Livije Kalogjera

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

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.

Lack of efficacy of long-term, low-dose azithromycin in chronic rhinosinusitis: a randomized controlled trial

To cite this article: Videler WJ, Badia L, Harvey RJ, Gane S, Georgalas C, van der Meulen FW, Menger DJ, Lehtonen MT, Toppila‐Salmi SK, Vento SI, Hytönen M, Hellings PW, Kalogjera L, Lund VJ, Scadding G, Mullol J, Fokkens WJ. Lack of Efficacy of long‐term, low‐dose azithromycin in chronic rhinosinusitis: a randomized controlled trial. Allergy 2011; 66: 1457–1468.

Diagnostic tools in Rhinology EAACI position paper

This EAACI Task Force document aims at providing the readers with a comprehensive and complete overview of the currently available tools for diagnosis of nasal and sino-nasal disease. We have tried to logically order the different important issues related to history taking, clinical examination and additional investigative tools for evaluation of the severity of sinonasal disease into a consensus document. A panel of European experts in the field of Rhinology has contributed to this consensus document on Diagnostic Tools in Rhinology.

The influence of dopamine agonists and antagonists on indomethacin lesions in stomach and small intestine in rats

Dopamine agents (saline in control groups) were coadministered with indomethacin by either single or repeated application. The ulcerogenic effect (erosions and/or ulcers) of repeated given indomethacin on gastric mucosa differed clearly from that on intestinal mucosa. The effect on intestinal mucosa was markedly greater than after a single dose. The effects of dopamine agents appeared to be more consistent. Domperidone and haloperidol, given as single or repeated doses, strongly aggravated both the gastric and intestinal lesions. Bromocriptine and amantadine had a protective effect. The adverse effects of both dopamine antagonists (increased after repeated administration) were strongly inhibited by the simultaneous administration of either bromocriptine or amantadine. The involvement of the dopamine system (central or peripheral) in the mechanisms that maintain gastric (probably related to cytoprotection also) and intestinal mucosa integrity is therefore suggested.

Executive summary of European Task Force document on diagnostic tools in rhinology

This Executive Summary of the EAACI Task Force document on Diagnostic Tools in Rhinology provides the readers with an over- view of the currently available tools for diagnosis of nasal and sino-nasal disease, published in full version in the first issue of Clini- cal and Translational Allergy. A panel of European experts in the field of Rhinology have contributed to this consensus document on Diagnostic Tools in Rhinology. Important issues related to history taking, clinical examination and additional investigative tools for evaluation of the severity of nasal and sinonasal disease are briefly highlighted in this executive summary.

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.

Histopathologic Parameters as Predictors of Response to Endoscopic Sinus Surgery in Nonallergic Patients with Chronic Rhinosinusitis

OBJECTIVE: To estimate the predictable value of histopathologic parameters in chronic rhinosinusitis (CRS) for response to endoscopic sinus surgery (ESS). STUDY DESIGN: Symptomatology was rated in 100 patients prior to as well as 12 and 24 months after surgery. Specimens taken during the procedure were examined and scored for goblet cells, subepithelial thickening, mast cells, and eosinophils. Multiple regression analysis was performed to predict the total score of subjective symptoms before treatment by histopathologic parameters. The correlation between histopathologic parameters and postoperative symptoms was then evaluated. RESULTS: Goblet cells were the best predictor correlating with 5 symptoms. Subepithelial thickening correlated with 4 symptoms. Mast cell infiltration correlated with 3 symptoms. Eosinophilic infiltration correlated with only one symptom (P < 0.05). CONCLUSION: Certain histopathologic parameters in CRS are predictive of favorable response to ESS. SIGNIFICANCE: Pathologic evaluation may help the ENT surgeon to predict the persistence of certain CRS symptoms after ESS, even in patients at low risk for surgical failure. EBM rating: C-4

Perceived stress and severity of chronic rhinosinusitis in allergic and nonallergic patients.

Chronic stress exposure carries greater risk of onset of atopic respiratory disorders such as rhinitis and asthma. The interaction between depression, anxiety, and severity of chronic rhinosinusitis (CRS) has been suggested. We aimed to access the relationship between psychological stress, severity of CRS, and atopy. Sixty-three consecutive patients referred with CRS were asked to score the severity of rhinosinusitis symptoms on a visual analog scale and to fill in questionnaires on the disease-specific quality of life and perceived stress-22-item Sino-Nasal Outcome Test (SNOT-22) and measure of perceived stress (MPS) scale, respectively. Inclusion criteria for the study were a reliable allergy evaluation and a recent computerized tomography (CT) scan of the sinuses. Patients with nasal polyps (NPs), asthma, and previous surgery were excluded. The study group consisted of 14 allergic and 18 nonallergic patients with CRS without NPs (CRSsNPs). Correlation between MPS and SNOT-22 scores in the study group was highly significant (Pearson r = 0.61; p = 0.001). Patients with higher stress scores had significantly stronger postnasal discharge, thick discharge, cough, disturbed sleep, fatigue, and sadness. Postnasal drip was significantly stronger in patients with allergy. The correlation between SNOT-22 and CT scores was insignificant. The correlation between MPS and SNOT-22 scores suggests an interaction between severity of CRS and chronic stress, but not with the extent of the disease on CT in CRSsNPs. Chronic psychological stress might be one of the factors that modifies the disease severity and may lead to uncontrolled disease in CRS patients.

Management of Smell Dysfunction

Olfaction is an essential chemosensory system in the living world. Although less appreciated in humans, smell impairment significantly affects many aspects of quality of life. Smell disorders may be caused by an impaired nasal airway or by lesions in the olfactory system, leading to reduced or distorted smell perception. The most common causes of smell disorders are aging, upper respiratory tract infection, sinonasal disease, and head trauma. Recovery is rarely complete. Counseling is important in progressive or severe smell loss. In patients with distorted smell perception, antidepressant medication is sometimes necessary. Best response to treatment is achieved for nasal obstruction and sinonasal inflammatory disease. Treatment of olfactory impairment caused by sinonasal disease includes medication with topical and systemic steroids, or surgery for refractory cases. Although there are reports that surgical resection of olfactory neurons may lead to reinnervation and recovery of smell, adequate treatment of the smell loss remains an unmet need.