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    Open in a separate window The table describes the main outcome measure, stimulation parameters and most important key findings from each study. The studies are ordered as they appear in the in-text references. Modulating skill learning Skill learning refers to a process that results in improving the trade-off between speed and accuracy Reis et al. Investigations have used tDCS to either modulate learning or to better understand the underlying learning processes Orban de Xivry and Shadmehr, ; Savic and Meier, However, the number of brain regions involved in skill learning is vast Ungerleider et al. Table 2 Characterization of the main motor paradigms described in this mini-review. Motor task Description SRTT Participants respond to visual cues presented on a screen by pressing an associated keyboard response.

    Rhinitis, as well as nasal congestion, may also lead to airway obstruction and an increased number of sleep microarousals, both in children and adults. Sleep disturbances can detrimentally affect daytime energy levels, mood, and, consequently, determine daytime fatigue [ 1 ].

    Main text Appropriate use of medical therapies is necessary to optimize patient quality of life and daily functioning and minimize the risk of acute inflammatory exacerbations and complications. The most common therapies for the aforementioned diseases are topical nasal sprays which could be natural or pharmaceutical products.

    Intranasal route is generally preferred by both patients and doctors: it is fast, simple, does not require cooperation, the drug assimilation is direct and quick and compliance to therapy is high. Among these sprays, corticosteroid topical application is undoubtedly the most widely used and most effective [ 2 , 3 ] although minor side effects could be reported nose bleeding, dryness, crusting.

    There are many other possible therapies, either medical or surgical, and especially for allergic rhinitis management many different therapeutical strategies are available. Effective measures include allergen avoidance pollens, fungi, dust , mite-proof covers, air filters and nasal irrigation, and the best results are obtained when combined with intranasal steroids.

    Other pharmacological options should be taken into account if those measures are not effective, and they include antihistamine drugs, that could be taken orally or nasally, pseudoephedrine, cromolyn, leukotriene receptor antagonists.

    Thus far, evidence suggests that intranasal corticosteroids produce greater relief of nasal symptoms than topical antihistamines H1 receptor antagonists , even if no difference in ocular symptoms has been reported [ 4 ].

    Long-term tolerance to allergens can be induced by immunotherapy, but the desensitiziation therapy is often considered to be quite expensive [ 5 ]. Moreover, the capacity of sublingual allergen immunotherapy SLIT to provide effective symptom relief in seasonal allergic rhinitis has also been questioned. It has been reported that SLIT tablets had a greater clinical impact than second-generation antihistamines and montelukast, but when compared to nasal corticosteroids, the beneficial effects were the same [ 6 ].

    Alternative treatments such as acupuncture and homeopathy, even if quite popular, are not supported by any evidence.

    Intranasal corticosteroids may be useful in the treatment of some forms of non-allergic rhinitis and should be an appropriate choice for mixed rhinitis. Evidence [ 7 ] declares them to be useful for the treatment of non allergic rhinitis with eosonophilia syndrome.

    Also for chronic CRS and acute ARS rhinosinusitis various topical therapies are available: saline solutions, antibiotics, corticosteroids, and antifungals. Topical saline and corticosteroids should be considered as the first line of therapy for CRS [ 8 ] and evidence supports its use as a monotherapy or as an adjuvant therapy to antibiotics in ARS [ 9 ].

    Corticosteroid nasal sprays include: beclometasone diproprionate, budesonide, ciclesonide, flunisolide, fluticasone furoate, fluticasone proprionate, triamcinolone acetonide, and mometasone furoate.

    With so many different sprays available in the market, many authors decided to compare efficacy, side-effect profile and relative cost of each product, to assess which - and if - one is the best [ 2 ]. Results have too often been controversial and there is no clear evidence in favour of one or the other. Thus far it has been established that all the sprays have a similar side-effect profile, and the most significant differences might be related to patient's personal preference for each product sensory attributes [ 10 — 12 ] and costs.

    Mometasone furoate MF is used in the treatment of rhinitis and rhinosinusitis as well as asthma [ 13 ], inflammatory skin disorders and penile phimosis. Evidence suggests that its usage improves symptoms related to adenoid hypertrophy, too.

    To assess MF nasal spray effectiveness and safety we decided to analyze the scientific publications related to this molecule and to perform a comparative analysis between MF and its main intranasal competitors. Out of these, met eligibility criteria and were assessed independently by two authors for further evaluation. A sample of 40 articles was considered for this review, taking into account relevance and date of publication. We then proceded to evaluate mometasone furoate nasal spray efficacy, safety, and cost-effectivenes.

    In , mometasone furoate was introduced as a nasal spray. MF has been largely successful since it was first sold. Evidence [ 14 — 16 ] shows that - at least for asthma maintenance - 1spray daily should be enough thus diminishing both costs and side effects.

    To obtain the best results, as most topical intranasal corticosteroids, it is strongly suggested to blow the nose to clear the passageway before the application or perform a nasal irrigation, and to avoid sneezing or blowing the nose right after spraying. Intranasal corticosteroid therapy also has a beneficial effect in relieving eye symptoms in allergic conjunctivitis, similar to oral or intranasal antihistamines [ 19 — 21 ] according to reviews.

    Even though it has not been clearly assessed for MF in particular, its usage should improve other forms of rhinitis, like mixed forms or NARES.

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    Compared with antibiotics monotherapy, using MF nasal spray for initial ARS treatment, alone or combined with an antibiotic, has been demonstrated to reduce the recurrence rate and decrease the usage of related prescriptions and medical consultations [ 22 ].

    As regards the treatment of nasal polyposis, MF, if administered daily, reduces polyp size and the nasal congestion, improving quality of life and sense of smell, with no unusual or unexpected adverse events [ 23 — 25 ].

    Furthermore, regarding other minor complaints associated with rhinitis and rhinosinusitis, mometasone furoate nasal spray has been shown to be safe, effective and well tolerated in the treatment of daytime cough, too [ 26 ]. In , Minshall et al. Through nasal biopsies, they assessed that long-term administration of the drug attenuates the inflammatory process decreasing the extent of inflammatory cell infiltration especially eosinophils and did not determine changes in epithelial thickness or atrophy.

    It has also been well established that the topical use of MF in the pediatric population shows great efficacy for management of adenoidal hypertophy [ 28 ] and otitis media with effusion [ 29 ], despite the concomitant presence of atopy [ 30 ].

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    Lastly, as reported in a recent cost-effectiveness analysis [ 31 ] when compared to beclomethasone diproprionate, the therapy with mometasone furoate for treating children suffering from allergic rhinitis showed a greater improvement, better efficacy, safety, and lower total treatment cost.

    As regards the safety of the drug, the same results were obtained when administered in children for nasal polyps, even at double the recommended pediatric dosage for allergic rhinitis [ 32 ].

    Pregnant women can safely use intranasal steroids. The sprays work only in the nasal passageway and the medicine does not affect other parts of the body unless too much is used [ 3 ]. Until now, despite parents apprehension, topical application of MF - respecting the recommended dosage - has not shown systemic effects. Many studies have been conducted to investigate its effects on growth velocity and its potential to cause adrenal suppression [ 33 , 34 ].

    Thus far, no significant difference has been reported and the current guidelines for asthma recommend inhaled corticosteroids for the control of mild to severe persistent asthma in adults as well as adolescents.

    MF dry powder inhaler has been demonstrated to have an excellent safety and efficacy profile, and during post-marketing surveillance and in clinical trials no significant adverse side effects have been reported. In addition, its simple use seems to improve asthma management by addressing issues that generally inhibit proper adherence to therapy [ 35 — 38 ].

    These considerations for the usage of MF in asthma could be extended to MF administered via the intranasal route.

    Each steroid preparation comes with patient instructions for safe and effective use. For best results, the medication should be used following this direction carefully and according to medical advice. Adherence to long-term therapy is essential to have the desired results.

    In fact, intermittent therapy may not guarantee the same benefits. This is even more true in the case of a chronic disease. Moreover, non-adherence to treatment may also require that, if an acute attack occurs, a higher dose of medication would be required, and possibly even asteroid molecule orally or intramuscularly administered.

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    The large quantity of different preparations available could also allow the doctor - in case of molecules with the same efficacy, dosage and quality of the dispenser - to choose the most convenient for the patient, taking into account the expenses related with long term use. Results were not always in favour of MF, but Meltzer et al. Last but not least, it is a fact that all steroids suppress gene expression of factors responsible for generating and supporting inflammatory processes but furoates earn special attention as their lateral furoate ester chain makes the molecules highly lipophilic.

    Thus, the moleculas are easily absorbed by mucous membranes, epithelium and cell membrane phospholipids. This minimizes their general action and maximizes local action [ 39 ]. Conclusions MF has been demonstrated to be safe, effective and, if compared to its competitors, it shows symptom control greater than the other products in the market.

    Footnotes The authors declare that they have no competing interests. All authors read and approved the final manuscript. Anna Crisanti, Email: ti.

    Luisa Maria Bellussi, Email: ti. References 1. Nasal congestion secondary to allergic rhinitis as a cause of sleep disturbance and daytime fatigue and the response to topical nasal corticosteroids.

    J Allergy Clin Immunol. Intranasal steroid sprays in the treatment of rhinitis: is one better than another? J Laryngol Otol. The diagnosis and management of rhinitis: an updated practice parameter. Intranasal corticosteroids versus topical H1 receptor antagonists for the treatment of allergic rhinitis: a systematic review with meta-analysis.

    Ann Allergy Asthma Immunol. Clin Exp Allergy. A meta-analysis of sublingual allergen immunotherapy and pharmacotherapy in pollen-induced seasonal allergic rhinoconjunctivitis.

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