Functional Examination of the Upper and Lower Airways in Asthma and Respiratory Allergic Diseases: Considerations in the Post-SARS-CoV-2 Era

Airway examination procedures can potentially transmit infectious diseases to patients and to the health care professionals who perform them via various mechanisms. The COVID-19 pandemic has halted most of the activity of the clinics and laboratories involved in assessment of lung and nasal function, and clear recommendations in this regard have been made. Today, we still do not know for sure what its consequences will be in the short or long term, since important gaps remain in our knowledge of aspects as fundamental as virus transmission mechanisms, pathophysiology, immune response, and diagnosis. In this review, we study the examination techniques used to assess patients with respiratory allergy, asthma, and associated diseases during this period and highlight their possible advantages and disadvantages. Therefore, we focus on exploring the entire upper and lower airways, from the perspective of the safety of both health professionals and patients and their specific characteristics. We also analyze the intrinsic value of these interventions in terms of diagnosis and patient management. The changing situation of COVID-19 may mean that some of the assertions presented in this review will have to be modified in the future. While we seek to ensure a consistently broad approach, some differences in operational details may apply owing to local regulations.

Personal protection and delivery of rhinologic and endoscopic skull base procedures during the COVID-19 outbreak

On March 11th 2020, the World Health Organization (WHO) declared COVID-19 pandemic, with subsequent profound impact on the entire health care system. During the COVID-19 outbreak, activities in the rhinology outpatient clinic and operation rooms are limited to emergency care only. Health care practitioners are faced with the need to perform rhinological and skull base emergency procedures in patients with a positive or unknown COVID-19 status. This article aims to provide recommendations and relevant information for rhinologists, based on the limited amount of (anecdotal) data, to guarantee high-quality patient care and adequate levels of infection prevention in the rhinology clinic.

Olfactory Dysfunction in the COVID-19 Outbreak

The first cases of coronavirus 2019 disease (COVID-19) occurred in Wuhan, China, and the disease rapidly become a public health emergency of international proportions. COVID-19 can cause mild-to-severe acute respiratory syndrome (SARS) and is caused by the SARS-CoV-2 coronavirus. The clinical manifestations of COVID-19 include fever, dry cough, fatigue, sputum production, shortness of breath, sore throat, and headache. We performed this narrative review to analyze the current literature on postviral olfactory dysfunction related to the SARSCoV- 2 pandemic. Since the initial anecdotal reports from China, increasingly frequent international reports on COVID-19 indicate that 5% to 85% of affected patients lose their sense of smell, thus highlighting the very heterogeneous nature of the literature in this area. Therefore, we advise home isolation measures and/or social distancing, as well as tests to detect SARS-CoV-2 when possible, in patients with sudden and severe loss of smell who cannot be promptly evaluated.

European Position Paper on Rhinosinusitis and Nasal Polyps 2020

The European Position Paper on Rhinosinusitis and Nasal Polyps 2020 is the update of similar evidence based position papers published in 2005 and 2007 and 2012. The core objective of the EPOS2020 guideline is to provide revised, up-to-date and clear evidence-based recommendations and integrated care pathways in ARS and CRS. EPOS2020 provides an update on the literature published and studies undertaken in the eight years since the EPOS2012 position paper was published and addresses areas not extensively covered in EPOS2012 such as paediatric CRS and sinus surgery. EPOS2020 also involves new stakeholders, including pharmacists and patients, and addresses new target users who have become more involved in the management and treatment of rhinosinusitis since the publication of the last EPOS document, including pharmacists, nurses, specialised care givers and indeed patients themselves, who employ increasing self-management of their condition using over the counter treatments. The document provides suggestions for future research in this area and offers updated guidance for definitions and outcome measurements in research in different settings. EPOS2020 contains chapters on definitions and classification where we have defined a large number of terms and indicated preferred terms. A new classification of CRS into primary and secondary CRS and further division into localized and diffuse disease, based on anatomic distribution is proposed. There are extensive chapters on epidemiology and predisposing factors, inflammatory mechanisms, (differential) diagnosis of facial pain, allergic rhinitis, genetics, cystic fibrosis, aspirin exacerbated respiratory disease, immunodeficiencies, allergic fungal rhinosinusitis and the relationship between upper and lower airways. The chapters on paediatric acute and chronic rhinosinusitis are totally rewritten. All available evidence for the management of acute rhinosinusitis and chronic rhinosinusitis with or without nasal polyps in adults and children is systematically reviewed and integrated care pathways based on the evidence are proposed. Despite considerable increases in the amount of quality publications in recent years, a large number of practical clinical questions remain. It was agreed that the best way to address these was to conduct a Delphi exercise . The results have been integrated into the respective sections. Last but not least, advice for patients and pharmacists and a new list of research needs are included. The full document can be downloaded for free on the website of this journal: http://www.rhinologyjournal.com.

[MASK (Mobile Airways Sentinel Network), a mobile App with ARIA's comprehensive solution in Spanish-speaking countries]

Although there are high quality clinical guidelines about allergic rhinitis, many patients receive deficient treatment, partly due to the high level of self-medication. MASK (Mobile Airways Sentinel Network) is an integral part of a project against chronic diseases which it is focused on active and healthy aging and is supported by the European Union. It forms the third phase of ARIA (Allergic Rhinitis and its Impact on Asthma) in which, through a mobile app on a smart device, the purpose is to guide patients in the control of their multimorbidity, allergic rhinitis or conjunctivitis, or asthma. The "Allergy Diary" app by MACVIA-ARIA is free and it is available for Android and iOS; on it, patients indicate how unpleasant the symptoms are on a daily basis through five screens with an analogous visual scale; two more screens were recently added (sleep affectation). With the app, it is also possible to download the information of the "Allergy Diary" on the physician's computer through a QR code at the moment of the medical consultation. In this article, we review the first year of experience in Spain, Mexico and Argentina, where the Spanish version is used.

Benefits and harm of systemic steroids for short- and long-term use in rhinitis and rhinosinusitis: an EAACI position paper

Because of the inflammatory mechanisms of most chronic upper airway diseases such as rhinitis and chronic rhinosinusitis, systemic steroids have been used for their treatment for decades. However, it has been very well documented that—potentially severe—side-effects can occur with the accumulation of systemic steroid courses over the years. A consensus document summarizing the benefits of systemic steroids for each upper airway disease type, as well as highlighting the potential harms of this treatment is currently lacking. Therefore, a panel of international experts in the field of Rhinology reviewed the available literature with the aim of providing recommendations for the use of systemic steroids in treating upper airway disease.

[MASK (Mobile Airways Sentinel Network). ARIA's comprehensive solution for mobile app for the multimorbidity of allergic rhinitis and asthma]

The vast majority of patients with allergic rhinitis (AR) do not receive the proper management which is recommended by the guidelines, but they frequently self-medicate. MASK (Mobile Airways Sentinel Network) is an integral part of a project that is supported by the European Union against chronic diseases and focused on active and healthy aging. MASK represents the third phase of ARIA (Allergic Rhinitis and its Impact on Asthma), in which, by using a mobile application in a smart device, the objective is to guide the patient in the control of his/her multi-morbidity, AR and/or allergic conjunctivitis (AC) and/or asthma. The mobile app Allergy Diary by MACVIA-ARIA is free and it is available for both Android and iOS platforms. After it is downloaded to the patient's cell phone, it first requests some information about the patient's profile, allergic pathologies and medication; afterwards, through a visual analog scale, the patient is invited to determine the degree of affectation in the nose, eyes, and bronchi, and its influence on their productivity at work / school. After analyzing the data generated by filling the Allergy Diary, it became clear there is a new clinical entity: allergic rhinitis+ allergic conjunctivitis +asthma, with greater effect; in addition to a high level of self-medication: in general, the patient takes medication on days when symptoms are present. The app has already been deployed in 23 countries, including several Spanish-speaking countries.

Self-perception of olfactory dysfunction is associated with history of Traumatic Brain Injury: post-hoc analysis from the OLFACAT survey

BACKGROUND: Traumatic brain injury (TBI) is one of the main causes of smell loss. However, epidemiological studies evaluating the incidence in general population are scarce. The aim of this analysis is to investigate the prevalence of TBI-induced olfactory dysfunction (OD) in a general-based population study. METHODOLOGY: A cross-sectional population-based survey was distributed to general population (260,000 households) through the newspaper. The survey included four microencapsulated odorants (smell test) to assess smell loss and two self-administered questionnaires (odour description and epidemiology/health status). Participants were divided into two groups, with or without a history of TBI. RESULTS: From 10,783 returned surveys, 9,348 were analysed. The survey profile was a 43-year old woman with medium-high educational level, living in a city. The overall prevalence of TBI was 5% (N=464, 44.5±14.1 years old, 57% females). Recorded causes of TBI were traffic, domestic, or work accidents. Subjects with TBI reported a poorer subjective smell self-perception compared to non-TBI participants, and a decreases ability to identify mercaptan (odour added to gas used in cities). Although, using the smell test, both groups showed similar smell capacities. CONCLUSIONS: Subjects with TBI history report a higher frequency of self-perceived OD, and a decrease ability to smell the odour added to domestic gas. Having said that, the prevalence of OD, according to the smell test, was similar in both groups.

Lack of additive benefit of oral steroids on short-term postoperative outcomes in nasal polyposis

OBJECTIVES

There is a lack of evidence concerning the efficacy of oral corticosteroids (OCS) as a postoperative treatment for patients with chronic rhinosinusitis with nasal polyps (CRSwNP). The objective of our study was to determine the short-term additive benefit of postoperative OCS in CRSwNP patients.

METHODS

We prospectively randomized CRSwNP patients who were treated by endoscopic sinus surgery. All patients were resistant to maximum medical treatment according to European position paper on rhinosinusitis and nasal polyps 2012 guidelines. Treatment group received postoperative OCS in descending doses plus nasal douching over a period of 4 weeks, whereas the control group received only nasal douching. The efficacy of OCS was determined by a total 5 item symptoms score (T5SS), polyp size score, Barcelona Smell Test 24 and Medical Outcome Study Short Form-36 questionnaire for quality of life (QoL).

RESULTS

Of the 70 enrolled patients, 35 were in the treatment group and 35 in the control group. After 4 weeks of follow-up, patients from both groups improved in T5SS, QoL, endoscopic findings (except for crusts that increased in both) and sense of smell, without significant differences between OCS and control groups.

CONCLUSION

Postoperative OCS as an add-on treatment for CRSwNP patients does not improve sinonasal and QoL outcomes; thus, they should not be routinely recommended.

LEVEL OF EVIDENCE

Ib Laryngoscope, 2019.

Patient Advisory Board for Chronic Rhinosinusitis - A EUFOREA initiative

Despite the high prevalence of chronic rhinosinusitis (CRS) and its impact on patients' quality of life, no European patient organization that advocates for patients with CRS currently exists. To fill this gap and give a voice to CRS patients, EUFOREA has created a patient advisory board, whose goal is to better understand the real-life needs of patients, to raise awareness at political level and to involve patients in the development of novel integrated solutions to accelerate access to accurate diagnosis and treatments. This report summarizes the key discussion points from the kick-off meeting of the board on the 8th June 2018 and provides an outline of the key objectives for the future.

The GALEN rhinosinusitis cohort: chronic rhinosinusitis with nasal polyps affects health-related quality of life

BACKGROUND

Chronic rhinosinusitis (CRS) significantly affects health-related quality of life (HRQoL). Few multinational observational studies have evaluated the impact of CRS with nasal polyps (CRSwNP) on patients’ HRQoL. This study aimed to assess HRQoL outcomes (including analyses by disease severity and impact of comorbidities and refractory disease) in CRSwNP patients from a large European database.

METHODOLOGY

Data were analysed from the Global Allergy and Asthma European Network (GALEN) Rhinosinusitis Cohort, including sociodemographic data, patient-reported disease severity (visual analogue scale), and scores on the 36-Item ShortForm Health Survey (SF-36) questionnaire. Differences in mean SF-36 scores were evaluated between patients with CRSwNP and population norms and between subgroups of interest (disease severity, comorbidity, and refractory disease, defined by a history of sinonasal surgery).

RESULTS

Patients with CRSwNP (N = 445) had significantly lower mean SF-36 Physical Component Summary (PCS) and Mental Component Summary (MCS) scores vs population norms, demonstrating that CRSwNP negatively affects HRQoL. The presence of comorbidities affected HRQoL, as shown by significant differences in PCS scores in patients with asthma or non-steroidal antiinflammatory drug-exacerbated respiratory disease, compared with patients without asthma. Patients with moderate-to-severe disease had significantly lower PCS scores than patients with mild disease. Severe disease had a significant impact on MCS score. History of surgery had a clinically meaningful negative effect on HRQoL compared with no history of surgery.

CONCLUSIONS

CRSwNP patients have significantly lower HRQoL compared with population norms. The impact is greater in patients with greater disease severity, comorbidities, or refractory disease.

European position paper on diagnostic tools in rhinology

The accurate diagnosis of rhinologic disease depends on the clinical history, examination findings and, in many cases, further investigations. There are a wide variety of diagnostic tests available, the choice of which depends upon the condition being assessed. This position paper is intended to provide an up-to-date comprehensive description of the diagnostic tools available to rhinologists, allergists, general otolaryngologists and other physicians with an interest in sinonasal disease. The literature has been reviewed and evidence-based recommendations are included. The relevant history and examination techniques are described, including endoscopic assessment of the nose. General and disease-specific quality of life instruments are an important tool in assessing the impact of rhinologic disease and the response to treatment. Relevant blood tests are discussed, as well as the various methods of allergy testing. Techniques for collecting microbiological and tissue samples are described, as well as the use of more specialised tests such as nasal nitric oxide and those evaluating ciliary structure and function. Imaging techniques and their indications are included. Chemosensory (smell and taste) testing is explained, and the available techniques for objective measurement of nasal airflow and patency are reviewed. Prompt and accurate diagnosis allows appropriate management to be initiated; an understanding of the currently available diagnostic tools is a vital part of the assessment of rhinologic disease.

Modified nasal floor and inferior meatus flap for septal perforation repair. Extension and limits

BACKGROUND

The nasal floor and inferior meatus (NFIM) flap represents an available option for the reconstruction of a septal perforation (SP). This study explores the feasibility of repairing SPs using a modified simple and extended (including inferior turbinate) NFIM flap.

METHODS

An anatomic study was achieved in fresh frozen cadaveric specimens to measure the area and lengths of NFIM flap. The repair of SP with simple and extended NIFM flaps was performed in some of these cadaveric specimens. Preoperative radiological evaluation of CT scans allowed studying the reconstruction limits of the simple or extended NFIM flap. A cohort of patients with SP who underwent reconstruction with an NFIM flap was also included.

RESULTS

Complete SP repair with NFIM was achieved in all specimens (n=10). In 38 fresh cadaveric specimens, coronal and sagittal lengths and area of simple NFIM flaps were smaller than in extended NFIM flaps. The radiological analysis of 75 CT scans revealed that the septal height could be reconstructed with a simple and extended NFIM flap. Complete SP repair wasachieved in 5 patients (4 male, mean age 57.4 years) using modified NFIM flaps.

CONCLUSION

The simple or expanded NFIM flap represents a feasible option to repair small or medium-sized perforations located at the lower 1/3 or 3/4 of the nasal septum.

Superior effect of MP-AzeFlu than azelastine or fluticasone propionate alone on reducing inflammatory markers

BACKGROUND

MP-AzeFlu, intranasal formulation of azelastine hydrochloride (AZE) and fluticasone propionate (FP), is superior to AZE or FP alone for treatment of allergic rhinitis (AR). However, the precise anti-inflammatory mechanism of action of MP-AzeFlu has not been characterized.

OBJECTIVE

To investigate the anti-inflammatory effects of MP-AzeFlu compared with AZE or FP alone in an established in vitro model of eosinophilic inflammation.

METHODS

Nasal mucosal epithelial cells and peripheral blood eosinophils were obtained from human volunteers. Epithelial cells were stimulated with 10% fetal bovine serum (FBS) in the presence of MP-AzeFlu, AZE, or FP (1:102 to 1:105 dilution). Concentrations of interleukin (IL)-6, IL-8, and granulocyte-macrophage colony-stimulating factor (GM-CSF) were measured by ELISA. Eosinophils were incubated in 10% human epithelial cell-conditioned medium (HECM) and survival assessed by trypan blue dye exclusion. Results are expressed as mean ± SEM percentage secretion/survival compared with FBS/HECM (respectively).

RESULTS

FP and MP-AzeFlu (all dilutions) and AZE (1:102) significantly reduced IL-6 secretion and eosinophil survival compared with positive controls. At 1:102 dilution, IL-6 secretion was significantly lower with MP-AzeFlu (38.3 ± 4.2%, compared with FBS = 100%) than with AZE (76.1 ± 4.9%) or FP (53.0 ± 4.9%). At 1:102 dilution, eosinophil survival was significantly lower with MP-AzeFlu at day 3 (17.5 ± 3.0%) and day 4 (2.4 ± 1.4%, compared with HECM = 100%) than with AZE (day 3: 75.2 ± 7.2%; day 4: 44.0 ± 9.7%) or FP (day 3: 38.5 ± 3.5%; day 4: 14.6 ± 4.0%).

CONCLUSION

Greater reductions in cytokine secretion and eosinophil survival observed with MP-AzeFlu in vitro may underlie MP-AzeFlu's superior clinical efficacy vs. AZE or FP alone observed in AR patients.

Olfactory Training in Post-Traumatic Smell Impairment: Mild Improvement in Threshold Performances: Results from a Randomized Controlled Trial

Traumatic Brain Injury (TBI) can be associated with partial or total smell loss. Recent studies have suggested that olfactory outcome can be positively modulated after olfactory training (OT). This study's aim was to investigate OT's potential role in smell recovery after TBI-induced olfactory loss. A prospective, randomized, and controlled study was developed. Patients with TBI-induced olfactory dysfunction (n = 42) were randomized into an experimental group with OT and a control group without (nOT). OT was performed twice daily with a six odor training set during 12 weeks. Olfactory loss was assessed using subjective olfactometry (Barcelona Smell Test [BAST] 24), a visual analogue scale (VAS), and n-butanol threshold (n-BTt) at baseline at 4, 12, and 24 weeks. Additionally, patients underwent MRI of the olfactory brain and olfactory bulbs (OB). Based on the MRI results, an overall score (0-16) was developed to associate the structural neurological damage with olfactory outcomes. The primary outcome was the change in olfactory measurements (VAS and BAST-24) between baseline and 12 weeks. The secondary outcome was the association of the MRI score with olfactory outcomes at baseline, and the impact on quality of life (QoL). After 12 weeks of training, OT patients showed a significant improvement in n-BTt (0.6 ± 1.7 OT vs. -0.6 ± 1.8 nOT, p < 0.05), but not in the smell VAS and BAST-24 scores. Olfactory outcomes (VAS, BAST-24, and n-BTt) were significantly associated with MRI structural findings (p < 0.001), but not with the OB volume or olfactory sulcus length. The present study suggests that 12 weeks of OT mildly improves the olfactory threshold in TBI, whereas the overall MRI score may be used as an imaging marker of olfactory dysfunction and disease severity in TBI patients.