Nasal provocation test is useful for discriminating allergic,

nonallergic, and local allergic rhinitis

Tae Young Jang, M.D., Ph.D., and Young Hyo Kim, M.D., Ph.D.

Y
ABSTRACT
Background: No standard study protocol or diagnostic criteria based on nasal provocation test (NPT) and acoustic rhinometry (AR) results are available
for allergic rhinitis.

P
Objective: We aimed to evaluate the usefulness of NPT plus AR for the differential diagnosis of local allergic rhinitis (LAR), allergic, and nonallergic rhinitis.
Methods: The medical records and skin-prick test (SPT) and NPT results of 262 patients with symptoms of chronic rhinitis were reviewed. Patients were
allocated to one of three groups, that is, group A [n ⫽ 110, negative SPT result for Dermatophagoides pteronyssinus (DP)], group B (n ⫽ 53, weakly positive
result), or group C (n ⫽ 99, strongly positive result).
Results: Twelve patients had a negative SPT result and provoked response in NPT [ⱖ29% decrease of minimal cross-sectional area (MCA) after DP

O
challenge] were diagnosed to have LAR. After DP challenge, group C showed significant aggravation of nasal symptoms and a greater decrease in acoustic
parameters than groups A and B (p ⬍ 0.01). In patients with a more than or equal to 2 visual analog scale (VAS) increase in nasal obstruction (NO) after
DP challenge, the criterion “a change of total nasal symptom score (TNSS) of more than or equal to 6.5” had 90.6% sensitivity and 77.4% specificity for the
diagnosis of allergic rhinitis, whereas the diagnostic criterion “a total nasal volume (TNV) change at 30 minutes after DP challenge of more than or equal to

C
27.6%” had 73.4% sensitivity and 58.1% specificity.
Conclusion: NPT with AR could be a useful tool for the differential diagnosis of allergic, nonallergic, and local allergic rhinitis.
(Am J Rhinol Allergy 29, e100 –e104, 2015; doi: 10.2500/ajra.2015.29.4214)

N asal provocation test (NPT) involves direct exposure of nasal MATERIALS AND METHODS

T
mucosa to provocative allergen extracts and evaluates allergic
reaction and hyperreactivity in the nasal cavity.1 When patients are Subjects
suspected to have allergic rhinitis, but their laboratory test results,
A total of 262 patients (156 males and 106 females, 11–69 years old,
such as skin-prick test (SPT) results, intradermal test (IDT) results,
mean age 33.2 ⫾ 13.7 years) who visited our outpatient clinic suffering
and specific immunoglobulin E (IgE), are negative, NPT could be

O
from symptoms of chronic rhinitis (runny nose, nasal stuffiness, sneez-
used to evaluate local mucosal allergy.2–4 NPT could also be useful for
ing) were enrolled by a retrospective analysis using medical record.
confirming hyperreactivity to specific allergens before starting immu-
During routine allergic workups, all patients underwent SPT, which
notherapy.5 In patients polysensitive to multiple allergens, practitio-
included more than 40 allergens, such as house dust mite (DP and
ners could use NPT to identify provocative allergens.6 Furthermore,
Dermatophagoides farinae), fungi, various plant pollens, pets dander (cat

N
NPT could be used for the diagnosis of occupational rhinitis.7
and dog), and cockroach. We excluded those who had used antihista-
Despite its extensive clinical indications and usefulness, the clinical
mines and/or vasoconstrictors within a week, intranasal corticosteroid
application of NPT is still limited, because of a lack of standardized
within a month, and systemic corticosteroid within three months. We
study protocols and widely accepted diagnostic criteria. In our pre- also excluded those with an unstable systemic disease, pregnant or
vious studies, we demonstrated the usefulness of NPT in combination lactating women, those who had undergone nasal surgery within the
with acoustic rhinometry (AR) for the diagnosis of allergic rhinitis.8 previous three months, and those with chronic rhinosinusitis and/or
However, we selected only patients with a positive SPT result for

O
Dermatophagoides pteronyssinus (DP), and those with negative SPT
results, that is, patients with a positive SPT result to any other
allergen, were excluded.
Therefore, in the present study, we included all patients that had
nasal polyps (confirmed by rigid endoscopy, paranasal x ray, and/or
computed tomography) and those exposed to chemical irritants or cig-
arette smoke. This study was approved by the Inha University Institu-
tional Review Board Committee on Studies Involving Human Beings.
We grouped all 262 patients according to their SPT result to DP,

D
undergone SPT and NPT for the differential diagnosis of rhinitis. We
aimed 1) to evaluate the usefulness of NPT for the differential diag-
nosis of local allergic rhinitis (LAR); 2) to compare symptoms and
acoustic parameters (nasal cavity volume and dimension) between
allergic and nonallergic patients; and 3) to propose diagnostic criteria
based on the results of receiver-operator curve (ROC) analysis.
that is, to group A (n ⫽ 110, negative SPT result for DP), group B (n ⫽
53, weakly positive result, wheal sizes for DP smaller than that of
histamine), and group C (n ⫽ 99, strongly positive result for DP,
wheal size of any allergen larger than that of histamine).9 A summary
of patient demographics and severities of rhinitis (according to the
Allergic Rhinitis and its Impact on Asthma [ARIA] 2008 classification)
in the three groups is provided in Table 1.

From the Department of Otorhinolaryngology, Head and Neck Surgery, Inha Univer-
sity College of Medicine, Incheon, Republic of Korea
Y.H. Kim received support from the Basic Science Research Program through the
NRF funded by the Ministry of Education, Science, and Technology (NRF-
2013R1A1A1006382). T.Y. Jang and Y.H. Kim were recipients of Inha University
Research Grants
The authors have no conflicts of interest to declare pertaining to this article
Address correspondence to Young Hyo Kim, M.D., Ph.D., Department of Otorhino-
laryngology, Head and Neck Surgery, Inha University College of Medicine, 27 Inhang-
ro, Junggu, Incheon 400-711, Republic of Korea
E-mail address: inhaorl@inha.ac.kr
Copyright © 2015, OceanSide Publications, Inc., U.S.A.
NPT Using DP Allergen Extracts and AR10
We used an ECCOVISION acoustic rhinometer (E. Benson Hood
Laboratories, Allergopharma, Reinbek, Germany) and DP allergen
extract (Allergopharma) 50,000 standardized biologic units/mL di-
luted to 1:10 with sterile saline. The examination room was main-
tained at 22°C and a relative humidity of 10%.
Before any challenge, patients were asked to complete a visual
analog scale (VAS) questionnaire for nasal symptoms [nasal obstruc-
tion (NO), rhinorrhea, sneezing, and itching]. Patients simply marked
subjective discomforts on a 10-cm long line marked at centimeter
intervals. AR was performed before DP challenge and baseline min-

e100 July–August 2015, Vol. 29, No. 4

Delivered by Ingenta to: Economics Dept IP: 193.0.129.4 On: Wed, 29 Jun 2016 01:36:49
Copyright (c) Oceanside Publications, Inc. All rights reserved.
For permission to copy go to https://www.oceansidepubl.com/permission.htm
Table 1 Demographic data for the three study groups defined based on skin-prick test results to Dermatophagoides pteronyssinus
allergen extract
Group A Group B Group C p value
(negative result, (weakly positive, (strongly positive,
n ⴝ 110) n ⴝ 53) n ⴝ 99)
Male:female ratio 62:48 31:22 63:36 0.556
Age (mean ⫾ SD) 36.5 ⫾ 13.8 37.9 ⫾ 14.8 27.0 ⫾ 10.5 ⬍0.001*

Y
ARIA classification Intermittent: persistent 19:91 16:37 27:72 0.108
Mild: moderate-to-severe 30:80 15:38 26:73 0.963
The ␹2 test was used to compare sex ratio and ARIA classifications, and ANOVA was used to compare ages.
*Statistically significant.

P
ARIA ⫽allergic rhinitis and its impact on asthma; SD ⫽ standard deviation

C O
T
N O
Figure 1. (A) Baseline nasal symptoms, (B) changes in symptoms after DP challenge, and (C) changes in acoustic parameters after DP challenge. No

O
significant difference in baseline nasal symptoms was found between the three groups. However, group C (strongly positive SPT result for DP) showed greater
aggravations of nasal symptoms and decreases in acoustic parameters after DP provocation than group A (negative SPT result to DP) or group B (weakly
positive result). R, rhinorrhea; Sn, sneezing, It, itching; ch, change of symptom (VAS score); 15 min, change after 15 minutes; 30 min, change after 30 minutes.
**, p ⬍ 0.01; ***, p ⬍ 0.001. ANOVA and the independent t-test.

D
imal cross-sectional area (MCA) and total nasal volume (TNV) were
determined. MCA was defined as the MCA of the nasal cavity, and
TNV as the sum of the cross-sectional areas from the nostril to 7 cm
deep into the nasal cavity.
After being allowed to relax for 15 minutes for acclimatization
purposes, patients received intranasal challenge with sterile saline to
rule out nonspecific hyperreactivity. Fifteen minutes after saline chal-
lenge, TNV and MCA were measured. Then patients waited 10 min-
utes to allow the effect of sterile saline to disappear. After 10 minutes,
parameters among groups. Linear regression analysis was used to
evaluate correlations between changes in symptoms and changes
in TNV and MCA after provocation. ROC analysis was used to
devise diagnostic criteria. The analysis was conducted using
SPSS version 19.0, and statistical significance was accepted for
p ⬍ 0.05.

patients were administered DP extract (⬃50 ␮L) intranasally using a

pump driven spray. VAS scores of nasal symptoms and acoustic
parameters (TNV and MCA) were measured 15 and 30 minutes after
intranasal challenge. Changes in TNV and MCA from baseline value
were recorded as percentages of baseline values.
Statistical Analysis
Analysis of variance (ANOVA), the independent t-, and the ␹2
tests were used to compare changes in symptoms and acoustic
RESULTS
Diagnosis of LAR
LAR was defined as in our previous study11 as 1) a negative SPT
result to DP; 2) a normal serum-specific IgE level; and 3) a positive
provoked NPT response (⬎29% decrease in MCA after DP intra-
nasal challenge). According to these criteria, 12 patients in group A
were clinically diagnosed as having LAR and excluded from group
A. Therefore, the final number of patients in group A was 98.

American Journal of Rhinology & Allergy e101

Delivered by Ingenta to: Economics Dept IP: 193.0.129.4 On: Wed, 29 Jun 2016 01:36:49
Copyright (c) Oceanside Publications, Inc. All rights reserved.
For permission to copy go to https://www.oceansidepubl.com/permission.htm
 than 3.5 points of TNSS change after DP challenge,” we obtained a
Table 2 Linear correlation analysis showed a significant
sensitivity of 73.7% and a specificity of 86.8% for the diagnostic
correlation between changes in nasal symptoms and changes in
criteria of allergic rhinitis (Fig. 2). ROC curve analysis of changes in
acoustic parameters after Dermatophagoides pteronyssinus
TNV and MCA after DP challenge revealed that the AUCs of these
challenge
acoustic parameters were both between 0.700 and 0.729 (Fig. 3). The
Independent Variable Dependent R (correlation P Value cut-off value of “a decrease in MCA at 15 minutes after DP challenge
Variable coefficient) of more than or equal to 13.3%” had a sensitivity and specificity of
TNV_15 minutes NO_ch 0.767 ⬍0.001 60.6% and 70.2%, respectively.
Of the 99 patients in group C, 64 reported that NO was aggravated

Y
R_ch 0.545
Sn_ch 0.353 by more than or equal to 2 VAS points, and 35 reported aggravation
It_ch 0.476 of less than 2 VAS points (the NO[⫹] and NO[⫺] subgroups, respec-
MCA_15 minutes NO_ch 0.799 ⬍0.001 tively). The changes in all nasal symptoms and acoustic parameters
after DP challenge were significantly greater in the NO[⫹] subgroup

P
R_ch 0.558
Sn_ch 0.372 (Fig. 4). When ROC analysis was reperformed on the NO[⫹] sub-
It_ch 0.489 group, the AUC for TNSS change after DP provocation was found to
TNV_30 minutes NO_ch 0.352 ⬍0.001 be as high as 0.843. When the diagnostic criterion was “a change in
R_ch 0.269 ⬍0.001 TNSS of more than 6.5,” we obtained a sensitivity and specificity of

O
Sn_ch 0.150 0.015 90.6% and 77.4% for allergic rhinitis, respectively, and when a diag-
It_ch 0.212 0.001 nostic criterion of “a TNV change at 30 minutes of more than 27.6%”
MCA_30 minutes NO_ch 0.815 ⬍0.001 was used, we obtained a sensitivity and specificity of 73.4% and
R_ch 0.585 58.1%, respectively. In patients with a VAS NO score of less than 2
Sn_ch 0.353 VAS score, no suitable diagnostic criterion was identified.

C
It_ch 0.458
NO ⫽ nasal obstruction; R ⫽ rhinorrhea; Sn ⫽ sneezing; It ⫽ itching; ch ⫽
DISCUSSION
change of symptom (VAS score); TNV ⫽ total nasal volume; MCA ⫽
minimal cross-sectional area; 15 minutes, change after 15 minutes; 30 NPT is mainly used to confirm the presence of nasal hyperreactiv-
minutes, change after 30 minutes. ity. In the present study, we were able to diagnose local mucosal

T
hyperreactivity to specific allergens when a positive NPT result was
obtained in patients with wholly negative SPT results.2–4 The original
definition of LAR was elevated specific IgE in nasal secretion after
Comparisons of Change in Nasal Symptoms and nasal provocation with allergen in patients without systemic atopy.12
Acoustic Parameters In another study, it was suggested that numbers of mucosal mast cells

O
and eosinophils were increased in the nasal mucosa of patients with
No significant difference was observed among the three groups in
LAR.13 However, according to these criteria, it is important to obtain
terms of baseline nasal symptoms before provocation except for an
nasal secretion for enzyme-linked immunosorbent assay (ELISA) and
itching sensation (p ⫽ 0.709 for NO, p ⫽ 0.377 for rhinorrhea, p ⫽
histopathologic examinations for the diagnosis of LAR. In the present
0.313 for sneezing, and p ⫽ 0.014 for itching). However, after DP

N
study, we suggest the clinical criterion “a decrease in MCA of more
allergen challenge, group C (strongly positive result to DP) showed
than 29% after provocation, in patients without systemic atopy,”
significant aggravation of all nasal symptoms (p ⬍ 0.001), and reduc-
because this produces highly reproducible results and can be easily
tions in TNV and MCA at 15 and 30 minutes after challenge (p ⬍ 0.01)
and quickly performed in the outpatient setting with minimal patient
(Fig. 1), whereas group A and group B did not. Linear regression
cooperation.11 Using this criterion, we diagnosed 12 LAR patients
analysis showed significant correlations between changes in symp-
among the 262 patients (4.6%).
toms and acoustic parameters after DP challenge (Table 2).

O
Diagnostic Criteria for Allergic Rhinitis
ROC curve analysis was used to identify diagnostic criteria for
allergic rhinitis based on NPT and AR results. Total nasal symptom
Compared with group A (nonallergic) and group B (weakly posi-
tive SPT result to any allergen), group C (strongly positive SPT result,
wheal size of any allergen larger than that of histamine) showed
significantly more aggravation of each nasal symptom and greater
decreases in the acoustic parameters TNV and MCA, which concurs

D
score (TNSS) was defined as the sum of all nasal symptoms. TNSS with previous studies.14 In addition, a significant correlation was
change after DP challenge was found to have the largest area under found between symptom aggravation and decreases in TNV/MCA
the curve (AUC). When we used the diagnostic criterion of “more after provocation. Therefore, we suggest that NPT in combination

Figure 2. ROC analysis for (A) changes in

nasal symptoms and (B) changes in TNSS.
AUC for TNSS change had the highest value
of 0.832. R, rhinorrhea; Sn, sneezing; It,
itching; ch, change in symptom (VAS score).

e102 July–August 2015, Vol. 29, No. 4

Delivered by Ingenta to: Economics Dept IP: 193.0.129.4 On: Wed, 29 Jun 2016 01:36:49
Copyright (c) Oceanside Publications, Inc. All rights reserved.
For permission to copy go to https://www.oceansidepubl.com/permission.htm
 and their nasal volumes and dimensions were not significantly
changed, atopic without clinical symptoms.
In the present study, we were able to categorize all patients with
different SPT statuses and changes in symptoms and acoustic param-
eters to allergic rhinitis, nonallergic rhinitis, LAR, or symptom-free
atopic groups (Fig. 5).
The main advantage of our study is that it involved a large patient
population (n ⫽ 262), and included patients with allergic rhinitis
sensitized to one allergen, nonallergic, and LAR. Using NPT in com-

Y
bination with AR, we were able to differentiate these various kinds of
rhinitis. Some could argue that the study was limited by the lack of a
healthy control group, but we expected that changes in nasal symp-
toms and acoustic parameters in such controls would be considerably

P
smaller than in NAR patients. However, as we did not enroll healthy
volunteers in this study, we could not rule out the irritant effect of DP
extract itself. This is one of the pitfalls of our current study.
NPT with AR could be used in various clinical situations. Muñoz-

Figure 3. ROC analysis of changes in acoustic parameters after DP prov-
ocation. 15 min, change after 15 minutes; 30 min, change after 30 minutes.
O
Cano et al. suggested that in patients with aspirin-intolerant asthma,
intranasal challenge with lysine-aspirin caused significant decrease of
MCA (⬎25%) in 60 minutes.17 Fabbri et al. tried to evaluate the
antiallergic effect of intranasal spray using NPT and AR. In their
research, they suggested that after combination treatment using

with AR could be a useful tool for differentiating LAR, allergic rhinitis
and nonallergic rhinitis.
In this study, AUCs for changes of each nasal symptom were all
above 0.74, which indicates suitability for diagnostic criteria. In par-
ticular, as the AUC for TNSS change was 0.832 (Fig. 2), we expected
C
budesonide and azelastine, there was less decrease of MCA after
intranasal challenge with histamine.18 Because the protocols and pro-
vocative agents are so different between laboratory, it is still difficult
to directly compare their results.
NPT using mixture of multiple aeroallergens could be useful in

T
diagnostic criteria with high predictive values. We found a cut-off selected patients with allergic rhinitis, especially for polysensitized
value of “a TNSS change of more than 3.5” had a sensitivity of 73.7% patients.19 However, house dust mite is an absolute majority as the
and a specificity of 86.8%. provocative allergen in Korea.20,21 It is, therefore, more useful to use
Decreases in nasal cavity volume and internal dimensions would single DP allergen extract considering this regional characteristics. In
be expected to be closely associated with nasal stuffiness. Therefore, polysensitized patients including DP and other allergens, NPT using

O
we subdivided patients according to degree of NO change. As a
result, patients in the NO[⫹] subgroup (patients who responded an
increase in VAS score for NO aggravation) were found to experience
significantly more aggravation of all nasal symptoms and greater
single DP allergen could confirm or rule out DP as a cause of allergic
rhinitis.
We classified patients with negative SPT results as nonallergic
group. Recently, however, Larrabee and Reisacher suggested that as

N
decreases in acoustic parameters after DP challenge than patient in
the NO[⫺] subgroup. When we performed ROC analysis on patients
showing an NO change of more than or equal to 2, we obtained
another diagnostic criterion, viz., “a TNSS change of more than 6.5,”
which had a higher sensitivity of 90.6% and a specificity of 77.4%. “A
TNV decrease 30 minutes after challenge of more than or equal to
many as 20.8% of patients with negative SPT results showed positive
IDT results.22 For more accurate diagnosis of patients’ allergic status,
further evaluation with IDT is required.
NPT could be performed unilaterally or bilaterally. Baroody et al.
suggested that unilateral allergen challenge caused eosinophilic infil-
tration in the contralateral nasal mucosa.23 We have conducted uni-

O
27.6%” also showed reasonable sensitivity and specificity. Until re-
cently, the most widely accepted criterion for NPT was a 29% de-
crease versus baseline.15 Terrien et al. also suggested a 30% decrease
as a criterion for allergic rhinitis.16 In our NO[⫺] subgroup (strongly
positive to DP), patients showed only slight symptom aggravation
lateral NPT and proved its usefulness in our several papers.8,10,14
Systematic comparison between unilateral and bilateral NPT could
yield more meaningful conclusion in a future study.
Because nasal provocation with allergens could provoke allergic
reaction by naso-ocular reflex, symptoms of allergic conjunctivitis

D
Figure 4. The 99 patients in group C (strongly positive SPT results to DP) were subdivided into a NO[⫹] subgroup (change of VAS score of ⱖ2 for NO)
and NO[⫺] subgroup (change of ⬍2 for NO). We then compared changes in nasal symptoms (A) and changes in acoustic parameters (TNV and MCA) (B)
after DP challenge. The NO[⫹] subgroup showed more symptom aggravation and greater decreases in acoustic parameters than the NO[⫺] subgroup. R,
rhinorrhea; Sn, sneezing, It, itching; ch, change of symptom (VAS score); 15 min, change after 15 minutes; 30 min, change after 30 minutes. ***, significant
difference, p ⬍ 0.001. Independent t-test.

American Journal of Rhinology & Allergy e103

Delivered by Ingenta to: Economics Dept IP: 193.0.129.4 On: Wed, 29 Jun 2016 01:36:49
Copyright (c) Oceanside Publications, Inc. All rights reserved.
For permission to copy go to https://www.oceansidepubl.com/permission.htm

Figure 5. The differential diagnosis of rhinitis using NPT and AR criteria.
could be aggravated by performing NPT. Recently, Callebaut et al.
suggested that nasal deposition of ovalbumin caused increase of mast
cell degranulation in sensitized mice.24 Evaluation of ocular symp-
toms and analysis of tear before and after NPT could be an interesting
topic.
We conclude NPT in combination with AR could be a useful tool
for the differential diagnosis of allergic, nonallergic, and LAR.
O
ACKNOWLEDGMENTS
REFERENCES
N
1. Gosepath J, Amedee RG, and Mann WJ. Nasal provocation testing as
an international standard for evaluation of allergic and nonallergic
rhinitis. Laryngoscope 115:512–516, 2005.
2. Malm L, Gerth van Wijk R, and Bachert C. Guidelines for nasal
provocations with aspects on nasal patency, airflow, and airflow
resistance. International Committee on Objective Assessment of the
Nasal Airways, International Rhinologic Society. Rhinology 38:1–6,
O
2000.
3. Testa B, Mesolella C, Testa F, et al. Comparison of SPT and NPT in
the ascertainment of nasal mucosa as shock organ. Rhinology 34:160–
162, 1996.
4. Kanthawatana S, Maturim W, Fooanan S, and Trakultivakorn M. Skin
D
prick reaction and nasal provocation response in diagnosis of nasal
allergy to the house dust mite. Ann Allergy Asthma Immunol 79:
427–430, 1997.
5. Passalacqua G, Albano M, Pronzato C, et al. Long-term follow-up of
nasal immunotherapy to Parietaria: Clinical and local immunological
effects. Clin Exp Allergy 27:904–908, 1997.
e104
Delivered by Ingenta to: Economics Dept IP: 193.0.129.4 On: Wed, 29 Jun 2016 01:36:49
Copyright (c) Oceanside Publications, Inc. All rights reserved.
For permission to copy go to https://www.oceansidepubl.com/permission.htm
6. Lavasa S, Kumar L, Kaushal SC, and Ganguli NK. Wheat threshing
dust–a “new allergen” in April-May nasobronchial allergy. Indian
Pediatr 33:566–570, 1996.
7. Hytönen M, and Sala E. Nasal provocation test in the diagnostics of
occupational allergic rhinitis. Rhinology 34:86–90, 1996.
8. Kim YH, and Jang TY. Proposed diagnostic standard using visual
analogue scale and acoustic rhinometry in nasal provocation test in
allergic patients. Auris Nasus Larynx 38:340–346, 2011.
9. Demoly P, Gaeta F, Bousquet J, et al. Allergy diagnosis. In Allergy
Frontiers: Diagnosis and Health Economics. Pawankar R, Holgate ST,
Y
and Rosenwasser LJ (Eds). Tokyo, Japan: Springer, 4:21–47, 2009.
10. Kim YH, and Jang TY. Nasal provocation test using allergen extract
versus cold dry air provocation test: Which and when? Am J Rhinol
Allergy 27:113–117, 2013.
P
11. Kim YH, and Jang TY. Clinical characteristics and therapeutic out-
comes of patients with localized mucosal allergy. Am J Rhinol Al-
lergy 24:e89–e92, 2010.
12. Huggins KG, and Brostoff J. Local production of specific IgE anti-
bodies in allergic-rhinitis patients with negative skin tests. Lancet
O
2:148–150, 1975.
13. Powe DG, Huskisson RS, Carney AS, et al. Evidence for an inflam-
matory pathophysiology in idiopathic rhinitis. Clin Exp Allergy 31:
864–872, 2001.
14. Kim YH, Yang TY, Lee DY, et al. Evaluation of acoustic rhinometry
C
in a nasal provocation test with allergic rhinitis. Otolaryngol Head
Neck Surg 139:120–123, 2008.
15. Ganslmayer M, Spertini F, Rahm F, et al. Evaluation of acoustic
rhinometry in a nasal provocation test with allergen. Allergy 54:974–
979, 1999.
16. Terrien MH, Rahm F, Fellrath JM, and Spertini F. Comparison of the
T
effects of terfenadine with fexofenadine on nasal provocation tests
with allergen. J Allergy Clin Immunol 103:1025–1030, 1999.
17. Muñoz-Cano R, Bartra J, Sanchez-Lopez J, et al. Acoustic rhinometry
and aspirin nasal challenge in the diagnosis of aspirin-intolerant
asthma: Clinical finding and safety aspects. Int Arch Allergy Immu-
nol 160:307–312, 2013.
18. Fabbri NZ, Abib-Jr E, and de Lima Zollner R. Azelastine and budes-
onide (nasal sprays): Effect of combination therapy monitored by
acoustic rhinometry and clinical symptom score in the treatment of
allergic rhinitis. Allergy Rhinol (Providence) 5:78–86, 2014.
19. Rondón C, Campo P, Herrera R, et al. Nasal allergen provocation test
with multiple aeroallergens detects polysensitization in local allergic
rhinitis. J Allergy Clin Immunol 128:1192–1197, 2011.
20. Kim J, Hahm MI, Lee SY, et al. Sensitization to aeroallergens in
Korean children: A population-based study in 2010. J Korean Med Sci
26:1165–1172, 2011.
21. Park HJ, Lee JH, Park KH, et al. A nationwide survey of inhalant
allergens sensitization and levels of indoor major allergens in Korea.
Allergy Asthma Immunol Res 6:222–227, 2014.
22. Larrabee YC, and Reisacher W. Intradermal testing after negative
skin prick testing for patients with high suspicion of allergy. Int
Forum Allergy Rhinol 5:547–550, 2015.
23. Baroody FM, Detineo M, and Naclerio RM. Unilateral nasal allergic
reactions increase bilateral sinus eosinophil infiltration. J Appl
Physiol (1985) 115:1262–1267, 2013.
24. Callebaut I, De Vries A, and Steelant B, et al. Nasal allergen deposi-
tion leads to conjunctival mast cell degranulation in allergic rhino-
conjunctivitis. Am J Rhinol Allergy 28:290–296, 2014. e
July–August 2015, Vol. 29, No. 4