Editorial: New perspectives in the pathogenesis and management of rhinologic and allergic airway disease

It is such an honor to have the opportunity to serve as Guest Editor for this edition of the American Journal of Rhinology and Allergy (AJRA), and I want to express my deepest thanks to the Editors-in-Chief Alexander Chiu, Rakesh Chandra, and Anju Peters for their continued support and outstanding leadership. The AJRA is committed to presenting the latest and highest quality clinical and translational research in the fields of rhinology, allergy, and skull base pathology. To that end, the March/April issue of the AJRA encompasses a broad spectrum of studies offering novel perspectives on a variety of allergy and rhinology related topics. Since its characterization, much knowledge has been gained regarding the multifaceted inflammatory nature of chronic rhinosinusitis (CRS), with both host (i.e., allergy, immunodeficiency, anatomic obstruction, etc.) and environmental factors (i.e., bacterial/viral infections, biofilms, pollutants, etc.) understood to be involved in its pathogenesis.1 However, despite extensive research efforts, no clear etiology for CRS has been delineated.1 In this issue, several studies aim to deepen our understanding of the complex pathophysiology of CRS and provide further insight into new treatment alternatives for this disease entity. On a molecular level, Lawrence et al investigate the effects of superoxide dismutase (SOD) on fungal antigen induced inflammatory responses in human sinonasal epithelial cells (HSNECs).2 SOD treatment of HSNECs derived from CRS with nasal polyp patients attenuated inflammation triggered by Aspergillus and Alternaria, suggesting that SOD could be used as a potential therapeutic option for CRS in the future.2 From a clinical aspect, Stevens and Peters examine how underlying immunodeficiencies may contribute to CRS.3 In their review, multiple immune disorders (i.e., common variable immunodeficiency, selective IgA deficiency, and specific antibody deficiencies) are discussed including appropriate diagnosis, treatment, and impact on CRS.3 Timely management of such immunodeficiencies with immunoglobulin replacement, etc. may have beneficial effects on the clinical course of CRS, particularly in patients with refractory disease. Likewise, Sedaghat and colleagues explore clustering patterns of CRS symptoms to determine correlations with demographic characteristics, comorbidities, and other objective findings.4 Such unique associations indicate that distinct pathophysiologic processes may be responsible for specific CRS symptomatology. Endoscopic sinus surgery (ESS) plays an integral role in the surgical therapy of CRS, with well-documented benefits in both symptoms and quality of life (QOL).5 However, local complications such as synechiae formation, middle turbinate lateralization, and mucosal edema can impede postoperative healing and ultimately compromise long-term surgical outcomes.6,7 In their systematic review, Hobson and colleagues evaluate the utility of middle meatal packing in reducing the risk of scarring following ESS.8 A meta-analysis of pooled data from eighteen randomized controlled trials was performed, which demonstrated a nonsignificant trend toward decreased adhesions in patients in whom middle meatal packing was placed.8 Like ESS, endonasal endoscopic skull base surgery (EESBS) can also lead to significant changes in intranasal anatomy. Utilizing 3-dimensional computational fluid dynamic simulations and virtual surgery models, Frank-Ito et al illustrate the effects of EESBS on sinonasal physiology.9 Alterations in severity, direction, and allocation of airflow were reported with EESBS as well as disruption of mucosal wall interactions.9 Although smaller in scope, partial turbinectomy has also been presumed to negatively impact nasal functionality.10 In their in vivo study, Tsakiropoulou et al compare the intranasal air conditioning capacity of healthy controls to patients with partial inferior turbinate resection.10 Diminished air heating was observed in the latter group but no change in humidification was reported.10 Similar to surgery, radiation therapy can also lead to long-term adverse local effects. Riva et al evaluate nasal cytological alterations in patients who received chemoradiation for nasopharyngeal carcinoma.11 Radiated subjects exhibited a significantly higher percentage of rhinorrhea, nasal obstruction, and nasopharyngeal secretions than healthy controls.11 A greater proportion of treated patients also showed neutrophilic inflammation and squamous cell metaplasia on histopathology, implying that radiation induced mucosal changes can contribute to clinical rhinitis symptoms.11 With continual advances in endoscopic transnasal surgical approaches, indications for such procedures have broadened considerably to encompass increasingly more novel applications. In their review, Miyake and Bleier discuss the challenges of formulating drug targeting strategies to bypass the blood-brain barrier and deliver therapeutics to the central nervous system (CNS).12 The authors describe the innovative use of endoscopic grafting techniques to facilitate drug administration to the subarachnoid space via an intranasal route.12 A nasal mucosal surgical flap is created employing established skull base reconstruction methods to serve as a vehicle for pharmaceutical delivery to the CNS.12 As more advanced endoscopic skull base procedures are developed, it is important to assess the clinical outcomes of such surgeries. In their study, Deckard et al track QOL measures following endoscopic resection of sinonasal and skull base neoplasms.13 Concurrent use of multiple validated instruments elucidated significant changes in QOL metrics following surgery and enabled identification of various factors (malignant histopathology, advanced tumor staging, etc.) associated with worsened postoperative QOL.13 Recent years have also witnessed introduction of new materials and approaches in esthetic and reconstructive rhinologic surgery. In their retrospective study, Kim et al evaluated the use of tutoplast-processed fascia lata for dorsal augmentation in primary and revision rhinoplasty and reported positive surgical outcomes with minimal morbidity.14 In addition to CRS, this issue also includes studies investigating the pathogenesis and management of other allergic and non-allergic inflammatory airway diseases. As sensitization has been shown to occur early in life, Yu and colleagues analyze the impact of gestational environment on the neonatal immune response.15 Interestingly, maternal atopic status was not found to influence neonatal sensitization and maternofetal transfer of allergen specific IgE was not detected.15 Similarly, Tokunaga et al conduct an epidemiologic survey of high school students in Japan to identify factors influencing development and remission of a spectrum of allergic processes, including rhinitis and asthma.16 Their findings lend further support to the hygiene hypothesis and the potential effects of intestinal flora on the clinical course of allergic airway disease.16 In their prospective study, Yenigan et al compare plasma 24-hydroxyvitamin D levels in patients with and without allergic rhino-conjunctivitis (ARC).17 Significantly lower plasma vitamin D measurements were observed in the ARC group, Jivianne T. Lee, M.D.