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26.  Beware of the caterpillar: Anaphylaxis to the spotted tussock moth caterpillar, Lophocampa maculata 
Allergy & Rhinology  2014;5(2):e113-e115.
We present a case report of a 5-year-old boy with presumed anaphylaxis to the caterpillar, Lophocampa maculata, manifesting as the acute development of diffuse urticaria and progressive dyspnea. This reaction required prompt treatment with antihistamines and a bronchodilator. Allergen scratch testing with a homogenized caterpillar extract suggests that immunoglobulin E–mediated type I hypersensitivity as the pathophysiological mechanism responsible for the boy's anaphylaxis. This case report represents the first documented occurrence of an anaphylactic reaction to Lophocampa maculata and adds to the rare incidence of documented hypersensitivity to the order Lepidoptera.
doi:10.2500/ar.2014.5.0086
PMCID: PMC4124577  PMID: 24988176
Anaphylaxis; caterpillar; childhood; hypersensitivity; insect; Lophocampa maculata; spotted tussock moth; tiger moth
27.  The usefulness of preoperative biopsy in unilateral nasal masses 
Allergy & Rhinology  2014;5(2):e53-e55.
Unilateral nasal masses are considered suspicious for proliferative diseases. Several tools are routinely used to investigate unilateral lesions such as imaging and nasal biopsy. This study investigated the usefulness of nasal biopsy in predicting the actual nature of unilateral lesions. Preoperative nasal biopsy pathological results were compared with the final pathology obtained during an operation. Forty-six patients with unilateral nasal masses were included in the study group. In 40 patients the final pathology was similar to the preoperative nasal biopsy. In three patients the biopsy specimen was a benign polyp and the final pathology was of an inverted papilloma in two patients and hemangiopericytoma in one patient. In two patients the biopsy specimen was suspicious for an inverted papilloma and the final pathology was a benign polyp. In one patient the biopsy specimen was chordoma and the final pathology was osteosarcoma. The total agreement was 86.9%. The kappa value was 81.2%. Preoperative nasal biopsy is important and useful in evaluating unilateral nasal masses.
doi:10.2500/ar.2014.5.0082
PMCID: PMC4124578  PMID: 24684868
Nasal biopsy; operation; pathology; polyps; preoperative nasal biopsy; proliferative disease; unilateral nasal mass
28.  Assessment of allergenicity to fungal allergens of Rohtak city, Haryana, India 
Allergy & Rhinology  2014;5(2):e56-e65.
Fungal spores are known as one of the important bioparticles causing allergic manifestation in human beings. Hence, knowledge of season and prevalence of the airborne allergens to which the patients are exposed is a prerequisite for proper diagnosis and treatment of allergic disorders in hypersensitive individuals. Keeping this in view, aerial survey was performed in the atmosphere of Rohtak city for 2 consecutive years (March 2008–February 2010), using a volumetric petri plate sampler. A total of 45 fungal spore types were recorded during the survey period. In the present study, February–April and July–November were identified as the peak seasons for Rohtak city. Cladosporium was the main contributor to the total fungal load with 25.14% followed by Alternaria (18.05%), Aspergillus niger (7.66%), Curvularia (5.31%), and Epicoccum (5.29%). Fifteen dominant viable fungal spore types were represented in the form of a fungal calendar. An attempt has also been made to assess the allergenicity of some of the fungal types recorded from the atmosphere of Rohtak city. The magnitude of variations observed in markedly positive skin reactions (2+ and above) varied from 17.3 to 2.3%. Penicillium oxalicum showed a markedly positive reaction in maximum number of patients (26; 17.3%) followed by Rhizopus nigricans (23; 15.3%). ELISA was performed with the sera of patients showing markedly positive skin reactions and the sera were classified into four groups based on percent binding. The majority of the sera showed 0–15% binding to different antigenic extracts, while sera showing >60% binding were least in number. Greater than 30% binding was observed against antigens of Rhizopus nigricans, Epicoccum purpurascens, Penicillium oxalicum, Curvularia lunata, Aspergillus flavus, Candida albicans and Neurospora sitophila. The concordance between positive skin reaction and serum-specific IgE antibodies ranged from 16.7 to 69.2%.
doi:10.2500/ar.2014.5.0088
PMCID: PMC4124579  PMID: 24988378
Aerobiology; asthma; allergens; bioassay; fungal calendar; fungus; hypersensitivity; immunoassay; immunoglobulin E; seasonal variations
29.  Modified oral metronidazole desensitization protocol 
Allergy & Rhinology  2014;5(2):e66-e69.
The Center for Disease Control guidelines recommend desensitization to metronidazole in patients with trichomoniasis and hypersensitivity to metronidazole. There is only one published oral metronidazole desensitization protocol. The purpose of this study was to design a new, more gradual oral desensitization protocol to decrease systemic reactions that may occur when using the previously published protocol. We present two patients with presumed IgE-mediated allergy to metronidazole who underwent oral desensitization using our modified protocol. Case 1 was a 65-year-old woman with trichomoniasis who presented for metronidazole desensitization with a history of intraoperative anaphylaxis and positive skin tests to metronidazole. The patient tolerated six doses of the modified desensitization but developed systemic symptoms of nasal congestion and diffuse pruritus after the 25- and 100-mg doses. Both reactions were treated with intravenous (i.v.) antihistamines. Because of gastrointestinal irritation, the desensitization was completed at a dose of 250 mg orally every 6 hours. Case 2 was a 42-year-old woman with trichomoniasis and a history of hives immediately after administration of i.v. metronidazole who presented for desensitization. The patient had negative skin-prick and intradermal testing to metronidazole. She developed lip tingling and pruritus on her arms 15 minutes after the 10-mg dose. Fexofenadine at 180 mg was given orally and symptoms resolved. She tolerated the rest of the protocol without reaction and received a total dose of 2 g of metronidazole. Our oral metronidazole desensitization for presumed IgE-mediated reactions offers a second option for physicians wishing to use a more gradual escalation in dose.
doi:10.2500/ar.2014.5.0080
PMCID: PMC4124580  PMID: 24612959
Anaphylaxis; desensitization; drug allergy; immediate-type allergy; intradermal skin test; metronidazole; nitroimidazoles; skin-prick testing; tinidazole; trichomonas
30.  Numerical investigation of the flow field in realistic nasal septal perforation geometry 
Allergy & Rhinology  2014;5(2):e70-e77.
The computational fluid dynamics (CFD) are used to evaluate the physiological function of the nose. We evaluated the aerodynamics of the nasal cavity in a patient with septal perforation (SP), pre- and postvirtual repair. Three-dimensional nasal models were reconstructed, and then a wide range of the pressure drops and flow rates were analyzed. The airflow velocity is higher in the central region and is lower around the boundary of the SP. The air velocity in the SP increases as the pressure drop increases. Furthermore, at the anterior part of the SP, the shear stress is higher in the upper part. In addition, the repair of SP does not affect the total nasal airflow rate and the velocity contour patterns. The potential usage of the CFD technique as a predictive technique to explore the details and a preoperative assessment tool to help in clinical decision making in nasal surgery is emphasized.
doi:10.2500/ar.2014.5.0090
PMCID: PMC4124581  PMID: 24988523
Aerodynamics; airflow velocity; computational fluid dynamics; geometry; nasal cavity; nasal septal perforation
31.  Azelastine and budesonide (nasal sprays): Effect of combination therapy monitored by acoustic rhinometry and clinical symptom score in the treatment of allergic rhinitis 
Allergy & Rhinology  2014;5(2):e78-e86.
The aim of this study was to objectively evaluate the effects of intranasal therapy with azelastine (AZE), budesonide (BUD), and combined AZE plus BUD (AZE/BUD) using a nasal provocation test (NPT) and acoustic rhinometry in patients with allergic rhinitis. A randomized, single-blind, crossover study with three treatment sequences was used. Thirty patients with persistent AR received the three treatments using a nasal spray twice daily for 30 days and were evaluated by an NPT with histamine before and after each period of treatment. The treatment comparison, assessed by the nasal responsiveness to histamine, was monitored based on subjective (symptom score) and objective parameters (acoustic rhinometry). The minimal cross-area 2 (MCA2) was measured by acoustic rhinometry at 1, 4, 8, and 12 minutes after NPT for each histamine concentration administered (0.5, 1, 2, 4, and 6 mg/mL) up to at least a 20% reduction in the MCA2 from baseline (NPT20). The subjects were scored regarding nasal response encompassing histamine dose and time after histamine administration that caused nasal obstruction (NPT20 score) to assess the treatments' effects. Combination therapy produced a significant increase in baseline MCA2, viz., the improvement of nasal patency (p = 0.005). The symptoms score was significantly decreased after treatment with AZE (p = 0.03), BUD (p < 0.0001), and AZE/BUD (p < 0.0001), compared with pretreatment. The NPT20 score was significantly higher (p = 0.0009) after AZE/BUD, compared with AZE and BUD on their own. Thus, AZE therapy combined with BUD might provide more therapeutic benefits than the isolated drugs for improving nasal patency.
doi:10.2500/ar.2014.5.0089
PMCID: PMC4124582  PMID: 24988550
Acoustic rhinometry; allergic rhinitis; azelastine; budesonide; histamine; intranasal drug; nasal obstruction; nasal patency; nasal provocation test
32.  Mycobacterium chelonae dacryocystitis after endoscopic dacryocystorhinostomy 
Allergy & Rhinology  2014;5(2):e87-e90.
Mycobacterium chelonae is a rapidly growing nontuberculous Mycobacterium and an uncommon cause of aggressive, treatment-resistant ocular and periocular infection. This is the first known case report of a woman who developed unilateral M. chelonae dacryocystitis after undergoing endoscopic sinus surgery and right endoscopic dacryocystorhinostomy (DCR) with Crawford stent placement. We describe our findings and effective methods to manage the infection. Three weeks after undergoing DCR, the patient acutely developed symptoms consistent with dacryocystitis. The patient was treated with broad-spectrum antibiotics followed by incision and drainage of the dacryocystocele abscess, with initial cultures showing no organisms. With continued signs of infection, the Crawford stent was later removed. Cultures eventually grew M. chelonae and the patient was treated with 4 months of antibiotic therapy. While receiving antibiotics, the patient developed three abscesses along the inferior lid requiring excision. After 21 months, the patient remains free of infection and has not experienced any other complications. This case serves as a reminder to consider M. chelonae as a potential cause of periocular infection, which may be more likely to occur postoperatively with indwelling devices, as well as in patients with sinonasal issues requiring nasal irrigations. This organism can be difficult to treat because of multidrug resistance and biofilm production. Recommended therapy includes surgical debridement, removal of any implanted devices, and a two-drug antibiotic regimen for at least 4 months.
doi:10.2500/ar.2014.5.0081
PMCID: PMC4124583  PMID: 24613068
Atypical Mycobacterium; bicanalicular stent; chronic rhinosinusitis; dacryocystitis; dacryocystorhinostomy; endoscopic dacryocystorhinostomy; endoscopic sinus surgery; Mycobacterium chelonae; nasal polyps; nontuberculous Mycobacterium
33.  Expression of surface markers on the blood cells during the delayed asthmatic response to allergen challenge 
Allergy & Rhinology  2014;5(2):e96-e109.
Patients with bronchial asthma develop various types of asthmatic response to bronchial challenge with allergen, such as immediate/early asthmatic response (IAR), late asthmatic response (LAR) or delayed asthmatic response (DYAR), because of different immunologic mechanisms. The DYAR, occurring between 24 and 56 hours after the bronchial allergen challenge (p < 0.01), differs from IAR and LAR in clinical as well as immunologic features. This study investigates the expression of CD molecules (markers) on the surface of particular cell populations in the peripheral blood and their changes during the DYAR. In 17 patients developing the DYAR (p < 0.01), the bronchial challenge with allergen was repeated 2–6 weeks later. The repeated DYAR (p < 0.001) was combined with recording of CD molecule expression on various types of blood cells by means of flow cytometry up to 72 hours after the challenge. The results were expressed in percent of the mean relative fluorescence intensity. The DYAR was accompanied by (a) increased expression of CD11b, CD11b/18, CD16,CD32, CD35, CD62E, CD62L, CD64, and CD66b on neutrophils; CD203C on basophils; CD25 and CD62L on eosinophils; CD14, CD16, CD64, and CD86 on monocytes; CD3, CD4, CD8, CD11a, CD18, and CD69 on lymphocytes; CD16, CD56, CD57, and CD94 on natural killer (NK) cells; and CD31, CD41, CD61, CD62P, and CD63 on thrombocytes and (b) decreased expression of CD18 and CD62L on eosinophils, CD15 on neutrophils, and CD40 on lymphocytes. These results suggest involvement of cell-mediated hypersensitivity mechanism, on participation of Th1- lymphocytes, neutrophils, monocytes, NK cells, and thrombocytes in the DYAR.
doi:10.2500/ar.2014.5.0087
PMCID: PMC4124585  PMID: 24988283
Bronchial provocation tests with allergen; CD molecules; delayed asthmatic response; monocytes; neutrophils; NK cells; Th1 lymphocytes; thrombocytes
34.  Egg baked in product open oral food challenges are safe in selected egg-allergic patients 
Allergy & Rhinology  2014;5(2):e110-e112.
Egg allergy is one of the most common food allergies in children. Most egg-allergic children are able to tolerate egg baked in product (EBP) and will likely outgrow his/her egg allergy. By introducing EBP in the diet of an egg-allergic child, diet can be expanded and family stress can be reduced. Recent evidence suggests that children who tolerate EBP and continue to consume it will have quicker resolution of egg allergy than those who strictly avoid EBP; therefore, we aimed to evaluate the egg-allergic children who underwent EBP oral food challenge (OFC) in our allergy clinic to help define any specific predictors to be used in predicting the outcome of such challenges. We performed a retrospective chart review and 43 egg-allergic patients underwent EBP OFC in our outpatient allergy office from January 2011 to December 2012 were excluded. Nine patients who did not have a prior history of symptomatic egg ingestion. Clinical characteristics and laboratory findings of the remaining 34 patients were all recorded and analyzed. Of the remaining 34 patients, 22 (64.7%) were boys. Average age of first reaction to egg was 12.90 months, with average age at EBP OFC of 71.32 months. The average of the most recent skin-prick test wheal size was 10.10 mm and serum-specific IgE to egg white was 3.21 kU/L. Twenty-eight of the 34 patients (82.4%) passed the EBP OFC. Of the six patients who failed, none required epinephrine. After analysis of all of the clinical characteristics and laboratory findings, no risk factors, such as skin-prick test wheal size, were identified to be associated with an increased risk of failing EBP OFC. EBP OFC is a valuable tool to assess tolerance. As seen in our group of patients, the majority of egg-allergic patients pass EBP OFC. Thus, OFC should be considered as a clinical tool to expand a patient's diet and to improve quality of life as early as possible. Because we were unable to determine any clinical or laboratory predictors helpful to select egg-allergic patients who are likely to pass EBP OFC, additional prospective studies are necessary to determine the ideal egg-allergic patient who is likely to pass EBP OFC.
doi:10.2500/ar.2014.5.0092
PMCID: PMC4124576  PMID: 25198996
Baked egg; baked egg oral food challenge; egg allergy; egg baked in product; egg baked in product oral food challenge; food allergy; oral food challenge; serum-specific IgE; skin-prick testing
35.  Very low dose bevacizumab for the treatment of epistaxis in patients with hereditary hemorrhagic telangiectasia 
Allergy & Rhinology  2014;5(2):e91-e95.
Hereditary hemorrhagic telangiectasia (HHT) is a disease characterized by mucocutaneous telangiectasias and visceral arteriovenous malformations. The genetic mutations that cause this disease result in elevated levels of vascular endothelial growth factor, which is inhibited by bevacizumab. Previous studies have shown bevacizumab treatment to be effective in reducing symptoms, but study protocols have all used oncological dosing parameters, which carry several well-described serious side effects. This study investigates whether drastically lower dosages of bevacizumab than normally used in oncological treatment could control epistaxis in patients with HHT and medically refractory epistaxis. A prospective, open-label, noncomparative study enrolled six patients receiving 0.125-mg/kg infusions of bevacizumab once every 4 weeks for a total of six infusions. Severity of epistaxis was assessed with the epistaxis severity score, and quality-of-life measures were followed with the 20-item Sino-Nasal Outcome Test and 36-item Short Form surveys. A statistically significant improvement was seen in the control of epistaxis severity and frequency, with minimal negative side effects and high patient satisfaction. Very low dose bevacizumab treatment is an effective method of controlling medically refractory epistaxis in patients with HHT and additional investigation to optimize dosing guidelines is warranted.
doi:10.2500/ar.2014.5.0091
PMCID: PMC4124584  PMID: 25199101
Angiogenesis; Avastin; bevacizumab; epistaxis; hereditary hemorrhagic telangiectasia; Osler–Weber–Rendu disease; VEGF
36.  Introducing a New Feature to Allergy and Rhinology 
Allergy & Rhinology  2014;5(1):e1.
doi:10.2500/ar.2014.5.1418
PMCID: PMC4019737  PMID: 25199143
37.  Radiofrequency inferior turbinate reduction improves smell ability of patients with chronic rhinitis and inferior turbinate hypertrophy 
Allergy & Rhinology  2014;5(1):e12-e16.
Radiofrequency inferior turbinate reduction (RFITR) of inferior turbinate hypertrophy (ITH) is an effective way to treat patients with intractable nasal mucosal obstruction. The objective of this study was to assess smell ability, nasal symptoms, inferior turbinate grading (ITG), peak nasal inspiratory flow (PNIF) of patients with chronic rhinitis (CR), and ITH before and after RFITR. Patients with CR and ITH, aged 18–60 years, who underwent RFITR, were prospectively recruited. Smell ability (measured by smell detection threshold [SDT]), visual analog scale (VAS) of nasal symptoms, ITG, and PNIF before and 6–10 weeks after RFITR were compared. Forty-eight subjects were included. All nasal symptoms were significantly decreased after RFITR. After surgery, SDT (tested by phenyl ethyl alcohol) was worsened in 7 patients (14.6%), improved in 8 patients (16.7%), and did not change in 33 patients (68.7%). SDT after RFITR of six patients in the worsened SDT group were still within normal range (> −6.5). There was only one patient whose SDT changed from normosmia to mild hyposmia (−7.25 to −5.38). In the improved SDT group, two of eight patients had obviously better SDT after RFITR, which changed from moderate hyposmia to normosmia (−3.65 to −10; −3.73 to −10), whereas six of eight patients had little better SDT after RFITR. RFITR also significantly reduced ITG and improved PNIF. In conclusion, the treatment of patients with CR and ITH with RFITR significantly improved PNIF, ITG, and nasal symptoms assessed by VAS, although SDT after RFITR could be the same or improved or worsened.
doi:10.2500/ar.2014.5.0077
PMCID: PMC4019738  PMID: 24612902
Chronic rhinitis; inferior turbinate hypertrophy; peak nasal inspiratory flow; radiofrequency inferior turbinate reduction; smell detection threshold
38.  Comparison of two nasal cell collection methods in determining cyclic adenosine monophosphate levels and its association with olfaction: A feasibility study 
Allergy & Rhinology  2014;5(1):e17-e21.
Cyclic adenosine monophosphate (cAMP) is a second messenger that may be associated with olfactory function. No known studies have compared existing collection methods for determining nasal cAMP levels. This is a prospective study comparing the comfort and reliability of the nasal curette and cytobrush. A secondary outcome collected for feasibility testing was characterizing the association between cAMP and olfactory function. We enrolled 19 normal olfaction and 10 olfactory dysfunction subjects. Olfaction was measured by the University of Pennsylvania Smell Identification Test. Two samples were obtained from each nasal cavity at the initial visit and at 1 week follow-up. Comfort was measured by a visual analog scale (VAS). cAMP levels were determined by an enzyme immunoassay. For the curette and cytobrush, mean VAS scores were 0.3 and 0.7 cm (p = 0.48). Intraclass correlation coefficients were 0.81 (curette) and 0.65 (cytobrush) for the initial visit and 0.64 and 0.54 between the initial and follow-up visit. Using the curette, mean cAMP was 537 and 480 fmol/(mg/mL) for the normal and dysfunction cohorts (p = 0.18). Using the cytobrush, cAMP was 505 and 477, respectively (p = 0.65). The curette and cytobrush are both comfortable and reliable collection methods for determining nasal cAMP levels.
doi:10.2500/ar.2014.5.0079
PMCID: PMC4019739  PMID: 24613015
Anosmia; cAMP; curette; cytobrush; olfaction; olfactory epithelium; UPSIT
39.  Evaluation on quality of life in patients with nasal polyposis managed with optimal medical therapy 
Allergy & Rhinology  2014;5(1):e2-e8.
Nasal polyposis (NP) has a great impact on quality of life (QOL) and its management involves a combination of medical therapy and surgery. To the authors' knowledge, no publication has extensively examined NP after optimal medical treatment based on subjective evaluations. The aim of this prospective study was designed to evaluate the QOL in NP patients after (1) a short course of oral steroids, (2) initial 3-month course of macrolide, and (3) long-term treatment with intranasal steroids. A total of 55 patients with grades I and II NP were consecutively treated with oral prednisolone at 25 mg in a single dose for 2 weeks, macrolide at 250 mg daily for the first 3 months, and long-term intranasal steroids. Patients were followed up and evaluated at baseline and 3, 6, and 12 months for QOL measure. At baseline, patients with grade I and grade II NP showed significantly worse QOL scores on all Rhinosinusitis Disability Index domains, particularly for physical function (4.59 ± 1.41) and were significantly higher in social function (3.16 ± 1.17). At 3, 6, and 12 months of treatment, patients showed a significant improvement in all impaired QOL domains compared with baseline after optimal medical therapy (p < 0.05). These results suggest that the optimal medical treatment to improve QOL incorporates medical polypectomy with a short course of oral steroids in addition to macrolide and this can be maintained by long-term intranasal steroid therapy.
doi:10.2500/ar.2014.5.0075
PMCID: PMC4019740  PMID: 24612853
Aspirin sensitivity; asthma; grade I and I nasal polyps; loss sense of smell; macrolide; medical polypectomy; nasal obstruction; nasal polyposis; quality of life; topical intranasal steroids
40.  Local expression of interleukin-17a is correlated with nasal eosinophilia and clinical severity in allergic rhinitis 
Allergy & Rhinology  2014;5(1):e22-e27.
Interleukin (IL)-17A is a major cytokine produced by Th17 cells, which are associated with chronic inflammations. The local expression of IL-17A in allergic rhinitis (AR) remains to be characterized. We sought to determine the role of IL-17A expression in human inferior turbinate mucosa in the pathophysiology of AR. Inferior turbinate mucosa was sampled from medical treatment–resistant, surgery-required patients with perennial AR (PAR, n = 21), nonallergic rhinitis with eosinophilia syndrome (NARES, n = 7), and nonallergic hypertrophic rhinitis (HR, n = 13). IL-17A expression was determined with immunohistochemical staining. The mean number of IL-17A+ cells and eosinophils per field were counted. Total serum immunoglobulin E (IgE) levels, blood eosinophil count, and forced expiratory volume in 1 second (FEV1)/forced vital capacity (FVC) ratio were also examined in each patient. IL-17A was primarily expressed in infiltrating inflammatory cells. The number of IL-17A+ cells in nasal mucosa was significantly higher in the PAR group compared with HR (p = 0.002) and NARES (p = 0.021) groups. There was a significant and positive correlation between the number of IL-17A+ cells and total nasal symptom score (rho = 0.403; p = 0.011), especially sneezing score (rho = 0.471; p = 0.003). The number of IL-17A+ cells was significantly and positively correlated with the degree of eosinophil infiltration (rho = 0.623; p < 0.001), but not with total serum IgE levels (rho = 0.284; p = 0.098), blood eosinophil counts (rho = 0.302; p = 0.056), or FEV1/FVC ratio (rho = 0.092; p = 0.569). The present study provides evidence that IL-17A expression in the nasal mucosa is associated with the pathophysiology of AR, including disease severity and nasal eosinophilia.
doi:10.2500/ar.2014.5.0078
PMCID: PMC4019741  PMID: 24758732
Allergic rhinitis; eosinophil; IL-17A; nasal mucosa; total nasal symptom score
41.  Validation of the applicability of the traditional Chinese version of the University of Pennsylvania Smell Identification Test in patients with chronic rhinosinusitis 
Allergy & Rhinology  2014;5(1):e28-e35.
The 40-item University of Pennsylvania Smell Identification Test (UPSIT) is the most widely used smell test in the world. Presently, culturally modified versions of this test are available in multiple languages. A traditional Chinese version of the UPSIT (UPSIT-TC) has been developed for administration in Taiwan. The purpose of this study was to investigate the validity and reliability of the UPSIT-TC in Taiwanese patients with chronic rhinosinusitis (CRS). The phenylethyl alcohol (PEA) odor detection threshold test, the North American version of UPSIT (UPSIT-NA), and the UPSIT-TC were administered to 40 healthy subjects and to 100 CRS patients before and after functional endoscopic sinus surgery (FESS). The UPSIT-TC showed good internal consistency (Cronbach's alpha = 0.887, 0.886, and 0.870 at three test occasions) and test–retest reliability (p < 0.001). The scores of UPSIT-TC were significantly correlated to the PEA thresholds (p < 0.001). The UPSIT-TC scores were significantly higher than those of the UPSIT-NA (p = 0.028) when analysis was performed with logistic regression with independent variables including test occasions (before or after FESS), test methods (UPSIT-NA or UPSIT-TC), status of polyp (with or without), and PEA thresholds (improved or did not improve). In addition, there were significant between-group differences in UPSIT-TC scores including healthy versus CRS, CRS with polyps versus CRS without polyps, and PEA thresholds improved versus PEA thresholds which did not improve. The UPSIT-TC is reliable and valid for measuring olfactory function in Taiwanese patients with rhinosinusitis. In addition, the UPSIT-TC clearly resulted in better performance than that of UPSIT-NA.
doi:10.2500/ar.2014.5.0084
PMCID: PMC4019742  PMID: 25199144
Chronic rhinosinusitis; functional endoscopic sinus surgery; nasal polyp; olfactory function; phenyl ethyl alcohol odor detection threshold test; reliability; smell test; traditional Chinese version; UPSIT; validity
42.  Frontal sinus cholesterol granuloma: Case report 
Allergy & Rhinology  2014;5(1):e36-e38.
A case report of a massive cholesterol granuloma (CG) of the frontal sinus in a 15-year-old male subject treated endoscopically is reported. CGs are slowly expanding, cystic lesions that are rarely observed in the frontal sinus. Frontal sinus CGs characteristically present with proptosis, diplopia, and a unilateral painless expanding mass above the orbit. Patients frequently report a history of chronic nasal obstruction or head trauma. Although the pathogenesis is unclear, it is likely multifactorial in etiology. Surgical resection via endoscopic sinus surgery has been gaining popularity because of the minimally invasive approach and lower rates of recurrence.
doi:10.2500/ar.2014.5.0073
PMCID: PMC4019743  PMID: 24612824
Case report; cholesteatoma; cholesterol; cholesterol granuloma; endoscopic sinus surgery; frontal sinus; granuloma; surgical technique
43.  Smell sparing unilateral intracranial dermoid resection 
Allergy & Rhinology  2014;5(1):e39-e40.
Intracranial dermoid cysts are congenital ectodermal inclusion cysts that have a propensity to occur in the midline sellar, parasellar, or frontonasal regions. These cysts enlarge by means of glandular secretion and epithelial desquamation. Surgical resection has traditionally included a craniotomy, but endoscopic approaches are now used with increasing regularity. A binostril approach is normally used to access dermoid cysts due to the midline nature of the lesions. In this case report, we describe the successful surgical resection of a dermoid with 1.5-cm of intracranial extension using a unilateral endonasal endoscopic approach with no complications and with no postoperative anosmia. Although the unilateral endoscopic technique is not plausible for all epidermoid or dermoid cysts of the anterior cranial fossa, it should be considered a viable alternative technique when faced with a dermoid limited to one side of the falx cerebri.
doi:10.2500/ar.2014.5.0074
PMCID: PMC4019744  PMID: 24612984
Anosmia; dermoid cyst; endoscopic sinus surgery; hyposmia; nasoseptal flap; skull base surgery
44.  Asthma linked with rhinosinusitis: An extensive review 
Allergy & Rhinology  2014;5(1):e41-e49.
Current literature related to asthma diagnosis, epidemiology, pathogenesis, and treatment linked with rhinosinusitis is important. Asthma is very heterogeneous; new theories and treatments are emerging. It is a growing epidemic among children and adults in the United States and the severity of asthma is caused by many factors such as lack of education, poor early recognition, decreased symptom awareness, improper medications, and phenotypic changes. Genetic variation, innate immune genes, those involved in tissue remodeling and arachidonic acid metabolism, and inflammatory mediators might contribute to the pathogenesis of chronic rhinosinusitis (CRS) linked with asthma. This extensive review addresses concepts of the burden of asthma and sinusitis, altered innate immunity, adaptive immunity, asthma remodeling, the airway epithelium, the role of airway smooth muscle cells, united allergic airway, genetics, an integral part in asthma, and CRS. In addition, the role of vitamin D in both asthma and CRS in the elderly and pediatric population, various treatment options, and exhaled nitric oxide are briefly addressed.
doi:10.2500/ar.2014.5.0083
PMCID: PMC4019745  PMID: 24684837
Asthma; FeNO; genetics; phenotypes; remodeling; sinusitis; treatments; vitamin D
45.  Pathology quiz case: Plasmacytoid dendritic cell neoplasm 
Allergy & Rhinology  2014;5(1):e50-e52.
Blastic plasmacytoid dendritic cell neoplasm (BPDCN) is a rare hematologic malignancy that possesses a heterogenous clinical and immunophenotypic presentation. The current case report describes an interesting and unique presentation of BPDCN as a primary paranasal sinus tumor without evidence of cutaneous or systemic involvement. As such, the report further contributes to the ongoing debate regarding the true putative origin of the neoplasm, as well as highlights the optimal diagnostic modalities, paramount importance of early diagnosis, and vast heterogeneity exhibited by this fascinating malignancy. The atypical presentation described here indicates the manifestations of BPDCN are more heterogenous than previously documented and thus can not be definitively ruled out in the absence of bone marrow, peripheral blood, or cutaneous involvement. Furthermore, atypical neoplastic presentations mandate flow cytometry and adjunctive immunohistochemistry for the definitive diagnosis of BPDCN, and early diagnosis of such neoplasms are critical for rapid initiation of treatment and improved outcomes.
doi:10.2500/ar.2014.5.0085
PMCID: PMC4019746  PMID: 25199145
Blastic plasmacytoid dendritic cell neoplasm; endoscopic sinus surgery; ethmoid sinus; flow cytometry; immunohistochemistry; maxillary sinus; sphenoid sinus
46.  Soluble HLA-G serum levels depend on allergy type and IgE levels 
Allergy & Rhinology  2014;5(1):e9-e11.
Allergic rhinitis (AR) is characterized by Th2 polarized immune response. Soluble HLA (sHLA) molecules play an immunomodulatory activity. Two different studies evidenced that both patients with seasonal AR (SAR) and patients with perennial AR (PAR) had higher sHLA-G levels than normal controls. The aim of this study was to compare sHLA-G serum levels in SAR and PAR patients, also considering allergen-specific IgE. One hundred sixty-eight AR patients were enrolled, 94 with SAR and 74 with PAR. A group of 116 healthy subjects was considered as control. sHLA-G and allergen-specific IgE serum levels were determined by immunoenzymatic method. SAR patients had significantly higher levels of sHLA-G than PAR patients (p = 0.0194). sHLA-G was moderately related to allergen-specific IgE both in SAR (r = 0.497) and in PAR patients (r = 0.584). The present study provides evidence that sHLA-G serum levels depend on the type of allergy and are related to allergen-specific IgE serum levels. These findings may suggest that sHLA-G could be a biomarker of allergic reaction.
doi:10.2500/ar.2014.5.0076
PMCID: PMC4019747  PMID: 24612937
Allergic rhinitis; IgE; perennial allergens; pollens; sHLA-G
47.  The anatomical and functional relationship between allergic conjunctivitis and allergic rhinitis 
Allergy & Rhinology  2013;4(3):e110-e119.
There are numerous anatomic connections between the allergic conjunctivitis and allergic rhinitis. The most obvious reason is the physical connection via the nasolacrimal apparatus. However, a closer look at innervation, circulatory, lymphatic, and neurogenic systems reveals much more than a physical connection. The eye is richly innervated by parasympathetic nerves that enter the eyes after traveling in conjunction with the parasympathetic input to the nasal cavity. Parasympathetic innervation governing the tear film and nasal secretion can intersect at the pterygopalatine ganglion. Neurogenic inflammation affects both the eye and the nose as evidenced by the presence of the same neurogenic factors. Venous flow is in the SOV area connecting the eye and the nose, once thought to be without valves. In the past, this thinking is the basis for concern about the danger triangle of the face. Recent literature has shown otherwise. Although valves are present, there are still pathways where bidirectional flow exists and a venous connection is made. The most likely area for venous communication is the pterygoid plexus and cavernous sinus. The venous flow and connections also offers a pathway for allergic shiners. Understanding the mutual connections between the nasal mucosa and the ocular surface can also affect treatment strategies.
doi:10.2500/ar.2013.4.0067
PMCID: PMC3911799  PMID: 24498515
Allergic conjunctivitis; cavernous sinus; nasolacrimal; naso-ocular reflex; neurogenic inflammation; ocular allergy; pterygoid plexus; pterygopalatine ganglion; rhinitis
48.  Efficacy of mometasone furoate and fluticasone furoate on persistent allergic rhinoconjunctivitis 
Allergy & Rhinology  2013;4(3):e120-e126.
Allergic rhinoconjunctivitis denotes both nasal and ocular manifestation of allergy, which may be solely treated with intranasal steroid. This study compares the efficacy of mometasone furoate nasal spray (NS) and fluticasone furoate NS in treatment of allergic rhinoconjunctivitis. The secondary objective is to study the severity of baseline ocular symptoms in allergic rhinoconjunctivitis. Seventy-eight patients with allergic rhinoconjunctivitis were assessed subjectively and objectively using twice-daily symptom scores for nasal (reflective total nasal symptom score [rTNSS] and instantaneous TNSS [iTNSS]) and ocular (reflective total ocular symptom score [rTOSS] and instantaneous TOSS [iTOSS]) symptoms, rhinoconjunctivitis quality-of-life questionnaires (RQOLQs), and acoustic rhinometry. All measurements were taken at baseline and at 4 and 8 weeks of treatment. Sixty-three patients who were randomized into the mometasone furoate group (n = 36) and the fluticasone furoate group (n = 27) completed the study. Seventy-six percent of patients had mild ocular symptoms, 20.5% had moderate symptoms, and only 2.6% had severe symptoms at baseline based on the iTOSS; 65.1% had mild nasal symptoms and 3% had severe nasal symptoms. There was significant reduction in the symptom scores after 1 week (p < 0.05). Both groups had significant improvement in RQOLQ scores after 1 month, which further improved at 2 months (p < 0.05). The nasal dimensions also improved in both groups (p < 0.05) but there was no statistically significant difference between groups. Both mometasone furoate and fluticasone furoate are effective as single-modality treatment of allergic rhinoconjunctivitis. The majority of patients manifest mild ocular symptoms that may be solely treated with intranasal steroids.
doi:10.2500/ar.2013.4.0065
PMCID: PMC3911800  PMID: 24498516
Allergic rhinoconjunctivitis; fluticasone furoate; intranasal steroids; mometasone furoate; ocular symptoms; perennial allergic rhinitis
49.  Retrospective cohort study of leukotriene receptor antagonist therapy for preventing upper respiratory infection-induced acute asthma exacerbations 
Allergy & Rhinology  2013;4(3):e127-e131.
Upper respiratory tract infections (URIs) represent the most frequent cause of acute asthma exacerbations. It has yet to be determined whether leukotriene receptor antagonist (LTRA) treatment prevents URI-induced acute asthma exacerbations in adults. The objective of the present study was to evaluate the preventive effects of LTRA treatment on URI-induced acute asthma exacerbations. The incidences of URI alone, acute asthma exacerbation without URI, and URI-induced acute asthma exacerbation were determined retrospectively by analyzing diary and medical records of 321 adult asthmatic patients (mean age, 56.3 ± 17.2 years; male/female ratio, 117:204) over 1 year. Results were compared between patients who had been taking an LTRA (n = 137) and those who had never taken any LTRA (n = 184) during the study periods. Significantly fewer URIs alone and acute asthma exacerbations without URI occurred in patients with than in those without prophylactic daily use of LTRA. LTRA treatment significantly reduced the durations of URIs alone and of total acute asthma exacerbations, as well as the incidence of mild exacerbations of asthma. In contrast, in patients with URI-induced acute asthma exacerbations, LTRA treatment failed to significantly reduce the interval between URI onset and acute asthma exacerbation, as well as the duration and severity of both URIs and acute asthma exacerbations. Use of an LTRA for adult asthmatic patients appears to reduce the incidences of URIs alone and acute asthma exacerbations without URI, but it failed to prevent URI-induced acute asthma exacerbations once a URI occurred.
doi:10.2500/ar.2013.4.0062
PMCID: PMC3911801  PMID: 24498517
Acute asthma exacerbation; bronchial asthma; inhaled corticosteroids; inhaled long-acting beta2-agonist; leukotriene receptor antagonist; montelukast; pranlukast; retrospective cohort study; short-acting beta2-agonist; upper respiratory tract infection
50.  Association of matrix metalloproteinase 8 genetic polymorphisms with bronchial asthma in a Japanese population 
Allergy & Rhinology  2013;4(3):e132-e139.
Asthma has a strong genetic component. The final disease phenotype results from complex interactions between environment and multiple genes of small-to-modest effects. We investigated whether the polymorphism in genes encoding inflammatory mediators and cytokines is important for solving the onset and progression of asthma. We investigated whether 31 single nucleotide polymorphisms (SNPs) in genes encoding cytokines or monokines (interleukin [IL]-5R, matrix metalloproteinase [MMP] 8, beta2 adrenergic receptor, cytotoxic T-lymphocyte–associated antigen 4, IL-3, C-reactive protein, cytochrome P450 (CYP) 2C9, CYP3A4, a disintegrin and metalloproteinase [ADAM] 33, cysteinyl leukotriene receptor [CysLTR] 1, CysLTR2, eosinophilic cationic protein, glucocorticoid receptor, and leukotriene A 4 hydrolase) are related to asthma development in 206 Japanese bronchial asthma patients and 127 healthy controls. Using multifactor dimensionality reduction (MDR), we identified rs17099451 in MMP8, using a single locus model, with a mean cross-validation of 87.0%. Using a two-locus model, combinations of MMP8 and rs44707 in ADAM33, and MMP8 and rs40401 in IL-3, were identified, with mean cross-validation consistencies reaching 45.0%. Of the SNPs selected by the MDR method, rs17099451 in MMP8 and rs40401 in IL-3 were regarded as the most significant results in a 2 × 2 dominant model analysis. The finding that an MMP8 allele was most strongly related to asthma development indicates that metalloproteinase function is crucial to the airflow limitation process involved in this disease.
doi:10.2500/ar.2013.4.0063
PMCID: PMC3911802  PMID: 24498518
Asthma; Japanese population; multifactor dimensionality reduction (MDR); rs17099451 in MMP8; rs44707 in ADAM33; rs40401 in IL-3; single nucleotide polymorphism (SNP)

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