Hindawi

International Journal of Clinical Practice

Volume 2023, Article ID 6731414, 8 pages
https://doi.org/10.1155/2023/6731414

Research Article
Clinical Characteristics and Risk Factors for Allergic Rhinitis in
Children with Epistaxis

Jing Qing ,1 Yili Cai,2 Shixiong Tang,1 and Yaowen Wang1

1
Department of Otorhinolaryngology, Ningbo First Hospital, Ningbo 315000, Zhejiang, China
2
Department of Acupuncture, Ningbo First Hospital, Ningbo 315000, Zhejiang, China

Correspondence should be addressed to Jing Qing; [email protected]

Received 22 March 2023; Revised 2 August 2023; Accepted 19 August 2023; Published 31 August 2023

Academic Editor: Constantine Saadeh

Copyright © 2023 Jing Qing et al. Tis is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Background. Epistaxis is frequently observed in children with allergic rhinitis. However, few studies have addressed the clinical
characteristics and risk factors for allergic rhinitis in children with epistaxis. Tis study aimed to describe the factors associated
with allergic rhinitis in children with epistaxis. Methods. In total, we recruited 80 children (aged 3–14 years) who presented with
epistaxis at a tertiary hospital between January 2014 and January 2022. Te follow-up duration was at least 3 months, and we
performed a multivariate logistic regression analysis to identify the risk factors for allergic rhinitis. Results. Among the 80 children
examined, 57 (71.25%) had allergic rhinitis. Epistaxis mainly occurred in autumn in children with allergic rhinitis; in contrast, it
mostly occurred in summer in children without it (P = 0.029). Mites are common allergens for allergic rhinitis in children with
epistaxis; the univariate analysis revealed signifcant diferences between allergic-rhinitis group and nonallergic-rhinitis group in
the number of allergens (P < 0.001) and total IgE (P < 0.001). Te diference in severity of nasal symptoms between the two
groups was statistically signifcant and included nasal obstruction (P < 0.001), rhinorrhea (P < 0.001), sneezing (P < 0.001),
and nasal itching (P < 0.001). After adjusting for potential confounders, the severity of rhinorrhea symptoms was found to be
associated with an increased risk of allergic rhinitis in children with epistaxis (odds ratio: 3.86; 95% confdence interval: 1.61–9.26;
P = 0.003). Conclusions. Observing the onset season, number of allergens, total IgE, and nasal symptoms in cases of epistaxis could
suggest the presence of associated allergic rhinitis and reduce the number of missed diagnoses; antiallergic drugs could help
control epistaxis in these cases.

1. Introduction meteorological factors are considered the most common

causes [6, 7].
Epistaxis is a common complaint encountered in children Allergic rhinitis is a chronic IgE-mediated in-
in the otorhinolaryngology department, and the incidence fammation of the nasal mucosa, with a prevalence of
of epistaxis is the highest in patients aged between <10 and 15.79% among Chinese children [8]. Te typical pre-
>70 years [1, 2]. Nearly half of the children present at least sentations include nasal symptoms (rhinorrhea, conges-
one episode of epistaxis, and more than 60% of the general tion, itching, and sneezing), ocular symptoms (itchy and
population report at least one episode during their life- watery eyes), and general manifestations (cough and
time [3, 4]. Tese events afect approximately 64% of headache). Te diagnosis of this disease depends on the
children aged 11–15 years, 56% of those aged 6–10 years, symptoms and signs, skin-prick test, or sIgE tests. Allergic
and 30% of children younger than 5 years [4, 5]. Epistaxis rhinitis is signifcantly associated with the risk of con-
in children is often spontaneous and self-limited; how- junctivitis, atopic dermatitis, and allergic asthma [9, 10],
ever, repeated attacks can lead to anxiety among children and it impairs the children’s quality of life, concentration,
and parents. Its pathogenesis is unknown; however, in- productivity, and sleep [9, 11]; thus, early diagnosis and
fections, infammation, injuries, air pollutants, and treatment of this disease are important.
2 International Journal of Clinical Practice

Children with epistaxis related to allergic rhinitis are A visual analog scale (VAS) of individual nasal symp-
often seen in hospitals as they attract their parents’ attention toms ranging from 0 (minimal) to 10 (extremely bother-
more frequently than those with other typical nasal symp- some) was used to assess their severity. Individuals with
toms of allergic rhinitis. However, few studies have in- scores of 0–4 were considered to have mild symptoms, while
vestigated allergic rhinitis in children with epistaxis. scores of 5–10 indicated moderate/severe symptoms [14].
Terefore, we performed a retrospective study to summarize Epistaxis severity was assessed using the ESS, and the scoring
the clinical characteristics and risk factors associated with system ranged from 0 (no epistaxis) to 10 (most severe
allergic rhinitis in children with epistaxis. epistaxis). Scores of 1–3 indicated mild epistaxis, 4–7 in-
dicated moderate, and 8–10 indicated severe [14].
2. Materials and Methods All patients were administered with nasal isotonic saline
irrigation and aureomycin ointment to maintain the nasal
2.1. Subjects. Tis retrospective study was conducted in cavity’s cleanliness and moisture. After the blood test results
the Department of Otorhinolaryngology in the Premier were obtained, the patients diagnosed with allergic rhinitis
Hospital in Ningbo City, Zhejiang Province, China, be- were instructed to avoid allergens. Tese patients were also
tween January 2014 and January 2022. Children aged administered the oral antihistamine cetirizine (0.5 ml per
between 3 and 14 years who presented with epistaxis were day after dinner for 2 weeks in children 2–6 years of age and
included in the study. Te same associate chief physician 1 ml per day after dinner for 2 weeks in children >6 years)
treated all otorhinolaryngology patients, and children and mometasone (adults and children>12 years of age: 2
with a specifc intranasal pathology (other than prominent sprays (100 μg) per nostril q.d; children of 3–11 years of age: 1
vessels on the nasal septum, crusting, or irritation) were spray (50 lg) per nostril q.d, and it was administered in the
excluded from the analysis. Patients with nasal infections, morning). Each parent or guardian was trained on the
tumors, cardiovascular diseases, or blood system diseases proper use of nasal saline irrigation, aureomycin ointment,
were also excluded. Tis study was conducted following and nasal steroid spray to avoid drug-induced epistaxis.
the tenets of the Declaration of Helsinki and was approved Patients and guardians were told not to plug their nostrils
by the Ethics Committee of the Premier Hospital in with tissue to stop bleeding, gently wash their face, and hold
Ningbo City. Informed consent was obtained from the the nose for 3-5 minutes when bleeding. Sublingual de-
guardians of all study participants. Te diagnosis of al- sensitization with Dermatophagoides farinae drops was
lergic rhinitis was based on the Guidelines for the Di- provided to patients who were allergic only to mites, older
agnosis and Treatment of Allergic Rhinitis [12] and than 5 years, and willing to continue the desensitization for
Chinese Society of Allergy Guidelines for the Diagnosis more than 3 years. All patients were followed up for
and Treatment of Allergic Rhinitis [13], including (1) 3 months, except those treated with sublingual de-
patients presented with watery nasal discharge, nasal sensitization, who needed long-term follow-up. VAS, ESS,
obstruction, sneezing, or itching in the nose; the history and nasal endoscopy were performed on the frst visit and
and physical examination were consistent with an allergic 3 months after treatment.
cause; (2) positive for specifc IgE to antigens, such as
house dust mites; (3) the allergic status was assessed using
serum-specifc IgE to common inhalant and food aller- 2.3. Statistical Analysis. All statistical analyses were per-
gens, including dust mites, pets, molds, cockroaches, eggs, formed using IBM SPSS Statistics version 26 software (IBM
milk, and beef and so on, and the IgE level above 0.35 kU/L Corp, Armonk, NY, USA). Continuous data that followed
is usually testifed as a positive result. normal or nonnormal distribution were described using the
mean ± standard deviation or median (quartiles), re-
spectively. Te diferences between the groups were assessed
2.2. Study Procedures. Te clinical characteristics and risk using the Student’s t-test or Mann–Whitney U test. Te
factors collected for the analysis included the seasonal onset categorical data were described using event and frequency,
of disease; sex; age; test results for the number of allergens, and the diferences between groups were examined using the
total IgE; red blood cells, hemoglobin, leukocytes, and blood chi-square or Cochran–Mantel–Haenszel tests. Te Wil-
platelets; nasal obstruction; rhinorrhea; sneezing; nasal coxon signed-rank test was used to compare the VAS scores
itching; need for medical attention; anemia; epistaxis se- of each nasal symptom before and after treatment. A
verity score (ESS); and family history. According to the multivariate logistic regression analysis was used to identify
allergic rhinitis and its impact on asthma guidelines and the potential risk factors for allergic rhinitis accompanying
Chinese Society of Allergy Guidelines for Diagnosis and epistaxis. Te tests were two-sided, and the values of
Treatment of Allergic Rhinitis, the severity of allergic rhinitis P < 0.05 were considered statistically signifcant.
symptoms is classifed as intermittent mild, intermittent
moderate-severe, persistent mild, or persistent moderate- 3. Results
severe [12, 13]. Intermittent and persistent symptoms are
defned as symptoms lasting less or more than 4 days/week In total, 80 patients were included in the analysis. Te age
or 4 weeks/year, respectively. Symptoms with no impact on range was 3–14 years, and the median age was 9.0 years; 52
daily life and sleep are considered mild, whereas those af- (65.0%) patients were males, and 28.75% had a family
fecting them are defned as moderate to severe. history. Fifty-seven participants (71.25%) met the diagnostic
International Journal of Clinical Practice 3

criteria for allergic-rhinitis and comprised the corre- seven patients (12.28%) in the allergic-rhinitis group and two
sponding group, whereas 23 (28.75%) were included in the (8.70%) in the nonallergic-rhinitis group had mild anemia.
nonallergic-rhinitis group. 8 patients experienced symptoms Te platelet count and coagulation function were normal.
and signs consistent with allergic rhinitis, though the serum Tere were no signifcant diferences between the groups in
sIgE test results were negative. Te baseline characteristics of terms of the frequency (P � 0.774), duration (P � 0.664) of
the patients examined are shown in Table 1. Tere were no epistaxis, and ESS score (P � 0.528).
signifcant diferences between the two groups in terms of Allergic shiners (13 cases) and facies (11 cases) were
sex (P = 0.623), age (P = 0.348), red blood cell count observed in the allergic-rhinitis group. Endoscopy revealed
(P = 0.094), hemoglobin level (P = 0.678), leukocyte count hypervascularity of the nasal septal mucosa with vascular
(P = 0.291), and blood platelet count (P = 0.882). Moreover, dilatation and tortuosity. Additional symptoms included
the incidence of the need for medical attention (P > 0.99), mucus on the middle turbinate, possibly accompanied by
anemia (P = 0.946), and family history (P = 0.738) between pale or slightly cyanotic swollen mucosa and hypertrophic
the study groups was not signifcantly diferent. In contrast, inferior turbinate (Figure 2). A cobblestone appearance in
there was a signifcant diference between the study groups the posterior pharyngeal wall was common. Figure 3 shows
in the number of allergens (P < 0.001) and total IgE prominent vessels with crusts in the anterior septal region of
(P < 0.001). a nonallergic patient. Mucous secretion and adenoid hy-
We noted that the incidence of epistaxis in the allergic- pertrophy were occasionally present in patients from both
rhinitis group was at its highest in autumn (50.88%), whereas in groups.
the nonallergic-rhinitis group it was at its highest in summer Furthermore, all patients were treated with nasal isotonic
(30.43%). Figure 1 shows a histogram of the number of patients saline irrigation throughout the follow-up period, along with
with epistaxis in the diferent months. In the allergic-rhinitis aureomycin ointment for 2 weeks. In the allergic-rhinitis
group (Figure 1(a)), epistaxis occurred mainly in August (14 group, oral cetirizine was administered for at least 2 weeks
cases), followed by September and May (both 10 cases), and and then discontinued, whereas the nasal steroid spray was
most patients were allergic to mites. In the nonallergic-rhinitis used for 2 months and then stopped within 1 month after
group (Figure 1(b)), the highest incidence of epistaxis was progressively reducing the dose. In addition, three patients
observed in August and April (both 4 cases), followed by underwent sublingual desensitization. Finally, after adjust-
January (3 cases). We noted a signifcant diference between the ing for potential confounders, we noted that the probability
two groups in the season of onset (P = 0.029). of allergic rhinitis diagnosis was higher in subjects with more
In addition, previous medical records showed that 10 severe rhinorrhea (odds ratio: 3.86; 95% confdence interval
patients visited our hospital twice and one patient three (CI): 1.61–9.26; P � 0.003).
times for recurrent epistaxis, and they were not diagnosed
with allergic rhinitis at the frst or second visits. Te interval 4. Discussion
from their frst visit to the fnal diagnosis ranged from
11 days to 5 years, with a mean of 2.2 years. Before the di- Te present study aimed to describe the clinical charac-
agnosis of allergic rhinitis, all patients were treated with teristics of patients with epistaxis related to allergic rhinitis.
aureomycin ointment and nasal saline irrigation; however, Eighty children were selected using a broad range of
epistaxis still occurred intermittently. For patients in the characteristics. Te age and sex of the patients in our study
allergic-rhinitis group, the most common inhalant allergens were similar to those of the population of previous studies
were Dermatophagoides farina (D. farina) and Dermato- that investigated the clinical characteristics, treatment, and
phagoides pteronyssinus (D. pteronyssinus), having positive prognosis of epistaxis [1, 15–21]. Moreover, most patients
results in 46 patients (80.7%), and the most common food included had been diagnosed with allergic rhinitis, sug-
allergens were milk (28.1%), egg white (26.3%), and beef gesting that patients with allergic rhinitis had a higher in-
(21.1%). 27 patients (47.4%) were sensitive to one allergen, cidence of epistaxis than those without this allergy [22]. We
13 (22.8%) to two allergens, 12 (21.0%) to three, 4 (7.0%) to observed signifcant diferences between allergic-rhinitis
four, and 1 (1.8%) was sensitive to fve allergens. Te VAS of group and nonallergic-rhinitis group regarding the disease
four nasal symptoms before treatment was summarized in onset season, total IgE, severity of nasal obstruction, rhi-
Table 1. All patients with allergic rhinitis presented with norrhea, sneezing, and nasal itching. After adjusting for
a persistent mild form of the disease. Moreover, we noted potential confounders, we noted that the epistaxis in the
a signifcant diference between allergic-rhinitis group and allergic-rhinitis group presented with more severe rhinor-
nonallergic-rhinitis group in the severity of nasal obstruc- rhea symptoms.
tion (P < 0.001), rhinorrhea (P < 0.001), sneezing Several studies have addressed the potential association
(P < 0.001), and nasal itching (P < 0.001). between epistaxis and seasonality. Numerous studies have
Te severity of epistaxis in both groups was mainly mild. shown that the incidence of epistaxis is related to seasonal
Four patients in the allergic-rhinitis group and one in the variations, mostly occurring in winter [23–26]. Shay et al.
other group exhibited moderate symptoms, and no severe observed that pediatric epistaxis occurred mainly during the
cases were noted. None of the patients in either group spring and summer months, in contrast with previous re-
described their epistaxis intensity as gushing or pouring; ports in the literature, and the most severe episodes of
mostly it was dripping or outfowing. None of the patients epistaxis occurred during winter and spring [18]. Lu et al.
received red blood cell transfusions. Blood tests showed that observed that nosebleeding in children in Beijing mainly
4 International Journal of Clinical Practice

Table 1: Baseline characteristics of the patients.

Group
Variable Overall (N � 80) Allergic rhinitis group
Nonallergic rhinitis (N � 23) P value
(N � 57)
Onset season 0.029
Spring 7 (8.75) 2 (3.51) 5 (21.74)
Summer 25 (31.25) 18 (31.58) 7 (30.43)
Autumn 35 (43.75) 29 (50.88) 6 (26.09)
Winter 13 (16.25) 8 (14.04) 5 (21.74)
Gender 0.623
Girl 28 (35.00) 19 (33.33) 9 (39.13)
Boy 52 (65.00) 38 (66.67) 14 (60.87)
Age (years) 9.00 (6.00, 12.00) 9.00 (6.00, 11.00) 10.00 (7.00, 12.00) 0.348
Number of allergen <0.001
0 21 (26.25) 0 (0.00) 21 (91.30)
1 29 (36.25) 27 (47.37) 2 (8.70)
2 13 (16.25) 13 (22.81) 0 (0.00)
3 12 (15.00) 12 (21.05) 0 (0.00)
4 4 (5.00) 4 (7.02) 0 (0.00)
5 1 (1.25) 1 (1.75) 0 (0.00)
Total IgE 55.80 (22.42, 189.71) 79.61 (35.93, 292.13) 33.12 (14.80, 50.50) <0.001
Red blood cell 4.65 (0.41) 4.70 (0.43) 4.53 (0.36) 0.094
Hemoglobin 13.00 (12.30, 14.00) 12.90 (12.30, 14.10) 13.00 (12.50, 13.60) 0.678
Leukocyte 6.96 (1.64) 6.84 (1.65) 7.27 (1.62) 0.291
Blood platelet 268.50 (236.00, 301.50) 265.00 (239.00, 303.00) 270.00 (232.00, 299.00) 0.882
Nasal obstruction severity 0.00 (0.00, 3.00) 1.00 (0.00, 5.00) 0.00 (0.00, 0.00) <0.001
Rhinorrhea severity 1.00 (0.00, 4.00) 2.00 (1.00, 5.00) 0.00 (0.00, 0.00) <0.001
Sneezing severity 1.00 (0.00, 4.00) 2.00 (0.00, 5.00) 0.00 (0.00, 1.00) <0.001
Nasal itching severity 3.00 (2.00, 5.00) 3.00 (2.00, 5.00) 2.00 (0.00, 3.00) <0.001
Frequency of epistaxis 0.774
Once per month 14 (17.50) 9 (15.79) 5 (21.74)
Once per week 37 (46.25) 26 (45.61) 11 (47.83)
Several per week 21 (26.25) 17 (29.82) 4 (17.39)
Once per day 6 (7.50) 4 (7.02) 2 (8.70)
Several each day 2 (2.50) 1 (1.75) 1 (4.35)
Duration of epistaxis 0.664
<1 minute 51 (63.75) 36 (63.16) 15 (65.22)
1–5 minutes 27 (33.75) 19 (33.33) 8 (34.78)
6–15 minutes 2 (2.50) 2 (3.51) 0 (0.00)
Need for medical attention 1.000
No 76 (95.00) 54 (94.74) 22 (95.65)
Yes 4 (5.00) 3 (5.26) 1 (4.35)
Anemia 0.946
No 71 (88.75) 50 (87.72) 21 (91.30)
Yes 9 (11.25) 7 (12.28) 2 (8.70)
ESS score 1.40 (1.00, 2.50) 1.40 (1.00, 2.50) 1.00 (1.00, 2.50) 0.528
Family history 0.738
No 57 (71.25) 40 (70.18) 17 (73.91)
Yes 23 (28.75) 17 (29.82) 6 (26.09)

occurred from May to June and August to September, es- epistaxis associated with allergic rhinitis has a seasonality
pecially in 2017 [27]. Bray et al. reported that ambient and is related to the type of allergens. Lu et al. observed that
temperature and season had no relationship with the epi- pediatric epistaxis in Beijing mainly occurred in the months
staxis presentation rate [28]. Our results suggest that pe- corresponding to the pollen season, suggesting a specifc
diatric epistaxis related to allergic rhinitis is more likely to relationship with the outbreak of allergic rhinitis [27]. A
occur in late summer and early autumn, followed by spring; cross-sectional survey performed by Li et al. on 6,304 pa-
most patients with rhinitis were allergic to mites, while four tients with asthma, rhinitis, or both in 17 cities from four
patients were allergic to food or plants. regions of China showed that the most common aero-
Moreover, 11 cases of recurrent epistaxis related to al- allergens in this country were house dust mites, and 87.2% of
lergic rhinitis occurred at the same time of the year or during patients were sensitive to one or more species of mites. In
the season of allergic rhinitis; therefore, we speculate that particular, the coastal regions were more susceptible to the
International Journal of Clinical Practice 5

4
12.5

3
10.0
Frequency

Freqency
7.5
2

5.0
1
2.5

0.0 0
0 2 4 6 8 10 12 0 2 4 6 8 10 12
Month Month
(a) (b)

Figure 1: Histograms of the number of children with epistaxis in the allergic (a) and nonallergic (b) groups during diferent months.

(a) (b) (c)

Figure 2: Nasal endoscopic manifestations of epistaxis in a patient with allergic rhinitis.

(a) (b)

Figure 3: Nasal endoscopic manifestations of epistaxis in a nonallergic patient.

6 International Journal of Clinical Practice

growth of dust mites due to their high humidity and tem- Most pediatric epistaxis cases are venous and tend to
perature [29]. Arlian et al. reported that dust mites had the recur, especially if the cause is unknown. Common therapies
highest proliferation at a relative humidity of 75%, and the include nasal saline irrigation and local use of ointments to
number of dust mites in the northern USA varied with seasonal moisten the nasal mucosa and reduce infammation and
humidity, which is high in wet summers and low in dry winters crusting [41, 42]. Alternatively, silver nitrate cautery is more
[30, 31]. Lintner and Brame also observed that dust mite al- suitable for older children who do not respond to simple
lergens are associated with seasonal variations [32]. Ningbo, medical treatment and have prominent hemorrhagic spots
a city close to the East China Sea, is humid and hot in late [43]. Our study observed that 11 patients with a missed
summer and early autumn and is favorable for mites’ survival. diagnosis of allergic rhinitis had a history of recurrent at-
All patients in this study lived in Ningbo, and most patients in tacks, even when treated with saline and aureomycin
the allergic-rhinitis group were allergic to mites; hence, this ointment. We speculate that these methods alone have
factor may be the main cause of epistaxis observed in patients limited efects when epistaxis is related to allergic rhinitis.
with allergic rhinitis during our study’s period. Some limitations of this study should be acknowledged.
Children with epistaxis did not always exhibit clearly First, the number of patients was small; thus, the results may
the symptoms of allergic rhinitis, and their parents or not be reliable, as shown by the broad 95% CI. Second, the
guardians failed to notice these symptoms. We observed diference in severity of the nasal symptoms before and after
that nasal itching was the most evident symptom; in treatment was examined in the allergic-rhinitis group only,
contrast, nasal congestion was the most neglected, possibly and the diferences between the groups were not in-
because the parents more easily noticed allergic salute and vestigated. Tird, the baseline characteristics of the children
nasal rubbing caused by itching. In addition, the feeling of examined had a wide variability, possibly afecting the
itching could be expressed more clearly by children. It was treatment and prognosis of epistaxis.
difcult for children to report nasal obstruction volun-
tarily, unless the stufness was severe. Te parents often 5. Conclusions
ignored this symptom because they felt that their children
did not snore or open their mouths sufciently to breathe Pediatric epistaxis related to allergic rhinitis is common, and
during sleep. allergic rhinitis is easily overlooked when the allergic
Moreover, we noted that the severity of rhinorrhea symptoms are atypical. Terefore, otorhinolaryngologists
symptoms was signifcantly related to allergic rhinitis, as need to collect a detailed history, including the frequency of
already demonstrated in previous studies [33–35]. We also epistaxis, season of most common attacks, and habits of
noted that pediatric epistaxis occurred once or more times allergic salute or nasal rubbing, and perform a nasal en-
per week, and the attack time did not exceed 5 min. Most doscopy to observe the site and characteristics of epistaxis
cases of epistaxis resolve without the need for a hospital visit; and possible changes in the nasal mucosa, such as edema or
however, chronic and recurrent epistaxis markedly impacts color changes in the turbinates. If necessary, a skin-prick or
the patients’ health. In our study, seven patients in the serum-specifc IgE test can help reduce the rate of missed
allergic-rhinitis group and two in the nonallergic group had diagnoses. Moreover, the severity of rhinorrhea symptoms is
mild anemia. signifcantly related to allergic rhinitis in children with
Nasal endoscopy revealed nasal vasodilatation, angio- epistaxis. Large-scale prospective studies should be con-
genesis, and increased vascular permeability of the anterior ducted to confrm these fndings and develop a predictive
nasal septum in the allergic-rhinitis group. However, the model for epistaxis related to allergic rhinitis.
specifc mechanisms linking allergic rhinitis and such
changes in the nasal mucosa, leading to epistaxis, remain to Data Availability
be determined. Girsh thought that epistaxis was more likely
to occur in children with allergic rhinitis because nasal Te datasets generated and/or analyzed during the current
itching could cause allergic salutes, and repeated rubbing study are available from the corresponding author upon
could damage the nasal mucosa, making infamed and fri- reasonable request.
able by the vascular congestion and infammation associated
with allergic rhinitis [22]. Moreover, airway remodeling may Conflicts of Interest
cause changes in the nasal mucosa and blood vessels. Pre-
vious studies have revealed that airway remodeling is less Te authors declare that there are no conficts of interest
extensive in allergic rhinitis than in asthma [36–40]; it in- regarding the publication of this paper.
volves smooth muscle hypertrophy, goblet cell hyperplasia,
infltration of infammatory cells, and vascular remodeling. References
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