Detection of the nasal cycle.

The nasal cycle is a fluctuation of nasal patency due to the stages of congestion and decongestion of the nasal mucosa on both the right and left nasal conchae. We compared the effectiveness of the rhinostereometer in detecting the presence of a nasal cycle with the acoustic rhinometer whose effectiveness we have demonstrated in previous studies. The rhinostereometer measures the horizontal range of the most anterior portion of the inferior turbinate. The acoustic rhinometer measures the volume and various cross-sectional areas of the nostril using a pulse emitted from a sound tube. Among some of the subjects tested, it was found that rhinostereometer and acoustic rhinometer measurements of nasal patency correlated reasonably well with r values up to 0.78. The overall correlation between rhinostereometry and acoustic rhinometry was not as strong at r = 0.36. Observed variations between rhinostereometry and acoustic rhinometry could be a result of certain confounding variables that may have altered the nasal cycle between measurements.

Absence of nasal mucosal atrophy with fluticasone aqueous nasal spray.

OBJECTIVE: To evaluate whether 1 year of continuous treatment with intranasal fluticasone propionate would lead to atrophy in the nasal mucosa compared with an active control, oral terfenadine. DESIGN: Prospective, randomized, multicenter, open-label, parallel-group study. SETTING: Two tertiary care academic institutions. PATIENTS: Seventy-five subjects older than 18 years with perennial allergic rhinitis. INTERVENTIONS: Patients received either fluticasone propionate aqueous nasal spray, 200 microg once daily, or terfenadine, 60 mg twice daily, for 1 year. Nasal biopsy specimens were obtained before and after 1 year of treatment and were evaluated for evidence of atrophy. MAIN OUTCOME MEASURES: Epithelial and collagen layer thickness of the nasal mucosa as assessed by light microscopy and the presence and degree of edema, and regularity of collagen fibrils as assessed by electron microscopy. Analyses were performed without knowledge of subject identity or treatment assignment. RESULTS: Neither fluticasone nor terfenadine treatment led to atrophy in the nasal mucosa by clinical or histologic observation. No significant changes from baseline were observed for any assessment of atrophy. In contrast to what would have been expected if atrophy were to occur, mean epithelial layer thickness in the fluticasone group significantly increased compared with terfenadine treatment (P = .03). CONCLUSIONS: Treatment with intranasal fluticasone for 1 year increases the thickness of the nasal epithelium as compared with a year's treatment with terfenadine and does not lead to atrophy in the nasal mucosa. The increased thickness in the fluticasone treatment may represent repair from epithelial damage caused by chronic allergic inflammation.

Nasal congestion: a review of its etiology, evaluation, and treatment.

The most common clinical syndromes that cause nasal congestion are allergic rhinitis, vasomotor rhinitis, chronic sinusitis, and upper respiratory viral infections (common colds). Nasal congestion, in turn, can lead to sequelae such as sinusitis, otitis media, and the onset or worsening of mild to severe sleep disturbances, including obstructive sleep apnea. There is a host of conservative treatments, including decongestant pharmacotherapy, antiallergy measures, and nasal dilation devices. Several surgical procedures are also available. This article reviews the current guidelines for the workup and diagnosis of nasal congestion and briefly describes the many and varied approaches to treatment.

Acoustic rhinometry and computed tomography scans for the diagnosis of nasal septal deviation, with clinical correlation.

OBJECTIVE: The aim in this study was to analyze the efficiency and reliability of acoustic rhinometry (AR) readings in recognition of nasal septal deviation. METHOD: We compared 24 patients' AR readings with their sinus CT scans. The patient data were analyzed by comparison with normative data, area, and percentage differences between the two sides. Additionally, the data further analyzed by receiver operating characteristic curve and Spearman correlation of CT and AR in determining nasal septal deviation. RESULTS: The sensitivity of AR in detecting anterior septal deviations was found to be 54%, with a specificity of 70%. A very highly significant correlation (P < or = 0.001) was found between minimal cross-sectional area (CSA) 1 values and CT results. DISCUSSION: In the interpretation of AR readings, comparison of each CSA value should be included, in addition to use of the total absolute CSA values. CONCLUSION: According to our findings the diagnosis of nasal septal deviation can be supported by AR readings.

Health status in allergic rhinitis.

Although valid and reliable instruments exist to measure the quality of life of allergic rhinitis patients, a statistically sensitive and clinically meaningful way to evaluate patients undergoing immunotherapy has not been reported. A 21-site prospective, observational study was performed in a population of consecutive patients with allergic rhinitis. Baseline general health measures revealed significant (P < 0.05) decrements from reported normative levels in 8 domains for patients choosing to undergo immunotherapy and 5 domains for patients choosing not to undergo immunotherapy. The General Health Survey was less sensitive in detecting change than the Nasal Health Survey (Chronic Sinusitis Survey) and allergy-specific (Rhinoconjunctivitis Quality of Life Questionnaire and Allergy Outcome Survey) surveys. Severity of symptoms was associated with both the likelihood to choose immunotherapy and the likelihood for early improvement. We conclude that general and condition-specific measures can be used to observe patients after immunotherapy; however, obtaining baseline data and controlling for seasonality are important considerations.

Allergic fungal rhinosinusitis: pathophysiology, epidemiology, and diagnosis.

Allergic fungal rhinosinusitis (AFRS) is believed to have a cause similar to allergic bronchopulmonary aspergillosis (ABPA). Both are thought to be mediated by both type I (IgE) and type III (IgE-antigen immune complexes) Gell and Coombs reactions. ABPA patients also exhibit unique characteristics, such as HLA-DR2 or HLA-DR5 genotypes, and elevated suppressor T cell activity. While the pathophysiology of AFRS is similar histopathologically, similar immunologic studies have not been as well documented. Most cases of AFRS involve dematiaceous fungi, rather than Aspergillus. A suggested laboratory work-up for the disease is presented.

ImmunoCAP and HY*TEC enzyme immunoassays in the detection of allergen-specific IgE compared with serial skin end-point titration by receiver operating characteristic analysis.

OBJECTIVES: In this study, we compared 2 different immunoassays, HY*TEC enzyme immunoassay (Hycor Biomedical Inc, Garden Grove, CA) and Pharmacia Upjohn ImmunoCAP (Pharmacia and Upjohn, Kalamazoo, MI) using skin end-point titration as a gold standard by receiver operating characteristic analysis. MATERIALS: One hundred patients were enrolled in this study and were tested with the above 3 modalities. The results were analyzed by receiver operating characteristic analysis, in which the curves give a decision criterion for any diagnostic test relative to its sensitivity and specificity against an accepted gold standard test. Only inhalant allergens (Dermatophagoides pteronyssinus, Dermatophagoides farina, cat dander, giant ragweed, English plantain weed, timothy grass, Alternaria tenuis, Aspergillus fumigatus, meadow fescue, oak tree, white ash tree, and lamb's-quarter weed) were studied. RESULTS: The results obtained with both ImmunoCAP and HY*TEC showed a good correlation with skin end-point titration for D pteronyssinus, D farina, cat dander, giant ragweed, timothy grass, A tenuis, and meadow fescue, with sensitivities ranging from 71% to 88%. However, the sensitivity of both tests to English plantain weed, lamb's-quarter weed, oak tree, and white ash tree was lower (66% down to 39%). Additionally, HY*TEC results were not satisfactory for detecting specific IgE to A fumigatus (30% sensitivity). The overall sensitivity for each test was 65.67% for the HY*TEC and 71.25% for the ImmunoCAP. CONCLUSION: The 2 in vitro testing systems are comparable for most of the allergens, except for A fumigatus, English plantain, lamb's-quarter, and white ash tree; ImmunoCAP and HY*TEC would benefit from improved technology for detecting these specific IgE antibodies. The HY*TEC assay did not give acceptable results for A fumigatus. The overall assay characteristics were good to excellent for each system tested.

Effect of nasal surgery on the nasal cavity as determined by acoustic rhinometry.

Acoustic rhinometry (AR) was used to objectively measure the success of septoplasty in relieving nasal obstruction caused by septal deviation. In addition, the patients were given a questionnaire to subjectively assess symptoms of congestion, rhinorrhea, and sneezing. Patients diagnosed with a septal deviation requiring surgery to eliminate obstruction were enrolled in this study. A septal deviation often results in concomitant sinonasal or respiratory problems that require septoplasty plus other surgeries to treat the patient effectively. AR measurements for patients who underwent septoplasty or septoplasty plus other surgeries were taken before and after surgery. To avoid confounding results caused by different levels of congestion, we used only postdecongestant values to analyze the data and only the side of the nose with the smaller volume for analysis. Patients in the septoplasty-only group showed a statistically significant (P < 0.01) increase in volume as measured by AR, a decrease in the symptom of congestion, and a decrease in the symptom of rhinorrhea. Patients who had septoplasty plus other sinonasal procedures showed significant increases in volume and cross-sectional area (CSA) 3, whereas CSAs 1 and 2 increased also, but not significantly.

Anatomic correlates of acoustic rhinometry as measured by rigid nasal endoscopy.

Acoustic rhinometry (AR) evaluates the cross-sectional areas and volume of the nasal cavity through acoustic reflections. Successive valleys displayed on an AR graph are believed to correspond to anatomic landmarks. To assess the anatomic accuracy of AR, we performed AR and endoscopic measurements with a rigid endoscope in 85 normal human subjects after topical decongestion. Endoscopic measurements were recorded for distances between the midcolumella and the nasal valve, the anterior end of the inferior turbinate, the anterior end of the middle turbinate, the midportion of the middle turbinate, and the posterior nasopharynx. The first AR valley most closely corresponded with endoscopic measurements of the nasal valve. The second valley had a mean value that corresponded with the anterior end of the inferior turbinate. The third valley matched best with the values of the anterior end of the middle turbinate. Nasopharyngeal measurements by each modality yielded a good agreement. AR appears to correspond to nasal anatomic landmarks but not in an exact point-to-point manner.

Decreased neuropeptide release may play a role in the pathogenesis of nasal polyps.

In this in vivo prospective, controlled study, we have examined the capsaicin-induced levels and secretion patterns of the colocalized neuropeptides substance P, calcitonin gene-related peptide (CGRP), and neurokinin A in nasal secretions of subjects with nasal polyps, and we compared these with secretion patterns from healthy subjects and from subjects with allergic rhinitis. Capsaicin was used to elicit neuropeptide release. The neuropeptide levels were measured by an ELISA technique. For substance P, subjects with nasal polyps responded very poorly to capsaicin stimulation. The atopic group was more reactive to capsaicin stimulation than control subjects. For CGRP the increase was immediate in all groups. Atopic subjects and subjects with polyps had a less pronounced but sustained response to capsaicin stimulation. CGRP levels in atopic subjects and those with polyps were restored rapidly. Atopic subjects had higher neurokinin A levels with an immediate and sustained response to capsaicin. Control subjects had higher levels than those with polyps, but both groups were nonresponsive to capsaicin stimulation.

Development of the allergy outcome survey for allergic rhinitis.

The Allergy Outcome Survey (AOS) is a reliable measure used to monitor patients with allergic rhinitis. It was developed for and included in the Outcomes Measures of Immunotherapy in Allergic Rhinitis (OMIAR-1) project, designed to study the benefits of immunotherapy in the treatment of allergic rhinitis. Preliminary results indicate that AOS is specific, brief, reliable, and easy to use. Also, it is useful for evaluating change with therapy and can be used alone as a performance metric or in combination with other measures as part of a more complete outcomes monitoring system. As the OMIAR-1 study progresses, more information will be available on the advantages and limitations of the AOS.

The distribution of nasal erectile mucosa as visualized by magnetic resonance imaging.

We analyzed the distribution of nasal erectile tissue by reviewing five sets of magnetic resonance imaging scans that were obtained pre- and post-decongestion. We found that cavernous tissues were located at three sites: the inferior turbinate, the middle turbinate, and the nasal septum. This study reaffirms the findings of previous studies that were performed with other modalities such as computed tomography scanning and cadaver dissections.

Detection of the nasal cycle with acoustic rhinometry: techniques and applications.

Acoustic rhinometry is an appropriate method for detecting and recording the nasal cycle in normal subjects in terms of the cross-sectional areas and volume of the nasal cavity. In this study, we tried to detect and to define the nasal cycle in normal subjects so that we might develop a reliable and reproducible technique to be used in conjunction with studies on the physiology and pathology of nasal disease. We used normal volunteer adult subjects and performed bilateral acoustic rhinometry measurements every 15 minutes over 4 hours, along with the use of a visual analog scale for assessment of the subjective feeling of congestion (or patency) just before each acoustic rhinometry measurement. Volume and cross-sectional area changes were observed along with subjective patency-score changes in each subject. The subjective feeling of patency was not related to the volume and cross-sectional area changes measured simultaneously. The technique of recording the nasal cycle with acoustic rhinometry in nasal research is presented.

The effect of external nasal dilators as measured by acoustic rhinometry.

The effect of a commercially available external nasal dilator, Breathe Right (CNS, Inc., Minneapolis, MN) was measured with acoustic rhinometry in 11 healthy subjects. The cross-sectional areas--1, 2 and 3--and nasal volume--from 0 to 6 cm2--were obtained in four situations: 1) pre-decongested with no dilator, 2) pre-decongested with dilator, 3) post-decongested without dilator, and 4) post-decongested with dilator. The device significantly increased cross-sectional area (CSA) 1, which corresponds to the nasal valve area in both the pre-decongestant and post-decongestant states (p = .0001 for both). The appliance also significantly increased the nasal volume in the pre-decongested state (p = .0002), but was not significant for the post-decongested state (p = .0707). The appliance caused a significantly greater increase in CSA 1 as compared to that achieved with decongestion alone. The results of this study indicate that the Breathe Right nasal dilator may be used ot increase the area of the nasal valve.

Normative standards for nasal cross-sectional areas by race as measured by acoustic rhinometry.

Acoustic rhinometry evaluates the geometry of the nasal cavity with acoustic reflections and provides information about nasal cross-sectional area and nasal volume within a given distance. Variations in internal nasal diameters have attracted increased interest since the advent of endoscopic surgical techniques. Race is known to be one of the most important factors affecting the nasal structure. In this study, we evaluated 106 healthy adult volunteers with acoustic rhinometry to determine internal nasal diameters and volumes and obtained normative data for four racial/ethnic groups. The data were analyzed with regard to race, sex, height, and weight. All measurements were made before and after the application of a topical nasal decongestant so that the effects of the nasal cycle were eliminated by decongestion.

Allergy for the laryngologist.

Allergic disease can affect any portion of the respiratory tract, including the larynx, trachea, bronchial tree, nasal cavity, paranasal sinuses, nasopharynx, and pharynx. This review evaluates laryngeal manifestations of allergic disease and the impact of allergic mechanisms in disorders, within the scope of laryngology.

Fungal sinusitis: progression of disease in immunosuppression--a case report.

Fungal sinusitis is a disease which can be grouped into invasive and noninvasive forms. The invasive entities include the acute/fulminant and chronic/indolent forms. The noninvasive entities include the fungus ball and allergic forms. The noninvasive forms, however, can develop into invasive disease under certain immunosuppressive states. The patient in this case report had the fungus ball form of fungal sinusitis which evolved into chronic, and then the acute/fulminant form approximately two weeks after undergoing cadaver-donor kidney transplantation. Due to the patient's immunosuppressed state, the fungus spread beyond the sinus region and eventually lead to fulminant disseminated disease. The severity of the fungal disease corresponded directly to the severity of the patient's immunosuppression.

Assessment of the indoor environment in respiratory allergy.

Many types of allergens may be present in the indoor environment and may lead to sensitization and respiratory allergy. Common indoor allergens include dust mites, animal dander, cockroach exposure and molds. Exposure to indoor pollutants, such as tobacco smoke, wood-burning stoves or fireplaces and chemical sprays, can precipitate and exacerbate symptoms. An allergic reaction in the airways caused by natural exposure to allergens has been shown to lead to an increase in inflammatory reaction, increased airway hyperresponsiveness and increased eosinophils in bronchoalveolar lavage. Other research has demonstrated that asthma symptoms correlate with levels of domestic dust mite and cockroach exposure. In the case of dust mites, ending exposure results in symptomatic relief.

Prevalence of mold-specific immunoglobulins in a Midwestern allergy practice.

Mold allergy surveys are an important part of the correct identification and treatment of mold allergies. This study included 100 patients who were referred to a Midwestern allergy clinic for the evaluation of rhinitis, suspected to be of allergic origin. An in vitro screening test for allergen-specific IgE (ImmunoCAP) comprised of 10 allergens, including Candida, Aspergillus, Helminthosporium, and Alternaria, was used. To assess the seasonal distribution of mold allergies, we randomly selected 8 patients out of the 100 from each season during which the clinical contact occurred, and we tested them for 14 varieties of mold. The overall incidence of mold allergy in atopic subjects was 44%. The most common molds were (in descending order of frequency) Alternaria, Helminthosporium, Aspergillus, Candida, and Curvularia. Mold allergy was diagnosed most frequently in the winter; the second highest period was the fall. Population surveys of IgE antibody sensitization by in vitro techniques can provide useful information about fungal allergy.

A comparison of the nasal cross-sectional areas and volumes obtained with acoustic rhinometry and magnetic resonance imaging.

Acoustic rhinometry (AR) evaluates the geometry of the nasal cavity with acoustic reflections and provides information about nasal cross-sectional areas (CSA) and nasal volume within a given distance. The accuracy of the information obtained by AR was compared with that of magnetic resonance imaging (MRI) of the nasal cavity. Five healthy subjects were evaluated with AR and the MRI before and after the application of a long-acting nasal decongestant spray, to eliminate possible interference of the nasal cycle with both measurement techniques. The MRI images of 2 mm coronal sections of the nasal cavity were traced by three independent observers and the CSAs were calculated by computer-aided imaging digitization, to be compared with the calculated CSAs obtained with the AR at the corresponding distance from the nasal tip. Digitized data from the MRI images were also used to calculate the nasal volume within the first 6 cm from the nasal tip and compared with the AR volume measurements. The interobserver variation of digitized MRI data predecongestant and postdecongestant was not significant. The correlations of CSA and volume measurements between the AR and MRI were high (0.969) after the application of the decongestant. The correlation between the AR and MRI measurements before the decongestant was low (0.345). This may have been the result of interference of the nasal cycle during the long MRI measurements (1 hour) or other unknown factors. We conclude that AR measurements of nasal CSAs and volumes provide accurate information when compared with the MRI of the decongested nasal airway.