Cemal Cingi

Uncontrolled allergic rhinitis and chronic rhinosinusitis: where do we stand today?

State‐of‐the‐art documents like ARIA and EPOS provide clinicians with evidence‐based treatment algorithms for allergic rhinitis (AR) and chronic rhinosinusitis (CRS), respectively. The currently available medications can alleviate symptoms associated with AR and RS. In real life, a significant percentage of patients with AR and CRS continue to experience bothersome symptoms despite adequate treatment. This group with so‐called severe chronic upper airway disease (SCUAD) represents a therapeutic challenge. The concept of control of disease has only recently been introduced in the field of AR and CRS. In case of poor control of symptoms despite guideline‐directed pharmacotherapy, one needs to consider the presence of SCUAD but also treatment‐related, diagnosis‐related and/or patient‐related factors. Treatment‐related issues of uncontrolled upper airway disease are linked with the correct choice of treatment and route of administration, symptom‐oriented treatment and the evaluation of the need for immunotherapy in allergic patients. The diagnosis of AR and CRS should be reconsidered in case of uncontrolled disease, excluding concomitant anatomic nasal deformities, global airway dysfunction and systemic diseases. Patient‐related issues responsible for the lack of control in chronic upper airway inflammation are often but not always linked with adherence to the prescribed medication and education. This review is an initiative taken by the ENT section of the EAACI in conjunction with ARIA and EPOS experts who felt the need to provide a comprehensive overview of the current state of the art of control in upper airway inflammation and stressing the unmet needs in this domain.

Prevalence and diversity of allergic rhinitis in regions of the world beyond Europe and North America

There is comparatively little information in the public domain on the diversity in prevalence and triggers/factors associated with allergic rhinitis (AR) or allergic rhinoconjunctivitis (AR/C) in countries beyond western‐Europe and North America.

EAACI Guidelines on Allergen Immunotherapy: Allergic Rhinoconjunctivitis.

Allergic rhinoconjunctivitis (AR) is an allergic disorder of the nose and eyes affecting about a fifth of the general population. Symptoms of AR can be controlled with allergen avoidance measures and pharmacotherapy. However, many patients continue to have ongoing symptoms and an impaired quality of life; pharmacotherapy may also induce some side‐effects. Allergen immunotherapy (AIT) represents the only currently available treatment that targets the underlying pathophysiology, and it may have a disease‐modifying effect. Either the subcutaneous (SCIT) or sublingual (SLIT) routes may be used. This Guideline has been prepared by the European Academy of Allergy and Clinical Immunologys (EAACI) Taskforce on AIT for AR and is part of the EAACI presidential project “EAACI Guidelines on Allergen Immunotherapy.” It aims to provide evidence‐based clinical recommendations and has been informed by a formal systematic review and meta‐analysis. Its generation has followed the Appraisal of Guidelines for Research and Evaluation (AGREE II) approach. The process included involvement of the full range of stakeholders. In general, broad evidence for the clinical efficacy of AIT for AR exists but a product‐specific evaluation of evidence is recommended. In general, SCIT and SLIT are recommended for both seasonal and perennial AR for its short‐term benefit. The strongest evidence for long‐term benefit is documented for grass AIT (especially for the grass tablets) where long‐term benefit is seen. To achieve long‐term efficacy, it is recommended that a minimum of 3 years of therapy is used. Many gaps in the evidence base exist, particularly around long‐term benefit and use in children.

Allergen immunotherapy for allergic rhinoconjunctivitis: A systematic review and meta‐analysis

The European Academy of Allergy and Clinical Immunology (EAACI) is in the process of developing Guidelines on Allergen Immunotherapy (AIT) for Allergic Rhinoconjunctivitis. To inform the development of clinical recommendations, we undertook a systematic review to assess the effectiveness, cost‐effectiveness, and safety of AIT in the management of allergic rhinoconjunctivitis.

Endoscopic versus microscopic approach to type 1 tympanoplasty in children

OBJECTIVES We investigated the outcomes of the endoscopic versus microscopic approach to type 1 tympanoplasty in pediatric patients. METHODS In this retrospective study, the outcomes of 61 ears of 60 pediatric patients (33 male and 27 female) who underwent type 1 tympanoplasty were evaluated. One patient underwent a bilateral operation. The age range of the patients was 7-16 years. Group 1 underwent tympanoplasty with an endoscopic technique (n=32), and Group 2 underwent tympanoplasty with the conventional microscopic technique (n=29). A boomerang-shaped chondroperichondrial graft was used in both groups. The outcomes were analyzed in terms of the hearing gain, duration of surgery, and graft success rate. RESULTS In both groups, the postoperative air-bone gap (ABG) was significantly lower than the preoperative ABG. There were no significant differences between the preoperative and postoperative ABG values (in dB) in either group. The mean operative duration in Group 1 was significantly lower than that in Group 2 (51.37 vs. 67.03 min, respectively). In the preoperative evaluation, 65.6% of patients in Group 1 had larger perforations and 34.4% had smaller perforations. In Group 2, 58.6% and 41.3% of patients had larger and smaller perforations, respectively. Perforations were detected in two (6.25%), four (12.50%), and four (12.50%) of the patients in Group 1 at postoperative months 1, 6, and 12, respectively. Perforations were detected in two (5.71%) patients in Group 2 at postoperative months 1, 6, and 12. At 12 months postoperatively, there were smaller perforations in four (12.5%) of the children in Group 1 and in two (5.71%) of the children in Group 2. The difference between the perforation conditions (larger vs. smaller) was not significant in either group. The preoperative and postoperative increases in the ABG were associated. The operative duration was shorter in Group 1 than in Group 2. CONCLUSION In pediatric patients undergoing type 1 tympanoplasty, especially if the external ear canal is narrow and the anterior canal wall is prominent, the endoscopic and microscopic approaches appear to give equal results in terms of easy visualization of the entire tympanic membrane and no requirement for extra intervention to evaluate the ossicular system. A shorter operative duration is an advantage of the endoscopic tympanoplasty technique.

Efficacy of leukotriene antagonists as concomitant therapy in allergic rhinitis

The symptoms of allergic rhinitis result from an immunoglobulin E‐dependent mast cell activation cascade, marked by the release of inflammatory mediators, including histamine. Patients with perennial allergic rhinitis also have elevated levels of cysteinyl leukotrienes (CysLTs) in nasal lavage fluid. Histamine and CysLTs produce different responses in the pathogenesis of allergic rhinitis, and this study tested the hypothesis that the effects of combined antihistamine and leukotriene antagonist therapy would be more effective than antihistamine alone.

Skin prick test reactivity in allergic rhinitis patients to airborne pollens

The aim was to investigate the impact of atmospheric pollen in determining allergic rhinitis. It was conducted with 130 patients with allergic rhinitis in three different sites in Eskisehir, Turkey, in 2000–2001, using a gravimetric method with a Durham sampler. Skin prick test results, the symptoms of patients and their findings all confirmed the presence of allergic reactions to pollen allergens in the patients observed. During the period, a total of 47,082 pollen grains/cm2 belonging to 45 taxa were recorded. Of the total pollen grains, 81.0% were arboreal and 18% non-arboreal. The majority of the investigated pollen grains were from Pinaceae, Salix spp., Chenopodiaceae/Amaranthaceae, Cupressaceae and Poaceae. Pollen concentrations reached the highest level in May (54.36%). The pollen allergens provoking severe sensitization were grasscereal mixtures (58.5%), followed by arboreals (33.8%). All patients (100.0%) were sensitive to grass. This study emphasizes the significance of determining the types and concentrations of pollen with a view to comparing changes in highly concentrated allergens.

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

Abstract 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.

Quality of life and control of allergic rhinitis in patients from regions beyond western Europe and the United States

There is comparatively little information on health‐related quality of life (HRQoL) in subjects with allergic rhinitis (AR) or allergic rhinoconjunctivitis (AR/C) in countries beyond western Europe and North America. The primary aim of this investigation was therefore to review and assess the information in the public domain on HRQoL in AR/C patients from diverse regions of the world, represented by different countries, including Argentina, Australia, Brazil, Russia, Singapore, South Africa and Turkey. Second, in view of the absence of a standardized definition for ‘AR control’, the review aimed to determine whether a working definition of AR/C can be inferred from validated tests or other instruments documented to date. Despite the comparatively low number of studies, this review demonstrated that overall the symptoms of AR/C impair the HRQoL of patients in these regions by adversely impacting sleep, daily activities, physical and mental status and social functioning, similar to that demonstrated in much larger numbers of studies of AR/C patients in Europe and the United States. Furthermore, the findings of the review suggest that ‘overall’ control of the disease should encompass reduction of nasal and ocular symptoms, as well as improvements in HRQoL, comorbid conditions and cognition. Although some instruments are currently available for measuring control of AR, none are capable of assessing all these aspects, emphasizing the need to develop appropriate new instruments.

Outcomes research in rhinoplasty: body image and quality of life.

Background Although hundreds of quality-of-life (QOL) studies are available in the literature, very few were designed that include both a global and a procedure-specific evaluation of QOL and an inventory for the assessment of body image. The purpose of this study was to use condition-specific and global measures as well as psychological evaluations in a case series of rhinoplasties for a more comprehensive assessment of patient-reported outcomes. Methods Records of 225 patients aged 18–57 years who underwent rhinoplasty were prospectively included in the study. Study participants completed both a baseline questionnaire before the rhinoplasty operation and a postsurgical patient questionnaire 12 months after the operation, including the European QOL Questionnaire (EQ), Rhinoplasty Outcomes Evaluation Questionnaire (ROE), and the Multidimensional Body–Self Relations Questionnaire (MBSRQ). Results Mean values corresponding to the EQ VAS results except for discomfort and anxiety domains increased after treatment compared with baseline. Both male and female patients experienced significant improvement in ROE scores, with larger differences between pre- and postoperative ROE scores in male patients compared with female patients. The analyses of variance in the MBSRQ results revealed significant postsurgical improvements on the appearance orientation subscale. Conclusion The development, standardization, and use of validated procedure-specific QOL tools are essential components for accurately measuring patient-reported outcomes of facial plastic surgery procedures. To measure patient satisfaction in a more objective and standardized manner, specific questionnaires or instruments should be used that can determine the QOL changes associated with each procedure of interest.