Clinical practice guideline: Allergic rhinitis

Type 2 inflammation: a Portuguese consensus using Web-Delphi and decision conferencing (INFLAT2-PT)

OBJECTIVES

Atopic/allergic diseases impose a growing burden on public health, affecting millions of patients worldwide. The main objective of this study was to develop a national expert consensus on relevant clinical questions related to type 2 inflammation.

METHODS

We conducted: a comprehensive literature review with a qualitative analysis to identify the most repeated themes on the overlap of conditions; a modified 3-round Web-Delphi (or e-Delphi); and a final online decision conference.

RESULTS

We included 51 studies. Following three Web-Delphi rounds, we ended up with 30 statements with a 76% overall full agreement rate, 16% agreement, 2% disagreement, and 0% full disagreement. The decision conference enabled adjustments, and the expert panel agreed unanimously on the final set of statements. The consensus used evidence synthesis, Web-Delphi, and decision conference to produce 30 statements on type 2 inflammation as a driver for multimorbidity in asthma, certain rhinitis phenotypes, atopic dermatitis, chronic rhinosinusitis with nasal polyps, and eosinophilic esophagitis grouped under five domains in underlying pathophysiology, multimorbidity, diagnosis and management, multidisciplinary management, and impact on mental health.

CONCLUSION

We expect the first Portuguese expert consensus INFLAT2-PT to promote understanding of type 2 inflammation diseases, multidisciplinary care, integrated care pathways, future research, and inform health authorities.

Global Incidence and Prevalence of Chronic Rhinosinusitis: A Systematic Review

OBJECTIVE

Data on the global prevalence of chronic rhinosinusitis (CRS) is significantly varied and limited across countries and over time. Therefore, we aimed to conduct a comprehensive investigation into the global, regional, and national burden of CRS from the years 1980 to 2021, as well as identify those factors that influence levels of such burden.

DESIGN

We conducted a systematic review and meta-analysis of general population-based observational studies focusing on CRS. We calculated pooled estimates of CRS prevalence and incidence with 95% confidence intervals (CIs). Subgroup analyses were conducted stratifying by sex, age cohorts, geographic regions, smoking status, obesity, and comorbid conditions.

DATA SOURCES

PubMed/MEDLINE, EMBASE, CINAHL, Google Scholar, and Cochrane databases.

ELIGIBILITY CRITERIA FOR SELECTION

We included general population-based observational studies on CRS published from database inception through October 20, 2023.

RESULTS

A total of 28 eligible studies, encompassing more than 237 million participants and 11,342,923 patients with CRS from 20 countries across four continents, were included in the analysis. Global pooled prevalence of CRS and CRS with nasal polyps (CRSwNP) was found to be 8.71% (95% CI, 6.69-11.33; number of studies, 20) and 0.65% (95% CI, 0.56-0.75; number of studies, 4), respectively. The prevalence of CRS was greater in Europe compared with North America, South America, and Asia; adults compared with children; smokers compared with never-smoker; those with obesity compared with normal weight; and those with comorbidities such as asthma, diabetes mellitus, eczema, and nasal septal deviation. Pooled prevalence of CRS increased from 1980 to 2020 (1980-2000: 4.72%; 95% CI, 2.12-10.49; 2014-2020: 19.40%; 95% CI, 12.12-31.07). Similar patterns were observed in CRS incidence.

CONCLUSIONS

Our study provides valuable insights into CRS prevalence and incidence across diverse demographic and clinical factors, highlighting its increasing global burden. The reported prevalence of CRS varies internationally, and may be increasing over time. To enhance data quality and comparability, standardization of reporting methodologies is imperative.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO (registration no. CRD42024527805).

Medication adherence in allergic diseases and asthma: a literature review

Patients' collaboration with healthcare providers, along with their individual dedication to follow medical recommendations, is a crucial component of effective therapy in chronic diseases. If a patient fails to fill their prescription, administers the medication improperly in terms of method and/or dosage, misses follow-up visits, or discontinues the treatment for any reason, these lapses can adversely affect disease management, impairing the effectiveness of symptom relief and prevention of progression and complications. A comparable situation pertains to allergic diseases, which require long-term and consistent treatment to achieve symptom alleviation and control. Research has shown that adherence rates for long-term therapy in chronic diseases have improved marginally over the years and continue to hover at approximately the figure published in a World Health Organization (WHO) report "Adherence to long-term therapies: evidence for action." from 2003, which had stated that only 50% of patients in developed countries follow medical recommendations and that this rate would be even lower in developing countries. Over 20 years later, literature indicated that there has been only a slight improvement on the matter, leaving room for developing and implementing effective solutions to improve medication compliance. Further investigation on this matter is required. Causes for non-adherence classified by the Global Initiative for Asthma in their main report seem to correspond to those of the report by the WHO. Similar dependency might be determined by other allergic diseases as they fit chronic disease criteria, and the issue of non-adherence affects them too. This literature review seeks to compile and synthesize current insights on factors that influence adherence, as well as explore potential methods for monitoring, evaluating, and improving its outcomes in chronic diseases related to the medical field of allergology, such as asthma, allergic rhinitis, allergic conjunctivitis, rhinoconjunctivitis, atopic dermatitis, and urticaria.

Research progress in OX40/OX40L in allergic diseases

OX40/OX40L are costimulatory molecules in the tumor necrosis factor superfamily. Numerous studies have shown that OX40/OX40L are involved in immune regulation, especially in the proliferation and differentiation of T cells and the generation of memory T cells, which play important roles in allergic diseases. In recent years, the use of OX40/OX40L as therapeutic targets for treating T-cell-mediated diseases has attracted the interest of scholars. This paper reviews the role of OX40/OX40L in allergic diseases and the progress in clinical treatments targeting this signaling pathway.

LuLIPLEX: A Fast, Highly Sensitive, and Multiplexed Method for the Detection of IgE Against Major Allergens

BACKGROUND

Diagnosis of allergies is mostly based on the patient's clinical history and allergen provocation tests. Determination of specific IgE (sIgE) profiles can be performed to support allergy diagnosis. This is commonly done in vivo by the skin prick test or in vitro with automated systems. Several platforms exist to quantify sIgE levels, but all these methods require access to specific instruments, often delaying the test's results. The IgE luciferase-linked immunosorbent assay (LuLISA) allows bioluminescent quantification of IgE against peanut in microliter samples, but this method awaits extension to other allergens. This study aimed to validate a new method, named LuLIPLEX, for multiplexed bioluminescent detection of sIgE against 20 major molecular allergens.

METHODS

Quantification of sIgE against 12 recombinant or purified food allergens and eight aeroallergens was performed by LuLIPLEX versus standard IgE detection methods (ImmunoCAP, ISAC, ALEX, or NOVEOS). Multiplexed detection of IgE against these 20 allergens was performed within 45 min using 50 μL of serum, plasma, or whole blood samples.

RESULTS

A head-to-head comparison between LuLIPLEX and standard IgE detection methods showed a high correlation among all allergens tested. sIgE profiles in polysensitized subjects could be determined within 45 min in serum and plasma samples, as well as using a single drop of capillary blood.

CONCLUSIONS

LuLIPLEX is a rapid and sensitive method to quantify sIgE levels against multiple allergens. Given that the test is very fast and can be performed on small and inexpensive luminometers, the IgE LuLIPLEX could allow point-of-care testing of sIgE profiles in allergic subjects.

Predicting Adherence to Topical Medications in Chronic Rhinologic Disease: A Systematic Review

OBJECTIVE

To determine risk factors of medical adherence and describe strategies to increase adherence in patients with chronic rhinologic disease.

DATA SOURCES

PubMED, SCOPUS, CINAHL, and Cochrane.

REVIEW METHODS

Systematic review of 4 databases (PubMED, SCOPUS, CINAHL, Cochrane) from inception of databases to September 1, 2022 to identify studies that evaluated factors related to and affected by medical adherence in patients with chronic rhinologic disease.

RESULTS

Of 1491 studies screened, 25 studies met inclusion criteria. Of these, 7 studies described how sensory attributes of intranasal sprays affect adherence, including odor, taste, aftertaste, and side effects. Five studies described record keeping diaries/notification systems to improve adherence, with demonstration of web-based platforms to send reminders as well as keep record of medication usage to improve adherence. Eight studies described patient-specific risk factors to nonadherence, with demonstration of increased age and conscientious personalities correlating with medical adherence. Five studies looked at pediatric patients specifically, with adherence rates in children parallelling that of adults. Additionally, nonadherence in children may have greater implications for school performance.

CONCLUSION

Overall, adherence to topical medical therapy in patients with chronic rhinologic disease is affected by patient-related and medication-specific factors which should be considered when counseling patients. Web-based diary or notification systems may help increase adherence. Additionally, children are equally adherent to topical medical therapy as adults and nonadherence may have negative implications for school performance.

New progress in pediatric allergic rhinitis

The prevalence of allergic rhinitis (AR) in children is steadily increasing, and its onset is closely associated with genetic factors, living environment, and exposure to allergens. In recent years, an increasing number of diagnostic methods have been employed to assist in diagnosing AR. In addition to pharmaceutical treatments, personalized approaches such as environmental control and allergen-specific immunotherapy are gradually gaining popularity. In this article, we reviewed recent research on the etiology, diagnostic classification, treatment methods, and health management of AR in children. These insights will benefit the implementation of personalized diagnosis and treatment for children with AR, promoting health management strategies that improve symptoms and quality of life.

Psychological Status as an Effect Modifier of the Association Between Allergy Symptoms and Allergy Testing

OBJECTIVE

Patient-reported outcome measures, while valuable, may not correlate with diagnostic test results. To better understand this potential discrepancy, our objective was to determine whether psychological health is an effect modifier of the association between patient-reported allergy outcome scores and allergy test results.

STUDY DESIGN

Prospective outcomes study.

SETTING

Tertiary care hospital and community-based clinic.

METHODS

This study included 600 patients at least 18 years of age who presented for symptoms related to allergic rhinitis and completed the related sinonasal outcome test (SNOT), which includes validated nasal, allergy, and psychological domains. Stratified analyses of odds ratios and Spearman correlation coefficients were utilized to assess for effect modification by psychological status.

RESULTS

Worse patient-reported allergic rhinitis symptoms were significantly associated with positive allergy test results (odds ratio [OR] 1.69, 95% confidence interval [CI] 1.22-2.34, P = .002) in patients with better psychological health. In contrast, there was no association in patients with worse psychological health (OR 1.06, 95% CI 0.36-3.10, P = .92). These findings were corroborated by assessments of correlation: allergy domain scores were positively correlated with allergy testing scores (Spearman rho 0.18, 95% CI 0.10-0.25, P < .001) in patients with better psychological health, while there was no correlation in patients with worse psychological health (-0.02, 95% CI -0.16-0.12, P = .77).

CONCLUSIONS

Psychological status was an effect modifier of the association between allergy domain and allergy testing data. When assessing the relationship between subjective measures, such as sinonasal validated instruments, and objective measures, such as allergy test results, accounting for effect modifiers such as psychological state can provide clinical and research-related insights.

Efficacy and safety of various corticosteroids in the treatment of children with allergic rhinitis: A systematic review and network meta-analysis

BACKGROUND

Intranasal corticosteroids were recommended as first-line drugs for the treatment of allergic rhinitis (AR) children. A variety of corticosteroids were available for clinical choice; however, which could relieve the clinical symptoms of patients to the greatest extent was currently unknown. Thus, we performed a network meta-analysis (NMA) to systematically evaluate the effectiveness and safety of different corticosteroids in treating children with AR, which might provide a basis for more rational clinical treatment decisions.

METHODS

Seven electronic databases were searched, and the retrieval time range was the time from their inception to November 2023. The literature screening, data extraction, and assessment of the risk of bias of included studies were completed independently by two reviewers. A frequentist NMA was performed with Stata17.0 software.

RESULTS

A total of 43 RCTs covering 10,897 participants were included. In the improvement of reflective total nasal symptom score (rTNSS) and instantaneous total nasal symptom score (iTNSS), fluticasone furoate nasal spray (FFNS) and beclomethasone dipropionate (BDP) nasal aerosol presented the best efficacy. Regarding the incidence of adverse reactions, mometasone furoate aqueous nasal spray (MFANS) and BDP showed a good safety profile. In terms of the influence of cortisol (urinary free cortisol, plasma cortisol) and growth, no significant difference was observed between the different groups.

CONCLUSION

The results showed that BDP nasal aerosol and FFNS had best efficacy; MFANS and BDP had the best safety profile. However, this conclusion was less convincing because of the limited numbers of patients/controls and study quality.

Prevalence and Regional Factors in the Development and Course of Allergic Diseases in Children in Southern Kyrgyzstan

Background: The prevalence of allergic diseases in children worldwide has increased rapidly over the past 30 years. This study aimed to identify regional factors influencing the development and course of allergic diseases for further prevention, control, and reduction of the risk and frequency of complications. Methods: To investigate the issue, 104 studies by different authors and countries, as well as topics related to allergy in children, air pollution, and regional factors of detection and prevalence of this disease in Kyrgyzstan, were selected. Of these, 52 studies were noted and analysed, which met the selection criteria and were of direct importance in this topic. Results: This study of allergic diseases in children found that more than 35% of children worldwide suffer from allergic diseases. Of these, allergic rhinitis occurs in 12% of children, atopic dermatitis is less common, but its incidence is 10-20%, and bronchial asthma, according to statistics, covers more than 14% of children. Conclusion: The results of the study helped to investigate the prevalence of allergic diseases relative to the region of residence, the impact of environmental pollution, geographical significance, and the effect of smoking on the development of allergies in children.

Debunking myths in headache diagnosis for the pain practitioner

With headache being one of the most common chief complaints, it is essential for pain practitioners to interpret and differentiate a variety of headache characteristics to accurately diagnose and treat specific headache disorders. Certain misconceptions often lead to misdiagnosis. This article presents and discusses six myths about several common headache disorders (migraine, tension-type headache, cluster headache, cervicogenic headache, sinus headache, and occipital neuralgia) often encountered in clinical practice. The discussion is based primarily on the International Classification of Headache Disorders, 3rd edition and the latest studies. Recognizing and understanding the intricacies behind key headache diagnoses will help providers devise appropriate plans to better care for their patients.

A novel dose-adjustment protocol for interrupted subcutaneous immunotherapy in children with allergic rhinitis

Aim: To assess the effectiveness and safety of a new protocol for adjusting doses during interrupted subcutaneous immunotherapy maintenance, exceeding an 8-week interval, with mite allergen injections in children with allergic rhinitis.Patients & methods: 194 children with allergic rhinitis who underwent subcutaneous immunotherapy and experienced interruptions lasting more than 8 weeks during maintenance were enrolled. Following the adoption of a novel dose-adjustment protocol, a real-world study was conducted.Results: After 3 years of subcutaneous immunotherapy, the novel group exhibited a significant reduction in allergy symptoms compared with baseline. Systemic reactions related to the novel protocol did not significantly increase.Conclusion: The novel protocol was deemed safe and effective, offering advantages of time savings and reduced burdens.

AM-301, a barrier-forming nasal spray, versus saline spray in seasonal allergic rhinitis: A randomized clinical trial

RATIONALE

Saline nasal sprays are frequently used in the management of seasonal allergic rhinitis (SAR) for the cleansing and clearing of aeroallergens from the nasal cavity. Also using a drug-free approach, AM-301 nasal spray is forming a thin film barrier on the nasal mucosa to prevent contact with allergens, trap them, and facilitate their discharge. A clinical trial compared the efficacy, safety, and tolerability of AM-301 and saline spray in SAR.

METHODS

A total of 100 patients were randomized 1:1 to self-administer AM-301 or saline 3 × daily for 2 weeks. Primary efficacy endpoint: reduction in mean daily reflective Total Nasal Symptom Score (rTNSS). Secondary efficacy endpoints: reduction in mean instantaneous TNSS and Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ), global impression of efficacy. Safety and tolerability: adverse events, relief medication use, symptom-free days, global impression of tolerability.

RESULTS

AM-301-treated patients achieved a significantly lower rTNSS than the saline group (LS square means difference -1.1, 95% CI -1.959 to -0.241, p = .013) with improvement observed across all individual nasal symptoms. Likewise, all secondary endpoints showed statistical significance in favor of AM-301; for example, quality of life was significantly improved overall (p < .001) as well as for each individual RQLQ domain. Both treatments showed similarly good safety and tolerability. With AM-301, fewer patients used relief medication and more enjoyed symptom-free days compared to saline treatment.

CONCLUSIONS

AM-301 was more effective than saline in improving SAR nasal symptoms and related quality of life while offering similar tolerability, demonstrating the benefits of a barrier approach.

Treatment of Allergic Rhinitis with Acupuncture Based on Pathophysiological

Allergic rhinitis is a prevalent allergic diseases and has a profound impact on physical well-being. In recent years, more and more people have changed to allergic diseases, such as allergic rhinitis, allergic asthma, allergic dermatitis and so on. In the incidence of allergic rhinitis, covering all ages. The common clinical treatment of allergic rhinitis are drugs and immunotherapy, but these therapies have certain limitations. Therefore, an effective and economical treatment for AR is urgently needed. Acupuncture are widely used in the clinical treatment of various diseases, but the effect of acupuncture in the treatment of allergic rhinitis (AR) is significant, and the mechanism of acupuncture in the treatment of AR is also a hot spot. Acupuncture is one of the traditional treatment methods of traditional Chinese medicine, which achieves therapeutic effect by pressing a needle or other means at a specific location on the skin to produce a special sensation. Among them, acupuncture, as a popular treatment method, has attracted more and more attention. In this review, we provide an overview of the current understanding of acupuncture and AR, as well as current studies investigating the efficacy and safety of acupuncture for AR.

Hematological, Biochemical, and Serum Levels of Allergic Mediators in Individuals with and without Allergic Rhinitis

Background

Allergic rhinitis (AR) is the most prevalent form of non-infectious rhinitis and is characterized by an immune response mediated by immunoglobulin E (IgE).

Aim

This study aims to compare the levels of biochemical markers and other parameters in individuals with AR, non-allergic rhinitis(n-AR), allergic rhinitis accompanied by symptoms of the lower respiratory tract(AR-SLRT), and healthy controls.

Study Design

Case control study.

Methods

Blood samples from the three study groups, AR (n = 22), n-AR (n=20), AR-SLRT group (n = 21), and the control group (n = 18), were analyzed to ascertain the levels of total IgE, specific IgE, periostin, pendrin, vitamin D, thyroid-stimulating hormone (TSH), free triiodothyronine (Ft3), free thyroxine (Ft4), anti-thyroid peroxidase (TPO), and eosinophilic cationic protein (ECP), as well as the leukocyte formula and hemogram.

Results

The AR and n-AR groups had significantly higher hematocrit values in comparison to the control group(p<0.05). Further, eosinophil counts were significantly higher in the AR and AR-SLRT groups than in the control group(p<0.05). Total IgE levels were significantly higher in the AR-SLRT group than in the AR, n-AR, and control groups (p<0.05). The AR group had higher total IgE values compared to the control group and the n-AR group(p<0.05). The values of ECP, periostin, pendrin, Ft3, Ft4, TSH, anti-TPO, and vitamin D did not differ significantly between the groups(p>0.05).

Conclusion

All the investigated groups did not differ in ECP, periostin, pendrin, Ft3, Ft4, TSH, anti-TPO, or vitamin D parameters. The groups with positive AR and AR-SLRT had higher eosinophil counts than the control group. The group with AR-SLRT had higher total IgE concentrations than the other groups.

Performance and Consistency of ChatGPT-4 Versus Otolaryngologists: A Clinical Case Series

OBJECTIVE

To study the performance of Chatbot Generative Pretrained Transformer-4 (ChatGPT-4) in the management of cases in otolaryngology-head and neck surgery.

STUDY DESIGN

Prospective case series.

SETTING

Multicenter University Hospitals.

METHODS

History, clinical, physical, and additional examinations of adult outpatients consulting in otolaryngology departments of CHU Saint-Pierre and Dour Medical Center were presented to ChatGPT-4, which was interrogated for differential diagnoses, management, and treatment(s). According to specialty, the ChatGPT-4 responses were assessed by 2 distinct, blinded board-certified otolaryngologists with the Artificial Intelligence Performance Instrument.

RESULTS

One hundred cases were presented to ChatGPT-4. ChaGPT-4 indicated a mean of 3.34 (95% confidence interval [CI]: 3.09, 3.59) additional examinations per patient versus 2.10 (95% CI: 1.76, 2.34; P = .001) for the practitioners. There was strong consistency (k > 0.600) between otolaryngologists and ChatGPT-4 for the indication of upper aerodigestive tract endoscopy, positron emission tomography and computed tomography, audiometry, tympanometry, and psychophysical evaluations. Primary diagnosis was correctly performed by ChatGPT-4 in 38% to 86% of cases depending on subspecialty. Additional examinations indicated by ChatGPT-4 were pertinent and necessary in 8% to 31% of cases, while the treatment regimen was pertinent in 12% to 44% of cases. The performance of ChatGPT-4 was not influenced by the human-reported level of difficulty of clinical cases.

CONCLUSION

ChatGPT-4 may be a promising adjunctive tool in otolaryngology, providing extensive documentation about additional examinations, primary and differential diagnoses, and treatments. The ChatGPT-4 is more effective in providing a primary diagnosis, and less effective in the selection of additional examinations and treatments.

Effect of GHX02 on an Asthma-Rhinitis Mouse Model Induced by Ovalbumin and Diesel Particulate Matter

Fine dust concentrations come in direct contact with the human respiratory system, thereby reducing lung function and causing respiratory diseases such as asthma and rhinitis. The aim of this study was to evaluate the efficacy of GHX02 (combination of four herbs [Trichosanthes kirilowii, Prunus armeniaca, Coptis japonica, and Scutellaria baicalensis]), a herbal extract with established efficacy against bronchitis and pulmonary disease, in the treatment of asthma accompanied by rhinitis aggravated by fine dust. Therefore, we constructed an asthma-rhinitis mouse model of Balb/c mice challenged with ovalbumin (OVA) and fine diesel particulate matter, which were administered with three concentrations of GHX02. GHX02 significantly inhibited the increase of total cells and immune cells in bronchoalveolar lavage fluid, lung tissue, and nasal ductal lymphoid tissue (NALT). GHX02 also reduced the severity of histological lung injury and the expression of interleukin (IL)-1α and nuclear factor kappa B (NF-κB), which regulate inflammatory responses. The results indicate that GHX02 inhibited the inflammatory immune response in mice. Therefore, this study highlights the potential of GHX02 as a treatment for patients with asthma accompanied by rhinitis. Balb/c mice were challenged with OVA and PM10D, and then treated with three concentration of GHX02. GHX02 significantly inhibited the increase of total cells, immune cells lymphocytes, neutrophils, and macrophages, as well as their expression in lung tissue. GHX02 significantly inhibited the increase of total cells and immune cells in NALT. GHX02 decreased the severity of histological lung injury, expression of IL-1α and NF-κB. This study suggests the probability that GHX02 is effective for asthma patients with rhinitis by inhibiting inflammatory immune response.

Promising New Diagnostic and Treatment Modalities for Allergic Rhinitis: What's Coming Next?

Novel diagnostic tests may help diagnose patients with local allergic rhinitis (AR) when systemic testing is negative or inconclusive. Surgical approaches including septoplasty, inferior turbinate reduction, nasal swell body reduction, and posterior nasal nerve ablation may improve symptoms in patients whose symptoms are refractory to medical therapy, though high-quality evidence is lacking in the AR population. Intralymphatic and epicutaneous immunotherapy have the potential to improve adherence to allergen immunotherapy, though comparisons with current gold standard treatments are lacking and studies reporting long-term outcomes are needed. Immunomodulatory agents in combination with subcutaneous immunotherapy (SCIT) may improve tolerance of SCIT but reports to date do not demonstrate a clear benefit in symptom alleviation. Future work in these areas may support these options as beneficial for testing and treatment of AR.

In Vivo Fluticasone Absorption in Surgical Patients

BACKGROUND

Intranasal corticosteroids (INCS) are a treatment mainstay of chronic rhinosinusitis and allergic rhinitis. Current computational models demonstrate that >90% of INCS drug deposition occurs on the head of the inferior turbinate and nasal valve, rather than the actual sinuses. These models do not consider mucociliary clearance which propels mucus posteriorly, nor do they consider the absorption of the drug. The purpose of this study is to better understand the exact anatomical location where INCS are absorbed.

METHODS

Patients with chronic rhinosinusitis and allergic rhinitis taking fluticasone pre-operatively who were scheduled for functional endoscopic sinus surgery and inferior turbinate reduction, respectively, were recruited. Intra-operative tissue samples were obtained from predetermined locations within the sinonasal cavity. Mass spectrometry was then used to quantify the amount of absorption in each specific anatomic location to determine the largest amount of absorption.

RESULTS

Eighteen patients were included in our study. The greatest fluticasone absorption levels across the sinonasal anatomy were at the anterior inferior turbinate (5.7 ngl/mL), ethmoid sinus, (4.4 ng/mL), posterior inferior turbinate (3.7 ng/mL), maxillary sinus (1.3 ng/mL), and the sphenoethmoidal recess (0.72 ng/mL) respectively. Absorption was significantly higher in revision surgery compared to surgically naïve patients.

CONCLUSIONS

Computation fluid dynamic models of the nasal passage are useful models to help predict intranasal particle flow. However, these models do not incorporate or consider the important mucociliary clearance system, leading to absorption of fluticasone throughout the sinonasal cavity far beyond that predicted by these models.

LEVEL OF EVIDENCE

2 Laryngoscope, 134:1551-1555, 2024.

Efficacy and safety of turbinate reduction surgery in children: a systematic review

PURPOSE

Inferior turbinate hypertrophy is not a rare problem in children, it causes chronic nasal obstruction which can severely impact the quality of life. This study aimed to investigate the efficacy and safety of turbinate reduction surgery in children with impaired nasal breathing due to hypertrophied inferior turbinate that's refractory to medical treatment.

METHODS

We included 23 articles with various study designs: randomized controlled trials, single-arm clinical trials, and prospective and retrospective cohort studies. We searched PubMed, Scopus, Cochrane Library, and Web of Science with the relevant keywords till April 9th, 2023. The inclusion criteria were studied with the three prespecified study design that addressed children under 18 years who underwent turbinate reduction with any technique and evaluating the improvement whether by objective or subjective methods.

RESULTS

Studies used objective measures favor turbinate surgery except two that showed no significant difference between pre and postoperative results. All studies used subjective measures showed an improvement postoperatively except one study. Complication rates are rare, with crust formation is being the commonest (6.03%), however, the procedure is generally safe in children. In addition, follow-up periods varied widely between 2 weeks and more than 5 years.

CONCLUSION

Turbinate reduction in children is an effective as a treatment method for nasal blockage due to inferior turbinate hypertrophy which is resistant to medical treatment. It is a safe procedure with low rates of complications, however, due to the heterogenicity of the study designs, with a possible risk of bias we could not conduct a meta-analysis besides our systematic review.

Cost-effectiveness Analysis of Inferior Turbinate Reduction and Immunotherapy in Allergic Rhinitis

BACKGROUND

Allergic rhinitis (AR) is a common condition that is frequently associated with atopic inferior turbinate hypertrophy (ITH) resulting in nasal obstruction. Current guidelines support the use of subcutaneous allergen immunotherapy (SCIT) when patients fail pharmacologic management. However, there is a lack of consensus regarding the role of inferior turbinate reduction (ITR), a treatment that we hypothesize is cost-effective compared with other available treatments.

METHODS

We conducted a cost-effectiveness analysis comparing the following treatment combinations over a 5-year time horizon for AR patients presenting with atopic nasal obstruction who fail initial pharmacotherapy: (1) continued pharmacotherapy alone, (2) allergy testing and SCIT, (3) allergy testing and SCIT and then ITR for SCIT nonresponders, and (4) ITR and then allergy testing and SCIT for ITR nonresponders. Results were reported as incremental cost-effectiveness ratios (ICERs).

RESULTS

For patients who fail initial pharmacotherapy, prioritizing ITR, either by microdebrider-assisting submucous resection or radiofrequency ablation, before SCIT was the most cost-effective strategy. Probabilistic sensitivity analysis demonstrated that prioritizing ITR before SCIT was the most cost-effective option in 95.4% of scenarios. ITR remained cost-effective even with the addition of concurrent septoplasty.

CONCLUSION

For many AR patients who present with nasal obstruction secondary to atopic inferior turbinate hypertrophy that is persistent despite pharmacotherapy, ITR is a cost-effective treatment that should be considered prior to immunotherapy.

LEVEL OF EVIDENCE

NA - Laryngoscope, 2023 Laryngoscope, 134:1572-1580, 2024.

Prenatal Exposure to Air Pollutants Associated with Allergic Diseases in Children: Which Pollutant, When Exposure, and What Disease? A Systematic Review and Meta-analysis

This systematic review aims to identify the association between prenatal exposure to air pollutants and allergic diseases in children, focusing on specific pollutants, timing of exposure, and associated diseases. We searched PubMed, Scopus, and Web of Science for English articles until May 1, 2023, examining maternal exposure to outdoor air pollutants (PM1, PM2.5, PM10, NO, NO2, SO2, CO, and O3) during pregnancy and child allergic diseases (atopic dermatitis (AD), food allergy (FA), asthma (AT) and allergic rhinitis (AR)/hay fever (HF)). The final 38 eligible studies were included in the meta-analysis. Exposure to PM2.5 and NO2 during pregnancy was associated with the risk of childhood AD, with pooled ORs of 1.34 (95% confidence interval (CI), 1.10-1.63) and 1.10 (95%CI, 1.05-1.15) per 10 µg/m3 increase, respectively. Maternal exposure to PM1, PM2.5, and NO2 with a 10 µg/m3 increase posed a risk for AT, with pooled ORs of 1.34 (95%CI, 1.17-1.54), 1.11 (95%CI, 1.05-1.18), and 1.07 (95%CI, 1.02-1.12), respectively. An increased risk of HF was observed for PM2.5 and NO2 with a 10 µg/m3 increase, with ORs of 1.36 (95%CI, 1.17-1.58) and 1.26 (95%CI, 1.08-1.48), respectively. Traffic-related air pollutants (TRAP), particularly PM2.5 and NO2, throughout pregnancy, pose a pervasive risk for childhood allergies. Different pollutants may induce diverse allergic diseases in children across varying perinatal periods. AT is more likely to be induced by outdoor air pollutants as a health outcome. More research is needed to explore links between air pollution and airway-derived food allergies.

Validation of a Novel Allergy-Specific Domain for the 22-Item Sino-Nasal Outcomes Test

OBJECTIVES

To develop and assess the validity of a novel allergy-specific domain for the 22-item sino-nasal outcomes test (SNOT-22), to provide a new tool that efficiently quantifies the impact of allergic rhinitis (AR) concurrent with chronic rhinosinusitis.

STUDY DESIGN

Prospective validation study.

SETTING

Tertiary care hospital and community-based clinic.

METHODS

Proposed items were developed based on clinician and patient input, and further assessed via factor analysis and for internal consistency (n = 1987). Items were then additionally assessed for convergent and discriminant validity (n = 415), applying data from concurrent completions of the Nasal Obstruction and Septoplasty Effectiveness Scale (NOSE), Mini-Rhinoconjunctivitis Quality-of-Life Questionnaire (MiniRQLQ), and validated global health assessments. Assessments of intra-rater reliability, responsiveness to change, and qualitative input were also performed.

RESULTS

Factor analysis demonstrated that proposed allergy items mapped to a single domain. Items were internally consistent (Cronbach α: 0.80 within domain, 0.91 within all SNOT). In assessments of convergent validity, domain scores were associated with MiniRQLQ (Spearman's ρ: 0.46, 95% confidence interval [CI]: 0.30-0.59) and NOSE scores (0.36, 95% CI: 0.27-0.44). The novel items also discriminated among clinical states: a 1-point increase in domain score was associated with an 8.32 (95% CI: 5.43-12.75) increase in the odds of prompting a visit for allergy-related symptoms and a 1.52 (95% CI: 1.13-2.05) increase in the odds of positive allergy testing. Intra-rater reliability was substantial (Cohen's κ: 0.8, 95% CI: 0.8-0.9), and responsiveness to change was demonstrated (mean difference: -0.6, 95% CI: -0.8 to -0.4).

CONCLUSIONS

This novel domain is a valid, efficient measure of AR alongside rhinosinusitis.

Pediatric Inferior Turbinate Hypertrophy: Diagnosis and Management. A YO-IFOS Consensus Statement

OBJECTIVE

Pediatric inferior turbinate hypertrophy (PedTH) is a frequent and often overlooked cause or associated cause of nasal breathing difficulties. This clinical consensus statement (CCS) aims to provide a diagnosis and management framework covering the lack of specific guidelines for this condition and addressing the existing controversies.

METHODS

A clinical consensus statement (CCS) was developed by a panel of 20 contributors from 7 different European and North American countries using the modified Delphi method. The aim of the CCS was to offer a multidisciplinary reference framework for the management of PedTH on the basis of shared clinical experience and analysis of the strongest evidence currently available.

RESULTS

A systematic literature review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria was performed. From the initial 96 items identified, 7 articles were selected based on higher-evidence items such as randomized-controlled trials, guidelines, and systematic reviews. A 34-statement survey was developed, and after three rounds of voting, 2 items reached strong consensus, 17 reached consensus or near consensus, and 15 had no consensus.

CONCLUSIONS

Until further prospective data are available, our CCS should provide a useful reference for PedTH management. PedTH should be considered a nasal obstructive disease not necessarily related to an adult condition but frequently associated with other nasal or craniofacial disorders. Diagnosis requires clinical examination and endoscopy, whereas rhinomanometry, nasal cytology, and questionnaires have little clinical role. Treatment choice should consider the specific indications and features of the available options, with a preference for less invasive procedures.

LEVEL OF EVIDENCE

5 Laryngoscope, 134:1437-1444, 2024.

Endoscopic vidian and vidian-branch neurectomy for refractory allergic rhinitis: A systematic review

BACKGROUND

Endoscopic vidian neurectomy is expected to provide good therapeutic relief in patients with allergic rhinitis (AR) being refractory to medication therapy or conservative surgery. However, the evidence bases for its benefit remain debatable. In this study, we conducted a systematic review and meta-analysis to clarify the therapeutic role of various forms of vidian neurectomy in refractory AR.

METHOD

Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were used to conduct a systematic review of primary studies that reported original patient data for endoscopic vidian neurectomy (EVN) and vidian-branch neurectomy, which includes selective vidian neurectomy (SVN) and posterior nasal neurectomy (PNN). The primary outcome was patient-reported outcome measures (PROMs), including the Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) and Visual Analog Scale (VAS), to assess an improvement in nasal symptom severity and quality of patient's life. The incidence of surgical complications and other objective outcomes were considered secondary outcomes.

RESULTS

This review included 24 clinical studies involving 1677 patients with refractory AR, of which 510 patients in six studies had combined chronic rhinosinusitis with nasal polyps (CRSwNP) and 95 patients in one study had combined asthma. Postoperative PROMs were significantly better than preoperatively in almost all patients who underwent vidianp (RQLQ: standardized mean difference [SMD] = 2.66, 95% confidence interval [CI] = 2.40-2.92, p < 0.001; VAS: SMD = 5.15, 95% CI = 4.29-6.02, p < 0.001) or vidian-branch neurectomy (RQLQ in PNN: SMD = 3.29, 95% CI = 2.45-4.13, p < 0.001; VAS in PNN: SMD = 4.38, 95% CI = 3.41-5.34, p < 0.001), and were generally better than in the conservative treatment group. Dividing with 18 months as the cutoff point, a subgroup analysis of the follow-up period was conducted, and the results showed that both long-term and short-term postoperative patients had considerably reduced symptoms compared to the preoperative period. The two surgical procedures, SVN and PNN, attributed to vidian-branch neurectomy have extremely few complications. However, EVN is more likely to cause dry eyes and palatal numbness, with no other serious complications. In patients with AR and CRSwNP, vidian or selective vidian neurectomy combined with functional endoscopic sinus surgery (FESS) is more effective than conventional FESS (RQLQ: SMD = 2.17, 95% CI = 1.66-2.69, p < 0.001; VAS: SMD = 6.42, 95% CI = 4.78-8.06, p < 0.001). For patients who have both AR and asthma, SVN with pharyngeal branch excision is a potential treatment option.

CONCLUSION

EVN and vidian-branch neurectomy (including SVN and PNN) are effective treatments, but the former has a higher risk of complications. Additionally, vidian-branch neurectomy with FESS is beneficial for patients with mixed CRSwNP. SVN is a potential approach for patients with coexisting AR and asthma.

Clinical Practice Guideline: Immunotherapy for Inhalant Allergy

OBJECTIVE

Allergen immunotherapy (AIT) is the therapeutic exposure to an allergen or allergens selected by clinical assessment and allergy testing to decrease allergic symptoms and induce immunologic tolerance. Inhalant AIT is administered to millions of patients for allergic rhinitis (AR) and allergic asthma (AA) and is most commonly delivered as subcutaneous immunotherapy (SCIT) or sublingual immunotherapy (SLIT). Despite its widespread use, there is variability in the initiation and delivery of safe and effective immunotherapy, and there are opportunities for evidence-based recommendations for improved patient care.

PURPOSE

The purpose of this clinical practice guideline (CPG) is to identify quality improvement opportunities and provide clinicians trustworthy, evidence-based recommendations regarding the management of inhaled allergies with immunotherapy. Specific goals of the guideline are to optimize patient care, promote safe and effective therapy, reduce unjustified variations in care, and reduce the risk of harm. The target patients for the guideline are any individuals aged 5 years and older with AR, with or without AA, who are either candidates for immunotherapy or treated with immunotherapy for their inhalant allergies. The target audience is all clinicians involved in the administration of immunotherapy. This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the guideline development group (GDG). It is not intended to be a comprehensive, general guide regarding the management of inhaled allergies with immunotherapy. The statements in this guideline are not intended to limit or restrict care provided by clinicians based on their experience and assessment of individual patients.

ACTION STATEMENTS

The GDG made a strong recommendation that (Key Action Statement [KAS] 10) the clinician performing allergy skin testing or administering AIT must be able to diagnose and manage anaphylaxis. The GDG made recommendations for the following KASs: (KAS 1) Clinicians should offer or refer to a clinician who can offer immunotherapy for patients with AR with or without AA if their patients' symptoms are inadequately controlled with medical therapy, allergen avoidance, or both, or have a preference for immunomodulation. (KAS 2A) Clinicians should not initiate AIT for patients who are pregnant, have uncontrolled asthma, or are unable to tolerate injectable epinephrine. (KAS 3) Clinicians should evaluate the patient or refer the patient to a clinician who can evaluate for signs and symptoms of asthma before initiating AIT and for signs and symptoms of uncontrolled asthma before administering subsequent AIT. (KAS 4) Clinicians should educate patients who are immunotherapy candidates regarding the differences between SCIT and SLIT (aqueous and tablet) including risks, benefits, convenience, and costs. (KAS 5) Clinicians should educate patients about the potential benefits of AIT in (1) preventing new allergen sensitizations, (2) reducing the risk of developing AA, and (3) altering the natural history of the disease with continued benefit after discontinuation of therapy. (KAS 6) Clinicians who administer SLIT to patients with seasonal AR should offer pre- and co-seasonal immunotherapy. (KAS 7) Clinicians prescribing AIT should limit treatment to only those clinically relevant allergens that correlate with the patient's history and are confirmed by testing. (KAS 9) Clinicians administering AIT should continue escalation or maintenance dosing when patients have local reactions (LRs) to AIT. (KAS 11) Clinicians should avoid repeat allergy testing as an assessment of the efficacy of ongoing AIT unless there is a change in environmental exposures or a loss of control of symptoms. (KAS 12) For patients who are experiencing symptomatic control from AIT, clinicians should treat for a minimum duration of 3 years, with ongoing treatment duration based on patient response to treatment. The GDG offered the following KASs as options: (KAS 2B) Clinicians may choose not to initiate AIT for patients who use concomitant beta-blockers, have a history of anaphylaxis, have systemic immunosuppression, or have eosinophilic esophagitis (SLIT only). (KAS 8) Clinicians may treat polysensitized patients with a limited number of allergens.

Undaria pinnatifida ameliorates nasal inflammation by inhibiting eosinophil and mast cell activation and modulating the NF-κB/MAPKs signaling pathway

BACKGROUND

Allergic rhinitis (AR) is the most prevalent form of atopic disease. Undaria pinnatifida has potent antioxidative, antidiabetic, and anti-inflammatory properties.

AIMS

We investigated the immunomodulatory effect of Undaria pinnatifida extract (UPE) on allergic inflammation in an AR mouse model.

MATERIALS & METHODS

Mice were sensitized and intranasally challenged with ovalbumin (OVA), and the Th1/Th2 and Th17/Treg-related cytokines and histopathology were exanimated after UPE treatments. Enzyme-linked immunosorbent assay was performed using serum samples and NALF to detect OVA-specific immunoglobulins and inflammatory cytokines. Mitogen-activated protein kinases (MAPKs) were measured by western blotting analysis, and an in vitro study measured mast cell activation induced by compound 48/80.

RESULTS

After UPE treatment, nasal and lung allergy symptoms, nasal mucosal swelling, and goblet cell hyperplasia were ameliorated. Oral UPE regulated the balance of Th1/Th2 and Th17/Treg cell differentiation in AR mice in a dose-dependent manner. In addition, UPE attenuated the migration of eosinophils and mast cells to the nasal mucosa by suppressing nuclear factor kappa B (NF-κB)/MAPKs. The levels of anti-OVA IgE and IgG1 were also decreased.

DISCUSSION

UPE inhibited inflammation by regulating the NF-κB/MAPKs signaling pathway and supressing the activation of critical immune cells such as eosinophils and mast cells.

CONCLUSION

UPE may have therapeutic potential for AR.

Plain Language Summary: Immunotherapy for Inhalant Allergy

The plain language summary explains allergen immunotherapy to patients, families, and caregivers. The summary is for patients aged 5 years and older who are experiencing symptoms from inhalant allergies and are considering immunotherapy as a treatment option. It is based on the 2024 "Clinical Practice Guideline: Immunotherapy for Inhalant Allergy." This plain language summary is a companion publication to the full guideline, which provides greater detail for health care providers. Guidelines and their recommendations may not apply to every patient, but they can be used to find best practices and quality improvement opportunities.

Executive Summary of Clinical Practice Guideline on Immunotherapy for Inhalant Allergy

OBJECTIVE

Allergen immunotherapy (AIT) is the therapeutic exposure to an allergen or allergens selected by clinical assessment and allergy testing to decrease allergic symptoms and induce immunologic tolerance. Inhalant AIT is administered to millions of patients for allergic rhinitis (AR) and allergic asthma (AA) and is most commonly delivered as subcutaneous immunotherapy (SCIT) or sublingual immunotherapy (SLIT). Despite its widespread use, there is variability in the initiation and delivery of safe and effective immunotherapy, and there are opportunities for evidence-based recommendations for improved patient care.

PURPOSE

The purpose of this clinical practice guideline is to identify quality improvement opportunities and provide clinicians trustworthy, evidence-based recommendations regarding the management of inhaled allergies with immunotherapy. Specific goals of the guideline are to optimize patient care, promote safe and effective therapy, reduce unjustified variations in care, and reduce risk of harm. The target patients for the guideline are any individuals aged 5 years and older with AR, with or without AA, who are either candidates for immunotherapy or treated with immunotherapy for their inhalant allergies. The target audience is all clinicians involved in the administration of immunotherapy. This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the guideline development group. It is not intended to be a comprehensive, general guide regarding the management of inhaled allergies with immunotherapy. The statements in this guideline are not intended to limit or restrict care provided by clinicians based on their experience and assessment of individual patients.

ACTION STATEMENTS

The guideline development group made a strong recommendation that (Key Action Statement [KAS] 10) the clinician performing allergy skin testing or administering AIT must be able to diagnose and manage anaphylaxis. The guideline development group made recommendations for the following KASs: (KAS 1) Clinicians should offer or refer to a clinician who can offer immunotherapy for patients with AR with or without AA if their patients' symptoms are inadequately controlled with medical therapy, allergen avoidance, or both, or have a preference for immunomodulation. (KAS 2A) Clinicians should not initiate AIT for patients who are pregnant, have uncontrolled asthma, or are unable to tolerate injectable epinephrine. (KAS 3) Clinicians should evaluate the patient or refer the patient to a clinician who can evaluate for signs and symptoms of asthma before initiating AIT and for signs and symptoms of uncontrolled asthma before administering subsequent AIT. (KAS 4) Clinicians should educate patients who are immunotherapy candidates regarding the differences between SCIT and SLIT (aqueous and tablet) including risks, benefits, convenience, and costs. (KAS 5) Clinicians should educate patients about the potential benefits of AIT in (1) preventing new allergen sensitization, (2) reducing the risk of developing AA, and (3) altering the natural history of the disease with continued benefit after discontinuation of therapy. (KAS 6) Clinicians who administer SLIT to patients with seasonal AR should offer pre- and co-seasonal immunotherapy. (KAS 7) Clinicians prescribing AIT should limit treatment to only those clinically relevant allergens that correlate with the patient's history and are confirmed by testing. (KAS 9) Clinicians administering AIT should continue escalation or maintenance dosing when patients have local reactions to AIT. (KAS 11) Clinicians should avoid repeat allergy testing as an assessment of the efficacy of ongoing AIT unless there is a change in environmental exposures or a loss of control of symptoms. (KAS 12) For patients who are experiencing symptomatic control from AIT, clinicians should treat for a minimum duration of 3 years, with ongoing treatment duration based on patient response to treatment. The guideline development group offered the following KASs as options: (KAS 2B) Clinicians may choose not to initiate AIT for patients who use concomitant beta-blockers, have a history of anaphylaxis, have systemic immunosuppression, or have eosinophilic esophagitis (SLIT only). (KAS 8) Clinicians may treat polysensitized patients with a limited number of allergens.

Multicenter study of seasonal and regional airborne allergens in Chinese preschoolers with allergic rhinitis

This study is nationwide multicenter epidemiological research, aimed at investigating the distribution changes and seasonal patterns of various airborne allergens among preschool children with allergic rhinitis (AR) in different regions of China, and analyzing the clinical correlation between sensitization to various airborne allergens and AR symptoms in children. Information on children was collected through standard questionnaires, and total IgE (tIgE) and specific IgE (sIgE) for 11 inhalant allergens were tested. The results showed that dust mites are the primary allergens for preschool AR children (39%). Among pollen allergens, Amb a had the highest positivity rate (8.1%), followed by Art v (7.8%). The sensitization rates for two mites peaked in May (46.9% and 40.6%). Art v peaked in August (21.5%), while Amb a had peaks in May (12.7%) and August (17.8%). The sensitization peaks for various tree pollens mainly occurred in August. In the Eastern monsoon region, the sensitization rate to mites was significantly higher than in the Northwest arid and semi-arid regions; whereas, for pollen allergens, the sensitization rates to Amb a, Pla a, Pin a, Pop d, and Bet v were significantly higher in the Northwest arid and semi-arid regions than in the Eastern monsoon region. The correlation among various tree pollens, specifically between Pla a, Pin r, Pop d, and Bet v was strong (0.63 ~ 0.79), with a cross-overlapping percentage of 53.9%. Children with multiple pollen sensitizations had higher cumulative nasal symptom scores than those negative for pollen (P < 0.01). Children with only pollen sensitization had higher cumulative rhinitis symptom scores than the all-negative group (P < 0.0001) and the mite-only sensitization group [P < 0.05], while the mite-only sensitization group also had higher scores than the all-negative group [P < 0.05], and the group sensitized to both pollen and mites had lower scores than the pollen-only group [P < 0.05]. This study indicates that sensitization to mites and grass pollens exhibits significant regional differences, with grass pollen allergies primarily occurring in autumn, sensitization to pollens in general exhibits a pronounced seasonal pattern. Moreover, pollen sensitization aggravates nasal and ocular symptoms in AR children.

New Insights into Mechanisms Traditional Chinese Medicine for Allergic Rhinitis by Regulating Inflammatory and Oxidative Stress Pathways

Allergy rhinitis (AR) is becoming more common and has serious medical and societal consequences. Sneezing, paroxysmal nasal blockage, nasal itching, mucosal edema, coughing, and rhinorrhea are symptoms of this type I allergic immunological illness. Immunoglobulin E-mediated inflammation is the cause of it. Because AR is prone to recurrent attacks, extended medication therapy may impair its effectiveness. In addition to negatively affecting the patients' physical health, this can also negatively impact their mental health. During AR development, there are inflammatory and oxidative stress responses that are linked to problems in a number of signal transduction pathways. By using the terms "allergic rhinitis", "traditional Chinese medicine", "inflammation", and "oxidative stress", we screened for pertinent research published over the previous five years in databases like PubMed. We saw that NF-KB, TLR, IL-33/ST2, PI3K/AKT, MAPK, and Nrf2 are some of the most important inflammatory and oxidative stress pathways in AR. Studies have revealed that antioxidant and anti-inflammatory therapy reduced the risk of AR and was therapeutic; however, the impact of the therapy varies widely. The Chinese medical system places a high value on traditional Chinese medicine (TCM), which has been there for virtually all of China's 5000-year history. By influencing signaling pathways related to inflammation and oxidative stress, Chinese herbal medicine and its constituent compounds have been shown to prevent allergic rhinitis. This review will focus on this evidence and provide references for clinical treatment and scientific research applications.

Are you congested? A comparison of definitions between otolaryngologists and their patients

OBJECTIVE

To assess for differences of intended meaning in the description of congestion-related symptoms among otolaryngology patients and clinicians.

MATERIALS AND METHODS

Between June 2020 and October 2022, a questionnaire consisting of 16 common descriptors of congestion-related symptoms within four domains (obstructive-related, pressure-related, mucus-related, and other symptoms) was completed by patients and otolaryngologists at five tertiary otolaryngology practices. The primary outcome was to assess differences in patient and clinician perceptions of congestion-related symptoms. Differences based on geographic location was a secondary outcome.

RESULTS

A total of 349 patients and 40 otolaryngologists participated. Patients selected a median of 6.8 (standard deviation [SD] 3.0) terms compared with 4.0 (SD 1.6) terms for otolaryngologists (p < 0.001). Otolaryngologists were more likely to select obstruction-related symptoms (difference 6.3%; 95% confidence interval [CI] 3.8%, 8.9%). Patients were more likely to describe congestion using pressure-related (-43.7%; -58.9%, -28.5%), mucus-related (-43.5%; -59.3%, -27.8%), and other symptoms (-44.2; -51.3%, -37.1%) compared with otolaryngologists. There were no significant differences identified based on geographic location with regard to symptom domains on multivariate analysis.

CONCLUSIONS

There are differences between otolaryngologists and their patients in the interpretation of the symptoms of congestion. Clinicians tended to have a narrower interpretation of congestion that was limited to the obstruction-related symptom domain, while patients defined congestion more broadly. This has important counseling and communication implications for the clinician.

Correlation Between a Deficiency of D3 Levels and the Development of Allergic Rhinitis

<b>Background and Objective:</b> Allergic rhinitis (AR) is a common disorder characterized by sneezing, runny nose, nasal congestion and lacrimation, which negatively affects the quality of life to a large extent. The study aimed to find a link between the effect of vitamin D3 levels on Immunoglobulin (IgE) levels in patients with allergic AR. <b>Materials and Methods:</b> This study included 30 patients with AR, with ages ranging from 18 to 35, of both sexes. For vitamin D levels, <u>></u>30 ng/mL is considered sufficient and <u><</u>20 ng/mL is a deficiency. The second group includes 30 people with adequate levels of vitamin D3 as a control group. All results were analyzed statistically by ANOVA, in addition to using the regression coefficient test to test the extent of the effect of D3 on the development of allergic rhinitis at a significant level of p<u><</u>0.05 using the SPSS program 24. <b>Results:</b> The results showed a significant decrease in the levels of vitamin D3 in the serum of the AR patients compared with the control group and a substantial increase in the levels of IgE in the serum of the AR patients compared with the control group at a significant level of p<u><</u>0.05. Additionally, the results showed in the regression coefficient an inverse and significant effect of vitamin D3 concentration on serum IgE levels, which is significant in terms of the p-value, which appeared equal to 0.010. By observing the value of the R² coefficient of determination, it is clear that a change in the concentration of vitamin D3 causes 58% of the changes in IgE levels. <b>Conclusion:</b> Through linear regression correlation, an inverse linear relationship emerged linking low vitamin D3 levels to increased IgE levels with an effect rate of 58%.

Improvements after dry needling for craniofacial pain in a patient with chronic rhinosinusitis: a case report

BACKGROUND

Typically treated medically, chronic rhinosinusitis (CRS) is a prevalent condition characterized by multiple craniofacial symptoms, some of which may respond favorably to dry needling intervention.

OBJECTIVE

To describe the outcomes of a patient presenting with craniofacial pain and symptoms consistent with a diagnosis of CRS who was treated with dry needling. Case Description: A 41-year-old male, self-referred to physical therapy with a diagnosis of CRS, with a 20-year history of signs and symptoms associated with CRS, including craniofacial pain and headaches. The patient had been treated with multiple medication regimens over this time, including antihistamines, anti-inflammatories, decongestants, leukotriene inhibitors, and antibiotics; all of which provided only short-term relief. On initial examination, the patient was tender to palpation in multiple muscles of the head, neck, and face. Intervention consisted of dry needling to these muscular tender points once or twice weekly over 2 months.

OUTCOMES

After 2 months of dry needling, the patient demonstrated clinically meaningful improvements in pain and quality of life, which included a decrease in both medication usage and the frequency of sinus infections.

CONCLUSION

Although CRS is generally managed medically, we observed areas of muscular tenderness in this case, which were effectively managed with dry needling. Rehabilitative providers may consider screening CRS patients for muscular impairments that may be modifiable with dry needling. Further research should be performed to determine whether dry needling has a role in the management of CRS.

The Impact of Sinonasal Symptoms in Relation to Potentially Life-Threatening Comorbidities

OBJECTIVE

While general health may be influenced by sinonasal symptoms, their effects may be overshadowed by comorbid states which may be more serious. To assess the validity of this postulate, we measured the extent to which sinonasal symptoms and concurrent conditions influenced general health.

STUDY DESIGN

Observational outcomes study.

SETTING

Academic medical center, community care sites.

METHODS

Adults with sinonasal symptoms completed the 22-item Sinonasal Outcome Test, along with the Patient-Reported Outcomes Measurement Information System global health short form. Comorbidities were categorized with the Deyo modification of the Charlson comorbidity index. Multivariate regression analyses were utilized to determine the relative impact of sinonasal symptoms and concurrent comorbid conditions on general health.

RESULTS

Data from 219 consecutive patients demonstrated that sinonasal symptoms were associated with significantly diminished general physical (β = -1.431, p < .001), mental (β = -1.000, p < .001), overall (β = -1.026, p < .001), and social health (β = -0.872, p = .003), regardless of the presence of potentially life-threatening comorbid conditions. Comorbid conditions included cardiovascular disease, chronic obstructive pulmonary disease, connective tissue disease, peptic ulcer, diabetes mellitus, and hepatic disease. The effect of sinonasal symptoms was neither subsumed nor overshadowed by the effects of comorbid states. Nasal, ear, sleep, and psychological domain scores were also associated with general physical, mental, and global health while adjusting for the impact of comorbidities.

CONCLUSION

Sinonasal symptoms have a substantial effect on general health which is not subsumed by the presence of potentially life-threatening concurrent comorbidities. These data may help support the importance of funding and resource allocation for conditions causing sinonasal symptoms.

Effect of second-generation antihistamines on nighttime sleep and daytime sleepiness in patients with allergic rhinitis

BACKGROUND

The daytime tiredness experienced by the vast majority of allergic rhinitis (AR) sufferers is directly related to the fact that they experience disrupted sleep at night. This study compared the effects of recently marketed second-generation H1 antihistamines (SGAs) on nighttime sleep and daytime sleepiness in patients with AR, with patients grouped into those taking non-brain-penetrating antihistamines (NBP group) and those taking brain-penetrating antihistamines (BP group).

METHODS

Patients with AR completed self-administered questionnaire-based surveys to determine Pittsburgh Sleep Quality Index (PSQI) before and after taking SGAs. Statistical analysis was performed on each evaluation item.

RESULTS

Of 53 Japanese patients with AR between 6 and 78 years old, median (SD) age was 37.0 (22.4) years old and 21 were men (40%). Of the 53 patients, 34 were the NBP group and 19 were the BP group. In the NBP group, mean (SD) subjective sleep quality score after medication was 0.76 (0.50), which was significantly lower (better) than the score of 0.97 (0.52) before medication (p = 0.020). In the BP group, mean (SD) subjective sleep quality score after medication was 0.79 (0.54), which was not significantly different from the score of 0.74 (0.56) before medication (p = 0.564). In the NBP group, mean (SD) global PSQI score was 3.47 (1.71) after medication, which was significantly lower (better) than the score of 4.35 (1.92) before medication (p = 0.011). In the BP group, mean (SD) global PSQI score was 2.47 (2.39) after medication, which was not significantly different from the score of 3.00 (2.71) before medication (p = 0.125).

CONCLUSION

Subjective sleep quality and global PSQI score were improved only in the group taking non-brain-penetrating SGAs.

Intranasal Schirmer Test in Allergic Rhinitis: Relationship to Symptom Scores and Role in Determining Response to Treatment

OBJECTIVES

The Intranasal Schirmer test (INS) is an easy to administer test that can yield objective measurement of the quantity of nasal secretion and has been studied in patients with various nasal and systemic pathologies; however, the role of INS in patients with allergic rhinitis remains unclear. Our aim was to determine the relationship between various allergic symptoms and the Intranasal Schirmer Test (INS) score and to evaluate the utility of INS in determining treatment effect in patients with allergic rhinitis.

METHODS

This prospective study included patients with allergic rhinitis who were randomly divided into 3 treatment groups (nasal steroid only, oral antihistamine only, nasal steroid and oral antihistamine). For all patients, Total Nasal Symptom Score (TNSS) was used to measure symptom severity and INS was administered before and after treatment. Pre-treatment and post treatment TNSS and INS scores were compared between different treatment groups and within each group.

RESULTS

The study included 120 patients, with 40 patients in each group. There were significant differences both in pre-treatment and post-treatment symptom severity score with changes of INS scores between treatment groups (P < .001 and P = .002, respectively). There was a significant difference between pre-treatment and post-treatment symptom severity scores and the INS score in each treatment group (P < .001). There was also a significant positive correlation between INS score and TNSS (r = .591 and P < .001).

CONCLUSION

The Intranasal Schirmer Test can be used as an objective tool for patients with allergic rhinitis as an adjunct to subjective patient symptom reports and can also be used to determine the response to treatment.

Clinical feature-based diagnosis criteria of eosinophil and non-eosinophil chronic rhinosinusitis in Taiwan

Background

The prevalence of eosinophilic chronic rhinosinusitis (ECRS) has increased in Taiwan with a higher recurrence rate of nasal polyps after surgery. Therefore, we aimed to formulate the pre-operative diagnostic criteria for patients with ECRS in Taiwan.

Methods

This case-control study included patients diagnosed with CRS with nasal polyps (CRSwNP) who underwent functional endoscopic sinus surgery (FESS) at a tertiary hospital in Taiwan. The patients were classified into ECRS and non-eosinophilic CRS (NECRS) groups based on their histopathology. Demographic data, symptom severity scores, and computed tomography findings of the two groups were analyzed. We utilized receiver operating characteristic curve (ROC) analysis to evaluate parameters that could predict the diagnosis of ECRS.

Results

Total 408 CRSwNP patients were enrolled (ECRS group: 163; NECRS group: 245). ECRS group was strongly associated with asthma (6.1% vs. 2.0%, p = .03), higher blood eosinophil counts (4.3% vs. 2.7%, p < .01), higher serum IgE (285.3 vs. 50.2 IU/mL, p = .02), and higher 22-item Sino-Nasal Outcome Test (SNOT-22) score (40.5 vs. 36.7, p = .03). The ECRS criteria based on ROC curve included the SNOT-22 (>45, 2 points), serum eosinophil count percentage (>4%, 4 points), asthma (4 points), total serum IgE (>140 IU/mL, 4 points), Lund-Mackay score (>9.5, 4 points), and ethmoid-to-maxillary opacification ratio on CT (>1.5, 5 points). The cutoff score was 14 points (sensitivity, 70.2%; specificity, 93.3%).

Conclusions

Clinical-feature-based criteria may predict the diagnosis of ECRS before FESS in Taiwan.

Level of Evidence

Level 3.

Allergic rhinitis: Review of the diagnosis and management: South African Allergic Rhinitis Working Group

BACKGROUND

Allergic rhinitis (AR) has a significant impact on the community as a whole with regard to quality of life and its relationship to allergic multi-morbidities. Appropriate diagnosis, treatment and review of the efficacy of interventions can ameliorate these effects. Yet, the importance of AR is often overlooked, and appropriate therapy is neglected. The availability of effective medications and knowledge as to management are often lacking in both public and private health systems.

METHODS

This review is based on a comprehensive literature search and detailed discussions by the South African Allergic Rhinitis Working Group (SAARWG).

RESULTS

The working group provided up-to-date recommendations on the epidemiology, pathology, diagnosis and management of AR, appropriate to the South African setting.

CONCLUSION

Allergic rhinitis causes significant, often unappreciated, morbidity. It is a complex disease related to an inflammatory response to environmental allergens. Therapy involves education, evaluation of allergen sensitisation, pharmacological treatment, allergen immunotherapy (AIT) and evaluation of the success of interventions. Regular use of saline; the important role of intranasal corticosteroids, including those combined with topical antihistamines and reduction in the use of systemic steroids are key. Practitioners should have a thorough knowledge of associated morbidities and the need for specialist referral.Contribution: This review summarises the latest developments in the diagnosis and management of AR such that it is a resource that allows easy access for family practitioners and specialists alike.

The Impact of Surgical Posterior Nasal Nerve Cryoablation on Symptoms and Disease-Specific Quality of Life in Patients With Chronic Rhinitis

OBJECTIVE

Preliminary data have demonstrated long-term efficacy of posterior nasal nerve (PNN) cryoablation in reducing rhinitis symptoms for patients with allergic rhinitis (AR) and nonallergic rhinitis (NAR). We sought to evaluate the impact of procedural cryoablation of the PNN on quality of life (QOL) in patients with AR and NAR.

METHODS

Adult patients undergoing PNN cryoablation for AR or NAR after appropriate medical therapy were included for analysis. Demographics, medical therapies, baseline rhinitis symptom (total nasal symptom score [TNSS]), and disease-specific QOL (mini-rhinoconjunctivitis quality of life questionnaire [mini-RQLQ]) were recorded. The Wilcoxon signed-rank test was used to test for significant changes in baseline test scores posttreatment. Absolute and relative improvement in outcomes was determined for each participant. Secondary outcomes were assessed with univariate and multivariate analyses.

RESULTS

Fourteen patients were enrolled with a mean follow-up of 16.5 weeks. The TNSS and mini-RQLQ scores significantly improved after PNN cryoablation (median δs [interquartile range]: -4 [3] and -1.61 [1.08], respectively; both P = .0002). The minimal clinically important difference for the TNSS and mini-RQLQ was obtained in 92.9% of patients in each category. Relative mean percentage (%) improvement after PNN cryoablation in the TNSS and mini-RQLQ was 40.7% and 40.5% (standard deviation = 24.9 and 29.5, respectively), respectively, for all patients. Patients with NAR (n = 10) reported mean improvement of 41.3% (29.1) as measured by the TNSS and 49.6% (25.9) by mini-RQLQ. Patients with AR reported mean percentage improvement in TNSS and mini-RQLQ scores of 39.5% (12.1) and 24.6% (28.5), respectively. Patients who had been prescribed a nasal anticholinergic for management prior to PNN cryoablation had statistically significantly increased improvement in mini-RQLQ scores from pre- to post-procedure (P = .0387).

CONCLUSION

Surgical cryoablation of the PNN significantly improves both symptoms and disease-specific QOL in majority of patients with AR and NAR.

Environmental Risk Factors, Protective Factors, and Biomarkers for Allergic Rhinitis: A Systematic Umbrella Review of the Evidence

Many potential environmental risk factors, protective factors, and biomarkers of AR have been published, but so far, the strength and consistency of their evidence are unclear. We conducted a comprehensive review of environmental risk, protective factors, and biomarkers for AR to establish the evidence hierarchy. We systematically searched Embase, PubMed, Cochrane Library, and Web of Science electronic database from inception to December 31, 2022. We calculated summary effect estimate (odds ratio (OR), relative risk (RR), hazard ratio (HR), and standardized mean difference (SMD)), 95% confidence interval, random effects p value, I2 statistic, 95% prediction interval, small study effects, and excess significance biases, and stratification of the level of evidence. Methodological quality was assessed by AMSTAR 2 (A Measurement Tool to Assess Systematic Reviews 2). We retrieved 4478 articles, of which 43 met the inclusion criteria. The 43 eligible articles identified 31 potential environmental risk factors (10,806,206 total population, two study not reported), 11 potential environmental protective factors (823,883 total population), and 34 potential biomarkers (158,716 total population) for meta-analyses. The credibility of evidence was convincing (class I) for tic disorders (OR = 2.89, 95% CI 2.11-3.95); and highly suggestive (class II) for early-life antibiotic use (OR = 3.73, 95% CI 3.06-4.55), exposure to indoor dampness (OR = 1.49, 95% CI 1.27-1.75), acetaminophen exposure (OR = 1.54, 95% CI 1.41-1.69), childhood acid suppressant use (OR = 1.40, 95% CI 1.23-1.59), exposure to indoor mold (OR = 1.66, 95% CI 1.26-2.18), coronavirus disease 2019 (OR = 0.11, 95% CI 0.06-0.22), and prolonged breastfeeding (OR = 0.72, 95% CI 0.65-0.79). This study is registered in PROSPERO (CRD42022384320).

Impact of antiallergy agents on CPAP therapy and sleep quality with spring pollinosis in Japanese

PURPOSE

Allergic rhinitis (AR) is associated with obstructive sleep apnea (OSA) and nasal obstruction causes decreased adherence to continuous positive airway pressure (CPAP). The purpose is to evaluate the effects of antiallergic agents on CPAP adherence and sleep quality.

METHODS

A longitudinal study was made of patients who use CPAP for OSA and treated with antiallergy agents for spring pollinosis. We compared the Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS), nasal symptoms scores (NSS), and data from CPAP before and after treatment. Then, we classified the subjects into two groups based on the baseline PSQI score: one group without a decreased sleep quality (PSQI < 6) and the other group with decreased sleep quality (PSQI ≥ 6).

RESULTS

Of 28 subjects enrolled, 13 had good sleep quality and 15 had poor sleep quality. PSQI showed significant improvements after medication (p = 0.046). ESS showed no significant differences after AR medication (p = 0.565). Significant improvement was observed after the prescription of antiallergy agents in all items of NSS (sneezing, p < 0.05; rhinorrhea, p < 0.01; nasal obstruction, p < 0.01; QOL, p < 0.01). The percentage of days with CPAP use more than 4 h increased significantly after the administration of rhinitis medication (p = 0.022). In the intragroup comparisons of PSQI ≥ 6 group, PSQI decreased significantly (p < 0.05). For the NSS in intragroup comparisons of PSQI ≥ 6 group, all parameters showed significant improvement (sneezing, p = 0.016; rhinorrhea, p = 0.005; nasal obstruction, p < 0.005; QOL, p < 0.005).

CONCLUSION

The use of antiallergy agents can improve CPAP adherence and sleep quality in patients with OSA on CPAP.

Pharmacokinetics of Nasal Esketamine in Patients with Allergic Rhinitis with and Without Nasal Decongestant Pretreatment and in Healthy Subjects with and Without Nasal Corticosteroid Pretreatment

BACKGROUND AND OBJECTIVES

Nasal esketamine is indicated for the treatment of adults with treatment-resistant depression and depressive symptoms in adults with major depressive disorder with acute suicidal ideation or behavior. Primary objectives of this study were to evaluate the effect of nasal decongestant pretreatment in patients with allergic rhinitis and the impact of daily nasal corticosteroid administration by healthy subjects on nasal esketamine pharmacokinetics.

METHODS

Patients with allergic rhinitis self-administered 56 mg of nasal esketamine after pretreatment with nasal oxymetazoline (0.05%) at 1 h before esketamine and without oxymetazoline pretreatment. They were exposed to grass pollen in an allergen challenge chamber to induce allergic rhinitis symptoms at approximately 2 h before each esketamine administration until 1 h after. Healthy subjects self-administered esketamine (56 mg) before and after administration for 16 consecutive days of mometasone (200 µg), with the second esketamine dose administered 1 h after the last mometasone dose. The plasma pharmacokinetics of esketamine and noresketamine were assessed after each esketamine administration. The tolerability of esketamine, including effects on dissociative and potential psychotomimetic symptoms and level of sedation and suicidal ideation and behavior, was evaluated.

RESULTS

The rate of esketamine absorption was slightly greater in patients exhibiting symptoms of allergic rhinitis (decrease in median tmax from 32 min to 22 min). Increases in esketamine Cmax and AUC were also small (mean, ≤ 21%). The pharmacokinetics of esketamine was not affected by oxymetazoline or mometasone pretreatment. Esketamine was well tolerated when it was administered with or without pretreatment of oxymetazoline or mometasone.

CONCLUSIONS

Patients exhibiting symptoms of rhinitis may receive nasal esketamine spray without dose adjustment. In addition, esketamine may be administered 1 h after using a nasal decongestant or corticosteroid.

TRIAL REGISTRATION

The study was registered in the Clinical Trials (NCT02154334) and EudraCT (2014-000534-38) registries.

Clinical Characteristics and Risk Factors for Allergic Rhinitis in Children with Epistaxis

Background

Epistaxis is frequently observed in children with allergic rhinitis. However, few studies have addressed the clinical characteristics and risk factors for allergic rhinitis in children with epistaxis. This study aimed to describe the factors associated with allergic rhinitis in children with epistaxis.

Methods

In total, we recruited 80 children (aged 3-14 years) who presented with epistaxis at a tertiary hospital between January 2014 and January 2022. The follow-up duration was at least 3 months, and we performed a multivariate logistic regression analysis to identify the risk factors for allergic rhinitis.

Results

Among the 80 children examined, 57 (71.25%) had allergic rhinitis. Epistaxis mainly occurred in autumn in children with allergic rhinitis; in contrast, it mostly occurred in summer in children without it (P = 0.029). Mites are common allergens for allergic rhinitis in children with epistaxis; the univariate analysis revealed significant differences between allergic-rhinitis group and nonallergic-rhinitis group in the number of allergens (P  <  0.001) and total IgE (P  <  0.001). The difference in severity of nasal symptoms between the two groups was statistically significant and included nasal obstruction (P  <  0.001), rhinorrhea (P  <  0.001), sneezing (P  <  0.001), and nasal itching (P  <  0.001). After adjusting for potential confounders, the severity of rhinorrhea symptoms was found to be associated with an increased risk of allergic rhinitis in children with epistaxis (odds ratio: 3.86; 95% confidence interval: 1.61-9.26; P = 0.003).

Conclusions

Observing the onset season, number of allergens, total IgE, and nasal symptoms in cases of epistaxis could suggest the presence of associated allergic rhinitis and reduce the number of missed diagnoses; antiallergic drugs could help control epistaxis in these cases.

Exploring Associations Between Short-Term Air Pollution and Daily Outpatient Visits for Allergic Rhinitis

Purpose

Many studies have reported that exposure to air pollution increases the likelihood of acquiring allergic rhinitis (AR). This study investigated associations between short-term air pollution exposure and AR outpatient visits.

Patients and Methods

The Department of Otorhinolaryngology, Affiliated Hospital of Hangzhou Normal University provided AR outpatient data from January 1, 2019 to December 31, 2021. Daily air quality information for that period was gathered from the Hangzhou Air Quality Inspection Station. We used the Poisson's generalized additive model (GAM) to investigate relationships between daily outpatient AR visits and air pollution, and investigated lag-exposure relationships across days. Subgroup analyses were performed by age (adult (>18 years) and non-adult (<18 years)) and sex (male and female).

Results

We recorded 20,653 instances of AR during the study period. Each 10 g/m3 increase in fine particulate matter (PM10 and PM2.5) and carbon monoxide (CO) concentrations was associated with significant increases in AR outpatient Visits. The relative risks (RR) were: 1.007 (95% confidence interval (CI): 1.001-1.013), 1.026 (95% CI: 1.008-1.413), and 1.019 (95% CI: 1.008-1.047). AR visits were more likely due to elevated PM2.5, PM10, and CO levels. Additionally, children were more affected than adults.

Conclusion

To better understand the possible effects of air pollution on AR, short-term exposure to ambient air pollution (PM2.5, PM10, and CO) may be linked to increased daily outpatient AR visits.

Cost of Serum Versus Skin Allergy Testing Among Medicare Fee-for-Service Beneficiaries in the United States

Background: Testing for allergic sensitization can be achieved similarly via skin or serum specific immunoglobulin E (sIgE) testing, although the costs of each method differ. Objective: This study compared cost and utilization of allergy testing utilizing skin vs sIgE testing and whether equal access (parity) to both testing methods affects overall allergy testing costs among Medicare fee-for-service beneficiaries in the United States. Methods: Allergy test utilization and payment data were analyzed using 100% 2019 Medicare fee-for-service claims data. Beneficiaries with any sIgE test, skin prick test, or intradermal skin test associated with ICD-10 codes of allergic rhinitis, asthma, and food allergy were included. Aggregate and per-beneficiary testing cost, number of allergens tested, and number of allergy-related specialist visits incurred were estimated by the testing patterns of sIgE only, skin prick only, intradermal only, skin prick and intradermal, and sIgE plus prick and/or intradermal. Medicare Administrative Contractors (MACs) with parity for all allergy tests and those which restricted sIgE testing were compared. Multivariate linear regression was performed on the association between testing patterns and each cost and utilization measure, controlling for parity, age, sex, race/ethnicity, and dual-eligible status. Results: We analyzed 270 831 patients and 327 263 allergy-related claims. Total payment for all allergy tests was $71 380 866, including $15 903 954 for sIgE tests, $42 223 930 for skin prick tests, and $13 252 982 for intradermal tests. Beneficiaries receiving sIgE tests had only 1.8 fewer allergist visits than those with skin prick tests only (0.8 vs 2.6). Cost of testing per beneficiary was also lower in sIgE testing only compared with skin prick tests only ($161 vs $247). Multivariable regression results showed per-beneficiary payments for allergy testing were on average $22 lower in MACs with parity compared with MACs without parity. Discussion: Serum specific IgE testing is associated with lower costs and fewer allergy specialist visits compared with skin testing. Insurance coverage with parity toward sIgE and skin testing is associated with lower overall costs of allergy testing. Conclusion: Among Medicare fee-for-service beneficiaries in the United States, sIgE testing may be more cost effective compared with skin testing in the management of allergic disease.

Pharmacotherapy and immunotherapy of allergic rhinitis induced by house dust mite, grass, and birch pollen allergens: a meta-analysis of randomized clinical trials

BACKGROUND

The aim of this study was to assess the efficacy and safety of oral antihistamines (AHs), intranasal antihistamines (INAH) intranasal glucocorticosteroids (INCS), subcutaneous immunotherapy (SCIT), and sublingual immunotherapy (SLIT) in the management of allergic rhinitis (AR). The authors focused on the division into selected AR's triggers: house dust mites (HDMs), grass pollen, and birch pollen.

METHODS

For each drug and allergen class, a meta-analysis of the efficacy and adverse events (AEs) was performed. The obtained results were presented as a therapeutic index (TIX-Score).

RESULTS

Twenty-seven randomized clinical trials (RCTs) were included. The best total efficacy was observed for: HDMs for INCS and grass pollen for combination of INCS with INAH in a single device and for INAH. Considering the data that was obtained for birch pollen, SLIT showed statistically significant total efficacy. Summation scores for efficacy and AEs showed highest TIX-Score for combination of INCS and INAH in a single device in grass pollen.

CONCLUSIONS

Treatment methods selected for this review may serve as an effective and safe treatment in reducing perennial and seasonal AR's symptoms. However, due to high heterogeneity probably associated with potential confounders existence in control in some cases, results should be interpreted with caution.

Siblings and risk of allergic rhinitis: A systematic review and meta-analysis

Following the "hygiene hypothesis" and the increase in the prevalence of atopic diseases such as allergic rhinitis, a plethora of studies have investigated the role of sibship composition as a protective factor, but findings are conflicting. The aim of this study was to synthesize the global literature linking birth order and sibship size (number of siblings) to the risk of allergic rhinitis. Fifteen databases were systematically searched, with no restrictions on publication date or language. Observational studies with defined sibship composition (birth order or sibship size) as exposure and allergic rhinitis or allergic rhinoconjunctivitis (self-reported or clinically diagnosed) as outcome were eligible. Study selection, data extraction, and quality assessment were performed independently in pairs. Relevant data were summarized in tables. Comparable numerical data were analyzed using meta-analysis with robust variance estimation (RVE). Seventy-six reports with >2 million subjects were identified. Being second- or later-born child was associated with protection against both current (pooled risk ratio [RR] 0.79, 95% CI 0.73-0.86) and ever (RR 0.77, 95% CI 0.68-0.88) allergic rhinitis. Having siblings, regardless of birth order, was associated with a decreased risk of current allergic rhinitis (RR 0.89, 95% CI 0.83-0.95) and allergic rhinoconjunctivitis (RR 0.92, 95% CI 0.86-0.98). These effects were unchanged across age, time period, and geographical regions. Our findings thus indicate that primarily, a higher birth order, and to a lesser extent the number of siblings, is associated with a lower risk of developing allergic rhinitis.

Assessment of multiple-opinion referrals and consults at the BC Children's Hospital Allergy Clinic

BACKGROUND

Allergic disease is on the rise. Waitlists for specialists are long, and many referred patients have already received prior allergic assessment, either by a certified Allergist, Primary Care Provider, or other Specialist. It is important to understand the prevalence and motivating factors for multiple-opinion referrals, to deliver timely assessment for patients with allergic disease.

METHODS

A retrospective chart review of demographic information, number of previous consultations, and motivation for new consults and multiple-opinion referrals, of pediatric patients aged 8 months-17 years to BC Children's Hospital Allergy Clinic from September 1, 2016-August 31, 2017, was performed. Referral data including reason for referral or multiple-opinion, primary allergic concerns, and others, from referral forms and consult notes were accessed through local Electronic Medical Records and subsequently analyzed for trends in categorical variables to assess the rationale for and impact of multiple-opinion referrals to our clinic.

RESULTS

Of 1029 new referrals received, 210 (20.4%) were multiple-opinion referrals. Food allergy was the predominant allergic concern prompting further opinion (75.7%). The main rationale for seeking further opinions was wanting an assessment by a certified allergist in cases where prior consultation was performed by non-allergist specialist, primary care provider, or alternative health care provider. Of second-opinion referrals generated, 70 (33.3%) initial consultations were performed by an Allergist, whereas 140 (66.7%) were performed by a non-allergist.

CONCLUSIONS

Many new consults at the BCCH Allergy Clinic are multiple-opinion assessments, contributing to long waitlists. Advocacy at the systems level through standardized referral guidelines, centralized triaging systems, and stronger support for Primary Care Providers is needed to provide better access in Canada for children needing a specialized Allergist. Trial registration UBC/BCCH Research Ethics Board.

A Novel Approach to Posterior Lateral Nasal Neurectomy

Background Allergic rhinitis (AR) is a major health concern throughout the world. By severing the parasympathetic supply to the lateral wall of the nose, posterior lateral nasal neurectomy (PLNN), a form of highly selective vidian neurectomy, decreases nasal allergy symptoms. This study attempts to characterize the demographic and surgical characteristics of study participants in relation to PLNN, as well as to identify the risk factors associated with these characteristics. Methodology A five-year, cross-sectional study was undertaken among patients diagnosed with AR at a tertiary care center in Tamaka, Kolar. Case sheets accessible in the department of medical records were used to compile a list of 50 study patients. SPSS version 21 was used for data analysis (IBM Corp., Armonk, NY, USA). Results The study revealed that the average age of the sample population was 30.4 years. The majority of the study participants were less than or equal to 30 years old (54%). In our study, the majority of the participants were male (60%). This study revealed that around 46% of the surgeries were independent PLNNs and that most of them (76%) were observed to have four nerves following surgery. The average intraoperative blood loss during PLNN surgery was 43.14 mL. The mean hemoglobin levels before and after surgery were 13.11 and 12.78 g/dL, respectively. The average duration of the surgical procedure was 62 minutes. The average duration of PLNN surgery in females was 52.75 minutes, whereas the average duration in males was 68.33 minutes. According to an independent t-test (p = 0.045), this difference in mean was statistically significant. Approximately 85% of female study participants were identified with four nerves during PLNN surgery compared to 70% of male study participants. According to the chi-square test (p = 0.018), this proportional difference was statistically significant. Conclusions The majority of the participants in this study were male and younger. The typical PLNN surgical procedure lasted one hour. Males and females require different amounts of time, with females requiring less time. During PLNN surgery, most females detected four nerves, as opposed to most males.