Impact and modulation of nasal obstruction

Assessing the relationship between serum resistin and nasal obstruction in children with allergic rhinitis

BACKGROUND

Nasal obstruction has been reported as a "key symptom" of allergic rhinitis (AR) because it is deeply associated with impaired quality of life and it reflects more directly the allergic inflammation in the nasal mucosa. Resistin is known to be involved in inflammatory processes exerting an important role in the regulation of cytokine production even though its effective proinflammatory activity at nasal level has never been fully established. This study investigates the relationship between resistin levels and nasal obstruction assessed by an objective method such as active anterior rhinomanometry.

METHODS

Fifty-three children between 4 and 10 years of age affected by persistent allergic rhinitis (PAR) were enrolled and subdivided in two groups. Serum resistin levels were detected in all children. The same day patients underwent rhinomanometry, which was considered negative (no nasal obstruction) when the fraction of predicted values (p.v.'s) was between 71 and 100% and it was considered positive when the fraction of p.v. was ≤70%.

RESULTS

The serum resistin levels were significantly higher in children with moderate-severe PAR than in patients with mild PAR (p < 0.03). Furthermore, serum resistin levels were significantly higher in children with positive rhinomanometry compared with negative rhinomanometry (p < 0.03). The fraction of p.v.'s of nasal flows in patients with nasal obstruction had a significant negative correlation with serum resistin levels (p < 0.001).

CONCLUSION

This study provides evidence that resistin levels are increased in children with severe nasal obstruction measured by an objective and quantitative approach.

Characterisation of interleukin-10 expression on different vascular structures in allergic nasal mucosa

BACKGROUND

Interleukin-10 (IL-10) is a negative regulator of immune responses and was previously shown to be expressed by human nasal endothelial cells, while the adhesion molecule MECA-79 plays a role in trans-endothelial migration of immune competent cells. In this study we investigate the relationship between endothelial IL-10 and MECA-79 expression to address the question whether immune competent cells could be affected at the mucosal entry site.

METHODS

Nasal turbinate biopsies were taken from house dust mite allergic patients, before and after nasal allergen provocation. Subsequent slides of biopsies were stained for IL10, MECA-79, CD34, and IL10-Receptor. Capillaries, arteries/veins, and sinusoids were evaluated separately.

RESULTS

90% of sinusoids are IL-10 positive and all sinusoids are negative for MECA-79, while 4.8% of capillaries are positive for IL-10, and 2.2% are positive for MECA-79. Although about 47% of arteries/veins are positive for IL-10 and 57.1% are positive for MECA-79, only about 20% are positive for both markers. Furthermore, we showed that the myo-fibroblasts surrounding all sinusoids stain positive for IL10R.

CONCLUSIONS

IL10 expression on vascular structures is not related to MECA expression for sinusoids and capillaries and only partly related on arteries/veins, however sinusoidal endothelial IL10 expression is always seen in combination with IL-10R expression of sinusoidal myo-fibroblasts.

Correlation between nasal eosinophils and nasal airflows in children with asthma and/or rhinitis monosensitised to house dust mites

BACKGROUND

Allergic rhinitis and asthma due to mite sensitisation are diseases which are frequently associated and characterised by persistent inflammation. In the present study, we aimed to investigate the relationship between nasal airflows and nasal eosinophils in patients with asthma and/or rhinitis due to house dust mite sensitisation.

METHODS

Twenty-four children with both rhinitis and asthma (R+A), 13 children with rhinitis and no asthma (R) and 10 non-allergic healthy children were evaluated prospectively. The patients belonging to the first two groups had moderate-severe grade of nasal obstruction. Total nasal symptom scores, peak nasal inspiratory flows (PNIFs) obtained by anterior rhinomanometry, skin prick tests, nasal eosinophils and FEV1 values were all assessed.

RESULTS

Percentages of nasal eosinophils and PNIFs in patients with R+A and R (r=-0.415, p=0.04) were found to be statistically significant and to have an inverse correlation. Skin prick tests were also significantly correlated with nasal eosinophils and PNIFs (r=0.372, p=0.01 and r=-0.306, p=0.04, respectively). Both PNIFs and nasal eosinophils of patients with R+A were significantly correlated with FEV1 values (r=-0.641, p=0.001 and r=0.548, p=0.007, respectively).

CONCLUSION

In this study, a close relationship was demonstrated between eosinophil infiltration and nasal airflows in children having asthma and/or rhinitis monosensitised to mites. Additionally, the significant association found between FEV1 values and nasal eosinophils or PNIFs supported the close link of upper and lower airways.

Intranasal steroids in the treatment of allergy-induced rhinorrhea

While nasal congestion has been identified as one of the most bothersome and prevalent symptoms of allergic rhinitis, it is underappreciated that many patients find rhinorrhea also to be bothersome. Rhinorrhea as a symptom of allergic rhinitis virtually never occurs alone; about 97% of patients with allergic rhinitis suffer from at least two symptoms, a finding that underscores the advantage of treating a broad range of symptoms with a single medication. Along with sneezing and nasal obstruction, rhinorrhea is a classic acute symptom of allergic rhinitis; it appears as a late-phase symptom as well. In this review, the characterization and epidemiology of rhinorrhea, the pathophysiology of rhinorrhea in allergic rhinitis, the roles played by mediators in early- and late-phase rhinorrhea, the prevalence and impact of this symptom, and the efficacy and safety of available treatment options are all discussed in context of relevant literature. A review of the clinical studies assessing the efficacy of intranasal corticosteroids (INS) for rhinorrhea is presented. Many clinical studies and several meta-analyses conclusively demonstrate that, in addition to being safe and well-tolerated, INS are more effective than other agents (including oral and intranasal antihistamines) across the spectrum of AR symptoms, including rhinorrhea and nasal congestion.

Nasal endoscopy in children with suspected allergic rhinitis

OBJECTIVES/HYPOTHESIS

Ear, nose, and throat assessment may be frequently requested for children with allergic rhinitis (AR). Nasal endoscopy allows a thorough evaluation of the nose. The aim of the study was to investigate whether there are endoscopic signs predictive for AR diagnosis in a cohort of children with suspected AR.

STUDY DESIGN

Cohort of observational study.

METHODS

There were 176 children (99 males; mean age, 7.5 years) studied. Clinical visit, nasal endoscopy, and skin prick test were performed in all patients. Nasal endoscopic signs were pale turbinates, middle turbinate contact, and inferior turbinate contact. The AR diagnosis was made when nasal symptom history was concordant with sensitization.

RESULTS

AR was diagnosed in 141 children. Inferior and middle turbinate contact were reliable predictive factors for AR (odds ratio 5.38 and 3.42, respectively), whereas pale turbinates did not predict it.

CONCLUSIONS

This study suggests that nasal endoscopy may reveal signs predictive for AR diagnosis in children.

Morning and evening efficacy evaluation of rupatadine (10 and 20 mg), compared with cetirizine 10 mg in perennial allergic rhinitis: a randomized, double-blind, placebo-controlled trial

Background:

A circadian rhythm of symptoms has been reported in allergic rhinitis (AR). Severity of all major symptoms of AR, including runny nose, sneezing, and nasal congestion, is typically at its peak in the morning. The objective of this study was to explore the efficacy of the antihistamine and platelet activating factor (PAF) antagonist rupatadine in the morning and evening and to evaluate whether rupatadine provides effective symptom relief throughout the 24-hour dosing interval.

Methods:

A total of 308 patients ≥18 years of age with PAR was randomly assigned to once-daily rupatadine 10 mg, rupatadine 20 mg, or cetirizine 10 mg for 4 weeks in a placebo-controlled, double-blind study. The main outcome was the morning/evening reflective total symptom score (5TSS) over the treatment period. Secondary endpoints included morning/evening reflective nasal total symptom score (4NTSS), individual symptoms, Pdmax1 as percentage of days with daily severest symptom score ≤1, and subject/investigator evaluation of therapeutic response.

Results:

All active groups were significantly more effective than placebo in improving morning and evening evaluations of 5TSS (P < 0.001) and 4NTSS (P < 0.001) at 2 or 4 weeks. At morning evaluation, there was a significant reduction from baseline for 5TSS with rupatadine 10 mg (−36.8%, P < 0.01) and 20 mg (−46.3%, P < 0.01) compared with placebo. Similarly, 4NTSS was reduced significantly more with rupatadine 10 mg (−34%, P < 0.05) and 20 mg (−41%, P < 0.01) compared with placebo. In the cetirizine 10 mg group, the reduction was −32.7% and −32.2% for 5TSS and 4NTSS, respectively, but this reduction was not significant compared with placebo. The percentage reduction was greater at evening than at morning evaluation. 5TSS reduction with rupatadine 10 mg (−40.7%, P < 0.05) and 20 mg (−49.9%, P < 0.01) and cetirizine 10 mg (−40.1%, P < 0.05) was significantly better than with placebo. 4NTSS values for active groups were also significantly improved versus placebo. When individual symptoms were assessed, statistically significant differences for rhinorrhea (P < 0.01), nasal itching (P < 0.01), and sneezing (P < 0.01) were shown in all active groups compared with placebo at morning and evening evaluations. Pdmax1 index was significantly improved for all active groups and the overall efficacy assessed by patients or investigators showed a significant improvement (P < 0.01) versus placebo at 2 and 4 weeks. The incidence of somnolence was significantly greater in all active groups versus placebo.

Conclusion:

The sustained 24-hour action of rupatadine 10 mg provides an effective control of morning and evening symptoms in patients with PAR treated for up to 4 weeks.

Synthesis and structure-activity relationship of tricyclic carboxylic acids as novel anti-histamines

A series of tricyclic carboxylic acids having 6-amino-pyrimidine-2,4(1H,3H)-dione with piperazino or homopiperazino moiety linked by propylene, were synthesized and evaluated for their affinity toward human histamine H(1) receptor and Caco-2 cell permeability. Selected compounds were further evaluated for their oral anti-histaminic activity in mice, bioavailability in rats, and their anti-inflammatory activity in mice OVA-induced biphasic cutaneous reaction model. Among the compounds tested, dibenzoxazepine carboxylic acid 13b showed both histamine H(1) receptor antagonistic activity and anti-inflammatory activity in vivo. In addition, 13b exhibited low affinity toward α(1) receptor and low occupancy of H(1) receptor in the brain. It is therefore, believed that 13b is a potential candidate for development as 3rd generation anti-histamine.

Comparison between symptoms and endoscopy in children with nasal obstruction

OBJECTIVE

Nasal obstruction is a common symptom in childhood. It may be frequently observed in children with allergic rhinitis and/or adenoidal hypertrophy. However, its assessment is very difficult. The aim of the study was to compare the use of both a Face Related Scale (FRS), recorded by children and their parents, and a simplified Visual Analogue Scales (sVAS) with nasal endoscopy in children complaining nasal obstruction.

METHODS

121 children (75 males, mean age 7.5 years) were studied. FRS and sVAS for nasal obstruction and endoscopy were performed in all patients.

RESULTS

A moderate correlation has been observed between FRS and sVAS and obstruction of nasal anterior segment (r=0.51 for FRS; r=0.52 for sVAS), a strong correlation was observed with nasal posterior segment (r=0.60 for FRS; r=0.61 for sVAS) assessed by endoscopy. However, parents' perception did not relate with objective parameters.

CONCLUSIONS

This study suggests that assessment of FRS and sVAS for nasal obstruction may be used in clinical practice to approximately quantify this symptom in children.

Visual analog scale (VAS) and nasal obstruction in persistent allergic rhinitis

OBJECTIVE

Nasal airflow resistance, as measured by rhinomanometry, is frequently impaired in allergic rhinitis (AR). However, rhinomanometry is scarcely available. The aim of this study was to verify the suitability of the use of visual analog scales (VAS) as a surrogate for rhinomanometry in quantifying nasal obstruction in patients with persistent allergic rhinitis.

STUDY DESIGN

Prospective study on patients with allergic rhinitis.

SETTING

ENT clinic.

SUBJECTS AND METHODS

Fifty patients (27 males, mean age 23 years, SD 2.24) were studied. VAS for nasal obstruction and other AR symptoms and rhinomanometry were performed in all patients.

RESULTS

A significant, very strong correlation has been observed between VAS for nasal obstruction and nasal airflow resistance (Spearman r = 0.879, P < 0.001). Moreover, a significant correlation exists between VAS for rhinorrhea and resistance (Spearman r = 0.313, P = 0.027).

CONCLUSION

The use of VAS for assessing the nasal obstruction appears clinically relevant in that it allows, with good reliability, the quantification of this symptom in the absence of rhinomanometry.

Ebastine in the light of CONGA recommendations for the development of third-generation antihistamines

In 2003 a consensus group on new-generation antihistamines (CONGA) defined the characteristics required for a third-generation H(1) antihistamine as there had been much controversy about this issue since the early 1990s. One of the antihistamines that had been claimed to belong to such a group is the second-generation antihistamine, ebastine. The objective of this review is to analyze the pharmacology of ebastine, in light of the CONGA recommendations for the development of new-generation antihistamines: (1) anti-inflammatory properties, (2) potency, efficacy and effectiveness, (3) lack of cardiotoxicity, (4) lack of drug interactions, (5) lack of CNS effects, and (6) pharmacological approach. Ebastine seems to have anti-inflammatory properties that help to ameliorate nasal congestion, though this has not yet been conclusively demonstrated. Its pharmacological-therapeutic profile does not differ greatly from that of other second-generation antihistamines. Its cardiac safety has been widely assessed and no cardiac toxicity has been found at therapeutic doses despite initial concerns. The risk of potentially relevant drug interactions has been investigated and ruled out. Ebastine does not produce sedation at therapeutic doses and drug interaction studies with classical CNS depressants have not demonstrated a synergistic effect. Pharmacologically, ebastine is an H(1) inverse agonist. Perhaps the answer to the quest for new-generation antihistamines lies not only in H(1) but in a combined approach with other histamine receptors.

Effect of levocetirizine on nasal provocation testing with adenosine monophosphate compared with allergen challenge in allergic rhinitis

BACKGROUND

End-organ hyperreactivity is an important feature of the allergic airway. There are no data directly comparing the responsiveness to treatment of different nasal provocation tests (NPT).

OBJECTIVE

We compared the effect of levocetirizine on nasal adenosine 5'-monophosphate (AMP) with specific allergen challenge in patients with intermittent and persistent allergic rhinitis (AR).

METHODS

Patients with AR were randomized in double-blind cross-over fashion to receive single doses of levocetirizine 5 mg or identical placebo, with nasal challenge performed 12 h after dosing. Sixteen participants completed per protocol. Nasal AMP or allergen challenge was conducted on separate days with 1- and 2-week washout periods in between, respectively. Measurements of peak nasal inspiratory flow (PNIF) were made over 60 min after each challenge. The primary end-point was the provocative concentration of AMP or allergen causing a 20% drop in the PNIF (PC(20)).

RESULTS

The time-profile for PNIF recovery [area under the 60 min time-response curve as % PNIF change (min)] were significantly attenuated for AMP challenge, as mean difference [95% confidence interval (CI)]: 11.57 (3.87, 19.25), P=0.005 and for allergen challenge: 17.82 (0.11, 35.53), P=0.04. A highly significant correlation was shown between methods for the area under the curve: (R=0.86, P<0.001). A statistically significant correlation was also seen for the PC(20): (R=0.94, P<0.001). PC(20) improvement amounted to a 1.26 (95% CI 0.16, 2.35) and 0.16 (95% CI -0.41, 0.73) doubling-dilution shifts for allergen and AMP challenges, respectively. Bland-Altman plots confirmed good agreement between methods.

CONCLUSION

A high correlation and statistical agreement has been demonstrated between AMP and allergen challenge for all outcome measures. In particular, the recovery profile after NPT is a sensitive and discriminatory measure of anti-allergic treatment.

Clinical assessment of nasal decongestion test by VAS in adolescents

Nasal airflow, as measured by rhinomanometry, is frequently impaired in allergic rhinitis (AR). The decongestion test evaluates whether the application of an intranasal vasoconstrictor drug increases nasal airflow. The aim of this study was to verify the suitability of the use of the visual analogue scales (VAS) as a surrogate for rhinomanometry in the decongestion test assessment in adolescents with atopic rhinitis. Forty adolescents [16 males and 24 females, mean age 15 (s.d. 2) yr] with AR were studied. Nasal symptoms, VAS, rhinomanometry, and nasal decongestion test were assessed in all patients. A significant association was observed between VAS and nasal airflow after performing the decongestion test (Spearman's r is -51.7%, p < 0.001). The associated sensitivity and specificity were 84.8 (95% confidence interval, CI 68.1-94.8) and 85.7 (95% CI 42.2-97.6), respectively. The corresponding area under the receiver operating characteristic (ROC) curve of 0.83 (95% CI 0.67-0.93) indicated a good discriminating ability for the decongestion measured on the VAS scale. In conclusion, the use of VAS appears as clinically relevant, in that it allows, with a fair reliability, to perform the decongestion test in the absence of rhinomanometry.

Clinical assessment of a nasal decongestion test by visual analog scale in allergic rhinitis

BACKGROUND

Nasal airflow, as measured by rhinomanometry, is frequently impaired in allergic rhinitis (AR). The decongestion test evaluates whether the application of an intranasal vasoconstrictor drug increases nasal airflow. That allergy is characterized by inflammation and that the response to the decongestion test correlates with the grade of inflammatory reaction has previously been shown. The aim of this study was to verify the suitability of the use of the visual analog scales (VASs) as a surrogate for rhinomanometry in the decongestion test assessment in patients with persistent allergic rhinitis.

METHODS

One hundred three patients (mean age, 23 years [2.24 SD]) were studied. Nasal symptoms, VAS, rhinomanometry, and nasal decongestion test were assessed in all patients.

RESULTS

A significant association was observed between VAS and nasal airflow after the decongestion test (Spearman R = -33.3%; p < 0.001). Moreover, a significant inverse association between changes in decongestion measures was detected, with a Spearman R = -64.7% (p < 0.001). The associated sensitivity was of 92.5%, and the specificity for this test was 60.0%. The corresponding area under the receiver operating characteristic curve was 0.81.

CONCLUSION

The use of VAS for assessing the decongestion test appears clinically relevant in that it allows, with a fair degree of reliability, such a test to be performed in the absence of rhinomanometry.

Nasal decongestion test in allergic rhinitis: Definition of responder

BACKGROUND

Nasal airflow, as measured by rhinomanometry, is frequently impaired in allergic rhinitis (AR). The decongestion test evaluates whether the application of an intranasal vasoconstrictor drug increases nasal airflow.

OBJECTIVE

The aim of this study was to define the characteristics of decongestion test responders.

METHODS

123 subjects (112 males and 11 females, mean age 22.9+/-5.7 years) with AR were studied. Nasal eosinophils, rhinomanometry, and decongestion test were assessed in all subjects.

RESULTS

The optimal cut-off for % variation of nasal airflow and nasal eosinophils >5 was = 34.4, with sensibility = 82.7% (95%CI 73.7-89.6) and specificity = 80% (95%CI 59.3-93.1).

CONCLUSIONS

The clinical relevance of this study is that non-responders may have a likely moderate-severe allergic inflammation that should be adequately evaluated and treated.

The importance of rhinitis on sleep, daytime somnolence, productivity and fatigue

PURPOSE OF REVIEW

The goal of treatment of allergic rhinitis should include improvement of daytime and nighttime symptoms, sleep, and quality of life. Congestion from allergic rhinitis is associated with decreased learning and productivity at work and school and a reduced quality of life. The release of inflammatory mediators and activation of inflammatory cells results in nasal congestion, causing disrupted sleep and subsequent daytime somnolence.

RECENT FINDINGS

This review presents evidence that allergic rhinitis causes sleep disruption, and discusses the pathophysiology of this process. The medications used to treat allergic rhinitis and their ability to improve sleep in patients with allergic rhinitis are reviewed.

SUMMARY

Some allergic rhinitis medications can be sedating; therefore, it is important to treat allergic rhinitis with medications that improve symptoms while producing few adverse effects. Medications such as the second-generation antihistamines and anticholinergic drugs are well tolerated, but have little effect on congestion. Intranasal corticosteroids reduce congestion, improve sleep and sleep problems, and reduce daytime sleepiness, fatigue, and inflammation. Recently, montelukast, a leukotriene receptor antagonist, has been added to the therapies approved for allergic rhinitis. Montelukast significantly improves both daytime and nighttime symptoms.

Pathophysiology of nasal obstruction and meta-analysis of early and late effects of levocetirizine

Nasal obstruction, also referred to as congestion, blockage or stuffiness, is a crucial symptom in allergic rhinitis (AR) and may affect sleep as well as quality of life. Early- and late-phase-allergic reactions both contribute to nasal obstruction, although it primarily represents a major symptom in the chronic allergic reaction. A complex network of inflammatory and neurogenic phenomena relates to chronic nasal obstruction, including the subepithelial accumulation of inflammatory cells, particularly mast cells and eosinophils, and the release of neuropeptides. Nasal obstruction is a difficult-to-treat symptom. Vasoconstrictors (decongestants) and intranasal corticosteroids, due to their anti-inflammatory properties, have mainly been used for relieving the nasal passages from the congested mucosa. However, there is accumulating evidence recently that the latest-generation potent antihistamines have decongestant properties in AR. This paper aims to review the pathophysiologic background of nasal obstruction and the evidence for an antihistamine, levocetirizine, in relieving nasal congestion. A meta-analysis on the early and late effects of levocetirizine on nasal obstruction under artificial and natural allergen exposure conditions is presented, demonstrating convincingly that levocetirizine shows a consistent effect on nasal obstruction as early as over the first 2 h and sustained over 6 weeks.

Association between response to decongestion testing and sensitizations and allergic inflammation

BACKGROUND

Rhinomanometry is used to measure nasal airflow, which is frequently impaired in allergic rhinitis (AR). Decongestion testing consists of spraying an intranasal vasoconstrictor drug to evaluate recovery of nasal airflow.

OBJECTIVE

To evaluate the relationships among type and number of sensitizations, nasal airflow recovery after topical vasoconstrictor drug use, and allergic inflammation.

METHODS

A total of 123 patients (112 men and 11 women; mean +/- SD age, 22.9 +/- 5.7 years) were studied: 40 with perennial AR (PAR), 43 with mixed AR (MAR), and 40 with seasonal AR (SAR). Patients with anatomic nasal defects were excluded. Total symptom scores (including nasal itching, sneezing, rhinorrhea, and nasal obstruction), sensitizations, nasal eosinophils, and cytokines (including interleukin 4 [IL-4], IL-5, and interferon-gamma) were evaluated. Electronic rhinomanometry and decongestion testing were performed in all the patients.

RESULTS

After administration of a topical nasal vasoconstrictor agent, mean nasal airflow significantly increased from 471 to 580 mL/s (P < .001). In 12 patients (3 with PAR, 3 with MAR, and 6 with SAR), no increase was shown. Changes from baseline were different in the PAR, MAR, and SAR populations (PAR vs MAR, P < .001; PAR vs SAR, P < .001; and MAR vs SAR, P = .25). Type of sensitization (MAR, PAR, or SAR), concentration of eosinophils, and levels of IL-4, IL-5, and interferon-gamma were associated with nasal airflow recovery of at least 120 mL/s.

CONCLUSIONS

This study provides the first evidence of a different response to decongestion testing taking into consideration the type of AR.

Decongestion test in patients with allergic rhinitis: functional evaluation of nasal airflow

BACKGROUND

Rhinomanometry measures nasal airflow that is frequently impaired in allergic rhinitis. Decongestion tests consist of spraying an intranasal vasoconstrictor drug to evaluate the reversibility of nasal airflow limitation. The aim of this study was to evaluate the decongestion test in patients with seasonal allergic rhinitis (SAR) caused by pollen sensitization, perennial allergic rhinitis (PAR) caused by sensitization to perennial allergens only, or mixed allergic rhinitis (MAR) caused by sensitization to both allergens.

METHODS

One hundred twenty-three subjects (112 men and 11 women, mean age, 22.9 +/- 5.7 years) were studied; 40 subjects had PAR, 43 subjects had MAR, and 40 subjects had SAR. Total symptom score (including: nasal itching, sneezing, rhinorrhea, and nasal obstruction) was assessed. Rhinomanometry and decongestion tests were performed in all subjects.

RESULTS

Nasal symptom severity was superimposable in the three groups (p was not significant). After decongestion tests, an increase of nasal airflow and a decrease of nasal resistance was shown in PAR (p < 0.01), MAR (p < 0.001), and SAR subjects (p < 0.001). The intergroup analysis showed that SAR patients had less reversibility than PAR (p < 0.01).

CONCLUSION

This study provides the first evidence of the different response to decongestion tests, taking into consideration the causal allergens.

Effects of rupatadine vs placebo on allergen-induced symptoms in patients exposed to aeroallergens in the Vienna Challenge Chamber

BACKGROUND

Rupatadine is a novel compound with potent dual antihistamine and platelet-activating factor antagonist activities and no sedative effects.

OBJECTIVE

To evaluate the efficacy of rupatadine, 10 mg once daily, and placebo on allergen-induced symptoms (including nasal congestion), nasal airflow, nasal secretion, and subjective tolerability in response to grass pollen in a controlled allergen-exposure chamber.

METHODS

In a randomized, double-blind, placebo-controlled, crossover trial, 45 patients with a history of seasonal allergic rhinitis received rupatadine or placebo every morning for 8 days in 2 different periods separated by a 14-day washout interval. On day 8 of each crossover period, patients underwent a 6-hour allergen exposure in the Vienna Challenge Chamber, where a constant and homogeneous concentration of aeroallergens was maintained. Subjective and objective assessments were performed online during the exposure.

RESULTS

Subjective single and composite nasal and nonnasal symptoms were consistently less severe with rupatadine use than with placebo use starting from the first evaluation at 15 minutes to the end of the 6-hour Vienna Challenge Chamber challenge, with the most significant effects seen for nasal rhinorrhea, nasal itching, sneezing attacks, and total nasal symptoms (P < .001 for all). All the other symptoms (including nasal congestion, P < or = .005) were also significantly reduced with active treatment compared with placebo use. Mean secretion weights and overall feeling of complaint were significantly lower with rupatadine therapy than with placebo use (P < or = .001). Overall, rupatadine treatment was well tolerated.

CONCLUSION

Rupatadine treatment is effective and well tolerated in patients with allergen-induced symptoms exposed to aeroallergens in a controlled exposure chamber.

Nasal surgery and eustachian tube function: effects on middle ear ventilation

OBJECTIVES

To investigate the effect of nasal obstruction surgery on eustachian tube function and middle ear ventilation.

DESIGN

Prospective study.

SETTING

University Campus Bio-Medico of Rome.

PARTICIPANTS

Forty consecutive patients who underwent nasal surgery were evaluated for middle ear ventilation and tubal function.

MAIN OUTCOME MEASURES

Pre- and postoperative Valsalva and Toynbee tubal function tests, tympanometry and ear fullness sensation were evaluated for both ears of each patient.

RESULTS

Results of postoperative tubal function tests were significantly better than preoperative ones (90% versus 46%; P<0.001). No significant difference in tympanometric values was found. The majority (95%) of the patients reported a postoperative improvement of ear fullness sensation compared with preoperative (25%; P<0.001).

CONCLUSIONS

Surgery for chronic nasal obstruction significantly improves clinical tubal function but 1-month postoperative tympanometric findings remain almost the same.

Relationships between allergic inflammation and nasal airflow in children with persistent allergic rhinitis due to mite sensitization

BACKGROUND

Allergic rhinitis is associated with Th2-dependent inflammation. Nasal obstruction is the most typical symptom in children with mite allergy.

OBJECTIVES

The aim of this study was to evaluate the possible relationships among nasal symptoms, allergic inflammation, including inflammatory cells and cytokine pattern, and nasal airflow in children with persistent allergic rhinitis because of mite sensitization.

METHODS

Twenty children (13 males and seven females, mean age 13.4 +/- 1.6 years) with persistent rhinitis because of mite allergy were evaluated. All of them had moderate-severe grade of nasal obstruction. Total symptom score (TSS), rhinomanometry, nasal lavage, and nasal scraping were obtained in all subjects. Inflammatory cells were counted by conventional staining; interleukin (IL)-5, and IL-8 were measured by immunoassay on fluids recovered from nasal lavage.

RESULTS

Eosinophils were significantly associated with TSS (R = 74.4%, P = 0.0002), with IL-5 (R = 90.6%, P < 0.0001) and with nasal flow (R = -69%, P = 0.0007), but not with IL-8 (R = 0.1%, P = 0.995). Eosinophil levels were shown to independently predict nasal flow (P < 0.001), with flow decreasing linearly for increasing eosinophils, together with a significant effect of neutrophils (P = 0.016, linear increase in flow) and a borderline effect of IL-8 (P = 0.063, linear increase in flow).

CONCLUSIONS

This study demonstrates the close association between IL-5 concentration and eosinophil infiltration. In addition, there is clear evidence concerning the relationship between eosinophil infiltration and nasal airflow. Thus, nasal eosinophils can be regarded as the most important predictor of upper airway function. These findings constitute first evidence of the relationship between nasal airflow impairment and Th2-related eosinophilic inflammation in children with persistent allergic rhinitis because of mite sensitization.

Desloratadine and levocetirizine improve nasal symptoms, airflow, and allergic inflammation in patients with perennial allergic rhinitis: a pilot study

BACKGROUND

Nasal obstruction is the main symptom in patients with perennial allergic rhinitis. Some new antihistamines have been demonstrated to be capable of improving this symptom.

OBJECTIVE

The aim of this pilot study was to evaluate nasal symptoms, nasal airflow, eosinophils, and IL-4 in patients with perennial allergic rhinitis, before and after treatment with two new antihistamines: desloratadine and levocetirizine.

METHODS

Thirty patients with perennial allergic rhinitis were evaluated, 26 males and 4 females (mean age 26+/-7.1 years). All of them received either desloratadine (5 mg/daily) or levocetirizine (5 mg/daily) or placebo for 4 weeks. The study was double-blind, parallel-group, placebo-controlled, and randomized. Total symptom score (including: rhinorrhea, nasal itching, sneezing, and nasal obstruction) was assessed before and after treatment. Rhinomanometry and decongestion test, nasal lavage, and nasal scraping were performed in all subjects before and after treatment. Eosinophils were counted by conventional staining; IL-4 was measured by immunoassay of fluids recovered from nasal lavage.

RESULTS

Desloratadine and levocetirizine treatment induced significant symptom relief and significant reduction of IL-4. Both antihistamines significantly affected all parameters in comparison with placebo.

CONCLUSIONS

This pilot study demonstrates the effectiveness of antihistaminic treatment in: i) relieving nasal symptoms, including obstruction, ii) improving nasal airflow, iii) exerting decongestant activity, iv) reducing eosinophil infiltration, and v) diminishing IL-4 levels.

Relationships between allergic inflammation and nasal airflow in children with seasonal allergic rhinitis

BACKGROUND

Allergic rhinitis is characterized by a T(H)2-dependent inflammation. Nasal obstruction is a typical symptom of allergic rhinitis.

OBJECTIVE

To evaluate the possible relationships among nasal symptoms, allergic inflammation, including inflammatory cells and cytokine pattern, and nasal airflow in children with seasonal allergic rhinitis.

METHODS

Children with seasonal allergic rhinitis and moderate-severe nasal obstruction were evaluated during the pollen season. Total symptom score, rhinomanometry, nasal lavage, and nasal scraping were evaluated in all patients. Inflammatory cells were counted by conventional staining; interleukin 5 (IL-5) and IL-8 levels were measured by immunoassay on fluids recovered from nasal lavage.

RESULTS

Twenty children (11 boys and 9 girls; mean +/- SD age, 12.9 +/- 1.7 years) participated in this study. Eosinophil levels were significantly associated with total symptom score (r = 90.6%, P < .001), IL-5 (r = 94.9%, P < .001), and nasal flow (r = -93.6%, P < .001). No association was elicited with IL-8 (r = 9.4%, P = .69). In a multivariate analysis that included eosinophils, neutrophils, and IL-5, eosinophil levels were shown to be the only independent predictor of nasal flow.

CONCLUSIONS

This study demonstrates the close connection between T(H)2 cytokines and eosinophil infiltration. In addition, there is clear evidence concerning the relationship among nasal symptoms, eosinophil infiltration, and nasal airflow. These findings constitute evidence of the relationship between nasal airflow impairment and eosinophilic inflammation in children with seasonal allergic rhinitis.

Levocetirizine improves nasal obstruction and modulates cytokine pattern in patients with seasonal allergic rhinitis: a pilot study

BACKGROUND

Allergic rhinitis is characterized by an IgE-dependent inflammation. Nasal obstruction is related to allergic inflammation. Some antihistamines have been demonstrated to be capable of improving this nasal symptom.

OBJECTIVE

The aim of this pilot study was to evaluate nasal symptoms, nasal airflow, inflammatory cells, and cytokine pattern in patients with seasonal allergic rhinitis (SAR), before and after treatment with levocetirizine, desloratadine, or placebo.

METHODS

Thirty patients with SAR were evaluated, 27 males and three females (mean age 26.9+/-5.4 years). All of them received levocetirizine (5 mg/day), desloratadine (5 mg/day), or placebo for 2 weeks. The study was double-blind, parallel-group, placebo-controlled, and randomized. Total symptom score (TSS) (including: rhinorrhea, nasal itching, sneezing, and nasal obstruction) was assessed before and after treatment. Rhinomanometry, nasal lavage, and nasal scraping were performed in all subjects before and after treatment. Inflammatory cells were counted by conventional staining; IL-4 and IL-8 were measured by immunoassay on fluids recovered from nasal lavage.

RESULTS

Levocetirizine treatment induced significant symptom relief (P=0.0009) and improved nasal airflow (P=0.038). Desloratadine also relieved TSS (P=0.01), but did not affect nasal airflow. Levocetirizine significantly reduced eosinophils (P=0.029), neutrophils (P=0.005), IL-4 (P=0.041), and IL-8 (P=0.02), whereas desloratadine diminished IL-4 only (P=0.044). Placebo treatment did not significantly affect any evaluated parameters.

CONCLUSIONS

This pilot study demonstrates the effectiveness of levocetirizine in: (i) relieving nasal symptoms, (ii) improving nasal airflow, (iii) reducing leucocyte infiltration, and (iv) diminishing cytokine levels. These findings are the first evidence of the effectiveness of levocetirizine in SAR.