Autonomic nervous system dysfunction and sinonasal symptoms

Three-Year Outcomes After Posterior Nasal Neurectomy in Perennial Moderate and Severe Allergic Rhinitis Patients

BACKGROUND

Posterior nasal neurectomy (PNN) has been shown to reduce the symptom burden of patients with perennial moderate and severe allergic rhinitis (AR).

OBJECTIVES

To evaluate the long-term safety and effectiveness of PNN for the treatment of perennial moderate and severe AR.

METHODS

A prospective 3-year single-arm study was conducted in which the reflective total nasal symptom score (rTNSS) and total non-nasal symptom score (rTNNSS) were collected preoperatively and at 3 months, 6 months, 1 year, 2 years, and 3 years postoperatively.

RESULTS

A total of 213 patients with AR were recruited and received PNN, of whom 154 patients completed the 3-year follow-up. The mean rTNSS of the long-term follow-up patients improved from 7.74 (95% confidence interval [CI] 7.507-7.974) at baseline to 2.604 (95% CI 2.221-2.986), P < .001, at 6 months and showed sustained improvement to 3.156 (95% CI 2.806-3.506), P < .001, at 3 years. The mean rTNNSS ranged from 1.301 (95% CI 1.112-1.491) at baseline to 0.564 (95% CI 0.441-0.688) (P < .001) at 6 months and showed sustained improvement to 0.641 (95% CI 0.533-0.749) (P < .001) at 3 years. The rTNSS subscores (sneezing, congestion, rhinorrhea, and itching) and rTNNSS subscores (lacrimation, eye itching, postnasal drip, and cough) remained significantly improved from the baseline at all follow-up time points (all P < .001).

CONCLUSION

Posterior nasal neurectomy significantly and sustainably alleviated nasal and non-nasal symptoms of perennial moderate and severe AR and improved patient quality of life through 3 years postprocedure.

Association of Autonomic Symptom Burden with Sudden Sensorineural Hearing Loss

OBJECTIVE

To investigate the autonomic symptom burden in patients with sudden sensorineural hearing loss (SSNHL) and its association with the severity and prognosis.

STUDY DESIGN

Observational prospective study.

SETTING

Tertiary academic medical center.

METHODS

Patients diagnosed with SSNHL at a single medical center completed the COMPASS 31 questionnaire, which assesses dysautonomia across 6 domains with 31 questions. A total COMPASS 31 score was calculated by summing the scores from each weighted domain. The treatment outcome was evaluated by the percentage of recovery, calculated as the hearing gain in pure tone average (PTA) after treatment divided by the pretreatment PTA difference between the 2 ears. We defined poor recovery as a percentage of recovery <80%.

RESULTS

A total of 63 SSNHL patients were included. The mean COMPASS 31 score was 23.4 (SD 14). Patients with poor recovery had significantly higher COMPASS 31 scores than those with good recovery (mean 26.4 [SD 14.4] vs 16.9 [SD 10.4]; 95% confidence interval [CI] 2-17). There was a negative association between COMPASS 31 score and both hearing gain (r = -.323, 95% CI -0.082 to -0.529) and percentage of recovery (r = -.365, 95% CI -0.129 to -0.562). Multivariate analyses of independent factors indicate that patients with higher COMPASS 31 scores had a greater risk for poor recovery (OR 1.06 [95% CI 1.003-1.117]).

CONCLUSION

This study highlights the association between autonomic symptom burden and poor hearing outcomes in SSNHL patients. The findings underscore the importance of evaluating autonomic function during the treatment of SSNHL.

Neonatal rhinorrhea, heart rate variability, and childhood exercise-induced wheeze

Background

There is increasing evidence linking infant rhinorrhea to school-age exercise-induced wheeze (EIW) via a parasympathetic nervous system pathway. The ratio of the root mean square of successive differences in heart beats (RMSSD) measured in quiet sleep versus active sleep (RMSSDQS:AS) is a novel biomarker in asthma.

Objective

We tested the hypotheses that (1) neonatal rhinorrhea predicts childhood EIW independent of other neonatal respiratory symptoms, (2) neonatal RMSSDQS:AS predicts childhood EIW, and (3) RMSSDQS:AS mediates the association between neonatal rhinorrhea and childhood EIW.

Methods

Participants from the Safe Passage/Environmental Influences on Child Health Outcomes (PASS/ECHO) prospective birth cohort had heart rate variability extracted from electrocardiogram traces acquired in the first month of life. Parents reported on rhinorrhea in their child at age 1 month and on EIW in their child at ages 4 to 11 years.

Results

In models (N = 831) adjusted for potential confounders and covariates, including neonatal wheeze, cough and fever, neonatal rhinorrhea-predicted childhood EIW (relative risk [RR] = 2.22; P = .040), specifically, among females (RR = 3.38; P = .018) but not males (RR = 1.39; P = .61). Among participants contributing data in both active and quiet sleep (n = 231), RMSSDQS:AS predicted EIW (RR = 2.36; P = .003) and mediated the effect estimate of neonatal rhinorrhea predicting EIW among females. Half of the females with a higher RMSSDQS:AS and neonatal rhinorrhea (n = 5 of 10) developed EIW as compared with 1.8% of the other females (n = 2 of 109) (P < .001).

Conclusions

Our findings support dysregulation of the parasympathetic nervous system in infancy as one of the possible underlying mechanisms for the development of EIW later in childhood among females, which could aid in the development of future interventions.

Effects of modified posterior nasal nerve neurectomy combined with accessory posterior nasal nerve neurectomy on controlling intractable allergic rhinitis

OBJECTIVES

A subset of intractable allergic rhinitis (iAR) patients experience severe symptoms which cannot be effectively controlled by standard drug therapy and/or antigen specific immunotherapy. In recent decades, endoscopy vidian neurectomy and posterior nasal nerve neurectomy (PNNN) were introduced as treatments of iAR that have shown to be highly successful at symptom management in a number of patients. But some patients experience relapse or suboptimal symptom control postoperation. To improve the effectiveness of PNNN to control iAR, a modified PNNN surgical approach (mPNNN) combined with accessory posterior nasal nerve neurectomy (aPNNN), which called as mPNNN-aPNNN was used. This study aims to compare the effects between mPNNN-aPNNN and PNNN on controlling the symptoms of iAR and evaluate the surgical effectiveness and safety of mPNNN-aPNNN.

METHODS

The patients with iAR experienced mPNNN-aPNNN or PNNN surgery at the department of Otolaryngology Head and Neck Surgery of the Second Xiangya Hospital, Central South University from January 2018 to December 2019 were analyzed retrospectively. The approach of PNNN, a selective resection of the posterior nasal nerve branches, was modified to the neurectomy of total branches of posterior nasal nerve at the sphenopalatine foramen, and combined the operation of aPNNN in which the accessory posterior nasal nerve at the palatine bone perpendicular plate was resect in our study. Daily Nasal Symptom Scores (DNSS), Total Rhinitis Medication Score (TRMS), and the Rhinoconjunctivitis Qualities of Life Questionnaires Scores (RQLQS) were used to evaluate the complications during the operation and after the operation at the 3rd, 6th, 12th, and 24th month postoperatively. Total Nasal Symptom Scores (TNSS) was used to assess the total effective rate and markedly effective rate of the operations.

RESULTS

A total of 140 iAR patients experienced mPNNN-aPNNN or PNNN. Those with concomitant septoplasty and/or inferior turbinate reduction, and were absent during the postoperative follow-up were excluded. The final 62 patients with mPNNN-aPNNN and 34 with PNNN were enrolled. DNSS, TNSS, TRMS, and RQLQS at the postoperation were significantly improved compared with the preoperation in all patients (all P<0.001). Compared with PNNN, the postoperative DNSS, TNSS, and TRMS of mPNNN-aPNNN were obviously improved (all P<0.001). There was a persisted relief of symptoms at the postoperation in all patients with mPNNN-aPNNN. The total effective rate and markedly effective rate at the postoperative 24th month were 100% and 83.3%, respectively. Furthermore, the postoperative RQLQS decreased significantly (P<0.001). Only 5 sides of all patients (5/192, 2.6%) reported upper palate numbness during the first week after operation, with all recovered spontaneously in 1 month without treatment. No other postoperative complications occurred in mPNNN-aPNNN and PNNN.

CONCLUSIONS

The surgery of mPNNN-aPNNN improve TNSS more significantly than PNNN. The operation of mPNNN-aPNNN is safe and effective to control iAR symptoms.

Allergic rhinitis children with obesity are more vulnerable to air pollution: a cross sectional study

The association between air pollution, allergic rhinitis (AR), and obesity has not been studied. From 2007 to 2011, 52 obese and 152 non-obese children (7-17 years old) with AR were recruited. Pediatric-Rhinoconjunctivitis-Quality-of-Life Questionnaire (PRQLQ) and nasal peak expiratory flow (NPEF) were tested. Association between the scores and rates of the two tests and mean air pollutant concentrations within 7 days before the tests were compared. When exposed to higher concentrations of CO, PM₁₀, and PM_2.5, the rates of worse nasal discomfort were 39.4%, 44.4% and 39.3% in obese children; and 18.0%, 21.9% and 19.7% in non-obese children, respectively. Compare to non-obese children, the rates in obese children were higher for CO (odds ratio (OR) 3.54, 95% confidence interval (CI) 1.15 ~ 10.92); PM₁₀ (OR 3.26, 95% CI 1.01 ~ 10.57) and PM2.5 (OR 3.30; 95% CI 1.03 ~ 10.54). In obese children, correlations between higher concentrations of CO, PM₁₀, PM_2.5 and higher nasal discomfort (higher PRQLQ); and correlations between higher concentrations of CO, PM₁₀, PM_2.5, NMHC (non-methane hydrocarbon) and higher nasal mucosa inflammation (lower NPEF) were noted. Obesity negatively affected AR severity when AR children experienced higher concentrations of CO, PM₁₀, and PM_2.5. Increased nasal inflammation induced by air pollutants might be the underlying mechanism.

Clinical characteristics of chronic rhinitis following stroke

Background

We previously observed that patients with stroke complained of rhinitis symptoms that developed following the occurrence of stroke.

Objectives

To investigate the relationship between chronic rhinitis (CR) and stroke.

Methods

This retrospective study analyzed the medical records and questionnaires of patients with stroke who visited our outpatient clinic from June to December 2020. Stroke lesions were mainly classified as supratentorial, infratentorial, and supra/infratentorial lesions. Supratentorial lesions were further divided into cortex, subcortex, and mixed. Participants were screened for CR and were subsequently divided into the CR and non-CR groups. The Sino-Nasal Outcome Test questionnaire and a questionnaire on autonomic nervous system symptoms were administered to all patients.

Results

Clinically evaluated indicators were not significantly different between the two groups. The number of patients with lesions in both the cortex and subcortex was significantly higher in the CR group than in the non-CR group. The risk of CR was higher in male patients with stroke than their female counterparts; additionally, the risk of CR was higher in patients with stroke who had both cortical and subcortical lesions, as well as autonomic dysfunction.

Conclusions

Individuals with subcortical stroke damage had a greater probability of developing CR. The risk was increased in men, as compared with that in women, when autonomic symptoms were present.

Neuronal-Immune Cell Units in Allergic Inflammation in the Nose

Immune cells and immune-derived molecules, endocrine glands and hormones, the nervous system and neuro molecules form the combined tridirectional neuroimmune network, which plays a significant role in the communication pathways and regulation at the level of the whole organism and local levels, in both healthy persons and patients with allergic rhinitis based on an allergic inflammatory process. This review focuses on a new research paradigm devoted to neuronal-immune cell units, which are involved in allergic inflammation in the nose and neuroimmune control of the nasal mucociliary immunologically active epithelial barrier. The categorization, cellular sources of neurotransmitters and neuropeptides, and their prevalent profiles in constituting allergen tolerance maintenance or its breakdown are discussed. Novel data on the functional structure of the nasal epithelium based on a transcriptomic technology, single-cell RNA-sequencing results, are considered in terms of neuroimmune regulation. Notably, the research of pathogenesis and therapy for atopic allergic diseases, including recently identified local forms, from the viewpoint of the tridirectional interaction of the neuroimmune network and discrete neuronal-immune cell units is at the cutting-edge.

Cough as a neurological sign: What a clinician should know

Cough is a common respiratory complaint driving patients to seek medical advice. Besides being a fundamental respiratory sign, it is also a crucial neurological sign. There are three main types of coughs: Reflex cough (type I), voluntary cough (type II), and evoked cough (type III). Cough is a reflex predominantly mediated by control centers in the respiratory areas of the brainstem, modulated by the cerebral cortex. Cough reflex sensitivity could be increased in many neurological disorders such as brainstem space-occupying lesions, medullary lesions secondary to Chiari type I malformations, tics disorders such as Tourette's syndrome, somatic cough, cerebellar neurodegenerative diseases, and chronic vagal neuropathy due to allergic and non-allergic conditions. Meanwhile, cough sensitivity decreases in multiple sclerosis, brain hypoxia, cerebral hemispheric stroke with a brainstem shock, Parkinson's disease, dementia due to Lewy body disease, amyotrophic lateral sclerosis, and peripheral neuropathy as diabetic neuropathy, hereditary sensory and autonomic neuropathy type IV, vitamin B12, and folate deficiency. Arnold's nerve ear-cough reflex, syncopal cough, cough headache, opioids-associated cough, and cough-anal reflex are signs that could help diagnose underlying neurological conditions. Cough reflex testing is a quick, easy, and cheap test performed during the cranial nerve examination. In this article, we reviewed the role of cough in various neurological disorders that increase or decrease cough sensitivity.

Effect of Nasal Dominance on Pulmonary Function Test and Heart Rate: A Pilot Study

Background:

The nasal cycle is one of the many cyclic events in a human being. Nasal airflow is greater in one nostril at any given point in time and this alternates between right and left nostrils over time. Its periodicity ranges from 25 min to 8 h. This alteration has been known to be controlled by the autonomic nervous system. The current study was designed to assess the effect of nasal dominance during rest on pulmonary function parameters and heart rate.

Materials and Methods:

A cross-sectional study was done on 35 apparently healthy individuals of the age group of 18–30 years. Based on a cold mirror test, the participants were categorized into two groups of right nasal dominance (RND) and left nasal dominance (LND). The parameters recorded were forced expiratory volume in the first sec (FEV₁), forced vital capacity (FVC), FEV₁/FVC, peak expiratory flow rate, forced expiratory flow between 25%-75%, SpO₂, and pulse rate. Data were expressed as mean ± standard deviation and were analyzed using SPSS version 20.

Results:

All pulmonary function parameters exhibited higher values in RND participants compared to LND participants and the difference was found to be statistically significant (P < 0.05).

Conclusion:

Nasal dominance has a measurable effect on pulmonary functions and heart rate hence emphasizing the role of autonomic control of airways. This influence can be used as adjuvant therapy for certain disorders.

Upper digestive tract abnormalities in dogs with chronic idiopathic lymphoplasmacytic rhinitis

BACKGROUND

Chronic idiopathic lymphoplasmacytic rhinitis (CILPR) is a common inflammatory disorder of unknown etiology affecting the nasal cavity of dogs. The diagnosis is made by exclusion of other causes of nasal disease and specific therapeutic protocols are lacking. In human medicine, a relationship between CILPR and gastrointestinal clinical signs has been postulated, and remission of respiratory signs after clinical trials with medications for gastrointestinal disorders has been observed.

OBJECTIVES

To describe history, clinical presentation, endoscopic and histopathologic concurrent respiratory and digestive tract abnormalities, and to evaluate improvement of respiratory signs after treatment for gastrointestinal signs.

ANIMALS

Twenty-five dogs with CILPR.

METHODS

Prospective study. For inclusion, following information had to be available: respiratory and digestive clinical signs, airway and digestive tract endoscopic abnormalities, histologic evaluation of respiratory and gastrointestinal tract biopsy specimens, and clinical response to different treatment strategies.

RESULTS

Twenty-two dogs had endoscopic gastrointestinal lesions, whereas 13 dogs had concurrent gastrointestinal signs. Most esophageal and duodenal endoscopic abnormalities were classified as moderate or severe. Respiratory and gastrointestinal tract histologic evaluation identified mostly chronic inflammation. Remission or marked improvement of respiratory signs was observed in the majority of dogs treated only for gastrointestinal signs up to 12 months after endoscopy. No significant associations between treatments and follow-up information were found.

CONCLUSION AND CLINICAL IMPORTANCE

Nasal and upper digestive tract abnormalities coexist in some dogs with CILPR. Lack of standardized therapeutic protocols suggests caution when interpreting improvement in nasal clinical signs. Additional studies are needed to explore the possibility of a cause-effect relationship between the 2 processes.

Gastroesophageal reflux disease increases the risk of chronic rhinosinusitis: a nested case-control study using a national sample cohort

BACKGROUND

The purpose of this study was to evaluate the relations between gastroesophageal reflux disease (GERD) and chronic rhinosinusitus (CRS) in a Korean population.

METHODS

Subjects from the Korean National Health Insurance Service-National Sample Cohort, all ≥20 years old, were assessed from 2002 to 2013. In total, 23,489 CRS participants were matched with 93,956 controls at a ratio of 1:4 with respect to age, group, sex, income group, region of residence, hypertension, diabetes, and dyslipidemia. We analyzed previous history of GERD in the CRS and control groups. The CRS group included patients identified using International Classification of Diseases 10th edition (ICD-10) codes (J32) who had treated their CRS ≥2 times and had undergone head and neck computed tomography (CT). The GERD group included patients identified using the ICD-10 (K21) code who had treated their GERD ≥2 times and had taken a proton pump inhibitor (PPI) for ≥2 weeks. Crude and adjusted odds ratios (ORs) were analyzed using unconditional logistic regression analyses. The 95% confidence intervals (CIs) were calculated. Subgroup analyses were performed according to age and sex.

RESULTS

The rate of GERD was higher in the CRS group (17.1% [4020 of 23,489]) than in the control group (9.1% [8522 of 93,956]; p < 0.001). The adjusted OR of GERD was 2.04 (95% CI, 1.96-2.13; p < 0.001) in the CRS group. The results of the subgroup analyses were consistent.

CONCLUSION

The ORs of GERD were increased in CRS participants. This relationship was consistent in all age and sex groups.