Can a Pretreatment Visual Analog Scale Predict Treatment Outcome in Allergic Rhinitis?

BACKGROUND: The visual analogue scale (VAS) is a simple and useful tool to assess the severity of allergic rhinitis. Whether a pretreatment VAS score can guide appropriate medication is unclear. OBJECTIVE: The aim of this study was to evaluate whether a pretreatment VAS score could be used to predict therapeutic response. METHODS: A prospective 4-week cohort study involving 101 allergic rhinitis patients was carried out. All patients were treated with triamcinolone acetonide aqueous nasal spray 220 µg once daily for 28 days. The treatment outcomes were evaluated using VAS scores (0-10 cm), total nasal symptoms scores (TNSSs), nasal mucociliary clearance times (NMCCTs), and global symptom controls (GSCs). The minimal clinically important differences (MCIDs) method was used to separate the patients into with and without improvement groups. Receiver operating characteristic curve analysis was performed to evaluate the predictive value of pretreatment VAS scores in relation to MCIDs after treatment. RESULTS: Pretreatment VAS scores showed a positive correlation with pretreatment TNSSs and NMCCTs (ρ = 0.66, p < 0.001 and r = 0.44, p < 0.001, respectively), and a negative correlation with GSCs after treatment (r = -0.53, p < 0.001). The MCID values of TNSSs and NMCCTs were 3.19 and 2.78, respectively. The cutoff value of pretreatment VAS ranged between 6.5 and 7.7 points, with an average value of 7.1. CONCLUSION: A pretreatment VAS score of 7 or higher was associated with an unfavorable treatment outcome, which suggests the potential therapeutic predictive value of VAS scoring.

Correlation Between Peak Nasal Flow Reversibility and Mucociliary Clearance in Allergic Rhinitis.

OBJECTIVES/HYPOTHESIS: Reversibility of nasal airflow after decongestion measured by rhinomanometry is associated with the severity of allergic inflammation. Peak nasal flow is a simpler alternative method for assessing nasal patency. The aim of this study was to evaluate the correlation between changes in peak nasal expiratory and inspiratory flows (PNEFs and PNIFs) after decongestion and nasal mucociliary clearance times (NMCCTs). STUDY DESIGN: Single-center, prospective cross-sectional study. METHODS: One hundred one allergic rhinitis patients were enrolled. Nasal symptoms and NMCCTs were assessed. PNEF and PNIF were performed before and after decongestion. Correlations between changes in PNEF and PNIF after decongestion and NMCCTs were analyzed. One-half the standard deviation of baseline peak nasal flows was used to estimate the minimal clinically important differences (MCIDs) and discriminate between patients with reversible mucosa and with irreversible mucosa. RESULTS: PNEF showed more peak flow improvements after decongestion compared to PNIF. Changes in PNEF had better negative correlations with NMCCTs than PNIF (ρ = -0.49, P < .001 and ρ = -0.34, P < .001, respectively). The MCID values of the PNEF and PNIF were 27.93 and 19.74, respectively. In comparisons of NMCCTs between patients with or without MCID of peak nasal flow after decongestion, PNEF had better discrimination ability compared to PNIF (P = .003 and P = .026, respectively). CONCLUSIONS: The limitation of reversibility as measured by peak nasal flows could indirectly point to the affection of mucosal inflammation as indicated by NMCCTs. PNEF is more sensitive to assess peak flow changes after decongestion than PNIF. LEVEL OF EVIDENCE: 2 Laryngoscope, 130:1372-1376, 2020.

Does oxymetazoline increase the efficacy of nasal steroids in treating nasal polyposis?

BACKGROUND: Although nasal steroids are the mainstay treatments in nasal polyposis, up to one-half of patients do not respond and need surgical treatment. This study aimed to evaluate whether oxymetazoline administration produces any additive effect on nasal steroid therapy and whether rebound congestion develops after oxymetazoline treatment. METHODS: Sixty-eight patients with nasal polyposis were randomly assigned in a 1:1 ratio to receive either oxymetazoline plus mometasone furoate nasal spray (MFNS) or placebo plus MFNS, 2 sprays per nostril twice daily, with an interval of 5 minutes between each medication for 4 weeks. All the patients were then treated with MFNS, 2 sprays per nostril twice daily for 2 weeks. The nasal symptoms score, peak inspiratory flow index, nasal mucociliary clearance time (NMCCT), and total nasal polyps score were used to evaluate treatment outcomes. An intention-to-treat analysis was performed, and a worst case sensitivity analysis was applied to missing cases. RESULTS: Thirty-four patients were allocated to the oxymetazoline-MFNS group, and 34 to the placebo-MFNS group. One patient in each group was lost to last-visit follow-up. At 4 weeks after beginning treatment, the oxymetazoline-MFNS group showed significantly greater improvement in blocked nose, hyposmia, peak flow, NMCCT, and total nasal polyps score than the placebo-MFNS group. During the nasal steroid phase, both groups showed continuing improvement in all outcome variables. However, the oxymetazoline-MFNS group still showed significantly greater improvement in blocked nose, hyposmia, NMCCT, and total nasal polyps score, but not peak flow, than the placebo-MFNS group at the end of the study. CONCLUSION: The use of nasal steroids with oxymetazoline was more effective over 6 weeks than nasal steroids alone in improving blocked nose, hyposmia, nasal mucociliary clearance, and polyp size in treatment of nasal polyposis. There was no evidence of rebound congestion after 4 weeks of oxymetazoline treatment.

Clinical efficacy of nasal steroids on nonallergic rhinitis and the associated inflammatory cell phenotypes.

BACKGROUND: Although good response to nasal steroid therapy has been documented in allergic rhinitis (AR), the efficacy of this treatment in non-AR, and the associated inflammatory cell phenotypes has not been fully investigated. OBJECTIVE: To compare the response to steroids in non-AR versus AR and to assess the impact of inflammatory cell phenotypes on non-AR treatment outcomes. METHODS: A total of 149 patients with rhinitis were divided into non-AR and AR groups by using the allergy skin-prick test. Based on nasal cytology, the non-AR group was further divided into inflammatory non-AR (INAR) and noninflammatory non-AR (NINAR) groups, and the INAR groups were further subdivided into four phenotypes according to inflammatory cell type: non-AR with eosinophils (NARES), non-AR with mast cells (NARMA), non-AR with neutrophils (NARNE), and NARES and mast cells (NARESMA). All the patients were treated over 28 days with 220 µg of nasal triamcinolone acetonide once daily. Nasal symptom score, peak inspiratory flow index, and nasal mucociliary clearance time (NMCCT) were used to evaluate treatment outcomes. RESULTS: The initial screening found 67 patients with non-AR and 82 patients with AR. At 28 days after nasal steroid treatment, all nasal symptom score, peak inspiratory flow indexes, and NMCCTs were significantly improved within each group; however, the non-AR group recorded significantly lower levels of improvement in blocked nose, rhinorrhea, sneezing, nasal itching, peak flows, and NMCCTs than the AR group. The NINAR group overall indicated lower levels of improvement than the INAR group. Among the INAR subgroups, the NARESMA, NARES, and NARMA phenotypes had similar outcome improvements, all better than the NARNE phenotype. CONCLUSION: Although both patients with non-AR and those with AR had good steroid response, the patients with non-AR had less improvement than the patients with AR. Patients with NINAR had the worst treatment outcome among the non-AR phenotypes.

Nasal peak inspiratory and expiratory flow measurements for assessing nasal obstruction in allergic rhinitis.

BACKGROUND: Although nasal peak flow measurements have been proposed as a simple alternative method to assess nasal patency, which of nasal peak expiratory flow or nasal peak inspiratory flow (NPEF/NPIF) or the peak expiratory flow index or peak inspiratory flow index (PEFI/PIFI; the ratios between nasal and oral PEF or nasal and oral PIF, respectively) is the more accurate method is unclear. The aim of this study was to evaluate the correlation between NPEF, NPIF, PEFI, and PIFI, and blocked nose score (BNS) and mucociliary clearance time (MCCT) in diagnostic and follow-up assessments. METHODS: Ninety-nine allergic rhinitis (AR) patients were treated with 220 micrograms once daily of intranasal triamcinolone acetonide for 28 days. BNS, NPEF, NPIF, PEFI, and PIFI and MCCT were used to evaluate treatment outcome. Correlations of initial visit scores and score changes after treatment between peak flow rates and BNSs and MCCTs were analyzed. RESULTS: All nasal symptoms, peak flows, and MCCTs showed statistically significant improvements after the nasal steroid treatment. PEFI showed the best negative correlation with BNS and MCCTs, followed by PIFI, NPEF, and NPIF. Nasal peak flows showed better correlations with MCCTs than BNSs. Mean changes of peak flow rates between visits showed better correlation with BNSs and MCCTs than absolute values of peak flow rates at the initial visit. CONCLUSION: Among nasal peak flow measurements, PEFI is the most appropriate objective tool for assessing nasal patency in AR. Peak flows can indicate underlying mucosal inflammation and are more sensitive to assess score changes after treatment than cross-sectional assessment at the initial visit.

Does oral prednisolone increase the efficacy of subsequent nasal steroids in treating nasal polyposis?

BACKGROUND: Although combined oral and nasal steroid therapy is widely used in nasal polyposis, a subset of patients show an unfavorable therapeutic outcome. This study aimed to evaluate whether oral prednisolone produces any additive effects on subsequent nasal steroid therapy and to evaluate if any clinical variables can predict therapeutic outcome. METHODS: Using a 3:2 randomization ratio, 67 patients with nasal polyposis received 50 mg of prednisolone and 47 patients received placebo daily for 2 weeks, followed by mometasone furoate nasal spray (MFNS) at 200 micrograms twice daily for 10 weeks. Clinical response was evaluated by nasal symptom score (NSS), peak expiratory flow index (PEFI), and total nasal polyps score (TNPS). Potential predictor variables were assessed by clinical history, nasal endoscopy, allergy skin test, and sinus radiography. RESULTS: At the end of the 2-week oral steroid phase, the prednisolone group showed significantly greater improvements in all nasal symptoms, nasal airflow, and polyp size than the placebo group. In the nasal steroid phase, while the MFNS maintained the outcome improvements in the prednisolone group, all outcome variables in the placebo group showed continuing improvements. At the end of the nasal steroid phase, there were no significant differences of most outcome improvements between the two groups, except in hyposmia, PEFI, and TNPS (p = 0.049, p = 0.029, and p = 0.005, respectively). In the prednisolone group, patients with polyps grade 3 and endoscopic signs of meatal discharge showed significantly less improvement in total NSS, PEFI, and TNPS than patients with grade 1-2 size and negative metal discharge. CONCLUSION: In the 12-week treatment evaluation of nasal polyposis, pretreatment with oral steroids had no significant advantage for most nasal symptoms other than earlier relief; however, combined oral and nasal steroid therapy more effectively improved hyposmia, polyps size, and nasal airflow. Polyps size grade 3 and/or endoscopic signs of meatal discharge predisposed to a poorer treatment outcome.

Clinical efficacy of a short course of systemic steroids in nasal polyposis.

BACKGROUND: Although oral steroids are widely used for the treatment of nasal polyposis, a subset of patients shows an unfavorable therapeutic outcome. The aim of this study was to evaluate the efficacy of a short course of oral prednisolone in nasal polyposis and to evaluate which, if any, clinical variables can predict treatment outcome in these patients. METHODOLOGY/PRINCIPAL: Using a 3:2 randomization ratio, 63 patients with nasal polyposis received 50 mg of prednisolone and 46 patients received placebo daily for 14 days. Clinical response was evaluated by total nasal symptoms score (TNSS), peak expiratory flow index (PEFI) and total nasal polyps score (TNPS). Potential predictor variables were assessed by clinical history, nasal endoscopy, allergy skin test and sinus radiography. RESULTS: The prednisolone-treated group showed significantly greater improvements in all nasal symptoms, nasal flow and polyp size than the placebo-treated group (p < 0.001, all). In the prednisolone-treated group, patients with grade 3 polyps and positive nasal endoscopy showed significantly less improvement in TNSS, PEFI and TNPS than patients with grades 1-2 size and with negative nasal endoscopy. CONCLUSIONS: A short course of oral steroids showed good clinical efficacy in the treatment of nasal polyposis, however, polyps size grade 3 and/or positive nasal endoscopy predispose to a poorer treatment outcome.

Impact of IgE-mediated hypersensitivity on nasal mucociliary clearance.

OBJECTIVE: To evaluate the effect of IgE-mediated hypersensitivity on mucociliary clearance time (MCCT) and clinical severity, as indicated by total nasal symptoms score (TNSS) and peak expiratory flow index (PEFI). DESIGN: A prospective cross-sectional study. SETTING: Tertiary medical center. PARTICIPANTS: One hundred twenty-nine patients with rhinitis and 48 healthy control subjects. MAIN OUTCOME MEASURES: Results of an allergy skin prick test in the patients with rhinitis categorized them as allergic (AR) or nonallergic (non-AR). We evaluated TNSS and PEFI in the patient group and assessed MCCTs from the patients in the rhinitis groups and the healthy controls. RESULTS: The AR group patients had the longest MCCT, followed by patients in the non-AR group and the healthy controls (mean MCCTs, 14.36, 10.87, and 6.55 minutes, respectively). The AR group patients had significantly higher TNSS and worse PEFI compared with patients in the non-AR group (P = .002 and P = .03, respectively). We found a significant positive correlation of MCCTs with TNSS, and MCCTs showed a tendency to be inversely correlated with PEFI (rho = 0.43 [P < .001] and r = -0.22 [P = .05], respectively). In AR group patients, the wheal responses to Dermatophagoides pteronyssinus, Dermatophagoides farinae, American cockroach, and Bermuda grass were fairly correlated with the MCCTs (r = 0.39 [P = .001], r = 0.40 [P = .001], r = 0.34 [P = .01], and r = 0.36 [P = .02], respectively). The maximal wheal response among various positive allergen responses was well correlated with the MCCTs (r = 0.54 [P < .001]). CONCLUSION: A prolonged MCCT, significant correlation between MCCTs and the magnitude of allergen reactivity, and clinical severity suggest an impact of IgE-mediated hypersensitivity on mucociliary clearance function.

Impact of pretreatment nasal symptoms on treatment outcome in allergic rhinitis.

OBJECTIVE: The Allergic Rhinitis and its Impact on Asthma (ARIA) classification of allergic rhinitis (AR) is based on the severity and duration of nasal symptoms. Whether nasal symptoms have an impact on treatment outcome is unclear. The aim of this study was to evaluate the correlation between pretreatment nasal symptoms and therapeutic response in AR. STUDY DESIGN: Case series with planned data collection. SETTING: Tertiary medical center. SUBJECTS AND METHODS: Sixty-nine AR patients were classified according to ARIA class: mild or moderate-severe intermittent AR (MIAR or MSIAR) and mild or moderate-severe persistent AR (MPAR or MSPAR). All patients were treated over 28 days with 220 microg of intranasal triamcinolone acetonide once daily. Nasal symptoms, peak expiratory flow index, and global symptom control were used to evaluate treatment outcome. RESULTS: At 28 days after treatment, MSPAR patients showed the worst global symptom control, followed by MSIAR, MPAR, and MIAR (mean global symptom controls were 76.5%, 83.8%, 87.7%, and 89.0%, respectively). Pretreatment total nasal symptom score was inversely correlated with global symptom control (rho = -0.405, P < 0.001), but positively correlated with percent total nasal symptom score and peak expiratory flow index improvements (rho = 0.271, P = 0.024; and rho = 0.371, P = 0.002, respectively). Blocked nose had the best inverse correlation with global symptom control (rho = -0.389, P = 0.001). CONCLUSION: A worse treatment outcome despite more clinical improvements during the treatment period in a higher severity score suggests the therapeutic predictive value of pretreatment nasal symptom scoring and the need for more dosing and continuing medication in higher scores, especially in blocked nose.

The correlation between nasal symptom and mucociliary clearance in allergic rhinitis.

OBJECTIVE/HYPOTHESIS: The Allergic Rhinitis and Its Impact on Asthma (ARIA) classification of allergic rhinitis (AR) is based on the severity and duration of nasal symptoms. Whether the nasal symptoms actually represent underlying nasal inflammation is unclear. The aim of this study was to evaluate the correlation between nasal symptoms and nasal inflammation using mucociliary clearance time (MCCT) in AR. STUDY DESIGN: A prospective cross-sectional study. METHODS: 73 AR patients were classified according to ARIA class: mild or moderate-severe intermittent AR (MIAR or MSIAR) and mild or moderate-severe persistent AR (MPAR or MSPAR). Each nasal symptom was scored as 1 to 3 on a severity scale (mild-moderate-severe). The sum of the individual nasal symptom scores gave the total symptoms score (TSS). MCCT was determined with the charcoal-saccharin method. MCCTs between ARIA classes were compared and correlations between TSS or days with symptoms per week (DSW) and MCCT were analyzed. RESULTS: Of the patients, 67.1% were moderate-severe degree. MSPAR had the worst MCCT, followed by MSIAR, MPAR, and MIAR (mean MCCTs of 14.32, 13.87, 11.94, and 10.28 minutes, respectively). TSS was well correlated with MCCT (P = .538, P < .001). DSW was also correlated with MCCT, but did not reach statistical significance (r = 0.217, P = .065). The mean MCCT of overall nasal symptoms increased along with each score step and a significant difference was noted between scores 2 and 3 (P < .001). CONCLUSIONS: A high percentage of moderate-severe disease and a significant correlation of the severity and MCCTs suggest an important heterogeneity in this disease severity group. Discriminating between moderate and severe rhinitis should help to obtain homogeneous populations and develop improved disease management strategies.

Dose-related effect of intranasal corticosteroids on treatment outcome of persistent allergic rhinitis.

OBJECTIVES: To evaluate the efficacy of the self-adjustable dosing regimen and explore potential dose-response relationships of intranasal corticosteroids in persistent allergic rhinitis. STUDY DESIGN: Prospective cohort study. SUBJECTS AND METHODS: Sixty-nine persistent allergic rhinitis patients were treated with 220 mcg of intranasal triamcinolone acetonide for 28 days. Patients with mild, intermittent symptoms were instructed to use the medication only after symptoms occurred once a day. Patients with symptoms that lasted more than 1 day and/or interrupted daily activities/sleep were instructed to continue the morning daily dose until they were symptom-free for 24 hours before stopping usage. RESULTS: All nasal symptom scores and peak expiratory flow index (PEFI) showed statistically significant improvements after treatment. At 28 days after treatment, the number of puffs and weight of steroids used were positively correlated with percentages of improvement in total symptoms score (TSS) and PEFI (rho = 0.529, r = 0.571 and rho = 0.350, r = 0.509 respectively). When at least 1400 mcg or 44 puffs were used, 60% TSS and 10% PEFI improvement were achieved. CONCLUSION: A self-adjustable dosing approach proved to be an efficacious approach to controlling allergic rhinitis.

The relationship between allergy and rhinosinusitis.

BACKGROUND: IgE-mediated hypersensitivity is considered by some to be a predisposing factor for developing rhinosinusitis, although the theory is still controversial. The purpose of this study was to evaluate the relationship between allergy and rhinosinusitis. DESIGN: A cross-sectional study. METHODS: 198 rhinitis patients were enrolled. An allergy skin prick test was done and the subjects categorized as allergic or nonallergic. Nasal endoscopy and sinus radiography were performed. The criteria for diagnosis of rhinosinusitis were rhinitis symptoms and positive nasal endoscopy (discharge from middle and/or superior meatus) and/or abnormal sinus radiography. RESULTS: Allergic patients were significantly more likely to have abnormal findings on sinus radiography than non-allergic patients (p < 0.001) and would therefore fulfill the criteria on which rhinosinusitis may be diagnosed, but the two groups were not significantly different in positive nasal endoscopy results (p = 0.553). Among the patients with abnormal sinus radiography, the allergic patients were significantly less likely to have a positive nasal endoscopy compared to the nonallergic patients (p = 0.006). CONCLUSIONS: Allergic rhinitis subjects were significantly more likely to have abnormal findings on sinus radiography compared with nonallergic subjects potentially leading to a diagnosis of rhinosinusitis. However, they were also significantly more likely to have abnormal sinus radiography with negative nasal endoscopy than the nonallergic subject. These findings could suggest an association between allergic rhinitis and rhinosinusitis via IgE mediated hypersensitivity.