Association of Autonomic Dysfunction and Mild Obstructive Sleep Apnea

BACKGROUND: Autonomic dysfunction (AD) has been independently associated with obstructive sleep apnea (OSA). Autonomic abnormalities are generally considered to be secondary to OSA. Autonomic dysfunction may also contribute to OSA. If AD contributes to OSA, we postulated that abnormalities may be present in mild OSA where the confounding causal effects of hypoxemia and sleep disruption are reduced.

OBJECTIVE: We evaluated autonomic function tests and sleep studies in a cohort of subjects with no known diagnosis of OSA.

METHODS: We prospectively enrolled a cohort without diagnosed OSA who were part of an ongoing study of vasomotor rhinitis (VMR) for testing. A battery of autonomic nervous system tests (sudomotor and cardiovagal), nonattended polysomnography, and three-site esophageal/pharyngeal pH monitoring were performed.

RESULTS: Twenty of 22 patients completed the test battery and 12 (60%) met criteria for OSA (Apnea/Hypopnea Index “AHI” >5 events/hour). AHI correlated to mean tilt table blood pressure decrease (R = 0.58, P = 0.007) and the Valsalva-mediated phase 2 mean blood pressure decrease (R = 0.52, P = 0.017). OSA severity was related to sympathetic but not parasympathetic abnormalities. No differences in blood pressure responses were related to age, oxygen desaturation nadir, gastroesophageal reflux, VMR, or sleepiness.

CONCLUSION: Autonomic abnormalities suggestive of decreased adrenergic tone are associated with mild OSA. These abnormalities may potentially be secondary but may also precede development of OSA. (Otolaryngol Head Neck Surg 2004;130: 643-8.)

"Overlapped" rhinitis: a real trap for rhinoallergologists

Under the broad heading of "vasomotor" rhinitis two big groups can be distinguished: allergic rhinitis (IgE-mediated), and nonallergic rhinitis. Since they are two separate nosological entities, they can co-exist in the same patient, classifying themselves in the group of "overlapped" rhinitis (OR). Although not absolutely rare (indeed it is estimated a 15-20% incidence among all vasomotor rhinopathies), this condition is not investigated and diagnosed, with significant implications in the clinical-diagnostic and therapeutic field.

[Diagnosis and clinical characteristics of patients with non-allergic rhinitis]

OBJECTIVE

To explore a step-by-step exclusive diagnosis and analyze the clinical characters of non-allergic rhinitis (NAR).

METHODS

Patients with symptoms (nasal itching, sneezing, rhinorrhea, nasal congestion) were selected to take four-step exclusive diagnosis for NAR and we tried to eliminate the false NAR and retain the true NAR. First step was to exclude the patients who were not suitable for skin prick test (SPT, such as during pregnancy, breastfeeding, asthma, oral antihistamine medication in 7 day, severe skin diseases). The second step was to exclude the patients with positive SPT and the third step was to exclude the patients with 1 level or above of specific sero-immunoglobulin E (sIgE). The fourth step was to exclude the patients with infection rhinitis, clear abnormal nasal structure, drug-induced rhinitis, nasal neoplasm. The remained patients were finally diagnosed as NAR and who were further differential diagnosed as vasomotor rhinitis (VMR) or non-allergic rhinitis with eosinophilia syndrome (NARES) according to the eosinophilia counts in nasal secretion and venous blood. The common characters of patients with NAR were analyzed and their symptoms and quality of life were evaluated by visual analogue scale (VAS) and rhino-conjunctivitis quality of life questionnaire (RQLQ) separately.

RESULTS

One thousand four hundred and thirty-seven patients were included after first step exclusion and 735 cases with negative SPT were remained after second step exclusion. Of 735 patients, 302 were tested in vitro for sIgE and 93 cases with 0 level of sIgE and total IgE were remained after third step exclusion. Sixty-two patients were finally diagnosed as NAR after fourth step exclusion. The NAR diagnosis rate was 51.15% (735/1 437) with negative SPT alone and the NAR diagnosis rate was 29.06% (93/302) with combination of negative SPT and sIgE. Of 62 patients with NAR, 47 patients (75.81%) were diagnosed as VMR and 15 cases (24.19%) as NARES. There were 23 males and 39 females in the 62 patients aged 11 - 77 years. The history was 11-47 months. The biggest numbers of patients with VMR or NARES were among 41-50 years. Their onset ages were among 21-30 years in both two groups. VAS scores of nasal congestion in VMR patients were the highest with significant difference among nasal symptoms (F = 3.958 0, P = 0.009 1). VAS scores of sneezing in NARES patients were the highest but without significant difference among nasal symptoms. There were no difference in seven domain scores of RQLQ and the total mean scores between VMR group and NARES group but the nasal symptoms got the highest scores with significant difference among the seven domains in each group (VMR group, F = 9.771 2, P = 0.000 0;NRAES group, F = 3.226 9, P = 0.006 2).

CONCLUSIONS

SPT combined with sIgE may exclude much more patients with AR. Females with NAR are much more than males. Patients with NAR aged 21-30 years. The characters of NAR are helpful to improve our knowledge about NAR. VAS and RQLQ may be a suitable tool in assessment of NAR.

Chapter 6: Nonallergic rhinitis

Nonallergic rhinitis represents a non-IgE-mediated group of disorders that share the symptoms of nasal congestion, rhinorrhea, sneezing, and/or postnasal discharge but not pruritus that characterizes allergic rhinitis. Nonallergic rhinitis may be divided into two broad categories, inflammatory and noninflammatory etiologies. The inflammatory causes include postinfectious (viral and bacterial), rhinitis associated with nasal polyps, and nonallergic rhinitis with eosinophilia, where eosinophils are present in nasal smears but skin testing for aeroallergens is negative. The noninflammatory causes include idiopathic nonallergic rhinitis (formerly referred to as vasomotor rhinitis or colloquially as an "overreactive nose"); rhinitis medicamentosa, which is medication-induced rhinitis; hormone related (pregnancy); systemic disease related (severe hypothyroidism); and structural defect related (deviated septum, head trauma causing cerebrospinal fluid rhinorrhea). The classic symptoms of idiopathic nonallergic rhinitis are nasal congestion, postnasal drip, and sneezing triggered by irritant odors, perfumes, wine, and weather changes. The diagnosis of rhinitis begins with a directed history and physical exam. Examination of the nasal cavity with attention to appearance of the septum and inferior turbinates is recommended. Skin testing for seasonal and perennial aeroallergens is helpful in establishing the presence or absence of IgE antibodies and to help differentiate nonallergic from allergic rhinitis. Topical H(1)-receptor antagonist (antihistamine) nasal sprays, intranasal steroids, intranasal anticholinergics, and oral decongestants are options for pharmacotherapy. It is important to inquire about hypertension, arrhythmias, insomnia, prostate hypertrophy, or glaucoma to prevent undesirable side effects associated with the oral decongestant pseudoephedrine.

Sphenopalatine artery ligation with nerve resection in patients with vasomotor rhinitis and polyposis: a prospective, randomized, double-blind investigation

CONCLUSIONS

Sphenopalatine artery ligation relieves symptoms of rhinorrhea, sneezing, and nasal itching in patients with vasomotor rhinitis associated with nasal polyps.

OBJECTIVES

Nasal polyps often arise in a setting of vasomotor rhinitis. Dysfunctions in nerve fiber activity of the sympathetic and parasympathetic systems are responsible for the accompanying symptoms of rhinorrhea, sneezing, and nasal itching. Sphenopalatine pedicle resection with autonomic denervation could potentially reduce related symptoms.

METHODS

In a prospective, double-blind setting, 60 patients with vasomotor rhinitis and bilateral nasal polyps randomly assigned to functional endoscopic surgery either with (group A) or without (group B) sphenopalatine artery ligation completed a 3-year follow-up. Preoperative and postoperative (at 1 and 3 years) evaluations included symptom score, fiberendoscopy, and active anterior rhinomanometry.

RESULTS

In both treatment groups nasal breathing had improved at 1-year and 3-year follow-up (p < 0.001), whereas an improvement in rhinorrhea (p < 0.001) and sneezing and itching (p < 0.01) was attained only in group A. The inter-group comparison showed that a statistically significant improvement in rhinorrhea and nasal itching (p = 0.002) and in sneezing (p < 0.001) was present in group A at both follow-up visits. Rhinomanometry improved in both treatment groups (p < 0.01). Inter-group comparison showed a significant difference only at the 3-year follow-up visit (p < 0.05).

[Clinical characteristics in patients with non-allergic rhinitis and allergic rhinitis: preliminary analysis]

OBJECTIVE

To compare and analyze the clinical characteristics in patients with hyperreactive non-allergic rhinitis (HNAR) and allergic rhinitis (AR).

METHODS

A questionnaire survey on AR and HNAR patients between January and August 2009 was conducted. The clinical data of 298 AR patients and 100 HNAR patients were analyzed, including gender, age distribution, seasonal, clinical symptom and induced factors.

RESULTS

The number of male patients was more than female in AR, while in NAR, the number of female patients was more than male (χ(2) = 6.415, P = 0.01). The highest morbidity age in AR was teenagers, aged between 10 - 19 (χ(2) = 12.772, P = 0.00), while in HNAR, the highest morbidity age was middle-aged and youth, aged between 30 - 39 (χ(2) = 51.533, P = 0.00). The main onset seasons in AR was autumn, while there was no seasonal diversity in HNAR. The main allergen in AR was mugwort and ragweed, consistent with the vegetative cover characteristic in Jilin province. The main classification of AR was moderate-severe persistent (χ(2) = 123.991, P = 0.00), while the main classification of HNAR was moderate-severe intermittent (χ(2) = 97.420, P = 0.00). The clinical symptoms were significantly different between AR and HNAR except rhinocnesmus (all P < 0.05). There was consistency about non-specificity induced factors in AR and HNAR (all P > 0.05).

CONCLUSIONS

There were significant differences between AR and HNAR in sex, age, classification and seasons. The severity of clinical symptoms in AR was higher than that in HNAR except sneezing and gasping. There was consistency about induced factors in AR and HNAR.

[The role of neurovegetative disturbances in the clinical picture and treatment of vasomotor rhinitis]

Sixty four patients of different age groups having vasomotor rhinitis underwent submucous vasotomy of inferior nasal turbinates combined with mucosal biopsy. Neuromorphological studies have demonstrated mucosal desympathization especially pronounced in the patients aged between 51 and 70 years. Comparative evaluation of the efficacy of surgical and conservative (dimephosphon therapy) treatment of vasomotor rhinitis was conducted.

[Otorhinolaringologyc approach of the chronic cough. Clinical case]

Chronic cough is defined as that which is persisting at least for trhee weeks without an evident cause. It is very common on the otorhinological practice to receive patients with chronic cough in order to rule out that their chronic cough is not produced because of an alteration in the high respiratory system. We show a clinical case with chronic cough and we make reference to the physical exploration, diagnostical method, and possibilities of medical and surgical treatment.

[Allergy in general practice in Arhus County. Quality assessment of diagnosis, treatment and instructions to patients: II. Rhinitis]

INTRODUCTION

The aim of this study was to evaluate adult patients in general practice suspected of having rhinitis.

MATERIALS AND METHODS

A total of 72 patients suspected of having rhinitis underwent a secondary specialist investigation, resulting in 55 final specialist diagnoses of rhinitis. Through interviews of patients and a questionnaire mailed to the primary physician, information on diagnostic strategy, final diagnosis, suggested treatments and patients' knowledge about rhinitis were determined.

RESULTS

One third of the 72 patients examined for possible rhinitis would have benefited from a supplementary specialist examination, where one group was made up of patients with negative allergy tests and chronic symptoms of either non-rhinitis disease or vasomotoric rhinitis and the other group was made up of patients with severe seasonal allergic rhinitis, who would benefit from immunotherapy. The suggested medical treatments followed modern treatment principles. Of the patients with a final diagnosis of rhinitis, only one third were informed about treatment principles with inhalation steroids, while half of the patients knew about the basic principles of antihistamine treatment. Of 53 patients with rhinitis, 6 were prepared to change medical treatment without first contacting their physician.

CONCLUSION

Patients with chronic or recurrent symptoms should be referred to specialists more often, and patients who might benefit from allergen-specific treatment, such as immunotherapy or allergen prevention, should be evaluated by an allergy specialist. Patients with rhinitis should be given more information on disease mechanisms and treatment principles.

Nasal wall compliance in vasomotor rhinitis

Nasal compliance is a measure related to the blood volume in the nasal mucosa. The objective of this study was to better understand the vascular response in vasomotor rhinitis by measuring nasal cross-sectional area and nasal compliance before and after mucosal decongestion in 10 patients with vasomotor rhinitis compared with 10 healthy subjects. Nasal compliance was inferred by measuring nasal area by acoustic rhinometry at pressures ranging from atmospheric pressure to a negative pressure of -10 cmH2O. Mucosal decongestion was obtained with one puff per nostril of 0.05% oxymetazoline. At atmospheric pressure, nasal cross-sectional areas were similar in the vasomotor rhinitis group and the healthy subject group. Mucosal decongestion did not induce any decrease of nasal compliance in patients with vasomotor rhinitis in contrast with healthy subjects. Our results support the hypothesis, already proposed, of an autonomic dysfunction based on a paradoxical response of the nasal mucosa in vasomotor rhinitis. Moreover, the clearly different behavior between healthy subjects and vasomotor rhinitis subjects suggests that nasal compliance measurement may therefore represent a potential line of research to develop a diagnostic tool for vasomotor rhinitis, which remains a diagnosis of exclusion.

Treatment of nonallergic perennial rhinitis

Nonallergic perennial rhinitis (also commonly referred to as vasomotor rhinitis) is a chronic non-IgE-mediated condition that is characterized by symptoms which are similar to those seen in allergic rhinitis, but which persist for over nine months each year. Although treatment of vasomotor rhinitis involves the use of either intranasal corticosteroids or antihistamines, the corticosteroids are generally not effective in treatment of all the symptoms of vasomotor rhinitis and have generally been shown to be effective in patients with eosinophilia. With the exception of azelastine, the only topical antihistamine to be approved by the FDA for the treatment of nonallergic rhinitis, the antihistamines have also produced inconsistent results. While clinical studies of azelastine have demonstrated that this drug is highly efficacious in the treatment of all the symptoms of vasomotor rhinitis, mechanistic studies have demonstrated that azelastine has potent anti-inflammatory effects (in particular attenuation of the expression and synthesis of pro-inflammatory cytokines, leukotrienes, and cell adhesion molecules), which are likely to contribute to its clinical efficacy. Furthermore, pharamacokinetic studies have suggested that since azelastine has a more rapid onset of action, compared to most other antihistamines and intranasal corticosteroids, then azelastine nasal spray may be considered as primary therapy for patients with symptoms of both allergic and/or vasomotor (nonallergic perennial) rhinitis.

Persistent rhinitis - allergic or nonallergic?

Although rhinitis has been classified as being either allergic, noninfectious, or "other forms" (nonallergic noninfectious), these categories lack strict classification criteria and often overlap. The term "nonallergic noninfectious rhinitis" is commonly applied to a diagnosis of any nasal condition, in which the symptoms are similar to those seen in allergic rhinitis but an allergic aetiology has been excluded. This group comprises several subgroups with ill-defined pathomechanisms, and includes idiopathic rhinitis, irritative-toxic (occupational) rhinitis, hormonal rhinitis, drug-induced rhinitis, and other forms (non-allergic rhinitis with eosinophilia syndrome [NARES], rhinitis due to physical and chemical factors, food-induced rhinitis, emotion-induced rhinitis, atrophic rhinitis). Unlike allergic rhinitis, there are no specific diagnostic tests and diagnosis is primarily based on a history of reaction to specific irritant-toxic triggering agents (either general or occupational), drugs, infections, and hormonal status, coupled with exclusion of allergic rhinitis and other forms of non-allergic rhinitis by skin prick testing. Accordingly, from a clinical standpoint NARES, irritative-toxic, hormonal, drug-induced and idiopathic rhinitis are possibly the least difficult forms of nonallergic rhinitis to diagnose.

Recognizing And Treating Non-Infectious Rhinitis

PURPOSE

To increase clinicians' familiarity with nonallergic and mixed rhinitis and to differentiate these from allergic rhinitis, thus providing for an accurate diagnosis and facilitating a successful initial treatment program.

DATA SOURCES

A Medline search of published journal articles was supplemented with known books and proceedings pertaining to rhinitis.

CONCLUSIONS

Although there is significant overlap of symptoms among the three types of rhinitis (i.e., allergic, nonallergic, and mixed), the patient history often contains clues that can aid in establishing a correct diagnosis. The new Patient Rhinitis Screen, a questionnaire developed for use in the primary care arena, facilitates the diagnostic process.

IMPLICATIONS FOR PRACTICE

As the most common condition in the outpatient practice of medicine, rhinitis is frequently treated by primary care practitioners. Recent guidelines for the diagnosis and management of rhinitis suggest that a specific diagnosis of allergic, nonallergic, or mixed rhinitis leads to more effective treatment strategies. The result is successful and efficient care utilizing, as appropriate, broad-based and symptom-specific therapies.

Rhinitis: a dose of epidemiological reality

In the wide spectrum of medical practice, rhinitis is often incorrectly assumed to be solely allergic in etiology. Consequently, other rhinitis subtypes (nonallergic and mixed) remain under-diagnosed. This is of concern because inaccurate diagnosis may lead to unsatisfactory treatment outcome. Contributing to this under-diagnosis is the fact that primary care practitioners do not often have at their disposal the same diagnostic tools as the allergist. Tools that the allergist is more likely to use include nasal cytology, skin testing and in vitro assays for specific immunoglobulin E. Patients with pure nonallergic rhinitis have negative skin tests or clinically irrelevant positive results. Mixed rhinitis refers to the presence of both allergic and nonallergic rhinitis components within the same individual. Allergic rhinitis more commonly develops before the age of 20, whereas nonallergic rhinitis affects an older population and disproportionately more females. The type of nasal symptoms manifested by the patient usually does not differentiate allergic from nonallergic rhinitis. Vasomotor rhinitis is the most common form of nonallergic rhinitis, followed by nonallergic rhinitis with eosinophilia and others. In terms of estimated prevalence, allergic rhinitis affects approximately 58 million Americans, 19 million have pure nonallergic rhinitis and 26 million have mixed rhinitis. Thus a wide spectrum of relevant epidemiologic information can be used to assist in determining the differential diagnosis of rhinitis. Physicians are reminded to look further and consider whether a rhinitis patient truly has pure allergic rhinitis or whether a diagnosis of mixed rhinitis or nonallergic rhinitis is more appropriate.

Rhinorrhea induced by loading of dental implants supporting an obturator prosthesis: a clinical report

This clinical report describes an unusual situation of nasal discharge that was initially considered to be caused by a leaking obturator prosthesis in a partially repaired cleft palate patient. Ultimately, the diagnosis was rhinorrhea induced by the loading of dental implants that supported the obturator. The differential diagnoses of nasal irritation, blocking of nasal drainage posterior or anterior through a premaxillary defect, vasomotor rhinitis, and gustatory rhinorrhea are presented and discussed, as well as the measures taken to reach the final diagnosis.

Bipolar radiofrequency-induced thermotherapy of turbinate hypertrophy: pilot study and 20 months' follow-up

OBJECTIVES/HYPOTHESIS

The present report is a pilot clinical study about a new bipolar ablation technique for the treatment of turbinate hypertrophy, which offers an alternative to conventional methods.

STUDY DESIGN

Prospective, clinical.

METHODS

From August 1999 to March 2000, a new bipolar radiofrequency system with acoustic feedback control was submucosally applied for the treatment of 38 patients with nasal airway obstruction of vasomotor (n = 31) or allergic (n = 7) genesis. The therapy was made ambulatory with surface anesthesia. Data were collected by questionnaire and rhinomanometry preoperatively and 2 and 20 months postoperatively.

RESULTS

Nearly all patients reported an improvement of their nasal breathing, with 68% of them reporting a full and 29% a partial recovery. No significant differences were reported with regard to the response of the allergic versus the vasomotor rhinitis. On average, a definite benefit was observed after 2 weeks. Side effects, such as bleeding, synechia, or atrophic changes of the mucosa, which would have to be treated, were not observed.

CONCLUSION

The new bipolar radiofrequency thermotherapy presents an efficient option for the treatment of turbinate hypertrophy, which meets the requirements for an outpatient treatment.

Clinicocytological correlation in establishing the aetiology of chronic rhinitis

Two hundred patients clinically diagnosed as having chronic rhinitis were provisionally grouped into allergic and non-allergic types of rhinitis on the basis of history, clinical examination, X-ray of the paranasal sinuses using the occipitomental view and other relevant investigations like differential and total leucocyte count. Whereas 158 cases were categorized into allergic rhinitis, 13 were diagnosed as suffering from vasomotor rhinitis, 25 from infective rhinitis and 4 patients from atrophic rhinitis. A nasal cytogram performed in all these cases showed allergic rhinitis in 107 cases, vasomotor rhinitis in 30 cases, infective on top of allergic rhinitis in 32 cases, common cold over allergic rhinitis in 3 cases, infective rhinitis in 20 cases, a non-infective non-allergic type in 4 cases and atrophic rhinitis in 4 cases. There was a good clinicocytological correlation; however, 30 patients clinically suspected to be having allergic rhinitis had an infective episode alone or on top of allergic rhinitis. Nasal cytology was thus found useful in modifying the treatment. It is a simple, easy and reliable investigation that can be done routinely in the out-patient department.

[Ho:YAG and diode laser treatment of hyperplastic inferior nasal turbinates]

BACKGROUND

Since the early 80's, chronic nasal obstruction due to hyperplastic turbinates is treated by laser light. Comparative clinical studies were performed to assess the clinical outcome of laser assisted endonasal turbinate surgery in longterm.

METHODS

By means of a pulsed Ho:YAG laser emitting light at lambda = 2100 nm (0.8 - 1.2 J/pulse, 4 - 8 Hz), 69 patients suffering from nasal obstruction due to allergic rhinitis (46 %) and vasomotor rhinitis (54 %) were treated under local anesthesia. Furthermore, 50 patients (52 % with allergic rhinitis and 48 % with vasomotor rhinitis) were treated by means of a GaAlAs-diode laser (c. w., lambda = 940 nm, 8 - 10 W). The treatment time took 3 - 10 min/turbinate and nasal packing was not necessary after the laser procedure. The study was conducted by a standardized questionnaire, photo documentation, allergy test, mucociliar function test, rhinomanometry, and acoustic rhinometry.

RESULTS

Within 4 weeks after laser treatment, an improvement of nasal airflow correlating to the extent of the ablated turbinate tissue could be determined in more than 80 % of the patients. Rhinomanometry revealed a significant improvement of the nasal airflow 6 months and 1 year after the laser treatment compared to the preoperative data. Side effects like nasal dryness and pain were rare (< 5 %). Diode laser treatment revealed more effective results than Ho:YAG laser treatment, however there was no significant difference between the two investigated groups. Patients suffering from vasomotor rhinitis showed far better results in long term in comparison to allergic rhinitis patients.

CONCLUSIONS

Ho:YAG and diode laser treatment can be performed as an outpatient procedure under local anesthesia in a short treatment time with promising results. It could become a time and cost effective treatment modality in endonasal laser surgery.

Electrophoretic evaluation of nasal discharge in patients with allergic rhinitis and vasomotor rhinitis

BACKGROUND

Allergic rhinitis and vasomotor rhinitis are two common diseases that have similar symptoms and physical findings. This study was designed to assess the efficacy of electrophoretic analysis of nasal discharge for the differential diagnosis of allergic rhinitis and vasomotor rhinitis.

METHODS

Two different groups of patients with allergic rhinitis (n = 18) and with vasomotor rhinitis (n = 18) diagnosed by current methods and 10 healthy subjects as a control group were included in this study. Component analyses of proteins in nasal wash were made by sodium dodecyl sulfate-polyacrylamide gel electrophoresis.

RESULTS

The mean levels of total protein, 66-kDa proteins and 26-kDa proteins (277.2 +/- 9 microg/mL, 114.5 +/- 9 microg/mL, and 67.0 +/- 4 microg/mL, respectively), in nasal washing samples of patients with allergic rhinitis were found to be higher than in the samples, (222.0 +/- 6 microg/mL, 65.6 +/- 6 microg/mL, and 42.9 +/- 4 microg/mL respectively) obtained from patients with vasomotor rhinitis. The control group showed the lowest rate of these proteins (167.8 +/- 7 microg/mL 34.3 +/- 3 microg/mL, and 25.0 +/- 3 microg/mL, respectively). The differences between mean levels of these proteins in all groups were statistically significant (p < 0.05).

CONCLUSIONS

These findings indicate that electrophoretic analysis of nasal discharge can be used for the diagnosis of allergic rhinitis and vasomotor rhinitis. However, further studies are needed to standardize the technique of nasal wash and to determine the range of proteins in nasal secretions that will confirm the diagnosis.

A characteristic protein in nasal discharge differentiating non-allergic chronic rhinosinusitis from allergic rhinitis

To differentiate non-allergic chronic rhinosinusitis (vasomotor rhinitis) from allergic rhinitis, a characteristic protein in the nasal discharge was studied. The subjects consisted of 10 patients with perennial allergic rhinitis to house dust, 10 patients without perennial rhinitis without antigen (clinically defined as non-allergic chronic rhinosinusitis) and 5 normal volunteers without nasal disease as a control group. The total protein in the nasal discharge was determined by Lowry's method and analysis of the protein components was made by SDS-PAGE. It was found that the nasal discharge obtained from the case with perennial allergic rhinitis contained a high concentration of albumin (25.9 micrograms/ml) and a characteristic protein band with an estimated molecular weight of 26 kilo-Daltons (kD) on a SDS-PAGE, in a concentration of 15.8 micrograms/ml. In contrast, the nasal discharge from non-allergic chronic rhinosonusitis patients contained a lower concentration of albumin (12.9 micrograms/ml) than that of the allergic rhinitis patients, and the concentration of the characteristic protein 26 kD was only 2.3 micrograms/ml. The 26 kD protein was considered to originate from the nasal glands, since its secretion could be provoked by stimulation of the nasal glands of the normal volunteers with a 1% pilocarpine spray. The low concentration of albumin and the characteristic protein 26 kD in the nasal discharge thus appeared to differentiate patients with non-allergic chronic rhinosinusitis from those with perennial allergic rhinitis.

[Rhinitis in old age]

The chronic rhinitis is a frequent problem with age. In the nose, normal physiologic changes of aging include loss of nasal tip support, atrophy of mucus-producing mucosal glands, and decreased olfaction. The fragmentation and weakening of the cartilage of the septum also causes airflow changes contributing to nasal stuffiness. These changes contribute to geriatric rhinitis, the symptoms of which are often attributed by the older patient to "allergies" or "sinus trouble". An understanding of these anatomic changes, linked with a thorough history and physical examination, allows the physician to properly manage geriatric rhinitis. Earnest causes like tumors or mycosis must be excluded. The treatment depends on the etiology of the rhinitis and also the symptoms of the patient. Therapy includes avoidance of all sorts of allergens (dust, fumes, sprays) and appropriate attention to minimizing home environmental and occupational exposures. Pharmacotherapy most often involves liquifying--not drying--nasal secretions with oral and topical preparations. Conservative surgical treatment is occasionally indicated.

[Clinical and immunohistoenzymatic investigations in patients with vasomotor and perennial allergic rhinitis]

The aim of our study was evaluation of the results of clinical examination in patients with vasomotor and perennial allergic rhinitis and assessment of number of blood vessels, nerve fibres and mast cells on the basis of immunohistoenzymatic examination. There were 42 patients examined aged from 18 to 50 and divided into three groups: I--16 patients with vasomotor rhinitis and II--14 patients with perennial allergic rhinitis and III--12 patients (control) with nasal septum deviation. On the basis of the patient's history data, clinical otorhinolaryngologic examination and active anterior rhinomanometry the patients were qualified to bilateral inferior turbinectomy. The nasal mucosa removed during surgery underwent immunohistoenzymatic examination using the monoclonal antibody against the tryptase of mast cells (MCT company, DAKO), the endothelin of blood vessels (EC - DAKO) and the neurospecific enolase (NSE - DAKO). In examined groups of patients with vasomotor and perennial allergic rhinitis and control group similar escalation of clinical symptoms expressed by means of points index were stated. In immunohistoenzymatic studies the differences in mean number of blood vessels and nerve fibres between examined groups were not statistically significant, however statistically significant difference concerned higher number of mast cells patients with vasomotor rhinitis in comparison to perennial allergic rhinitis.

Autonomic nervous system evaluation of patients with vasomotor rhinitis

OBJECTIVE

To demonstrate the utility of quantitative neurological laboratory testing of autonomic nervous system dysfunction and to apply this methodology to further study the relation of chronic vasomotor (nonallergic) rhinitis to the autonomic nervous system.

METHODS

It has been suspected that vasomotor rhinitis is due either to a hyperactive parasympathetic nervous system or an imbalance between it and the sympathetic nervous system. The exact relation has not been determined. Recently neurological laboratories have been developed in which a battery of tests can be performed to determine reactivity of the autonomic nervous system.

RESULTS

Autonomic nervous system testing was performed on 19 patients with symptoms fulfilling the diagnostic criteria for vasomotor rhinitis and the results were compared with 75 sex- and age-matched control subjects. Patients with vasomotor rhinitis had significant abnormalities of their sudomotor, cardiovagal, and adrenergic subscores. Their composite autonomic scale score was significantly impaired at 2.43, as compared with 0.11 for controls (P < .005).

CONCLUSION

Autonomic nervous system dysfunction is significant in patients with vasomotor rhinitis. Possible factors that trigger this dysfunction including nasal trauma and extraesophageal manifestations of gastroesophageal reflux are discussed.

[Allergic rhinitis]

Allergic rhinitis is one of the commonest diseases. The main allergens responsible are respiratory allergens. Pollinic or seasonal allergic rhinitis is currently distinguished from perannual or nonseasonal rhinitis, generally related to sensitization to allergens of the home environment. The diagnostic approach of allergic rhinitis is based on a careful clinical examination, in order to eliminate other causes of nasal dysfunction, and on complementary investigations, most importantly allergic skin tests. Several types of drugs, topically or systemically administered are currently available to treat allergic rhinitis. Surgical techniques should be reserved to patients who resist to medical treatment or to correct nasal architectural abnormality.

Treatment of chronic rhinitis by an allergy specialist improves quality of life outcomes

BACKGROUND

Allergic rhinitis is associated with significant impairment in quality of life and therefore has a significant impact on the indirect health care costs associated with treatment of chronic rhinitis in the United States. It has been stated that early intervention in the treatment of chronic rhinitis by an allergy specialist improves health outcomes but few unbiased studies have been conducted to substantiate this claim.

OBJECTIVE

This study measured quality of life outcomes in the treatment of chronic rhinitis by an allergy specialist.

METHODS

Quality of life changes were assessed using the Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) and the "Short-Form" 36-item questionnaire (SF-36) in patients before and after treatment of chronic rhinitis symptoms by a board-certified allergist. Patients with chronic rhinitis were asked by a 3rd year medical student to complete these questionnaires prior to any contact with the allergist. Treatment by the allergist included counseling on avoidance measures when appropriate and a new medication regimen. Patients were contacted by the 3rd year medical student 3 to 5 months later to complete follow-up RQLQ and SF-36 surveys. All data analysis was conducted independently by the 3rd year medical student.

RESULTS

Complete sets of pre-treatment and post-treatment surveys were obtained from 19 patients. Perennial allergic rhinitis was diagnosed for 13 patients, perennial allergic rhinitis with a seasonal component was diagnosed for three patients, vasomotor rhinitis was diagnosed for two patients and mixed allergic and non-allergic rhinitis was diagnosed for one patient. Statistically significant improvement was observed in four of the nine health concepts measured by the SF-36 questionnaire. Significant changes above the minimal important difference (MID) were observed post-treatment in six of eight RQLQ dimensions.

CONCLUSIONS

This study indicates that intervention by a board-certified allergist significantly improves many areas of health-related quality of life. Further studies comparing health care outcomes and costs of treating chronic rhinitis by primary care physicians to early intervention by allergy specialists are warranted.

Histamine releasability after adenosine challenge in subjects with allergic and non-allergic rhinitis: possible implications for mast cell priming

Nasal provocation with adenosine 5'-monophosphate elicits nasal symptoms in subjects with rhinitis. Histamine released from airway mast cells may play a role in adenosine-induced nasal responses. To investigate the possible role of histamine in mediating adenosine-induced nasal responses, we measured its release in the fluid obtained by nasal lavage after adenosine 5'-monophosphate, guanosine 5'-monophosphate, and placebo instillations. Nasal lavages were performed before and 3, 5, 10, 15, 30 and 45 min after challenge with adenosine 5'-monophosphate, guanosine 5'-monophosphate, and normal saline in 11 patients with rhinitis and 7 normal subjects in a double-blind randomized placebo-controlled cross-over study to evaluate symptoms and to monitor changes in histamine levels. No symptoms or significant increases in histamine were observed after guanosine 5'-monophosphate and placebo challenge. Symptom scores increased in response to adenosine 5'-monophosphate challenge in the rhinitic subjects but not in the normal controls. Nasal provocation with adenosine elicited a significant release of histamine in the nasal lavage fluids with an immediate peak response: its median (range) concentration increased from the baseline value of 1.33 (0.16-14.54) ng/mL to 2.68 (0.31-61.11) ng/mL at 3 min. However, increased histamine levels were not associated with nasal symptom scores. When compared to non-atopic subjects, significantly higher levels of histamine were seen in the nasal lavage fluids of the atopic subjects following adenosine challenge. In the atopic subjects, the median (range) histamine concentration increased from the baseline value of 1.54 (0.16-14.54) ng/mL to that of 4.21 (0.70-61.11) ng/mL at 3 min, whereas no increment was seen in the non-atopic subjects, their histamine concentration being 0.81 (0.29-5.56) ng/mL and 0.74 (0.31-14.25) ng/mL at baseline and 3 min after adenosine challenge respectively. These findings indicate that adenosine elicits nasal responses in patients with rhinitis but not in normal controls. Moreover, adenosine elicits an immediate rise in histamine levels in the nasal lavage fluid, with the highest rise in atopic compared to non-atopic volunteers, suggesting that the nasal responses to adenosine may be an index of mast cell priming.

State and trait anxiety in women affected by allergic and vasomotor rhinitis

It is still debatable whether anxiety and depression in patients affected by rhinitis could play a role in the genesis of the disease, whether they are a consequence of the symptoms. The aim of this study was to evaluate anxiety levels in both state and trait forms, and depression, in patients affected by allergic (AR) and vasomotor rhinitis (VMR). A total of 45 women, 24 AR and 21 VMR were compared with 64 healthy nonallergic women matched for age and sociodemographic characteristics. All subjects were administered the State and Trait Anxiety Inventory (STAI) and the Zung self-rating depression scale. The percentage of subjects with high levels of state anxiety was significantly higher in AR (p<0.005) and VMR (p<0.01) with respect to controls. The percentage of subjects with high levels of trait anxiety was significantly higher in AR (p<0.001) and VMR (p<0.05) than controls. There was no significant difference in depression between AR and VMR and controls. No significant difference was found in state anxiety, trait anxiety, or depression between AR and VMR. In conclusion, anxiety in patients with rhinitis is present both as a state and as a trait, at least when measured with the STAI.

Intranasal cold dry air is superior to histamine challenge in determining the presence and degree of nasal hyperreactivity in nonallergic noninfectious perennial rhinitis

The objective of the study was to compare cold dry air (CDA) and histamine in differentiating patients with nonallergic noninfectious perennial rhinitis (NANIPER) from control subjects. Nasal reactivity (nasal patency, mucus production, and sneezing) in 16 symptomatic nonsmoking patients with NANIPER and seven nonsmoking control subjects was measured with standardized CDA and histamine provocation series in a randomized crossover study. Intranasal CDA resulted in increased mucus production and nasal blockage in a dose-dependent manner in patients with NANIPER but not in control subjects. Sneezing did not occur. The reproducibility of CDA for patency and mucus production was good. Sensitivity for CDA was 87% compared with 100% for histamine. However, specificity was 71% for CDA and 0% for histamine. It is concluded that the new standardized intranasal CDA provocation method uses a recognizable natural nonspecific stimulus and seems to be more suitable than histamine for characterizing and assessing the presence and degree of nasal reactivity in NANIPER.

Vasomotor rhinitis and sphenopalatine ganglion block

The effectiveness of the sphenopalatine ganglion (SPG) block for the relief of symptoms in chronic vasomotor rhinitis was assessed in 30 patients of both genders. The number of blocks required for complete relief was three (range from two to four) at weekly intervals in 66.7% of volunteers. There was no recurrence of symptoms during a follow-up period of 12-20 months in 29 patients, and one patient was symptom free for 8 months. The technique is simple and can be performed as an outpatient procedure without side effects.

Specific nasal provocation test with powder allergen

Reported here are the results of a large-scale trial conducted under the guidance of Prof. Giovanni Motta, which I coordinated. A total of 656 patients with nasal hyperreactivity were recruited in 51 Italian centres (18 in the north of Italy, 20 in central Italy and 13 in the south). The trial's results were as follows. 1) A clear clinical prevalence of sensitization to different allergens in the different areas of Italy, which could be roughly classified thus: a) in Northern Italy birch and grasses were in the main species; b) in Central Italy mites prevailed but oleaceae were also significant; c) in Southern Italy parietaria and oleaceae were the prevailing species. 2) Most cases were sensitive to several allergens, although a considerable proportion (22%) actually presented reactions only to one allergen and those responding account of the patients sensitive to only one allergen and those responding to a main allergen, the proportion of patients reacting clinically to only one allergen rises to 64%. 4) The specific nasal provocation test (sNPT) offers specificity comparable to in vivo diagnostic methods such as the prick test, and in vitro methods such as RAST, but is much more sensitive. 5) The sNPT can be done in any season. 6) The sNPT is highly specific below a threshold value of nasal reactivity, which can be identified for each allergen studied and expressed in Allergenic Units. 7) In patients in whom the prick test shows multiple sensitivity, the specific NPT identifies the allergen presumably responsible for the nasal reactions (main allergen). In the light of these findings double-blind specific immunotherapy was started, to last 1 year, in 107 patients (49 given placebo and 58 active treatment), with nasal allergy to grasses, parietaria and mites. The results of this treatment were as follows: 74.1% of patients presented a reduction in nasal resistance, measured by dynamic anterior rhinomanometry, indicating relief of nasal obstruction; mucociliary transport time became normal in 81% of patients, meaning that rhinorrhoea had become less marked; there was significant rise in the nasal reactivity threshold in 74.1% of patients, illustrating the degree of desensitization achieved; nasal IgA increased by 62.5% of patients and IgG in 55.2% indicating improvement in the local immunological picture. No such improvements were detectable in the patients given placebo. In conclusion, therefore, the findings of this trial in allergic rhinitis underline that the specific NPT proved more sensitive than other in vivo and in vitro diagnostic methods and is unquestionably a fundamental investigational approach for assessing nasal allergies, identifying the allergens causing the symptoms and setting up rational local immunotherapy. The sNPT also showed the efficacy of specific intranasal immunotherapy.

A comparative immunological study of vasomotor rhinitis and pollinosis

Differentiation between pollinosis and vasomotor rhinitis creates great diagnostic difficulties. The aim of this study was to conduct comparative immunological clinical studies contrasting these two distinct diseases. Thirty-one subjects with untreated pollinosis and 29 subjects with untreated symptoms of rhinitis were tested, determining their T and B lymphocyte counts and the counts of their subpopulations, the levels of immunoglobulin A, M, G, D and E, both separately and in total, and levels of both basal and whole histamine. The control group was comprised of 30 healthy subjects. The results of this study show that these two diseases differ from each other (p < 0.05) in the recorded levels of basal histamine, total IgE, and IgG, IgM and IgD, as well as the count of T-RFC lymphocytes, T lymphocytes with receptors for Fc IgG and B lymphocytes with superficial receptors for IgG. The most useful laboratory methods for diagnosing the difference between pollinosis and vasomotor rhinitis appear to be the determination of levels of basal histamine and IgD in the blood.

The nasal response to isometric exercise in non-eosinophilic intrinsic rhinitis

The exact pathophysiology of intrinsic rhinitis is not fully understood. The generally held belief is that it is due to an imbalance between the outflow of the nasal sympathetic and parasympathetic nervous systems, perhaps due to excessive parasympathetic or reduced sympathetic activity. In this study the nasal airway response to a predominantly sympathetic stimulus, isometric exercise, was studied in 19 patients with intrinsic rhinitis and compared with 16 normal patients. Isometric exercise took the form of a handgrip stimulus using a hand dynomometer. Following sustained handgrip, a small fall of nasal resistance in the normal group (0.058 kPas/1) and a moderate rise in nasal resistance in the rhinitis group (0.242 kPas/1) was found. Pulse and blood pressure changes were the same in both groups with a significant rise in pulse rate and diastolic blood pressure. The study shows that there is an abnormal response to isometric exercise in intrinsic rhinitis, perhaps due to relative nasal sympathetic hyposensitivity.

[The treatment of allergic vasomotor rhinitis: diagnostic problems and local immunotherapy]

Treatment of allergic vasomotor rhinitis is to be regarded with the factors that modify the symptomatology. In fact must be considered the morphological changes (septum deviation, adenoids, turbinates hypertrophy, polyps) infections (bacteria, chlamydiae, micetes) and specific allergens. Identification of allergens and sensitization threshold is to be studied; then specific hyposensitization will be assessed. In the present study, 68 subjects having nasal reactivity have been observed and underwent to different ways of treatment: 18 with permanent stenosis identified by rhinomanometry and not modified with vasoconstrictors were operated; 25 of the 50 patients with normal nasal cavities showed contemporary infections: after a specific antimicrobic or antimycotic treatment, a clear improvement was obtained documented by rhinomanometry before and after nasal stimulations. The 50 patients with normal morphology underwent a local hyposensitization against the allergens. As a matter of fact: a) in all cases a clear improvement was obtained in phase of increasing; b) after one year of maintainance just 13 over 50 (26%) returned to previous conditions. The Authors remark how local immunotherapy by the nasal way give good possibilities in a high percentage of cases in the following conditions: correct clinical evaluation, especially concerning the identification of factors determining vasomotor rhinitis; employment of precise techniques for diagnosis; observation of clinical data and results turning out from instrumental investigations, especially concerning the nasal provocation test evaluated by rhinomanometry.

The differential diagnosis of rhinorrhea

Rhinorrhea disrupts the quality of life of a large segment of the population. The first step to treating it properly is to make an accurate diagnosis of its underlying cause. This is not always a simple proposition, however, because rhinorrhea has many causes that can easily be confused in clinical practice. Diagnosis has come to rely increasingly on testing, but test costs add significantly to the health-care burden. This article reviews the use of medical logic in the differential diagnosis of rhinorrhea and describes the relative usefulness of various testing methods.

[Differentiation between allergic rhinitis and vasomotor rhinitis by electrophoretic evaluation of the protein in pituita]

Application of trichloro-acetic acid (TCA) to the inferior turbinates is being performed at our hospital to treat allergic rhinitis. However, some patients have continous rhinorrhea even though the provocation test after treatment was negative. Electrophoretic studies were performed on the nasal discharge of such continuous rhinorrhea patients to analyze its protein components, albumin and 23kD protein. The results showed that the pituita in the unimproved cases with negative provocation result was similar in nature to the pituita in vasomotor rhinitis patients. It was concluded that the proteins in the pituita were not attributable to an antigen-antibody reaction, because the provocation test was negative, but they were the result of angiogenic factors (= vasomotor rhinitis). Thus it appears that allergic rhinitis can be classified into two types: genuine allergic rhinitis and allergic rhinitis associated with vasomotor rhinitis. TCA therapy was not effective in the cases of allergic rhinitis with vasomotor rhinitis, because they had a pathophysiological feature of vasomotor rhinitis. Genuine allergic rhinitis can be differentiated from vasomotor rhinitis clinically by measuring albumin and 23kD protein in pituita. It was concluded that measurement of 23kD protein concentrations in pituita is effective for determining indications for TCA chemotherapy and evaluating its clinical results.

[Exercise rhinomanometric test in the diagnosis of vasomotor rhinopathy]

The Authors examined 55 patients divided into two groups, one of 30 vasomotor rhinopatic patients and the other of 25 normal subjects. The aim of the study was to set up an objective diagnostic rhinomanometer test through observation and evaluation of reaction brought about by physical exertion following an exertion test of 5 minutes which employed a computerized climb simulator. Nasal resistance was measure before and immediately after exertion and then at intervals of 10, 20 and 50 minutes. Our data reveal a noteworthy decrease in nasal resistance brought about by the sympathetic nervous system in normal and rhinopathic subjects. Return to pre-exertion values, however occurred difference in the two groups: in the control group nasal resistance returned to pre-exertion values slowly, while in the rhinopathic group, it decreased rapidly and a rebound effect was observed. In vasomotor rhinopathy the orthosympathetic system is overcome by the para sympathetic system with regard to nasal vascularization control and, therefore, in rhinopatic patients exertion stimulates efficacions activation of the orthosympathetic system a phenomenon which does not occur in healthy subject. On the basis of our results an intensive stimulus such as physical exertion seems to have a different effect on the two groups suggesting that the vessels of nasal mucosa do not always respond in the same way, and that in vasomotor patients there is an alternate reactivity of neural control of nasal mucosa. The rhinomanometric exercise test seems to be useful in revealing this phenomenon and to be diagnostically reliable. The method is easily reproducible, non-invasive and can be usefully applied in clinical practice associated with the normal rhinomanometric challenge test.

Pseudo-cerebrospinal fluid rhinorrhea

Because of its potentially serious sequelae, cerebrospinal fluid (CSF) leakage following surgery for lesions of the cranial base is given immediate attention by neurosurgeons. Despite a multitude of approaches used to prevent its occurrence, CSF leakage complicates up to 30% of difficult skull-base tumor operations. The authors describe the cases of 11 patients who developed a syndrome, not previously described in the literature, termed "pseudo-CSF rhinorrhea." This syndrome occurs after surgery of the cranial base, usually involving dissection or removal of the petrous or cavernous carotid artery, the greater superficial petrosal nerve, and the pericarotid sympathetic plexus. It is characterized by nasal stuffiness and nasal hypersecretion and is sometimes accompanied by facial flushing. The symptoms are characteristically exacerbated by exertion or by elevated ambient room temperatures. Lacrimation is typically absent ipsilateral to the pseudo-CSF rhinorrhea. It is believed that pseudo-CSF rhinorrhea developed in these patients because of a relative imbalance of the regulatory autonomic supply of the nasal mucosa.