1
|
Grimm D, Hwang PH, Lin YT. The link between allergic rhinitis and chronic rhinosinusitis. Curr Opin Otolaryngol Head Neck Surg 2023; 31:3-10. [PMID: 36729858 DOI: 10.1097/moo.0000000000000865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
PURPOSE OF REVIEW Allergic rhinitis and chronic rhinosinusitis (CRS) are common disorders affecting millions of people worldwide. Although allergic rhinitis and CRS are distinct clinical entities, certain CRS endotypes share similar pathological mechanisms as those seen in patients with allergic rhinitis. This review assesses the literature behind the similarities and differences seen in patients with CRS and allergic rhinitis, and the role atopy might play in the pathophysiology of CRS. RECENT FINDINGS In examining the associations between allergic rhinitis and CRS, most studies have focused primarily on CRS with nasal polyps and type 2 inflammation in CRS. Recent studies have demonstrated the similarities and differences in pathologic mechanisms behind allergic rhinitis and CRS, with an emphasis on patient endotypes, genetics, and the nasoepithelial immunologic barrier. Related immunopathology shared by allergic rhinitis and type 2 inflammation in CRS has allowed for therapeutic overlap with biologic treatments. SUMMARY Allergic rhinitis and CRS often present as comorbid conditions, and understanding the relationship between allergic rhinitis and CRS is important when considering treatment options. Advances in understanding the genetics and immunology, as well as biologic and immunotherapeutic treatments have improved outcomes in patients with CRS, especially in the setting of atopy.
Collapse
Affiliation(s)
| | - Peter H Hwang
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Yi-Tsen Lin
- Department of Otolaryngology, National Taiwan University Hospital, Taipei, Taiwan
| |
Collapse
|
2
|
Schmale IL, Yao WC, Luong AU, Citardi MJ. The role of CT and endoscopy in the evaluation of patients referred for intranasal Cryoablation. Am J Otolaryngol 2021; 42:102971. [PMID: 33667795 DOI: 10.1016/j.amjoto.2021.102971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 02/14/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Cryoablation (CA) of the posterior nasal nerves has garnered increasing interest as an office-based procedure for chronic rhinitis (CR). Standardized preoperative evaluation, specifically the role of computed tomography (CT) and nasal endoscopy, has yet to be defined. We report a series of patients who underwent CT and endoscopy as part of CR work-up in patients referred for CA. OBJECTIVE Highlight the importance of both nasal endoscopy and CT scan in the evaluation of CR given significant overlap of symptoms and common occurrence of related sinonasal conditions. METHODS Retrospective analysis of all patients referred to a single tertiary rhinology practice for CA was performed. RESULTS Fifteen patients were sent for CA by medical allergists. Five patients were deemed CA candidates, and 1 patient received only medical CR treatment. Four patients had evidence of incomplete prior sinus surgery and/or continued chronic rhinosinusitis on endoscopic exam. These 4 patients received a combination of medical and surgical management with either complete resolution or improvement in CR symptoms. In 3 patients, CT confirmed chronic rhinosinusitis that was not apparent on endoscopy, and received a combination of medical and surgical management with symptom improvement. In the last two patients, final diagnoses were nasal valve collapse and recurrent acute rhinosinusitis. CONCLUSIONS Referrals for CA are becoming more common and the optimal preoperative work up remains unclear. In this limited retrospective review, 67% of patients had diagnoses other than CR and thus were not deemed candidates for CA. Both CT and endoscopy are complementary to a detailed history and physical examination and can aid in CA candidate selection.
Collapse
Affiliation(s)
- Isaac L Schmale
- Department of Otolaryngology Head and Neck Surgery, University of Rochester Medical Center, Rochester, NY, United States of America; Department of Otorhinolaryngology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States of America.
| | - William C Yao
- Department of Otorhinolaryngology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States of America
| | - Amber U Luong
- Department of Otorhinolaryngology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States of America
| | - Martin J Citardi
- Department of Otorhinolaryngology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States of America
| |
Collapse
|
3
|
Odat H, Alali M, Al-Qudah M. Aeroallergen sensitization profile in medically resistant chronic rhinosinusitis. SAGE Open Med 2020; 8:2050312120933809. [PMID: 32637103 PMCID: PMC7323274 DOI: 10.1177/2050312120933809] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 05/21/2020] [Indexed: 11/30/2022] Open
Abstract
Objectives: The aim of this study is to report the aeroallergen sensitization profile in medically resistant chronic rhinosinusitis with or without nasal polyps and its relationship to asthma. Methods: Retrospective charts review of 402 chronic rhinosinusitis patients who failed to respond to medical treatment and scheduled for surgery at a tertiary academic center was performed. One hundred and fifty-five patients had chronic rhinosinusitis with nasal polyps and 247 patients had chronic rhinosinusitis without nasal polyps, furthermore; the two phenotypes were subdivided according to the presence or absence of asthma. Allergen-specific immunoglobulin E to 24 inhalant allergens was measured to all patients by the enzyme allergo-sorbent test. Results: The average age was 35 years (SD ± 13) with 236 males and 166 females. Two hundred and fifty-three patients (63%) were tested positive for at least one allergen with no significant difference between patients with or without polyp (in chronic rhinosinusitis with nasal polyps, 103 patients (66%) were positive compared with 150 patients (61%) in chronic rhinosinusitis without nasal polyps). There were no significant differences in the prevalence, type, and number of positive allergens between the two phenotypes. The prevalence of asthma was found to be 19% in patients with chronic rhinosinusitis without nasal polyps versus 46% in those with chronic rhinosinusitis with nasal polyps (p = 0.001), and the prevalence of high eosinophils was 27%, and 47% in both phenotypes, respectively (p = 0.0001). Conclusions: The prevalence of inhalational allergy in medically resistant chronic rhinosinusitis is high, however, this profile does not differ based on the presence of polyp. Patients with chronic rhinosinusitis with nasal polyps had a higher prevalence of asthma and blood eosinophils as compared with chronic rhinosinusitis without nasal polyps. Our results showed a little role of inhalant allergens in nasal polyps or asthma comorbidity in refractory sinusitis patients.
Collapse
Affiliation(s)
- Haitham Odat
- Division of Otolaryngology, Department of Special Surgery, King Abdullah University Hospital, Jordan University of Science and Technology, Irbid, Jordan
| | - Maulla Alali
- Division of Otolaryngology, Department of Special Surgery, King Abdullah University Hospital, Jordan University of Science and Technology, Irbid, Jordan
| | - Mohannad Al-Qudah
- Division of Otolaryngology, Department of Special Surgery, King Abdullah University Hospital, Jordan University of Science and Technology, Irbid, Jordan
| |
Collapse
|
4
|
Schwarzbach HL, Mady LJ, Lee SE. What is the Role of Air Pollution in Chronic Rhinosinusitis? Immunol Allergy Clin North Am 2020; 40:215-222. [DOI: 10.1016/j.iac.2019.12.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
|
5
|
Liu C, Zheng K, Liu X, Zheng M, Liu Z, Wang X, Zhang L. Use of Nasal Nitric Oxide in the Diagnosis of Allergic Rhinitis and Nonallergic Rhinitis in Patients with and without Sinus Inflammation. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:1574-1581.e4. [DOI: 10.1016/j.jaip.2019.12.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 12/07/2019] [Accepted: 12/09/2019] [Indexed: 10/25/2022]
|
6
|
Helman SN, Barrow E, Edwards T, DelGaudio JM, Levy JM, Wise SK. The Role of Allergic Rhinitis in Chronic Rhinosinusitis. Immunol Allergy Clin North Am 2020; 40:201-214. [PMID: 32278445 PMCID: PMC7472891 DOI: 10.1016/j.iac.2019.12.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
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.
Collapse
Affiliation(s)
- Samuel N Helman
- Department of Otolaryngology, Emory University, Medical Office Tower (MOT), 11th Floor, 550 Peachtree Street Northeast, Atlanta, GA 30308, USA
| | - Emily Barrow
- Department of Otolaryngology, Emory University, Medical Office Tower (MOT), 11th Floor, 550 Peachtree Street Northeast, Atlanta, GA 30308, USA
| | - Thomas Edwards
- Department of Otolaryngology, Emory University, Medical Office Tower (MOT), 11th Floor, 550 Peachtree Street Northeast, Atlanta, GA 30308, USA
| | - John M DelGaudio
- Department of Otolaryngology, Emory University, Medical Office Tower (MOT), 11th Floor, 550 Peachtree Street Northeast, Atlanta, GA 30308, USA
| | - Joshua M Levy
- Department of Otolaryngology, Emory University, Medical Office Tower (MOT), 11th Floor, 550 Peachtree Street Northeast, Atlanta, GA 30308, USA
| | - Sarah K Wise
- Department of Otolaryngology, Emory University, Medical Office Tower (MOT), 11th Floor, 550 Peachtree Street Northeast, Atlanta, GA 30308, USA.
| |
Collapse
|
7
|
Updates to the Current Understanding of the Relationship Between Allergy and Chronic Sinusitis. CURRENT OTORHINOLARYNGOLOGY REPORTS 2020. [DOI: 10.1007/s40136-020-00287-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
|
8
|
Sella GCP, Tamashiro E, Sella JA, Aragon DC, Mendonça TND, Arruda LKDP, Anselmo Lima WT, Valera FCP. Asthma Is the Dominant Factor for Recurrence in Chronic Rhinosinusitis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 8:302-309. [PMID: 31425833 DOI: 10.1016/j.jaip.2019.08.007] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 07/22/2019] [Accepted: 08/08/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND Factors associated with recurrence of chronic rhinosinusitis (CRS) are still poorly recognized. OBJECTIVE To evaluate which risk factors could influence the risk of recurrence among patients undergoing endoscopic sinus surgery in long-term follow-up. METHODS Patients with CRS who underwent endoscopic sinus surgery were followed for an average period of 12 years in a nonconcurrent cohort. After surgery, patients were considered to an additional endoscopic sinus surgery if appropriate medical therapy failed during this period. The presence of nasal polyps, asthma, nonsteroidal anti-inflammatory drug-exacerbated respiratory disease, smoking habits, peripheral blood eosinophilia, and atopy were assessed. The recurrence-free interval between groups (with or without these risk factors) was analyzed by Kaplan-Meyer curves, and the indication for a revisional surgery was considered to be the unfavorable event. RESULTS A total of 201 patients were enrolled in this study. Patients with chronic rhinosinusitis with nasal polyps (CRSwNP) were more likely than patients with chronic rhinosinusitis without nasal polyps (CRSsNP) to need revisional surgery (adjusted hazard ratio, 2.02). Asthma was the only factor that was significantly related to recurrence both in patients with CRSsNP (hazard ratio, 5.54) and in patients with CRSwNP (hazard ratio, 3.27). Although eosinophilia itself was not related to a higher chance of recurrence, its presence influenced the outcome of CRSwNP compared with CRSsNP and the impact of asthma among patients with CRSwNP. CONCLUSIONS Prognosis in patients with CRSwNP was inferior to that in patients with CRSsNP. Asthma was the only factor that increased the chance of recurrence in patients with either CRSsNP or CRSwNP.
Collapse
Affiliation(s)
- Guilherme Constante Preis Sella
- Department of Ophthalmology, Otorhinolaryngology, and Head and Neck Surgery, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Edwin Tamashiro
- Department of Ophthalmology, Otorhinolaryngology, and Head and Neck Surgery, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Juliana Augusta Sella
- Department of Allergology and Immunology, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Davi C Aragon
- Department of Pediatrics, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Thais Nociti de Mendonça
- Department of Allergology and Immunology, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Luisa Karla de Paula Arruda
- Department of Allergology and Immunology, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Wilma Terezinha Anselmo Lima
- Department of Ophthalmology, Otorhinolaryngology, and Head and Neck Surgery, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Fabiana Cardoso Pereira Valera
- Department of Ophthalmology, Otorhinolaryngology, and Head and Neck Surgery, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil.
| |
Collapse
|
9
|
Abstract
PURPOSE OF REVIEW Most children and adolescents with allergic rhinitis (AR) present extra-nasal multimorbid conditions, including conjunctivitis, asthma, atopic dermatitis, rhinosinusitis, or seromucous otitis. Additionally, they may present nasal obstructive disorders, such as septal deformity, turbinate enlargement, and adenoidal hyperplasia, which worsen nasal symptoms, especially nasal obstruction. This is a narrative review on the current state of the concomitant presence of AR and one or more multimorbidities. RECENT FINDINGS The presence of AR and one or more accompanying multimorbidities is associated to a higher severity and duration of the disease, a negative impact on quality of life, with worse control and lack of improvement with medical treatment. Therefore, AR needs to be managed with a multidisciplinary collaborative approach. Pediatric AR needs to be considered in the context of a systemic disease, which requires a coordinated therapeutic strategy.
Collapse
|
10
|
Marcus S, DelGaudio JM, Roland LT, Wise SK. Chronic Rhinosinusitis: Does Allergy Play a Role? Med Sci (Basel) 2019; 7:medsci7020030. [PMID: 30781703 PMCID: PMC6410311 DOI: 10.3390/medsci7020030] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Revised: 02/02/2019] [Accepted: 02/12/2019] [Indexed: 12/12/2022] Open
Abstract
A few chronic rhinosinusitis (CRS) variants have demonstrated a strong association with environmental allergy, including allergic fungal rhinosinusitis (AFRS) and central compartment atopic disease (CCAD). However, the overall relationship between CRS and allergy remains poorly defined. The goal of this review is to evaluate the relationship between CRS and allergy with a focus on specific CRS variants.
Collapse
Affiliation(s)
- Sonya Marcus
- Department of Otolaryngology-Head and Neck Surgery, Emory University, Atlanta, GA 30308, USA.
| | - John M DelGaudio
- Department of Otolaryngology-Head and Neck Surgery, Emory University, Atlanta, GA 30308, USA.
| | - Lauren T Roland
- Department of Otolaryngology-Head and Neck Surgery, Emory University, Atlanta, GA 30308, USA.
| | - Sarah K Wise
- Department of Otolaryngology-Head and Neck Surgery, Emory University, Atlanta, GA 30308, USA.
| |
Collapse
|
11
|
Marcus S, Roland LT, DelGaudio JM, Wise SK. The relationship between allergy and chronic rhinosinusitis. Laryngoscope Investig Otolaryngol 2019; 4:13-17. [PMID: 30828613 PMCID: PMC6383312 DOI: 10.1002/lio2.236] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Revised: 11/06/2018] [Accepted: 11/23/2018] [Indexed: 01/28/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Sonya Marcus
- Department of Otolaryngology‐Head & Neck SurgeryEmory University School of MedicineAtlantaGeorgiaU.S.A.
| | - Lauren T. Roland
- Department of Otolaryngology‐Head & Neck SurgeryEmory University School of MedicineAtlantaGeorgiaU.S.A.
| | - John M. DelGaudio
- Department of Otolaryngology‐Head & Neck SurgeryEmory University School of MedicineAtlantaGeorgiaU.S.A.
| | - Sarah K. Wise
- Department of Otolaryngology‐Head & Neck SurgeryEmory University School of MedicineAtlantaGeorgiaU.S.A.
| |
Collapse
|
12
|
Oh SY, Hwang J, Ryu Y, Won JY, Kwon SO, Lee WH. Blood eosinophils may predict radiographic sinus opacification in patients with chronic rhinitis. Int Forum Allergy Rhinol 2018; 9:522-527. [DOI: 10.1002/alr.22270] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Revised: 11/12/2018] [Accepted: 11/29/2018] [Indexed: 12/11/2022]
Affiliation(s)
- Seung Yong Oh
- Department of OtolaryngologyNational Police Hospital Seoul Korea
| | - Junho Hwang
- Department of OtolaryngologyNational Police Hospital Seoul Korea
| | - Yoon‐Jong Ryu
- Department of OtolaryngologyKangwon National University Hospital Chuncheon Korea
| | - Jun Yeon Won
- Department of OtolaryngologyKangwon National University Hospital Chuncheon Korea
| | - Sung Ok Kwon
- Biomedical Research InstituteKangwon National University Hospital Chuncheon Korea
| | - Woo Hyun Lee
- Department of OtolaryngologyKangwon National University Hospital Chuncheon Korea
| |
Collapse
|
13
|
DelGaudio JM, Loftus PA, Hamizan AW, Harvey RJ, Wise SK. Central compartment atopic disease. Am J Rhinol Allergy 2018; 31:228-234. [PMID: 28716173 DOI: 10.2500/ajra.2017.31.4443] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Isolated polypoid changes of the middle turbinate were recently reported as having a high association with inhalant allergy. A more advanced manifestation of this association may present as polypoid changes of the entire central sinonasal compartment (i.e., the middle and superior turbinates, and the posterosuperior nasal septum), while the lateral sinus mucosa remains relatively normal. OBJECTIVE To introduce and describe this newly recognized variant of chronic rhinosinusitis (CRS), termed central compartment atopic disease (CCAD). METHODS A case series of 15 patients from two institutions who presented with sinonasal symptoms and demonstrated central compartment polypoid mucosal changes on computed tomography (CT). The endoscopic appearance of central compartment edema was assessed. Allergy status was determined by skin or serum in vitro testing. RESULTS The mean ± standard deviation patient age was 42.4 ± 14.8 years, and 47% of the patients were women. All 15 patients had a diagnosis of allergic rhinitis symptomatically, and those who underwent allergy assessment (14/15) tested positive. All the patients had central compartment polypoid edema on endoscopy and central nasal soft-tissue thickening with peripheral clearing on CT. Even with more severe sinus disease, a central focus of inflammatory change existed. CONCLUSION CCAD may represent a local inhalant allergy process that affects the central nasal structures of ethmoid origin. Although inhalant allergy changes mainly appear within the nasal cavity, medial-to-lateral progression to involve the sinuses can occur as a simple obstructive phenomenon. This is a pattern of CRS distinct from the more diffuse sinonasal inflammatory disease and likely requires allergy management as a core component.
Collapse
Affiliation(s)
- John M DelGaudio
- Department of Otolaryngology-Head and Neck Surgery, Emory University, Atlanta, Georgia, USA
| | | | | | | | | |
Collapse
|
14
|
Wise SK, Lin SY, Toskala E, Orlandi RR, Akdis CA, Alt JA, Azar A, Baroody FM, Bachert C, Canonica GW, Chacko T, Cingi C, Ciprandi G, Corey J, Cox LS, Creticos PS, Custovic A, Damask C, DeConde A, DelGaudio JM, Ebert CS, Eloy JA, Flanagan CE, Fokkens WJ, Franzese C, Gosepath J, Halderman A, Hamilton RG, Hoffman HJ, Hohlfeld JM, Houser SM, Hwang PH, Incorvaia C, Jarvis D, Khalid AN, Kilpeläinen M, Kingdom TT, Krouse H, Larenas-Linnemann D, Laury AM, Lee SE, Levy JM, Luong AU, Marple BF, McCoul ED, McMains KC, Melén E, Mims JW, Moscato G, Mullol J, Nelson HS, Patadia M, Pawankar R, Pfaar O, Platt MP, Reisacher W, Rondón C, Rudmik L, Ryan M, Sastre J, Schlosser RJ, Settipane RA, Sharma HP, Sheikh A, Smith TL, Tantilipikorn P, Tversky JR, Veling MC, Wang DY, Westman M, Wickman M, Zacharek M. International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis. Int Forum Allergy Rhinol 2018; 8:108-352. [PMID: 29438602 PMCID: PMC7286723 DOI: 10.1002/alr.22073] [Citation(s) in RCA: 218] [Impact Index Per Article: 36.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Revised: 12/01/2017] [Accepted: 12/01/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Critical examination of the quality and validity of available allergic rhinitis (AR) literature is necessary to improve understanding and to appropriately translate this knowledge to clinical care of the AR patient. To evaluate the existing AR literature, international multidisciplinary experts with an interest in AR have produced the International Consensus statement on Allergy and Rhinology: Allergic Rhinitis (ICAR:AR). METHODS Using previously described methodology, specific topics were developed relating to AR. Each topic was assigned a literature review, evidence-based review (EBR), or evidence-based review with recommendations (EBRR) format as dictated by available evidence and purpose within the ICAR:AR document. Following iterative reviews of each topic, the ICAR:AR document was synthesized and reviewed by all authors for consensus. RESULTS The ICAR:AR document addresses over 100 individual topics related to AR, including diagnosis, pathophysiology, epidemiology, disease burden, risk factors for the development of AR, allergy testing modalities, treatment, and other conditions/comorbidities associated with AR. CONCLUSION This critical review of the AR literature has identified several strengths; providers can be confident that treatment decisions are supported by rigorous studies. However, there are also substantial gaps in the AR literature. These knowledge gaps should be viewed as opportunities for improvement, as often the things that we teach and the medicine that we practice are not based on the best quality evidence. This document aims to highlight the strengths and weaknesses of the AR literature to identify areas for future AR research and improved understanding.
Collapse
Affiliation(s)
| | | | | | | | - Cezmi A. Akdis
- Allergy/Asthma, Swiss Institute of Allergy and Asthma Research, Switzerland
| | | | - Antoine Azar
- Allergy/Immunology, Johns Hopkins University, USA
| | | | | | | | | | - Cemal Cingi
- Otolaryngology, Eskisehir Osmangazi University, Turkey
| | | | | | | | | | | | | | - Adam DeConde
- Otolaryngology, University of California San Diego, USA
| | | | | | | | | | | | | | - Jan Gosepath
- Otorhinolaryngology, Helios Kliniken Wiesbaden, Germany
| | | | | | | | - Jens M. Hohlfeld
- Respiratory Medicine, Hannover Medical School, Airway Research Fraunhofer Institute for Toxicology and Experimental Medicine, German Center for Lung Research, Germany
| | | | | | | | | | | | | | | | | | | | | | | | | | - Amber U. Luong
- Otolaryngology, McGovern Medical School at the University of Texas Health Science Center Houston, USA
| | | | | | | | - Erik Melén
- Pediatric Allergy, Karolinska Institutet, Sweden
| | | | | | - Joaquim Mullol
- Otolaryngology, Universitat de Barcelona, Hospital Clinic, IDIBAPS, Spain
| | | | | | | | - Oliver Pfaar
- Rhinology/Allergy, Medical Faculty Mannheim, Heidelberg University, Center for Rhinology and Allergology, Wiesbaden, Germany
| | | | | | - Carmen Rondón
- Allergy, Regional University Hospital of Málaga, Spain
| | - Luke Rudmik
- Otolaryngology, University of Calgary, Canada
| | - Matthew Ryan
- Otolaryngology, University of Texas Southwestern, USA
| | - Joaquin Sastre
- Allergology, Hospital Universitario Fundacion Jiminez Diaz, Spain
| | | | | | - Hemant P. Sharma
- Allergy/Immunology, Children's National Health System, George Washington University School of Medicine, USA
| | | | | | | | | | | | - De Yun Wang
- Otolaryngology, National University of Singapore, Singapore
| | | | | | | |
Collapse
|
15
|
Mady LJ, Schwarzbach HL, Moore JA, Boudreau RM, Kaffenberger TM, Willson TJ, Lee SE. The association of air pollutants and allergic and nonallergic rhinitis in chronic rhinosinusitis. Int Forum Allergy Rhinol 2017; 8:369-376. [DOI: 10.1002/alr.22060] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 10/23/2017] [Accepted: 11/16/2017] [Indexed: 02/05/2023]
Affiliation(s)
- Leila J. Mady
- Department of Otolaryngology; University of Pittsburgh; Pittsburgh PA
| | | | - John A. Moore
- Department of Otolaryngology; University of Pittsburgh; Pittsburgh PA
| | - Robert M. Boudreau
- Department of Epidemiology; University of Pittsburgh Graduate School of Public Health; Pittsburgh PA
| | | | - Thomas J. Willson
- Department of Otolaryngology; San Antonio Military Medical Center; Uniformed Services University of the Health Sciences; San Antonio TX
| | - Stella E. Lee
- Department of Otolaryngology; University of Pittsburgh; Pittsburgh PA
| |
Collapse
|
16
|
Halderman AA, Tully LJ. The Role of Allergy in Chronic Rhinosinusitis. Otolaryngol Clin North Am 2017; 50:1077-1090. [DOI: 10.1016/j.otc.2017.08.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
17
|
Brook CD, Kuperstock JE, Rubin SJ, Ryan MW, Platt MP. The association of allergic sensitization with radiographic sinus opacification. Am J Rhinol Allergy 2017; 31:12-15. [PMID: 28234144 DOI: 10.2500/ajra.2017.31.4394] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND The relationship between allergic sensitization and radiographic sinus inflammation remains unclear. OBJECTIVES To determine whether specific allergen sensitization is correlated with sinonasal radiographic opacification. METHODS Patients with chronic sinonasal symptoms were selected and included if they had allergy testing and a computed tomography (CT) of the paranasal sinuses. Data regarding demographic characteristics, in vitro allergy test results, and comorbidities were collected. CTs were reviewed, and an overall Lund-Mackay score (LMS) was calculated for each patient. A two-sample t-test was used to compare mean LMS between patients who were sensitized and patients who were not sensitized. A multiple linear regression model was used to determine whether a relationship existed among LMS and allergy results, asthma, nasal polyps, immunoglobulin E (IgE) level, medication usage, in-season versus out-of-season CTs, age, and sex. Significance was determined at an alpha level of 0.05. RESULTS There were 437 patients included, of whom, 251 had positive specific allergen test results and 186 had negative test results. A total of 282 patients had allergic rhinitis symptoms without a documented diagnosis of sinusitis, and 155 carried a diagnosis of chronic rhinosinusitis. The mean LMS did not differ between patients who were sensitized and patients who were not sensitized (5.56 versus 5.28; p = 0.61). Linear regression demonstrated an increase in LMS in patients with asthma (p = 0.02), male sex (p < 0.01), elevated IgE (p < 0.01), a history of anaphylaxis (p = 0.03), and nasal polyps (p < 0.01). There was a statistically significant decrease in LMS in patients with an in-season CT (p = 0.02). CONCLUSIONS Patients with a positive specific in vitro allergen test result did not have higher overall rates of radiographic sinus inflammation. Asthma, male sex, polyps, elevated IgE, and a history of anaphylaxis were associated with higher LMS.
Collapse
Affiliation(s)
- Christopher D Brook
- Department of Otolaryngology-Head and Neck Surgery, Boston University School of Medicine, Boston, Massachusetts, USA
| | | | | | | | | |
Collapse
|
18
|
Paraskevopoulos GD, Kalogiros LA. Non-Allergic Rhinitis. CURRENT TREATMENT OPTIONS IN ALLERGY 2016. [DOI: 10.1007/s40521-016-0072-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
|
19
|
Abdollahi-Fakhim S, Sadegi-Shabestari M, Mousavi-Agdas M, Naghavi-Behzad M, Alikhah H. Medical treatment of allergy in children with recurrent or chronic sinusitis. Niger Med J 2014; 55:474-9. [PMID: 25538365 PMCID: PMC4262843 DOI: 10.4103/0300-1652.144700] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Diagnosis and treatment of chronic and recurrent sinusitis in children is of potential importance and many factors can havean influence on it. This study assessed the chronic and recurrent sinusitis and affecting factors, as well as the role of allergy in its course and treatment in children. Materials and Methods: A total of 106 children with the diagnosis of chronic or recurrent sinusitis, referred to specialty clinics of otolaryngology and allergy of Tabriz Children Educational-Medical centres since 2010 to 2012, were enrolled. The history and physicalexamination findings were recorded for all patients and allergy Prick test was done for all. Response to treatment was evaluated during the follow-up visits. Results: The mean age of studied patients was 6.5 ± 2.9 years. Of all the patients, 54 (50.9%) were male and 52 (49.1%) were female. Skin Prick test was positive in 69.8%. Response to treatment was seen in 86.8% of the patients while 7.5% did not have any favourable outcome. Anti-allergic treatment caused better outcomes in patients with positive Skin Prick test than those with negative results. Conclusion: The prevalence of allergic disease in children with chronic or recurrent sinusitis is considerable and anti-allergic treatments can result infavourable therapeutic outcomes in children with sinusitis, especially with positive skin prick test results.
Collapse
Affiliation(s)
| | | | | | - Mohammad Naghavi-Behzad
- Department of Medical Philosophy and History Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Hossein Alikhah
- Department of Medical Philosophy and History Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| |
Collapse
|
20
|
Batra PS, Tong L, Citardi MJ. Analysis of comorbidities and objective parameters in refractory chronic rhinosinusitis. Laryngoscope 2014; 123 Suppl 7:S1-11. [PMID: 24122826 DOI: 10.1002/lary.24418] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2013] [Revised: 08/10/2013] [Accepted: 08/28/2013] [Indexed: 11/07/2022]
Abstract
OBJECTIVES/HYPOTHESIS The objective of this study was to construct the clinical profile of patients with chronic rhinosinusitis (CRS) with/without polyposis undergoing revision sinus surgery and to evaluate the relationship of polyposis, asthma, acetylsalicylic acid (aspirin) (ASA) sensitivity, inhalant allergies, and previous sinus surgery on disease severity as measured by objective parameters. STUDY DESIGN Cross-sectional study. METHODS Two-hundred twenty-five patients were accrued at a tertiary care academic center. Categorical factors recorded included presence of polyps, asthma, inhalant allergy, and ASA sensitivity. Continuous variables assessed included mean number of previous sinus surgeries, Lund-Kennedy endoscopy score, Lund-Mackay computed tomography (CT) score, absolute eosinophil count (AEC), and total immunoglobulin E (tIgE) level. Statistical analysis was performed to analyze the impact of polyposis, asthma, inhalant allergy, and ASA sensitivity on objective parameters. The mean number of previous surgeries was also correlated with objective parameters. RESULTS The mean age was 50.1 years with a male:female ratio of 1.1:1. The overall prevalence of polyposis, asthma, inhalant allergy, and ASA sensitivity was 56.4%, 48.4%, 38.7%, and 16.0%, respectively. The mean endoscopy and CT scores were 9.0 (± 4.0) and 11.4 (± 5.8), respectively. The mean AEC and tIgE were 0.4 k/μL (± 0.4) and 161.4 IU/mL (± 251.4). The mean number of previous endoscopic sinus surgeries was 1.8. Patients with CRS with polyposis had a statistically significant increase in presence of asthma (odds ratio [OR]: 7.5, P < .0001), inhalant allergy (OR: 3.6, P < .0001), and ASA sensitivity (OR: 78.6, P < .0001). Patients with polyposis had a statistically significant increase in endoscopy score (P < .0001), CT score (P < .0001), AEC (P < .0001), and tIgE (P = .0002). Patients with asthma had a statistically significant increase in endoscopy (P < .0001) and CT scores (P < .0001), AEC (P < .0001), and tIgE (P = .0002). Patients with inhalant allergy had a statistically significant increase in endoscopy (P = .0069), CT scores (P = .0017), and tIgE (P = .0084) but not AEC (P = .1492). Patients with ASA sensitivity had a statistically significant increase in endoscopy score (P < .0001), CT score (P < .0001), and AEC (P = .003) but not tIgE level (P = .186). The number of previous surgeries had a statistically significant correlation with endoscopy (P = .006) and CT scores (P = .03) but not AEC (P = .48) or tIgE (P = .66). CONCLUSIONS The current analysis constructed the clinical profile of the recalcitrant CRS patient undergoing revision sinus surgery. In general, this patient group has a high prevalence of polyposis, asthma, inhalant allergy, ASA sensitivity, and elevated disease burden as measured by objective measures. The polyp phenotype signifies statistically higher prevalence of associated comorbidities and greater objective disease severity. The presence of asthma, inhalant allergy, and ASA sensitivity also predicts statistically higher disease burden. The endoscopy and CT scores statistically correlate with the number of previous surgeries. LEVEL OF EVIDENCE 4 Laryngoscope, 123:E1-E11, 2013.
Collapse
Affiliation(s)
- Pete S Batra
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | | |
Collapse
|
21
|
Wilson KF, McMains KC, Orlandi RR. The association between allergy and chronic rhinosinusitis with and without nasal polyps: an evidence-based review with recommendations. Int Forum Allergy Rhinol 2014; 4:93-103. [DOI: 10.1002/alr.21258] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2013] [Revised: 10/24/2013] [Accepted: 10/29/2013] [Indexed: 11/08/2022]
Affiliation(s)
- Kevin F. Wilson
- Division of Otolaryngology-Head and Neck Surgery; University of Utah; Salt Lake City UT
| | | | - Richard R. Orlandi
- Division of Otolaryngology-Head and Neck Surgery; University of Utah; Salt Lake City UT
| |
Collapse
|
22
|
Tan BK, Chandra RK, Pollak J, Kato A, Conley DB, Peters AT, Grammer LC, Avila PC, Kern RC, Stewart WF, Schleimer RP, Schwartz BS. Incidence and associated premorbid diagnoses of patients with chronic rhinosinusitis. J Allergy Clin Immunol 2013; 131:1350-60. [PMID: 23541327 PMCID: PMC3788631 DOI: 10.1016/j.jaci.2013.02.002] [Citation(s) in RCA: 160] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2012] [Revised: 02/02/2013] [Accepted: 02/07/2013] [Indexed: 12/30/2022]
Abstract
BACKGROUND Chronic rhinosinusitis (CRS) is a prevalent condition with underexplored risk factors. OBJECTIVES We sought to determine CRS incidence and evaluate associations with a range of premorbid medical conditions for chronic rhinosinusitis without nasal polyps (CRSsNP) and chronic rhinosinusitis with nasal polyps (CRSwNP) using real-world clinical practice data. METHODS Electronic health records data from 446,480 Geisinger Clinic primary care patients were used for a retrospective longitudinal cohort study for data from 2001-2010. By using logistic regression, newly diagnosed CRS cases between 2007 and 2009 were compared with frequency-matched control subjects on premorbid factors in the immediate (0-6 months), intermediate (7-24 months), and entire observed timeframes before diagnosis. RESULTS The average incidence of CRS was 83 ± 13 CRSwNP cases per 100,000 person-years and 1048 ± 78 CRSsNP cases per 100,000 person-years. Between 2007 and 2009, 595 patients with incident CRSwNP and 7523 patients with incident CRSsNP were identified and compared with 8118 control subjects. Compared with control subjects and patients with CRSsNP, patients with CRSwNP were older and more likely to be male. Before diagnosis, patients with CRS had a higher prevalence of acute rhinosinusitis, allergic rhinitis, chronic rhinitis, asthma, gastroesophageal reflux disease, adenotonsillitis, sleep apnea, anxiety, and headaches (all P < .001). Patients with CRSsNP had a higher premorbid prevalence of infections of the upper and lower airway, skin/soft tissue, and urinary tract (all P < .001). In the immediate and intermediate timeframes analyzed, patients with CRS had more outpatient encounters and antibiotic prescriptions (P < .001), but guideline-recommended diagnostic testing was performed in a minority of cases. CONCLUSIONS Patients who are given a diagnosis of CRS have a higher premorbid prevalence of anxiety, headaches, gastroesophageal reflux disease, sleep apnea, and infections of the respiratory system and some nonrespiratory sites, which results in higher antibiotic, corticosteroid, and health care use. The use of guideline-recommended diagnostic testing for confirmation of CRS remains poor.
Collapse
Affiliation(s)
- Bruce K Tan
- Department of Otolaryngology Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
23
|
Contreras JI, Ferguson BJ, Wang EW, Lee S. The Role of Allergy Therapy in Chronic Rhinosinusitis: A Systematic Review. CURRENT OTORHINOLARYNGOLOGY REPORTS 2012. [DOI: 10.1007/s40136-012-0001-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
|
24
|
Marple BF. Allergic rhinitis and inflammatory airway disease: interactions within the unified airspace. Am J Rhinol Allergy 2011; 24:249-54. [PMID: 20819460 DOI: 10.2500/ajra.2010.24.3499] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Allergic rhinitis (AR), the most common chronic allergic condition in outpatient medicine, is associated with immense health care costs and socioeconomic consequences. AR's impact may be partly from interacting of respiratory conditions via allergic inflammation. This study was designed to review potential interactive mechanisms of AR and associated conditions and consider the relevance of a bidirectional "unified airway" respiratory inflammation model on diagnosis and treatment of inflammatory airway disease. METHODS MEDLINE was searched for pathophysiology and pathophysiological and epidemiologic links between AR and diseases of the sinuses, lungs, middle ear, and nasopharynx. RESULTS Allergic-related inflammatory responses or neural and systemic processes fostering inflammatory changes distant from initial allergen provocation may link AR and comorbidities. Treating AR may benefit associated respiratory tract comorbidities. Besides improving AR outcomes, treatment inhibiting eosinophil recruitment and migration, normalizing cytokine profiles, and reducing asthma-associated health care use in atopic subjects would likely ameliorate other upper airway diseases such as acute rhinosinusitis, chronic rhinosinusitis (CRS) with nasal polyposis (NP), adenoidal hypertrophy, and otitis media with effusion. CONCLUSION Epidemiological concordance of AR with several airway diseases conforms to a bidirectional "unified airway" respiratory inflammation model based on anatomic and histological upper and lower airway connections. Epidemiology and current understanding of inflammatory, humoral, and neural processes make links between AR and disorders including asthma, otitis media, NP, and CRS plausible. Combining AR with associated conditions increases disease burden; worsened associated illness may accompany worsened AR. AR pharmacotherapies include antihistamines, leukotriene antagonists, intranasal corticosteroids, and immunotherapy; treatments attenuating proinflammatory responses may also benefit associated conditions.
Collapse
Affiliation(s)
- Bradley F Marple
- Department of Otolaryngology-Head and Neck Surgery, UT Southwestern Medical Center at Dallas, Dallas, Texas 75390-9035, USA.
| |
Collapse
|
25
|
Abstract
A variety of systemic conditions impact the incidence, severity, prognosis, and treatment approach in patients with chronic rhinosinusitis (CRS). The controversy surrounding the impact of allergic rhinitis on CRS continues, but it is reasonable to consider and treat allergic sources of inflammation in any patient with CRS. CRS is more severe in patients with aspirin sensitivity but improves--at least temporarily--to the same degree as in non-aspirin-sensitive patients, given appropriate therapy. Polypoid rhinosinusitis in cystic fibrosis patients is characterized by compromised mucociliary clearance and infection with staphylococcal and pseudomonal organisms. Affected individuals require frequent antibiotic treatment, saline lavage, and repeated surgeries. Rhinosinusitis is among the most common infectious complications of humoral immunodeficiency, which is not uncommon in patients with refractory CRS. The treatment approach in immunodeficiency includes aggressive antibiotic treatment and intravenous immunoglobulin. Specific diagnosis of comorbid systemic conditions with CRS will facilitate appropriate management.
Collapse
|
26
|
Quan M, Casale TB, Blaiss MS. Should clinicians routinely determine rhinitis subtype on initial diagnosis and evaluation? A debate among experts. ACTA ACUST UNITED AC 2009; 9:54-60. [PMID: 19781517 DOI: 10.1016/s1098-3597(09)80014-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
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.
Collapse
Affiliation(s)
- Martin Quan
- David Geffen School of Medicine at UCLA, Los Angeles, California 90095, USA.
| | | | | |
Collapse
|