The earlier the merrier – But how?Thomas Eiwegger, MD,1,2,3,4 Oliver Pfaar, MD51 Karl Landsteiner University, Department of Pediatrics and Adolescent Medicine, Krems, Austria;2 Department of Pediatric and Adolescent Medicine, University Hospital St. Pölten, St. Pölten, Austria;3 Translational Medicine Program, Research Institute, Hospital for Sick Children, Toronto, ON, Canada;4 Department of Immunology, University of Toronto, Temerty Faculty of Medicine, Toronto, ON, Canada5. Department of Otorhinolaryngology, Head and Neck Surgery, Section of Rhinology and Allergy, University Hospital Marburg, Philipps University of Marburg, Marburg, Germany.

To the EditorIn 2022, a group of clinician scientists working in the field of research in chronic rhinosinusitis with nasal polyps (CRSwNP), came together under the auspices of the European Academy of Allergy and Clinical Immunology (EAACI) to achieve greater clarity with respect to scoring of nasal polyp size and published the definitions in a Position Paper (PP)1. Before this initiative, several scoring systems had previously been described. However, the lack of standardisation across their application in research trials and clinical practice prevented comparison and led to inter-rater variability2. Our aim was therefore to propose a unified scoring system with high validity and reproducibility. The system we devised is already being widely utilised in both randomised controlled trials and real-life registries evaluating the effectiveness of CRSwNP treatment3-6.A recent trial investigator meeting highlighted the benefits of this standardised approach, however one area of ambiguity was identified which needs clarification.In the position paper we stated that where the middle turbinate is not visible and no assessment can be made regarding whether nasal polyps are located medial or lateral to it, provided the nasal polyps can be seen to come below the level of upper margin of the inferior turbinate they will be scored 2, unless they reach the lower limit of the inferior turbinate (Nasal Polyp Score (NPS) 3) or the floor (NPS4)1.This was intended to be applied only when anatomical features such as a septal deviation prevent the view of the middle turbinate. (Figure 1)However, in the case that the middle turbinate is not visible due to the presence of a single or multiple nasal polyps completely obstructing visualisation and further passage of the endoscope, such that it is not possible to assess whether nasal polyps are located medial or lateral to the middle turbinate, then this will be scored as 3, provided the lower limit extends below the reference line of the upper margin of the inferior turbinate, or 4 if the nasal polyps reach the floor of the nose. (Figure 1)This requires further clarification, as if the first rule were applied to cases where the view of the middle turbinate was obscured by large nasal polyps which did not reach the lower margin of the inferior turbinate, they would be scored as 2. However, if they reduced in size sufficiently to allow a view of the turbinate such that polyps could be seen both medial and lateral to the middle turbinate, and extending below its inferior margin, paradoxically the NPS might increase to 3 despite the reduction in polyp volume.This was agreed at the original task force discussions, and we had intended that the figures provided in the position paper would provide sufficient guidance. Recent discussions have highlighted that the failure to specify in the text that the first rule above did not apply when the view of the middle turbinate was obscured by polyps has led to confusion, and in some cases may contribute to screening failures and discordance between blinded reviewers. We hope that this addendum will address this accordingly.As a practical consideration in a research setting, every effort should be made to visualise the middle turbinate and its relationship to any nasal polyps that are present to facilitate consistent application of the NPS and reduce inter-rater variability.References1. Gevaert P, De Craemer J, Bachert C, et al. European Academy of Allergy and Clinical Immunology position paper on endoscopic scoring of nasal polyposis. Allergy . Apr 2023;78(4):912-922. doi:10.1111/all.156502. Djupesland PG, Reitsma S, Hopkins C, Sedaghat AR, Peters A, Fokkens WJ. Endoscopic grading systems for nasal polyps: are we comparing apples to oranges? Rhinology . Jun 1 2022;60(3):169-176. doi:10.4193/Rhin21.4013. De Corso E, Porru DP, Corbò M, et al. Comparative real-world outcomes of dupilumab versus endoscopic sinus surgery in the treatment of severe CRSwNP patients. Clin Otolaryngol . Jul 2024;49(4):481-489. doi:10.1111/coa.141724. Huber P, Förster-Ruhrmann U, Olze H, et al. Real-world data show sustained therapeutic effects of dupilumab in chronic rhinosinusitis with nasal polyps (CRSwNP) over 3 years. Allergy . Nov 2024;79(11):3108-3117. doi:10.1111/all.162635. van der Lans RJL, Otten JJ, Adriaensen G, et al. Two-year results of tapered dupilumab for CRSwNP demonstrates enduring efficacy established in the first 6 months. Allergy . Oct 2023;78(10):2684-2697. doi:10.1111/all.157966. Homøe AS, Aanæs K, Tidemandsen JE, et al. Superior Benefits of Combining Mepolizumab With Sinus Surgery Compared to Mepolizumab Alone: Results From a Randomised 6-Month Trial. Int Forum Allergy Rhinol . Jul 2025;15(7):724-733. doi:10.1002/alr.23562AuthorsPhilippe Gevaert1, Elke Vandewalle1, Isam Alobid2, Claus Bachert3, Adam M Chaker4, Cemal Cingi5, Eugenio De Corso6, Joaquim Mullol7, Joseph K Han8, Peter W Hellings9, Valerie Hox10, Wytske J Fokkens11, Ludger Klimek12, Stella E Lee13, Valerie J Lund14, Ralph Mösges15, Oliver Pfaar16, Sietze Reitsma11, Glenis K Scadding14, Thibaut Van Zele1, Stephan Vlaminck17, Martin Wagenmann18, Sanna Toppila-Salmi19, Claire Hopkins201 Upper Airways Research Laboratory, Department of Head and Skin, Ghent University, Ghent, Belgium.2 Rhinology and Skull Base Unit. ENT Department, Hospital Clinic de Barcelona. IDIBAPS, CIBERES, Universitat de Barcelona, Barcelona, Spain.3 Department of Otorhinolaryngology Head and Neck Surgery, University Hospital of Münster, Münster, Germany. International Airway Research Center, First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China.4 Department of Otolaryngology and Center for Allergy and Environment, Technical University of Munich, TUM School of Medicine, Klinikum rechts der Isar, Munich, Germany.5 Department of Otorhinolaryngology, Faculty of Medicine, Eskisehir Osmangazi University, Eskisehir.Department of Otorhinolaryngology, Faculty of Medicine, Biruni University, Istanbul, Turkey.6 Otorhinolaryngology Unit, A. Gemelli University Hospital Foundation IRCCS, Rome, Italy.7 Rhinology Unit & Smell Clinic, ENT Department, Hospital Clínic Barcelona, FRCB-IDIBAPS, Universitat de Barcelona, CIBERES, Barcelona, Catalonia, Spain.8 Department of Otolaryngology Head and Neck Surgery, Eastern Virginia Medical School, Norfolk, Virginia, USA.9 Allergy and Clinical Immunology Research Unit, Department of Microbiology and Immunology, Catholic University of Leuven, Leuven, Belgium.Clinical Department of Otorhinolaryngology, Head and Neck Surgery, University Hospitals Leuven, Leuven, Belgium.10 Department of Otorhinolaryngology, Head and Neck Surgery, Cliniques Universitaires Saint-Luc, Brussels, Belgium.11 Amsterdam Rhinology Team (ART), Department of Otorhinolaryngology and Head/Neck Surgery, Amsterdam University Medical Centre (UMC), University of Amsterdam, Amsterdam, the Netherlands.12 Department of Otolaryngology, Head and Neck Surgery, Universitätsmedizin Mainz, Mainz, GermanyCenter for Rhinology and Allergology, Wiesbaden, Germany.13 Division of Otolaryngology - Head and Neck Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA.14 Royal National Ear, Nose, Throat and Eastman Dental Hospital, University College London, UCLH, London, United Kingdom.15 IMSB, Medical Faculty University at Cologne, Cologne, Germany.ClinCompetence Cologne GmbH, Cologne, Germany.16 Department of Otorhinolaryngology, Head and Neck Surgery, Section of Rhinology and Allergy, University Hospital Marburg, Philipps-Universität Marburg, Marburg, Germany.17 Department of Otorhinolaryngology, Centre Hospitalier de Mouscron, Mouscron, Belgium.18 Department of Otorhinolaryngology, Universitätsklinikum Düsseldorf, Dusseldorf, Germany.19 Department of Otorhinolaryngology, University of Eastern Finland and the North Savo Wellbeing Services County, Kuopio, Finland.Department of Allergy, Skin and Allergy Hospital, Inflammation Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.20 ENT Department, Guys and St Thomas’s Hospital, London, United Kingdom.King’s College, London, United Kingdom.Funding sourcesEuropean Academy of Allergy and Clinical Immunology:EAACI task force on nasal polyp scoringFigure legendsFigure 1. Visual representations of the nasal polyp score (NPS).NPS 0 = No nasal polyps.NPS 1 = Small nasal polyps in the middle meatus not reaching below the lower border of the middle turbinate.NPS 2 = Nasal polyps reaching below the lower border of the middle turbinate*.*The scoring is modified to accommodate patients who have had a middle turbinectomy, such that the nasal polyp must reach the top of the inferior turbinate to be scored 2. When anatomical features such as septal deviation prevent the view of the middle turbinate, nasal polyps seen to come below the level of the upper margin of the inferior turbinate are scored 2, unless they reach the lower limit of the inferior turbinate (NPS 3) or the floor (NPS 4).NPS 3 = Large nasal polyps reaching the lower border of the inferior turbinate or (large) nasal polyps medial to the middle turbinate**.**Large nasal polyps which score 2 plus additional polyps medial and beyond the borders of the middle turbinate. When a single or multiple nasal polyps completely obstruct visualisation of the middle turbinate, nasal polyps reaching below the reference line of the upper margin of the inferior turbinate are scored 3, unless they reach the floor (NPS 4).NPS 4 = Large nasal polyps causing complete obstruction of the inferior nasal cavity***. ***Large nasal polyps touching the floor of the nose.

Background: Guidelines advise for the implementation of patient-reported outcomes (PROMs). Our objective is to identify the utilization patterns of PROMs, together with the reasons for their usage and the barriers to their adoption among practitioners managing patients with asthma, allergic rhinitis (AR), and rhinosinusitis (RS). Methods: This was a cross-sectional observational study using a questionnaire encompassing all pertinent PROMs and disseminated to practitioners associated with the ARIA, UCARE, ADCARE, and ACARE networks. Individuals unfamiliar with PROMS or lacking prior experience with it were eliminated. Descriptive and analytical data were utilized, categorized by the frequency and type of PROMs applied. Stata 18.0 was utilized, with p<0.05 indicating statistical significance. Results: A total of 439 practitioners participated, with PROMs predominantly utilized by physicians certified for over 30 years and by respiratory specialists (16.67% and 12.46%, respectively; p<0.05). Pulmonologists exhibited the greatest utilization of asthma PROMs at 86%, while allergists predominantly employed AR and RS PROMs at 38.42% and 33.33%, respectively (p < 0.001). ACT (66.74%), RCAT (27.79%), and SNOTT22 (15.26%) were the predominant PROMs utilized primarily for asthma (79.19%), AR (51.23%), and RS (57.26%), respectively (p<0.001). The foremost purposes for their application were disease control monitoring (93.39%) and evaluation of performance of therapy approaches (90.2%). The most significant barrier identified was time constraint, rated at 75.40% (p>0.05 across all groups). Conclusions: The use of PROMs is suboptimal, primarily due to time limitations. It is imperative that methods be swiftly implemented to include these techniques into the therapeutic environment to attain enhanced outcomes.

Background: Artificial Intelligence (AI) technologies could potentially change many aspects of clinical practice. While Allergen Immunotherapy (AIT) can change the course of allergic diseases providing relief of symptoms that extend for many years after treatment completion, it can also bring uncertainty to patients, who turn to readily available resources such as ChatGPT-4 to address these doubts. The aim of this study was to use validated tools to evaluate the information provided by ChatGPT-4 regarding AIT in terms of quality, reliability and readability. Methods: In accordance with AIT clinical guidelines, 24 questions were selected and introduced in ChatGPT-4. Answers were evaluated by a panel of allergists, using validated tools DISCERN, JAMA Benchmark and Flesch Reading Ease Score and Grade Level. Results: Questions were sorted into 6 categories. ChatGPT provided bad quality information according to DISCERN medians scores in the “Definition”, “Standardization and Efficacy”, and “Safety and Adverse Reactions” categories. It provided insufficient information according to JAMA Benchmark across all categories. Finally, ChatGPT-4 answers required a “college graduate” level of education to be understood as they were very difficult to read. Conclusions: ChatGPT-4 exhibits potential as a valuable complement to healthcare; however, it requires further refinement. The information it provides should be approached with caution regarding its quality, as significant details may be omitted or may not be fully comprehensible. Artificial intelligence models continue to evolve, and medical professionals should participate in this process, given that AI impacts various aspects of life, including health, to ensure the availability of optimal information.

Background: Subcutaneous immunotherapy has emerged as an effective option for treating allergic diseases. Here, we assessed the clinical impact of the mannan-conjugated birch pollen polallergoid T502 in birch pollen-induced allergic rhinoconjunctivitis. Methods: In this prospective, randomized, double-blind placebo-controlled phase III trial, 298 birch pollen–allergic adult patients were treated across 28 trial sites in Germany. Patients received either placebo or 23,000 mTU T502 subcutaneously over five pre-seasonal visits. Efficacy was assessed by comparing the combined symptom and medication score (CSMS) between placebo and T502 during the peak birch pollen season 2022. Safety, tolerability and immunologic effects were also analysed. Results: During the peak birch pollen season, the median CSMS of the T502 group was reduced by 33.00% (p=0.002) compared to placebo. The median daily symptom score and daily medication score were reduced by 30.43% (p<0.001) and 56.25% (p=0.045), respectively. Health related quality of life improved as reflected by reduction of RQLQ values by 31.54% (p<0.0001). Production of Bet v 1 sIgG4 and sIgG increased up to 6.2-fold and 3-fold respectively in the T502 group (p<0.0001). The sIgE/sIgG4 ratio was strongly reduced in the T502 group at V7 (-62.90%, p<0.0001). No fatalities nor serious adverse events were reported. In total, 16 systemic allergic reactions occurred (Grade I/II). Conclusions: Treatment with T502 significantly reduced symptoms and medication need in rhinoconjunctivitis patients. The treatment is well tolerated and safe.

Adolescence is a critical stage of rapid biological, emotional and social change and development. Adolescents and young adults (AYA) with asthma and allergies need to develop the knowledge and skills to self-manage their health independently. Healthcare professionals (HCP), parents and their wider network play an essential role in supporting AYA in this process. Previous work showed significant limitations in transition care across Europe. In 2020, the first evidence-based guideline on effective transition for AYA with asthma and allergies was published by EAACI. We herein summarize practical resources to support this guideline’s implementation in clinical practice. For this purpose, multi-stakeholder Task Force members searched for resources in peer review journals and grey literature. These resources were included if relevant and of good quality, and were pragmatically rated for their evidence-basis and user friendliness. Resources identified covered a range of topics and targeted healthcare professionals, AYA, parents/carers, schools, workplace, and wider community. Most resources were in English, web-based and had limited evidence-basis. This position paper provides a valuable selection of practical resources for all stakeholders to support effective transitional care for AYA with asthma and allergies. Future research should focus on developing validated, patient-centred tools to further assist evidence-based transition care.

Non-steroidal anti-inflammatory drugs (NSAIDs) and other eicosanoid pathway modifiers are among the most ubiquitously used medications in the general population. Their broad anti-inflammatory, antipyretic and analgesic effects are applied against symptoms of respiratory infections, including SARS-CoV-2, as well as in other acute and chronic inflammatory diseases that often coexist with allergy and asthma. However, the current pandemic of COVID-19 also revealed the gaps in our understanding of their mechanism of action, selectivity and interactions not only during viral infections and inflammation, but also in asthma exacerbations, uncontrolled allergic inflammation, and NSAIDs-exacerbated respiratory disease (NERD). In this context, the consensus report summarises currently available knowledge, novel discoveries and controversies regarding the use of NSAIDs in COVID-19, and the role of NSAIDs in asthma and viral asthma exacerbations. We also describe here novel mechanisms of action of leukotriene receptor antagonists (LTRAs), outline how to predict responses to LTRA therapy and discuss a potential role of LTRA therapy in COVID-19 treatment. Moreover, we discuss interactions of novel T2 biologicals and other eicosanoid pathway modifiers on the horizon, such as prostaglandin D2 antagonists and cannabinoids, with eicosanoid pathways, in context of viral infections and exacerbations of asthma and allergic diseases. Finally, we identify and summarise the major knowledge gaps and unmet needs in current eicosanoid research.

Immune modulation is a key therapeutic tool for allergic diseases and asthma. It can be achieved in an antigen-specific way via allergen immunotherapy (AIT) or in endotype-driven approach using biologicals that target the major pathways of the type 2 (T2) immune response: IgE, IL-5 and IL-4/IL-13. COVID-19 vaccine provides an excellent opportunity to tackle the global pandemics and is currently being applied in an accelerated rhythm worldwide. It works as well through immune modulation. Thus, as there is an obvious interference between these treatment modalities recommendations on how they should be applied in sequence are expected. The European Academy of Allergy and Clinical Immunology (EAACI) gathered an outstanding expert panel under its Research and Outreach Committee (ROC). This expert panel was called to evaluate the evidence and formulate recommendation on the administration of COVID-19 vaccine in patients with allergic diseases and asthma receiving AIT or biologicals. The panel also formulated recommendations for COVID-19 vaccine in association with biologicals targeting the type 1 or type 3 immune response. In formulating recommendations, the panel evaluated the mechanisms of COVID-19 infection, of COVID-19 vaccine, of AIT and of biologicals and considered the data published for other anti-infectious vaccines administered concurrently with AIT or biologicals.

Vaccines are essential public health tools with a favorable safety profile and prophylactic effectiveness that have historically played significant roles in reducing infectious disease burden in populations, when the majority of individuals are vaccinated. The COVID-19 vaccines are expected to have similar positive impacts on health across the globe. While serious allergic reactions to vaccines are rare, their underlying mechanisms and implications for clinical management should be considered to provide individuals with the safest care possible. In this review, we provide an overview of different types of allergic adverse reactions that can potentially occur after vaccination and individual vaccine components capable of causing the allergic adverse reactions. We present the incidence of allergic adverse reactions during clinical studies and through post-authorization and post-marketing surveillance and provide plausible causes of these reactions based on potential allergenic components present in several common vaccines. Additionally, we review implications for individual diagnosis and management and vaccine manufacturing overall. Finally, we suggest areas for future research.

This systematic review evaluates the efficacy and safety of biologicals for chronic rhinosinusitis with nasal polyps (CRSwNP) compared to the standard of care. Pubmed, EMBASE and Cochrane Library were searched for RCTs. Critical and important CRSwNP-related outcomes were considered. The risk of bias and the certainty of the evidence were assessed using GRADE. RCTs evaluated (dupilumab-2, omalizumab-4, mepolizumab-2, reslizumab-1) included 1236 adults, with follow-up 20-64 weeks. Dupilumab reduces the need for surgery (NFS) and oral corticosteroid (OCS) use (RR 0.28; 95%CI 0.20-0.39, moderate certainty) and improves with high certainty smell (mean difference (MD) +10.54; 95%CI +9.24 to +11.84) and quality of life (QoL) (MD -19.14; 95%CI 95%CI -22.80 to -15.47), with fewer treatment-related adverse events (TAEs) (RR 0.95; 95%CI 0.89-1.02, moderate certainty). Omalizumab reduces NFS (RR 0.85; 95%CI 0.78 to 0.92, high certainty), decreases OCS use (RR 0.38; 95%CI 0.10-1.38, moderate certainty), improves with high certainty smell (MD +3.84; 95%CI +3.64 to +4.04) and QoL (MD -15.65; 95%CI -16.16 to -15.13), with increased TAE (RR 1.73; 95%CI 0.60-5.03, moderate certainty). There is low certainty for mepolizumab reducing NFS (RR 0.78; 95%CI 0.64 to 0.94) and improving QoL (MD -13.3; 95% CI -23.93 to -2.67) and smell (MD +0.7; 95%CI -0.48 to +1.88), with increased TAEs (RR 1.64; 95%CI 0.41-6.50). The evidence for reslizumab is very uncertain.

Although there is a considerable body of knowledge about allergen immunotherapy (AIT), there is a lack of data on the reliability of real-world evidence (RWE) in AIT and consequently, a lack of information on how AIT effectively works in real life. To address the current unmet need for an appraisal of the quality of RWE in AIT, the European Academy of Allergy and Clinical Immunology Methodology Committee recently initiated a systematic review of observational studies of AIT, which will use the RELEVANT tool and the Grading of Recommendations Assessment, Development and Evaluation approach (GRADE) to rate the quality of the evidence base as a whole. The next step will be to develop a broadly applicable, pragmatic “real-world” database using systematic data collection. Based on the current RWE base, and perspectives and recommendations of authorities and scientific societies, a hierarchy of RWE in AIT is proposed, which places pragmatic trials and registry data at the positions of highest level of evidence. There is a need to establish more AIT registries that collect data in a cohesive way, using standardised protocols. This will provide an essential source of real-world data that can be easily shared, promoting evidence-based research and quality improvement in study design and clinical decision-making.

Modern healthcare requires a proactive and individualized response to diseases, combining precision diagnosis and personalized treatment. Accordingly, the approach to patients with allergic diseases encompasses novel developments in the area of personalized medicine, disease phenotyping and endotyping and the development and application of reliable biomarkers. A detailed clinical history and physical examination followed by the detection of IgE immunoreactivity against specific allergens still represents the state of the art. However, nowadays, further emphasis focuses on the optimization of diagnostic and therapeutic standards and a large number of studies have been investigating the biomarkers of allergic diseases, including asthma, atopic dermatitis, allergic rhinitis, food allergy, urticaria and anaphylaxis. Various biomarkers have been developed by omics technologies, some of which lead to a better classification of the distinct phenotypes or endotypes. The introduction of biologicals to clinical practice increases the need for biomarkers for patient selection, prediction of outcomes and monitoring, to allow for an adequate choice of the duration of these costly and long-lasting therapies. Escalating healthcare costs together with questions on the efficacy of the current management of allergic diseases requires further development of a biomarker-driven approach. Here, we review biomarkers in diagnosis and treatment of asthma, atopic dermatitis, allergic rhinitis, viral infections, chronic rhinosinusitis, food allergy, drug hypersensitivity and allergen-immunotherapy with a special emphasis on specific IgE, microbiome and epithelial barrier. In addition, EAACI guidelines on biologicals are discussed within the perspective of biomarkers.