The risk of sinusitis in children with allergic rhinitis

Intranasal corticosteroids reduced acute rhinosinusitis in children with allergic rhinitis: A nested case-control study

BACKGROUND

Children with allergic rhinitis (AR) have substantially more acute rhinosinusitis than children without AR. We evaluated whether intranasal corticosteroids (INCS), second-generation antihistamines (SGH), and/or intranasal antihistamines (INH) for AR affect acute rhinosinusitis in children with AR aged 2-18 years.

METHODS

By using the National Health Research Institutes Database 2005 of Taiwan, a cohort of patients with AR aged 2-18 years treated with AR medications between 2002 and 2018 was made, within which a nested case-control study was performed. Risk settings for acute rhinosinusitis cases matched controls for age, sex, and comorbidities. Current users of INCS, INH, and/or SGH were compared with remote and recent users of any AR medications and current users of INCS with and without SGH were compared with current users of SGH.

RESULTS

Current users of SGH and/or INCS had a higher risk of acute rhinosinusitis than remote users of AR drugs, and current users of SGH had a higher risk of acute rhinosinusitis than recent users; however, no difference in the risk of acute rhinosinusitis was found between current users of INCS and recent users of AR drugs. Current users of INCS with and without SGH had a lower risk of acute rhinosinusitis than current users of SGH alone.

CONCLUSIONS

Treatment of INCS with and without SGH diminished the risk of acute rhinosinusitis compared with treatment using SGH alone. Adequate INCS treatment for patients with AR is important to reduce the incidence of acute rhinosinusitis.

Microbial diversity in homes and the risk of allergic rhinitis and inhalant atopy in two European birth cohorts

BACKGROUND

Microbial exposures in early childhood direct the development of the immune system and their diversity may influence the risk of allergy development. We aimed to determine whether the indoor microbial diversity at early-life is associated with the development of allergic rhinitis and inhalant atopy.

METHODS

The study population included children within two birth cohorts: Finnish rural-suburban LUKAS (N = 312), and German urban LISA from Munich and Leipzig study centers (N = 248). The indoor microbiota diversity (Chao1 richness and Shannon entropy) was characterized from floor dust samples collected at the child age of 2-3 months by Illumina MiSeq sequencing of bacterial and fungal DNA amplicons. Allergic rhinitis and inhalant atopy were determined at the age of 10 years and analyzed using logistic regression models.

RESULTS

High bacterial richness (aOR 0.19, 95%CI 0.09-0.42 for middle and aOR 0.12, 95%CI 0.05-0.29 for highest vs. lowest tertile) and Shannon entropy were associated with lower risk of allergic rhinitis in LISA, and similar trend was seen in LUKAS. We observed some significant associations between bacterial and fungal diversity measured and the risk of inhalant atopy, but the associations were inconsistent between the two cohorts. High bacterial diversity tended to be associated with increased risk of inhalant atopy in rural areas, but lower risk in more urban areas. Fungal diversity tended to be associated with increased risk of inhalant atopy only in LISA.

CONCLUSIONS

Our study suggests that a higher bacterial diversity may reduce the risk of allergic rhinitis later in childhood. The environment-dependent heterogeneity in the associations with inhalant atopy - visible here as inconsistent results between two differing cohorts - suggests that specific constituents of the diversity may be relevant.

Clinical Evidence and Biomarkers Linking Allergy and Acute or Chronic Rhinosinusitis in Children: a Systematic Review

Purpose of the Review

We provide a systematic review of experimental and clinical evidences linking allergy to acute, including common cold, and chronic rhinosinusitis in children. Furthermore, we questioned if anti-allergy treatment may prevent the occurrence of rhinosinusitis or improve outcomes of its specific management.

Recent Findings

Allergic rhinitis is a common childhood disease in industrialized countries that is responsible for a major impact on quality of life and healthcare resources. Over the years many authors tried to correlate allergy with comorbidities and in particular to the onset of rhinosinusitis including common cold, even though conflicting results are frequently reached. We performed a systematic review in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) process. Our search yielded 7103 that were finally screened. This resulted in 25 publications of which the full texts were assessed and included in a qualitative analysis per different phenotypes of rhinosinusitis.

Summary

The evidence suggests that allergy may lead to overall impairment of mechanical and immunological defense function of the nasal mucosa against viruses and that anti-allergy treatment may significantly decrease the number and severity of upper respiratory tract infections including common colds in children. It was not possible to perform the analysis for allergy and post-viral acute rhinosinusitis, bacterial acute rhinosinusitis, and recurrent acute rhinosinusitis because of paucity and heterogeneity of data. Although there is no definitive proof of causation linking allergy to chronic rhinosinusitis, studies lead to suppose that anti-allergy treatment may improve outcomes of specific CRS treatments.

Allergic sensitization does not predispose to sinus inflammation in externalized paranasal sinuses

BACKGROUND

Chronic rhinosinusitis (CRS) has a multifactorial etiology, with a debate about the role of inhalant allergy in the pathogenesis of CRS.

OBJECTIVE

This study assessed the impact of allergy status on externalized paranasal sinuses after tumor resection to determine if a predisposition to inhalant allergy brought about additional inflammation after sinus surgery.

METHODOLOGY

A case-control study was performed on patients who had no history of CRS who underwent paranasal sinus tumor resection. Allergic sensitization was defined by a positive serum ImmunoCAP test result. Outcomes were measured at least 6 months after surgery by using the modified Lund-MacKay endoscopic score and the 22-item Sino-Nasal Outcome test, with rhinitis, sleep, psychological, ear and/or facial, and sinus subscores to assess the impact of allergy status on mucosal inflammation.

RESULTS

A total of 103 patients (53.44 ± 17.46 years; 46% women) were assessed. Of these, 61.17% were allergically sensitized at the time of surgery. Postsurgery endoscopic assessment was similar [the modified Lund-Mackay endoscopic score allergic sensitized 0.5 (1.7) versus nonallergic sensitized 0.0 (0.9); p = 0.15]. Sinonasal symptoms were also similar between the groups' 22-item Sino-Nasal Outcome test scores, allergic sensitized versus allergic nonsensitized, (allergic 28.9 ± 20.8 versus nonallergic 33.5 ± 19.7; p = 0.31), rhinitis score (5.9 ± 5.5 versus 6.4 ± 4.7; p = 0.66), sleep score (6.9 ± 5.9 versus 7.7 ± 4.8; p = 0.50), ear and/or facial symptom score (3.4 ± 3.6 versus 4.3 ± 3.3; p = 0.22), psychological score (6.9 ± 6.0 versus 8.3 ± 6.7; p = 0.29), and of nasal symptom score (6.4 ± 5.2 versus 7.0 ± 5.3; p = 0.61).

CONCLUSIONS

Externalization of the sinuses in patients with inhalant allergy did not bring about significant additional inflammation in patients after tumor surgery.

Allergic sensitization in Canadian chronic rhinosinusitis patients

BACKGROUND

Chronic rhinosinusitis (CRS) is a societal burden and cause of morbidity in Canada; however, the prevalence of allergic sensitization in Canadian CRS patients has remained poorly characterized.

OBJECTIVE

In this study, we used skin prick test (SPT) and specific immunoglobulin E (sIgE) and G (sIgG) titers to regionally relevant allergen sources in order to determine whether allergic sensitization is more prevalent in CRS patients compared to chronic idiopathic urticaria (CIU) control patients.

METHODS

One hundred and fifty eight subjects (19-70 years of age) were recruited into the study. 101 subjects had a confirmed diagnostic history of CRS and 57 subjects with a clinical diagnosis of CIU were recruited as controls. Enrolled subjects underwent SPT to a panel of perennial and seasonal allergens and sIgE titers were quantified to selected environmental allergen mixes (grass, mold, and tree species) using Phadia ImmunoCAP. sIgG was additionally quantified to Alternaria alternata, Aspergillus versicolor, Cladosporium herbarum, and Stachybotrys atra. Differences between CRS and control CIU patient SPT and serological data were examined by chi-squared analysis and analysis of variance.

RESULTS

Reactivity to at least one SPT extract occurred in 73% of CRS patients. Positive SPT reactivity to A. alternata (odds ratio (OR): 4.34, 95% confidence interval: 1.57, 12.02), cat (OR: 3.23, 95% CI: 1.16, 9.02), and ragweed (OR: 2.31, 95% CI: 1.02, 5.19) extracts were more prevalent in patients with CRS (p < 0.05). Although dust mite and timothy grass sensitization approached statistical significance in the chi-squared analysis of SPT data, other common perennial and seasonal allergens were not associated with CRS. No statistically significant differences were observed between mean sIgE and sIgG titers in CRS and control patients.

CONCLUSIONS

This study supports previous data that suggests A. alternata sensitization is associated with CRS; however, these findings additionally highlight the contribution of other regionally important allergens including cat and ragweed.

Current and future directions in pediatric allergic rhinitis

BACKGROUND

Allergic rhinitis (AR) is a common pediatric problem that significantly affects sleep, learning, performance, and quality of life. In addition, it is associated with significant comorbidities and complications.

OBJECTIVE

The aim was to provide an update on the epidemiology, comorbidities, pathophysiology, current treatment, and future direction of pediatric AR.

METHODS

Literature reviews in each of these areas were conducted, and the results were incorporated.

RESULTS

The prevalence of AR is increasing in the pediatric population and is associated with significant morbidity, comorbidities, and complications. The mainstay of current treatment strategies includes allergen avoidance, pharmacotherapy, and allergen specific immunotherapy.

CONCLUSIONS

In the future, diagnosis will be improved by microarrayed recombinant allergen testing and therapy will be expanded to include emerging treatments such as sublingual immunotherapy and combination products.

Synergism of Staphylococcus aureus colonization and allergic reaction in the nasal cavity in mice

BACKGROUND

The aim of this study is to investigate the reciprocal effect of Staphylococcus aureus colonization and allergic rhinitis in an allergy model of mice.

METHODS

BALB/c mice with intraperitoneal ovalbumin (OVA) sensitization and/or intranasal S. aureus inoculation were prepared. The following 4 groups were designed: an OVA-sensitized S. aureus-inoculated (AR-SA) group, an OVA-sensitized uninoculated (AR) group, a nonsensitized S. aureus-inoculated (SA) group, and a nonsensitized uninoculated (control) group. After intranasal OVA challenge, nasal lavage fluid, peripheral blood, and nasal mucosa were collected. Polymorphonuclear cells in the nasal lavage fluid were counted, serum OVA-specific IgE and IgG1 were measured by enzyme immunoassays, and IL-4, IL-5, and IFN-γ mRNAs in the nasal mucosa were assessed by quantitative real-time reverse transcription-PCR. The number of S. aureus in the nasal mucosa and lavage fluid was counted.

RESULTS

Both eosinophil and neutrophil counts were larger in the AR-SA group than in the other groups. Both IgE and IgG1 levels were higher in the AR and AR-SA groups than in the SA and control groups, and the IgG1 level was higher in the AR-SA group than in the AR group. The expression of IL-4 mRNA was higher in the AR-SA group than in the other groups, and the expression of IL-5 mRNA was higher in the AR-SA group than in the SA group. The AR-SA group showed higher counts of S. aureus in the nasal mucosa than the SA group.

CONCLUSION

These results indicate the mutually potentiating effect of S. aureus colonization and allergic rhinitis.

Long-term evaluation after endoscopic sinus surgery for chronic pediatric sinusitis with polyps

OBJECTIVE

Long-term retrospective evaluation was performed of computed tomography (CT) images and endoscopic findings after endoscopic sinus surgery for 88 cases of chronic pediatric sinusitis with nasal polyps. The objective was to determine the appropriate duration of such postoperative evaluation for children.

METHODS

Fifty-one patients had both sinusitis and nasal polyps (BSP group), and the surgical procedure was decided in consideration of each patient's age (for less than 10 years of age, polypectomy (n=12); for 10-13 years old, anterior ethmoidectomy plus opening of the fontanelle and nasofrontal duct (n=20); and for serious cases older than 13 years, total sinusectomy (n=19)). On the other hand, for cases of unilateral sinusitis with antrochoanal polyps (USP group), anterior ethmoidectomy plus opening of the fontanelle was performed regardless of the patient's age (n=37, 5-15 years old).

RESULTS

The postoperative endoscopic findings indicated that the polyps had been eliminated in approximately 91% of total patients. Good postoperative findings of CT images in most patients of USP group are observed at one year after the operation like the same of the postoperative course of adult chronic sinusitis. On the other hand CT images in BSP group evaluated one year after the operation were rated as unchanged or worsened in approximately half of the patients. However, at 4 years after the operation nearly all the patients were rated as improved or better. In addition, comparison of the age at final observation and the postoperative course found a striking decrease in the proportion of unchanged and worsened patients aged 12 and above.

CONCLUSION

Accordingly, it was concluded that there is difference of healing process after the operation between USP and BSP group. Postoperative evaluation of BSP group should be performed for 4 years and up to an age of at least 12 years although post-ESS following of USP group is similar to that of adult sinusitis.

Predisposing factors associated with chronic and recurrent rhinosinusitis in childhood

Purpose

There is currently no information regarding predisposing factors for chronic and recurrent rhinosinusitis (RS), although these are considered to be multifactorial in origin, and allergic diseases contribute to their pathogenesis. We evaluated the predisposing factors that may be associated with chronic and recurrent RS.

Methods

In this prospective study, we examined patients with RS younger than 13 years of age, diagnosed with RS at six tertiary referral hospitals in Korea between October and December, 2006. Demographic and clinical data related to RS were recorded and analyzed.

Results

In total, 296 patients were recruited. Acute RS was the most frequent type: 56.4% of the patients had acute RS. The prevalences of other types of RS, in descending order, were chronic RS (18.9%), subacute RS (13.2%), and recurrent RS (11.5%). Factors associated with recurrent RS were similar to those of chronic RS. Patients with chronic and recurrent RS were significantly older than those with acute and subacute RS. The prevalences of allergic rhinitis, atopy, and asthma were significantly higher in patients with chronic and recurrent RS than those with acute and subacute RS.

Conclusions

An association between atopy and chronic/recurrent RS, compared to acute and subacute RS, suggests a possible causal link.

Rhinosinusitis: prevention strategies

Risk factors of recurrent sinusitis involve upper respiratory infections, bacterial load of the adenoids, day care attendance and exposure to tobacco smoke as well as sinonasal abnormalities, including septal deviation, choanal atresia, polyps and hypoplasia of sinuses. Furthermore, several systemic disorders can facilitate the development of chronic sinusitis, such as allergic rhinitis, gastro-esophageal reflux disease (GER), cystic fibrosis, primary ciliary dyskinesia, and immunodeficiency diseases. A clinical practice guideline for the management of sinusitis is available only for the acute disease, but does not include for the management of the chronic form (i.e. chronic/recurrent sinusitis) and even less for the prevention strategies. As several studies indicate that the majority of children respond to sequential medical followed by surgical interventions, when needed, the best prevention of recurrence or chronicity is to properly treat acute sinusitis; in addition, children should be removed from larger and crowded day care whenever possible and should not be exposed to cigarette smoke. If allergic rhinitis co-exists, it can be managed with nasal steroids sprays and anti-histamines, although the long-term results are controversial. In case of chronic sinusitis, the strategy of prevention is to assess and to cure the associated conditions.

Health effects of mold in children

Mold is ubiquitous, and exposure to mold and its products of metabolism is unavoidable, whether indoors or outdoors. Mold can produce a variety of adverse health outcomes by four scientifically validated pathophysiologic mechanisms: hypersensitivity, toxicity, infection, and irritation. Some adverse health outcomes have been attributed to mold for which mechanisms of injury are not well defined or are implausible. This article discusses these adverse health outcomes, focusing predominantly on those for which valid associations have been established.

Long-Term Follow-Up for Children Treated With Surgical Intervention for Chronic Rhinosinusitis

OBJECTIVES/HYPOTHESIS

The goal of this study is to retrospectively compare the long-term, 10 year, outcomes of surgical versus medical management of young children with chronic rhinosinusitis.

STUDY DESIGN

This is a retrospective, age-matched, cohort outcome study performed at a tertiary-care hospital.

METHODS

Two groups of young children (2-5 yr old) with chronic rhinosinusitis were treated with endoscopic sinus surgery or medically managed and evaluated 10 years after their initial therapy. Of the 131 eligible patients, 67 could be located and consented to participate in the study. Six symptoms (day cough, night cough, irritability or crankiness, headaches, nasal airway obstruction, and purulent rhinorrhea) were used to assess the outcome of their treatment.

RESULTS

Children undergoing endoscopic sinus surgery had more significant disease as noted on the computed tomography (CT) scans. Their symptom severity, however, was similar. When individual symptoms were compared, there were no statistically significant differences between the surgically and medically managed groups. When the mean was controlled for baseline symptom severity and CT severity, there was statistical improvement in nasal airway obstruction and decreased rhinorrhea. There was a trend toward improvement in cough, but this was not statistically significant. Parenteral assessment of improvement (change) in symptoms (P = .001) and their degree of satisfaction with treatment (P = .005) was significantly higher in the surgically managed group.

CONCLUSIONS

Children who have chronic rhinosinusitis improve in their symptoms of nasal airway obstruction and purulent discharge if they undergo surgery. Parents of young children with chronic rhinosinusitis appear to be more satisfied with the outcome of surgical management than medical management when assessed 10 years later.

The impact of allergic and nonallergic rhinitis on pediatric sinusitis

There is a great deal of published evidence that there is a relationship between both allergic and nonallergic rhinitis and sinusitis in both pediatric and adult patients. The relationship between rhinitis and sinusitis may involve inflammation in one compartment leading to secondary inflammation in the other compartment, such as in the case of rhinitis leading to obstruction of the osteomeatal complex. The relationship may also involve individual manifestations of a shared process, such as allergic disease. A better understanding of the relationship between rhinitis and sinusitis may significantly influence the treatment of these common and important conditions.

Allergic rhinoconjunctivitis: epidemiology

Allergic rhinoconjunctivitis has been studied much less frequently than asthma using epidemiologic approaches. Population-based studies are difficult to conduct because of misclassification arising from the reliance on self-reported questionnaires that use terms such as allergic rhinitis or hay fever to establish the diagnosis. In addition, many epidemiologic studies focus on diagnostic skin testing or allergen-specific IgE antibodies (RASTs) as an objective outcome to assess for hay fever. These techniques are helpful but not perfect measures for predicting hay fever outcomes in epidemiologic studies. It is generally accepted, however, that allergic rhinoconjunctivitis is one of the most common of chronic diseases and is the most common atopic disorder. This article reviews the definition of allergic rhinoconjunctivitis, the epidemiology of this disorder from infancy into adulthood, and environmental risk factors for development of sensitization to certain allergens.

Immunological evaluation of allergic respiratory children with recurrent sinusitis

The objective of this study was to evaluate humoral immunity of allergic respiratory children with chronic/recurrent sinusitis. Twenty-seven allergic respiratory (persistent mild/moderate asthma and persistent allergic rhinitis) children (7-15-year old) with chronic or recurrent sinusitis were evaluated. Patients had symptoms and abnormal computer tomography scan even after two adequate treatments (long-lasting antibiotics, decongestants, and short-term oral corticosteroids). clinical examination, sweat test, total blood cell count, measurement of serum levels of: total and specific IgE, immunoglobulins (G, M, A), IgG subclasses, antibodies to Haemophilus influenza type b (IgG anti-Ps Hib) and pneumococcal serotypes (IgG anti-Ps 1, 3, 5, 6B, 9V, and 14) before and after active immunization (Act-Hib and Pneumo23, Aventis Pasteur SA, Lyon, France), Rubella neutralizing antibody titers and human immunodeficiency virus antibodies. Specific IgE to inhalant allergens higher than class III were observed in 24/27 patients. One patient had IgA plus IgG2 deficiency and other an IgG3 deficiency. Eight and 12 of 27 patients had IgG2 and IgG3 serum levels below 2.5th percentile, respectively. Immunological responses to protein and polysaccharide antigens were normal in all patients. Although our patients have been appropriately treated of their allergic diseases, they persisted with chronic/recurrent sinusitis and 60% of them had a documented osteomeatal complex blockade. In spite of the diagnosis of IgA plus IgG2 deficiency and an isolated IgG3 deficiency, in all patients an adequate response to Ps antigens was observed. Primary and/or secondary humoral immunodeficiency seems not to be the main cause of chronic/recurrent sinusitis in patients with respiratory allergic disease.

Prevalence of allergy in patients with chronic rhinosinusitis

OBJECTIVES

The purpose of this study was to provide further evidence that allergic rhinitis is an important factor in chronic and recurrent acute rhinosinusitis. Specifically, this study shows that perennial allergens play a more significant role than seasonal allergens.

STUDY DESIGN AND SETTING

Census by chart review of patients with chronic and recurrent acute rhinosinusitis presenting to the Department of Otolaryngology at the MetroHealth Medical Center, Cleveland, OH.

METHODS

All participants had allergy testing done either by RAST or intradermal skin endpoint titration utilizing a battery of seasonal and perennial antigens.

RESULTS

Of the 48 voluntary participants analyzed in this study, 57.4% had a positive allergy test. Most patients in the study were sensitive to more than one allergen. Of the patients with a positive allergy test, 92% demonstrated sensitivity to one or more perennial allergens-most prominently, molds and dust mites.

CONCLUSIONS

Perennial allergy has a statistically significant association with chronic and recurrent acute rhinosinusitis.

SIGNIFICANCE

The diagnosis and management of perennial allergies may be beneficial when treating chronic sinus disease.

Perennial rhinitis in the under 4s: a difficult problem to treat safely and effectively? A comparison of intranasal fluticasone propionate and ketotifen in the treatment of 2-4-year-old children with perennial rhinitis

To compare the safety and efficacy of fluticasone propionate aqueous nasal spray (FPANS) and oral ketotifen in children aged 2-4 years with perennial rhinitis. A randomized, multicentre, double-blind, double dummy, placebo-controlled study. Paediatric patients between the ages of 2-4 years with perennial rhinitis. Rhinitis symptoms score (parent-rated), clinical evaluation of symptoms (investigator-rated) and adverse event profiles during the treatment period. Patients treated with FPANS had a significant reduction in both the total night-time rhinitis symptom assessment for weeks 4-6 (p-value 0.036), and the total daytime rhinitis symptom score over the same period (p-value 0.049). Generally, except for nasal itching/rubbing over weeks 1-3, the patients taking FPANS had lower recorded symptom scores for all individual symptoms measured. Nasal blockage, in particular, was significantly reduced over the 4-6 week period (p-value 0.027). The overall investigator-rated clinical evaluation showed substantial improvement or improvement in nine of 12 of the children taking FPANS compared with four of 14 taking ketotifen. Finally, there were no reports of serious adverse events, the incidence of drug-related adverse events was low and there was no statistical difference between the groups. FPANS may be an appropriate treatment to control the symptoms of rhinitis in children between 2 and 4 years old.

Relationships between atopy and bacterial infections

Atopy in its most common forms (asthma, allergic rhinitis, and atopic dermatitis) has a significant impact on society in terms of health care costs and quality of life. Aside from having significant morbidity from these diseases, patients with atopy have also been noted to have a high incidence of comorbidities, including bacterial infections such as otitis media and sinusitis. In this paper, current evidence is reviewed that supports the close associations among allergic rhinitis and the two commonly diagnosed bacterial diseases, otitis media and sinusitis.

The risk of adenoid hypertrophy in children with allergic rhinitis

BACKGROUND

Adenoid hypertrophy (AH) may cause significant morbidity in children but its relationship to allergic rhinitis (AR) has not been studied.

OBJECTIVE

To determine the risk factor of AH in patients with AR.

METHODS

We studied 315 children (ages 1 to 18 years) who had AH and AR. We compared them with 315 age-matched controls who had AR alone. To identify risk factors, they were divided into four groups according to age and clinical parameters, including the prevalence of otitis media, sinusitis, lower respiratory infection, exposure to smoking, sleep disorders, use of antihistamine/decongestants, and results of allergy skin testing.

RESULTS

The prevalence of upper or lower respiratory infections was higher in the group with AR and AH, but not in all age groups. A high prevalence of exposure to smoking and skin test reactivity against house dust mites were found in both groups. However, the prevalence of positive reactivity to molds was significantly higher in the group with AH and AR (P ranged from 0.013 to <0.0001 and the relative risk ranged from 1.609 to 2.375). Further, the risk of AH was positively correlated with number of skin test reactivity to mold spores (P ranged from 0.0035 to 0.0001). Positive skin test reactivity to animal danders or seasonal allergens failed to predict the risk of AH.

CONCLUSIONS

Sensitivity to mold allergens is an important risk factor for AH in children with AR; therefore, early prevention of exposure to molds may help reduce occurrence of AH.