Proposed diagnostic standard using visual analogue scale and acoustic rhinometry in nasal provocation test in allergic patients

Objective

The authors aimed to analyze symptom change after nasal provocation and acoustic rhinometry results of a larger number of allergic rhinitis patients and also aimed to propose a new diagnostic threshold by investigating the difference between patients with allergic and non-allergic perennial rhinitis.

Methods

The authors checked symptom change and performed acoustic rhinometry before and after nasal provocation in 208 patients (114 males and 94 females, 19-58 years old) with allergic rhinitis and 222 patients (116 males and 106 females, 20-74 years old) clinically diagnosed with non-allergic perennial rhinitis (control group). Then the authors compared VAS (visual analogue scale), TNV (total nasal volume), MCA (minimal cross-sectional area), length of MCA and change of these values between allergic patients group and control group, to propose the new diagnostic standard.

Results

The change of symptom score and number of sneezing after nasal provocation were significantly different between allergic patient and control group. The basal TNV, MCA, length of MCA, and changes of these values were also significantly different. By drawing the ROC (receiver operator characteristic) curve and evaluating the sensitivity and specificity for each criteria, we could set the diagnostic criteria as follows: (1) symptom change: more than 2 points in the case of nasal obstruction and more than 1 point for the case of rhinorrhea or itching, (2) more than 24.5% change of the TNV, and (3) more than 20% change of the MCA.

Conclusion

VAS change and acoustic rhinometry in nasal provocation test could be a valuable tool in diagnosing allergic rhinitis with high sensitivity and specificity.     

Distilled water nasal provocation in hyperreactive patients.

Nonisotonic aerosol may act as a provocation agent in the upper and lower airways of hyperreactive individuals. The purpose of the study was to compare the results of nasal challenge with distilled water in patients with allergic rhinitis to those with noninfective nonallergic rhinitis (NINAR), with respect to the potential clinical use of the obtained data. A group of 68 ambulatory patients with allergic rhinitis or NINAR (39 perennial allergic, 6 seasonal, 23 NINAR) were challenged with 10 mL of distilled water aerosol after the baseline active anterior rhinomanometry. Patients with nasal polyposis at endoscopy, significant unilateral septal deviation, positive bacteriologic swab, recent nasal surgery, and uncertain anamnestic data about the medication taken 6 weeks before the provocation were excluded from the study. After 10 minutes of nasal provocation, rhinomanometry was repeated to assess the response. In 15 patients of the perennial allergic group, the same measurements were performed after a 2-week oral antihistamine and topical steroid therapy. Nasal resistance was significantly increased on the more patent side of the nose after nasal provocation with distilled water aerosol in allergic patients in comparison to the nasal resistance before provocation. In the patients with NINAR, the provocation resulted in a significant rise on the more patent side, but the total nasal airway resistance (NAR) levels were also significantly increased. The systemic antihistamine and topical steroid 2-week therapy in patients with perennial allergic rhinitis significantly reduced the response to nasal distilled water provocation. Nasal provocation with distilled water aerosol is a cheap, simple, and acceptable method that provides useful clinical data on the level of nonspecific nasal hyperreactivity and the therapy success.     

Monitoring methods of nasal pathology

The importance of correct clinical and therapeutic monitoring of allergic rhinitis is understandable in the light of the social and economic impact of this pathology: its prevalence is over 10% of the total population all over the world. For the evaluation of the local nasal pathology we include: (1) anterior rhinoscopy, (2) active anterior rhinomanometry, (3) positioned acoustic rhinometry, (4) determination of mucociliary transport time, (5) specific nasal provocation test. Active anterior rhinomanometry allows reliable assessment of the nasal respiratory function, acoustic rhinometry shows the geometry of nasal cavity, mucociliary transport time is an indicator of the mucosa eutrophism. In our experience, the specific nasal provocation test is one of the most important tests in this field. It is more sensitive than the skin test and the radioallergosorbent test (RAST) in the asymptomatic phase and it is able to show organ allergies. In this study we review the importance of this test and the methodology we commonly use.     

Efficacy of a leukotriene receptor antagonist in the treatment of perennial allergic rhinitis

The objectives of this study were to investigate the efficacy of leukotriene receptor antagonists in the treatment of perennial allergic rhinitis. The study was designed as a randomized, 14-day treatment to compare the efficacy of zafirlukast, loratadine, and the combination of loratadine and pseudoephedrine in the treatment of perennial allergic rhinitis. Rhinitis symptom scores, acoustic rhinometry, and rhinomanometry were used to evaluate the efficacy. The results showed that after a 14-day treatment period, patients in all treatment groups had a lower mean score for the symptoms of rhinorrhea, nasal itching, and nasal obstruction (p < .05). Patients who took zafirlukast did not report a significant decrease in sneezing score (p = .1456), but the decrease in nasal obstruction score was more pronounced than in those who took loratadine or loratadine- pseudoephedrine (p = .014). However, the results of acoustic rhinometry and rhinomanometry did not have a significant difference among the three groups (p > .05). The study concluded that zafirlukast seemed to have a better effect on relieving the symptom of nasal obstruction in patients with perennial allergic rhinitis, but the actual mechanism needs further investigation.     

Acoustic rhinometry compared with anterior rhinomanometry in the assessment of the response to nasal allergen challenge

Acoustic rhinometry was used to assess nasal airway patency objectively and was compared with the more established method of anterior rhinomanometry. Ten patients with allergic rhinitis underwent 15 nasal challenges with allergen to which they showed positive skin-prick tests. Responses were assessed by measuring the minimum nasal cross-sectional area (Amin.) using acoustic rhinometry and by measuring nasal airway resistance (NAR) using anterior rhinomanometry. The measurements of Amin. and NAR showed a significant negative correlation. Acoustic rhinometry appears to be superior to anterior rhinomanometry in quantifying the response to nasal allergen challenge and may be particularly useful in patients with initial nasal blockage.     

Nasal passage patency in patients with allergic rhinitis measured by acoustic rhinometry: nasal responses after allergen and histamine provocation

We investigated nasal passage patency after allergen and histamine provocation in patients with allergic rhinitis by acoustic rhinometry. In total, 75 outpatients with allergic rhinitis were studied. The threshold of nasal hypersensitivity to histamine was measured by the 10 μl instillation of serial 10-fold dilution in the ipsilateral nasal cavity. Nasal provocation testing to specific antigen was applied to the anterior part of inferior turbinate in bilateral sides in sitting position. Measurement of nasal patency by acoustic rhinometry was repeated three times in each nasal cavity. The minimal cross-sectional area and total volume of nasal cavity were measured in an individual subject. The minimal cross-sectional area and total volume in the histamine challenged-side significantly decreased on the 10⁻², 10⁻¹, 10⁻⁰ of end point, and up to 30 min after challenge with the threshold dose, but not in the unchallenged side. This means acoustic reflection technique is sensitive at least 100-fold in comparison with classical method like findings by anterior rhinoscopy and symptom scores. Nasal passage patency after bilateral allergen provocation showed predominant in the unilateral side, suggesting the cross over-reflex effects.It was concluded that acoustic rhinometry is one of the highly quantitative and sensitive method which can observe the change of nasal congestion.     

特异性鼻粘膜激发试验中鼻气道的反应性

目的：探讨对特异性鼻粘膜激试验（ＳＮＰＴ）阳性的评价方法。方法：对３０例常年性变应性鼻炎患者（鼻炎组）和１４例正常成年人（对照组）进行ＳＮＰＴ，观察鼻部症状及鼻气道阻力变化。结果：激发后，鼻炎组在多数患者在０．５￣３．０ｍｉｎ内出现鼻痒、喷嚏、流清滋等症状。连续喷嚏５个以上者占８３．３％，与对照组（２１．４％）之间有显著性差异（Ｐ〈０．０１）；鼻腔总阻力和激发侧鼻阻力增加比例，两组间有明显差异，而     

Nasal provocation tests with house dust mite in patients with perennial rhinitis

The aim of this study was to evaluate a response of the upper airways mucosae to allergens house dust mite: Dermatophagoides farinae and Dermatophagoides pteronyssinus. Compared were results of nasal challenge with results of skin prick tests. 87 patients with perennial rhinitis allergic to Dermatophagoides farinae and/or Dermatophagoides pteronyssinus were included. There were 58 men, 29 women, age 18-54 years, mean age 26 years. Nasal provocation tests were performed first with solvent, and next if flow rate did not change more than 20%, with Dermatophagoides farinae and Dermatophagoides pteronyssinus extracts. The nasal response was evaluated with active anterior rhinomanometry. Nasal flow was measured at 15, 30 and 45 minutes after allergen challenge. There were 99% positive skin prick tests Dermatophagoides farinae and 94% positive skin prick tests Dermatopagoides pteronyssinus. Nasal provocation tests with Dermatophagoides farinae extract were positive in 63% patients and Dermatophagoides pteronyssinus extract--in 62% patients. Majority of nasal challenges were positive at 15th minute. There is association between skin prick tests Dermatophagoides farinae and Dermatophagoide pteronyssinus 4+ and positive nasal provocation tests with the same allergen (p < 0.05). We have found correlation between skin tests Dermatophagoides farinae and Dermatophagoides pteronyssinus (correlation index = 0.58) and no correlation between nasal provocation Dermatophgoides farinae and Dermatophagoides pteronyssinus extracts. CONCLUSION: Nasal provocation tests are more specific than skin prick tests in patients with perennial rhinitis.     

Nasal hyperreactivity to methacholine measured by acoustic rhinometry in asymptomatic allergic and perennial nonallergic rhinitis

This study was carried out to assess nasal response to different doses of methacholine and to evaluate the diagnostic possibilities of this test. Thirty-seven patients with allergic rhinitis induced by pollen (out of season), 16 with nonallergic rhinitis, and 25 normal subjects were evaluated. After provocation with saline, increasing doses of methacholine, ranging from 0.5 to 16 mg/mL, were applied. Nasal obstruction was assessed by acoustic rhinometry 10 minutes after each dose, the minimum cross-sectional area and the nasal volume in both fossae were obtained. Ipratropium bromide was applied after the last dose of methacholine to evaluate reversibility. After methacholine challenge with 0.5, 1, 2, and 4 mg/mL there was a statistically significant decrease (p < 0.05) in nasal area and volume in a dose-dependent manner in patients with allergic and nonallergic rhinitis in comparison with controls. A ROC (receiver-operating characteristic) analysis showed that a decrease in nasal volume > or = 20% at methacholine concentration of 2 mg/mL is able to predict the presence of rhinitis (positive predicted value 93%, negative predicted value 79%) in 75% of subjects. The clinical relevance of this finding suggests that patients with symptomatic nonallergic rhinitis or even asymptomatic patients with allergic rhinitis out of pollen season present a nasal hyperreactivity to methacholine, and that a decrease of nasal volume > 20% by acoustic rhinometry after challenge with methacholine at 2 mg/mL is able to discriminate these patients from normal subjects. This method seems to be a suitable tool in the diagnosis of rhinitis.     

Thresholds in nasal histamine challenge in patients with allergic rhinitis, patients with hyperreflectory rhinopathy, and healthy volunteers

BACKGROUND: Characteristic symptoms of hyperreflectory rhinopathy include recurrent sneezing, nasal obstruction, and nasal secretion without an allergic background. The diagnosis can only be made if all differential diagnoses have been excluded. So far no clinical test has been established to reliably diagnose hyperreactivity of the nasal mucosa. The present study aimed to investigate whether nasal provocation with histamine allows identification of patients with hyperreflectory rhinopathy. MATERIALS AND METHODS: One-sided nasal challenge with histamine was applied to 13 patients with allergic rhinitis, 13 patients with hyperreflectory rhinitis, and 12 healthy volunteers. Histamine concentrations used were 0.25, 0.5, 1.0, 2.0, 4.0, 8.0, and 16.0 mg/mL. Test results were quantified using a symptom score (positive at values above 3) and active anterior rhinomanometry (positive at a reduction of airflow of 40% or more in comparison to challenge with solvent). RESULTS: While there was a significant difference between controls and patients with allergic rhinitis or hyperreflectory rhinopathy, respectively, no significant difference was observed between the two groups of patients. Results indicated that one-sided nasal provocation with histamine at a concentration of 1 mg/mL is sufficient to separate healthy subjects from patients with hyperreactivity of the nasal mucosa. In terms of the differentiation between subjects with hyperreactivity of the nasal mucosa and healthy controls, the sensitivity of one-sided nasal histamine provocation with 1 mg/mL was found to be 100%; its specificity was 83% if it was evaluated by rhinomanometry and symptom score. CONCLUSION: The present results indicate that one-sided nasal challenge with histamine at a concentration of 1 mg/mL is sufficient to separate healthy subjects from patients with hyperreactivity of the nasal mucosa. However, the test does not differentiate between patients with allergic rhinitis and patients with hyperreflectory rhinitis.     

Nasal provocation testing as an international standard for evaluation of allergic and nonallergic rhinitis

Standardized nasal provocation testing (NPT) has been shown to be a safe and very useful tool in the diagnosis of allergic and nonallergic rhinitis. However, in the United States, its use has been mostly limited to scientific investigations, and it has not yet been widely accepted as a standard diagnostic procedure in clinical practice. NPT aims to identify and quantify the clinical relevance of inhalant allergens or occupational irritants. During NPT, nasal respiratory mucosa is exposed to an airborne substance suspected to cause symptoms in the respective individual. Clinical reactions are monitored in a controlled and standardized fashion. Nasal secretions, symptoms such as itching, sneezing and, most importantly, nasal obstruction are assessed as well as ocular, bronchial, cutaneous, and systemic reactions. To achieve objective data on changes in nasal airflow and patency after the challenge, anterior rhinomanometry and acoustic rhinometry have been included in the standard protocol of NPT. By monitoring changes of nasal airflow on one hand and of nasal geometry on the other hand, these methods display nasal function in a graphic way just as speech and pure tone audiometry do for auditory function. Also, by their objective nature, these methods offer a clear and internationally comparable standard. This review outlines a protocol for NPT and discusses practical applications and clinical indications. The use of rhinomanometry and acoustic rhinometry as objective diagnostic tools is emphasized. For the diagnosis of allergic and occupational rhinitis, standardized NPT should be regarded as an international diagnostic standard.     

The effect of allergen provocation on the nasal cycle estimated by acoustic rhinometry

Conclusion. The overall duration and reciprocity of the nasal cycle were not changed after allergen provocation. The duration of immediate response was 38 min, but the amplitude of the nasal cycle was increased significantly after allergen provocation.

Objective. Nasal airflow is asymmetrical and subjected to spontaneous reciprocal changes which are referred to as the nasal cycle. Limited information is available on how this is affected by allergens. The purpose of this study was to evaluate the effects of allergen provocation on the nasal cycle.

Materials and methods. This study was performed on 25 patients with allergic rhinitis and 25 subjects in a control group with no symptoms of allergic rhinitis. Acoustic rhinometry was used to test patients before and after allergen provocation. The patients underwent acoustic rhinometry at 15-min intervals for evaluation of nasal cycle and 3-min intervals for immediate response.

Results. With the allergic patients, 21 of the 25 patients (84.0%) showed a nasal cycle and they still had a nasal cycle after the allergen provocation. In the study on the changes in the immediate responses, the average recovery time was 38 min and the reduction rate of the non-patent side was higher than that of the patent side. Also, the average period of the nasal cycle was 153 min before the allergen provocation and 140 min on average after the allergen provocation; there were no statistical differences. The amplitude of each nasal cycle increased after allergen provocation and the difference had statistical meaning.     

Clinical and immunohistoenzymatic investigations in patients with vasomotor and perennial allergic rhinitis

The aim of our study was evaluation of the results of clinical examination in patients with vasomotor and perennial allergic rhinitis and assessment of number of blood vessels, nerve fibres and mast cells on the basis of immunohistoenzymatic examination. There were 42 patients examined aged from 18 to 50 and divided into three groups: I--16 patients with vasomotor rhinitis and II--14 patients with perennial allergic rhinitis and III--12 patients (control) with nasal septum deviation. On the basis of the patient's history data, clinical otorhinolaryngologic examination and active anterior rhinomanometry the patients were qualified to bilateral inferior turbinectomy. The nasal mucosa removed during surgery underwent immunohistoenzymatic examination using the monoclonal antibody against the tryptase of mast cells (MCT company, DAKO), the endothelin of blood vessels (EC - DAKO) and the neurospecific enolase (NSE - DAKO). In examined groups of patients with vasomotor and perennial allergic rhinitis and control group similar escalation of clinical symptoms expressed by means of points index were stated. In immunohistoenzymatic studies the differences in mean number of blood vessels and nerve fibres between examined groups were not statistically significant, however statistically significant difference concerned higher number of mast cells patients with vasomotor rhinitis in comparison to perennial allergic rhinitis.     

Specific local nasal immunotherapy: Single center experience on 324 patients

ObjectiveTo evaluate the efficacy and safety of specific local nasal immunotherapy (LNIT) in patients with allergic rhinitis.Materials and methodsA retrospective single-center study of 324 patients with allergic rhinitis (191 allergic to mites, 133 allergic to Grarninaceae or Parietaria pollen) treated with specific LNIT was carried out. As control group, 158 patients without allergic rhinitis were enrolled. All patients were evaluated before and after 32 weeks of treatment by subjective analysis of their self-reported symptoms and by objective analysis of nasal provocation test, nasal resistance by anterior rhinomanometry, and mucociliary clearance time.ResultsClinical efficacy of LNIT for allergy to mites and pollens was confirmed by the differences in the symptoms score between the active group and the placebo group. The nasal provocation test and the rhinomanometric analysis confirm the result with a difference statistically significant. No differnces in mucociliary clearance time were found.ConclusionsSpecific LNIT is a valide alternative to subcutaneous and sublingual administration. It is effective, safe, well tolerated by the patient, it can be done at home with fewer systemic reactions.     

The effect of beclomethasone dipropionate treatment on the nasal provocation test

A total of 50 patients with hay fever of perennial rhinitis were treated for 14 days with beclomethasone dipropionate nasal spray. Dosage was one puff (50 micrograms) in each nostril four times a day to a total daily dose of 400 micrograms. Rhinomanometry was used to determine the efficacy of beclomethasone dipropionate in immediate type allergic responses provoked by a nasal challenge with either grass pollen or house dust/house mite allergen. Treatment with beclomethasone dipropionate nasal spray resulted in a significant increase in tolerance to both house dust/house mite allergen (P = 0.01) and grass pollen allergen (P = 0.005). Passive anterior rhinomanometry would seem to offer an easy suitable technique for measuring nasal resistance during nasal provocation tests.     

The effect of allergen provocation on the nasal cycle estimated by acoustic rhinometry

CONCLUSION: The overall duration and reciprocity of the nasal cycle were not changed after allergen provocation. The duration of immediate response was 38 min, but the amplitude of the nasal cycle was increased significantly after allergen provocation. OBJECTIVE: Nasal airflow is asymmetrical and subjected to spontaneous reciprocal changes which are referred to as the nasal cycle. Limited information is available on how this is affected by allergens. The purpose of this study was to evaluate the effects of allergen provocation on the nasal cycle. MATERIALS AND METHODS: This study was performed on 25 patients with allergic rhinitis and 25 subjects in a control group with no symptoms of allergic rhinitis. Acoustic rhinometry was used to test patients before and after allergen provocation. The patients underwent acoustic rhinometry at 15-min intervals for evaluation of nasal cycle and 3-min intervals for immediate response. RESULTS: With the allergic patients, 21 of the 25 patients (84.0%) showed a nasal cycle and they still had a nasal cycle after the allergen provocation. In the study on the changes in the immediate responses, the average recovery time was 38 min and the reduction rate of the non-patent side was higher than that of the patent side. Also, the average period of the nasal cycle was 153 min before the allergen provocation and 140 min on average after the allergen provocation; there were no statistical differences. The amplitude of each nasal cycle increased after allergen provocation and the difference had statistical meaning.     

鼻声反射与鼻阻力检查在原发性萎缩性鼻炎诊断中的应用

目的探讨鼻声反射和鼻阻力检查在原发性萎缩性鼻炎患者诊断中的应用价值。方法31例实验者中选取25例正常成年受试者为对照组,6例原发性萎缩性鼻炎患者为实验组,分别行鼻声反射(acoustic rhinometry,AR)和鼻阻力(rhinomanometry,RM)测量,获得单侧鼻腔第1狭窄面积、单侧鼻腔第2狭窄面积、单侧鼻腔最小截面积、单侧及总的0～5 cm和2～5 cm鼻腔容积(UV5、UV2～5、TV5、TV2～5)、单侧吸气阻力、单侧呼气阻力及鼻气道总阻力参数,比较两组间的差异并进行相关性分析。结果实验组单侧鼻腔第1狭窄面积明显小于对照组(T=9.189,P<0.05),其余各参数差异无统计学意义。结论鼻阻力与鼻声反射检查可为原发性萎缩性鼻炎的诊断和治疗提供客观参数。     

Peak inspiratory flow rate is more sensitive than acoustic rhinometry or rhinomanometry in detecting corticosteroid response with nasal histamine challenge

Nasal histamine challenge testing is a standard method of assessing upper airway hyperreactivity although there is still debate as to the best measure of response. The aim of the study was to evaluate peak nasal inspiratory flow rate (PIFR) as an endpoint during histamine challenge and compare this with rhinomanometry (Rhino) and acoustic rhinometry (AR). Twenty two patients with perennial allergic rhinitis (PAR) were enrolled into a 2-way randomised crossover study comparing placebo with intra-nasal mometasone furoate (MF) 200 mg once daily, with laboratory measurements of PIFR, AR and Rhino being made during histamine nasal challenge after each 10-14 day treatment period. Patients also recorded their domiciliary nasal symptoms and PIFR on a daily basis. With nasal challenge testing using PIFR PC30 there was a significant (p < 0.05) difference between MF and placebo but not with PC30 AR or PC175 Rhino. There was also significant (p < 0.05) improvement in terms of domiciliary total nasal symptom scores but not domiciliary PIFR. In conclusion PIFR after nasal challenge with histamine is a sensitive test of response to treatment with intra-nasal corticosteroids in PAR.     

A multicenter trial of specific local nasal immunotherapy

OBJECTIVE: To assess the efficacy and safety of specific local nasal immunotherapy (LNIT) in powder form in patients with allergic rhinitis, using subjective and objective parameters. STUDY DESIGN: A double-blind randomized multicenter trial of 102 patients with allergic rhinitis who were treated with specific LNIT for 8 consecutive months. METHODS: After identifying allergens with the skin prick test and sensitization threshold dose with the specific nasal provocation test, 102 patients were selected, of whom 55 were allergic to mites and 47 were allergic to Graminaceae or Parietaria pollen. The specific treatments were self-administered using an insufflator in two phases (phase 1: increasing doses; phase: 2, maintenance dose). Patients were evaluated before and after 32 weeks of treatment by subjective analysis of their self-reported symptoms and by objective analysis of nasal provocation test, nasal resistance by anterior rhinomanometry, and mucociliary clearance time. RESULTS: Clinical efficacy of LNIT for allergy to mites and pollens was confirmed by the differences in the symptoms score between the active group and the placebo group. The nasal provocation test results confirmed that this difference was statistically significant. The rhinomanometric analysis gave positive results for the treated group mainly in LNIT for mites. No differences in mucociliary clearance time were found. CONCLUSIONS: Specific LNIT is effective for allergic rhinitis and appears to offer considerable advantages over other hyposensitization methods. It can be done at home, patient compliance is good, and the treatment is safe.     

Turbinate hypertrophy in habitual snorers and patients with obstructive sleep apnea: Findings of acoustic rhinometry

Forty-five habitual snorers (mean respiratory disturbance index = 6) and 22 patients with obstructive sleep apnea syndrome (mean respiratory disturbance index = 36) were examined by polysom-nography, radiocephalometry, rhinomanometry, na-sopharyngeal videoendoscopy, and acoustic rhinometry. In 97% of these patients, hypertrophy of the inferior nasal turbinates was found by acoustic rhinometry, while increased nasal resistance of various degrees was measured in 93% of all patients by active anterior rhinomanometry. Acoustic rhinometry demonstrated that the most resistive segment was located in the anterior parts of the nasal cavity and was built up by two compartments: the region of the isthmus nasi and the region of the head of the inferior turbinate. In our snoring patients, the cross-sectional areas at the head of the inferior turbinate were always smaller than the cross-sectional areas in the isthmus nasi, which in normal controls presented the minimal cross-sectional values of the whole nasal cavity. While rhinomanometry can only measure the amount of nasal resistance, acoustic rhinometry can clearly determine the exact size and location of the different stenoses in the nasal cavity that contribute to the increased nasal resistance.