Objective monitoring of nasal patency and nasal physiology in rhinitis

Analyzing phenotypes post-exposure in allergic rhinitis in the environmental exposure unit

BACKGROUND

Previous studies have defined clinical phenotypes of allergic rhinitis (AR) after allergen exposure using the time course of the total nasal symptom score (TNSS).

OBJECTIVE

To validate previously proposed AR phenotypes across different allergens (birch, grass, ragweed, and house dust mite) after exposure in the environmental exposure unit.

METHODS

The Analyzing Phenotypes Post-Exposure in Allergic Rhinitis (APPEAR) database comprises 153 participants from environmental exposure unit studies conducted between 2010 and 2021 by Kingston Allergy Research. TNSS, nasal congestion symptom scores, and percent change in peak nasal inspiratory flow from baseline (%ΔPB) were recorded for each participant. Participants were phenotyped using previously described criteria.

RESULTS

There were 65 participants (42.5%) classified as early-phase responders (EPRs), 58 (37.9%) as protracted EPRs (pEPRs), 13 (8.5%) as dual responders (DRs), and 17 (11.1%) as low responders (LoRs). Significant negative correlations exist between TNSS and %ΔPB (r = -0.99, P < .0001) and nasal congestion symptom score and %ΔPB (r = -0.99, P < .0001). At the beginning of the late-phase AR response (6-7 hours), pEPRs had significantly higher TNSS compared with EPRs, DRs, and LoRs (P < .0001). By the end of the study (up to 12 hours), DRs and pEPRs had significantly higher TNSS compared with EPRs and LoRs (P < .0001). Visible validity and statistical validity between the phenotypes were also confirmed by assessing participants' mean TNSS and mean %ΔPB over time when grouping by phenotype.

CONCLUSION

This study confirms that distinct phenotypes exist in the late-phase AR response among different allergens and in a greater sample size than described previously, which could provide clinical benefit.

Exploring the Relationships Between Clinical Examination Findings, Subjective Reported Symptoms and Objective Nasal Patency Measures in Nasal Obstruction: A Baseline NAIROS Sub-Study Analysis

BACKGROUND

The role of objective nasal airflow measures using peak nasal inspiratory flow (PNIF) and rhinospirometry in supporting clinical examination findings when offering patients septoplasty remain undefined.

OBJECTIVE

To explore the baseline relationships between clinical examination findings, subjective reported symptoms and objective nasal patency measures in nasal obstruction.

METHODS

This is a sub-study of the NAIROS trial. Participants with nasal obstruction secondary to septal deviation were included in this NAIROS sub-study. The side of septal deviation, enlargement of inferior turbinate (IT), the need for IT reduction if septoplasty was being performed, the area of septum deflecting into the airway and observer rated airway block (ORAB-arbitrarily divided by <50% and >50% blockage) were assessed by clinicians. The subjective score of nasal obstruction was assessed using the Double Ordinal Assessed Subjective Scale (DOASS). Objective nasal patency measures (e.g., nasal partitioning ratio, [NPR] and PNIF) were measured using PNIF and rhinospirometry.

RESULTS

The mean NPR for left-sided, both-sided and right-sided septal deviation was -0.35, -0.02 and 0.51, respectively (p < 0.001). There was very weak correlation between the requirement for IT reduction and PNIF change (0.13, p < 0.01). There was no difference in mean PNIF (94 L/min vs. 93 L/min) and mean DOASS (0.33 vs. 0.38) for participants with ORAB rated <50% and >50%. The mean NPR for participants with ORAB >50% was higher than for those with ORAB <50% (0.51 vs. 0.41, p = 0.002). There was strong correlation between the DOASS and NPR (+0.737, p < 0.001). The mean DOASS score for right-sided, both-sided and left-sided septal deviation was 0.32, 0.05 and -0.29, respectively (p < 0.001).

CONCLUSION

This study identified strong relationships between the clinician rated side of septal deflection, the patient reported DOASS and the objective NPR measurements. NPR and the clinician rated degree of airway blockage were concordant.

The relationship of nasal mucus properties and symptoms in allergic and acute non-allergic rhinitis

BACKGROUND

Allergic rhinitis (AR) and acute non-allergic rhinosinusitis (ARS) often present with similar symptoms. While these are generally differentiated by history and occasionally by secretion cell counts, there are few data temporally comparing these conditions.

METHODS

A prospective, observational study was conducted to assess nasal mucus properties, nasal obstruction, nasal secretion cells, and health related QOL during the acute phase (Day 5) and during a later phase of illness (Day 14/28). We screened 280 patients and enrolled 42 subjects (ARS, n = 34; and AR, n = 8) who were otherwise healthy and met eligibility criteria. Nasal secretions for cell count and rheology, and acoustic rhinometry were measured on days 5 and 14 of symptoms. SNOT-20 was administered on Day 5, 14, 10 and 28.

RESULTS

In subjects with ARS, there was significantly improved SNOT-20 and major symptom score at day 28 in association with increased nasal cavity volume by acoustic rhinometry and decreased mast cells; all consistent with improvement. However, in subjects with AR there was no symptomatic improvement or change in nasal volume and although there were fewer mast cells and epithelial cells, there was no decrease in the number of eosinophils, neutrophils, or goblet cells in secretions. There was no change in in vitro secretion mucociliary clearability in either group, although values were normal at baseline.

CONCLUSIONS

These results suggest that nasal symptoms in ARS are improved over 14-28 days with the reduction of mast cells, and increased nasal volume, while in AR, symptoms persist.

The Use of Rhinomanometry in Mouth Breathing: A Systematic Review of the Literature

Introduction  Mouth breathing generates imbalances in the musculature, in craniofacial morphofunctionality, and in the stomatognathic system. Therefore, it is essential to make a diagnosis of mouth breathing through the quantitative assessment of nasal permeability, which can be performed through rhinomanometry. Objective  To investigate the effectiveness of rhinomanometry in the diagnosis of mouth breathing in pediatric patients through a systematic review of the literature. Data synthesis  The guiding question was: "Is the use of rhinomanometry as an assessment tool effective in the diagnosis of mouth breathing in pediatric patients?". We conducted a search on the following databases: Latin American and Caribbean Center on Health Sciences Information (BIREME), Latin American and Caribbean Health Sciences Literature (LILACS), PubMed/Medical Literature Analysis and Retrieval System Online (MEDLINE), Scientific Electronic Library Online (SciELO), Web of Science, and Science Direct. The Health Sciences Descriptors (Descritores em Ciências da Saúde, DECS, in Portuguese) and Medical Subjects Headings (MESH) were combined with the Boolean operator AND in the search strategy: rhinomanometry AND mouth breathing AND diagnosis AND nasal pressure AND nasal airflow AND nasal resistance . Observational cohort and cross-sectional studies that addressed the effectiveness of rhinomanometry in the diagnosis of mouth breathing were included. The reviewers independently extracted the information and scored the review quality based on the Physiotherapy Evidence Database (PEDro) scale and the grading of evidence levels according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. Of the 1,536 articles identified, only 3 were selected for the present review after the application of the eligibility criteria. Conclusion  There is great concern regarding the assessment of nasal function. There was a lack of standardization of rhinomanometry to test the effectiveness of nasal resistance as an aid in the diagnosis of breathing mode.

Utility of silver birch and house dust mite extracts derived from licensed sublingual tablets for nasal allergen challenge

BACKGROUND

Nasal allergen challenge (NAC) is used to investigate the effects of allergen exposure and assess treatment efficacy in allergic rhinitis (AR). This study aims to establish dose-responses to NAC using licensed silver birch (SB) pollen and house dust mite (HDM) sublingual tablets as sources of the allergen extracts in participants with AR.

METHODS

Sixteen volunteers with HDM-induced perennial AR and 15 volunteers with SB pollen-induced seasonal rhinitis underwent a graded up-dosing NAC with extracts derived from HDM allergen (Acarizax®) and SB (Itulazax®) tablets, respectively. Total nasal symptom score (TNSS, range 0-12) and peak nasal inspiratory flow (PNIF) were recorded before, at 10 min and at the end of the NAC. The dose of each allergen that provoked a TNSS of at least 7 ("provoking dose 7") in most allergic participants was identified. NACs using the "provoking dose 7" were performed on 5 non-allergic individuals to test for irritant effects. The "provoking dose 7" of HDM extract was used in a subgroup of two SB allergic, non-HDM allergic, volunteers, and vice versa for SB extract, to test for allergen specificity of the responses.

RESULTS

Most patients experienced a TNSS of at least 7/12 at a median concentration of 1500 AU/mL for both SB pollen and HDM. The average decline in PNIF at this dose was 63.15% for SB and 63.99% for HDM. NACs using the 1500 AU/mL concentrations were performed on 5 non-allergic individuals with no symptomatic or PNIF response. 1500 AU/mL of HDM extract produced no symptoms in SB allergics nor 1500 AU/mL SB extract in HDM allergics.

CONCLUSION

For both SB and HDM extracts, the optimal allergen dose for NAC to cause a moderate-severity response ("provoking dose 7/12") was 1500 AU/mL. Licensed sublingual allergen tablets provide a readily available and inexpensive source of SB and HDM extracts for use in future interventional studies in AR.

Rhinomanometry: A Comprehensive Review of Its Applications and Advancements in Rhinology Practice

Rhinomanometry is a pivotal diagnostic technique in rhinology, providing a quantitative assessment of nasal airflow and resistance. This review comprehensively examines the historical development, principles and clinical applications of rhinomanometry, emphasising its role in diagnosing nasal obstructions, preoperative evaluations and monitoring therapeutic outcomes. Recent advancements, including the integration with imaging technologies and the application of artificial intelligence (AI), have significantly enhanced the accuracy and utility of rhinomanometry. Despite facing challenges such as technical limitations and the need for standardisation, rhinomanometry remains an invaluable tool in both clinical and research settings. The review also explores future directions, highlighting the potential for device miniaturisation, telemedicine integration, personalised protocols and collaborative research efforts. These advancements will likely expand the accessibility, accuracy and clinical relevance of rhinomanometry, solidifying its importance in the ongoing evolution of rhinology practice.

Evaluation of Nasal Mucociliary Clearance as an Indicator of Nasal Function in Obsessive-Compulsive Patients: A Cross-Sectional Study

This clinical study aimed to compare the mucociliary clearance time in patients with OCD, a disease associated with neural olfactory disorders, with a healthy control group. The mucociliary clearance time of fifty-one patients with OCD and fifty-two healthy patients (control group) was compared. The saccharin nasal mucociliary clearance test (NMCT) was applied and recorded the sociodemographic data of all participants. The NMCT was longer in OCD patients than healthy controls. There was no statistically significant difference in sociodemographic data between the groups. Our results show that olfactory transmission pathways may be affected in OCD patients.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-023-03972-2.

Allergic rhinitis children with obesity are more vulnerable to air pollution: a cross sectional study

The association between air pollution, allergic rhinitis (AR), and obesity has not been studied. From 2007 to 2011, 52 obese and 152 non-obese children (7-17 years old) with AR were recruited. Pediatric-Rhinoconjunctivitis-Quality-of-Life Questionnaire (PRQLQ) and nasal peak expiratory flow (NPEF) were tested. Association between the scores and rates of the two tests and mean air pollutant concentrations within 7 days before the tests were compared. When exposed to higher concentrations of CO, PM₁₀, and PM_2.5, the rates of worse nasal discomfort were 39.4%, 44.4% and 39.3% in obese children; and 18.0%, 21.9% and 19.7% in non-obese children, respectively. Compare to non-obese children, the rates in obese children were higher for CO (odds ratio (OR) 3.54, 95% confidence interval (CI) 1.15 ~ 10.92); PM₁₀ (OR 3.26, 95% CI 1.01 ~ 10.57) and PM2.5 (OR 3.30; 95% CI 1.03 ~ 10.54). In obese children, correlations between higher concentrations of CO, PM₁₀, PM_2.5 and higher nasal discomfort (higher PRQLQ); and correlations between higher concentrations of CO, PM₁₀, PM_2.5, NMHC (non-methane hydrocarbon) and higher nasal mucosa inflammation (lower NPEF) were noted. Obesity negatively affected AR severity when AR children experienced higher concentrations of CO, PM₁₀, and PM_2.5. Increased nasal inflammation induced by air pollutants might be the underlying mechanism.

Efficacy of subcutaneous house dust mite immunotherapy in patients with moderate to severe allergic rhinitis

Aim: To evaluate the efficacy of subcutaneous immunotherapy (SCIT) for the treatment of allergy to house dust mites (HDM) in adults with moderate/severe allergic rhinitis (AR). Methods: Patients sensitized to HDM were randomized to SCIT plus rescue medication (Group A, n = 38) or rescue medication alone (Group B, n = 18), and assessed at baseline and 2, 6 and 12 months. Results: At month 12, Group A presented significant improvement with respect to baseline as evaluated by a visual analogue scale at three concentrations of antigen (0.1, 1 and 10 IR/ml; p < 0.0001). Group A presented significant decreases in symptom scores after 2 months of treatment, which were maintained after 1 year. After 12 months of treatment, Group A showed rescue medication consumption reductions (p < 0.001) and quality of life improvements (p < 0.0001). SCIT elicited a strong immunological response and was well tolerated. Conclusion: SCIT is efficacious for HDM allergy in patients with AR, generating a strong immunological response. Trial Registration Number: EUCTR2009-018155-16-ES (Cochrane Central Register of Controlled Trials).

Effect of Medical Therapy in Allergic Rhinitis: A Systematic Review and Meta-Analysis

BACKGROUND

Intranasal corticosteroids (INCS), oral antihistamines (POAH), and allergen-specific immunotherapy (ASIT) are widely used in the treatment of allergic rhinitis (AR); however, appraisal of treatment effect has been heterogenous, and few studies have interpreted these outcomes in context with measures of nasal airflow.

OBJECTIVE

To provide a systematic review and meta-analysis of randomized placebo-controlled trials for common therapy classes for AR to assess standardized treatment effect on validated patient-reported outcomes and physiologic measures of airflow.

METHODS

A systematic search was performed in PubMed, Scopus, OVID, and Cochrane library databases to identify randomized controlled trials meeting inclusion criteria. Treatment effects of INCS, POAH, and ASIT on total nasal symptom score (TNSS), visual analog scale (VAS), Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ), and peak nasal inspiratory flow (PNIF) were analyzed by meta-analysis.

RESULTS

Twenty-two studies with 4673 AR patients were identified, with 5 INCS, 8 POAH, and 9 ASIT trials. INCS improved TNSS (mean difference [MD] 0.90; P = .002) and PNIF (MD 13.31 L/min [P = .0007]. POAH improved quality of life assessed by RQLQ [MD 0.36; P < .001], but no improvement was found in PNIF. ASIT improved RQLQ [MD 0.65; P < .001], with a trend toward improvement in TNSS.

CONCLUSION

Overall, INCS resulted in a clinically and statistically meaningful improvement in symptom scores and physiologic measures in AR. POAH and ASIT both improved symptom scores and quality of life, but their impacts upon nasal airflow are uncertain. There is a lack of studies assessing the effect of INCS on quality of life and the effect of POAH on symptom severity, particularly for mild AR. Future studies should assess the effect of treatment for each of these patient-reported measures.

PAP Adherence and Nasal Resistance. A Randomized Controlled Trial of CPAPflex versus CPAP in World Trade Center Responders

Rationale: Continuous positive airway pressure (CPAP) adherence is often poor in obstructive sleep apnea (OSA) and may be influenced by nasal resistance. CPAP with a reduction of expiratory pressure (CPAPflex) may reduce discomfort in those with high nasal resistance and improve adherence in this subgroup.Objectives: To evaluate the association of positive airway pressure (PAP) treatment adherence to nasal resistance and examine if CPAPflex improves adherence over CPAP in subjects with high nasal resistance.Methods: A randomized double-blind crossover trial of 4 weeks each of CPAPflex versus CPAP in subjects exposed to World Trade Center dust with OSA stratified by nasal resistance, measured by 4-Phase Rhinomanometry.Results: Three hundred seventeen subjects with OSA (mean, apnea-hypopnea index with 4% O₂ desaturation for hypopnea = 17 ± 14/h) were randomized. Overall, PAP adherence was poor, but adherence to CPAP (n = 239; mean hours per night [95% confidence interval (CI)]), 1.97 h (1.68 to 2.26) was greater than adherence to CPAPflex (n = 249; 1.65 h [1.39 to 1.91]; difference of 0.31 h [0.03; 0.6]; P < 0.05). Contrary to our hypothesis there was no correlation between nasal resistance and adherence to CPAP (r = 0.098; P = not significant) or CPAPflex (r = 0.056; P = not significant). There was no difference in adherence between CPAP and CPAPflex (mean Δ hours [95% CI]) in subjects with low resistance (0.33 h [-0.10 to 0.76]) or high nasal resistance (0.26 h [-0.14 to 0.66]). No significant differences were observed in any of the secondary outcomes between PAP modes.Conclusions: Contrary to expectations, our data do not show better adherence to CPAPflex than to CPAP in subjects with high or low nasal resistance and do show clinically insignificant better adherence overall with CPAP.Clinical trial registered with www.clinicaltrials.gov (NCT01753999).

Does Mini Screw Assisted Rapid Palatal Expansion (MARPE) have an influence on airway and breathing in middle-aged children and adolescents? A systematic review

OBJECTIVE

This systematic review assessed the effects of tooth-borne (TB), tooth-bone-borne (TBB) and bone-borne (BB) micro-implant assisted rapid maxillary expansion (RPE) on airway dimensions and function in young children and adolescents (10- to 17-years-old).

MATERIALS AND METHODS

Unrestricted search in 5 electronic databases until June 6th, 2020 was undertaken. This was supplemented with search in 6 additional resources for published, unpublished and ongoing trials up. Randomized (RCT) and non-randomized (Non-RCT) prospective studies that assessed the influence of the mini-screw-assisted rapid palatal expansion (MARPE) approach on airway and breathing in young children and adolescents were included. Two reviewers performed the study selection and data extraction blindly and in duplicate by two authors while disagreements. A random-effects model with a 95% confidence interval (CI), I2 and Chi2 tests were done. ROBINS-I, Cochrane Risk of Bias and GRADE tools were used. Reporting of this review was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

Overall, 518 articles were retrieved; only 3 studies (2 RCT and one non-RCT) met the inclusion criteria. Both TB RPE and BB RPE improved on a short-term basis the dimensions of the airway, though the difference was not significant (P>0.05). TBB RPE significantly improved nasal airflow [(Mean difference (MD) 52.7 cm3/s, 95% confidence interval (95% CI) 9.0-96.4), P=0.020)], reduced nasal resistance (MD -0.20Pa/cm3, 95% (-0.38)-(-0.02), P=0.028), and changed respiratory muscle strength variables (P>0.05). No correlation was found between the anatomical dimensions of the airway and the functional airway parameters (P>0.05).

CONCLUSIONS

The short-term airway volumetric changes secondary to MARPE were not significant. The influence of MARPE appliances on breathing is still not clear. Registration PROSPERO database (CRD42020183340).

Open, prospective, multicenter study on postoperative intranasal phototherapy in nasal polyposis

BACKGROUND

The therapeutic effect of ultraviolet (UV) light is generally attributed to its immunosuppressive and immunomodulatory effects. Since chronic inflammation is the major factor in the development of nasal polyposis, we have previously used mixed ultraviolet-visible light (mUV-VIS, Rhinolight®) phototherapy for the treatment of nasal polyps.

AIMS

In the present open, multicenter study, our aim was to delineate whether mUV-VIS applied postoperatively in vivo together with intranasal steroid treatment could reduce the recurrence of nasal polyps.

METHODS

After functional endoscopic sinus surgery, one group of patients received mUV-VIS light together with standard intranasal steroid (mometason furoate 2 × 200 μg) application for a 12-week treatment period, whereas the other patient group obtained only intranasal steroid for the same duration. We recorded nasal endoscopy images and obtained demographical and clinical data, total nasal score (TNS), and nasal obstruction symptom evaluation (NOSE). We performed acoustic rhinometry and measured nasal inspiratory peak flow. Follow-up was 12 months.

RESULTS

We found that the recurrence of nasal polyps was significantly diminished, and based on video-endoscopic measurements, the size and grade of recurrent polyps were significantly smaller in the phototherapy-receiving group. Nasal obstruction values and NOSE were significantly better throughout the follow-up period in the mUV-VIS light-treated group than in the intranasal steroid monotreatment group.

CONCLUSIONS

Rhinophototherapy together with standard nasal steroid application may have a supportive role in the treatment of recurrent bilateral nasal polyps.

Occupational rhinitis

Occupational rhinitis (OR) has so far received little attention even though it shares common pathophysiological features and trigger factors and is closely associated with occupational asthma (OA). Work-related exposure to certain substances, such as animal dander, is considered to be the main factor for the development of OR. The new EAACI definition of OR stresses the causal relationship between workplace exposure and onset of rhinitis symptoms as opposed to previous definitions that mainly focused on a temporal relationship between workplace exposure and occurrence of nasal symptoms. Also, it has been suggested to use the term “work-related rhinitis” for classifying the different forms of rhinitis associated with the workplace. These forms can be subdivided into allergic or non-allergic OR, which is due to causes and conditions related to a particular work environment, as well as work-exacerbated rhinitis, which is defined as a pre-existing rhinitis exacerbated by exposure at the workplace. Even though taking a detailed patient history is especially important when it comes to diagnosing OR, the gold standard for confirming the diagnosis is nasal provocation testing. Best possible symptomatic relief and prevention of development of OA constitute the main therapeutic objectives in OR. Treatment options consist of total avoidance of trigger substances (main goal), reduction of exposure to certain substances, and pharmacotherapy. Furthermore, it is important to note that allergic OR is an occupational disease in Germany (Berufskrankheit No 4301) and needs to be reported to health authorities.

Cross-cultural adaptation and validation of Lithuanian-NOSE scale

PURPOSE

To evaluate validity and reliability of Lithuanian version of Nasal Obstruction Symptom Evaluation Scale (L-NOSE), designed for the assessment of nasal obstruction.

METHODS

Cross-cultural adaptation of L-NOSE was accomplished according to generally accepted methodology. L- NOSE was tested for its reliability, validity, and responsiveness in the group of 50 septoplasty patients and 100 healthy volunteers' controls.

RESULTS

L- NOSE showed good internal consistency (Cronbach's alpha coefficient 0.796 for test, 0.791 for retest, 0.792 for post-operative group, and 0.817 for control group) scores and high test-retest reliability (r = 0.94, p < 0.01) scores. In patients' group, positive moderate correlations between L-NOSE scores and Sino-nasal Outcome Test-22 logically similar domain scores were found, thus indicating good convergent construct validity. L-NOSE scores for control subjects were generally lower than for patients with nasal obstruction (p < 0.001), thereby indicating good discriminant validity of questionnaire. The exploratory factor analysis confirmed one-factor structure of questionnaire. The component matrix of L-NOSE ranged from 0.667 to 0.781 (KMO = 0.754, p < 0.0001). The mean L-NOSE score improved from 58.4 ± 18.2 points to 11.1 ± 9.5 points after septoplasty (p < 0.0001), indicating good responsiveness of questionnaire.

CONCLUSION

The L-NOSE questionnaire is a valid instrument with satisfactory reliability, validity, and responsiveness.

Computational technology for nasal cartilage-related clinical research and application

Surgeons need to understand the effects of the nasal cartilage on facial morphology, the function of both soft tissues and hard tissues and nasal function when performing nasal surgery. In nasal cartilage-related surgery, the main goals for clinical research should include clarification of surgical goals, rationalization of surgical methods, precision and personalization of surgical design and preparation and improved convenience of doctor-patient communication. Computational technology has become an effective way to achieve these goals. Advances in three-dimensional (3D) imaging technology will promote nasal cartilage-related applications, including research on computational modelling technology, computational simulation technology, virtual surgery planning and 3D printing technology. These technologies are destined to revolutionize nasal surgery further. In this review, we summarize the advantages, latest findings and application progress of various computational technologies used in clinical nasal cartilage-related work and research. The application prospects of each technique are also discussed.

Occupational Rhinitis

There is convincing evidence that tight relationships between the upper and lower airways also apply to the workplace context. Most patients with occupational asthma (OA) also suffer from occupational rhinitis (OR), although OR is 2 to 3 times more common than OA. OR most often precedes the development of OA, especially when high-molecular-weight protein agents are involved, and longitudinal cohort studies have confirmed that OR is associated with an increased risk for the development of OA. The level of exposure to sensitizing agents at the workplace is the most important determinant for the development of IgE-mediated sensitization and OR. Atopy is a risk factor for the development of IgE-mediated sensitization only to high-molecular-weight agents. In workers with work-related rhinitis symptoms, documentation of IgE-mediated sensitization to a workplace agent via skin prick testing or serum specific IgE confirms a diagnosis of probable OR, whereas specific nasal provocation testing in the laboratory remains the reference method to establish a definite diagnosis of OR. Complete avoidance of exposure to the causal agent is the most effective therapeutic option for controlling work-related nasal symptoms and preventing the development of OA. If complete elimination of exposure is expected to induce meaningful adverse socioeconomic consequences, reduction of exposure can be considered as an alternative approach, but it is important to consider the individual risk factors for the development of OA to implement a more personalized management of OR.

Treatable traits in chronic rhinosinusitis with nasal polyps

PURPOSE OF REVIEW

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a complex inflammatory sinonasal disease that deserves a multidisciplinary precision medicine approach. In a precision medicine model, a more pragmatic approach taking in consideration disease features that are potentially treatable should be considered.

RECENT FINDINGS

Several treatable traits in CRSwNP can be identified: from disease-related ones, to extra-ENT features, to behavioral and environmental factors. This review article summarizes primarily the recent findings of CRSwNP-related treatable traits and how they can be modified by given treatments.

SUMMARY

The advent of biological agents acting directly to the endotype underlying CRSwNP pushes the scientific community to integrate clinical, surgical and immunological evaluations for each single patient; this naturally leads to the identification of specific treatable traits that can serve as possible outcomes for any single biological.

Nasal Peak Inspiratory Flow in Healthy and Obstructed Patients: Systematic Review and Meta-Analysis

OBJECTIVES

Nasal peak inspiratory flow (NPIF) is a practical and affordable tool that measures maximum inspiratory flow rate through both nostrils. Although NPIF values for healthy controls and patients appear to differ considerably, a generally expected value for populations with and without nasal obstruction has yet to be established. The aim of this systematic review and meta-analysis was to determine the mean NPIF value in populations with and without nasal obstruction.

METHODS

Medline (1946-) and Embase (1947-) were searched until July 1, 2017. A search strategy was used to identify studies that reported NPIF values for defined healthy or disease states. All studies providing original data were included. The study population was defined as having either normal nasal breathing or nasal obstruction. A meta-analysis of the mean data was presented in forest plots, and data were presented as mean (95% confidence interval [CI]).

RESULTS

The search yielded 1,526 studies, of which 29 were included. The included studies involved 1,634 subjects with normal nasal breathing and 817 subjects with nasal obstruction. The mean NPIF value for populations with normal nasal breathing was 138.4 (95% CI: 127.9-148.8) L/min. The mean value for populations with nasal obstruction was 97.5 (95% CI: 86.1-108.8) L/min.

CONCLUSIONS

Current evidence confirms a difference between mean NPIF values of populations with and without nasal obstruction. The mean value of subjects with no nasal obstruction is 138.4 L/min, and the mean value of nasally obstructed populations is 97.5 L/min. Prospective studies adopting a standardized procedure are required to further assess normative NPIF values. Laryngoscope, 131:260-267, 2021.

Assessment of respiratory and systemic toxicity of Benzalkonium chloride following a 14-day inhalation study in rats

Background

Although biocides at low concentrations have been used to control pests, they can be more harmful than industrial chemicals as humans are directly and frequently exposed to such biocides. Benzalkonium chloride (BAC or BKC) is a non-toxic substance used to control pests. Recently, BAC has been increasingly used as a component in humidifier disinfectants in Korea, raising a serious health concern. Moreover, it poses significant health hazards to workers handling the chemical because of direct exposure. In the present study, we aimed to evaluate the respiratory toxicity of BAC due to its inhalation at exposure concentrations of 0.8 (T1 group), 4 (T2 group) and 20 (T3 group) mg/m³.

Results

In our previous study on the acute inhalational toxicity of BAC, bleeding from the nasal cavity was observed in all the rats after exposure to 50 mg/m³ BAC. Therefore, in this study, 20 mg/m³ was set as the highest exposure concentration, followed by 4 and 0.8 mg/m³ as the medium and low concentrations for 6 h/day and 14 days, respectively. After exposure, recovery periods of 2 and 4 weeks were provided. Additionally, alveolar lavage fluid was analyzed in males of the BAC-exposed groups at the end of exposure and 2 weeks after exposure to evaluate oxidative damage.

In the T3 group exposed to BAC, deep breathing, hoarseness, and nasal discharge were observed along with a decline in feed intake and body weight, and nasal discharge was also observed in the T1 and T2 groups. ROS/RNS, IL-1β, IL-6, and MIP-2 levels decreased in a concentration-dependent manner in the bronchoalveolar lavage fluid. Histopathological examination showed cellular changes in the nasal cavity and the lungs of the TI, T2, and T3 groups.

Conclusions

As a result, it was confirmed that the target organs in the respiratory system were the nasal cavity and the lungs. The adverse effects were evaluated as reversible responses to oxidative damage. Furthermore, the no observed adverse effect level was found to be less than 0.8 mg/m³ and the lowest benchmark dose was 0.0031 mg/m³. Accordingly, the derived no-effect level of BAC was calculated as 0.000062 mg/m³.

A Randomized Trial of Comparing a Combination of Montelukast and Budesonide With Budesonide in Allergic Rhinitis

OBJECTIVES/HYPOTHESIS

It is not unequivocally proven whether a combination of an intranasal corticosteroids (INSs) and a cysteinyl leukotriene receptor antagonist has greater efficacy than INSs in the treatment of seasonal allergic rhinitis (SAR).

STUDY DESIGN

Single-center, randomized, open-label study.

METHODS

Study subjects included 46 participants with SAR. Participants were randomized to receive budesonide (BD; 256 μg) plus montelukast (MNT; 10 mg) (BD + MNT) or BD alone (256 μg) for 2 weeks. Visual analog scale scores for five major symptoms of SAR, nasal cavity volume (NCV), nasal airway resistance (NAR), and fractional exhaled nitric oxide (FeNO) were assessed before and at the end of treatments.

RESULTS

Both treatments significantly improved the five main SAR symptoms from baseline; however, BD + MNT produced significantly greater improvements in nasal blockage and nasal itching compared to BD alone. At baseline, the nasal blockage score was significantly correlated with NCV and NAR (r = -0.473, P = .002 and r = -0.383, P = .013, respectively). After 2 weeks of treatment, BD + MNT significantly improved NCV, but not NAR, to a greater level than BD. The number of patients with FeNO concentration ≥ 30 ppb at baseline was significantly decreased after BD + MNT treatment, but not after BD treatment. Similarly, BD + MNT treatment led to a significantly greater decrease in FeNO concentration than BD treatment.

CONCLUSIONS

BD + MNT treatment may have an overall superior efficacy than BD monotherapy for patients with SAR, especially in improvement of nasal blockage, itching, and subclinical lower airway inflammation. Also, NCV and NAR could be used to assess nasal blockage more accurately.

LEVEL OF EVIDENCE

1b Laryngoscope, 131:E1054-E1061, 2021.

Correlation Between Objective Evaluation Result of Nasal Congestion and Life Quality in Patients with Acute Rhinosinusitis

Rhinosinusitis is an inflammatory process involving the nasal mucosa and paranasal sinuses. Rhinitis and sinusitis generally occur simultaneously and thus the current terminology used is rhinosinusitis. The blind nose can negatively affect the overall quality of life including the physical or emotional condition of the sufferer and disruption to work or school (reduced productivity and difficulty in concentrating). To analyse correlation between objective evaluation results of nasal congestion through NIPF and life quality based on sinonasal outcome Test-20 score in patients with acute rhinosinusitis. The study was conducted at Otolaryngology Outpatient Clinic at Dr. Soetomo General Hospital Surabaya. The time of study began in July 2011 until the minimum sample size was met. The sample of the study was patients diagnosed with acute rhinosinusitis treated at Otolaryngology Outpatient Clinic at Dr. Soetomo General Hospital Surabaya and meet the research criteria. Based on statistical analysis with Spearman rank correlation test, correlation between NIPF value and SNOT-20 score on 16 samples got correlation coefficient-0.310 and p = 0.243. The scatter diagram showed the NIPF value variables and the SNOT-20 scores being scattered in uneven spots and erratic patterns. This indicated that an objective evaluation of nasal congestion based on NIPF and subjective assessment of quality of life based on SNOT-20 score was not obtained correlation (p > 0.05). The results of the objective nasal obstruction examination based on Nasal Inspiratory Peak Flow have no correlation with subjective subjective assessment of quality of life based on Sino-Nasal Outcome Test-20 score in patients with acute rhinosinusitis.

Impact of adenotonsilectomy on nasal airflow and pulmonary blood pressure in mouth breathing children

INTRODUCTION

Adenotonsillar hyperplasia (ATH) causing upper airway obstruction (UAO) may increase pulmonary artery systolic pressure (PASP). Early diagnosis and mouth breathing (MB) management may help in cases of high PASP. Total inspiratory nasal airflow (TINAF) obtained by active anterior rhinomanometry (AARM) is a means to quantify nasal patency. This study aimed to correlate TINAF with high PASP.

METHODS

This is a prospective study involving 30 children between two and twelve years of age, with indication for adenotonsillectomy due to ATH, evaluated before and six months after surgery; and 29 nasal breathing (NB) children in the same age group. We obtained the PASP, calculated for tricuspid regurgitation, by means of a transthoracic echocardiography. We assessed nasal patency using the AARM to estimate the TINAF.

RESULTS

The mean PASP among mouth breathing children was 25.99 mmHg, with a Standard Deviation of (±) 3.27, p = 0.01 in the preoperative period; and 21.79 mmHg (±2.48; p = 0.01) in the postoperative period. Among nasal breathers, this mean value was 21.64 mmHg (±3.87, p = 0.01). The mean pre-operative TINAF was 266.76 cm³/s (±112.21, p = 0.01); and 498.93 cm³/s (±137.80, p = 0.01) after surgery. Among nasal breathers it was 609.37 cm³/s (±109.16; p = 0.01). The mean nasal patency in the preoperative period was 42.85% (±17.83; p = 0.01); and 79.33% (±21.35; p = 0.01) in the post-op. Among nasal breathers it was 112.94% (±15.88, p = 0.01). There was a significant Spearman correlation value between TINAF and PASP (r = -0.459; p = 0.01) when we analyzed all the groups.

CONCLUSION

PASP and TINAF values improved postoperatively and had an inverse correlation. This study suggests that by improving TINAF there was a decrease in PASP.

Correlation Between Peak Nasal Flow Reversibility and Mucociliary Clearance in Allergic Rhinitis

OBJECTIVES/HYPOTHESIS

Reversibility of nasal airflow after decongestion measured by rhinomanometry is associated with the severity of allergic inflammation. Peak nasal flow is a simpler alternative method for assessing nasal patency. The aim of this study was to evaluate the correlation between changes in peak nasal expiratory and inspiratory flows (PNEFs and PNIFs) after decongestion and nasal mucociliary clearance times (NMCCTs).

STUDY DESIGN

Single-center, prospective cross-sectional study.

METHODS

One hundred one allergic rhinitis patients were enrolled. Nasal symptoms and NMCCTs were assessed. PNEF and PNIF were performed before and after decongestion. Correlations between changes in PNEF and PNIF after decongestion and NMCCTs were analyzed. One-half the standard deviation of baseline peak nasal flows was used to estimate the minimal clinically important differences (MCIDs) and discriminate between patients with reversible mucosa and with irreversible mucosa.

RESULTS

PNEF showed more peak flow improvements after decongestion compared to PNIF. Changes in PNEF had better negative correlations with NMCCTs than PNIF (ρ = -0.49, P < .001 and ρ = -0.34, P < .001, respectively). The MCID values of the PNEF and PNIF were 27.93 and 19.74, respectively. In comparisons of NMCCTs between patients with or without MCID of peak nasal flow after decongestion, PNEF had better discrimination ability compared to PNIF (P = .003 and P = .026, respectively).

CONCLUSIONS

The limitation of reversibility as measured by peak nasal flows could indirectly point to the affection of mucosal inflammation as indicated by NMCCTs. PNEF is more sensitive to assess peak flow changes after decongestion than PNIF.

LEVEL OF EVIDENCE

2 Laryngoscope, 130:1372-1376, 2020.

Inhalation toxicity of benzalkonium chloride and triethylene glycol mixture in rats

Benzalkonium chloride (BAC), a disinfectant, and triethylene glycol (TEG), an organic solvent/sanitizer, are frequently combined in commercially available household sprays. To assess the respiratory effect of this combination, Sprague-Dawley rats were exposed to an aerosol containing BAC (0.5%, w/v) and TEG (10%, w/v) for up to 2 weeks in a whole-body inhalation chamber. BAC (4.1-4.5 mg/m³, sprayed from 0.5% solution) promoted pulmonary cell damage and inflammation as depicted by the increase in total protein, lactate dehydrogenase, polymorphonuclear leukocytes, and macrophage inflammatory protein-2 in the bronchoalveolar lavage fluid, whereas TEG (85.3-94.5 mg/m³, sprayed from 10% solution) did not affect the lung. Rats exposed to the BAC/TEG mixture for 2 weeks showed severe respiratory symptoms (sneezing, wheezing, breath shortness, and chest tightness), but no lung damage or inflammation was observed. However, significant ulceration and degenerative necrosis were observed in the nasal cavities of rats repeatedly exposed to the BAC/TEG mixture. The mass median aerodynamic diameters of the aqueous, BAC, TEG and BAC/TEG aerosols were 1.24, 1.27, 3.11 and 3.24 μm, respectively, indicating that TEG-containing aerosols have larger particles than those of the aqueous and BAC alone aerosols. These results suggest that the toxic effects of BAC and BAC/TEG aerosols on the different respiratory organs may be associated with the difference in particle diameter, since particle size is important in determining the deposition site of inhaled materials.

Automatic Processing of Nasal Pressure Recordings to Derive Continuous Side-Selective Nasal Airflow and Conductance

Monitoring of nasal airflow and conductance provides crucial insights into the variable nature of the nasal resistance, nasal cycle, and ventilation. We have previously shown that tracking of pressure swings at the entrance of each nasal passage by a dedicated catheter system allows bilateral monitoring of nasal airflow over several hours but requires complex linearization and calibration procedures. Side-selective nasal conductance is derived from linearized and calibrated bilateral nasal pressure swings and corresponding driving pressure, i.e., the transnasal pressure difference derived from an epipharyngeal catheter. Manual analysis of such recordings and computation of instantaneous conductance as the ratio of flow to driving pressure over several hours is extremely tedious, time consuming, and therefore not suitable for routine practice. To address this point, we developed and validated a software for automatic processing of nasal and epipharyngeal pressure recordings as a convenient tool for studying the nasal ventilation. The software applies an eight-parameter logistic model to transform nasal pressure swings into side-selective estimates of airflow that are calibrated and further processed along with epipharyngeal pressure to compute bilateral nasal conductance over consecutive, user-selectable time-segments. Essential processing steps include (1) offset correction, (2) low-pass filtering, (3) cross-correlation, (4) cutting of signals into individual breaths, (5) normalization, (6) ensemble averaging to obtain a mean pressure signal for each nasal side, (7) derivation of airflow, conductance, and further variables. Among four evaluated algorithms for calculation of nasal conductance, the derivative of the airflow-pressure curve according to the mean value theorem agreed closest with the gold standard, i.e., the conductance derived from airflow measured by a pneumotachograph attached to an oral-nasal mask and transnasal pressure. In combination with the nasal catheter system, our novel software represents a valuable tool for use in clinical practice and research to conveniently investigate nasal ventilation and its changes occurring spontaneously or in response to various exposures and therapeutic interventions.

Validity and the reliability of the Turkish version of the control of allergic rhinitis and asthma test for children (CARATKids)

Aim: Asthma occurs in association with allergic rhinitis. Control of Allergic Rhinitis and Asthma Test for Children (CARATKids) is a questionnaire to assess control of both diseases. The aim of this study was to assess the validity and reliability of the CARATKids in Turkish children aged 6-12 years. Methods: After a cultural adaptation process, children with asthma and allergic rhinitis were recruited. CARATKids, childhood Asthma Control Test, total nasal symptom score, visual analog scale scores for asthma and rhinitis, peak nasal inspiratory flow and peak expiratory flow values were obtained at baseline and after 4-6 weeks. The patients were classified according to the control level for asthma and rhinitis and stable/unstable groups. Discriminative properties, internal consistency, test-retest reliability, responsiveness, validity and minimal clinically important difference (MCID) were assessed. Receiver operating characteristic curve analysis was performed. Results: About 174 patients were included. The Cronbach's alpha was 0.841. Correlation coefficients between CARATKids and external measures of control were 0.42-0.77, and between the score changes of CARATKids and external measures of control it was 0.56-0.78. Guyatt's responsiveness index was -1.88, within-patient change of CARATKids score was significant. The intra-class correlation coefficient was 0.973. The MCID was 4. A cutoff score of ≤5 on the CARATKids had a sensitivity of 100% to distinguish the controlled groups according to both the GINA and ARIA. Conclusion: CARATKids is a reliable and valid tool to assess asthma and allergic rhinitis control in Turkish children. A score of ≤5 on CARATKids defines controlled disease for both diseases simultaneously.

Dependence of Anterior Active Rhinomanometry Indices on Nasal Obstructive Disorders in Children with Atopic Bronchial Asthma Complicated by Nasal Symptoms

BACKGROUND

Atopic bronchial asthma (BA) in children is associated with upper airways pathology (UAP). Among them, a combination of allergic rhinitis (AR) and nasal obstructive disorders (NOD), including hypertrophy of the pharyngeal tonsil (HPT) and anomalies of the intranasal structures (AINS), is abundant. In such patients, anterior active rhinomanometry (AARM) is an important method of examining nasal patency. However, NOD can influence the AARM parameters in children with BA and nasal symptoms, and this effect must be taken into account in clinical practice. Study goal was to elucidate the effect of NOD on rhinomanometric parameters in this group of patients.

METHODS

Total of 66 children with BA and AR were examined with AARM, rhinovideoendoscopy, spirometry, and standard clinical tests allowing revealing the structure of comorbid pathologies. In order to avoid the influence of anthropometric parameters of children and their age on AARM parameters, a special index of reduced total nasal airflow was used.

RESULTS

It has been established that NOD, especially HPT, have a significant negative impact on the indices of anterior active rhinomanometry during the periods of both AR remission and AR exacerbation. The effect of AINS is much weaker and was remarkable only in combination with HPT.

Noninvasive allergic sinus congestion and resolution assessments using microcomputed tomography imaging

Sinus congestion resultant of allergic rhinosinusitis is associated with development and worsening of asthma and can result in difficulty breathing, headaches, and missed days of school and work. Quantification of sinus congestion is important in the understanding of allergic rhinosinusitis and the development of new drugs for its treatment. Noninvasive microcomputed tomography (micro-CT) was investigated in a guinea pig model of allergic rhinosinusitis to determine its utility to determine accurately the degree of sinus congestion and resolution with anti-inflammatory drug administration. Three-dimensional sinus air-space volume, two-dimensional sinus width, sinus image air-space area, and sinus image sinus perimeter were measured in guinea pigs administered ragweed pollen (RWP), intranasally (i.n.), followed by administration of fluticasone, i.n. To determine their relative accuracy in assessing sinus congestion, the micro-CT image results were compared with the "gold-standard" method of sinus fluid fill-volume (SFFV) measurements. As measured by SFFV method, RWP increased sinus congestion in a RWP concentration-dependent fashion, approaching near-total sinus blockage with concentrations ≥22 µg of RWP. At this level of congestion, fluticasone (25-100 µg) progressively decreased sinus congestion in a concentration-dependent fashion. The noninvasive micro-CT methods were found to accurately determine the amount of sinus congestion and resolution, with patterns of increases and decreases of congestion that were nearly identical to the SFFV method. We conclude that noninvasive micro-CT measurements of allergic sinus congestion can be useful as an investigative tool in the assessment of congestion intensity and the development of new drug therapies for its treatment. NEW & NOTEWORTHY Allergic rhinosinusitis afflicts significant portions of the world population, resulting in loss of work productivity and decreased quality of life. Thus the development of methodological approaches, which incorporate accurate and reproducible noninvasive assessments of sinus congestion, are desirable. Microcomputed tomography of the guinea pig sinuses offers a noninvasive evaluation tool in an animal model of IgE-dependent allergy similar to that in humans, with potential relevance toward development of therapeutics for human sinus diseases.

EAACI Position paper on the standardization of nasal allergen challenges

Nasal allergen challenge (NAC) is an important tool to diagnose allergic rhinitis. In daily clinical routine, experimentally, or when measuring therapeutic success clinically, nasal allergen challenge is fundamental. It is further one of the key diagnostic tools when initiating specific allergen immunotherapy. So far, national recommendations offered guidance on its execution; however, international divergence left many questions unanswered. These differences in the literature caused EAACI to initiate a task force to answer unmet needs and find a consensus in executing nasal allergen challenge. On the basis of a systematic review containing nasal allergen challenges of the past years, task force members reviewed evidence, discussed open issues, and studied variations of several subjective and objective assessment parameters to propose a standardized way of a nasal allergen challenge procedure in clinical practice. Besides an update on indications, contraindications, and preparations for the test procedure, main recommendations are a bilaterally challenge with standardized allergens, with a spray device offering 0.1 mL per nostril. A systematic catalogue for positivity criteria is given for the variety of established subjective and objective assessment methods as well as a schedule for the challenge procedure. The task force recommends a unified protocol for NAC for daily clinical practice, aiming at eliminating the previous difficulty of comparing NAC results due to unmet needs.

Association between allergic and nonallergic rhinitis and obstructive sleep apnea

PURPOSE OF REVIEW

Allergic rhinitis and nonallergic rhinitis (NAR) are common disorders, which have been considered as potential risk factors for obstructive sleep apnea (OSA). This review summarizes the proposed underlying pathophysiological mechanisms to provide a better understanding of the relationship between these conditions.

RECENT FINDINGS

In adults, allergic rhinitis and NAR may be considered as symptoms potentiating, rather than risk potentiating factors in the pathophysiology of OSA, whereas in children, these are considered to be independent predictors for sleep-disordered breathing (SDB) and failure of adeno-tonsillectomy, the recommended first-line therapy for children with OSA. Current advances suggest IL-6 may be important in regulating the sleep-wake cycle, and serum soluble IL-6 receptor (sIL-6R) levels may reflect the severity of OSA. Elevated Th17/Treg ratio correlates positively with apnea-hypopnea index of OSA patients, and Th17 and Treg imbalances caused by allergic rhinitis and OSA, respectively, may possibly promote each other, leading to further imbalance. Moreover, obesity is a strong risk factor for OSA, and leptin plays an important role in ventilatory function and upper airway obstruction. The variant trigeminocardiac reflex and nasotrigeminal reflex may also be involved in the association between rhinitis and OSA.

SUMMARY

Allergic rhinitis/NAR and OSA are closely associated, and each condition can be detrimental to the other. Thus, clinicians should pay attention to the potential presence of allergic rhinitis/NAR in OSA patients and vice versa.

Improvement in minimal cross-sectional area and nasal-cavity volume occurs in different areas after septoplasty and radiofrequency therapy of inferior turbinates

PURPOSE

Septoplasty and radiofrequency therapy for inferior turbinate hypertrophy (RFIT) are common techniques used to improve nasal patency. Our aim was to compare nasal geometry and function using acoustic rhinometry and peak nasal inspiratory flow (PNIF) in three patients groups undergoing surgery for nasal obstruction, and to investigate if the improvement in minimal cross-sectional area (MCA) and nasal-cavity volume (NCV) occurred in different cavity areas in the groups. Finally, we evaluated the correlation between the objective measurements and the patients' assessment of nasal obstruction (SNO).

METHODS

This prospective, observational study investigated 148 patients pre-operatively and 6 months post-operatively. Fifty patients underwent septoplasty (group 1), 51 underwent septoplasty combined with RFIT (group 2), and 47 underwent RFIT alone (group 3). The MCA and NCV were measured at two distances (MCA/NCV_0-3.0 and MCA/NCV_3-5.2), in addition to measuring PNIF and SNO.

RESULTS

Pre-operatively, groups 1 and 2 had narrower MCA_0-3.0 on one side than group 3 (0.31 ± 0.14 and 0.31 ± 0.14) versus (0.40 ± 0.16) cm². Post-operatively, total MCA_0-3.0 and MCA/NCV_3-5.2 increased in group 1. In group 2, MCA/NCV_0-3.0 at the narrow side and total MCA/NCV_3-5.2 increased, while total MCA/NCV_3-5.2 increased in group 3. PNIF improved from 106 ± 49 to 150 ± 57 l/min post-operatively. We found a correlation between increased MCA and NCV and less SNO in the septoplasty group (p < 0.01).

CONCLUSION

Surgery produced an improvement in MCA and NCV in all groups. The improvement occurred in different areas of the nasal cavity in the patient groups. Both anterior and posterior areas increased in the septoplasty groups, while only the posterior area increased in the RFIT group. PNIF improved in all three patient groups, indicating that surgery produced an improvement in nasal patency.

The Effects of Mometasone Furoate and Desloratadine in Obstructive Sleep Apnea Syndrome Patients with Allergic Rhinitis

Background

Allergic rhinitis (AR) and obstructive sleep apnea syndrome (OSAS) are worldwide prevalent diseases. These diseases impair patient quality of life. The aim of this study was to investigate and compare the efficacy of treatment of AR on OSAS by objective and subjective methods.

Methods

The study group was composed of 80 OSAS patients with AR between the ages of 30 and 50 years. The patients were admitted with the complaint of snoring, and they were asked about AR-related symptoms (nasal discharge, nasal itching, sneeze, and nasal obstruction). Daytime somnolence was measured by the Epworth sleepiness scale (ESS). Sleep parameters on polysomnography tests before and after treatment were compared, and the effects of different AR treatment protocols on sleep quality were evaluated.

Results

When pretreatment and posttreatment apnea–hypopnea index (AHI) values of the groups were compared, the most significant difference was observed in the nasal steroid (Ns) + antihistamine (Ah) group (p < 0.05). The ESS results were significantly decreased in the Ns and Ns + Ah groups after treatment (p < 0.05). AHI oxygen saturation <90% were significantly decreased in the Ns and Ns + Ah groups after treatment (p < 0.05).

Conclusion

Nasal obstruction due to nasal congestion causes increases in airway resistance and can lead to development of OSAS. We concluded that treating AR with Ns has both positive effects on OSAS and daily activity. However, adding Ah to this treatment did not show improved effects compared with placebo treatment.

Efficacy of Odiosoft-Rhino in Assessment of Nasal Obstruction: A Comparative Study with Acoustic Rhinometry after Treatment with Budesonide Nasal Spray in Patients with Perennial Allergic Rhinitis

Background

Odiosoft-Rhino (OR) is new software and equipment that can be used to measure changes in nasal obstruction after intranasal steroid treatment. OR is a promising method for measuring the degree of nasal obstruction. OR can precisely analyze nasal sound spectra in decibels, which is generated by nasal airflow. We studied the reliability of OR for assessing declining nasal obstruction after budesonide nasal spray treatment.

Methods

Sixty-five patients with perennial allergic rhinitis (PAR) were enrolled in the study, and 52 of these patients completed the study. Nasal endoscopic examination, acoustic rhinometry (AR), and OR were performed and symptom scores were compared before and after 3 months of treatment with intranasal budesonide. All of the patients received 7 days of placebo treatment before receiving budesonide.

Results

There was a significant difference in the visual analog scores of nasal obstruction and in the examination scores before and after the treatment for both the right and the left nasal cavities. Pretreatment AR findings and OR findings in the 2000- to 4000-Hz and 4000-to 6000-Hz intervals for both sides were significantly different from the posttreatment measurements (p = 0.000). Both AR and OR can assess the efficacy of budesonide nasal spray treatment for nasal obstruction in patients with PAR.

Conclusion

Both AR and OR are effective for assessing nasal obstruction and monitoring treatment efficacy but, as a simple and noninvasive test, OR can be used with confidence.

Evaluation of a new and simple classification for endoscopic sinus surgery

OBJECTIVE

In 2013, the Japanese Rhinologic Society proposed a simple classification for endoscopic sinus surgery (ESS). This classification consists of five procedures (type I, fenestration of the ostiomeatal complex, with uncinectomy and widening of the natural ostium; type II, single-sinus procedure, with manipulating the inside of the sinus; type III, polysinus procedure; type IV, pansinus procedure; type V, extended procedure beyond the sinus wall). The clinical relevance of this classification in chronic rhinosinusitis (CRS) and paranasal sinus cyst was evaluated.

STUDY DESIGN

A retrospective validation study.

METHODS

A total of 122 patients (195 sinuses) who underwent ESS in Okayama University Hospital in 2012 were enrolled. The relationships between the ESS classification and the clinical course, including the operation time, bleeding amounts during surgery and postoperative changes of olfaction, the computed tomography (CT) score, and nasal airway resistance were analyzed.

RESULTS

A total of 195 ESS procedures were classified into type I (n = 3), type II (n = 17), type III (n = 91), type IV (n = 82), and type V (n = 2). The major phenotypes of type II, III, and IV ESS were paranasal sinus cyst (68%), CRS without nasal polyps (77%), and CRS with nasal polyps (55%), respectively, and the difference was significant. The degree of ESS based on this classification was positively and significantly correlated with the operation time and bleeding amounts. As a whole, olfaction, CT score, and nasal airway resistance were significantly improved after surgery. The degree of improvement was similar between type III and type IV ESS.

CONCLUSION

This simple classification for ESS reflected the perioperative burden of the disease.

Peak nasal inspiratory flow as outcome for provocation studies in allergen exposure chambers: a GA2LEN study

Background

The GA²LEN chamber has been developed as a novel mobile allergen exposure chamber (AEC) allowing standardized multicenter trials in allergy. Hitherto, subjective nasal symptom scores have been the most often used outcome parameter, but in standardized modern trials objective parameters are preferred. Despite its practicability, the objective parameter peak nasal inspiratory flow (PNIF) has been rarely used for allergy trials in the setting of allergen exposure chambers. This study aims to evaluate PNIF as an outcome parameter for provocation studies in AECs.

Methods

In a randomized controlled blinded setting subjects suffering from allergic rhinitis were exposed to grass pollen, birch pollen, house dust mite and/or placebo in the GA²LEN chamber. Different allergen concentrations were used to evaluate symptom severities. Patients had to perform PNIF before and every 30 min during a challenge using a portable PNIF meter.

Results

86 subjects participated in 203 challenges, altogether. House dust mite provocations caused the greatest reduction in PNIF values, followed by grass pollen and birch pollen. Provocations with every allergen or pollen concentration led to a significant decrease (p < 0.05) in PNIF compared to baseline. Furthermore, positive correlations were obtained between PNIF and peak expiratory flow, height and weight, and inverse correlations between PNIF and total nasal symptom score, nasal congestion score and visual analog scale of overall subjective symptoms.

Conclusion

PNIF is a helpful and feasible tool for conducting provocation trials with allergens, especially grass pollen and house dust mite, in an AEC.

Electronic supplementary material

The online version of this article (doi:10.1186/s13601-017-0169-4) contains supplementary material, which is available to authorized users.

The prevalence and associated lifestyle risk factors of self-reported allergic rhinitis in Kazakh population of Fukang City

This study is to analyze the prevalence and the associated lifestyle risk factors of self-reported allergic rhinitis (AR) in Kazakh population of Fukang City.A cross-sectional study was conducted using stratified random sampling method and 1689 Kazak people were surveyed. A standard questionnaire was used for face-to-face interview.The prevalence of self-reported AR of Kazakh population in Fukang City was 13.7%, and sneezing was the most common symptoms (54.6%) with no significant differences among age, sex, and weight. The incidence of asthma in Kazakh people was correlated with age, and the incidence of allergies in Kazakh people was correlated with weight. Skin pruritus was the most common symptom for allergy (42.7%). The AR incidence was correlated with sinusitis and asthma, and was mostly associated with carpet use. For diet, the AR incidence was positively correlated with meat and fruit, and negatively correlated with beans and milk.The prevalence of AR is high among Kazakh people in Fukang City, and its incidence is closely related with lifestyle risk factors such as carpet use and meat and fruit consumption.

Kinetic oscillatory stimulation of nasal mucosa in non-allergic rhinitis: comparison of patient self-administration and caregiver administration regarding pain and treatment effect. A randomized clinical trial

CONCLUSION

Patient self-administration of the Kinetic Oscillatory Stimulation (KOS)-catheter was a fully acceptable alternative to insertion of the catheter by physician with helmet fixation, in patients with non-allergic rhinitis (NAR). The approaches were equivalent regarding pain. The treatment effect in the patient self-administration group was not inferior.

OBJECTIVES

To evaluate whether self-administration of a KOS-catheter was different compared to insertion by a physician, assessed with patient reported pain on a visual analogue scale (VAS). Also, to evaluate the difference in nasal stuffiness with the Sino-Nasal Outcome Test (SNOT-22) and Peak Nasal Inspiratory Flow (PNIF).

METHODS

Patients with NAR were randomized to group 1, patient insertion of catheter and manual fixation, and group 2, catheter insertion by physician and fixation with a helmet. Patients were treated once, 10 min in each nasal cavity, and followed up 14 days later.

RESULTS

Twenty-nine patients were included (group 1, n = 14; group 2, n = 15). There was no statistical significant difference in patient reported pain between groups. There was a decrease in nasal stuffiness after treatment in the total study population (n = 26, p = 0.001). In group 1 nasal stuffiness was decreased and in group 2 there was no change (group 1, p = 0.004; group 2, p = 0.071). No statistical significant change in PNIF was observed.

A UK survey of current ENT practice in the assessment of nasal patency

BACKGROUND

Nasal obstruction is a common ENT complaint; however, decisions on its management are challenging, with high rates of dissatisfaction following surgery. This study investigated the practice of UK clinicians in the evaluation of nasal patency.

METHOD

Seventy-eight UK-based rhinologists were surveyed at the 2015 British Academic Conference in Otolaryngology.

RESULTS

Clinical history and examination are almost universally used to evaluate nasal blockage. The most commonly used test was the nasal misting pattern (73 per cent), followed by peak nasal inspiratory flow (19 per cent). The Sino-Nasal Outcome Test 22 or 23 was utilised by 29 per cent of respondents. Sixty-three per cent of respondents reported that a lack of equipment was the principle reason for not using objective measures, followed by time constraints and a lack of correlation with symptom scores.

CONCLUSION

British clinicians rely on clinical skills to evaluate nasal blockage. There is a desire for a simple, non-invasive device that objectively measures airflow for nasal breathing during physiological resting and correlates with subjective symptom scores.

Control of Allergic Rhinitis and Asthma Test for Children (CARATKids): Validation in Brazil and cutoff values

BACKGROUND

The Control of Allergic Rhinitis and Asthma Test for Children (CARATKids) assesses asthma and allergic rhinitis control in children younger than 12 years.

OBJECTIVE

To validate the Brazilian Portuguese version of the CARATKids and to define the cutoff values for identifying uncontrolled disease.

METHODS

Children aged 6 to 12 years with asthma and allergic rhinitis were studied (n = 102). CARATKids, childhood Asthma Control Test (cACT), total nasal symptom score (TNSS), and visual analog scale (VAS) scores were obtained at baseline and after 4 to 6 weeks. Internal consistency, test-retest reliability, responsiveness, and validity of the Brazilian CARATKids were assessed according to the Consensus-based Standards for the Selection of Health Measurements Instruments checklist. The minimal clinically important difference (MCID) was evaluated using distribution and anchor methods. Spearman correlations were used to compare CARATKids scores with external measures of control. Receiver operating characteristic curve analysis was performed to establish cutoff values.

RESULTS

Fifty children completed both visits. The Cronbach α and intraclass correlation coefficient of CARATKids were 0.81 and 0.85, respectively. The Guyatt responsiveness index was -1.34, and within-patient change in clinically unstable patients (n = 31) was significant (P = .02). As for cross-sectional and longitudinal validity, correlation coefficients ranged from 0.58 to 0.77 (P < .001) and 0.30 to 0.57 (P < .05), respectively. The estimated MCID for CARATKids was 3. The optimal cutoffs (sensitivity and specificity) to exclude uncontrolled and controlled disease were 3 or less (97% and 67%) and 6 or greater (56% and 96%), respectively.

CONCLUSION

CARATKids is a reliable and valid tool to assess asthma and allergic rhinitis control in Brazilian children. A score of 6 or higher on CARATKids identifies uncontrolled disease, and a score of 3 or lower excludes poor disease control.

Sleep disorders in children with moderate to severe persistent allergic rhinitis

Introduction

Allergic rhinitis is associated with several complications, including sleep disorders. The Children's Sleep Habits Questionnaire has been recently translated and validated in Portuguese for the evaluation of sleep disorders in children.

Objective

To assess sleep disorders in children with moderate to severe persistent allergic rhinitis and to correlate the findings with disease severity markers.

Methods

We evaluated 167 children (4–10 years), 112 with allergic rhinitis and 55 controls. Parents/guardians of the children answered the Children's Sleep Habits Questionnaire, consisting of 33 questions divided into eight subscales, which refers to the previous week. Patients with rhinitis were also evaluated regarding the score of nasal and extra-nasal symptoms related to the previous week and the peak nasal inspiratory flow.

Results

There were no significant differences between groups of different age. All patients with rhinitis were being treated with nasal topical corticosteroids. The total Children's Sleep Habits Questionnaire score was significantly higher among children with rhinitis than in controls (median 48 vs. 43, p < 0.001). Significantly higher values were also observed for the parasomnia (9 vs. 8), respiratory disorders (4 vs. 3) and daytime sleepiness (14 vs. 12) subscales. Among the patients with rhinitis, no significant correlation was observed between the total Children's Sleep Habits Questionnaire score and disease activity variables, but moderate correlations were observed for the respiratory distress subscale vs. nasal symptom score (r = 0.32) and vs. extra-nasal symptom score (r = 0.32).

Conclusion

Children with moderate to severe persistent allergic rhinitis, even when submitted to regular treatment, have a higher frequency of sleep disorders than controls, particularly concerning nocturnal breathing disorders, daytime sleepiness, and parasomnias. The intensity of sleep disorders found in some subscales was correlated with objective markers of allergic rhinitis severity.

Body dysmorphic disorder in patients undergoing septorhinoplasty surgery: should we be performing routine screening?

OBJECTIVE

Body dysmorphic disorder (BDD) is defined as having a preoccupation with a perceived flaw in one's appearance, which appears slight to others and significantly interferes with a person's functioning. When undetected in septorhinoplasty patients, it will often lead to poor outcomes.

DESIGN

We performed a prospective cohort study to determine the prevalence of BDD in our patients and whether surgical correction could be considered.

SETTING AND PARTICIPANTS

We recruited 34 patients being considered for septorhinoplasty in a tertiary referral rhinology clinic and a control group of 50 from the otology clinic giving a total of 84.

MAIN OUTCOME MEASURES

Participants completed the Body Dysmorphic Disorder Questionnaire (BDDQ), the sino-nasal outcome test-23 (SNOT-23) and underwent nasal inspiratory peak flow (NIPF). Those found to be at high risk for BDD were referred to a clinical psychologist.

RESULTS

Of the septorhinoplasty patients, 11 (32%) were high risk for BDD. Following psychological assessment, 7 (63%) patients were felt to be unsuitable for surgery and were offered psychological therapy. SNOT-23 scores were significantly higher in the BDD group indicating a negative impact on quality of life. NIPF readings were not significantly different in the BDD group compared to the control group.

CONCLUSIONS

The BDDQ is a valid tool for identifying patients at risk of BDD. A close working relationship with clinical psychology has been advantageous to help the selection process of candidates for surgery when there is a high risk of BDD.

Association between desloratadine and prednisolone in the treatment of children with acute symptoms of allergic rhinitis: a double-blind, randomized and controlled clinical trial

Introduction

A combination of antihistamines and oral corticosteroids is often used to treat acute symptoms of allergic rhinitis.

Objective

To evaluate safety and efficacy of desloratadine plus prednisolone in the treatment of acute symptoms of children (2–12 years) with allergic rhinitis, and to compare it to dexchlorpheniramine plus betamethasone.

Methods

Children with moderate/severe persistent allergic rhinitis and symptomatic (nasal symptoms score [0–12] ≥ 6) were allocated in a double-blind, randomized fashion to receive dexchlorpheniramine plus betamethasone (n = 105; three daily doses) or desloratadine plus prednisolone (n = 105; single dose followed by two of placebo) for 7 days. At the beginning and end of the evaluation, the following were obtained: nasal symptoms score, extra nasal symptoms score, peak nasal inspiratory flow, blood biochemistry, and electrocardiogram. Ninety-six children of the dexchlorpheniramine plus betamethasone group and 98 of the desloratadine plus prednisolone group completed the protocol.

Results

The two groups were similar regarding initial and final nasal symptoms scores, extra nasal symptoms scores and peak nasal inspiratory flow. A drop of 76.4% and 79.1% for nasal symptoms score, 86.0% and 79.2% for extra nasal symptoms score, as well as an increase of 25.2% and 24.3% for peak nasal inspiratory flow occurred for those treated with desloratadine plus prednisolone and dexchlorpheniramine plus betamethasone, respectively. There were no significant changes in blood chemistry. Sinus tachycardia was the most frequent electrocardiogram change, but with no clinical significance. Drowsiness was reported significantly more often among those of dexchlorpheniramine plus betamethasone group (17.14% × 8.57%, respectively).

Conclusion

The desloratadine plus prednisolone combination was able to effectively control acute symptoms of rhinitis in children, improving symptoms and nasal function. Compared to the dexchlorpheniramine plus betamethasone combination, it showed similar clinical action, but with a lower incidence of adverse events and higher dosing convenience.

Outcome of Nasal Valve Obstruction After Functional and Aesthetic-Functional Rhinoplasty

INTRODUCTION

Nasal valve insufficiency is distinct from other anatomic causes of nasal obstruction. Functional rhinoplasty refers to the collective techniques used to reconstruct the lateral nasal wall, typically achieved with the use of spreader and alar grafts. Patients undergoing functional rhinoplasty can also have aesthetic desires and goals achievable with combined aesthetic-functional rhinoplasty.

OBJECTIVE

To evaluate the improvement in nasal obstruction symptoms after cartilage graft reconstruction in patients with nasal valve insufficiency and to compare the postoperative improvement between patients undergoing functional and aesthetic-functional rhinoplasty.

DESIGN, SETTING, AND PARTICIPANTS

In this prospective multicenter cohort study, 12 participating surgeons enrolled 79 consecutive patients diagnosed as having nasal valve insufficiency as the primary cause of nasal obstruction. Patients underwent functional or aesthetic-functional rhinoplasty. The study collected demographic, clinical, and surgical data from March 2006 to September 2008. Nasal symptoms were evaluated using a validated, disease-specific, quality-of-life instrument. The Nasal Obstruction Symptom Evaluation (NOSE) scale was administered to participants at baseline and 3, 6, and 12 months postoperatively. Follow-up was completed on September 2008, and data were analyzed in September 2009 and in September 2013.

MAIN OUTCOMES AND MEASURES

Changes in NOSE scale score (range, 0 to 100, with a higher score indicating greater severity of obstruction) at 3 months between the functional and aesthetic-functional groups.

RESULTS

Of the 79 patients, 31 underwent functional and 48 underwent aesthetic-functional rhinoplasty. Overall, an improvement was found in nasal breathing, with a mean decrease of 48.6 points (95% CI, 41.9-55.2; P < .001) at the 3-month assessment compared with the preoperative baseline NOSE scale score (mean [SD], 67.1 [19.7]). The improvement in nasal breathing was similar whether patients underwent functional or aesthetic-functional rhinoplasty (mean [95% CI] NOSE scale score change, 51.4 [42.1-60.7] and 46.6 [37.1-56.1], respectively; P = .49).

CONCLUSIONS AND RELEVANCE

Nasal valve reconstruction with spreader and alar grafts is effective in treating patients with nasal valve insufficiency. Combining aesthetic interventions with functional rhinoplasty did not seem to affect the magnitude of improvement in nasal breathing outcome.

LEVEL OF EVIDENCE

2.

Effect of acupuncture on house dust mite specific IgE, substance P, and symptoms in persistent allergic rhinitis

BACKGROUND

Clinical evidence suggests that acupuncture improves symptoms in persistent allergic rhinitis, but the physiologic basis of these improvements is not well understood.

OBJECTIVE

A randomized, sham-controlled trial of acupuncture for persistent allergic rhinitis in adults investigated possible modulation of mucosal immune responses.

METHODS

A total of 151 individuals were randomized into real and sham acupuncture groups (who received twice-weekly treatments for 8 weeks) and a no acupuncture group. Various cytokines, neurotrophins, proinflammatory neuropeptides, and immunoglobulins were measured in saliva or plasma from baseline to 4-week follow-up.

RESULTS

Statistically significant reduction in allergen specific IgE for house dust mite was seen only in the real acupuncture group, from 18.87 kU/L (95% CI, 10.16-27.58 kU/L) to 17.82 kU/L (95% CI, 9.81-25.83 kU/L) (P = .04). A mean (SE) statistically significant down-regulation was also seen in proinflammatory neuropeptide substance P (SP) 18 to 24 hours after the first treatment from 408.74 (299.12) pg/mL to 90.77 (22.54) pg/mL (P = .04). No significant changes were seen in the other neuropeptides, neurotrophins, or cytokines tested. Nasal obstruction, nasal itch, sneezing, runny nose, eye itch, and unrefreshed sleep improved significantly in the real acupuncture group (postnasal drip and sinus pain did not) and continued to improve up to 4-week follow-up.

CONCLUSION

Acupuncture modulated mucosal immune response in the upper airway in adults with persistent allergic rhinitis. This modulation appears to be associated with down-regulation of allergen specific IgE for house dust mite, which this study is the first to report. Improvements in nasal itch, eye itch, and sneezing after acupuncture are suggestive of down-regulation of transient receptor potential vanilloid 1.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry Identifier: ACTRN 12610001052022.

Measurements of nasal airflow and patency: a critical review with emphasis on the use of peak nasal inspiratory flow in daily practice

Objective measures can be used to assist the clinician to diagnose and treat nasal obstruction and also to quantify nasal obstruction in research. Objective measurements of nasal obstruction are as important as objective measurements of lung function. peak nasal inspiratory flow (PNIF), acoustic rhinometry (AR) and rhinomanometry (RM), with their specific peculiarity, assess different aspects of nasal obstruction. From the studies available in the literature, it seems that these methods roughly correlate with each other and that all of them can be alternatively utilized very well in research as well as in clinical practice. This review describes the various methods that can be used to measure nasal patency, airflow and resistance, mainly peak nasal inspiratory flow, rhinomanometry and acoustic rhinometry. PNIF has been demonstrated to be reproducible and as good an indication of objective nasal patency as formal rhinomanometry and has the advantage to be cheap, simple and suitable for serial measurements and for home use even in the paediatric population. PNIF normative data are available for children, adults and elderly subjects, and the availability of unilateral PNIF normal values allows evaluation of nasal sides separately. Just as in the lower airways, objective and subjective evaluation gives different information that together optimizes the diagnosis and the treatment of our patients. We argue that PNIF should be used regularly in every outpatient clinic that treats patients with nasal obstruction.

Effects of CT resolution and radiodensity threshold on the CFD evaluation of nasal airflow

The article focuses on the robustness of a CFD-based procedure for the quantitative evaluation of the nasal airflow. CFD ability to yield robust results with respect to the unavoidable procedural and modeling inaccuracies must be demonstrated to allow this tool to become part of the clinical practice in this field. The present article specifically addresses the sensitivity of the CFD procedure to the spatial resolution of the available CT scans, as well as to the choice of the segmentation level of the CT images. We found no critical problems concerning these issues; nevertheless, the choice of the segmentation level is potentially delicate if carried out by an untrained operator.