Rhinitis in the Geriatric Population: Epidemiological and Cytological Aspects

Didikoglu A., Guler E.S., Turk H.K., Can K., Erim A.N., Payton A., Murgatroyd C., Pakpahan E., Minshull J., Robinson A.C., Maharani A.

Depression among older adults is a global concern, contributing to disability and overall illness burden. Understanding its trajectory, associated risk factors, and implications for mortality is essential for effective intervention. Moreover, the relationship between depression, sleep disturbances, and synaptic density in the ageing brain remains complex and poorly understood.

Klimek L., Mullol J., Ellis A.K., Izquierdo-Domínguez A., Hagemann J., Casper I., Davis A., Becker S.

Allergic rhinitis (AR) is the most common allergic disease worldwide and one of the most common chronic diseases in general. Allergic rhinitis is caused by inhalant allergens from outdoor and indoor environments with varying significance of different allergens in global regions. We provide options for the current management for AR including pharmacological treatments and nonpharmacological options and allergen immunotherapy (AIT). A literature review has been conducted in Medline, Pubmed, as well as the national and international study (ClinicalTrials.gov) and guideline registers and the Cochrane Library. Human studies published on the topic in the period up to and including November 2023 were taken into account. Allergen avoidance measures, pharmacotherapy, and AIT are the cornerstones of AR treatment. Nonpharmacological measures and behavioral recommendations should be adequately added. Tools of precision medicine are already playing a significant role and will be part of the diagnostic and therapeutic standard in the future. Patients benefit most in a network of different pharmacological and nonpharmacological treatment measures including AIT. Application of precision medicine tools for diagnosis and treatment will improve standards of care. Allergic rhinitis (AR) is the most common allergic disease worldwide and one of the most common chronic diseases in general. Allergic rhinitis is caused by inhalant allergens from outdoor and indoor environments with varying significance of different allergens in global regions. We provide options for the current management for AR including pharmacological treatments and nonpharmacological options and allergen immunotherapy (AIT). A literature review has been conducted in Medline, Pubmed, as well as the national and international study (ClinicalTrials.gov) and guideline registers and the Cochrane Library. Human studies published on the topic in the period up to and including November 2023 were taken into account. Allergen avoidance measures, pharmacotherapy, and AIT are the cornerstones of AR treatment. Nonpharmacological measures and behavioral recommendations should be adequately added. Tools of precision medicine are already playing a significant role and will be part of the diagnostic and therapeutic standard in the future. Patients benefit most in a network of different pharmacological and nonpharmacological treatment measures including AIT. Application of precision medicine tools for diagnosis and treatment will improve standards of care. Nose WoesThe Journal of Allergy and Clinical Immunology: In PracticeVol. 12Issue 6PreviewEveryone has experienced problems (woes) with their nose. These problems can be acute or chronic and range from the sniffles to complete nasal blockage. Regardless of the cause, the maladies affect an individual's quality of life as well as school and work productivity. In addition, there is not a reader of this journal who has not seen patients or family members with rhinitis, who have not tried prior treatment. Thus, it is important to review this topic periodically and update your knowledge. This theme issue focuses on the chronic forms of allergic and nonallergic rhinitis, with an emphasis on important clinical considerations, particularly on the advanced understanding of the disorders and their management. Full-Text PDF Current Management of Allergic RhinitisThe Journal of Allergy and Clinical Immunology: In PracticeVol. 12Issue 6Preview Full-Text PDF

Lo C.W., Pathadka S., Qin S.X., Fung L.W., Yan V.K., Yiu H.H., Bloom C.I., Wong I.C., Chan E.W.

Background:The United States Food and Drug Administration issued a black box warning on the mental health adverse effects of montelukast in 2020. Age-related effects on the risk of developing specific neuropsychiatric events in montelukast users remain largely unknown.Objective:To describe the risk of neuropsychiatric events associated with montelukast in adults and children with asthma.Methods:A systematic search of all studies investigating neuropsychiatric events in montelukast users was performed in PubMed, the Cochrane Library and Embase from inception to 7 September 2022. Animal studies and conference abstracts were excluded.Results:59 studies (21 pharmacovigilance studies, four reviews from 172 randomised controlled trials, 20 observational studies, 10 case reports and four case series) evaluating neuropsychiatric events in patients with asthma on montelukast were reviewed. No significant association was shown between montelukast and suicide-related events in six of the observational studies. No association was found for depression as defined by the International Classification of Diseases 10threvision codes in three observational studies and a review of randomised clinical trials. However, findings from four studies using antidepressant prescriptions as the outcome identified significant associations. Consistent with nine pharmacovigilance studies, two large-scale observational studies revealed possible associations of montelukast with anxiety and sleeping disorders in adult patients with asthma, respectively. However, the results were not replicated in two observational studies on children.Conclusion:Montelukast is not associated with suicide- and depression-related events in asthma patients. Older adults may be particularly susceptible to anxiety and sleeping disorders.

Gelardi M., Fiore V., Giancaspro R., Di Canio F.M., Fiorentino C., Patruno S., Ruzza A., Cassano M.

Abstract Background Rhinitis is as an inflammation of the nasal mucosa, characterized by high prevalence, widespread morbidity, and a significant financial burden on health care systems. Nevertheless, it is often considered as no more than a mere annoyance. This point of view has progressively led to underestimate and trivialize the disease. Therefore, there are numerous, mostly overlapping classifications of rhinopaties, but clear and standardized guidelines for diagnosis and treatment are still lacking. In the context of Precision Medicine, the development of a classification system focused on the endotypes of rhinitis to be widely adopted appears of utmost importance, also by virtue of study of the nasal immunophlogosis that, thanks to nasal cytology (NC), has recently allowed to better define the different forms of rhinitis, giving a new nosological dignity to several rhinopaties. Aim We aimed to summarize the current knowledge regarding rhinitis and to propose a systematic classification of rhinitis, based on both etiology and cytological findings

Bożek A.

Purpose of review This review aims to present the current knowledge on the effectiveness and safety of allergen immunotherapy (AIT) in patients over 60 years of age with inhalant allergies. Recent findings Over the last 10 years, the problem of immunoglobulin E allergy in seniors has been noticed by many authors. At the same time, in the 1990s, trials of desensitization to selected inhalant allergens were started, obtaining evidence of the effectiveness of AIT, both with the use of sublingual immunotherapy (SLIT) and injection immunotherapy (SCIT), in patients over 60 years of age with allergic rhinitis. Such data have been confirmed for AITs for grasses, birch, and house dust mites. Currently, these patients are being monitored to assess the long-term effect of AIT. All available observations confirm the high safety of AIT in seniors. Summary Seniors with allergic rhinitis or asthma may qualify for AIT if they do not have contraindications. These patients can experience a sustained clinical benefit even after completing AIT treatment. Studies indicate that injectable and sublingual routes of administration may be effective in this age group, provided the suspect allergen is accurately diagnosed.

Okano M., Fujieda S., Gotoh M., Kurono Y., Matsubara A., Ohta N., Kamijo A., Yamada T., Nakamaru Y., Asako M., Sakurai D., Terada T., Yonekura S., Sakashita M., Okubo K.

The Practical Guideline for the Management of Allergic Rhinitis, the fist guideline for allergic rhinitis in Japan, was prepared after a symposium held by the Japanese Society of Allergology in 1993. The current 9th edition was published in 2020 and is widely used today. The most recent collection of evidence from the literature was supplemented to the revised guideline to incorporate evidence-based medicine. The revised guideline includes updated epidemiology of allergic rhinitis in Japan, a figure representing the mechanisms of allergic rhinitis in both the onset and sensitization phases with the introduction of regulatory T cells and type 2 innate lymphoid cells, practical assessment for diagnosis, new pharmacotherapy agents such as anti-IgE mAb and a new drug delivery system for antihistamines, sublingual immunotherapy for children, dual sublingual immunotherapy for house dust mites and Japanese cedar pollen extract, new classification for surgery for allergic rhinitis, and treatment and prescriptions for older adults. An evidence-based step-by-step strategy for treatment is also described.

Xu H., Zhang Y., Gu M., Shan Y., Zhang Q.

The guiding significance of existing guidelines for the diagnosis, treatment and health management of AR in elderly patients is unclear. The aim of this study is to analyze the clinical characteristics and therapeutic effects of elderly and adult AR patients by prospective study. A total of 131 AR patients were recruited and divided into elderly group and adult group according to age. After receiving the same pharmacological treatment for 4 weeks, the differences of the two groups in clinical scores including TNSS-4, RQLQ and VAS were compared. After 4 weeks treatment, all clinical scores in the adult group were improved compared with the baseline levels, while in the elderly group, only the TNSS-4 score was significantly reduced, and the RQLQ and VAS scores were not significantly improved. The changes of TNSS-4, RQLQ, and VAS scores in the elderly group were significantly inferior to those in the adult group (LS mean differences were 1.60, 8.80, and 11.10, respectively; P < 0.001). We confirmed that elderly and adult AR patients had different clinical characteristics and outcomes, and the degree of improvement in the adult group was significantly better than that in the elderly group. Therefore, it is urgent for us to establish a clinical guideline suitable for the elderly AR population to give more scientific and reasonable recommendations for diagnosis and treatment.

Li L.J., Wang S., Tsai C., Wu C.

A 34-year-old male with a history of allergic rhinitis presented with nasal obstruction for 2 months. According to him, he is allergic to the most common indoor allergens such as dust mites, cat and dog dander. The main symptoms were associated with difficulty in nasal breathing. He also suffered

Gelardi M., Giancaspro R., Cassano M., Ribatti D.

Mast cells (MCs) are involved in several biological processes, such as defense against pathogens, immunomodulation, tissue repair after injury, and angiogenesis. MCs have been shown to change from protective immune cells to potent pro-inflammatory cells, influencing the progression of many pathological conditions, including autoimmune diseases and cancers. The role of MCs in the pathogenesis of rhinopathies has often been underestimated, since previous studies have focused their attention on eosinophils and neutrophils, while MCs were considered involved exclusively in allergic rhinitis. However, recent nasal cytology findings have shown the involvement of MCs in several rhinopathies, such as NARMA, NARESMA, and CRSwNP. These recent evidences highlight the crucial role that MCs play in orchestrating the inflammation of the nasal mucosa, through complex biological mechanisms, not yet fully understood. In this context, a better understanding of these mechanisms is fundamental for practicing Precision Medicine, which requires careful population selection and stratification into subgroups based on the phenotype/endotype of the patients, in order to guarantee the patient a tailored therapy. Based on this background, further studies are needed to understand the pathophysiological mechanisms involving MCs and, consequently, to develop targeted therapies aimed to obtain a selective inhibition of tissue remodeling and preventing MC-mediated immune suppression.

Gelardi M., Giancaspro R., Pecoraro P., Cassano M.

Woo S., Lee S., Ye Y., Kim S., Lee Y., Shin Y., Park H.

Dykewicz M.S., Wallace D.V., Amrol D.J., Baroody F.M., Bernstein J.A., Craig T.J., Dinakar C., Ellis A.K., Finegold I., Golden D.B., Greenhawt M.J., Hagan J.B., Horner C.C., Khan D.A., Lang D.M., et. al.

This comprehensive practice parameter for allergic rhinitis (AR) and nonallergic rhinitis (NAR) provides updated guidance on diagnosis, assessment, selection of monotherapy and combination pharmacologic options, and allergen immunotherapy for AR. Newer information about local AR is reviewed. Cough is emphasized as a common symptom in both AR and NAR. Food allergy testing is not recommended in the routine evaluation of rhinitis. Intranasal corticosteroids (INCS) remain the preferred monotherapy for persistent AR, but additional studies support the additive benefit of combination treatment with INCS and intranasal antihistamines in both AR and NAR. Either intranasal antihistamines or INCS may be offered as first-line monotherapy for NAR. Montelukast should only be used for AR if there has been an inadequate response or intolerance to alternative therapies. Depot parenteral corticosteroids are not recommended for treatment of AR due to potential risks. While intranasal decongestants generally should be limited to short-term use to prevent rebound congestion, in limited circumstances, patients receiving regimens that include an INCS may be offered, in addition, an intranasal decongestant for up to 4 weeks. Neither acupuncture nor herbal products have adequate studies to support their use for AR. Oral decongestants should be avoided during the first trimester of pregnancy. Recommendations for use of subcutaneous and sublingual tablet allergen immunotherapy in AR are provided. Algorithms based on a combination of evidence and expert opinion are provided to guide in the selection of pharmacologic options for intermittent and persistent AR and NAR.

Mandolesi D., Schiavon P., Ioannou A., Mancini M., Cimatti M.C., Azzaroli F., Liverani E., Pierantoni C., Pirodda A., De Giorgio R., Bazzoli F., Torresan F.

AbstractBackground & Aim Chronic rhinitis, a diffuse disease with a prevalence of 40%, can be classified in allergic (AR) and non-allergic rhinitis (NAR). Nasal cytology allows for the identification of different NAR sub-types according to the inflammatory cell infiltrate. NAR etiopathogenesis is not well clarified and, for NARNE (non-allergic rhinitis with neutrophils) subtype, gastroesophageal reflux disease (GERD) has been suggested as one of the etiopathogenetic factors. Aim of this study is to evaluate the role of GERD in patients with NARNE. Methods Fifty-one consecutive patients referred to our Ear, Nose and Throat (ENT) unit with nasal symptoms and cytology suggestive for NAR, were enrolled in the study. All the patients performed a gastroenterological evaluation, high resolution esophageal manometry and a 24-h pH-Impedance monitoring. Results Twenty-five (49%) patients tested positive at nasal cytology for NARNE. A pathologic pH-impedance was identified in seven patients (28%) with NARNE, as opposed to only one (4%) with different NAR subtypes. Statistical analysis showed that higher acid exposure time (AET) and weaker post nasal drainage were more common in NARNE vs. other NAR patients. Conclusions NARNE strongly correlates with higher AET and refluxes number; thus, NARNE patients should be tested with pH-impedance monitoring in addition to nasal cytology.

Green R.J., Feldman C., van Niekerk A., McDonald M., Friedman R., Richards G.A.

Acute nasal symptoms are troublesome for patients. In addition, these symptoms are encountered frequently by individuals because of common infectious diseases, especially rhinovirus, giving rise to a 'common cold'. Acute nasal symptoms include rhinorrhoea, sneezing, nasal itch and congestion. Of these, nasal congestion is the most irritating. Because topical nasal decongestants provide rapid and dramatic relief from these symptoms, especially nasal congestion, they are frequently used and abused by patients. Guidance for indications, choice of most efficacious decongestant and recommendations for limiting side effects are thus essential to be imparted to patients by doctors.

Leszczyńska J., Stryjewska-Makuch G., Ścierski W., Lisowska G.

Chronic rhinosinusitis (CRS) is one of the most common chronic diseases in the geriatric population. However, CRS inflammatory mechanisms in older people have not been thoroughly investigated. Our work aimed to analyze the bacterial flora of the nose and paranasal sinuses in patients with CRS over 65 years of age, including comorbidities, previously performed endoscopic sinus surgery (ESS), presence or absence of polyps and the extent of the inflammatory process.The study involved 529 patients between 18 and 84 years of age with chronic rhinosinusitis who underwent endoscopic sinus surgery. There were 101 patients separated over 65 years of age (M = 52, K = 49, mean age 69 ± 0.7 years). The control group consisted of 168 patients aged 18-40 years with CRS. The bacterial culture of material collected from the patients during ESS was analyzed.In the group of patients over 65 years of age, more frequent occurrence of Proteus spp. and Pseudomonas aeruginosa was found in comparison to younger patients. In older patients with bronchial asthma, the occurrence of S. aureus, Escherichia coli, and Citrobacter spp. was more frequent than in control group. Multiple sinus surgical procedures in older patients were associated with the dominance of Staphylococcus aureus and Escherichia coli, which was not demonstrated in the control group. There were no statistically significant differences between the occurrence of bacterial strain and the presence of polyps, both in the group of patients over 65 years of age as well as in the control group.The bacterial flora of patients with CRS is different in older and younger patients. A different therapeutic approach should be considered in older patients with CRS, but this problem requires further studies.