Rinite vasomotora e rinorreia: um possível papel para o efeito anticolinérgico da amitriptilina / Vasomotor rhinitis and rhinorrhea: a possible role for the anticholinergic effect of amitriptyline

Introdução: A rinite vasomotora (RVM), também denominada idiopática, é um tipo de rinite não alérgica. Pode ser muitas vezes ativada por mudanças de temperatura, especialmente com o ar frio e outras irritantes de vias aéreas. A dosagem de IgE e o citograma nasal são normais, e os testes de inalantes são negativos. A etiologia pode estar associada à desregulação de nervos simpáticos e parassimpáticos da mucosa nasal, onde aumenta a rinorreia e a obstrução nasal. Objetivo: Avaliar a eficácia da amitriptilina no controle da rinorreia vasomotora. Método: Através de estudo retrospectivo, avaliaram-se pacientes com RVM (n = 110), no qual um grupo de n = 12 (11%) apresentava rinorreia profusa há mais de um ano, não controlada, na sua totalidade, com corticosteroide nasal. Usou-se a amitriptilina, um antidepressivo tricíclico, com intensa atividade anticolinérgica com dose de 25 mg/50 mg diária para a rinorreia nesses pacientes. Resultados: Foram avaliados através de uma escala de sintomas (modificada de Wilson AM): 0 = ausente, 1 = leve, bem tolerado, 2 = desconforto interferindo com a concentração, 3 = forte intensidade interferindo no sono e na concentração. Dez pacientes catalogados apresentaram sintomas no grau 3, e dois, no grau 2. A pontuação foi reduzida para grau 0-1 após 4-6 semanas com o uso de amitriptilina por sintomas reflexivos matinais e noturnos. Conclusão: Futuros estudos controlados e com maior número de pacientes seriam necessários para confirmação do efeito farmacológico da amitriptilina na rinorreia da RVM.

Background: Vasomotor rhinitis (VMR), also referred to as idiopathic rhinitis, is a type of nonallergic rhinitis. It can often be triggered by changes in temperature, especially with cold air and other airway irritants. Immunoglobulin E (IgE) levels and nasal cytograms are normal, and inhalant skin tests are negative. The etiology may be associated with dysregulation of the sympathetic and parasympathetic nervous systems in the nasal mucosa, with increased rhinorrhea and nasal obstruction. Objective: To evaluate the efficacy of amitriptyline in the control of VMR-related rhinorrhea. Method: We retrospectively evaluated 110 patients with VMR, of whom 12 (11%) had profuse rhinorrhea for more than 1 year, not completely controlled with nasal corticosteroids. In these 12 patients, rhinorrhea was treated with amitriptyline, a tricyclic antidepressant with intense anticholinergic activity, at a daily dose of 25 mg/50 mg. Results: Patients were evaluated using a symptom scale (modified from Wilson AM): 0 = absent; 1 = mild, well tolerated; 2 = discomfort interfering with concentration; and 3 = severe intensity interfering with sleep and concentration. Ten patients had grade 3 symptoms, and 2 had grade 2 symptoms. The score decreased to grade 0-1 after 4-6 weeks of amitriptyline use for reflex symptoms in the morning and at night. Conclusion: Further controlled studies with a larger sample size are needed to confirm the pharmacological effect of amitriptyline on VMRrelated rhinorrhea.

Evidences for Local Allergic Rhinitis

Local allergic rhinitis is defined as a localized allergic reaction of the nasal mucosa in the absence of systemic atopy. Its main pathophysiological mechanism can be summarized as: 1) increased specific immunoglobulin E in the nasal fluid, and 2) Th2 allergic mechanism localized in the nasal mucosa. In patients whose result of a skin prick test is totally negative for all antigens, practitioners could diagnose local allergic rhinitis using a nasal provocation test. Oral antihistamines and intranasal steroids can be an effective treatment. Subcutaneous immunotherapy can also be helpful. Further study is essential to further elucidate the detailed pathophysiologic mechanism and set up global standard diagnostic criteria.

Symptomatic differences between allergic and nonallergic rhinitis in children

PURPOSE: Children and adolescent have high prevalences of allergic rhinitis (AR) and nonallergic rhinitis (NAR) as well as adult. The purpose of this study was to assess the symptomatic differences between AR and NAR in children. METHODS: This study included 138 patients with 2 or more of rhinitis symptoms, including rhinorrhea, nasal obstruction, nasal itching, and sneezing for over 1 hour on most days who visited Kyungpook National University Children's Hospital between March 2013 and June 2014. The levels of total IgE, specific IgE, eosinophil cationic protein, peripheral blood eosinophil count, and the skin prick test were carried out. All the patients or parents were asked to fill out a rhinitis symptom questionnaire and contents were rechecked by physician during the consultation. The symptoms of rhinorrhea, sneezing, nasal itching, nasal obstruction and eye itching were checked. Family history and comorbidity were also evaluated. RESULTS: Ninety-one patients were diagnosed with AR, 47 patients with NAR. Their age ranged from 1 to 16 years. AR patients had more sneezing, nasal pruritus and eye symptoms than NAR patients (P=0.003, P=0.036, and P=0.003, respectively). CONCLUSION: This study shows that the several symptomatic differences may help to diagnose the AR. It will be helpful in establishing diagnostic and treatment plans for rhinitis patients before allergic tests.

Vitamin D serum levels in children with allergic and vasomotor rhinitis / 소아과

PURPOSE: In addition to regulating calcium and phosphorus homeostasis and bone metabolism, vitamin D is known as an immune modulator. Recently, there has been increased worldwide interest in the association between low levels of vitamin D and allergic diseases. The purpose of this study was to assess the relationship between serum vitamin D levels and allergic/vasomotor rhinitis (AR/VR) in children. METHODS: This study included 164 patients. The sample included 59 patients with AR, 42 patients with VR, and 63 controls. Their ages ranged from 0 to 16 years. We examined the levels of 25-hydroxyvitamin D, Immunoglobulin E, specific IgE, and eosinophil cationic protein; peripheral blood eosinophil count; and the results of a skin prick test. RESULTS: Serum 25-hydroxyvitamin D levels were 19.0+/-8.5 ng/mL in the AR group, 25.5+/-10.9 ng/mL in the VR group, and 26.9+/-10.7 ng/mL in the control group. After adjustment for body mass index and season at the time of blood sampling, vitamin D levels in the AR group were lower than those of the VR group (P=0.003) and control group (P<0.001). Vitamin D levels were inversely correlated with Immunoglobulin E levels (r=-0.317, P<0.001). AR patients with food allergy or atopic dermatitis did not have lower levels of 25-hydroxyvitamin D than AR patients without these diseases. CONCLUSION: This study demonstrates a possible relationship between vitamin D levels and allergic rhinitis in Korean children.

Clinical Efficacy of Intranasal Azelastine Hydrohloride Spray in Korean Vasomotor Rhinitis Patients

Background & Objectives: Vasomotor rhinitis (VMR) is a chronic non-allergic rhinitis without the increased Ig E level and eosinophilia. Azelastine hydrochloride is a second generation anti-histamine medication with anti-inflammatory properties that inhibits the synthesis of inflammatory materials. There are reports that azelastine hydrochloride can be effective in the treatment of VMR. Therefore, this study examined the clinical efficacy of intranasal azelastine hydrochloride spray in comparison with placebo for the treatment of VMR. MATERIALS AND METHOD: This study was a prospective double blind randomized test. The subjects consisted of 84 VMR patients. Among them, 54 patients were treated with intranasal azelastine hydrochloride for 4 weeks and 30 patients with intranasal normal saline. Following the treatment, an analysis of the symptom score was performed in order to compare the treatment effects between the study group and the control group. RESULTS: In the study group, the symptom score was significantly improved in the areas of sneezing (1.38 to 0.72), rhinorrhea (1.57 to 0.76), nasal obstruction (1.76 to 1.01) and postnasal drip (1.43 to 0.65). In the control group, however, the symptom score was significantly improved in a single area of rhinorrhea (1.73 to 0.65). Patients in the study group, thus, displayed greater improvements in the areas of sneezing, rhinorrhea, nasal obasturction and postnasal drip comparative to the control group. Consequently, the study group patients were more satisfied with their quality of life than those of the control group. CONCLUSION: Azelastine chloride is a useful medicine for the treatment of VMR, especially in controlling sneezing, rhinorrhea, nasal obstruction and postnasal drip.

Long-Term Results of Laser Surgery for Nasal Hyper-Reactivity / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Laser vaporization on the inferior turbinate can be an valuable surgical method with safety, less morbidity and good efficacy. However, long term results are not exactly known. Furthermore, concrete data for success rates using different laser techniques is not available yet. The aim of this study is to evaluate the long-term result of laser surgery using different laser technique in patients with hypersensitive nasal diseases. SUBJECTS AND METHOD: We retrospectively reviewed 53 cases which had been treated with CO2 laser and followed up for more than 3 years. The subjects consisted of 29 patients with allergic rhinitis and 24 patients with vasomotor rhinitis. Laser surgical techniques were divided into two groups;vaporization of only inferior turbinate (conventional group) and inferior turbinate, upper septum, middle turbinate, agger nasi (extended group). Changes in the degree of nasal obstruction, watery rhinorrhea, sneezing were compared postoperatively between the two surgical procedure, and two different diseases. RESULTS: Long-term result (67%) was slightly lower than short-term result (69%). There was no difference in the success rates (68%) for both laser and surgical technique. Patients with vasomotor rhinitis (75%) showed better success rate than with allergic rhinitis (62%). Rate of success was better in the extended group than in the conventional group for watery rhinorrhea and sneezing. CONCLUSION: Success rate of laser surgery performed at Inha university hospital was 68%. The extended technique was more effective than the conventional technique for short-term result. However, there was no difference in the long-term results using different laser techniques.

Eosinophilic Nonallergic Rhinitis: Clinical Characteristics and Efficacy of Nasal Steroids / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Although eosinophilic nonallergic rhinitis (ENR) is a well recognized entity, its clinical features and the response to the treatment have not been definitively elucidated. Authors aimed to investigate the clinical characteristics of ENR and the response to the nasal steroids. MATERIALS AND METHOD: A prospective study was conducted for 59 patients diagnosed as ENR at the department of Center between 1994 and 2001. Diagnostic criteria include rhinitis symptoms lasting more than 3 months, nasal eosinophilia, and negative results for allergic skin test or MAST. Patients were treated with nasal steroids for three weeks and compared the pre-treatment and post-treatment symptom scores. RESULTS: Of 59 patients, 25 were males and 34 females. Their age ranged from 6 to 67 years (average : 35 years). Nasal obstruction was most frequently complained by the patients, followed by rhinorrhea, and sneezing. The percentage of nasal secretion eosinophils ranged from 10 to 100% with a mean of 71%. Treatment with topical steroids was effective in 53 patients (90%) to relieve symptoms. CONCLUSION: Unlike allergic rhinitis, ENR commonly develops in the adults with an average age of 31 years. Topical steroid is effective in 90% of patients to relieve rhinitic symptoms. Differential diagnosis of chronic rhinitis using allergic skin test and nasal secretion eosinophils is needed for the adequate treatment.

Evaluacion clinica y patologica de la rinitis vasomotora / Clinical and pathological evaluation of vasomotor rhinitis

Se presentan los resultados de un estudio hecho en 38 pacientes con diagnostico clinico y por laboratorio de Rinitis Vasomotora y 14 controles, que asistieron a la consulta externa otorrinolaringologica del Hospital Universitario San Vicente de Paul, en Medellin, Colombia, entre mayo de 1987 y diciembre de 1988. Se encontro que la RV en nuestro medio es una enfermedad que predomina en mujeres jovenes entre 12 y 34 anos con obstruccion nasal de mas de un ano de evolucion como principal motivo de consulta y tumefaccion de cornetes con buena respuesta vasoconstrictora como hallazgo predominante al examen fisico. Los estudios realizados (IgE serica total, prueba de Anderson, espirometria, recuento de celulas metacromaticas en raspado de mucosa nasal y biopsia de cornete inferior) no fueron de valor diagnostico. Como hallazgo importante se encontro mediante la espirometria, en el 73% de los pacientes, obstruccion pulmonar en ausencia de sintomatologia respiratoria inferior. p<0.05).8

We performed a case-control study of 38 cases of vasomotor rhinitis (VR) diagnosed at the Otorrhinolaryngology Outpatient Clinic at Hospital Universitario San Vicente de Paúl, Medellin, Colombia, between May 1987 and December 1988. These cases were proved both clinically and by laboratory evaluation and were compared to 14 controls. VR was predominant in young women aged 12 to 34 years (75%). Nasal congestion of more than one year evolution was the outstanding symptom and edematous turbinates with good vasoconstriction retraction was the predominant sign on physical examination. The tests performed (serum total lgE, Anderson's test, pulmonary function tests, nasal metachromatic cell counts and turbinate biopsy) had no diagnostic value. One Important finding was the spirometric detection of pulmonary obstruction without clinical manifestations that was observed in 73% of the cases (p