CT assessment of the effect of fluticasone propionate aqueous nasal spray treatment on lower turbinate hypertrophy due to vasomotor rhinitis

Eustachian Tube Dysfunction in Children with Adenoid Hypertrophy: The Effect of Intranasal Azelastine-Fluticasone Spray Treatment on Middle Ear Ventilation and Adenoid Tissue

OBJECTIVES

Eustachian tube dysfunction (ETD) is frequent in children with adenoid hypertrophy (AH). Although the most common treatment of AH is surgical removal of adenoid tissue, numerous studies have reported the efficacy of intranasal steroids. The effects of the intranasal steroid and azelastine combination on AH and ETD have not been reported before. In this study, we tried to determine the effects of 3-month intranasal Azelastine-Fluticasone dipropionate combination (Aze-Flu) treatment in children with ETD and AH.

MATERIALS AND METHODS

100 children who had open mouth sleep, snoring, and sleep apnea and were diagnosed with AH and ETD participated in this study. The mean age was 7.73 ± 2.37 (4-14 years). The rates of adenoid tissue hypertrophy and choanal occlusion were evaluated using a rigid pediatric nasal endoscope and reassessed after 3 months of Aze-Flu nasal spray treatment. The function of the Eustachian tube (ET) was evaluated before and after medical treatment using the Eustachian tube score, the Eustachian dysfunction test-7 (ETS-7) and tubomanometry (TMM).

RESULTS

The results were evaluated in 100 patients with AH and ETD. The adenoid tissue to choana rate was 82% before treatment and decreased to 37% after treatment. The ETS-7 test score was 6.36 before treatment and increased to 9.72 at the end of 3 months. Both the regression of the adenoid tissue and the improvement in the Eustachian function scores were statistically significant (p < 0.05).

CONCLUSIONS

AH significantly increases the frequency of ETD. In this study, it was observed that Aze-Flu treatment was significantly effective in both regression of the adenoid tissue and Eustachian tube dysfunction. We believe that it can be applied as an initial therapy in children with AH and associated ETD.

Efficacy of Topical Azelastine and Fluticasone Dipropionate Combination in Children With Adenoid Hypertrophy

OBJECTIVE

Adenoid hypertrophy (AH) is one of the common childhood diseases. Surgical and non-surgical treatment of AH in children is planned according to the severity of symptoms and associated complications. In recent years, treatment methods with intranasal sprays have been reported quite frequently in uncomplicated cases. We aim to evaluate the effectiveness of a new combination of azelastine - fluticasone (AZE-FLU) (137mcg azelastine and 50mcg fluticasone) nasal spray in children with uncomplicated AH.

METHODS

Sixty-five children diagnosed with AH were included in the study. The mean age of the children was 7.42 ± 2.26 (4-13 years). The cohort consisted of 29 males and 36 females. All children were evaluated clinically and endoscopically. AZE-FLU nasal spray was applied to both nostrils twice a day for three months. Adenoid/choana ratio and symptom scores were evaluated before treatment and at the end of the 12th week.

RESULTS

At the end of 24 weeks of AZE-FLU application, there was a statistically significant decrease in both adenoid/choana ratio and symptom scores. While the initial adenoid/choana (A/C) score was 3.57 ± 0.58, it decreased to 1.74 ± 0.61 following treatment. A dramatic decrease in total symptom scores was observed. The total symptom score average was 15.63 ± 1.28 before treatment, while it was 2.31 ± 1.4 after the treatment with the difference being statistically significant (P < .01).

CONCLUSION

In this study, the effectiveness of AZE-FLU nasal spray on AH was investigated for the first time. This treatment provides an effective alternative to the surgical approach in children with uncomplicated adenoid hypertrophy. Using this protocol, 96% of patients were removed from the surgery list.

LEVEL OF EVIDENCE

is IV.

Intranasal corticosteroids for non-allergic rhinitis

BACKGROUND

Non-allergic rhinitis is defined as dysfunction and non-infectious inflammation of the nasal mucosa that is caused by provoking agents other than allergens or microbes. It is common, with an estimated prevalence of around 10% to 20%. Patients experience symptoms of nasal obstruction, anterior rhinorrhoea/post-nasal drip and sneezing. Several subgroups of non-allergic rhinitis can be distinguished, depending on the trigger responsible for symptoms; these include occupation, cigarette smoke, hormones, medication, food and age. On a cellular molecular level different disease mechanisms can also be identified. People with non-allergic rhinitis often lack an effective treatment as a result of poor understanding and lack of recognition of the underlying disease mechanism. Intranasal corticosteroids are one of the most common types of medication prescribed in patients with rhinitis or rhinosinusitis symptoms, including those with non-allergic rhinitis. However, it is unclear whether intranasal corticosteroids are truly effective in these patients.

OBJECTIVES

To assess the effects of intranasal corticosteroids in the management of non-allergic rhinitis.

SEARCH METHODS

The Cochrane ENT Information Specialist searched the Cochrane ENT Register; Cochrane Central Register of Controlled Trials (CENTRAL 2019, Issue 7); PubMed; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 1 July 2019.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing intranasal corticosteroids, delivered by any means and in any volume, with (a) placebo/no intervention or (b) other active treatments in adults and children (aged ≥ 12 years).

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane. The primary outcomes were patient-reported disease severity and a significant adverse effect - epistaxis. Secondary outcomes were (disease-specific) health-related quality of life, objective measurements of airflow and other adverse events. We used GRADE to assess the certainty of the evidence for each outcome.

MAIN RESULTS

We included 34 studies (4452 participants); however, only 13 studies provided data for our main comparison, intranasal corticosteroids versus placebo. The participants were mainly defined as patients with perennial rhinitis symptoms and negative allergy tests. No distinction between different pheno- and endotypes could be made, although a few studies only included a specific phenotype such as pregnancy rhinitis, vasomotor rhinitis, rhinitis medicamentosa or senile rhinitis. Most studies were conducted in a secondary or tertiary healthcare setting. No studies reported outcomes beyond three months follow-up. Intranasal corticosteroid dosage in the review ranged from 50 µg to 2000 µg daily. Intranasal corticosteroids versus placebo Thirteen studies (2045 participants) provided data for this comparison. These studies used different scoring systems for patient-reported disease severity, so we pooled the data in each analysis using the standardised mean difference (SMD). Intranasal corticosteroid treatment may improve patient-reported disease severity as measured by total nasal symptom score compared with placebo at up to four weeks (SMD -0.74, 95% confidence interval (CI) -1.15 to -0.33; 4 studies; 131 participants; I² = 22%) (low-certainty evidence). However, between four weeks and three months the evidence is very uncertain (SMD -0.24, 95% CI -0.67 to 0.20; 3 studies; 85 participants; I² = 0%) (very low-certainty evidence). Intranasal corticosteroid treatment may slightly improve patient-reported disease severity as measured by total nasal symptom score change from baseline when compared with placebo at up to four weeks (SMD -0.15, 95% CI -0.25 to -0.05; 4 studies; 1465 participants; I² = 35%) (low-certainty evidence). All four studies evaluating the risk of epistaxis showed that there is probably a higher risk in the intranasal corticosteroids group (65 per 1000) compared to placebo (31 per 1000) (risk ratio (RR) 2.10, 95% CI 1.24 to 3.57; 4 studies; 1174 participants; I² = 0%) (moderate-certainty evidence). The absolute risk difference (RD) was 0.04 with a number needed to treat for an additional harmful outcome (NNTH) of 25 (95% CI 16.7 to 100). Only one study reported numerical data for quality of life. It did report a higher quality of life score in the intranasal corticosteroids group (152.3 versus 145.6; SF-12v2 range 0 to 800); however, this disappeared at longer-term follow-up (148.4 versus 145.6) (low-certainty evidence). Only two studies provided data for the outcome objective measurements of airflow. These data could not be pooled because they used different methods of outcome measurement. Neither found a significant difference between the intranasal corticosteroids and placebo group (rhinomanometry SMD -0.46, 95% CI -1.06 to 0.14; 44 participants; peak expiratory flow rate SMD 0.78, 95% CI -0.47 to 2.03; 11 participants) (very low-certainty evidence). Intranasal corticosteroids probably resulted in little or no difference in the risk of other adverse events compared to placebo (RR 0.99, 95% CI 0.87 to 1.12; 3 studies; 1130 participants; I² = 0%) (moderate-certainty evidence). Intranasal corticosteroids versus other treatments Only one or a few studies assessed each of the other comparisons (intranasal corticosteroids versus saline irrigation, intranasal antihistamine, capsaicin, cromoglycate sodium, ipratropium bromide, intranasal corticosteroids combined with intranasal antihistamine, intranasal corticosteroids combined with intranasal antihistamine and intranasal corticosteroids with saline compared to saline alone). It is therefore uncertain whether there are differences between intranasal corticosteroids and other active treatments for any of the outcomes reported.

AUTHORS' CONCLUSIONS

Overall, the certainty of the evidence for most outcomes in this review was low or very low. It is unclear whether intranasal corticosteroids reduce patient-reported disease severity in non-allergic rhinitis patients compared with placebo when measured at up to three months. However, intranasal corticosteroids probably have a higher risk of the adverse effect epistaxis. There are very few studies comparing intranasal corticosteroids to other treatment modalities making it difficult to draw conclusions.

[Mechanism of action of nasal glucocorticosteroids in the treatment of allergic rhinitis. Part 2: Practical aspects of application]

Allergic rhinitis (AR) is the single most common allergic disease and one of the most common chronic diseases. It affects approximately 25-30% of the population, and can substantially worsen patients' medical conditions, reduce quality of life, and contribute to absenteeism from work or school. It is also responsible for substantial direct and indirect economic burdens on the health care system. The medical management of allergic rhinitis includes several available pharmacotherapies, such as α-sympathomimetics, anticholinergic drugs, natural saline or other nasal rinses, mast cell-stabilizing agents, topical and systemic antihistamines, topical and systemic glucocorticosteroids, leukotriene-receptor antagonists and the new monoclonal antibodies following a stepwise approach. Allergen-specific immunotherapy is the only treatment option that interferes with the natural course of the disease and, besides allergen elimination, is thought to be the only causative treatment option. Nasal glucocorticosteroids (nGCS) are thought to be the most effective treatment choice for controlling the symptoms of AR. Double-blind, randomized clinical trials have demonstrated greater efficacy of nGCSs versus placebo, antihistamines or montelukast for relief of all nasal symptoms, especially congestion. Therefore, especially in the management of AR-related nasal inflammation and congestion, nGCSs are considered the most appropriate treatment. Patients should be informed that symptom improvement can be expected after 2-4 days for intermittent rhinitis and after up to 2-3 weeks for persistent rhinitis. The medication has to be taken regularly and not as "on-demand" treatment. Adherence to treatment also affects outcomes, and this may be influenced by patient preferences for the sensory attributes of an individual drug and the awareness of possible side effects. More recently, safety studies have shown that the newer nGCS agents have improved safety profiles compared with older nGCS agents. The newer nGCS drugs have been found to have minimal adverse effects on growth and hypothalamic-pituitary-adrenal-axis function in children. This review will discuss the pathophysiology of allergic inflammation in the nasal mucosa and the mechanism of action of nGCSs; also the efficacy and safety of nGCSs will be discussed by focusing on clinical evidence.

Scientific rationale for the use of alpha-adrenergic agonists and glucocorticoids in the therapy of pediatric stridor

Purpose. The most common pharmacological therapies used in the treatment of stridor in children are glucocorticosteroids (GC) and alpha-adrenergic (αAR) agonists. Despite the long-standing reported efficacy of these medications, there is a paucity of data relating to their actual mechanisms of action in the upper airway. Summary. There is compelling scientific evidence supporting the use of αAR-agonists and GCs in pediatric stridor. αAR signaling and GCs regulate the vasomotor tone in the upper airway mucosa. The latter translates into better airflow dynamics, as delineated by human and nonhuman upper airway physiological models. In turn, clinical trials have demonstrated that GCs and the nonselective αAR agonist, epinephrine, improve respiratory distress scores and reduce the need for further medical care in children with stridor. Future research is needed to investigate the role of selective αAR agonists and the potential synergism of GCs and αAR-signaling in the treatment of upper airway obstruction and stridor.

The role of nasal corticosteroids in the treatment of rhinitis

Intranasal corticosteroids (INSs) are the first choice for rhinitis pharmacotherapy. This preference is because of their broad range of actions that result in reductions of proinflammatory mediators, cytokines, and cells. Over the past 30 years, INSs have been modified to improve their pharmacodynamic, pharmacokinetic, and delivery system properties, with attention to improving characteristics such as receptor binding affinity, lipophilicity, low systemic bioavailability, and patient preference. Clinically, they have been shown to be the most effective class of nasal medications for treating allergic rhinitis and nonallergic rhinopathy, with no clear evidence that any specific INS is superior to others.

Physiology and pathophysiology of respiratory mucosa of the nose and the paranasal sinuses

In this review, anatomy and physiology of the respiratory mucosa of nose and paranasal sinuses are summarized under the aspect of its clinical significance. Basics of endonasal cleaning including mucociliary clearance and nasal reflexes, as well as defence mechanisms are explained. Physiological wound healing, aspects of endonasal topical medical therapy and typical diagnostic procedures to evaluate the respiratory functions are presented. Finally, the pathophysiologies of different subtypes of non-allergic rhinitis are outlined together with treatment recommendations.

A radiofrequency vs topical steroid treatment of chronic nasal obstruction: A prospective randomized study of 84 cases

CONCLUSIONS

Nasal congestion caused by mucosal swelling and conch hypertrophy impairs breathing and causes snoring and headaches. Treatment of conch hypertrophy with radiofrequency (RF) allows reduction of mucosal swelling, minimization of hyperplasia, and decreased mucus production. This treatment provides a clinically significant improvement in snoring, headaches, and mouth breathing.

OBJECTIVE

To compare the efficacy of RF surgery to nasal steroid; each method used separately and both in combination.

METHODS

This was a consecutive randomized study, which included 84 patients with 3 outpatient visits, where the first visit included a complete medical history, assessment of ENT status, and skin tests. Nasal flow measured with rhinomanometry was done at the first visit and then before and after each treatment. Patients were asked to respond to a questionnaire at the first visit and after each subsequent treatment. Thereafter the variables were analyzed with established statistical methods.

RESULTS

Measurement of variables and patient questionnaire responses showed a clear improvement in several symptoms, such as sneezing and headache, and a clinically significant improvement in nasal congestion and snoring.

Medical treatment of adenoid hypertrophy with "fluticasone propionate nasal drops"

BACKGROUND

Adenoid hypertrophy treatment for children is generally planned in accordance with the degree of airway obstruction and related morbidity. If surgical treatment is indicated, the individual risk/benefit analysis of patients should be assessed in terms of anesthetic and postoperative complications. Although there are few alternative treatment options, these may be considered as a nonsurgical approach in less serious cases. Accordingly, studies about intranasal steroid applications under various protocols have been presented.

STUDY DESIGN

The prospective, randomized, placebo-controlled study.

SETTING

Tertiary referral center.

PATIENTS AND METHODS

Patients indicated for surgery were randomly divided into two groups. The study group was treated by fluticasone propionate nasal drops (NSD-nasal steroid drops) of 400 microg/day for 8 weeks. The control group was treated by normal saline (NS) in the same way. All the patients were called for follow-up every 4 weeks.

RESULTS

At the end of 8 weeks, statistically significant improvement (p<0.05) was observed in the NSD treated group compared to the NS treated group in terms of nasal airway obstruction, mouth breathing, speech abnormalities, apnea and night cough. At the end of 8 weeks, the average total symptoms score of the NSD treated group dropped from 13.7 to 2.9 while the NS treated group's score changed from 14.8 to 14.6. After 8 weeks of NSD treatment the initial adenoid/choana (A/C) rate had dropped from 87 to 56% and a total decrease of 35.6% was observed. After 8 weeks of NS treatment the A/C rate dropped from 87 to 85% and a total decrease of 2.2% was observed.

CONCLUSIONS

In this study, the effect of fluticasone propionate nasal drops on adenoid hypertrophy is examined for the first time. This method provides an effective alternative to surgical treatment in children with adenoid hypertrophy. With the protocol applied in this study 76% of the patients were eliminated the surgery and removed from the surgical waiting list.

The treatment of vasomotor rhinitis with intranasal corticosteroids

Objective

Intranasal steroids (INS) are firmly established as the therapy for choice for allergic rhinitis, but their role in vasomotor rhinitis (VMR) is not fully characterized. This review examines the potential mechanisms of action and reported efficacy of INS in patients with VMR.

Results

INS, through intracellular activation of the glucocorticoid receptor, down-regulate the recruitment and activation of inflammatory cells (T-lymphocytes, eosinophils, mast cells, basophils, neutrophils, macrophages), increase degradation of neuropeptides, and reduce epithelial cell activity, vascular permeability, and chemokine secretion. It is likely that more than vasoconstriction is responsible for the clinical effects of INS.

Eight INS can be prescribed for rhinitis in the US; only 4 have been studied for VMR. Seventy-four percent of patients treated with beclomethasone dipropionate considered themselves symptom-free or greatly improved versus 31% with placebo. Budesonide significantly reduced rhinitis symptoms and methacholine-induced nasal secretions compared with placebo. Fluticasone propionate compared with placebo provided significantly greater relief from nasal obstruction; computed tomographic scans showed significant reductions in the mucosal area of the lower turbinates. Mometasone furoate produced numerically better rhinitis symptom scores and, when discontinued, lower relapse rates than placebo.

Conclusion

Data supports INS as beneficial pharmacotherapy for VMR.

Mechanisms and clinical implications of glucocorticosteroids in the treatment of allergic rhinitis

Allergic rhinitis is a common airway disease characterized by hypersensitivity, exudation, hypersecretion, inflammatory cell infiltration and remodelling. Intranasal glucocorticosteroids are the most effective drugs for controlling the inflammation caused by allergic rhinitis. Glucocorticosteroids exert anti-inflammatory effects through at least two pathways: the transactivation pathway and the transrepression pathway. Glucocorticosteroids also exert regulatory functions by inducing regulatory cytokines and forkhead box P3 (FoxP3(+)) regulatory T cells. Evidence suggests that intranasal glucocorticosteroids control not only nasal symptoms but also ocular symptoms. In contrast to sedating H1 receptor antagonists, intranasal glucocorticosteroids can improve impaired performance symptoms, such as daytime sleepiness, associated with allergic rhinitis. Recent studies suggest that intranasal glucocorticosteroids might also be useful for the prophylactic treatment of pollinosis; this possibility is supported by the molecular mechanism of the anti-inflammatory action of glucocorticosteroids. These findings suggest that intranasal glucocorticosteroids might be positioned as first-line drugs for the treatment of both perennial and seasonal allergic rhinitis.

Pathogenic mechanisms of idiopathic nonallergic rhinitis

Idiopathic nonallergic rhinitis (iNAR) has been difficult to define because of the long differential diagnosis of rhinopathy in the absence of allergic rhinitis. iNAR has traditionally been a diagnosis of exclusion with no clear unifying pathophysiology. Increased sensitivity to triggers such has climate changes, cold air, tobacco smoke, strong odors, and perfumes have been thought to be characteristic, but recent studies do not support this hypersensitivity hypothesis. New investigations of the local nasal environment and systemic "functional" syndromes have offered new insights into this condition. iNAR may be a heterogenous disorder that includes (1) anatomic abnormalities requiring nasal endoscopy for diagnosis, (2) incipient, local atopy (entopy), (3) dysfunction of nociceptive nerve sensor and ion channel proteins, and (4) autonomic dysfunction as found in chronic fatigue syndrome and other functional disorders.