Journal Reading Nasal Obstructive Disorders

Journal Reading
NASAL OBSTRUCTIVE DISORDERS

INDUCE
MEDICAL TREATMENT FAILURE
IN PAEDIATRIC PERSISTENT ALLERGIC
RHINITIS
Presentant: Alfira Ulfa, dr
Supervisor: : Dr. dr. Lina Lasminingrum, M.Kes, Sp.T.H.T.K.L(K)
DEPARTMENT OF OTORHINOLARYNGOLOGY-HEAD & NECK SURGERY

FACULTY OF MEDICINE PADJADJARAN UNIVERSITY-HASAN SADIKIN GENERAL HOSPITAL
BANDUNG
2020
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3
INTRODUCTION
Allergic rhinitis (AR) is the most Anatomical nasal obstructive disorders
common chronic condition in (NOD) may also be a significant
childhood comorbidity in AR children.
The Allergic Rhinitis and its Impact on

Septal deformity (SD), turbinate
Asthma (ARIA) guidelines developed a
enlargement (TE) and adenoidal
classification on the basis of the
hyperplasia (AH) may cause nasal
impairment of quality of life (mild and
obstruction in children
moderate/severe)
There are no published studies

Modified ARIA criterion (m-ARIA) has
describing the prevalence of NOD on
been introduced which discriminates
paediatric AR patients nor its
moderate from severe patients in
relationship with medical treatment
paediatric untreated patients
failure.
Mariño‐Sánchez, Franklin S., et al. Nasal obstructive disorders induce medical treatment failure in paediatric persistent allergic rhinitis (The NODPAR Study). Pediatric Allergy and
4
Immunology 28.2. 2017; 176-184.
5
ALLERGIC RHINITIS
Definition
Rhinitis  an inflammation of the lining of the nose and is characterized
by nasal symptoms including anterior or posterior rhinorrhoea, sneezing,
nasal blockage and/or itching of the nose
Allergic rhinitis  the most common form of noninfectious rhinitis and is

associated with an IgE-mediated immune response against allergens  associated
with ocular symptoms.
Updated ARIA Recomendation 2010

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CLASSIFICATION
Of Allergic Rhinitis
Intermittent Persistent
Symptoms Symptoms
• < 4 days per week • > 4 days per week
• or < 4 weeks at a time • and > 4 weeks at a time
Moderate-severe
Mild one or more items
• normal sleep • abnormal sleep
• no impairment of daily activities, • impairment of daily activities, sport,
sport, leisure leisure
• normal work and • abnormal work and school
school • troublesome symptoms
• no troublesome symptoms
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Pathogenesis
Wheatley, Togias . Allergic Rhinitis. The New England Journal of Medicine. N Engl J Med 2015; 372:456-63
8
Wheatley, Togias . Allergic Rhinitis. The New England Journal of Medicine. N Engl J Med 2015; 372:456-63 .
Diagnosis in Primary Care Setting

10
Updated ARIA Guideline 2019 11
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METHODS
Study Population & Design
This study was a non-randomized, prospective study
The participants were 130 children and adolescents diagnosed with

moderate/severe Persistent AR (PER) according to ARIA guidelines criteria
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Immunology 28.2. 2017; 176-184.
Exclusion criteria were as follows:

• upper respiratory tract infection in the last 2 weeks,
• previous nasal/adenoidal surgery or
• the presence of a serious concomitant illness.
15
Immunology 28.2. 2017; 176-184.
Then the participants were assessed for their response to medical
treatment
They received daily intranasal steroids (fluticasone or mometasone) for

at least 2 consecutive months at recommended doses
Asthmatic patients received daily

Non-asthmatic subjects added leukotriene receptor antagonists
daily antihistamines (montelukast), Asthma
(desloratadine) pharmacotherapy was also
prescribed
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Immunology 28.2. 2017; 176-184.
After 2 months patients then were asked wether the symptoms have
improved, and then were included into two different groups
Non-responders (NR) group

No symptom improvement
Responders (R) group
Symptom improvement
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Immunology 28.2. 2017; 176-184.
Nasal Symptoms
Anterior and Posterior
Nasal Obstruction
Rhinorrhea
Smell Loss Facial Pain
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Immunology 28.2. 2017; 176-184.
Nasal Symptoms
Itching Epistaxis
Sneezing
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Immunology 28.2. 2017; 176-184.
Nasal Symptoms
The severity of each symptoms then were assessed with visual

analogue scale score (VASs) ranging from 0 (not at all bothersome)
to 100 mm (extremely bothersome).
Children under 12 years old were additionally guided by

a faces rating scale (FRS) located above the VASs line
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Immunology 28.2. 2017; 176-184.
Nasal obstructive disorders (NOD)
Septal deformity
Turbinate size
Adenoid size
21
Immunology 28.2. 2017; 176-184.
Nasal Symptoms
Nasal examination was carried out with a 2.4-
mm flexible endoscope.
Each nasal obstructive disorder severity were

assessed using Nasal Endoscopy Scoring
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Immunology 28.2. 2017; 176-184.
Nasal Endoscopy Scoring
23
Immunology 28.2. 2017; 176-184.
24
RESULTS
Demographic Characteristics 25
No mild patients were The most frequent

included in the study. comorbidities were
The two groups (R and
Prevalence of severe asthma and
NR) were homogeneous
rhinitis was higher in the conjunctivitis, without
in gender and age
NR group compared to differences between NR
the R group. and R groups
Mariño‐Sánchez,
Mariño‐Sánchez, Franklin
Franklin S.,
S., et
et al.
al. Nasal
Nasal obstructive
obstructive disorders
disorders induce
induce medical
medical treatment
treatment failure
failure in
in paediatric
paediatric persistent
persistent allergic
allergic rhinitis
rhinitis (The
(The NODPAR
NODPAR Study). Pediatric
Study). Pediatric Allergy
Allergy and
and
Immunology 28.2.
Immunology 28.2. 2017;
2017; 176-184.
176-184.
26
Immunology 28.2. 2017; 176-184.
Nasal Symptoms
All symptoms except epistaxis were significantly worse, displaying
statistically significant higher VASs, in the NR group than in the R group
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Immunology 28.2. 2017; 176-184.
Nasal Endoscopic Disorders
After 2 months of treatment, the NR group presented a higher prevalence of
obstructive septal deformity and severe inferior turbinate enlargement when
compared with the R group
The tendency of higher frequency of obstructive Adenoid Hyperplasia in the NR

group was observed, although did not reached statistical significance in these
comparisons
Nearly half of the patients (45.5%) presented bilateral endoscopic nasal

obstruction in the NR group, whereas no cases were found in the R group
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Immunology 28.2. 2017; 176-184.
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Immunology 28.2. 2017; 176-184.
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Immunology 28.2. 2017; 176-184.
Medical treatment responsiveness
Higher septal deformity and
turbinate enlargement scores were
strongly associated with treatment
refractoriness
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Immunology 28.2. 2017; 176-184.
PER Severity & Comorbidities
The prevalence of severe PER was found higher for the NR group
As severe turbinate hyperplasia, bilateral endoscopic nasal obstruction,

TES and TNDS were strongly associated with severe PER.
Higher asthma control scores were associated with the probability of treatment-
induced improvement
Although asthma prevalence, conjunctivitis and CRS were not statistically different
between NR and R groups, asthmatic patients in the R group had a better control of
asthma
32
Immunology 28.2. 2017; 176-184.
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DISCUSSION
34
Study Findings
VASs can be used as a simple quantitative method to evaluate nasal
symptoms, disease severity and response to medical treatment in
paediatric PER patients
nasal obstruction is the main symptom associated with medical

treatment failure
There is a higher prevalence of NOD in PER paediatric patients refractory

to medical treatment
Immunology 28.2. 2017; 176-184.
Study Findings
SD and TE are independent risk factors associated with
the lack of improvement after medical treatment
In PER paediatric patients, a higher control of asthma is

associated with AR improvement with medical treatment
m-ARIA classification is a valid tool to discriminate severe

from moderate PER paediatric patients, and could associate
medical treatment refractoriness with a higher PER severity
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Immunology 28.2. 2017; 176-184.
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CONCLUSION
m-ARIA classification is a valid tool to discriminate severe from
moderate PER paediatric patients
In paediatric PER patients, medical therapy refractoriness was

associated with NOD, mainly septal deformity and turbinate
enlargement.
In those patients, ENT examination will facilitate an early NOD

diagnosis in order to indicate potential corrective surgery.
37
THANK
YOU
38

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Journal Reading

NASAL OBSTRUCTIVE DISORDERS

DEPARTMENT OF OTORHINOLARYNGOLOGY-HEAD & NECK SURGERY

The Allergic Rhinitis and its Impact on

There are no published studies

Allergic rhinitis  the most common form of noninfectious rhinitis and is

Updated ARIA Recomendation 2010

Updated ARIA Recomendation 2019

Updated ARIA Recomendation 2008

This study was a non-randomized, prospective study

The participants were 130 children and adolescents diagnosed with

Exclusion criteria were as follows:

They received daily intranasal steroids (fluticasone or mometasone) for

Asthmatic patients received daily

Non-responders (NR) group

Smell Loss Facial Pain

The severity of each symptoms then were assessed with visual

Children under 12 years old were additionally guided by

Each nasal obstructive disorder severity were

No mild patients were The most frequent

The tendency of higher frequency of obstructive Adenoid Hyperplasia in the NR

Nearly half of the patients (45.5%) presented bilateral endoscopic nasal

As severe turbinate hyperplasia, bilateral endoscopic nasal obstruction,

nasal obstruction is the main symptom associated with medical

There is a higher prevalence of NOD in PER paediatric patients refractory

In PER paediatric patients, a higher control of asthma is

m-ARIA classification is a valid tool to discriminate severe

In paediatric PER patients, medical therapy refractoriness was

In those patients, ENT examination will facilitate an early NOD

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