Specific IgE measurements obtained from patients suffering from respiratory allergy (n = 952) show that, despite similar climatic conditions, there are clear regional differences in pollen sensitization between North Rhine-Westphalia and Bavaria. The data on sensitization levels and pollen concentration was taken from the research and development project Ufoplan 3710 61 228 of the German Environment Agency for North Rhine-Westphalia and Bavaria (2011 - 2014). Most poly-sensitized patients have already shown sensitization, both in the form of cross-reactivity and species-specific sensitization, to "new" pollen allergens, such as Bermuda grass and olive tree. These plants are currently not common in Germany, but may become considerably more widespread due to the increase in average yearly temperatures caused by the global warming. The other "new" aeroallergens discussed here are plants that can be found throughout Germany, such as nettle, cypress, and pine. Their current sensitization levels are higher than 8%; however, their clinical impact appears to be underestimated. For clinical practice it is important to identify when patients' symptoms are typically severe and which regional plants might be responsible for the patients' complaints in this period of time, as this affects further diagnostic strategy. Allergens having an immune effect can then be targeted by specific immunotherapies. The information on complaints of the patients should be regularly recorded in symptom diaries. Recording this information for at least 1 year may allow to discover a correlation between specific types of pollen and allergy symptoms.

Aquired angioedema are the most frequent bradykinin induced angioedema. Here are the drug induced angioedema the most significant angioedema form. In this group, the angiotensin-converting-enzym-inhibitor (ACEi) induced angioedema is the most important. With an incidence of 0,5%, we have only in Germany every year approximately 30.000 angioedema cases. The manifestation is only in the head and neck and upper airo-digestive ways. So far none drug is approved for this potential life-threatening emergency situation. However succesfull treatment is possible with the bradykinin-receptor blocker Icatibant. Angiotensin type 1 receptor blocker is also able to develop bradykinin induced angioedema. Though, this form is not so frequent (incidence 0,1%).

Durch die Tracheotomie werden während der Inspiration die oberen Atemwege umgangen und die Atemluft durch die fehlende Befeuchtung, Reinigung und Erwärmung nicht mehr präkonditioniert, was zu Irritationen der unteren Atemwege führt. Trotz verschiedener Inhalationsstrategien gibt es bisher keine allgemein anerkannten Empfehlungen zur strukturierten Behandlung dieses Patientengutes.

After tracheostomy patients demonstrate shunt ventilation bypassing the sinonasal and pharyngeal system. The physiological moistening, cleaning and warming of the breathing air fail resulting in respiratory inflammation. Beside a variety of supportive medical devices, no general recommendation exists at present. Aim of the study is to maintain the functional integrity of the tracheobronchial system after tracheostomy resulting in a general therapeutic recommendation.

PURPOSE:Acute edema of the head and neck region may lead to life-threatening dyspnea and require quick and targeted treatment. They can be subdivided in bradykinin- and histamine-mediated swellings, which require treatment with different classes of pharmaceuticals. Clinical pathways for differential diagnoses do not exist so far, although it is known that early treatment is decisive for faster symptom relief and reduced expression of the swellings. Aim of the study was the creation of a clinical algorithm for identification of bradykinin-mediated angioedema.METHODS:188 patients that presented to our outpatient department between 2010 and 2016 with an acute, non-inflammatory swelling of the head and neck region were included in our retrospective study. All available anamnestic and clinical parameters were obtained from patient files. Parameters showing significant differences between the two groups were included in our score. Utilization of the Youden's index allowed determination of an optimal cut-off value.RESULTS:76 patients could be assigned to the histamine and 112 patients to bradykinin group. The following parameters were included in our score: age, dyspnea, itching or erythema, glucocorticoid response and intake of ACEi/AT-II blockers. The cut-off value is set at three points. The proposed score yielded a sensitivity for identification of bradykinin-mediated angioedema of 96%, a specificity of 84%, a positive predictive value of 91% and a negative predictive value of 93%.CONCLUSIONS:Utilization of the proposed score allows quick and reliable assignment of patients to the correct subgroup and thereby reduces time for treatment.

Background The role of sonography in the evaluation of salivary gland alterations in patients with suspected Sjögren9s Syndrome (SS) and its benefit with regard to the diagnosis is part of continuing investigation. Studies on sonoelastographic alterations in the salivary glands of patients with SS have been published during the last years and were able to prove significant differences compared to patients with sicca-symptoms without fulfilling the AECG classification criteria [1, 2]. The available knowledge on longitudinal changes in sonoelastographic characteristics is still limited. Objectives Which variations of sonoelastographic salivary gland alterations can be observed during the five-year follow up of patients with primary Sjögren9s Syndrome? Methods Patients with primary Sjögren9s Syndrome (pSS) diagnosed according to the AECG classification criteria were included in this study. The EULAR SS Patient Reported Index (ESSPRI) was applied for the evaluation of patient9s symptoms and the EULAR SS Disease Activity Index (ESSDAI) for systemic features. During 2011 and 2016 the sonoelastographic alterations of the salivary glands in patients with primary Sjögren9s Syndrome were evaluated. Acoustic Radiation Force Impulse (ARFI) imaging (=shear wave velocity), Real Time Tissue Elastography (RTTE) and Virtual Touch Tissue Imaging (VTTI) were applied for the sonoelastographic evaluation in addition to B-Mode sonography (BMUS). Results of BMUS, RTTE and VTTI were graded with appropriate scoring systems. Results Fifty patients diagnosed with pSS were included (45 female, age: 56 years SD =16). In 2011 the mean ESSPRI score was 8.3 (SD =4.6) and the mean ESSDAI score was 5.6 (SD =7.5). Initially, the mean ARFI value of parotid glands was 2.99m/s (SD =0.93) and the mean ARFI value of the submandibular glands was 2.15m/s (SD =0.57). Clinical examination and sonoelastographic evaluation was repeated after five years in 2016, revealing a mean ESSPRI score of 6.1 (SD =3.2, p=0.002) and a mean ESSDAI score of 4.6 (SD =7.0, p<0.001). After five years a significant decline of ARFI values could be observed in the parotid gland (2.33m/s, SD =0.70, p<0.001) while no significant changes of the ARFI of the submandibular gland could be observed. Results of RTTE and VTTI did not change significantly. The mean time interval between onset of first symptoms and first sonographic examination in 2011 was 57.3 months (SD =60.8). Conclusions The five-year sonoelastographic follow up of salivary gland alterations in patients with pSS revealed a decline in the severity of sonoelastographic alterations of the parotid gland in ARFI imaging, indicating a certain capability for modulation of salivary gland affection in pSS. References Hofauer B et al. Sonoelastographic Modalities in the Evaluation of Salivary Gland Characteristics in Sjögren9s Syndrome. Ultrasound Med Biol 2016; 2) Knopf A et al. Diagnostic utility of Acoustic Radiation Force Impulse (ARFI) imaging in primary Sjoegren9s syndrome. Eur Radiol 2015. Disclosure of Interest None declared

Purpose: The evolution of sonoelastographic modalities facilitated new diagnostic options in the evaluation of pathologies in numerous regions of the human body. While sonoelastographic modalities could be implemented in the clinical routine of various specialities, its benefit in the clarification of salivary gland pathologies, despite good accessibility, is still part of ongoing investigation.

SummaryBackgroundBesides allergens, pollen release bioactive, low molecular weight compounds that modulate and stimulate allergic reactions. Clinical relevance of these substances has not been investigated to date.ObjectiveTo elucidate the effect of a non‐allergenic, low molecular weight factors from aqueous birch pollen extracts (Bet‐APE < 3 kDa) on the human allergic immune response in vivo.MethodsBirch and grass pollen allergic individuals underwent skin prick testing with allergen alone, allergen plus Bet‐APE < 3 kDa, or allergen plus pre‐identified candidate substances from low molecular pollen fraction. Nasal allergen challenges were performed in non‐atopic and pollen allergic individuals using a 3 day repeated threshold challenge battery. Subjects were either exposed to allergen alone or to allergen plus Bet‐APE< 3 kDa. Local cytokine levels, nasal secretion weights, nasal congestion and symptom scores were determined.ResultsSkin prick test reactions to pollen elicited larger weals when allergens were tested together with the low molecular weight compounds from pollen. Similar results were obtained with candidate pollen‐associated lipid mediators. In nasal lining fluids of allergic patients challenged with allergen plus Bet‐APE < 3 kDa, IL‐8 and IgE was significantly increased as compared to allergen‐only challenged patients. These patients also produced increased amounts of total nasal secretion and reported more severe rhinorrhea than the allergen‐only challenged group.ConclusionsLow molecular compounds from pollen enhance the allergen specific immune response in the skin and nose. They are therefore of potential clinical relevance in allergic patients.

While many high quality studies are available for the specific immunotherapy of the allergic rhinitis and limited for the angiotensin-converting enzyme inhibitor induced angioedema available, the evidence is very low for Meniere's disease or for the medicinal treatment of post-surgery laryngeal edema. This paper discusses the study data and evidence of the respective diseases.

Background Sonography in the evaluation of salivary gland alterations in suspected Sjögren9s Syndrome (SS) and its benefit with regard to the diagnosis is part of continuing investigation. With most studies concentrating on the contribution to the diagnosis, few reports exist on longitudinal changes in the sonomorphology of salivary glands in SS. An improvement of salivary gland echostructure six months after rituximab infusion [1] and a decline of salivary gland stiffness evaluated with shear wave elastography after a two months period of a liposomal local therapy could be observed [2]. Despite intense research, many questions in ultrasound of salivary glands remain unanswered. Amongst other things it is unclear why not all patients with SS manifest sonographic abnormalities, when during the course of SS sonographic changes occur or if theses sonographic observations proceed the clinical symptomatic. Objectives Which variation of sonographic salivary gland alterations can be observed during the five-year follow up of patients with primary Sjögren9s Syndrome (pSS)? Methods Patients with pSS diagnosed according to the AECG classification criteria were included in this study. The EULAR SS Patient Reported Index (ESSPRI) was applied for the evaluation of patient9s symptoms and the EULAR SS Disease Activity Index (ESSDAI) for systemic features. During 2011 and 2016 the sonographic evaluation of salivary gland alterations in patients with primary Sjögren9s Syndrome were evaluated. The echostructure of the parotid (PG) and submandibular glands (SMG) was graded on a scale of 0 to 4 (grade 0=normal, homogeneous gland; grade 1=mild parenchymal inhomogeneity (PIH), hypoechoic areas <2mm; grade 2=evident PIH, hypoechoic areas of 2–6mm; grade 3=gross PIH, hypoechoic areas >6mm; grade 4=adipose degeneration of the gland and parenchymal atrophy). Results Fifty patients diagnosed with pSS were included (45 female, age: 56y). In 2011 the mean ESSPRI score was 8.3 (SD=4.6) and the mean ESSDAI score was 5.6 (SD=7.5). The sonographic evaluation of the PG resulted in a mean score of 1.6 (SD=0.6) and in the SMG of 1.7 (SD=1.0). The sonographic score did not correlate with the time since onset of symptoms. Clinical examination and ultrasonographic evaluation was repeated after five years in 2016, revealing a mean ESSPRI score of 6.1 (SD=3.2, p=0.002) and a mean ESSDAI score of 4.6 (SD=7.0, p<0.001). The mean sonographic score of the PG was 1.4 (SD=0.7, p<0.001) and of the SMG was 1.9 (SD=1.0, p=0.034). There was a decline in the sonographic score of the PG of 0.27 (SD=0.5) and increase of the SMG of 0.1 (SD=1.1) on average. The mean time interval between onset of first symptoms and first sonographic examination in 2011 was 57.3 months (SD=60.8). Conclusions The five-year sonographic follow up of salivary gland alterations in patients with pSS revealed only minor alterations, even in patient with short illness duration. The relation to systemic or local therapeutic interventions is part of on-going analysis. References Jousse-Joulin S, Devauchelle-Pensec V, Cornec D et.al. Brief Report: Ultrasonographic Assessment of Salivary Gland Response to Rituximab in Primary Sjögren9s Syndrome. Arthritis Rheumatol. 2015 Jun;67(6):1623–8 Hofauer B, Bas M, Heiser C et.al. FRI0388 Monitoring Local Therapy in Sjögren9s Syndrome with Virtual Touch Tissue Quantification Sonography. Ann Rheum Dis 74(Suppl 2):567.2 Disclosure of Interest None declared

Swelling of single or multiple major salivary glands can be caused by various local or systemic diseases. In differential diagnosis, congenital cystic or vascular malformations should be considered, as well as infectious or tumorous alterations. Salivary duct obstructions due to sialolithiasis or stenosis can cause salivary gland enlargement. Multiple systemic diseases can have manifestations in the parotid or submandibular glands. As therapy varies from cause to cause, knowledge of the different potential diagnoses is crucial.

Eine Vielzahl von lokalen oder systemischen Erkrankungen kann zu Schwellungen einer oder mehrerer Kopfspeicheldrüsen führen. Neben kongenitalen zystischen oder vaskulären Fehlbildungen können sowohl entzündliche als auch tumoröse Prozesse differenzialdiagnostisch abgegrenzt werden. Auch Obstruktionen der Ausführungsgänge, verursacht durch Konkremente oder Stenosen, können zu Schwellungen der Speicheldrüsen führen. Verschiedene Systemerkrankungen können sich im Bereich der Ohr- oder Unterkieferspeicheldrüsen manifestieren. Da sich die Therapie je nach Ursache erheblich unterscheidet, ist die Kenntnis der unterschiedlichen Differenzialdiagnosen für den Hals-Nasen-Ohren-Arzt von großer Bedeutung.

During the last years, two new cardiovascular drug classes, namely inhibitors of DPP IV or neprilysin, have been developed. In both cases, there is clinical evidence for their potential to induce angioedema as known already from blockers of the renin–angiotensin–aldosterone system ( RAAS ). The majority of angioedema induced by DPP IV inhibitors occurs during concomitant treatment with ACE i and is therefore likely mediated by overactivation of bradykinin type 2 receptors (B2). In striking contrast, the molecular pathways causing angioedema induced by neprilysin inhibitors, that is, sacubitril, are unclear, although a contribution of bradykinin appears likely. Nevertheless, there is no clinical evidence suggesting that inhibition of B2 might relieve the symptoms and/or prevent invasive treatment including coniotomy or tracheotomy in angioedema caused by these drugs. Therefore, the risk of angioedema should always be considered, especially in ambulatory care situations where patients have no rapid access to intensive care.

Bradykinininduzierte Angioödeme haben eine deutlich geringere Inzidenz als die klinisch ähnlich imponierenden histamininduzierten Formen. Entsprechend ist auch das Wissen über Diagnostik und Therapie dieser Krankheitsbilder weniger verbreitet. Zu den bradykinininduzierten Angioödemen gehören das hereditäre Angioödem (HAE) sowie erworbene Formen, ausgelöst durch Medikamente oder Antikörper, z. B. bei onkologischer Grunderkrankung. Eine zielgerichtete Diagnostik und Therapie kann lebensrettend sein, da insbesondere medikamentös induzierte Formen fast ausschließlich im Kopf-Hals-Bereich auftreten. Wichtig ist die Abgrenzung zu den histamininduzierten Angioödemen (z. B. bei Allergie und/oder Urtikaria), um die richtige kausale Therapie zu wählen. Antihistaminika und Kortisonderivate erweisen sich bei bradykinininduzierten Angioödemen als weitestgehend wirkungslos. Therapeutisch effektiv sind C1-Esterase-Inhibitor-Konzentrate und Antagonisten des Bradykininrezeptors 2 – sowohl in der Akuttherapie als auch prophylaktisch.

Einleitung: Mittels Acoustic Radiation Force Impulse (ARFI) Bildgebung ist es möglich, die Steifigkeit verschiedener Gewebe objektiv zu beurteilen. Als Kritikpunkt wird jedoch angeführt, dass die Messergebnisse zwischen verschiedenen Untersuchern oder bei Wiederholungen der Untersuchung eine große Varianz aufweisen. Ziel dieser Untersuchung war es daher, die Inter- und Intrarater-Reliabilität der ARFI-Bildgebung der Speichel- und Schilddrüse zwischen einer Gruppe mit geübten und einer Gruppe ungeübter Sonographeure zu bestimmen.