As-needed intranasal corticosteroid spray for allergic rhinitis: a systematic review and meta-analysis.

BACKGROUND: As-needed intranasal corticosteroid spray (INCS) is commonly used by patients with allergic rhinitis (AR) who have suboptimal symptom control. This systematic review aimed to assess the effectiveness of as-needed INCS for treating AR. METHODOLOGY: Systematic searches for randomized controlled trials studying the effects of as-needed INCS compared to regular INCS, as-needed antihistamine, or placebo were performed. Primary outcomes were total nasal symptom score (TNSS) and disease-specific quality of life (DSQoL). RESULTS: Eight studies (882 participants) met the criteria. Regular use of INCS showed greater improvements than as-needed INCS in TNSS, DSQoL, nasal peak inspiratory flow, sneezing, and nasal congestion scores with small effect sizes. There were no differences between regular and as-needed INCS usage for ocular symptoms, symptom-free days, nasal itching, and rhinorrhea scores. As-needed INCS was superior to as-needed antihistamine and placebo with medium effect sizes. There were no differences in risk of adverse events between the groups in all three comparisons. CONCLUSIONS: Regular use of INCS improved total nasal symptoms score and DSQoL better than as-needed INCS. However, as-needed INCS improved TNSS better than as-needed antihistamine and placebo. The effects of as-needed INCS were closer to regular INCS usage than to placebo or as-needed AH usage.

Allergen-specific immunotherapy for local allergic rhinitis: a systematic review and meta-analysis.

BACKGROUND: Local allergic rhinitis (LAR) is a phenotype of chronic rhinitis exhibiting a local Th2-driven inflammation without positive clinical markers of atopy. Immunomodulatory effects of allergen-specific immunotherapy (AIT) induce allergen-specific tolerance. However, AIT is not well-recognized as a treatment for LAR. METHODOLOGY: Systematic search on six electronic databases and registries was performed. Experimental and observational studies of AIT for LAR patients were retrieved. The primary outcomes were symptom score, medication score, combined symptom medication score, and disease-specific quality of life. Secondary outcomes were serum specific(s) IgG4, sIgE, and adverse events. RESULTS: Four double-blind randomized controlled trials (156 patients) from two research units assessed the effects of subcutaneous immunotherapy (SCIT). Compared with placebo, SCIT showed significant reductions in symptom score, medication score, combined symptom medication score, disease-specific quality of life, and an increase in serum sIgG4. There was no significant change in serum sIgE. Likewise, two observational studies (one using SCIT and one using sublingual immunotherapy) improved post-therapeutic symptom score. No studies assessed the effects after discontinuation of treatment. AIT was safe without serious adverse events. CONCLUSION: AIT has beneficial effects and safe for LAR. Its effects are restricted to studies with short-term follow-up. AIT may be considered in LAR patients.

Intralymphatic immunotherapy for allergic rhinoconjunctivitis: a systematic review and meta-analysis.

BACKGROUND: Intralymphatic immunotherapy (ILIT) is a new route of allergen-specific immunotherapy. Data confirming its effect is restricted to a small number of studies. METHODOLOGY: A systematic review with meta-analysis was conducted. The short-term (less than 24 weeks), medium-term (24-52 weeks), and long-term (more than 52 weeks) effects of ILIT in patients with allergic rhinoconjunctivitis (ARC) were assessed. The outcomes were combined symptom and medication scores (CSMS), symptoms visual analog scale (VAS), disease-specific quality of life (QOL), specific IgG4 level, specific IgE level, and adverse events. RESULTS: Eleven randomized controlled trials and 2 cohorts (483 participants) were included. Compared with placebo, short term benefits of ILIT for seasonal ARC improved CSMS, improved VAS and increased specific IgG4 level but did not change QOL or specific IgE level. Medium-term effect improved VAS. Data on the long-term benefit of ILIT remain unavailable and require longer term follow-up studies. There were no clinical benefits of ILIT for perennial ARC. ILIT was safe and well-tolerated. CONCLUSION: ILIT showed short-term benefits for seasonal ARC. The sustained effects of ILIT were inconclusive. It was well tolerated.

Correlation between extent of sinus surgery, radiographic disease, and postoperative outcomes.

BACKGROUND: The extent of endoscopic sinus surgery (ESS) required for optimal outcomes in chronic rhinosinusitis (CRS) is undefined. We evaluated whether concordance between the extent of surgery and degree of radiographic disease influences postoperative outcomes. METHODS: 247 CRS patients who underwent ESS were retrospectively assigned a concordance score reflecting the similarity between the extent of surgery and degree of radiographic disease. 0 points were assigned when sinusotomy was performed on a diseased sinus, or no sinusotomy was performed on a nondiseased sinus; plus 1 for sinusotomy on a nondiseased sinus; and -1 for a diseased sinus left unopened. The total possible score ranged from minus 10 to plus 10. Patients were divided into 5 subgroups according to variance from complete concordance. SNOT-22 scores and revision rates were compared at 6 and 24 months. RESULTS: All five subgroups had similar preoperative SNOT-22 scores and improved at 6 months postoperatively. At 6 months postoperatively, the most conservatively operated and most extensively operated subgroups each achieved equivalent improvements in SNOT-22 as the completely concordant subgroup. At 24 months, the most extensively operated subgroup had a 12.5-point smaller improvement in SNOT-22 scores compared to the completely concordant subgroup. Multivariate analysis showed no association between concordance score and revision rate. CONCLUSIONS: Symptom improvement and revision rates after ESS do not appear to correlate with the degree of concordance between extent of surgery and radiographic disease. More extensive surgery than indicated by CT confers neither greater symptomatic improvement nor long-term detriment.

EPOS2012 has better specificity compared to IDSA2012 for diagnosing acute bacterial rhinosinusitis.

BACKGROUND: Acute bacterial rhinosinusitis (ABRS) is a subtype of acute rhinosinusitis (ARS). To prevent excessive antibiotic prescribing, clinical criteria for diagnosing ABRS are presented in two major international guidelines from European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS2012) and the Infectious Diseases Society of America (IDSA2012). This study aims to assess accuracy of these criteria. METHODOLOGY: Patients with ARS were recruited. Clinical features were collected including discolored nasal discharge, facial pain, fever, double sickening, symptoms persisting longer than 10 days, and elevated serum C reactive protein (CRP) and erythrocyte sedimentation rate (ERS). Using middle meatal bacterial culture as a reference, accuracy of EPOS2012 and IDSA2012 criteria were analyzed. RESULTS: Eighty-eight patients (age 43.2+/-14.5 years, 67% female) with ARS were recruited. Using the two criteria for diagnosing ABRS, EPOS2012 and IDSA2012 have sensitivity of 50% (95%CI: 38%-62%) versus 69% (95%CI: 57%-79%), specificity of 63% (95%CI: 43%-79%) versus 46% (95%CI: 28%-65%), and accuracy of 53% versus 63%, respectively. CONCLUSION: Both EPOS2012 and IDSA2012 had modest accuracy. EPOS2012 had less sensitivity but a better specificity compared to IDSA2012. This suggests that IDSA2012 diagnostic criteria may contribute to inappropriate use of antibiotics due to poorer specificity.

Antihistamines for treating rhinosinusitis: systematic review and meta-analysis of randomised controlled studies.

BACKGROUND: Without the release of histamines, patients with rhinosinusitis may not benefit from antihistamines. Additionally, anticholinergic effects may do more harm than good. This study aimed to investigate the effectiveness of antihistamines in treating rhinosinusitis. METHODS: An electronic search was performed. Randomised controlled trials comparing antihistamines with either placebo or other treatments for patients with rhinosinusitis were selected. RESULTS: Two studies (184 patients) met the inclusion criteria. Loratadine decreased nasal obstruction in allergic rhinitis patients with acute rhinosinusitis (mean difference = -0.58; confidence interval = -0.85 to -0.31, p < 0.01), but had no benefit on total symptom score (mean difference = -1.25; confidence interval = -2.77 to 0.27, p = 0.11), or rhinorrhoea symptoms (mean difference = -0.06; confidence interval = -0.37 to 0.25, p = 0.71). CONCLUSION: There is limited evidence to support the use of antihistamines in treating rhinosinusitis. The number of included studies in this systematic review is limited. Antihistamines may relieve nasal obstruction in allergic rhinitis patients with acute rhinosinusitis.