CD4+ Foxp3+ Regulatory T-cells in Modulating Inflammatory Microenvironment in Chronic Rhinosinusitis with Nasal Polyps: Progress and Future Prospect.

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a subtype of chronic rhinosinusitis (CRS) characterized by the presence of nasal polyps (NP) in the paranasal mucosa. Despite the complex etiology, NP is believed to result from chronic inflammation. The long-term aftermath of the type 2 response is responsible for symptoms seen in NP patients, i.e. rhinorrhea, hyposmia, and nasal obstruction. Immune cellular tolerogenic mechanisms, particularly CD4 + Foxp3 + regulatory T cells (Tregs), are crucial to curtail inflammatory responses. Current evidence suggests impaired Treg activity is the main reason underlying the compromise of self-tolerance, contributing to the onset of CRSwNP. There is compelling evidence that tumor necrosis factor 2 (TNFR2) is preferentially expressed by Tregs, and TNFR2 is able to identify the most potent suppressive subset of Tregs. Tumor necrosis factor (TNF)-TNFR2 interaction plays a decisive role in the activation and expansion of Tregs. This review summarizes current understanding of Tregs biology, focusing on the discussion of the recent advances in the study of TNF-TNFR2 axis in the upregulation of Treg function as a negative feedback mechanism in the control of chronic inflammation. The role of dysregulation of Tregs in the immunopathogenesis of CRSwNP will be analyzed. The future perspective on the harnessing Tregs-mediated self-tolerant mechanism in the management of CRSwNP will be introduced.

Efficacy of topical tranexamic acid to reduce bleeding in endoscopic sinus surgery for chronic rhinosinusitis with polyposis.

PURPOSE: To evaluate the efficacy of topical tranexamic acid (TXA) in reducing intraoperative and immediate postoperative bleeding during functional endoscopic sinus surgery (FESS) among patients with chronic rhinosinusitis with nasal polyposis (CRSwNP). METHODS: This is a double-blind randomized clinical trial, involving 26 patients with CRSwNP, who underwent FESS for failed medical therapy. The intervention nostril was packed with ribbon gauze soaked in 500 mg/5 ml TXA. The control nostril was packed with ribbon gauze soaked in Moffett's solution, containing 2 ml 10% cocaine, 1 ml adrenaline 1:1000, and 4 ml 0.9% sodium bicarbonate. Both nostrils were packed for 15 min before FESS. Intraoperative bleeding was recorded in the initial 30 min after commencing the surgery. The recordings were reviewed by two surgeons using Boezaart's scoring system. The scores were taken at 15 and 30 min of surgery. The mean score was then calculated. At the end of the surgery, the intervention nostril was packed with Merocel® soaked in 500 mg/5 ml TXA and the control nostril was packed with Merocel® soaked in normal saline. The amount of bleeding within 24 h post-surgery was evaluated using a bolster gauze. RESULTS: There was no significant difference in intraoperative bleeding between the intervention (1.54 ± 0.71) and control nostrils (1.69 ± 0.55) with p = 0.172. The amount of bleeding in the postoperative period was significantly reduced in the intervention nostril (1.33 ± 0.55) compared to the control nostril saline (1.81 ± 0.48) with p = 0.001. CONCLUSIONS: We found that the nasal packing soaked in TXA reduced intraoperative and immediate postoperative bleeding. It is a safe, efficacious and cost-effective alternative to Moffett's solution during FESS and also an alternative to normal saline post-surgery among patients with CRSwNP. TRIAL REGISTRATION NUMBER: FF-2015-232, 2015.

Diagnostic value of serum and tissue eosinophil in diagnosis of asthma among patients with chronic rhinosinusitis.

BACKGROUND: Chronic rhinosinusitis (CRS) is one of the most common chronic inflammatory diseases of sinonasal mucosa. Asthma among CRS patients is often underdiagnosed which makes the management of CRS more challenging. Therefore, using serum and tissue eosinophil as an indicator and predictor of asthma in CRS patients is vital for further preventing recurrent and increasing the effectiveness of treatment for CRS. OBJECTIVE: To determine the association and diagnostic ability of serum and tissue eosinophils in the diagnosis of asthma among CRS patients. METHODS: A cross-sectional study was conducted involving 24 CRS patients with asthma and without asthma, respectively, from the Otorhinolaryngology clinic of two tertiary hospitals located on the East Coast of Peninsular Malaysia. Serum and tissue eosinophils (obtained from nasal polyp) levels between both groups were compared. Association between serum and tissue eosinophils with asthma was evaluated using logistic regression analysis, adjusting for important sociodemographic characteristics. The diagnostic ability of serum and tissue eosinophil was then evaluated by assessing the receiver operating characteristic curve. RESULTS: A total of 48 CRS patients with a mean [SD] age of 47.50 [14.99] years were included. Patients with asthma had significantly higher serum [0.48 vs 0.35 × 109/L] and tissue eosinophil [100 vs 8.5 per HPF] levels. Tissue eosinophils were found to be an independent predictor of asthma with adjusted OR 1.05, p < 0.001, after adjusting for age and serum eosinophils. The area under the receiver operating characteristic curve for serum eosinophil was 69.0%. At optimal cut-off value (0.375 × 109/L), the sensitivity and specificity for serum eosinophil was 75.0% and 70.8%. The area under the receiver operating characteristic curve for tissue eosinophil was 93.4%. At the optimal cut-off value (58.0 per HPF), the sensitivity and specificity for tissue eosinophils were 79.2% and 91.7%, respectively. CONCLUSION: This study indicates a significantly higher level of serum and tissue eosinophils in CRS with asthma. However, there was no correlation between serum and tissue eosinophils in both group. Based on this study, the CRS patient needs to be screened for asthma if the level of serum eosinophil is > 0.375 × 109/L and tissue eosinophil > 58 per HPF.

Overall survival and prognostic factors in diabetic patients with invasive fungal rhinosinusitis.

BACKGROUND: Patients with diabetes mellitus (DM) are susceptible to invasive fungal rhinosinusitis (IFRS). The mortality rate of IFRS varies greatly among the patients with DM. OBJECTIVE: To identify the prognostic factors for the overall survival of patients with DM and IFRS. METHODS: A retrospective study was conducted in four tertiary hospitals in Thailand, Malaysia and Myanmar. Patients diagnosed with IFRS and DM from 2008 to 2019 were identified. The outcome was the overall survival. Variables analyzed for risk factors were age, HbA1C level, ketoacidosis, white blood cell count, hyperglycemia, duration of DM, current use of diabetic medications, serum creatinine level, and the extensions of IFRS to the orbit, the cavernous sinus and intracranial cavity. RESULTS: Sixty-five diabetic patients with IFRS (age 57.9 ± 13.4 years, male 60%) were identified. The mortality rate was 21.5%. The extensions of IFRS to the cavernous sinus (hazard ratio 5.1, 95% CI [1.4-18.2], p = 0.01) and intracranial cavity (hazard ratio 3.4, 95% CI [1.1-11.3, p = 0.05) predicted mortality. Current use of diabetic medications decreased the mortality risk (hazard ratio 0.2, 95% CI [0.1-0.9], p = 0.03). The 6-month overall survival of the patients with and without the cavernous sinus extension were 51.4% and 83.6%, (p = 0.001), with and without intracranial extension 53.3% and 88.9%, (p = 0.001), and with and without current diabetic medications 82.3% and 57.5%, respectively (p = 0.045). CONCLUSIONS: The extensions of IFRS to the cavernous sinus and intracranial cavity increased the risk of death in patients with DM. Survival was primarily related to current use of diabetic medications.

Radiological anatomical variations of the lateral nasal wall and anterior skull base amongst different populations: A systematic review and meta-analysis.

OBJECTIVES: To determine the anatomical variations of the lateral nasal wall and anterior skull base amongst populations in different geographical regions. DESIGN: Systematic review and meta-analysis. METHODS: Using PRISMA guidelines, SCOPUS and PUBMED databases were searched from inception until 1 March 2022. The regions and populations identified were from Europe, Asia, Middle East, Australia-New Zealand-Oceania, South America, North America and Africa. Random-effects model was used to estimate the pooled prevalence with 95% confidence intervals (CIs). Heterogeneity was assessed using the I2 statistic and Cochran's Q test. MAIN OUTCOME MEASURES: Anatomical variations of the lateral nasal wall and anterior skull base confirmed by computed tomography scan. RESULTS: Fifty-six articles were included with a total of 11 805 persons. The most common anatomical variation of the ostiomeatal complex was pneumatization of the agger nasi (84.1%), olfactory fossa was Keros type 2 (53.8%) and ethmoids was asymmetry of the roof (42.8%). Sphenoethmoidal and suprabullar cells have a higher prevalence in North Americans (53.7%, 95% CI: 46.00-61.33) while asymmetry of ethmoid roof more common in Middle Easterns (85.5%, 95% CI: .00-100). Bent uncinate process has greater prevalence in Asians while supraorbital ethmoid cells and Keros type 3 more common in non-Asians. The overall studies have substantial heterogeneity and publication bias. CONCLUSION: Certain anatomic variants are more common in a specific population. The 'approach of analysis' plays a role in the prevalence estimates and consensus should be made in future studies regarding the most appropriate 'approach of analysis' either by persons or by sides.

The prevalence of frontal cell variants according to the International Frontal Sinus Anatomy Classification and their associations with frontal sinusitis.

BACKGROUND: The International Frontal Sinus Anatomy Classification (IFAC) is introduced to simplify the classification of different frontal cell variants based on their topographical structures. The objectives of our study were to determine the prevalence of the frontal cell variants according to IFAC and their association with the development of frontal sinusitis. METHODOLOGY: A retrospective chart review on computed tomography paranasal sinus (CTPNS) was conducted. A total of 200 patients who had clinical and endoscopic findings of chronic rhinosinusitis (CRS) and undergone CTPNS were reviewed. The CTPNS was evaluated for the presence of frontal cell variants according to IFAC and mucosal changes consistent with frontal sinus involvement. RESULT: A total of 400 sides of the CTPNS were analyzed. The agger nasi cells (ANCs) were the most common (95.5%) followed by supra bulla cells (SBCs) (60.8%), supra bulla frontal cells (SBFCs) (53.0%), supra agger cells (SACs) (50.0%), supra agger frontal cells (SAFCs) (36.0%), frontal septal cells (FSCs) (8.3%), and supraorbital ethmoidal cells SOECs (5.5%). There was significant association between SOEC (p = 0.001) and FSC (p = 0.044) with the development of frontal sinusitis. CONCLUSIONS: Apart from ANCs, the posterior-based cells (SBCs and SBFCs) have higher prevalence than the anterior-based cells (SACs and SAFCs). Despite being the least, both SOECs and FSCs are significantly associated with frontal sinusitis.

Bilateral accessory middle turbinate presenting as double middle turbinate: A unique case report.

Many anatomical variations of the middle turbinate (MT), including pneumatized, paradoxically curved, bifurcate, trifurcate, secondary, and accessory, have been described. The most common is pneumatized MT (concha bullosa), but other less common variations may also impact the outcome of clinical management. Anatomical variations of the MT, particularly with a concomitant deviated nasal septum, tend to obstruct the middle meatus leading to disruption of the normal sinus drainage and worsening the symptoms of rhinosinusitis. By recognizing the unique anatomical variant by endoscopy or imaging will help us to improve the management. We report an endoscopic presentation of a rare accessory MT.

Preliminary Comparison of Transseptal Microscopic Versus Endoscopic Transsphenoidal Surgery in a University Teaching Hospital.

Background: Transsphenoidal surgery (TSS) is an increasing preferred treatment for sella lesions. In a university teaching hospital, the novel endoscopic TSS was adopted with ongoing resident teaching. We evaluated a single institutional series of preliminary comparisons of transseptal microscopic with endoscopic TSS. Methods: A retrospective data analysis included 37 patients and 19 patients who underwent microscopic and endoscopic TSS, respectively. The demographic characteristics of the patients, intra-operative analyses, morbidity, mortality and visual assessments were included in this analysis. Results: The study included 31 men and 25 women, and median age at surgery was 49 years old (range 14-70 years old). There were no differences between the rates of cerebrospinal fluid (CSF) fistula, sinus complications, anterior pituitary hormone deficiency and diabetes insipidus between the groups. Total length of stay and intensive care unit stay were similar between the groups. Patients who underwent endoscopic TSS were at significantly increased risk of epistaxis (P = 0.010), respiratory event (P = 0.014) and post-operative visual deterioration prior to discharge (P = 0.032). Conclusion: Endoscopic TSS is a promising procedure that allows sufficient visualisation of the surgical field and adequate tumour removal. It is comparable to microscopic TSS but has a higher complication rate notably due to steep learning curve required to gain the expertise.

Reduced CD4+ terminally differentiated effector memory T cells in moderate-severe house dust mites sensitized allergic rhinitis patients.

BACKGROUND: Terminally differentiated effector memory (TEMRA) T cells exert potent effector function after activation. The proportions of CD4+ T cell subsets especially memory cells in allergic rhinitis (AR) patients sensitized to house dust mites (HDMs) have not been extensively studied. OBJECTIVE: This study aimed to compare the mean percentages and absolute counts of CD4+ memory T cell subsets between: (i) non-allergic controls and AR patients; (ii) mild AR patients and moderate-severe AR patients. METHODS: Sensitization to Dermatophagoides farinae and Dermatophagoides pteronyssinus were determined in 33 non -allergic controls, 28 mild AR and 29 moderate-severe AR patients. Flow cytometry was used to determine the percentage of CD4+ na?ve (TN; CD45RA+CCR7+), central memory (TCM; CD45RA-CCR7+), effector memory (TEM; CD45RA-CCR7-) and TEMRA (CD45RA+CCR7-) T cells from the peripheral blood. The absolute counts of CD4+ T cell subsets were obtained by dual platform method from flow cytometer and hematology analyzer. RESULTS: There were no significant differences in the mean percentages and absolute counts of CD4+ T cell subsets between non-allergic controls and AR patients sensitized to HDMs. However, there were significant reduction in the mean percentage (p=0.0307) and absolute count (p=0.0309) of CD4+ TEMRA cells in moderate-severe AR patients compared to mild AR patients sensitized to HDMs and 13/24 (54.2%) moderate-severe AR patients sensitized to HDMs had persistent symptoms. CONCLUSION: Reduction in the mean percentage and absolute count of CD4+CD45RA+CCR7- TEMRA cells were observed in moderate-severe AR patients compared to mild AR patients in our population of AR patients sensitized to HDMs.

Anatomical variations of anterior ethmoidal artery and their significance in endoscopic sinus surgery: a systematic review.

PURPOSE: Anterior ethmoidal artery (AEA) is at risk of injury in endoscopic sinus surgery due to its location. The aim of this review was to assess the anatomical variations of AEA and their significance. METHODS: A literature search was performed on PUBMED, SCOPUS AND EMBASE. The following keywords were used: ethmoidal artery; anterior ethmoidal artery; anterior ethmoidal canal; ethmoid sinus; ethmoid roof; skull base. The search was conducted over a period of 6 months between October 2016 and April 2017. RESULTS: 105 articles were retrieved. 76 articles which were either case reports or unrelated topics were excluded. Out of the 29 full text articles retrieved, 16 articles were selected; 3 were cadaveric dissection, 5 combined cadaveric dissection and computed tomography (CT) and the rest were of CT studies. All studies were of level III evidence and a total of 1985 arteries were studied. Its position at the skull base was influenced by the presence of supraorbital ethmoid cell (SOEC) and length of the lateral lamella of cribriform plate (LLCP). Inter population morphological variations contribute to the anatomical variations. CONCLUSIONS: The average diameter of AEA was 0.80 mm and the intranasal length was 5.82 mm. 79.2% was found between the second and third lamellae, 12.0% in the third lamella, 6% posterior to third lamella and 1.2% in the second lamella. Extra precaution should be taken in the presence of a well-pneumatized SOEC and a long LLCP as AEA tends to run freely below skull base.

Anatomical variations of anterior ethmoidal artery at the ethmoidal roof and anterior skull base in Asians.

PURPOSE: The variations of the anterior ethmoidal artery (AEA) in different populations should be recognized by surgeons to prevent unwarranted complications during surgery. The aim of this study was to assess the anatomical variations of AEA in Asian population. METHODS: A cross-sectional study of 252 AEA identified by computed tomography (CT) of the paranasal sinuses. The multiplanar CT images were acquired from SOMATOM® Definition AS+ and reconstructed to axial, coronal and sagittal view at 1 mm slice thickness. RESULTS: 42.5% of AEA was within skull base (grade I), 20.2% at skull base (grade II) and 37.3% coursed freely below skull base (grade III). The prevalence of supraorbital ethmoid cell (SOEC) and suprabullar cell (SBC) was 29.8% and 48.0%. The position of AEA at skull base has significant association with SOEC (p < 0.001), but not with SBC (p = 0.268). Type I Keros was 42.1% and Type 11 Keros was 57.9%. When lateral lamella's height is longer, the probability increases for AEA to course freely within the ethmoid sinus (p = 0.016). The mean distance of AEA from skull base was 1.93 ± 2.03 mm, orbital floor 21.91 ± 2.47 mm and nasal floor 49.01 ± 3.53 mm. CONCLUSIONS: The position of AEA at skull base depends on the presence of SOEC and length of lateral lamella, but not with SBC. When compared to European population, the mean distance between AEA and nasal floor is shorter in Asians.

Validation of Bahasa Malaysia STOP-BANG questionnaire for identification of obstructive sleep apnea.

PURPOSE: The diagnosis of obstructive sleep apnea (OSA) by polysomnography (PSG) is time-consuming and expensive. The STOP-BANG questionnaire (SBQ) is an adequate screening tool and easily applied. We aimed to validate the Bahasa Malaysia version for use in sleep clinic. METHODS: A cross-sectional study was carried out in the sleep clinic. Standard forward-backward method was used for translation. Patients were required to answer a translated version of the questionnaire in Bahasa Malaysia and underwent a PSG study. Apnea-hypopnea index (AHI) of five and more was considered diagnostic. SBQ score was divided into two groups, less than 3 and 3 or more to determine its correlation with mild, moderate, or severe OSA. The reliability of the questionnaire was compared against that of the PSG result. RESULTS: We recruited 134 patients with mean age of 41.22 ± 12.66 years old. 9.7% patients have low risk, 48.5% moderate risk, and 41.8% high risk of OSA by SBQ scoring. 28.4% of patients had mild, 33.6% had moderate, and 38.0% had severe OSA by PSG. The Bahasa Malaysia version had sensitivity, specificity, and positive and negative predictive value of 61.42, 71.05, and 84.06 and 41.54% respectively. When the score is higher, the probability increases for patients to have moderate or severe OSA. SBQ score showed moderate value of agreement to AHI. CONCLUSIONS: The Bahasa Malaysia version of SBQ is a valid tool for the identification of OSA. It is useful to detect patients at risk for further investigation and management.

Is orbital floor a reliable and useful surgical landmark in endoscopic endonasal surgery?: a systematic review.

BACKGROUND: The orbital floor is considered as an important intraoperative reference point in endoscopic sinonasal surgery. The aim of this review is to evaluate its reliability and usefulness as a surgical landmark in endoscopic endonasal surgery. METHODS: A literature search was performed on electronic databases, namely PUBMED. The following keywords were used either individually or in combination: orbital floor; maxillary sinus roof; endoscopic skull base surgery; endoscopic sinus surgery. Studies that used orbital floor as a landmark for endoscopic endonasal surgery were included in the analysis. In addition, relevant articles were identified from the references of articles that had been retrieved. The search was conducted over a period of 6 months between 1st June 2017 and 16th December 2017. RESULTS: One thousand seven hundred forty-three articles were retrieved from the electronic databases. Only 5 articles that met the review criteria were selected. Five studies of the orbital floor (or the maxillary sinus roof) were reviewed, one was a cadaveric study while another 4 were computed tomographic study of the paranasal sinuses. All studies were of level III evidence and consists of a total number of 948 nostrils. All studies showed the orbital floor was below the anterior skull base irrespective of the populations. The orbital floor serves as a guide for safe entry into posterior ethmoids and sphenoid sinus. CONCLUSIONS: The orbital floor is a reliable and useful surgical landmark in endoscopic endonasal surgery. In revision cases or advanced disease, the normal landmarks can be distorted or absent and the orbital floor serves as a reference point for surgeons to avoid any unintentional injury to the skull base, the internal carotid artery and other critical structures.

Cognitive Function Among Obstructive Sleep Apnea Patients in North East Malaysia.

INTRODUCTION: Obstructive sleep apnea patients may develop deficits in the cognitive domains of attention, concentration, executive function, verbal and visuospatial memory, constructional abilities, and psychomotor functioning. As cognitive performance will improve with the treatment, early screening for cognitive dysfunction should be done to prevent further deterioration. OBJECTIVE: We aim to evaluate the cognitive function of obstructive sleep apnea patients by using the 'Mini Mental State Examination'. METHODOLOGY: This was a cross sectional study to evaluate the cognitive function of moderate and severe obstructive sleep apnea patients with age ranged from 18 to 60 old who attended our sleep clinic. These patients were confirmed to have moderate and severe obstructive sleep apnea by Type 1 polysomnography (attended full overnight study). The age, gender and ethnicity were noted and other relevant data such as weight, height, body mass index and apnea and hypopnoea index were recorded accordingly. The cognitive function was evaluated using validated Malay version of Mini Mental State Examination which measured 5 areas of cognitive functions comprising orientation, registration, attention and calculation, word recall and language abilities, and visuospatial. RESULTS: A total of 38 patients participated in this study. All 19 patients of moderate group and 14 patients of severe group had normal cognitive function while only 5 patients in severe group had mild cognitive function impairment. There was a statistically significant difference between the moderate group and severe group on cognitive performance (p value = 0.042). CONCLUSIONS: Severe obstructive sleep apnea patients may have impaired cognitive function. Mini Mental State Examination is useful in the screening of cognitive function of obstructive sleep apnea patients but in normal score, more sophisticated test batteries are required as it is unable to identify in 'very minimal' or 'extremely severe' cognitive dysfunction.

Nasal nitric oxide measurement in allergic rhinitis and non-allergic rhinitis: a meta-analysis.

The goal of this meta-analysis was to study nasal nitric oxide (nNO) measurements in allergic rhinitis (AR) and non-allergic rhinitis (non-AR). The protocol was registered with PROSPERO (no: CRD4202124828). Electronic databases from PubMed, Google Scholar, Scopus, Web of Science, and Cochrane were all thoroughly searched and studies were chosen based on the qualifying requirements. The quality of the studies was evaluated by Joanna Briggs Institute evaluation tools, and publication bias using funnel plots. The meta-analysis included 18 studies, whereas the systematic review included 20 studies, totaling 3097 participants (1581 AR, 458 non-AR, and 1058 healthy/control). Patients with AR had significantly greater nNO levels than the control group, although this did not change significantly before or after treatment. AR patients had significantly greater nNO levels than non-AR patients, but there was no significant difference between non-AR patients and healthy controls. Nineteen of the studies were of high quality and the remaining one was of moderate quality. nNO measurement has a promising role in the management of AR and non-AR patients, but more investigations are needed to document clinical benefits.

A meta-analysis comparing the performance of narrowband CE-Chirp and 500 Hz tone burst stimuli in recording cervical vestibular evoked myogenic potential (cVEMP).

Due to contradictory outcomes in the literature, the aim of this meta-analysis is to verify whether the narrowband (NB) CE-Chirp stimulus (centred at 500 Hz) would produce more robust cervical vestibular evoked myogenic potential (cVEMP) responses relative to the conventional 500 Hz tone burst. The literature search was conducted using PubMed, Scopus, and Web of Science databases and the terms used were "vestibular evoked myogenic potential" and "chirp". The cVEMP parameters to be analysed were P1 latency, N1 latency, and P1-N1 amplitude. A total of 59 potential articles were obtained from the database search. Eventually, five articles were found to be eligible for the meta-analysis (with n = 222). As found, P1 and N1 latencies of cVEMP were significantly shorter for the chirp stimulus (p < 0.001), with substantially large effect sizes. On the other hand, P1-N1 amplitude values were found to be not statistically different between the two stimuli (p = 0.189), with a small effect size. It appears that there is no indication to support the superiority of the NB CE-Chirp stimulus (centred at 500 Hz) in the cVEMP testing (relative to the conventional 500 Hz tone burst). In particular, both stimuli produce comparable P1-N1 amplitude values. Even though P1 and N1 latencies are statistically shorter for the chirp stimulus, this may not reflect that it should be the preferred stimulus for recording cVEMP responses (and the reasons for this are discussed accordingly).

A Rare Case and Literature Review of Endoscopic Endonasal.

We report a rare case of localized anterior clinoid mucocele (ACM) with acute visual loss and a literature review of the endoscopic endonasal surgery. We advocate that endoscopic endonasal approach is the best choice. To our knowledge there a limited report on localized ACM that treated via endoscopic endonasal approach.

Diagnostic Value and Clinical Application of Nasal Fractional Exhaled Nitric Oxide in Subjects with Allergic Rhinitis.

PURPOSE: Nitric oxide (NO) is a potential marker in the diagnosis and monitoring of treatment for the management of patients with allergic rhinitis (AR). The study aimed to determine the value of nasal fractional exhaled nitric oxide (FeNO) in the diagnosis and treatment response of AR patients. METHODS: The participants were divided into control and allergic rhinitis groups based on the clinical symptoms and skin prick tests. The AR group was treated with intranasal corticosteroid after the diagnosis. The nasal fractional exhaled nitric oxide (FENO) levels were compared between control and AR groups. In the AR group, the visual analogue scale (VAS), Nasal Obstruction Symptoms Evaluation (NOSE) questionnaire, and nasal fractional exhaled nitric oxide (FeNO) were assessed pre- and post-treatment. RESULTS: One hundred ten adults were enrolled. The nasal FeNO level was significantly higher in AR compared to control (p < 0.001). Both the subjective (VAS and NOSE), both (p < 0.01) and objective (nasal FeNO, p < 0.001) assessments showed significant different pre- and post-treatment. The threshold level of nasal FeNO in the diagnosis of AR was 390.0 ppb (sensitivity of 73% and specificity of 80%) based on the receiver operator characteristic curve. CONCLUSION: Nasal FeNO level is significantly higher in AR compared to control group with significant difference pre- and post-treatment. The findings suggest nasal FeNO can serve as an adjunct diagnostic tool together with the monitoring of treatment response in AR.

Malaysian Society of Allergy and Immunology Consensus Statement on Sublingual Immunotherapy in Allergic Rhinitis.

Allergic rhinitis (AR) is an IgE-mediated inflammatory disease of the upper airway. AR affects the patients' quality of life, is a known risk factor for asthma and a socio-economic burden. Allergen-specific immunotherapy (AIT), comprising sublingual immunotherapy (SLIT) and subcutaneous immunotherapy (SCIT), involves administering increasing doses of the causative allergen to induce clinical and immunologic tolerance to the allergens. It is the only currently available treatment for AR that has been proven to induce disease-modifying effects (i.e., long-term remission of allergic symptoms or potential prevention of asthma and new sensitizations). Although AIT is conventionally recommended for patients who are non-responsive to symptom-relieving pharmacotherapy, it is presently recommended as a first-line treatment for patients with moderate to severe AR who prefer a treatment with the potential for long-term remission. In light of the relatively recent implementation of AIT in Malaysia, guidelines on its appropriate indication and application are important to attain optimal outcomes. This consensus statement was developed by an expert group formed by the Malaysian Society of Allergy and Immunology to provide evidence-based recommendations for the practice of AIT in Malaysia. Patient and product selection, choice of AIT, and strategy towards an effective treatment outcome in AIT are presented.

ARIA Care Pathways 2019: Next-Generation Allergic Rhinitis Care and Allergen Immunotherapy in Malaysia.

An increase in the prevalence of allergic rhinitis (AR) worldwide presents a significant burden to the health care system. An initiative was started in Europe designated as Allergic Rhinitis and Its Impact on Asthma (ARIA) to develop internationally applicable guidelines by utilising an evidence-based approach to address this crucial issue. The efforts are directed at empowerment of patients for self-management, the use of digital mobile technology to complement and personalise treatment, and establishment of real-life integrated care pathways (ICPs). This guideline includes aspects of patients' and health care providers' management and covers the main areas of treatment for AR. The model provides better real-life health care than the previous traditional models. This review summarises the ARIA next-generation guideline in the context of the Malaysian health care system.