Desiderio Passali

Consensus statement on the treatment of allergic rhinitis.

Allergic rhinitis (AR) is a high-prevalence disease in many developed countries, affecting about 10±20% of the general population (1±5). Several studies based on questionnaire and objective testing or medical examination indicate an increasing prevalence of AR in European countries over the last decades (6, 7). AR is characterized by nasal itching, sneezing, watery rhinorrhoea, and nasal obstruction. Additional symptoms such as headache, impaired smell, and conjunctival symptoms can be associated. According to the time of exposure, AR can be subdivided into perennial, seasonal, and occupational disease. Perennial AR (PAR) is most frequently caused by dust mites and animal dander. Seasonal AR (SAR) is related to a wide variety of pollen allergens including grasses, Parietaria, Ambrosia, Artemisia, birch, olive, hazelnut, and cypress. The morbidity of SAR obviously depends on the geographic region, the pollen season of the plants, and the local climate. Several other conditions can cause similar symptoms and are referred to as nonallergic (noninfectious) rhinitis: NARES (nonallergic rhinitis with eosinophilia syndrome); aspirin sensitivity; endocrine, occupational, postinfectious, and side-effects of systemic drugs; abuse of topical decongestants (rhinitis medicamentosa); and idiopathic rhinitis. Furthermore, diseases such as nasal polyposis, chronic sinusitis, cystic ®brosis, Wegeners disease, benign or malignant tumours, etc. have to be excluded carefully. Therefore, current guidelines (4) emphasize the importance of an accurate diagnosis of patients presenting with rhinitis symptoms. In fact, several causes may commonly coexist in the same *European Academy of Allergology and Clinical Immunology. Allergy 2000: 55: 116±134 Printed in UK. All rights reserved Copyright # Munksgaard 2000

EAACI Position Paper on Rhinosinusitis and Nasal Polyps Executive Summary

OS document, initated by the Academy ofAllergology and Clinical Immunology (EAACI) andapproved by the European Rhinologic Society (ERS), isintended to be state-of-the art for the specialist as well asfor the general practitioner:• to update their knowledge of rhinosinusitis and nasalpolyposis;• to provide an evidence-based documented revision ofthe diagnostic methods;• to provide an evidence-based revision of the availabletreatments;• to propose a stepwise approach to the management ofthe disease;• to propose guidance for definitions and outcomemeasurements in research in different settings.This executive summary focuses on definitions, diagnosisand treatment and the relation to allergy and lowerairway disease. The whole document is published at theEAACI website (http://www.eaaci.org) and in the JournalRhinology (Supplement 18, March 2005).Definition of rhinosinusitis/nasal polypsRhinitis and sinusitis usually coexist and are concurrentin most individuals; thus, the correct terminology is nowrhinosinusitis.In 2001 the WHO put together a working group onrhinitis and its impact on asthma (ARIA) (9). In thisgroup rhinitis was classified according to duration andseverity. Because rhinitis and sinusitis are so closelylinked the definition of CRS/NP in the EPOS document isdeveloped from the ARIA classification of rhinitis andbased on symptomatology, duration and severity ofdisease.The diagnosis of rhinosinusitis is made by a widevariety of practitioners, including allergologists, otolar-yngologists, pulmonologists, primary care physicians andmany others. Due to the large differences in technicalpossibilities to diagnose and treat rhinosinusitis/nasalpolyps by various professions, definitions of CRS/NPshould be tailored to the individual group.Clinical definition of rhinosinusitis/nasal polypsRhinosinusitis (including nasal polyps) is defined as:• Inflammation of the nose and the paranasal sinusescharacterised by two or more symptoms:– blockage/congestion– discharge: anterior/post nasal drip– facial pain/pressure– reduction or loss of smelland either• Endoscopic signs:– polyps– mucopurulent discharge from middle meatus– oedema/mucosal obstruction primarily in middlemeatusand/or• CT changes:– mucosal changes within ostiomeatal complex and/or sinusesSeverity of disease. The disease can be divided intoMILD and MODERATE/SEVERE based on total visualanalogue scale (VAS) score (0–10 cm): MILD ¼ VAS0–4, MODERATE/SEVERE ¼ VAS 5–10.To evaluate the total severity the patient is asked toindicate on a VAS the question:How troublesome are your symptoms of rhinosinusitis?Not troublesome Most troublesome

Treatment of Hypertrophy of the Inferior Turbinate: Long-Term Results in 382 Patients Randomly Assigned to Therapy

A number of surgical techniques are commonly performed to control the symptoms of inferior turbinate hypertrophy unresponsive to medical treatment. We report long-term results in 382 patients randomly assigned to receive electrocautery (62), cryotherapy (58), laser cautery (54), submucosal resection without lateral displacement (69), submucosal resection with lateral displacement (94), and turbinectomy (45). Outcomes of objective test results from rhinomanometry, acoustic rhinometry, mucociliary transport time, and secretory immunoglobulin A levels were compared to the symptom scores before and yearly after surgical treatment. These data indicate that submucosal resection with lateral displacement of the inferior turbinate results in the greatest increases in airflow and nasal respiratory function with the lowest risk of long-term complications.

Treatment of inferior turbinate hypertrophy: a randomized clinical trial

In the past 130 years, many surgical procedures for turbinate reduction have been developed. We analyzed the long-term efficacy of 6 of these surgical techniques (turbinectomy, laser cautery, electrocautery, cryotherapy, submucosal resection, and submucosal resection with lateral displacement) over a 6-year follow-up period. We randomly divided 382 patients into 6 therapeutic groups and surgically treated them at the Department of Otorhinolaryngology of the University of Siena. After 6 years, only submucosal resection resulted in optimal long-term normalization of nasal patency and in restoration of mucociliary clearance and local secretory IgA production to a physiological level with few postoperative complications (p < .001). The addition of lateral displacement of the inferior turbinate improved the long-term results. We recommend, in spite of the greater surgical skill required, submucosal resection combined with lateral displacement as the first-choice technique for the treatment of nasal obstruction due to hypertrophy of the inferior turbinates.

The management of horizontal-canal paroxysmal positional vertigo.

Horizontal-canal paroxysmal positional vertigo (HC-PPV) is a vestibular syndrome due to canalolithiasis of the horizontal canal. The more common posterior-canal paroxysmal positional vertigo has a well defined and effective therapy, while there have been few reports on physical therapy for HC-PPV, and these have been tried in relatively few patients. We report the results of two different types of treatment of HC-PPV in 92 patients. A group of 21 untreated patients acted as a control group. One method, known as forced prolonged position (FPP), proposes liberating the affected canal by gravitation, and involves having the patient lie on the healthy side for many hours. The other method (the barbecue rotation) is a liberatory manoeuvre which proposes to expel the otoconia from the canal by rotating the patient 270 degrees around the longitudinal axis of the body in rapid steps of 90 degrees. FPP was successful in more than 70% of our patients; the barbecue rotation had slightly less successful but more immediate results. Both methods enable otoconial debris to migrate into the posterior canal. We suggest treating all patients with the two methods in succession.

Rhinitis and asthma in athletes: an ARIA document in collaboration with GA2LEN

This consensus document is aimed at reviewing evidence that the rhinits‐asthma links have peculiar features in athletes. Beside a review of epidemological data on the high prevalence of rhinitis and asthma in athletes, the effects on intense physical exercise on the immune system and repiratory functions are discussed, with special reference to the role of allergens and pollutants. In extending the Allergic Rhinitis and its Impact on Asthma (ARIA) recommendations to athletes, the issue is addressed of adapting diagnosis and management to criteria set by the International Olympic Committee (IOC) and regulations adopted by the World Anti‐Doping Agency (WADA).

Treatment of benign paroxysmal positional vertigo: No need for postmaneuver restrictions

The liberatory maneuver of Semont is an effective physical treatment for benign paroxysmal positional vertigo. It works because it causes otoconia to move out the posterior canal. The effectiveness of the maneuver is thought to be indicated by the appearance of a liberatory nystagmus. After the maneuver, patients are usually instructed to keep their heads erect for several days and not to lie on the pathologic side for about a week. Here we investigated the prognostic value of liberatory nystagmus and whether restrictions are necessary after treatment. Fifty-six patients with posterior canal benign paroxysmal positional vertigo underwent the Semont maneuver and were checked after 20 minutes, 24 hours, and 1 week. The patients were told that they could sleep or move as they pleased, without any particular precautions. We found that liberatory nystagmus had a high prognostic value and that it was not necessary for patients to avoid certain positions or movements after treatment.

International Consensus Statement on Allergy and Rhinology: Rhinosinusitis

Isam Alobid, MD, PhD1, Nithin D. Adappa, MD2, Henry P. Barham, MD3, Thiago Bezerra, MD4, Nadieska Caballero, MD5, Eugene G. Chang, MD6, Gaurav Chawdhary, MD7, Philip Chen, MD8, John P. Dahl, MD, PhD9, Anthony Del Signore, MD10, Carrie Flanagan, MD11, Daniel N. Frank, PhD12, Kai Fruth, MD, PhD13, Anne Getz, MD14, Samuel Greig, MD15, Elisa A. Illing, MD16, David W. Jang, MD17, Yong Gi Jung, MD18, Sammy Khalili, MD, MSc19, Cristobal Langdon, MD20, Kent Lam, MD21, Stella Lee, MD22, Seth Lieberman, MD23, Patricia Loftus, MD24, Luis Macias‐Valle, MD25, R. Peter Manes, MD26, Jill Mazza, MD27, Leandra Mfuna, MD28, David Morrissey, MD29, Sue Jean Mun, MD30, Jonathan B. Overdevest, MD, PhD31, Jayant M. Pinto, MD32, Jain Ravi, MD33, Douglas Reh, MD34, Peta L. Sacks, MD35, Michael H. Saste, MD36, John Schneider, MD, MA37, Ahmad R. Sedaghat, MD, PhD38, Zachary M. Soler, MD39, Neville Teo, MD40, Kota Wada, MD41, Kevin Welch, MD42, Troy D. Woodard, MD43, Alan Workman44, Yi Chen Zhao, MD45, David Zopf, MD46

Normal values of mucociliary transport time in young subjects

The authors studied the behaviour of nasal mucociliary transport (MCT) in 54 (33 female/21 male) normal children aged between 3 and 12 years, in orthostatic and clinostatic positions. The nasal MCT time was recorded with the stained tracer method; vegetal coal powder was used since it fulfills the required characteristics: it is neither toxic, nor soluble and can be easily detected. The examinations were carried out at the same time of day on two consecutive days under the same conditions of temperature and relative humidity. The statistical analysis of the results indicated an average nasal MCT time of 9.96 +/- 2.61 min in the orthostatic (upright) position and of 9.98 +/- 2.31 min in the clinostatic (lying) position: these values should be considered normal. No statistically significant difference was noted attributable to sex or posture.

Ingested foreign bodies causing complications and requiring hospitalization in European children: Results from the ESFBI study

Background:  In young children, particularly those aged 1–3 years, aerodigestive tract foreign bodies (FB) are a common pediatric problem. The aim of the present study was therefore to characterize the risk of complications and prolonged hospitalization due to FB in the upper digestive tract in terms of the characteristics of the injured patients (age, gender), typology and features of the FB, the circumstances of the accident and hospitalization details.