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Otolaryngology: Open Access Sami et al.
, Otolaryngol (Sunnyvale) 2017, 7:1

DOI: 10.4172/2161-119X.1000294
Research Article OMICS International
Response to Combination Intranasal Corticosteroid and Intranasal Antihistamine

in Allergic Rhinitis, A Questionnaire Based Study in ENT Outpatients
Amtul Salam Sami1*, Sabahat Ahmed2, Nida Ahmed3
1
Department of ENT and Allergy, University Hospital Lewisham, Lewisham and Greenwich NHS Trust, UK
2
GKT School of Medicine, Kings College, UK
3
London North West Healthcare NHS Trust, UK
*
Corresponding author: Amtul Salam Sami, MBBS, BSc, ODTC, MCPS, MA, M.Sc., Department of ENT and Allergy, University Hospital Lewisham, Lewisham and
Greenwich NHS Trust, UK, Tel: 020 7474 2595; E-mail: amtul_salam@hotmail.com
Received date: February 02, 2017; Accepted date: February 21, 2017; Published date: February 28, 2017
Copyright: 2017 Sami AS, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author and source are credited.
Abstract
Aim: To analyse the effect of combination intranasal corticosteroid and antihistamine spray in patients suffering
from proven Allergic Rhinitis who have failed primary care therapy.
Background: Allergic Rhinitis is prevalent in the community and worldwide, with a rising trend, it also impacts on
health related quality of life, sleep and (in appropriate age groups) school attendance.
Method: The MSNOT-20 is a validated and reliable questionnaire for use in Rhinitis. It was used in two 4 month
periods (2014 and 2016) in patients with Allergic Rhinitis who have failed primary care treatment. They were then
commenced on a combination nasal spray of azelastine hydrochloride (antihistamine) and fluticasone propionate
(corticosteroid).
Results: There was improvement in overall symptom severity score (MSNOT-20 score) for each patient, with
improvement in all five subgroups; nasal, paranasal, sleep, social and emotional. The MSNOT-20 score is closely
correlated with sleep, social and paranasal subgroups. The top 5 most severe symptoms identified by MSNO T-20
questionnaire objectively were also identified by patients as their most troublesome symptoms and include (in
descending order); blocked nose, need to blow nose, sneezing, runny nose, post nasal discharge.
Conclusion: Allergic rhinitis has widespread impact on different domains of the patients life. This combination
treatment is an effective treatment regime for patients who have failed primary care and has been proven to be of
benefit in seasonal and perennial Allergic Rhinitis by improving all symptom subgroups.
Keywords: Allergic rhinitis; Nasal spray; Corticosteroid; Anti- Skin Prick Testing (SPT) is used to identify allergens patients are
allergy drugs allergic to and has been shown to be superior to patient-reported
allergen identification or allergens as identified on allergy history take
Introduction [8]. One meta-analysis reported that on SPT the top three allergens
identified in 15 developed countries (covering Europe including the
UK, USA and Australia) were house dust mite, grass pollen and cat
Allergic rhinitis
(median prevalence across all centres 21.7%, 16.9% and 8.8%,
Rhinitis means inflammation of the nasal mucous membrane; when respectively) [9].
this is caused by an abnormal IgE-mediated response to an otherwise
Epidemiological data suggests that worldwide 400 million people
innocuous stimulant, i.e., an allergen, this is known as allergic
are currently suffering from allergic rhinitis and that its prevalence is
rhinitis and is the most common form of non-infectious rhinitis [1-4].
on the rise globally [1]. Though the cause for this rising trend is
Affecting 1 in 4 people seasonal allergic rhinitis, also known as hay unknown, contributing factors include a higher concentration of air
fever [5], presents with nasal congestion, rhinorrhea, itching and/or borne allergens, poor air quality due to pollution, poor indoor
sneezing. Allergic rhinoconjucntivitis is the associated watery eyes, ventilation, smoking and a more sedentary lifestyle among others [10].
itching, burning/irritability, redness and injection of the conjunctiva
which has been documented in 71% of European patients who Treatment of allergic rhinitis
concurrently had nasal symptoms [6].
The British Society of Allergy and Clinical Immunology (BSACI)
Importantly, Allergic Rhinitis has consequences beyond its have developed a pathway for the treatment of Rhinitis, adapted in
prevailing symptoms by having significant impact on quality of life Figure 1 [2].
and social life, these include mood changes, anxiety, depression and
impairment of cognitive function [7].
Otolaryngol (Sunnyvale), an open access journal Volume 7 Issue 1

ISSN:2161-119X 1000294
Citation: Sami AS, Ahmed AS, Ahmed N (2017) Response to Combination Intranasal Corticosteroid and Intranasal Antihistamine in Allergic
Rhinitis, A Questionnaire Based Study in ENT Outpatients. Otolaryngol (Sunnyvale) 7: 294. doi:10.4172/2161-119X.1000294
Page 2 of
7
Figure 1: BSACI algorithm for the treatment of rhinitis, SPT: Skin Prick Test; LTRA: Leukotriene Receptor Antagonist.
Primary Rhinitis,
care A Questionnaire
has ENT Outpatients. Otolaryngol (Sunnyvale) 7: 294. doi:10.4172/2161-119X.1000294
Based Studyinin patients
an propionate)
increasingly heavy burden of suffering from proven allergic
Allergic Rhinitis, in England rhinitis who have failed primary
primary care prescriptions for therapy in the GP setting.
Allergic Rhinitis have gone up Page 3 of
by 41.7% from 2001-2005, Secondary aims included 7
which includes antihistamines subgroup analysis as defined by
and topical nasal corticosteroids the MSNOT-20 questionnaire
(also includes topical nasal and exploring symptom
antihistamine and topical nasal responsiveness based upon skin
cromoglicate) [11]. prick test results.
Specialist centres can Method

provide Immunotherapy for
patients who have had optimal The MSNOT-20
medical treatment yet symptom questionnaire is a validated,
control has been either minimal disease specific questionnaire
or non-existent, there is impact (Appendix 1) which can identify
on quality of life and no contra- rhinitis, its associated impact on
indications to immunotherapy. quality of life and disease
Immunotherapy treatment itself response to treatment in the
has lasting benefits for the first adult population, its modified
few years after treatment version has similar proven
though this will diminish over qualities in the paediatric
time [12]. population of 11-16 year olds
[3,13]. It consists of three
Study aim sections; section one comprises
of demographic details, section
The primary aims of this two is the disease specific
study is to analyse the effect of section and section three is
combination nasal spray the quality of life section. In
(azelastine hydrochloride and the disease specific section,
fluticasone patients would describe the
severity of their symptoms
based on a Likert 1 to 5 scale
with 5 being
Page 4 of
7
Rhinitis,
quantified as badA Questionnaire
as it can Based At Study
firstin ENT Outpatients.
clinical each (Sunnyvale)
contactOtolaryngol of the twenty7: 294. doi:10.4172/2161-119X.1000294
questions changes in each subgroup
be. The related questions are patients had a full clinical were calculated to produce the before and after treatment
grouped together into assessment, completed the MSNOT-20 score and is delineated in Figures 4a-4e.
subgroups, each of which is MSNOT-20 questionnaire and, represented in Figure 2 for each There was a greater than 50%
composed of the following if relevant, had skin prick test. subject. All patients had decrease in symptomology Page 5 post
of
questions from this section: significant improvement in their treatment with all subgroups 7
Subsequent management plan overall symptom severity. showing improvement, though
Nasal: questions 1, 2, 3, 19 including pharmaceutical option
The mean and standard the improvement was greatest in
was discussed; if eligible and
Paranasal: 5, 6, 7, 8, 9, 10-
clinically appropriate (using deviations were calculated for the nasal subgroup.
can be further split into the before and after treatment
treatment guidelines and Mean before Mean
below for further analysis responses and shown in Figure
clinical experience), treatment treatment treatm
was advised with the 3. Similar calculation was then (Standard (Stan
carried out for all five subgroups Subgroup Deviation) Devia
aforementioned combination
S nasal spray and, following as shown in Table 1 with the Nasal 15.69 (4.04) 6.08 (
i informed consent, initiated as
n per manufacturers guidelines; 1 Paranasal 9.40 (5.54) 3.56 (
u spray in each nostril twice a
Sleep 6.29 (6.82) 2.44 (
s day in those over 12 years (at
: the time of the study). Where Social 4.10 (5.15) 1.90 (
needed, a patient information
Emotional 1.83 (2.36) 0.83 (
5 leaflet and clinical
, demonstration of the correct
technique when using a nasal Table 1: Representing total
spray was carried out. subgroup mean and standard
6
deviation for each subgroup
, As this particular brand before and after treatment with p
combination was initially not value quoted.
1 available at the index hospital a
0 GP prescription was provided.
After four weeks, patients were
asked to repeat section two of
the MSNOT-20 questionnaire
E
a again, results were sent back to
r the researchers. Data was then
: collated and statistical analysis
was carried out.
7
, R
e
8 s
, u
l
9 t Figure 2: MSNOT-20 score
Sleep: 11, 12, 13,14 s before and after treatment
for each subject, n=48,
Social: 15, 16, 17 In total, 48 candidates (24 p<0.01.
males, 24 females) were
Emotional: 18, 20
eligible for inclusion into the
Inclusion criteria: Patients study, age range 20-69 with just
being referred from their GP to under 2/3rd (65%) being in the
the ENT and Allergy 20-44 age group. There was no
department at Royal National statistically significant difference
Throat, Nose and Ear hospital, in symptom severity between
London due to nasal and sinus males and females and between
symptoms. These patients those with a positive family
showed no response to history compared to those
optimal primary care treatment without.
along the Figure 1 algorithm
(which begins with Before
monotherapy agents) or and
practice-specific guidelines. after
Participants were enrolled in treatm
two four- month periods, Figure 3: Mean of MSNOT-
ent
February-May 2014 and 20 scores before and after
February-May 2016.
compa
treatment, blue box
risons representing the mean with
Exclusion criteria: Patients
with nasal polyposis. The sum of the symptom black lines representing
severity patients reported for standard deviation,
numerical values
Rhinitis,shown at
A Questionnaire Based Study in ENT Outpatients. Otolaryngol (Sunnyvale) 7: 294. doi:10.4172/2161-119X.1000294
the bottom of the graph,
n=48, p<0.01.
Page 6 of
7
Page 4 of 7
Figure 4: a) Nasal subgroup histogram of change in score following treatment, p<0.01, b) Paranasal subgroup histogram of change in score
following treatment, p<0.01, c) Sleep subgroup histogram of change in score following treatment, p<0.01, d) Social subgroup histogram
of change in score following treatment, p<0.01, e) Emotional subgroup histogram of change in score following treatment, p<0.01.
Citation:
Sami AS, Ahmed AS, Ahmed N (2017) Response to Combination Intranasal Corticosteroid and Intranasal Antihistamine in Allergic
Rhinitis, A Questionnaire Based
Key symptoms Studytoinblow
2nd Need ENT Outpatients.
nose Otolaryngol (Sunnyvale) 7: 294. doi:10.4172/2161-119X.1000294
Figure 5 represents the mean 3rd Sneezing

responses to each question
4th Runny nose
before and after treatment,
showing the improvement in all 5th Post nasal discharge
symptoms post treatment whilst
The questionnaire asked
also showing what the most
patients to report the top five
severe symptoms patients
symptoms they felt were most
presented with were (below, in
important to them in terms of
descending order), this order
impact on their health. All
remained the same post
responses to this were collated
treatment.
and the top 5 symptoms
1st Blocked nose
Grass
Rhinitis, A Questionnaire Based pollen:
Study in ENTn=37 294. 5doi:10.4172/2161-119X.1000294
Outpatients. Otolaryngol (Sunnyvale) 7:Page of 7 In subgroup analysis, the
individuals positive on skin biggest improvement post
patients perceived to be of prick testing MSNOT-20 treatment was seen in the
greatest importance to them Tree pollen: n=17 score MSNOnasal subgroup, followed by
were the same as the above list. individuals positive on skin Allergen before score after
the paranasal subgroup
prick testing Seasonal showing the effective beneficial
Mould: n=5 individuals Allergen relief this local agent is able to
positive on skin prick testing achieve. Though it is a case that
Grass pollen 41 16.54
Aspergillus: n=3 individuals all subgroups improved this was
positive on skin prick testing Tree Pollen 45.29 17.82 small (but significant) in the
Cat: n=16 individuals emotional subgroup indicating
positive on skin prick testing Perennial the variety of different causes
Allergen
Dog: n=13 individuals of impairment in this domain
positive on skin prick testing House dust mite 41.41 16.9 and importance of assessing the
impact of treatment based on the
Table 2 shows the Mould 51.4 16.8 overall response.
improvement in MSNOT-20
score and Nasal subgroup Aspergillus 30.33 14.67 This study also demonstrated
score before and after the widespread impact that this
Cat 48.44 19.5
treatment and has been split condition has; as seen by the fact
by seasonal (grass or tree pollen Dog 49.08 19.92 that some of the strongest
Figure 5: Mean responses to correlation noted with a high
in this study) and perennial
all questions in disease MSNOT-20 score (i.e., most
(allergens present all year Table 2: MSNOT-20 before and
specific section before and symptomatic) is with the sleep
round, this study included after treatment and Nasal
after treatment, n=48, p<0.01. and social subgroups. This study
house dust mite, mould, subgroup before and after
aspergillus, cat and dog) also represents the dominant
treatment split by individual
allergens. The results show that role of paranasal symptoms in
allergen (as confirmed by skin
Subgroup Correlation the total MSNOT-20 was Allergic Rhinitis, which also
prick test), n=48, p<0.01.
reduced by two and a half responded to the treatment
Spearmans Rank Correlation provided here. Paranasal
times through the treatment in D
Coefficient test was used to subgroup itself correlated with
the seasonal allergens, this was
determine correlations between
also similar in the nasal score.
i sleep and social subgroups as
the subgroup as defined in the s well as the emotional subgroup.
A considerable improvement in
Method section. The strength of c
MSNOT-20 score and Nasal This study has shown that the
the correlation is represented by
the R value; a score of greater
subgroup was also noted for u MSNOT-20 is able to detect
perennial allergens. s objectively the most severe
than 0.30 is considered a
positive, an R score of greater s symptoms of the patient
(among others) and correlate
0.50 considered moderately i
strong positive correlation this with what the patients
o perceive to be their most
whilst a score over
n troublesome symptoms,
0.70 in strength is considered a
strongly positive correlation ensuring this very important
[14]. S aspect of management is noted
u as early as possible. In this
The MSNOT-20 correlates study, Blocked nose was the
m
strongest with the sleep most severe symptom both
m
subgroup (R=0.90, p<0.05) objectively and as perceived by
followed by social (0.85, a
the patient as most impacting
p<0.05), paranasal (0.78, r
on their health, this is
p<0.05) and emotional (0.76, y
decreased by more than two-
p<0.05) There was improvement in and-a-half times through this
Paranasal subgroup overall symptom severity and intranasal effective treatment in
correlates positively with in all subgroups following patients who had initially failed
sleep (0.62, p<0.05) treatment in patients with treatment through their GP.
followed by social (0.52, seasonal Allergic Rhinitis and
p<0.05) and emotional perennial Allergic Rhinitis who
subgroups (0.46, p<0.05) had failed community treatment
and been referred to
Skin prick test results and secondary care. It can take
correlation with overall approximately 6 weeks from GP
score referral to presentation at clinic;
our results showed that patients
The breakdown of the skin had a high burden of symptoms
prick test results for the at presentation to clinic
entire cohort indicating inadequacy of initial
(n=48) are shown below: treatment and unlikelihood of
House dust mite: n=29 symptom resolution independent
individuals positive on skin of our interventions.
prick testing
Rhinitis, A Questionnaire Based Study in ENT Outpatients. Otolaryngol (Sunnyvale) 7: 294. doi:10.4172/2161-119X.1000294 Page 6 of 7
The majority of our patients were within the young working age Conflict of Interest
group which is likely to have impact on occupation, among others,
however Section 3 of the MSNOT-20 questionnaire which addresses A.S.S has received fees from Meda Pharmaceuticals. Meda
this was not reviewed in this analysis, as were data on ethnicity, Pharmaceuticals had no role in study design, collection, analysis,
housing, smoking due to incomplete results available allowing for interpretation of data, writing the report or decision to submit for
scope to further look into this. publication.
Skin prick testing revealed our cohort had sensitisation to multiple

allergens, which is not uncommon in clinical practise. One study of
Funding
200 patients with medically unresponsive chronic or recurrent A.S.S received fees from Meda Pharmaceuticals.
rhinosinusitis revealed that 52% of these had multiple allergy
sensitivities however this did not appear to determine the severity of References
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Otolaryngology: Open Access Sami et al.

, Otolaryngol (Sunnyvale) 2017, 7:1

Research Article OMICS International

Response to Combination Intranasal Corticosteroid and Intranasal Antihistamine

Otolaryngol (Sunnyvale), an open access journal Volume 7 Issue 1

Specialist centres can Method

Figure 5 represents the mean 3rd Sneezing

Skin prick testing revealed our cohort had sensitisation to multiple

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