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C. M. McLarnon
septal deformities are a more accepted reason for
considering surgical correction in childhood
compared to cosmetic considerations. These
should include:
• Symmetry of the nostrils and midline position
of the columella and anterior septum.
• Shape and alignment of the nasal tip and dorsum—palpation is important to assess for tip
and dorsal support.
• Consideration of the relation of the nose to the
maxilla and overall facial symmetry.
• Check/look for alar collapse on inspiration—
weak external nasal valve (very rare in children due to strong soft tissues)
• Septal deviations
• Inferior turbinate size and appearance
• Checking of nasopharynx for any persisting
adenoidal hypertrophy
• Assessment for any other intra-nasal polyps/
masses
According to the author’s opinion, children
aged 7years old (and sometimes younger) will,
in general, accept nasoendoscopy with preprocedure topical anaesthesia spray and an honest and reassuring explanation of the process.
Rhinometry to assess nasal airway compe-
tency could be considered but clinically has little
to add to the clinical assessment. Similarly, radiological investigation is rarely indicated unless to
assess a more complex congenital deformity or
complex nasofacial injury.
thetic and/or functional problems do manifest
later, resulting to the child being referred to a
specialist, often several years after the injury. The
decision whether a surgical intervention is indicated, at what age and which surgical technique
will then require careful consideration. In many
cases a ‘wait and see’ policy might be preferable
and surgery even postponed until after the adolescent growth spurt. As many surgeons do opt to
wait, there is still a paucity of evidence to support
clinical decisions. Many of the experiments following nasal growth after injuries and/or surgical
interventions are in animals (usually rabbit) or
case reports, thus making it difcult to extrapolate to current-day decision-making. Sarnat and
his co-workers published many experimental
studies on rabbit midfacial growth patterns noting the impact that resection, particularly of the
anterior septum, had on snout growth [8–10].
The decision-making process when counselling children and their caregivers can be complex
and should include a discussion on:
1. the end goal—cosmetic vs functional
outcome,
2. avoidance of doing harm by disrupting nor-
mal nasofacial growth,
3. context of child’s current environment—love
of sports, risk of further injury, and
4. psychological aspects—teenagers can be very
concerned with their appearance and issues
with body condence and peer pressure are
not uncommon.
Nasal Trauma inChildren
Trauma to the nose is common in children, and in
many cases if the child is otherwise well, it is part
and parcel of the minor knocks and bumps children incur in daily life; for example, trips and
falls when running around, falling off bicycles
and scooters, playing around with siblings, etc.
As such, only a minority of cases will lead to the
child being brought to the Emergency Department
for review. Therefore, it is easy to understand
why many injuries of the nasal skeleton are not
diagnosed or treated at the time. However, aes-
The age of the ‘sele’ photograph has led to
many children and adolescents overanalysing
and becoming very concerned about the size,
symmetry and shape of their nose, when in fact
there is often no signicant or concerning deformity. During the adolescent growth spurt, the
nose, in keeping with the rest of the body, does
undergo signicant physical changes into the
‘adult’ body. It is during this time that the nose
takes on its adult appearance, which may include
inherited and normal ethnic morphology, which
can cause distress and lead to requests for surgery
in some children and/or their caregivers. Purely
cosmetic Rhinoplasty surgery in otherwise
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235
healthy children is a contentious issue with many
interplaying factors including psychosocial
impact and private cosmetic surgical practice.
Ultimately, as surgeons we have a duty to do no
harm and as such extreme caution should be
given to consideration of such surgery in preadolescent children.
Septoplasty
Many of the injuries more typically incurred by
children usually involve damage to the nasal septum. Injuries include septal fractures and dislocations. Septal haematomas can also result, posing
the risk of septal perforation and abscess development if left untreated. The underlying cartilage
takes its blood supply from the overlying mucoperichondrium, so when this is disrupted, such as
in a septal haematoma or abscess, then the underlying cartilage may undergo necrosis, leaving a
septal perforation. Septal perforations can have
disastrous effects both functionally and
cosmetically.
Poor outcomes of septum surgery (septoplasty) in children were described over 100years
ago by Hayton using submucous resection [11].
Other similar reports up to the 1940s led to
extreme caution in dealing with nasal anomalies
in young children. During the mid-twentieth century, however, a resurgence of surgical approaches
to the septum resumed with some preliminary
successful reports of septoplasty published.
However, the reports varied considerably, and
most were too short a follow up in relation to the
adolescent growth spurt. In the 1970s, Huizing
followed 150 children up after septoplasty and
described for the rst time a boy who had surgery
at the age of 4years and developed characteristic
midfacial disturbances following puberty, more
than 12years after his surgery [12].
Therefore, in younger pre-pubertal children,
the decision to operate on the nasal septum must
be carefully balanced with the deformities and
functional problems that result in nasal airway
obstruction. A signicant traumatic septal deviation and/or dislocation in a young child can go on
to form a complex situation as the child grows,
leaving not just the resultant septal deformity but
also its adverse effects on nasal growth. These
can include asymmetric nasal growth and midfacial stunted growth. Learnings from previous
case series reports and animal studies include the
following:
• Preservation of the septodorsal cartilage in the
growing nose and avoidance of resection
wherever possible is vital.
• Autologous cartilage grafts are best, but these
heal by forming brous unions and sometimes
lamellar bone remodelling can occur.
• Proper end-to-end anastomosis of cartilaginous septum/autologous graft is critical to preventing surgery-induced growth anomalies in
the long run.
• Submucosal implants of cartilage including
crushed cartilage do not restore normal septal
growth or midfacial development.
• Nasal septal cartilage scoring is unreliable
(scoring techniques are used to encourage
cartilage to deviate away from scored side)
and can lead to weakening of the cartilage.
Long- term outcomes of this technique are
not known.
Septal Perforation
The most common aetiologies of nasal septal
perforation in children are trauma, nasal cautery
and, more recently, button battery insertion. A
summary of potential causes is given below:
Most likely causes:
• Trauma: direct nasal injury.
• Iatrogenic: cauterisation for epistaxis, septoplasty, nasotracheal intubation.
• Small batteries insertion: button batteries
pose a serious risk as they start to corrode
on contact with the moist epithelium inside
the nose and can lead to alkaline burns with
rapid tissue necrosis. This can progress on
to septal perforation, so any child presenting with the possibility of a battery in the
nose should be treated as a medical
emergency.
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C. M. McLarnon
Uncommon causes to be considered in the differential diagnosis:
• Cocaine use should be considered in adolescents, especially in their late teenage years
(but legally still referred to as children).
• Nasal packing: very unusual now that rm
packing is rarely used in children.
• Chronic use of vasoconstrictor nasal sprays
and, in rare cases, steroid nasal sprays.
• Granulomatous lesions: rare reports can be
found in cases of childhood onset granulomatosis with polyangiitis (previously known as
Wegner’s granulomatosis) [13].
• Neoplastic lesions are quite rare.
Nose picking is common in children and as a
consequence, digital trauma is often cited as
being a common cause of septal perforation, but
in reality, the pathogenesis is unlikely to be as
simple as this. Nose picking is a natural response
to clear irritating crusts. Local mucosal trauma
may well induce chronic perichondritis that eventually leads to septal perforation. The simple
explanation of scratching through the sensitive
mucosa and exposed cartilage would be very
painful, induce bleeding and be highly unlikely.
However, there is a rare psychiatric disorder,
called rhinotillexomania, in which the patient
repeatedly picks at the nasal septum, but most
publications are single case reports in adults.
The site of the perforation in children usually
involves the anterior nasal septum. Anterior perforations are typically more symptomatic and can
present with nasal crusting, bleeding and nasal
obstruction. Perforations in early childhood have
been reported to adversely affect nasal and midfacial growth both in clinical case reports and in
animal studies [14]. Larger perforations can also
lead to supratip depression.
Management options for septal perforations in
children include medical management, septal
button and surgical closure. The choice of treatment is complex and involves consideration of
the symptoms and age of the child in discussion
with the child and his/her caregivers. It is also
important to consider the aetiology of the perforation, co-morbidities, ability to comply with
post-operative care/restrictions, availability of
adjacent tissue/grafts and potential effects on
nasal growth. Generally, septal perforations that
are asymptomatic and stable in size can be managed expectantly until the child reaches the end
of their pubertal growth spurt and with the child’s
informed consent. Larger, symptomatic perforations that have failed medical management
(avoidance of picking nose, nasal saline douches
and topical antibiotic cream) may be considered
for surgical correction. There is a paucity of longterm outcome data to recommend the best modality in children and adolescents. Endonasal and
open approach techniques have been used in children with the use of pedicled aps and interposition cartilage to repair the defect.
Nasal Fracture
Assessing the child following nasal trauma can
be difcult due to the small nose and the immediate resultant soft tissue swelling. However, in any
case of trauma, the child should also be assessed
for a potential head injury, additional facial and
orbital rim fractures and in rare cases consideration of non-accidental injury (NAI). NAI should
be considered where the described cause of injury
does not correspond with the clinical ndings,
delayed presentation, other signs of bruising or
neglect and a previous history of NAI.Any concerns should be referred to the local child protection ofcer or paediatrician to further investigate.
The risk of nasal fracture tends to increase with
age and is also more common in boys.
Symptoms and signs of nasal fracture are as
follows:
• Nosebleed
• Swelling
• Bruising around nose and under eye
• Tenderness
• Crepitus on palpation
• Blocked nose
• Nasal deformity
Ideally, the child should be reviewed 5–7days
following injury to better assess for any persisting deformity. In younger children (pre-puberty),
18 Paediatric Nasal Deformity
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nasal bone injuries are less likely than cartilaginous ones but should be assessed for—particularly dehiscence of the nasal bone sutures. Plain
X-rays are not useful in helping evaluate or diagnose a nasal bone fracture; however, CT scan
may be considered in cases of more severe injury
where other facial/orbital/head injuries may be
suspected. Closed reduction of the nasal fracture
under general anaesthesia should be offered and,
in general, the same techniques are used to
manipulate/reduce the nasal fracture as in adults.
This involves both elevation of a depressed nasal
dorsum along with external digital compression
of the nasal bones until a satisfactory position is
achieved. Post-operative external nasal splinting
may be considered depending on the stability of
the reduction.
Rhinoplasty
A detailed discussion on Rhinoplasty techniques
is out of the scope of this chapter and is a topic
that is still very much debated when managing
childhood deformities. Severe breathing difculties due to a deviated septum with signicant
external deviation, however, do present a clinical
dilemma. A signicant injury left untreated risks
the longer term nasal and midfacial growth problems already discussed, which needs to be balanced against the risk of operating in a child under
16 years. Less severe deformities and breathing
problems would be better monitored and surgery
postponed (especially where the injuries do not
progress to more severe problems) until the child
has passed their adolescent growth spurt and is
mature enough to better engage in the decisionmaking process. After reviewing the available literature, there are some key factors to consider
when a decision to perform a Rhinoplasty has
been made.
• Avoid resection or incisions of the septal cartilage, and most importantly, do not disrupt
the septal bony–cartilaginous junction. This is
often separated in adult Rhinoplasty practice
but could lead to signicant growth disruption
in childhood.
• Deviated or dislocated cartilaginous fragments
should be carefully re-aligned end to end.
• Avoid disruption of the anterior nasal spinal–
cartilaginous ligament as it anchors the septum midline and may cause disruption of
normal forward growth of the maxilla.
• Higher risk of injury to the skull base due to
variable ossication of the septum to skull
base, with risk of CSF leak and olfactory
dysfunction.
• Currently, there is no strong evidence to support open versus closed septorhinoplasty surgery in children. The least disruption to normal
anatomical support structures, however, would
support a closed approach. However, open
approaches have been used successfully in
even very young children to remove congenital
lesions such as nasal dermoid cysts, although
division of the intra- cartilaginous ligaments is
rarely needed in this situation.
Other factors also important to consider when
exploring the risks and benets of performing
septorhinoplasty in pre-adolescent children
include the following:
• Aftercare—keeping the splint clean and in place.
Attending post-operative visits is important.
• Social—risk of further injury after surgery.
Particular note should be taken of the child’s
sporting interests and general likelihood of
further accidents.
• Psychological: Body dysmorphic syndrome
and social peer pressures both in person and
via social media are increasing and sadly
occurring in younger children. Input from a
child psychologist prior to surgery may be
valuable when there is signicant anxiety
around the external nasal deformity.
• Conict between the child’s wishes and their
caregivers: In many cases the caregivers may
be pushing for early intervention despite the
child not expressing any signicant concerns
and vice versa.
• Experience of the surgeon: Rhinoplasty is
challenging and especially in pre-adolescent
children a referral to an experienced
Rhinoplasty surgeon should be made.
238
Anterior view Lateral view Oblique view
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Fig. 18.4 Preoperative ‘Rhinoplasty’ views
C. M. McLarnon
Basal view
Case Presentation 2
A 15-year-old boy was referred complaining of
worsening nasal obstruction and a bump on the
nasal dorsum following a nasal fracture during a
rugby game 2years prior. Examination ndings
included a prominent nasal dorsum, signicant
subluxation of nasal septum into left nasal airway
causing obstruction and reduced nasal tip support. His preoperative appearance is shown in
Fig.18.4.
After a detailed discussion of risks and benets, a closed septorhinoplasty was performed.
Surgical correction included reduction of a maxillary crest spur, re-alignment of the nasal septum
and reduction of the nasal hump followed by
medial and lateral osteotomies.
Conclusion
Nasal congenital deformities are rare, but an
understanding of how they may present and the
underlying embryology is important, especially
when planning any surgical interventions. Such
cases should be referred to specialists and/or
multidisciplinary teams where available because
of the complexity of these deformities.
Conversely, paediatric nasal trauma is relatively
common although the majority will not present to
medical services at the time of injury. Timing
corrective surgery to both the nasal septum and
nasal bones is still an area of controversy in children and adolescents, and ideally it is best performed by surgeons with signicant expertise in
septorhinoplasty surgery.
Key Learning Points
• Early closed reduction of a traumatic nasal
deformity should be offered.
• Septorhinoplasty surgery in pre-adolescent
children should be very carefully balanced
with the severity of the deformity and functional impact. A high level of surgical expertise and opinion should be sought.
• Congenital nasal deformities, especially when
associated with other craniofacial abnormalities, should be managed by a specialist multidisciplinary craniofacial team.
• The risk of future underdevelopment of the
midface and nose following nasal trauma
needs to be carefully weighed against the
same risk that surgical intervention may lead
to.
• To date, the evidence on the impact of both
trauma and surgery to the nose in childhood is
mostly based on animal studies and case/
series reports.
• A holistic approach to the child and his/her
nasal deformity is required in the decisionmaking process, including consideration of
the social, psychological and educational
18 Paediatric Nasal Deformity
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239
impact of the deformity and any surgical
intervention.
• Non-accidental injury in cases of trauma
should be considered.
• A button battery in the nose is a surgical
emergency.
References
1. Verwoerd CDA, Verwoerd-Verhoef HL.Rhinosurgery
in children: developmental and surgical aspects of the
growing nose. GMS Curr Topics Otorhinolaryngol
Head Neck Surg. 2010;9, ISSN: 1865-1011.
2. Van der Heijden P, Korsten-Meijer AG, van der
Laan BF, Wit HP, Goorhuis-Brouwer SM. Nasal
growth and maturation age in adolescents: a systematic review. Arch Otolaryngol Head Neck Surg.
2008;134(12):1288–93. https://doi.org/10.1001/
archoto.2008.501.
3. Zankl A, Eberle L, Molinari L, Schinzel A. Growth
charts for nose length, nasal protrusion and philtrum length from birth to 97 years. Am J Med
Genet. 2002;111:388–91. https://doi.org/10.1002/
ajmg.10472.
4. Genecov JS, Sinclair PM, Dechow PC.Development
of the nose and soft tissue prole. Angle Orthod.
1990;60(3):191–8.
5. Losee JE, Kirschner RE, Whitaker LA, et al.
Congenital nasal anomalies: a classication scheme.
Plastic Reconstr Surg. 2004;113:676–89.
6. Zawawi F, McVey MJ. The pathogenesis of choanal atresia. JAMA Otolaryngol Head Neck Surg.
2018;144(8):758–9.
7. Hengerer AS, Strome M. Choanal atresia: a new
embryologic theory and its inuence on surgical management. Laryngoscope. 1982;92(8):913–21.
8. Selman AJ, Sarnat BG.Growth of the rabbit snout
after extirpation of the frontonasal suture: a gross and
serial roentgenographic study by means of metallic
implants. Am J Anatomy. 1957;101:273–93.
9. Sarnat BG, Wexler MR.Growth of the face and jaws
after resection of the septal cartilage in the rabbit. Am
J Anatomy. 1966;118:755–67.
10. Sarnat BG. Some factors related to experimental
snout growth. J Craniofac Surg. 2008;19:1308–14.
11. Hayton CH. An investigation into the results of the
submucous resection of the septum in children. J
Laryngol. 1916:132–8.
12. Huizing EH.Septum surgery in children; indications,
surgical technique and long-term results. Rhinology.
1979;17(2):91–100.
13. Akikusa JD, Schneider R, Harvey EA, Hebert D,
Thorner PS, Laxer RM, Silverman ED.Clinical features and outcome of pediatric Wegener's granulomatosis. Arthritis Rheumatism (Arthritis Care Res).
2007;57(5):837–44.
14. Jenning JJ, Shaffer AD, Stapleton AL.Pediatric nasal
septal perforation. Int J Pediatr Otorhinolaryngol.
2019;118:15–20.
Section IV
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Inammatory Sinus Disorders
Non-allergic Rhinitis
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WoutBackaert andLauraVan Gerven
19
Introduction
Strictly speaking, rhinitis is dened as inammation of the nasal mucosa. In clinical practice, however, inammatory parameters are seldomly
assessed. Consequently, the term ‘rhinitis’ is used
for the presence of nasal complaints that have no
anatomical cause. Various rhinitis phenotypes can
be distinguished. Allergic rhinitis (AR) is present
when rhinological symptoms are caused by a type
1 hypersensitivity reaction to one or more airborne allergens. The term ‘infectious rhinitis’ is
used in case of presence of microbial or viral
infection, such as seen in the common cold. A
W. Backaert
Department of Otorhinolaryngology, University
Hospitals Leuven, Leuven, Belgium
Department of Microbiology, Immunology and
Transplantation, Allergy and Clinical Immunology
Research Unit, KU Leuven, Leuven, Belgium
e-mail: wout.backaert@kuleuven.be
L. Van Gerven (*)
Department of Otorhinolaryngology, University
Hospitals Leuven, Leuven, Belgium
Department of Microbiology, Immunology and
Transplantation, Allergy and Clinical Immunology
Research Unit, KU Leuven, Leuven, Belgium
Department of Neurosciences, Experimental
Otorhinolaryngology, KU Leuven, Leuven, Belgium
e-mail: laura.vangerven@uzleuven.be
nal group, non-allergic rhinitis (NAR)—previously known as non-allergic, non- infectious rhinitis (NANIR); non-allergic, non- infectious
perennial rhinitis (NANIPER); or vasomotor rhinitis—is dened when no sensitisation or sign of
nasal infection can be determined.
For all rhinitis phenotypes, clinical presentation is similar with patients reporting mainly
nasal obstruction, rhinorrhoea/post-nasal drip,
nasal itch or sneezing. By denition, symptoms
should be present for two or more consecutive
days and for more than 1h on most days. These
symptoms can be acute when lasting less than
12 weeks or persistent when lasting longer. In
addition, sinusitis symptoms like facial pain and
reduced sense of smell may be reported. Making
a correct diagnosis based on the individual
patient’s history alone is not easy. A thorough
clinical investigation with nasal endoscopy and
additional technical investigations such as a skin
prick test may assist in reaching the correct diagnosis. NAR remains a diagnosis per exclusionem,
i.e. when symptoms cannot be explained by allergic inammation, infection or anatomical factors
(Fig.19.1). Once the diagnosis of NAR has been
made, the patient’s history is the most important
tool for further subcategorisation.
In practice, the clinical diagnosis can be complicated by the presence of two or more phenotypes. For example, when a patient with hay fever
has symptoms during the pollen season, but also
throughout the year, there is the possibility of
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
A. C. Swift et al. (eds.), Contemporary Rhinology: Science and Practice,
https://doi.org/10.1007/978-3-031-28690-2_19
243
244
MUCOSAL PATHOLOGY STRUCTURAL PATHOLOGY
NASAL SYMPTOM SEVERITY
lem
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W. Backaert and L. Van Gerven
Turbinate
Allergic
rhinitis
Non-allergic, non-infectious
Fig. 19.1 Both mucosal and structural factors contribute
to nasal symptom severity. © 2017 EAACI and John
Wiley and Sons A/S. Adapted with permission from
Hellings PW, Klimek L, Cingi C, Agache I, Akdis C,
Mixed
rhinitis
rhinitis
Infectious
rhinitis
concomitant AR and NAR. This phenotype is
Hypertrophy
Concha bullosa
middle turbinate
Septum
Deviation
Perforation
Bachert C, etal. Non-allergic rhinitis: Position paper of
the European Academy of Allergy and Clinical
Immunology. Allergy. 2017;72(11):1657–65
Patient History
referred to as ‘mixed rhinitis’. Lastly, overlap is
possible between mucosal and structural pathology, both contributing to the patients’ symptoms
(Fig.19.1).
In cases of NAR, symptoms are usually bilateral
and similar to other rhinitis phenotypes. The subcategorisation of NAR is mainly based on the
patient history because of current limitations in
diagnostic testing. In reality, there is often over-
Assessment
lap between physiological and pathophysiological processes. In other words, multiple NAR
Patients with NAR often have nasal symptoms
with neither clinical signs of infection such as
purulent secretions, nor signs of allergic inammation such as allergen-specic IgE in serum or
a positive skin prick test. NAR is a heterogeneous
group of inammatory phenotypes, covering all
non-allergic, non-infectious rhinitis phenotypes
(Fig.19.2). In NAR, one can distinguish various
subgroups including occupational/irritantinduced rhinitis, drug-induced rhinitis, hormonal
rhinitis, rhinitis of the elderly/senile rhinitis, gustatory rhinitis, smoking rhinitis and—by exclusion—idiopathic rhinitis. Since there is no clear
consensus on the diagnostic criteria, epidemiological data is scarce. However, it is estimated
that more than 200million people worldwide suffer from NAR [1].
subtypes can be present at the same time.
In cases of occupational or irritant-induced
rhinitis, symptoms are triggered by specic irritants or molecules present in the workplace. In
order to make a diagnosis, a thorough occupational patient’s history is mandatory. What is the
patient’s job title? Where does the patient work?
What is the patient’s specic role in the workplace? Do co-workers experience nasal symptoms as well? Are the nasal symptoms linked to
recent changes in work processes or materials?
Does the patient work in an environment or with
products that are known to frequently lead to
occupational rhinitis such as laboratory animals,
cleaning agents, chemicals, dyes, pharmaceutical
products, etc.? It is often easier to ask the patient
what he/she is actually doing in the workplace
Nasopharynx
Adenoid hypertrophy
Valve
Alar collapse
Internal valve prob
Inf
Persistent rhinitis
s
19 Non-allergic Rhinitis
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(symptoms > 12 weeks)
ectious rhinitis Allergic rhinitis Non-allergic, non-infectious rhinitis
Occupational/irritant rhiniti
Drug-induced rhinitis
Hormonal rhinitis
Rhinitis of the elderly
Gustatory rhinitis
Idiopathic rhinitis
245
Fig. 19.2 Approach to the persistent rhinitis patient.
Non-allergic, non-infectious rhinitis is diagnosed after
exclusion of infectious and allergic rhinitis by absence of
purulent secretions on nasal endoscopy and a negative
skin prick test/specic IgE in the serum. Patient history
remains the most important tool for further categorisation
rather than asking what he/she is exposed to. For
example, a patient will know he/she is working
with paint products but could be unaware that the
paint contains isocyanates, which are potent low
molecular weight sensitisers. At onset of the disease, there is a clear relationship with exposure,
i.e. patients may have nasal symptoms during
work but less or none during weekends or holidays. However, this relationship can diminish
with time and symptoms may persist outside the
work environment. A diary where nasal symptoms can be scored on a daily basis over a longer
period of time covering both working days and
holidays can be a useful tool. If available, a peak
nasal inspiratory ow (PNIF) device can be used
at home and work to easily and objectively monitor nasal patency. Since occupational rhinitis
often precedes occupational asthma, one should
also address lower airway symptoms such as dyspnoea, wheezing and cough during history
taking.
in subgroups. © 2017 EAACI and John Wiley and Sons
A/S.Adapted with permission from Hellings PW, Klimek
L, Cingi C, Agache I, Akdis C, Bachert C, et al. Nonallergic rhinitis: Position paper of the European Academy
of Allergy and Clinical Immunology. Allergy.
2017;72(11):1657–65
Industrialisation has led to a substantial
increase in the amount of air pollutants in the
environment. Many of these pollutants have detrimental effects on respiratory health and can
lead to chronic rhinitis. Indeed, pollutants promote the formation of reactive oxygen species,
leading to oxidative damage. In patients with
chronic rhinosinusitis undergoing functional
endoscopic sinus surgery, it has been shown that
exposure to environmental low molecular weight
agents correlates with the need for revision surgery [2]. Additionally, diesel exhaust particles
can aggravate asthma and anthropogenic
nanoparticles can enhance allergic inammation.
Indeed, pollutant-exposure increases allergenspecic IgE levels, severity of asthma and airway
hyper-responsiveness. Therefore, one should
address questions on pollutant-exposure during
history taking. Where does the patient live: in a
rural, urban or industrial environment? Did the
nasal complaints start after a domestic reloca-
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