are much more severe in these patients (2, 12, 19, 22). Asthmatic patients with NERD have the highest exacerbation rates and NP have a tendency to reoccur after treatment (8). Some say that a viral infection in genetically predisposed patients is the trigger that leads to oversensitivity (6, 19, 21). There’s a persistent eosinophilic inflammation caused by high levels of cytokines, chemokines and IgE (20, 21). NERD is less prevalent in neutrophilic polyps (22). Patients should avoid NSAIDs to prevent symptoms. It is also possible to create aspirin tolerance by administering aspirin at proper intervals (21).

2.1.5 Treatment Compared to CRSsNP, CRSwNP is less sensitive to medical and surgical treatment (10). Which therapy is used, depends on the severity of symptoms. The standard medical treatment of NP consists out of saline irrigation and intranasal corticosteroids (2). In mild disease, this should be sufficient to achieve control (2, 23). When symptoms haven’t improved after 1 month of treatment, the patient should be referred to a specialist.

Antibiotics can be beneficial in severe cases. They are used for acute exacerbations (2). Doxycyline during 20 days, has proven to suppress S.aureus and reduce polyp size in eosinophilic polyps (2, 8, 24). Neutrophilic polyps can be treated with macrolide antibiotics (2, 8). Both have an additional anti-inflammatory effect (4). Corticosteroids can be administered systemically but due to many negative side effects their use should be avoided

6

(2, 23, 24). In addition to normal treatment, underlying allergic rhinitis and NERD treatment can improve the therapeutic outcome, especially in those refractory to medical and surgical treatment (2, 19). When medical treatment fails, surgical intervention is considered. QOL increases significantly after surgery (2, 5). FESS led to improvement in up to 98% of the patients (2). There’s a high risk of reoccurrence after surgery, therefor further treatment is necessary (19).

Lately new drugs are tested in the treatment of severe CRSwNP. Anti-IL-5 seems to reduce polyp size in eosinophilic nasal polyps (2, 13). Anti-IgE has shown positive results in patients with both nasal polyps and asthma, supporting the role of S. aureus antigens in NP (13). In the future, a better understanding of pathophysiologic processes in CRSwNP might further improve treatment options by targeting other specific molecules (4). 2.2 Chronic rhinosinusitis without nasal polyposis 2.2.1 Epidemiology Few studies have investigated the epidemiology of CRSsNP, so the exact prevalence is not clear. The study of Tan et al. found that CRSsNP has a higher incidence than CRSwNP. They reported 1048 cases of CRSsNP per 100.000 person-years compared to 83 cases of CRSwNP per 100.000 person-years (25). Other studies found that people with a low income had a higher risk of developing CRSsNP (3). Overall the population suffering from CRSsNP is younger and characteristics are more similar to healthy individuals than to CRSwNP patients (25). The incidence of CRSsNP is highest in fall and winter (25).

2.2.2 Diagnosis The EPOS criteria can be used to diagnose chronic rhinosinusitis. Anterior rhinoscopy and symptoms are suggestive for CRSsNP but the diagnosis is confirmed by nasal endoscopy. Obstruction of the osteomeatal complex by fibrosis can be visualized in CRSsNP (3). The most common symptoms reported by patients with CRSsNP are facial pain, facial pressure, headache, postnasal drip and fullness of the nose (2, 14). Overall, patients with CRSsNP have a lower total symptom score (8). On a CT-scan, patients with CRSsNP show a lower opacification compared to CRSwNP patients (14).

2.2.3 Pathophysiology In CRSsNP patients, concentrations of SE-IgE antibodies aren’t higher than in healthy subjects (5, 13, 14). This suggests a distinct pathogenesis and etiology compared to CRSwNP (3). Whereas eosinophilic inflammation is typical for CRSwNP, neutrophilic inflammation is

7

more common in CRSsNP (2, 14). A mainly Th1-driven, less severe inflammation is typical (2, 3, 8). Thickening of collagen fibers, an overactive collagen deposition with excessive tissue repair and fibrosis formation are the results of this mechanism (2, 13, 14). Obstruction of the osteomeatal complex arises. Remodeling can also precede inflammation (13). Eosinophilic inflammation is less common in CRSsNP but not impossible. It is unclear why eosinophilic inflammation leads to CRSwNP in one patient and to CRSsNP in another (14).

2.2.4 Comorbidity 2.2.4.1 Asthma About 10–15% of the people suffering from CRSsNP is also suffering from asthma (23). Research disagrees about the role of CRSsNP in the development of asthma. Tan et al. wrote that asthma was strongly associated with an additional diagnosis of CRSsNP while Bachert et al. denied that the development of asthma is influenced by the presence of CRSsNP (2, 25). Both agreed that the association of asthma with CRSwNP is more significant. COPD comorbidity is present in 3,6% of the patients, which is significantly higher than in CRSwNP patients (8).

2.2.5 Treatment The treatment of CRSsNP is comparable with the treatment of CRSwNP. Saline sprays, irrigation and intranasal corticosteroids are the first steps (2, 14). If symptoms remain troublesome after 3 months of treatment, a culture is taken and long-term macrolide antibiotics are started (2). If this is still not enough to reduce suffering, a CT-scan and surgery must be considered (2, 14). Surgery reduces the obstruction of the osteomeatal complex and increases QOL (2). Mucosal damage is reversible in CRSsNP, so the prognosis and surgical outcome is better compared to CRSwNP (2, 14). 2.3 Allergic rhinitis 2.3.1 Epidemiology Allergic rhinitis is a common disorder which strikes 10-20% of the general population (18, 26). The incidence rises, especially in industrialized countries (27, 28). In adulthood, the prevalence is equal in boys and girls (28). People usually develop symptoms before the age of 20 but the clinical phenotype may change over time (23, 28). An IgE-mediated immune response leads to inflammation of the nose. The ARIA classification is used to diagnose the different grades of severity (29).

8

Symptoms occur as a result of exposure to allergens. The most common triggers are house dust mite, grass and tree pollen (28). Typical symptoms are sneezing, itchy nose, nasal congestion and rhinorrhea (8, 27). AR is a risk factor for poor asthma control and therefor needs adequate treatment (28, 30).

2.3.2 Diagnosis Allergic rhinitis is characterized by typical symptoms (18, 28). These symptoms occur within minutes after exposure to allergen and can last over 2 hours. Possible late-phase nasal symptoms are nasal obstruction, hyposmia, post-nasal mucous discharge, and nasal hyperreactivity (28). To confirm the diagnosis, objective tests can be performed to detect specific IgE reactivity. Useful tools to screen for IgE-mediated allergy are skin prick tests and allergen-specific serum IgE measurements (27, 28).

2.3.3 Pathophysiology Allergic rhinitis is a genetically predisposed disease (28). Other factors that are linked to its development are childhood eczema, being a white European, environmental pollution, exposure to cigarette smoke during childhood, being born during a pollen season, higher blood IgE levels as child, exposure to indoor allergens, early introduction of food and formula and factors fitting in the hygiene hypothesis like high socio-economic status, being only child and late entry into nursery or preschool education (28). Heavy alcohol consumption in adulthood is also a risk factor (28).

Dendritic cells and T lymphocytes are crucial in the process responsible for the development of AR (28). Infectious organisms may initiate this process (27). For example, S. aureus colonization is significantly higher in AR patients than in control subjects (12). After sensitization, exposure to allergens causes an increase in inflammation of the basement membrane by binding allergen-specific IgE in the surface of mast cells. As a result of this interaction, there’s a release of histamine and other mediators causing the early nasal response. These substances attract eosinophils, basophils, Th2 and Treg cells (12, 27, 28). The produced cytokines are crucial for the allergic immune response (28).

2.3.4 Comorbidity 2.3.4.1 Asthma People with an atopic background have an increased risk of developing asthma (8). Asthma occurs in 15% to 40% of the patients with allergic rhinitis and its prevalence is positively correlated with severity of AR symptoms (12). Patients with both disorders report higher

9

symptom scores (11, 31). AR is usually the first disease to be diagnosed (31). Atopy at an early age gives a higher risk of developing asthma into late childhood (12). It is not clear whether allergic rhinitis is causative for asthma or if AR is an early stage of allergic disease which eventually becomes asthma (12). S. aureus colonization exists in both asthma and AR (12). Decreasing inflammation in the nose might prevent asthma development by reducing inflammation of the lower airways (32). There is some evidence that an appropriate rhinitis treatment improves asthma moderately (11, 12). Poor asthma control is linked with more severe symptoms of rhinitis (11, 28).

2.3.5 Treatment Allergic rhinitis treatment depends on the ARIA classification of a patients’ disease. Patient education is necessary because even with maximum medical treatment, one in five patients remains symptomatic (28). Prevention of allergen contact is essential to reduce symptoms and the risk of asthma development but isn’t always possible (28). Pharmacotherapy and immunotherapy are considered (28). Treating AR properly reduces healthcare use for asthma and has a huge impact on patients’ QOL (12). Undertreatment of AR is common (28).

Medical treatment options of AR aim to either reduce symptoms or induce tolerance to allergens (28). Saline douching reduces the amount of pharmacotherapy needed (28). Possible treatment options are oral H1-antihistamine, oral leukotriene receptor antagonists and intranasal glucocorticosteroids (12, 26). Oral glucocorticosteroids should be avoided (26). In addition to other drugs, a course of intranasal decongestant can be considered when patients suffer from severe nasal obstruction (26). Immunotherapy is the only treatment option that not only reduces symptoms but also alters the disease course. It prevents new sensitizations and progression to asthma (28). In patients with an IgE-dependent allergic component of asthma who remain uncontrolled despite optimal therapy, antibodies against IgE are an effective treatment option (26, 28).

10

2.4 Alcohol intolerance in airway disease 2.4.1 What is already known? 2.4.1.1 Epidemiology Clinical expertise has suggested the role of alcoholic beverages as inducer of upper and lower respiratory symptoms. Previous studies especially focused on asthma exacerbations provoked by alcohol consumption so study populations mostly consisted out of asthmatics. In the study of Ayres et al. 25% of the asthma patients reported exacerbations due to the use of minimum 1 kind of alcohol (33). Other numbers were found in the study of Dahl et al., namely 10%, and Vally et al., where 33% of the patients had had 2 or more asthma exacerbations following alcohol use (34, 35). Characteristics that seemed to increase the risk on alcohol-induced symptoms were female sex, treatment with oral steroids and first asthma exacerbation on a young age (35). In the study of Liu et al. alcohol intolerance was seen as a sort of food allergy and in asthmatic patients, a higher prevalence of food allergy was found (36). Alcohol may even be a factor that increases the risk of developing adult-onset asthma in heavy drinkers (37).

Few studies have investigated alcohol-induced airway symptoms in a general population. Nihlen et al. found a prevalence of 3,4% in a Swedish study population (38). Andersson et al. found that approximately 3% of their test group showed nasal symptoms after drinking red wine (39). In the study of Linneberg et al. the self-reported prevalence of symptoms from nose, lower airways or skin after alcohol ingestion in a Northern European population was 13,9% (40). The higher the number of affected regions, the higher the prevalence of AR and asthma (40). Also associations with chronic bronchitis, COPD and NP were found (38).

The study of Cardet et al. found that in a healthy population 14% suffered from rhinorrhea or nasal congestion after alcohol ingestion (41). In patients with airway diseases however, more people were affected (38). Upper airway symptoms were reported by 75% of the patients with NERD, 40% of the patients with CRSwNP, 33% of the patients with aspirin-tolerant asthma and 30% of the patients with CRS in general (41). The prevalence in patients with allergic rhinitis was also higher (40). Lower respiratory symptoms were only reported by patients with NERD and ATA, respectively 51% and 20% of the patients complained of wheezing or dyspnea after alcohol consumption (41).

11

Rhinitis symptoms had a peak prevalence among 40-60 year olds (40). People reacting to alcohol were on average 2,4 years older than people who weren’t responsive (38). Symptoms of the nose and skin where more common in women (38, 40).

2.4.1.2 Characteristics All types of alcohol have shown to cause alcohol-induced symptoms (33, 35, 38, 40, 41). More than one third of the ATA and NERD patients reacted to all alcoholic beverages (41). Red wine has been reported as the most frequent inducer of symptoms (33, 35, 38, 40). In the study of Vally et al. 33,3% of the responders indicated wine as cause of their symptoms, 9,8% chose beer and spirit-based drinks were least common (35). ATA and NERD patients experienced the most forceful reactions after drinking red wine (41). Nihlen et al. found that hyper-responsiveness to white wine was associated with nasal allergy and hyper- responsiveness to beer was associated with NP (38). Provocation studies with red wine have shown to induce both rhinitis and bronchoconstriction (39, 42). The study of Sisson et al. found contradictory results. In asthmatic patients 23% reported improvement of their asthma symptoms after alcohol ingestion (43). This indicates that alcohol also can have a slow bronchodilator effect, next to the immediate upper airway irritant response (43).

Nasal blockage is the most prominent nasal alcohol-induced symptom (79%), followed by sneezing, nasal discharge and itching (38). Most individuals develop symptoms within one hour after alcohol intake (35, 41). The speed seems to depend on the grade of inflammation in the nose. 84% of the NERD patients developed symptoms within one hour compared to 78% in the ATA group (41). A few sips of alcohol is usually enough to cause trouble (41). 65% of the NERD patients suffered over half of the times after drinking alcohol, in ATA patients this was 61% (41).

Mostly alcohol-induced symptoms were mild to moderate in a Caucasian population in contrast to symptoms caused by an enzyme defect in Asians (35, 40). More severe symptoms were found in patients with NERD (41). The severity of aspirin-induced reactions was positively correlated with the severity of alcohol-induced reactions (35, 38, 41). When NERD patients retried drinking after aspirin therapy, 63% noticed improvement (41). Furthermore, not every person who reported alcohol-induced HR developed symptoms after a challenge test (34). This may indicate that whether symptoms occur or not, may be influenced by the disease state at that certain moment. Dahl et al. researched the influence of the percentage sulfur dioxide in wine (34). Patients experienced the most forceful reactions after drinking wine with the highest concentration of sulfite dioxide (34).

12

Heavy drinkers don’t have more alcohol-induced symptoms (38). On the contrary, alcohol- induced reactions are a reason to reduce or quit alcohol consumption (40, 41). In the study of Cardet et al. 73% of the NERD patients and 57% of the ATA patients reported reduced alcohol consumption (41). Also avoidance of other foods containing sulfites was reported to improve symptoms (44).

2.4.1.3 Mechanisms Research has been done on the pathophysiologic mechanisms of alcohol-induced respiratory symptoms in asthmatics. In an Asian population sensitivity to alcohol is more common, due to a polymorphism in acetaldehyde dehydrogenase (40, 41). 50-60% of the asthmatic population is affected by this defect (40, 43). Alcohol ingestion causes the serum acetaldehyde concentration to rise, which is followed by bronchoconstriction caused by histamine release from mast cells and basophils (40). As a result, facial flushing and occasionally respiratory symptoms occur. Symptoms can be prevented by alcohol avoidance or histamine receptor blockers (40, 43). In a Caucasian population, this enzymatic defect is rare, but acetaldehyde as a histamine-releasing factor may play a role in alcohol-related asthma symptoms (40).

Respiratory symptoms can be provoked by inhalation of alcohol. Acetaldehyde levels in blood aren’t rising after inhalation, so other factors must be important (45). People used to think that it were mostly the congeners in alcoholic beverages that caused bronchoconstriction and that bronchodilation occurred the moment ethanol was absorbed (33). Now we know that ethanol itself plays a role in the induction of symptoms too. In the study of Linneberg et al. this was confirmed by challenging both healthy and asthmatic patients with ethanol (40). 50% of the participants who reported AHR before the challenge test, developed symptoms.

Other components of alcoholic drinks have also been identified as triggers of asthma attacks (35). Sulfite hypersensitivity for example has been found to trigger bronchoconstriction in some asthmatics (31, 35, 44, 46). Sulfite hypersensitivity usually occurs in asthmatic patients and is very rare in non-asthmatics (44, 46). The prevalence has been estimated 0,05% in a general population and 3-10% in asthmatic patients (44, 46) Asthma severity is positively correlated with the prevalence of sulfite hypersensitivity (44, 46). Red wine and certain kinds of food like cheese contain sulfites and can trigger reactions (35).

That histamine also plays a role is proven by the fact that pre-treatment with anti-histamines reduces rhinitis symptoms and nasal secretion after red wine challenge (39, 40). It has no influence on nasal blockage and itching of the nose so not everything can be explained by the

13

release of histamine (39). Red wine is the alcoholic drink with the highest level of histamine and is the most frequent cause of alcohol-induces respiratory symptoms (40). Some patients are probably intolerant to histamine because of a reduced activity of diamine oxidase (42). Plasma histamine levels don’t rise in tolerant people after drinking red wine (42). Wine also contains salicylates, so when people are aspirin-intolerant, they are likely to react to wine too which may explain the higher prevalence of AHR in NERD (35).

Alcohol intake has a proven effect on almost every aspect of the immune response. The level of total serum immunoglobulin E rises after alcohol consumption and decreases after alcohol abstinence (37, 40, 47, 48). The Th1 function is impaired causing a relative Th2 dominance (40, 47). This leads to a higher susceptibility to bacterial infections (40). Less is known about the influence of alcohol on the atopic immune response although atopy has an important influence (47). Self-reported alcohol intake was positively correlated with total serum IgE in atopic individuals (47). A few studies have linked alcohol consumption to IgE sensitization against inhalant allergens (40). This may be due to cross-reactivity of alcohol-induced IgE (48). Alcohol is also known to modify mucin production and mucociliary clearance (43). The study of Sisson et al. found that brief exposure to alcohol stimulated ciliary motility, while prolonged contact with alcohol was correlated with reduced mucociliary clearance (43). Lung defense mechanisms are thus imposed.

In asthmatics and patients with NERD, bronchoconstriction has been reported due to rising LTE4 levels after drinking alcohol. Healthy individuals normally don’t react on this elevation but asthmatic patients are 200 times more sensitive and NERD patients are another 16 times more sensitive to LTE4 bronchoconstriction (41). A possible explanation may be that asthmatics have a decreased threshold of bronchial response caused by an increased bronchial hyperreactivity (40).

The exact cause of alcohol-induced upper respiratory symptoms remains unknown. The fact that people react to all types of alcoholic drinks suggest that alcohol itself, and not an additive like sulfite or histamine, is the culprit of these reactions (38, 40, 41). However, sulfite and histamine intolerance may play a role too. Also non-specific mechanisms like vasodilation can be important (49). Most symptoms occur within one hour after alcohol consumption, this corresponds with the peak blood alcohol levels (41). Alcohol-induced symptoms are more reported by women than men. Whether this is due to a higher sensitivity of women to alcohol or because women are more likely to report symptoms has yet to be determined (38). The relationship between nasal symptoms after alcohol consumption and airway diseases like AR,

14

NP, asthma, chronic bronchitis and COPD is suggested by some studies but should be further investigated (38).

2.4.2 Aim of this study Multiple chronic rhinosinusitis patients with nasal polyps have reported increased symptom burden after consuming alcoholic drinks. In this study, we will investigate the significance of this phenomenon.

In the existing literature, studies focused primarily on the association of asthma and alcohol- induced respiratory symptoms. Not much is known about the effect of alcohol in patients with chronic upper airway diseases, especially in CRSwNP. Our main focuses in this study will be the prevalence and significance of this problem and the characteristics of nasal alcohol- induced symptoms. We are interested in the causal beverages, the amount of alcohol needed to induce reaction, the duration of symptoms, the time to onset and how frequently alcohol use causes problems.

In this study, we focus on patients with NP. We will compare the results of this group with those of healthy subjects, patients with AR and patients with CRSsNP. We will also investigate the role of comorbidity asthma and aspirin-intolerance as they aggravate the burden of NP. We hope to find out if the severity of the disease is correlated with the severity of alcohol-induced symptoms and if the grade of inflammation is of importance. We will also try to find out if there are other confounding factors like age or sex that explain the presence of alcohol-induced symptoms. To do that, we have developed a questionnaire assessing every aspect of alcohol hyper-responsiveness in CRSwNP, AR, CRSsNP and healthy subjects. Furthermore, we were able to collect data on inflammatory markers from CRSwNP patients who previously underwent FESS surgery.

15

3 Materials and methods 3.1 Questionnaires 4 separate questionnaires were developed. One for CRSwNP patients, one for CRSsNP patients, one for AR patients and one for healthy controls. Each questionnaire contained information about alcohol-induced airway symptoms. Questioned elements were date of diagnosis and patient characteristics like age, origin, smoking habits and exposure to chemical substances. Also co-morbidities such as asthma, allergy, aspirin-intolerance and food allergy were questioned. We asked if patients consume alcohol, what kind of alcohol they drink and which symptoms usually occur after alcohol use. If a person suffered from AHR, we asked about the characteristics of these reactions. Disease severity was analyzed under current treatment based on visual analogue scales. Medical treatment with antibiotics, oral steroids and previous surgeries were noted. CRSwNP was considered as recurrent when 2 or more FESS were performed. The ethical committee of the Ghent University Hospital, Ghent, Belgium, approved the study. 3.2 Research population The CRSwNP, CRSsNP and AR patients used in our study were recruited from databases of University Hospitals in Ghent and Leuven, Belgium. The questionnaires were sent to 534 CRSwNP patients, 198 CRSsNP patients and 369 allergic rhinitis patients. A reminder questionnaire was sent after 6 weeks to the non-responders to increase response rate. Healthy control subjects from all ages were randomly contacted and included. Exclusion criteria for healthy volunteers were asthma, AR, aspirin-intolerance and chronic rhinosinusitis. Questionnaires with crucial missing answers were excluded, like disease that wasn’t confirmed by a specialist or disease that was influenced by abnormality of the nasal cavity. 420 questionnaires from CRSwNP patients were included, next to 137 AR questionnaires, 97 CRSsNP questionnaires and 180 healthy volunteer questionnaires. We intentionally chose to include more CRSwNP patients, although in a general population, the prevalence of CRSwNP is lower than the prevalence of AR and CRSsNP. Each responder gave his written informed consent. 3.3 Processing of the questionnaires In this study, we primarily focused on the prevalence of alcohol-induced airway hyperreactivity in nasal polyps. We compared these results with the prevalence in our control populations of AR, CRSsNP and healthy volunteers. We were also interested in the type of

16

symptoms induced by alcohol. Nasal blockage and rhinorrhea were considered as nasal hyperreactivity. Bronchial hyperreactivity gave symptoms like cough, wheezing, dyspnea and exacerbation of asthmatic symptoms. Itching, eczema, facial swelling and allergic exacerbations were defined as ‘other symptoms’. Patients also reported flushing but this was considered a physiological phenomenon rather than a symptom.

Next to the prevalence, our study also evaluated the characteristics of nasal alcohol-induced HR reactions. The severity, duration, onset, causal beverage and quantity necessary to provoke symptoms were analyzed. We represented the necessary quantity as ‘units’ of alcoholic drinks because the volume of 1 unit depends on the type of alcohol. Severity was analyzed by visual analogue scales. A score lower than 3 was considered mild, higher than 7 severe and the scores in between moderate. Other secondary endpoints were most reported symptoms and causal beverages. 3.4 Correlation with inflammatory markers If patients had had a previous functional endoscopic sinus surgery in the Ghent University Hospital, tissue was preserved if the patient had consented. We collected the data available for our study population. 138 CRSwNP patients had an available tissue sample. We analyzed following inflammatory markers, namely ECP, IL-5, IgE, S.aureus enterotoxin-specific IgE, IL-17, TNF α and IFN γ. 3.5 Statistical analysis The collected data were exported to SPSS to perform statistical analysis. The Fisher exact test was used to analyze categorical data and the Mann-Whitney-U test was performed to evaluate continuous data. The χ²-test with Bonferroni correction was used to compare the results of patients with nasal polyps to the control populations. We performed a multiple logistic regression test with age and gender as covariates to show that significance was independent from age and gender. The Spearman correlation coefficient was used to evaluate ECP-levels. For each test, a P-value of 0,05 or lower was considered as statistically significant.

17

4 Results 4.1 Demographics and characteristics of our study population

From the 1281 questionnaires that were sent, 834 questionnaires were included in this study. There was a response rate of 65% and 3 questionnaires were excluded. The majority of questionnaires in this study are taken from CRSwNP patients, 420 questionnaires were included. They are the main focus of our study. We compared their results with 137 questionnaires in the AR group, 97 questionnaires in the CRSsNP group and 180 questionnaires from healthy volunteers.

In table 1, the general characteristics of our study population are noted for each disease separately. In our healthy control group, people suffering from asthma and allergy were excluded. We found that 4 individuals of our healthy control group were aspirin-intolerant (2,2% of the control group) although normally, the prevalence of aspirin-intolerance varies between 0,3 and 0,9% (19). This difference is probably due to the small counts in this study. Aspirin-intolerance was more common in CRSwNP (14,5%) than in CRSsNP (4,1%) and AR (2,9%) (p < 0,001). This is normal because CRSwNP is known to be correlated with aspirin- intolerance.

The mean age of the healthy controls was 50 years, compared to 55 years in the CRSwNP group, 52 years in the CRSsNP group and 41 in the AR group. Epidemiological studies have shown that NP appear at the average age of 42, so we expected our CRSwNP patients to be older than our control group (p < 0,001) (6) . Normally the population suffering from CRSsNP is younger and the characteristics are more similar to healthy control individuals than to people suffering from CRSwNP (25). Our results confirmed these statements. Compared to CRSwNP, the diagnosis of CRSsNP was set earlier and the CRSsNP patients included in this study had a lower mean age. We found the lowest average age in the group of AR patients. The diagnosis was made at an average age of 22 which is normal because research has shown that symptoms usually occur before the age of 20 (23, 28).

Studies have suggested that CRSwNP is more common in men and asthmatics (5, 6). In our study 66,2% of the CRSwNP patients were male compared to 55,7% in the CRSsNP group and 38,7% in the AR group. So men indeed tent to develop polyps more easily (p < 0,001). In

18

the control group, both genders are almost equally represented. The higher percentage of female responders in AR can’t be declared by previous research. The prevalence of AR in adulthood is usually equal in boys and girls (28). 42,4% of our patients with nasal polyps also had comorbidity asthma, which is significantly more compared to the 14,4% in the group of CRSsNP patients and the 21,9% in the group of AR patients (p < 0,001). This is in line with prevalence’s found in studies, namely 15 to 40% for AR and 10-15% for CRSsNP (12, 23).

The prevalence of allergic rhinitis in patients with CRSwNP has been reported varying from 10% to 64% (3). In our study it is 47,1%. Allergy is less common in the group of CRSsNP patients than in the group of CRSwNP patients (18, 26). Food allergy had a higher prevalence in chronic airway diseases compared to healthy subjects (p < 0,001). In some studies cigarette smoking was correlated with a higher prevalence of CRSwNP (3). In our study, smoking habits were similar between groups. Almost all individuals included in the study were from European origin.

Except for the higher percentage of aspirin-intolerance in the control group and a bigger share of woman in the AR group, we found no differences with epidemiologic data found in previous research. No arguments suggest that the subjects in this study are not representative for the general population of patients from each disease.

19

Tabel 1: Characteristics of the study population Disease CRSwNP CRSsNP AR Healthy age mean 55 52 41 50 median 57 52 37 51 percentiles 25 46 41 28 33 75 65 62 37 51 minimum 19 24 21 22 maximum 96 83 78 91 SD 13,9 14,4 14,6 17,0 gender Male 278 (66,2%) 54 (55,7%) 53 (38,7%) 93 (51,7%) female 142 (33,8%) 43 (44,3%) 84 (61,3%) 87 (48,3%) ethnicity Europe 415 (98,8%) 96 (99,0%) 137 (100,0%) 178 (98,9%) Asia 4 (1,0%) 1 (1,0%) 0 Africa 1 (0,2%) 0 missing 2 (1,1%) allergic Yes 198 (47,1%) 33 (34,0%) 137 (100,0%) No 218 (51,9%) 64 (66,0%) 179 (99,4%) missing 4 (1,0%) 1 (0,6%) asthma yes 178 (42,4%) 14 (14,4%) 30 (21,9%) No 242 (57,6%) 82 (84,5%) 106 (77,4%) 180 (100,0%) missing 0 1 (1,0%) 1 (0,7%) aspirin tolerant 359 (85,5%) 92 (94,8%) 133 (97,1%) 176 (97,8%) intolerant 61 (14,5%) 4 (4,1%) 4 (2,9%) 4 (2,2%) food allergy 77 (18,3%) 21 (21,6%) 34 (24,8%) 13 (7,2%) no allergy 341 (81,2%) 74 (76,3%) 103 (75,2%) 165 (91,7%) missing 2 (0,5%) 2 (2,1%) 2 (1,1%) smoking never 199 (47,4%) 52 (53,6%) 90 (65,7%) 102 (56,7%) used to 175 (41,7%) 37 (38,1%) 31 (22,6%) 55 (30,6%) active 44 (10,5%) 8 (8,2%) 16 (11,7%) 23 (12,8%) missing 2 (0,5%) age diagnosis mean 40 38 22 median 40 38 19 percentiles 25 29 23 9 75 52 52 19 minimum 2 4 0 maximum 83 78 75 SD 15,7 19,1 16,5 duration disease mean 15 15 18 median 11 9 13 percentiles 25 5 6 5 75 21 9 26 minimum 2 1 2 maximum 66 57 62 SD 11,8 13,2 15,7

20

4.2 Correlations in healthy subjects?

In our healthy control group, 166 individuals drank alcohol and 14 didn’t. Based on the Mann-Whitney U-test, there was no significant difference in age between the two groups (p = 0,402). Based on the Fisher exact test, there was also no significant difference in gender (p = 0,270). Other features we tested with the Fisher exact test were aspirin-intolerance, food- allergy, contact with chemical substances, smoking habits, medication and skin disease. None of them were significant more common in one of the two groups (p > 0,05).

After excluding the 14 people who didn’t drink alcohol, we analyzed the remaining 166 subjects on alcohol-induced symptoms. 124 persons reported no additional symptoms after consuming alcohol, 27 persons reported blushing, 1 person reported more blockage of the nose, 3 persons reported an increase in nasal discharge, 1 person reported more coughing and breathing problems, 1 person reported both nasal and allergic symptoms, 2 persons reported eczema and 4 individuals chose the option ‘other’.

In this study, we considered blushing as a normal effect in response to alcohol. Therefore, only 6 persons complained of actual nasal and bronchial alcohol-induced symptoms. When we compared the characteristics of the individuals with alcohol-induced symptoms with the group who didn’t experienced any trouble with the Mann-Whitney U-test and the Fisher exact test, we found no differences in gender, age, aspirin-intolerance, food allergy, skin disease, medication, smoking habits and contact with chemical substances (p > 0,05). As expected, there was a significant difference in the VAS-scores (p < 0,05). Especially the VAS-score of itching ears, nose, throat and running nose were significantly different.

4.3 Alcohol-induced respiratory reactions in upper airway disease 4.3.1 Prevalence 4.3.1.1 Alcohol abstainers When we look at the alcohol consumption in the different subgroups of our study population, we see a big difference in the percentage of alcohol abstainers in each group (table 2). It is remarkable that the subgroup with the highest degree of inflammation, NERD, has the highest percentage of alcohol abstainers (23,4%). This percentage is significantly higher compared to

21

the control group (p < 0,001), the AR group (p < 0,001) and the CRSsNP group (p < 0,001) but also compared to the other subgroup of CRSwNP, namely CRSwNP without comorbidities (p < 0,001). Diseases with a lower grade of inflammation like AR, CRSsNP and CRSwNP alone have comparable abstainer levels as the healthy control group (p > 0,05). No significant difference was found between CRSwNP alone and AR or CRSsNP (p > 0,05). Neither between AR and CRSsNP mutually (p > 0,05). In the alcohol-consuming group characteristics weren’t significantly different from the abstainer group, except for smoking habits and gender. More people smoked in the alcohol-consuming group of CRSwNP and AR (p < 0,001) and in CRSwNP patients, there were more females who didn’t drink alcohol than men (p = 0,001).

Tabel 2: Alcohol consumption in our study population NERD CRSwNP CRSwNP CRSsNP AR healthy with asthma alone alcohol abstainer, 11 (23,4%) 20 (15,3%) 27 (11,8%) 11 (11,8%) 12 (8,8%) 14 (7,8%) n (%) units of 4 (0,5-10) 5 (2-10,75) 4 (1-10) 5 (2-10) 4 (2-7) 5 (2-10) alcohol/week, median (IQR)

4.3.1.2 Alcohol hyper-responsiveness After excluding the alcohol abstainers in each group, 738 subjects remained. 361 of them belonged to the CRSwNP subgroup, 125 to the AR subgroup, 86 to the CRSsNP subgroup and 166 to the control group.

22

Type of AHR 100%

90%

80%

70% upper and lower respiratory symptoms 60% lower respiratory symptoms 50% upper respiratory symptoms 40% Studypopulation 30% other symptoms

20% no alcohol hyper-responsiveness 10%

0% CRSwNP CRSwNP CRSwNP CRSsNP AR control with with alone NERD asthma

Figure 1: Prevalence of alcohol-induced symptoms

Figure 1 gives us a clear view at the variety of reactions induced by alcohol in the different disease (sub)groups of our study. CRSwNP with concomitant NSAID sensitivity has the highest percentage of AHR reactions, followed by CRSwNP with concomitant asthma, CRSwNP without comorbidities, AR and CRSsNP. We found the smallest amount of alcohol- induced symptoms in the control group. In all 6 categories upper respiratory symptoms were more common than lower respiratory symptoms. Diseases with a higher grade of inflammation had a higher percentage of both upper and lower respiratory symptoms. In the control group nobody reported both upper and lower respiratory symptoms.

The Fisher exact test found that the differences in nasal alcohol HR (table 3) were significant between CRSwNP, CRSsNP, AR and the control group (p < 0,001). But also between CRSwNP and AR or CRSwNP and CRSsNP (p < 0,001). Within the group of CRSwNP, comparisons were made between the different subgroups. A significant difference in alcohol- induced nasal HR was found between CRSwNP without comorbidities and NERD and between CRSwNP without comorbidities and CRSwNP with asthma (p < 0,001). The amount of people suffering from nasal and bronchia AHR was not significantly different in AR and CRSsNP (p > 0,05). Bronchial alcohol HR was significantly different in chronic airway

23

diseases compared to the control group (p < 0,005) and between the different subgroups of CRSwNP mutually (p < 0,001), except for NERD and CRSwNP with asthma (p > 0,05). Bronchial reactions were more common in patients with concomitant asthma (p < 0,001).

Tabel 3: Prevalence of alcohol hyper-responsiveness NERD CRSwNP CRSwNP CRSsNP AR healthy with asthma alone nasal HR, n (%) 44 (62,9%) 102 (46,4%) 124 (30,8%) 88 96 (25,8%) 6 (3,7%) (26,2%) respiratory HR, n (%) 20 (28,6%) 38 (17,1%) 20 (5,0%) 24 (7,0%) 21 (5,6%) 1 (0,6%)

To exclude that differences in age and gender are causative for the significant differences in AHR between diseases, we performed a multiple logistic regression test with age and gender as covariates. The odds of alcohol-induced HR remained significantly higher in CRSwNP compared to AR, CRSsNP and controls.

We found that in CRSwNP patients characteristics of a more aggressive disease were positively correlated with more alcohol-induced nasal hyper-responsiveness. The Fisher exact test found significant results for a VAS-score of more than 5 (p <0,001), recurrence of the polyps after FESS (p = 0,001), treatment with oral steroids (p < 0,001), treatment with antibiotics (p < 0,001), asthma and asthma treatment (p < 0,001), NSAID sensitivity and food allergy (p < 0,001). No significant results were found for treatment with only physiologic fluids and nasal steroids (p > 0,05) as they are the first step in CRSwNP treatment and thus used in lighter forms of CRSwNP. Neither treatment with anti-histamine (p = 0,197), IT (p = 0,091) or allergy itself (p = 0,107) were significantly correlated with more HR. We also found a significant difference between AHR and gender (p = 0,001) in CRSwNP, more female patients reported AHR compared to men. Smoking didn’t seem to influence AHR (p= 0,060).

24

4.3.2 Characteristics Nasal alcohol HR was the main focus of this study. 39,2% of our CRSwNP population reported to experience these symptoms. Among them, prevalence was highest in subjects with CRSwNP and NSAID intolerance (62,9%), followed by the subgroup with CRSwNP and asthma (46,4%). Alcohol-induced nasal symptoms were also reported by 26,2% of CRSsNP subjects, 25,8% of AR patients and 3,7% of the control population. More specific information about the characteristics of AHR was available for 129 CRSwNP patients (NERD n=20, CRSwNP with asthma n=45, CRSwNP patients without asthma n=64), 29 AR patients, 18 CRSsNP patients and 5 healthy subjects.

4.3.2.1 Causal beverages

Causal beverages 100% 90% 80% 70% all beverages 60% beer and wines 50% white wine 40% red wine 30% beers 20%

%of responders with AHR nasal spirits 10% 0% NERD CRSwNP CRSwNP CRSsNP AR control with alone asthma

Figure 2: Causal beverages of alcohol-induced nasal HR In our questionnaire, we asked responders which kind of beverages caused nasal AHR (figure 2). We clearly see here that there wasn’t a specific kind of drink that caused more symptoms than others. In almost every category the biggest group reacts to all types of alcoholic beverages, except for CRSwNP without comorbidities and CRSsNP. In these categories, symptoms after drinking respectively red wine and white wine were more common. The group of people reacting after drinking red wine is almost the same in each category. It is remarkable that red wine wasn’t more common in CRSwNP with asthma as previous research has indicated red wine as the most frequent inducer of asthma exacerbation.

25

4.3.2.2 Frequency of alcohol-induced nasal symptoms after alcohol

Frequency of nasal HR after alcohol 100% 90% 80% 70% 60% always 50% mostly 40% 30% sometimes 20% 10% %ofresponders with nasal AHR 0% CRSwNP CRSsNP AR control

Figure 3: Frequency of nasal HR after drinking alcohol People usually don’t always develop symptoms after drinking alcohol (figure 3). The categories ‘mostly’ and ‘always’ were more frequent in chronic airway diseases compared to healthy subjects. In our control subjects nobody reported symptoms every time they used alcohol. The biggest category in all 4 groups was the category ‘mostly’, meaning nasal symptoms occur in more than 50% of the cases after drinking alcohol. The highest percentage of the category ‘sometimes’, thus less than 50%, was found in the control group.

4.3.2.3 Severity of alcohol-induced nasal symptoms

Severity of alcohol-induced nasal symptoms 100% 90% 80% 70% 60% severe 50% moderate 40% mild 30% 20% % % resonders of with nasal AHR 10% 0% CRSwNP CRSsNP AR control

Figure 4: Severity of alcohol-induced nasal symptoms

26

Based on the VAS-scores of alcohol-induced nasal symptoms reported by patients, 3 grades of severity were constructed. Nasal symptoms in chronic airway diseases were generally more severe than in healthy subjects (figure 4). Symptoms reported by the control group were ‘mild’ in most cases. The most severe symptoms were reported by CRSwNP patients, followed by AR and CRSsNP. CRSwNP patient who experience symptoms after drinking alcohol reported nasal blockage to be their most frequent symptom (26,2%), rhinorrhea was also frequent (11,4%). Additionally, a change in smell was reported by the majority of patients.

4.3.2.4 Time to onset of alcohol-induced nasal symptoms

Onset of alcohol-induced nasal symptoms 100% 90% 80% 70% 60% >1 day 50% > 1h <1day 40% > 30 min 30% immediate 20%

% % respondersof withnasal AHR 10% 0% CRSwNP CRSsNP AR control

Figure 5: Onset of alcohol-induced nasal symptoms The time between drinking alcohol and developing symptoms can variate individually. In all four categories the biggest group of people developed nasal symptoms more than one hour and less than one day after drinking alcohol (figure 5). Patients with chronic airway disease reacted in approximately half of the cases within one hour after alcohol consumption. This in contrast to the control group, where nobody reacted this early. Only in AR some patients reported symptoms starting after more than one day.

27

4.3.2.5 Duration of alcohol-induced nasal symptoms

Duration of alcohol-induced nasal symptoms 100% 90% 80% 70% 60% > 1 day 50% > 1h < 1 day 40% < 1h 30% 20% % of responders with AHR nasal 10% 0% CRSwNP CRSsNP AR control

Figure 6: Duration of alcohol-induced nasal symptoms Nasal symptoms lasting less than 1 hour were only reported by patients with a chronic airway disease (figure 6). The highest percentage of this category was found in CRSwNP, the lowest percentage suffered from AR. In our control group, approximately half of the responders experienced symptoms lasting more than one day. In chronic airway diseases less people reported symptoms lasting this long. In all 3 chronic airway diseases most patients experienced symptoms during more than one hour and less than one day.

4.3.2.6 Quantity of units alcohol needed to elicit nasal symptoms

Quantity of units needed to elicit nasal symptoms 100% 90% 80% 70% 60% > 3 units 50% 2 units 40% 1 unit 30% 20%

% of responderswith nasal AHR 10% 0% CRSwNP CRSsNP AR control

Figure 7: Quantity of units needed to elicit nasal symptoms

28

Nasal symptoms were induced by a smaller amount of alcohol in chronic airway diseases compared to our control group (figure 7). Almost 80% of the healthy subjects with AHR only reacted to alcohol after more than 3 units of alcohol and nobody reported symptoms after one unit. In chronic airway disease symptoms could be provoked by 1 unit of alcohol in 36% of the cases of CRSwNP, in 44% of the cases of CRSsNP and in 22% of the cases of AR. Also the onset of symptoms was significantly correlated with the amount of alcohol consumed in CRSwNP (p < 0,001), CRSsNP (p < 0,001) and AR (p < 0,001). The more someone drank, the sooner symptoms occurred.

4.3.2.7 Relation of disease onset to nasal alcohol hyper-responsiveness

Relation of disease onset to nasal AHR 100% 90% 80%

70% 60% first diagnosis 50% at the same time 40% first alcohol HR 30% 20% % % responders of with AHR nasal 10% 0% CRSwNP CRSsNP AR

Figure 8: Relation of time of diagnosis to nasal alcohol hyper-responsiveness In our questionnaire, we investigated the time of diagnosis of chronic airway diseases in relation to the time of AHR onset (figure 8). We found a difference in diagnosis of the different diseases in relation to the moment nasal symptoms of AHR occurred. In AR and CRSwNP, alcohol HR symptoms were mostly present before the diagnosis of AR or CRSwNP was made. In CRSsNP, symptoms developed more frequently after the diagnosis of the disease was set.

29

4.4 Inflammatory markers in alcohol hyper-responsiveness in CRSwNP patients

Tissue from previous surgeries was available for 134 patients with CRSwNP. We compared levels of IgE, SAE-IgE, ECP, IL-5, IL-17, TNF α and IFN γ. A significant positive correlation between the level of ECP and the VAS-score after alcohol consumption was found with a spearman correlation coefficient of 0,248 (p = 0,005)(figure 9). So, a high level of ECP is positively correlated with a high burden of hyper-responsiveness after alcohol consumption. IgE, SAE-IgE, IL-5, IL-17, TNF α and IFN γ were not significantly correlated with the VAS- score after consuming alcohol.

VAS < 5 VAS > 5

Figure 9: Correlation between ECP and VAS-score after consuming alcohol

30

5 Discussion 5.1 Prevalence

3,7% of our healthy controls reported alcohol-induced nasal HR. In chronic airway diseases however, the prevalence was much higher. The highest prevalence was found in the group of patients with NERD (62,9%), followed by CRSwNP and asthma (46,4%), CRSwNP without comorbidities (30,8%), CRSsNP (26,2%) and AR (25,8%). These percentages were significantly higher than the one found in healthy subjects but also the differences between the different diseases were significant, except for the difference between AR and CRSsNP.

Upper alcohol-induced respiratory symptoms were more frequent compared to lower alcohol- induced respiratory symptoms. This is in line with the existing literature (41). Possible explanations for this observation can be found in a higher irritability of the nasal mucosa or maybe the selection of chronic upper airway diseases caused this finding. Bronchial HR was less common and was positively correlated with the presence of asthma (p < 0,001). In the study of Cardet et al. lower respiratory symptoms were only reported by NERD and ATA patients (41). In a NERD population, previous research has proven that alcohol-induced respiratory symptoms couldn’t be declared by asthma severity (41). In this study, lower respiratory symptoms were reported by patients in each disease group, even in the category CRSwNP without comorbidities. Asthma presence wasn’t necessary to develop lower respiratory symptoms.

In CRSwNP patients, more symptoms were reported by patients with a severe or recurrent form of the disease. Patient who already had had 2 of more FESS were more likely to report symptoms. People taking oral steroids or antibiotics and patients with a VAS-score higher than 5 out of 10 were also more susceptible. ECP-levels were positively correlated with the VAS-score after drinking alcohol, suggesting that AHR is more common in CRSwNP patients with a higher degree of eosinophilic inflammation.

We chose to use the term ‘hyper-responsiveness’ rather than sensitivity or allergy because symptoms are more a result of severe inflammation than a reaction to alcohol itself. This is shown by the fact that in susceptible people symptoms not always occur after drinking alcohol. Why someone develops symptoms at a certain moment is not completely clear. The disease state on that very moment is probably of importance. For example, in patients with seasonal allergy, symptoms may aggravate during pollen season or after exacerbations. Nasal

31

AHR may improve during treatment with oral steroids or after surgery. When NERD patients retried drinking after aspirin therapy in the study of Cardet et al., 63% noticed improvement (41). This supports our statement that the degree of eosinophilic inflammation is correlated with the presence of AHR.

No major arguments were found that patients in this study were not representative for the general group of patients from each disease. Only the female majority in the group of AR patients didn’t fit epidemiological data. This may be due to the fact that in general, woman are more likely to reply to questionnaires. Age and gender were different in the chronic airway diseases. This is normal because each disease has its own epidemiological profile. To exclude that these variations caused our significant results, we performed a multiple logistic regression test. Differences between the disease groups remained significant. 5.2 Characteristics

We compared characteristics of nasal alcohol-induced symptoms between the different disease entities and healthy controls. We found that in chronic airway diseases, people usually developed symptoms in more than 50% of the cases after drinking alcohol. These symptoms were more severe and occurred sooner compared to healthy subjects. Approximately 50% of patients with chronic airway diseases developed symptoms within one hour and symptoms usually disappeared within one day. The most severe reactions were reported by CRSwNP patients. This is in line with previous research where ATA and NERD patients experienced the most forceful reactions after drinking red wine (41). In healthy subjects, symptoms occurred less than 50% of the times after drinking alcohol and it took more time for symptoms to occur. They usually developed within one day after drinking alcohol.

The quantity of alcohol necessary to develop symptoms is much higher in control subjects than in people with chronic airway diseases. This may indicate that people suffering from an airway disease are more sensitive to alcohol than healthy individuals. We also found that the more someone drank, the sooner symptoms occurred. In CRSwNP and AR patients, AHR mostly occurred before the diagnosis of the disease was set. However, it’s possible that nasal polyps were already present.

As previous research suggested, we found that all alcoholic beverages could cause AHR (33, 35, 38, 40, 41). This suggests that components common to all alcoholic drinks are causative for AHR. Previously, red wine was reported as the most frequent trigger of asthma

32

exacerbations in asthma patients (33, 35, 38, 40). In our study, we found that people with nasal AHR mostly reported ‘all alcoholic beverages’ as inducer of symptoms, although red wine alone was also frequently reported. This can be due to the fact that literature mostly focused on lower airway symptoms and asthma exacerbations, unlike our study which focuses on nasal symptoms. 5.3 Mechanisms

Mechanisms that explain the existence of AHR symptoms are not unraveled yet. Our results suggest that components common to all alcoholic beverages are causative for AHR. Previous studies have suggested that both additives and alcohol itself can provoke alcohol-induced respiratory symptoms. Proposed additives are sulfites (44, 46), histamine (39, 40) and salicylates (35). 2 arguments make it unlikely that sulfites are the main cause of AHR (44, 46). Firstly, sulfite hypersensitivity is a rare phenomenon in non-asthmatics and secondly responders with AHR did not indicate additional hyper-responsiveness to sulfite-containing foods. Histamine isn’t the main cause of AHR either. People who took an anti-histaminic before drinking red wine reported a decrease in rhinitis symptoms but the most prominent symptom, nasal blockage, wasn’t influenced (39).

Furthermore, the level of total serum immunoglobulin E rises after alcohol consumption (37, 40, 47, 48). This can be the cause or consequence of adapted immune responses. The role of this phenomenon has yet to be determined. Both aspirin hypersensitivity as AHR are a result of eosinophilic inflammation in chronic inflammatory airway diseases. A common pathogenesis has been suggested (41). Finally, non-specific mechanisms like vasodilatation are proposed too (49). They may be responsible for the small percentage of AHR in control subjects. We propose a challenge test with diluted ethanol to further investigate underlying mechanisms of AHR. 5.4 Clinical implications

The results in this study are of clinical significance because they suggest that patients with chronic airway diseases should be warned for the effects of alcohol. Alcohol avoidance may give better symptom control and prevent a lot of suffering. These results are also of importance for the ENT-specialist because polyp recurrence after FESS and uncontrollable

33

disease are more likely in patients with AHR. Furthermore, this study shows that alcohol as a carrier in topical medication should be avoided. 5.5 Limitations

Due to the method we chose to evaluate our research population, certain limits were inevitable. A questionnaire was used to collect data, so disease severity and comorbidities were self-reported. The date of diagnosis of CRSwNP, CRSsNP or AR was obligatory for inclusion in the study, but asthma, allergy and NSAID exacerbated disease were not further confirmed. This also means that AHR was not measured objectively and that individual features influenced to what degree symptoms were experienced as troublesome. This may explain why the prevalence of AHR in NERD was lower than reported by Cardet et al..

Secondly, we can’t rule out the presence of response bias. It is possible that people who experience more symptoms after drinking alcohol were more likely to answer the questionnaire. Also, we asked for drinking habits which is a sensitive issue. People possibly reported to drink less than they normally do or didn’t fill in the questionnaire at all. Furthermore, alcohol abstainers were not asked about characteristics of AHR and were excluded from further analysis. Our questionnaire should have asked about the reason for alcohol avoidance as alcohol-induced symptoms may cause persons to quit drinking. Especially because abstainer levels paralleled the grade of inflammation in each disease.

We should keep in mind that almost the complete study population existed out of people from European origin so our results shouldn’t be generalized. Differences are possible in subsets with a different ethnicity. Finally, there were only 6 healthy individuals who reported AHR symptoms. We compared characteristics of nasal hyper-responsiveness symptoms in chronic upper airway diseases with only a few subjects. We weren’t able to find confounding factors in the healthy control group that could explain the existence of AHR but possibly the test subset was too small to find statistically significant results. 5.6 Provocation study

A second follow-up study is currently performed to further investigate the conclusions made based on the questionnaires. Our goal is to compare the results of the subjective reports in the questionnaires with objective parameters measured after alcohol challenge. In this study, CRSwNP patients and healthy controls are both asked to smell and drink diluted ethanol.

34

Afterwards, CRSwNP patients with a positive outcome after alcohol challenge are treated with medrol, if they consent, to investigate the role of inflammation in AHR. With this study, we want to determine whether patients show the same reactions after drinking pure diluted ethanol as they reported in the questionnaires after drinking alcoholic beverages.

34 CRSwNP patients and 14 control individuals were included in the challenge study. 21 CRSwNP patients reported to suffer from AHR before the challenge test. Two of them had a positive outcome after placebo challenge and nine of them had a positive outcome after alcohol challenge. From the CRSwNP patients who didn’t reported AHR before the challenge study, one person had a positive outcome after the placebo challenge test and three persons had a positive outcome after the alcohol challenge test. In the control group, nobody reported to develop symptoms after alcohol consumption but still one person had a positive outcome after placebo challenge and four persons had a positive outcome after alcohol challenge.

So far, the most prominent measurable changes were noted in the mean rhinomanometry scores compared to baseline. A decrease is seen in subjects with a positive outcome after alcohol challenge and an increase occurred in individuals with a negative outcome after alcohol challenge (figures 10 and 11).

180,00% 160,00% 140,00% 120,00% 100,00% positive outcome in 80,00% CRSwNP patients 60,00% 40,00% negative outcome in CRSwNP patients 20,00% 0,00% general

Figure 10: The evolution of the mean rhinomanometry scores compared to baseline in CRSwNP patients

35

240,00% 220,00% 200,00% 180,00% 160,00% 140,00% 120,00% positive outcome in 100,00% control patients 80,00% 60,00% negative outcome in 40,00% control patients 20,00% 0,00% general

Figure 11: The evolution of the mean rhinomanometry scores compared to baseline in control subjects

36

6 Conclusion

In this study, we found that the prevalence of self-reported hyper-responsiveness was higher in chronic airway diseases compared to healthy controls. The highest prevalence was found in NERD, the most severe disease entity of CRSwNP. Recurrent, uncontrollable and aggressive forms of CRSwNP were also more likely to report AHR. We conclude that AHR after alcohol consumption is common and that the prevalence is positively correlated with the severity of chronic upper airway disease. The percentage of abstainers in each group seemed to parallel the severity too. In each disease subgroup nasal hyper-responsiveness symptoms were more common than bronchial hyper-responsiveness symptoms. Characteristics of nasal alcohol- induced symptoms differed between the different diseases. We found that ECP levels in nasal tissue were higher in patients who reported to react to alcohol. This further suggests the correlation between eosinophilic inflammation and AHR. To conclude, our study found that nasal AHR is related to the severity of upper airway inflammation.

37

7 References 1. Van Crombruggen K, Zhang N, Gevaert P, Tomassen P, Bachert C. Pathogenesis of chronic rhinosinusitis: inflammation. J Allergy Clin Immunol. 2011;128(4):728-32. 2. Bachert C, Pawankar R, Zhang L, Bunnag C, Fokkens WJ, Hamilos DL, et al. ICON: chronic rhinosinusitis. World Allergy Organ J. 2014;7(1):25. 3. Fokkens WJ, Lund VJ, Mullol J, Bachert C, Alobid I, Baroody F, et al. EPOS 2012: European position paper on rhinosinusitis and nasal polyps 2012. A summary for otorhinolaryngologists. Rhinology. 2012;50(1):1- 12. 4. Akdis CA, Bachert C, Cingi C, Dykewicz MS, Hellings PW, Naclerio RM, et al. Endotypes and phenotypes of chronic rhinosinusitis: a PRACTALL document of the European Academy of Allergy and Clinical Immunology and the American Academy of Allergy, Asthma & Immunology. J Allergy Clin Immunol. 2013;131(6):1479-90. 5. Fu QL, Ma JX, Ou CQ, Guo C, Shen SQ, Xu G, et al. Influence of self-reported chronic rhinosinusitis on health-related quality of life: a population-based survey. PLoS One. 2015;10(5):e0126881. 6. Chaaban MR, Walsh EM, Woodworth BA. Epidemiology and differential diagnosis of nasal polyps. Am J Rhinol Allergy. 2013;27(6):473-8. 7. Bachert C, Zhang N, van Zele T, Gevaert P. Chronic rhinosinusitis: from one disease to different phenotypes. Pediatr Allergy Immunol. 2012;23 Suppl 22:2-4. 8. Bachert C, Claeys SE, Tomassen P, van Zele T, Zhang N. Rhinosinusitis and asthma: a link for asthma severity. Curr Allergy Asthma Rep. 2010;10(3):194-201. 9. Chung JH, Lee YJ, Kang TW, Kim KR, Jang DP, Kim IY, et al. Altered Quality of Life and Psychological Health (SCL-90-R) in Patients With Chronic Rhinosinusitis With Nasal Polyps. Ann Otol Rhinol Laryngol. 2015;124(8):663-70. 10. Hulse KE, Stevens WW, Tan BK, Schleimer RP. Pathogenesis of nasal polyposis. Clin Exp Allergy. 2015;45(2):328-46. 11. Dixon AE, Kaminsky DA, Holbrook JT, Wise RA, Shade DM, Irvin CG. Allergic rhinitis and sinusitis in asthma: differential effects on symptoms and pulmonary function. Chest. 2006;130(2):429-35. 12. Bachert C, Vignola AM, Gevaert P, Leynaert B, Van Cauwenberge P, Bousquet J. Allergic rhinitis, rhinosinusitis, and asthma: one airway disease. Immunol Allergy Clin North Am. 2004;24(1):19-43. 13. Bachert C, Zhang N. Chronic rhinosinusitis and asthma: novel understanding of the role of IgE 'above atopy'. J Intern Med. 2012;272(2):133-43. 14. Huvenne W, van Bruaene N, Zhang N, van Zele T, Patou J, Gevaert P, et al. Chronic rhinosinusitis with and without nasal polyps: what is the difference? Curr Allergy Asthma Rep. 2009;9(3):213-20. 15. Constantino Gde T, Mello Jr JF. Remodeling of the lower and upper airways. Braz J Otorhinolaryngol. 2009;75(1):151-6. 16. Jarvis D, Newson R, Lotvall J, Hastan D, Tomassen P, Keil T, et al. Asthma in adults and its association with chronic rhinosinusitis: the GA2LEN survey in Europe. Allergy. 2012;67(1):91-8. 17. Keith PK, Conway M, Evans S, Wong DA, Jordana G, Pengelly D, et al. Nasal polyps: effects of seasonal allergen exposure. J Allergy Clin Immunol. 1994;93(3):567-74. 18. Bonfils P, Avan P, Malinvaud D. Influence of allergy on the symptoms and treatment of nasal polyposis. Acta Otolaryngol. 2006;126(8):839-44. 19. Choi JH, Kim JH, Park HS. Upper airways in aspirin-exacerbated respiratory disease. Curr Opin Allergy Clin Immunol. 2015;15(1):21-6. 20. Choi JH, Kim MA, Park HS. An update on the pathogenesis of the upper airways in aspirin-exacerbated respiratory disease. Curr Opin Allergy Clin Immunol. 2014;14(1):1-6. 21. Babu KS, Salvi SS. Aspirin and asthma. Chest. 2000;118(5):1470-6. 22. Rajan JP, Wineinger NE, Stevenson DD, White AA. Prevalence of aspirin-exacerbated respiratory disease among asthmatic patients: A meta-analysis of the literature. J Allergy Clin Immunol. 2015;135(3):676-81 e1. 23. Bousquet J, Anto JM, Demoly P, Schunemann HJ, Togias A, Akdis M, et al. Severe chronic allergic (and related) diseases: a uniform approach--a MeDALL--GA2LEN--ARIA position paper. Int Arch Allergy Immunol. 2012;158(3):216-31. 24. Van Zele T, Gevaert P, Holtappels G, Beule A, Wormald PJ, Mayr S, et al. Oral steroids and doxycycline: two different approaches to treat nasal polyps. J Allergy Clin Immunol. 2010;125(5):1069-76 e4. 25. Tan BK, Chandra RK, Pollak J, Kato A, Conley DB, Peters AT, et al. Incidence and associated premorbid diagnoses of patients with chronic rhinosinusitis. J Allergy Clin Immunol. 2013;131(5):1350-60. 26. Brozek JL, Bousquet J, Baena-Cagnani CE, Bonini S, Canonica GW, Casale TB, et al. Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines: 2010 revision. J Allergy Clin Immunol. 2010;126(3):466-76.

38

27. Bousquet J, Fokkens W, Burney P, Durham SR, Bachert C, Akdis CA, et al. Important research questions in allergy and related diseases: nonallergic rhinitis: a GA2LEN paper. Allergy. 2008;63(7):842-53. 28. Greiner AN, Hellings PW, Rotiroti G, Scadding GK. Allergic rhinitis. Lancet. 2011;378(9809):2112-22. 29. Baiardini I, Braido F, Tarantini F, Porcu A, Bonini S, Bousquet PJ, et al. ARIA-suggested drugs for allergic rhinitis: what impact on quality of life? A GA2LEN review. Allergy. 2008;63(6):660-9. 30. Obaseki D, Potts J, Joos G, Baelum J, Haahtela T, Ahlstrom M, et al. The relation of airway obstruction to asthma, chronic rhinosinusitis and age: results from a population survey of adults. Allergy. 2014;69(9):1205- 14. 31. Feng CH, Miller MD, Simon RA. The united allergic airway: connections between allergic rhinitis, asthma, and chronic sinusitis. Am J Rhinol Allergy. 2012;26(3):187-90. 32. Bousquet J, Schunemann HJ, Zuberbier T, Bachert C, Baena-Cagnani CE, Bousquet PJ, et al. Development and implementation of guidelines in allergic rhinitis - an ARIA-GA2LEN paper. Allergy. 2010;65(10):1212-21. 33. Ayres JG. Alcohol-induced bronchial asthma. J Allergy Clin Immunol. 1997;99(6 Pt 1):860. 34. Dahl R, Henriksen JM, Harving H. Red wine asthma: a controlled challenge study. J Allergy Clin Immunol. 1986;78(6):1126-9. 35. Vally H, de Klerk N, Thompson PJ. Alcoholic drinks: important triggers for asthma. J Allergy Clin Immunol. 2000;105(3):462-7. 36. Liu AH, Jaramillo R, Sicherer SH, Wood RA, Bock SA, Burks AW, et al. National prevalence and risk factors for food allergy and relationship to asthma: results from the National Health and Nutrition Examination Survey 2005-2006. J Allergy Clin Immunol. 2010;126(4):798-806 e13. 37. Lieberoth S, Backer V, Kyvik KO, Skadhauge LR, Tolstrup JS, Gronbaek M, et al. Intake of alcohol and risk of adult-onset asthma. Respir Med. 2012;106(2):184-8. 38. Nihlen U, Greiff LJ, Nyberg P, Persson CG, Andersson M. Alcohol-induced upper airway symptoms: prevalence and co-morbidity. Respir Med. 2005;99(6):762-9. 39. Andersson M, Persson CG, Svensson C, Cervin-Hoberg C, Greiff L. Effects of loratadine on red wine- induced symptoms and signs of rhinitis. Acta Otolaryngol. 2003;123(9):1087-93. 40. Linneberg A, Berg ND, Gonzalez-Quintela A, Vidal C, Elberling J. Prevalence of self-reported hypersensitivity symptoms following intake of alcoholic drinks. Clin Exp Allergy. 2008;38(1):145-51. 41. Cardet JC, White AA, Barrett NA, Feldweg AM, Wickner PG, Savage J, et al. Alcohol-induced respiratory symptoms are common in patients with aspirin exacerbated respiratory disease. J Allergy Clin Immunol Pract. 2014;2(2):208-13. 42. Wantke F, Hemmer W, Haglmuller T, Gotz M, Jarisch R. Histamine in wine. Bronchoconstriction after a double-blind placebo-controlled red wine provocation test. Int Arch Allergy Immunol. 1996;110(4):397-400. 43. Sisson JH. Alcohol and airways function in health and disease. Alcohol. 2007;41(5):293-307. 44. Vally H, Misso NL, Madan V. Clinical effects of sulphite additives. Clin Exp Allergy. 2009;39(11):1643-51. 45. Zellweger JP. Alcohol-induced asthma: Not only in Asians. Journal of Allergy and Clinical Immunology. 1997;99(6):860. 46. Lester MR. Sulfite sensitivity: significance in human health. J Am Coll Nutr. 1995;14(3):229-32. 47. Friedrich N, Husemoen LL, Petersmann A, Nauck M, Volzke H, Linneberg A. The association between alcohol consumption and biomarkers of alcohol exposure with total serum immunoglobulin E levels. Alcohol Clin Exp Res. 2008;32(6):983-90. 48. Gonzalez-Quintela A, Garrido M, Gude F, Campos J, Linneberg A, Lojo S, et al. Sensitization to cross- reactive carbohydrate determinants in relation to alcohol consumption. Clin Exp Allergy. 2008;38(1):152-60. 49. Puddey IB, Zilkens RR, Croft KD, Beilin LJ. Alcohol and endothelial function: a brief review. Clin Exp Pharmacol Physiol. 2001;28(12):1020-4.

39

8 Appendices Appendix 1: Informed Consent

VII

VIII

Appendix 2: Questionnaire for healthy volunteers

IX

X

XI

XII

XIII

XIV

Appendix 3: Questionnaire for CRSwNP patients

XV

XVI

XVII

XVIII

XIX

XX

XXI

Appendix 4: Questionnaire for CRSsNP patients

XXII

XXIII

XXIV

XXV

XXVI

XXVII

Appendix 5: Questionnaire for AR patients

XXVIII

XXIX

XXX

XXXI

XXXII

XXXIII

XXXIV

Appendix 6: Publication Alcohol hyper-responsiveness in chronic rhinosinusitus with nasal polyps

XXXV

XXXVI

XXXVII

XXXVIII

XXXIX

XL

XLI

XLII

XLIII