Pediatric allergic rhinitis and comorbid disorders

Allergen Immunotherapy for the Prevention and Treatment of Asthma

Allergic asthma is the predominant phenotype among asthmatics. Although conventional pharmacotherapy is a central component in the management of asthma, it does not enable control of asthma symptoms in all patients. In recent decades, some uncontrolled asthmatic patients, especially those with allergic asthma, have benefited from biological therapies. However, biologics do not address all the unmet needs left by conventional pharmacotherapy. Furthermore, it is noteworthy that neither conventional pharmacotherapy nor biological therapies have disease-modifying properties. In this context, allergen immunotherapy (AIT) represents an indispensable component of the therapeutic arsenal against allergic asthma, due to its disease-modifying immunological effects. In this review article, funded by an AIT manufacturer, we find clinical trials support AIT as the only treatment option able both to improve allergic asthma symptoms and to prevent the onset and worsening of the condition. For patients with severe asthma or other safety concerns, the combination of AIT and biologics offers very promising new treatment modalities for the management of allergic asthma. Trial Registration: clinicaltrials.gov identifier: NCT06027073.

Features of Importance in Nasal Endoscopy: Deriving a Meaningful Framework

OBJECTIVE

Critical components of the nasal endoscopic examination have not been definitively established for either the normal examination or for clinical disorders. This study aimed to identify concordance among rhinologists regarding the importance of examination findings for various nasal pathologies.

STUDY DESIGN

A consortium of 19 expert rhinologists across the United States was asked to rank the importance of findings on nasal endoscopy for 5 different sinonasal symptom presentations.

SETTING

An online questionnaire was distributed in July 2023.

METHODS

The questionnaire utilized JotForm® software and featured 5 cases with a set of 4 identical questions per case, each covering a common indication for nasal endoscopy. Rankings were synthesized into Normalized Attention Scores (NASs) and Weighted Normalized Attention Scores (W-NASs) to represent the perceived importance of each feature, scaled from 0 to 1.

RESULTS

General concordance was found for examination findings on nasal endoscopy within each case. The perceived features of importance differed between cases based on clinical presentation. For instance, in evaluating postnasal drip, the middle meatus was selected as the most important structure to examine (NAS, 0.73), with mucus selected as the most important abnormal finding (W-NAS, 0.66). The primary feature of interest for mucus was whether it was purulent or not (W-NAS, 0.67). Similar analyses were performed for features in each case.

CONCLUSION

The implicit framework existing among rhinologists may help standardize examinations and improve diagnostic accuracy, augment the instruction of trainees, and inform the development of artificially intelligent algorithms to enhance clinical decision-making during nasal endoscopy.

Causal relationship between allergic rhinitis and otitis media: A Mendelian randomization study

Otitis media and allergic rhinitis are prevalent conditions. Some data posit a significant association between the 2 ailments, proposing mechanisms such as allergic rhinitis-induced Eustachian tube dysfunction or concurrent allergic pathophysiology affecting both the nasal and aural cavities. Observational studies hint at an association between allergic rhinitis (AR) and nonsuppurative otitis media, yet definitive causality remains elusive. Thus, to elucidate the causal impact of AR on otitis media, a 2-sample Mendelian randomization study was undertaken. Data on AR, acute suppurative otitis media, chronic suppurative otitis media, and nonsuppurative otitis media were sourced from the Genome for Extensive Association Study, encompassing individuals of European ancestry. Single nucleotide polymorphisms linked with AR were utilized as instrumental variables. The inverse-variance weighting (IVW) method, alongside sensitivity analyses employing the weighted median and Mendelian randomization-Egger methods, was employed to assess causal effects. Our analysis revealed a significant causal effect of AR on nonsuppurative otitis media (IVW, odds ratio [OR] = 12.22, 95% confidence interval, 1.38-107.93, P = .024) and indicated an association with acute suppurative otitis media (IVW, OR = 6.95, 95% confidence interval, 0.80-60.35, P = .078). However, no causal effect of AR on chronic suppurative otitis media was discerned. Our findings delineate a measurable causal link between AR and nonsuppurative otitis media (OR = 12.22) and suggest an association with acute suppurative otitis media (OR = 6.95), though lacking evidence for a causal effect on chronic suppurative otitis media. These results underscore the propensity of AR to correlate with diverse forms of otitis media and furnish high-quality causal evidence pertinent to clinical management.

Intranasal administration of a synthetic TLR4 agonist INI-2004 significantly reduces allergy symptoms following therapeutic administration in a murine model of allergic sensitization

Introduction

Atopic diseases have been steadily increasing over the past decades and effective disease-modifying treatment options are urgently needed. These studies introduce a novel synthetic Toll-like receptor 4 (TLR4) agonist, INI-2004, with remarkable efficacy as a therapeutic intranasal treatment for seasonal allergic rhinitis.

Methods

Using a murine airway allergic sensitization model, the impact of INI-2004 on allergic responses was assessed.

Results

One or two intranasal doses of INI-2004 significantly reduced airway resistance, eosinophil influx, and Th2 cytokine production - providing strong evidence of allergic desensitization. Further investigations revealed that a liposomal formulation of INI-2004 exhibited better safety and efficacy profiles compared to aqueous formulations. Importantly, the liposomal formulation demonstrated a 1000-fold increase in the maximum tolerated intravenous dose in pigs. Pre-clinical GLP toxicology studies in rats and pigs confirmed the safety of liposomal INI-2004, supporting its selection for human clinical trials.

Discussion

These findings lay the groundwork for the ongoing clinical evaluation of INI-2004 in allergic rhinitis as a stand-alone therapy for individuals poly-sensitized to multiple seasonal allergens. The study underscores the significance of innovative immunotherapy approaches in reshaping the landscape of allergic rhinitis management.

Risk factors and management countermeasures for obstructive sleep apnea hypoventilation syndrome in children

BACKGROUND

Obstructive sleep apnea hypoventilation syndrome (OSAHS) in children is a sleep respiratory disorder characterized by a series of pathophysiologic changes. Statistics in recent years have demonstrated an increasing yearly incidence.

AIM

To investigate the risk factors for OSAHS in children and propose appropriate management measures.

METHODS

This study had a case-control study design. Altogether, 85 children with OSAHS comprised the case group, and healthy children of the same age and sex were matched at 1:1 as the control group. Basic information, including age, sex, height, weight and family history, and medical history data of all study participants were collected. Polysomnography was used to detect at least 8 h of nocturnal sleep. All participants were clinically examined for the presence of adenoids, enlarged tonsils, sinusitis, and rhinitis.

RESULTS

The analysis of variance revealed that the case group had a higher proportion of factors such as adenoid grading, tonsil indexing, sinusitis, and rhinitis than the control group.

CONCLUSION

A regression model was established, and glandular pattern grading, tonsil indexing, sinusitis, and pharyngitis were identified as independent risk factors affecting OSAHS development.

Long-term effects of pollen allergoid tyrosine-adsorbed subcutaneous immunotherapy on allergic rhinitis and asthma

BACKGROUND

Allergen immunotherapy (AIT) may have a long-term disease-modifying effect. The aim of this study was to demonstrate the long-term effects of pollen allergoid tyrosine-adsorbed subcutaneous AIT on allergic rhinitis (AR) and asthma (AA) in clinical practice.

METHODS

This retrospective study, funded by an AIT manufacturer, analysed the impact of AIT on AR progression and onset of need for AA medication, using a German database covering ~35% of national prescriptions during 2008-2020. Anonymized prescription data of AR patients aged 5-65 years treated with grass or tree pollen AIT between 2009 and 2013 and followed for at least 2 years after AIT cessation were compared with matched control patients with seasonal AR.

RESULTS

181,496 patients received AIT prescriptions. 5959 fulfilled the inclusion criteria. The median AIT treatment duration was 1092 days and the follow-up duration was 6.4 years. Less patients treated with AIT received prescriptions for symptomatic AR medication in the follow-up versus controls (AIT: OR: 0.37; 95% Confidence Interval (CI) 0.34, 0.40; p < .001, tyrosine-adsorbed AIT: OR: 0.27; 95% CI 0.20, 0.35 p < .001). Less asthmatic patients under AIT received prescriptions for AA medications versus controls (AIT: OR: 0.48; 95% CI 0.41, 0.55; p < .001, tyrosine-adsorbed AIT: OR: 0.48; 95% CI 0.29, 0.79; p = .004). AR and AA medication prescriptions for AIT patients were reduced in the follow-up versus baseline and controls (AIT: AR: 20.0%; 1.5 vs. 0.2 prescriptions; AA: 29.1%; 2.0 vs. 0.6 prescriptions, p < .001; tyrosine-adsorbed AIT: AR: 24.2%, 1.4 vs. 0.2 prescriptions; AA: 35.6%, 2.1 vs. 0.6 prescriptions, p < .001). The probability of AA medication onset in non-asthmatic patients during follow-up was reduced for AIT patients compared to controls (OR: 0.77, 95% CI 0.66, 0.90; p = .001). All endpoints were significant for children/adolescents and adults in stratified analyses.

CONCLUSIONS

We found evidence for long-term effects up to 9.5 years for tyrosine-adsorbed AIT.

Fungi and bacteria in the beds of rural and urban infants correlate with later risk of atopic diseases

INTRODUCTION

Rural children have a lower risk of asthma and atopic diseases than urban children. However, whether indoor microbiota in non-farming rural homes provides protection is unclear.

METHODS

Here, we examine if microbes in the beds of rural and urban infants are associated with later development of atopic diseases. We studied fungi and bacteria in the beds of 6-month-old infants (n = 514) in association with the risk of asthma, allergic rhinitis, eczema and aeroallergen sensitization at 6 years of age in the prospective COPSAC2010 cohort.

RESULTS

Both fungal and bacterial diversity were lower in the beds of children, who later developed allergic rhinitis (-0.22 [-0.43,-0.01], padj  = .04 and -.24 [-0.42,-0.05], padj  = .01 respectively) and lower bacterial richness was discovered in beds of children later developing asthma (-41.34 [-76.95,-5.73], padj  = .02) or allergic rhinitis (-45.65 [-81.19,-10.10], padj  = .01). Interestingly, higher fungal diversity and richness were discovered in the beds of children developing eczema (0.23 [0.02,0.43], padj  = .03 and 29.21 [1.59,56.83], padj  = .04 respectively). We defined a limited set of fungal and bacterial genera that predicted rural/urban environment. Some rural-associated bacterial genera such as Romboutsia and Bacillus and fungal genera Spegazzinia and Physcia were also associated with reduced risk of diseases, including eczema. These fungal and bacterial fingerprints predicting the living environment were associated with asthma and allergic rhinitis, but not eczema, with rural compositions being protective. The bed dust bacteria mediated 27% of the protective association of a rural living environment for allergic rhinitis (p = .04).

CONCLUSIONS

Bed dust microbes can be differentially associated with airway- and skin-related diseases. The differing bed dust microbiota between rural and urban infants may influence their later risk of asthma and allergic rhinitis.

Allergic Rhinitis

Allergic rhinitis (AR) affects more than 400 million people worldwide, making it 1 of the most prevalent chronic diseases. Childhood AR is increasing, and almost half of patients with AR develop symptoms before age 6 years. Although a diagnosis of AR is associated with higher socioeconomic status, underserved and urban populations have more indoor aeroallergen sensitizations and are likely underdiagnosed with AR, further exacerbating health-care disparities. AR negatively impacts quality of life, school performance, and overall health outcomes. Untreated AR in children increases the risk for poor asthma control, increased asthma severity, and exacerbations. Many patients believe that they have seasonal allergies only but in reality have both perennial and seasonal AR, which may change the approach to allergen avoidance measures and treatment recommendations. Pharmacotherapy of AR has expanded, with many intranasal corticosteroids, intranasal antihistamines, and second-generation oral antihistamines approved for pediatric use. Allergen immunotherapy, including both subcutaneous and sublingual forms, are approved for children and are disease modifying, potentially reducing further allergen sensitization and progression to asthma. Many of the currently available biological therapies indicated for pediatric asthma and/or atopic diseases reduce AR symptoms as well. Children with moderate to severe or refractory AR or those with comorbidities should be referred to allergists for diagnostic testing and expanded management options, including immunotherapy and potential biological treatment.

The Role of Airway Epithelial Cell Alarmins in Asthma

The airway epithelium is the first line of defense for the lungs, detecting inhaled environmental threats through pattern recognition receptors expressed transmembrane or intracellularly. Activation of pattern recognition receptors triggers the release of alarmin cytokines IL-25, IL-33, and TSLP. These alarmins are important mediators of inflammation, with receptors widely expressed in structural cells as well as innate and adaptive immune cells. Many of the key effector cells in the allergic cascade also produce alarmins, thereby contributing to the airways disease by driving downstream type 2 inflammatory processes. Randomized controlled clinical trials have demonstrated benefit when blockade of TSLP and IL-33 were added to standard of care medications, suggesting these are important new targets for treatment of asthma. With genome-wide association studies demonstrating associations between single-nucleotide polymorphisms of the TSLP and IL-33 gene and risk of asthma, it will be important to understand which subsets of asthma patients will benefit most from anti-alarmin therapy.

Effects of ambient air pollution on childhood asthma exacerbation in the Philadelphia metropolitan Region, 2011-2014

Fine particulate matter (PM_2.5) and ozone (O₃) air pollutants are known risk factors for asthma exacerbation. We studied the association of these air pollutants with pediatric asthma exacerbation in the Philadelphia metropolitan region, and evaluated potential effect modification by children's characteristics (e.g., race/ethnicity, atopic conditions) and environmental factors (e.g., neighborhood tree canopy, meteorological factors, aeroallergens). We conducted a time-stratified case-crossover study of 54,632 pediatric (age ≤18 years) asthma exacerbation cases occurring from 2011 to 2014, identified through electronic health records (EHR) of the Children's Hospital of Philadelphia (CHOP) health system. We applied conditional logistic regression to estimate associations between air pollution and asthma exacerbation, using daily census-tract level pollutant concentrations estimated from the EPA Fused Air Quality Surface Using Downscaling (FAQSD) files. The associations were estimated within warm (Apr-Sep) and cold (Oct-Mar) months for unlagged exposure and for cumulative effects up to 5 days after exposure, with adjustment for temperature, relative humidity, and holidays. We found small increases in odds of asthma exacerbation with higher pollutant concentrations, with positive associations (OR, comparing concentrations of 75th to 25th percentile) observed for PM_2.5 during both warm (1.03, 95% CI: 0.98-1.08) and cold months (1.05, 95% CI: 1.02-1.07), and for O₃ during cold months (1.08, 95% CI: 1.02-1.14). The exposure-response relationship with PM_2.5 during the cold months was essentially linear, whereas thresholds of effect were observed for the other associations at low-medium pollutant concentrations. Results were robust to multi-pollutant modeling and adjustment for additional covariates. We found no effect modification by most children's characteristics, while effect sizes were higher on days with detected tree and grass pollens during warm months. Our results suggest that even small decreases in pollutant concentrations could potentially reduce risk of childhood asthma exacerbation - an important finding, given the high burden of childhood asthma and known disparities in asthma control.

"Effects of Tobacco Smoke on Aeroallergen Sensitization and Clinical Severity among University Students and Staff with Allergic Rhinitis"

Allergic diseases, affecting a variety of organs, have continuously increased both in developed and developing countries. Tobacco smoke exposure increases prevalence of allergic rhinitis (AR) and may affect allergic sensitization. This study was designed to compare indoor-aeroallergen sensitization between those not exposed and exposed to tobacco smoke in university students and staff with allergic rhinitis. A cross-sectional descriptive study among university students and staff with allergic rhinitis was performed from February 1, 2018, to March 31, 2019. Questionnaires regarding demography, clinical symptoms, and tobacco smoke exposure were implemented. A current smoker was defined as using, at least, 1 cigarette per day for, at least, 1 month. A secondhand smoker was defined as the one who never smoked, but lived with a current smoker, at least, for 1 month. A skin prick test for eight common indoor aeroallergens, Dermatophagoides pteronyssinus, Dermatophagoides farinae, Periplaneta americana, cat dander, dog dander, para grass, careless weed, and Cladosporium spp., was performed. Sensitization was defined as positivity to, at least, 1 aeroallergen. One hundred and twenty-eight adult patients were eligible participants for the study, and 68 cases (53.10%) were classified as having tobacco smoke exposure. Among these, most of them were secondhand smokers (50 cases, 73.50%). There was no statistically significant difference between exposure and nonexposure to tobacco smoke and indoor aeroallergen sensitization, except for the Periplaneta americana antigen (p=0.013). Most of those in the nonexposure group (34 cases, 56.70%) were classified as having intermittent allergic rhinitis, whereas the tobacco exposure group had significantly more prevalence of severe clinical symptoms. In conclusion, tobacco smoke exposure did not appear to have much influence on aeroallergen sensitization for 7 of the 8 antigens examined. However, for the Periplaneta americana antigen, there was a highly significant correlation with patients experiencing worsened allergic rhinitis symptoms. Overall, it was observed that allergic rhinitis patients exposed to tobacco smoke had more severe clinical symptoms. Future studies should look for other potential antigens of interest, such as mould. Implementation of public health practices reducing exposure to tobacco smoke could have benefits in allergic rhinitis patients.

Intranasal Corticosteroid Therapy: Systematic Review and Meta-analysis of Reported Safety and Adverse Effects in Children

OBJECTIVES

To address concerns related to the safety profile of both Food and Drug Administration (FDA)-approved and non-FDA-approved intranasal corticosteroid (INCS) use in the pediatric population.

DATA SOURCE

Systematic review of MEDLINE, PubMed, and EMBASE databases using comprehensive search strategy, including all INCS formulations and adverse events. The study design was developed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Additional sources were identified from study references of relevant articles.

REVIEW METHODS

A structured literature search was conducted. Extracted data included age, population size, study design, drug (dosage, route, and frequency), presence of hypothalamic-pituitary-adrenal (HPA) axis suppression, ocular symptoms, and growth velocity adverse events.

RESULTS

A total of 33 studies met inclusion criteria. The studies included use of INCS as nasal sprays and drops. There were no persistent abnormalities noted in cortisol level or intraocular pressure change. Growth velocity reduction was reported in 3 of 10 randomized trials. Meta-analysis of epistaxis and headache showed no significant difference in the incidence of headache or epistaxis when FDA-approved INCSs were compared to placebo, with a relative risk of 1.12 (95% CI, 0.77-1.63; P = .56) and 0.84 (95% CI, 0.60-1.18; P = .32), respectively. Meta-analysis was not performed for growth velocity, HPA axis suppression, and ocular change.

CONCLUSIONS

INCSs in FDA-approved routes of administration are generally safe to use in the pediatric population. Use of non-FDA-approved INCS drops may increase risk of iatrogenic Cushing's syndrome. Growth velocity reduction, HPA axis suppression, and visual changes due to INCS are uncommon.

Illness perception of adolescents with allergic conditions under specialist care

BACKGROUND

Our understanding of how adolescents perceive and cope with their allergic condition/s is limited. This study used the Brief Illness Perception Questionnaire (BIPQ) in a group of adolescents with allergies and correlates the findings with demographic and clinical conditions.

METHODS

In this retrospective questionnaire-based study, we analysed 100 valid questionnaires from adolescents (11-18 years) attending our service after receiving management and treatment for their allergic condition/s.

RESULTS

The overall BIPQ score was 4.8 (IQR 3.6-5.6). The highest item-related scores were for "timeline" (illness duration) followed by "concern." The lowest scores were found for "coherence/understanding," demonstrating that adolescents do not perceive that they have a sound understanding of their condition/s. We found a significant difference in the overall BIPQ scores between the genders and in the emotional representation score, with females showing a highest score. Older adolescents reported a more chronic perception of the allergic disease/s.

CONCLUSION

Our results suggest that a better understanding and support of the allergic condition/s in adolescents, particularly in females, are likely an important target for intervention intended to improve their quality of life. BIPQ can be used as adjunct to routine allergy clinic appointments for further exploration of the wider impact of allergies on adolescents' lives.

The Use of Heated Tobacco Products is Associated with Asthma, Allergic Rhinitis, and Atopic Dermatitis in Korean Adolescents

The increasing use of new and emerging tobacco products has raised public health concern worldwide. This study aimed to assess the association between tobacco product use and the risk of allergic diseases. We used cross-sectional data of 58,336 students aged 12–18 years from the 2018 Korea Youth Risk Behavior Survey. This study considered three tobacco products, namely cigarettes, electronic cigarettes (e-cigarettes), and heated tobacco products. Descriptive analyses, as well as simple and multinomial logistic regression analyses with a complex sampling design, were performed. Multiple tobacco use had an association with the risk of each allergic disease. Use of each tobacco product was significantly associated with an increased risk of multi-morbidity of asthma, allergic rhinitis, and atopic dermatitis. Furthermore, lifetime use of each tobacco product was associated with the prevalence of atopic dermatitis. This highlights the importance of paying close attention to smoking by adolescents and its association with allergy epidemics. Future research should consider intensity of smoking and/or severity of allergic symptoms.

Correlation Between SNOT-22, Nasal Cytology, and Mood Disorders in Patients With Allergic Rhinitis Treated With a Liposomal Nasal Spray

Patients with allergic rhinitis (AR) can suffer from mood disorders. The aim of this study was to investigate the clinical effect of a liposomal nasal spray (LN) containing vitamins A and E on the nasal mucosa in patients suffering from AR who had refused any type of anti-allergic treatment. For this purpose, the results of nasal cytology, Visual Analog Scale (VAS), Sino-Nasal Outcome Test-22 (SNOT-22), and Hospital Anxiety and Depression Scale (HADS) test were analyzed. Moreover, we evaluated the relationship between SNOT-22 and nasal cytology and between nasal symptoms and HADS scores. Statistical analysis revealed a significant decrease of scores at T1 in the LN treatment group as concerns VAS, SNOT-22, HADS-Anxiety test and a remarkable reduction of inflammatory cells detected with nasal cytology. Our study showed that higher levels of SNOT-22 corresponded to a higher level of HADS-Anxiety. The mechanisms underlying this relationship in AR patients are currently unknown, but we can suppose that improving mucosal trophism may contribute to the decrease of nasal symptoms and anxiety scores. The improvement of nasal symptoms, as measured by SNOT-22, was significantly correlated with the objective results of nasal cytology. These relationships between SNOT-22 and nasal cytology and between anxiety and cytology were investigated for the first time in our research.

Real-world benefits of allergen immunotherapy for birch pollen-associated allergic rhinitis and asthma

BACKGROUND

Real-world evidence is sparse on the benefits of allergen immunotherapy [AIT; subcutaneous/sublingual immunotherapy (SCIT/SLIT)], the only disease-modifying intervention for allergic rhinitis (AR) with long-term efficacy. This real-life study evaluated the effect of six AITs (native pollen SLIT/SCIT, four allergoid SCITs) vs symptomatic medication use, on AR symptoms and asthma symptoms/onset, in patients with birch pollen-associated AR and/or asthma.

METHODS

In this retrospective cohort analysis of a German longitudinal prescription database, AIT patients received ≥2 successive seasonal treatment cycles; non-AIT patients had ≥3 AR prescriptions in three seasons or previous month. Patients were matched for: index year, age, gender, main indication at index, number of seasonal cycles within treatment period, baseline AR/asthma treatment prescriptions. Multiple regression analysis compared prescription data in AIT and non-AIT groups as proxy for clinical status/disease progression.

RESULTS

Up to 6 years of follow-up, significantly more AIT (65.4%) vs non-AIT (47.4%) patients were AR medication-free; odds ratio (OR) [95% confidence interval (CI)]: 0.51 [(0.48-0.54); P < 0.001] (28.6% covariate-adjusted reduction vs non-AIT; P < 0.001), and significantly more AIT (49.1%) vs non-AIT (35.1%) patients were asthma medication-free [OR (95% CI): 0.59 (0.55-0.65); P < 0.001] (32% reduction vs non-AIT; P < 0.001), or reduced existing asthma medication use (32% covariate-adjusted reduction vs non-AIT; P < 0.001). During treatment, new-onset asthma risk was significantly reduced in the AIT vs non-AIT group (OR: 0.83; P = 0.001).

CONCLUSIONS

Birch pollen AIT demonstrated real-world benefits up to 6 years post-treatment cessation through significantly reduced AR and asthma medication intake, and significantly decreased risk of new-onset asthma medication use on-treatment.

Association between otitis media infection and failed hearing screenings in children

This study aims to assess prospectively whether there is an association between frequencies of upper respiratory tract infections (URTI) or asthma in early childhood and failed otoacoustic emission (OAE) screenings later in life. There are no clear recommendations for hearing testing following acute otitis media (AOM) infection. This is a retrospective, practice based chart review. Participants from a primary care setting were 517 pre-adolescent and adolescent children (49.9% female) (ages 10-21; mean, 15 y/o), who had presented with at least one specific bacterial URTI (AOM, Group A Streptococcus (GAS) tonsillitis, or Influenza) during childhood. Hearing testing was recorded incidentally at all subsequent routine health care maintenance visits (OAE hearing screen). Simple linear regression analyses were performed using R (v3.4.4). We found that number of episodes of AOM infections strongly correlated with number of failed OAE screenings later in life (F = 76.37; P = <0.001; R2 = 0.1279), while GAS (F = 1.859; P = 0.1733; R2 = 0.0016) or Influenza infection (F = 2.624; P = 0.1059; R2 = 0.0031) were not associated with failed OAE screening. Correlation between number of AOM infections and number of failed OAE screenings was not strengthened by presence of asthma. This study found evidence of an association between childhood history of AOM and failed OAE screenings in adolescence. Since this population may be at a higher risk for developing permanent or fluctuating hearing losses, further studies to clarify indications and timing of standard audiological testing among these children should be considered.

Inhaled Tobramycin in Children with Acute Bacterial Rhinopharyngitis

Antibiotic abuse for treating rhinopharyngitis induces the occurrence of resistant bacteria. As topical drugs might reduce this phenomenon, the aims of our study were to evaluate inhaled tobramycin in children with acute bacterial rhinopharyngitis and to compare it with oral amoxicillin/clavulanate. The trial was conducted as randomized, parallel group and double blind. Children, aged 3–6 years, with acute bacterial rhinopharyngitis were treated with 15 mg of aerosolized tobramycin (Group A) or 50 mg/Kg of amoxicillin/clavulanate (Group B) twice daily for 10 days. The following parameters were assessed: nasal obstruction, mucopurulent rhinorrhea, post-nasal drip, adenoidal hypertrophy, tympanic inflammation, tympanogramm, rhinomanometry and cultures. Of 416 patients screened, 311 children (178 females and 133 males), median age 4.5 years, completed the study: 156 in Group A and 155 in Group B. Both treatments improved all parameters (p<0.01 for all). Intergroup analysis showed that inhaled tobramycin induced a better improvement versus amoxicillin/clavulanate concerning nasal obstruction (p<0.05), adenoidal hypertrophy (p<0.01), tympanic inflammation (p<0.01), rhinomanometry (p<0.01) and cultures (p<0.05). In conclusion, inhaled tobramycin may represent a valid treatment for acute bacterial rhinopharyngitis in children, as it is effective, safe, economic and simple to use.

Effects of pepsin and pepstatin on reflux tonsil hypertrophy in vitro

There is evidence that pepsin can aggravate tonsil hypertrophy. Pepstatin is a potent inhibitor of pepsin activity and could protect patients against reflux tonsil hypertrophy by inhibiting pepsin. We examined the effects of pepstatin on the development of tonsil hypertrophy to investigate pepsin’s role in the pathogenesis of tonsil lesions. We investigated whether pepstatin suppresses pepsin-mediated lymphocyte proliferation in tonsil hypertrophy. Forty-nine children with tonsil hypertrophy and twenty-two adults with tonsillitis were recruited to the study prior to surgery. Tonsil tissue from each patient was harvested and assessed for changes in the number of lymphocytes and macrophages in the presence of pepsin and pepstatin. We found that the proportions of CD4- and CD14-positive cells were significantly lower (p < 0.05), but that the proportions of CD19- and CD68-positive cells were significantly higher (p < 0.05), in children than in adults. There were significantly more CD4-positive cells after pepsin treatment, but these numbers were reduced by pepstatin. The levels of both interleukin-2 (IL-2) and interferon gamma (IFN-γ) increased significantly in response to pepsin, but were reduced when pepsin was inhibited by pepstatin. The level of IL-10 is reduced in pepsin-treated CD4 cells and the level is restored by pepstatin. IL-2 blocking reduced the increased CD4 cell number by pepsin. But, an additive or a synergic effect is not founded in combined with IL-2 blocking and pepstatin. Pepsin-positive cells did not co-localize with CD20 and CD45 cells, but they were found surrounding CD20- and CD45-positive hypertrophic tonsil cells. Pepsin-positive cells co-localized with CD68-positive cells. It is probable that pepsin from extraesophageal reflux aggravates tonsil hypertrophy and pepstatin exerts a protective effect by inhibiting pepsin activity.

[Allergic rhinitis: the modern aspects of therapy]

The main objectives of the present article were to systematize the modern views of the causes and risk factors of allergic rhinitis, to clarify the manner of its development, to define the leading etiological mechanism underling the pathogenesis of this condition, to consider the methods used for the diagnostics and the treatment of this disease, and to sum up the clinical experience with the use of Levocetirizine (Allerwey) for the management of allergic rhinitis. Special attention is given to the achievement and the maintenance of control of the persistent or intermittent forms of allergic rhinitis and to approaches to its treatment based on the medications registered in the Russian Federation.

Association of Ugrp2 gene polymorphisms with adenoid hypertrophy in the pediatric population

INTRODUCTION

Adenoid hypertrophy is a condition that presents itself as the chronic enlargement of adenoid tissues; it is frequently observed in the pediatric population. The Ugrp2 gene, a member of the secretoglobin superfamily, encodes a low-molecular weight protein that functions in the differentiation of upper airway epithelial cells. However, little is known about the association of Ugrp2 genetic variations with adenoid hypertrophy.

OBJECTIVE

The aim of this study is to investigate the association of single nucleotide polymorphisms in the Ugrp2 gene with adenoid hypertrophy and its related phenotypes.

METHODS

A total of 219 children, comprising 114 patients suffering from adenoid hypertrophy and 105 healthy patients without adenoid hypertrophy, were enrolled in this study. Genotypes of the Ugrp2 gene were determined by DNA sequencing.

RESULTS

We identified four single nucleotide polymorphisms (IVS1-189G>A, IVS1-89T>G, c.201delC, and IVS2-15G>A) in the Ugrp2 gene. Our genotype analysis showed that the Ugrp2 (IVS1-89T>G) TG and (c.201delC) CdelC genotypes and their minor alleles were associated with a considerable increase in the risk of adenoid hypertrophy compared with the controls (p=0.012, p=0.009, p=0.013, and p=0.037, respectively). Furthermore, Ugrp2 (GTdelCG, GTdelCA) haplotypes were significantly associated with adenoid hypertrophy (four single nucleotide polymorphisms ordered from 5' to 3'; p=0.0001). Polymorfism-Polymorfism interaction analysis indicated a strong interaction between combined genotypes of the Ugrp2 gene contributing to adenoid hypertrophy, as well as an increased chance of its diagnosis (p<0.0001). In addition, diplotypes carrying the mutant Ugrp2 (c.201delC) allele were strongly associated with an increased risk of adenoid hypertrophy with asthma and with allergies (p=0.003 and p=0.0007, respectively).

CONCLUSION

Some single nucleotide polymorphisms and their combinations in the Ugrp2 gene are associated with an increased risk of developing adenoid hypertrophy. Therefore, we tried to underline the importance of genetic factors associated with adenoid hypertrophy and its related clinical phenotypes.

Montelukast Effectively Treats the Nighttime Impact of Seasonal Allergic Rhinitis

Background

Nighttime problems constitute a significant burden on the quality of life of patients with seasonal allergic rhinitis (SAR). The aim of this study was to evaluate the effectiveness of montelukast on nighttime AR symptoms.

Methods

In seven multicenter, double-blind, parallel-group trials, nighttime problems were assessed as the nighttime symptoms score (NSS), an average of three individual symptom scores: difficulty going to sleep, nighttime awakening, and nasal congestion on awakening (each rated 0 = none to 3 = severe). Patients (aged 15–82 years) were randomized to receive montelukast, 10 mg (n = 1751), placebo (n = 1557), or the positive control loratadine, 10 mg (n = 1616).

Results

In a combined analysis, changes from baseline (mean ± SE) in NSS were -0.28 ± 0.01, -0.16 ± 0.01, and —0.24 ± 0.01 for the montelukast, placebo, and loratadine groups, respectively. Difference versus placebo in least-squares mean change from baseline were —0.11 (95% confidence interval, -0.14, -0.08; p ≤ 0.001) for montelukast and -0.09 (-0.12, -0.06; p ≤ 0.001) for loratadine. Strong baseline correlations (R > 0.70; p < 0.001) of NSS and two of its individual symptoms with the sleep domain of the validated Rhinoconjunctivitis Quality of Life Questionnaire support the validity and importance of measuring nighttime morbidity in SAR. Furthermore, a clinically important benefit of montelukast on the nighttime impact of SAR was shown using an analysis anchored on the Patient's Global Evaluation.

Conclusion

These data underscore the importance of nighttime problems in patients with SAR and the need to treat nighttime symptoms. In these studies, montelukast significantly improved the NSS, a clinically relevant and valid measure in patients with SAR.

Clinical associations between allergies and rapid eye movement sleep disturbances

Background

Allergic rhinitis, an immunoglobulin E inflammatory condition including nasal congestion, obstruction, sneezing, pruritus, and fatigue symptoms, has significant impact on quality of life and impairs sleep. Sleep‐disordered breathing (SDB) patients often have normal all‐night apnea‐hypopnea (AHI) or respiratory‐disturbance (RDI) indices on polysomnography (PSG). We hypothesized that the rapid eye motion–respiratory disturbance index (REM‐RDI) may be a novel predictor of allergic status.

Methods

A retrospective analysis of 100 patients compared REM‐RDI results in 67 allergen‐positive patients with 33 nonallergic patients who presented with nasal blockage. Subjects completed STOP‐Bang©, 22‐item Sino‐Nasal Outcome Test (SNOT‐22)©, and Epworth Sleepiness Scale© questionnaires and underwent skin‐prick testing (SPT) and PSGs including REM‐RDI values. Using multivariate logistic regression models, we evaluated relationships between allergic status and sleep parameters while controlling for possible confounders including body mass index (BMI).

Results

Using REM‐RDI as the outcome of interest, allergen‐positive patients were 3.92 times more likely to have REM‐RDI values in a moderate/severe range (≥15 events/hour); and patients with moderate/severe REM‐RDI values were more likely to be allergen positive (p < 0.05). Allergic status was not significantly related to all‐night AHI, RDI, or REM‐AHI. BMI was not significantly related to REM‐RDI. STOP‐Bang© was related to allergy status (p = 0.02) and REM‐RDI (p < 0.01). Allergic patients had increased REM latency and less total amount of REM.

Conclusion

We revealed significant bidirectional associations between allergen positivity and increased REM‐RDI values independent of BMI, AHI, RDI, and REM‐AHI. Allergic inflammation and REM‐RDI data may play important roles in diagnosing and treating fatigued SDB patients and as objective perioperative safety and outcomes measures.

The International Study of the Allergic Rhinitis Survey: outcomes from 4 geographical regions

Background

Allergic rhinitis (AR) is a global health problem and is characterised by one or more symptoms, including sneezing, itching, nasal congestion and rhinorrhea.

Objective

We investigated the features of AR and the physician's approach to the management of AR patients in four geographical regions.

Methods

In this cross-sectional study, a questionnaire survey concerning AR was completed by Honorary and Corresponding Members of the Italian Society of Rhinology from different countries among 4 world geographical regions—Asia, Europe, the Americas, and Africa.

Results

The prevalence of AR was reported to be 15%–25%. Children and adolescents, as well as young adults, were the age groups more affected by AR with comorbidities of asthma, sinusitis, conjunctivitis, and nasal polyposis. Nasal symptoms of AR were more intense in the spring (51.92%) and autumn (28.85%). The most common aero-allergens were pollen and mites (67.31%), animal dander and pollutants (23.08%), and fungal allergens (21.15%). Allergen-specific immunotherapy was prescribed for both perennial and seasonal allergens (32.69%) via sublingual swallow (46.15%) and subcutaneous (32.69%) routes. For the AR patients, the most prescribed drugs were intranasal corticosteroids (86.54%) and oral H₁-antihistamines (82.69%).

Conclusion

A network of experts can improve our knowledge concerning AR epidemiology, and together with guidelines, could assist practitioners and otolaryngologists in standardising the diagnosis and treatment of AR.

Multi-morbidities of allergic rhinitis in adults: European Academy of Allergy and Clinical Immunology Task Force Report

This report has been prepared by the European Academy of Allergy and Clinical Immunology Task Force on Allergic Rhinitis (AR) comorbidities. The aim of this multidisciplinary European consensus document is to highlight the role of multimorbidities in the definition, classification, mechanisms, recommendations for diagnosis and treatment of AR, and to define the needs in this neglected area by a literature review. AR is a systemic allergic disease and is generally associated with numerous multi-morbid disorders, including asthma, eczema, food allergies, eosinophilic oesophagitis (EoE), conjunctivitis, chronic middle ear effusions, rhinosinusitis, adenoid hypertrophy, olfaction disorders, obstructive sleep apnea, disordered sleep and consequent behavioural and educational effects. This report provides up-to-date usable information to: (1) improve the knowledge and skills of allergists, so as to ultimately improve the overall quality of patient care; (2) to increase interest in this area; and (3) to present a unique contribution to the field of upper inflammatory disease.

The proportion of local allergic rhinitis to Dermatophagoides pteronyssinus in children

BACKGROUND

Local allergic rhinitis (LAR) is diagnosed by the positive response to nasal allergen provocation test (NAPT) to aeroallergen and/or local synthesis of specific IgE (sIgE). This entity is found in half of the adults with non-allergic rhinitis (NAR). In children, very few data of the prevalence and characteristics of LAR were reported.

METHODS

Children 8-18 years with NAR were recruited. A NAPT with Dermatophagoides pteronyssinus extract (NAPT-Dp) at 200, 600, and 2000 AU/ml, respectively, at 15-min interval was performed. The immediate response was assessed using the clinical symptom score, peak nasal inspiratory flow (PNIF), and acoustic rhinometry (ARM). The nasal tryptase and sIgE-Dp were measured at baseline and 15 min and 1 h after a positive NAPT-Dp. Two allergic rhinitis (AR) patients were used as positive controls.

RESULTS

Fifty-four NAR children (61.1% boys) with the mean ± SD age of 11.1 ± 2.1 years were enrolled. The median duration of disease was 6.3 years. The most frequent comorbidity was asthma (38.9%). Eighty-seven percent of patients had mild persistent severity. NAPT-Dp was positive in 2/54 (3.7%) of NAR children who had increased symptom score and decreased minimal cross-sectional area (MCA) on ARM as well as PNIF. However, there was no change in the nasal tryptase and sIgE-Dp. The control AR patients had positive NAPT-Dp and increased nasal tryptase at 15 min without the change of sIgE-Dp.

CONCLUSION

LAR is an uncommon condition in children. Further investigation in a large population of children with NAR is needed.

Association of serum eosinophilia and total immunoglobulin E concentration with the risk of allergic symptoms and allergic sensitization, respectively: A 2-year follow-up study

OBJECTIVES

Serum eosinophil percentage (SEP), eosinophil cationic protein (ECP) concentration, and total IgE (TIgE) concentration are known to increase in patients with allergic disease; however, the relevance of these elevated markers in children with negative allergic test results remains unclear. Therefore, this 2-year follow-up study aimed to investigate whether SEP, ECP concentration, and TIgE concentration are associated with an increased risk for allergic sensitization and allergic symptoms.

METHODS

In 2012, SEP, ECP concentration, and TIgE concentration of third- and fourth-grade students from 6 elementary schools were measured. Skin prick test was performed, and the presence of allergic nasal symptoms was investigated using a questionnaire. In 2014, the same examinations were performed in the same set of students, who were then in the fifth and sixth grades, respectively, of the same schools. The cut-off value and usefulness of serologic markers (eosinophil count, ECP concentration, and TIgE concentration) were calculated using the receiver operating characteristic curve.

RESULTS

Serum eosinophil percentage (cut-off value, 3.8%) was associated with the newly developed allergic nasal symptoms (sensitivity, 77.9; specificity, 41.8). A high serum TIgE concentration (cut-off value, 17.7 IU/mL) was also associated with the risk for allergic sensitization (sensitivity, 46.3; specificity, 85.3).

CONCLUSION

SEP and TIgE concentration were associated with the development of allergic symptoms and allergic sensitization, respectively, 2 years after the first examination.

Medical Treatment for Rhinosinusitis Associated with Adenoidal Hypertrophy in Children: An Evaluation of Clinical Response and Changes on Magnetic Resonance Imaging

Objectives:

The association between adenoidal hypertrophy and rhinosinusitis with upper airway inflammation is increasingly recognized; however, no study has used magnetic resonance imaging (MRI) to assess the changes in adenoid size after medical treatment of rhinosinusitis.

Methods:

Thirteen children referred to a tertiary allergy clinic with symptoms of rhinosinusitis received medical treatment over a 4-month period. All underwent MRI before and after treatment. The medical treatment regimen comprised a short course of oral antibiotics and oral steroids and a longer course of oral antihistamines and intranasal steroids.

Results:

The pretreatment MRI demonstrated enlarged adenoids and rhinosinusitis in all 13 children, with evidence of extensive rhinosinusitis in 9 of the 13. The treatment resulted in an improvement in overall symptom score; the most significant improvement was seen in mouth breathing. The posttreatment MRI showed a statistically significant reduction in adenoid size and adenoid/nasopharynx ratio, which was associated with a significant decrease in sinus involvement on MRI.

Conclusions:

There is a high association between adenoidal hypertrophy and rhinosinusitis in the context of an allergy clinic. Magnetic resonance imaging can document the changes in adenoid size associated with resolution of rhinosinusitis. Further studies are necessary to validate these pilot data and further assess the effects of medical treatment and the role of MRI in adenoidal hypertrophy.

The Role of Co-Morbidities

Medical conditions can impact sleep and breathing in children. Gastroesophageal reflux disease, allergic rhinitis and asthma are common in children and often coexist with obstructive sleep apnea. Appropriate identification and management of these conditions can improve nocturnal and diurnal symptoms of sleep disordered breathing. We discuss the relationship between these medical conditions and obstructive sleep apnea in children.

Allergic rhinitis is associated with open-angle glaucoma: a population-based case-control study

BACKGROUND

Despite many reports linking allergic rhinitis (AR) to problems of the eye, the relationship between AR and open-angle glaucoma (OAG) has not been studied. The purpose of this epidemiology study was to provide an estimation of the association of OAG with AR by using a population-based data set in Taiwan.

METHODS

We retrieved our study sample for this case-control study from the Longitudinal Health Insurance Database 2000. We extracted 7063 subjects with OAG as cases and 21,189 matched controls (three controls per case). We used conditional logistic regression analyses to calculate the odds ratio (OR) and corresponding 95% confidence interval (CI) to describe the association between OAG and having previously been diagnosed with AR.

RESULTS

A chi-squared test showed that there was a significant difference in the prevalence of prior AR between cases and controls (28.8% versus 22.3%; p < 0.001). A conditional logistic regression analysis suggested that the OR of having previously been diagnosed with AR for cases was 1.40 (95% CI, 1.31∼1.48; p < 0.001) compared with controls after adjusting for monthly income, geographic region, urbanization level, hypertension, diabetes, asthma, coronary heart disease, hyperlipidemia, and hypothyroidism. It also revealed that OAG was consistently and significantly associated with prior AR across all age groups. In particular, subjects aged 50∼59 years had the highest OR for prior AR among cases compared with controls (OR, 1.77; 95% CI, 1.53∼2.06; p < 0.001).

CONCLUSION

This outcome research found that there was an association between AR and OAG.

Possible role of apoptosis in pathogenesis of adenoid hypertrophy and chronic adenoiditis: Prospective case-control study

OBJECTIVE

Apoptosis is a programmed cell death; it provides an important balance between lymphocytes in adenoid tissue. The aim of this study is to investigate the role of apoptosis in chronic adenoiditis and adenoid hypertrophy. This is the first study in the literature about apoptosis in adenoid hypertrophy and chronic adenoiditis.

METHODS

Prospective case-control study in a tertiary referral university hospital was conducted. 46 patients who had chronic adenoiditis and adenoid hypertrophy underwent adenoidectomy. Adenoids were evaluated for apoptosis and assembled into groups according to their size. Apoptotic cells were counted in three different microscopic fields and their average was taken for every microcompartment. As a result of immunohistochemical staining, specimens were compared for their apoptotic cell rate.

RESULTS

The difference in apoptosis of chronic adenoiditis and adenoid hypertrophy groups is statistically significant (p<0.05). The age 6 was used as a cut-off to compare apoptosis in adenoid tissue. The difference was not statistically significant for patients at and below 6 years of age; however, the difference was statistically significant for patients above 6 years of age. The comparison of apoptosis in microcompartments of adenoid tissue (intrafollicular, interfollicular, subepithelial and intraepithelial) between chronic adenoiditis and adenoid hypertrophy groups revealed significant differences for intrafollicular and intraepithelial areas, and insignificant differences for interfollicular and subepithelial areas.

CONCLUSION

Although apoptosis could not totally explain the pathogenesis of chronic adenoiditis and adenoid hypertrophy, it appeared to play an important role in it. Apoptosis functions to limit adenoid hypertrophy. Adenoid apoptosis appears to be age-dependent.

Adenoid hypertrophy in children with allergic disease and influential factors

OBJECTIVES

Adenoid hypertrophy (AH) may cause several comorbid conditions including sleep apnea, chronic serous otitis and sinusitis. Such conditions are more common among children with allergic diseases. In our study, we aimed to determine the patient profile associated with higher incidence of adenoid hypertrophy and the related influential factors.

METHODS

The study included 1322 children being treated and followed up for allergic conditions. 100 children with no allergic diseases presenting during the same period to the clinic were included as the control group. Skin prick test for the same allergens was performed for all patients. Adenoid tissue was analyzed by an ENT specialist and the diagnosis was confirmed based on the patient history, endoscopic physical examination and radiology.

RESULTS

Of the patients, 765 (57.9%) were males and 557 (42.1%) were females and their mean age was 5.9±3.3 years. In the control group, 56 (56%) children were males and 44 (44%) were females and their mean age was 6.3±4.1 years. Children with allergic disease and control subjects did not differ significantly by age and gender. Adenoid hypertrophy was identified in 164 (12.4%) of the patients with allergic disease and in 3 (3%) of the controls. Allergic children were divided into two groups, as children with and without AH, respectively. The groups did not differ statistically significantly by gender, age or familial history of atopic disease. However, cigarette smoke exposure at home and presence of allergic rhinitis was significantly more frequent in the group of patients with AH. In the logistic model investigating the effect of variables on AH presence (according to age, gender, cigarette smoke exposure, asthma, AR, AD presence, atopy presence, sensitivity to house dust, pollen, epithelium, Alternaria alternata and cockroach), AR presence and cigarette smoke exposure were statistically significant.

CONLUSIONS

AH frequency is higher in children with allergic disease compared to controls. The most common sensitivity to allergens among patients with AH was to house dust. Presence of allergic rhinitis and cigarette smoke exposure are risk factors for developing AH. Children with these risk factors should be questioned for AH during their routine examinations.

Apoptosis in chronic tonsillitis and tonsillar hypertrophy

OBJECTIVE

Chronic tonsillitis is the persistent inflammation of the tonsillar tissue that occurs due to recurrent, acute or subclinical infection. The recurrent and chronic inflammation of palatine tonsils sometimes results in hypertrophy. Apoptosis provides an important balance between lymphocytes in tonsillar lymphoid tissue. The aim of this study is to investigate the apoptosis in tonsillar diseases.

METHODS

43 patients with chronic tonsilitis and tonsillar hypertrophy underwent tonsillectomy. The specimens were examined immunohistochemically for apoptosis. Tonsils were assembled into groups according to their size. Specimens were compared for their apoptotic cell count.

RESULTS

The apoptosis difference between the tonsil size groups is not statistically significant (p>0.05). However, when the study group was divided into two at age 6, the difference was not statistically significant for patients at and below 6 years of age; but, the difference was statistically significant for patients above 6 years of age (p<0.05). The comparison of apoptosis in microcompartments of tonsil tissue (intrafollicular, interfollicular, subepithelial and intraepithelial) between tonsil size stages and between chronic tonsillitis and tonsillar hypertrophy groups revealed no statistical significance (p>0.05). There was a statistically significant positive correlation between intrafollicular and interfollicular, interfollicular and intraepithelial & subepithelial and intraepithelial areas (p<0.05).

CONCLUSIONS

In the light of these findings, it was concluded that apoptosis played a role in the tonsillar hypertrophy and atrophy. Apoptosis functioned to balance lymphocyte proliferation in tonsil tissue. The association of apoptosis with tonsillar hypertrophy seemed to be age-dependent.

The need for patient-focused therapy for children and teenagers with allergic rhinitis: a case-based review of current European practice

Allergic rhinitis is a common problem in childhood and adolescence, with a negative impact on the quality of life of patients and their families. The treatment modalities for allergic rhinitis include allergen avoidance, anti-inflammatory symptomatic treatment and allergen specific immunotherapy. In this review, four cases of children with allergic rhinitis are presented to illustrate how the recently published EAACI Guidelines on Pediatric Allergic Rhinitis can be implemented in clinical practice.

The impact of intranasal corticosteroids on lung function in children with allergic rhinitis

BACKGROUND

Subjects with allergic rhinitis (AR) suffer from impaired lung function, especially decreased FEF(25-75%). The purpose of this study was to examine lung function and the long-term response to INCS in AR patients with impaired lung function, and to characterize the phenotype of these children.

METHODS

Two hundred two children with AR underwent an allergy evaluation including a skin prick test and spirometry. Children with impaired lung function were treated with daily nasal corticosteroids spray (INCS) and antihistamine as needed.

RESULTS

Fifty-three children out of 202 (26.3%) had impaired lung function: 34 of them (64.2%) had FEF(25-75%) values under 80% of predicted and normal FEV(1) values, and 19 individuals (35.8%), had both FEF(25-75%) and FEV(1) values below 80% of predicted. A positive correlation between FEV(1) and FEF(25-75%) values (r = 0.369, P = 0.007) and a reverse correlation between duration of nasal symptoms and FEF(25-75%) values (r = -0.364, P = 0.012) were found. Post-ronchodilation FEV(1) levels increased from 81.9 ± 8.0 to 87.7 ± 10.4 (P < 0.0001). Thirty-five of the 53 children complied with a continuous INCS treatment regimen over a period of 3-12 months, demonstrated increased FEF(25-75%) (84.4 ± 13.6 vs. 70.1 ± 7.1, P < 0.001) and FEV(1) (92.3 ± 10.9 vs. 84.4 ± 7.8, P < 0.0001) after INCS treatment. However, FEF(25-75%) values were still significantly lower compared to the group of AR children with normal lung function (84.4 ± 13.6 vs. 95.7 ± 8.8, P < 0.0001).

CONCLUSIONS

INCS improve FEF(25-75%) above 80% of predicted values in 2/3 of children with abnormal lung function. However, this improvement does not reach levels of AR children with normal lung function. Pediatr

Cough in children

Cough during childhood is very common, and is one of the most frequent reasons for consultation in daily pediatric practice. The causes differ from those in adults, and specific pediatric guidelines should be followed for correct diagnosis and treatment. The most common cause of cough in children is viral infection producing "normal cough", but all children with persistent cough, i.e. a cough lasting more than 4-8weeks or "chronic cough", must be carefully evaluated in other to rule out specific causes that may include the entire pediatric pulmonology spectrum. The treatment of cough should be based on the etiology. Around 80% of cases can be diagnosed using an optimal approach, and treatment will be effective in 90% of them. In some cases of "nonspecific chronic cough", in which no underlying condition can be found, empirical treatment based on the cough characteristics may be useful. There is no scientific evidence to justify the use of over-the-counter cough remedies (anti-tussives, mucolytics and/or antihistamines), as they could have potentially serious side effects, and thus should not be prescribed in children.

Prevalence of and associations with allergic rhinitis in children with chronic rhinosinusitis

OBJECTIVES

Chronic rhinosinusitis (CRS) in children has been associated with a variety of disorders including atopic disease, cystic fibrosis, immunologic disorders and ciliary dyskinesia. Although a strong association, or even cause and effect relationship, between allergic rhinitis (AR) and CRS is commonly assumed, the epidemiologic relationship between these disorders has not yet been defined in children.

METHODS

A retrospective review of all children diagnosed with CRS on otolaryngology or allergy office evaluation at a large tertiary-care pediatric hospital over a ten-year period was performed. Demographic data and concomitant diagnoses of AR, cystic fibrosis, immunologic disorders and primary ciliary dyskinesia were analyzed for relationships with CRS.

RESULTS

A total of 4044 children with an average age of 8.9 years and a slight male predominance (53.8%) with CRS were identified. Of these children, 0.2% had primary ciliary dyskinesia, 4.1% had cystic fibrosis, 12.3% had an immunologic disorder, and 26.9% had AR. A concomitant asthma diagnosis was positively associated with a diagnosis of AR (OR=6.24, 95% CI: 5.27-7.39, P<0.001), whereas a concomitant cystic fibrosis diagnosis was negatively associated (OR=0.12, 95% CI: 0.06-0.26, P<0.001).

CONCLUSIONS

AR is more prevalent than the other comorbidities combined in children with CRS, and is independently associated with the presence of asthma. Formal allergy testing, guided by clinical history and regional allergen sensitivity prevalence, should be strongly considered in all children with CRS, in particular those with reactive airway disease.

The impact of concomitant allergic rhinitis on asthma control: a cross-sectional nationwide survey in China

OBJECTIVES

Understanding the interactions between allergic rhinitis (AR) and asthma is important for asthma management. This study explored the clinical features of AR as a comorbidity in Chinese asthmatic patients and its impact on asthma control.

METHODS

This cross-sectional survey was conducted among 20 051 patients with asthma in an out-patient setting and covered all of the territories of China. The patients were interviewed face-to-face. A standardized questionnaire was completed by each patient. AR was defined according to the ARIA criteria. The level of asthma control was assessed by the Asthma Control Test. A score ≤19 indicated poorly controlled asthma.

RESULTS

AR was present in 69.9% of patients with asthma. Of them, 72.4% had intermittent symptoms, and 93.1% presented with moderate/severe symptoms. Cold air, irritant air and household mites were the most common triggers for AR. A higher percentage of patients with AR experienced poorly controlled asthma compared with those without AR (56.2% versus 51.5%, p < 0.001). AR was associated with an increased risk of poorly controlled asthma [odds ratio (OR): 1.21, p < 0.001]. Moderate/severe or persistent symptoms were associated with a higher risk of poorly controlled asthma than those with mild or intermittent symptoms (OR: 2.34 and 1.78, respectively, p < 0.001). In contrast, diagnosed AR (OR: 0.84, p < 0.001), being currently treated with medication (OR: 0.91, p = 0.004) and a prior skin prick test (OR: 0.90, p = 0.003) showed a significantly negative association with poorly controlled asthma.

CONCLUSION

This study confirms that concomitant AR and asthma are highly prevalent in China and that AR is associated with poor asthma control.

Prevalence and comorbidity of allergic diseases in preschool children

Purpose

Allergic disease and its comorbidities significantly influence the quality of life. Although the comorbidities of allergic diseases are well described in adult populations, little is known about them in preschool children. In the present study, we aimed to assess the prevalence and comorbidity of allergic diseases in Korean preschool children.

Methods

We conducted a cross-sectional study comprising 615 Korean children (age, 3 to 6 years). Symptoms of allergic diseases were assessed using the Korean version of the International Study of Asthma and Allergies in Childhood (ISAAC) questionnaire that was modified for preschool children. Comorbidities of allergic diseases were assessed by 'In the last 12 months, has your child had symptoms?'.

Results

The prevalence of symptoms of asthma, allergic rhinitis, and atopic dermatitis as recorded using the ISAAC questionnaire, within the last 12 months was 13.8%, 40.7%, and 20.8%, respectively. The symptom rates of allergic conjunctivitis, food allergy, and drug allergy were 14.8%, 10.4%, and 0.8%, respectively. The prevalence of allergic rhinitis in children with asthma was 64.3% and that of asthma in children with allergic rhinitis was 21.6%. The prevalence of rhinitis in children with conjunctivitis was 64.8% and that of conjunctivitis in children with rhinitis was 23.6%.

Conclusion

The prevalence of current rhinitis in our preschool children is shown to be higher than that previously reported. Allergic conjunctivitis is closely associated with asthma and allergic rhinitis. However, further studies are warranted to determine the prevalence and effects of these comorbidities on health outcomes in preschool children.

Sleep impairment and daytime sleepiness in patients with allergic rhinitis: the role of congestion and inflammation

OBJECTIVE

To investigate the association of rhinitis with stress, fatigue, decrease productivity, inflammation, and sleep disordered breathing.

DATA SOURCES

Medical literature obtained from OVID and PubMed searches in February 2013 using the search terms "sleep," "rhinitis," "allergic rhinitis," "somnolence," and "fatigue".

STUDY SELECTIONS

Studies were selected based on the US Preventive Services Task Force levels 1, 2, and 3.

RESULTS

Allergic rhinitis is a disease that severely affects patients' quality of life and is increasing in prevalence worldwide. Nasal congestion is reported as the most common and bothersome symptom; it is often associated with sleep-disordered breathing, a likely cause of sleep impairment in rhinitis-affected individuals. The end result is a reduced quality of life and productivity and an increase in daytime sleepiness, fatigue, and stress. Current treatment modalities include intranasal corticosteroids, which have been found to reduce nasal congestion. Clinical trials on intranasal corticosteroids have provided data on sleep-related end points, and these studies report that the improved nasal congestion is associated with improved quality of life with better sleep and reduced daytime fatigue. Alternate therapies, including montelukast, also decrease nasal congestion and positively influence sleep, but to a lesser extent.

CONCLUSION

This review examines nasal congestion and cytokine changes and the associated sleep impairment in allergic rhinitis patients and the effect on daytime performance. It elaborates the adverse effects of disturbed sleep on quality of life and how therapies directed at reducing nasal congestion can relieve such effects.

Sinus imaging for diagnosis of chronic rhinosinusitis in children

Chronic rhinosinusitis (CRS) is a relatively common disease in children but is often overlooked because at times the clinical symptoms are subtle and nonspecific. This makes imaging very important in the diagnosis. Among the different techniques, plain radiography has limited utility,whereas CT scan and MRI have a major role in evaluating the modifications caused by the disease. In particular, a CT scan provides higher resolution of bone and soft tissue and removes the overlapping structures that are present in conventional radiography. CT is recommended in isolated sphenoid sinusitis, is essential in diagnosing fungal sinusitis, and is the technique of choice when orbital complications are suspected. MRI allows investigation of not only the morphology of structures, but their intrinsic biophysical and biochemical properties, such as water content, cellular density, lipid or blood product deposits, and fibrosis. MRI allows better soft tissue differentiation and high spatial resolution images depicting fine details. When indicated, MRI with contrast gadolinium-based agents may better characterize the local disease extension or its diffusion beyond paranasal and nasal cavities and has excellent contrast resolution. A combination of CT and MRI is useful in cases of diagnostic difficulties,especially when complications are involved.

Nasal mucosa temperature as a marker of disease in children with allergic rhinitis

BACKGROUND

Allergic rhinitis (AR) is a symptomatic disorder of the nose induced after allergen exposure by an IgE-mediated inflammation of the nasal mucosa. This study was designed to investigate the role of nasal mucosa temperature in AR.

METHODS

We investigated the relationship between eosinophilic infiltration, nasal obstruction, and nasal mucosa temperature in 35 children with rhinitis aged 6-12 years.

RESULTS

A significant relationship was shown between nasal temperature values and eosinophil infiltration at nasal cytology (p < 0.01). Nasal temperature was also significantly associated with nasal obstruction, assessed in terms of nasal volume (Vol [2-5 cm]; p < 0.05) and minimum cross-sectional area (p < 0.01). No significant correlation emerged between the degree of nasal obstruction and presence of eosinophils at nasal cytology (p > 0.05).

CONCLUSION

These results suggest a relationship between nasal temperature and nasal mucosa inflammation and obstruction.

Diagnosis of chronic rhinosinusitis

Chronic rhinosinusitis (CRS) is a rather common disease in children, but its symptoms are often subtle and non-specific and this may result in overlooking a correct diagnosis. In turn, a missed diagnosis of CRS prevents a correct management to be performed and is associated with uneffective investigations and improper treatments. Actually, when CRS symptoms, which are mainly nasal congestion and obstruction, nasal discharge, facial pain, cough, and halitosis, are correctly assessed, the clinical diagnosis of CRS may be achieved, and confirmation may be obtained by imaging criteria or nasal fibroendoscopy. In imaging, computed tomography (CT) is the first choice technique for the evaluation of CRS and is able to provide an anatomic road map when surgery is required. Magnetic resonance imaging (MRI) of the sinuses, orbits, and brain should be performed whenever extensive or multiple complications of sinusitis are suspected. Also for middle ear disorders, CT is the first choice because it detects opacification of the middle ear cavity and mastoid cells, presence of fluids or debris, and allows the ossicular chain and the cortical bone of the mastoid to be evaluated. Another important diagnostic issue is the need to look for disorders that are frequently associated with CRS, such as obstructive sleep apnea syndrome (OSAS), that has some recognized risk factors in adenotonsillar hypertrophy, craniofacial anomalies, obesity, and neuromuscular disorders. Other associated disorders requiring investigation are recurrent or persistent otitis media and difficult asthma.