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Cerebrospinal fluid (CSF) leaks originating from defects within the anterior and middle cranial fossa typically manifest as unilateral clear watery rhinorrhea. Continuous CSF leakage mandates surgical repair due to the risk of meningitis and brain abscess. It can be categorized based on its underlying etiology into traumatic, iatrogenic and non-traumatic CSF leaks.

Background: Chronic rhinosinusitis (CRS) disease control is a global metric of disease status for CRS. While there is broad acceptance that it is an important treatment goal, there has been inconsistency in the criteria used to define CRS control. The objective of this study was to identify and develop consensus around essential criteria for assessment of CRS disease control., Methods: Modified Delphi methodology consisting of three rounds to review a list of 24 possible CRS control criteria developed by a 12-person steering committee. The core authorship of the multidisciplinary EPOS 2020 guidelines was invited to participate., Results: Thirty-two individuals accepted the invitation to participate and there was no dropout of participants throughout the entire study (3 rounds). Consensus essential criteria for assessment of CRS control were: overall symptom severity, need for CRS-related systemic corticosteroids in the prior 6 months, severity of nasal obstruction, and patient-reported CRS control. Near-consensus items were: nasal endoscopy findings, severity of smell loss, overall quality of life, impairment of normal activities and severity of nasal discharge. Participants’ comments provided insights into caveats of, and disagreements related to, near-consensus items., Conclusions: Overall symptom severity, use of CRS-related systemic corticosteroids, severity of nasal obstruction, and patient-reported CRS control are widely agreed upon essential criteria for assessment of CRS disease control. Consideration of near-consensus items to assess CRS control should be implemented with their intrinsic caveats in mind. These identified consensus CRS control criteria, together with evidence-based support, will provide a foundation upon which CRS control criteria with wide-spread acceptance can be developed.

Asthma, rhinitis, and atopic dermatitis (AD) are interrelated clinical phenotypes that partly overlap in the human interactome. The concept of "one-airway-one-disease," coined over 20 years ago, is a simplistic approach of the links between upper- and lower-airway allergic diseases. With new data, it is time to reassess the concept. This article reviews (i) the clinical observations that led to Allergic Rhinitis and its Impact on Asthma (ARIA), (ii) new insights into polysensitization and multimorbidity, (iii) advances in mHealth for novel phenotype definitions, (iv) confirmation in canonical epidemiologic studies, (v) genomic findings, (vi) treatment approaches, and (vii) novel concepts on the onset of rhinitis and multimorbidity. One recent concept, bringing together upper- and lower-airway allergic diseases with skin, gut, and neuropsychiatric multimorbidities, is the "Epithelial Barrier Hypothesis." This review determined that the "one-airway-one-disease" concept does not always hold true and that several phenotypes of disease can be defined. These phenotypes include an extreme "allergic" (asthma) phenotype combining asthma, rhinitis, and conjunctivitis. Rhinitis alone and rhinitis and asthma multimorbidity represent two distinct diseases with the following differences: (i) genomic and transcriptomic background (Toll-Like Receptors and IL-17 for rhinitis alone as a local disease; IL-33 and IL-5 for allergic and non-allergic multimorbidity as a systemic disease), (ii) allergen sensitization patterns (mono- or pauci-sensitization versus polysensitization), (iii) severity of symptoms, and (iv) treatment response. In conclusion, rhinitis alone (local disease) and rhinitis with asthma multimorbidity (systemic disease) should be considered as two distinct diseases, possibly modulated by the microbiome, and may be a model for understanding the epidemics of chronic and autoimmune diseases., (© 2023 The Authors. Allergy published by European Academy of Allergy and Clinical Immunology and John Wiley & Sons Ltd.)

Chronic rhinosinusitis (CRS) is known to affect around 5 % of the total population, with major impact on the quality of life of those severely affected (1). Despite a substantial burden on individuals, society and health economies, CRS often remains underdiagnosed, under-estimated and under-treated (2). International guidelines like the European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS) (3) and the International Consensus statement on Allergy and Rhinology: Rhinosinusitis 2021 (ICAR) (4) offer physicians insight into the recommended treatment options for CRS, with an overview of effective strategies and guidance of diagnosis and care throughout the disease journey of CRS.

The prevalence of allergic disorders has increased drastically over the last 50 years to the extent that they can be considered epidemic. At present, allergen-specific immunotherapy (AIT) is the only therapy that targets the underlying cause of allergic disorders, and evidence of its superiority is based on data accumulated from clinical trials and observational studies demonstrating efficacy and safety. However, several aspects remain unresolved, such as harmonization and standardization of manufacturing and quantification procedures across manufacturers, homogeneous reporting of strength, and the establishment of international reference standards for many allergens. This article discusses issues related to the measurement of major allergen content in AIT extracts, raising the question of whether comparison of products from different manufacturers is an appropriate basis for selecting a specific AIT product. Allergen standardization in immunotherapy products is critical for ensuring quality and, thereby, safety and efficacy. However, lack of harmonization in manufacturing processes, allergen quantification (methodologies and references), national regulatory differences, clinical practice, and labeling shows that the comparison of AIT products based solely on major allergen amounts is not rational and, in fact, impossible. Moreover, when rating the information given for a specific product, it is necessary to take into account further inherent characteristics of products and their application in clinical practice, such as the state of extract modification, addition of adjuvant or adjuvant system, route of administration (sublingual/ subcutaneous), and cumulative dose as per posology (including the volume per administration). Finally, only convincing clinical data can serve as the basis for product-specific evaluation and cross-product comparability of individual products.

Competing Interests: L. Klimek berichtet über Zuschüsse und/oder Honorare von Allergopharma, MEDA/Mylan, HAL Allergie, ALK Abelló, LETI Pharma, Stallergenes, Quintiles, Sanofi, ASIT biotech, Lofarma, Allergy Therapeut., AstraZeneca, GSK, Inmunotk, Cassella med, außerhalb der eingereichten Arbeit; und folgende Mitgliedschaften: AeDA, DGHNO, Deutsche Akademie für Allergologie und klinische Immunolgie, HNO-BV, GPA, EAACI;Ch. Bergmann berichtet über Referentenhonorare von Sanofi Genzyme;S. Becker gibt folgende potenziellen Interessenkonflikte an: Wissenschaftliche Beratung: Novartis, Sanofi-Genzyme, Bencard Allergie; Vortragshonorare: Novartis, Sanofi-Genzyme, Bencard Allergie, HAL-Allergie, MSD, AstraZeneca; Studien: Otonomy, Regeneron, Sensorien, AstraZeneca, Auris medical;M. Cuevas berichtet über Honorare von AstraZeneca, GSK, Sanofi und Novartis;P. V. Tomazic, C. A. Hintschich, F. Klimek, U. Förster-Rurmann, I. Casper, H. J. Welkoborsky, J. Hagemann, K.-Ch. Bergmann, T. Huppertz hat keine Interessenkonflikte im Zusammenhang mit dieser Publikation.

The feasibility and surgical effort of a pre-lacrimal window approach (PLWA) depends on the width of the bony window anterior to the nasolacrimal duct. This study aimed to investigate gender-specific differences in feasibility of PLWA. A consecutive series of paranasal computed tomography scans from 50 females (n = 100) and 50 males (n = 100) were retrospectively analyzed. The primary outcome measure was the antero-posterior length of the bony pre-lacrimal window (BPLWA). The secondary outcome measure was the distribution of Simmen's PLWA feasibility types (major, moderate and minor surgical effort). On average, males had a 1.5 mm (95% CI 0.8-2.2) significantly higher BPLW length in comparison to females [t(198) = 4.4, p < 0.0001]. The requirement of major surgical effort occurred 29% more frequently in females [χ 2 (1) = 17.7, p < 0.0001], whereas the necessity of moderate surgical effort was 21% more prevalent in males [χ 2 (1) = 8.8, p = 0.003]. The need of only minor surgical effort was twice as high in males compared to females [χ 2 (1) = 3, p = 0.081]. Our data indicates that females require more significant surgical effort during a PLWA to gain access to the maxillary sinus. These results are highly informative as a high amount of bone removal and nasolacrimal duct dislocation are associated with a higher likelihood of complications.

Background: The analysis of mobile health (mHealth) data has generated innovative insights into improving allergic rhinitis control, but additive information is needed. A cross-sectional real-world observational study was undertaken in 17 European countries during and outside the estimated pollen season. The aim was to collect novel information including the phenotypic characteristics of the users., Methods: The Allergy Diary-MASK-air-mobile phone app, freely available via Google Play and App, was used to collect the data of daily visual analogue scales (VASs) for overall allergic symptoms and medication use. Fluticasone Furoate (FF), Mometasone Furoate (MF), Azelastine Fluticasone Proprionate combination (MPAzeFlu) and eight oral H1-antihistamines were studied. Phenotypic characteristics were recorded at entry. The ARIA severity score was derived from entry data. This was an a priori planned analysis., Results: 9037 users filled in 70,286 days of VAS in 2016, 2017 and 2018. The ARIA severity score was lower outside than during the pollen season. Severity was similar for all treatment groups during the pollen season, and lower in the MPAzeFlu group outside the pollen season. Days with MPAzeFlu had lower VAS levels and a higher frequency of monotherapy than the other treatments during the season. Outside the season, days with MPAzeFlu also had a higher frequency of monotherapy. The number of reported days was significantly higher with MPAzeFlu during and outside the season than with MF, FF or oral H1-antihistamines., Conclusions: This study shows that the overall efficacy of treatments is similar during and outside the pollen season and indicates that medications are similarly effective during the year.

Competing Interests: R. Buhl gibt Folgendes an: Vorträge und/oder Beratungen für AstraZeneca, Boehringer Ingelheim, Chiesi, Cipla, Novartis, Roche, Sanofi und Teva; Forschungsunterstützung der Universitätsmedizin Mainz: Boehringer Ingelheim, GlaxoSmithKline, Novartis und Roche – außerhalb der vorliegenden Arbeit.R. Brehler gibt Folgendes an: Vortragstätigkeit für ALK, Allergopharma, Almirall, AstraZeneca, Bencard, Gesellschaft zur Förderung der Dermatologischen Forschung und Fortbildung, Gesellschaft für Information und Organisation, GSK, Dr. Pfleger, HAL, Leti, Merck, Novartis, Oto-Rhino-Laryngologischer Verein, Pierre Fabre, Pohl Boskamp, Stallergenes, Thermo-Fischer; Beratertätigkeit für Allergopharma, Bencard, HAL, Leti, Novartis; klinische Studien fürAllergopharma, Bencard, Biotech Tools, Genentech, Leti, Novartis, Circassia – außerhalb der vorliegenden Arbeit.U. Darsow war Referent, Prüfarzt und Berater für ALK Abello, Bencard and Novartis Pharma – außerhalb der vorliegenden Arbeit.T. Jakob hat Zuschüsse, Honorare oder nichtfinanzielle Unterstützung von Novartis, ALK-Abelló, Bencard/Allergy Therapeutics, Allergopharma, Thermo Fisher Scientific und Celgene erhalten – außerhalb der vorliegenden Arbeit.M. Jutel gibt an, Honorare von ALK Abello, Allergopharma, Stallergenes, Anergis, Allergy Therapeutics, Circassia, Leti, Biomay und HAL erhalten zu haben – während der Durchführung der Studie. Außerdem gibt er an, Honorare von AstraZeneka, nGSK, Novartis, Teva, Vectura, UCB, Takeda, Roche, Janssen, Medimmune und Chiesi erhalten zu haben – außerhalb der vorliegenden Arbeit.L. Klimek gibt an, Zuschüsse und/oder Honorare von Allergopharma, MEDA/Mylan, HAL Allergie, ALK Abelló, Leti, Stallergenes, Quintiles, Sanofi, ASIT bio tech, Lofarma, Allergy Therapeut., Astra- Zeneca, GSK, Inmunotk erhalten zu haben – außerhalb der vorliegenden Arbeit. Außerdem ist er Mitglied bei folgenden Organisationen: AeDA, DGHNO, Deutsche Akademie für Allergologie und Klinische Immunologie, HNO-BV GPA, EAACI.S. Lau war beratend für Allergopharma tätig.P. Matricardi gibt an, Zuschüsse und/oder Honorare von DFG, Hycor, Omron, Stallergens, Euroimmun, Novartis, TPS, Stallergenes- Greer erhalten zu haben – außerhalb der vorliegenden Arbeit. Außerdem hat er nichtfinanzielle Unterstützung von Thermo Fisher Scientific erhalten – ebenfalls außerhalb der vorliegenden Arbeit.O. Pfaar gibt an, für die letzten 36 Monate Forschungsmittel und/oder Honorare von ALK-Abelló, Allergopharma, Stallergenes Greer, HAL Allergy Holding B. V./HAL Allergie GmbH, Bencard Allergie GmbH/ Allergy Therapeutics, Lofarma, Biomay, Circassia, ASIT Biotech Tools S. A., Laboratorios LETI/LETI Pharma, MEDA Pharma/MYLAN, Anergis S. A., Mobile Chamber Experts (a GA2LEN Partner), Indoor Biotechnologies, Glaxo Smith Kline, Astellas Pharma Global, EUFOREA, Roxall, Novartis, Sanofi Aventis, Med Update Europe GmbH und streamedup! GmbH erhalten zu haben – alle außerhalb der vorliegenden Arbeit.P. Schmid-Grendelmeier gibt Honorare für Teilnahme an Adboards von Allergopharma, ALK-Abello, Bencard u. Stallergenes an.R. Valenta hat Forschungsgelder von Viravaxx, Vienna, Austria und HVD Life Sciences, Vienna, Austria erhalten. Außerdem war er als Berater für Viravaxx tätig.M. Worm erklärt den Erhalt von Honoraren und/oder Beratungsgebühren von folgenden Unternehmen: ALK Abelló Arzneimittel GmbH, Mylan Deutschland GmbH, Leo Pharma GmbH, Sanofi-Aventis Deutschland GmbH, Regeneron Pharmaceuticals, DBV Technologies SA, Stallergenes GmbH, HAL Allergie GmbH, Allergopharma GmbH & Co.KG, Bencard Allergie GmbH, Aimmune Therapeutics UK Limited, Actelion Pharmaceuticals Deutschland GmbH, Novarits AG und Biotest AG.M. Wagenmann gibt an, Forschungsmittel und/oder Honorare von folgenden Firmen erhalten zu haben: ALKAbelló, Allergopharma, AstraZeneca, Bencard, Genzyme, GlaxoSmithKline,HAL Allergie, LETI Pharma, MEDA Pharma, Novartis, Sanofi Aventis, Stallergenes und Teva.T. Werfel gibt Folgendes an: Adboards, honorierte Vorträge für ALK Scherax, Bencard, Leti und Stallergens.T. Zuberbier war als Berater tätig für Bayer Health Care, FAES, Novartis und Henkel; er hat Forschungsgelder erhalten von Novartis und Henkel. Außerdem hat er Vortragshonorare erhalten von AstraZeneca, AbbVie, ALK, Almirall, Astellas, Bayer Health Care, Bencard, Berlin Chemie, FAES, HAL, Leti, Meda, Menarini, Merck, MSD, Novartis, Pfizer, Sanofi, Stallergenes, Takeda, Teva, UCB, Henkel, Kryolan und L’Oréal – außerhalb der vorliegenden Arbeit.S. Wöhrl gibt Advisory boards bei Bencard und ALK-Abelló und bezahlte Vorträge für Bencard, ALK-Abelló und Allergopharma an.W. Aberer, C. Akdis, M. Akdis, S. Becker, K.-C. Bergmann, T. Bieber, T. Biedermann, J. Bousquet, J. Buters, A. Chaker, W. Czech, A. Fink-Wagner, T. Fuchs, M. Gerstlauer, E. Hamelmann, K. Hoffmann-Sommergruber, F. Horak, K. Jung, T. Keil, N. Khaltaev, J. Kleine-Tebbe, M. Maurer, H. Merk, J.-P. Michel, R. Mösges, N. Mülleneisen, K. Nemat, L. Nicod, V. Niederberger- Leppin, I. Pali- Schöll, W. Pohl, K. Rabe, U. Rabe, J. Ring,R. Roller-Wirnsberger, J. Saloga, W. Schlenter, F. Spertini, O. Spranger, P. Staubach, P. Stute, C. Taube, P.- V. Tomazic, C. Vogelberg, C. Vogelmeier, W. Wehrmann und H. Wrede erklären, dass keine Interessenkonflikte bestehen.

The European Position Paper on Rhinosinusitis and Nasal Polyps 2020 is the update of similar evidence based position papers published in 2005 and 2007 and 2012. The core objective of the EPOS2020 guideline is to provide revised, up-to-date and clear evidence-based recommendations and integrated care pathways in ARS and CRS. EPOS2020 provides an update on the literature published and studies undertaken in the eight years since the EPOS2012 position paper was published and addresses areas not extensively covered in EPOS2012 such as paediatric CRS and sinus surgery. EPOS2020 also involves new stakeholders, including pharmacists and patients, and addresses new target users who have become more involved in the management and treatment of rhinosinusitis since the publication of the last EPOS document, including pharmacists, nurses, specialised care givers and indeed patients themselves, who employ increasing self-management of their condition using over the counter treatments. The document provides suggestions for future research in this area and offers updated guidance for definitions and outcome measurements in research in different settings. EPOS2020 contains chapters on definitions and classification where we have defined a large number of terms and indicated preferred terms. A new classification of CRS into primary and secondary CRS and further division into localized and diffuse disease, based on anatomic distribution is proposed. There are extensive chapters on epidemiology and predisposing factors, inflammatory mechanisms, (differential) diagnosis of facial pain, allergic rhinitis, genetics, cystic fibrosis, aspirin exacerbated respiratory disease, immunodeficiencies, allergic fungal rhinosinusitis and the relationship between upper and lower airways. The chapters on paediatric acute and chronic rhinosinusitis are totally rewritten. All available evidence for the management of acute rhinosinusitis and chronic rhinosinusitis with or without nasal polyps in adults and children is systematically reviewed and integrated care pathways based on the evidence are proposed. Despite considerable increases in the amount of quality publications in recent years, a large number of practical clinical questions remain. It was agreed that the best way to address these was to conduct a Delphi exercise . The results have been integrated into the respective sections. Last but not least, advice for patients and pharmacists and a new list of research needs are included. The full document can be downloaded for free on the website of this journal: http://www.rhinologyjournal.com.

Background: The aims of this study were to propose a novel and uniï¬ed classiï¬cation system of the optico-carotid recess (OCR) and anterior clinoid process (ACP) pneumatization, determine their frequency in a Caucasian population and measure the size of the OCR., Methodology: A total of 200 specimen (400 sphenoid sinuses) were evaluated in a separate anatomic cadaveric study (n=100) and radiologic study (n=100) by using sphenoidal sinus cast and computed tomography (CT) scan. OCR was divided according to its location to the optic nerve into sub-optical and latero-optical OCR grade I-III., Results: An OCR was found in 39% of the samples (78/200) and in 19% (38/200) it occurred bilaterally. Both, sub-optical and latero-optical OCR were identiï¬ed in 14% of the sides (58/400), with a mean length and depth of 6.9 mm; 7.7 mm and 2.3 mm, 7.1 mm, respectively. We determined the pneumatized ACP frequency with 23% (46/200) and deï¬ned 3 uniï¬ed different types of pneumatization., Conclusions: The OCR is a reliable landmark to identify the optico-carotid region in endoscopic sphenoid sinus surgery, and can even be visualized by CT. Hence, preoperative investigation of the sphenoid region is mandatory. In our opinion, the classiï¬cation presented in this study can be useful in order to avoid surgical complications.

Despite the high prevalence of chronic rhinosinusitis (CRS) and its impact on patients' quality of life, no European patient organization that advocates for patients with CRS currently exists. To fill this gap and give a voice to CRS patients, EUFOREA has created a patient advisory board, whose goal is to better understand the real-life needs of patients, to raise awareness at political level and to involve patients in the development of novel integrated solutions to accelerate access to accurate diagnosis and treatments. This report summarizes the key discussion points from the kick-off meeting of the board on the 8th June 2018 and provides an outline of the key objectives for the future.

The accurate diagnosis of rhinologic disease depends on the clinical history, examination findings and, in many cases, further investigations. There are a wide variety of diagnostic tests available, the choice of which depends upon the condition being assessed. This position paper is intended to provide an up-to-date comprehensive description of the diagnostic tools available to rhinologists, allergists, general otolaryngologists and other physicians with an interest in sinonasal disease. The literature has been reviewed and evidence-based recommendations are included. The relevant history and examination techniques are described, including endoscopic assessment of the nose. General and disease-specific quality of life instruments are an important tool in assessing the impact of rhinologic disease and the response to treatment. Relevant blood tests are discussed, as well as the various methods of allergy testing. Techniques for collecting microbiological and tissue samples are described, as well as the use of more specialised tests such as nasal nitric oxide and those evaluating ciliary structure and function. Imaging techniques and their indications are included. Chemosensory (smell and taste) testing is explained, and the available techniques for objective measurement of nasal airflow and patency are reviewed. Prompt and accurate diagnosis allows appropriate management to be initiated; an understanding of the currently available diagnostic tools is a vital part of the assessment of rhinologic disease.

Background: The European Position Papers on Rhinosinusitis from 2005, 2007 and 2012 have had a measurable impact on the way this common condition with high impact on quality of life is managed around the world. EPOS2020 will be the latest iteration of the guideline, addressing new stakeholders and target users, presenting a summary of the latest literature and evolving treatment modalities, and formulating clear recommendations based on all available evidence., Methodology: Based on the AGREE II framework, this article demonstrates how the EPOS2020 steering group will address six key areas to ensure consistency in quality and presentation of information in the latest rhinosinusitis clinical practice guideline: scope and purpose; stakeholder involvement; rigour of development; clarity of presentation; recommendations and applicability; editorial independence., Results: By analysing the guidance from AGREE II, we formulated a detailed development strategy for EPOS2020. We identify new stakeholders and target users and ratify the importance of patient involvement in the latest EPOS guideline. New and expanded areas of research to be addressed are highlighted. We confirm our intention to use mixed methodologies, combining evidence-based medicine with real life studies; when no evidence can be found, use Delphi rounds to achieve clear, inclusive recommendations. We also introduce new concepts for dissemination of the guideline, using Internet and social media to improve accessibility., Conclusion: This article is an introduction to the EPOS2020 project, and presents the key goals, core stakeholders, planned methodology and dissemination strategies for the latest version of this influential guideline.

Aims: Mobile Airways Sentinel NetworK (MASK) belongs to the Fondation Partenariale MACVIA-LR of Montpellier, France and aims to provide an active and healthy life to rhinitis sufferers and to those with asthma multimorbidity across the life cycle, whatever their gender or socio-economic status, in order to reduce health and social inequities incurred by the disease and to improve the digital transformation of health and care. The ultimate goal is to change the management strategy in chronic diseases., Methods: MASK implements ICT technologies for individualized and predictive medicine to develop novel care pathways by a multi-disciplinary group centred around the patients., Stakeholders: Include patients, health care professionals (pharmacists and physicians), authorities, patient's associations, private and public sectors., Results: MASK is deployed in 23 countries and 17 languages. 26,000 users have registered., Eu Grants 2018: MASK is participating in EU projects (POLLAR: impact of air POLLution in Asthma and Rhinitis, EIT Health, DigitalHealthEurope, Euriphi and Vigour)., Lessons Learnt: (i) Adherence to treatment is the major problem of allergic disease, (ii) Self-management strategies should be considerably expanded (behavioural), (iii) Change management is essential in allergic diseases, (iv) Education strategies should be reconsidered using a patient-centred approach and (v) Lessons learnt for allergic diseases can be expanded to chronic diseases.

Mobile health technology is emerging to take a prominent position in the management of chronic diseases. These technologies aim at enhancing patient empowerment via education and self-management. To date, of all the different apps available for patients with sinus disease, none were developed by medical experts dealing with chronic rhinosinusitis (CRS). The European Forum for Research and Education in Allergy and Airway diseases (EUFOREA) has undertaken a multi-stakeholder approach for designing, developing and implementing a tool to support CRS patients in monitoring their symptoms and to provide patients with a digital support platform containing reliable medical information about their disease and treatment options. mySinusitisCoach has been developed by medical experts dealing with CRS in close collaboration with patients, primary care physicians and community pharmacists, meeting the needs of both patients and health care providers. From a research perspective, the generation of real life data will help to validate clinical studies, patient stratification and improve understanding of the socio-economic impact of CRS, thereby paving the way for better treatment strategies.

Background: Large observational implementation studies are needed to triangulate the findings from randomized control trials as they reflect "real-world" everyday practice. In a pilot study, we attempted to provide additional and complementary insights on the real-life treatment of allergic rhinitis (AR) using mobile technology., Methods: A mobile phone app (Allergy Diary, freely available in Google Play and Apple App stores) collects the data of daily visual analog scales (VAS) for (i) overall allergic symptoms, (ii) nasal, ocular, and asthma symptoms, (iii) work, as well as (iv) medication use using a treatment scroll list including all medications (prescribed and over the counter (OTC)) for rhinitis customized for 15 countries., Results: A total of 2871 users filled in 17 091 days of VAS in 2015 and 2016. Medications were reported for 9634 days. The assessment of days appeared to be more informative than the course of the treatment as, in real life, patients do not necessarily use treatment on a daily basis; rather, they appear to increase treatment use with the loss of symptom control. The Allergy Diary allowed differentiation between treatments within or between classes (intranasal corticosteroid use containing medications and oral H1-antihistamines). The control of days differed between no [best control], single, or multiple treatments (worst control)., Conclusions: This study confirms the usefulness of the Allergy Diary in accessing and assessing everyday use and practice in AR. This pilot observational study uses a very simple assessment (VAS) on a mobile phone, shows novel findings, and generates new hypotheses., (© 2018 EAACI and John Wiley and Sons A/S. Published by John Wiley and Sons Ltd.)

Background: Multimorbidity in allergic airway diseases is well known, but no data exist about the daily dynamics of symptoms and their impact on work. To better understand this, we aimed to assess the presence and control of daily allergic multimorbidity (asthma, conjunctivitis, rhinitis) and its impact on work productivity using a mobile technology, the Allergy Diary., Methods: We undertook a 1-year prospective observational study in which 4 210 users and 32 585 days were monitored in 19 countries. Five visual analogue scales (VAS) assessed the daily burden of the disease (i.e., global evaluation, nose, eyes, asthma and work). Visual analogue scale levels <20/100 were categorized as "Low" burden and VAS levels ≥50/100 as "High" burden., Results: Visual analogue scales global measured levels assessing the global control of the allergic disease were significantly associated with allergic multimorbidity. Eight hypothesis-driven patterns were defined based on "Low" and "High" VAS levels. There were <0.2% days of Rhinitis Low and Asthma High or Conjunctivitis High patterns. There were 5.9% days with a Rhinitis High-Asthma Low pattern. There were 1.7% days with a Rhinitis High-Asthma High-Conjunctivitis Low pattern. A novel Rhinitis High-Asthma High-Conjunctivitis High pattern was identified in 2.9% days and had the greatest impact on uncontrolled VAS global measured and impaired work productivity. Work productivity was significantly correlated with VAS global measured levels., Conclusions: In a novel approach examining daily symptoms with mobile technology, we found considerable intra-individual variability of allergic multimorbidity including a previously unrecognized extreme pattern of uncontrolled multimorbidity., (© 2018 EAACI and John Wiley and Sons A/S. Published by John Wiley and Sons Ltd.)

Background: Collecting data on the localization of users is a key issue for the MASK (Mobile Airways Sentinel networK: the Allergy Diary) App. Data anonymization is a method of sanitization for privacy. The European Commission's Article 29 Working Party stated that geolocation information is personal data.To assess geolocation using the MASK method and to compare two anonymization methods in the MASK database to find an optimal privacy method., Methods: Geolocation was studied for all people who used the Allergy Diary App from December 2015 to November 2017 and who reported medical outcomes. Two different anonymization methods have been evaluated: Noise addition (randomization) and k-anonymity (generalization)., Results: Ninety-three thousand one hundred and sixteen days of VAS were collected from 8535 users and 54,500 (58.5%) were geolocalized, corresponding to 5428 users. Noise addition was found to be less accurate than k-anonymity using MASK data to protect the users' life privacy., Discussion: k-anonymity is an acceptable method for the anonymization of MASK data and results can be used for other databases., Competing Interests: No ethical committee was required for the study.Not needed. JB reports personal fees and other from Chiesi, Cipla, Hikma, Menarini, Mundipharma, Mylan, Novartis, Sanofi-Aventis, Takeda, Teva, Uriach, other from Kyomed, outside the submitted work.RA reports grants from North Portugal Regional Operational Programme (NORTE 2020), under the PORTUGAL2020 Partnership Agreement and through the European Regional Development Fund (ERDF), during the conduct of the study.AC reports grants and personal fees from GlaxoSmithKline, personal fees from Boehringer Ingelheim, MEDA Pharma, CHIESI, AstraZeneca, om Merck, Sharp & Dohme, Novartis EUROFARMA outside the submitted work.H reports personal fees from Munidpharma, Novartis, OrionPharma, outside the submitted work. PK reports personal fees from Adamed, Boehringer Ingelheim, AstraZeneca, Chiesi, FAES, Berlin Chemie, Novartis, Polpharma, Allergopharma, outside the submitted work.V.K has received payment for consultancy from GSK and for lectures from StallergensGreer, Berlin-CHemie outsaide the submitted work.LL reports personal fees from MSD, Pfizer, GSK, Astrazeneca, MEDA, Boehringer Ingelheim, Novartis, Grunenthal, UCB, TEVA, Amstrong, Siegfried, DBV Technologies, grants from Sanofi, Pfizer, Astrazeneca, Novartis, UCB, outside the submitted work.RM reports personal fees from ALK, allergopharma, Allergy Therapeutics, Bayer, Friulchem, FAES, GSK, Hexal, Servier, Klosterfrau, MSD, Johnson&Johnson, Meda, Stada, UCB, Nuvo; grants and personal fees from Bencard, Stallergenes; grants from Leti, Optima, ASIT biotech, BitopAG, Hulka, Ursapharm; grants, personal fees and non-financial support from Lofarma; non-financial support from Atmos, Roxall, Bionorica, Otonomy, Ferrero; personal fees and non-financial support from Novartis; outside the submitted work.NGP reports personal fees from Abbvie Novartis, Faes Farma, BIOMAY, HAL, Nutricia Research, Menarini, Novartis, MEDA, MSD, Omega Pharma, Danone, grants from Menarini, outside the submitted work.0P reports grants and personal fees from ALK-Abelló, Allergopharma, Stallergenes Greer, HAL Allergy Holding B.V./HAL Allergie GmbH, Bencard Allergie GmbH/Allergy Therapeutics, Lofarma, Biotech Tools S.A., Laboratorios LETI/LETI Pharma, Anergis S.A., grants from Biomay, Nuvo, Circassia, Glaxo Smith Kline, personal fees from Novartis Pharma, MEDA Pharma, Mobile Chamber Experts (a GA2LEN Partner), Pohl-Boskamp, Indoor Biotechnologies, grants from, outside the submitted work.RS reports grants from São Paulo Research Foundation, MSD, grants and personal fees from Novartis, grants, personal fees and non-financial support from AstraZeneca, Chiesi, personal fees and non-financial support from Boheringer Ingelheim, outside the submitted work.TBAM reports grants and personal fees from Novartis, Boehringer Ingelheim, Mundipharma, GSK (GlaxoSmithKline), personal fees from Teva Pharma, AstraZeneca, grants from Leti, outside the submitted work. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

The vision of European Academy of Allergy and Clinical Immunology (EAACI) and the Union of European Medical Specialists Section and Board on allergology is to promote and to establish a full specialty of allergology in all European countries. In many European countries, a full specialty does not exist. In those countries, organ-based (sub)specialists or paediatricians and internists with an expertise in allergology may deliver allergy care. There are no generally accepted requirements for the training of subspecialists available. To fill the gap between the need and availability of experienced and accredited physicians who can deliver optimal care to the allergic patients, the EAACI Specialty Committee proposes the minimal requirements for training and certification of subspecialists in allergology. This paper describes the required theoretical knowledge, skills, competences and training facilities (staff and institution). The subspecialist as described in this paper should ideally show the necessary competence in providing good quality care to patients in an environment lacking those full specialists in allergology or tertiary care paediatric subspecialists in allergy., (© 2017 EAACI and John Wiley and Sons A/S. Published by John Wiley and Sons Ltd.)

Mobile technology has been used to appraise allergic rhinitis control, but more data are needed. To better assess the importance of mobile technologies in rhinitis control, the ARIA (Allergic Rhinitis and its Impact on Asthma) score ranging from 0 to 4 of the Allergy Diary was compared with EQ-5D (EuroQuol) and WPAI-AS (Work Productivity and Activity Impairment in allergy) in 1288 users in 18 countries. This study showed that quality-of-life data (EQ-5D visual analogue scale and WPA-IS Question 9) are similar in users without rhinitis and in those with mild rhinitis (scores 0-2). Users with a score of 3 or 4 had a significant impairment in quality-of-life questionnaires., (© 2017 EAACI and John Wiley and Sons A/S. Published by John Wiley and Sons Ltd.)

Background: Visual Analogue Scale (VAS) is a validated tool to assess control in allergic rhinitis patients., Objective: The aim of this study was to validate the use of VAS in the MASK-rhinitis (MACVIA-ARIA Sentinel NetworK for allergic rhinitis) app (Allergy Diary) on smartphones screens to evaluate allergic rhinitis symptoms and disease control., Methods: Each user filled 4 different VAS measuring overall, nasal, ocular, and asthma symptoms at least once. Following COSMIN guidelines, we evaluated internal consistency, (Cronbach's alpha coefficient and test-retest), reliability (intraclass correlation coefficients), sensitivity, and acceptability of the MASK-Rhinitis VAS., Results: Between 1 August 2015 and 31 July 2016, the app was used 14 612 times in 15 countries. A total of 1225 users used it more than once, during the evaluated period. The tool resulted to be statistically satisfactory, showing excellent internal consistency (Cronbach's test > 0.84, test-retest > 0.7), reliability (>0.9), and acceptability. In addition, the tool had a good sensitivity when users (n = 521) answered the VAS twice in less than 3 hours., Conclusions and Clinical Relevance: The MASK-rhinitis VAS is a reliable and valid tool to assess allergic control on smartphone screens, at the population level., (© 2017 John Wiley & Sons Ltd.)

A Good Practice is a practice that works well, produces good results, and is recommended as a model. MACVIA-ARIA Sentinel Network (MASK), the new Allergic Rhinitis and its Impact on Asthma (ARIA) initiative, is an example of a Good Practice focusing on the implementation of multi-sectoral care pathways using emerging technologies with real life data in rhinitis and asthma multi-morbidity. The European Union Joint Action on Chronic Diseases and Promoting Healthy Ageing across the Life Cycle (JA-CHRODIS) has developed a checklist of 28 items for the evaluation of Good Practices. SUNFRAIL (Reference Sites Network for Prevention and Care of Frailty and Chronic Conditions in community dwelling persons of EU Countries), a European Union project, assessed whether MASK is in line with the 28 items of JA-CHRODIS. A short summary was proposed for each item and 18 experts, all members of ARIA and SUNFRAIL from 12 countries, assessed the 28 items using a Survey Monkey-based questionnaire. A visual analogue scale (VAS) from 0 (strongly disagree) to 100 (strongly agree) was used. Agreement equal or over 75% was observed for 14 items (50%). MASK is following the JA-CHRODIS recommendations for the evaluation of Good Practices.

Allergic rhinitis often impairs social life and performance. The aim of this cross-sectional study was to use cell phone data to assess the impact on work productivity of uncontrolled rhinitis assessed by visual analogue scale (VAS). A mobile phone app (Allergy Diary, Google Play Store and Apple App Store) collects data from daily visual analogue scales (VAS) for overall allergic symptoms (VAS-global measured), nasal (VAS-nasal), ocular (VAS-ocular) and asthma symptoms (VAS-asthma) as well as work (VAS-work). A combined nasal-ocular score is calculated. The Allergy Diary is available in 21 countries. The app includes the Work Productivity and Activity Impairment Allergic Specific Questionnaire (WPAI:AS) in six EU countries. All consecutive users who completed the VAS-work from 1 June to 31 October 2016 were included in the study. A total of 1136 users filled in 5818 days of VAS-work. Symptoms of allergic rhinitis were controlled (VAS-global <20) in approximately 60% of the days. In users with uncontrolled rhinitis, approximately 90% had some work impairment and over 50% had severe work impairment (VAS-work >50). There was a significant correlation between VAS-global calculated and VAS-work (Rho=0.83, P<0.00001, Spearman's rank test). In 144 users, there was a significant correlation between VAS-work and WPAI:AS (Rho=0.53, P<0.0001). This pilot study provides not only proof-of-concept data on the work impairment collected with the app but also data on the app itself, especially the distribution of responses for the VAS. This supports the interpretation that persons with rhinitis report both the presence and the absence of symptoms., (© 2017 EAACI and John Wiley and Sons A/S. Published by John Wiley and Sons Ltd.)

Background: The use of Apps running on smartphones and tablets profoundly affects medicine. The MASK-rhinitis (MACVIA-ARIA Sentinel NetworK for allergic rhinitis) App (Allergy Diary) assesses allergic rhinitis symptoms, disease control and impact on patients' lives. It is freely available in 20 countries (iOS and Android platforms)., Aims: To assess in a pilot study whether (i) Allergy Diary users were able to properly provide baseline characteristics (ii) simple phenotypic characteristics based upon data captured by the Allergy Diary could be identified and (iii) information gathered by this study could suggest novel research questions., Methods: The Allergy Diary users were classified into six groups according to the baseline data that they entered into the App: (i) asymptomatic; (ii) nasal symptoms excluding rhinorrhea; (iii) rhinorrhea; (iv) rhinorrhea plus 1-2 nasal/ocular symptoms; (v) rhinorrhea plus ≥3 nasal/ocular symptoms; and (vi) rhinorrhea plus all nasal/ocular symptoms., Results: By 1 June 2016, 3260 users had registered with the Allergy Diary and 2710 had completed the baseline questionnaire. Troublesome symptoms were found mainly in the users with the most symptoms. Around 50% of users with troublesome rhinitis and/or ocular symptoms suffered work impairment. Sleep was impaired by troublesome symptoms and nasal obstruction., Conclusions: This is the first App (iOS and Android) to have tested for allergic rhinitis and conjunctivitis. A simple questionnaire administered by cell phones enables the identification of phenotypic differences between a priori defined rhinitis groups. The results suggest novel concepts and research questions in allergic rhinitis that may not be identified using classical methods., (© 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

The Allergic Rhinitis and its Impact on Asthma (ARIA) initiative commenced during a World Health Organization workshop in 1999. The initial goals were (1) to propose a new allergic rhinitis classification, (2) to promote the concept of multi-morbidity in asthma and rhinitis and (3) to develop guidelines with all stakeholders that could be used globally for all countries and populations. ARIA-disseminated and implemented in over 70 countries globally-is now focusing on the implementation of emerging technologies for individualized and predictive medicine. MASK [MACVIA ( Contre les Maladies Chroniques pour un Vieillissement Actif )-ARIA Sentinel NetworK] uses mobile technology to develop care pathways for the management of rhinitis and asthma by a multi-disciplinary group and by patients themselves. An app (Android and iOS) is available in 20 countries and 15 languages. It uses a visual analogue scale to assess symptom control and work productivity as well as a clinical decision support system. It is associated with an inter-operable tablet for physicians and other health care professionals. The scaling up strategy uses the recommendations of the European Innovation Partnership on Active and Healthy Ageing. The aim of the novel ARIA approach is to provide an active and healthy life to rhinitis sufferers, whatever their age, sex or socio-economic status, in order to reduce health and social inequalities incurred by the disease.

Our goal in treating chronic rhinosinusitis (CRS) is to reduce sinonasal symptoms and improve quality of life (QoL). In patients with CRS, sinonasal symptoms have a significant impact on QoL. Various validated measures exist to quantify QoL such as the 22-item Sinonasal Outcomes Test (SNOT- 22) and MSNOT-20 Young Persons Questionnaire (MSYPQ) specific to CRS, while others measure general QoL, such as the EuroQol 5-Dimensional general health-related QoL survey (EQ5D).

Background: Inverted papilloma (IP) is a benign lesion of the sinonasal tract. Clinical problems arise from expansive growth and bone destruction, a possible association with malignancy and a tendency to recur. Complete subperiostal/subperichondral removal via endoscopic sinus surgery (ESS) is the treatment of choice. The purpose of this study was to evaluate the theory of an elevated recurrence rate after secondary resection., Patients and Methods: The retrospective analysis comprised 66 patients, who were treated for IP at the University Clinic of Otorhinolaryngology Graz between 2000 and 2011. The mean follow-up was 33.85 months. 18 patients were lost to follow-up., Results: The study group consisted of 51 males and 15 females. 65 (98.5%) of which had been operated on purely endoscopic or via a combined approach. Recurrence was diagnosed in 14 cases (29.2%), on average 11.9 months after surgery, 71.5% of these in the first 12 months. The recurrence rate was significantly higher after revision surgery (50%) when patients had been previously operated elsewhere as compared to primary resection (12%). The analysis also showed a significant increase in recurrences for Krouse stages 3 and 4., Conclusion: The collected data confirms ESS as the best treatment option. Due to recurrences and malignant transformation, follow-up should be performed within 5 years postoperatively. We could statistically verify the prognostic value of Krouse's staging system. The elevated recurrence rate after secondary resection emphasises the significance of removing the tumour completely during the first surgery., (© Georg Thieme Verlag KG Stuttgart · New York.)

The anterior wall of the maxillary sinus represents a blind spot in maxillary sinus endoscopic surgery because of the absence of proper visualisation and instrumentation to reach it. The aim of this study was to validate a new approach through the oral cavity into the nose with a flexible video endoscope (oro-nasal endoscopic approach; ONEA) to visualise the entire anterior maxillary wall including the anteromedial angle. We started from a dried bone cadaver model, and then dissected fresh-frozen cadavers. The maxillary sinus was explored with a rigid and a flexible endoscope entering from the nose. Next, a flexible endoscope was introduced through the mouth and back up through the choana, it accessed the maxillary middle antrostomy, entering inside the sinus and looking at the anterior wall. A small ruler inserted inside the sinus demonstrated all the angles visualised. The new ONEA technique allows complete visualisation of the anterior wall of the maxillary sinus with inspection of all blind spots. It is therefore possible to detect lesions that would normally not be visible with a normal rigid endoscope. We demonstrate the validity of a novel technique that allows visualisation of the infero-medial angle of the anterior wall of the maxillary sinus.

Background: Balloon sinuplasty (BSP) is a catheter-based technique to dilate sinus ostia and drainage pathways to create ventilation and drainage. The aim of this study was to evaluate the feasibility of BSP in routine treatment of patients suffering from chronic rhinosinusitis (CRS)., Methodology: Patients with CRS refractory to medical therapy who had been scheduled for endoscopic sinus surgery between 2009 and 2011 were included in this study., Results: Forty-five consecutive patients were included in this study, in whom 112 sinuses were approached by BSP. Of the 112 sinuses, 68 (60%) were planned as a "Balloon-Only" procedure and 44 (40%) were planned as a "Hybrid" procedure. Of the 68 sinuses in the "Balloon-Only" group, in 44 sinuses BSP failed, equating to a failure rate of 65%. Forty-four sinuses were planned for "Hybrid" procedures. In 29 of these sinuses BSP failed, giving a failure rate of 66%., Conclusion: According to literature, BSP can be a useful adjunct technique to standard FESS. In our experience, however, a failure rate of 65% for "Balloon-Only" and of 66% for "Hybrid" procedures occurred, which was regarded as unacceptable by the study group. Therefore, the study initially scheduled for 200 consecutive patients, was abandoned.

Objective: Cholesterol granulomas are benign lesions that sometimes occur on the petrous apex (PA). We report our experience using an endoscopic endonasal approach to remove PA cholesterol granulomas., Material and Methods: A retrospective patient chart analysis was conducted at a tertiary care university hospital., Results: Four patients (3 females, 1 male) were included in this study. Patients' ages ranged from 27 to 78 years. Computed tomography (CT) and magnetic resonance imaging (MRI) for diagnosis and computer-assisted navigation were performed. The most common symptom was abducens nerve palsy. The largest granuloma measured 5 x 2 cm and was located on the left side. An endoscopic endonasal approach was chosen and navigation was applied (3/4 patients) to identify the optimal area for opening the granuloma. No complications occurred, and patients were free from recurrence during the follow-up period., Conclusion: The endoscopic endonasal approach to PA cholesterol granulomas is feasible and safe. Intra-operative navigation is recommended to identify the position of the internal carotid artery and determine the safest area for opening the granuloma without damaging the artery. Another advantage of this approach is an easier follow-up through diagnostic nasal endoscopy.

Introduction: Arnold Chiari Malformation Type II can be associated with basilar invagination through an elongated retroflexed odontoid process (dens axis). Traditionally, decompression surgery has been performed transorally under microscopic vision or via transcutaneous latero-cervical/posterior approaches. Endoscopic approaches were introduced a few years ago., Case Report: We report of an eleven-year-old girl with Arnold Chiari Malformation Type II who had undergone surgery eight years ago for posterior cranial fossa decompression at the department of neurosurgery. At that time, an external transcutaneous median approach was performed to resect the posterior arch of the atlas. The patient now presented with the initial symptoms of brainstem compression as a result of an elongated retroflexed odontoid process and craniocervical instability., Surgical Technique: An endoscopic transoral/transnasal approach was chosen for the resection of the dens., Conclusion: Endoscopic surgery was successful and the complete resection of the dens was achieved without any complications. In a second intervention, orthopaedic surgeons performed cranio-cervical arthrodesis.

Objectives: To increase awareness of neuroendocrine adenomas of the middle ear (NAME), rare lesions often mistaken for other entities or chronic otitis media. Histogenesis remains controversial, although the consensus tends toward a pluripotent stem cell of the middle ear mucosa as the origin of the lesion. The tumour is characterised by dual differentiation with exocrine and endocrine components. The most common symptoms are conductive hearing loss, tinnitus and vertigo. The treatment of choice is complete surgical removal of the tumour with no adjuvant radiotherapy being required., Case Report: We report the case of a 23-year-old man presenting with chronic otitis media, conductive hearing loss, vertigo and tinnitus who, some years previously, had suffered from an episode of facial nerve palsy. Conservative therapy failed and so surgery was performed. Tumour-like masses were encountered and histological and immunohistochemical examination revealed a neuroendocrine adenoma of the middle ear., Conclusion: This rare entity should be considered as differential diagnosis when treating chronic inflammatory disease not responding to conservative therapy or dealing with unclear expansive processes of the middle ear. MRI scans should be performed since CT scans are inconclusive.

Introduction: Though clear indications for its clinical application are not established yet, balloon sinuplasty technology per se is considered safe and very few severe complications have been mentioned in literature as of today., Case Report: We report the case of a 36-year-old female patient who presented with right sided rhinorrhea from a CSF-leak in the ethmoidal roof after balloon sinuplasty, aimed at her right frontal sinus. Apparently, the surgeon was unaware of having penetrated the skull base through the lateral lamella of the cribriform plate intraoperatively. CSF rhinorrhea became evident 3 weeks postoperatively only when fever, headaches and moderate nausea developed. Upon revision, diameter, size and shape of the bony defect exactly matched with the tip of a standard sinus balloon catheter device, as could be demonstrated and documented. A small posttraumatic encephalocele had intermittently blocked the leak. Endoscopic surgery and duraplasty were performed under intrathecal fluorescein control, applying CT image-guided navigation. Since two-layer fascia lata closure of the defect, the patient has remained free of symptoms without any evidence of CSF leakage., Conclusion: Balloon sinuplasty per se is considered a safe technique, though in inexperienced hands or wrongly applied, complications may occur, as with any surgical tool rigid enough to breach through skull base.