Evaluation of acoustic rhinometry in a nasal provocation test with allergen

Peak Nasal Inspiratory Flow (PNIF) for Nasal Breathing Evaluation

Measuring nasal airflow and nasal breathing has been a major goal of rhinology. Many objective methods for measuring nasal airflow or nasal airway resistance or dimensions provide valuable data but are time-consuming and require expensive equipment and trained technicians, thus making these methods less practical for clinical practice. Peak nasal inspiratory flow (PNIF) measurement is fast, unexpensive, noninvasive, and able to provide an objective evaluation of nasal airflow in real-time. Unilateral PNIF measurements allow separated evaluation of each side of the nasal airway and may prove particularly useful when clinical assessment detects significant asymmetry between both nasal cavities.PNIF measurements are most useful for assessing changes in nasal airflow achieved by any form of therapy, including surgical treatment of the nasal airway. These measurements generally correlate with other objective methods for nasal airway evaluation, but not unequivocally with patient-reported evaluation of nasal breathing. Nevertheless, as low PNIF values prevent the sensation of a suitable nasal breathing, PNIF measurement may also prove useful to optimize the decision of how to best address patients with complaints of nasal airway obstruction.

Objectification of the nasal patency assessment techniques used in nasal allergen provocation testing

Topical allergen application in nasal provocation testing (NPT) is associated with remarkably rapid changes in nasal patency. Thus, selecting the techniques of assessing the extent of nasal obstruction (as one of the responses to topical allergen application) is an important component of NPT. The study attempted to systematize and evaluate the techniques selected for assessing nasal patency during NPT based on a review of relevant literature. We reviewed the literature on the attempts to standardize the objective techniques for assessing nasal patency and their use in NPT. The best known, well-established technique for assessing nasal patency as part of NPT was rhinomanometry, followed by peak nasal inspiratory flow (PNIF) testing and acoustic rhinometry.

Positive allergen reaction in allergic and nonallergic rhinitis: a systematic review

BACKGROUND

The diagnosis of allergic rhinitis (AR) is based on cutaneous and serological assessment to determine immunoglobulin E (IgE)-mediated disease. However, discrepancies between these tests and nasal provocation exist. Patients diagnosed as non-allergic rhinitis (NAR) but with positive nasal allergen provocation test (NAPT) may represent a local allergic condition or entopy, still suitable to allergy interventions. The objective of this study was to determine the frequency of nasal reactivity toward allergens among AR and NAR patients, and to describe the diagnostic characteristics of NAPT methodologies.

METHODS

EMBASE (1947-) and Medline (1946-) were searched until December 8, 2015. A search strategy was used to identify studies on AR or NAR patients subjected to diagnostic local nasal provocation. All studies providing original NAPT data among the AR or NAR population were included. Meta-analysis of proportion data was presented as a weighted probability % (95% confidence interval [CI]).

RESULTS

The search yielded 4504 studies and 46 were included. The probability of nasal allergen reactivity for the AR population was 86.3% (95% CI, 84.4 to 88.1) and in NAR was 24.7% (95% CI, 22.3 to 27.2). Reactivity was high with pollen for both AR 97.1% (95% CI, 94.2 to 99.2) and NAR 47.5% (95% CI, 34.8 to 60.4), and lowest with dust for both AR 79.1% (95% CI, 76.4 to 81.6) and NAR 12.2% (95% CI, 9.9 to 14.7). NAPT yielded high positivity when defined by subjective end-points: AR 91.0% (95% CI, 86.6 to 94.8) and NAR 30.2% (95% CI, 22.9 to 37.9); and lower with objective end-points: AR 80.8% (95% CI, 76.8 to 84.5) and NAR 14.1% (95% CI, 11.2 to 17.2).

CONCLUSION

Local allergen reactivity is demonstrated in 26.5% of patients previously considered non-allergic. Similarly, AR, when defined by skin-prick test (SPT) or serum specific IgE (sIgE), may lead to 13.7% of patients with inaccurate allergen sensitization or non-allergic etiologies.

Nasal provocation test is useful for discriminating allergic, nonallergic, and local allergic rhinitis

BACKGROUND

No standard study protocol or diagnostic criteria based on nasal provocation test (NPT) and acoustic rhinometry (AR) results are available for allergic rhinitis.

OBJECTIVE

We aimed to evaluate the usefulness of NPT plus AR for the differential diagnosis of local allergic rhinitis (LAR), allergic, and nonallergic rhinitis.

METHODS

The medical records and skin-prick test (SPT) and NPT results of 262 patients with symptoms of chronic rhinitis were reviewed. Patients were allocated to one of three groups, that is, group A [n = 110, negative SPT result for Dermatophagoides pteronyssinus (DP)], group B (n = 53, weakly positive result), or group C (n = 99, strongly positive result).

RESULTS

Twelve patients had a negative SPT result and provoked response in NPT [≥29% decrease of minimal cross-sectional area (MCA) after DP challenge] were diagnosed to have LAR. After DP challenge, group C showed significant aggravation of nasal symptoms and a greater decrease in acoustic parameters than groups A and B (p < 0.01). In patients with a more than or equal to 2 visual analog scale (VAS) increase in nasal obstruction (NO) after DP challenge, the criterion "a change of total nasal symptom score (TNSS) of more than or equal to 6.5" had 90.6% sensitivity and 77.4% specificity for the diagnosis of allergic rhinitis, whereas the diagnostic criterion "a total nasal volume (TNV) change at 30 minutes after DP challenge of more than or equal to 27.6%" had 73.4% sensitivity and 58.1% specificity.

CONCLUSION

NPT with AR could be a useful tool for the differential diagnosis of allergic, nonallergic, and local allergic rhinitis.

The Relation Between Body Mass Index and Nasal Airflow

BACKGROUND

Nasal obstruction and complaints are common attendance causes in otorhinolaryngology clinics. Obese patients are especially more vulnerable for these complaints. There is not enough data about nasal resistance and weight.

PATIENTS AND METHODS

One hundred ten patients who had no nasal complaint and nasal pathology were investigated by peak nasal inspiratory flow meter, nasal symptom evaluation scale (NOSE), and visual analog scale (VAS) calculation.

RESULTS

According to the statistical analyses among the BMI groups, there is no significant difference detected. Peak nasal inspiratory flow values highly correlated with height. Height correlated with VAS and weight correlated with NOSE scores. VAS score highly correlated with NOSE score. Also, there is a negative statistically significant correlation between BMI and nasal congestion index.

CONCLUSION

All these data show that there is no relation between BMI and nasal resistance, and although the nasal congestion cycle is preserved in all BMI groups, nasal congestion index is decreased when the weight is raised.

The nasal vestibular body: anatomy, clinical features, and treatment considerations

Nasal obstruction is a common presenting complaint, with many possible etiologies. Herein, we provide an introductory anatomic description, clinical relevance, and proposed nomenclature for an underappreciated soft tissue focus in the nasal vestibule-the nasal vestibular body (NVB)-that can contribute to nasal obstruction in a subset of patients. This is a small mound of dynamic soft tissue in the lateral aspect of the internal nasal valve, situated inferior and anterior to the head of the inferior turbinate that can be missed on routine examination for many salient reasons. In well-selected patients, whose symptoms of nasal obstruction may in part be secondary to the presence of this soft tissue focus, directed testing and tissue reduction can be performed.

Peak nasal inspiratory flowmetry for selection of patients for radiofrequency ablation of turbinates

OBJECTIVES

Our goals were to investigate (I) the effectiveness of the topical vasoconstrictor test (TVT) and peak nasal inspiratory flow (PNIF) measurement for the selection of patients with inferior turbinate hypertrophy (ITH) who will benefit from radiofrequency ablation (RFA) of the turbinates and (2) the efficacy of the TVT and PNIF in follow-up of treatment outcomes.

METHODS

Patients with bilateral chronic nasal obstruction due to ITH underwent assessment with a visual analog scale (VAS) and PNIF before and after the TVT. Twenty patients with symptom improvement according to VAS and PNIF results were enrolled in the study. These patients underwent RFA, and PNIF and VAS scores were determined before and I and 6 months after the TVT. These results were compared to evaluate the preoperative prediction of RFA treatment success.

RESULTS

Radiofrequency ablation of the turbinates resulted in significant changes in objective and subjective scores. Preoperative (baseline) subjective and objective responses to decongestant were positively correlated (P = .024 and P < .05, respectively). Preoperative (baseline) objective responses to decongestant were significantly correlated with the objective outcomes of surgery (P = .006 and P < .05, respectively).

CONCLUSION

The combined use of PNIF and the TVT allows for the preoperative prediction of the success of RFA and the selection of patients who will benefit most from RFA.

Structural characterization and antioxidant activities of polysaccharides extracted from the pulp of Elaeagnus angustifolia L

In this study, two polysaccharides (Elaeagnus angustifolia L. polysaccharide-1 (PEA-1) and PEA-2) were prepared from Elaeagnus angustifolia L. Then, the preliminary structure and antioxidant activities of all the samples were investigated. The results showed that the average molecular weights for PEA-1 and PEA-2 were 9113 and 5020 Da, respectively. And, PEA-1 was mainly composed of rhamnose, xylose, mannose, glucose, and galactose, respectively. The components of PEA-2 were rhamnose, mannose, glucose, and galactose, respectively. Moreover, the Antioxidant assays demonstrated that PEA-1 possessed of strong free radicals scavenging activity and hydroxyl radicals scavenging activities, suggesting that PEA-1 could potentially be used as natural antioxidant.

Comparison of two oral probiotic preparations in a randomized crossover trial highlights a potentially beneficial effect of Lactobacillus paracasei NCC2461 in patients with allergic rhinitis

Background

There is promising but conflicting evidence to recommend the addition of probiotics to foods for prevention and treatment of allergy. Based on previous studies with fermented milk containing Lactobacillus paracasei NCC2461, we aimed to compare the effect of a powder form of the latter probiotic with the effect of a blend of Lactobacillus acidophilus ATCC SD5221 and Bifidobacterium lactis ATCC SD5219 in patients with allergic rhinitis.

Methods

A double-blind, randomized, cross-over study, involving 31 adults with allergic rhinitis to grass pollen, was performed outside the grass pollen season (registration number: NCT01233154). Subjects received each product for 4-weeks in two phases separated by a wash-out period of 6 to 8 weeks. A nasal provocation test was performed before and after each 4-week product intake period, and outcome parameters (objective and subjective clinical symptoms; immune parameters) were measured during and/or 24 hours after the test.

Results

Out of the 31 subject enrolled, 28 completed the study. While no effect was observed on nasal congestion (primary outcome), treatment with NCC2461 significantly decreased nasal pruritus (determined by VAS), and leukocytes in nasal fluid samples, enhanced IL-5, IL-13 and IL-10 production by peripheral blood mononuclear cells in an allergen specific manner and tended to decrease IL-5 secretion in nasal fluid, in contrast to treatment with the blend of L. acidophilus and B. lactis.

Conclusions

Despite short-term consumption, NCC2461 was able to reduce subjective nasal pruritus while not affecting nasal congestion in adults suffering from grass pollen allergic rhinitis. The associated decrease in nasal fluid leukocytes and IL-5 secretion, and the enhanced IL-10 secretion in an allergen specific manner may partly explain the decrease in nasal pruritus. However, somewhat unexpected systemic immune changes were also noted. These data support the study of NCC2461 consumption in a seasonal clinical trial to further demonstrate its potentially beneficial effect.

Nonspecific Hyper-reactivity and Localized Allergy

Objective

Disagreement between results of skin prick test (SPT) and nasal provocation tests (NPT) causes difficulty in differential diagnosis of allergic rhinitis (AR) and nonallergic rhinitis (NAR). We hypothesized this discrepancy could be due to the nonspecific hyper-reactivity (NHR) and localized allergy of the nasal cavity.

Study Design

Prospective pilot.

Setting

Academic tertiary rhinologic practice.

Subjects and Methods

Sixty patients with AR and 62 with NAR were enrolled. We categorized patients according to results of SPT and NPT. We compared: (1) the clinical characteristics and severity of the disease, (2) change of minimal cross-sectional area (MCA) and total nasal volume (TNV) after normal saline (NS) challenge, and (3) change of nasal symptoms and acoustic parameters after intranasal house dust mite (HDM) challenge between groups.

Results

Patients in groups A (SPT[+]/NPT[+]) and C (SPT[–]/NPT[+]) complained of more persistent discomfort than those in groups B (SPT[+]/NPT[–]) and D (SPT[–]/NPT[–]). The proportion of moderate to severe symptoms was significantly higher in groups A, B, and C compared to group D. After NS challenge, MCA/TNV showed a significantly greater decrease in groups A (MCA: 27.6% ± 21.3%, TNV: 24.6% ± 16.4%) and C (MCA: 31.2% ± 24.0%, TNV: 24.1% ± 23.4%) compared to groups B (MCA: 0.1% ± 13.2%, TNV: 3.9% ± 13.5%) and D (MCA: 2.1% ± 12.1%, TNV: 2.0% ± 17.2%) ( P < .05). After HDM challenge, groups A/B showed a greater decrease in MCA (Group A: 62.4% ± 16.1%, Group B: 6.4% ± 11.3%) compared to groups C/D (Group C: 45.5% ± 14.4%, Group D: –3.0% ± 9.5%).

Conclusion

NHR and/or localized allergy should be considered in patients with rhinitis whose SPT and NPT results are not in agreement.

Use of nasal inspiratory flow rates in the measurement of aspirin-induced respiratory reactions

BACKGROUND

Nasal ketorolac challenge with modified oral aspirin challenge is a safe and effective alternative for desensitizing patients with aspirin-exacerbated respiratory disease. In addition to clinical judgment, objective tests assessing nasal flow may help in diagnosing nasal reactions.

OBJECTIVE

To evaluate the feasibility of peak nasal inspiratory flow (PNIF) as an objective measurement in the assessment of a reaction to nasal ketorolac and to determine changes in PNIF that have adequate sensitivity and specificity.

METHODS

One hundred fifty-one patients referred to the Scripps Clinic for aspirin challenge and desensitization and 14 healthy controls participated in the study. Percentages of decrease in PNIF during reactions were compared with the nonreactors' measurements. A receiver operating characteristic curve was constructed to assess the diagnostic performance of PNIF measurement during a clinically positive nasal challenge.

RESULTS

A total of 165 subjects participated in the study. One hundred fourteen patients (69.1%) clinically reacted to the nasal ketorolac challenge. There was no statistical difference between nasal reactors and nonreactors regarding sex, baseline forced expiratory volume in 1 second, and use of systemic steroid before challenge. The mean percentage of decrease in PNIF was significantly higher in the reactor group (-0.30 ± 0.29 vs -0.07 ± 0.16, P < .001). A cutoff value of 25% decrease in PNIF had the maximum sensitivity and specificity (56.1% and 94.1%).

CONCLUSION

The high specificity of a 25% decrease in PNIF found in receiver operating characteristic curve analysis indicated that PNIF measurements can be useful for assessing nasal reactions during nasal ketorolac challenges in the diagnosis of aspirin-exacerbated respiratory disease.

Correlation between nasal resistance and different acoustic rhinometry parameters in children and adolescents with and without allergic rhinitis

Acoustic rhinometry and rhinomanometry are important tests used to assess nasal function. The degree to which the parameters of these tests are correlated is yet to be established.

Objective

This paper aimed to study the correlations between nasal resistance (NR) and acoustic rhinometry parameters in children and adolescents with allergic rhinitis and controls.

Method

Twenty patients with allergic rhinitis and 20 controls were enrolled. NR, volumes (V4, V5, V2-5), and minimal cross-sectional areas (MC1, MC2) were measured in three moments: baseline, after induction of nasal obstruction and after topical decongestant administration.

Results

Patients with allergic rhinitis had significant correlation between NR and all volumes (V5: r = -0.60) and with MC2. Among controls, MC1 was the parameter with the strongest correlation with NR at baseline (r = -0.53) and after decongestant administration. In the combined analysis, V5 had the highest correlation coefficients at baseline (r = -0.53), after obstruction (r = -0.58) and after decongestant (r = -0.46).

Conclusions

Our data showed that NR and acoustic rhinometry parameters have negative and significant correlations. Nasal volumes are, in general, better correlated than minimal cross-sectional areas. V5 was the parameter with the highest correlation in the rhinitis group and in the combined analysis.

Nasal obstruction and rhinorrhea reflect nonspecific nasal hyper-reactivity as evaluated by cold dry air provocation

CONCLUSION

Nasal obstruction, rhinorrhea, and the amount of rhinorrhea that confidently reflect the parasympathetic stimulation can be used to more precisely predict nonspecific nasal hyper-reactivity (NHR).

OBJECTIVE

We aimed to identify factors that confidently reflected the presence and the degree of NHR, measured by cold dry air (CDA) provocation and acoustic rhinometry.

METHODS

A total of 156 patients with allergic or non-allergic rhinitis were classified into three groups according to the decrease of minimal cross-sectional area (MCA) after CDA provocation (group A: n = 40, MCA decrease >60%; group B: n = 29, MCA decrease 30-60%; group C: n = 87, MCA decrease <29%). Symptom scores using the visual analog scale (VAS) were obtained before and after CDA provocation. Changes of VAS were compared between groups. The amount of rhinorrhea was measured after CDA provocation.

RESULTS

VAS scores for nasal obstruction, rhinorrhea, and sneezing were significantly higher in groups A and B than in group C before and after CDA provocation. Change of nasal obstruction and rhinorrhea was significantly larger in group A compared with group B or C. There were also significant differences in the amount of rhinorrhea between groups. All these parameters significantly correlated with the change of MCA values after CDA provocation.

Effect of Lactobacillus paracasei ST11 on a nasal provocation test with grass pollen in allergic rhinitis

BACKGROUND

Probiotics have been associated with prevention and improvement of symptoms in atopic diseases such as atopic dermatitis. However, few studies exist that document their efficacy for upper airways allergies such as allergic rhinitis.

OBJECTIVE

To investigate the effect of short-term oral administration of Lactobacillus paracasei ST11 on a nasal provocation test (NPT) with grass pollen.

METHODS

Thirty-one adult volunteers with allergic rhinitis were enrolled in a randomized, double-blind, placebo-controlled study, based on two 4-week cross-over periods of product consumption (ST11-fermented milk vs. placebo), separated by a wash-out period of 6-8 weeks. Objective and subjective clinical parameters of NPT as well as systemic and nasal immunological parameters were compared between the two treatment periods (registration number: NCT 011 50 253).

RESULTS

Subjects that received ST11-fermented milk had lower nasal congestion than subjects under placebo (visual analogical scale; P<0.05). Nasal pruritus followed the same trend. However, no significant change in combined nasal reaction threshold was observed between the two periods. IL-5 secretion by peripheral blood mononuclear cells and serum allergen-specific IgG4 were significantly lower in ST11-fermented milk group compared to placebo group. IL-8 and IL-10 secretion followed the same trend.

CONCLUSION AND CLINICAL RELEVANCE

Short-term treatment with ST11-fermented milk before NPT significantly improved a clinical marker of NPT (subjective nasal congestion) and down-regulated systemic immune markers (IL-5 from peripheral blood mononuclear cells and serum IgG4). These data strongly suggest that probiotics may down modulate key parameters of allergic rhinitis and warrant future evaluation in seasonal trials.

Proposed diagnostic standard using visual analogue scale and acoustic rhinometry in nasal provocation test in allergic patients

OBJECTIVE

The authors aimed to analyze symptom change after nasal provocation and acoustic rhinometry results of a larger number of allergic rhinitis patients and also aimed to propose a new diagnostic threshold by investigating the difference between patients with allergic and non-allergic perennial rhinitis.

METHODS

The authors checked symptom change and performed acoustic rhinometry before and after nasal provocation in 208 patients (114 males and 94 females, 19-58 years old) with allergic rhinitis and 222 patients (116 males and 106 females, 20-74 years old) clinically diagnosed with non-allergic perennial rhinitis (control group). Then the authors compared VAS (visual analogue scale), TNV (total nasal volume), MCA (minimal cross-sectional area), length of MCA and change of these values between allergic patients group and control group, to propose the new diagnostic standard.

RESULTS

The change of symptom score and number of sneezing after nasal provocation were significantly different between allergic patient and control group. The basal TNV, MCA, length of MCA, and changes of these values were also significantly different. By drawing the ROC (receiver operator characteristic) curve and evaluating the sensitivity and specificity for each criteria, we could set the diagnostic criteria as follows: (1) symptom change: more than 2 points in the case of nasal obstruction and more than 1 point for the case of rhinorrhea or itching, (2) more than 24.5% change of the TNV, and (3) more than 20% change of the MCA.

CONCLUSION

VAS change and acoustic rhinometry in nasal provocation test could be a valuable tool in diagnosing allergic rhinitis with high sensitivity and specificity.

Does nasal obstruction mean that the nose is obstructed?

OBJECTIVES/HYPOTHESIS

It is still a matter of controversy to what extent the sense of nasal obstruction is associated with objective measures for nasal space and airflow. Knowledge about this is important in the evaluation of nasal complaints and the planning of its treatment. In this study, we evaluated the relationship between subjective nasal obstruction and the corresponding anatomic and physiological nasal parameters using acoustic rhinometry (AR) and peak nasal inspiratory flow (PNIF).

STUDY DESIGN

Two thousand five hundred twenty-three consecutive patients were included in this cross-sectional study. Eligible subjects were adults referred to the Ear, Nose, and Throat Department, Sørlandet Hospital, Kristiansand, Norway, for evaluation of chronic nasal or sleep related complaints.

METHODS

Subjects underwent AR and nasal flow measurements. Subjective grading of nasal obstruction was obtained by a nasal obstruction visual analogue scale. Associations between nasal obstruction visual analogue scale scores, AR, and PNIF were assessed using multiple linear regression, adjusting for age, gender, body mass index, and asthma, allergy, and smoking history.

RESULTS

The sense of nasal obstruction was associated with nasal cavity volumes in both anterior and middle segments of the nasal cavities, with minimal cross-sectional areas in middle segments and for the nasal cavity as a whole, and with PNIF. Associations with minimal cross-sectional areas in anterior segments did not reach significance.

CONCLUSIONS

The present study demonstrates highly significant associations between the subjective sensation of nasal obstruction and corresponding measures for nasal cavity volume, area, and airflow. We conclude that AR and PNIF are valuable objective instruments for evaluation of subjective nasal obstruction.

Multiallergen nasal challenges in nonallergic rhinitis

BACKGROUND

It has been proposed that some patients with nonallergic rhinitis may have "localized allergy" of the nasal mucosa. Nasal challenges with aeroallergens can help determine whether a patient is clinically allergic via an IgE-mediated pathway.

OBJECTIVE

To determine the prevalence of localized allergy in patients with negative skin prick test results via nasal challenges with an array of allergens.

METHODS

Twenty individuals with perennial rhinitis and negative epicutaneous test results to common perennial aeroallergens underwent nasal challenges to glycerin, Alternaria, cockroach, timothy grass, cat hair, and Dermatophagoides pteronyssinus. Total symptom scores, peak nasal inspiratory flow rates, and nasal eosinophil counts were determined.

RESULTS

Of 20 patients with nonallergic rhinitis, 4 were hyperresponsive to glycerin and were not subsequently challenged. Eleven patients had negative nasal challenges. Five patients developed positive challenges (total symptom score > or = 5) to 7 allergens. These 5 patients returned for nasal provocation testing to their offending allergens, and these repeated challenges were negative. Three control subjects with allergic rhinitis developed positive challenges after nasal allergen challenge.

CONCLUSIONS

Although some individuals with nonallergic rhinitis can have positive nasal allergen challenges, these results were not reproducible in the present patient population.

Evidence-based recommendations regarding the differential diagnosis and assessment of nasal congestion: using the new GRADE system

Nasal congestion is an important symptom in nasal pathology and can be defined as an objective restriction of nasal cavity airflow because of mucosal pathology and/or increased mucus secretion (excluding anatomical variants). Using the new Grading Recommendations Assessment, Development and Evaluation system, evidence-based recommendations are made that will encompass different clinical questions regarding diagnostic modalities of nasal congestion: (i) their usefulness in assessment of presence and severity of congestion; (ii) their usefulness in assessment of etiological pathology responsible for congestion; and (iii) their usefulness in follow up and treatment effectiveness evaluation of nasal congestion.

Evaluation of acoustic rhinometry in a nasal provocation test with allergic rhinitis

Objective

The nasal provocation test is not widely available due to lack of standardized methods and related research. We evaluated the clinical utility of the nasal provocation test using acoustic rhinometry.

Study Design

All patients underwent skin tests and were graded according to severity of reaction.

Methods

We performed nasal provocation tests using acoustic rhinometry in patients with allergic rhinitis from January 2003 to December 2006. A total of 836 patients participated in our study. The mean age was 36 years and the male:female ratio was 5:4.

Results

The mean nasal volume was 10.86 cm3 and the mean minimal cross-sectional area (MCA) was 0.66 cm3 before the study. Relationship between the severity of the reaction and change in mean nasal volume and MCA was statistically significant. The relationship between the severity of the reaction against the antigen and the severity of clinical symptoms was also statistically significant.

Conclusion

The nasal provocation test can be helpful in evaluating the severity of allergic rhinitis. However, we must be careful in interpreting the results alone.

Objective monitoring of nasal patency and nasal physiology in rhinitis

Nasal obstruction can be monitored objectively by measurement of nasal airflow, as evaluated by nasal peak flow, or as airways resistance/conductance as evaluated by rhinomanometry. Peak flow can be measured during inspiration or expiration. Of these measurements, nasal inspiratory peak flow is the best validated technique for home monitoring in clinical trials. The equipment is portable, relatively inexpensive, and simple to use. One disadvantage, however, is that nasal inspiratory peak flow is influenced by lower airway as well as upper airway function. Rhinomanometry is a more sensitive technique that is specific for nasal measurements. The equipment, however, requires an operator, is more expensive, and is not portable. Thus, it is applicable only for clinic visit measures in clinical trials. Measurements require patient cooperation and coordination, and not all can achieve repeatable results. Thus, this objective measure is best suited to laboratory challenge studies involving smaller numbers of selected volunteers. A nonphysiological measure of nasal patency is acoustic rhinometry. This sonic echo technique measures internal nasal luminal volume and the minimum cross-sectional area. The derivation of these measures from the reflected sound waves requires complex mathematical transformation and makes several theoretical assumptions. Despite this, however, such measures correlate well with the nasal physiological measures, and the nasal volume measures have been shown to relate well to results obtained by imaging techniques such as computed tomography scanning or magnetic resonance imaging. Like rhinomanometry, acoustic rhinometry is not suitable for home monitoring and can be applied only to clinic visit measures or for laboratory nasal challenge monitoring. It has advantages in being easy to use, in requiring little patient cooperation, and in providing repeatable results. In addition to nasal obstruction, allergic rhinitis is recognized to be associated with impaired mucociliary clearance and altered nasal responsiveness. Measures exist for the monitoring of these aspects of nasal dysfunction. Although measures of mucociliary clearance are simple to perform, they have a poor record of reproducibility. Their incorporation into clinical trials is thus questionable, although positive outcomes from therapeutic intervention have been reported. Measures of nasal responsiveness are at present largely confined to research studies investigating disease mechanisms in allergic and nonallergic rhinitis. The techniques are insufficiently standardized to be applied to multicenter clinical trials but could be used in limited-center studies to gain insight into the regulatory effects of different therapeutic modalities.

Assessing outcomes from the sleep disturbance associated with rhinitis

PURPOSE OF REVIEW

The purpose of this review is to identify which aspects of allergic rhinitis limit the quality of life in patients, to present information on how rhinitis affects sleep, and to review instruments available to assess the impact that rhinitis has on sleep.

RECENT FINDINGS

Subjective and objective instruments reveal patients with allergic rhinitis frequently suffer from sleep-disordered breathing, poor sleep quality, daytime somnolence, and fatigue. Sleep disturbances associated with allergic rhinitis can lead to decreased cognitive and psychomotor abilities, impaired work performance, decreased productivity, impaired learning, difficulty concentrating, and memory deficits.

SUMMARY

Objective and subjective instruments are available to measure the extent of compromise in quality of life in affected patients. Subjective measurements available to evaluate allergic rhinitis include general and disease specific quality of life questionnaires, including rhinitis specific and sleep specific questionnaires. Objective measurements available include evaluation of nasal patency and physiology in rhinitis, nasal inspiratory peak flow, acoustic rhinometry, rhinomanometry, polysomnography, the Multiple Sleep Latency Test, the Maintenance of Wakefulness Test, and learning and performance testing. The continued utilization of these and other available instruments is vital for further assessment on the effect of allergic rhinitis on sleep.

Acoustic rhinometry in nasal provocation test in perennial allergic rhinitis

Acoustic rhinometry is one method to evaluate nasal geometry by an acoustic reflection technique. The aim of this study was to investigate the changes in acoustic rhinometry after nasal provocation in patients with exclusively perennial allergic rhinitis. In 19 patients, acoustic rhinometry and active anterior rhinomanometry were performed before and after nasal provocation test. There was a statistically significant nasal flow reduction measured by active anterior rhinomanometry after nasal provocation (p < 0.05) and a median symptom score of four points, both indicating a positive response to nasal provocation. On the other hand, there was no statistically significant change in the values of acoustic rhinometry after nasal provocation (p > 0.05). In patients with exclusively perennial allergic rhinitis, acoustic rhinometry does not seem to significantly change after nasal provocation. In contrast, active anterior rhinomanometry values decreased significantly after nasal provocation. The presented results indicate that acoustic rhinometry does not seem to be a diagnostic method superior to active anterior rhinomanometry in this context.

The effect of allergen provocation on the nasal cycle estimated by acoustic rhinometry

CONCLUSION

The overall duration and reciprocity of the nasal cycle were not changed after allergen provocation. The duration of immediate response was 38 min, but the amplitude of the nasal cycle was increased significantly after allergen provocation.

OBJECTIVE

Nasal airflow is asymmetrical and subjected to spontaneous reciprocal changes which are referred to as the nasal cycle. Limited information is available on how this is affected by allergens. The purpose of this study was to evaluate the effects of allergen provocation on the nasal cycle.

MATERIALS AND METHODS

This study was performed on 25 patients with allergic rhinitis and 25 subjects in a control group with no symptoms of allergic rhinitis. Acoustic rhinometry was used to test patients before and after allergen provocation. The patients underwent acoustic rhinometry at 15-min intervals for evaluation of nasal cycle and 3-min intervals for immediate response.

RESULTS

With the allergic patients, 21 of the 25 patients (84.0%) showed a nasal cycle and they still had a nasal cycle after the allergen provocation. In the study on the changes in the immediate responses, the average recovery time was 38 min and the reduction rate of the non-patent side was higher than that of the patent side. Also, the average period of the nasal cycle was 153 min before the allergen provocation and 140 min on average after the allergen provocation; there were no statistical differences. The amplitude of each nasal cycle increased after allergen provocation and the difference had statistical meaning.

Repeatability of peak nasal inspiratory flow measurements and utility for assessing the severity of rhinitis

BACKGROUND

The measurement of peak nasal inspiratory flow (PNIF) provides a simple, cheap, fast and readily available tool for determining the extent of nasal airway patency. However, there are questions regarding its repeatability when used to assess the degree of nasal obstruction in large populations. Therefore, this study aimed to evaluate the repeatability of PNIF measurements and to assess their association with the signs and symptoms of rhinitis.

METHODS

The PNIF, rhinitis symptoms, judged by Meltzer questionnaire and rhinitis signs, as determined by anterior rhinoscopy, were assessed in 283 adults representative of the general population. One training and two test PNIF measurements were recorded during the same session.

RESULTS

The PNIF was highly reproducible (ICC = 0.92; 95% limits of agreement: +/-36 l/min). The PNIF was strongly correlated with rhinitis signs, measured by anterior rhinoscopy (rs= -0.38, P < 0.0001) but was not correlated with rhinitis symptoms, measured by questionnaire (rs= -0.11, P = 0.057). Differences in PNIF for subjects categorized as asymptomatic, mild or moderate/severe on the basis of rhinitis signs, were highly significant (P < 0.0001), but less significant on the basis of rhinitis symptoms (P = 0.04). A PNIF cut-off of 115 l/min had moderately high specificity (72%) and sensitivity (65%) and a high negative predictive value (90%) for moderate/severe signs of rhinitis.

CONCLUSION

In a large general population-based sample of young adults, PNIF was highly reproducible and closely related to the signs of rhinitis, as determined by clinical examination. The PNIF provides information that is qualitatively different to that provided by symptom scores and may be useful to measure the extent of nasal obstruction.

Evaluation of an intranasal house dust mite provocation model as a tool in clinical research

BACKGROUND

As a result of the all-year-round exposure to house dust mite (HDM), perennial rhinitis patients never have a clear symptom-free period. In this study, we investigated whether, despite these symptoms, we can still use nasal HDM provocations to study perennial allergic rhinitis and the effects of treatment.

METHODS

In a parallel-group study, after 1 week treatment with either fluticasone propionate aqueous nasal spray (FPANS) or placebo, 20 patients, allergic to HDM, registered symptoms (nasal obstruction, rhinorrhoea, sneezing, pruritus and eye symptoms) using three different scoring methods [Lebel, categorical and visual analogue scale (VAS)] and peak nasal inspiratory flow (PNIF) after HDM provocations. Provocations were performed with 1000 biological units/ml and 24 h later with 10,000 biological units/ml of HDM. Before and after the provocations, nasal mucosa biopsies were taken for immunohistochemical staining to determine the number of eosinophils.

RESULTS

House dust mite provocations resulted in an increase in symptoms and a decrease in PNIF. Even at high-dose provocation, the FPANS group registered significantly lower symptoms than the placebo group for nasal blockage, sneezing, eye symptoms, and PNIF in both early and late phases. FPANS also suppressed rhinorrhoea during the late phase and the influx of eosinophils in the lamina propria.

CONCLUSION

Despite the high background of symptoms, allergic responses can be induced in this perennial rhinitis model. The VAS score seems most suited to detect these changes and the suppression of symptoms by 7 days of FPANS treatment. Epithelial eosinophilia at baseline was correlated positively with the severity of the reaction after the first provocation.

Induction of nasal hyper-responsiveness by allergen challenge in allergic rhinitis: the role of afferent and efferent nerves

BACKGROUND

Hyper-responsiveness of nasal secretory function and volume changes are features of allergic rhinitis (AR) that are mediated in part by neural mechanisms. The finding of nasal hyper-responsiveness in subjects with AR who are currently symptomatic, but not in those who are currently out of season and asymptomatic, suggests that induction of neural reflexes in allergic subjects occurs as a result of allergic inflammation.

OBJECTIVES

To investigate whether allergen exposure in subjects with asymptomatic seasonal allergic rhinitis (SAR) may lead to induction of neural reflexes, and to investigate the components of the reflexes involved in this induction.

METHODS

Asymptomatic subjects with (out-of-season) SAR underwent a nasal bradykinin challenge, before and 24 h after preceding ipsilateral (n = 11) and contralateral (n = 11) antigen challenge. Challenges were performed and nasal secretions collected using filter paper disks, and changes in nasal minimal cross-sectional area (A(min)) were measured using acoustic rhinometry.

RESULTS

Preceding ipsilateral antigen challenge led to the induction of a contralateral secretory reflex (P = 0.01), which was absent in control experiments (P = 0.34). Ipsilateral secretion weights were also enhanced. Preceding contralateral antigen challenge also induced a contralateral secretory reflex (P = 0.03). Enhancement of the reduction in contralateral A(min) was also seen (P = 0.02). Ipsilateral responses were unchanged.

CONCLUSIONS

Allergen exposure in asymptomatic allergic subjects leads to induction of neural reflexes, resulting in nasal hyper-responsiveness, which persists beyond the resolution of the acute allergic response. Our data suggest that the mechanisms of allergen-induced hyper-responsiveness involve both afferent and efferent components.

Bilateral nasal allergen provocation monitored with acoustic rhinometry. Assessment of both nasal passages and the side reacting with greater congestion: relation to the nasal cycle

BACKGROUND

The effect of bilateral nasal provocation on nasal mucosa measured with the use of acoustic rhinometry (AR) can be assessed for both nasal passages or for the side responding with greater congestion. Assessment of changes in nasal congestion during the nasal provocation test (NPT) can be affected by the nasal cycle (NC). The aim of this study was to find out the most accurate method to evaluate changes observed during bilateral nasal provocation.

METHODS

Cross-sectional areas (CSA) at the level of inferior nasal turbinate (CSA-2) were recorded by AR in 26 volunteers with allergic rhinitis during the NC for 5-7 h and subsequently during NPT. The risk of spontaneous total and unilateral CSA-2 decrease was established. Sensitivity of the NPT assessment for the total CSA-2 and for the side responding with greater congestion was evaluated at chosen thresholds. These thresholds were selected in a way that the risk levels of spontaneous decrease of unilateral and total CSA-2 were equal.

RESULTS

The assessment of the total CSA-2 was found to be more sensitive than the assessment of the side responding with greater congestion. The highest sensitivity and specificity of the test was achieved by using a combination of both assessments. Optimum thresholds of the CSA-2 decrease for assessment at 15 min after provocation, with this method, were 27% and 40% for the side responding with greater congestion and for the total CSA-2, respectively.

CONCLUSIONS

Recognition of the risk of spontaneous unilateral and total CSA-2 decreases enables introduction of combined assessment of bilateral NPT. This assessment seems to be the most accurate method for evaluation of the test results.

Acoustic rhinometry in nasal allergen challenge study: which dimensional measures are meaningful?

BACKGROUND

Acoustic rhinometry (AR) is commonly used as a quantitative assessment of nasal response to nasal allergen challenge (NAC). However, sources of error and physical limitations of various AR area-distance measurements have not been adequately evaluated.

OBJECTIVE

To investigate the clinical value of AR measurements, and the relationship between subjective sensation and objective AR measurements in the NAC study.

METHODS

Nasal challenge using increasing concentrations of crude Blomia tropicalis (Bt) extracts (0.6, 6, and 60 microg/mL) was performed in 15 adult patients (eight males and seven females) with ongoing persistent allergic rhinitis. Subjective symptom scores of nasal obstruction were recorded together with the objective AR measurements of the minimum cross-sectional area (MCA), distance to MCA and cross-sectional area (CSA) at 3.3, 4.0 and 6.4 cm from the nostril, during the 7 h after the last challenge.

RESULTS

The dose-response increase in nasal obstruction score was significantly (P<0.001 for all) associated with decreases in mean MCA (r=0.75), mean CSA3.3 (r=0.54), mean CSA4.0 (r=0.53) and mean CSA6.4 (r=0.20). The mean MCA (+/-SD) for each subjective symptom score 0, 1, 2 and 3 was found to be 0.73 (+/-0.22) cm2, 0.63 (+/-0.29) cm2, 0.33 (+/-0.17) cm2 and 0.21 (+/-0.14) cm2, respectively. When the MCA (left and right separately) reached an area <0.2 cm2, measurements of CSA3.3 and CSA4.0 were significantly reduced by 60-70%.

CONCLUSION

This study demonstrates that AR is a useful and objective investigational tool, which correlates well with the sensation of nasal obstruction. MCA, CSA3.3 and CSA4.0 are more reliable measurements than CSA6.4 due to physical limitations. It is important to note that when the MCA is smaller than 0.2 cm2, a common condition in the early-phase reaction, area-distance measurements beyond this point can be misinterpreted and should be considered with caution.

Allergenicity and cross-reactivity of Russian olive pollen (Eleagnus angustifolia)

BACKGROUND

The purposes of this study were: to determine the prevalence of sensitization and immunochemical characterization of Eleagnus angustifolia pollen (Russian olive) that belongs to the family Eleagnaceae.

METHODS

A total of 134 patients with rhinoconjunctivitis and/or asthma were studied. Its allergenicity, cross-reactivity with olive pollen and the presence of Ole e 1 and Ole e 4-like molecules were evaluated.

RESULTS

Eleagnus angustifolia pollen was detected from May to June. Seventy-three of 134 (30.5%) had positive skin test to E. angustifolia, all of them were positive to olive. There was a good correlation between specific immunoglobulin (Ig)E levels to E. angustifolia and Olea europaea (r = 0.77, P = 0.002). Sodium dodecyl sulphate polyacrylamide gel electrophoresis (SDS-PAGE) immunoblots revealed major IgE-binding bands in the E. angustifolia extract of 43 and 63.7 kDa. The E. angustifolia extract was not able to inhibit olive, whereas O. europaea inhibited E. angustifolia up to 41%. The presence of Ole e 1- and Ole e 4-like allergens in E. angustifolia extract was confirmed by enzyme-linked immunosorbent (ELISA) inhibition assays. Nasal challenge with E. angustifolia was positive in three of six patients with positive skin test to both pollens and negative in five patients with positive skin test only to O. europaea.

CONCLUSIONS

This study confirms that E. angustifolia is capable of sensitizing individuals in Madrid. A minimal-to-moderate cross-reactivity with olive pollen was established, suggesting some cross-reactivity but not excluding co-sensitization.

Reproducibility of response to nasal lysine-aspirin challenge in patients with aspirin-induced asthma

BACKGROUND

Peak nasal inspiratory flow (PNIF) and acoustic rhinometry objectively measure the effects of nasal provocation testing. Although the latter is conventionally used in nasal lysine-aspirin challenge, use of the former in aspirin-induced asthma (AIA) has never been evaluated.

OBJECTIVE

To evaluate the reproducibility of PNIF and acoustic rhinometry following nasal lysine-aspirin challenge in AIA.

METHODS

Fourteen patients with a clear-cut history of AIA underwent nasal lysine-aspirin challenge at 2 separate visits 1 week apart. Both PNIF and minimum cross-sectional area (MCA) were measured using acoustic rhinometry for 120 minutes following standard nasal lysine-aspirin challenge (25 mg).

RESULTS

Prechallenge values were not significantly different at visit 1 vs visit 2 for mean [SEM] PNIF (128 [13] vs 127 [9] L/min) and MCA (6.89 [0.51] vs 6.94 [0.57] cm2). The mean (SEM) maximum percent PNIF change from baseline for visit 1 and visit 2 was -42 (5) and -42 (6), respectively, and the mean (SEM) average percent PNIF change from baseline was -25 (4) and -25 (6), respectively. The mean (SEM) maximum percent MCA change from baseline for visit 1 and visit 2 was -49 (4) and -48 (3), respectively, and the mean (SEM) average percent MCA change from baseline was -25 (8) and -24 (4), respectively. Coefficients of variation for maximum and average responses were 2.3% and 6.5%, respectively, for PNIF and 7.4% and 16.1% for MCA.

CONCLUSIONS

Measurement of PNIF following nasal lysine-aspirin challenge is a simple and reproducible alternative to acoustic rhinometry, with maximum response being a more reproducible outcome measure than average response.

Levocetirizine better protects than desloratadine in a nasal provocation with allergen

BACKGROUND

Direct comparisons of antihistamines are rare but very much needed. Newly available antihistamine preparations, levocetirizine, the R-enantiomer of racemate cetirizine, and desloratadine, an active metabolite of loratadine, have been recently released for allergic rhinitis.

OBJECTIVE

We sought to compare levocetirizine and desloratadine in a nasal provocation test (NPT) with grass pollen.

METHODS

Twenty-four volunteers with grass pollen allergy and a history of rhinitis were enrolled in a double-blind, placebo-controlled, crossover study. Three NPTs were performed in a dose-escalating manner during the out-of-season period 4 hours after a single dose of levocetirizine (5 mg), desloratadine (5 mg), or placebo.

RESULTS

CONCLUSIONS

This study demonstrates a better overall protection of a single dose of levocetirizine compared with desloratadine in an NPT with grass pollen allergen. In contrast to late-phase inflammatory markers, which were unaffected, extravascular leakage of the early-phase marker albumin was significantly limited by levocetirizine.

La obstrucción nasal y su medida

Nasal obstruction is an important symptom of rhinitis. The present article presents the inflammatory mechanisms that lead to the clinical presentation of this symptom: conchal vasodilation, infiltration of mainly eosinophilic cells with activation of these cells and release of intracellular mediators. Given the importance of this symptom and its effects both on function and on quality of life, the various methods used to study it are discussed. Active anterior rhinometry (AAR), measurement of nasal peak inspiratory flow (NPIF), and acoustic rhinometry (AR) are discussed. The underlying principles, based on the trajectory of nasal air flow, techniques, and their advantages and disadvantages are presented. In conclusion, any of these methods can be used to evaluate nasal obstruction.