Professional Documents
Culture Documents
Third Edition
2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
Nasal
insufficiency
can be
multifactorial
This cigarette
smoker has a
septal deviation,
turbinate
hypertrophy
from allergies,
polyps, &
rhinosinusitis.
2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
Laryngitis,
Pharyngitis
Asthma
Allergic
Rhinitis
Rhinosinusitis
Chronic
Rhinitis
2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
Allergic Rhinitis
Provoked by exposure to antigens
(allergens) in the environment and food
Symptoms:
Nasal congestion with nasal mucosal edema or
obstruction (mouth breathing, midfacial
fullness / pressure or headache.)
Sneezing, nasal, conjunctival and/or palatal
pruritis
Watery rhinorrhea, post nasal drip, lacrimation
Diminished sense of smell, Eustachian tube
dysfunction
2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
Definition of Allergy
Von Pirquet 1906 Allergy
An altered reactivity to a foreign substance
after prior exposure to the same material
Allergy & Hypersensitivity are used
interchangeably to describe an adverse
clinical reaction to an environmental agent
caused by an immunological reaction
(Antigen-Antibody reaction).
2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
Hypersensitivity Reactions
(Allergic Rhinitis is primarily a Type I,
IgE mediated reaction)
Type I
Immediate (allergic rhinitis, asthma,
immediate onset food reactions)
Type II Cytotoxic (hemolytic anemia, Hashimotos)
Type III Immune Complex (serum sicknesss,
delayed onset food reactions,
glomerulonephritis)
Type IV Delayed, Cell Mediated (TB, poison ivy)
Type V Stimulating Antibody Reaction (Graves)
Type VI Antibody Dependent Cell Cytoxicity
(transplant rejection)
2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
Allergen (Antigen):
A foreign substance that when introduced into the
body elicits a specific immunologic response.
Antibody:
A protein (immunoglobulin) that selectively binds
to a specific allergen.
2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
6. End-organ response
2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
Pathophysiology of Allergic
Inflammation: Sensitization
Phase 1 :
Sensitization
Allergens
Antigen-presenting
cell
Processed
allergens
B cell
CD4
T cell
IgE antibodies
Plasma cell
Naclerio, RM. New Engl J Med 1991:325; 860-9
2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
Pathophysiology of Allergic
Inflammation: Clinical Disease
Phase 2 :
Clinical Disease
Early
Inflammation
Late
Inflammation
Allergens
Cellular
infiltration
Mast
cell
Mediator release
Nerves
Blood
vessels
Glands
Resolution
Late-phase
reaction
IgE antibodies
Eosinophils
Basophils
Monocytes
Lymphocytes
Hyperresponsiveness
Complications
Priming
Sneezing
Rhinorrhea
Congestion
2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
Irreversible
disease (?)
Antigen
Lipid
Mediators
PGs
LTs
Cytokines
IL4,5,6,8
Nucleus
Nucleus
Preformed
Mediators
Histamine
Heparin
Tryptase(MastCells)
2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
Basic Immunology:
Sensitization vs. Subsequent
Exposure
I
Antigen
II
Macrophage
Cytokines
T-cell
TH2
IgE
B-cell
Sensitization
Mast Cell
IgE presentation
Degranulation
IgE bridging
2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
Mediators
2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
Early Phase
Response
Late Phase
Response
Types of Rhinitis - 1
Seasonal allergic rhinitis (classic hayfever with
spring, summer &/or fall symptoms)
2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
Types of Rhinitis - 2
Vasomotor rhinitis (temperature variation
induced, either inhaled or with food intake)
Symptoms
Symptoms<<44days
daysper
perweek
week
or
orSymptoms
Symptoms<<44weeks
weeks
Mild
Mild
Normal
Normalsleep
sleep
&&no
noimpairment
impairmentof
ofdaily
daily
activities,
activities,sport,
sport,leisure
leisure
&&normal
normalwork
workand
andschool
school
&&no
notroublesome
troublesomesymptoms
symptoms
Persistent
Persistent
>>44days
daysper
perweek
week
and
and>>44weeks
weeks
Moderatesevere
Moderatesevere
One
Oneor
ormore
moreitems
items
Abnormal
Abnormalsleep
sleep
Impairment
Impairmentof
ofdaily
daily
activities,
activities,sport,
sport,leisure
leisure
Abnormal
Abnormalwork
workand
andschool
school
Troublesome
Troublesomesymptoms
symptoms
2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
Chance of
having
atopy
based on
family
history
2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
L
2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
R
2003 The American Academy of Otolaryngology
Head and Neck Surgery Foundation
.
2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
Physical Examination
of Allergy Patient
Dental: crowded teeth, high arched palate
Nasopharynx: hypertrophic adenoids
(adenoid facies), lateral pharyngeal bands
Larynx: edematous / polypoid vocal cords
Lungs: sibilant rales, wheezing suggestive of
bronchospasm
Skin: eczema or other pruritic rashes
(especially if food allergic)
2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
L
2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
IgE testing
Skin In vivo (prick or intradermal tests)
Laboratory In vitro antigen specific assay
(radioallergosorbent / RAST Test or enzyme linked
immunosorbent / ELISA Test)
Other Laboratory testing:
Eosinophil count (also may be elevated in asthma,
NARES, parasitic infection, etc.)
Nasal cytology
Dietary Elimination and Challenge Feeding tests
2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
Seasonal pollens
Immunotherapy
2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
Treatment Considerations in
Allergic Rhinitis
Pharmacotherapy Factors :
Effectiveness
Side effect profile
Dosing schedule
Affordability
2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
Action
Antihistamines
Intranasal Steroids
Cromolyn sodium
Decongestants
Leukotrienes
Immunotherapy
IgE specific agents
Block histamine
Local anti-inflammatory
Stabilizes mast cells
Vasoconstriction
Block cytokine action
Competing antibodies, etc.
Bind IgE, block receptor
sites, etc.
2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
Sneezing Rhinorrhea
Nasal
obstruction
Nasal itch
Eye
symptoms
H1-antihistamines
Oral
Intranasal
Intraocular
Corticosteroids
Intranasal
Cromolyn sodium
Intranasal
Intraocular
Decongestants
Intranasal
Oral
Anticholinergics
Antileukotrienes
++
++
0
++
++
0
+
+
0
+++
++
0
++
0
+++
+++
+++
+++
++
++
+
0
+
0
+
0
+
0
0
++
0
0
0
++
0
0
++
++
++++
+
0
+
0
0
0
++
0
0
0
++
Adapted from van Cauwenberge P, et al. Allergy. 2000;55:116-134 and Nayak AS, et al.
Ann Allergy Asthma Immunol. 2002;88:592-600.
2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
Mild
intermittent
Moderatesevere
intermittent
Mild
persistent
Moderatesevere
persistent
Intranasal corticosteroid
Cromolyn Sodium
Patient
education
and
allergen
and irritant avoidance
Patient
education
and
allergen
avoidance
2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
Prescription Antihistamines
Relieves rhinitis, excess mucous production, as well
2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
(in younger
children, use drugs least absorbed & effective with once
daily dosing, particularly if also on steroids for asthma)
2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
Leukotriene Suppressors
Leukotriene synthesis inhibitors or receptor
antagonists commonly used for asthma (after
therapies with inhaled steroids & B-agonists fail)
Consider in patients with persisting symptoms
despite topical steroids &/or antihistamines,
especially in asthmatics or those with ASA triad
May be useful (variable effect) on polyps or
hyperplastic nasal / sinus mucosa
Few side effects, safe in children > 2y/o
2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
Scratch Test
(poor
reproducibility)
Prick Test
single prick test
multi-test devices
Intradermal Tests
single intradermal
skin endpoint
titration (serial
dilutions, multiple
tests to quantitate
sensitivity)
2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
Prick Testing
Strength of antigen predetermined
usually 1:10 or 1:20 antigen weight to volume of liquid
2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
SET Diagram
2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
5
7
2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
Antigen Dose
Comparisons among
Skin Testing
Techniques
Prick 1:10 w/v = .30 g
0.01 ml of
various antigen
dilutions
delivered by SET
#6 = 0.03 g
#5 = 0.16 g
#4 = 0.80 g
0.02ml
0.02ml
#3 = 4.0 g
#2 = 20 g
#1 = 100 g
2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
In Vitro Methodology
Courtesy Scientific American
Class 0
Class 1/0
Class 1
Class 2
Class 3
Class 4
Class 5
2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
Comparison of
Scoring
Systems
2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
Relative Advantages:
In Vivo vs. In Vitro Testing
In Vitro (immunoassay)
No risk of allergic reaction
Not affected by drugs or
skin conditions
Patient convenience
(single venipuncture)
Easy to document quality
control, reproducibility
Most convenient for allergy
screen
2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
Testing
Treatment
Food Allergy
(2 basic types : Fixed and Cyclic)
May cause nasal congestion & rhinitis, in
addition to more common food sensitivity
manifestations: GI disturbance, rash,
headache, vertigo
Consider evaluation if patient has positive
history for food reactions (or colic/eczema
as child), inhalant allergy workup is
unimpressive, or therapy (environmental
modification, pharmacotherapy,
immunotherapy) fails to bring expected relief
2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
Food Reactions
Prevalence greatest < 3 years of age, & declines
over next decade
90% of food allergy reactions in children are
caused by 6 foods : milk, egg, soy (all of which can
be outgrown), & wheat, peanut, tree nuts
90% of food allergy reactions in adults are caused
by 4 foods: peanut, tree nuts, fish, shellfish
Common cross reactions between inhalants &
foods: ragweed & melon / banana; birch &
apple / carrot / potato / hazelnut / almond
2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
Patient improves
Reintroduce suspect
food into diet
Symptoms recur
Patient unchanged
2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
Immunotherapy Failure:
Common Reasons
Patient failure to regularly comply with the
immunotherapy regimen
Incorrect antigen dosing &/or too infrequent shot
intervals
Food or chemical sensitivities, or inhalants to
which patient was not tested or for which
commercial antigens are unavailable
Non-allergic rhinitis (vasomotor, occupational,
atrophic, medication-induced)
Rhinosinusitis, Anatomic airway obstruction
2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
References
Fornadley J, Corey J, Osguthorpe J, et al: Allergic
Rhinitis: Clinical Practice Guidelines. Otolaryngol
Head Neck Surg 115:115, 1996 (consensus of American
Academy of Otolaryngology - Head and Neck Surgery & American
Academy of Otolaryngic Allergy).
2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation