Update on nonallergic rhinitis

Enhanced nerve growth factor expression by mast cells does not differ significantly between idiopathic and allergic rhinitis

BACKGROUND

The role of neurotrophins in allergic rhinitis (AR) has been well studied, but it has not been evaluated in idiopathic rhinitis (IR).

OBJECTIVE

We aimed to evaluate the nasal β-nerve growth factor (β-NGF) expressions of mast cells in patients with AR and IR.

METHODS

Seventeen patients with house dust mites-induced persistent moderate/severe allergic rhinitis (mean age: 29.7 ± 11.96), 14 patients with idiopathic rhinitis (mean age, 29.3 ± 10.62), and 16 healthy controls (29.9 ± 11.57) were included in the study. Nasal biopsy specimens were taken from the posterior part of the inferior turbinate from all of the study subjects. Nasal β-nerve growth factor and its receptors, pan-neurotrophin receptor p75, and tyrosine kinase A (trkA) were assessed with an immunofluorescence assay. Mast cells were determined by both an immunofluorescence assay and immunohistochemistry as tryptase-positive cells.

RESULTS

The β-NGF, trkA, and p75 receptor counts were significantly higher in AR and IR patients than in the control group (P < .001, for each), but they were not different between AR and IR patients. Similarly, the ratio of β-NGF+ mast cells/total mast cells and the ratio of β-NGF+ mast cells/total β-NGF+ cells in AR and IR patients was found to be elevated when compared with the control group (P < .001, P < .001, P < .001, and P = .046, respectively); furthermore, the 2 ratios were not statistically different between the 2 patient groups.

CONCLUSION

The increase in β-NGF-expressing mast cells does not differ between idiopathic and allergic rhinitis. Therefore, we propose that mast cells do play a role in the pathogenesis of IR as important as in that of AR.

Clinical characteristics of chronic rhinitis patients with high vs low irritant trigger burdens

BACKGROUND

Patients with chronic allergic rhinitis (AR) and nonallergic rhinitis (NAR) often experience irritant-induced symptoms. The clinical relevance of the magnitude of their symptoms in response to these nonspecific stimuli remains unclear.

OBJECTIVE

To determine the internal consistency and validity of an irritant index questionnaire (IIQ) and whether reclassification of physician-diagnosed rhinitis subtypes based on IIQ scores results in rhinitis subtypes with different clinical characteristics.

METHODS

Patients 18 to 65 years old with physician-diagnosed AR (n = 404), mixed rhinitis (MR; n = 129), or NAR (n = 123) completed an IIQ that rated rhinitis symptom severity in response to 21 nonallergic irritant triggers on a 1- to 10-point scale. Multistage sex-specific statistical analyses were performed using IIQ responses to reclassify physician-diagnosed AR, MR, and NAR into categories with high and low irritant burdens.

RESULTS

The IIQ demonstrated good internal consistency and cross-validation. After reclassification, 48% and 52% of patients with physician-diagnosed AR patients (n = 533) were categorized as having low-burden AR and high-burden AR, respectively, whereas 64% and 36% of NAR (n = 123) patients were categorized as having low-burden NAR and high-burden NAR, respectively. Reclassified high-burden AR and high-burden NAR patients were more likely to have a physician diagnosis of asthma and a greater number of self-reported rhinitis symptoms and perennial symptoms with seasonal exacerbations than reclassified low-burden AR and low-burden NAR patients, respectively (P < .01).

CONCLUSION

The IIQ resulted in significant reclassification of physician-diagnosed rhinitis patients into different diagnostic categories with unique clinical characteristics. Further studies are necessary to confirm the IIQ's utility as a tool for characterizing rhinitis patients in clinical practice and research.

Characteristics of a patient population seeking medical advice for nasal symptoms in Bulgaria

BACKGROUND

The proportion of patients visiting general practitioners (GPs), otorhinolaryngologists (ORLs), and allergologists (ALRGs) for nasal complaints is unknown but important in estimating the number of subjects with nasal symptoms bothersome enough to warrant physician consultations and assessing nasal pathological conditions' burden on a national health care system.

OBJECTIVE

The Symptoms of Nasal Inconvenience Fact Finding (SNIFF) survey was developed to (1) assess incidence of physician visits attributable to nasal complaints; (2) characterize patients' nasal conditions; and (3) outline differences across physician categories.

METHODS

The SNIFF survey was completed over 20 days by Bulgarian GPs, ORLs, and ALRGs whom patients consulted for nasal symptoms. Survey forms differentiated type and severity of patients' conditions according to Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines and ranked bothersome symptoms. Smell impairment, comorbidities, and prescription practices were documented.

RESULTS

Sixty-nine physicians (30 GPs, 8 ORLs, 31 ALRGs) completed 1,685 surveys. The proportion of patients with nasal symptoms over the total patients seen was 15.7%: ALRGs, 18.0%; GPs, 14.6%; ORLs, 13.1%. Patients were classified as having intermittent (38.8%) or persistent (61.2%) rhinitis, with most having moderate/severe symptoms (94.4%). Congestion was the leading symptom in 59.1%. Smell was impaired in 69.8% of patients, asthma was present in 21.4%, and cough in 62.9%. ALRGs were more likely to diagnose and manage patients per ARIA guidelines than were ORLs or GPs.

CONCLUSION

The SNIFF survey results demonstrate congestion's role as a leading symptom motivating patients to seek medical advice. SNIFF also uncovered differences in practices among different categories of health care providers.

Epidemiological analysis of chronic rhinitis in pediatric patients

BACKGROUND

Nonallergic rhinitis is a poorly understood entity, especially among pediatric patients.

OBJECTIVE

The objective of this study was to identify clinical features that may distinguish phenotypes of allergic and nonallergic patients and to evaluate the usefulness of current diagnostic modalities.

METHODS

We reviewed medical records for 151 pediatric patients with perennial rhinitis, evaluated in a multidisciplinary allergy and otolaryngology clinic. Results obtained by standard history, validated sinus and Nasal Quality of Life Survey (SN-5), epicutaneous allergy testing, acoustic rhinometry, and sinus CT were compared.

RESULTS

Nasal congestion was the most frequent primary presenting complaint (62%). Among subjects having a positive allergy test, associated eye symptoms were more frequent (p = 0.01) and responses to the SN-5 allergic domain were higher (p = 0.02). Sinus CT scores were similar among allergic and nonallergic subjects (median 7 and 8, respectively) and did not correlate with symptom scores (p = 0.6). Among nonallergic subjects, quality of life ratings weakly correlated with sinus CT scores (r = 0.4; p = 0.05). By rhinometry, absolute mean cross-sectional area was similar among allergic (0.32 cm(2)) and nonallergic (0.36 cm(2)) subjects and did not correlate with symptom scores (p = 0.8 for allergic and p = 0.6 for nonallergic subjects). Distinct groups of nonallergic patients including those with prominent conjunctival pruritus (n = 24), frequent cold symptoms (n = 3), and chronic sinus disease (n = 2) were observed.

CONCLUSION

It is difficult to distinguish allergic and nonallergic rhinitis in patients with perennial disease, but associated eye symptoms and questionnaire responses are predictive of allergy. Acoustic rhinometry and sinus CT suggest that physical obstruction and sinus disease are not related to nasal symptoms including, surprisingly, the sensation of congestion.

[Comparative assessment of cryosurgical treatment results in allergic and non-allergic rhinitis]

INTRODUCTION

The aim of the work was to assess the treatment efficiency in patients with allergic and non-allergic vasomotor rhinitis after cryoablation procedures.

MATERIAL AND METHODS

The study covered 60 patients, including 32 women and 28 men, aged 18-66. The patients were divided into two groups: I - 30 patients with chronic allergic rhinitis, II - 30 patients with non-allergic vasomotor rhinitis. The study methodology involved: an otorhinolaryngological interview with a questionnaire and an allergological interview, an objective otolaryngological and rhinomanometrical examination with Homoth apparatus, a subjective evaluation questionnaire for nasal blockage intensification (the scale ranging from 0 to 10), skin tests to aeorallergens and food allergens (Allergopharma Co.), nasal endoscopy with a straight rigid Eleps endoscope before the treatment and 3 months following it. The cryoablation of nasal conchas was performed under local infiltration anesthesia (1% Xylokaina solution) using the Cryo-S apparatus from CryoFlex Poland Company and a flat probe in a spatula shape (L-50) that was placed on the outer surfaces of the inferior nasal concha.

RESULTS

The inferior nasal concha cryoablation resulted in a statistically significant improvement in the subjective assessment scale in group I by 82.6% and group II by 141.2%. In the endoscopic examination 3 months following the cryoablation a good nasal patency was achieved in 63.3% patients from group I and 76.7% patients from group II. The conducted studies show a better nasal passages patency in patients with non-allergic rhinitis than in those with allergic rhinitis.

CONCLUSIONS

Cryoablation procedures on the inferior nasal conchas are not the primary therapy, but together with other methods they can immensely improve the life comfort of a rhinitis patient.

Nonallergic rhinitis and its association with smoking and lower airway disease: A general population study

BACKGROUND

The cause of nonallergic rhinitis (NAR) and its relation to lower airway disease remains unclear. The purpose of this study was to perform a descriptive analysis of the occurrence of rhinitis in a Danish general population with focus on NAR and its association with smoking and lower airway disease.

METHODS

A population-based, cross-sectional study conducted in Copenhagen, Denmark was performed. A random sample from the general population (n = 7931; age, 18-69 years) was invited to a general health examination including measurements of serum-specific immunoglobulin E (IgE) to common aeroallergens; 3471 (44%) persons were accepted. For further analysis, we divided the population into the following groups: (I) negative specific IgE and no rhinitis (controls); (II) negative specific IgE and rhinitis (NAR); (III) positive specific IgE and rhinitis (allergic rhinitis [AR]); and (IV) positive specific IgE but no rhinitis (sensitized).

RESULTS

We found that NAR was associated with asthma (odds ratio [OR] = 2.51 [1.87-3.37]); chronic bronchitis (OR = 2.27 [1.85-2.79]); current smoking (>15 g/day; OR = 1.57 [1.18-2.08]); lower forced expiratory volume in 1 second/forced vital capacity (FEV(1)/FVC) ratios and reduced FEV(1) values. The association with chronic bronchitis was stronger in NAR than in AR, whereas the opposite was true for asthma. FEV(1)/FVC of <70% was not significantly associated to any group.

CONCLUSION

This epidemiological study indicates that both asthma and chronic bronchitis are important comorbidities in NAR confirming the "united airway" hypothesis, and that smoking might be a significant modulator of disease. Although NAR was significantly associated with poor lung function, no significant association with chronic obstructive pulmonary disease was shown.

Nonallergic rhinopathy (formerly known as vasomotor rhinitis)

This review focuses on the poorly understood condition of nonallergic rhinopathy (NAR) at a clinical level, with an eye on current optimal treatment. NAR is the new designation for the conditions formerly referred to as vasomotor rhinitis or nonallergic idiopathic rhinitis. The clinical characteristics and differential diagnosis are provided in detail in this review, and the disease should now be characterized sufficiently for clinical studies.

Nasal eosinophilia can predict bronchial hyperresponsiveness in persistent rhinitis: evidence for united airways disease concept

BACKGROUND

Nasal eosinophils may be indicative of bronchial hyperresponsiveness (BHR) in rhinitis concerning the "united airways disease" theory. This study was designed to evaluate the relationship between nasal eosinophilia and BHR in persistent perennial rhinitis patients.

METHODS

Thirty-seven patients (12 males and 25 females, mean age: 33.3 ± 10.4 years) were included in the study. Skin-prick test, nasal symptom score, nasal smears, methacholine bronchial challenge test, and nasal rhinometry were obtained in all patients. Eosinophil count in nasal smears was expressed as a percentage of the total cells. None of the patients had asthma.

RESULTS

There was no difference between the number of atopic and nonatopic patients having BHR (4/20 versus 4/17; chi-squared = 0.07; p > 0.05). Total nasal flow was lower and percentage of nasal eosinophils was higher in the patients with BHR than in patients without BHR (p = 0.012 and p = 0.009, respectively). A cutoff point of 68% nasal eosinophils yielded a sensitivity of 100% (63.1-100) and a specificity of 58.6% (38.9-76.5) to determine the presence of BHR. Positive likelihood ratio for the value of eosinophils above cutoff value was 2.42 (1.8-3.3).

CONCLUSION

This study shows the relationship between nasal eosinophils and BHR in persistent perennial rhinitis patients. Nasal eosinophil percentage below cutoff value indicates that a patient does not have BHR.

Differential diagnosis in allergy

The otolaryngic allergist must be able to distinguish between common nonallergic diagnoses that present very similarly to allergic conditions. This article describes a few of the vast myriad of conditions that must be ruled out before a diagnosis of allergy may be made. After reading this article clinicians will be able to identify various conditions, which will enhance their ability to appropriately make correct decisions for prompt and efficient management of their patients with allergic or nonallergic diseases of the head and neck.

A randomized, double-blind, parallel trial comparing capsaicin nasal spray with placebo in subjects with a significant component of nonallergic rhinitis

OBJECTIVE

To investigate the efficacy and safety of ICX72 or Sinus Buster, a proprietary homeopathic preparation of Capsicum annum and Eucalyptol, versus placebo administered continuously over 2 weeks in subjects with a significant component of nonallergic rhinitis (NAR).

METHODS

Forty-two consented subjects meeting inclusion/exclusion criteria were randomized to ICX72 (n = 20) or control (n = 22) administered twice daily over 2 weeks. The primary endpoint was change in total nasal symptom scores (TNSS) from baseline to end of study. Secondary endpoints included changes in individual symptom scores (ISS) over 2 weeks and average time to first relief. Mean TNSS and ISS were recorded after single dosing at different intervals over 60 minutes. Rhinitis quality-of-life, rescue medication, and safety endpoints were analyzed.

RESULTS

ICX72 versus placebo subjects exhibited significant differences in changes from baseline to end of study for TNSS and each ISS (P < .01), had an average time to first relief of 52.6 seconds (P < .01), and improvement in nasal congestion, sinus pain, sinus pressure, and headache at 5, 10, 15, and 30 minutes, persisting at 60 minutes for nasal congestion and sinus pain (P < .05). No difference between groups in adverse events or rescue medication was observed. ICX72 versus placebo subjects experienced no rebound congestion or impaired olfaction at the end of the study.

CONCLUSION

This is the first controlled trial demonstrating intranasal capsaicin, when used continuously over 2 weeks, rapidly and safely improves symptoms in rhinitis subjects with a significant NAR component.

Management of rhinitis: allergic and non-allergic

RHINITIS IS A GLOBAL PROBLEM AND IS DEFINED AS THE PRESENCE OF AT LEAST ONE OF THE FOLLOWING: congestion, rhinorrhea, sneezing, nasal itching, and nasal obstruction. The two major classifications are allergic and nonallergic rhinitis (NAR). Allergic rhinitis occurs when an allergen is the trigger for the nasal symptoms. NAR is when obstruction and rhinorrhea occurs in relation to nonallergic, noninfectious triggers such as change in the weather, exposure to caustic odors or cigarette smoke, barometric pressure differences, etc. There is a lack of concomitant allergic disease, determined by negative skin prick test for relevant allergens and/or negative allergen-specific antibody tests. Both are highly prevalent diseases that have a significant economic burden on society and negative impact on patient quality of life. Treatment of allergic rhinitis includes allergen avoidance, antihistamines (oral and intranasal), intranasal corticosteroids, intranasal cromones, leukotriene receptor antagonists, and immunotherapy. Occasional systemic corticosteroids and decongestants (oral and topical) are also used. NAR has 8 major subtypes which includes nonallergic rhinopathy (previously known as vasomotor rhinitis), nonallergic rhinitis with eosinophilia, atrophic rhinitis, senile rhinitis, gustatory rhinitis, drug-induced rhinitis, hormonal-induced rhinitis, and cerebral spinal fluid leak. The mainstay of treatment for NAR are intranasal corticosteroids. Topical antihistamines have also been found to be efficacious. Topical anticholinergics such as ipratropium bromide (0.03%) nasal spray are effective in treating rhinorrhea symptoms. Adjunct therapy includes decongestants and nasal saline. Investigational therapies in the treatment of NAR discussed include capsaicin, silver nitrate, and acupuncture.

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.

Compliance with topical nasal medication--an evaluation in children with rhinitis

It is our impression that children with rhinitis often dislike or struggle with the administration of topical nasal sprays and drops. This study aims to investigate children's acceptance of topical nasal sprays/drops, and to identify patient factors that may affect their acceptance. An interview (by WYZI) questionnaire survey was carried out on parents/guardians of children aged 1-15 with rhinitis, where information on the diagnosis and treatment, patients' use and responses to these medications, and their preferred treatment routes were collected. Two hundred questionnaires were completed, of which 194 were valid for analysis. The mean age of patients was 7.54 yr; male to female ratio was 1:1.6, and Chinese made up the majority (62.4%). About one quarter (24.7%) of children disliked the use of topical nasal sprays/drops sufficiently to affect compliance with the medication. Furthermore, of those who could indicate their preferred route of drug administration (n = 75), 73% indicated a preference for oral medication, while only 11% preferred the nasal route. Topical nasal sprays/drops were more acceptable in older children (7-15 yr) compared to the younger ones (1-6 yr) (OR = 2.383, CI 1.223-4.644). The acceptance of nasal sprays/drops was not associated with gender, ethnic group, concurrent use by other family members, length and amount of usage, and the response to therapy. A substantial proportion of children prescribed topical nasal sprays/drops did not find it acceptable. Age played a significant factor to the acceptance of the use of topical nasal sprays/drops.

Efficacy and Safety of Once Daily Fluticasone Furoate Nasal Spray for Treatment of Irritant (Non-allergic) Rhinitis

INTRODUCTION

The safety and efficacy of fluticasone furoate nasal spray (FFNS) for the symptoms of seasonal and perennial allergic rhinitis have been previously demonstrated in several clinical studies. The objective of this pilot study was to compare the efficacy and safety of FFNS 110 mcg once daily with placebo in patients with irritant (non-allergic) rhinitis triggered predominantly by air pollution.

METHODS

This was a randomized, double-blind, placebo-controlled, 4-week study of subjects in Thailand with irritant rhinitis who received either FFNS 110 mcg (N=53) or placebo (N=49) once-daily. Subjects with a ≥2 year history of air pollution as their predominant rhinitis trigger, negative skin test to local seasonal/perennial allergens, positive histamine skin test, and normal sinus radiograph were enrolled if they met minimum reflective total nasal symptom score (rTNSS) ≥4.5 (maximum=9) and a nasal congestion score of ≥2 (maximum =3). All were assessed for nasal eosinophilia at study entry and completion. Air quality was monitored throughout the study. The primary efficacy endpoint was the mean change from baseline over the treatment period in daily rTNSS, the average of the morning and evening rTNSS. The key secondary measure was the mean change from baseline over the entire treatment period in morning pre-dose instantaneous total nasal symptom score (iTNSS).

RESULTS

The Air Quality Index (AQI) during the study generally did not reach unhealthy levels. Baseline daily rTNSS scores were similar between treatment groups (FFNS=6.7; placebo=6.4). The least square mean change from baseline in rTNSS was -2.17 and -2.10 for FFNS and placebo, respectively, with a difference of -0.065 (p=0.845). Gradual improvements were seen in both treatment groups for iTNSS; however, the treatment difference (-0.075) was not statistically significant (p=0.827). Additionally, there were no statistically significant differences between treatment groups for AM and PM rTNSS, individual nasal symptoms, daily reflective, AM and PM reflective and AM pre-dose instantaneous total ocular symptom scores (TOSS) or individual ocular symptom scores. Nasal cytology at baseline found more than two-thirds of subjects had <20% eosinophils. Adverse events were few and similar between groups and noted as mild in intensity.

CONCLUSION

Subjects receiving FFNS had similar improvement to placebo in their rhinitis symptoms. The lack of a treatment effect may be in part due to the overall good air quality present throughout the study or an insufficient dose or duration of FFNS. The safety findings showed FFNS 110 mcg once daily to be well tolerated.

Vasomotor rhinitis

Vasomotor rhinitis is a common disorder that is seen routinely in allergy practice. It affects millions of Americans and results in significant morbidity. The pathophysiology of this complex heterogeneous disorder is unknown, but we are making advances in this regard. Symptoms and signs can closely resemble those of allergic rhinitis and can be difficult to differentiate from those resulting from allergy. A careful history, physical examination, and diagnostic testing help clinicians arrive at a definitive diagnosis, but treatment can be challenging. Therapy should be based on the presenting symptoms of vasomotor rhinitis. Combination therapy with topical corticosteroids and azelastine is useful. However, in patients whose predominant symptom is rhinorrhea, use of atopical anticholinergic agents can be quite useful. Up-to-date pathogenesis, epidemiology, diagnosis, and treatment approaches are discussed in this review.

Rhinitis in the geriatric population

The current geriatric population in the United States accounts for approximately 12% of the total population and is projected to reach nearly 20% (71.5 million people) by 20301. With this expansion of the number of older adults, physicians will face the common complaint of rhinitis with increasing frequency. Nasal symptoms pose a significant burden on the health of older people and require attention to improve quality of life. Several mechanisms likely underlie the pathogenesis of rhinitis in these patients, including inflammatory conditions and the influence of aging on nasal physiology, with the potential for interaction between the two. Various treatments have been proposed to manage this condition; however, more work is needed to enhance our understanding of the pathophysiology of the various forms of geriatric rhinitis and to develop more effective therapies for this important patient population.

Occupational rhinosinusitis and upper airway disease: the world trade center experience

The World Trade Center disaster and its recovery work involved a range of hazardous occupational exposures that have not been fully characterized but that can be reasonably assumed to have the potential to cause mucosal inflammation, preferentially (but not exclusively) in the upper airway. A high prevalence of rhinosinusitis and upper airway disease (UAD) symptoms was reported by several early surveys. Clinical studies demonstrated objective, clinically significant, and persistent chronic perennial rhinosinusitis and UAD-with or without seasonal exacerbation-in a large proportion of patients. Demonstration of an association between UAD and available exposure indicators has been limited. Atopy seemed to be associated with increased UAD symptom severity and to be a risk factor for upper, but not lower, airway disease. World Trade Center-related UAD is considered an irritant-induced disease but not, in many cases, of acute onset. No data thus far suggest an increased upper airway cancer incidence.

Non-allergic rhinitis: a case report and review

Rhinitis is characterized by rhinorrhea, sneezing, nasal congestion, nasal itch and/or postnasal drip. Often the first step in arriving at a diagnosis is to exclude or diagnose sensitivity to inhalant allergens. Non-allergic rhinitis (NAR) comprises multiple distinct conditions that may even co-exist with allergic rhinitis (AR). They may differ in their presentation and treatment. As well, the pathogenesis of NAR is not clearly elucidated and likely varied. There are many conditions that can have similar presentations to NAR or AR, including nasal polyps, anatomical/mechanical factors, autoimmune diseases, metabolic conditions, genetic conditions and immunodeficiency. Here we present a case of a rare condition initially diagnosed and treated as typical allergic rhinitis vs. vasomotor rhinitis, but found to be something much more serious. This case illustrates the importance of maintaining an appropriate differential diagnosis for a complaint routinely seen as mundane. The case presentation is followed by a review of the potential causes and pathogenesis of NAR.

Should clinicians routinely determine rhinitis subtype on initial diagnosis and evaluation? A debate among experts

Rhinitis is one of the most prevalent conditions affecting Americans today. Twenty to 40 million Americans (10%-30% of adults and up to 40% of children) are estimated to have allergic rhinitis. In recent decades, its prevalence in Western societies has increased dramatically, and studies from around the world are reporting similar trends. Although studies have traditionally reported a 3:1 ratio of allergic to nonallergic rhinitis, recent data suggest that as many as 87% of patients with rhinitis may have mixed rhinitis, a combination of both allergic and nonallergic rhinitis. Untreated or inappropriately managed rhinitis can significantly affect a patient's quality of life and ability to perform activities of daily living. It is often associated with concomitant conditions, such as fatigue, headache, sleep disturbance, cognitive impairment, and respiratory conditions, complicated by rhinitis, including asthma and sinusitis. It is a significant cause of morbidity, health care expenditure, reduced work productivity, and absences from school. According to the recently released updated practice parameters, The Diagnosis & Management of Rhinitis, rhinitis is characterized by the presence of one or more of the following nasal symptoms: Congestion, Rhinorrhea (anterior and posterior), Sneezing, Itching. Inflammation is normally associated with rhinitis, but certain subtypes of the disease, such as vasomotor (increasingly known as chronic idiopathic rhinitis) or nonallergic rhinitis and atrophic rhinitis, are not predominantly inflammatory. The diagnosis of rhinitis may appear to be a fairly straightforward undertaking; however, rhinitis is composed of numerous subtypes and etiologies, and differentiating them can be a challenge for primary care practitioners. Further complicating matters is the fact that many patients have both an allergic and a nonallergic component to their rhinitis. Whether or not identification of rhinitis subtype should be an integral component of initial diagnosis remains an area of controversy. While standard treatment for allergic and nonallergic rhinitis is often the same, certain subtypes of the disease do not respond well to the usual first-line treatments for allergic rhinitis. Identification of subtype, therefore, can potentially have important implications for treatment choice. In the following section, we present a discussion between 2 members of the Respiratory & Allergic Disease (RAD) Foundation, Thomas B. Casale, MD, and Michael S. Blaiss, MD. Drs. Casale and Blaiss debate the question, "Should clinicians routinely determine rhinitis subtype on initial diagnosis and evaluation?" Each expert was randomly assigned a position to take: Dr. Casale's views represent the "pro" argument while Dr. Blaiss was asked to speak to the "con" argument. The debate concludes with a synthesis of their arguments and final points, including important takeaway messages for the primary care practitioner.

Clinical Importance of Eosinophil Count in Nasal Fluid in Patients with Allergic and Non-Allergic Rhinitis

Eosinophil count in nasal fluid (ECNF) was used to differentiate nasal pathologies. Receiver Operating Characteristic (ROC) curve analysis and the area under the curve (AUC) were performed to evaluate the ECNF's accuracy in distinguishing allergic rhinitis (AR) from non-allergic rhinitis (NAR). We also evaluated the accuracy of ECNF in recognizing patients with mild and severe symptoms of rhinitis and patients with ineffective and effective clinical responses to antihistamines. 1,170 consecutive adult patients with a clinical history of rhinitis were studied. ECNF's median in AR was 6.0 and 2.0 in NAR and the best cut-off value was > 3.0, AUC = 0.75. ECNF's median in AR with mild nasal symptoms was 3.0 and 7.0 with severe symptoms, and the best cut-off value was 4.0, AUC = 0.90. ECNF's median in NAR with mild nasal symptoms was 2.0 and 8.5 with severe symptoms, and the best cut-off value was > 4.0, AUC = 0.86. ECNF's median in AR with effective clinical response to antihistamines was 4.0 and 8.0 with ineffective response, the best cut-off value was ≤ 5.0, AUC = 0.94. ECNF's median in NAR with an effective clinical response to antihistamines was 1.0 and 2.0 with ineffective response, and the best cut-off value was ≤ 3.0, AUC = 0.64. Our results suggest an interesting practical use of ECNF data as evaluator of the clinical severity both AR and NAR. As predictor of the clinical response to antihistamines, ECNF is accurate only in patients with AR. The ECNF's performance was moderately accurate in distinguish patients with AR and NAR.

Evaluation of nasal cytology in subjects with chronic rhinitis: a 7-year study

BACKGROUND

No diagnostic test had been specifically developed to diagnose nonallergic rhinitis (NAR). Also a negative nasal smear for eosinophils does not rule out the diagnosis. There is a significant diagnostic problem in patients with NAR. How can we solve this problem?

OBJECTIVES

Assessment of other cells than eosinophils present in the cytogram such as basophils, neutrophils, and goblet cells may help us to classify and management of diagnostic problem of rhinitis. We sought to characterize the cellular pattern of patients with allergic rhinitis (AR) and compare them with those of NAR.

METHODS

According to the skin prick test positivity or negativity, individuals were divided into AR and NAR groups, respectively. Allergic rhinitis group was further divided into seasonal, perennial, and mixed subgroups. Nonallergic rhinitis group was also divided into the following 5 subgroups according to the nasal smear cytologic result: basophilic, neutrophilic, eosinophilic, mixed, and nonallergic noninfectious type. So the frequency rates of the subgroups were calculated and also smear cytologic results were compared.

RESULTS

Frequency of AR was approximately equal to NAR in subjects with chronic rhinitis. Neutrophilic, eosinophilic, mixed, and nonallergic noninfectious types were the common types of NAR. An evident nasal eosinophilia was found in AR and eosinophilic NAR, whereas a higher percentage of goblet cells were determined in nonallergic noninfectious rhinitis. There is no significant difference between cytologic results from NAR and AR patients.

CONCLUSION

In the patient with positive skin test result, the presence of nasal eosinophilia strongly supports the diagnosis of AR. No diagnostic test had been specifically developed to diagnose chronic NAR. Also, a negative nasal smear for eosinophils does not rule out the diagnosis. Assessment of other cells present in the cytogram such as basophils, neutrophils, and goblet cells may also provide valuable information for differential diagnosis and management of these conditions.

The role of antihistamines in the treatment of vasomotor rhinitis

Background

The pathogenesis of vasomotor rhinitis is not understood. It is unlikely that antihistamines, based on their H1 antagonist activity alone, would be effective in this disorder.

Methods

Nonetheless, at least one double-blind, placebo-controlled multicenter trial has found that intranasal azelastine relieves symptoms of this disorder better than placebo. The mechanism responsible for its beneficial effect in nonallergic rhinitis is unclear but probably relates to "anti-inflammatory/antiallergic" activities.

Results

Such mechanisms have been demonstrated for a number of different oral antihistamines, but often the concentrations required in vitro are higher than those that are normally achieved in vivo using recommended dosing. It has been postulated that intranasal administration, which can achieve high local levels, might be a factor responsible for enhancing the "anti-inflammatory/antiallergic" properties.

Conclusions

Interpreting this information allows one to conclude that antihistamines may be potentially effective agents in vasomotor rhinitis, and are more likely to be so when administered intranasally, despite the fact that data documenting this beneficial effect are sparse.

Consensus Description of Inclusion and Exclusion Criteria for Clinical Studies of Nonallergic Rhinopathy (NAR), Previously Referred to as Vasomotor Rhinitis (VMR), Nonallergic Rhinitis, and/or Idiopathic Rhinitis

"Nonallergic rhinopathy" was defined by consensus at a Roundtable conference in December 2008 as "a chronic nasal condition with symptoms that may be perennial, persistent, intermittent or seasonal and/or elicited by recognized triggers." The definition includes a well-recognized set of clinical exposures that lead to the symptoms, predominantly congestion, rhinorrhea, and postnasal drip. These clinical characteristics help to identify patients for participation in clinical trials examining the efficacy of treatments for this important disease. The next step is to establish inclusion and exclusion criteria that will provide a framework for the clinical trials. Agreement on study criteria was obtained at the consensus conference by discussion, counterpoint, and compromise.

Anticholinergic drugs in nonallergic rhinitis

BACKGROUND

The parasympathetic nervous system contributes to the pathophysiology of multiple forms of allergic and nonallergic rhinitis. Stimulation of the parasympathetic nervous system leads to glandular activation, which produces watery secretions. In excess, these secretions discharge from the anterior Nares and produce the symptom of watery anterior rhinorrhea.

METHOD

Review of literature.

RESULTS

Treatment with topical, intranasal anticholinergic drugs inhibits activation of the nasal mucosal glands and is effective in reducing the watery secretions associated with parasympathetic stimulation of the glands with little, if any, effect on the symptoms of congestion and sneezing. In general, these drugs have no systemic adverse effects, but can cause crusting and local irritation.

CONCLUSION

Anticholinergic drugs are useful for the treatment of anterior rhinorrhea associated with allergic and nonallergic rhinitis.

Clinical presentation and management of geriatric rhinitis

The population of Americans over 65 years of age is growing at an unprecedented rate. Rhinitis is a common and burdensome complaint in this group, and physicians should be aware of the diagnosis and management of the disease. Geriatric rhinitis is a nasal disorder of older persons that presents with a constellation of nasal symptoms. The etiologies of this condition include both inflammatory diseases and the effects of aging on physiology of the upper airway. Possible causes include allergic rhinitis, nonallergic rhinitis (vasomotor rhinitis and gustatory rhinitis), adverse effects of medications, hormonal changes, postnasal drip syndrome, chronic rhinosinusitis and atrophic rhinitis. Nasal symptoms in the older patient present a clinical challenge because of the physiologic effects of the aging nose, the unusual clinical presentation, the presence of multiple comorbidities and the problem of polypharmacy. A number of therapeutic options exist for this disorder, although definitive studies of effective regimens are needed.

Epidemiology of vasomotor rhinitis

Vasomotor rhinitis is the most common form of nonallergic rhinitis, comprising approximately 71% of all nonallergic rhinitis conditions. Although the epidemiology of this subtype of nonallergic rhinitis has not been definitively studied, it is estimated that 14 million Americans suffer from vasomotor rhinitis, with a worldwide prevalence approaching 320 million.

Characteristics of nonallergic vasomotor rhinitis

Nonallergic rhinitis (NAR) conditions are currently considered diagnoses by exclusion. A diagnosis of NAR requires negative specific IgE responses by skin or serologic testing and more recently testing to exclude localized production of specific IgE in the nose. Symptoms are classically aggravated by irritant triggers such as tobacco smoke, perfumes/fragrances, and temperature or barometric pressure changes. A previously developed questionnaire survey designed to help physicians recognize differences between allergic rhinitis and nonallergic rhinitis subtypes found that patients with symptom onset later in life (> 35 years), no family history of allergies, no seasonality or cat-induced symptoms, and symptoms induced by perfumes and fragrances had > 95% likelihood of having a physician diagnosis of NAR. Of note, clinical symptoms were not generally useful for differentiating chronic rhinitis subtypes which has also been confirmed in a more recent study investigating the relationship between headaches and chronic rhinitis subtypes (Table 1). In subsequent studies it was found that a significant percentage of NAR patients did not experience irritant-induced symptoms, suggesting that these triggers are not a clinical characteristic that can be uniformly used for all NAR patients. However, a newly developed Irritant Index Scale can be used to reliably differentiate pure allergic rhinitis from nonallergic rhinitis with trigger phenotypes. The use of standardized and validated questionnaires allows objective characterization of chronic rhinitis subtypes that appears to improve the accuracy of clinically diagnosing these patients.

Prevalence of Autoimmune Thyroid Disease in Chronic Rhinitis

A retrospective, controlled study was undertaken to determine the prevalence of autoimmune thyroid disease in 111 adult patients with allergic (77) and nonallergic (34) rhinitis seen in a private ENT/allergy practice in the lower Hudson Valley, New York. The control group consisted of 101 patients with no history of chronic rhinitis. Autoimmune thyroid disease was found in 10.4% of the allergic rhinitis group, 14.7% of the nonallergic rhinitis group, and 9.9% of controls, with a trend toward higher prevalence in the nonallergic rhinitis group compared with controls. No statistically significant association was noted between the 3 groups. The female-to-male ratio in the nonallergic rhinitis group was approximately twice as high as in the control group.

Primary care: the cornerstone of diagnosis of allergic rhinitis

Allergic rhinitis (AR) is a very common disease with over 600 million people (200 million of them with concomitant asthma) worldwide suffering from it. The majority of patients who seek medical advice are seen in primary care. Although there is a selection of guidelines focused on the management of AR, there is a paucity of guidance on how best to identify patients who would most benefit from treatment. The aim of this paper was to review the best practice for primary care with respect to the diagnosis of AR within that clinical environment.

Effect of once-daily fluticasone furoate nasal spray on nasal symptoms in adults and adolescents with perennial allergic rhinitis

BACKGROUND

Intranasal corticosteroids are recommended as first-line therapy for the treatment of allergic rhinitis. Fluticasone furoate is a novel enhanced-affinity glucocorticoid for the treatment of allergic rhinitis.

OBJECTIVE

To compare the efficacy and safety of intranasal fluticasone furoate with those of vehicle placebo nasal spray in adult and adolescent patients with perennial allergic rhinitis (PAR).

METHODS

After screening (7-14 days), patients 12 years and older with confirmed PAR were randomized to receive fluticasone furoate, 110 microg once daily, or placebo once daily intranasally for 4 weeks in this double-blind, multicenter study. The primary end point was mean change from baseline during the entire treatment period in daily reflective total nasal symptom score (rTNSS), recorded on diary cards by patients, using a 4-point categorical scale.

RESULTS

The mean reduction from baseline during the treatment period in daily rTNSS was significantly greater in fluticasone furoate recipients than in placebo recipients (P = .005). This finding was supported by significantly greater mean reductions in morning rTNSS and evening rTNSS (P = .004 and P = .011, respectively). A significantly greater mean reduction in instantaneous morning predose TNSS with fluticasone furoate compared with placebo (P = .006) confirmed the efficacy of once-daily administration. Fluticasone furoate was also significantly more effective than placebo in overall response to therapy (P = .005).

CONCLUSIONS

Fluticasone furoate nasal spray, 110 microg once daily, effectively relieved nasal symptoms of PAR in adults and adolescents 12 years and older.

Lack of effect on adult and adolescent hypothalamic-pituitary-adrenal axis function with use of fluticasone furoate nasal spray

BACKGROUND

Intranasal corticosteroids are recommended as first-line therapy for allergic rhinitis (AR), and because of their pharmacologic class, hypothalamic-pituitary-adrenal (HPA) axis function is evaluated.

OBJECTIVE

To evaluate whether cortisol production was suppressed (as a measure of HPA axis function) by 6 weeks of treatment with fluticasone furoate nasal spray, 110 microg once daily, in patients with perennial AR.

METHODS

A double-blind, randomized, placebo- and active-controlled (prednisone), parallel-group study. Outpatients aged 12 to 65 years with perennial AR for 2 years or more were from 1 center in the United States and 1 center in Canada. Pharmacodynamic and pharmacokinetic samples were collected during 24-hour domiciled visits (overnight in clinic). Measurements included change from baseline in 24-hour serum cortisol weighted mean and 24-hour urinary free cortisol excretion, total 24-hour urinary free cortisol excretion and 6-beta hydroxycortisol excretion, and plasma concentration of fluticasone furoate.

RESULTS

A total of 112 of 183 patients were randomized. Fluticasone furoate was noninferior to placebo with respect to the ratio from baseline in serum cortisol weighted mean (treatment ratio, 0.98; 95% confidence interval, 0.89 to 1.07). In contrast, use of prednisone, 10 mg once daily, significantly reduced the ratio from baseline compared with placebo. Change from baseline in 24-hour urinary cortisol excretion was similar in the fluticasone furoate and placebo groups. Plasma levels of fluticasone furoate were undetectable after 6 weeks of treatment.

CONCLUSION

Fluticasone furoate nasal spray, 110 microg once daily, was not associated with HPA axis suppression in patients 12 years and older with perennial AR.

Prevalence and food avoidance behaviors for gustatory rhinitis

BACKGROUND

Gustatory rhinitis is a type of nonallergic rhinitis that is usually associated with ingestion of hot or spicy foods. Characteristics of this condition and its impact on food choices have not been studied.

OBJECTIVE

To survey individuals regarding causative foods, association with atopic conditions, and food avoidance behaviors for gustatory rhinitis.

METHODS

An original, self-administered questionnaire was distributed to children and adults who were seen in a busy outpatient dermatology clinic. Atopic history, frequency of rhinorrhea after food ingestion, intake of foods associated with gustatory rhinitis, symptom severity, and food avoidance were evaluated.

RESULTS

Of the 571 participants who completed the survey, 396 (69%) indicated at least 1 food resulted in gustatory rhinitis symptoms. Patients with allergic rhinitis (P < .001) and a history of smoking (P = .049) were more likely to have experienced gustatory rhinitis. Bread (6%) and hot chili peppers (49%) represented the least and most common foods identified, respectively. A total of 65% of patients who experienced gustatory rhinitis never avoided the causative food, whereas 46% were never bothered by their symptoms. Patients who reported more causative foods were also more likely to use medications before eating to lessen their symptoms (P = .03).

CONCLUSION

The results presented herein suggest that almost all foods can be implicated, both children and adults develop this condition, and patients with a history of allergic rhinitis or smoking are more likely to report gustatory rhinitis symptoms. Most patients though do not avoid the causative food(s) and are not significantly bothered by symptoms.

Pediatric sinusitis

Although sinusitis is one of the most common problems encountered in clinical practice, it can be a challenge to diagnose and treat appropriately. Sinusitis refers to inflammation (infectious or noninfectious) in the paranasal sinuses. Infectious sinusitis can be bacterial or viral. This article focuses on bacterial sinusitis. Acute bacterial sinusitis usually follows a viral upper respiratory infection (URI) but can also present with severe symptoms 3 to 5 days after onset. Chronic sinusitis has less prominent symptoms and can be easily missed. When antibiotic therapy is warranted, the antibiotic should be chosen based on knowledge of antimicrobial resistance in specific geographic areas and populations. Adjunctive measures include saline irrigation, steam inhalation, nasal and systemic steroids, mucolytics, and decongestants. It is important to identify and treat predisposing factors, including viral URIs, allergic rhinitis, nasal structural abnormalities, gastroesophageal reflux disease, and immune deficiencies.

Exhaled nitric oxide in persistent rhinitis with or without lower airway involvement: a review of the literature

The link between upper and lower respiratory airways has been investigated in the past decade leading to the concept of united airways disease. This hypothesis was suggested by several epidemiological observations, which had shown the high prevalence of rhinitis and sinusitis in patients with asthma, and indirectly, by observing the effects of drugs used for rhinitis on asthma symptoms. A broad spectrum of airway involvement severity can be associated with rhinitis or rhinosinusitis: from a subclinical/asymptomatic inflammatory involvement with an increase in eosinophils in induced sputum cell count, to asthma-like symptoms without functional features of asthma with or without extrathoracic airway hyperresponsiveness, to respiratory symptoms with clinical and functional criteria of asthma. The aim of this paper is to review the literature about the role of breath analysis in the relationship between nose and lung, focusing on exhaled nitric oxide (FE(NO)) measurement, a non-invasive marker of inflammation, in rhinitis and in chronic rhinosinusitis in patients complaining or not of asthma symptoms.

Differences between allergic and nonallergic rhinitis in a large sample of adolescents and adults

BACKGROUND

The aim of this study was to describe differences between allergic rhinitis (AR) and nonallergic rhinitis (NAR) in a large community-based sample of Danish adolescents and adults.

METHODS

A total of 1,186 subjects, 14-44 years of age, who in a screening questionnaire had reported a history of airway symptoms suggestive of asthma and/or allergy, or who were taking any medication for these conditions were clinically examined. All participants were interviewed about respiratory symptoms and furthermore skin test reactivity, lung function and airway responsiveness were measured using standard techniques.

RESULTS

A total of 77% of the subjects with rhinitis had AR, whereas 23% had NAR. Subjects with NAR were more likely to be females, OR = 2.05 (1.31-3.20), P = 0.002, to have persistent symptoms within the last 4 weeks, OR = 1.88 (1.23-2.89), P = 0.003, and to have recurring headaches, OR = 1.94, (1.12-3.37), P = 0.019. On the other hand, subjects with NAR were less likely to have airway hyperresponsiveness, OR = 0.40, (0.24-0.66), P < 0.001, food allergy, OR = 0.40, (0.19-0.36), P = 0.009 and to have been treated with antihistamines in the last 4 weeks, OR = 0.22, (0.13-0.38), P < 0.001 compared with subjects with AR. Subjects with AR were symptomatically worse within their season in terms of sneezing (P < 0.001) and itchy eyes (P < 0.001), compared to subjects with NAR, whereas nasal congestion and rhinorrhea were equally frequent in the two groups (P = 0.901 and P = 0.278, respectively).

CONCLUSIONS

The proportion of subjects with NAR in an adolescent and adult population with rhinitis is around one-fourth. Women have NAR twice as often as men. In general, subjects with NAR have more persistent but equally severe symptoms compared to subjects with AR. However, subjects with AR have more sneezing and itchy eyes within their particular season of allergy compared to subjects with NAR.

Today's allergic rhinitis patients are different: new factors that may play a role

Most of today's patients suffering from allergic rhinitis (AR) are sensitized to more than one trigger and suffer from persistent and moderate/severe symptoms, which severely impair their quality of life (QOL). The objective of this article was to review the data on the effect of increased air pollution, changes in indoor environment/lifestyle/affluence, exposure to new allergens and psychologically stressful lifestyles, as also to explore their potential in the development of this more 'aggressive' form of disease. Increased fossil fuel-generated air pollution may increase the risk of allergic sensitization, airway responsiveness to allergens, and allergenicity and the bioavailability of airborne allergens. Changes in indoor environment/lifestyle/affluence appear to have led to more time being spent indoors and resulted in perennial exposure to indoor allergens, changes in sensitization patterns, and polysensitization to a variety of novel cross-reacting exotic food and pet allergens. Although evidence suggests an association between psychological stress and increased risk for atopy and allergic disease, further studies are required to demonstrate this unequivocally. The more persistent and moderate/severe nature of the disease suggests a need for modification of current treatment strategies and advocacy of the use from the outset of agents, which are both efficacious and safe in managing severe and persistent AR symptoms and in improving the QOL of affected individuals.

Nasal hyperreactivity in allergic and non-allergic rhinitis: a potential risk factor for non-specific building-related illness

Self-reported non-allergic nasal symptom triggers in non-allergic ('vasomotor') rhinitis overlap with commonly identified environmental exposures in non-specific building-related illness. These include extremes of temperature and humidity, cleaning products, fragrances, and tobacco smoke. Some individuals with allergic rhinitis also report non-allergic triggers. We wished to explore the phenotypic overlap between allergic and non-allergic rhinitis by ascertaining self-reported non-allergic nasal symptom triggers among allergic rhinitics. Sixty subjects without work-related respiratory exposures or symptoms, aged 19-68 years, stratified by age, gender and (skin test-proven) allergic rhinitis status, were queried with regard to self-reported non-allergic nasal symptom triggers (aggregate score 0-8). In this sample, the number of self-reported non-allergic triggers was bimodal, with peaks at 1 and 5. Forty-two percent of seasonal allergic rhinitic subjects reported more than three non-allergic triggers, compared with only 3% of non-allergic non-rhinitics (P < 0.01). Subjects over 35 years were more likely to report one or more non-allergic triggers, particularly tobacco smoke (P < 0.05). Allergic rhinitics reported more non-allergic symptom triggers than did non-allergic, non-rhinitics. As indexed by self-reported reactivity to non-specific physical and chemical triggers, both non-allergic rhinitics and a subset of allergic rhinitics may constitute susceptible populations for non-specific building-related illness.

PRACTICAL IMPLICATIONS

Judging by self-report, a substantial subset of individuals with allergic rhinitis--along with all individuals with nonallergic rhinitis (by definition)--are hyperreactive to non-allergic triggers. There is overlap between these triggers (elicited in the process of obtaining a clinical diagnosis) and environmental characteristics associated with ''problem buildings.'' Since individuals with self-identified rhinitis report an excess of symptoms in most epidemiologic studies of problem buildings (even in the absence of unusual aeroallergen levels), rhintics may be acting as a ''sentinel'' subgroup when indoor air quality is suboptimal. Together, non-allergic rhinitics plus allergic rhinitics with prominent non-allergic triggers, are thought to constitute approximately one-sixth of the US population.

Rhinitis and asthma symptoms in non-domestic cleaners from the Sao Paulo metropolitan area, Brazil

BACKGROUND

Exposure to cleaning products has frequently been reported as a symptom trigger by workers with work-related asthma diagnosed in workers' health clinics in the city of São Paulo, Brazil.

OBJECTIVES

To estimate rhinitis and asthma symptoms prevalence and to analyse associated risk factors.

METHOD

A respiratory symptoms questionnaire (Medical Research Council 1976) and the International Study of Asthma and Allergies in Childhood questionnaire were applied to 341 cleaners working in the city of São Paulo, along with obtaining full occupational histories, skin prick tests and spirometry. Timing their symptoms onset in relation to occupational history allowed estimation of work-related asthma and/or rhinitis. Risk factors related to selected outcomes were analysed by logistic regression.

RESULTS

11% and 35% of the cleaners had asthma and rhinitis, respectively. The risk of work-related asthma/rhinitis increased with years of employment in non-domestic cleaning (OR 1.09, 95% CI 1.00 to 1.18, >0.92-3 years; OR 1.28, 95% CI 1.01 to 1.63, >3-6.5 years; OR 1.71, 95% CI 1.02 to 2.89, >6.5 years). Atopy was associated with asthma and rhinitis (OR 2.91, 95% CI 1.36 to 6.71; OR 2.06, 95% CI 1.28 to 3.35, respectively). There was a higher risk of rhinitis in women (OR 2.07, 95% CI 1.20 to 3.70).

CONCLUSIONS

Cleaning workers are at risk of contracting work-related asthma and/or rhinitis, and the risk increases with years of employment in non-domestic cleaning. Women present higher risk of rhinitis than men.

Nonallergic rhinitis in children

Nonallergic rhinitis in children is a medical condition that has not been well defined and the true incidence is unknown. Current treatment recommendations are based on data obtained from adult studies. The mechanisms of pediatric nonallergic rhinitis are also unclear. The concept that laryngopharyngeal reflux (LPR) events may play a critical role in the pathogenesis of upper airway disease is presently under investigation. Although LPR is being better delineated and appropriate methods of diagnosis and treatment are being studied, substantial evidence links LPR with several disease states including rhinitis, sinus disease, and middle ear disease. Due to the lack of information concerning the etiology of nonallergic rhinitis in children, LPR should be considered in the differential diagnosis of a child with negative skin tests and chronic rhinitis symptoms. The clinician should especially give attention to this diagnosis when a child presents with recurrent co-morbid conditions such as chronic sinusitis or persistent middle ear disease.

Diagnostic classification of persistent rhinitis and its relationship to exhaled nitric oxide and asthma: a clinical study of a consecutive series of patients

BACKGROUND

Rhinitis and asthma represent the manifestation of one syndrome. Our hypothesis is that in patients with symptoms of persistent rhinitis, lower airway inflammation, lower respiratory symptoms, and lung function abnormalities compatible with asthma are more frequently associated with the diagnosis of allergic rhinitis (AR) and chronic rhinosinusitis (CRS) than with nonallergic rhinitis (NAR).

METHODS

One hundred eight of 590 consecutive patients referred in 1 year for rhinitis were enrolled on the basis of nasal symptoms lasting > 4 weeks. Asthma was diagnosed on the basis of symptoms and a positive bronchodilation testing result and/or methacholine hyperresponsiveness. Exhaled nitric oxide (Feno) was measured with the single exhalation method at 50 mL/s.

RESULTS

AR was diagnosed in 39%, NAR in 21%, and CRS in 40%. The prevalence of asthma was significantly higher in AR patients (33%) and CRS patients (42%) than in NAR patients (8.7%) [p = 0.036 and p = 0.005, respectively]. Feno was significantly higher in patients with AR and CRS compared to patients with NAR (44.3 parts per billion [ppb]; 95% confidence interval [CI], 34 to 54 ppb; and 53 ppb; 95% CI, 42 to 64 ppb; vs 22 ppb; 95% CI, 18 to 27 ppb; p = 0.002 and p = 0.001, respectively). Patients with asthma had Feno values significantly higher than patients without asthma (64 ppb; 95% CI, 51 to 77 ppb; vs 33.3 ppb; 95% CI, 28 to 39 ppb; p < 0.001).

CONCLUSIONS

The diagnostic classification of persistent rhinitis helps to predict lower airway inflammation (increased Feno) and prevalence of asthma: AR and CRS are associated with higher mean Feno values and higher prevalence of asthma than NAR.

An immunological approach to chronic and recurrent sinusitis

PURPOSE OF REVIEW

Sinusitis is an illness that is often successfully treated by primary care physicians. Recurrent or chronic rhinosinusitis, however, can be frustrating for patients as well as primary care and subspecialty providers. The present review details the approach to recurrent or chronic sinusitis. We give a broad overview of the workup of chronic rhinosinusitis, focusing on immune deficiency, an often overlooked but clinically important aspect of the sinusitis workup.

RECENT FINDINGS

Immune deficiency is prevalent in patients with recurrent or chronic sinus disease. An immunologic workup, as well as a workup for other chronic treatable diseases, should be undertaken before sinus surgery or in patients who have been unresponsive to surgery. This approach can enhance visualization during surgery, minimize postoperative complications, improve surgical outcomes, and possibly obviate the need for surgery altogether.

SUMMARY

Elucidating the cause of recurrent or refractory sinus disease can be challenging. Allergic disease should be evaluated and treated early in the process. An immunologic evaluation should be performed and uncommon causes of sinus inflammation should be addressed later in the course to reduce inflammation either to avoid surgery or improve surgical outcomes.