Local allergic rhinitis: a new entity, characterization and further studies

JACQLQ subjective symptom questionnaire score and clinical test results for patients with allergic conjunctival disease

We investigated the relationship between subjective symptoms and objective findings in patients with allergic conjunctival diseases (ACD) and test results for tear total IgE (t-tIgE), conjunctival eosinophils (c-Eo), serum total IgE (s-tIgE), serum-antigen specific IgE (s-sIgE), and serum eosinophils (s-Eo). Subjective symptoms and objective findings of patients with ACD were evaluated using Japanese Allergic Conjunctival Disease Quality of Life Questionnaire (JACQLQ), which described disability score and emotional score written by patient and clinical findings score written by ophthalmologist. We investigated the relationship between questionnaire scores and laboratory data for t-tIgE, c-Eo, s-tIgE, s-sIgE, and s-Eo. Scores of impediments to life and of moods were highest in vernal keratoconjunctivitis among ACD. Cases with positive pollen-sIgE showed significantly more nasal symptom score than those with negative pollen-sIgE (P < 0.05). Cases with positive t-tIgE or c-Eo showed significantly more objective symptoms' JACQLQ score than those with negative t-tIgE or c-Eo (P < 0.05), respectively. Cases positive for house dust/mite-sIgE, showed significantly more objective symptoms' JACQLQ score than those without for house dust/mite-sIgE (P < 0.05). These results indicate that ACD could be analyzed more accurately by the combination of JACQLQ and laboratory data.

Clinical characteristics of local allergic rhinitis sensitized to house dust mites in Asia

PURPOSE

Local allergic rhinitis (LAR) is characterized by a localized nasal allergic response without evidence of systemic atopy. LAR is an underdiagnosed entity and is a diagnostic and therapeutic challenge for clinicians. This study aimed to investigate the prevalence and clinical characteristics of patients with LAR to house dust mites (LAR-HDM) in Korea.

METHODS

We performed a retrospective chart review of 336 adult patients with rhinitis symptoms who visited the Rhinologic Clinic at Korea University Guro Hospital from October 2019 to April 2021. Using results of the skin prick test, serologic test, and nasal provocation test, patients were classified as allergic rhinitis (AR) to HDM (AR-HDM), AR to other allergens, non-allergic rhinitis (NAR), or LAR-HDM. We excluded patients with AR to other allergens and compared the clinical characteristics of the remaining three groups. Patient demographic data were reviewed, and patients' nasal symptoms, olfactory function, serum total IgE, and severity of accompanying rhinosinusitis were evaluated.

RESULTS

In total, 336 patients were examined. AR-HDM was diagnosed in 138 (41.1%) patients, AR to other allergens in 36 (10.7%) patients, NAR in 21 (42.0%) patients, and LAR-HDM in 21 (6.3%) patients. The mean age of patients with LAR-HDM was significantly higher than that of patients with AR-HDM. There were no significant differences in sex, smoking history, asthma, and family history of allergic diseases between the groups. Compared to NAR patients, there were significantly more patients with LAR-HDM who had persistent nasal symptoms. The frequency of nasal itching and sneezing was significantly higher in the LAR-HDM group than in the NAR group. The olfactory function score in the LAR-HDM group was significantly worse than that in the AR-HDM group, and the Lund-Mackay score was significantly higher in the LAR-HDM group than in the other groups.

CONCLUSION

Clinical history and nasal symptoms are very similar in LAR-HDM and AR-HDM. Clinicians should take more care to differentiate them. LAR-HDM should also be considered in patients with persistent and severe nasal symptoms without systemic atopy.

The Role of Nasal Cytology and Serum Atopic Biomarkers in Paediatric Rhinitis

A Nasal Provocation Test allows the differentiation of allergic and non-allergic rhinitis, but it is difficult and expensive. Therefore, nasal cytology is taking hold as an alternative. We carried out a cross-sectional study, including 29 patients with persistent rhinitis according to ARIA definition and negative skin prick tests. Nasal symptoms were scored from 0 to 5 using a visual analogue scale, and patients underwent blood tests to investigate blood cell count (particularly eosinophilia and basophilia), to analyze serum total and specific IgE and eosinophil cationic protein (ECP), and to perform nasal cytology. We performed a univariate logistical analysis to evaluate the association between total serum IgE, serum eosinophilia, basophils, and ECP and the presence of eosinophils in the nasal mucosa, and a multivariate logistic model in order to weight the single variable on the presence of eosinophils to level of the nasal mucosa. A statistically significant association between serum total IgE levels and the severity of nasal eosinophilic inflammation was found (confidence interval C.I. 1.08-4.65, odds ratio OR 2.24, p value 0.03). For this reason, we imagine a therapeutic trial with nasal steroids and oral antihistamines in patients with suspected LAR and increased total IgE levels, reserving nasal cytology and NPT to non-responders to the first-line therapy.

The Beneficial Effects of Hydrogen-Rich Saline Irrigation on Chronic Rhinitis: A Randomized, Double-Blind Clinical Trial

Purpose

Chronic rhinitis (CR) is a common chronic inflammation of the nasal mucosa. Nasal saline irrigation has been demonstrated to be an effective treatment for CR. In this study, we investigated the beneficial effects of hydrogen-rich saline irrigation as an anti-inflammatory irrigation therapy for CR and compared its effectiveness over saline irrigation. Hydrogen-rich saline (HRS) was investigated due to its antioxidant and anti-inflammatory properties.

Methods

A total of 120 patients with CR were randomly divided into two groups, patients irrigated with HR (HRS group) and the control group irrigated with saline (NS group). A randomized, double-blind control study was performed. The main observation index in this study was the total score of nasal symptoms (TNSS). In addition, eosinophilic protein (ECP) of the nasal secretions, nasal nitric oxide (nNO) levels, and levels of regulatory T cells (Treg) and regulatory B cells (Breg) were also compared between the two groups. Furthermore, patients with allergic rhinitis (AR) and non-allergic rhinitis (NAR) were also evaluated based on serum-specific IgE positivity.

Results

After treatment, TNSS and nasal ECP in the two groups decreased significantly (P<0.05), with patients in the HRS group showing significantly lower levels compared to the NS group (P<0.05). There were no significant differences in Treg and Breg levels between the two groups. Subgroup analysis showed that TNSS in the AR-HRS group showed a more significant reduction compared to the AR-NS group (P<0.05); however, there were no significant differences for the other inflammatory biomarkers (P>0.05). ECP levels were reduced significantly in the NAR subgroup compared to NS irrigation (P<0.05). There were no obvious adverse events observed in patients during the entire treatment period.

Conclusion

Compared to saline irrigation, HRS nasal irrigation was found to improve CR clinical symptoms, especially in patients with AR. HRS could effectively be used for the clinical treatment of patients with CR.

Point your SmartPhone at the code above. If you have a QR code reader the video abstract will appear. Or use:

https://youtu.be/8YpkEFCYNzI

Diagnosis and Treatment of Local Allergic Rhinitis

Some patients with chronic rhinitis have a positive nasal allergen provocation test (NAPT) without systemic IgE sensitization by skin prick tests or serum allergen-specific IgE (sIgE). This novel concept is called local allergic rhinitis (LAR) and affects children and adults worldwide, but is underdiagnosed. LAR is not just the initial state of allergic rhinitis (AR), it is a unique form of chronic rhinitis that is neither classical AR nor non-AR. Many of the features of AR and LAR are similar, such as a positive NAPT, positive type 2 inflammatory markers, including the nasal discharge of sIgE, and a high incidence of asthma. A differential diagnosis of LAR needs to be considered in patients with symptoms suggestive of AR in the absence of systemic atopy, regardless of age. The diagnostic method for LAR relies on positive responses to single or multiple allergens in NAPT, the sensitivity, specificity, and reproducibility of which are high. The basophil activation test and measurement of IgE in nasal secretions also contribute to the diagnosis of LAR. Treatment for LAR is similar to that for AR and is supported by the efficacy and safety of allergen exposure avoidance, drug therapy, and allergen immunotherapy. This review discusses current knowledge on LAR.

Local Allergic Inflammation in Chronic Rhinosinusitis With Nasal Polyps Could Influence on Disease Severity and Olfaction

Background and Objectives: Chronic rhinosinusitis with nasal polyps (CRSwNP) is a multifactorial disease resulting from inflammation of the nasal cavity and paranasal sinuses. Systemic allergic inflammation is an important cause of CRSwNP; however, the effect of local allergic inflammation is unclear. This study was designed to investigate the effect of local allergic inflammation in CRSwNP.Materials and Methods: The study included 11 patients with CRSwNP and 18 control subjects. Olfactory function was measured with the Korean Version of Sniffin’s stick test. Nasal lavage fluids (NLFs) were collected from all subjects and analyzed for total IgE, eosinophilic cationic protein (ECP), and cytokines (tumor necrosis factor [TNF]-α, interleukin [IL]-4, IL-10, IL-17A, interferon-γ). Flow cytometry was used to measure various inflammatory cells in the NAL fluids.Results: On analysis of flow cytometry and enzyme-linked immunosorbent assay, we found that CRSwNP patients had significantly increased eosinophil (%) and ECP levels in NLFs. In addition, there was significant local-systemic correlation between ECP level in NLFs and blood eosinophils (%) (r=0.391); however, there was no significant association between eosinophils (%) in NLFs and blood eosinophils. Moreover, in CRSwNP patients, the severity of disease was related with blood eosinophil (%), eosinophil (%), and ECP levels in NLFs, whereas olfactory function was associated with blood eosinophil (%) and ECP levels in NLFs.Conclusion: CRSwNP is a disease with high allergic inflammation that has negative impacts on the severity of disease and olfactory function. Therefore, we suggest that control of local allergic inflammation will be helpful to treat CRSwNP patients.

Validity of Skin Prick Test to Bermuda Grass in a desert environment

Background and aim:

Skin prick test (SPT) with a wheal diameter of >3 mm, generally accepted as a positive, is most commonly use diagnostic tool for Allergic rhinitis. Aim was to validate wheal size of Skin Prick Test for the Bermuda grass, in desert environment, with positive Bermuda grass Nasal challenge in same environment.

Methods:

In 53 adults, mean age 33.43 ± 9.36 years, both gender (females: 33.96%), SPT positive on Bermuda grass with cut off wheal longest diameter of 3 mm, Bermuda grass nasal challenge test (bgNCT) was carried out. Response was assessed subjectively (scored) and objectively (PNIF). Safety profile was assessed by PEF measurement.

Results:

Mean weal size of SPT (mm) was bigger in bgNCT positive patients (n=47; 88.68%) 8 [4, 15] vs 5 [3, 6] (p<0.0001). ROC analysis showed Bermuda Grass SPT at the threshold of >6.5mm enabled identification of Bermuda challenge with sensitivity of 82.98% and specificity of 100.0% (area under the curve 0.9326, standard error 0.03528; 95% confidence interval (CI): 0.8635 to 1.002; p=0.0006203).

Conclusions:

A SPT wheal size ≥6.5mm might be considered as an appropriate wheal size for confirming Bermuda grass allergy in adults with SAR, avoiding the demanding, time consuming and often unavailable bgNCT, especially in patients eligible for allergen immunotherapy. In these patients, bgNCT is recommended if SPT wheal size is <6.5 mm. (www.actabiomedica.it)

The Importance of Nasal Provocation Testing in the Diagnosis of Dermatophagoides pteronyssinus-Induced Allergic Rhinitis

BACKGROUND

Allergen identification is the first step for allergen-specific immunotherapy (AIT) of allergic rhinitis (AR). Currently, the diagnosis of AR is based mainly on the positive results of the skin prick test (SPT) and/or serum specific immunoglobulin E (sIgE) measurement. However, the results of these two tests may not always directly correlate with AR.

OBJECTIVE

To investigate the importance of nasal provocation testing (NPT) in the diagnosis of Dermatophagoides pteronyssinus (Der p)-induced AR.

METHODS

Rhinitis patients willing to undergo AIT (n = 171) were enrolled. The correlations of Der p SPT, sIgE, NPT, and clinical symptom severity were assessed.

RESULTS

NPT-positive responses were more common in patients with higher SPT and sIgE levels. The optimal cut-off value for a NPT-positive response for SPT was 5.5 mm and for sIgE was 2.77 kUA/L, based on the respective receiver operating characteristic (ROC) curves. The area under the curve (AUC) of the ROCs was 0.814 (SPT only) and 0.794 (sIgE only) and increased to 0.828 with the combination of SPT and sIgE. The Der p-NPT concentration was inversely correlated with SPT and sIgE levels (r = -0.477, P < .001, and r = -0.461, P < .001, respectively), but none was correlated with the total nasal symptom score.

CONCLUSION

For patients who are willing to receive Der p AIT, NPT is a useful and safe test to confirm diagnosis prior to treatment initiation, especially in patients with lower levels of Der p SPT (< 5.5 mm) or sIgE (< 2.77 kUA/L).

Local Allergic Rhinitis Revisited

PURPOSE OF REVIEW

Local allergic rhinitis (LAR) represents a diagnostic and therapeutic challenge for clinicians. Even though it affects a considerable number of chronic rhinitis patients and a significant number of articles regarding prevalence, evolution, diagnosis, and treatment have been published, the condition remains still largely unrecognized and therefore misdiagnosed and mistreated.

RECENT FINDINGS

LAR is a unique form of chronic rhinitis; it is neither classical allergic rhinitis (AR) nor non-allergic rhinitis (NAR). The symptoms, duration, severity, and complications of LAR are similar to those of AR and can affect adults and children. Thus, a portion of patients diagnosed with NAR or chronic rhinitis of unknown etiology may have LAR. The relationship between LAR inflammation and systemic allergic inflammation is unclear. Patients are frequently misdiagnosed with idiopathic NAR, and distinguishing between both entities is difficult without specific diagnostic tests. Underdiagnosis of LAR has implications on the management of these patients, as they are deprived of allergen immunotherapy (AIT) that has been demonstrated to modulate the immune mechanisms underlying allergic diseases. This review aims to comprehensively summarize the current knowledge on LAR and address unmet needs in the areas of disease diagnosis and treatment.

Relationship between tissue and serum eosinophilia in children undergoing adenotonsillectomy with allergic rhinitis

Background/aim

Previous reports suggested that allergic/eosinophilic inflammation affects the adenoid and tonsillar tissue. The aim of this study is to evaluate and compare the tissue and serum eosinophilia in children undergoing adenotonsillectomy with allergic rhinitis.

Materials and methods

The clinical registers of 125 children undergoing adenoidectomy/tonsillectomy due to adenoid/tonsil hypertrophy were examined and reviewed retrospectively. Fifty-seven children with positive skin prick test and symptoms of allergic rhinitis were included in the study as the atopic group, whereas 68 children with no allergic symptoms and negative skin prick test were included as the nonatopic group. Consequently, the total immunoglobulin E level and the serum and tissue eosinophilia of the atopic and nonatopic groups were compared.

Results

Serum eosinophilia in the atopic group was found to be significantly higher than in the nonatopic group (P = 0.045). A significantly higher eosinophil count was found in adenoid/tonsil tissue of the atopic group (P < 0.001, P = 0.023, respectively). However, no significant correlation between tissue and serum eosinophilia was found.

Conclusion

The inconsistency between tissue and serum eosinophilia in atopic children would particularly indicate a role of local atopy in adenotonsillar hypertrophy. Further studies are needed to better understand the effect and usefulness of serum and tissue eosinophilia in children with allergic rhinitis.

Novel therapeutic targets for allergic airway disease in children

The aim of precision medicine is setting up targeted therapies for selected patients that would ideally have high effectiveness and few side effects. This is made possible by targeted therapy drugs that selectively act on a specific pathway. Precision medicine is spreading to many medical specialties, and there is increasing interest in the context of allergic airway diseases, such as allergic rhinitis, chronic rhinosinusitis, and asthma. This review is an update of new targets in the treatment of childhood allergic upper airway diseases and asthma, including the most recent biologic drugs that have already been licensed or are in the pipeline to be tested with children.

Detection of local allergic rhinitis in children with chronic, difficult-to-treat, non-allergic rhinitis using multiple nasal provocation tests

BACKGROUND

There is little evidence on the incidence and characteristics of local allergic rhinitis (LAR) in children. Most studies have included subjects with perennial rhinitis only, and results are based on the investigation of no more than three allergens per study. Our aim was to determine the proportion of children with LAR amongst children with chronic, difficult-to-treat, perennial or seasonal, rhinitis but no evidence of sensitization to aeroallergens, or other alternative diagnosis.

METHODS

We performed multiple nasal provocation tests (M-NPTs) with four locally relevant aeroallergens (Phleum pratense, Olea europea, Alternaria alternata, and Dermatophagoides pteronyssinus) in children with absence of aeroallergen sensitization, seen during a calendar year in a specialized rhinitis clinic. We additionally performed single NPT to children with allergic rhinitis (AR; positive control group). The result of the NPT was based on symptoms and acoustic rhinometry. Identification of nasal hyper-reactivity (NHR) triggers was through a questionnaire.

RESULTS

Local allergic rhinitis was confirmed in 29.2% (7/24) of the negative SPT/blood testing population. All but one of the children reacted to one allergen and one to two. All AR children had positive single NPT with results similar to the LAR. There were no differences in age at examination and rhinitis onset, gender distribution, family atopy, and past or current environment of residency, while the prevalence of reported NHR triggers was comparable amongst the three groups.

CONCLUSION

This is the first pediatric study where the seasonal or perennial rhinitis population was thoroughly tested for LAR against four aeroallergens. LAR is present in a considerable proportion of children with chronic, difficult-to-treat rhinitis and no sensitization to aeroallergens, and therefore, the performance of NPT should be strongly considered in these cases. There were no distinct clinical characteristics between LAR, AR, and non-allergic rhinitis in children.

Sensitization to Cat: When Is Nasal Challenge Needed?

INTRODUCTION

Although the skin prick test (SPT) is a reliable diagnostic tool in perennial allergic rhinitis (PER) for patients allergic to cats, the minimum necessary SPT wheal size required to distinguish cat sensitization from true allergy remains controversial. The cat nasal challenge test (cNCT) could be considered the gold standard for detecting true cat allergy.

AIMS

To assess the difference in the frequency of cNCT positivity between cat owners and non-owners and to determine an appropriate cut-off level for SPT wheal size in detecting positive cNCT in PER patients who are candidates for allergen immunotherapy (AIT) with cat allergen extracts.

SUBJECTS AND METHODS

cNCT in the form of a nasal spray was administered to 60 adult patients with PER, i.e., cat owners (n = 19) and cat non-owners (n = 41) with positive SPT to cat fur allergen (Diater, Spain). Subjective (total nasal symptom score [TNSS]) and objective measurements (peak nasal inspiratory flow [PNIF]) for assessment of nasal patency and nasal eosinophil count [NEo]) were used to assess the nasal response. Peak expiratory flow (PEF) was used as a safety parameter during cNCT.

RESULTS

No differences were obtained in SPT wheal size and cNCT positivity between cat owners and non-owners. Positive cNCT detecting true cat allergy could be predicted by a cat SPT wheal size > 6.5 mm with 71.11% sensitivity and 100% specificity.

CONCLUSIONS

In adult patients with PER, the frequency of cat allergy was similar among cat owners and non-owners. A cat SPT wheal size ≥6.5 mm could be helpful in detecting true cat allergy by avoiding the demanding, time-consuming, and often unavailable cNCT when cat AIT is needed.

Is the evidence of local allergic rhinitis growing?

PURPOSE OF REVIEW

To examine the recent advances on epidemiological studies, diagnostic approach and clinical management of local allergic rhinitis (LAR) in adults and children.

RECENT FINDINGS

Evidence about LAR is growing especially in pediatric and Asian populations. The prevalence of LAR is lower in Asian countries compared with western countries in both children and adults. LAR is considered a chronic condition and an independent rhinitis phenotype that affects up to 26.5% of nonatopic rhinitis patients. The disease rapidly progress toward the clinical worsening with associated onset of asthma and conjunctivitis, which further impairs patient's quality of life. Nasal Allergen Provocation Test is the diagnostic gold standard that can be complemented by basophil activation test and the detection of specific IgE in nasal secretions. Allergen immunotherapy induces a significant and early improvement in both clinical symptoms and quality of life in LAR patients.

SUMMARY

LAR is a common entity, with different prevalence depending on geographical locations. LAR has to be considered in the process of differential diagnosis in children and adults with rhinitis. Diagnosis of LAR is crucial in order to start an etiologic treatment such as allergen immunotherapy, which has proven to be very effective in these patients.

Recent advances in the diagnosis of allergic rhinitis

INTRODUCTION

Allergic rhinitis (AR) is a disorder with high prevalence worldwide. Identification of clinically relevant allergens is the key step for the diagnosis, allergen avoidance and allergen specific immunotherapy for AR. Areas covered: With the new findings of mechanisms of AR and the development of technology, much progress has been achieved in the diagnosis of AR recently. We review the recent advances about local IgE, in vivo and in vitro tests, cytological diagnosis and nitric oxide (NO) in the diagnosis of AR. Expert commentary: AR is traditionally diagnosed with the combined evaluation of history and allergen sensitization by in vivo skin prick tests and in vitro allergen specific IgE in serum, to confirm the correlation between clinical history and potential allergens. Nasal provocation test and local IgE measurement can be used to diagnose local AR. Allergen microarray has the ability to detect more potential allergens. Basophil activation and mast cell activation tests can be used in allergen diagnosis and to modify the response to immunotherapy, while cytological diagnosis is useful in the differential diagnosis of AR and non-AR. Nasal NO has been confirmed to be an optimal biomarker to discriminate between AR and non-AR.

Utility of narrow band imaging in the diagnosis of middle turbinate head edema

PURPOSE

Middle turbinate head edema has recently been found to have high specificity for diagnosis of inhalant allergy. However, subtle mucosal edema can be difficult to appreciate under white light endoscopy. Narrow band imaging (NBI) has the potential to demonstrate edema by identifying reduced mucosal vascularity and improve sensitivity for the detection of mucosal edema. Narrow band imaging was assessed to determine its utility in objectifying mucosal edema.

MEATERIALS AND METHODS

A cross-sectional diagnostic study was performed on patients with edematous mucosa of the middle turbinate head. Under traditional white light endoscopy, areas of edematous mucosa were identified. Using NBI, these areas were compared to areas of normal mucosa on the middle turbinate head. NBI images of these same areas were then converted to grey scale and a vascularity index was created by pixel analysis and brightness in Fiji Image J software (Wisconsin, US).

RESULTS

Thirty-three middle turbinates were assessed (age 42.4 ± 12.5, 42.4% female). NBI discriminated between areas identified under white light endoscopy as edematous and normal (158.2 ± 48.4 v 96.9 ± 32.7 p < 0.01). Receiver operating curve (ROC) analysis suggested a threshold of 115 brightness units to define endoscopically visible edematous mucosa with sensitivity 70% and specificity 79% (ROC AUC, p = 0.85).

CONCLUSIONS

NBI can differentiate edematous from normal mucosa. The potential for an objective measure of mucosal edema may assist research efforts and may provide a more sensitive tool for subtle mucosal inflammatory changes.

EAACI Position paper on the standardization of nasal allergen challenges

Nasal allergen challenge (NAC) is an important tool to diagnose allergic rhinitis. In daily clinical routine, experimentally, or when measuring therapeutic success clinically, nasal allergen challenge is fundamental. It is further one of the key diagnostic tools when initiating specific allergen immunotherapy. So far, national recommendations offered guidance on its execution; however, international divergence left many questions unanswered. These differences in the literature caused EAACI to initiate a task force to answer unmet needs and find a consensus in executing nasal allergen challenge. On the basis of a systematic review containing nasal allergen challenges of the past years, task force members reviewed evidence, discussed open issues, and studied variations of several subjective and objective assessment parameters to propose a standardized way of a nasal allergen challenge procedure in clinical practice. Besides an update on indications, contraindications, and preparations for the test procedure, main recommendations are a bilaterally challenge with standardized allergens, with a spray device offering 0.1 mL per nostril. A systematic catalogue for positivity criteria is given for the variety of established subjective and objective assessment methods as well as a schedule for the challenge procedure. The task force recommends a unified protocol for NAC for daily clinical practice, aiming at eliminating the previous difficulty of comparing NAC results due to unmet needs.

Local allergic rhinitis: Implications for management

A significant proportion of rhinitis patients without systemic IgE-sensitisation tested by skin prick test and serum allergen-specific IgE (sIgE) display nasal reactivity upon nasal allergen provocation test (NAPT). This disease phenotype has been termed local allergic rhinitis (LAR). LAR is an underdiagnosed entity affecting children and adults from different parts of the world, with moderate-to-severe symptoms, impairment of quality of life and rapid progression to symptom worsening. LAR is a stable phenotype and not merely an initial state of AR. Allergic rhinitis and LAR share many clinical features including a positive NAPT response, markers of type 2 nasal inflammation including sIgE in nasal secretions and a significant rate of asthma development. LAR should be considered as a differential diagnosis in those subjects of any age with symptoms suggestive of AR but no evidence of systemic atopy. Although LAR pathophysiology is partially unknown, in some patients sIgE can be demonstrated directly in the nasal secretions and/or indirectly via positive responses in basophil activation test (BAT). LAR can coexist with other rhinitis phenotypes, especially AR. The diagnosis currently relies on the positivity of NAPT to a single or multiple allergens. NAPT has high sensitivity, specificity and reproducibility, and it is considered the gold standard. BAT and the measurement of nasal sIgE can also contribute to LAR diagnosis. LAR patients benefit from the same therapeutic strategies than AR individuals, including the avoidance of allergen exposure and the pharmacotherapy. Moreover, several recent studies support the effectiveness and safety of allergen immunotherapy for LAR, which opens a window of treatment opportunity in these patients.

Optimizing Protein Harvest From Nasal Brushings for Determining Local Allergy Responses

Background Rhinitis is a highly prevalent yet often misdiagnosed condition. Patients who have local allergic rhinitis are regularly mislabeled as having a nonallergic etiology. Thus, a highly accurate, reproducible, and noninvasive assessment, which can be performed quickly and with minimal discomfort to the patient, is required. Objective The aim of this research was to identify the efficiency of various nasal brushes as tools for harvest and collection of epithelial proteins and its suitability for identification of rhinitis. Methods Nasal epithelial mucosa samples were taken from patients undergoing turbinate surgery using a cytology brush, a dental brush, and a nasal curette in random order. After washing in phosphate-buffered saline, the suspended cells were sonicated. Total protein content was assessed for all samples by bicinchoninic acid assay measured using a Nanodrop machine. Identification of nasal-specific immunoglobulin E (spIgE) was then assessed using immunoassay and compared to the patient's allergic status from epicutaneous and serum testing. The lower threshold limit for the spIgE in nasal brushings was determined using the results of serum spIgE tests as the reference. The diagnostic accuracy of this new established cutoff value was determined. Results The cytology brush was found to be the optimal tool for maximal nasal mucosa protein collection followed by dental brush and nasal curette (0.75 ± 0.45 mg/mL vs 0.43 ± 0.24 mg/mL vs 0.071 ± 0.55 mg/mL, respectively; P < .01). The optimal cutoff value of nasal spIgE from the cytology nasal brushings was 0.14 kUA/L to predict allergic status from serum testing. This gave a sensitivity of 75%, specificity of 86%, positive predictive value of 74%, likelihood ration positive of 5.40, and diagnostic odds ratio of 18.62. Conclusion The cytology brush is the optimal tool for protein collection. This is an easy and direct method to sample the nasal mucosa for assessment of nasal allergy or future biomarkers.

Correlation of Nasal Eosinophilia and Response after Nasal Provocation Test in Patients with Nonallergic Rhinitis

Objectives

We aimed to evaluate the relationship between nasal eosinophilia and nasal hyperresponsiveness to allergen extract.

Study Design

Retrospective chart review.

Setting

Academic tertiary rhinologic practice.

Subjects and Methods

We performed allergy tests (skin prick test and multiple allergosorbent test) and nasal cytology for 194 patients with rhinitis symptoms (76 males and 118 females; age, 11-69 years). According to the results, they were classified into 4 groups: group A (allergic rhinitis with eosinophilia, n = 26), group B (allergic rhinitis without eosinophilia, n = 77), group C (nonallergic rhinitis with eosinophilia syndrome, n = 20), and group D (nonallergic rhinitis without eosinophilia, n = 71). We performed a nasal provocation test (NPT) using house dust mite extract and assessed the changes in symptoms and the decrease in acoustic parameters (total nasal volume and minimal cross-sectional area [MCA]).

Results

Patients in group C were more likely to have severe rhinorrhea and sneezing than those in group D ( P < .001). After NPT, group C had greater aggravation of nasal obstruction than group D ( P < .001). Group C also showed markedly greater MCA changes as compared with group D 15 minutes after the antigen challenge ( P = .002). There was significant correlation between the number of eosinophils and an increase in nasal obstruction ( r = 0.319, P = .0009), rhinorrhea ( r = 0.302, P = .0017), sneezing ( r = 0.219, P = .0241), change in the total nasal volume 15 minutes after NPT ( r = 0.287, P = .0028), and change in the MCA 15 minutes ( r = 0.322, P = .0008) and 30 minutes ( r = 0.250, P = .0098) after NPT.

Conclusion

In patients with NAR, nasal eosinophilia is associated with provocative response after NPT. Further research should be performed to elucidate the mechanisms that underlie this phenomenon.

EAACI Guidelines on Allergen Immunotherapy: Allergic rhinoconjunctivitis

Allergic rhinoconjunctivitis (AR) is an allergic disorder of the nose and eyes affecting about a fifth of the general population. Symptoms of AR can be controlled with allergen avoidance measures and pharmacotherapy. However, many patients continue to have ongoing symptoms and an impaired quality of life; pharmacotherapy may also induce some side-effects. Allergen immunotherapy (AIT) represents the only currently available treatment that targets the underlying pathophysiology, and it may have a disease-modifying effect. Either the subcutaneous (SCIT) or sublingual (SLIT) routes may be used. This Guideline has been prepared by the European Academy of Allergy and Clinical Immunology's (EAACI) Taskforce on AIT for AR and is part of the EAACI presidential project "EAACI Guidelines on Allergen Immunotherapy." It aims to provide evidence-based clinical recommendations and has been informed by a formal systematic review and meta-analysis. Its generation has followed the Appraisal of Guidelines for Research and Evaluation (AGREE II) approach. The process included involvement of the full range of stakeholders. In general, broad evidence for the clinical efficacy of AIT for AR exists but a product-specific evaluation of evidence is recommended. In general, SCIT and SLIT are recommended for both seasonal and perennial AR for its short-term benefit. The strongest evidence for long-term benefit is documented for grass AIT (especially for the grass tablets) where long-term benefit is seen. To achieve long-term efficacy, it is recommended that a minimum of 3 years of therapy is used. Many gaps in the evidence base exist, particularly around long-term benefit and use in children.

Local allergic rhinitis is an independent rhinitis phenotype: The results of a 10-year follow-up study

BACKGROUND

The knowledge about the natural history of local allergic rhinitis (LAR) is limited. One unmet question is to demonstrate whether LAR should be considered the first step in the development of allergic rhinitis (AR) or an independent phenotype. The aim of this study was to prospectively evaluate the natural history of a population with LAR, the potential conversion to AR with systemic atopy and the development of asthma during 10 years.

METHODS

This is the second phase of a 10-year follow-up study of a cohort of 176 patients with LAR of recent onset and 115 age- and sex-matched healthy controls prospectively evaluated from 2005 to 2016. Clinical-demographic questionnaire, spirometry, skin prick test and specific IgE were evaluated yearly. Nasal allergen provocation tests (NAPT) with Dermatophagoides pteronyssinus, Alternaria alternata, Olea europaea and grass pollen were performed at baseline, and after 5 and 10 years.

RESULTS

After 10-year LAR, patients experienced a significant and clinically relevant worsening of the rhinitis, with increase in emergency assistance, development of asthma, loss of allergen tolerance and impairment of the quality of life. This worsening became significant after 5 years and progressed throughout 10 years. A similar rate of development of AR with systemic atopy was detected in patients and controls (9.7% vs 7.8%, log-rank P=.623). In 5 patients, conversion to systemic atopy occurred >10 years (3%).

CONCLUSIONS

LAR is a well-differentiated clinical entity with a low rate of development of systemic atopy, a natural evolution towards worsening and a risk factor for suffering asthma.

Local allergic rhinitis: evolution of concepts

The discovery of an exclusive local production of IgE antibodies dates back to the 1970s, but only recently the pathophysiology of such phenomenon was deeply investigated, leading to the concept of local allergic rhinitis (LAR). Currently, LAR is defined by the occurrence, in patients with symptoms clearly suggesting allergic rhinitis but with negative results to common allergy testing, of allergen specific IgE in the nasal mucosa. Most studies investigating LAR were based on the development of rhinitis symptoms following nasal provocation test (NPT) with the suspected allergens, but such test may be performed by a number of options, none of them being as yet acknowledged and recommended in consensus document. On the other hand, also the mere detection of IgE in the nasal mucosa indicates, as for IgE measurement in blood or other tissues, allergic sensitization but cannot give the certainty of clinical allergy. Therefore, the combination of IgE detection in nasal mucosa and a positive result of NPT should be used to diagnose LAR. Recent data on the use for in vitro testing of molecular allergy diagnostics in place of whole allergen extracts suggest that this method could improve the sensitivity and specificity of laboratory tests, and an appraisal of the basophil activation test as a third level technique, to be implemented when the results of local IgE testing and NPT are uncertain, is currently ongoing.

Pharmacological Management of Allergic Rhinitis in the Elderly

Recent studies suggest that allergic rhinitis is highly prevalent in the elderly population, but is underdiagnosed and undertreated. This review article briefly introduces allergic rhinitis in the elderly (epidemiology and pathophysiology) and identifies the main goals of treatment in these patients with respect to age-related physiological factors, comorbid conditions and polypharmacy. The primary focus of the article is a narrative review of the literature concerning the different types of treatment options in elderly patients aged 60+ years (pharmacological therapy and allergen-specific immunotherapy). The main management trend for allergic rhinitis in elderly patients is the same as the trend in young patients. Second-generation antihistamines and nasal glucocorticosteroids are also the first-line therapies in seniors. In a few trials, allergen-specific immunotherapy for grass pollen or house dust mites has been shown to be effective and safe in patients aged 60 years or older with allergic rhinitis. In conclusion, undertreatment of allergic rhinitis in the elderly is a reality. Pharmacological treatment is quite similar in both older and younger patients with allergic rhinitis.

Role of local allergic inflammation and Staphylococcus aureus enterotoxins in Chinese patients with chronic rhinosinusitis with nasal polyps

Objective:

To investigate the role of local allergic inflammation and Staphylococcus aureus enterotoxins in chronic rhinosinusitis with nasal polyps.

Methods:

This study included 36 patients with chronic rhinosinusitis with nasal polyps and 18 controls. Total immunoglobulin E, eosinophil cationic protein, staphylococcal enterotoxin types A and B specific immunoglobulin E, staphylococcal enterotoxin types A and B, and myeloperoxidase levels were determined.

Results:

Four patients with chronic rhinosinusitis with nasal polyps had a local allergy. All chronic rhinosinusitis with nasal polyps patients tested negative for staphylococcal enterotoxin types A and B specific immunoglobulin E. The chronic rhinosinusitis with nasal polyps group had significantly elevated staphylococcal enterotoxin types A and B levels in the supernatant. Fourteen patients belonged to the eosinophilic chronic rhinosinusitis with nasal polyps group and the others were characterised as having non-eosinophilic chronic rhinosinusitis with nasal polyps.

Conclusion:

Local allergy may play a role in chronic rhinosinusitis with nasal polyps, independent of staphylococcal enterotoxin superantigens. Staphylococcal enterotoxins may be important in the pathogenesis of chronic rhinosinusitis with nasal polyps; however, their roles as superantigens were not confirmed in this study. In Chinese subjects, chronic rhinosinusitis with nasal polyps usually manifests as a neutrophilic inflammation.

The role of local allergy in the nasal inflammation

Local allergic inflammation (LAI) is recognized recently. 'entopy' was used to define LAI, which was positively correlated with allergen provocation testing, local sIgE up-regulation, inflammatory mediator secretion, and a lack of systemic allergy. The study of LAI is in its infancy and focuses mainly on the respiratory system. It is closely related to nasal inflammation and plays important roles in patients with nonallergic rhinitis (NAR), nonallergic chronic sinusitis with nasal polyps (CRSwNP), and nonallergic fungal rhinosinusitis (NAFRS). Based on studies using nasal allergen provocation testing, 40-57% of patients with NAR exhibited positive results and could be diagnosed as local allergic rhinitis. Total IgE and common airborne allergen-sIgE were up-regulated in eosinophilic CRSwNP patients compared to noneosinophilic CRSwNP patients and healthy controls, possibly due to local allergic inflammation. Some researchers also found that the level of local sIgE was increased in patients with NAFRS; they suggested that local allergic inflammation occurs in NAFRS. Studies of LAI will increase our understanding of nasal inflammation and help to establish novel treatments. However, the diagnosis of local allergic inflammation is complex due to the lack of convenient detection methods. The relationship between local allergic inflammation and systemic allergic inflammation is unclear, and an appropriate treatment for local allergic inflammation is required.

Local allergic rhinitis to pollens is underdiagnosed in young patients

BACKGROUND

Local allergic rhinitis (LAR) has been observed in patients without atopy. However, LAR is still underdiagnosed in patients with perennial or seasonal nasal symptoms.

OBJECTIVE

The aim of this study was to determine the prevalence of LAR in young patients with a previous diagnosis of nonallergic rhinitis or suspicion of allergy.

METHODS

A total of 121 patients, ages 12-18 years old, with confirmed nonallergic rhinitis and typical seasonal nasal symptoms were examined. Skin-prick tests; serum and nasal specific immunoglobulin E (IgE) measurements; and nasal provocation tests by using grass (Phleum partense), Artemisia, and birch pollens were performed. A control group of age-matched patients with a diagnosis of seasonal allergic rhinitis underwent the same procedures as the test group.

RESULTS

LAR to grass pollen (P. partense), Artemisia, and birch was confirmed in 17 (16.6%), 6 (5.9%), and 9 (8.9%) of patients, respectively. Polyvalent allergy was established in 21 subjects (20.8%): grass and Artemisia, 11 patients (10.9%); and grass and birch, 10 patients (9.9%). The remaining 48 patients (47.5%) were diagnosed with nonallergic rhinitis. The results of the nasal provocation tests and the concentrations of nasal IgE were similar among the analyzed groups. Furthermore, the concentration of nasal IgE increased faster in patients with LAR than in patients with allergic rhinitis; however, this difference was not statistically significant.

CONCLUSION

LAR is a serious problem in young patients; however, its significance is still unappreciated.

Impact of self-reported symptoms of allergic rhinitis and asthma on sleep disordered breathing and sleep disturbances in the elderly with polysomnography study

BACKGROUND

Sleep disordered breathing (SDB) and sleep disturbances have been reported to be associated with allergic rhinitis and asthma. However, population-based studies of this issue in the elderly are rare.

OBJECTIVE

To investigate the impact of self-reported rhinitis and asthma on sleep apnea and sleep quality using polysomnography in an elderly Korean population.

METHODS

A total of 348 elderly subjects who underwent one-night polysomnography study among a randomly selected sample were enrolled. Study subjects underwent anthropometric and clinical evaluations. Simultaneously, the prevalence and co-morbid status of asthma and allergic rhinitis, and subjective sleep quality were evaluated using a self-reported questionnaire.

RESULTS

Ever-diagnosis of allergic rhinitis was significantly more prevalent in subjects with SDB compared with those without SDB. Subjects with an ever-diagnosis of allergic rhinitis showed a higher O2 desaturation index and mean apnea duration. Indices regarding sleep efficiency were affected in subjects with a recent treatment of allergic rhinitis or asthma. Waking after sleep onset was longer and sleep efficiency was lower in subjects who had received allergic rhinitis treatment within the past 12 months. Subjects who had received asthma treatment within the past 12 months showed significantly lower sleep efficiency than others.

CONCLUSION

Our study indicates that a history of allergic rhinitis is associated with increased risk of SDB in the elderly. Sleep disturbance and impaired sleep efficiency were found in the subjects who had received recent treatment of allergic rhinitis or asthma. Physicians should be aware of the high risk of sleep disorders in older patients with respiratory allergic diseases.

Nonallergic rhinitis and lower airway disease

In the past years, several investigators have demonstrated the existence of local nasal responses in some patients with typical allergic rhinitis symptoms but without atopy and have defined a new phenotype called local allergic rhinitis (LAR) or 'entopy'. In a percentage of LAR subjects, the upper airway disease is also associated with lower airway symptoms. After the description of this phenotype, the differential diagnosis between LAR and nonallergic rhinitis (NAR) has become a challenge for the clinician. To correctly identify LAR patients is of high importance for treatment and management of these patients, and for an appropriate inclusion of patients in clinical trials and genetics studies. The treatment of LAR patients, in contrast with NAR, is oriented to allergen avoidance and specific treatment. Allergen immunotherapy, the aetiological treatment for allergic respiratory diseases, has demonstrated to be an effective and safe treatment in LAR, increasing immunological tolerance, and reducing the clinical symptoms and the use of medication. In this article, the important and novel aspects of LAR in terms of mechanisms, diagnosis and treatment will be discussed. Also, the involvement of the lower airway and the potential role of IgE in the bronchial disease will be also reviewed.

Usefulness of Allerkin House Dust Mite Extract for Nasal Provocation Testing

Objectives

We evaluated the clinical usefulness of Allerkin (Lofarma) for nasal provocation testing (NPT) in patients with rhinitis symptoms, by examining changes in nasal symptoms and acoustic parameters after exposure to house dust mite (HDM) extract.

Methods

Twenty patients (16 males and 4 females, mean age: 29.6±14.6 years) were enrolled. We performed skin prick test (SPT) before and 15 and 30 minutes after intranasal challenge with Allerkin HDM extract, and we evaluated symptom changes (nasal obstruction, rhinorrhea, sneezing, and itching) using a visual analogue scale. We also evaluated changes in acoustic parameters such as total nasal volume (TNV) and minimal cross-sectional area (MCA) before and after challenge.

Results

Group A (the nonallergic group, n=8) showed negative results for all tested aeroallergens in SPT and nonprovocative results (<25% decrease of TNV and MCA from the baseline value) in NPT. Group B (the allergic group, n=7) exhibited strongly positive results (wheal size larger than that of histamine) for HDM allergens on SPT. Group C (the local allergic group, n=5) showed negative results on SPT, but a provocative response on NPT (>29% decrease in TNV/MCA from the baseline value). Patients in group C showed significant aggravation of nasal obstruction compared to those in group A (P<0.05). Thirty minutes after HDM challenge, patients in groups B and C showed significantly greater decreases in MCA compared to those in group A (P<0.01).

Conclusion

Allerkin HDM extract can be a useful provocative agent in NPT for diagnosing allergic rhinitis and local allergic rhinitis.

Local allergic rhinitis: A critical reappraisal from a paediatric perspective

The so-called local allergic rhinitis (LAR) has been proposed as a phenotype of rhinitis with Th2-driven prominent local allergic inflammation, nasal synthesis of specific IgE and a positive response to a nasal allergen provocation test, in the absence of 'systemic' atopy (negative skin prick test and serum allergen-specific IgE antibodies). To date, available data on LAR are mostly focused on adults. The purpose of this 'Rostrum' was to critically discuss data and implications of the 'LAR concept' in paediatrics. In the natural history of rhinitis due to IgE-mediated reactions triggered by exposure to allergens, a 'LAR' can be either the initial, transient stage of classical allergic rhinitis or a stable phenotype never evolving to 'systemic' IgE sensitization. Given the present difficulties in performing routinely nasal allergen provocation test in children, the development of sensitive and specific tests to detect IgE in the child's nasal secretions is a research priority. We suggest also the hypothetical role of allergen immunoprophylaxis or immunotherapy in LAR. Last, the term 'local allergic rhinitis' may be inappropriate, as rhinitis is always 'local', while IgE sensitization can be either 'local' or 'systemic'.

Immunologic responses to the major allergen of Olea europaea in local and systemic allergic rhinitis subjects

OBJECTIVE

To evaluate the in vivo and in vitro responses to nOle e 1 in allergic rhinitis (AR) and local allergic rhinitis (LAR) patients sensitized to olive tree pollen (OL) confirmed by nasal allergen provocation test (NAPT).

METHODS

Twelve subjects with AR, 12 with LAR and 12 subjects as control group (CG) were selected. Skin testing and NAPT with nOle e 1 were performed. Eosinophilic cationic protein (ECP) and tryptase were measured in nasal lavages before and after NAPT. Serum IgE to OL allergens was measured by ELISA. Basophil activation tests (BAT) with OL and nOle e 1 and dendritic cell maturation/proliferation studies were carried out.

RESULTS

All AR (12/12) and 10/12 (83%) of LAR had a +NAPT to nOle e 1. ECP levels in nasal lavages were significantly increased after NAPT in both AR and LAR compared with CG at 15 min (P < 0.05). Serum IgE was positive only in AR. All AR had +BAT responses to OL and 10/12 to nOle e 1 (83%); 8/12 LAR (66.6%) had a +BAT to OL and 4/12 (33%) to nOle e 1, with only one subject of the CG with a +BAT to both OL and nOle e 1 (8%). Dendritic cell proliferation to nOle e 1 was increased in AR compared to LAR and CG (P = 0.019 and P = 0.001, respectively).

CONCLUSION

Both AR and LAR had a similar in vivo response to nOle e 1 with release of inflammatory mediators. Specific basophil activation with OL and nOle e 1 was observed in LAR confirming previous data obtained with dust mites.

Update on local allergic rhinitis

We here provide an update on the literature regarding local allergic rhinitis (LAR). In reviewing LAR, we have included an updated definition, classifications, mechanisms, comorbidities, and recommendations for diagnosis and treatment for LAR, as well as the defined research areas for future evidence-based studies. LAR is a localised nasal allergic response in the absence of systemic atopy characterised by local production of specific IgE (sIgE) antibodies, a TH2 pattern of mucosal cell infiltration during natural exposure to aeroallergens, and a positive nasal allergen provocation test response, with the release of inflammatory mediators. The localised allergic response of LAR is an important topic for the study of allergies. This review provides an update on the current knowledge of LAR.

Efficacy and safety of D. pteronyssinus immunotherapy in local allergic rhinitis: a double-blind placebo-controlled clinical trial

The effects of allergen immunotherapy (AIT) on local allergic rhinitis (LAR) are largely unknown. We conducted the first randomized, double-blind, placebo-controlled (DBPC), phase II trial of D. pteronyssinus (DP) subcutaneous AIT (DP-AIT) on LAR (clinicaltrials.gov identifier: NCT02123316). Thirty-six LAR patients received Pangramin PLUS DP or placebo for 24 months. The primary endpoints were symptoms, medication scores, and medication-free days. The secondary included skin test, serum specific IgE and IgG4, nasal allergen provocation test (NAPT), and adverse events. AIT-DP produced significant improvements in both primary and secondary endpoints vs placebo. After 12 months of AIT-DP, we detected a significant and marked increase in allergen tolerance with negative NAPT in 50% of patients, and significant increases of serum sIgG4. Immunotherapy was well tolerated; no systemic reactions were reported. This study demonstrated that AIT-DP is a safe and clinically effective treatment for LAR, confirming that LAR is a new indication for AIT.

Rhinitis in the Elderly

By 2050, the US aging population will nearly double. It will be increasingly important for health care providers to diagnose and manage rhinitis. Nasal symptoms of rhinorrhea, congestion, sneezing, nasal/ocular pruritus, and postnasal drainage affect up to 32% of older adults, and can impact quality of life. Several underlying factors associated with aging may contribute to the pathogenesis of rhinitis in older adults. Although treatment options for rhinitis exist, special considerations need to be made because comorbidities, limited income, memory loss, and side effects of medications are common in older adults and may impact outcomes.

Rhinitis Subtypes, Endotypes, and Definitions

Rhinitis is often seen as posing a small burden. However, rhinitis is a complex disease that is underpinned by a plethora of different mechanisms and causes. Rhinitis is frequently associated with other comorbid conditions but, by itself, is a source of considerable morbidity for patients and creates a significant financial burden on health systems worldwide. This article approaches this condition from both a phenotypic and mechanistic standpoint, focusing on the complexity of characterizing these subtypes. Developing a clearer demarcation of the currently obscure rhinitis phenotypes and endotypes will substantially improve their future prevention and treatment.

Local Allergic Rhinitis

This review focuses on local allergic rhinitis, a new phenotype of allergic rhinitis, commonly misdiagnosed as nonallergic rhinitis. It has gained attention over last decade and can affect patients from all countries, ethnic groups and ages, impairing their quality of life, and is frequently associated with conjunctivitis and asthma. Diagnosis is based on clinical history, the demonstration of a positive response to nasal allergen provocation test and/or the detection of nasal sIgE. A positive basophil activation test may support the diagnosis. Recent studies have demonstrated that allergen immunotherapy is an effective immune-modifying treatment, highlighting the importance of early diagnosis.

The importance of mold sensitivity in nonallergic rhinitis patients

BACKGROUND

In recent studies, local specific immunoglobulin E (sIgE) production against allergens in nasal mucosa and a positive response to a nasal allergen provocation test (NAPT) have been demonstrated in some patients initially diagnosed as nonallergic rhinitis (NAR) or idiopathic rhinitis (IR). The aim of this study was to evaluate the presence of local allergic rhinitis (LAR) in patients who experience rhinitis symptoms in indoor and outdoor moldy conditions and to investigate the role of the NAPT in diagnosis.

METHODS

A total of 40 NAR patients with a history of persistent rhinitis and who had negative skin-prick tests (SPTs) and serum sIgE levels to common aeroallergens, as well as 20 healthy subjects were included in the study. NAPTs were performed with Aspergillus fumigatus (group 1) or a mixture of Alternaria alternata and Cladosporium herbarum extracts (group 2).

RESULTS

In patient nasal lavage fluids, tryptase and mold sIgE levels were not significantly different from the control group. NAPT with Aspergillus fumigatus was positive in 8 of 12 NAR patients (66.6%) in group 1 and NAPT with the mixture of extracts was positive in 9 of 13 NAR patients (69.2%) in group 2.

CONCLUSION

This study suggests that LAR may exist in a significant number of the persistent rhinitis patients who were previously considered as NAR based on negative SPTs or serum sIgE tests. To the best of our knowledge, this is the first study evaluating a nasal local allergic response to both indoor and outdoor molds.

Characterization of immunoglobulin E plasma cells that are elevated in the upper airway mucosa of nonatopic patients with chronic rhinosinusitis without nasal polyps

BACKGROUND

The immunologic mechanisms driving inflammation in the upper airways of patients with chronic rhinosinusitis (CRS) are poorly understood. Previous studies have shown that B cells and immunoglobulin E (IgE) levels are elevated in the nasal tissue of patients with atopic chronic rhinosinusitis without nasal polyps (CRSsNP). However, less is known regarding B cell subsets and IgE-producing plasmablasts in nonatopic CRSsNP patients.

METHODS

Human blood and ethmoid sinus mucosa samples were analyzed from control (n = 6) and nonatopic CRSsNP (n = 11) patients. Tissue samples were evaluated using high-dimensional flow cytometry.

RESULTS

A population of IgE antibody secreting cells is significantly increased in situ within inflamed nasal tissue of nonatopic CRSsNP subjects when compared to control nasal tissue and the circulating peripheral blood (p < 0.05). This IgE plasma cell population displays ∼90% cell surface Ig lambda light chain, is mitotically active (Ki-67(+)), and displays intracellular IgE expression. The predominant B cell population expressing IgE are plasmablasts (CD38(high), CD138(-)) not typically found in the blood or peripheral tissue of these patients.

CONCLUSION

The nasal mucosa from nonatopic CRSsNP patients demonstrate a significant regional spike in resident in situ IgE plasmablast cells not seen in control nasal tissue or peripheral blood from the same patient. The restricted expression of Ig lambda light chain in this mitotically active IgE plasmablast population supports the hypothesis of aberrant B cell proliferation in the context of CRS. These findings suggest the presence of a unique regional immune microenvironment for B cell priming and/or selection within chronically inflamed airway tissues.

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

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

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

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

Nasal histamine responses in nonallergic rhinitis with eosinophilic syndrome

Background:

Nonallergic rhinitis with eosinophilic syndrome (NARES) is persistent, without atopy, but with ≥25% nasal eosinophilia. Hypereosinophilia seems to contribute to nasal mucosa dysfunction.

Objectives:

This analytical case-control study aimed at assessing the presence and severity of nonspecific nasal hyperactivity and at finding out whether eosinophilia may be correlated with the respiratory and mucociliary clearance functions.

Materials:

The symptom score was assessed in 38 patients and 15 controls whose nasal smear was also tested for eosinophils and mucociliary transport (MCT). Nonspecific nasal provocation tests (NSNPT) with histamine were also carried out, and total nasal resistance (TNR) was determined.

Results:

The symptom score of NARES after NSNPT were not significantly different from the control group, and there was poor or no correlation among the single symptoms and the differences studied for every nasal reactivity class. This correlation improved when using the composite symptom score. The most severe eosinophilia was observed in high reactivity groups, and it was correlated with an increase in TNR. MCT worsened as eosinophilia and nasal reactivity increased. Unlike controls, a significant correlation was observed between the increase in MCT and TNR.

Conclusions:

In NARES, nonspecific nasal hyperreactivity is the result of epithelial damage produced by eosinophilic inflammation, which causes MCT slow down, an increase in TNR, and nasal reactivity classes, with possible impact on classification, prognosis, and treatment control.

Optimal management of allergic rhinitis

Allergic rhinitis (AR), the most common chronic disease in childhood is often ignored, misdiagnosed and/or mistreated. Undertreated AR impairs quality of life, exacerbates asthma and is a major factor in asthma development. It can involve the nose itself, as well as the organs connected with the nose manifesting a variety of symptoms. Evidence-based guidelines for AR therapy improve disease control. Recently, paediatric AR guidelines have been published by the European Academy of Allergy and Clinical Immunology and are available online, as are a patient care pathway for children with AR and asthma from the Royal College of Paediatrics and Child Health. Management involves diagnosis, followed by avoidance of relevant allergens, with additional pharmacotherapy needed for most sufferers. This ranges, according to severity, from saline sprays, through non-sedating antihistamines, oral or topical, with minimally bioavailable intranasal corticosteroids for moderate/severe disease, possibly plus additional antihistamine or antileukotriene. The concept of rhinitis control is emerging, but there is no universally accepted definition. Where pharmacotherapy fails, allergen-specific immunotherapy, which is uniquely able to alter long-term disease outcomes, should be considered. The subcutaneous form (subcutaneous immunotherapy) in children has been underused because of concerns regarding safety and acceptability of injections. Sublingual immunotherapy is both efficacious and safe for grass pollen allergy. Further studies on other allergens in children are needed. Patient, carer and practitioner education into AR and its treatment are a vital part of management.

Phenotypes and endotypes of rhinitis and their impact on management: a PRACTALL report

Rhinitis is an umbrella term that encompasses many different subtypes, several of which still elude complete characterization. The concept of phenotyping, being the definition of disease subtypes on the basis of clinical presentation, has been well established in the last decade. Classification of rhinitis entities on the basis of phenotypes has facilitated their characterization and has helped practicing clinicians to efficiently approach rhinitis patients. Recently, the concept of endotypes, that is, the definition of disease subtypes on the basis of underlying pathophysiology, has emerged. Phenotypes/endotypes are dynamic, overlapping, and may evolve into one another, thus rendering clear-cut definitions difficult. Nevertheless, a phenotype-/endotype-based classification approach could lead toward the application of stratified and personalized medicine in the rhinitis field. In this PRACTALL document, rhinitis phenotypes and endotypes are described, and rhinitis diagnosis and management approaches focusing on those phenotypes/endotypes are presented and discussed. We emphasize the concept of control-based management, which transcends all rhinitis subtypes.

Local allergic nasal reactions convert to classic systemic allergic reactions: a long-term follow-up

BACKGROUND

There is poor knowledge about the evolution of the negative skin test in local allergy over time. Does the negative skin test of patients with local allergies remain negative permanently or does it become positive?

METHODS

We describe our long-term observation concerning the evolution of the negative skin test over time. This is a retrospective, follow-up study using data from the medical records of a group of patients with local allergy. A total of 42 patients aged between 3 and 70 years (median age: 31.5 years) were studied. The duration of follow-up varied from 1 to 27 years. Skin tests were performed using the skin-prick test and intracutaneous techniques for pollen, molds, mites, feathers (goose and duck) and animal danders. Nasal provocation tests were conducted with the same allergens. Additionally, specific IgE in 17 patients was measured by enzyme allergosorbent test.

RESULTS

During the period of observation, the negative skin test reactions converted into positive reactions in 17 patients (40%). In addition to the negative skin reactions, 55% of the patients also presented positive skin reactions. The conversion rate was higher in children and adolescents than in adults. In 4 patients, conversions occurred >7 years after the initial examination. Specific IgE was negative in all but 2 patients, in whom the conversion in the skin test was accompanied by a switch from negative to positive specific IgE.

CONCLUSION

Conversions from local to classic systemic respiratory allergic reactions appear to be a common phenomenon.