Differences in clinical features of cluster headache between drinkers and nondrinkers in Japan.

OBJECTIVE: Alcohol has been recognized as the main trigger for a cluster headache attack, but clinical features to distinguish between cluster headache in drinkers and nondrinkers are unclear. Thus, the present study aimed to investigate the differences in clinical features of cluster headache between drinkers and nondrinkers. METHODS: This retrospective, observational study compared the clinical features of cluster headache between drinkers and nondrinkers among patients who were diagnosed with cluster headache between November 2004 and April 2018 at the Japanese Red Cross Shizuoka Hospital. Demographic and clinical data were collected from medical records and/or by patient interview. RESULTS: Of 131 patients, 98 (75%) were drinkers, and 33 (25%) were nondrinkers. Compared with nondrinkers, drinkers had significantly more frequent conjunctival injection (43% vs. 21%, p = 0.037) but significantly less frequent nasal congestion (31% vs. 52%, p = 0.0037), vomiting (11% vs. 30%, p = 0.014), and photophobia (29% vs. 45%, p = 0.008). CONCLUSION: Among individuals with cluster headache, the frequencies of conjunctival injection, nasal congestion, vomiting, and photophobia were different between drinkers and nondrinkers. These results suggested that drinking might influence the responses of the cranial autonomic reflex with respect to conjunctival injection or nasal congestion.

Comorbid disorders associated with asthma in children in Germany - National analysis of pediatric primary care data.

BACKGROUND: Using routine healthcare data, the goal of this study was to examine the association between asthma and comorbid disorders in children in Germany. METHODS: Patients with a diagnosis of asthma documented by a German pediatrician in 2015 were identified. Demographic data included age and gender. Patients younger than 6 and older than 17 and individuals followed for less than a year before index date were excluded. Each patient was matched for age, sex, and physician with an asthma-free control. A total of 34,305 cases and 34,305 controls were available for analysis. There were three different age groups: 6-9 years, 10-13 years, and 14-17 years. Several disorders known to be associated with asthma or found in more than 1% of children and adolescents were also determined on the basis of primary care diagnoses. A multivariate logistic regression model was used to estimate the association between asthma and comorbid disorders. RESULTS: The mean age was 10.9 years, and 61.6% of the subjects were boys. The most common diseases found in the three age groups were vasomotor and allergic rhinitis, chronic bronchitis, chronic rhinitis, pneumonia, and atopic dermatitis. These five comorbid disorders were associated with asthma to a significant extent. CONCLUSIONS: Overall, this study, based on primary healthcare data, found a considerably high prevalence of several comorbid diseases in German children with asthma.

Diseases of the Upper Respiratory Tract in Preschool and School Age Children in Ambulatory Ear Nose Throat Practice.

The most common diseases of the upper respiratory tract in children treated by ear-nose-throat (ENT) specialists in ambulatory practice are infections, such as colds, rhinitis, sinusitis and pharyngitis, very frequently accompanied and promoted by chronic nasal obstructions of various etiology. These diseases, when treated incorrectly or for too long, cause frequent school absenteeism and may also lead to hearing disorders linked with acute or suppurative otitis. They may also habitually perpetuate abnormal breathing and result in occlusal disorders. The aim of this study was to assess the incidence and type of upper respiratory tract diseases in children, depending on age and sex of patients and on the seasons. We also discussed the role of the ENT specialist in the diagnosis and treatment of certain diseases. In the study we analyzed the medical records of patients of preschool and school age treated in the ENT outpatient clinic over one calendar year. It was found that the largest group of patients comprised children of 3-7 years of age, and most children visited the outpatient clinic in the period March-May. The most common main disorder, according to ICD-10, was acute nasopharyngitis (J00) and vasomotor and allergic rhinitis (J30). Among the comorbid disorders H65 and H66 were the most frequent. No significant gender differences were noted in the frequency of particular types of disease.

Chapter 14: Nonallergic rhinitis.

Rhinitis is characterized by one or more of the following nasal symptoms: congestion, rhinorrhea (anterior and posterior), sneezing, and itching. It is classified as allergic or nonallergic, the latter being a diverse syndrome that is characterized by symptoms of rhinitis that are not the result of IgE-mediated events. Excluding infectious rhinitis and underlying systemic diseases, clinical entities that can be classified among the disorders that make up the nonallergic rhinitis syndromes include gustatory rhinitis, nonallergic rhinitis with eosinophilia syndrome (NARES), atrophic, drug-induced (rhinitis medicamentosa), hormone induced, senile rhinitis (of the elderly), rhinitis associated with chronic rhinosinusitis with or without nasal polyps, and the idiopathic variant formerly known as vasomotor rhinitis but more accurately denoted as nonallergic rhinopathy (NAR). The prevalence of nonallergic rhinitis has been observed to be one-third that of allergic rhinitis, affecting ~7% of the U.S. population or ~22 million people. NAR is the most common of the nonallergic rhinitis subtypes, comprising at least two-thirds of all nonallergic rhinitis sufferers. Although certain precipitants such as perfume, strong odors, changes in temperature or humidity, and exposure to tobacco smoke are frequently identified as symptom triggers, NAR may occur in the absence of defined triggers. The diagnosis of nonallergic rhinitis is purely clinical and relies on a detailed history and physical exam. Skin testing or in vitro testing to seasonal and perennial aeroallergens is required to make the diagnosis of nonallergic rhinitis. Because of the heterogeneous nature of this group of disorders, treatment should be individualized to the patient's underlying pathophysiology and/or symptoms and is often empiric.

Allergic rhinitis and non-allergic rhinitis in children in the tropics: prevalence and risk associations.

BACKGROUND: The age-related comparative prevalence of allergic rhinitis (AR) and non-allergic rhinitis (NAR) in children is poorly defined. We aimed to characterize AR and NAR in children. METHODS: This study enrolled children with chronic rhinitis who presented to a tertiary paediatric center for a diagnostic skin prick test (SPT). Parents completed a medical history questionnaire for their child, including disease activity for asthma and rhinitis. Sociodemographic data was obtained and all participants underwent a common inhalant SPT panel. A positive SPT indicated AR. RESULTS: From March 2001 to March 2009, 6,660 children (64% male) were enrolled (aged 6 months to 19 years, mean 7.82 years). Only 3.7% (249) of the children were <2 years old, and almost 30% of these had AR. Most children with AR (73%) presented after age 6. Males were more likely to have AR (vs. NAR) (OR 1.5; CI 1.39-1.77). Antihistamine and salbutamol use did not differ between children with AR and NAR. Children with AR were more likely to require adjunct therapy with inhaled corticosteroids (51.2% vs. 43.2%, P < 0.001), have drug hypersensitivity (especially antipyretic drugs) (2.5% vs. 1.3%, P = 0.384) or an asthma admission (9.1% vs. 6.0%, P < 0.001). CONCLUSIONS: AR is more common in male children, is relatively rare below the age of 2 years, and accounts for two-thirds of all childhood chronic rhinitis and 73.3% of all chronic rhinitis in school-aged children (≥6 years old). Children with AR have more severe rhinitis symptoms and more often suffer from asthma-related events and admissions.

Nonallergic rhinopathy (formerly known as vasomotor rhinitis).

This review focuses on the poorly understood condition of nonallergic rhinopathy (NAR) at a clinical level, with an eye on current optimal treatment. NAR is the new designation for the conditions formerly referred to as vasomotor rhinitis or nonallergic idiopathic rhinitis. The clinical characteristics and differential diagnosis are provided in detail in this review, and the disease should now be characterized sufficiently for clinical studies.

Vasomotor rhinitis.

Vasomotor rhinitis is a common disorder that is seen routinely in allergy practice. It affects millions of Americans and results in significant morbidity. The pathophysiology of this complex heterogeneous disorder is unknown, but we are making advances in this regard. Symptoms and signs can closely resemble those of allergic rhinitis and can be difficult to differentiate from those resulting from allergy. A careful history, physical examination, and diagnostic testing help clinicians arrive at a definitive diagnosis, but treatment can be challenging. Therapy should be based on the presenting symptoms of vasomotor rhinitis. Combination therapy with topical corticosteroids and azelastine is useful. However, in patients whose predominant symptom is rhinorrhea, use of atopical anticholinergic agents can be quite useful. Up-to-date pathogenesis, epidemiology, diagnosis, and treatment approaches are discussed in this review.

[Comparison of risk factors between patients with non-allergic rhinitis and allergic rhinitis].

OBJECTIVE: To investigate and describe the differences in age, sex, seasonality distribution, and related environmental factors between patients with non-allergic rhinitis (NAR) and allergic rhinitis (AR). METHODS: One hundred and eleven patients with NAR and 112 patients with AR were enrolled in this study. All patients were first diagnosed in outpatient department between January and August 2010. Questionnaires were distributed to all participants to record the general information, medical history, and the factors relevant to symptom onset. Statistical analysis was performed using a SPSS13.0 software. RESULTS: The proportion of patients with NAR increased with age, compared to patients with AR. The peak age was 21 - 30 years old in patients with NAR, whereas 11 - 20 years old in patients with AR. In adults more than 18 years old, the average age (years, x(-) ± s) of patients with NAR (38.6 ± 14.5) was significantly higher than those with AR (32.8 ± 13.0; t = 2.58, P = 0.024). NAR was more likely to be males before 30 years old, while after 30 years old, it likely to be female predominance. The same case occurred in AR subjects but in their 20 years old. NAR was symptomatically worse in winter (χ(2) = 27.57, P = 0.000), whereas AR worse in spring (χ(2) = 13.75, P = 0.003). The cases of NAR were significantly more than those of AR during the winter season (χ(2) = 12.34, P = 0.000). Among the disease-related environmental factors, living or working place near the traffic artery had 1.94-fold increased risk for development of NAR compared with AR; however, living or working in ground floor or sunshine time less than 2 h per day had 1.77- or 1.91-fold increased risk for development of NAR compared with NAR. Subjects with personal or family history of allergic disease had 2.14 to 4.06-fold increased risk for development of AR compared with NAR. The self-reported predisposing factors in NAR patients were mainly including temperature shift (56.3%), common cold (52.8%), climate change (32.4%), and strong odors (31.1%). However, there were no significant differences in these nonspecific triggers between NAR and AR (all P > 0.05). CONCLUSION: There are significant differences in the distribution of age, sex and seasonality, personal and family history of allergic disease, and some environmental factors relevant to the onset of symptom between patients with NAR and AR.

[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.

Weather/temperature-sensitive vasomotor rhinitis may be refractory to intranasal corticosteroid treatment.

Vasomotor rhinitis (VMR) is a common but poorly understood disorder of which there are two major subgroups: VMR(w/t), triggered by weather/temperature and VMR(ir), triggered by airborne irritants. No specific biological pathways or specific treatments for VMR(w/t) or VMR(ir) have been identified. However, intranasal corticosteroids (INSs) are effective in treating many forms of nonallergic rhinitis that include these conditions. A recently introduced INS with established efficacy in allergic rhinitis and enhanced affinity, fluticasone furoate, may possess the potency and safety profile required to treat chronic VMR(w/t). Two replicate studies (FFR30006 and FFR30007) were conducted in six countries to evaluate the efficacy and safety of fluticasone furoate nasal spray in subjects with VMR(w/t). After a 7- to 14-day screening period, subjects (n = 699) with symptomatic VMR(w/t) received fluticasone furoate, 110 mug q.d. or placebo for 4 weeks in these two randomized, double-blind, parallel-group studies. Subjects rated their nasal symptoms (congestion, rhinorrhea, and postnasal drip) twice daily on a 4-point categorical scale and evaluated their overall response to treatment at study end. Fluticasone furoate did not significantly improve daily reflective total nasal symptom scores, the primary end point, versus placebo (p = 0.259) and there was no improvement in any other measure of efficacy. The active treatment was well tolerated. Fluticasone furoate was not effective in treating subjects with a newly defined condition, weather-sensitive VMR. These unexpected results suggest that VMR(w/t) is a distinct subgroup of VMR that is refractory to treatment with INSs. Additional study of other treatments for VMR(w/t) (including INSs) is warranted.

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.

Rhinitis in pregnancy.

About 30% of women suffer from nasal symptoms during pregnancy. The hormonal changes occurring during pregnancy favour per se mucosal oedema and relaxation of smooth muscles, thus contributing to nasal congestion. The most common forms of rhinitis are allergic, drug-induced, infectious and vasomotor rhinitis. In addition to the detrimental effects that rhinitis can have on quality of life, it is important to correctly treat rhinitis itself since it can influence concomitant asthma, as underlined in ARIA document. In pregnancy, the safety profile of drugs is the primary item to be considered. The American FDA pointed out that foetal damage could not be totally excluded with the majority of antirhinitis drugs. It is recommended to use "older drugs" because more data about their safety are available. Cromones are the safest drugs but, although they need multiple daily administrations. Antihistamines should be considered as second choice drugs, and their use is not recommended during the first three months of pregnancy. Topical steroids are useful in moderate-severe rhinitis, being beclometasone the most documented molecule. Topical vasoconstrictors should not be used continuously because they can induce pharmacological rhinitis. It is not recommended to start specific immunotherapy in pregnancy but it can be continued in patients who benefit from its use. Infective rhinitis should be treated with beta-lactams, cephalosporins or macrolides. Finally it is important to evaluate the cost/usefulness ratio before any drug prescription.

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.

Vasomotor rhinitis following trauma to the nose.

Complaints of nasal obstruction following nasal trauma without any deformation have been noticed by rhinologists for many years. However, neither an epidemiologic nor a pathophysiologic connection has ever been established. The complaints and physical examination findings of these patients resemble those of vasomotor rhinitis. Only very few articles suggesting nasal trauma as a possible cause for vasomotor rhinitis have ever been published. We present a retrospective study that found 87 of 802 patients to suffer from vasomotor rhinitis following nasal trauma. No other factors known to cause vasomotor rhinitis were present in these patients. None had any previous nasal problems. We therefore suggest that nasal trauma was the causative factor in their vasomotor rhinitis.

A prevalence study of chronic rhinitis among residents in Telok Blangah Town, Singapore.

A community-based questionnaire survey on a random sample of 562 persons aged seven to 81 years residing in the flatted housing estate of Telok Blangah, Singapore, was studied to determine the prevalence of chronic rhinitis, its associated risk factors and severity of the symptomatology. Chronic rhinitis was defined as the presence of nasal obstruction or clear, watery discharge together with any or both of the following: tearing eyes or sneezing, for a period of more than one month. The overall prevalence was 32.5% with Chinese having the highest ethnic specific rate of 33.9% followed by Indians (27.1%) and Malays (25.4%). The age-specific prevalence rates showed a clear downward trend with increasing age (P < 0.0001). Among the risk factors studied, family history of atopy ranked the highest followed by personal history of atopy and age group (< 30 years and 30 years or more). Most of the chronic rhinitis' symptoms (79%) were graded as not severe.

Evaluacion clinica y patologica de la rinitis vasomotora / Clinical and pathological evaluation of vasomotor rhinitis

Se presentan los resultados de un estudio hecho en 38 pacientes con diagnostico clinico y por laboratorio de Rinitis Vasomotora y 14 controles, que asistieron a la consulta externa otorrinolaringologica del Hospital Universitario San Vicente de Paul, en Medellin, Colombia, entre mayo de 1987 y diciembre de 1988. Se encontro que la RV en nuestro medio es una enfermedad que predomina en mujeres jovenes entre 12 y 34 anos con obstruccion nasal de mas de un ano de evolucion como principal motivo de consulta y tumefaccion de cornetes con buena respuesta vasoconstrictora como hallazgo predominante al examen fisico. Los estudios realizados (IgE serica total, prueba de Anderson, espirometria, recuento de celulas metacromaticas en raspado de mucosa nasal y biopsia de cornete inferior) no fueron de valor diagnostico. Como hallazgo importante se encontro mediante la espirometria, en el 73% de los pacientes, obstruccion pulmonar en ausencia de sintomatologia respiratoria inferior. p<0.05).8

We performed a case-control study of 38 cases of vasomotor rhinitis (VR) diagnosed at the Otorrhinolaryngology Outpatient Clinic at Hospital Universitario San Vicente de Paúl, Medellin, Colombia, between May 1987 and December 1988. These cases were proved both clinically and by laboratory evaluation and were compared to 14 controls. VR was predominant in young women aged 12 to 34 years (75%). Nasal congestion of more than one year evolution was the outstanding symptom and edematous turbinates with good vasoconstriction retraction was the predominant sign on physical examination. The tests performed (serum total lgE, Anderson's test, pulmonary function tests, nasal metachromatic cell counts and turbinate biopsy) had no diagnostic value. One Important finding was the spirometric detection of pulmonary obstruction without clinical manifestations that was observed in 73% of the cases (p