Rinitis alérgica en pediatría: recomendaciones para su diagnóstico y tratamiento / Allergic rhinitis in pediatrics: recommendations for diagnosis and treatment

La rinitis alérgica (RA) es una de las enfermedades crónicas más frecuentes de la infancia. Sin embargo, permanece subdiagnosticada y subtratada. Su prevalencia ha aumentado en los últimos años y varía del 2 % al 25 %. Los síntomas de la RA incluyen estornudos, prurito, rinorrea y congestión nasal. Un correcto diagnóstico y tratamiento de la RA y sus comorbilidades, tales como rinosinusitis con o sin poliposis nasal, conjuntivitis, otitis media, asma bronquial e infecciones del tracto respiratorio, son importantes para reducir el impacto negativo en la afectación de la calidad de vida del paciente y sus familiares, y los gastos sanitarios que ocasiona. La inmunoterapia alérgeno específica, en pacientes correctamente seleccionados, previene nuevas sensibilizaciones y reduce la hiperreactividad bronquial asociada a la RA. Considerando todos estos factores, el Comité Nacional de Alergia de la Sociedad Argentina de Pediatría propone recomendaciones basadas en la evidencia actual.

Allergic rhinitis (AR) is one of the most common chronic diseases in children. However, it remains underdiagnosed and undertreated. Its prevalence has increased in recent years and varies from 2 to 25 %. Symptoms include sneezing, itching, runny nose, and nasal congestion. A correct diagnosis and treatment of AR and its comorbidities such as rhinosinusitis with or without nasal polyposis, conjunctivitis, otitis media, bronchial asthma and respiratory tract infections, are important to reduce the negative impact on the quality of life of the patient and their relatives, and in medical costs. Specific allergen immunotherapy, in correctly selected patients, prevents new sensitizations and reduces bronchial hyperreactivity associated with AR. Taking into account all these reasons, the National Allergy Committee of the Sociedad Argentina de Pediatría proposes current evidence based recommendations

Evaluation of the efficacy of endoscopic posterior nasal neurectomy with pharyngeal neurectomy of allergic rhinitis combined with chronic rhinosinusitis with nasal polyps / 临床耳鼻咽喉头颈外科杂志

Objective:To investigate the effect of posterior nasal neurectomy（PNN） with pharyngeal neurectomy （PN） on chronic sinusitis with nasal polyps （CRSwNP）complicated with perennial allergic rhinitis （PAR）. Methods:83 patients with perennial allergic rhinitis combined with chronic group-wide sinusitis with nasal polyps who attended our hospital from July 2020 to July 2021 were selected. All patients underwent conventional functional endoscopic sinusitis surgery（FESS）+ nasal polypectomy. Patients were divided according to whether they underwent PNN+PN. 38 cases in the experimental group underwent FESS combined with PNN+PN; 44 cases in the control group underwent conventional FESS alone. All patients underwent the VAS, RQLQ, and MLK before treatment, and at 6 months and 1 year after surgery. Meanwhile, other relevant data were collected and the preoperative and postoperative follow-up data were collected and analyzed to assess the differences between the two groups. Results:The total postoperative follow-up period was 1 year. The recurrence rate of nasal polyps at 1 year postoperatively and the nasal congestion VAS score at 6 months postoperatively were not statistically significant in the two groups（P>0.05）. However, the patients in the experimental group had statistically significantly lower effusion and sneezing VAS scores, MLK endoscopy scores and RQLQ scores at 6 months and 1 year postoperatively, and nasal congestion VAS scores at 1 year postoperatively compared to the control group（P<0.05）. Conclusion:For patients with perennial AR complicated with CRSwNP, the combination of the PNN+PN in FESS can significantly improve the short-term curative effect, and PNN+PN is a safe and effective surgical treatment.

Bacteriological analysis of nasal secretions in patients with nasal lymphoma / 临床耳鼻咽喉头颈外科杂志

Objective:To investigate the etiological characteristics of nasal bacterial infection in patients with nasal lymphoma. Methods:The results of bacterial culture of nasal secretions from 39 healthy people and 86 patients with nasal lymphoma in the Affiliated Hospital of Qingdao University from January 2019 to June 2022 were retrospectively analyzed, and the differences in nasal bacteria distribution between nasal lymphoma and healthy people were analyzed and compared. Results:Corynebacterium（38.90%） was the most common bacteria in the nasal cavity of healthy people, followed by coagulase-negative Staphylococcus（31.95%）, Staphylococcus epidermidis（15.28%） and Staphylococcus aureus（6.95%）. The most common bacteria in nasal lymphoma patients was Staphylococcus aureus（30.37%）, followed by Corynebacterium（9.63%）, Staphylococcus epidermidis（7.41%） and coagulase negative Staphylococcus（6.67%）. A total of 81 nasal lymphoma patients were detected with bacteria, positive rate is as high as 94.19%（81/86）. Conclusion:Staphylococcus aureus is the main pathogenic bacteria in nasal secretion of patients with nasal lymphoma, which provides guiding significance for the clinical prevention and treatment of nasal lymphoma complicated with infection or not.

Artificial intelligence-assisted prediction of olfactory disorders in patients with chronic rhinosinusitis / 临床耳鼻咽喉头颈外科杂志

Objective:To analyze the influencing factors and perform the prediction of olfactory disorders in patients with chronic rhinosinusitis（CRS） based on artificial intelligence. Methods:The data of 75 patients with CRS who underwent nasal endoscopic surgery from October 2021 to February 2023 in the Department of Otorhinolaryngology Head and Neck Surgery, the Third Affiliated Hospital of Sun Yat-sen University were analyzed retrospectively. There were 53 males and 22 females enrolled in the study, with a median age of 42.0 years old. The CRS intelligent microscope interpretation system was used to calculate the proportion of area glands and blood vessels occupy in the pathological sections of each patient, and the absolute value and proportion of eosinophils, lymphocytes, plasma cells and neutrophils. The patients were grouped according to the results of the Sniffin' Sticks smell test, and the clinical baseline data, differences in nasal mucosal histopathological characteristics, laboratory test indicators and sinus CT were compared between the groups. Determine the independent influencing factors of olfactory disorders and receiver operating characteristic curves（ROC） were used to evaluate the performance of the prediction model. Statistical analysis was performed using SPSS 25.0 software. Results:Among the 75 CRS patients, 25 cases（33.3%） had normal olfaction and 50 cases（66.7%） had olfactory disorders. Multivariate Logistic regression analysis showed that tissue eosinophils percentage（OR=1.032, 95%CI 1.002-1.064, P=0.036）, Questionnaire of olfactory disorders-Negative statement（QOD-NS）（OR=1.079, 95%CI 1.004-1.160, P=0.040） and Anterior olfactory cleft score（AOCS）（OR=2.672, 95%CI 1.480-4.827, P=0.001） were independent risk factors for olfactory disorders in CRS patients. Further research found that the area under the ROC curve（AUC） of the combined prediction model established by the tissue eosinophil percentage, QOD-NS and AOCS was 0.836（95%CI 0.748-0.924, P<0.001）, which is better than the above single factor prediction model in predicting olfactory disorders in CRS. Conclusion:Based on pathological artificial intelligence, tissue eosinophil percentage, QOD-NS and AOCS are independent risk factors for olfactory disorders in CRS patients, and the combination of the three factors has a good predictive effect on CRS olfactory disorders.

The efficacy and safety of glucocorticoid stent implantation compared with oral glucocorticoid during perioperative period in chronic rhinosinusitis with nasal polyps / 临床耳鼻咽喉头颈外科杂志

Objective:To compare the perioperative efficacy and safety of postoperative oral glucocorticoid and glucocorticoid stent implantation in patients with chronic rhinosinusitis with nasal polyps（CRSwNP） undergoing functional endoscopic sinus surgery（FESS）. Methods:Sixty patients with bilateral CRSwNP with similar degree of lesions were selected and divided into three groups: conventional surgical treatment group（20 cases）, glucocorticoid stent group（20 cases）, and oral glucocorticoid group（20 cases）. All three groups underwent routine FESS, patients in the sinus glucocorticoid stent group receiving sinus glucocorticoid stent placed in the ethmoid sinuses（one on each side） during surgery, and patients in the oral glucocorticoid group received postoperative oral methylprednisolone at a dose of 0.4 mg/kg per day for 7 days, followed by a tapering of 8 mg per week to 8 mg followed by maintenance therapy for 1 week, for a total of 3-4 weeks. Visual analog scale（VAS） scores were used to evaluate nasal congestion, rhinorrhea, olfaction, and facial pressure symptoms before surgery, as well as at 2, 4, 8, and 12 weeks after surgery. Nasal endoscopic Lund-Kennedy scores were recorded, and adverse reactions such as stent detachment, stent-related allergic reactions, sleep disorders, edema, gastrointestinal symptoms, rash/acne, behavioral/cognitive changes, weight gain, limb pain, and infection risk were documented. Results:The nasal congestion symptom scores at 2, 4, 8, and 12 weeks after surgery were significantly lower than those before operationin all three groups, and the differences were statistically significant（P<0.05）. The sinus glucocorticoid stent group exhibited significantly lower nasal congestion symptom scores at 4 and 8 weeks after surgery compared to the conventional surgical treatment group. The rhinorrhea symptom scores at 2, 8, and 12 weeks after surgery were significantly lower than preoperative scores in all three groups. Additionally, the sinus glucocorticoid stent group had significantly lower rhinorrhea scores than the conventional surgical treatment group at 2 weeks postoperatively. Concerning olfaction, the sinus glucocorticoid stent group showed a significant reduction in scores at 12 weeks postoperatively, while the oral glucocorticoid group exhibited significant improvement starting from 8 weeks after surgery. There were no statistically significant differences in nasal congestion, rhinorrhea, facial pressure, and olfaction scores between the sinus glucocorticoid stent and oral glucocorticoid groups at 2, 4, 8, and 12 weeks postoperatively. Nasal endoscopy scores revealed lower polyp scores and edema at 2, 4, 8, and 12 weeks postoperatively for all three groups compared to preoperative scores. The conventional surgical treatment group exhibited a significant reduction in nasal secretion scores starting from 8 weeks after surgery, while both the sinus glucocorticoid stent and oral glucocorticoid groups showed significant reductions starting from 2 weeks postoperatively, with scores significantly lower than those of the conventional surgical treatment group at 2 weeks. Scab/scar scores in the conventional surgical treatment group significantly decreased from 8 weeks after surgery, while both the sinus glucocorticoid stent and oral glucocorticoid groups exhibited significant reductions starting from 4 weeks. No statistically significant differences were observed in endoscopy scores（including polyps, edema, nasal secretion, scars, and scabs） between the sinus glucocorticoid stent and oral glucocorticoid groups at 2, 4, 8, and 12 weeks postoperatively. Regarding adverse reactions, no postoperative complications related to sinus glucocorticoid stent were observed in the sinus glucocorticoid stent group. In the oral glucocorticoid group,1 patient experienced irritability, and 1 patient experienced weight gain. Conclusion:The glucocorticoid stent implantation has comparable effects to oral glucocorticoid in improving postoperative nasal symptoms, reducing nasal mucosal edema, scar formation, and nasal secretion in patients with CRSwNP undergoing FESS, with a better safety profile.

The predicting role of postoperative changes in self-reported symptoms in patients with recurrence eosinophilic chronic sinusitis with nasal polyps / 临床耳鼻咽喉头颈外科杂志

Objective:To investigate whether changes in postoperative symptoms and signs in patients can predict the recurrence of ECRS after nasal endoscopic sinus surgery. Methods:A total of 70 adult patients with ECRS were enrolled for ESS surgery from June 2020 to March 2022 in a single center. There were 50 males and 20 females, with an average age of （46.9±14.5） years. Follow-up after ESS was at least 52 weeks. Patients undergo peripheral blood tests, CT of the sinuses, olfactory T&T test, visual analogue scale of symptoms（VAS）, and endoscopic scoring. Results:VAS scores and endoscopic scores were analyzed at preoperative and 6th week, 12th week, 24th week and 52th week postoperative. After 12th week postoperatively, there was a clear correlation between symptom scores and endoscopic scores. Moreover, olfactory disorder and nasal discharge were the two most obvious symptoms. There were differences in the expression of multiple preoperative clinical inflammatory indicators between the symptom-controled group and the symptom-uncontrolled group（previous surgical history, concomitant asthma, nasal smear eosinophil, serum EOS%, total IgE, CT score, olfactory score, and symptom score, all with P<0.05）, while there was no difference in baseline endoscopic score（P>0.05）. At 12th week postoperative, the two groups of patients showed significant differences in both symptom scores and endoscopic scores. The symptoms and endoscopic score at the 12th week point of follow-up were used as predictive indicators for recurrence, with sensitivity and specificity of 62.5% and 83.3%, respectively. Conclusion:The changes in postoperative symptom score and endoscopic score in ECRSwNP patients indicated that the recurred ECRS. In the symptom-uncontrolled group, symptomatic and endoscopic scores showed consistent increased scores; In the symptom-controlled group, conflicting results between increased endoscopic scores and stable symptoms suggest that the presence of asymptomatic recurrence must be considered. The changes in symptoms and signs at the 12th week point of follow-up can serve as clinical indicators for preventing disease recurrence.

The correlation between FCER2 gene polymorphism and the efficacy of inhaled corticosteroids in patients with chronic rhinosinusitis / 临床耳鼻咽喉头颈外科杂志

Objective:To investigate the correlation between FCER2（2206A>G） gene polymorphism and the efficacy of inhaled corticosteroids（ICS） in patients with chronic rhinosinusitis（CRS）. Methods:A total of 208 CRS patients were routinely treated with functional endonasal sinus surgery and postoperative ICS. DNA extraction, PCR amplification and gene sequencing were performed to observe the FCER2（2206A>G） gene polymorphism and calculate the allele frequency. The visual analog scale（VAS） score, Lund-Kennedy score, and computed tomography（CT） Lund-Mackay score were determined 6 months after surgery among patients with different genotypes. Moreover, the polymorphism frequency was compared among different subgroups（chronic rhinosinusitis with nasal polyps versus chronic rhinosinusitis without nasal polyps, eosinophilic chronic rhinosinusitis versus non-eosinophilic chronic rhinosinusitis）. Results:There were FCER2（2206A>G） gene polymorphism in patients with CRS, and the phenotypes included 3 genotypes, AA, AG and GG, with distribution frequencies of 68（32.7%）, 116（55.8%） and 24（11.5%） cases, respectively. No significant differences were found in age, VAS score, nasal endoscopic Lund-Kennedy score and CT imaging Lund-Mackay score among patients with CRS of each genotype before surgery. In patients with the AA genotype, the changes in VAS score（5.74±1.10）, Lund Kennedy score（5.92 ± 1.14）, and CT imaging Lund-Mackay score（13.26±4.26） were significantly higher than in patients with the AG（4.37±0.86, 5.37±1.24, 10.82±3.77） and GG（4.26±0.80, 5.18±1.56, 10.10±3.53） genotype（P<0.05）. However, there were no marked difference between patients with the AG genotype and those with the GG genotype（P>0.05）. Compared with patients with non-eosinophilic sinusitis, Among them, the differences between the GG genotype and AG /AA genes were more significant in eosinophilic sinusitis compared to non-eosinophilic sinusitis（P<0.01）. Conclusion:The FCER2（2206A>G） gene in patients with CRS has genetic polymorphism and is associated with the recovery of CRS patients after surgery, individual corticosteroid sensitivity, and subgroup variability.

Symptom assessment after nasal irrigation with xylitol in the postoperative period of endonasal endoscopic surgery / Avaliação dos sintomas após irrigação nasal com xilitol no período pós-operatório de cirurgias endoscópicas endonasais

Abstract Introduction: Chronic rhinosinusitis is an inflammatory condition of the nasal cavity and the paranasal sinuses that requires multifactorial treatment. Xylitol can be employed with nasal irrigation and can provide better control of the disease. Objective: To evaluate the association between the effects of nasal lavage with saline solution compared to nasal lavage with a xylitol solution. Methods: Fifty-two patients, divided into two groups (n = 26 in the "Xylitol" group and n = 26 in the "Saline solution" group) answered questionnaires validated in Portuguese (NOSE and SNOT-22) about their nasal symptoms and general symptoms, before and after endonasal endoscopic surgery and after a period of 30 days of nasal irrigation. Results: The "Xylitol" group showed significant improvement in pain relief and nasal symptom reduction after surgery and nasal irrigation with xylitol solution (p < 0.001). The "Saline solution" group also showed symptom improvement, but on a smaller scale. Conclusion: This study suggests that the xylitol solution can be useful in the postoperative period after endonasal endoscopic surgery, because it leads to a greater reduction in nasal symptoms.

Resumo Introdução: Rinossinusite crônica é um quadro de inflamação da cavidade nasal e dos seios paranasais que necessita de tratamento multifatorial. O xilitol pode ser associado às irrigações nasais e pode prover melhor controle da doença. Objetivo: Avaliar a relação entre os efeitos da lavagem nasal com solução fisiológica em comparação à lavagem nasal com solução de xilitol. Método: Divididos em dois grupos (n = 26 no grupo Xilitol e n = 26 no grupo Soro), 52 pacientes responderam à questionários validados em língua portuguesa (NOSE e SNOT-22) sobre seus sintomas nasais e sintomas gerais, antes e depois de cirurgia endoscópica endonasal e após um período de 30 dias de irrigação nasal. Resultados: O grupo Xilitol apresentou melhoria significativa dos sintomas de dor e sintomas nasais após a cirurgia e a irrigação nasal com solução de xilitol (p < 0,001). O grupo Soro também apresentou melhoria dos sintomas, porém em menor escala. Conclusão: Este estudo sugere que a solução de xilitol pode ser usada no período pós-operatório de cirurgia endoscópica endonasal por levar a uma maior redução nos sintomas nasais.

Expression of CD8+Treg cells in chronic rhinosinusitis and its correlation with eosinophilic infiltration / 中华耳鼻咽喉头颈外科杂志

Objective: To detect the percentages of CD8+Treg cells in the nasal mucosa and peripheral blood of chronic rhinosinusitis (CRS) and to explore their correlation with eosinophilic infiltration. Methods: Thirty-three chronic rhinosinusitis with polyp (CRSwNP), 26 chronic rhinosinusitis without polyp (CRSsNP) and 27 control patients who were collected with the nose mucosal tissue and peripheral blood in the Third Affiliated Hospital of Sun Yat-sen University from March 2017 to October 2018 were selected, including 59 males and 27 females, aging from 18 to 72 years. Hematoxylin and eosin (HE) staining was used to observe the number of eosinophils in the nasal tissues and to classify the CRS into eosinophilic CRS (ECRS) and non-eosinophilic CRS (Non-ECRS). Flow cytometry was used to detect the percentages of CD4+ and CD8+T cells in lymphocytes of nasal mucosa and peripheral blood. The percentages of CD8+Foxp3+Treg cells, CD8+Foxp3-IL-10+Treg cells, CD8+IFN-γ+T cells (Tc1), CD8+IL-4+T cells (Tc2) and CD8+IL-17A+T cells (Tc17) in lymphocytes of nasal mucosa and peripheral blood were also tested. Besides, the percentages of Foxp3+TGF-β+Treg cells and Foxp3+IL-10+Treg cells in CD8+T cells were determined. All data were represented by M (IQR). GraphPad 7.0 and SPSS 16.0 were used for illustration and statistical analysis. Results: The percentage of CD8+T cells (37.75%(17.35%)) was higher than that of CD4+T cells (4.72%(4.29%)) in nasal mucosa (Z=-5.70, P<0.001), while lower (23.60%(9.33%)) than that of CD4+T cells (44.05% (10.93%)) in peripheral blood (t=9.72, P<0.001). CRSwNP patients possessed the highest Tc2 (1.82% (1.22%)) and Tc17 (1.93% (2.32%)) percentages than CRSsNP (Tc2: 0.84% (0.79%); Tc17: 0.54% (1.04%)) and control (Tc2: 1.09% (0.92%); Tc17: 0.47% (0.51%), both P<0.05) patients. While, CRSwNP patients possessed the lowest CD8+Foxp3+Treg cells percentage (0.10% (0.32%)) than CRSsNP (0.43% (1.45%)) and control (0.48% (0.83%), Z value was -2.24, -2.22, respectively, P value was 0.025, 0.027, respectively). The percentages of Foxp3+TGF-β+Treg cells and Foxp3+IL-10+Treg cells of CD8+T cells in nasal mucosa in CRSwNP were also lower than controls (Z value was 1.46, 0.49, respectively, both P=0.001). Moreover, the percentage of CD8+Foxp3-IL-10+Treg cells of CD8+T cells was decreased in nasal mucosa of CRSwNP patients (0.14% (0.28%)) when compared with that of CRSsNP (0.89% (0.81%), Z=0.61, P=0.03). ECRS patients had the lower percentages of CD8+Foxp3+Treg cells (0.07% (0.44%)) and CD8+Foxp3-IL-10+Treg cells (0.13% (0.21%)) than Non-ECRS patients (CD8+Foxp3+Treg cells: 0.53% (0.75%); CD8+Foxp3-IL-10+Treg cells: 0.29% (0.76%), t value was 2.14, 2.78, respectively, both P<0.05). The percentage of CD8+Foxp3+Treg cells and the ratio of CD8+Foxp3-IL-10+T per CD8+T cells were negatively correlated with the percentage of eosinophils in CRS patients(R2 value was 0.56, 0.78, respectively, both P<0.001). There was no significant difference in the distribution of CD8+Fxop3+Treg cells and CD8+Fxop3-IL-10+Treg cells in peripheral blood among different groups. Conclusion: The percentages of CD8+Treg cells decrease in CRSwNP patients, especially in ECRS patients, which are opposite to that of Tc2 and Tc17, and negatively correlate with the eosinophils percentage. This indicates that the decrease in the ratio of CD8+Treg cell may be associated with the immune-imbalance and eosinophilic infiltration in nasal mucosa of CRS patients.

Studies on efficacy of a bioabsorbable steroid-eluting sinus stent in the frontal sinus opening of chronic rhinosinusitis with nasal polyps / 中华耳鼻咽喉头颈外科杂志

Objective: To assess the efficacy of a bioabsorbable steroid-eluting sinus stent in improving surgical outcomes when placed in the frontal sinus ostium (FSO) following full endoscopic sinus surgery (ESS) in patients with whole group chronic rhinosinusitis with nasal polyps (CRSwNP). Methods: Patients with whole group CRSwNP who had similar lesions on bilateral sinus between September 2019 and March 2020 in Department of Otorhinolaryngology Head and Neck Surgery, Shanghai Changhai Hospital were chosen. Patients with CRSwNP who underwent extended ESS were randomly assigned to receive a steroid-eluting sinus stent in one FSO whereas the contralateral side received surgery alone. Endoscopic evaluations recorded at 30, 90 days postoperative were graded by an independent assessment panel to assess the need for interventions in the FSO. Semi-quantitative data with CT and endoscopic score were performed by rank sum test. The need for postoperative intervention and the patency rate of FSO were analyzed using the McNemar test. Results: Thirty-one patients with whole group CRSwNP met all eligible criteria, including 17 males and 14 females, with the age of (44.5±11.8) years(x¯±s). Stents were successfully placed in one FSO of all patients. At 30 days post-ESS, the assessment panel reported that steroid-eluting stents reduced the need for postoperative interventions by 41.0% (χ2=5.314,P=0.021), the need for oral steroid interventions by 40.0% (χ2=4.133,P=0.042) and the need for surgical interventions by 74.8% (χ2=4.292,P=0.038) compared to control sinuses with no stents. Clinical surgeons also reported greater diameter of FSO compared to control sinuses at 30 days post-ESS (74.2% vs 48.4%, χ2=4.351, P=0.037). These results at 90 days post-ESS were consistent with those at 30 days post-ESS. Conclusion: Bioabsorbable steroid-eluting sinus stents in the FSO can reduce polyp formation, adhesion, and the need for postoperative interventions in FSO of CRSwNP patients and improve the early postoperative outcomes.

Micronucleus count in nasal epithelial cells from patients with chronic rhinosinusitis and polyps / Contagem de micronúcleos em células epiteliais nasais de pacientes com rinossinusite crônica e pólipos

Abstract Introduction: Chronic rhinosinusitis with nasal polyps, a prevalent disease affecting around 2% of the world population, is characterized by symptomatic inflammation of the nasal mucosa and impairment of quality of life. Chronic rhinosinusitis with nasal polyps has a multifactorial etiology, involving a dysfunctional host response to environmental factors. Thus, inflammatory models may be useful to shed light on the pathophysiology of this disease. Micronucleus count has been used to screen DNA damage in various tissues. Objective: To investigate the association between frequency of micronucleus in exfoliated cells from the nasal cavity of patients with chronic rhinosinusitis with nasal polyps and disease severity. Methods: This cross-sectional study included 21 patients with chronic rhinosinusitis with nasal polyps and 19 controls without disease. None of the participants were smokers. Results: Mean micronucleus count was 3.690 per 1000 cells (±2.165) in individuals with vs. 1.237 per 1000 cells (±0.806) in controls; (Student's t test = 4.653, p< 0.001). Nasal surgery in the past 5 years and aspirin-exacerbated respiratory disease were not associated with nicronucleus count (p= 0.251). Conclusion: Micronucleus count seems to be linked to chronic rhinosinusitis with nasal polyps, providing a new perspective for the evaluation of this disorder.

Resumo Introdução: A rinossinusite crônica com pólipos nasais, doença prevalente que afeta cerca de 2% da população mundial, é caracterizada por inflamação sintomática da mucosa nasal e comprometimento da qualidade de vida. A rinossinusite crônica com pólipos nasais tem etiologia multifatorial, envolvendo resposta disfuncional do hospedeiro a fatores ambientais. Assim, modelos inflamatórios podem ser úteis para esclarecer a fisiopatologia dessa doença. A contagem de micronúcleos tem sido usada para rastrear danos no DNA em vários tecidos. Objetivo: Investigar a associação entre a frequência de micronúcleos em células esfoliadas da cavidade nasal de pacientes com rinossinusite crônica com pólipos nasais e a gravidade da doença. Método: Estudo transversal que incluiu 21 pacientes com rinossinusite crônica com pólipos nasais e 19 controles sem doença. Nenhum dos participantes era fumante. Resultados: A contagem média de micronúcleos foi de 3,690 por 1.000 células (± 2,165) nos indivíduos doentes e 1,237 por 1.000 células (± 0,806) nos controles (teste t de Student = 4,653; p < 0,001). A cirurgia nasal nos últimos 5 anos e a doença respiratória exacerbada por aspirina não foram associadas à contagem de micronúcleos (p = 0,251). Conclusão: A contagem de micronúcleos parece estar ligada à rinossinusite crônica com pólipos nasais, proporcionando uma nova perspectiva para a avaliação dessa doença.

Growth and mouth breathers / Crescimento e respiradores orais

Abstract Objective: To assess the relationship between mouth breathing and growth disorders among children and teenagers. Data source: Search on MEDLINE database, over the last 10 years, by using the following terms: "mouth breathing", "adenotonsilar hypertrophy", "allergic rhinitis", "sleep disturbance" AND "growth impairment", "growth hormone", "failure to thrive", "short stature", or "failure to thrive". Data summary: A total of 247 articles were identified and, after reading the headings, this number was reduced to 45 articles, whose abstracts were read and, of these, 20 were deemed important and were included in the review. In addition of these articles, references mentioned in them and specific books on mouth breathing deemed important were included. Hypertrophy of palatine and/or pharyngeal tonsils, whether associated with allergic rhinitis, as well as poorly controlled allergic rhinitis, are the main causes of mouth breathing in children. Respiratory sleep disorders are frequent among these patients. Several studies associate mouth breathing with reduced growth, as well as with reduced growth hormone release, which are reestablished after effective treatment of mouth breathing (clinical and/or surgical). Conclusions: Mouth breathing should be considered as a potential cause of growth retardation in children; pediatricians should assess these patients in a broad manner.

Resumo Objetivo: Avaliar a relação entre respiração oral e distúrbios do crescimento entre crianças e adolescentes. Fonte de dados: Busca na base de dados do MEDLINE, nos últimos 10 anos, com o emprego dos seguintes termos: "mouth breathing" ou "adenotonsilar hypertrophy", ou "allergic rhinitis" ou sleep disturbance" AND "growth impairment" ou "growth hormone" ou "failure to thrive" ou "short stature" ou "failure to thrive". Síntese dos dados: Foram identificados 247 artigos, que após a leitura dos títulos foram reduzidos a 45, cujos resumos foram lidos e desses 20 foram considerados de importância e integraram a revisão. Além desses, referências por eles citadas e livros-texto específicos sobre respiração oral considerados importantes foram incluídos. A hipertrofia de tonsilas palatinas e/ou faríngeas, associada ou não à rinite alérgica, assim como a rinite alérgica mal controlada, é a principal causa de respiração oral na criança. Distúrbios respiratórios do sono são frequentes entre esses pacientes. Vários estudos associam a respiração oral à redução do crescimento, bem como à redução de liberação de hormônio do crescimento, que são restabelecidos após o tratamento efetivo da respiração oral (clínico e/ou cirúrgico). Conclusões: A respiração oral deve ser cogitada como possível causa de retardo de crescimento em crianças e cabe ao pediatra a tarefa de investigar esses pacientes de forma mais abrangente.

Relation between chronic rhinosinusitis and gastroesophageal reflux in adults: systematic review / Relação entre rinossinusite crônica e refluxo gastroesofágico em adultos: revisão sistemática

Abstract Introduction: The relationship between gastroesophageal reflux disease (GERD) and chronic rhinosinusitis (CRS) is still a controversial issue in literature. Objective: A systematic review of the association between these two diseases in adult patients. Methods: Systematic review in PubMed and Cochrane Database with articles published between 1951 and 2015. We included all articles that specifically studied the relationship between CRS and GERD. Results: Of the 436 articles found, only 12 met the inclusion criteria. Eight cross-sectional articles suggest a relation between CRS and GERD, especially on CRS that is refractory to clinical or surgical treatment. However, the groups are small and methodologies are different. Four other longitudinal studies have assessed the effect of treatment with proton pump inhibitors (PPIs) on the improvement of symptoms of CRS, but the results were conflicting. Conclusions: There seems to be relative prevalence of reflux with intractable CRS. There is still a lack of controlled studies with a significant number of patients to confirm this hypothesis. Few studies specifically assess the impact of treatment of reflux on symptom improvement in patients with CRS.

Resumo Introdução: A relação entre a Doença do Refluxo Gastroesofágico (DRGE) e a Rinossinusite Crônica (RSC) ainda é tema de controvérsia em literatura. Objetivo: Revisão sistemática sobre a associação entre essas duas doenças em pacientes adultos. Método: Revisão sistemática no Pubmed e Cochrane Database com os artigos publicados entre 1951 e 2015. Foram incluídos todos os artigos que estudassem especificamente a relação entre RSC e DRGE. Resultados: Dos 436 artigos encontrados, apenas 12 satisfaziam os critérios de inclusão. Oito artigos transversais sugerem relação da RSC com a DRGE, especialmente sobre a RSC refratária a tratamento clínico ou cirúrgico prévio. No entanto, os grupos são pequenos e as metodologias são muito diferentes. Outros quatro estudos longitudinais avaliaram o efeito do tratamento com Inibidores de Bomba de Prótons (IBP) sobre a melhora a dos sintomas de RSC, porém os resultados foram discordantes. Conclusões: Parece haver relação de prevalência de refluxo e RSC de difícil controle. Ainda faltam estudos controlados com um número expressivo de pacientes para que se confirme essa hipótese. São escassos os estudos que avaliem especificamente o impacto do tratamento de refluxo na melhora dos sintomas em pacientes com RSC.

Distinct characteristics of nasal polyps with and without eosinophilia / Diferenças nas características de pólipos nasais com e sem eosinofilia

Abstract Introduction Eosinophilic and noneosinophilic Nasal polyps (NPs) are different subtypes of NPs and require different treatment methods. Objective To compare the histologic characteristics, mRNA and protein expression between Nasal Polyps with and without eosinophilia. Methods NPs tissues were obtained from eighty-six NPs patients during surgery. Eosinophilic and noneosinophilic NPs were distinguished according to immunochemical results of the specimen. The histological, mRNA and protein expression features were compared between the two groups. Results In eosinophilic NPs, we observed a significantly higher GATA-3, IL-5, IL-4, IL-13 mRNA and protein expression. In noneosinophilic NPs, IL-17, IL-23 and RORc mRNA and protein expression were increased. Immunohistochemistry tests showed, more mast cells and less neutrophils in eosinophilic NPs compared with noneosinophilic NPs. Eosinophilic NPs patient presented more severe symptom scores when compared to noneosinophilic NPs. Conclusion We demonstrate for the first time that Th2 is the predominant reaction in eosinophilic NPs while Th17 is the predominant reaction in noneosinophilic NPs. Our study may provide new treatment strategy for NPs.

Resumo Introdução Pólipos nasais (PNs) eosinofílicos e não eosinofílicos são diferentes subtipos de PNs e requerem diferentes métodos de tratamento. Objetivo Comparar as características histológicas e a expressão de mRNAs e proteínas entre PNs com e sem eosinofilia. Método Amostras de PNs foram obtidos de 86 pacientes durante a cirurgia. PNs eosinofílicos e não eosinofílicos foram diferenciados segundo os resultados imunoistoquímicos de cada amostra. As características histológicas e de expressão de mRNAs e de proteínas foram comparadas entre os dois grupos. Resultados Em PNs eosinofílicos, observamos uma expressão significativamente maior dos mRNAs e proteínas GATA-3, IL-5, IL-4 e IL-13. Nos PNs não eosinofílicos, aumentou a expressão dos mRNAs e das proteínas IL-17, IL-23 e RORc. Nos testes imunoistoquímicos, observamos maior número de mastócitos e menor número de neutrófilos nos PNs eosinofílicos, em comparação com PNs não eosinofílicos. Os pacientes com PNs eosinofílicos obtiveram escores de sintomas mais graves vs. PNs não eosinofílicos. Conclusão Demonstramos, pela primeira vez, uma reação Th2 predominante em PNs eosinofílicos e uma reação Th17 predominante em PNs não eosinofílicos. Nosso estudo pode proporcionar novas estratégias terapêuticas para a rinossinusite crônica.

Recirculação de muco como causa de insucesso cirúrgico no tratamento da rinossinusite crônica / Mucus recirculation as a cause of surgical failure in the treatment of chronic rhinosinusitis

Uma das causas do insucesso da cirurgia endoscópica, com persistência da rinossinusite crônica, é o fenômeno da recirculação de muco. O muco retorna ao seio maxilar por uma antrostomia que não inclua o óstio natural de drenagem. Comumente, tal fenômeno é subdiagnosticado. O objetivo deste trabalho é relatar um caso clássico de uma paciente que realizou tratamento cirúrgico para rinossinusite crônica, sem sucesso devido à recirculação de muco, bem como discutir seus principais aspectos. Identificar a recirculação de muco em pacientes com rinossinusite crônica recalcitrante, especialmente em pacientes já operados, é muito importante, e seu tratamento cirúrgico pode resolver o problema (AU)

One of the causes of failure of endoscopic surgery, with persistent chronic rhinosinusitis, is the mucus recirculation phenomenon. The mucus returns to the maxillary sinus by a antrostomy that does not include natural ostium drainage. Commonly, such a phenomenon is underdiagnosed. The aim of this study is to report a classic case of a patient who underwent surgical treatment for chronic rhinosinusitis without success due to the recirculation of mucus, as well as discuss its key aspects. Identify the mucus recirculation in patients with recalcitrant chronic rhinosinusitis, especially in patients already operated, is very important and its surgical treatment can resolve the issue (AU)

Main causes and diagnostic evaluation in patients with primary complaint of olfactory disturbances / Principais causas e avaliação diagnóstica em pacientes com queixa primária de distúrbio olfatório

INTRODUCTION: Establishing a diagnosis in patients with olfactory disturbances has always been challenging for physicians.One reason for this is the rarity of some of the diseases that affect this sense, such as Kallmann's syndrome and post-viral olfactory loss. OBJECTIVE: To identify the major causes of olfactory disturbances and to describe the diagnostic evaluation in outpatients attended to at an ambulatory clinic specialized in olfaction disorders. METHODS: A retrospective analysis was performed in outpatients with primary olfactory complaint attended to between June 1, 2011 and September 30, 2013 in a center specialized in olfactory disorders. Patient history, nasofibroscopy, and the University of Pennsylvania Smell Identification Test (UPSIT) comprised the examination. RESULTS: Sixty-two patients were evaluated. The major causes were chronic rhinosinusitis (31%); rhinitis, primarily the allergic type (19%); post-viral olfactory loss (13%); and post-traumatic loss (8%). UPSIT scores were statistically different among different etiologies (p = 0.01). CONCLUSIONS: The major diagnoses that should be part of the physician assessment when a patient complains of olfactory disturbance are chronic rhinosinusitis with and without polyps, allergic rhinitis, post-viral olfactory loss, and post-traumatic loss. .

INTRODUÇÃO: Estabelecer um diagnóstico em pacientes com distúrbios olfatórios foi sempre um desafio aos médicos. Uma das razões para isso é a raridade de algumas doenças que afetam esse sentido como a Síndrome de Kallmann e a perda olfatória pós-viral. OBJETIVO: Identificar as principais causas das doenças olfatórias e descrever sua condução diagnóstica em um ambulatório direcionado a esses distúrbios. MÉTODO: Análise retrospectiva de pacientes ambulatoriais com queixa olfatória primária atendida entre 1º de junho de 2011 e 30 de setembro de 2013 em centro especializado. História clínica, nasofibroscopia e o Teste de Identificação do Olfato da Universidade da Pensilvânia (UPSIT) compuseram a avaliação. Sempre que necessário, foram solicitadas tomografia de seios paranasais e ressonância magnética de crânio. RESULTADOS: Sessenta e dois pacientes foram avaliados. As causas mais comuns encontradas foram respectivamente: rinossinusite crônica (31%), rinites (19%), principalmente a rinite alérgica, perda olfatória pós-viral (13%) e pós-traumática (8%). As pontuações no UPSIT foram estatisticamente diferentes entre as cinco principais causas (p = 0,01). CONCLUSÕES: Os principais diagnósticos que devem fazer parte na investigação médica diante de um paciente com queixa olfatória são: rinossinusite crônica com e sem polipose nasal, rinite alérgica, perda olfatória pós-viral e pós-traumática. .

Relación entre rinitis y asma: ¿esta todo dicho? / [The relationship between rhinitis and asthma: is that all?].

The link between upper and lower airways has been observed in the past, but only carefully investigated during the last years. Allergic rhinitis and asthma are often comorbid conditions. Its relationship is supported by epidemiological, anatomical and physiological, immunopathological, clinical and therapeutic studies, mostly related to allergic rhinitis. Rhinitis and asthma occur together at rates that greatly exceed what would be expected from the baseline prevalence of each disorder alone. Many researchers have considered rhinitis as a risk factor for developing asthma. Also, the severity of rhinitis has been directly correlated with the severity of asthma although less evidence supporting the reverse impact. Different clinical and experimental observations suggested the hypothesis of the unity of upper and lower respiratory tract. Evidence suggests that rhinitis and asthma are different facets of a broader systemic inflammatory process involving upper and lower airways. Treatment of rhinitis simultaneously produces a favorable effect on symptoms of asthma and concurrent improvement in lung function and bronchial hyperresponsiveness. In this article, we review the most relevant epidemiological, genetic and clinical evidence linking rhinitis and asthma, the possible mechanisms of the nose-lung interaction and the rational basis of a set treatment that support the hypothesis of "one airway, one disease "considering aspects not yet clarified on the subject.

A Case of IgG4-Related Disease with Bronchial Asthma and Chronic Rhinosinusitis in Korea

IgG4-related disease (IgG4-RD) is characterized by a systemic involvement of tumor-like lesions with IgG4-positive plasmacytes. We experienced a case of IgG4-RD developed in a patient with bronchial asthma (BA) and chronic rhinosinusitis (CRS). A 55-yr-old female patient with BA and CRS complained of both eyes and neck swelling as well as a recurrent upper respiratory infection in recent 1 yr. The serum levels of IgG4, creatinine, and pancreatic enzymes were elevated. A biopsy of the submandibular gland showed an abundant infiltration of IgG4-positive plasmacytes. Her symptoms remarkably improved after the treatment of a systemic steroid that has been maintained without recurrence. We report a rare case of IgG4-RD developed in a patient with BA and CRS.