The Impact of Allergic Rhinitis on Symptom Improvement in Pediatric Patients After Adenotonsillectomy

Comparative analysis of masseter muscle electrical activity by nasal patency in children with rhinitis and asthma: a pilot observational study

PURPOSE

This pilot cross-sectional study aimed to evaluate differences in electromyographic activity patterns of the masseter muscle according to the nasal patency in children with rhinitis and asthma.

METHODS

The study included 43 children aged 5-14 years with rhinitis and/or asthma. Patients underwent peak nasal inspiratory flow (PNIF) measurement to assess nasal patency, and electromyographic evaluation of the right and left masseter muscles during chewing and at rest. Electromyographic activity patterns according to nasal patency were compared using the Mann-Whitney test, and effect sizes were measured using the Glass rank biserial (rb) correlation. A p-value of < 0.05 was considered statistically significant.

RESULTS

No significant differences in electromyographic activity of the masseter muscle at rest, during unilateral chewing, or during habitual chewing were found between the groups. However, we found that patients with low nasal patency had a median electric activity of the right masseter muscle during maximum contraction of 60.53 (51.74-72.43), while those with adequate nasal patency had a median of 77.40 (56.71-88.45). Although the difference in myoelectric activity between the groups did not reach statistical significance (p = 0.061) at the adopted significance level of 5%, the size of the difference between groups were considered moderate (rb = 0.338) and a potential association between nasal patency and the muscular function of the masseter muscle could be suggested.

CONCLUSION

The study found no differences in the electromyographic activity of the masseter muscle at rest, during unilateral chewing, or during habitual chewing among children with rhinitis and asthma based on nasal patency. Further research with larger sample sizes is needed to validate these findings and gain a better understanding of the impact of nasal patency on the muscular function of the masseter muscle.

Association of allergic rhinitis with persistent obstructive sleep apnea: A secondary analysis of the childhood adenotonsillectomy trial

STUDY OBJECTIVES

Allergic rhinitis (AR) is frequently reported in children suffering from obstructive sleep apnea (OSA). This study aimed to assess whether children with AR are more likely to experience persistent OSA after AT.

METHODS

This study is a secondary analysis of a multi-center randomized clinical trial, the Childhood Adenotonsillectomy Trial. Children were categorized into the AR group or Non-AR group according to AR response. A subgroup analysis was conducted using a logistic regression model.

RESULTS

A total of 372 children (177 boys [47.6%]; median [IQR] age, 6.0 [5.0-8.0] years) were analyzed. Approximately 25% (93/372) of children presented with AR. Baseline data indicated higher PSQ scores and OSA-18 scores in the AR group. Children with AR demonstrated lower OSA resolution rates after AT (aOR, 0.43; 95% CI, 0.19 to 0.96). However, there was no significant difference in OSA resolution between the AR and Non-AR groups who underwent watchful waiting (aOR, 0.98; 95% CI, 0.50 to 1.93). Also, the AR group was more likely to maintain a PSQ score greater than 0.33 after AT (OR, 2.16; 95% CI, 1.01 to 4.61). There was no significant association between AR and higher follow-up OSA-18 scores after AT and watchful waiting.

CONCLUSIONS

In this secondary analysis, children with AR were more likely to experience persistent OSA, highlighting the importance of effective AR management even post-adenotonsillectomy. A purposefully designed, prospective randomized trial is needed to verify the association between AR and persistent OSA.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT00560859.

Clinical Impact of Preoperative Tonsil and Adenoid Size on Symptomatic Outcomes Following Adenotonsillectomy in Pediatric Patients

Background Adenotonsillar hypertrophy is a common clinical problem in pediatric patients. Adenotonsillectomy is a surgical intervention to remove airway obstruction and alleviate symptoms. However, some children continue to experience persistent symptoms after surgery. Objective This study aimed to investigate the relationship between preoperative tonsils and adenoid size and the persistence of symptoms, including snoring, mouth breathing, noisy breathing, and sleep apnea, after adenotonsillectomy in pediatric patients. Method This study was conducted in Taif, Saudi Arabia, and included 109 pediatric patients aged three to 14 years who underwent adenotonsillectomy. Data on preoperative and postoperative symptoms were collected through patient records and follow-up surveys. Tonsil and adenoid size were assessed using the Brodsky scale and endoscopic grading scales, respectively. Statistical analysis was performed using SPSS Version 26 (IBM Corp., Armonk, NY). Results The most prevalent presenting symptoms were snoring, mouth breathing, and noisy breathing. Tonsil size grades 3+ and 4+ were significantly more prevalent than the other grades (p<0.05). Adenoid size grades 3 and 4 were also significantly more prevalent than the other grades (p<0.05). Significant associations were observed between tonsil and adenoid size grades and specific presenting symptoms, such as snoring, mouth breathing, and noisy breathing. No significant correlations were found between preoperative tonsil or adenoid size and postoperative persistent symptoms. Conclusion While tonsil and adenoid size are essential factors in determining the need for surgery, they may not predict postoperative resolution of symptoms. A comprehensive evaluation of various clinical factors is necessary to understand the persistence of symptoms after surgery. Although adenotonsillectomy is an effective treatment for upper airway obstruction in pediatric patients, some individuals may experience residual symptoms.

Vitamin D Deficit as Inducer of Adenotonsillar Hypertrophy in Children with Obstructive Sleep Apnea-A Prospective Case-Control Study

(1) Objective: This prospective case-control study aimed to assess the level of serum vitamin D comparing pediatric non-allergic patients with obstructive sleep apnea (OSA) and healthy controls. (2) Methods: The period of the enrollment was from November 2021 to February 2022. Children with uncomplicated OSA caused by adenotonsillar hypertrophy (ATH) were recruited. Allergy was excluded by skin prick test (SPT), and the determination of serum IgE level using ELISA test. Plasma concentration of 25-hydroxy vitamin D (25-OHD) was quantitatively determined; then, the vitamin D concentration in patients was compared with healthy controls matched for sex, age, ethnicity, and characteristics. (3) Results: Plasma 25-OHD levels were significantly lower in patients than in healthy subjects (mean 17 ng/mL, 6.27 DS, range 6-30.7 ng/mL, vs. mean 22 ng/mL, 9.45 DS, range 7-41.2 ng/ ml; p < 0.0005). The prevalence of children with vitamin D deficiency was significantly higher in the ATH group than controls. The plasma 25-OHD level did not change following the ATH clinical presentation (III or IV grade according to the Brodsky scale), while the different categories of 25-OHD status (insufficiency, deficiency, and adequacy) in the ATH group were statistically significantly different (p < 0.001) from healthy controls. (4) Conclusions: This study identified statistically significant differences between the ATH group and control regarding the plasma concentration of vitamin D; this data, despite not being directly linkable to the lymphoid tissue hypertrophy (p-value not significant), might suggest a negative effect of vitamin D deficit on the immune system.

Paediatric Adenotonsillectomy: Its Safety and Outcome in a Malaysian Tertiary Medical Center

Adenotonsillectomy is the commonest otorhinolaryngology surgery for paediatrics. The purpose of this study was to determine the safety and outcome of adenotonsillectomy in a tertiary center in Malaysia. This was achieved by studying the demographics, indications, co-morbidities of patients and its association with the complications of the procedure. This retrospective study was conducted from November 2011 until October 2016. Medical records of patients aged 2-12 years old who had adenotonsillectomy done in our center were retrieved for data collection. A total of 143 patients who fulfilled the inclusion and exclusion criteria were recruited. Median age was 7.52 (± 2.98 SD) years old. Allergic rhinitis was the commonest co-morbidity (40%). Recurrent tonsillitis was the main indication (60%), followed by sleep disordered breathing (SDB) without apnea (29%), obstructive sleep apnea (OSA) (7%) and other indications (4%). Post-operative paediatric intensive care unit (PICU) admission was very low (1.4%) and was reserved for those with severe OSA with complications. None of the patients admitted to PICU post-operative had respiratory complications. The prevalence of post-tonsillectomy bleeding was only  2.1%. There was no significant association between patient's co-morbidity with operative complications (p = 0.269). Adenotonsillectomy is indicated for children with recurrent tonsillitis and paediatric SDB. The two most severe complications, namely post-tonsillectomy haemorrhage and respiratory complications occurred but incidence was low. Criteria of post-operative PICU or paediatric high dependency unit admission for paediatric SDB has to be based on multiple clinical and logistics factors and not only patients co-morbidity and indication of surgery.

Incidence of allergen-specific and total immunoglobulin E positivity in children undergoing adenotonsillectomy

AIM

To conduct a prospective, consecutive cohort study to evaluate the incidence of allergen-specific and total immunoglobulin E (IgE) in a paediatric population undergoing adenotonsillectomy for sleep-disordered breathing.

METHODS

A total of 64 consecutive patients presenting for adenotonsillectomy at a single centre were recruited over a period of 3 months. All patients underwent adenotonsillectomy and had allergen-specific and total IgE serum testing at the time of anaesthesia induction. Pre-operative history and examination were conducted to determine clinical allergy. Caregivers completed the Sleep-Related Breathing Disorder scale of the Paediatric Sleep Questionnaire and the Mini Rhinoconjunctivitis Quality of Life Questionnaire at baseline and at 6 weeks post-operatively.

RESULTS

A total of 37 (57.8%) patients had either allergen-specific or total IgE positivity. House dust mite was the most prevalent allergen-specific IgE finding, being present in moderate to high levels in 14 (21.9%) patients. A total of 17 (26.6%) patients had a history of atopy, while 34 (53.1%) had examination findings suggestive of allergy. Neither serum IgE testing nor clinical history and examination were independently associated with residual symptoms post adenotonsillectomy. Patients with concomitant serum IgE positivity and clinical allergy had higher residual symptom scores compared to those who did not using both Sleep-Related Breathing Disorder scale of the Paediatric Sleep Questionnaire (P = 0.035) and Mini Rhinoconjunctivitis Quality of Life Questionnaire (P = 0.02) questionnaires.

CONCLUSIONS

Our prospective, consecutive cohort of patients reflect a greater incidence of serum IgE positivity compared to historical figures. When utilised with clinical findings on history and examination, serum IgE is a useful adjunct that is associated with greater residual symptoms post-adenotonsillectomy.

Long-term outcome of concurrent coblator turbinoplasty with adenotonsillectomy in children with allergic rhinitis

BACKGROUND

Allergic rhinitis (AR) is one of the most prevalent chronic diseases in children. Patients with AR tend to have more persistent symptoms after adenotonsillectomy (T&A).

OBJECTIVES

This study was aimed to evaluate the outcome of additional concurrent coblation-assisted turbinoplasty with adenotonsillectomy (T&A + T) in patients with AR.

MATERIAL AND METHODS

This study included 104 children who underwent T&A, and 67 who underwent T&A + T. All patients were diagnosed as AR and were aged < 12 years at the time of surgery. Symptoms (snoring, mouth breathing, nasal obstruction, rhinorrhea, itching, and sneezing) were evaluated preoperatively and postoperatively via a questionnaire and a telephone survey.

RESULTS

None of the six symptoms investigated differed significantly between the two groups preoperatively, and all evaluated symptoms exhibited dramatic improvements after the surgery in both groups. The T&A + T group showed significantly greater difference of improvement in mouth breathing and nasal obstruction than T&A group. There were no significant difference of improvements in snoring, rhinorrhea, itching and sneezing postoperatively between two groups. In multiple regression analysis, postoperative obstructive symptoms including mouth breathing and nasal obstruction were significantly associated with concurrent turbinoplasty.

CONCLUSION

Concurrent turbinoplasty should be considered especially in patients who have AR and adenotonsillar hypertrophy to improve obstructive symptoms.

Association between nasal patency and orofacial myofunctional changes in patients with asthma and rhinitis

PURPOSE

To verify the association between orofacial myofunctional changes and nasal patency.

METHOD

Observational study of 43 children and adolescents with asthma and/or rhinitis, aged between 5 and 14 years, from May 2017 to September 2019. Patients underwent peak nasal inspiratory flow (PNIF) for nasal patency assessment and orofacial myofunctional assessment. Clinical data were obtained from an interview on the day of the patients' medical evaluation. The relationship between orofacial myofunctional changes and PNIF was analyzed using a logistic regression model. Estimates were reported as odds ratio (OR) and 95% confidence interval (95%CI). We evaluated multicollinearity using the variance inflation factor and analyzed the adjusted fit with the Akaike information criterion and McFadden's R² metric; p value < 0.05 was considered statistically significant.

RESULTS

Inadequate positioning of the mandible (OR = 11.22; 95%CI 1.83-69; p = 0.009) and the presence of tension in the facial muscles during the swallowing of liquid (OR = 4.61; 95%CI 1.31-16.20; p = 0.017) were associated with altered PNIF in children and adolescents with asthma and rhinitis.

CONCLUSION

Children and adolescents with asthma and rhinitis along with reduced nasal patency presented orofacial myofunctional changes, such as inadequate positioning of the jaw and the presence of tension in the facial muscles during swallowing of liquid.

Pulmonary arterial pressure and nasal obstruction in mouth-breathing children: Similarities between adenotonsillar hypertrophy and allergic rhinitis

BACKGROUND

Upper airway obstruction may cause pulmonary hypertension in childhood. In this study we aimed to identify a possible correlation of systolic pulmonary arterial pressure (SPAP), using Doppler echocardiography, with nasal patency (NP), as measured by rhinomanometry, in mouth-breathing (MB) children with allergic rhinitis (AR) and adenotonsillar hypertrophy (ATH).

METHODS

In this cross-sectional study we evaluated 183 patients, from 2 to 12 years of age, at an MB referral clinic in Brazil, from December 2013 to 2017. We allocated patients to 4 etiology groups: group 1, 60 MBs with ATH; group 2, 47 MBs with AR; group 3, 43 MBs with both ATH and AR; and group 4, 33 nasal breathing control subjects. The ratio of total nasal inspiratory flow (assessed by active anterior rhinomanometry) and expected inspiratory flow adjusted for height determined the percent NP (%NP).

RESULTS

The median %NP was higher in controls than in the MB groups (controls, 114% [79-147%]; ATH: 65% [5-116%]; AR: 57% [23-144%]; ATH and AR: 64% [3-120%]; p < 0.001). Median SPAP was higher in the MB groups than in controls (SPAP: ATH, 26.0 [20.0-35.0] mmHg; AR, 26.0 [22.0-32.0] mmHg; ATH and AR, 26.30 [20.0-34.0] mmHg; control, 22.0 [16.0-30.0] mmHg; p < 0.001). SPAP showed a negative association with %NP (Spearman's rho = -0.24; p < 0.001).

CONCLUSION

Reduced nasal airflow in MB children showed a correlation with higher levels of systolic pulmonary arterial pressure. The AR and ATH groups were similar in nasal obstruction severity and systolic pulmonary arterial pressure level distribution.

Cluster Analysis of Inhalant Allergens in South Korea: A Computational Model of Allergic Sensitization

Objectives.

Sensitization to specific inhalant allergens is a major risk factor for the development of atopic diseases, which impose a major socioeconomic burden and significantly diminish quality of life. However, patterns of inhalant allergic sensitization have yet to be precisely described. Therefore, to enhance the understanding of aeroallergens, we performed a cluster analysis of inhalant allergic sensitization using a computational model.

Methods.

Skin prick data were collected from 7,504 individuals. A positive skin prick response was defined as an allergen-to-histamine wheal ratio ≥1. To identify the clustering of inhalant allergic sensitization, we performed computational analysis using the four-parameter unified-Richards model.

Results.

Hierarchical cluster analysis grouped inhalant allergens into three clusters based on the Davies-Bouldin index (0.528): cluster 1 (Dermatophagoides pteronyssinus and Dermatophagoides farinae), cluster 2 (mugwort, cockroach, oak, birch, cat, and dog), and cluster 3 (Alternaria tenus, ragweed, Candida albicans, Kentucky grass, and meadow grass). Computational modeling revealed that each allergen cluster had a different trajectory over the lifespan. Cluster 1 showed a high level (>50%) of sensitization at an early age (before 19 years), followed by a sharp decrease in sensitization. Cluster 2 showed a moderate level (10%–20%) of sensitization before 29 years of age, followed by a steady decrease in sensitization. However, cluster 3 revealed a low level (<10%) of sensitization at all ages.

Conclusion.

Computational modeling suggests that allergic sensitization consists of three clusters with distinct patterns at different ages. The results of this study will be helpful to allergists in managing patients with atopic diseases.

Strain-Specific Differences in House Dust Mite (Dermatophagoides farinae)-Induced Mouse Models of Allergic Rhinitis

Objectives.

Limited information is available regarding strain-related differences in mouse models of allergic rhinitis induced by Dermatophagoides farinae (Der f1). In this study, we compared differences between two mouse strains and determined the optimal dose of Der f1 for allergic rhinitis mouse models.

Methods.

Forty-eight mice were assigned to the following six groups (n=8 per group): group A (control, BALB/c), group B (Der f1-sensitized BALB/c, 25 µg), group C (Der f1-sensitized BALB/c, 100 µg), group D (control, C57BL/6), group E (Der f1-sensitized C57BL/6, 25 µg), and group F (Der f1-sensitized C57BL/6, 100 µg). Allergic inflammation was induced with Der f1 and alum sensitization, followed by an intranasal challenge with Der f1. Rubbing and sneezing scores, eosinophil and neutrophil infiltration, and immunoglobulin, cytokine, and chemokine levels in the nasal mucosa and from splenocyte cultures were assessed.

Results.

Rubbing and sneezing scores were higher in groups B, C, E, and F than in groups A and D, with a similar pattern in both strains (i.e., group B vs. E and group C vs. F). Serum immunoglobulin levels were significantly elevated compared to the control in groups B and C, but not in groups E and F. Eosinophil and neutrophil infiltration increased (all P<0.05) after the Der f1 challenge (groups B, C, E, and F) compared to the control (groups A and D) in both the BALB/c and C57BL/6 strains, without any significant difference between the two strains (group A vs. D, group B vs. E, and group C vs. F) (P>0.05). BALB/c mice (group B) showed a greater elevation of splenic interleukin (IL)-4 (P<0.01), IL-5 (P<0.01), and IL-6 levels (P<0.05) and nasal IL-4 mRNA levels (P<0.001) than the C57BL/6 mice (group E). Interestingly, mice treated with 100 µg Der f1 showed a weaker allergic response than those treated with 25 µg.

Conclusion.

We found 25 µg to be a more appropriate dose for Der f1 sensitization. BALB/c mice are more biased toward a Th2 response and are a more suitable model for allergic rhinitis than C57BL/6 mice. This study provides information on the appropriate choice of a mouse model for allergic rhinitis.

Impact of allergic rhinitis on quality of life after powered intracapsular tonsillectomy and adenoidectomy

BACKGROUND

Allergic rhinitis (AR) has been reported to worsen quality of life (QoL) after adenotonsillectomy. Although powered intracapsular tonsillectomy and adenoidectomy (PITA) has been widely performed, it is not clear whether comorbid AR may worsen QoL in patients who undergo PITA.

PURPOSE

To evaluate QoL after PITA in relation to AR.

METHODS

Children undergoing PITA for sleep-disordered breathing were enrolled and divided into AR and non-AR groups. QoL was evaluated using serial applications of the Obstructive Sleep Apnea-18 (OSA-18) questionnaire and compared between the two groups.

RESULTS

Of 151 enrolled patients, 73 were categorized into the AR and 78 into non-AR groups. After surgery, patients exhibited marked improvement in OSA-18 scores in both groups, with similar results at each follow-up. The degree of improvement in OSA-18 scores was less in the AR group 3 months after surgery; however, this difference was not significant 6 months after surgery.

CONCLUSIONS

Although comorbid AR may initially appear to impede improvement in QoL after PITA, QoL was improved similarly 6 months after PITA, irrespective of AR status. In children with comorbid AR, PITA could be safely performed to treat sleep-disordered breathing without concerns regarding worsening of QoL.

Using high-throughput metabolomics to discover perturbed metabolic pathways and biomarkers of allergic rhinitis as potential targets to reveal the effects and mechanism of geniposide

In this study, we probed the molecular mechanisms of metabolic biomarkers and pathways affected by the bioactive ingredient geniposide (GP), which was shown to protect against experimental allergic rhinitis in mice. The methods used here involved a metabolomics strategy based on ultra-performance liquid chromatography coupled with quadrupole time-of-flight mass spectrometry (UPLC-TOF/MS). Using the metabolomics strategy, serum samples of mice in control, model and GP groups were used to explore the differential production of metabolites and pathways related to defense activity of GP towards allergic rhinitis. Allergic symptom, inflammatory factors, and cell populations in the mice spleens were reversed by GP treatment. Seventeen potential biomarkers were discovered in experimental allergic rhinitis mice. GP was shown to have a regulatory effect on 12 of them, which were associated with 8 key metabolic pathways. The ingenuity pathway analysis platform was used to further understand the relationship between metabolic changes and pharmacological activity of GP. The pathways which affected by GP involved cellular growth and proliferation, organismal development, and free radical scavenging. This metabolomics study produced valuable information about potential biomarkers and pathways affected by GP during its effective prevention and therapeutic targeting of allergic rhinitis.

In this study, we probed the molecular mechanisms of metabolic biomarkers and pathways affected by the bioactive ingredient geniposide (GP), which was shown to protect against experimental allergic rhinitis in mice.