talk about innate immunity in the nose, especially mucociliary clearance

1. 5th RMH FESS and 3rd Rhinoplasty Course
Riyadh Military Hospital
Sunday, Nov 13, 2011
Steven M. Houser, MD, FAAOA
Associate Professor,
Case Western Reserve University
Cleveland Ohio, USA
Nasal Mucosal Defense and
Mucociliary Clearance

2. Outline
• Adaptive
• T and B cells
• Innate
• Nasal/respiratory mucus
• Cilia
• Mucous membrane
• Mucociliary Clearance (MCC)
• Selected diseases affecting MCC

3. Adaptive Immunity
• CRS mediated by T helper cells
• Th1
• INF-γ, TNF-α: activate macrophages and cytotoxic T
lymphocytes
• Th2
• IL-4,5,9,13: promote IgG & IgE production, support
eosinophils & mast cells
• IL-13 pro-eo role appears central to CRS
• Generally Th1 and Th2 effects counter/balance each
other
Ramanathan, Oto HNS, 2007

4. Innate Immunity
• Respiratory epithelium critical for innate immunity
• appropriate mucus/periciliary fluid
• coordinated ciliary activity
• Respiratory secretions consist of:
• 95% water
• 1% sodium chloride
• 0.5-1% free protein
• 0.5-1% mucins (glycoproteins)
Houtmeyers, Eur Respir J 1999

5. Respiratory Mucus
• Gel and sol layers
• 10 µm thick
• 1 to 2 L per day are
produced under
normal
circumstances
• Mucus noted when:
• Too much produced
• Too dry

6. Respiratory Mucus
• Gel:
• Produced by goblet cells and submucosal glands
• Mucin (glycoprotein)
• Immunoglobulins (IgG/A), albumin, lactoferrin,
lysozyme
• Sol:
• Periciliary fluid
• Nonciliated columnar cells (microvilli)
• Minimal glycoprotein, serum protein
• H2O, electrolytes

7. Respiratory Mucus
• Mucus swept to nasopharynx by MCC at 1cm/min
• Mucus blanket swallowed & replaced q10-20min
under resting conditions
• (MCC to follow later)

8. Respiratory Mucus
• Major proteins:
• Albumin 15%
• IgG 2-4%
• s-IgA 15%
• Lactoferrin 2-4%
• Lysozyme 15-30%
• Secretory leukoprotease inhibitor 10%
• Mucous glycoproteins (MGP) 10-15%

9. Mucus glycoprotein (MGP)
• 2-400,000 daltons
• Rapid turnover
• Traps particulates, and removed per
MCC
• Insulates mucosa below
• Traps moisture below gel layer
• Acts as a reservoir for humidification
of inspired/expired air
• MUC1, MUC4, MUC16, MUC5AC,
MUC5B

10. Immunoglobulins
• Plasma cells in mucosa
make 25% IgG, 75% IgA
• S-IgA binds microorganisms
in airway
• IgG acts within the mucosa
itself
• IgG appears more essential
for defense IgG

11. Lysozyme
• 14,000 daltons (small)
• Produced by serous cell of
submucosal glands
• Kills airborne bacteria
• Prevents mucosal infection

12. Lactoferrin
• Made by serous cells
• Bacteriostatic and
bacteriocidal
• Binds iron, this seems to
play a role in its action to
kill bacteria

13. Additional innate defense molecules
• membrane-permeabilizing defensins
• cathelicidins
• secretory leukoprotease inhibitor (SLPI)
• elafin
• calcium-dependent collectins
• pulmonary surfactant proteins (SPA and SP-D)
• serum-derived mannose binding protein.
Kauffman, Clin Rev All Immunol 2006

14. Surfactant
• Phospholipids make up 80-90%
• Surfactant proteins 10-15%
• surfactant proteins (SPA and SP-D)
• Antimicrobial properties v Staph, Pseudo, Strep
• Inhibit growth of G(-) bacteria
• Dampen allergic immune response
• Coats gel layer to reduce surface tension
• Reduces mucosal viscosity at gel-sol interface
• Aids in elimination of deposited particles
Schlosser, Ann Otol Rhinol Laryngol 2006

15. Toll-like receptors (TLR)
• Transmembrane pattern recognition proteins
• Embryologically ancient
• Originally identified in Drosophila (fruit flies)
• Macrophages, dendritic cells, endothelial &
epithelial cells
• Recognize molecular patterns
• Endotoxin, flagellin, lipopeptides, ds RNA, bacterial
DNA
• Local immune response
• Initiate communication with adaptive immune system
Ramanathan, Oto HNS, 2007

16. Cilia
• Axoneme
• 2 central microtubules
• 9 doublets with dynein arms
• 6 µm long x 0.2 µm diameter
• Tipped by a “crown with bristles”
• Glycocalyx sheath
• 200 per ciliated cell
• 109
cilia/cm2
in respiratory tract

19. Cilia
• Normal CBF: 12-15 Hz
• Effective stroke:1 :: recovery stroke:3
• Weight capacity: 20mg/mm2
• 50%+ epith. destroyed before effect
• Transplant maintains previous direction
• Metachronal rhythm
• adjacent cilia recruited per hydrodynamic forces and intracellular
communication
Meeks, Pediatric Pulmonary 2000

20. Gel
Sol

21. Cilia
• Tubular anomalies: secondary, assoc.
with infection, of minor importance
• Compound cilia: irrelevant finding
Toskala, Acta Otolaryngol 1995

22. Mucous Membrane
• Pseudostratified ciliated columnar
• 100-200 cm2
mucosal surface within nose
• Ciliated (near 80% cells)
• Goblet (near 20% cells)
• Non-ciliated
• Basal
• (Clefts with normal epithelium)Al-Rawi, Laryngoscope 1998
Cohen, Ann Oto Rhin Laryng 2006

23. microvillar goblet
ciliated
basal

24. Mucous Membrane
• Submucosa
• tubuloalveolar
seromucinous glands
• blood vessels
• nerves
• transient inflammatory
cells

25. Mucociliary Clearance
• Mucus + ciliated epith. work together
• 6 mm/min. (range 1 - 20)
• 10 - 20 min. to clear inhaled particles
• Nearly 100% particles >4 µm removed

26. Sinuses
• Pseudostratified ciliated
columnar
• Approx. 300 cm2
surface
• 5% of mucus = from sinus
• scant submucosal glands
• less goblet cells (except
maxillary)

27. Mucus Flow
• Floor → directly posterior to soft palate
• Low/mid septum → upward and straight back
• Upper septum → downward to inf/post vomer
• Inf turb → lateral undersurface to torus
• Ant inf turb (1 cm) → anterior
Waguespack, Laryngoscope 1995

28. Mucus Flow
• Maxillary sinus: star-shaped from bottom of sinus to
natural ostium
• Frontal: sweeps in a large curve rising from medial
→ roof → lateral → nasofrontal duct
• Ethmoid and sphenoid not precisely described

29. Mucus Flow
• Ant ethmoidectomy with antrostomy
• Tracer circles around antrostomy → post/inf direction to
inf turb → pharynx
• Ant/post ethmoidectomy with antrost.
• Post eth → ant eth → post/inf to inf turb
• Post ethmoid recirculation (clockwise)
• Rare stasis at junction ant & post ethmoid

30. Mucus Flow
• Partially resected middle turbinate
• Superior
• Up to uncinate → ant/inf to inf turb
• Directly posterior along lateral undersurface
• Inferior
• Inferior along undersurface
• Lateral
• Medial

31. Mucus Flow
• Lateral wall concha bullosa taken
• Tracer moved laterally → ant eth region
• Sphenoid
• Med and lat toward ostium →
• Along rostrum to nasopharynx (NP)
• Posterior ethmoid → ant → inf turb → NP
• Spin around ostium → NP

34. MCC along lateral wall

35. MCC post uncinectomy

36. MCC at maxillary antrostomy

37. MCC at MT post part resect

38. MCC post concha resection

39. MCC post anterior ethmoidectomy

40. MCC post ant/post ethmoidectomy

41. MCC at sphenoidotomy

42. Mucus Flow
• Synechiae slow transport to lateral wall
• R vs L may show different pattern, despite same
surgery
• Flow around, not over, obstructions
• Stasis noted in up to 30%
• Unoperated middle turbinate may show stasis
• Recirculation phenomenon

43. Measurement
• In Vitro
• Mucus analysis
• frog palate, oscillating sphere magnetic rheometer, capillary
viscometer, Searle system, controlled stress technique
• Quraishi, Clin Otolaryngol 1998
• Ciliary beat frequency (CBF)
• photoelectric, laser scatter, visual counting (phase contrast
microscopy)

44. Measurement: in vitro
• Sampling
• nasal brushing
• nylon brush or calgi swab
• for ultrastructural studies
• cup forceps biopsy
• continuous layer of cells with basal layer
• nasal surgery
• whole turbinate specimens

45. Measurement: in vivo
• In Vivo
• Mucociliary wave frequency
• light scattering instrument
• Mucus transport time
• aluminum discs(G), radioactively-tagged resin particles(G),
graphite(G), dye(S/G), saccharin test(S/G)
• S=sol layer, G=gel layer

46. Measurement: in vivo
• Saccharin time (ST)(MTT, MTR)
• pharmaceutical grade saccharin (?)
• medial side of inferior turbinate, 1 cm back
• 1 mm saccharin on ring curette
• swallow Q 30 sec.; no nose blowing/snuffling
• 1st taste sweet=end test
• stop at 30 or 60 min. if not (+) and place on tongue to
confirm ability to taste
• Meta analysis of available literature: 13 min. mean ST
Cmejrek, OHNS 2005

47. Saccharin Test

48. Saccharin Test

49. Saccharin Test

50. Natural ostium Accessory ostium

52. Selected disorders affecting MCC
• Primary ciliary dyskinesia (PCD)
• Ciliary disorientation (CD)
• Cystic fibrosis
• Young’s syndrome
• Allergic rhinitis
• Chronic rhinosinusitis
• Viral rhinitis

53. Primary Ciliary Dyskinesia
• Autosomal recessive
• 1:15 - 30,000 in population
• Symptoms begin shortly after birth
• Chronic sinusitis & bronchiectasis
• Immotile sperm
• Kartagener’s = same + situs inversus
Li, Drugs 2007

54. Primary Ciliary Dyskinesia
• Ultrastructural
abnormalities
• Dynein arm defect
• Radial spoke defect
• Abnormal length
• Management
• Medical: ATB, chest
percussion
• Surgical: PE tubes (?), sinus
surgery

55. Ciliary Disorientation
• Clinically appear as PCD
• Absent MCC
• Normal CBF/axoneme/mucus
• Mean ciliary orientation:
• Disoriented: 23.30
• Normal: 12.80
Rayner, Am J Resp Crit Care Med, 1996
Bertrand, Acta Oto 2000

56. Ciliary Disorientation
=angle

57. Ciliary Disorientation
• Reversible if due to chronic upper resp tract
infection (viral or bacterial)
• Noted in asthma and bronchitis
• Irreversible cases treated as PCD
• CD a better correlate of poor MCC than reduced
CBF or abnl ciliary ultrastructure
Rayner, Am J Resp Crit Care Med 1996

58. Christmas, ENT J 2007

59. Cystic Fibrosis
• Autosomal recessive
• 1/2500 live Caucasian
births
• Defective CFTR (Cystic Fibrosis
Transmembrane Conductance Regulator)
• Poor chloride permeability
• Sodium hyperabsorbtion
• Desiccate mucus
• Tissue edema

60. Cystic Fibrosis
• Sx: chronic airway infect, exocrine pancreatic
insufficiency, abnormal sweat, urogenital
dysfunction
• Dx: clinical, sweat, genetic
• Tx: ATB, PP&D, DNAse, dependant sinus surgery
(?)

61. Young’s Syndrome
• Adult onset
• Unknown etiology
• Sx: sinusitis, bronchiectasis, obstructive
azoospermia
• Normal ciliary ultrastructure
• No CD at base, CD noted at tips
• secondary to abnormal mucus?
de Iongh , Thorax, 1992

64. Allergic Rhinitis
• Transient increased CBF acutely
• Increased CBF: leukotrienes (C4) & D4
• Altered rheologic properties & quantity of mucus
(increase submucosal glands)
• Cyrus, OHNS 1998
• Chronic depression of MCC
• Late effects of inflammation on rheology
• Nathan, JACI 2005

66. Chronic Rhinosinusitis
• Some debate as to effect
• CBF incr
• 15.9 Hz (normals) → 16.6 Hz (77% of CRS subjects)
• Nuutinen, Arch Otol H&N 1993
• Most agree MCC worsened
• Occluded OMC + bacteria = significant decrease CBF &
increase MTT
• CBF & MTR normalized 6 wk. post middle meatal
antrostomy
• Czaja, A J Rhinol 1998

67. Chronic Rhinosinusitis
• CBF reduction organism specific
• Decr: H. influenza, P. aeruginosa, S. epidermidis,
Mycoplasma p.
• Unchanged: S. pneumonia, M. catarrhalis
• Nuutinen, Arch Otol H&N 1993
• Toremalm, Eur J Respir Dis 1985
• Step pneumo > bacteroides:
• # of ciliary ultrastructural changes
• Toskala, Acta Otolaryngol 1997

68. Chronic Hyperplastic Rhinosinusitis
(CRSwNP)
• Polyps cause no significant
decrease in CBF & MCC
• If MCC worsened, then
likely due to mucus
changes
• Slater, Clin Otolaryngol 1995

69. Viral URI
• MCC
• Worsened by 120
post innoculation
• Maximal decrease by 3 days
• Slowed at 9 - 11 days
• Ultrastructural changes per EM
• 3 day: no change
• 1 week: few cilia remain
• 3 week: regenerating cilia, normal orient
Rautiainen, Ann Otol Rhinol Laryngol 1992

70. Conclusion
• Innate nasal mucosal defense plays an important
role in health
• Mucociliary clearance is a complex and vital
function of respiratory epithelium
• Multiple processes that derange MCC can cause
disease