Intranasal fluticasone propionate is effective for perennial nonallergic rhinitis with or without eosinophilia

V Brazilian Consensus on Rhinitis - 2024

Since we published the "IV Brazilian Consensus on Rhinitis", in2017, several advances have been achieved and have enabled a further understanding of the different aspects of "Rhinitis". This new guideline, developed jointly by ASBAI, SBP and SBORL, represents a relevant milestone in the updated and integrated management of the different forms of the disease, and it aims to unify evidence-based approaches to improve the diagnosis and treatment of this common and often underestimated condition. The document covers a wide range of topics, including clear definitions of the different phenotypes and endotypes of rhinitis, risk factors, updated diagnostic criteria, and recommended methods for clinical and laboratory investigation. We stress the importance of detailed clinical history and objective assessment, as well as tools for control and assessing severity tools an accurate diagnostic approach to the disease. Regarding treatment, it emphasizes the treatment customization, considering the severity of symptoms, the presence of comorbidities and the impact on the patient's quality of life. We discuss different drug treatment, in addition to non-pharmacological measures, such as environmental control and specific immunotherapy; and the possible role of immunobiological agents. Furthermore, the consensus addresses issues related to patient education, prevention and management of special situations, such as rhinitis in children, in pregnant women and in the elderly. In short, the "V Brazilian Consensus on Rhinitis" represents a comprehensive and updated guide for healthcare professionals involved in the diagnosis and management of rhinitis, aiming to improve patients' quality of life through an integrated and evidence-based approach.

Clinical Evidence of Type 2 Inflammation in Non-allergic Rhinitis with Eosinophilia Syndrome: a Systematic Review

PURPOSE OF REVIEW

Non-allergic rhinitis (NAR) includes different subtypes, among which NAR with eosinophilia syndrome (NARES) is the most important because of severity of symptoms and the high risk of comorbidities. Its pathophysiology is still object of debate, but a crucial role of chronic eosinophilic inflammation has been recognized. The aim of this review is to critically analyze the current evidence regarding the hypothesis that NARES may be considered a type 2 inflammatory disorder.

RECENT FINDINGS

The definition and diagnostic criteria for NARES are not universally shared and adopted, thus generating difficulties in reproducing the results. At present, there is extreme heterogeneity in sampling methods and disagreement in the cut-off of local eosinophilic count to determine a diagnosis of NARES. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) standard was applied to identify English-language experimental and clinical articles regarding NARES. The search was performed in April 2021. Twenty-six articles were included. Our data suggest a particular heterogeneity regarding sampling and specific cut-offs adopted for diagnosis of NARES and consensus should be reached. We suggest that eosinophil count should be reported as an absolute value for at least 10 observed rich fields in order to increase the level of standardization. Consensus among authors on this topic should be reached with particular attention to the cut-off for diagnosis. In the future, this limitation may be overcome by the identification of repeatable biomarkers to refine diagnosis and prognosis of NARES. Furthermore, our data strongly suggest that NARES have numerous similarities with clinical features of the most common type 2 diseases such as eosinophilic asthma and chronic rhinosinusitis with nasal polyps (CRSwNP): late onset, association with type 2 comorbidities, selective eosinophilic tissue infiltration, remarkable response to oral and intranasal corticosteroids, and progression in a type 2 CRSwNP.

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.

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.

Charcot-Leyden Crystal Protein in Nasal Secretions of Patients with Nonallergic Rhinitis with Eosinophilia Syndrome

INTRODUCTION

Charcot-Leyden crystal (CLC) protein has been regarded as a hallmark of eosinophilic inflammation.

OBJECTIVE

The purpose of this study was to investigate the role and levels of CLC protein in patients with nonallergic rhinitis with eosinophilia syndrome (NARES).

METHODS

Overall, 39 NARES patients and 19 controls were recruited. The severity of nasal symptoms was measured by visual analogue scale and serum and local specific immunoglobulin E were determined in all patients. Nasal eosinophilia was assessed by semiquantitative analysis of eosinophils in nasal scrapings. Nasal secretion CLC protein concentrations were evaluated by ELISA.

RESULTS

CLC protein concentrations were significantly higher in NARES patients than in controls (p < 0.0001). Nasal secretion CLC protein levels were significantly correlated with the degree of eosinophilia in nasal scrapings (rs = 0.331; p = 0.04) in NARES patients. Patients with high CLC protein concentrations displayed more severe nasal symptoms than patients with low CLC protein concentrations (p = 0.0080), particularly, nasal itching (p = 0.0029). Pilot study in 8 NARES patients demonstrated that treatment for 1 month with intranasal fluticasone propionate significantly decreased the nasal secretion CLC protein concentrations from baseline levels (p = 0.0335) and markedly attenuated the degree of swelling of inferior turbinate.

CONCLUSIONS

CLC protein levels are significantly higher in nasal secretions of NARES patients and associated with the degree of nasal eosinophilia and the severity of nasal symptoms. Significantly, nasal secretion CLC protein levels obviously decreased after treatment with intranasal corticosteroids, suggesting its possible role in evaluating the medical treatment.

Diagnosis and management of nonallergic rhinitis with eosinophilia syndrome using cystatin SN together with symptoms

Background

The diagnosis and treatment of nonallergic rhinitis with eosinophilia syndrome (NARES) remain controversial. The aim of this study was to evaluate whether Cystatin SN together with symptoms can be used to diagnose NARES and to measure the efficiency of medical treatment.

Methods

Seventy-five patients with chronic rhinitis (CR) and 18 control subjects were enrolled. Their clinical characteristics were reviewed and laboratory parameters were evaluated. The concentration of Cystatin SN in nasal secretions was determined using the enzyme-linked immunosorbent assay. The histological assessment of Cystatin SN in the nasal mucosa was conducted by hematoxylin and eosin staining. The logistic regression and receiver operating characteristic curves were used to assess the predictive value of parameters for NARES.

Results

Nasal obstruction, sneezing, loss of smell, and total visual analogue scale (VAS) score were significantly different among the patients with CR. In particular, olfaction score was higher in patients with NARES than in those without NARES (AR, LAR, or IR). Similarly, the Cystatin SN level was significantly different between the control subjects and patients with CR. After treatment for 2 weeks, the Cystatin SN level and VAS score were significantly decreased in the NARES group. The accuracy of Cystatin SN together with local sIgE and loss of smell to diagnose NARES was up to 0.987 (sensitivity, 100%; specificity, 93.1%).

Conclusions

Cystatin SN with local sIgE and loss of smell may serve as one of the reliable and alternative biomarkers for the diagnosis of NARES and be used to evaluate disease severity and NARES treatment efficacy.

Intranasal corticosteroids for non-allergic rhinitis

BACKGROUND

Non-allergic rhinitis is defined as dysfunction and non-infectious inflammation of the nasal mucosa that is caused by provoking agents other than allergens or microbes. It is common, with an estimated prevalence of around 10% to 20%. Patients experience symptoms of nasal obstruction, anterior rhinorrhoea/post-nasal drip and sneezing. Several subgroups of non-allergic rhinitis can be distinguished, depending on the trigger responsible for symptoms; these include occupation, cigarette smoke, hormones, medication, food and age. On a cellular molecular level different disease mechanisms can also be identified. People with non-allergic rhinitis often lack an effective treatment as a result of poor understanding and lack of recognition of the underlying disease mechanism. Intranasal corticosteroids are one of the most common types of medication prescribed in patients with rhinitis or rhinosinusitis symptoms, including those with non-allergic rhinitis. However, it is unclear whether intranasal corticosteroids are truly effective in these patients.

OBJECTIVES

To assess the effects of intranasal corticosteroids in the management of non-allergic rhinitis.

SEARCH METHODS

The Cochrane ENT Information Specialist searched the Cochrane ENT Register; Cochrane Central Register of Controlled Trials (CENTRAL 2019, Issue 7); PubMed; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 1 July 2019.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing intranasal corticosteroids, delivered by any means and in any volume, with (a) placebo/no intervention or (b) other active treatments in adults and children (aged ≥ 12 years).

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane. The primary outcomes were patient-reported disease severity and a significant adverse effect - epistaxis. Secondary outcomes were (disease-specific) health-related quality of life, objective measurements of airflow and other adverse events. We used GRADE to assess the certainty of the evidence for each outcome.

MAIN RESULTS

We included 34 studies (4452 participants); however, only 13 studies provided data for our main comparison, intranasal corticosteroids versus placebo. The participants were mainly defined as patients with perennial rhinitis symptoms and negative allergy tests. No distinction between different pheno- and endotypes could be made, although a few studies only included a specific phenotype such as pregnancy rhinitis, vasomotor rhinitis, rhinitis medicamentosa or senile rhinitis. Most studies were conducted in a secondary or tertiary healthcare setting. No studies reported outcomes beyond three months follow-up. Intranasal corticosteroid dosage in the review ranged from 50 µg to 2000 µg daily. Intranasal corticosteroids versus placebo Thirteen studies (2045 participants) provided data for this comparison. These studies used different scoring systems for patient-reported disease severity, so we pooled the data in each analysis using the standardised mean difference (SMD). Intranasal corticosteroid treatment may improve patient-reported disease severity as measured by total nasal symptom score compared with placebo at up to four weeks (SMD -0.74, 95% confidence interval (CI) -1.15 to -0.33; 4 studies; 131 participants; I2 = 22%) (low-certainty evidence). However, between four weeks and three months the evidence is very uncertain (SMD -0.24, 95% CI -0.67 to 0.20; 3 studies; 85 participants; I2 = 0%) (very low-certainty evidence). Intranasal corticosteroid treatment may slightly improve patient-reported disease severity as measured by total nasal symptom score change from baseline when compared with placebo at up to four weeks (SMD -0.15, 95% CI -0.25 to -0.05; 4 studies; 1465 participants; I2 = 35%) (low-certainty evidence). All four studies evaluating the risk of epistaxis showed that there is probably a higher risk in the intranasal corticosteroids group (65 per 1000) compared to placebo (31 per 1000) (risk ratio (RR) 2.10, 95% CI 1.24 to 3.57; 4 studies; 1174 participants; I2 = 0%) (moderate-certainty evidence). The absolute risk difference (RD) was 0.04 with a number needed to treat for an additional harmful outcome (NNTH) of 25 (95% CI 16.7 to 100). Only one study reported numerical data for quality of life. It did report a higher quality of life score in the intranasal corticosteroids group (152.3 versus 145.6; SF-12v2 range 0 to 800); however, this disappeared at longer-term follow-up (148.4 versus 145.6) (low-certainty evidence). Only two studies provided data for the outcome objective measurements of airflow. These data could not be pooled because they used different methods of outcome measurement. Neither found a significant difference between the intranasal corticosteroids and placebo group (rhinomanometry SMD -0.46, 95% CI -1.06 to 0.14; 44 participants; peak expiratory flow rate SMD 0.78, 95% CI -0.47 to 2.03; 11 participants) (very low-certainty evidence). Intranasal corticosteroids probably resulted in little or no difference in the risk of other adverse events compared to placebo (RR 0.99, 95% CI 0.87 to 1.12; 3 studies; 1130 participants; I2 = 0%) (moderate-certainty evidence). Intranasal corticosteroids versus other treatments Only one or a few studies assessed each of the other comparisons (intranasal corticosteroids versus saline irrigation, intranasal antihistamine, capsaicin, cromoglycate sodium, ipratropium bromide, intranasal corticosteroids combined with intranasal antihistamine, intranasal corticosteroids combined with intranasal antihistamine and intranasal corticosteroids with saline compared to saline alone). It is therefore uncertain whether there are differences between intranasal corticosteroids and other active treatments for any of the outcomes reported.

AUTHORS' CONCLUSIONS

Overall, the certainty of the evidence for most outcomes in this review was low or very low. It is unclear whether intranasal corticosteroids reduce patient-reported disease severity in non-allergic rhinitis patients compared with placebo when measured at up to three months. However, intranasal corticosteroids probably have a higher risk of the adverse effect epistaxis. There are very few studies comparing intranasal corticosteroids to other treatment modalities making it difficult to draw conclusions.

Rhinitis in children and adolescents with asthma: Ubiquitous, difficult to control, and associated with asthma outcomes

BACKGROUND

Rhinitis and asthma are linked, but substantial knowledge gaps in this relationship exist.

OBJECTIVE

We sought to determine the prevalence of rhinitis and its phenotypes in children and adolescents with asthma, assess symptom severity and medication requirements for rhinitis control, and investigate associations between rhinitis and asthma.

METHODS

Seven hundred forty-nine children with asthma participating in the Asthma Phenotypes in the Inner-City study received baseline evaluations and were managed for 1 year with algorithm-based treatments for rhinitis and asthma. Rhinitis was diagnosed by using a questionnaire focusing on individual symptoms, and predefined phenotypes were determined by combining symptom patterns with skin tests and measurement of serum specific IgE levels.

RESULTS

Analyses were done on 619 children with asthma who completed at least 4 of 6 visits. Rhinitis was present in 93.5%, and phenotypes identified at baseline were confirmed during the observation/management year. Perennial allergic rhinitis with seasonal exacerbations was most common (34.2%) and severe. Nonallergic rhinitis was least common (11.3%) and least severe. The majority of children remained symptomatic despite use of nasal corticosteroids with or without oral antihistamines. Rhinitis was worse in patients with difficult-to-control versus easy-to-control asthma, and its seasonal patterns partially corresponded to those of difficult-to-control asthma.

CONCLUSION

Rhinitis is almost ubiquitous in urban children with asthma, and its activity tracks that of lower airway disease. Perennial allergic rhinitis with seasonal exacerbations is the most severe phenotype and most likely to be associated with difficult-to-control asthma. This study offers strong support to the concept that rhinitis and asthma represent the manifestations of 1 disease in 2 parts of the airways.

[Possibilities of azelastine in the treatment of chronic rhinitis]

There is considered modern classification of rhinitis and the accents in diagnostic and therapeutic approaches to patients with this disease are indicated, as well as the possibilities of using topical intranasal antihistamines in the treatment of allergic, vasomotor and medicamentous rhinitis.

Mometasone furoate nasal spray: a systematic review

The inflammatory diseases of the nose, rhino-pharynx and paranasal sinuses (allergic and non allergic rhinitis, NARES; rhinosinusitis with/without nasal polyposis, adenoidal hypertrophy with/without middle ear involvement) clinically manifest themselves with symptoms and complications severely affecting quality of life and health care expenditure.

Intranasal administration of corticosteroids, being fast, simple, and not requiring cooperation, is the preferred way to treat the patients, to optimize their quality of life, at the same time minimizing the risk of exacerbations and complications.

Among the different topical steroids available on the market, we performed a comparative analysis in terms of effectiveness and safety between mometasone furoate (MF) and its main competitors.

Searching through Pub Med and Google Scholar and using as entries “mometasone furoate”, “rhinitis”, “sinusitis”, “asthma”, “polyposis”, “otitis media with effusion”, and “adenoid hypertrophy” we found 344 articles, 300 of which met the eligibility criteria.

Taking into account relevance and date of publication, a sample of 40 articles was considered for the review.

MF effectiveness for treatment and/or prophylaxis of nasal symptoms in seasonal and perennial allergic rhinitis has been fully established with a level of evidence Ia.

Even though it has not been assessed for MF in particular, topical steroids are the most appropriate treatment in mixed rhinitis and NARES.

In acute rhinosinusitis (ARS) evidences support their use as mono-therapy or as adjuvant to antibiotics for reducing the recurrence rate, and decrease the usage of related prescriptions and medical consultations.

In chronic rhinosinusitis (CRS) with Nasal polyposis, MF reduces polyps size, nasal congestion, improves quality of life and sense of smell and it is also effective in the treatment of daytime cough.

The topical use of MF has great efficacy in the management of adenoidal hypertrophy and otitis media of atopic children.

As regards the safety, MF has demonstrated an excellent safety profile: pregnant women can safely use it; no systemic effects on growth velocity and adrenal suppression have been shown; no changes in epithelial thickness or atrophy have been observed after long term administration of the drug.

Conclusions: MF has been demonstrated to be effective in the treatment of the inflammatory diseases of the nose and paranasal sinuses; when compared to its competitors it shows a greater symptom control; it is a reliable treatment in the long term thanks not only to its proven efficacy, but also to its safety being on the market since more than 17 years.

Clinically relevant outcome measures of novel pharmacotherapy for nonallergic rhinitis

PURPOSE OF REVIEW

The purpose of this review is to briefly provide the current understanding of the pathogenesis of nonallergic rhinitis (NAR), currently available pharmacotherapies as well as some recent advancement in pharmacotherapy for this condition. With this background on NAR, we then describe and contrast outcome measures used in previous NAR and allergic rhinitis clinical trials. Finally, we conclude with a brief discussion on which of these outcomes might be most suitable for future NAR clinical trials.

RECENT FINDINGS

NAR is a heterogeneous condition in which multiple mechanisms have been postulated to be involved. Patients with NAR commonly experience chronic nasal congestion and anterior and/or posterior drainage, which significantly affects their quality of life. Current standard of care is primarily symptom based, as specific therapies that target the underlying mechanisms of this condition are lacking. As there are no current treatment algorithms for NAR, clinical response and outcomes can vary widely between patients. Intranasal corticosteroids and intranasal antihistamines have been found to be effective in well designed clinical trials in the treatment of NAR and are therefore considered first-line therapies. Recently, studies investigating a combination of intranasal antihistamine/corticosteroid and an intranasal decongestant and with an intranasal corticosteroid have shown promise for allergic rhinitis and may also be more effective than monotherapy for NAR. Multiple outcome measures have been used in previous NAR trials, the most common being variations of nasal symptoms scores. Given the differences in prominent symptoms typically experienced by allergic rhinitis and NAR, accurate clinical outcomes used to evaluate new treatments for these two patient groups will likely differ. Further studies specifically designed to investigate the efficacy of various therapeutic agents in NAR are required to improve the management and outcomes of this chronic condition.

SUMMARY

Further research is required to expand our understanding of the pathobiology of NAR that should lead to novel therapeutic approaches for managing this condition. It will be necessary to have well established validated NAR outcomes that can be used to study these novel therapies.

Nonallergic Rhinitis: Treatment

Chronic nonallergic rhinitis (NAR) is a syndrome rather than a specific disease. A lack of understanding of the pathogenesis of this condition has led to imprecise terminology with several alternate names for the condition, including vasomotor rhinitis, nonallergic rhinopathy, and idiopathic rhinitis. The therapy for NAR is best based on the underlying pathology, which typically exists in a form whereby an abnormality of the autonomic nervous system is dominant or a form in which inflammation seems to be the cause of symptoms. In general the most effective therapy is the combination of an intranasal antihistamine and an intranasal corticosteroid.

[Local allergic rhinitis to Alternaria alternata : Evidence for local IgE production exclusively in the nasal mucosa]

In a subgroup of patients with symptoms of allergic rhinitis (AR), no systemic sensitization can be detected in skin tests or serum. These patients are considered to be afflicted with so-called "local allergic rhinitis" (LAR) with IgE-production exclusively at the site of the nasal mucosa. Patients without any positive allergy test results but seasonal (intermittent) or perennial (persistent) allergic symptoms were often misdiagnosed as having "non-allergic rhinitis" (NAR) in the past.However, there is evidence for a specific IgE-production in the nasal mucosa in these patients without systemic sensitization. The diagnosis of LAR is confirmed by clinical symptoms, the detection of specific IgE production in the nasal mucosa and/or nasal provocation tests.We report on two cases of LAR to Alternaria alternata with symptoms of persistent allergic rhinitis that have been diagnosed by positive allergenspecific nasal challenge tests and specific IgE determinations in nasal secretions.According to an actual literature research, this is the second report published on LAR caused by Alternaria alternata.

Non-allergic rhinitis with eosinophilia syndrome is not associated with local production of specific IgE in nasal mucosa

Non-allergic rhinitis with eosinophilia syndrome (NARES) is an eosinophilic inflammation of the nasal mucosa without evidence of an allergy or other nasal pathologies. Patients complain about perennial symptoms like nasal obstruction, rhinorrhea, itchiness and sneezing of the nose sometimes accompanied by hyposmia. The aim of the study was to better characterize NARES patients using immunoassay-biochip technology to examine serum and nasal secretion. Sera and nasal secretion of patients with NARES (perennial nasal symptoms, no evidence of acute or chronic rhinosinusitis with or without polyps, negative SX1-Screening test and/or negative skin prick test, eosinophilic cationic protein in nasal secretion >200 ng/ml) were tested by immunoassay-biochip technology (ImmunoCAP(®) ISAC, Phadia). 112 different allergen components from 51 allergen sources were tested on the chip. Furthermore, serum and nasal secretion were tested for specific IgE to Staphylococcus aureus enterotoxin TSST-1 by fluorescence-enzyme-immunoassay (UniCAP(®), Phadia). Unrecognized systemic sensitization could be ruled out by negative ISAC results in sera of all patients. Testing of nasal secretion for allergen-specific IgE by ISAC chip technology was negative as well in all cases. In one patient, a systemic sensitization to Staphylococcus aureus superantigen TSST-1 was detectable but no allergen-specific IgE to TSST-1 was measurable in nasal secretion of any patient. The results demonstrate that NARES is not associated with local allergy (entopy) nor with a local inflammation driven by Staphylococcus aureus enterotoxin TSST-1. Further studies are necessary to better understand the underlying mechanisms of NARES.

Clinical Efficacy of Nasal Steroids on Nonallergic Rhinitis and the Associated Inflammatory Cell Phenotypes

Background

Although good response to nasal steroid therapy has been documented in allergic rhinitis (AR), the efficacy of this treatment in non-AR, and the associated inflammatory cell phenotypes has not been fully investigated.

Objective

To compare the response to steroids in non-AR versus AR and to assess the impact of inflammatory cell phenotypes on non-AR treatment outcomes.

Methods

A total of 149 patients with rhinitis were divided into non-AR and AR groups by using the allergy skin-prick test. Based on nasal cytology, the non-AR group was further divided into inflammatory non-AR (INAR) and noninflammatory non-AR (NINAR) groups, and the INAR groups were further subdivided into four phenotypes according to inflammatory cell type: non-AR with eosinophils (NARES), non-AR with mast cells (NARMA), non-AR with neutrophils (NARNE), and NARES and mast cells (NARESMA). All the patients were treated over 28 days with 220 μg of nasal triamcinolone acetonide once daily. Nasal symptom score, peak inspiratory flow index, and nasal mucociliary clearance time (NMCCT) were used to evaluate treatment outcomes.

Results

The initial screening found 67 patients with non-AR and 82 patients with AR. At 28 days after nasal steroid treatment, all nasal symptom score, peak inspiratory flow indexes, and NMCCTs were significantly improved within each group; however, the non-AR group recorded significantly lower levels of improvement in blocked nose, rhinorrhea, sneezing, nasal itching, peak flows, and NMCCTs than the AR group. The NINAR group overall indicated lower levels of improvement than the INAR group. Among the INAR subgroups, the NARESMA, NARES, and NARMA phenotypes had similar outcome improvements, all better than the NARNE phenotype.

Conclusion

Although both patients with non-AR and those with AR had good steroid response, the patients with non-AR had less improvement than the patients with AR. Patients with NINAR had the worst treatment outcome among the non-AR phenotypes.

Azelastine desensitization of transient receptor potential vanilloid 1: a potential mechanism explaining its therapeutic effect in nonallergic rhinitis

BACKGROUND

Capsaicin, a prototypic transient receptor potential vanilloid 1 (TRPV1) agonist, has been shown to be more clinically effective in the treatment of nonallergic rhinitis (NAR) compared with other rhinitis subtypes. Azelastine has also been found to be clinically effective in the treatment of NAR but its mechanism(s) of action is still poorly elucidated. This study was designed to determine, using in vitro cell lines, whether topical therapies including azelastine have activity on TRPV1 ion channels similar to capsaicin.

METHODS

The effects of capsaicin (1 μM), azelastine (30 μM), bepotastine (10 μM), olopatadine (10 μM), and fluticasone (200 μM) on TRPV1 channels using mice neuronal cells (Cath.a), as surrogates for submucosal sensory neurons, and human nasal epithelial cells (hNEC) were determined and compared. For azelastine, bepotastine, and capsaicin, which elicited an agonist effect on TRPV1, live cell [Ca(2+)] signaling in Cath.a cells and hNECs expressing TRPV1 were performed in the absence and presence of capsazepine at 10 μM (a TRPV1 antagonist) or using wild-type mouse embryonic fibroblasts (wtMEFs) that express TRPV1 ion channels and TRPV1 homozygous null mutant (TRPV1-/-) knockout MEF cells as controls to establish TRPV1 channel selectivity. As azelastine has previously been found clinically effective in NAR, additional experiments were performed to determine its ability to desensitize TRPV1 ion channels and its effect on regulating intracellular calcium homeostasis.

RESULTS

Cath.a cells treated with azelastine, bepotastine, or capsaicin showed a significant increase in TRPV1-dependant (Ca(2+)) specific cytosolic fluorescence. Continuous treatment with azelastine or capsaicin resulted in desensitization of TRPV1 channels. In hNECs, azelastine stimulation resulted in Ca(2+) shifts from the cytosol to mitochondria and overexpression of hematopoietic cell-specific Lyn substrate 1-associated protein X1, which may thus be effective in cytosolic Ca(2+) homeostasis.

CONCLUSION

Azelastine, similar to capsaicin, exhibits direct activity on TRPV1 ion channels that may represent a novel mechanistic pathway explaining its clinical efficacy in NAR.

Diagnostic criteria for a curable form of chronic rhinosinusitis: the mucous recirculation syndrome

In clinical practice, nonallergic rhinosinusitis (rhinopathy) is a common diagnosis of exclusion. The mucous recirculation syndrome is one incompletely defined condition that masquerades as nonallergic rhinopathy. Mucous recirculation syndrome, a curable condition, should be differentiated from nonallergic rhinopathy. The underdiagnosis of this condition is due in part to a lack of diagnostic criteria. In this article, we review the medical literature to better characterize mucous recirculation syndrome and to establish diagnostic criteria for it.

Nonallergic rhinitis

Rhinitis is normally defined by the symptoms of nasal congestion, postnasal drainage, rhinorrhea, and sneezing. It has been associated with various pathologic changes, but can occur in the absence of any inflammation. Thus, the diagnosis is based on the clinical presentation. There are no clear-cut criteria to distinguish when rhinitis becomes chronic, but in its chronic form, it can be complex. Chronic forms of rhinitis that occur in the absence of any detectable specific IgE against relevant aeroallergens in its broadest sense can be called chronic nonallergic rhinitis. This review will concentrate on chronic nonallergic rhinitis in its various forms, discussing the epidemiology, underlying mechanisms, and its therapy.

Efficacy and safety of once daily triamcinolone acetonide aqueous nasal spray in adults with non-allergic and allergic rhinitis

BACKGROUND

The efficacy of corticosteroid has not been thoroughly studied in the treatment of non-allergic rhinitis. This study was designed to compare the efficacy of nasal corticosteroid in patients with allergic rhinitis (AR), and non-allergic rhinitis (NAR).

METHODS

The efficacy of triamcinolone acetonide nasal spray (TANS) on total nasal symptom scores (TNSS), and nasal peak inspiratory flow rate (nPIFR) was studied in a six-week parallel-group trial of NAR (n: 25), and AR (n: 16) patients. Health-related quality of life (HRQoL) and Epworth Sleepiness Scale (ESS) were also analysed.

RESULTS

The TNSSs, and symptom scores of conjunctivitis, snoring, and postnasal drainage were significantly improved in both groups, after two and six weeks of treatment. In contrast to AR, patients with NAR had statistically significant improvement in nasal obstruction, and postnasal drainage beginning from two weeks of the treatment. nPIFR slightly increased in both groups. Scores of generic (SF-36), rhinitis specific (MiniRQLQ) and ESS questionnaires generally improved better in AR than NAR. TANS was well-tolerated in AR and NAR groups with minor adverse events including headache, nasal burning, and bitter mouth taste.

CONCLUSIONS

Our study disproved the idea of ineffectiveness of corticosteroid treatment in NAR, and showed that triamcinolone acetate may be an alternative drug in the treatment of NAR.

[Local (exclusive) IgE production in the nasal mucosa. Evidence for local allergic rhinitis]

BACKGROUND

IgE production at the site of the nasal mucosa without systemic allergic sensitization in skin tests or in serum represents so-called "local allergic rhinitis (LAR)" as a subgroup of patients with symptoms of allergic rhinitis (AR). Formerly, in case of negative allergological test results, seasonal (intermittent) or perennial (persistent) allergic symptoms have been diagnosed as "non-allergic rhinitis" (NAR). However, there is evidence for specific Th2 cytokine, tryptase, and ECP (eosinophil catonic protein) production in the nasal secretion after allergen exposure in these patients without systemic sensitization.

DIAGNOSIS

Taking this into account, we recommend performing an allergen-specific nasal challenge and measuring the (local) nasal IgE-levels in addition to standard allergy tests in clinical routine in this subgroup of patients. These tests should be perfomed while or shortly after allergen exposure. In addition, an update of the allergy testing should be performed after a time interval since it has been demonstrated that patients formerly diagnosed with NAR may develop LAR or AR, or patients with LAR may develop AR in the future.

TREATMENT

The pharmacological therapeutic options in LAR are in line with the treatment of AR. If and to what extent this subgroup of AR patients benefit from allergen-specific immunotherapy (SIT) is currently being evaluated in clinical trials.

Nonallergic rhinitis, with a focus on vasomotor rhinitis: clinical importance, differential diagnosis, and effective treatment recommendations

The term "rhinitis" denotes nasal inflammation causing a combination of rhinorrhea, sneezing, congestion, nasal itch, and/or postnasal drainage. Allergic rhinitis is the most prevalent and most frequently recognized form of rhinitis. However, nonallergic rhinitis (NAR) is also very common, affecting millions of people. By contrast, NAR is less well understood and less often diagnosed. Nonallergic rhinitis includes a heterogeneous group of conditions, involving various triggers and distinct pathophysiologies. Nonallergic vasomo-tor rhinitis is the most common form of NAR and will be the primary focus of this review. Understanding and recognizing the presence of NAR in a patient is essential for the correct selection of medications and for successful treatment outcomes.

Reproducibility, validity, and responsiveness of cell counts in blown nasal secretions

Cell counts in nasal secretions are not used in routine clinical practice to decide on anti-inflammatory or antimicrobial therapy. This study investigated the reproducibility, reliability (validity), and responsiveness of cell counts in blown nasal secretions with a view to implementing this in routine clinical practice. Nasal secretions were obtained from 19 subjects with allergic rhinitis on 3 days in random order (each separated by 1–2 days) by spontaneously blowing their noses (on 2 days) and by a nasal lavage by the modified Grunberg method on the 3rd day. Total and differential cell counts were performed after dispersing the solutions with dithiothreitol as described previously. At the end of the study, subjects had 1 week of open label treatment with nasal corticosteroids if they had nasal eosinophilia or an antibiotic if they had nasal neutrophilia. If the cell counts were normal, they were not treated. The proportion of eosinophil (%) was highly reproducible (intraclass correlation coefficient [ICC], 0.93), and the total cell count (×106/g) and the proportion of neutrophil (%) were modestly reproducible in blown nasal secretions (ICC, 0.46 and 0.55, respectively). The total cell count was consistently and significantly higher in the blown nasal secretions. The proportion of eosinophils (R_s = 0.4; p < 0.05) and neutrophils (R_s = 0.6; p < 0.05) showed modest correlation in the two types of samples. The responsiveness index for eosinophil count was 4.0 and for neutrophil count was 1.5. Total and differential cell counts can be reliably and reproducibly obtained from spontaneously blown nasal secretions. The cell counts are responsive to treatment and can help identify allergic and infective rhinosinusitis and guide therapy and are easy to implement in routine clinical practice.

Severe chronic allergic (and related) diseases: a uniform approach--a MeDALL--GA2LEN--ARIA position paper

Concepts of disease severity, activity, control and responsiveness to treatment are linked but different. Severity refers to the loss of function of the organs induced by the disease process or to the occurrence of severe acute exacerbations. Severity may vary over time and needs regular follow-up. Control is the degree to which therapy goals are currently met. These concepts have evolved over time for asthma in guidelines, task forces or consensus meetings. The aim of this paper is to generalize the approach of the uniform definition of severe asthma presented to WHO for chronic allergic and associated diseases (rhinitis, chronic rhinosinusitis, chronic urticaria and atopic dermatitis) in order to have a uniform definition of severity, control and risk, usable in most situations. It is based on the appropriate diagnosis, availability and accessibility of treatments, treatment responsiveness and associated factors such as comorbidities and risk factors. This uniform definition will allow a better definition of the phenotypes of severe allergic (and related) diseases for clinical practice, research (including epidemiology), public health purposes, education and the discovery of novel therapies.

Scientific rationale for the use of alpha-adrenergic agonists and glucocorticoids in the therapy of pediatric stridor

Purpose. The most common pharmacological therapies used in the treatment of stridor in children are glucocorticosteroids (GC) and alpha-adrenergic (αAR) agonists. Despite the long-standing reported efficacy of these medications, there is a paucity of data relating to their actual mechanisms of action in the upper airway. Summary. There is compelling scientific evidence supporting the use of αAR-agonists and GCs in pediatric stridor. αAR signaling and GCs regulate the vasomotor tone in the upper airway mucosa. The latter translates into better airflow dynamics, as delineated by human and nonhuman upper airway physiological models. In turn, clinical trials have demonstrated that GCs and the nonselective αAR agonist, epinephrine, improve respiratory distress scores and reduce the need for further medical care in children with stridor. Future research is needed to investigate the role of selective αAR agonists and the potential synergism of GCs and αAR-signaling in the treatment of upper airway obstruction and stridor.

Management of rhinitis: guidelines, evidence basis, and systematic clinical approach for what we do

Whereas very mild rhinitis may be simply and successfully self-managed by patients using medications available over the counter, most patients with rhinitis who present to medical offices have more severe rhinitis that may need a more comprehensive diagnostic and therapeutic approach. Optimal care may require special diagnostic studies and combination therapies that are arrived at only after trying multiple different medication and therapeutic options. This article presents a systematic approach to office care of rhinitis from the perspective of an allergist-immunologist. More emphasis is given to discussion of dilemmas that face the specialist or more involved considerations that have been highlighted in recently published guidelines.

The role of nasal corticosteroids in the treatment of rhinitis

Intranasal corticosteroids (INSs) are the first choice for rhinitis pharmacotherapy. This preference is because of their broad range of actions that result in reductions of proinflammatory mediators, cytokines, and cells. Over the past 30 years, INSs have been modified to improve their pharmacodynamic, pharmacokinetic, and delivery system properties, with attention to improving characteristics such as receptor binding affinity, lipophilicity, low systemic bioavailability, and patient preference. Clinically, they have been shown to be the most effective class of nasal medications for treating allergic rhinitis and nonallergic rhinopathy, with no clear evidence that any specific INS is superior to others.

Nonallergic rhinopathy (formerly known as vasomotor rhinitis)

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

Management of rhinitis: allergic and non-allergic

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

Vasomotor rhinitis

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

Molecular mechanisms of glucocorticoids action: implications for treatment of rhinosinusitis and nasal polyposis

Intra-nasal glucocorticoids are the most effective drugs available for rhinosinusitis and nasal polyposis treatment. Their effectiveness depends on many factors and not all of them have been well recognized so far. The authors present the basic information on molecular mechanisms of glucocorticoid action, direct and indirect effects of glucocorticoids on transcription of genes encoding inflammatory mediators. They focus on recently proved nongenomic mechanisms which appear quickly, from several seconds to minutes after glucocorticoid administration and discuss clinical implications resulting from this knowledge. Discovery of nongenomic glucocorticoid actions allows for better use of these drugs in clinical practice.

Treatment of congestion in upper respiratory diseases

Congestion, as a symptom of upper respiratory tract diseases including seasonal and perennial allergic rhinitis, acute and chronic rhinosinusitis, and nasal polyposis, is principally caused by mucosal inflammation. Though effective pharmacotherapy options exist, no agent is universally efficacious; therapeutic decisions must account for individual patient preferences. Oral H₁-antihistamines, though effective for the common symptoms of allergic rhinitis, have modest decongestant action, as do leukotriene receptor antagonists. Intranasal antihistamines appear to improve congestion better than oral forms. Topical decongestants reduce congestion associated with allergic rhinitis, but local adverse effects make them unsuitable for long-term use. Oral decongestants show some efficacy against congestion in allergic rhinitis and the common cold, and can be combined with oral antihistamines. Intranasal corticosteroids have broad anti-inflammatory activities, are the most potent long-term pharmacologic treatment of congestion associated with allergic rhinitis, and show some congestion relief in rhinosinusitis and nasal polyposis. Immunotherapy and surgery may be used in some cases refractory to pharmacotherapy. Steps in congestion management include (1) diagnosis of the cause(s), (2) patient education and monitoring, (3) avoidance of environmental triggers where possible, (4) pharmacotherapy, and (5) immunotherapy (for patients with allergic rhinitis) or surgery for patients whose condition is otherwise uncontrolled.

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

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

The treatment of vasomotor rhinitis with intranasal corticosteroids

Objective

Intranasal steroids (INS) are firmly established as the therapy for choice for allergic rhinitis, but their role in vasomotor rhinitis (VMR) is not fully characterized. This review examines the potential mechanisms of action and reported efficacy of INS in patients with VMR.

Results

INS, through intracellular activation of the glucocorticoid receptor, down-regulate the recruitment and activation of inflammatory cells (T-lymphocytes, eosinophils, mast cells, basophils, neutrophils, macrophages), increase degradation of neuropeptides, and reduce epithelial cell activity, vascular permeability, and chemokine secretion. It is likely that more than vasoconstriction is responsible for the clinical effects of INS.

Eight INS can be prescribed for rhinitis in the US; only 4 have been studied for VMR. Seventy-four percent of patients treated with beclomethasone dipropionate considered themselves symptom-free or greatly improved versus 31% with placebo. Budesonide significantly reduced rhinitis symptoms and methacholine-induced nasal secretions compared with placebo. Fluticasone propionate compared with placebo provided significantly greater relief from nasal obstruction; computed tomographic scans showed significant reductions in the mucosal area of the lower turbinates. Mometasone furoate produced numerically better rhinitis symptom scores and, when discontinued, lower relapse rates than placebo.

Conclusion

Data supports INS as beneficial pharmacotherapy for VMR.

Nonallergic rhinitis, with a focus on vasomotor rhinitis: clinical importance, differential diagnosis, and effective treatment recommendations

The term "rhinitis" denotes nasal inflammation causing a combination of rhinorrhea, sneezing, congestion, nasal itch, and/or postnasal drainage. Allergic rhinitis is the most prevalent and most frequently recognized form of rhinitis. However, nonallergic rhinitis (NAR) is also very common, affecting millions of people. By contrast, NAR is less well understood and less often diagnosed. Nonallergic rhinitis includes a heterogeneous group of conditions, involving various triggers and distinct pathophysiologies. Nonallergic vasomotor rhinitis is the most common form of NAR and will be the primary focus of this review. Understanding and recognizing the presence of NAR in a patient is essential for the correct selection of medications and for successful treatment outcomes.

Allergic and idiopathic rhinitis: an ultrastructural study

Nasal hyperreactivity is one of the most important underlying mechanisms in both allergic (AR) and idiopathic rhinitis (IR). In order to study the pathomorphological changes in this entity, tissue samples from patients with AR, IR, and from patients without chronic inflammation were taken during nasal surgery. Primary antibodies against Substance P (SP), calcitonin gene-related peptide (CGRP), and endothelial nitric oxide synthases (NOS III) were applied and the immunocomplexes were visualized by immunocytochemistry. The nasal mucosa of patients with AR and IR showed similarities on the ultrastructural level. Neurogenic inflammation was indicated by a strong innervation pattern with sensory nerve fibers containing SP and CGRP. We could show that extensive edema and cellular infiltration might be characteristic for AR. On other hand there was no evidence of eosinophilic or NO involvement in IR. Finally, on the ultrastructural level, AR and IR showed many similarities. Based on these findings anti-inflammatory therapy modalities could be recommended for both types of rhinitis.

[Ultrastructural changes in allergic rhinitis vs. idiopathic rhinitis]

BACKGROUND

Nasal hyperreactivity is one of the most important underlying mechanisms in allergic rhinitis (AR) as well as idiopathic rhinitis (IR). The aim of the present study was to examine pathomorphological changes in nasal mucosa in these subgroups of rhinitis.

PATIENTS AND METHODS

Tissue samples of human inferior turbinates from 20 patients with AR and 16 patients with IR were taken during nasal surgery and preserved in glutaraldehyde or paraformaldehyde. Ultrathin sections of specimens from 15 patients without chronic inflammation of nasal mucosa were used as controls. Primary antibodies against substance P (SP), calcitonin-gene-related peptide (CGRP), and endothelial nitric oxide synthase (NOS III) were applied, and the immunocomplexes were visualized by an immunocytochemical staining technique using gold-labeled antibodies. Immunostained structures were photodocumented using light and transmission electron microscopy.

RESULTS

The nasal mucosa of patients with AR and IR showed similarities on the ultrastructural level. A strong innervation pattern with sensory nerve fibers containing SP and CGRP demonstrated neurogenic inflammation. Extensive edema and cellular infiltrations were found in AR. A decreased presence of eosinophils and nitric oxide was observed in IR.

CONCLUSIONS

On the ultrastructural level, AR and IR showed many similarities but also some differences. Based on these findings, anti-inflammatory therapy could be recommended for both types of rhinitis.

Important research questions in allergy and related diseases: nonallergic rhinitis: a GA2LEN paper

Nonallergic rhinitis (NAR) can be defined as a chronic nasal inflammation which is not caused by systemic IgE-dependent mechanisms. It is common and probably affects far more than 200 million people worldwide. Both children and adults are affected. However, its exact prevalence is unknown and its phenotypes need to be evaluated using appropriate methods to better understand its pathophysiology, diagnosis and management. It is important to differentiate between infectious rhinitis, allergic/NAR and chronic rhinosinusitis, as management differs for each of these cases. Characterization of the phenotype, mechanisms and management of NAR represents one of the major unmet needs in allergic and nonallergic diseases. Studies on children and adults are required in order to appreciate the prevalence, phenotype, severity and co-morbidities of NAR. These studies should compare allergic and NAR and consider different age group populations including elderly subjects. Mechanistic studies should be carried out to better understand the disease(s) and risk factors and to guide towards an improved diagnosis and therapy. These studies need to take the heterogeneity of NAR into account. It is likely that neuronal mechanisms, T cells, innate immunity and possibly auto-immune responses all play a role in NAR and may also contribute to the symptoms of allergic rhinitis.

Nonallergic rhinitis with eosinophilia syndrome

Nonallergic rhinitis with eosinophilia syndrome (NARES) is a clinical syndrome comprising symptoms consistent with allergic rhinitis in which an absence of atopy has been demonstrated by allergen skin testing, and nasal cytology analysis demonstrates more than 20% eosinophils. Anosmia is a prominent feature not shared with allergic rhinitis. The pathophysiology of NARES is poorly understood, but a key component involves a self-perpetuating, chronic eosinophilic nasal inflammation with development of nasal micropolyposis and polyposis. Mast cells likely play an important role as well. NARES is a risk factor for the development of nasal polyposis and aspirin sensitivity, as well as obstructive sleep apnea. Treatment consists mainly of intranasal corticosteroids with or without the addition of second-generation antihistamines and/or leukotriene-receptor antagonists.

Pharmacologic and anti-IgE treatment of allergic rhinitis ARIA update (in collaboration with GA2LEN)

The pharmacologic treatment of allergic rhinitis proposed by ARIA is an evidence-based and step-wise approach based on the classification of the symptoms. The ARIA workshop, held in December 1999, published a report in 2001 and new information has subsequently been published. The initial ARIA document lacked some important information on several issues. This document updates the ARIA sections on the pharmacologic and anti-IgE treatments of allergic rhinitis. Literature published between January 2000 and December 2004 has been included. Only a few studies assessing nasal and non-nasal symptoms are presented as these will be discussed in a separate document.

Effect of topical vapocoolant spray on skin test wheal, flare, and pain responses

BACKGROUND

Skin puncture and intradermal tests are commonly used to evaluate allergic rhinitis. Ethyl chloride, a topical vapocoolant spray, provides skin analgesia before venipuncture, but it has not been studied with allergy skin testing.

OBJECTIVE

To determine the effects of ethyl chloride vs placebo on skin puncture testing (SPT) and intradermal allergy testing.

METHODS

We enrolled 20 healthy adults with a history of positive aeroallergen skin test results in a randomized, double-masked, placebo-controlled study. Ethyl chloride and placebo sprays were randomly placed on the upper back. Paired SPT was performed with saline, histamine, and standardized aeroallergens, including Bermuda grass, Kentucky blue grass, timothy grass, cat, Dermatophagoides pteronyssinus, and Dermatophagoides farinae. Serial dilutional end-point intradermal tests were then performed using 1 standardized aeroallergen. Wheal and flare areas were outlined, scanned, and digitally measured. Participants used a 10-cm visual analog scale to record pain during skin testing.

RESULTS

Eighteen individuals completed the study. Compared with placebo, ethyl chloride had no significant effect on histamine wheal (P = .53), histamine flare (P = .39), aeroallergen wheal (P = .10), or aeroallergen flare (P = .71) area for SPT. Serial dilutional end-point intradermal testing was similar after ethyl chloride and placebo application (P = .75). Mean pain scores for SPT were improved with ethyl chloride compared with paired placebo skin tests, although pain scores did not reach significance for SPT (P = .21) or intradermal testing (P = .87).

CONCLUSIONS

Ethyl chloride does not significantly reduce histamine and aeroallergen wheal and flare areas during SPT and intradermal allergy skin testing. Ethyl chloride, vs placebo, reduced pain in some individuals during skin testing, although this did not attain statistical significance.