Positive allergen reaction in allergic and nonallergic rhinitis: a systematic review

Investigation of the diagnostic accuracy of basophil activation test for allergic phenotypes of rhinitis

INTRODUCTION

Basophil activation test (BAT) might be an alternative to nasal allergen challenge (NAC) to identify the allergic etiology in rhinitis patients. Here, we investigate the diagnostic performance of BAT for allergic phenotypes of rhinitis.

METHODS

Rhinitis patients and healthy controls were subjected to NAC with Dermatophagoides pteronyssinus (DP), Alternaria alternata (AA), grass (GP) and olive (OP) pollens. Rhinitis subjects also underwent skin prick test (SPT) with relevant allergens. Patients were classified into allergic rhinitis (AR, positive NAC and SPT), local allergic rhinitis (LAR, positive NAC and negative SPT), dual allergic rhinitis (DAR, defined as AR for ≥1 allergen and LAR for ≥1 allergen), and non-allergic rhinitis (NAR, negative NAC and SPT) phenotypes. BAT with DP, AA, GP and OP was conducted in study individuals and compared with NAC results.

RESULTS

A total of 47 AR, 31 DAR, 26 LAR, 12 NAR and 21 control subjects were recruited. The best positivity cut-offs of BAT for DP-, AA-, GP- and OP-driven allergy (all phenotypes) were a %CD63 cells of 8.650, 14.250, 26.200, and 12.780, respectively (AUC 0.851, 0.701, 0.887, and 0.921, respectively). Sensitivity, specificity, negative and positive predictive values of BAT (all phenotypes) ranged 43.5%(AA)-83.3%(OP), 88.9%(GP)-100%(AA), 87%(GP)-100%(AA), and 61.1%(DP)-80.0%(pollens), respectively. BAT identified 79%-100% of SPT-positive allergies (AR and DAR), and 25%-75% of SPT-negative allergies (LAR and DAR), while ≤10% of NAR/HC subjects tested positive. BAT positivity correlated with rhinitis severity in LAR patients (p = 0.018), and associated with conjunctivitis (p = 0.015) in allergic subjects.

CONCLUSION

BAT can replace NAC for AR confirmation, and limit the number of NAC required for LAR and DAR diagnosis. BAT can demonstrate sIgE in SPT-negative allergies.

Treatment of Allergies to Fur Animals

Allergy to fur animals is becoming an increasingly common clinical problem in everyday medical practice. Depending on the route of exposure to the allergen, patients present with many, often non-specific symptoms. The most common illnesses among people with allergies to the above-mentioned allergens are as follows: allergic rhinitis, allergic conjunctivitis, atopic bronchial asthma, food allergy, allergic contact dermatitis, and sometimes anaphylactic shock. In recent years, there has been a change in the holistic approach to the treatment of allergy patients. The method of treatment should be tailored to a specific patient, taking into account his or her predispositions, economic possibilities, and therapeutic goals. The article describes the main methods of treating allergies, focusing primarily on allergies to fur animals. Allergy treatment always requires great care, and qualification for specific types of therapy should be preceded by a thorough and accurate diagnosis.

Clinical characteristics of local allergic rhinitis sensitized to house dust mites in Asia

PURPOSE

Local allergic rhinitis (LAR) is characterized by a localized nasal allergic response without evidence of systemic atopy. LAR is an underdiagnosed entity and is a diagnostic and therapeutic challenge for clinicians. This study aimed to investigate the prevalence and clinical characteristics of patients with LAR to house dust mites (LAR-HDM) in Korea.

METHODS

We performed a retrospective chart review of 336 adult patients with rhinitis symptoms who visited the Rhinologic Clinic at Korea University Guro Hospital from October 2019 to April 2021. Using results of the skin prick test, serologic test, and nasal provocation test, patients were classified as allergic rhinitis (AR) to HDM (AR-HDM), AR to other allergens, non-allergic rhinitis (NAR), or LAR-HDM. We excluded patients with AR to other allergens and compared the clinical characteristics of the remaining three groups. Patient demographic data were reviewed, and patients' nasal symptoms, olfactory function, serum total IgE, and severity of accompanying rhinosinusitis were evaluated.

RESULTS

In total, 336 patients were examined. AR-HDM was diagnosed in 138 (41.1%) patients, AR to other allergens in 36 (10.7%) patients, NAR in 21 (42.0%) patients, and LAR-HDM in 21 (6.3%) patients. The mean age of patients with LAR-HDM was significantly higher than that of patients with AR-HDM. There were no significant differences in sex, smoking history, asthma, and family history of allergic diseases between the groups. Compared to NAR patients, there were significantly more patients with LAR-HDM who had persistent nasal symptoms. The frequency of nasal itching and sneezing was significantly higher in the LAR-HDM group than in the NAR group. The olfactory function score in the LAR-HDM group was significantly worse than that in the AR-HDM group, and the Lund-Mackay score was significantly higher in the LAR-HDM group than in the other groups.

CONCLUSION

Clinical history and nasal symptoms are very similar in LAR-HDM and AR-HDM. Clinicians should take more care to differentiate them. LAR-HDM should also be considered in patients with persistent and severe nasal symptoms without systemic atopy.

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.

Sequential class switch recombination to IgE and allergen-induced accumulation of IgE+ plasmablasts occur in the nasal mucosa of local allergic rhinitis patients

BACKGROUND

The involvement of allergen-specific (s)IgE in local allergic rhinitis (LAR) has been debated. Here, we investigate the effect of nasal allergen challenge with Dermatophagoides pteronyssinus (NAC-DP) in mucosal and peripheral B-cell subpopulations in LAR patients.

METHODS

Nine LAR, 5 allergic rhinitis (AR), and 5 non-atopic healthy control (HC) individuals were subjected to a 3-day NAC-DP protocol, and nasal biopsies and blood samples were collected before and after provocation. Nasal biopsies were used for immunohistochemistry and gene expression studies, whereas the frequency of lymphocyte subsets and basophil activation test (BAT) were analyzed in blood samples by flow cytometry. sIgG was measured in sera.

RESULTS

NAC-DP induced an increase in IgE⁺ CD38⁺ plasmablasts in the nasal mucosa of LAR patients, but not in AR or HC individuals. Markers of sequential recombination to IgE (εCSR) (from IgG) were observed in 33% of LAR, 20% of AR, and 0% of HC subjects. NAC-DP increased the proportion of peripheral CD19⁺ CD20⁺ CD38⁺ plasmablasts in AR and LAR patients, but not in HC. Expression of the mucosal homing receptor CXCR3 in peripheral CD19⁺ CD20⁺ CD38⁺ plasmablasts from LAR, AR, and HC individuals was 7%, 5%, and 0.5%, respectively. In vitro DP stimulation increased proliferating CD19⁺ CD20⁺ CD38⁺ plasmablasts in LAR and AR patients, but not in HC. Serum DP-sIgG was higher in LAR and AR patients as compared to HC. BAT was positive in 33%, 100%, and 0% of LAR, AR, and HC subjects, respectively.

CONCLUSION

These results suggest that allergen exposure induces the sequential εCSR of IgG⁺ CD19⁺ CD20⁺ CD38⁺ plasmablasts in the nasal mucosa of LAR patients.

Risk of Chronic Rhinosinusitis With Nasal Polyps in Endotypes of Dermatophagoides pteronyssinus-Induced Rhinitis

BACKGROUND

Observation of the natural history of two emerging endotypes of allergic rhinitis, local-sensitization rhinitis (LAR) and dual-allergic rhinitis (DAR), compared with systemic-sensitization rhinitis (AR), could improve knowledge of the role of allergy in chronic rhinosinusitis with nasal polyps (CRSwNP).

OBJECTIVE

To test the hypothesis that endotypes of Dermatophagoides pteronyssinus (DP)-induced rhinitis were risk factors for CRSwNP and adult-onset asthma and to investigate whether delayed hypersensitivity to DP, assessed by atopy patch test, could be a contributing factor.

METHODS

We conducted a prospective observational study over 15 years on a cohort of 999 patients: 468 with AR, 333 with LAR, and 198 with DAR. The latter endotype was characterized by the coexistence of seasonal disease caused by systemic sensitization to pollen in patients with DP-induced LAR. The study design included a physical visit; ear, nose, and throat examination with anterior rhinoscopy; skin prick test; serum-specific IgE; DP-atopy patch test; nasal allergen provocation test with DP; paranasal sinuses computed tomography scan; nasal endoscopy; and spirometry.

RESULTS

During 15 years of follow-up, 194 patients developed CRSwNP with a higher rate of LAR (28.2%) and DAR (22.2%) than AR (12%). For LAR and DAR, 7.5% and 10.6% of patients developed adult-onset asthma temporally linked to CRSwNP in 68% and 71.4% of cases, respectively. A total of 858 patients with rhinitis had delayed hypersensitivity to DP. Moreover, DP-ATP was an independent predictive factor for CRSwNP and had elevated positive and negative predictive values for localized allergic disease of the nasal mucosa.

CONCLUSIONS

Endotypes of DP-induced allergic rhinitis represent risk factors for CRSwNP. Patients with local-sensitization rhinitis and DAR are more at risk than those with AR. In these emerging endotypes, progression toward CRSwNP is often associated with the development of adult-onset asthma. Chronic rhinosinusitis with nasal polyps shows several possible indicators for type 2 endotype. Delayed hypersensitivity to DP is an independent predictive factor for CRSwNP.

Diagnosis and Treatment of Local Allergic Rhinitis

Some patients with chronic rhinitis have a positive nasal allergen provocation test (NAPT) without systemic IgE sensitization by skin prick tests or serum allergen-specific IgE (sIgE). This novel concept is called local allergic rhinitis (LAR) and affects children and adults worldwide, but is underdiagnosed. LAR is not just the initial state of allergic rhinitis (AR), it is a unique form of chronic rhinitis that is neither classical AR nor non-AR. Many of the features of AR and LAR are similar, such as a positive NAPT, positive type 2 inflammatory markers, including the nasal discharge of sIgE, and a high incidence of asthma. A differential diagnosis of LAR needs to be considered in patients with symptoms suggestive of AR in the absence of systemic atopy, regardless of age. The diagnostic method for LAR relies on positive responses to single or multiple allergens in NAPT, the sensitivity, specificity, and reproducibility of which are high. The basophil activation test and measurement of IgE in nasal secretions also contribute to the diagnosis of LAR. Treatment for LAR is similar to that for AR and is supported by the efficacy and safety of allergen exposure avoidance, drug therapy, and allergen immunotherapy. This review discusses current knowledge on LAR.

Allergen-specific immunotherapy for local allergic rhinitis: a systematic review and meta-analysis

BACKGROUND

Local allergic rhinitis (LAR) is a phenotype of chronic rhinitis exhibiting a local Th2-driven inflammation without positive clinical markers of atopy. Immunomodulatory effects of allergen-specific immunotherapy (AIT) induce allergen-specific tolerance. However, AIT is not well-recognized as a treatment for LAR.

METHODOLOGY

Systematic search on six electronic databases and registries was performed. Experimental and observational studies of AIT for LAR patients were retrieved. The primary outcomes were symptom score, medication score, combined symptom medication score, and disease-specific quality of life. Secondary outcomes were serum specific(s) IgG4, sIgE, and adverse events.

RESULTS

Four double-blind randomized controlled trials (156 patients) from two research units assessed the effects of subcutaneous immunotherapy (SCIT). Compared with placebo, SCIT showed significant reductions in symptom score, medication score, combined symptom medication score, disease-specific quality of life, and an increase in serum sIgG4. There was no significant change in serum sIgE. Likewise, two observational studies (one using SCIT and one using sublingual immunotherapy) improved post-therapeutic symptom score. No studies assessed the effects after discontinuation of treatment. AIT was safe without serious adverse events.

CONCLUSION

AIT has beneficial effects and safe for LAR. Its effects are restricted to studies with short-term follow-up. AIT may be considered in LAR patients.

The Importance of Nasal Provocation Testing in the Diagnosis of Dermatophagoides pteronyssinus-Induced Allergic Rhinitis

BACKGROUND

Allergen identification is the first step for allergen-specific immunotherapy (AIT) of allergic rhinitis (AR). Currently, the diagnosis of AR is based mainly on the positive results of the skin prick test (SPT) and/or serum specific immunoglobulin E (sIgE) measurement. However, the results of these two tests may not always directly correlate with AR.

OBJECTIVE

To investigate the importance of nasal provocation testing (NPT) in the diagnosis of Dermatophagoides pteronyssinus (Der p)-induced AR.

METHODS

Rhinitis patients willing to undergo AIT (n = 171) were enrolled. The correlations of Der p SPT, sIgE, NPT, and clinical symptom severity were assessed.

RESULTS

NPT-positive responses were more common in patients with higher SPT and sIgE levels. The optimal cut-off value for a NPT-positive response for SPT was 5.5 mm and for sIgE was 2.77 kUA/L, based on the respective receiver operating characteristic (ROC) curves. The area under the curve (AUC) of the ROCs was 0.814 (SPT only) and 0.794 (sIgE only) and increased to 0.828 with the combination of SPT and sIgE. The Der p-NPT concentration was inversely correlated with SPT and sIgE levels (r = -0.477, P < .001, and r = -0.461, P < .001, respectively), but none was correlated with the total nasal symptom score.

CONCLUSION

For patients who are willing to receive Der p AIT, NPT is a useful and safe test to confirm diagnosis prior to treatment initiation, especially in patients with lower levels of Der p SPT (< 5.5 mm) or sIgE (< 2.77 kUA/L).

Prevalence, comorbidities, diagnosis, and treatment of nonallergic rhinitis: real-world comparison with allergic rhinitis

Rhinitis is among the most common respiratory diseases in children. Nonallergic rhinitis, which involves nasal symptoms without evidence of systemic allergic inflammation or infection, is a heterogeneous entity with diverse manifestations and intensities. Nonallergic rhinitis accounts for 16%-89% of the chronic rhinitis cases, affecting 1%-50% (median 10%) of the total pediatric population. The clinical course of nonallergic rhinitis is generally rather mild and less likely to be associated with allergic comorbidities than allergic rhinitis. Here, we aimed to estimate the rate of coexisting comorbidities of nonallergic rhinitis. Nonallergic rhinitis is more prevalent during the first 2 years of life; however, its underestimation for children with atopic tendencies is likely due to low positive rates of specific allergic tests during early childhood. Local allergic rhinitis is a recently noted phenotype with rates similar to those in adults (median, 44%; range, 4%-67%), among patients previously diagnosed with nonallergic rhinitis. Idiopathic rhinitis, a subtype of nonallergic rhinitis, has been poorly studied in children, and its rates are known to be lower than those in adults. The prevalence of nonallergic rhinitis with eosinophilia syndrome is even lower. A correlation between nonallergic rhinitis and pollution has been suggested owing to the recent increase in nonallergic rhinitis rates in highly developing regions such as some Asian countries, but many aspects remain unknown. Conventional treatments include antihistamines, intranasal corticosteroids, and recent treatments include combination of intranasal corticosteroids with azelastin or decongestants. Here we review the prevalence, diagnosis, comorbidities, and treatment recommendations for nonallergic rhinitis versus allergic rhinitis in children.

Systematic evaluation of allergic phenotypes of rhinitis in children and adolescents

BACKGROUND

Three allergic phenotypes of rhinitis have been described in adults: allergic rhinitis (AR), local allergic rhinitis (LAR), and dual allergic rhinitis (DAR, coexistence of AR and LAR). Nevertheless, most centers follow a diagnostic approach only based on skin prick test and serum allergen-specific IgE (collectively called atopy tests, AT). This approach prevents the recognition of LAR and DAR, the diagnosis of which requires a nasal allergen challenge (NAC). Here, we investigate the existence of LAR and DAR phenotypes in children and adolescents, and the misdiagnosis rate associated with a work-up exclusively based on AT.

METHODS

Clinical data were obtained during physician-conducted interviews, and AT and NAC were systematically performed in 5- to 18-year-old patients with chronic rhinitis. The misdiagnosis rate was defined as the proportion of cases where AT and NAC results were discordant.

RESULTS

A total of 173 patients (mean age 15.1 years, 39.9% male) completed the study. AR (positive AT and NAC), LAR (negative AT and positive NAC), DAR (positive AT and NAC for some allergens and negative AT and positive NAC for other allergens), and non-allergic rhinitis (negative NAC) were diagnosed in 45.7%, 24.9%, 11.6%, and 17.9% of individuals, respectively. The clinical profile was comparable among allergic phenotypes, but allergic patients had a significantly earlier rhinitis onset, higher conjunctivitis prevalence, and more severe disease than NAR individuals. A diagnostic work-up exclusively based on AT misclassified 37.6% of patients.

CONCLUSIONS

LAR and DAR represent relevant differential diagnosis in pediatric rhinitis. NAC increases the diagnostic accuracy of clinical algorithms for rhinitis in children and adolescents.

Local Respiratory Allergy: From Rhinitis Phenotype to Disease Spectrum

Local respiratory allergy (LRA) is defined by the negativity of atopy tests, a clinical history suggestive of airway allergy and a positive response to the nasal and/or bronchial allergen challenge. The clinical spectrum of LRA is comprised of three conditions: local allergic rhinitis (LAR) and local allergic asthma in non-atopic patients, and dual allergic rhinitis (coexistence of allergic rhinitis and LAR) in atopic individuals. LRA is an independent disease phenotype not progressing to atopy over time, but naturally evolving to the clinical worsening and the onset of comorbidities. Published data suggests that LRA is mediated through the mucosal synthesis of allergen-specific (s)IgE, which binds to FcϵRI on resident mast cells, and in >50% of cases traffics to the blood stream to sensitize circulating basophils. To date, 4 clinical trials have demonstrated the capacity of allergen immunotherapy (AIT) to decrease nasal, conjunctival and bronchial symptoms, to improve quality of life, to increase the threshold dose of allergen eliciting respiratory symptoms, and to induce serum sIgG₄ in LRA individuals. Collectively, these data indicate that local allergy is a relevant disease mechanisms in both atopic and non-atopic patients with airway diseases.

Coexistence of nasal reactivity to allergens with and without IgE sensitization in patients with allergic rhinitis

BACKGROUND

Allergic rhinitis (AR) and local allergic rhinitis (LAR) are defined by nasal reactivity to aeroallergens with and without positive skin prick test (SPT), respectively. In this study, we aimed to investigate whether both types of allergen-specific reactivity can coexist in the same individual.

METHODS

Forty-eight patients with perennial rhinitis symptoms and positive SPT with seasonal allergens only (discrepant group) were subjected to consecutive nasal allergen challenges (NAC) with seasonal (NAC-S) and perennial allergens (NAC-P). A nasal lavage was collected before and after the NACs to measure eosinophil cationic protein (ECP). A basophil activation test (BAT) with seasonal and/or perennial allergens was performed in ten patients from the discrepant group and in six seasonal allergic rhinitis (SAR), eight perennial local allergic rhinitis (LAR), six nonallergic rhinitis (NAR), and six healthy control (HC) individuals.

RESULTS

All patients in the discrepant group tested positive in the NAC-S, and 41 of them (85.4%), also in the NAC-P (group A). Conversely, seven patients tested negative in the NAC-P (group B). ECP in the nasal lavage increased after the NAC-P in the group A (P = .004), but not in the group B. The BAT with seasonal allergens was positive in 100% of SAR and group A cases, whereas the BAT with perennial allergens was positive in 37.5% and 60% of LAR and group A cases, respectively. All NAR and HC subjects tested negative for the BAT.

CONCLUSION

This study shows that nasal reactivity to aeroallergens with and without positive SPT can coexist in the same patient. We propose the term dual allergic rhinitis for this rhinitis phenotype.

Local Allergic Rhinitis Revisited

PURPOSE OF REVIEW

Local allergic rhinitis (LAR) represents a diagnostic and therapeutic challenge for clinicians. Even though it affects a considerable number of chronic rhinitis patients and a significant number of articles regarding prevalence, evolution, diagnosis, and treatment have been published, the condition remains still largely unrecognized and therefore misdiagnosed and mistreated.

RECENT FINDINGS

LAR is a unique form of chronic rhinitis; it is neither classical allergic rhinitis (AR) nor non-allergic rhinitis (NAR). The symptoms, duration, severity, and complications of LAR are similar to those of AR and can affect adults and children. Thus, a portion of patients diagnosed with NAR or chronic rhinitis of unknown etiology may have LAR. The relationship between LAR inflammation and systemic allergic inflammation is unclear. Patients are frequently misdiagnosed with idiopathic NAR, and distinguishing between both entities is difficult without specific diagnostic tests. Underdiagnosis of LAR has implications on the management of these patients, as they are deprived of allergen immunotherapy (AIT) that has been demonstrated to modulate the immune mechanisms underlying allergic diseases. This review aims to comprehensively summarize the current knowledge on LAR and address unmet needs in the areas of disease diagnosis and treatment.

Allergen Immunotherapy for Local Respiratory Allergy

PURPOSE OF REVIESW

Local respiratory allergy (LRA) is an eosinophilic phenotype of chronic airway disease. Three entities have been described within the LRA spectrum: local allergic rhinitis (LAR) and local allergic asthma (LAA) in non-atopic patients, and dual allergic rhinitis (DAR) in atopic patients (coexistence of LAR and allergic rhinitis). In this article, we aim to review the current evidence on the therapeutic options for LRA.

RECENT FINDINGS

No controlled study has assessed the effect of standard therapy (oral antihistamines, intranasal or inhaled corticosteroids, bronchodilators) in LRA subjects. Three randomized clinical trials and one observational study demonstrated that allergen immunotherapy (AIT) is able to control nasal and ocular symptoms, decrease the need for rescue medication, and improve quality of life in LAR individuals. Nasal or inhaled steroids can be expected to improve eosinophilic inflammation in LRA patients but cannot change the natural course of the disease. Moreover, the long-term and disease-modifying effects of AIT in LRA subjects need to be investigated.

The Role of Allergic Rhinitis in Chronic Rhinosinusitis

This literature review collates and summarizes recent literature to explore the relationship between chronic rhinosinusitis (CRS) and allergy. The relationship between CRS and allergy is not fully understood. However, current evidence suggests a relationship between allergy and specific endotypes of CRS with nasal polyposis, including allergic fungal rhinosinusitis and central compartment atopic disease. Specific endotypes of CRS with nasal polyps seem to have an association with allergy. More evidence is necessary to better characterize this relationship. Level of evidence: 5.

Central compartment atopic disease: prevalence of allergy and asthma compared with other subtypes of chronic rhinosinusitis with nasal polyps

BACKGROUND

Central compartment atopic disease (CCAD) is a recently described variant of chronic rhinosinusitis with nasal polyp (CRSwNP) associated with inhalant allergy. An association with asthma was noted to be uncommon within our clinical practice. The purpose of this study was to determine allergy and asthma prevalence in CCAD and other CRSwNP subtypes.

METHODS

A retrospective analysis at a tertiary care institution was performed over the period from 2015 to 2019. CRSwNP was grouped into the following subtypes: allergic fungal rhinosinusitis (AFRS); aspirin-exacerbated respiratory disease (AERD); CCAD; and CRSwNP not otherwise specified (CRSwNP NOS). Patients with sinonasal polyps and concomitant polypoid disease in the central compartment (CRSwNP/CC) were analyzed as a separate cohort for the purpose of this study. Prevalence of allergy and asthma was compared between groups.

RESULTS

Three hundred fifty-six patients were included. CRSwNP NOS was the most common subtype (37.1%) and CRSwNP/CC was the least common (3.7%), with other CRS subtypes ranging between 11.5% and 24.2%. Asthma prevalence was highest in AERD (100%) and CRSwNP NOS (37.1%), but substantially lower in AFRS (19.0%) and CCAD (17.1%). Asthma was significantly more common in AERD and CRSwNP NOS when compared with CCAD (p < 0.001 and p = 0.039, respectively). Prevalence of allergy was significantly higher in AFRS (100%), CCAD (97.6%), CRSwNP/CC (84.6%), and AERD (82.6%) when compared with CRSwNP NOS (56.1%) (p < 0.001).

CONCLUSION

CCAD represents a clinically distinct phenotype of CRSwNP with a high prevalence of allergy and low prevalence of asthma. Patients with both CCAD and diffuse sinonasal polyps had an allergy prevalence approaching that of CCAD and an asthma prevalence approaching CRSwNP NOS.

Dietary flavonoids and respiratory diseases: a population-based multi-case-control study in Italian adults

OBJECTIVE

To analyse the associations between chronic respiratory diseases and intakes of total flavonoids and their major subclasses (flavanones, anthocyanins, flavan-3-ols, flavonols, flavones, polymers and proanthocyanidins).

DESIGN

Multi-case-control study.

SETTING

The analysis was conducted in the frame of the Genes Environment Interaction in Respiratory Diseases (GEIRD) study. The European Prospective Investigation into Cancer and Nutrition FFQ was used to ascertain dietary intake. Multinomial regression models adjusting for age, sex, centre, BMI, smoking habit, alcohol intake, education, total energy intake, vitamin C intake and total fruit intake were used to examine the associations between dietary exposures and the relative risk ratio (RRR) of being a case.

PARTICIPANTS

Individuals (n 990) hierarchically defined as follows: cases with asthma (current, n 159; past, n 78), chronic bronchitis (n 47), rhinitis (allergic rhinitis, n 167; non-allergic rhinitis, n 142) and controls (n 97).

RESULTS

An increase of 1 sd in flavanones was associated with a reduced risk of non-allergic rhinitis (adjusted RRR = 0·68, 95 % CI 0·47, 0·97); a similar result was found comparing the highest v. lowest quartile of flavanones intake (adjusted RRR = 0·24, 95 % CI 0·10, 0·59).

CONCLUSIONS

Flavonoids contained in fruits and vegetables, especially flavanones, might reduce the risk of non-allergic rhinitis. No associations were found between other flavonoids and the considered outcomes.

Bronchial asthma triggered by house dust mites in patients with local allergic rhinitis

BACKGROUND

Over 30% of local allergic rhinitis (LAR) patients self-report bronchial symptoms suggestive of asthma, but the relationship between the allergen exposure and the bronchial symptoms has not been studied.

OBJECTIVE

To investigate whether a bronchial counterpart of LAR exists.

METHODS

Patients were classified by clinical history, skin prick test/serum specific IgE (sIgE), and nasal allergen provocation test (NAPT) into the LAR, allergic rhinitis (AR), and nonallergic rhinitis (NAR) phenotypes. Twenty-eight LAR, 18 AR, and 19 NAR patients self-reporting bronchial symptoms suggestive of asthma and 8 healthy controls (HC) were subjected to a methacholine test (MT) before (Visit 1) and 24 hours after (Visit 3) a bronchial provocation test with Dermatophagoides pteronyssinus (BPT-DP) (Visit 2). Induced sputum and peripheral blood obtained after each MT were analyzed for immune cell populations, tryptase, ECP, and sIgE.

RESULTS

A positive MT was found in 50% of LAR, 83.3% of AR, 57.89% of NAR, and 0% of HC individuals (P = 0.022 AR vs LAR) at V1. BPT-DP was positive in 8 LAR and 15 AR patients (28% vs 83.3%, P < 0.001), with no positive responses in NAR and HC. All BPT-DP+ patients experienced a significant decrease of PC₂₀ at V3 vs V1 (P = 0.016 LAR, P ≤ 0.001 AR). BPT-DP+ patients also showed a significant increase of eosinophils, monocytes, and ECP in induced sputum at V3 compared with V1.

CONCLUSION

The results suggest the existence of a new asthma phenotype (local allergic asthma) defined by absence of systemic atopy and positivity to BPT with allergen.

How to Diagnose and Treat Local Allergic Rhinitis: A Challenge for Clinicians

Chronic rhinitis is a very common disease that can be divided in various phenotypes. Historically, the condition has been classified into the allergic rhinitis (AR) and non-allergic non-infectious rhinitis (NAR) forms, based on the results of the classical biomarkers of atopy: skin prick test and serum allergen-specific IgE However, this classification does not reflect the complexity of the rhinitis syndrome, as illustrated by the existence of non-atopic rhinitis patients who display a nasal reactivity to environmental allergens. This new phenotype has been termed local allergic rhinitis (LAR) and can be only recognized if an additional test such as the nasal allergen challenge (NAC) is integrated in the diagnostic algorithm for chronic rhinitis. Recent data shows that the NAC is a very safe and reliable technique ready for the clinical practice. LAR is a differentiated rhinitis phenotype which often commences during childhood and quickly progresses towards a clinical worsening and the association of comorbidities in other mucosal organs. Recent evidence supports the existence of a bronchial counterpart of LAR (local allergic asthma), which highlights the pathophysiological links between the upper and lower airways and reinforces the united airways concept. Importantly, several controlled studies have demonstrated the ability of allergen immunotherapy to control LAR symptoms while the therapy is being administered. This review emphasizes the need to implement the NAC in the clinical practice in order to facilitate the recognition of LAR patients, allowing for an early prescription of specific therapies with disease-modifying potential.

The Distinguishing Clinical Features of Nonallergic Rhinitis Patients

Background

Not all rhinitis patients are affected by an immunoglobulin E (IgE)-mediated inflammatory process. Skin and serum allergy assessments are limited in their ability to define local allergic rhinitis (LAR). Thus, patients with negative systemic allergy assessments comprise a mix of those who truly have nonallergic rhinitis (NAR) and patients with LAR.

Objective

To determine the clinical characteristics of patients with NAR.

Methods

A cross-sectional study was performed on consecutive adults with rhinitis symptoms who underwent turbinate surgery. NAR patients were defined by excluding allergy using both systemic (serum-specific IgE and/or skin prick test) and local (inferior turbinate tissue-specific IgE) tests. Allergic rhinitis (AR) patients were defined by any positive systemic or local test toward aeroallergens. The clinical characteristics studied included allergic comorbidities (asthma, eczema, allergic conjunctivitis), inhalant allergen triggers (dust, pollen, animal dander), and environmental triggers (Cincinnati Irritant Index [CII]).

Results

There were 154 participants (41.79 ± 14.78 years, 37.7% female). NAR patients (11.7%) were older (49.33 ± 15.99 vs 40.78 ± 14.38 years, P = .02), had less self-reported asthma (5.6% vs 36.3%, P < .01) and house dust inhalant trigger (38.9 vs 65.2%, P = .03) compared to AR patients. The CII score was similar for NAR and AR (31.06 ± 28.88 vs 35.49 ± 24.70, P = .61).

Conclusion

Patients who were older, without asthma, and lacked an inhalant allergy trigger were more likely to have true NAR. Environmental triggers are not distinguishing features of NAR. This may be used as a guide to identify rhinitis patients whose symptoms are truly nonallergic etiology compared to those with falsely negative systemic allergy assessment but may still need management for LAR.

Is the evidence of local allergic rhinitis growing?

PURPOSE OF REVIEW

To examine the recent advances on epidemiological studies, diagnostic approach and clinical management of local allergic rhinitis (LAR) in adults and children.

RECENT FINDINGS

Evidence about LAR is growing especially in pediatric and Asian populations. The prevalence of LAR is lower in Asian countries compared with western countries in both children and adults. LAR is considered a chronic condition and an independent rhinitis phenotype that affects up to 26.5% of nonatopic rhinitis patients. The disease rapidly progress toward the clinical worsening with associated onset of asthma and conjunctivitis, which further impairs patient's quality of life. Nasal Allergen Provocation Test is the diagnostic gold standard that can be complemented by basophil activation test and the detection of specific IgE in nasal secretions. Allergen immunotherapy induces a significant and early improvement in both clinical symptoms and quality of life in LAR patients.

SUMMARY

LAR is a common entity, with different prevalence depending on geographical locations. LAR has to be considered in the process of differential diagnosis in children and adults with rhinitis. Diagnosis of LAR is crucial in order to start an etiologic treatment such as allergen immunotherapy, which has proven to be very effective in these patients.

The relationship between allergy and chronic rhinosinusitis

OBJECTIVE

To summarize the current evidence regarding a relationship between chronic rhinosinusitis (CRS) and allergy.

METHODS

Literature review.

RESULTS

Despite frequent assumption of an association between CRS and allergy the relationship between these entities remains poorly defined. Certain CRS entities, however, have demonstrated a strong association with allergy-namely allergic fungal rhinosinusitis and central compartment atopic disease.

CONCLUSION

Studies are heterogeneous and largely retrospective in design with inconclusive evidence for an association between CRS and allergy. Knowledge of CRS endotypes is important in order to understand which entities may or may not be associated with allergy. Level of Evidence: 5.

Differences in the Nasal Inflammatory Response to Cynodon dactylon From Rural and Urban Areas in Patients With Allergic Rhinitis

Background

Epidemiological and experimental studies suggest that air pollution has a negative impact on human health and modifies the environment. However, the clinical implications of changes in environmental allergens secondary to air pollution have been little studied.

Objectives

To explore if the growth conditions of the Cynodon dactylon (rural vs urban area) modify the inflammatory response among patients with allergic rhinitis.

Methodology: Two extracts were prepared for diagnostic test with Cyn d proteins obtained from rural and urban environment. Skin prick test (SPT), nasal challenge test (NCT), and eosinophil count in nasal mucus were performed in 3 groups: healthy subjects without rhinitis, rhinitis with (+) Cyn d, and rhinitis with (−) Cyn d.

Results

There was a 97% concordance in the positive and negative results of the SPT with the 2 extracts. However, Cyn d-urban extract generated larger wheals (P = .03) and a higher number of patients with rhinitis presented a positive NCT to this extract (n = 7 vs 14, P = .04). Patients with positive NCT had a significant increase in eosinophils in mucus, but there was no difference between the extracts. The healthy controls did not react to the extracts tested in the skin or nasal test.

Conclusion

The findings suggest that the growth conditions in urban area of Cynodon dactylon can generate changes in the protein extract and have clinical implications in patients with allergic rhinitis.

Prevalence of allergic and nonallergic rhinitis in a rural area of northern China based on sensitization to specific aeroallergens

BACKGROUND

Most epidemiologic studies reporting prevalence of allergic rhinitis (AR) and nonallergic rhinitis (NAR) have assessed solely self-reported prevalence, without confirmation by objective measures. Furthermore, reports of prevalence of NAR in Chinese subjects are scarce. Thus, we aimed to explore the prevalence and risk factors of AR and NAR in a Chinese, based on both clinical manifestation and allergic status.

METHODS

We conducted a population-based cross-sectional survey, involving 1084 local residents from a rural area of Beijing, China. Participants were enrolled using a stratified two-stage cluster sampling method. All adult participants or the guardians of children completed standardized questionnaires to provide relevant demographic and clinical information. Skin prick tests were also performed to determine sensitization to specific aeroallergens. AR/NAR was classified according to Allergic Rhinitis and its Impact on Asthma criteria.

RESULTS

Prevalence of self-reported AR was 46.80%. Based on SPT results, the confirmed standardized prevalence of AR and NAR were 16.78% and 24.60%, respectively. Severity scores for nasal itching, sneezing, rhinorrhea and congestion were significantly higher in subjects with AR, than subjects with NAR (P < 0.05 for all). The three most common aeroallergens in self-reported AR group were Blattella germanica (16.6%), Dermatophagoides farinae (14.6%), and Dermatophagoides pteronyssinus (13.9%). Family history of AR and atopic dermatitis were significantly associated with AR (adjusted OR: 4.97 and 2.69, respectively), whereas family history of AR and asthma were significantly associated with NAR (adjusted OR: 3.53 and 2.45, respectively). Similarly, comorbid asthma, CRS, and atopic dermatitis were significant risk factors for both AR and NAR.

CONCLUSIONS

Combination of standardized questionnaires and specific allergen tests may provide more accurate estimates of prevalence of AR and NAR and associated risk factors.

Utility of narrow band imaging in the diagnosis of middle turbinate head edema

PURPOSE

Middle turbinate head edema has recently been found to have high specificity for diagnosis of inhalant allergy. However, subtle mucosal edema can be difficult to appreciate under white light endoscopy. Narrow band imaging (NBI) has the potential to demonstrate edema by identifying reduced mucosal vascularity and improve sensitivity for the detection of mucosal edema. Narrow band imaging was assessed to determine its utility in objectifying mucosal edema.

MEATERIALS AND METHODS

A cross-sectional diagnostic study was performed on patients with edematous mucosa of the middle turbinate head. Under traditional white light endoscopy, areas of edematous mucosa were identified. Using NBI, these areas were compared to areas of normal mucosa on the middle turbinate head. NBI images of these same areas were then converted to grey scale and a vascularity index was created by pixel analysis and brightness in Fiji Image J software (Wisconsin, US).

RESULTS

Thirty-three middle turbinates were assessed (age 42.4 ± 12.5, 42.4% female). NBI discriminated between areas identified under white light endoscopy as edematous and normal (158.2 ± 48.4 v 96.9 ± 32.7 p < 0.01). Receiver operating curve (ROC) analysis suggested a threshold of 115 brightness units to define endoscopically visible edematous mucosa with sensitivity 70% and specificity 79% (ROC AUC, p = 0.85).

CONCLUSIONS

NBI can differentiate edematous from normal mucosa. The potential for an objective measure of mucosal edema may assist research efforts and may provide a more sensitive tool for subtle mucosal inflammatory changes.

Local allergic rhinitis: Implications for management

A significant proportion of rhinitis patients without systemic IgE-sensitisation tested by skin prick test and serum allergen-specific IgE (sIgE) display nasal reactivity upon nasal allergen provocation test (NAPT). This disease phenotype has been termed local allergic rhinitis (LAR). LAR is an underdiagnosed entity affecting children and adults from different parts of the world, with moderate-to-severe symptoms, impairment of quality of life and rapid progression to symptom worsening. LAR is a stable phenotype and not merely an initial state of AR. Allergic rhinitis and LAR share many clinical features including a positive NAPT response, markers of type 2 nasal inflammation including sIgE in nasal secretions and a significant rate of asthma development. LAR should be considered as a differential diagnosis in those subjects of any age with symptoms suggestive of AR but no evidence of systemic atopy. Although LAR pathophysiology is partially unknown, in some patients sIgE can be demonstrated directly in the nasal secretions and/or indirectly via positive responses in basophil activation test (BAT). LAR can coexist with other rhinitis phenotypes, especially AR. The diagnosis currently relies on the positivity of NAPT to a single or multiple allergens. NAPT has high sensitivity, specificity and reproducibility, and it is considered the gold standard. BAT and the measurement of nasal sIgE can also contribute to LAR diagnosis. LAR patients benefit from the same therapeutic strategies than AR individuals, including the avoidance of allergen exposure and the pharmacotherapy. Moreover, several recent studies support the effectiveness and safety of allergen immunotherapy for LAR, which opens a window of treatment opportunity in these patients.

Optimizing Protein Harvest From Nasal Brushings for Determining Local Allergy Responses

Background Rhinitis is a highly prevalent yet often misdiagnosed condition. Patients who have local allergic rhinitis are regularly mislabeled as having a nonallergic etiology. Thus, a highly accurate, reproducible, and noninvasive assessment, which can be performed quickly and with minimal discomfort to the patient, is required. Objective The aim of this research was to identify the efficiency of various nasal brushes as tools for harvest and collection of epithelial proteins and its suitability for identification of rhinitis. Methods Nasal epithelial mucosa samples were taken from patients undergoing turbinate surgery using a cytology brush, a dental brush, and a nasal curette in random order. After washing in phosphate-buffered saline, the suspended cells were sonicated. Total protein content was assessed for all samples by bicinchoninic acid assay measured using a Nanodrop machine. Identification of nasal-specific immunoglobulin E (spIgE) was then assessed using immunoassay and compared to the patient's allergic status from epicutaneous and serum testing. The lower threshold limit for the spIgE in nasal brushings was determined using the results of serum spIgE tests as the reference. The diagnostic accuracy of this new established cutoff value was determined. Results The cytology brush was found to be the optimal tool for maximal nasal mucosa protein collection followed by dental brush and nasal curette (0.75 ± 0.45 mg/mL vs 0.43 ± 0.24 mg/mL vs 0.071 ± 0.55 mg/mL, respectively; P < .01). The optimal cutoff value of nasal spIgE from the cytology nasal brushings was 0.14 kUA/L to predict allergic status from serum testing. This gave a sensitivity of 75%, specificity of 86%, positive predictive value of 74%, likelihood ration positive of 5.40, and diagnostic odds ratio of 18.62. Conclusion The cytology brush is the optimal tool for protein collection. This is an easy and direct method to sample the nasal mucosa for assessment of nasal allergy or future biomarkers.

Effects of turbinoplasty versus outfracture and bipolar cautery on the compensatory inferior turbinate hypertrophy in septoplasty patients

Introduction

The most common cause of septoplasty failure is inferior turbinate hypertrophy that is not treated properly. Several techniques have been described to date: total or partial turbinectomy, submucosal resection (surgical or with a microdebrider), with turbinate outfracture being some of those.

Objective

In this study, we compared the pre- and postoperative lower turbinate volumes using computed tomography in patients who had undergone septoplasty and compensatory lower turbinate turbinoplasty with those treated with outfracture and bipolar cauterization.

Methods

This retrospective study enrolled 66 patients (37 men, 29 women) who were admitted to our otorhinolaryngology clinic between 2010 and 2017 because of nasal obstruction and who were operated on for nasal septum deviation. The patients who underwent turbinoplasty due to compensatory lower turbinate hypertrophy were the turbinoplasty group; Outfracture and bipolar cauterization were separated as the out fracture group. Compensatory lower turbinate volumes of all patients participating in the study (mean age 34.0 ± 12.4 years, range 17–61 years) were assessed by preoperative and postoperative 2 month coronal and axial plane paranasal computed tomography.

Results

The transverse and longitudinal dimensions of the postoperative turbinoplasty group were significantly lower than those of the out-fracture group (p = 0.004). In both groups the lower turbinate volumes were significantly decreased (p = 0.002, p < 0.001 in order). The postoperative volume of the turbinate on the deviated side of the patients was significantly increased: tubinoplasty group (p = 0.033).

Conclusion

Both turbinoplasty and outfracture are effective volume-reduction techniques. However, the turbinoplasty method results in more reduction of the lower turbinate volume than outfracture and bipolar cauterization.