The prevalence of allergic rhinosinusitis: a review

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.

Paranasal sinus disease could be a reason for unsuccessful immunotherapy of inhalant allergy in children

PURPOSE

The aim of this study was to evaluate the role of paranasal sinuses condition assessed in computed tomography on inhalant allergen desensitization effects.

MATERIALS & METHODS

Retrospective analysis of medical records of children undergoing allergen immunotherapy in outpatient otolaryngology clinic of University Children Hospital in Lublin was performed. Control group consisted of children who underwent allergen immunotherapy and obtained satisfying effects; study group consisted of children who did not experience significant improvement after desensitization therapy.

RESULTS

Computed tomography of nose cavity and paranasal sinuses exposed numerous pathologic changes affecting both, control and study group. Blockage of ostiomeatal complex was twice more common in children who did not respond adequately to desensitization therapy. In our study group, radiological findings suggesting rhinosinusitis were found in 73% of patients, while retention cysts in maxillary sinuses were discovered in 27% of patients.

CONCLUSIONS

Pathological findings in paranasal sinuses in computed tomography may arise from uncontrolled allergic rhinitis. If chirurgical management is indicated, allergen immunotherapy should be postponed until total recovery from operational procedure and repeated.

Prevalence of chronic rhinosinusitis in the setting of Behçet disease

Behçet disease (BD) is a systemic autoimmune/autoinflammatory, T helper 1-mediated condition. It is well known that the prevalence of a T helper 1-mediated disease increases in the presence of another T helper 1-mediated comorbidity. The purpose of this study was to investigate the prevalence of T helper 1-mediated chronic rhinosinusitis without nasal polyposis (CRSsNP) and T helper 2-mediated chronic rhinosinusitis with polyposis in the presence of comorbid BD. Sixty-nine patients and 74 healthy controls were included in the study. Participants were asked to complete a questionnaire for symptoms of rhinosinusitis. Nasal cavities were scored using the Lund-Kennedy endoscopy scores. Paranasal sinus computed tomography imagings were scored according to Lund-Mackay radiology scores. Skin prick tests were carried out for all participants to determine the predisposing role of allergy (T helper 2 disease) in the etiopathogenesis of rhinosinusitis among patients and controls. Patients' endoscopy, radiology, and skin prick testing scores were evaluated with regard to BD activity.The prevalence of CRSsNP was 23.2 % in BD and 2.7% in normal population. The CRSsNP was more frequently seen in patients than in the healthy controls (P = 0.002). The BD patients displayed worse scores on their left sinonasal endoscopy. No statistically significant difference was seen between BD and control groups with regard to Lund-Mackay radiology scores of both sides. The presence of an allergic response to a specific allergen in skin-prick testing were confirmed in 25 patients (36.2%) and 17 controls (23.0%). However, the difference was not statistically significant. There were positive responses to more allergens when BD activity was reduced.The CRSsNP thought to be of T helper 1-mediated origin was more frequently seen in the presence of comorbid BD.

Is chronic rhinosinusitis related to allergic rhinitis in adults and children? Applying epidemiological guidelines for causation

The relationship between allergic rhinitis and chronic rhinosinusitis has been assessed in a number of observational and experimental studies. In this review, we attempt their synthesis and evaluation using the modified Bradford Hill guidelines for causation. Although there is no proof of causation, especially in the pediatric literature, an evaluation of underlying allergies is recommended at least as an initial measure of symptoms relief.

Isotonic saline nasal irrigation is an effective adjunctive therapy to intranasal corticosteroid spray in allergic rhinitis

BACKGROUND

This study was designed to determine if the addition of large-volume, low-positive pressure nasal irrigations delivered with isotonic sodium chloride (hereinafter "saline") added to intranasal corticosteroid therapy improves quality of life and objective measures of nasal breathing in patients with allergic rhinitis when compared with intranasal corticosteroid alone.

METHODS

A prospective, unblinded, single-arm pilot study was performed of patients with allergic rhinitis already on intranasal corticosteroid pharmacotherapy. Patients added large-volume low-pressure saline irrigation twice daily for 8 weeks to their ongoing regiment of nasal corticosteroid. Mini-Rhinoconjunctivitis Quality of life Questionnaire (mRQLQ) assessment and nasal peak inspiratory flow (NPIF) were performed at baseline and at 4 and 8 weeks.

RESULTS

A total of 40 patients were enrolled. Twice-daily nasal irrigation with isotonic saline significantly (p < 0.001) reduced mRQLQ scores, from 36.7 ± 20.48 (baseline) to 14.9 ± 11.03 (4 weeks) to 10.10 ± 10.65 (8 weeks). No significant changes were seen in NPIF, pattern use of nasal steroid use, or adverse events.

CONCLUSION

Large-volume, low-positive pressure nasal irrigation with isotonic saline is an effective adjunctive therapy to improve quality of life in patients with allergic rhinitis already on intranasal corticosteroid therapy. This study was a part of the clinical trial NCT01030146 registered at clinicaltrials.gov.

Continuous 6-year follow-up study of sensitization to Japanese cedar pollen and onset in schoolchildren

BACKGROUND

Intra individual longitudinal data has been lacking for IgE-mediated seasonal allergic rhinitis (SAR), especially in young children. Little is known about the development and natural course of SAR in terms of prevalence and incidence rates in schoolchildren.

METHODS

In May or June each year from 1994 to 2007, schoolchildren were assessed for serum Japanese cedar pollen (JCP)-IgE and house dust mite (HDM)-IgE levels, and surveyed regarding nasal symptoms.

RESULTS

Among the 220 children initially assessed in the first grade, 69 (31.4%) were already sensitized to JCP at first grade and 119 (54.1%) did not develop JCP sensitivity during the 6-year study at all. In the first grade children who were HDM-sensitized but JCP non-sensitized, JCP-IgE level was significantly elevated compared to the JCP and HDM non-sensitized group. This seems to indicate that HDM sensitization was very strongly associated with JCP sensitization.

CONCLUSIONS

Elevated serum IgE is a consequence of specific sensitization to HDM and HDM sensitization appeared to develop prior to the start of primary school which distinguishes HDM sensitization from JCP sensitization.

Persistent Allergic Rhinitis and the XPERT Study

Allergic rhinitis (AR) is a chronic disease with an increasing trend in most of the Western Countries. It may significantly impair the individual quality of life (QoL) and also represents a social burden for its economic costs. Levocetirizine (XYZAL; UCB Pharma) as a second generation, nonsedating H1-antihistamine, has been shown to be clinically effective in patients with AR in different randomized controlled trials. The XPERT (XYZAL in Persistent Rhinitis Trial) is the first large, long-term clinical study involving patients with persistent rhinitis as defined by ARIA (Allergic Rhinitis and its Impact on Asthma). The XPERT was a 6-month double-blind, placebo-controlled, multicenter, multinational trial in 551 subjects. Adults with persistent rhinitis sensitized to both grass pollen and house dust mites were randomized to receive levocetirizine 5 mg/d or placebo. Two primary objectives were considered: comparison of the Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) overall score and Total 5 Symptoms Score (rhinorrhea, sneezing, nasal congestion, and nasal and ocular pruritus) (T5SS) between active and control group over a period of 4 weeks. As secondary endpoints, similar evaluations at 1 week and 3, 4, 5, and 6 months, summary scores for a general health status questionnaire (Medical Outcomes Survey Short Form 36), comorbidities, pharmacoeconomic and safety evaluations. Levocetirizine significantly improved both the RQLQ overall score and the T5SS from week 1 to 6 months (P <.001). Medical Outcomes Survey Short Form 36 summary scores were also improved in the group treated with levocetirizine with respect to placebo. Treatment cessation because of lack of efficacy, comorbidities, and overall costs of disease, and comorbidities per working patient per month (160.27 vs 108.18) were lower in the levocetirizine group. In conclusion, levocetirizine resulted to improve the quality of life and the symptoms related to AR and also to reduce the overall costs of the disease after 6 months treatment.

Dolichandrone platycalyx: New entomophilous pollen--A report on pollen sensitization in allergic individuals

BACKGROUND

Dolichandrone platycalyx, commonly known as Nile trumpet tree, is believed to have originated in East Africa. However, this and the variants of this tree are found in Europe, Asia, and America (California and Florida). The tree mostly grows in tropical climates, but temperate species are also found. This study was designed to evaluate the allergenicity of D. platycalyx, one of the most common entomophilous avenue trees in Karnataka state, and to determine the pollen production of D. platycalyx.

METHODS

All of the patients with allergic rhinitis and asthma attending a tertiary care center in South India during August 2007 to March 2008 underwent a detailed clinical evaluation and skin-prick testing to common allergens along with D. platycalyx. Control subjects without any symptoms of respiratory allergy also underwent skin testing. The pollen counts were determined for a mature unopened flower of D. platycalyx.

RESULTS

A total of 317 subjects with respiratory allergy and 30 controls were included in the study. A significant percentage (16.1%) of patients evaluated were observed to be sensitive to Dolichandrone pollen extract by skin-prick testing, whereas none of the control subjects were found to be sensitized. D. platycalyx was the fourth most common sensitizer after Parthenium hysterophorus, Prosopis juliflora, and Artemesia vulgaris. D. platycalyx was found to be a moderate pollen producer at 66,000 pollens/flower.

CONCLUSION

Sensitization to D. platycalyx is common in subjects with respiratory allergies. The clinical relevance of this sensitization and other entomophilous plants needs additional study.

Assessment of palatability of two sublingual diluents in allergic patients: a prospective pilot study

BACKGROUND

Taste of diluents could have an effect on the ultimate patient compliance and acceptability of allergenic extract formulations used in sublingual allergy immunotherapy. This study assessed the palatability and compared the flavor and taste preferences of two sublingual diluents in allergic adult patients.

METHODS

This was a prospective, randomized, double-blinded pilot study. Diluents A (50% glycerin and water) and B (0.4% phenol and water) were tested. Three drops were placed in the sublingual area beneath the tongue for 2 minutes before swallowing. A 5-point analog scale was used to allow ranking of the degree of taste acceptance. Patients were then given a 10-minute break where unsalted crackers and bottled water were provided to cleanse the palate between tasting periods. After tasting both samples, patients were asked to answer a final question regarding taste preference.

RESULTS

Of the 30 patients, there were 15 men and 15 women with a mean age of 38 years (range, 18 to 61 years). For diluent A, 18 (60.0%) patients graded the diluent as having a “pleasant” taste, 8 (26.7%) patients gave a grade of “very pleasant,” and 4 (13.3%) patients said that they were “not sure.” For diluent B, 16 (53.3%) patients gave a grade of “unpleasant” and only 6 (20.0%) patients gave a grade of “pleasant.” Finally, 28 (93.3%) of the 30 patients chose diluent A over diluent B as the preferred diluent of choice (p < 0.0001).

CONCLUSION

Fifty percent glycerin had better taste attributes and phenolated saline induced unpleasant oral sensation on sublingual dosing.

Minimally invasive application of botulinum toxin A in patients with idiopathic rhinitis

Background

Nasal hypersecretion due to idiopathic rhinitis can often not be treated sufficiently by conventional medication. Botulinum toxin A (BTA) has been injected into the nasal mucosa in patients with nasal hypersecretion with a reduction of rhinorrhea lasting for about 4 to 8 weeks. Since the nasal mucosa is well supplied with glands and vessels, the aim of this study was to find out if the distribution of BTA in the nasal mucosa and a reduction of nasal hypersecretion can also be reached by a minimally invasive application by sponges without an injection.

Methods

Patients were randomly divided into two groups. The effect of BTA (group A, C, D) or saline as placebo (group B) was investigated in 20 patients with idiopathic rhinitis by applying it with a sponge soaked with BTA (40 units each nostril) or saline. Subgroups C and D contained these patients of group A and B who did not improve in symptoms one week after the original treatment (either BTA or saline) who then received the alternative medication. Changes of symptoms (rhinorrhea, nasal obstruction) were scored by the patients in a four point scale and counted (consumption of tissues, sneezing) in a diary. The patients were followed up weeks 1, 2, 4, 8 and 12.

Results

There was a clear reduction of the amount of secretion in group A compared to group B, C and D. This did not correlate with the tissue consumption, which was comparably reduced in group A and B, but reduced less in group C and D. Sneezing was clearly reduced in group A but comparably unchanged in group B and C and increased in group D. Nasal congestion remained unchanged.

Conclusion

In some patients with therapy-resistant idiopathic rhinitis BTA applied with a sponge is a long-lasting and minimal invasive therapy to reduce nasal hypersecretion.

FUTURA STUDY-Evaluation of efficacy and safety of rupatadine fumarate in the treatment of persistent allergic rhinitis

Allergic rhinitis affects 10-30% of the population, negatively impacting one's quality of life and productivity. It has been associated with sinusitis, otitis media, sleep disorders, and asthma. Rupatadine is a second generation antihistamine with increased affinity to histamine receptor H1; it is also a potent PAF (platelet-activating factor) antagonist. It starts acting quite quickly, offers long lasting effect, and reduces the chronic effects of rhinitis.

Aim

this study aims to assess the efficacy and safety of rupatadine in the treatment of persistent allergic rhinitis.

Materials and method

this is a multi-centric open prospective study. This study included 241 patients from 13 centers in Brazil and was held between October of 2004 and August of 2005. Signs and symptoms of rhinitis and tolerance to medication were analyzed after one and two weeks of treatment.

Results

reduction on general scores from 8.65 to 3.21 on week 2 (p<0.001). All signs and symptoms improved significantly in the first day of treatment (p<0.001), except for nasal congestion and secretion, which improved from the second day of treatment (p<0.001). Adverse events occurred in 19.9% of the cases, 27.7% on week 1.

Conclusion

rupatadine effectively controls persistent allergic rhinitis; it is safe and presents low incidence of side effects.

Evaluation of the quality of life after individualized homeopathic treatment for seasonal allergic rhinitis. A prospective, open, non-comparative study

BACKGROUND

Quality of life (QoL) is an important outcome measure in the treatment of seasonal allergic rhinitis (SAR), a condition for which homeopathy is frequently used.

OBJECTIVE

The assessment of the effect of homeopathic medical prescriptions with the Rhino-conjunctivitis Quality of Life Questionnaire (RQLQ) in the treatment of SAR.

METHODS

A prospective, open, non-comparative study was conducted in Belgium. Patients aged between 14 and 68 years with SAR were treated by one of seven homeopathic physicians. Patients completed the RQLQ at baseline and again after three and four weeks of homeopathic treatment.

RESULTS

Seventy-four patients were screened, of whom 46 met the study eligibility criteria (average age 36 years, 70% female). The mean RQLQ score at baseline was 3.40 (+/-.98). After three and four weeks of homeopathic treatment it had fallen to 1.97 (+/-1.32) (P=0.0001), and 1.6 (+/-1.28) (P=0.0001), respectively.

CONCLUSIONS

After homeopathic treatment, patients reported an alleviation of their symptoms of allergic rhinitis as reported in the RQLQ. A formal Randomized Clinical Trial (RCT) is indicated.

Chronic rhinosinusitis and risk of lung cancer in the Singapore Chinese Health Study

Epidemiologic evidence suggests that chronic inflammatory conditions of the lung may increase lung cancer risk. These chronic conditions, such as chronic obstructive pulmonary disease and asthma, commonly coexist with chronic rhinosinusitis. We prospectively examined if chronic rhinitis or sinusitis was associated with lung cancer risk in the Singapore Chinese Health Study, a population-based cohort of 63,257 Singapore Chinese, who were aged 45-74 years when recruited between 1993 and 1998. Each subject completed a comprehensive interview on medical conditions, dietary and lifestyle factors at recruitment, and cancer occurrence and survival status were determined via linkage to population-based registries. As of 31 December, 2005, 954 cohort participants had developed lung cancer. Compared with subjects without such history, subjects who reported a history of physician-diagnosed rhinitis or sinusitis at baseline, whether allergic or nonallergic, had a statistically significant 59% increase in risk of lung cancer (hazard ratio [HR] = 1.59; confidence interval [CI] = 1.06-2.37). This association was significant and stronger in women (HR = 2.32; 95% CI = 1.23-4.39) compared to men, and for the adenocarcinoma cell type (HR = 1.91; 95% CI = 1.07-3.42) compared to other histologies. Overall, a history of asthma, hay fever, allergic dermatitis, food allergy or any other allergic conditions asked in a single question was not related to lung cancer risk (HR = 1.11; 95% CI = 0.90-1.36). Chronic rhinosinusitis may be a marker of pan-airway inflammation and its association with lung cancer risk provides evidence linking inflammation to lung carcinogenesis, especially among women.

Levocetirizine improves health-related quality of life and health status in persistent allergic rhinitis

BACKGROUND

Allergic rhinitis is a chronic respiratory disorder with a detrimental impact on health-related quality of life (HRQOL) and health status. Enhancement and maintenance of patient function and well-being are therefore considered as essential.

OBJECTIVE

To determine whether long-term treatment with levocetirizine 5mg improves HRQOL and health status in persistent allergic rhinitis (PER) patients assessed with RQLQ and SF-36 scales over a 6-month period.

METHODS

The Xyzal in PER Trial (XPERT) was a multi-center, double-blind, parallel-group study. A total of 551 patients were randomized to receive levocetirizine 5mg or placebo once daily for 6 months and assessed for symptoms, HRQOL (Rhinoconjunctivitis Quality of Life Questionnaire: RQLQ) and health status (SF-36). Sensitivity of the RQLQ and SF-36 to disease severity was tested to ensure their suitability for use in PER patients. Treatment effect was assessed by means of repeated measures analyses.

RESULTS

Over the 6-month treatment period, levocetirizine showed statistically significant improvements over placebo in HRQOL (P < 0.001 for all RQLQ domains and overall scores) and health status (P < or = 0.004 for SF-36 physical and mental summary scores; P < 0.05 for all SF-36 scales). The relative improvement of levocetirizine over placebo exceeded the predefined clinically meaningful threshold of 30% for all RQLQ scores and the improvement from baseline was 3 times the established MID for RQLQ.

CONCLUSION

The RQLQ and SF-36 could be used to measure HRQOL and health status in PER patients. Long-term treatment with levocetirizine provides sustained improvement of HRQOL and reduces disease burden in PER patients.

A case-control study of risk factors in men with chronic pelvic pain syndrome

OBJECTIVE

To compare the demographic, behavioural, clinical and medical history characteristics of men with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) and asymptomatic controls, to identify characteristics that might be associated with this syndrome.

PATIENTS AND METHODS

Self-administered epidemiological questionnaires were completed by 463 men with CP/CPPS and 121 asymptomatic age-matched controls. We compared the prevalence of possible risk factors between men with CP/CPPS and controls, using generalized Mantel-Haenszel tests, and developed multivariate predictive models using logistic regression methods, adjusting for clustering by clinical centre within both methods.

RESULTS

Compared to controls, men with CP/CPPS reported a significantly greater lifetime prevalence of nonspecific urethritis (12% vs 4%, P = 0.008), cardiovascular disease (11% vs 2%, P = 0.004), neurological disease (41% vs 14%, P < 0.001), psychiatric conditions (29% vs 11%, P < 0.001), and haematopoietic, lymphatic or infectious disease (41% vs 20%, P < 0.001).

CONCLUSION

A wide range of self-reported medical conditions was associated with CP/CPPS. Further studies are necessary to determine whether they play a role in the pathogenesis of CP/CPPS.

[Epidemiology of seasonal spring-time allergic rhinitis in adults in France]

OBJECTIVE

Describe the profile of patients consulting a general practitioner or allergologist for seasonal spring-time allergic rhinitis (SAR) in France.

METHODS

3.348 physicians (3.284 general practitioners and 64 allergologists) recruited in 4 monthly episodes from March to June 1998, 34.851 patients consulting for SAR. Using a questionnaire, demographical data concerning the practitioners consulted and all the patients were collected. For 12,420 patients the symptomatology, history of asthma and ongoing treatment for SAR were analysed by comparing the population consulting a general practitioner (A) or an allergologist (B).

RESULTS

Mean age for all patients with suspected SAR was of 37.1 +/- 15.7 years with a majority of women (54.90%). For 1,441 patients, it was the first consultation for this disorder, notably with a general practitioner, (11.1 vs. 2.4%). Aqueous rhinorrhea, sneezing and nasal obstruction were the most frequent symptoms noted, without significant difference between the type of practitioner consulted. 5.711 patients had undergone previous allergy tests, with more skin tests in the group consulting an allergologist (78 vs. 44.9%). Association with history of asthma was similar in both groups (30%). Impact on daily life was almost identical, whether isolated or associated with past history of asthma (56 vs. 51.6%), but differed with regard to sleep (56.7 vs. 21.1%). During the consultation, 5.889 patients were already treated with antihistamines (83.2%), whatever the type of practitioner consulted.

CONCLUSION

Seasonal spring-time allergic rhinitis is a frequent pathology, which significantly impairs quality of life. There is little difference in patients' profile whether they consult a general practitioner or an allergologist.

Oral antihistamines for the symptom of nasal obstruction in persistent allergic rhinitis - a systematic review of randomized controlled trials

BACKGROUND

Oral antihistamines are recommended by a World Health Organisation working group as a first-line pharmacological treatment in mild persistent allergic rhinitis. There is, however, uncertainty with respect to their effectiveness for a common symptom, that of nasal obstruction.

OBJECTIVE

To test the null hypothesis that oral antihistamines have no effect on the symptom of nasal obstruction in a clinical setting in patients with persistent allergic rhinitis.

METHODS

Protocol based review of double-blind randomized controlled trials of oral antihistamine (i.e. drugs considered to act as a histamine receptor type-1 antagonist) vs. placebo. A search was carried out for published and unpublished trials. Individuals had to be age 12 years or older (with a diagnosis confirmed by skin prick tests, IgE blood tests or nasal allergen challenge), experiencing their normal allergen exposure. A symptom score for nasal obstruction had to be recorded. Predetermined quality criteria were applied. Treating their data as 4-point scores, a meta-analysis was carried out for studies, which provided enough data to be pooled.

RESULTS

Meta-analysis found a weighted mean difference of -0.52 in favour of treatment for patient-assessed symptom scores (95% confidence interval (CI)-0.73,-0.31, P<0.00001), and of -0.33 in favour of treatment for healthcare worker assessed scores (95% CI -0.49, -0.16, P = 0.0001).

CONCLUSION

Oral antihistamines cause statistically significant improvement in the symptom of nasal obstruction in patients with persistent allergic rhinitis.

Monosodium benzoate hypersensitivity in subjects with persistent rhinitis

BACKGROUND

Very few data are available from the literature on whether nonatopic subjects affected by persistent rhinitis may show the appearance of objective symptoms of rhinitis after the ingestion of food additives such as tartrazine (E102), erythrosine (E127), monosodium benzoate (E211), p-hydroxybenzoate (E218), sodium metabisulphite (E223), and monosodium glutamate (E620). It is still unclear whether the ingestion of food additive may cause, as well, a consensual reduction of nasal peak inspiratory flow (NPIFR). Therefore, we used a double-blind placebo-controlled (DBPC) study to evaluate this hypothesis.

PATIENTS AND METHODS

Two hundred and twenty-six consecutive patients (76 males and 150 females) aged 12-60 years (mean age 40.2 +/- 16.3 years). After 1 month of an additive-free diet regimen, an open challenge was carried out (food additive-rich diet for 2 weeks). After this period, challenges were administered in a DBPC manner using the above-mentioned substances under investigation.

RESULTS

Twenty of 226 subjects (8.8%) reported an improvement of the symptoms of rhinitis after additive-free diet. More precisely, six of 226 (2.6%) were symptom-free and 14 of 226 (6.2%) showed an improvement in their symptoms after an additive-free diet. As far as the results for DBPC are concerned, 20 challenges with monosodium benzoate induced both objective (i.e. sneezing and rhinorrhoea) and subjective symptoms (nasal blockage and nasal itching) of rhinitis with reduction of NPIFR >/=20%, 45 challenges induced subjective symptoms of rhinitis (i.e. nasal blockage and nasal itching), without reduction of NPIFR >/=20% of the basal value, two with tartrazine, seven with erythrosine, 19 with monosodium benzoate, three with p-hydroxybenzoate, six with sodium metabisulphite, and eight with monosodium glutamate, respectively.

CONCLUSIONS

The observation that nonatopic persistent rhinitis may be caused by the frequent, probably daily, ingestion of small doses of a nontolerated substance is intriguing and suggests that at least some patients with 'chronic vasomotor rhinitis' may be intolerant to a particular food additive. Therefore, food additives can be considered triggers or aggravating factors, rather than aetiological factors.

Fungal biodiversity--as found in nasal mucus

The biodiversity of fungi isolated from the nasal mucus of patients suffering from chronic rhinosinusitis and from healthy persons was monitored over 28 months. Mucus samples were obtained by flushing the noses of patients with saline or by endoscopic sinus surgery. Fungi from mucus were cultivated on agar plates. Identification was performed microscopically and by polymerase chain reaction with subsequent sequencing of the ribosomal internal transcribed spacer region. Altogether, 619 strains of fungi were cultivated from 233 subjects. Eighty-one species were identified, with a maximum of nine different species per person. The most prevalent isolates belonged to the genera Penicillium, Aspergillus, Cladosporium, Alternaria and Aureobasidium. Whereas Aspergillus and Penicillium spp. occurred in more or less the same numbers throughout the year, Cladosporium spp., Alternaria spp. and Aureobasidium pullulans showed a significantly higher occurrence during late summer and early autumn.

Allergen sensitization and allergen exposure in Greenlander Inuit residing in Denmark and Greenland

The aim of this study was to estimate the prevalence of allergic sensitization and possible risk factors in a genetically homogenous Inuit population living under widely differing climatic and cultural conditions. A written questionnaire and skin prick test for 10 aeroallergens were obtained from 1119 adult Greenlanders residing in Denmark, Nuuk (main city in Southern Greenland) and Uummannaq (rural settlement in Northern Greenland). Allergen exposure was assessed by pollen counts, questions on pet keeping and counts of house dust mites in dust samples. The overall prevalence of at least one positive skin prick test was 22.8% in Denmark, 10.6% in Nuuk, and 6.4% in Uummannaq. In Denmark, the total birch pollen counts were 40-1000 times higher compared to Nuuk, whereas the grass pollen count was 13-30 times higher in Denmark compared to Nuuk. Dogs were held indoor with a similar frequency in Denmark and Nuuk, but much less frequently in Uummannaq. In Denmark, house dust mites were found in 72% of house holds (>10/0.1 g dust). Less than 15% of households in Greenland had measurable levels of house dust mites. The prevalence of sensitization to aeroallergens in Inuit Greenlanders differed significantly between Denmark, Nuuk and Uummannaq. These findings correlated with the observed differences in population allergen exposure in the three regions. Furthermore, differences in lifestyle factors such as educational level, stress and ethnic self-identification seemed to be associated with the risk of allergic sensitization in Greenland.

More siblings, less hay fever: more evidence

The prevalence of allergic rhinitis is increasing. Many authors have noted the prevalence of hay fever is less in children from large families and the 'hygiene hypothesis' has been suggested as an explanation. We looked at the association of sibling number and other variables on the prevalence of hay fever and perennial rhinitis. From 26100 households selected at random, 34362 questionnaires were returned from individuals over 14 years of age; 19.3% had symptoms of hay fever and a further 6.0% had symptoms of perennial rhinitis. A logistic regression analysis showed that for individuals with two or more siblings, the odds of suffering from hay fever are less than the odds for people with no siblings and that these odds decrease as the number of siblings increases. This effect was not found in subjects with perennial rhinitis. This study adds weight to the 'hygiene hypothesis'.

Rhinitis: do diagnostic criteria affect the prevalence and treatment?

BACKGROUND

Rhinitis is one of the world's most common health problems. Diagnostic criteria used in community surveys may affect reported prevalence and treatment.

METHODS

A proportionately stratified random sample study was performed to investigate the prevalence, comorbidities and management of community-based patients with rhinitis in the tropical urban city of Singapore.

RESULTS

The prevalence of at least one, two, three, or four nasal symptoms on most days during the past year in our study population was 25.5%, 13.1%, 6.5%, and 3.0%, respectively. Based on the definition of 'rhinitis' by the International Consensus Report (ICR), the prevalence was 13.1% in Singapore. There was significantly higher prevalence of self-reported allergy, asthma, and common cold/influenza-like illness among the rhinitis group. In the 53% of rhinitis subjects seeking for medical help, 71% visited a primary care physician and 20% an otolaryngologist. Treatments as reported by patients were decongestants (topical or oral) 27%, antibiotics 12%, antihistamines 6%, nasal steroids 3%, surgery 2%, traditional methods 28%, and 22% did not know what medication they had. Subjects considered the effectiveness of treatment unsatisfactory because the majority of them had only partial or no relief with any treatment.

CONCLUSIONS

The standardization of the definition of rhinitis in epidemiological studies is of crucial importance, especially when comparing the prevalence between studies. Appropriate patient education by physicians with a good understanding of the nature of rhinitis and the available treatment options (e.g. evidenced-based efficacy, safety, and a good cost-benefit ratio) will maximize patient compliance and treatment outcomes.

The nose and paranasal sinuses physiology and anatomy

The paranasal sinuses and nose are much more than two cavities behind a projection on the centre of the face. They humidify, filter, warm, and sense what we breathe. The anatomy and physiology interact forming a dynamic system. The anatomy, airflow, nasal resistance, its turbulence, the nasal cycle - a process by which the turbinates or cushions lining the nose alternatively swell and congest from side to side, can all potentially influence the nasal delivery of drugs. Along with these factors mucus rheology and mucociliary clearance influence the removal of substances delivered to the nose. The health of the nose and its immunological response to what is inhaled, be it pollutants, allergens, drugs or vaccines, all need to be considered. It is a fascinating sensor for the body, not only detecting the potentially harmful substances such as smoke, but its psychosexual aspects have far reaching implications and the olfactory pathway has potential as a pathway for the delivery of drugs.

Preliminary results of a pilot study investigating the potential of salivary cortisol measurements to detect occult adrenal suppression secondary to steroid nose drops

Adrenocortical suppression is a well-known risk of systemic steroids, but is thought less likely to occur with topical intranasal corticosteroids. However, the UK Committee on the Safety of Medicines (UKCSM) has expressed concern about the possibility of this complication. We assessed the prevalence of adrenal suppression in patients with rhinitis using intranasal beclomethasone and betamethasone; and the potential value of salivary cortisol as a tool for detecting this complication. Sixty-six patients (38 men: 28 women; mean age 49.6[SD 16.0] years) were prospectively screened for adrenal insufficiency using clinical assessment and salivary cortisol measurements. Abnormalities at this initial screening were confirmed with a Short Synacthen Test (SST). No patient was clinically Cushingoid. All 22 beclomethasone users had normal salivary cortisols. Eleven (25%) of 44 patients using betamethasone had subnormal salivary cortisol levels (mean morning cortisol 2.8[SD 0.9]nmol/l) suggesting adrenal suppression, which was confirmed by an impaired SST in each case. The positive predictive value of salivary cortisol measurements was 100%. Only patients with abnormal salivary cortisols had a SST, so no comment can be made about sensitivity/specificity. Topical betamethasone may produce occult adrenal insufficiency and assessment of adrenal function is recommended in these patients. Measurement of salivary cortisol is a useful, non-invasive and economical test for monitoring patients using intranasal corticosteroids.

Evidence for an inflammatory pathophysiology in idiopathic rhinitis

BACKGROUND

The pathophysiology of idiopathic rhinitis is unknown but the disease is classified as being non-allergic on the basis of negative serum IgE radioallergosorbent assay (RAST) and skin prick tests. In contrast, allergic rhinitis has a Th2 type inflammatory pathology mediated by IgE and mast cells.

OBJECTIVE

To test the null hypothesis that there would be no difference in the cellular infiltrate for key Th2-associated inflammatory cells between allergic and idiopathic rhinitis.

METHODS

We applied strict selection criteria in the recruitment of allergic and idiopathic rhinitis cases. In contrast to previous studies which used cytology or small biopsies, we studied all layers of the mucosa by using whole, full-thickness nasal turbinate specimens with an average length of 2.5 cm. Immunohistochemistry and in situ hybridization techniques were used to compare the distribution and cell populations of mast cells, IgE positive (IgE+) cells, eosinophils and plasma cells in perennial allergic (n = 11) and idiopathic (n = 17) rhinitis, and control nasal mucosal tissue (n = 9).

RESULTS

Mast cells and IgE+ cells were significantly increased within the epithelium of allergic and idiopathic mucosa compared to normal mucosa (P < 0.05). More IgE+ cells were present in the allergic group compared to the idiopathic group with the majority of IgE+ cells being mast cells. Both rhinitic groups showed increased eosinophilia localized to the superficial submucosa compared to normal mucosa (P < 0.05). More plasma cells were present in the allergic rhinitic tissue.

CONCLUSION

Idiopathic and allergic rhinitic mucosa show similarities in their inflammatory infiltrate suggesting that both groups share a highly localized Th2, IgE-mediated cellular immunopathology.

Seasonal allergic rhinoconjunctivitis and fatty acid intake: a cross-sectional study in Japan

PURPOSE

To investigate the associations of fatty acid intake with seasonal allergic rhinoconjunctivitis.

METHODS

The study subjects consisted of 1012 women aged 22 to 57 years (mean age +/- SD: 36.5+/-7.7 years), who had graduated from the Aichi Prefectural Junior College of Nursing, Nagoya, Japan. They completed a self-administered questionnaire on symptoms of the disease in August 1998. Symptoms of seasonal allergic rhinoconjunctivitis in spring were determined by response to the questionnaire, and fatty acid intake was estimated using a food frequency questionnaire. Odds ratios (ORs) were computed using unconditional logistic models to assess the strength of associations between the symptoms and fatty acid intake.

RESULTS

An increasing trend in the ORs was observed with increasing dietary intake of n-6 polyunsaturated fatty acids. After adjustment for potential confounders, the ORs for the second, third, and highest quartiles of intake relative to the lowest were 1.28 [95% confidence interval (CI), 0.78-2.10], 1.55 (0.96-2.50), and 1.74 (1.09-2.77), respectively (trend p = 0.015). Consumption of saturated, monounsaturated, and n-3 polyunsaturated fatty acids was not significantly related to the symptoms.

CONCLUSIONS

Dietary intake of n-6 polyunsaturated fatty acids was positively associated with seasonal allergic rhinoconjunctivitis in spring.

Paediatric issues relating to the pharmacotherapy of allergic rhinitis

The prevalence of allergic rhinitis in children has risen significantly over the last two decades. Important comorbidities like asthma have grown in parallel due to a complex mix of environmental and genetic factors. These conditions have similar allergic inflammatory mechanisms, which raises the possibility of treating both conditions by targeting shared inflammatory mediators pharmacologically. The first line treatment for paediatric allergic rhinitis is a topical nasal corticosteroid or a non-sedating antihistamine. Available intranasal corticosteroids show superior symptom control to second-generation antihistamines. However, most topical steroids and non-sedating antihistamines have equivalent clinical efficacy within their respective classes, so the choice of agent depends on safety and tolerability. Ideally, topical nasal steroids should exhibit high local receptor binding affinity and low systemic bioavailability, allied with a lack of long-term growth suppression in children and adolescents. Regular use of topical steroids is advisable, but intermittent and prophylactic use is also effective. Second-generation antihistamines are effective and some have no adverse cardiac or sedative effects. Non-sedating antihistamine treatment can ameliorate rhinitis-induced decrements in learning. alpha-Adrenergic nasal decongestants provide short-term benefit, but topical agents can cause rebound symptoms. Prophylactic treatment with chromones is safe and effective, but multiple daily dosing is needed. Ipratroprium bromide nasal spray is useful as an intermittent therapy for mild disease or as add-on treatment, but its effect is limited to the control of rhinorrhoea. Children with allergic rhinitis should receive pharmacotherapy if allergen avoidance measures are ineffective, ideally with a topical intranasal steroid or a second-generation antihistamine.

Development of seasonal allergic rhinitis during the first 7 years of life

BACKGROUND

Against the background of the controversial discussion about an increase in allergic rhinitis in recent years, intraindividual longitudinal data is lacking for IgE-mediated seasonal allergic rhinitis (SAR). Little is known about the development of SAR in terms of prevalence and incidence rates from birth to school age.

OBJECTIVE

In a prospective birth cohort, we investigated the development of sensitization and symptoms of SAR. SAR should be defined with high specificity, and associated risk factors should be determined.

METHODS

Annual longitudinal data about seasonal allergic symptoms and sensitization was available for 587 children from birth to their seventh birthday. The definition of SAR was based on a combination of exposure-related symptoms and sensitization.

RESULTS

Up to 7 years of age, SAR developed in 15% of the children. Incidence and prevalence of symptoms and sensitization were low during early childhood (<2%) and increased steadily with age. Children in which SAR had already developed in the second year all were born in spring or early summer, resulting in at least two seasons of pollen exposure before manifestation of SAR. Risk factors assessed by multiple logistic regression analysis were male sex (odds ratio [OR] = 2.4), atopic mothers (OR = 2.6) and fathers (OR = 3.6) having allergic rhinitis themselves, first-born child (OR = 2.0), early sensitization to food (OR = 3.3), and atopic dermatitis (OR = 2.5), whereas early wheezing was not associated with SAR.

CONCLUSION

The development of SAR is characterized by a marked increase in prevalence and incidence after the second year of life. Our longitudinal data further indicate that in combination with the risk of allergic predisposition, at least 2 seasons of pollen allergen exposure are needed before allergic rhinitis becomes clinically manifest.