Editorial: Studying the spectrum of allergic and rhinologic disease

The American Journal of Allergy and Rhinology is committed to expanding knowledge and publishing the best clinical and basic research within the fields of Rhinology & Allergy. The current issue furthers this mission, presenting novel studies investigating the molecular mechanisms of allergic rhinitis and chronic rhinosinusitis. Also presented are findings from several systematic reviews and randomized clinical trials which will directly impact care for patients with both allergic and rhinologic disease. High quality research is being done worldwide and this current reality is reflected in the breadth of regions represented by these investigators, including the Americas, Asia, Europe, and Australia. The prevalence of allergic rhinitis continues to increase worldwide, resulting in significant patient morbidity and healthcare expenditure. Min et al1 explored the regulation of psoriasin (an antimicrobial factor) by cytokines known to be up-regulated in allergic rhinitis. This study provides potential mechanisms to explain why patients with allergic rhinitis seem to be susceptible to upper respiratory infections. Furthermore, Tang et al2 explored serum cytokine levels in patients with allergic rhinitis, finding correlations between IL22 and IL17A expression and clinical disease severity. These cytokines may thus serve as future biomarkers of disease severity. Also in patients with allergic rhinitis, Ciprandi et al3 examined outcomes from methacholine bronchial challenge, showing that those with bronchial hyperreactivity had more severe nasal disease and likely represent a discrete phenotype with distinct clinical needs. Lastly, Serrano et al4 provide findings from four randomized clinical trials evaluating adult and children receiving grass pollen sublingual tables. Sublingual immunotherapy is gaining popularity worldwide and this data furthers the level I evidence supporting safety and efficacy of this method of immunotherapy. Chronic rhinosinusitis also remains one of the most prevalent diseases worldwide. Despite exponential increases in research over the last decade, much remains to be learned regarding underlying pathophysiologies. This issue includes a systematic review by Workman et al5 on the impact of drugs and other chemical compounds on ciliary beat frequency. This exhaustive review will be an important reference for any future research involving ciliary function in the sinonasal mucosa. One impediment to chronic rhinosinusitis research has been the lack of a relevant and reliable animal model which replicates disease. Kim et al6 report their findings with a mouse model utilizing ovalbumin and Aspergillus protease to induce eosinophilic inflammation. These findings extend the options available to researchers to better understand mechanisms of disease and test future therapeutics. Although many patients with chronic rhinosinusitis are successfully managed medically, a sizable portion will eventually go on to have endoscopic sinus surgery. This issue includes a North American Rhinology and Allergy Conference (NARAC) review by Yip et al7 which systematically reviews the surgical treatment of Aspirin Exacerbated Respiratory Disease (AERD), one of the most recalcitrant forms of the disease to treat. Choby et al8 also perform a systematic review on outcomes related to middle turbinate resection, a topic which has remained controversial since the early years of endoscopic sinus surgery. The authors concluded this practice can be appropriate in selected cases. Lastly, Matheny et al9 report their findings from a randomized clinical trial evaluating use of hyaluronic acid gel versus carboxymethylcellulose after sinus surgery. The hyaluronic acid was associated with more optimal healing at the end of the 12 week potoperative period. Sinus surgeons are always on the hunt for the ideal postsurgical dressing and findings from this study will add to the level 1 evidence available. This issue also includes articles reporting outcomes from other common rhinologic surgical procedures. Ali et al10 report outcomes of powered endoscopic dacryocystorhinostomy (DCR) showing overall excellent results and some small differences between experienced and inexperienced surgeons. Hong et al11 explored olfactory outcomes in patients undergoing septal flap repair after pituitary surgery, suggesting that elevation of the flap with electrocautery may result in worse olfaction. Lastly, Kim et al12 report their experience filling scoring adhesions with 2-octylcyanoacrylate tissue adhesive during septoplasty, revealing this practice to be of benefit to maintain a strait septum, although the authors did caution surgeons to limit the amount placed due to possible foreign body reaction. Also included in this issue are several studies which inform diagnosis and workup of patient with sinonasal disease. Overuse of antibiotics for acute sinusitis is a significant public health problem and likely relates to patient expectations and variations in physician practice. Mohan et al13 present survey data showing differences in expected treatment between patients and physicians, as well as variation between primary care providers and specialists in evaluation and management. One common clinical question is whether findings on computed tomography (CT) scan can predict presence of fungal disease. Killeen et al14 examined consecutive CT scans from patients with chronic rhinosinusitis, showing that specific findings can predict presence of allergic mucin or fungal balls, but no one finding in isolation had both high sensitivity and high specificity. Rereddy et al15 also examined fine-cut CT scans but looked at pneumatization patterns. They found five anatomic variations which were associated with increased pneumatization and that many were correlated. This study has implications for surgical planning before sinus or skull base procedures. Additionally, Al-Qudah16 examined whether the addition of epinephrine improved tolerance and performance of diagnostic sinonasal endoscopy. In this randomized, double-blind, placebo controlled study, the addition of epinephrine did not appear to add additional benefit to lidocaine alone. These findings call into question the common practice of treating patients with topical decongestants prior to diagnostic sinonasal endoscopy. This issue also includes two studies that will be of significant general interest to all readers. The first study by Geyton et al17 reports medical negligence claims as they relate to rhinologic practice in the United Kingdom. Interestingly, these claims involved not only surgical complications but also failure to diagnose and errors in medical management. This data and the recommendations put forth to avoid such claims will be of interest to surgeons and non-surgeons alike who manage patients with rhinologic disease. Lastly, Akdag et al18 present a study on the effects of prolonged room air fresheners on rat mucosa. They found significant inflammation and evidence of squamous metaplasia which occurred after 3 months of ongoing exposure, suggesting that additional safety studies should be done in human populations. Taken together, the current issue of the American Journal of Allergy and Rhinology covers the spectrum of allergic and rhinologic disease, from novel mechanistic studies to randomized clinical trials of current medical and surgical treatments. As an editorial board, we are proud to present these studies from researches across the world and hope that their findings will help inform current medical practice and inspire future high quality research. Zachary M. Soler, M.D., M.Sc. Zachary M. Soler, M.D., M.Sc.