Chronic rhinosinusitis (CRS) is defined as nasal obstruction, mucopurulent rhinorrhea, postnasal drip, and inflammation of the nasal cavity and sinus that lasts for at least 12 weeks.1) Allergic rhinitis (AR) is known to be one of the risk factors associated with the development of CRS.2)3) It is a series of inflammatory processes that occur within the nasal mucosa and is known to cause CRS by decreasing the integrity of the nasal mucosa and the patency of the sinus, as well as increasing nasal secretions.

AR and non-allergic rhinitis (Non-AR) are diagnosed on the basis of clinical symptoms as well as the response to an allergic skin prick test (AST) and the presence of serum specific immunoglobulin E antibody (sIgE). Recently, however, concern has been raised regarding varied interpretations of the test, and it has been argued that there is a problem with the existing rhinitis classification scheme.4)5) Local allergic rhinitis (LAR) is diagnosed when such symptoms as rhinorrhea, nasal obstruction, sneezing, itching, and local production of IgE are observed after exposure to a specific allergen with no evidence of systemic allergies.6)7)8)9)10) LAR is pathophysiologically characterized by the local production of IgE, Th2 cytokine mucosal cell infiltration, the secretion of tryptase and eosinophil cationic protein (ECP), and a positive NAPT result. In previous studies, 47% of the patients with Non-AR according to the conventional classification scheme were diagnosed with LAR when the above diagnostic criteria were applied.6)11)12)

Even though there are many reports evaluating the relationship between lower respiratory tract diseases such as asthma and sinonasal diseases including CRS in patients with AR, the role of allergic reaction in nasal mucosa on lower or upper airway diseases has not been identified well. Interestingly, previous studies have reported that allergic symptoms are associated with increases of local production of tryptase and ECP that is known as a poor prognostic factor of CRS.10) In this study, we aimed to evaluate the association of patient-reported local allergic symptoms (LAS) such as sneezing and itching with the recurrence of CRS in AR and Non-AR patients.

In this study, we showed that the rate of recurrence of CRS was significantly higher in the LAS (+) group than it was in the LAS (−) group. Furthermore, similar trend has been shown when we compared LAS (+) group and LAS (−) group in Non-AR patients.

Non-AR involves symptoms including sneezing, watery rhinorrhea, or having a congested nose without identified causes. Interestingly, recent studies have demonstrated an inflammatory infiltrate in the nasal mucosa of a subgroup of patients with non-AR that was very similar to that seen in patients with AR, suggesting the presence of LAR, or entopy, in these patients in the absence of systemic atopy.4)5) Even where there is no evidence of the presence of atopy, local allergic responses are frequently observed. It has been demonstrated that local IgE in nasal tissues did not correlate with the presence of atopy as determined by positive skin prick test responses to inhalant allergens or serum IgE.19) Furthermore, localized allergic responses to environmental allergens, microbial products, and fungal allergen in nasal mucosa have frequently shown regardless of the presence of atopy.20)21) However, it is not easy to diagnose LAR. The recommended diagnostic approach involves obtaining a detailed clinical history followed by AST. If a negative test result is obtained, serum total and sIgE antibody titers may be determined. If the sIgE antibody results are negative, the next step is to evaluate the target organ by quantifying nasal sIgE antibodies and performing an NAPT with the suspect allergen(s).7)11)12)22) NAPT known to be the gold standard test for LAR, can be performed with either a single allergen (NAPT-S) or multiple allergens (NAPT-M).6)9)11) The major disadvantage of NAPT-S is that it requires a wash-out period prior to provocation with the four most common allergens in the surrounding environment (Dermatophagoides pteronyssinus, Alternaria alternata, Olea europea, and grass pollen), and as a result it takes one week for each antigen test.12) The most important limitation is that it can be difficult to select the correct allergen for the provocation test if the patient has a negative response to the AST or serum sIgE test. Therefore, since the methods currently used to diagnose LAR are not efficient in terms of cost, time, and methodology, it may be necessary to replace these methods.

Rondon et al. used the visual analogue scale (VAS) to measure five symptoms (nasal obstruction, rhinorrhea, itching, sneezing, and ocular symptoms) when utilizing NAPT to diagnose LAR.10) In the study, a significant association was observed between an increase in the nasal production of ECP and tryptase measured after NAPT and a worsening of nasal symptoms.10) A similar association was observed between an increase in nasal tryptase and a worsening of nasal sneezing and itching and a positive correlation was observed between an increase in ECP and worsening of nasal obstruction.10) Separately, it has been reported that numerous inflammatory mediators including ECP, tryptase, and eotaxins are associated with prognostic outcomes of CRS after surgery and disease severity of CRS.23)24) Given that, development or worsening of nasal symptoms after exposure to allergens might be strongly related to allergic reaction with increased inflammatory mediators, resulting in poor prognosis of CRS. However, it has not been well identified the association between symptoms of local allergic reaction and prognosis of CRS. Thus, in this study, we sought to identify if specific symptoms among LAS itself is associated with prognosis of CRS after surgery. Among the four major symptoms of AR, we included sneezing and itching and 2 other major symptoms including nasal obstruction and rhinorrhea were excluded from analysis because they were most likely to be associated with CRS. In this study, the rate of recurrence of CRS was significantly higher in the LAS (+) group than it was in the LAS (−) group, suggesting that control of the associated allergic symptoms might be able to contribute to reduce recurrence rate of CRS. Although allergy in part plays a role in sinonasal inflammatory diseases such as CRS, there is no difference in the incidence of CRS, especially CRSwNP between allergic versus non-allergic patients and discrepancy between IgE levels in serum and in NP tissue is frequently found, suggesting an independent localized allergic response that may play a critical role in sinonasal inflammation, particularly in CRS.25) Supporting this, unlike LAS, we could not find any significantly different recurrence rate of CRS in AR versus Non-AR groups. In addition, we only found that recurrence rate of CRS was higher in LAS (+) group compared to LAS (−) group in patients without AR. The reasons for the discrepancies are unclear, but possible hypotheses include that patients with AR were treated more aggressively for AR following surgery, suggesting that well-controlled immunologic reaction including allergic reaction in nasal mucosa might contribute to lower recurrence rate of CRS. However, to identify this hypothesis, future studies including enough number of patients with or without AR treatment are warranted. Additionally, since severity of AR might affect postoperative recurrence of CRS, further studies should also aim to assess the influence of AR severity for better understanding.

Studies evaluating the mechanism by which AR induces CRS have previously been performed. A typical pathologic mechanism is an IgE-mediated reaction involving accumulation of Th2 cells, lymphocytes, antigen-presenting cells (APC), eosinophils, macrophages, and mast cells in the mucosa of AR patients.5) Immunoglobulin E is a local substance that can cause mast cells to become sensitized to common aeroallergens.3) This process is known to cause nasal mucosal thickening, decreased ciliary function, and proliferation of goblet cells in the sinus, resulting in ventilatory and drainage disorders in the sinus.14) In LAR patients, an inflammatory response of the Th2 cells, production of sIgE to aeroallergen, an increase in inflammatory mediators, and an increase in ECP in the nasal mucosa were observed, which is similar to the mechanism noted to cause CRS in AR patients.5) In addition, swelling of the nasal mucosa may lead to reduced patency of the ostia, reduced transport capacity related to abnormalities of the cilia, and increased secretions in the sinus resulting in CRS.3)

The present study has the following limitations. First, we used LAS instead of performing NAPT in patients suspected of having LAR. Further studies are therefore required to determine whether LAS is representative of the symptoms present in patients with LAR. Second, because the sample size was small, additional prospective large-scale studies are required.

Regardless of the presence of AR, recurrence of CRS tends to be more common in patients with LAS including sneezing and itching. We suggest here that control of LAS might contribute to prognosis of CRS after surgery.