Chronic rhinosinusitis: Allergy and sinus computed tomography relationships

The management of chronic or recurrent rhinosinusitis problems is multifaceted and should include consideration of contributory and potentially correctable medical and anatomic factors. To date, the relationship between allergy and rhinosinusitis has not been clearly defined. The purpose of this study is to improve understanding of the relative roles of perennial and seasonal allergens in the cause of chronic rhinosinusitis. A retrospective review of 200 consecutive patients was carried out on patients who had chronic rhinosinusitis refractory to medical therapy and who subsequently underwent functional endoscopic sinus surgery. All of these patients had allergy testing for common perennial and seasonal inhalant allergens before surgery. Each patient had sinus CT imaging before undergoing the surgery. The CT scans of each patient were staged according to a validated, standardized grading system by investigators blinded to allergic profile. Allergy testing indicated that 84% of all patients tested positive for allergies. Moreover, 60% of all patients had significant allergic sensitivity; 52% of all patients had multiple allergen sensitivities. Furthermore, there was a predominance of perennial allergens, especially house dust mite over seasonal allergens. The vast majority of our patients undergoing functional endoscopic sinus surgery had concomitant allergy. This study highlights the potential contribution of perennial allergies to the development of rhinosinusitis. Given this direction, future studies may reveal that in the care of patients with perennial allergic rhinitis, early intervention with identification of the offending allergen(s), and subsequent treatment through avoidance, pharmacotherapy, and/or immunotherapy may help in the prevention of recurrent and chronic rhinosinusitis.     

Prevalence of hypersensitivity to specific fungal allergens as determined by intradermal dilutional testing.

OBJECTIVE: To determine fungal allergen reactivity prevalence by intradermal dilutional testing in patients with and without chronic rhinitis or rhinosinusitis symptoms. STUDY DESIGN: Prospective comparison of fungal allergen reactivity prevalence in symptomatic and asymptomatic patients. SETTING: University medical center. METHODS: Group I (chronic rhinitis and/or rhinosinusitis symptoms) and Group II (asymptomatic) patients underwent intradermal dilutional testing with usual and fungal allergens. RESULTS: Fungal reactivity occurred in 65% (13/20) of Group I, and 13% (4/30) of Group II (P < 0.0002 by chi(2) testing). Group I was more reactive to non-fungal allergens (85% vs. 33%, p < 0.0004), and to all allergens considered together (95% vs. 40%, p < 0.0001). CONCLUSIONS: Patients with chronic rhinitis and rhinosinusitis symptoms were more reactive to fungal and nonfungal allergens. Fungal allergens were as likely as nonfungal to elicit reactivity. SIGNIFICANCE: These findings suggest a role for fungal hypersensitivity in chronic rhinitis and chronic rhinosinusitis.     

An unusual presentation of a common condition: Allergic contact dermatitis

Allergic contact dermatitis commonly affects patients with chronic venous leg ulcers and can contribute to impaired wound healing. Many allergens have been identified, and despite the use of advanced dressings, the incidence of allergy has remained high. We discuss an unusual presentation of allergic contact dermatitis in a patient with a chronic wound. The patient's history was consistent with a recurrent venous leg ulcer, but on this occasion, the wound continued to deteriorate despite optimal treatment. This prompted further investigation, which included patch testing. Although the clinical features were not suggestive of allergy, the patch test was positive for several allergens, including Atrauman^® dressings, which the patient was using at the time. This case highlights the importance of regular reassessment and accurate diagnosis for the management of chronic wounds. It also demonstrates that allergic contact dermatitis can contribute to delayed wound healing without causing the classical clinical features of inflammation of the surrounding skin, and even hypoallergenic, non‐adherent dressings can be sensitising.     

Epidemiology of seasonal and perennial rhinitis: clinical presentation and medical history.

BACKGROUND: Little is known about the epidemiology of rhinitis, particularly the perennial and non-allergic forms. The aim of this study was to compare the symptoms, atopic state, and medical history of individuals with seasonal and perennial rhinitis. DESIGN: Of 7702 adults aged 16-65 years registered with a London general practice, 2969 (30%) were screened by postal questionnaire. Samples of 113 subjects without rhinitis, 51 with seasonal symptoms alone, 128 with perennial symptoms and seasonal exacerbations were then interviewed. Atopic and non-atopic subjects were distinguished by skinprick testing with five common allergens. RESULTS: The estimated minimum prevalence of rhinitis was 24%: 3% had seasonal symptoms only, of whom 78% were atopic; 13% had perennial symptoms only, of whom 50% were atopic; and 8% had perennial symptoms with seasonal exacerbations, of whom 68% were atopic. Seasonal rhinitis was characterised by sneezing, itching, and a high prevalence of diurnal variation in symptoms. The most common provoking factors were dust, pollens, and infections. By comparison, perennial rhinitis was characterised by a higher prevalence of nasal blockage and catarrh, and a lower prevalence of diurnal variation and provocation by pollen. There were no significant differences among the groups in the sociodemographic characteristics examined. Subjects with seasonal rhinitis were more likely to be atopic and to have eczema and a family history of hayfever than those without rhinitis. Those with perennial rhinitis were more likely to have past or current eczema or migraine, be wheezy or labelled asthmatic, or have a family history of nose trouble other than hayfever. Subjects with both seasonal and perennial symptoms presented an intermediate clinical picture. CONCLUSIONS: Seasonal and perennial rhinitis differ in their atopic state, clinical presentation, and medical history. The extent to which these differences are genetically or environmentally determined requires further investigation.     

Labelling of rhinitis and hayfever by doctors

Factors influencing the labelling of rhinitis by doctors were examined in 7702 adults, aged 16-65 years, registered with a group general practice in south London. Individuals with rhinitis were identified by a postal screening questionnaire. Of the 2969 (39%) subjects who replied, 1309 (44%) reported rhinitis. A sample of 340 individuals with and 126 without rhinitis was studied, each being interviewed and having allergy skinprick tests. The information given at interview was compared with that recorded in the medical notes for 75 patients with rhinitis, selected at random to include 25 with seasonal symptoms only, 25 with perennial symptoms only, and 25 with both seasonal and perennial symptoms, plus 25 control subjects. Hayfever was defined as seasonal symptoms provoked by grass and a positive skin test response to grass pollen. Subjects with seasonal symptoms were nearly twice as likely as those with perennial symptoms to be labelled as having rhinitis by their doctor. More than a quarter of the subjects fulfilling our definition of hayfever had not been diagnosed as having hayfever. Subjects from the upper social classes were more likely than those from the lower social classes to be labelled as having hayfever, though there were no significant differences between social classes in the prevalence of hayfever according to our definition. It is concluded that rhinitis is frequently underdiagnosed and misdiagnosed. Increased detection of hayfever could account for the steep rise in consultation rates seen in recent decades.     

Herbal medicines for the treatment of rhinosinusitis: a systematic review.

OBJECTIVES: To assess the efficacy of herbal medicines for treating rhinosinusitis. DATA SOURCE: Five electronic databases, bibliographies of located papers, manufacturers, and experts in the field. REVIEW METHODS: Inclusion of randomized clinical trials (RCT) testing any herbal medicine in rhinosinusitis, as sole or adjunctive treatment. Data were extracted independently by two reviewers following a predetermined protocol. RESULTS: Ten RCTs, testing six different herbal products against placebo (8 RCTs) or "no additional treatment" (2 RCTs) were included. Four RCTs tested Sinupret as adjunctive treatment for either acute (3 RCTs) or chronic (1 RCT) rhinosinusitis. The quality of these studies varied, but two in acute sinusitis, including the largest and best quality study, and one in chronic sinusitis reported significant positive findings. Three RCTs tested bromelain in either acute sinusitis (2 RCTs) or patients of mixed diagnosis (chronic and acute sinusitis), and all reported some positive findings. Metanalysis of the two RCTs in acute sinusitis suggested that adjunctive use of bromelain significantly improves some symptoms of acute rhinosinusitis. Single RCTs were identified for 4 other herbal products (Esberitox, Myrtol, Cineole, and Bi Yuan Shu) as treatments for sinusitis, all reported some positive results. The median methodological quality score was 3 of 5. CONCLUSION: Evidence that any herbal medicines are beneficial in the treatment of rhinosinusitis is limited, particularly in chronic rhinosinusitis. There is encouraging evidence that Sinupret and bromelain may be effective adjunctive treatments in acute rhinosinusitis. Positive results from isolated RCTs of four other herbal products require independent replication.     

Clinical practice guideline on adult sinusitis.

This executive summary will alert clinicians to key evidence-based statements in a multidisciplinary, clinical practice guideline on adult sinusitis developed by the American Academy of Otolaryngology-Head and Neck Surgery Foundation. Included in the guideline are 17 boldfaced action statements: 3 on viral rhinosinusitis, 7 on acute bacterial rhinosinusitis, and 7 on chronic rhinosinusitis and recurrent acute rhinosinusitis. Evidence profiles that accompany each statement are summarized to show why it was made and how it can be implemented. Guideline statements regarding acute rhinosinusitis focus on diagnosing presumed bacterial illness and using antibiotics appropriately. Guideline statements regarding chronic rhinosinusitis or recurrent acute rhinosinusitis focus on appropriate use of diagnostic tests. Surgical therapy is not discussed.     

Prevalence of Latex Sensitivity Among Patients with Chronic Renal Failure: A New Risk Group?

Latex has been documented as causing immediate hypersensitivity reactions in forms ranging from contact urticaria to severe anaphylaxis. The prevalence of latex allergy appears to be higher in certain risk groups as a result of increased exposure or an increased intrinsic predilection for atopy. The purpose of the present study was to assess latex sensitivity in a large group of patients who are undergoing regular dialysis because of chronic renal failure (CRF) and to evaluate the relationship between latex sensitivity and skin prick test (SPT) responses to fruit allergens. Of the 268 patients tested, 3 subjects (1.1%) were found to have latex sensitivity via SPT. Although atopy was not demonstrated in any SPT positive subjects, there appears to be a considerable degree of crossreactivity between latex and certain fruit allergens which can be suggested as one subtext in the SPT positive patients. In conclusion, CRF patients with no history of hypersensitivity reactions should not be considered at risk for developing latex sensitization despite their frequent exposure.     

Analysis of aerobic bacterial strains found in chronic rhinosinusitis using the polymerase chain reaction.

INTRODUCTION: Rhinosinusitis is a common disease affecting an estimated 14% of the population. Although there is general agreement in the literature regarding acute rhinosinusitis, chronic rhinosinusitis is not as well studied, and no consensus has been reached regarding the bacterial etiology. The goal of this study was to test chronic rhinosinusitis mucosal specimens using the polymerase chain reaction (PCR) for aerobic bacterial content and to compare the results with standard culture data. RESULTS: Routine culture samples grew 50% aerobic bacteria, whereas PCR detected 62% aerobic bacteria contamination. CONCLUSION: PCR detected more bacteria in mucosal samples than in standard culture, but standard culture of this mucosa reflects the general aerobic bacteria found in chronic rhinosinusitis, with no predominant species of aerobic bacteria. SIGNIFICANCE: The analysis of chronic rhinosinusitis mucosa with the PCR method should give a more accurate picture of the bacteria found in chronic rhinosinusitis so that proper therapy can be instituted.     

Nasal colonization with Staphylococcus aureus is not associated with the severity of symptoms or the extent of the disease in chronic rhinosinusitis.

OBJECTIVES: There is an increasing knowledge that the severity of perennial allergic rhinitis is associated with nasal carriage of Staphylococcus aureus (S. aureus). The aim of this study was to evaluate the rate of bacterial colonization with S. aureus in the nose of subjects with and without chronic rhinosinusitis (CRS) and to correlate these findings with the severity of symptoms and the extent of the disease. STUDY DESIGN AND SETTING: Open, prospective controlled trial. METHODS: 190 subjects with CRS and 42 subjects with septal deviation without sinusitis (control subjects) were included in this study. Swabs were taken endoscopically from the middle meatus and bacteria were cultured and identified. Airway symptoms were assessed by subjects in standardized questionnaires and frequencies of respiratory tract infections were noted. The rhinosinusitis extent was graded by CT scan assessment. Analysis of variance, chi-square test, and Pearson's correlation test were applied for statistical analyses. RESULTS: The S. aureus carriage rate was 25.5% in CRS and 31.4% in control subjects. Further facultative pathogens were cultured in 20.6% of subjects with CRS and in 8.5% of controls. 73.8% of S. aureus were ampicillin-resistant, multiresistant strains were cultured in 5.8%. Most airway symptoms and the frequencies of respiratory tract infections were significantly higher in the CRS group compared with control subjects. In post hoc comparison between the subgroups with and without S. aureus colonization, no significant differences were found between the extent of rhinosinusitis and the severity of airway symptoms. CONCLUSIONS: Facultative pathogens were detected in more than 40% of CRS patients without acute respiratory tract infections. In contrast to the findings in atopic dermatitis and perennial allergic rhinitis, the colonization rate with S. aureus is not increased and S. aureus carriage is not a risk factor for the severity or the extent of rhinosinusitis.     

Immunoglobulin e-mediated allergies in lung-transplanted adults

BACKGROUND: Immunoglobulin E (IgE)-mediated allergy has repeatedly been reported after solid organ transplantation, apparently affecting approximately 10% of pediatric organ transplant recipients. Interestingly, type 1 allergy has not been described in transplanted adults, suggesting a particular propensity in childhood. METHODS: The present cross-sectional study assessed the prevalence of type 1 allergy in 42 adult lung transplant recipients aged 25 to 50 years. Instruments included standardized interviews, skin prick tests, and serum IgE measurements. RESULTS: Ten of 42 patients (23.8%) displayed elevated specific IgE levels or positive skin prick test results against one or more allergens. Five individuals (11.9%) additionally reported corresponding clinical symptoms of type 1 allergy. No statistically significant association of sensitization or allergy prevalence with patient age, kind of immunosuppressive therapy, and time since transplantation was found. CONCLUSIONS: The phenomenon of transplantation-associated allergy is not age-restricted and thus should be assessed more thoroughly in all age groups.     

Allergy to Ethylene Oxide in Chronic Hemodialysis Patients

Almost a decade ago, a single chronic hemodialysis patient in Hamilton, Ontario, Canada, who was experiencing recurrent acute reactions during hemodialysis was found to have become allergic to ethylene oxide gas (EO). This observation recently provided a stimulus to examine the possibility that others exhibiting acute allergic-type reactions during hemodialysis might be similarly sensitized. Serum was obtained from 27 reacting patients and tested in a radioallergosorbent test (RAST) for antibodies to EO. The test was positive for 22 of these sera. EO-related specificity of the antibodies was confirmed. However, EO sensitization was not found in other hemodialysis patients with isolated eosinophilia. In a survey of the current Hamilton chronic hemodialysis population for EO-related antibodies, 9% had a positive allergy skin test and 12% had a positive RAST. The sensitized individuals had no distinctive symptoms. The lesser sensitivity of the skin test contrasts with usual findings in allergic individuals; however, the use of histamine and codeine in chronic hemodialysis and peritoneal dialysis patients might well explain a reduced sensitivity of the EO-related allergy skin test. Chronic peritoneal dialysis could not be invoked as a source of sensitization. None of these patients had a positive skin test or RAST for EO-related antibodies that could be attributed to peritoneal dialysis.     

An analysis of skin prick test reactions in 656 asthmatic patients.

Of 656 asthmatic patients referred specifically for allergy assessments, 544 (84 percent) gave positive immediate skin prick tests to at least one of 22 common allergens used routinely. Comparison of these skin test positive patients with the 102 (16 percent) who were skin test negative showed a number of significant differences. The majority of the skin test positive patients (52 percent) were less than 10 years old at the time of onset of the asthma, whereas, of the skin test negative patients, 56 percent were aged over 30 years at the time of onset. Seventy per cent report rhinitis compared with 48 per cent of the skin test negative patients, and 29 per cent reported infantile eczema compared with 9 per cent. Symptoms attributed to house dust, pollens, and animals were noted two to three times more frequently by the skin test positive patients, while corticosteroid drugs had been used more commonly by the skin test negative patients (45 percent compared with 35 percent). No significant differences were observed with the other factors studied, namely, history of urticaria or angio-oedema, family history of "allergic" disease, and awareness of sensitivity to foods, aspirin or penicillin. Prick test reactions in the skin test positive patients were most commonly seen to house dust or the acarine mite, Dermatophagoides farinae (82 percent), followed by pollens (66 percent), animal danders (38 percent), foods (16 percent), Aspergillus fumigatus (16 percent), and other moulds (21 percent). There was a highly significant association of positive history with positive prick test for all allergens studied.     

Prevalence of elevated total IgE and food allergies in a consecutive series of ENT pediatric patients.

OBJECTIVE: Food allergies in childhood have been found to vary in frequency from 6% to 8% in the general population. Previous studies indicate milk allergy affects approximately 2.5% of infants and egg allergy has been estimated at 1.6% to 2.6%. Numerous allergists believe that the prevalence of food allergies is rising, similar to the rise in other atopic conditions. Prior studies have demonstrated that food-specific IgE is a useful test for diagnosing symptomatic allergies to certain foods, including milk and eggs, and could decrease the need to perform cumbersome multiple double-blind, placebo-controlled food challenges in children based on history alone. The purpose of this study was to determine the prevalence of food allergies and elevated IgE in a consecutive series of pediatric otolaryngology patients. STUDY DESIGN AND SETTING: ImmunoCap studies were drawn in a 2-year series of children undergoing ENT procedures of bilateral myringotomy with tubes (BMT) with or without adenoidectomy or tonsillectomy or adenoidectomy alone between 2001 and 2003. Sera was analyzed for increased total IgE antibodies, as well as specific IgE antibodies to antigens, including milk, egg, beef, and environmental allergens. A positive patient history or family history of allergy were documented. RESULTS: A total of 242 patients were assessed. Of the study population, milk allergy was found in 10.7%; egg white allergy was found in 5.0%. The prevalence of elevated IgE among participants was 11.2%. The overall food allergy prevalence was 14.5%. CONCLUSIONS: Although we cannot imply causality, the study demonstrated an increased prevalence of food allergy in children undergoing ENT procedures, specifically milk and eggs, than in previous population studies. EBM rating: C-4.     

Classification of chronic inflammation of the upper respiratory tract based on allergy status

Almost one third to one half of all patients in otorhinolaryngologic practice experience some kind of inflammation of the upper respiratory tract out of which allergic mechanisms, either as primary factors or secondary ones, appear in 30-40% of adults and 60-80% of children and adolescents. The objective of this study was to analyse inflammatory conditions of the upper airways on the basis of allergic state of the patient and to establish the classification that will respect the actual immunological alteration level (subclinical allergy, clinical allergy) and spreading (localized allergy, generalized allergy). Inclusion criteria for all sixty nine patients were the diagnosis of chronic upper airway inflammation and their exposition just to ubiquitous allergens. Diagnostic procedure included anamnesis, physical examination and allergic in vivo testing of the skin and nasal mucosa to inhalant allergens. The certain categories of results were established for the skin prick-test (positive, negative, indefinite), specific nasal provocation test (positive, negative, hyperreactive) and nasal symptoms (present, absent). By using a strictly determined combination of results, we were able to define the six groups in our classification: nasal clinical allergy (30% of patients), non-nasal clinical allergy (19% of patients), localized nasal allergy (11% of patients), latent allergy (3% of patient), nonspecific nasal hyperreactivity (12% of patient) and non-allergic inflammation (25% of patients). Our classification takes into consideration the modern knowledge in the field of allergology and may bring an additional quality in respect to selection of therapy options, long-term follow-up of allergy status evolution in the individual person as well as intragroup and intergroup analysis of parameters important to evaluate the effects of antiallergic prevention or therapy.     

Influence of sensitization to inhalative allergens on adenotonsillar disease.

OBJECTIVE: We sought to determine the influence of IgE-mediated sensitization on adenotonsillar disease in children. We compared follow-up after tonsillectomy/adenoidectomy of atopic and nonatopic children.Study design and setting A prospective study of 293 children consecutively undergoing tonsillectomy/adenoidectomy was conducted at a university hospital center. Preoperative and postoperative (1-year follow-up) allergy-related symptom scores were obtained by parents. Intraoperative total serum IgE, the screening test sx1 (Pharmacia), and, if positive, serum specific IgE to inhalative allergens were carried out. RESULTS: Sixty-seven children (22.9%) showed positive RAST results to inhalative allergens (class 1 to 6). In both sensitized and nonsensitized groups, the general health was improved in more than 89% at 1 year postoperatively. No significant difference of postoperative nasal symptoms between the atopic and nonatopic groups was found. CONCLUSION: Both atopic and nonatopic children with adenotonsillar disease improve health after adenoidectomy or adenotonsillectomy. In our opinion, routine allergy tests before adenotonsillectomy or adenoidectomy are not justified. Only if allergy is suspected due to clinical findings or family history should an allergy test be carried out.     

Nasal endoscopy and the definition and diagnosis of chronic rhinosinusitis

OBJECTIVES: Although endoscopy has been shown by a few authors to be a valuable tool for the diagnosis of chronic rhinosinusitis, its true role in the evaluation of the patient with chronic rhinosinusitis has not been elucidated. The current definition of chronic rhinosinusitis is a symptom-based definition, and objective testing such as endoscopy or computed tomography (CT) is not included. However, the current treatment paradigm for chronic rhinosinusitis is dependent on the definition for diagnosis. Patients are treated with 4 weeks of antibiotics and decongestant/antihistamines/steroids based on the definition. This study aims to evaluate in a prospective fashion the place of endoscopy in the diagnosis of chronic rhinosinusitis. STUDY DESIGN: A group of 78 patients meeting the definition of chronic rhinosinusitis were subjected to same-day endoscopy and CT scanning. RESULTS: Seventeen (22%) of 78 patients had positive endoscopic and CT results. There were 20 (26%) of 78 patients with negative endoscopic and positive CT results. Six (8%) patients had positive endoscopic and negative CT results, and 35 (45%) had negative endoscopic and negative CT results. Overall, 37 (47%) patients had positive CT results, and 41 (53%) patients had negative CT results. Endoscopy showing the presence of purulence, nasal polyps, or watery congested mucosa correlated well with CT results. Negative endoscopy correlated with CT results in 65% of patients. CONCLUSION: The use of endoscopy to corroborate the diagnosis in nonpolypoid or nonpurulent rhinosinusitis in previously unoperated patients is questioned. Patients who meet the subjective definition of chronic rhinosinusitis should have a high degree of sensitivity and specificity with endoscopy or CT. The fact this is not the case questions the accuracy of the definition and the treatment paradigm. SIGNIFICANCE: According to this study, positive endoscopic results correlated well with CT, and negative endoscopic results correlated in 71% of patients with negative CT results.     

Radiologic correlates of symptom-based diagnostic criteria for chronic rhinosinusitis.

OBJECTIVE: In 1997, the Task Force on Rhinosinusitis (TFR) set forth symptom-based diagnostic guidelines for chronic rhinosinusitis (CRS). In the present study, we examined radiologic correlates of the TFR diagnostic criteria for rhinosinusitis. STUDY DESIGN AND SETTING: One hundred twenty-five consecutive patients undergoing computed tomography (CT) scans of the sinuses were studied at Oregon Health and Science University. Patients were evaluated prospectively with a questionnaire based on the TFR criteria, and their CT scans were graded according to the Lund-Mackay scoring system. RESULTS: Of the 125 patients, 115 met the symptom criteria for CRS. However, 40 of 115 had negative scans (Lund-McKay score, 0) despite meeting the diagnostic criteria for rhinosinusitis. Of 115, 75 had positive scans (Lund-McKay score, >1). Of the 10 patients who had negative diagnoses for rhinosinusitis, 9 had a positive CT scan. The Kappa coefficient was -0.103 (+/-95% confidence interval, -0.201 to -0.004), indicating poor agreement between CRS positivity and CT positivity. The sensitivity of TFR criteria for detecting a positive scan was 89%, but the specificity was poor at only 2%. CONCLUSION AND SIGNIFICANCE: Based on these pilot data, it appears that the specificity and predictive value of the current TFR criteria may not be adequate to serve as a diagnostic standard for rhinosinusitis. Additional validating data may provide guidance for improving the sensitivity and specificity of symptom-based diagnostic instruments for rhinosinusitis.     

Refractory chronic sinusitis: evaluation of symptom improvement after Denker's procedure.

OBJECTIVES: Although there is ample literature describing various aspects of functional endoscopic sinus surgery (FESS) in relationship to its success rates, very little has been reported regarding possibilities in case of recurrent failure. We investigated subjective results of Denker's procedure used as a last resort for refractory chronic rhinosinusitis/polyposis. STUDY DESIGN AND SETTING: A retrospective questionnaire-based study of 82 patients who underwent Denker's procedure between 1986 and 1997 at the Erasmus University Medical Center, The Netherlands, was conducted. RESULTS: Eighty-four percent of patients reported reduction of overall symptomatology. A significant reduction of nasal obstruction, headache, feeling of fullness, post-nasal drip, rhinorrhoea, facial pain, dental pain, and coughing was reported. In addition, symptoms of lower airway inflammation did improve significantly in asthmatic patients. CONCLUSIONS: These data suggest that radical surgery using Denker's approach should be considered in selected cases after recurrent failure of functional sinus surgery. SIGNIFICANCE: A prospective study is warranted to validate this approach for refractory chronic rhinosinusitis.     

Clinical significance of aero-allergen identification in the western Cape

Positive identification and documentation of the seasonal variation of aero-allergens and the immune responses to them has important implications for the timing of allergen avoidance measures and the selection of patients suitable for immunotherapy. The relative abundance of aero-allergens in the Cape Peninsula during 1984-1987 was measured by continuous volumetric air sampling, using a Burkard spore trap. Mould spore counts of greater than 3,000 spores/m3 were found throughout the year and were only exceeded by pollen grains in the months of September and October (range 4,800-7,400 spores/m3). Gramineae and Compositae spores were found perennially in significant numbers. Pollen from allergenic trees peaked at fixed times each year: oak in August; plane in September and pine between August and October. Grasses found on the Peninsula include sweet vernal, Bermuda grass, rye grass, common reed, Johnson grass, brome grass, canary grass, annual meadow and kikuyu. In vivo skin tests in 209 children with known allergic disease were positive to Dermatophygoides pteronyssimus (73%), South African grasses (38%), tree pollens (22.4%), flower and weed pollens (19.6%), cat (27%), dog (12%) and feathers (18.6%). One-third of the 1,372 children screened at Red Cross War Memorial Children's Hospital Allergy Service had positive specific IgE responses to environmental allergens. Investigation of 62 children possibly allergic to grass using the radio-allergosorbent test revealed positive results in 25 (41%). Of these, 92% were positive to Timothy grass, a grass not occurring in the Cape Peninsula. Knowledge of cross-reactivity profiles for local allergens minimises the number of tests required in allergy diagnosis.