Obstructive Sleep Apnea Is Associated With Late-Onset Preeclampsia in Overweight Pregnant Women in Korea

Background@#Obstructive sleep apnea (OSA) is closely related to maternal obesity in pregnant women, and the association increases with later pregnancy. Obesity and OSA are risk factors of pregnancy-related complications, including gestational hypertension, gestational diabetes mellitus (GDM), and fetal morbidities. We aimed to determine the prevalence of OSA and to assess the impact of OSA on pregnancy-related disorders in overweight pregnant women. @*Methods@#Eligible participants who were overweight [body mass index (BMI) ≥ 23 kg/m 2 ] in gestational age 30 weeks or more, assessed OSA using a portable polysomnography at home.Clinical data were collected from pregnant women and their babies. @*Results@#The average age of 51 participants was 34.5 years (27–44 years). The number of primipara was 25 (49%) and that of multipara was 26 (51%). Eight cases of GDM (15.7%) and five cases of preeclampsia (9.8%) were reported, and six patients (11.8%) experienced preterm delivery. In results of polysomnography, 14 patients (27.5%) were diagnosed as OSA. Apnea-hypopnea index moderately correlated with BMI (r = 0.515, P < 0.001). The BMI (P < 0.005) and preeclampsia rate (P < 0.017) were higher in the OSA group compared to the control group. Odds ratios (ORs) adjusting age, BMI, parity, and abortion history were calculated. The presence of OSA increased OR of preeclampsia (OR, 13.1; 95% confidence interval, 1.1–171.3). The majority of preeclampsia patients (4/5, 80%) underwent preterm delivery. @*Conclusion@#OSA is an important risk factor for preeclampsia, resulting in preterm delivery.For overweight pregnant women, an OSA evaluation should be mandatory.

One-Unit Osteotomy to Correct Deviated Bony Dorsum

Objectives@#. A crooked nose is frequently caused by nasal bony vault deviation, and proper management of the bony vault is an integral part of rhinoplasty. Conventional osteotomy to correct a deviated nose favors simultaneous medial and lateral osteotomies, which allows the free independent movement of each nasal bone. However, patient satisfaction with deviated nose surgery is sometimes low. In the present study, we introduce a one-unit osteotomy procedure that combines bilateral and root osteotomies with unilateral triangular bony wedge resection to allow symmetry of both nasal bones. @*Methods@#. Twenty consecutive patients who presented with bony vault deviation and underwent one-unit osteotomy were enrolled in this retrospective single-center study. The Nasal Obstruction Symptom Evaluation (NOSE) questionnaire was used to evaluate each patient’s functional outcome. The angle of bony vault deviation before and after one-unit osteotomy was measured using a protractor and compared with the results of 14 patients who had undergone conventional osteotomy. The improvement in dorsal deviation was evaluated using facial photography preoperatively and 3 months postoperatively. @*Results@#. NOSE values improved from 8.4±6.4 to 4.1±4.2 (P =0.021). The angle of bony vault deviation improved from 6.9°±2.2° to 2.1°±1.2° (P <0.001) in one-unit osteotomy and from 7.3°±4.0° to 2.7°±1.2° (P =0.001) in conventional osteotomy. The preoperative deviation angle improved by 70.3% in one-unit osteotomy compared with 56.6% in conventional osteotomy, which was a significant difference (P =0.033). The mean grade of the postoperative esthetic outcomes for the remaining deviation was 1.6±0.5, which was similar to that in the conventional osteotomy group. @*Conclusion@#. One-unit osteotomy is a relatively simple procedure that balances the width of both lateral walls by removing excessive bony fragments from the wider bony wall and providing better structural integrity. This technique improves functional outcomes and has equivalent esthetic results to those of the traditional procedure.

Clinical Practice Guideline: Clinical Efficacy of Nasal Surgery in the Treatment of Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is a common disorder characterized by upper airway obstruction during sleep. To reduce the morbidity of OSA, sleep specialists have explored various methods of managing the condition, including manifold positive airway pressure (PAP) techniques and surgical procedures. Nasal obstruction can cause significant discomfort during sleep, and it is likely that improving nasal obstruction would enhance the quality of life and PAP compliance of OSA patients. Many reliable studies have offered evidence to support this assumption. However, few comprehensive guidelines for managing OSA through nasal surgery encompass all this evidence. In order to address this gap, the Korean Society of Otorhinolaryngology-Head and Neck Surgery (KORL-HNS) and the Korean Society of Sleep and Breathing designated a guideline development group (GDG) to develop recommendations for nasal surgery in OSA patients. Several databases, including OVID Medline, Embase, the Cochrane Library, and KoreaMed, were searched to identify all relevant papers using a predefined search strategy. The types of nasal surgery included septoplasty, turbinate surgery, nasal valve surgery, septorhinoplasty, and endoscopic sinus surgery. When insufficient evidence was found, the GDG sought expert opinions and attempted to fill the evidence gap. Evidence-based recommendations for practice were ranked according to the American College of Physicians’ grading system. The GDG developed 10 key action statements with supporting text to support them. Three statements are ranked as strong recommendations, three are only recommendations, and four can be considered options. The GDG hopes that this clinical practice guideline will help physicians make optimal decisions when caring for OSA patients. Conversely, the statements in this guideline are not intended to limit or restrict physicians’ care based on their experience and assessment of individual patients.

Two Cases of Herpes Virus Infection of Nose Mimicking Acute Invasive Fungal Infection in Immunocompromised Hosts

Various invasive fungal infections can occur in immunocompromised hosts, and an acute invasive fungal infection (AIFI) can be fatal. Because of its high mortality rate, AIFI must be quickly diagnosed and treated, such as anti-fungal agents or surgical debridement. In an immunocompromised host, nasal herpes simplex infection, usually caused by herpes simplex virus (HSV) type-1, can have various clinical manifestations, some of which can mimic AIFI. However, the management of acute viral infection differs significantly from invasive fungal infections of the nose. A fast and accurate differential diagnosis is mandatory because a delay in the disease-specific treatment of acute invasive infections can lead to mortality. This report describes two immunocompromised patients with mucosal and skin lesions around the nose. We provide clinical clues when mucosal lesions of the nasal cavity and skin lesions around the nose develop in immunocompromised hosts.

Long-Term Clinical Course of Benign Fibro-Osseous Lesions in the Paranasal Sinuses

Objectives@#. Fibro-osseous lesions of the paranasal sinuses can present various clinical manifestations. This study aimed to report the long-term clinical course of benign fibro-osseous lesions (BFOLs) in the paranasal sinuses, including clinical and radiologic features. @*Methods@#. Radiologically confirmed BFOLs between 1994 and 2016, with the exclusion of osteoma cases, were retrospectively reviewed. We compared demographic characteristics between the surgery and observation groups. The reasons for the imaging study, radiographic features, histopathology, and clinical course based on serial image scans were analyzed. @*Results@#. In total, 183 subjects were selected from a thorough review of head and neck radiologic tests (n=606,068) at a tertiary referral hospital over 22 years. Patients’ mean age was 28.6±18.1 years, and 56.3% were males. A diagnostic imaging workup was performed in 55.7% of patients due to facial asymmetry, headache, skull mass, or other symptoms related to BFOLs. In other patients (37.7%), BFOLs were found incidentally on computed tomography or magnetic resonance imaging. The most common diagnosis was fibrous dysplasia, followed by ossifying fibroma, based on both radiologic exams and histopathologic results. In total, 42.6% of the patients underwent surgery because of subjective symptoms or esthetic concerns. The patients who underwent surgery were younger (P<0.001) and had a longer follow-up duration (P<0.001) than those who underwent observation. Patients who experienced lesion growth (11.5%) were younger (P<0.001) and had more lesion sites (P=0.018) than those who did not, regardless of surgical treatment. Five patients underwent optic nerve decompression, and one patient experienced malignant transformation. @*Conclusion@#. BFOL in the paranasal sinuses is a rare disease, and most cases were observed without specific treatment. Surgical treatment should be considered in symptomatic patients with aggressive clinical features. Regular observation and management are needed, particularly in younger patients in their teens.

Inverse Relationship between Adenoid Size and Asthma or Atopy in Children: A Preliminary Study / 대한이비인후과학회지

Background and Objectives@#One of the most common surgical procedures in children is adenoidectomy, but the causes of adenoid hypertrophy are not fully understood. Some studies have found that allergies can be a risk factor for adenoid hypertrophy, asthma being one of these allergic diseases. This study aimed to investigate the relationship between adenoid size and asthma in a group of children.Subjects and Method This study reviewed a total of 2063 pediatric patients with or without atopy and asthma who visited the Otorhinolaryngology and Pediatric unit at a tertiary medical center from January 2011 to June 2016. We classified these patients into 4 groups according to the presence of asthma or atopy and randomly selected 100 patients from each group (to a total of 400 pts): group 1 (asthma-, atopy-); group 2 (asthma-, atopy+); group 3 (asthma+, atopy-) and group 4 (asthma+, atopy+). The presence of allergic sensitization (atopy) was evaluated by CAP test and total IgE. Asthma was diagnosed according to the diagnosis criteria in the Korean guideline for asthma. Adenoid size was evaluated with the adenoidal-nasopharyngeal ratio (A/N ratio) by the adenoid view. @*Results@#The four groups did not differ from each other significantly in age or sex. There was a negative correlation between adenoid size and atopic and asthmatic condition. Group 1 had a significantly larger A/N ratio than the other groups (group 1=0.534±0.138; group 2=0.469± 0.140; group 3=0.476±0.135; group 4=0.482±0.128, p<0.05). However, group 4 showed nearly identical results to groups 2 and 3, despite the combination of asthma and atopy in group 4. @*Conclusion@#Large adenoids were negatively associated with atopy and asthma. This finding may be explained by a decrease in adenoid stimulation by nasal obstruction and a difference in the immune system, including allergic immune reactions. Further studies are needed.

A Case of Arteriovenous Malformation of the Nasal Tip / 대한이비인후과학회지

Arteriovenous malformation is a vascular malformation with fast-flow shunt from the artery to the vein. Extracranial arteriovenous malformation in the head and neck area is rare disease compared to other vascular malformations such as venous malformation or lymphatic malformation. Extracranial arteriovenous malformations especially on face can cause aesthetic problems, therefore surgeons should consider an importance of cosmetic outcome and choose appropriate treatment plan. We report a case of 51-year-old male who presented with enlarged nasal tip diagnosed arteriovenous malformation. This case showed successful outcome after combination therapy consisted of superselective embolization and surgical resection.

Myoepithelioma of the Nasal Septum: A Case Report / 대한두경부종양학회지

Myoepithelioma is a rare benign neoplasm that mostly arises in the major salivary glands and sometimes in the minor salivary glands, which account only for less than 1% of all salivary glands neoplasms. However, its extra-salivary involvement is even rarer and only a few cases of nasal cavity myoepithelioma were reported in the English-language literature so far. In this case report, we present a 40-year-old female with unilateral nasal obstruction diagnosed as myoepithelioma of the nasal septum and treated with endoscopic sinus surgery.

Myoepithelioma of the Nasal Septum: A Case Report / 대한두경부종양학회지

Myoepithelioma is a rare benign neoplasm that mostly arises in the major salivary glands and sometimes in the minor salivary glands, which account only for less than 1% of all salivary glands neoplasms. However, its extra-salivary involvement is even rarer and only a few cases of nasal cavity myoepithelioma were reported in the English-language literature so far. In this case report, we present a 40-year-old female with unilateral nasal obstruction diagnosed as myoepithelioma of the nasal septum and treated with endoscopic sinus surgery.

The Effect of Triamcinolone-Soaked Gelfoam in Patients with Polypoid Mucosal Change after Endoscopic Sinus Surgery

Background and Objectives@#Chronic rhinosinusitis with nasal polyps (CRSwNP) recurs frequently after endoscopic sinus surgery (ESS). The aim of study was to evaluate the efficacy of triamcinolone-soaked absorbable gelatin foam (gelfoam) as a treatment for recurred polypoid changes after ESS.Subjects and Method: A total of 35 patients and 57 nasal cavities was retrospectively reviewed. All patients underwent triamcinolone- infused gelfoam packing for 1 week under nasal endoscopic guidance. Endoscopic scores were evaluated at 1 week, 1 month, and 3 months. We analyzed clinical characteristics between success and failure groups. @*Results@#Endoscopic scores were significantly improved after triamcinolone-soaked gelfoam packing, and the effects were maintained at 3-month follow-up (1.85±0.61 vs. 0.82±0.77, p＜0.001). Duration between surgery and gelfoam packing was shorter in the success group compared to the failure group (8.2±6.9 vs. 13.7±8.4 weeks, p=0.033). Serum eosinophil cationic protein and tissue eosinophil counts were significantly higher in the failure group (p=0.025 and p=0.010, respectively). @*Conclusion@#Triamcinolone-soaked gelfoam packing is an effective and safe method for managing recurrent polypoid change in patients with CRSwNP after ESS. Early intervention contributed to a successful result, and eosinophilic inflammation was associated with poor outcomes.

A Case of Intraosseous Hemangioma in the Nasal Cavity

Osseous hemangioma typically occurs in the vertebral column or skull bones. It it is extremely rare in the nasal bone. Only nine cases originating in the turbinate and maxillary bone have been reported in the English and Korean literature. Herein, we present the case of a 51-year-old women with a dorsum mass to share our experience with intraosseous hemangioma successfully removed and reconstructed by an endonasal approach.

A Comparison of Olfactory and Sinonasal Outcomes in Endoscopic Pituitary Surgery Performed by a Single Neurosurgeon or a Collaborative Team of Surgeons

Objectives@#. Endoscopic pituitary surgery usually requires a collaboration between neurosurgeons and ENT surgeons to achieve optimal outcomes. However, neurosurgeons occasionally perform these procedures alone without an ENT surgeon. In this study, postoperative sinonasal quality of life and olfactory function were compared in patients who underwent endoscopic pituitary surgery performed by a single neurosurgeon or by a collaborative team of a neurosurgeon and an ENT surgeon. @*Materials and Methods@#. A retrospective review of prospectively collected data was performed. Patients who underwent endoscopic pituitary surgery for pituitary adenoma from January 2015 to April 2018 were included. The study patients were divided into two groups; patients in group 1 underwent surgery performed by a single neurosurgeon, while patients in group 2 received surgery performed by a collaborative team of surgeons. Olfaction was assessed using a subjective Likert scale, the Cross-Cultural Smell Identification Test (CC-SIT), and the butanol threshold test (BTT). In addition, patients answered the Sino-nasal Outcome Test (SNOT-22) questionnaire regarding sinonasal quality of life before and 3 months after surgery. @*Results@#. This study included 152 patients (46 patients in group 1 and 106 patients in group 2). Significant differences were not observed between the two groups regarding age, sex, tumor size, or operation time. Although subjective olfaction was not significantly different before and after surgery, group 2 showed significantly better objective olfactory function based on the CC-SIT (8.44±3.00 vs. 9.84±1.40; P=0.012) and BTT (4.67±0.84 vs. 5.02±0.33; P=0.022) scores at 3 months after surgery. The SNOT-22 scores were not statistically significantly different between the two groups (P>0.05). @*Conclusion@#. In the present study, better olfactory outcomes were observed in patients who underwent surgery performed by a collaborative team of a neurosurgeon and an ENT surgeon. This result shows the need for collaboration between neurosurgeons and ENT surgeons in endoscopic pituitary surgery.

Clinical Manifestations and Risk Factors of Anaphylaxis in Pollen-Food Allergy Syndrome

PURPOSE: Many studies have reported that pollen-food allergy syndrome (PFAS) can cause anaphylaxis. No comprehensive investigations into anaphylaxis in PFAS have been conducted, however. In this study, we investigated the clinical manifestations and risk factors for anaphylaxis in PFAS in Korean patients with pollinosis. MATERIALS AND METHODS: Data were obtained from a nationwide cross-sectional study that previously reported on PFAS in Korean patients with pollinosis. Data from 273 patients with PFAS were collected, including demographics, list of culprit fruits and vegetables, and clinical manifestations of food allergy. We analyzed 27 anaphylaxis patients and compared them with patients with PFAS with oropharyngeal symptoms only (n=130). RESULTS: The most common cause of anaphylaxis in PFAS was peanut (33.3%), apple (22.2%), walnut (22.2%), pine nut (18.5%), peach (14.8%), and ginseng (14.8%). Anaphylaxis was significantly associated with the strength of sensitization to alder, hazel, willow, poplar, timothy, and ragweed (p<0.05, respectively). Multivariable analysis revealed that the presence of atopic dermatitis [odds ratio (OR), 3.58; 95% confidence interval (CI), 1.25–10.23; p=0.017]; sensitization to hazel (OR, 5.27; 95% CI, 1.79–15.53; p=0.003), timothy (OR, 11.8; 95% CI, 2.70–51.64; p=0.001), or ragweed (OR, 3.18; 95% CI, 1.03–9.87; p=0.045); and the number of culprit foods (OR, 1.25; 95% CI, 1.15–1.37; p<0.001) were related to the development of anaphylaxis in PFAS. CONCLUSION: The most common culprit foods causing anaphylaxis in PFAS were peanut and apple. The presence of atopic dermatitis; sensitization to hazel, timothy, or ragweed; and a greater number of culprit foods were risk factors for anaphylaxis in PFAS.

A Case of Subcutaneous Emphysema and Pneumomediastinum after Palatine Tonsillectomy / 대한이비인후과학회지

Palatine tonsillectomy is a very common procedure and it is relatively safe and has few complications. However, some severe, although rare, complications that can lead a patient to life-threatening status can occur following palatine tonsillectomy. Subcutaneous or mediastinal emphysema is one of the severe complications. We report a case of subcutaneous emphysema and pneumomediastinum after palatine tonsillectomy in a healthy 18-year-old man. After conservative management, subcutaneous emphysema was subsided without other complications.

A Case of Subcutaneous Emphysema and Pneumomediastinum after Palatine Tonsillectomy / 대한이비인후과학회지

Palatine tonsillectomy is a very common procedure and it is relatively safe and has few complications. However, some severe, although rare, complications that can lead a patient to life-threatening status can occur following palatine tonsillectomy. Subcutaneous or mediastinal emphysema is one of the severe complications. We report a case of subcutaneous emphysema and pneumomediastinum after palatine tonsillectomy in a healthy 18-year-old man. After conservative management, subcutaneous emphysema was subsided without other complications.

Comparison Between Endoscopic Prelacrimal Medial Maxillectomy and Caldwell-Luc Approach for Benign Maxillary Sinus Tumors

OBJECTIVES: Endoscopic prelacrimal medial maxillectomy (EPMM) was previously reported to treat maxillary inverted papilloma. This study aimed to compare prelacrimal recess approach with the conventional Caldwell-Luc approach (CLA) to remove benign maxillary sinus tumors and to evaluate the usefulness of this approach based on our experience. METHODS: Ten patients who underwent EPMM at our hospital from January 2013 to December 2017 were reviewed. We also reviewed 30 patients who underwent benign maxillary sinus tumor resection via CLA during the same period. From medical records, postoperative pathological results, complications due to surgery, and recurrence rate were evaluated. RESULTS: There were eight inverted papilloma, one ameloblastoma, and one ossifying fibroma in the EPMM group. In the CLA group, all 30 cases were inverted papilloma. There were no cases of failure at gross total removal during surgery, and no recurrences were observed during follow-up in either groups. Mean follow-up period was 13.0 months in CLA group and 10.8 months in EPMM group. Regarding postoperative complications, 11 patients of the CLA group (37%) and three patients of the EPMM group (30%) had numbness around the cheek and upper lip area after surgery (P=0.715). In the CLA group, there were eight patients who had numbness lasting more than 3 months after surgery, and two patients had numbness for more than 1 year. However, facial numbness disappeared within 3 months in all patients in the EPMM group, in which epiphora was not observed. CONCLUSION: EPMM is the effective surgical approach for resecting benign maxillary sinus tumor compared with CLA. Although facial numbness was reported in EPMM, the duration of numbness was shorter than CLA.

Erratum: Pollen-Food Allergy Syndrome in Korean Pollinosis Patients: A Nationwide Survey

This erratum is being published to correct the error on page 650 of the article. The number of participating research institution should be corrected.

Triangular Resection of the Upper Lateral Cartilage for Middle Vault Deviation

OBJECTIVES: Middle vault deviation has a significant effect on the aesthetic and functional aspects of the nose, and its management continues to be a challenge. Spreader graft and its modification techniques have been focused, but there has been scarce consideration for removing surplus portion and balancing the upper lateral cartilage (ULC). This study aimed to report the newly invented triangular-shaped resection technique (“triangular resection”) of the ULC and to evaluate its efficacy for correcting middle vault deviation. METHODS: A retrospective study included 17 consecutive patients who presented with middle vault deviation and underwent septorhinoplasty by using triangular resection at a tertiary academic hospital from February 2014 and March 2016. Their outcomes were evaluated pre- and postoperatively including medical photographs, acoustic rhinometry and subjective nasal obstruction using a 7-point Likert scale. RESULTS: The immediate outcomes were evaluated around 1 month after surgery, and long-term outcomes were available in 12 patients; the mean follow-up period was 9.1 months. Nasal tip deviation angle was reduced from 5.66° to 2.37° immediately (P < 0.001). Middle vault deviation also improved from 169.50° to 177.24° (P < 0.001). Long-term results were 2.49° (P=0.015) for nasal tip deviation and 178.68° (P=0.002) for middle vault deviation. The aesthetic outcome involved a complete correction in eight patients (47.1%), a minimally visible deviation in seven patients (41.2%) and a remaining residual deviation in two patients (11.8%). Pre- and postoperative minimal cross-sectional areas (summation of the right and left sides) were 0.86 and 1.07, respectively (P=0.021). Fifteen patients answered about their nasal obstruction symptoms and the median symptom score had alleviated from 6.0 to 3.0 (P=0.004). CONCLUSION: Triangular resection of the ULC is a simple and effective method for correcting middle vault deviation and balancing the ULCs without complications as internal nasal valve narrowing.

Efficacy of Endoscopic Electrocauterization for Recurrent Posterior Epistaxis

BACKGROUND AND OBJECTIVES: To investigate the common site of recurrent epistaxis after initial intervention such as packing and cauterization had failed and to evaluate the efficacy of surgical endoscopic electrocautery. SUBJECTS AND METHOD: Retrospective review of 47 patients with recurrent and uncontrolled idiopathic epistaxis between October 1995 and March 2016. All patients underwent endoscopic examination in the operating room after hospitalization. We performed electrocautery when a bleeding site was found. RESULTS: The most common sites of bleeding were the inferior meatus (28%), sphenoethmoid recess (23%), superior septum around the olfactory cleft (13%), and the posterior end of the middle turbinate (15%). There was no serious complication during the one week after surgery. In 46 (98%) patients, refractory epistaxis was successfully controlled. One patient had recurrent epistaxis after electrocautery and underwent endoscopic sphenopalatine artery ligation. CONCLUSION: In patients with refractory idiopathic epistaxis after failure of first-line treatment, endoscopic examination through a surgical approach and electrocautery for suspected bleeding are effective.

The Relationship between the Causative Allergens of Allergic Diseases and Environments in Korea Over a 8-Year-Period: Based on Skin Prick Test from 2006 to 2015

BACKGROUND AND OBJECTIVES: The present study evaluated the results of skin prick test using 55 allergens at 20 centers in the Republic of Korea in 2006, 2010, and 2014–2015. The aim was to assess changes in the positive rate of allergens according to temporal, regional, and environmental factors. MATERIALS AND METHODS: In total, 20 hospitals were selected based on the population distribution in the Republic of Korea. A skin prick test panel comprising 55 aeroallergens was distributed to 18 hospitals for this prospective study. The 2006 and 2010 skin prick test results were collected and analyzed retrospectively from 20 hospitals, while the 2014/2015 skin prick test results (from June 2014 to May 2015) were collected prospectively from 18 hospitals. RESULTS: A total of 14,897 SPT test results were analyzed: 4,319 in 2006, 7,431 in 2010, and 1,852 in 2014/2015. The overall rate of skin prick test positivity to more than two allergens was significantly higher in males than females. The positive rates of alder pollens and birch, oak and ragweed pollen positivity were increased in older patients. Several positive rates were increased according to the temperature in spring. The positive rates for beech pollen, birch pollen, hazel pollen, oak pollen, Tyrophagus putrescentiae, mugwort, cat, Acarus siro, Lepidoglyphus destructor and Tyrophagus putrescentiae were significantly increased, while those of Cult rye pollen and dandelion were significantly decreased over the three test periods. The overall positive rate for allergens in Jeju province varied significantly from Seoul and other cities. CONCLUSION: Change in the positive rate of multiple aeroallergens was evaluated in the Republic of Korea over time. Our findings can be used to recommend aeroallergens suitable for inclusion in skin prick test panels in the Republic of Korea and will facilitate further investigation of changes in the patterns of allergic diseases.