Authors Jan L. Brozek, MD, PhD – Department of Clinical Epidemiology & Biostatistics and Medicine, McMaster University, Hamilton, Canada Jean Bousquet, MD, PhD – Service des Maladies Respiratoires, Hopital Arnaud de Villeneuve, Montpellier, France, INSERM, CESP U1018, Respiratory and Environmental Epidemiology Team, France, and WHO Collaborating Center for Rhinitis and Asthma Carlos E. Baena-Cagnani, MD – Faculty of Medicine, Catholic University of Cordoba, Cordoba, Argentina Sergio Bonini, MD – Institute of Neurobiology and Molecular Medicine – CNR, Rome, Italy and Department of Medicine, Second University of Naples, Naples, Italy G. Walter Canonica, MD – Allergy & Respiratory Diseases, DIMI, Department of Internal Medicine, University of Genoa, Genoa, Italy Thomas B. Casale, MD – Division of Allergy and Immunology, Department of Medicine, Creighton University, Omaha, Nebraska, USA Roy Gerth van Wijk, MD, PhD – Section of Allergology, Department of Internal Medicine, Erasmus Medical Centre, Rotterdam, the Netherlands Ken Ohta, MD, PhD – Division of Respiratory Medicine and Allergology, Department of Medicine, Teikyo University School of Medicine, Tokyo, Japan Torsten Zuberbier, MD – Department of Dermatology and Allergy, Charite Universitatsmedizin Berlin, Berlin, Germany Holger J. Schunemann, MD, PhD, MSc – Department of Clinical Epidemiology & Biostatistics and Medicine, McMaster University, Hamilton, Canada

/pdf/allergic-rhinitis-and-its-impact-on-asthma-20b4c7y0pr.pdf

Allergic Rhinitis and Its Impact on Asthma

These parameters were developed by the Joint Task Force on Practice Parameters, representing the American Academy of Allergy, Asthma & Immunology; the American College of Allergy, Asthma and Immunology; and the Joint Council of Allergy, Asthma and Immunology. The American Academy of Allergy, Asthma & Immunology (AAAAI) and the American College of Allergy, Asthma and Immunology (ACAAI) have jointly accepted responsibility for establishing "The diagnosis and Management of Rhinitis: An Updated Practice Parameter." This is a complete and comprehensive document at the current time. The medical environment is a changing environment, and not all recommendations will be appropriate for all patients. Because this document incorporated the efforts of many participants, no single individual, including those who served on the Joint Task Force, is authorized to provide an official AAAAI or ACAAI interpretation of these practice parameters. Any request for information about or an interpretation of these practice parameters by the AAAAI or ACAAI should be directed to the Executive Offices of the AAAAI, the ACAAI, and the Joint Council of Allergy, Asthma and Immunology. These parameters are not designed for use by pharmaceutical companies in drug promotion.

The diagnosis and management of rhinitis: An updated practice parameter

Menthol and related cooling compounds such as 'coolant agent 10', are widely used in products ranging from common cold medications to toothpastes, confectionery, cosmetics and pesticides. The review brings together a range of information on production and chemistry of menthol, and its metabolism, mechanism of action, structure-activity relationships, pharmacology and toxicology. In particular, the coolant action and carminative actions of menthol are discussed in terms of actions on calcium conductance in sensory nerves and smooth muscle. The actions of menthol on the nose, respiratory reflexes, oral cavity, skin and gastrointestinal tract are reviewed.

https://onlinelibrary.wiley.com/doi/epdf/10.1111/j.2042-7158.1994.tb03871.x

Menthol and related cooling compounds.

Objective: To determine whether intranasal corticosteroids are superior to oral H 1 receptor antagonists (antihistamines) in the treatment of allergic rhinitis. Design: Meta-analysis of randomised controlled trials comparing intranasal corticosteroids with oral antihistamines. Setting: Randomised controlled trials conducted worldwide and published between 1966 and 1997. Subjects: 2267 subjects with allergic rhinitis in 16 randomised controlled trials. Main outcome measures: Nasal blockage, nasal discharge, sneezing, nasal itch, postnasal drip, nasal discomfort, total nasal symptoms, nasal resistance, and eye symptoms and global ratings. Outcomes measured on different scales were combined to determine pooled odds ratios (categorical outcomes) or standardised mean differences (continuous outcomes). Assessment of heterogeneity between studies, and subgroup analyses of eye symptoms, were undertaken. Results: Intranasal corticosteroids produced significantly greater relief than oral antihistamines of nasal blockage (standardised mean difference −0.63, 95% confidence interval −0.73 to −0.53), nasal discharge (−0.5, −0.6 to −0.4), sneezing (−0.49, −0.59 to −0.39), nasal itch (−0.38, −0.49 to −0.21), postnasal drip (−0.24, −0.42 to −0.06), and total nasal symptoms (−0.42, −0.53 to −0.32), and global ratings gave an odds ratio for deterioration of symptoms of 0.26 (0.08 to 0.8). There were no significant differences between treatments for nasal discomfort, nasal resistance, or eye symptoms. The effects on sneezing, total nasal symptoms, and eye symptoms were significantly heterogeneous between studies. Other combined outcomes were homogeneous between studies. Subgroup analysis of the outcome of eye symptoms suggested that the duration of assessment (averaged mean score over the study period versus mean score at end of study period) might have accounted for the heterogeneity. Conclusion: The results of this systematic review, together with data on safety and cost effectiveness, support the use of intranasal corticosteroids over oral antihistamines as first line treatment for allergic rhinitis.

https://www.bmj.com/content/bmj/317/7173/1624.full.pdf

Intranasal corticosteroids versus oral H1 receptor antagonists in allergic rhinitis: systematic review of randomised controlled trials

Background: There is no consensus about the value of objective measurements of nasal patency.



Objective:  To assess the correlation between the subjective sense of nasal patency and the outcomes found with rhinomanometry and acoustic rhinometry.



Type of review:  Structured literature search.



Search strategy and evaluation method:  Review of English-language articles in which correlations were sought between subjective nasal patency symptoms and objective scores as found with rhinomanometry [nasal airway resistance (NAR)] and acoustic rhinometry [minimal cross-sectional area (MCA)]. Correlations were related to unilateral or combined assessment of nasal passages and to symptomatic nasal obstruction or unobstructed nasal breathing.



Results:  Sixteen studies with a level of evidence II-a or II-b fit the inclusion criteria and were further analysed. Almost every possible combination of correlations or lack thereof in relation to the variables included was found. However, when obstructive symptoms were present, a correlation between the patency symptoms with nasal airway resistance and minimal crosssectional area was found more often than in the absence of symptoms. In cases of bilateral assessment a correlation was found almost as often as it was not between patency symptoms and total nasal airway resistance or combined minimal crosssectional areas, while in the limited amount of studies in which unilateral assessment was done a correlation was found each time between patency symptoms and nasal airway resistance.



Conclusions:  The correlation between the outcomes found with rhinomanometry and acoustic rhinometry and an individual’s subjective sensation of nasal patency remains uncertain. Based on this review, it seems that the chance of a correlation is greater when each nasal passage is assessed individually and when obstructive symptoms are present. There still seems to be only a limited argument for the use of rhinomanometry or acoustic rhinometry in routine rhinologic practice or for quantifying surgical results.



Clin. Otolaryngol. 2009, 34, 518–525.

Correlation between subjective and objective evaluation of the nasal airway. A systematic review of the highest level of evidence

Fifteen subjects underwent nasal pressure gradient studies to determine the resistance profile of the nose. Seventy-nine per cent of nasal resistance to airflow occurred in the segment 0 cm.-2.8 cm. from the posterior margin of the anterior nares. The greater part of this resistance (43 per cent) occurred in the segment 1.5 cm.-2.8 cm. within the nose, and this area approximated to the site of the pyriform aperture. Eighteen patients underwent a trial of radical trimming of the inferior turbinates (12 patients) versus anterior trimming of the inferior turbinates (6 patients). Both operations produced a similar fall in nasal resistance to airflow, confirming that the region of the pyriform aperture was the site of maximum nasal resistance. Whereas the radical operation significantly reduced the sensation of nasal obstruction, the anterior operation did not. The results of the study are discussed with reference to previous work on the subject.

The nasal valve: a physiological and clinical study.

The effect of local anaesthesia of the nasal vestibule on nasal sensation of airflow and nasal resistance was assessed in 15 subjects. A single blind parallel group trial was undertaken in 30 subjects, with lignocaine as the active drug, and normal saline as the placebo. Fifteen subjects were included in each group. Both agents were infiltrated bilaterally into the floor of the nasal vestibule on each side via the sublabial route. Local anaesthesia of the nasal vestibule by infiltrating lignocaine produced a sensation of nasal obstruction in 9 out of 15 subjects (P less than 0.02). The infiltration of normal saline had no such effect. The difference between the effect of the 2 agents on nasal airflow sensation was significant (P less than 0.05). Neither injection had any significant effect on nasal resistance to airflow as assessed by active anterior rhinomanometry.

The effect of local anaesthesia of the nasal vestibule on nasal sensation of airflow and nasal resistance

A method of rhinomanometry is described for use in clinical research work. The statistical distribution of nasal resistance values is studied in a sample of 59 normal individuals. The variation of nasal resistance within two individuals is studied over a period of 7 hours. The choice of appropriate statistical tests to be used when comparing nasal resistance values is discussed. The reproducibility of nasal resistance measurements is assessed in 47 normal individuals. The results were used to define a normal range of values for total nasal resistance to airflow.

https://www.cambridge.org/core/services/aop-cambridge-core/content/view/S0022215100102762

Nasal resistance to airflow (its measurement, reproducibility and normal parameters).

A randomized double blind placebo controlled cross-over study comparing budesonide 400 micrograms and budesonide 800 micrograms daily in 59 patients is presented. Nasal obstruction was the predominant symptom and was subjectively and objectively improved by both doses of budesonide (P less than 0.001). No significant difference was found between the two treatments. Both patient subgroups with non-allergic, non-eosinophilic rhinitis and perennial allergic rhinitis benefitted from therapy. Basal and stimulated plasma cortisol levels remained unchanged with either dose of budesonide, and no increase in adverse effects occurred with higher dose therapy.

A double blind comparison of intranasal budesonide 400 micrograms and 800 micrograms in perennial rhinitis.

Nasal resistance to airflow was measured by both anterior and posterior rhinomanometry in 15 healthy volunteers. It was found that the posterior method gave values on average 16% higher than the anterior method. This difference was statistically significant. We propose that this is due to posterior rhinomanometry measuring the resistance of the nasopharynx as well as the resistance of the nose. In the past a discrepancy between the 2 methods has been claimed to be due to an error in the standard form of the parallel resistance equation. This hypothesis was tested by measuring total nasal resistance by posterior rhinomanometry and comparing this with a total nasal resistance value derived from posterior rhinomanometric measurements of the resistance of the individual nasal cavities. The standard form of the parallel resistance formula was used to derive the total nasal resistance. There was no significant difference between the 2 values for total nasal resistance. We conclude that if measurements are made at the same pressure gradient then the use of this equation is valid.

Rhinomanometry: do the anterior and posterior methods give equivalent results?

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