Botulinum Toxin for Rhinitis

The application and therapeutic effect of botulinum toxin type a (BTX-A) in the treatment of patients with pain after cancer treatment: a systematic review and meta-analysis

BACKGROUND

Botulinum toxin type A (BTX-A) is a potential treatment for cancer pain. This study aimed to analyze the effectiveness and safety of BTX-A in the treatment of pain after cancer treatment.

PATIENTS AND METHODS

Systematic searches of PubMed, Cochrane Library, and Embase databases were conducted. Randomized controlled trials evaluating the efficacy and safety of BTX-A compared with either placebo or active treatment in patients with pain after cancer treatment were included. The outcomes included pain intensity, quality of life, and adverse events.

RESULTS

This systematic review included four studies of which two were included in the meta-analysis. Compared with a placebo, BTX-A injection in patients with pain after cancer treatment had a clinically meaningful reduction in self-reported pain post-treatment [mean difference=-1.79 (95% CI: -2.14--1.43), P <0.00001, I ²=0%].

CONCLUSION

This systematic review and meta-analysis demonstrated that BTX-A is safe and effective for pain relief in patients with pain after cancer treatment.

Neonatal rhinorrhea, heart rate variability, and childhood exercise-induced wheeze

Background

There is increasing evidence linking infant rhinorrhea to school-age exercise-induced wheeze (EIW) via a parasympathetic nervous system pathway. The ratio of the root mean square of successive differences in heart beats (RMSSD) measured in quiet sleep versus active sleep (RMSSDQS:AS) is a novel biomarker in asthma.

Objective

We tested the hypotheses that (1) neonatal rhinorrhea predicts childhood EIW independent of other neonatal respiratory symptoms, (2) neonatal RMSSDQS:AS predicts childhood EIW, and (3) RMSSDQS:AS mediates the association between neonatal rhinorrhea and childhood EIW.

Methods

Participants from the Safe Passage/Environmental Influences on Child Health Outcomes (PASS/ECHO) prospective birth cohort had heart rate variability extracted from electrocardiogram traces acquired in the first month of life. Parents reported on rhinorrhea in their child at age 1 month and on EIW in their child at ages 4 to 11 years.

Results

In models (N = 831) adjusted for potential confounders and covariates, including neonatal wheeze, cough and fever, neonatal rhinorrhea-predicted childhood EIW (relative risk [RR] = 2.22; P = .040), specifically, among females (RR = 3.38; P = .018) but not males (RR = 1.39; P = .61). Among participants contributing data in both active and quiet sleep (n = 231), RMSSDQS:AS predicted EIW (RR = 2.36; P = .003) and mediated the effect estimate of neonatal rhinorrhea predicting EIW among females. Half of the females with a higher RMSSDQS:AS and neonatal rhinorrhea (n = 5 of 10) developed EIW as compared with 1.8% of the other females (n = 2 of 109) (P < .001).

Conclusions

Our findings support dysregulation of the parasympathetic nervous system in infancy as one of the possible underlying mechanisms for the development of EIW later in childhood among females, which could aid in the development of future interventions.

Temperature-controlled radiofrequency neurolysis for treatment of chronic rhinitis: 12-month outcomes after treatment in a randomized controlled trial

BACKGROUND

Temperature-controlled radiofrequency (TCRF) neurolysis of the posterior nasal nerve (PNN) area for the treatment of chronic rhinitis was previously reported as superior to a sham-control procedure at 3 months postprocedure in a randomized controlled trial (RCT). The primary endpoint was a responder rate of ≥30% improvement (decrease) for 24-hour reflective total nasal symptom score (rTNSS) compared with baseline. Herein, 12-month outcomes after active treatment are reported.

METHODS

In this prospective, multicenter, patient-blinded RCT, patients in the index active treatment arm were unblinded at 3 months and followed through 12 months. At 3 months, eligible patients from the sham-control arm of the study were invited to crossover to active treatment. Eligibility criteria included rTNSS ≥6, with moderate-severe rhinorrhea and mild-severe congestion. The TCRF stylus was applied bilaterally to nonoverlapping areas in the region of the PNN.

RESULTS

Patients in the index active treatment arm (n = 77) had a mean baseline rTNSS of 8.3 (95% confidence interval [CI], 7.9-8.7). At 12 months, the responder rate was 80.6% (n = 67) (95% CI, 69.1%-89.2%). At 12 months, the mean change in rTNSS was -4.8 (95% CI, -5.5 to -4.1; p < 0.001), a 57.8% improvement. The available initial rTNSS-based outcomes in the crossover active treatment arm (n = 27) were following the same course as the index treatment arm. No serious adverse events and 8 adverse events related to the device/procedure were reported in the trial to date.

CONCLUSION

TCRF neurolysis of the PNN area is safe and the symptom burden improvement that was superior to a sham procedure at 3 months was sustained through 12 months.

[Research progress of botulinum toxin type A in the treatment of chronic rhinitis]

Botulinum toxin（BoNT）, a superfamily of neurotoxins produced by the bacterium Clostridium botulinum, disturbs the signal transmission at the neuromuscular and neuroglandular junctions by inhibiting the neurotransmitter release from the presynaptic nerve terminal. BoNT has been widely used in neuromuscular, hypersecretory, and autonomic nerve system disorders. In recent years, botulinum toxin type A（BoNT-A） has been used to treat chronic rhinitis. Studies have shown that intranasal administration of BoNT-A is safe and effective, and can reduce nasal symptoms in rhinitis patients with long-lasting effects. This article reviews the research progress of BoNT-A in the treatment of chronic rhinitis.

Long-term Outcomes Following Temperature-Controlled Radiofrequency Neurolysis for the Treatment of Chronic Rhinitis

Background

Temperature-controlled radiofrequency neurolysis of the posterior nasal nerve has been shown to reduce the symptom burden of patients with chronic rhinitis.

Objectives

To evaluate the long-term safety and effectiveness of temperature-controlled radiofrequency neurolysis of the posterior nasal nerve for the treatment of chronic rhinitis.

Methods

A prospective extension of a 12-month single-arm study, where reflective total nasal symptom score (rTNSS) and the responses to a study-specific quality of life questionnaire and patient satisfaction survey were collected at 24 months.

Results

Forty-seven patients completed initial 12-month follow-up after treatment with the study device, of which 34 patients were reconsented and completed 24-month follow-up. The mean rTNSS of the long-term follow-up patients improved from 8.4 (95% confidence interval (CI), 7.7 to 9.0) at baseline to 2.9 (95% CI, 2.1 to 3.6), P < .001 at 24 months, a 65.5% improvement. On a 6-point scale (0-5), postnasal drip improved from a mean of 4.1 (95% CI, 3.6 to 4.6) to 2.1 (95% CI, 1.7 to 2.5) and chronic cough improved from 3.2 (95% CI, 2.7 to 3.6) to 0.9 (95% CI, 0.5 to 1.3) from baseline through 24 months; P < .001 for both measures. The proportion of patients achieving a minimal clinically important difference of 30% improvement from baseline at 24 months was 88.2% (95% CI, 73.4%-95.3%). At 24 months, 24% of patients were taking overall fewer and 15% taking overall more rhinitis medication classes than at baseline. Patients reported a higher quality of life in terms of sleep, well-being, and lower oral medication/nasal spray use at 24 months. There were no serious adverse events considered related to the procedure in the 12-24-month period.

Conclusion

Temperature-controlled radiofrequency neurolysis results in a significant and durable reduction in the symptom burden of chronic rhinitis and patients reported improved quality of life through 24 months postprocedure.

[Symptoms, causes, and treatment options of geriatric nose]

With increasing age, structures of the internal and external nose change. Many elderly patients complain about rhinitis with nasal obstruction, endonasal crusting, epistaxis, intermittent rhinorrhea, and olfactory disorders. These symptoms are mainly caused by atrophy of the mucosa and the olfactory epithelium, but may also be an expression of drug side effects. Additionally, there are changes in the shape of the nose (continuous growth, altered elasticity of supporting structures) and in the dermis, which may develop tumors due to its sun-exposed position. These multiple internal and external changes of the nose can be summarized by the collective term "aging nose," whose treatment options are complex. These range from conservative (nasal care, medication changes, hemostatic measures) to surgical lines of therapy (septorhinoplasty, tumor excision, vascular ligation) and will require further scientific study in the future.

Effect of Radiofrequency Neurolysis on the Symptoms of Chronic Rhinitis: A Randomized Controlled Trial

Objective

To determine the safety and efficacy of temperature-controlled radiofrequency (RF) neurolysis of the posterior nasal nerve (PNN) area for the treatment of chronic rhinitis.

Study Design

A multicenter, prospective, single-blinded, randomized controlled trial, in which the control arm underwent a sham procedure.

Setting

Sixteen otolaryngology centers.

Methods

Patients with 24-hour reflective Total Nasal Symptom Score (rTNSS) ≥6, including moderate to severe rhinorrhea and mild to severe congestion, were randomized 2:1 to active treatment of the posterior nasal nerve area with a temperature-controlled RF device or a sham procedure, with no RF energy delivery. The stylus was applied bilaterally to nonoverlapping areas of the posterior middle meatus and posterior inferior turbinate in each nostril in the region of the PNN. The primary endpoint was responder rate at 3 months, where a response was defined as ≥30% improvement (decrease) in rTNSS from baseline.

Results

Patients had a mean baseline rTNSS of 8.3 (95% CI, 7.9-8.7) and 8.2 (95% CI, 7.6-8.8) (P = .797) in the active treatment (n = 77) and sham control (n = 39) arms, respectively. At 3 months, responder rate was significantly higher in the active treatment arm: 67.5% (95% CI, 55.9%-77.8%) vs 41.0% (95% CI, 25.6%-57.9%) (P = .009). The active treatment arm had a significantly greater decrease in rTNSS (mean, −3.6 [95% CI, −4.2 to −3.0] vs −2.2 [95% CI, −3.2 to −1.3]) (P = .013). Three adverse events related to the device/procedure were reported, and all resolved.

Conclusion

This randomized controlled trial showed temperature-controlled neurolysis of the PNN area is free from significant adverse events and superior to a sham procedure in decreasing the symptom burden of chronic rhinitis.

Botulinum toxin for chronic rhinitis: A systematic review and meta-analysis

BACKGROUND

Botulinum toxin type A (BTX-A) is a potential treatment for chronic rhinitis. This study aimed to assess the effectiveness and safety of BTX-A in treating patients with chronic rhinitis.

METHODS

Systematic searches of MEDLINE, Scopus, and EMBASE databases were performed. Randomized controlled trials (RCTs) that assessed the efficacy of BTX-A in allergic rhinitis and/or nonallergic rhinitis patients, compared with either placebo or active treatment, were included. The outcomes were total nasal symptom (TNSS), disease-specific quality of life (QOL), and adverse events.

RESULTS

Nine RCTs (340 patients) met the eligibility criteria. Compared with placebo, the ≤ 12-week effects favored BTX-A injection on TNSS (standardized mean difference [SMD] -2.22, 95% confidence interval [CI] -3.27 to -1.17, p < 0.01, four RCTs). Beneficial effects > 12 weeks over placebo (MD -9.69, 95% CI -11.29 to -8.09, p < 0.01, one RCT) were demonstrated up to 24 weeks. However, the benefits were not shown on nasal congestion and individual nasal symptoms. Compared with active comparators (triamcinolone injection, ipratropium bromide, and cetirizine), there was no difference in the < 12-week effect between groups on TNSS. There was no difference between BTX-A and cetirizine on QOL (one RCT). The > 12-week effects on TNSS and individual nasal symptoms favored BTX-A over triamcinolone injection (one RCT). The risk ratio of adverse events favored BTX-A over cetirizine (one RCT).

CONCLUSIONS

BTX-A improved TNSS and QOL in patients with chronic rhinitis. These effects were demonstrated up to 24 weeks post treatment. BTX-A was safe, well tolerated, and may be considered in patients who are refractory to current standard-of-care therapies.

The minimum effective dose of abobotulinum toxin A injection for allergic rhinitis: A dose-escalation randomized controlled trial

OBJECTIVE

To find the lowest effective injection dose of abobotulinum toxin A (Dysport) for allergic rhinitis.

STUDY DESIGN

Dose-escalation randomized controlled trial.

METHODS

We included all patients aged 18 years or older who had persistent allergic rhinitis and positive allergy skin prick test. The patients were randomly allocated to receive 40, 30, or 20 U of abobotulinum toxin A by injection at the inferior turbinate. We followed up on patients for 12 weeks to evaluate nasal symptoms, ocular symptoms, minimum nasal cross-sectional area as measured using acoustic rhinometry, and complications.

RESULTS

Seventeen patients were included in this study, with 7 receiving 20 U of abobotulinum toxin A and 5 each receiving 30 U and 40 U. Abobotulinum toxin A significantly improved nasal congestion, rhinorrhea, sneezing, and loss of smell at 40 U (P < .05) and nasal congestion, sneezing, and loss of smell at 30 U (P < .05). However, at a dose of 20 U, only nasal congestion and loss of smell improved (P < .05). Nasal patency had also significantly improved two weeks after treatment at doses of 40 and 30 U (P < .05). Complications included epistaxis (11.8%) and nasal dryness (23.5%).

CONCLUSION

Abobotulinum toxin A at a dose of at least 30 U effectively reduced most nasal symptoms.

LEVEL OF EVIDENCE

2.

TRIAL REGISTRATION

Clinicaltrials.in.th/ TCTR20200526014.

Rhinitis 2020: A practice parameter update

This comprehensive practice parameter for allergic rhinitis (AR) and nonallergic rhinitis (NAR) provides updated guidance on diagnosis, assessment, selection of monotherapy and combination pharmacologic options, and allergen immunotherapy for AR. Newer information about local AR is reviewed. Cough is emphasized as a common symptom in both AR and NAR. Food allergy testing is not recommended in the routine evaluation of rhinitis. Intranasal corticosteroids (INCS) remain the preferred monotherapy for persistent AR, but additional studies support the additive benefit of combination treatment with INCS and intranasal antihistamines in both AR and NAR. Either intranasal antihistamines or INCS may be offered as first-line monotherapy for NAR. Montelukast should only be used for AR if there has been an inadequate response or intolerance to alternative therapies. Depot parenteral corticosteroids are not recommended for treatment of AR due to potential risks. While intranasal decongestants generally should be limited to short-term use to prevent rebound congestion, in limited circumstances, patients receiving regimens that include an INCS may be offered, in addition, an intranasal decongestant for up to 4 weeks. Neither acupuncture nor herbal products have adequate studies to support their use for AR. Oral decongestants should be avoided during the first trimester of pregnancy. Recommendations for use of subcutaneous and sublingual tablet allergen immunotherapy in AR are provided. Algorithms based on a combination of evidence and expert opinion are provided to guide in the selection of pharmacologic options for intermittent and persistent AR and NAR.

Surgical Management of Nonallergic Rhinitis

Nonallergic rhinitis (NAR) describes chronic symptoms of nasal congestion, obstruction, and rhinorrhea unrelated to a specific allergen based on skin or serum testing. Vasomotor rhinitis is the most frequent subtype of NAR. Although medical management is the first-line treatment of NAR, there is a role for surgical therapy when medications fail to improve symptoms. Surgical options for NAR include inferior turbinate reduction and botulinum toxin injection as well as more directed targeting of the autonomic nerve supply to the nasal cavity through vidian neurectomy, posterior nasal neurectomy, and cryoablation of the posterior nerve.

Medical Treatment of Nasal Airway Obstruction

Nasal obstruction is a common, and potentially debilitating, problem. It is caused by a combination of structural factors and/or mucosal swelling/inflammation. The medical treatment of nasal obstruction is aimed at decreasing mucosal inflammation and edema and is generally guided by the underlying cause. Several different drug classes are commonly used in the treatment of nasal obstruction, each with different indications, and pros and cons to their use. This article discusses the most commonly used therapies for nasal obstruction. Current evidence on the efficacy and side effect profile of each therapy is reviewed.

High prevalence of olfactory dysfunction in cervical dystonia

INTRODUCTION

Olfactory dysfunction has been established as a frequent non-motor symptom in neurodegenerative and movement disorders such as Parkinson's disease, Alzheimer's disease, and hereditary ataxias. To expand knowledge of non-motor symptoms in dystonia, and to test for a potential endophenotype, we examined olfactory function in cervical dystonia (CD).

METHODS

In patients with CD, and neurologically healthy controls, olfactory function was examined by "Sniffin' Sticks", a test of nasal chemosensory function based on pen-like odor dispensing devices. This test enables to define an individual's odor threshold, odor discrimination, and odor identification. Owing to the etiological heterogeneity of olfactory dysfunction, strict exclusion criteria were applied, especially smoking, and sinonasal disease.

RESULTS

58 CD patients completed the study. Olfactory dysfunction was present in 29 patients (50.0%), significantly more frequent than in two groups of matched healthy control subjects (20.7%; 22.4%; p = 0.001). Analysis of the pattern of hyposmia revealed that odor threshold (p = 0.002), and odor identification (p < 0.001) were significantly worse in CD patients compared to controls, while odor discrimination was unchanged. Higher age was the only clinical characteristic to correlate with olfactory dysfunction in CD.

CONCLUSIONS

Our observations establish olfactory dysfunction, possibly of both peripheral and central origin, as a new non-motor, and probably motor-unrelated, symptom of CD. Additionally, the potential involvement of cerebellar functions in olfactory identification and discrimination tasks, as well as in pathophysiology of dystonia, justifies further studies of olfactory dysfunction as a possible endophenotype in dystonia.

Autonomic nervous system dysfunction and sinonasal symptoms

Background

The autonomic nervous system (ANS) richly innervates the nose and paranasal sinuses, and has a significant role in lower airway diseases, e.g., asthma. Nonetheless, its contribution to sinonasal symptoms is poorly understood. This review aimed to explore the complex relationship between the ANS and sinonasal symptoms, with reference to systemic diseases and triggers of ANS dysfunction.

Methods

A review of articles published in English was conducted by searching medical literature databases with the key words “autonomic nervous system” and (“sinusitis” or “nose” or “otolaryngology”). All identified abstracts were reviewed, and, from these, relevant published whole articles were selected.

Results

The ANS has a significant role in the pathophysiologic mechanisms that produce sinonasal symptoms. There was limited evidence that describes the relationship of the ANS in sinonasal disease with systemic conditions, e.g. hypertension. There was some evidence to support mechanisms related to physical and psychological stressors in this relationship.

Conclusion

The role of ANS dysfunction in sinonasal disease is highly complex. The ANS sits within a web of multiple factors, including personality and psychological distress, that contribute to sinonasal symptoms. Further research will help to clarify the etiology of ANS dysfunction and its contribution to common systemic conditions.

Antipruritic Effects of Botulinum Neurotoxins

This review explores current evidence to demonstrate that botulinum neurotoxins (BoNTs) exert antipruritic effects. Both experimental and clinical conditions in which botulinum neurotoxins have been applied for pruritus relief will be presented and significant findings will be highlighted. Potential mechanisms underlying antipruritic effects will also be discussed and ongoing challenges and unmet needs will be addressed.

SOCS Proteins as Regulators of Inflammatory Responses Induced by Bacterial Infections: A Review

Severe bacterial infections can lead to both acute and chronic inflammatory conditions. Innate immunity is the first defense mechanism employed against invading bacterial pathogens through the recognition of conserved molecular patterns on bacteria by pattern recognition receptors (PRRs), especially the toll-like receptors (TLRs). TLRs recognize distinct pathogen-associated molecular patterns (PAMPs) that play a critical role in innate immune responses by inducing the expression of several inflammatory genes. Thus, activation of immune cells is regulated by cytokines that use the Janus kinase/signal transducers and activators of transcription (JAK/STAT) signaling pathway and microbial recognition by TLRs. This system is tightly controlled by various endogenous molecules to allow for an appropriately regulated and safe host immune response to infections. Suppressor of cytokine signaling (SOCS) family of proteins is one of the central regulators of microbial pathogen-induced signaling of cytokines, principally through the inhibition of the activation of JAK/STAT signaling cascades. This review provides recent knowledge regarding the role of SOCS proteins during bacterial infections, with an emphasis on the mechanisms involved in their induction and regulation of antibacterial immune responses. Furthermore, the implication of SOCS proteins in diverse processes of bacteria to escape host defenses and in the outcome of bacterial infections are discussed, as well as the possibilities offered by these proteins for future targeted antimicrobial therapies.

Botulinum Neurotoxins: Biology, Pharmacology, and Toxicology

The study of botulinum neurotoxins (BoNT) is rapidly progressing in many aspects. Novel BoNTs are being discovered owing to next generation sequencing, but their biologic and pharmacological properties remain largely unknown. The molecular structure of the large protein complexes that the toxin forms with accessory proteins, which are included in some BoNT type A1 and B1 pharmacological preparations, have been determined. By far the largest effort has been dedicated to the testing and validation of BoNTs as therapeutic agents in an ever increasing number of applications, including pain therapy. BoNT type A1 has been also exploited in a variety of cosmetic treatments, alone or in combination with other agents, and this specific market has reached the size of the one dedicated to the treatment of medical syndromes. The pharmacological properties and mode of action of BoNTs have shed light on general principles of neuronal transport and protein-protein interactions and are stimulating basic science studies. Moreover, the wide array of BoNTs discovered and to be discovered and the production of recombinant BoNTs endowed with specific properties suggest novel uses in therapeutics with increasing disease/symptom specifity. These recent developments are reviewed here to provide an updated picture of the biologic mechanism of action of BoNTs, of their increasing use in pharmacology and in cosmetics, and of their toxicology.