A role for Waldeyer's ring in immunological response to allergens

Allergic Diseases and Chronic Adenotonsillar Diseases: A Mendelian Randomization Study

OBJECTIVE

The existing epidemiological evidence regarding the intricate relationship between allergic diseases and chronic adenotonsillar diseases (CATD) remains inconclusive. Herein, the objective of our study is to explore the causal association using Mendelian randomization (MR).

METHODS

Employing data from large genome-wide association studies, a comprehensive two-sample bidirectional MR study was conducted. The studied traits encompassed allergic rhinitis (cases n = 9707, controls n = 331173), allergic asthma (cases n = 8525, controls n = 193857), allergic conjunctivitis (cases n = 18321, controls n = 324178), atopic dermatitis (cases n = 11964, controls n = 306909), and CATD (cases n = 38983, controls n = 258553). All the patients were of European descent and participants in cohort studies. The primary analysis was executed using inverse-variance-weighted MR. Furthermore, six additional MR methods (MR-Egger, weighted median, simple mode, weighted mode, MR pleiotropy residual sum and outlier, MR robust adjusted profile score) were employed to ensure the reliability and detect potential horizontal pleiotropy within the results. The estimates obtained from the MR analysis were factored into the overall effect calculation.

RESULTS

Genetically anticipated outcomes demonstrated a significant association between CATD risk and allergic rhinitis (OR = 1.141, p = 6.30E-06), allergic asthma (OR = 1.115, p = 8.31E-05), allergic conjunctivitis (OR = 1.197, p = 8.69E-07), and a suggestive association with atopic dermatitis (OR = 1.053, p = 0.040). However, no substantial correlation was observed in the reverse direction.

CONCLUSIONS

Findings of our study provide evidence supporting a causal role of allergic diseases in the development of CATD, whereas the converse relationship does not appear to hold true.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:2653-2658, 2024.

Appropriate timing to perform an interim 18F-FDG PET/CT in patients with nasal-type extranodal natural killer/T cell lymphoma

Interim 18F-FDG PET/CT (I-PET) has a role in response evaluation and treatment guidance in patients with nasal-type extranodal natural killer/T cell lymphoma (ENKTL). However, there was no agreement on the timing of I-PET performed, after chemotherapy or after chemoradiotherapy. We aimed to find the appropriate timing for I-PET by assessing the prognostic value of I-PET in response evaluation in ENKTL patients. Two hundred and twenty-seven ENKTL patients who had undergone I-PET were retrospectively included. All patients were grouped based on their therapeutic strategy received, chemotherapy or chemoradiotherapy. The Deauville 5-point score (DS) was used to interpret the I-PET images. The hazard ratio (HR) and C-index were used to measure the discriminatory and prognostic capacities of I-PET performed at different times. One hundred and six patients underwent the I-PET after chemotherapy (chemotherapy group), while I-PET was performed after chemoradiotherapy in 121 patients (chemoradiotherapy group). Eighty-seven patients were classified as metabolic remission (DS score of 1-3), while the other 140 were classified as non-metabolic remission (DS score of 4-5) according to the Deauville criteria. There were no significant survival differences between patients in metabolic remission and in non-metabolic remission in either progression-free survival (PFS, p = 0.406) or overall survival (OS, p = 0.350). In the chemotherapy group, patients in metabolic remission had significantly superior PFS than patients in non-metabolic remission (p = 0.012). For OS, a discriminative trend was also found on the survival curve between patients in metabolic remission and in non-metabolic remission (p = 0.082). In the chemoradiotherapy group, there was no significant difference in PFS (P = 0.185) or OS (P = 0.627) between patients in metabolic remission and in non-metabolic remission. I-PET after chemotherapy yields higher discriminative power and has the ability for prognostic prediction in nasal-type ENKTL patients. I-PET after radiochemotherapy has no prognostic value. Thus, the appropriate timing for I-PET is after chemotherapy but before radiotherapy for response evaluation in nasal-type ENKTL patients.

Correlation Between Nasal Allergy and the Number of Eosinophils in Adenoid Tissue

To study adenoid tissue eosinophilia in allergic rhinitis. A single-centre clinical case-control prospective study with 66 subjects enrolled for the study after taking written informed consent from all the participants. All patients underwent adenoidectomy with histopathological evaluation of adenoid tissue samples for eosinophils. 36 patients (cases) with Symptoms for Allergic Rhinitis (SFAR) score indicative of allergic rhinitis. 30 patients (control) with SFAR scores not indicative of allergic rhinitis. All patients were evaluated for serum absolute eosinophil count and total serum immunoglobulin E (Ig-E). There was a significant relationship between allergic rhinitis and serum Ig-E levels using the Kruskal-Wallis rank sum test amongst case and control groups with a p-value of 0.031. Pathologically examined slides of adenoid tissue eosinophil count per 10 random high power fields in these patients showed significant results with a p-value of 0.002432, via the Kruskal-Wallis rank sum test. Statistical analysis, shows that adenoid tissue eosinophil count and serum Ig-E levels can somewhat predict the presence of clinical features of allergic rhinitis. Based on several similar studies with similar results, allergic rhinitis can be gauged with adenoid tissue histopathology and routine evaluation should be considered as a standard of care.

Medical treatment does not reduce surgery rates in children with adenoid hypertrophy

OBJECTIVE

We sought to study adenoidectomy rates in children with adenoid hypertrophy (AH) who were either treated with medical therapy or not during a 2-year follow-up period in a longitudinal population-based study.

METHODS

We retrospectively identified healthy children aged 1-18 years between 2014 and 2020 with AH diagnosis from the Clalit Health Services database, the largest healthcare maintenance organization in Israel. The main outcome was adenoidectomy alone or in combination with other procedures performed within 2 years after diagnosis. The treatment group consisted of children who received medical therapy, defined as a pharmacy purchase of montelukast, nasal steroid sprays and/or antihistamines (medical therapy aimed to reduce AH) for ≥2 consecutive months, while the control group consisted of untreated children.

RESULTS

We identified 68,356 unique children with AH, of them 56 % were boys, with a mean age of 4.9 ± 3.3 years. Of them, 5310 (7.7 %) received medical therapy. Overall, 6633 (9.7 %) underwent adenoidectomy within 2 years following diagnosis. There was no significant difference in surgery referral rates between the treatment and the control groups, 10 % vs. 9.7 %, respectively (p = 0.3). When adjusted for age and sex, the likelihood of undergoing adenoidectomy was similar in both groups (HR = 0.98, 95 % CI = 0.90-1.07, p = 0.6). Among operated children, the average time from diagnosis to surgery was statistically significantly longer in the treatment group than in the control group, 346 ± 180 vs 311 ± 175 days (p < 0.001).

CONCLUSION

Prescribing montelukast, nasal steroids and/or oral antihistamines was not associated with a reduction in adenoidectomy rates and was associated with an average surgery delay of 35 days.

International consensus statement on allergy and rhinology: Allergic rhinitis - 2023

BACKGROUND

In the 5 years that have passed since the publication of the 2018 International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis (ICAR-Allergic Rhinitis 2018), the literature has expanded substantially. The ICAR-Allergic Rhinitis 2023 update presents 144 individual topics on allergic rhinitis (AR), expanded by over 40 topics from the 2018 document. Originally presented topics from 2018 have also been reviewed and updated. The executive summary highlights key evidence-based findings and recommendation from the full document.

METHODS

ICAR-Allergic Rhinitis 2023 employed established evidence-based review with recommendation (EBRR) methodology to individually evaluate each topic. Stepwise iterative peer review and consensus was performed for each topic. The final document was then collated and includes the results of this work.

RESULTS

ICAR-Allergic Rhinitis 2023 includes 10 major content areas and 144 individual topics related to AR. For a substantial proportion of topics included, an aggregate grade of evidence is presented, which is determined by collating the levels of evidence for each available study identified in the literature. For topics in which a diagnostic or therapeutic intervention is considered, a recommendation summary is presented, which considers the aggregate grade of evidence, benefit, harm, and cost.

CONCLUSION

The ICAR-Allergic Rhinitis 2023 update provides a comprehensive evaluation of AR and the currently available evidence. It is this evidence that contributes to our current knowledge base and recommendations for patient evaluation and treatment.

Identification of gene biomarkers with expression profiles in patients with allergic rhinitis

Background

Allergic rhinitis (AR) is an upper respiratory tract inflammation disease caused by IgE-mediated reactions against inhaled allergens. The incidence of AR is significantly increasing throughout the world. Hence, more specific, and sensitive gene biomarkers and understanding the underlying pathways are necessary to further explore the AR pathogenesis.

Objective

To identify gene biomarkers in nasal mucosa and in blood from AR patients which could be used in AR diagnosis.

Methods

The gene expression profiles of GSE43523 from nasal epithelial cells and GSE75011 from Th2-enriched CD4+ T cells in blood were downloaded from the Gene Expression Omnibus database. Gene Ontology (GO), Kyoto Encyclopedia of Genes and Genomes (KEGG) analyses and protein–protein interaction (PPI) network analysis were conducted to investigate the functional changes of genes. The receiver operating characteristic (ROC) curves were used to assess the diagnostic values of the hub genes. Real-time quantitative PCR (RT-qPCR) was performed to validate the hub genes.

Results

Significant differentially enriched gene signatures in AR patients were identified in nasal epithelial cells (n-DEGs) and in blood (t-DEGs). Signatures associated with axoneme, extracellular matrix, collagen fibril organization, cell motility, calcium ion binding, and so on were more enriched in n-DEGs, whereas signatures associated with TNF signaling pathway, detoxification of inorganic compound, and cellular response to corticotropin-releasing hormone stimulus were enriched in t-DEGs. In addition, we identified 8 hub genes and 14 hub genes from n-DEGs and t-DEGs, respectively. The combination of POSTN in nasal mucosa and PENK and CDC25A in blood was constructed with a good AR predicting performance. The area under the curve (AUC) of the ROC curve of 3 hub genes’ combination was 0.98 for AR diagnosis.

Conclusion

This study utilized gene expression profiles and RT-qPCR validation on nasal mucosa and blood from AR patients to investigate the potential biomarkers for AR diagnosis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13223-022-00656-4.

An Up-to-Date Review on Bio-Resource Therapeutics Effective against Bacterial Species Frequently Associated with Chronic Sinusitis and Tonsillitis

Upper respiratory tract infections include inflammations of the nose, sinuses (sinusitis), pharynx (tonsillitis, pharyngitis) and larynx (laryngitis) with bacteria or viruses as the main cause of these conditions. Due to their repetitive nature, chronic respiratory infections represent a global problem which is often a result of improper treatment. If not treated adequately, these conditions may have serious consequences. On the other hand, mis - and overuse of antibiotics has reduced their efficiency and accelerated the development of resistant bacterial strains, which further complicates the treatment of infections. This literature review will focus on current knowledge regarding medicinal plants and mushrooms which have been traditionally used in the treatment of infections caused by chronic sinusitis and tonsillitis commonly linked to bacteria - Staphylococcus aureus, Streptococcus pneumoniae, Streptococcus pyogenes, Fusobacterium nucleatum, Haemophilus influenzae and Moraxella catarrhalis. The present literature overview might be considered as a starting point for the development of novel, natural antimicrobial products with potential practical use in the treatment of chronic tonsillitis and sinusitis.

Factors associated with the presence of headache in hospitalized COVID-19 patients and impact on prognosis: a retrospective cohort study

INTRODUCTION

Headache is one of the most frequent neurologic manifestations in COVID-19. We aimed to analyze which symptoms and laboratory abnormalities were associated with the presence of headache and to evaluate if patients with headache had a higher adjusted in-hospital risk of mortality.

METHODS

Retrospective cohort study. We included all consecutive patients admitted to the Hospital with confirmed SARS-CoV-2 infection between March 8th and April 11th, 2020. We collected demographic data, clinical variables and laboratory abnormalities. We used multivariate regression analysis.

RESULTS

During the study period, 576 patients were included, aged 67.2 (SD: 14.7), and 250/576 (43.3%) being female. Presence of headache was described by 137 (23.7%) patients. The all-cause in-hospital mortality rate was 127/576 (20.0%). In the multivariate analysis, patients with headache had a lower risk of mortality (OR: 0.39, 95% CI: 0.17-0.88, p = 0.007). After adjusting for multiple comparisons in a multivariate analysis, variables that were independently associated with a higher odds of having headache in COVID-19 patients were anosmia, myalgia, female sex and fever; variables that were associated with a lower odds of having headache were younger age, lower score on modified Rankin scale, and, regarding laboratory variables on admission, increased C-reactive protein, abnormal platelet values, lymphopenia and increased D-dimer.

CONCLUSION

Headache is a frequent symptom in COVID-19 patients and its presence is an independent predictor of lower risk of mortality in COVID-19 hospitalized patients.

Lingual Tonsil Hypertrophy in Patients With Allergic Rhinitis

Background

Lingual tonsils, part of the Waldeyers’ Ring, are located in base of the tongue. They are commonly observed in childhood, due to increased immunological activity. Several factors such as laryngopharyngeal reflux, younger age, smoking, and obesity are associated with hypertrophy of lingual tonsils (LTH) in adulthood. However, the relation between allergic rhinitis and LTH is not clearly highlightened in the literature so far.

Objective

To investigate the role of allergic rhinitis in the development of LTH.

Methods

Adult patients who were diagnosed with allergic rhinitis were included in the study group. The control group consisted of age- and sex-match healthy volunteers. Complete otorhinolaryngology examination including fiberoptic endoscopic evaluation was performed to both groups. Blood samples were obtained for total immunglobulin E levels, and skin prick tests were performed to both groups. Patients with allergy complaints and positive skin prick tests were included in the study group, while healthy volunteers with negative skin prick tests were enrolled in the control group. The grading for LTH was achieved by a physician who was blind to the study.

Results

The incidence of LTH was significantly higher in the study group when compared to the control group ( P = .001). Similarly, the incidence of grade 3 LTH was significantly higher in the study group compared to the controls ( P = .002).

Conclusion

According to our results, LTH is more frequently observed in patients with allergic rhinitis. Grade 3 representing larger LTH is more commonly seen in patients with allergic rhinitis.

Distinct transcriptomic profiles of early-onset atopic dermatitis in blood and skin of pediatric patients

BACKGROUND

Atopic dermatitis (AD) predominantly affects young children, but our understanding of AD pathogenesis is based on skin and blood samples from long-standing adult AD. Genomic biopsy profiling from early pediatric AD showed significant Th2 and Th17/Th22-skewing, without the characteristic adult Th1 up-regulation. Because obtaining pediatric biopsies is difficult, blood gene expression profiling may provide a surrogate for the pediatric skin signature.

OBJECTIVE

To define the blood profile and associated biomarkers of early moderate-to-severe pediatric AD.

METHODS

We compared microarrays and reverse transcription polymerase chain reaction (RT-PCR) of blood cells from 28 AD children (<5 years and within 6 months of disease onset) to healthy control blood cells. Differentially expressed genes (DEGs) in blood (fold change [FCH] > 1.2 and false discovery rate [FDR] < 0.05) were then compared with skin DEGs.

RESULTS

Eosinophil and Th2 markers (IL5RA, IL1RL1/ST2, HRH4, CCR3, SIGLEC8, PRSS33, CLC from gene arrays; IL13/IL4/CCL22 from RT-PCR) were up-regulated in early pediatric AD blood, whereas IFNG/Th1 was decreased. Th1 markers were negatively correlated with clinical severity (EASI, pruritus, transepidermal water loss [TEWL]), whereas Th2/Th17-induced interleukin (IL)-19 was positively correlated with SCORAD. Although a few RT-PCR-defined immune markers (IL-13/CCL22) were increased in blood, as previously also reported for skin, minimal overlap based on gene array DEGs was seen.

CONCLUSION

The whole blood signature of early moderate-to-severe pediatric AD blood cells show predominantly a Th2/eosinophil profile; however, markers largely differ from the skin profile. Given their complementarity, pooling of biomarkers from blood and skin may improve profiling and predictions, providing insight regarding disease course, allergic comorbidity development, and response to systemic medications.

Can the number of eosinophils in adenoid and tonsil tissue determine the allergy in children?

OBJECTIVE

Previous reports have indicated the association of allergy with Waldeyer's ring. The aim of this prospective study was to evaluate the correlation between the allergy and the number of eosinophils in the adenoid and tonsil tissue.

METHODS

101 children who were underwent adenoidectomy and/or tonsillectomy were prospectively enrolled in this study. 46 children who had positive skin-prick test for at least one of the allergen panel were sensitized and 55 children were nonsensitized as a result of skin-prick test. Hematoxylin-eosin stained sections were examined under 400× magnification in a blinded fashion in 10 random sections for all samples and compared the groups.

RESULTS

The number of eosinophils in adenoid and tonsil tissue was significantly higher in sensitized patients. The number of eosinophils in the adenoid and tonsil samples also were interrelated too (p < 0.001, kappa coefficient: 0.617). As a result of ROC analysis, patients with a cut-off of ≥5 eosinophils was in the sensitized group for adenoid samples [Sensitivity value: 72.09 and specifity value: 91.84]. Patients with a cut-off of ≥3 eosinophils are in the sensitized group for tonsil samples [Sensitivity value: 52.94 and specifity value: 92.11].

CONCLUSION

Presence of sensitization can be distinguished by looking at the number of eosinophils in the adenoid and tonsil tissue. It can be used to determine whether the patient is allergic or not. Examination of the routine hematoxylin-eosin stained adenotonsillary specimen for eosinophilia will guide us the diagnosis and treatment of allergic rhinitis and also reduce the cost considerably.

International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis

BACKGROUND

Critical examination of the quality and validity of available allergic rhinitis (AR) literature is necessary to improve understanding and to appropriately translate this knowledge to clinical care of the AR patient. To evaluate the existing AR literature, international multidisciplinary experts with an interest in AR have produced the International Consensus statement on Allergy and Rhinology: Allergic Rhinitis (ICAR:AR).

METHODS

Using previously described methodology, specific topics were developed relating to AR. Each topic was assigned a literature review, evidence-based review (EBR), or evidence-based review with recommendations (EBRR) format as dictated by available evidence and purpose within the ICAR:AR document. Following iterative reviews of each topic, the ICAR:AR document was synthesized and reviewed by all authors for consensus.

RESULTS

The ICAR:AR document addresses over 100 individual topics related to AR, including diagnosis, pathophysiology, epidemiology, disease burden, risk factors for the development of AR, allergy testing modalities, treatment, and other conditions/comorbidities associated with AR.

CONCLUSION

This critical review of the AR literature has identified several strengths; providers can be confident that treatment decisions are supported by rigorous studies. However, there are also substantial gaps in the AR literature. These knowledge gaps should be viewed as opportunities for improvement, as often the things that we teach and the medicine that we practice are not based on the best quality evidence. This document aims to highlight the strengths and weaknesses of the AR literature to identify areas for future AR research and improved understanding.

Tripterygium Wilfordii inhibits tonsillar IgA production by downregulating IgA class switching in IgA nephropathy

IgA nephropathy (IgAN) is characterized by high serum IgA levels and IgA deposition in the renal mesangium. Recent research has indicated that pathogenic IgA may originate from affected tonsils, where present enhancement of IgA production by IgA class switching and immuno-activation. Tripterygium Wilfordii (TW) was found to be especially effective in IgAN by its’ immunosuppression effect. Given this background, we investigated the mechanisms underlying the role of TW in the generation of IgA and IgA class switching in tonsillar GCs of IgAN patients. Immunohistochemistry and RT-PCR revealed that the expression of thymic stromal lymphopoietin (TSLP) and IgA inducing cytokines were decreased in the tonsils of IgAN patients with TW treatment compared with those without treatment, followed by significantly decreased of IgA-bearing cells. The location of TSLP and IgA inducing cytokines in tonsillar tissue was confirmed by double immunofluorescence. Importantly, TW inhibit TSLP and IgA production in isolated FDC-associated clusters. Serum TSLP levels were decreased and correlated with IgA downregulation in the tonsils and serum of IgAN patients. These data indicated that TW may be involved in IgA production in the tonsils of IgAN patients, inhibiting IgA class switching in IgAN patients through the cooperative roles of AID, TGF-β1, BAFF, and APRIL, highlighting a promising strategy for therapeutic intervention in IgAN.

Thymic stromal lymphopoietin in tonsillar follicular dendritic cells correlates with elevated serum immunoglobulin A titer by promoting tonsillar immunoglobulin A class switching in immunoglobulin A nephropathy

Immunoglobulin A (IgA) nephropathy (IgAN) is characterized by high serum IgA levels and IgA deposition in the renal mesangium. Previous studies suggest that elevated serum IgA partly originates from the tonsils. Here, we investigated the mechanisms of IgA production in the tonsils of patients with IgAN. Immunohistochemistry revealed that the number and relative percentage of IgA-bearing cells were significantly increased in the tonsils of IgAN patients. Compared with non-IgAN patients, enhanced IgA class switching and overexpression of thymic stromal lymphopoietin (TSLP), TSLP receptor (TSLPR), activation-induced cytidine deaminase (AID), transforming growth factor-β1 (TGF-β1), B cell-activating factor of the tumor necrosis factor family (BAFF), and a proliferation-inducing ligand (APRIL) were detected in follicular dendritic cells (FDCs) of tonsillar germinal centers from IgAN patients. Importantly, TSLP correlated with IgA production in isolated FDC-associated clusters. Serum TSLP levels were increased and correlated with IgA overexpression in the tonsils and serum of IgAN patients. These data indicated that TSLP overexpression in tonsillar FDCs may promote IgA class switching in IgAN patients through the cooperative roles of AID, TGF-β1, BAFF, and APRIL. Therefore, interactions between TSLP in FDCs and IgA production in tonsils may be an important mechanism contributing to the pathogenesis of IgAN.

The efficacy of tonsillectomy on clinical remission and relapse in patients with IgA nephropathy: a randomized controlled trial

BACKGROUND

The efficacy of tonsillectomy in immunoglobulin A nephropathy (IgAN) remains controversial. The aim of the study was to conduct a randomized controlled trial to evaluate the effect of tonsillectomy in patients with IgAN.

METHODS

We randomly selected 98 patients with biopsy-proven IgA nephropathy and randomly allocated to receive tonsillectomy combined with drug therapy (Group A) or drug therapy alone (Group B). The participating patients were entered into a 4-year single-center study. Remission and relapse rate were calculated for hematuria and proteinuria using the Kaplan-Meier method.

RESULTS

No differences were found between the two groups in their baseline clinical and histological characteristics. Patients with tonsillectomy exhibited considerable improvement in the following aspects compared to those patients who did not undergo tonsillectomy: time to reach first remission (3.1 vs. 24.9 months, p < 0.001) for hematuria and (2.5 vs. 26.1 months, p < 0.001) for proteinuria, cumulative remission rate (91.8% vs. 46.9%, p < 0.001 by log-rank test) for hematuria and (95.9% vs. 51.0%, p < 0.001) for proteinuria, the duration of first remission (26.5 vs. 11.8 months, p = 0.0047) for hematuria and (23.5 vs. 10.5 months, p = 0.0012) for proteinuria, as well as lower relapse rate for hematuria and proteinuria in Group A.

CONCLUSION

Our clinical data demonstrated that tonsillectomy could be beneficial for IgAN patients, particularly by contributing to faster and longer remission, as well as reducing the frequency of possible future relapses.

Mucoepidermoid Carcinoma of the Palatine Tonsil

Mucoepidermoid carcinoma (MEC) is the most common primary salivary gland malignancy in both adults and children. It has a slight female predilection and usually presents as a painless, rubber-like or soft mass, which may be fixed or mobile. Histologically, MEC is comprised of a mixture of cell types including mucous, epidermoid, and intermediate cells that can be arranged in solid nests or cystic structures. In the oral cavity, it most frequently occurs at the palate or buccal mucosa. The present paper aimed to describe an unusual case of MEC arising in the palatine tonsil.

Is there a need for a histological examination of the adenoid tissue after adenoidectomy?

OBJECTIVES

In Germany there is no uniform practice regarding the histological examination of removed tissue after an adenoidectomy. In addition, the unique benefits of routine histological examination of adenoid tissue cannot be ascertained from current literature due to varying opinion and evidence.

METHODS

This study was approved by the Medical Association and Ethics Committee in Cottbus, Brandenburg, Germany. We evaluated the pre- and intra-operative examination findings (direct and indirect epipharyngoscopy, digital palpation, intraoperative macroscopic assessment and examination of removed tissue) and the histopathological findings of excised adenoid tissue. A statistical analysis of obtained results was undertaken thereafter.

RESULTS

It was found that in all young patients included in the study, the histological results invariably represented lymphoepithelial hypertrophic mucosa with a varying inflammatory response, matching a clinical picture of adenoid vegetation and in keeping with the pre- and intraoperative investigations and findings.

CONCLUSION

The characteristic history of adenoid vegetation in combination with a classic pre- and intraoperative clinical examination and an inconspicuous macroscopic examination of removed tissue, renders routine histopathological workup dispensable. On suspicion of deviant pathology a histopathological examination is recommended and should be undertaken.

A survey of clinical features of allergic rhinitis in adults

BACKGROUND

Allergic rhinitis (AR) has high prevalence and substantial socio-economic burden.

MATERIAL/METHODS

The study included 35 Italian Centers recruiting an overall number of 3383 adult patients with rhinitis (48% males, 52% females, mean age 29.1, range 18-45 years). For each patient, the attending physician had to fill in a standardized questionnaire, covering, in particular, some issues such as the ARIA classification of allergic rhinitis (AR), the results of skin prick test (SPT), the kind of treatment, the response to treatment, and the satisfaction with treatment.

RESULTS

Out of the 3383 patients with rhinitis, 2788 (82.4%) had AR: 311 (11.5%) had a mild intermittent, 229 (8.8%) a mild persistent, 636 (23.5%) a moderate-severe intermittent, and 1518 (56.1%) a moderate-severe persistent form. The most frequently used drugs were oral antihistamines (77.1%) and topical corticosteroids (60.8%). The response to treatment was judged as excellent in 12.2%, good in 41.3%, fair in 31.2%, poor in 14.5%, and very bad in 0.8% of subjects. The rate of treatment dissatisfaction was significantly higher in patients with moderate-to-severe AR than in patients with mild AR (p<0.0001). Indication to allergen immunotherapy (AIT) was significantly more frequent (p<0.01) in patients with severe AR than with mild AR.

CONCLUSIONS

These findings confirm the appropriateness of ARIA guidelines in classifying the AR patients and the association of severe symptoms with unsuccessful drug treatment. The optimal targeting of patients to be treated with AIT needs to be reassessed.

New product development with the innovative biomolecular sublingual immunotherapy formulations for the management of allergic rhinitis

The molecular allergy technique, currently defined as component-resolved diagnosis, significantly improved the diagnosis of allergy, allowing for differentiation between molecules actually responsible for clinical symptoms (genuine sensitizers) and those simply cross-reacting or shared by several sources (panallergens), thus influencing the appropriate management of a patient's allergy. This also concerns allergen immunotherapy (AIT), which may be prescribed more precisely based on the component-resolved diagnosis results. However, the advance in diagnosis needs to be mirrored in AIT. According to consensus documents and to expectations of specialists, therapy should be based on standardized extracts containing measured amounts of the clinically relevant molecules, ie, the major allergens. The new generation of extracts for sublingual immunotherapy fulfills these requirements and are thus defined as biomolecular (BM). BM refers to natural extracts with a defined content of major allergens in micrograms. All Staloral BM products are indicated for the treatment of allergic rhinitis with or without asthma. The effectiveness of AIT is related to its ability to modify the immunological response of allergic subjects. The 5-grass and house dust mite extracts were evaluated addressing the T helper 1, T helper 2, and T helper 3 cells by polymerase chain reaction array on mRNA extracted from Waldeyer's ring tissue (adenoids). Sublingual immunotherapy with a defined content of major allergens in micrograms induced a strong downregulation of genes involved in T helper 2 and T helper 1 activation and function, allowing the definition of the immunologic effect as "bio-homeostatic". This clinical and immunological model must be implemented with respect to other allergens, thus expanding the application of a treatment with a unique disease-modifying capacity.