Local allergic rhinitis - a narrative review.

This narrative review aims to provide an up-to-date definition of local allergic rhinitis (LAR), its classification, mechanisms, comorbidities, recommendations for diagnosis and treatment, and define needs in this area. Both 'PubMed' and 'Science Direct' literature was reviewed systematically, and a manual search for studies not previously encountered in the databases was also carried out. Published studies were identified in PubMed covering the period from 1947 to 2022. The following keyword search strategy was used: (local allergic rhinitis* OR entopy* OR local Immunoglobulin E * OR nasal specific Immunoglobulin E). LAR involves Type 2 nasal inflammation with local IgE and cannot be diagnosed by systemic methods, such as skin prick or blood IgE tests. A nasal allergen challenge is necessary for diagnosis. LAR can respond to usual AR treatments, including allergen specific immunotherapy (AIT). LAR is a novel entity that requires additional investigation in terms of prevalence, proper diagnosis, treatment, and prognosis. The target outcomes and possible benefits of this review are to achieve a consensus for the study and diagnosis of LAR and increase interest in this area.

Reasons for rejection of rhinoplasty seeking patients: a multicentre observational study.

BACKGROUND: To date, research on preoperative patient selection has mainly focused on patient personality, with body dysmorphic disorder (BDD) being the most studied. Despite the many reasons for not planning a rhinoplasty, no data are available on the nature of these reasons. Our aim is to conduct a multicentre international observational study on the reasons for rejection of patients seeking rhinoplasty in 5 tertiary rhinoplasty care centres. METHODS: Surgeons documented the reasons for not scheduling a rhinoplasty in consecutive patients who consulted them between January 2021 and March 2022 using a predefined list of reasons for rejection. Surgeons were also asked to report on the patient attitudes after rejection, and about the advice given to patients in the event of refusal. RESULTS: 186 patients seeking rhinoplasty were included. Multiple reasons for rejection were present in 76% of patients, with a mean of 2.9 reasons for rejection per patient. Overall, patient-related factors were most frequently associated with rejection (64.3%), followed by nose-related factors (28.4%), surgeon-related factors (6.0 %) and surgery-related factors (1.3%). The presence of severe BDD symptoms was reported in only 11.3% of the rejected patients. Patients rejected for rhinoplasty were advised to reconsider the surgery (32.8 %) and/or were referred to another surgeon (32.8%). No further action was taken in 39.8% of the patients. Of the patients who were rejected, most had a neutral (39.2 %) or positive (37.1 %) attitude in relation to the lack of rhinoplasty planning. CONCLUSION: This study highlights the variety of reasons for which patients seeking rhinoplasty are not considered good candidates for a rhinoplasty, with patient-related factors being more prevalent than nose-related and other factors. Increasing awareness on the impact of adequate patient selection for rhinoplasty may contribute to better outcomes in rhinoplasty.

The EUFOREA pocket guide for chronic rhinosinusitis.

Chronic rhinosinusitis (CRS) is known to affect around 5 % of the total population, with major impact on the quality of life of those severely affected (1). Despite a substantial burden on individuals, society and health economies, CRS often remains underdiagnosed, under-estimated and under-treated (2). International guidelines like the European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS) (3) and the International Consensus statement on Allergy and Rhinology: Rhinosinusitis 2021 (ICAR) (4) offer physicians insight into the recommended treatment options for CRS, with an overview of effective strategies and guidance of diagnosis and care throughout the disease journey of CRS.

The intranasal trigeminal system: roles in rhinitis (allergic and non-allergic).

The aim of this paper is to review intranasal trigeminal system and associated reflexes. The literature survey was performed on PubMed, ProQuest Central database of Kirikkale University and Google Scholar. The intranasal trigeminal system and associated reflexes play an important role in humans in both health and disease, including in rhinitis of non-allergic and mixed type. The intranasal trigeminal nerve provides sensory perception to the lining of the nose, supplying information on how patent the nasal airway is and responding to various chemical signals. The reflexes known to exist within the intranasal trigeminal system are nasobronchial reflex, trigemino-cardiac reflex, nasogastric reflex, and nasal cycle. The intranasal trigeminal system and its reflexes play a vital role in normal human physiology. Alterations in how this system operates may underlie multiple forms of rhinitis and more research is needed to fully understand the mechanisms involved.

Rhinology Future Debates 2018, a EUFOREA Report.

The third Rhinology Future Debates was organized by the European Forum for Research and Education in Allergy and Airways diseases (EUFOREA) in 2018 in Brussels. Experts from different specialties and countries, alongside patients, health policy makers and industry representatives discussed relevant topics in Rhinology, in an attempt to improve current clinical practices, through implementation of precision medicine, by empowering patients' participation and the use of eHealth tools. The debates which are available on-line (www.rhinology-future.com) dealt with 5 topics in Rhinology: the adoption of allergen-specific immunotherapy (AIT) by implementing change management strategies, the needs and obstacles in care delivery in respiratory diseases, 3D technology in nose and sinus surgery, ambulatory nasal surgery, and clinical evidence for efficacy of biologicals in CRSwNP and asthma. This report summarizes the outcomes of the brainstorming sessions highlighting novel approaches and unmet needs in the field of respiratory diseases by focusing on integrated care pathways.

Effect of incidental parathyroidectomy on postoperative calcium levels after to-tal thyroidectomy.

BACKGROUND: Incidental parathyroidectomy during total thyroidectomy may occur even in the most experienced hands. This study aims to assess the incidence, risk factors, and impact of incidental parathyroidectomy on this very targeted group of patients. METHODS: Three hundred and four consecutive cases undergoing total thyroidectomy in a tertiary referral center were prospectively studied. Based on the histopathology report, incidental parathyroidectomy was assessed in relation to postoperative transient/permanent hypocalcemia. Demographic, clinical, and histological data were analyzed. RESULTS: The overall incidence of unintentional removal of parathyroid glands during total thyroidectomy was 35.5 %. Indicators were the postoperative hypocalcemia, the percent change of parathormone serum levels, and the presence of lymph nodes in the histopathology report. Patients with incidental parathyroidectomy exhibited a higher incidence of transient hypocalcemia and hypoparathyroidism postoperatively. CONCLUSIONS: Incidental parathyroidectomy is associated with transient hypocalcemia after total thyroidectomy. Even single parathyroid in the histopathology specimen may be sufficient for influencing postoperative PTH levels and calcium. Every effort should be made by surgeons to identify and protect all parathyroid glands successfully. HIPPOKRATIA 2020, 24(2): 72-76.

A Case Report of Aggressive Chronic Rhinosinusitis with Nasal Polyps Mimicking Sinonasal Malignancy.

INTRODUCTION: Cases of extensive nasal polyps rarely occur and may mimic more aggressive lesions of the nose and paranasal sinuses. A case of extensive nasal polyposis with unusually aggressive behavior and its management is presented. PRESENTATION OF CASE: A 27-year-old male patient visited the emergency department of a tertiary center, complaining of recurrent episodes of epistaxis. The patient presented with a large polypoid lesion protruding from the right nostril and producing asymmetry of the face. Diagnostic imaging illustrated a lesion of the right maxillary sinus producing excessive bone remodeling and extension into neighboring structures in every direction. Fine limits were noted, however, with no invasive characteristics. Biopsy under local anesthesia was performed, showing findings consistent with nonspecific inflammation. Open surgery through a lateral rhinotomy under general anesthesia was performed, and the mass was readily mobilized and removed. No macroscopic invasion of neighboring structures was noted. Permanent histology confirmed the diagnosis of nasal polyposis. Postoperative follow-up has shown no evidence of recurrence after 12 months. CONCLUSION: Nasal polyps do not typically expand in an aggressive manner, producing bone resorption or extending into neighboring structures. However, nasal polyposis should be included in the differential diagnosis of nasal tumors with such behavior.

Rhinology future trends: 2017 EUFOREA debate on allergic rhinitis.

The 2nd Rhinology Future Debate, organized by EUFOREA (European Forum for Research and Education in Allergy and Airways diseases) was held in Brussels in December 2017. One of these debates addressed the position of MP-AzeFlu in allergic rhinitis (AR) treatment. The current article summarizes this debate; reviewing recent data, and exploring how this has been interpreted by experts and incorporated into AR management guidelines and a clinical decision support system (CDSS). The Allergic Rhinitis & its Impact on Asthma (ARIA) guideline position MP-AzeFlu firstline for the treatment of AR, and in preference to intranasal corticosteroids (INSs) during the first 2 weeks of treatment. The AR CDSS recommends MP-AzeFlu as one of the firstline treatments for patients with a visual analogue scale (VAS) score lower than 5/10 cm, and in preference (along with INS) for those with a VAS score equal or higher than5/10 cm. Panellists agreed that AR management should be kept as simple as possible, with some preferring a one treatment fits all approach, while others preferred a step-up approach. The need to change the AR management mentality was acknowledged, accepting that most patients use their medication as needed and use multiple treatments; AR medications are needed which have a very fast onset of action and which target breakthrough symptoms. Panellists agreed that MP-AzeFlu has a role to play here, since it has a 5 minute onset-of-action, provides clinically-relevant symptom relief in 15 mins and AR control in less than 3 days, targets nasal hyper-reactivity (NHR) which likely contributes to uncontrolled AR and breakthrough symptoms, and provides more effective AR symptom relief than INS monotherapy or INS + oral antihistamine. Finally, experts considered it likely that MP-AzeFlu should have a greater impact on asthma control than INS in co-morbid patients, but clinical data is required to back up existing pharmacoeconomic evidence. The next Rhinology Future Debate will be in held in Brussels in Dec 2019.

Nutrigenetic genotyping study in relation to Sleep Apnea Clinical Score.

BACKGROUND: Conflicting results regarding associations between single nucleotide polymorphisms (SNPs) in IRS1, ACE, APOE, PPARG, MTHFR, 5HT2AR, BDNF, and FTO genes and obstructive sleep apnea have been reported in previous studies. OBJECTIVE: To assess pleiotropic associations between these gene polymorphisms that are commonly being studied in a nutrigenetic test and sleep apnea. METHODS: One hundred and nine subjects of Caucasian origin who have performed a commercially available nutrigenetic test that includes the aforementioned polymorphisms were divided into two groups depending on the results of their Sleep Apnea Clinical Score (SACS ≤ 15 or > 15). Statistical significant differences in the prevalence of the polymorphisms under study between the groups were assessed with the Chi-squared test. Possible associations of the polymorphisms with SACS and BMI were further evaluated with logistic regression analyses. RESULTS: From the polymorphisms studied, only variant rs9939609 in the FTO gene was more prevalent in people with high sleep apnea clinical score (χ2 = 7.1, P = 0.029). However, this association was attenuated after adjustment for body mass index (OR = 0.653, P = 0.178). CONCLUSION: We failed to confirm previously reported associations between the majority of the studied polymorphisms and sleep apnea. Body weight seems to be an important cofounding factor that needs to be accounted for, when genetic association studies are performed for sleep apnea.

Association between the increase in incidence of papillary thyroid carcinoma in Crete and exposure to radioactive agents.

The mean gamma-ray distribution in Crete during the years after the nuclear accident at Chernobyl and its correlation with the Papillary Thyroid Cancer (PTC) distribution was identified. A total of 4285 patients underwent total thyroidectomy in our centre between 1990 and 2012. Data of gamma-ray (nSv/h) distribution were selected from the Greek Statistical Authorisation. A geo-spatial statistical model was used to estimate the expected number of patients with PTC and Kriging interpolation prediction model to estimate their distribution. Geographical weighted regression was performed to estimate the risk of PTC in relation to gamma ray distribution. All factors that were examined were found to be statistically significant for PTC distribution in Crete. Gamma-ray was determined as a significant risk factor (OR = 2.89; 95% CI = 1.682-4.989; p value = 0.03). There is a significant correlation between gamma-ray exposure and the increased prevalence of the PTC suggesting that the former may have been a significant risk factor.

mySinusitisCoach: patient empowerment in chronic rhinosinusitis using mobile technology.

Mobile health technology is emerging to take a prominent position in the management of chronic diseases. These technologies aim at enhancing patient empowerment via education and self-management. To date, of all the different apps available for patients with sinus disease, none were developed by medical experts dealing with chronic rhinosinusitis (CRS). The European Forum for Research and Education in Allergy and Airway diseases (EUFOREA) has undertaken a multi-stakeholder approach for designing, developing and implementing a tool to support CRS patients in monitoring their symptoms and to provide patients with a digital support platform containing reliable medical information about their disease and treatment options. mySinusitisCoach has been developed by medical experts dealing with CRS in close collaboration with patients, primary care physicians and community pharmacists, meeting the needs of both patients and health care providers. From a research perspective, the generation of real life data will help to validate clinical studies, patient stratification and improve understanding of the socio-economic impact of CRS, thereby paving the way for better treatment strategies.

Multi-morbidities of allergic rhinitis in adults: European Academy of Allergy and Clinical Immunology Task Force Report.

This report has been prepared by the European Academy of Allergy and Clinical Immunology Task Force on Allergic Rhinitis (AR) comorbidities. The aim of this multidisciplinary European consensus document is to highlight the role of multimorbidities in the definition, classification, mechanisms, recommendations for diagnosis and treatment of AR, and to define the needs in this neglected area by a literature review. AR is a systemic allergic disease and is generally associated with numerous multi-morbid disorders, including asthma, eczema, food allergies, eosinophilic oesophagitis (EoE), conjunctivitis, chronic middle ear effusions, rhinosinusitis, adenoid hypertrophy, olfaction disorders, obstructive sleep apnea, disordered sleep and consequent behavioural and educational effects. This report provides up-to-date usable information to: (1) improve the knowledge and skills of allergists, so as to ultimately improve the overall quality of patient care; (2) to increase interest in this area; and (3) to present a unique contribution to the field of upper inflammatory disease.

Severe Chronic Upper Airway Disease (SCUAD) in children. Definition issues and requirements.

OBJECTIVES: Upper airway diseases are extremely common, and a significant proportion of patients are not adequately controlled by contemporary treatment algorithms. The term SCUAD (Severe Chronic Upper Airway Disease) has been previously introduced to describe such cases. However, this term has not been adequately focused on children. METHODS: This study aims to address the necessity of the term, as well as further details specifically for children. For this purpose, a review was performed of the current literature, with specific focus on issues regarding SCUAD in children. RESULTS: Paediatric SCUAD represents a heterogeneous group of patients and has significant clinical and socioeconomic implications. Relevant literature is generally lacking and questions regarding definition and pathogenesis remain unanswered. CONCLUSIONS: Accurate definition and acknowledgement of paediatric SCUAD cases may lead to better design of future clinical and molecular research protocols. This may provide improved understanding of the underlying disease processes, more accurate data regarding socioeconomic burden, and, above all, more successful treatment and prevention strategies.

Japanese traditional medicine, Senn-kinn-naidaku-sann up-regulates Toll-like receptor 4 and reduces murine allergic rhinitis.

OBJECTIVE: To determine the mechanisms by which a traditional herbal medicine, Senkinnaidakusan (SKNS), controls Th2 responses, we examined the production of IL-12 by murine macrophages treated with SKNS. RESULTS: Treatment with SKNS significantly increased TLR4 mRNA in macrophages. Furthermore, pre-treatment with SKNS enhanced the production of IL-12 by macrophages stimulated with LPS. When SKNS was orally administered to C3H/HeN mice at the induction phase after OVA sensitization, the serum levels of OVA-specific immunoglobulin (Ig)E and IgG1 decreased, Interleukin (IL)-4 production by spleen T cells in response to OVA was significantly suppressed, while interferon (IFN)-gamma production was increased. After nasal challenge of OVA, eosinophilic infiltration in the nasal mucosa and the number of sneezes were significantly inhibited in SKNS-treated mice compared with control mice. Besides, expression of IL-5 in the nasal mucosa was also inhibited. Using another strain of mice, C3H/HeJ (TLR4 negative), there was no difference in OVA-specific Igs or splenic cytokine production between the SKNS treatment and non-treatment groups. The eosinophilic infiltration in the nasal mucosa, the number of sneezes and IL-5 expression in the nasal mucosa were also not effected even after SKNS treatment. CONCLUSION: These results suggest that oral administration of SKNS inhibits Th2 responses by enhancement of IL-12 release from macrophages via up-regulation of TLR4 expression.

Treating medullary thyroid carcinoma in a tertiary center. Current trends and review of the literature.

OBJECTIVES: We present the clinical outcome and long-term survival in patients with medullary thyroid carcinoma treated in a tertiary center. A thorough review of published series and current therapeutic approaches is also addressed. STUDY DESIGN: A retrospective review. SETTING: An Academic Tertiary center. SUBJECTS/METHODS: An analysis of oncologic outcomes from 25 patients treated in our department for medullary thyroid carcinoma is performed, together with a comparison of relevant studies over the literature. RESULTS: The incidence of patients alive free of disease and the 5-year survival rate has been noticed to be slightly higher than the rate reported in most series. CONCLUSIONS: Total thyroidectomy and neck dissection remains the gold standard in the treatment of medullary thyroid carcinoma. Early diagnosis and aggressive surgical treatment lead to lower rates of recurrence and invasiveness. Tyrosine-kinase inhibitor, especially vantetanib, appears to be a promising target for treatment.

Is chronic rhinosinusitis related to allergic rhinitis in adults and children? Applying epidemiological guidelines for causation.

The relationship between allergic rhinitis and chronic rhinosinusitis has been assessed in a number of observational and experimental studies. In this review, we attempt their synthesis and evaluation using the modified Bradford Hill guidelines for causation. Although there is no proof of causation, especially in the pediatric literature, an evaluation of underlying allergies is recommended at least as an initial measure of symptoms relief.

SCUAD and chronic rhinosinusitis. Reinforcing hypothesis driven research in difficult cases.

BACKGROUND: Our objective is to present recent research findings on recalcitrant chronic rhinosinusitis (CRS) in relation to "Severe Chronic Upper Airway Disease" (SCUAD). METHODOLOGY: Literature review using Medline and Em base databases (search terms 'chronic rhinosinusitis'; "chronic sinusitis" or"Severe Chronic Upper Airway Disease") limited to articles published in the English language. RESULTS: Complex pathophysiological mechanisms characterize various forms of chronic rhinitis and rhinosinusitis (CRS), where inflammation persists in spite of adequate medical treatment. In these cases, a multifactorial etiology often underlies the development of sino-nasal inflammation. The interaction between chronic upper and lower airway inflammation via neurogenic and systemic pathways may complicate the therapy of these patients, and lead to insufficient symptom control. CONCLUSION: The recently introduced definition of"Severe Chronic Upper Airway Disease" (SCUAD) increases awareness of those patients with persistent inflammation and symptoms despite guideline-driven pharmacologic treatment. The concept of SCUAD may prove helpful in directing research towards clarifying the definition, diagnosis and pathophysiology of rhinitis and rhinosinusitis,their limits and overlap. In this review, a hypothesis on SCUAD immunopathology is also presented.

Nasal manifestations of systemic diseases.

OBJECTIVES: Signs and symptoms of the sinonasal tract may be originated in any organ system. Distinguishing these from original sinonasal disease poses a great diagnostic challenge. The ENT specialist usually faces an unresponsive or relapsing case, with an atypical presentation. We address this issue by trying to provide a wider perspective when dealing with sinonasal manifestations. METHODOLOGY: We reviewed the literature exploring heterogeneous groups of diseases and systemic conditions that might interfere with normal sinonasal physiology. The most current and valid information have been included in an effort to delineate such manifestations and clarify the distinguishing signs and tests. RESULTS: A great variety of systemic conditions with sinonasal manifestations, including connective tissue, autoimmune, infectious, vascular, hematological, gastrointestinal, and endocrine diseases, were included. We address their distinguishing characteristics and diagnostic work-up. CONCLUSIONS: Signs and symptoms of the sinonasal tract can originate from either local or systemic disorders. The keys to dealing with such disorders are understanding the patterns in which systemic diseases can manifest, and using special diagnostic tools specific to each condition to confirm or rule out particular diagnoses.

Knowledge of primary care doctors about laryngopharyngeal reflux disease.

OBJECTIVES: Many patients with reflux disease present with atypical symptoms (globus pharyngeus, constant throat clearing, chronic cough, hoarseness, catarrh, dysphagia, halitosis, choking episodes, or asthma-like symptoms) due to laryngopharyngeal reflux (LPR). Because such patients can be easily misdiagnosed, doctors in primary care should be aware of LPR and its proper treatment. This study aimed to determine whether doctors working in the primary care setting are aware of the atypical manifestations of reflux and the differences in treatment between LPR and gastroesophageal reflux disease (GERD). METHODOLOGY: This study was conducted among primary care doctors referring to the Ear, Nose, and Throat department of Karditsa (Greece) General Hospital. A questionnaire regarding the clinical manifestation and treatment of GERD and LPR was supplied to 60 doctors working in the primary care setting of Karditsa prefecture. RESULTS: Fifty-one doctors returned the questionnaire. Twenty-three (45%) were acquainted with the entity of LPR and 8 (15.7%) were acquainted with the Reflux Symptom Index (RSI). The most common symptoms, for which proton pump inhibitors (PPIs) were prescribed, were: heartburn (76.5%), heartburn combined with other symptoms (17.6%), halitosis (1.96%), hoarseness (1.96%), and choking episodes (1.96%). Most of the surveyed doctors prescribed PPIs for fewer than 12 weeks (92%), once daily (70.6%), and preferably in the morning (50%). Forty-seven (92%) provided advice regarding lifestyle modifications. CONCLUSION: The majority of surveyed doctors were unaware of LPR or the RSI. More awareness is required in the primary care setting to recognize LPR early and treat it properly.

Rhabdomyoma of the pyriform sinus: case report and review of the literature.

OBJECTIVE: Adult rhabdomyoma is a rare benign tumour that arises from skeletal muscle. It is mostly found in the head and neck region, and it should be included in the differential diagnosis of benign lesions. METHODS: A 62-year-old man presented with dysphagia, and flexible endoscopy revealed a submucosal mass obliterating the right pyriform sinus. Computed tomography imaging revealed that the mass was hyperattenuated and extended from the right pyriform sinus to the true vocal cord. The mass was excised transorally under general anesthesia with a carbon dioxide laser. Microscopically, the tumour demonstrated features of adult-type rhabdomyoma. RESULTS: One year after surgery, the patient had no signs of recurrence. CONCLUSIONS: Rhabdomyoma is a rare neoplasm of the pyriform sinus. This entity should be considered in the differential diagnosis of tumours in this region.