coass ii-allergy rhinitis
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2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
Allergic RhinitisAllergic RhinitisThird EditionThird Edition
James A. Hadley, M.D. andJames A. Hadley, M.D. andJ. David Osguthorpe, M.D.J. David Osguthorpe, M.D.
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Nasal Airway InsufficiencyNasal Airway Insufficiency(the stuffy nose)(the stuffy nose)
ALLERGYALLERGY(medically reported as 1 ! ""# of population)(medically reported as 1 ! ""# of population) ANAT$%I& $'TR&TI$NANAT$%I& $'TR&TI$N(septum* tur+inate)(septum* tur+inate) R,IN$INITIR,IN$INITI (self reported +y 1- !1./0# of population)(self reported +y 1- !1./0# of population)
NON-ALLERGIC RHINITISNON-ALLERGIC RHINITIS(asomotor* gustatory* etc/)(asomotor* gustatory* etc/) %E2I&ATI$N I2E E33E&T%E2I&ATI$N I2E E33E&T(rhinitis medicamentosa*(rhinitis medicamentosa*
anti!,TN* +irth control pills* estrogen* etc/)anti!,TN* +irth control pills* estrogen* etc/)
4RE5NAN&6 or $T,ER EN2$&RINE4RE5NAN&6 or $T,ER EN2$&RINE
$R&E* 37I2 RETENTI$N$R&E* 37I2 RETENTI$N NE$47A%* 3$REI5N '$26* ET&/NE$47A%* 3$REI5N '$26* ET&/
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2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
Nasal Insufficienty can e multifactorial.Nasal Insufficienty can e multifactorial.NasalNasal
insufficiencyinsufficiency
can +ecan +emultifactorialmultifactorial
This cigarette
smo8er has aseptal deiation*tur+inatehypertrophyfrom allergies*polyps* 9rhinosinusitis/
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2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
Allergic and Non! Allergic RhinitisAllergic and Non! Allergic Rhinitis
This educational slide seriesThis educational slide series
will reiew thewill reiew the
pathophysiology* impact*pathophysiology* impact*
diagnosis and managementdiagnosis and managementscenarios of +oth allergic andscenarios of +oth allergic and
non!allergic rhinitis/non!allergic rhinitis/
A summary of theA summary of the
otolaryngolgist:s perspectieotolaryngolgist:s perspectieand treatment paradigms/and treatment paradigms/
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2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
Impact of Allergic RhinitisImpact of Allergic Rhinitis
;;thth
most prealent chronic* 9 most commonmost prealent chronic* 9 most commonrespiratory* disease (most prealent chronicrespiratory* disease (most prealent chronic
condition in those < 1= y>o)condition in those < 1= y>o)
"/0# physician office isits* common reason for"/0# physician office isits* common reason for
+oth $T& 9 physician prescriptions+oth $T& 9 physician prescriptions Diminished QOLDiminished QOL(irrita+ility* fatigue* sleep(irrita+ility* fatigue* sleep
distur+ance* depression)distur+ance* depression)
2irect costs to economy of appro?imately @/02irect costs to economy of appro?imately @/0
+illion>year* plus !+illion>year* plus ! ./= million lost wor8 9 school days annually./= million lost wor8 9 school days annually
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2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
Allergic Rhinitis B Associated 2iseasesAllergic Rhinitis B Associated 2iseases
AllergicRhinitis
OtitisOtitisMediaMedia
AsthmaAsthma
Laryngitis,
Pharyngitis Rhinosinusitis
Chronic
Rhinitis
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2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
&omplications of Allergic Rhinitis&omplications of Allergic Rhinitis
Rhinosinusitis* Nasal 4olypsRhinosinusitis* Nasal 4olyps
4haryngitis* 7aryngitis4haryngitis* 7aryngitis
$titis %edia* $titis E?terna$titis %edia* $titis E?terna
&onCunctiitis&onCunctiitis E?acer+ation of Asthma* 'ronchitis* Dertigo*E?acer+ation of Asthma* 'ronchitis* Dertigo*
%igraine* Ecema%igraine* Ecema
Impaired $lfaction > Taste* leep Apnea*Impaired $lfaction > Taste* leep Apnea*
3acial 5rowth A+normalities in3acial 5rowth A+normalities in &hildren&hildren(all(all
from nasal o+struction)from nasal o+struction)
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2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
Allergic RhinitisAllergic Rhinitis
Provoked by e!os"re #o $n#i%ensProvoked by e!os"re #o $n#i%ens (allergens) in the enironment and food(allergens) in the enironment and food
Sym!#oms&Sym!#oms&
! Nasal congestion with nasal mucosal edema orNasal congestion with nasal mucosal edema or
o+struction (mouth +reathing* midfacialo+struction (mouth +reathing* midfacialfullness > pressure or headache/)fullness > pressure or headache/)
! neeing* nasal* conCunctial and>or palatalneeing* nasal* conCunctial and>or palatal
pruritispruritis
! Fatery rhinorrhea* post nasal drip* lacrimationFatery rhinorrhea* post nasal drip* lacrimation! 2iminished sense of smell* Eustachian tu+e2iminished sense of smell* Eustachian tu+e
dysfunctiondysfunction
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2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
2efinition of Allergy2efinition of Allergy
'on Pir("e# )*+,'on Pir("e# )*+,Aer%yAer%yAn $#ered re$.#ivi#y #o $ /orei%n s"bs#$n.eAn $#ered re$.#ivi#y #o $ /orei%n s"bs#$n.e$/#er !rior e!os"re #o #he s$me m$#eri$0$/#er !rior e!os"re #o #he s$me m$#eri$0
Allergy 9 ,ypersensitiity are usedAllergy 9 ,ypersensitiity are usedinterchangea+ly to descri+e an aderseinterchangea+ly to descri+e an aderseclinical reaction to an enironmental agentclinical reaction to an enironmental agentcaused +y an immunological reactioncaused +y an immunological reaction(Antigen!Anti+ody reaction)/(Antigen!Anti+ody reaction)/
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2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
,ypersensitiity Reactions,ypersensitiity Reactions(Allergic Rhinitis is primarily a Type I*(Allergic Rhinitis is primarily a Type I*
IgE mediated reaction)IgE mediated reaction)
Ty!e ITy!e I Immediate (Immediate ($er%i. rhini#is$er%i. rhini#is* asthma** asthma*
immediate onset food reactions)immediate onset food reactions)
Type II &ytoto?icType II &ytoto?ic (hemolytic anemia* ,ashimoto:s)(hemolytic anemia* ,ashimoto:s)
Type III Immune &omple?Type III Immune &omple? (serum sic8nesss*(serum sic8nesss*
delayed onset food reactions*delayed onset food reactions*
glomerulonephritis)glomerulonephritis)
Type ID 2elayed* &ell %ediatedType ID 2elayed* &ell %ediated (T'* poison iy)(T'* poison iy)
Type D timulating Anti+ody ReactionType D timulating Anti+ody Reaction (5raes:)(5raes:)
Type DI Anti+ody 2ependent &ell &yto?icityType DI Anti+ody 2ependent &ell &yto?icity
(transplant reCection)(transplant reCection)
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2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
2efinitions Releant to Allergic Rhinitis2efinitions Releant to Allergic Rhinitis
,ypersensitiity,ypersensitiity! A heightened or e?aggerated immune responseA heightened or e?aggerated immune response
that deelops after G1 e?posure to a specificthat deelops after G1 e?posure to a specific
antigen/antigen/
Allergen (Antigen)BAllergen (Antigen)B! A foreign su+stance that when introduced into theA foreign su+stance that when introduced into the
+ody elicits a specific immunologic response/+ody elicits a specific immunologic response/
Anti+odyBAnti+odyB! A protein (immunoglo+ulin) that selectiely +indsA protein (immunoglo+ulin) that selectiely +inds
to a specific allergen/to a specific allergen/
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2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
1/ ,ost sensitiation to allergen
"/ IgE production +y host
./ %ast cell sensitiation
/ Allergen proocation +y furthere?posure after sensitiing eent
0/ %ediator releaseB
His#$mine1 kinins1 e"ko#rienes1 .y#okines
;/ End!organ response
4athophysiology of Allergic 2isease4athophysiology of Allergic 2isease
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2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
4athophysiology of Allergic4athophysiology of Allergic
InflammationB ensitiationInflammationB ensitiation
4hase 1 B ensitiation4hase 1 B ensitiation
Antigen!presentingcell
&2T cell
' cell
IgE anti+odies
Allergens
4rocessedallergens
4lasma cell
Naclerio, "M. Ne# $ngl J Med %&&%'()*+ -/&
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2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
4athophysiology of Allergic4athophysiology of Allergic
InflammationB &linical 2iseaseInflammationB &linical 2isease
4hase " B &linical 2isease4hase " B &linical 2iseaseEarly
Inflammation
Allergens
0nee1ing
"hinorrhea
2ongestion
Mast
cell
Ig$ antiodies
Mediator release
3loodvessels
Nerves
4lands
7ateInflammation
2ellularinfiltration
$osinophils
3asophils
Monocytes
5ymphocytes
"esolution
2omplications
Irreversiledisease 678
7ate!phasereaction
4riming
,yper!responsieness
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2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
%ast &ells > 'asophils and%ast &ells > 'asophils and
Inflammatory &ascadeInflammatory &ascade
NucleusNucleusNucleusNucleus9999
PreformedPreformed
MediatorsMediators-Histamine-Histamine
-Heparin-Heparin
-Tryptase (Mast Cells)-Tryptase (Mast Cells)
CytokinesCytokines-IL-4,5,6,8-IL-4,5,6,8
LipidLipid
MediatorsMediators-PGs-PGs
-LTs-LTs
AntigenAntigen
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2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
&hemical %ediators of Allergic* and ome&hemical %ediators of Allergic* and ome
Non!Allergic* RhinitisNon!Allergic* Rhinitis(principally from %ast cells 9 'asophils)(principally from %ast cells 9 'asophils)
4re!formed (stored)4re!formed (stored)
mediatorsmediators
! ,istamine,istamine! HininsHinins
! ,eparin,eparin
! 4latelet actiating4latelet actiatingfactor (4A3)factor (4A3)
Newly formed mediatorsNewly formed mediators(created +y 9 after reaction)(created +y 9 after reaction)
! 7eu8otrienes7eu8otrienes 7T'* 7T&* 7T27T'* 7T&* 7T2
! &yto8ines&yto8ines E&3!A*E&3!A*
! 4rostaglandins4rostaglandins 452"452"
! Interleu8insInterleu8ins
' i I l
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2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
'asic ImmunologyB'asic ImmunologyB
ensitiation s/ u+seuentensitiation s/ u+seuent
E?posureE?posure
Mast CellB-cell Degranulation
Sensitization IgE presentation IgE bridgingSensitization IgE presentation IgE bridging
Macrophage
Antigen
T-cell
TH2
Cytokines
I
II
IgE
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2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
Mast Cell Mediators
Early 4hase Reaction 7ate 4hase Reaction(ma?imum 1-!.- minutes) (ma?imum at 1-!1" hours)4ruritis* neeing Infiltration with Eosinophilsmooth muscle contraction 3i+rin deposition3lush* Dascular lea8age with Infiltration with %onocytesRhinorrhea Tissue destruction
Nasal congestion%ucous ecretion
Atg
&onseuences of %ediator Release&onseuences of %ediator Release
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Nasal Response to Inhaled AllergenNasal Response to Inhaled Allergen
Time in Hours from Initial
Challenge
Early Phase
Response
Late Phase
Response
y
m
p
to
m
s
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Types of Rhinitis ! 1Types of Rhinitis ! 1
Se$son$ $er%i. rhini#isSe$son$ $er%i. rhini#is(classic hayfeer with(classic hayfeer withspring* summer 9>or fall symptoms)spring* summer 9>or fall symptoms) Perenni$ $er%i. rhini#isPerenni$ $er%i. rhini#is(mite* mold*(mite* mold*
coc8roach* animal dander)coc8roach* animal dander)
Infectious rhinitisInfectious rhinitis(irus* +acteria* fungi)(irus* +acteria* fungi) $ccupational rhinitis$ccupational rhinitis(late?)(late?) &hemical > irritatie rhinitis&hemical > irritatie rhinitis(perfumes*(perfumes*
strong odors* fine particles)strong odors* fine particles)
Anatomic rhinitisAnatomic rhinitis(nasal drainage o+struction(nasal drainage o+struction+y septum* etc/)+y septum* etc/)
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Tur+inate ,ypertrophy>Rhinitis of 4regnancyTur+inate ,ypertrophy>Rhinitis of 4regnancy
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Types of Rhinitis ! "Types of Rhinitis ! "
'$somo#or rhini#is'$somo#or rhini#is(temperature ariation(temperature ariationinduced* either inhaled or with food inta8e)induced* either inhaled or with food inta8e)
Non!allergic rhinitis with eosinophiliaNon!allergic rhinitis with eosinophilia
%edication!induced rhinitis%edication!induced rhinitis (rhinitis(rhinitis
medicamentosa* oral contracepties* anti!medicamentosa* oral contracepties* anti!hypertensies)hypertensies)
,ormonal rhinitis,ormonal rhinitis (pregnancy* menopause*(pregnancy* menopause*hypothyroidism)hypothyroidism)
Atrophic rhinitisAtrophic rhinitis (ageing* surgery* infection)(ageing* surgery* infection)
5ustatory rhinitis5ustatory rhinitis(food allergy induced)(food allergy induced)
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ARIA &lassification 9 Allergic RhinitisARIA &lassification 9 Allergic Rhinitis
%oderateJseereOne or more i#ems
A+normal sleep
Impairment of daily
actiities* sport* leisure A+normal wor8 and school
Trou+lesome symptoms
%oderateJseereOne or more i#ems
A+normal sleep
Impairment of dailyactiities* sport* leisure
A+normal wor8 and school
Trou+lesome symptoms
4ersistent G days per wee8
and G wee8s
4ersistent G days per wee8
and G wee8s
%ild Normal sleep9 no impairment of daily
actiities* sport* leisure
9 normal wor8 and school9 no trou+lesome symptoms
%ild Normal sleep9 no impairment of daily
actiities* sport* leisure
9 normal wor8 and school
9 no trou+lesome symptoms
Intermittent ymptoms < days per wee8
or ymptoms < wee8s
Intermittent ymptoms < days per wee8
or ymptoms < wee8s
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2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
ymptoms of Allergic Rhinitisymptoms of Allergic Rhinitis
4roo8ed +y e?posure to Antigens4roo8ed +y e?posure to Antigens (in atopic conte?t*(in atopic conte?t*called Allergens)called Allergens)in enironment 9 foodin enironment 9 food
&ommon ymptomsB&ommon ymptomsB
! Nasal* conCunctial 9>or palatal pruritisNasal* conCunctial 9>or palatal pruritis
!neeing* watery rhinorrhea* post nasal drip*neeing* watery rhinorrhea* post nasal drip*lacrimationlacrimation
! %ucosal edema with nasal congestion >%ucosal edema with nasal congestion >o+structiono+struction (mouth +reathing* sleep distur+ances)(mouth +reathing* sleep distur+ances)**sinus ostial 9>or eustachian tu+e dysfunctionsinus ostial 9>or eustachian tu+e dysfunction
(midfacial pressure>pain* headache* ear pressure 9(midfacial pressure>pain* headache* ear pressure 9occasional mild diyness)occasional mild diyness)* 9 diminished olfaction* 9 diminished olfaction
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2iagnosis and the Allergic 4atient2iagnosis and the Allergic 4atient
2iagnosis +ased onB2iagnosis +ased onB
1/ ,istory1/ ,istory
"/ 4hysical E?amination"/ 4hysical E?amination
././7a+oratory 9>or 8in Testing7a+oratory 9>or 8in TestingNoteB K 1 9 K" suffice for initiation ofNoteB K 1 9 K" suffice for initiation of
Enironmental %easures 9 4harmacotherapy*Enironmental %easures 9 4harmacotherapy*and may +e all that is necessary in mild toand may +e all that is necessary in mild to
moderate casesL K. affords definitie diagnosismoderate casesL K. affords definitie diagnosis9 is reuired prior to Immunotherapy9 is reuired prior to Immunotherapy
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2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
Allergies 9 4ast %edical ,istoryAllergies 9 4ast %edical ,istory
&hildhood allergy > asthma&hildhood allergy > asthma
Recurrent $%* recurrentRecurrent $%* recurrent
acute or chronic Racute or chronic R
EcemaEcema &olic > formula intolerance&olic > formula intolerance
Anaphylactic reaction (foodAnaphylactic reaction (food
or drug)or drug)
easonal colds (spring*easonal colds (spring*fall)fall)
urgeryurgery
T 9>or AT 9>or A
4 E Tu+es4 E Tu+es
inusinus $T& or R?$T& or R?
medications withmedications with
anti!allergy* coldanti!allergy* cold
or decongestantor decongestanteffectseffects
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2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
Allergies 9 3amily ,istoryAllergies 9 3amily ,istory
&hance ofhaing
$#o!y+ased onfamilyhistory
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4hysical E?amination of Allergy 4atient4hysical E?amination of Allergy 4atient
EyesB conCunctiitis*EyesB conCunctiitis* Dennie2s ines1 3shinersDennie2s ines1 3shiners
EarsB otitis media or e?terna* retractedEarsB otitis media or e?terna* retracted
tympanic mem+rane from ET dysfunctiontympanic mem+rane from ET dysfunction
NoseB +oggy > pale nasal mucosa* clear > thinNoseB +oggy > pale nasal mucosa* clear > thinmucoid rhinitis* tur+inate hypertrophy* polyps*mucoid rhinitis* tur+inate hypertrophy* polyps*
transerse nasal crease fromtranserse nasal crease from 3$er%i. s$"#e03$er%i. s$"#e0
ThroatB prominent lymphoid patchesThroatB prominent lymphoid patches
(co++lestoning)* lateral pharyngeal +ands(co++lestoning)* lateral pharyngeal +ands
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2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
R MR Mtur+inate congestion 9 hypertrophy fromtur+inate congestion 9 hypertrophy from
allergiesLallergiesL 7 M allergic conCunctiitis7 M allergic conCunctiitis
!
R L
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4osterior 4haryngeal &o++lestoning (su+mucosal4osterior 4haryngeal &o++lestoning (su+mucosal
lymphoid hyperplasia from chronic post!nasal driplymphoid hyperplasia from chronic post!nasal drip
of inhalant allergies)of inhalant allergies)
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4hysical E?amination4hysical E?amination
of Allergy 4atientof Allergy 4atient
2entalB crowded teeth* high arched palate2entalB crowded teeth* high arched palate
Nasopharyn?B hypertrophic adenoidsNasopharyn?B hypertrophic adenoids (adenoid facies)* lateral pharyngeal +ands(adenoid facies)* lateral pharyngeal +ands
7aryn?B edematous > polypoid ocal cords7aryn?B edematous > polypoid ocal cords
7ungsB si+ilant rales* wheeing suggestie of7ungsB si+ilant rales* wheeing suggestie of
+ronchospasm+ronchospasm
8inB ecema or other pruritic rashes8inB ecema or other pruritic rashes(especially if food allergic)(especially if food allergic)
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7 M7 MRash from 'irch &ontaining hampooLRash from 'irch &ontaining hampooL
R MR MAtopic Ecema from 3ood ensitiitiesAtopic Ecema from 3ood ensitiities
L R
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IgE testingSkin 3In vivo0 4!ri.k or in#r$derm$ #es#s)
7a+oratory In itro antigen specific assay(radioallergosor+ent > RAT Test or enyme lin8ed
immunosor+ent > E7IA Test) $ther 7a+oratory testingB
!Eosinophil count (also may +e eleated in asthma*NARE* parasitic infection* etc/)
!Nasal cytology 2ietary Elimination and &hallenge 3eeding tests
Testing for Allergic RhinitisTesting for Allergic Rhinitis
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In Dio or In Ditro Allergy creensIn Dio or In Ditro Allergy creens
Test 'attery of = ! 1" common Allergens in patient:sTest 'attery of = ! 1" common Allergens in patient:sgeographic region is ;# efficient 9 /"#geographic region is ;# efficient 9 /"#sensitie in detecting those with clinicallysensitie in detecting those with clinicallysignificant sensitiitiessignificant sensitiities(unless there is an unusual(unless there is an unusualor occupational e?posure* e/g/ late? in health careor occupational e?posure* e/g/ late? in health care
wor8er* mice in la+oratory wor8er)wor8er* mice in la+oratory wor8er)
E?ample of common inhalant screenB " trees* 1!"E?ample of common inhalant screenB " trees* 1!"weeds* 1!" grasses* 1 mite* coc8roach* " molds*weeds* 1!" grasses* 1 mite* coc8roach* " molds*cat dandercat dander
In children with ecema* colic* etc/* common foodsIn children with ecema* colic* etc/* common foodscan +e added to screen* such as mil8* soy+ean*can +e added to screen* such as mil8* soy+ean*peanut* egg* wheat* cornpeanut* egg* wheat* corn
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Nasal &ytogramNasal &ytogram// mucous* epithelial cells and some +acteria*mucous* epithelial cells and some +acteria*with leu8ocytes (9 more +acteria) in infection* 9 eosinophils in allergywith leu8ocytes (9 more +acteria) in infection* 9 eosinophils in allergy
(most of the time)(most of the time)
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&linical Approach to the Allergic 4atient&linical Approach to the Allergic 4atient
C$ssi. Q"$r#e# o/ Tre$#men# A!!ro$.hes&C$ssi. Q"$r#e# o/ Tre$#men# A!!ro$.hes&
11/ Aoidance 9 Enironmental %easures/ Aoidance 9 Enironmental %easures
""/ &ounseling of 4atient 9 3amily/ &ounseling of 4atient 9 3amily
(home* ocation* aocation* school(home* ocation* aocation* school))
./ 4hysical fitness./ 4hysical fitness/ 4harmacotherapy (e/g/* steroids* antihistamines)/ 4harmacotherapy (e/g/* steroids* antihistamines)
00// Eradicate comor+idityEradicate comor+idity
;/;/ ImmunotherapyImmunotherapy
Oif warranted +y s8in or in itro testing that confirms IgE toOif warranted +y s8in or in itro testing that confirms IgE tooffending Allergens* plus inadeuate (or unrealistic) controloffending Allergens* plus inadeuate (or unrealistic) control
+y +oth K" 9 K .P+y +oth K" 9 K .P
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2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
2iagnosis and Treatment of Inhalant Allergy2iagnosis and Treatment of Inhalant Allergy
,istory and 4hysical E?amination
easonal pollens 4erennial dust* mold* danders
Education* Enironmental &ontrol*4harmacotherapy
Allergy Testing B &onsider screen* then if positie* full +attery of tests
Immunotherapy
If 3ailure
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2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
Air 3iltrationB 4ersonal* Room* ,ouse* &arAir 3iltrationB 4ersonal* Room* ,ouse* &ar
Air 3ilters* inAir 3ilters* in&onsumer&onsumerReports ofReports of1>"--"1>"--"
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2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
Indoor Enironmental Allergen &ontrolBIndoor Enironmental Allergen &ontrolB
E?ample for Allergic (E?trinsic) AsthmaE?ample for Allergic (E?trinsic) Asthma
;-!=-# with asthma hae IgE sensitiities* commonly mite*;-!=-# with asthma hae IgE sensitiities* commonly mite*
coc8roach* cat 9>or Alternaria speciescoc8roach* cat 9>or Alternaria species
Indoor allergen reduction decreases seerity of asthmaBIndoor allergen reduction decreases seerity of asthmaB
! %ite allergen B mite impermea+le mattress 9 pillow%ite allergen B mite impermea+le mattress 9 pillow
coersL wash comforters* +edding* etc at G1.-3L mitecoersL wash comforters* +edding* etc at G1.-3L mite8illing powders (acaricides) on rugs* upholstered8illing powders (acaricides) on rugs* upholstered
furniture* drapesL house humidity < 0-#furniture* drapesL house humidity < 0-#
! &oc8roach allergen B e?termination* cleaning&oc8roach allergen B e?termination* cleaning
! %old B house humidity < 0-#L clean +athrooms*%old B house humidity < 0-#L clean +athrooms*
8itchens* laundry roomsL ent moist areas8itchens* laundry roomsL ent moist areas! ,igh efficiency air filtration 9 acuum cleaner +ags,igh efficiency air filtration 9 acuum cleaner +ags
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2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
Treatment &onsiderations inTreatment &onsiderations in
Allergic RhinitisAllergic Rhinitis
4harmacotherapy 3actors B4harmacotherapy 3actors B! EffectienessEffectieness
! ide effect profileide effect profile
! 2osing schedule2osing schedule
! Afforda+ilityAfforda+ility
Immunotherapy 3actors (Allergy shots) BImmunotherapy 3actors (Allergy shots) B! Effectie in -!=-# with allergic rhinitis* must +e continuedEffectie in -!=-# with allergic rhinitis* must +e continued
for .!0 years in most (seems to reuire such for sustaina+lefor .!0 years in most (seems to reuire such for sustaina+le
leels of +loc8ing anti+odies 9 the li8eL some reuireleels of +loc8ing anti+odies 9 the li8eL some reuirelifelong therapy)lifelong therapy)
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2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
Treatment of Allergic RhinitisTreatment of Allergic Rhinitis
Ty!e o/ Dr"%Ty!e o/ Dr"%AntihistaminesAntihistamines
Intranasal teroidsIntranasal teroids
&romolyn sodium&romolyn sodium
2econgestants2econgestants
7eu8otrienes7eu8otrienes
ImmunotherapyImmunotherapy
IgE specific agentsIgE specific agents
A.#ionA.#ion'loc8 histamine'loc8 histamine
7ocal anti!inflammatory7ocal anti!inflammatory
ta+ilies mast cellsta+ilies mast cells
DasoconstrictionDasoconstriction
'loc8 cyto8ine action'loc8 cyto8ine action
&ompeting anti+odies* etc/&ompeting anti+odies* etc/
'ind IgE* +loc8 receptor'ind IgE* +loc8 receptor
sites* etc/sites* etc/
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2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
Effects of Darious 4harmacotherapiesEffects of Darious 4harmacotherapies:herapy:herapy 0nee1ing0nee1ing "hinorrhea"hinorrhea
NasalNasalostructionostruction
Nasal itchNasal itch$ye$ye
symptomssymptoms
HH%%/antihistamines/antihistaminesOralOral ; ;; ; ; ;; ; ;; ; ; ;; ; ; ; ;; ;
IntranasalIntranasal ; ;; ; ; ;; ; ;; ; ;; ;
IntraocularIntraocular ; ; ;; ; ;
2orticosteroids2orticosteroids
IntranasalIntranasal ; ; ;; ; ; ; ; ;; ; ; ; ; ;; ; ; ; ;; ; ; ;; ;
2romolyn sodium2romolyn sodium
IntranasalIntranasal ;; ;; ;; ;;
IntraocularIntraocular ; ;; ;
DecongestantsDecongestants
IntranasalIntranasal ; ; ; ;; ; ; ;
OralOral ;;
AnticholinergicsAnticholinergics ; ;; ;
Antileu
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2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
%ild%ildintermittentintermittent
%ild%ildpersistentpersistent%oderate!%oderate!
seereseereintermittentintermittent
%oderate!%oderate!seereseere
persistentpersistent
4atient education andallergen and irritant aoidance
Immunotherapy* if otherImmunotherapy* if other therapiestherapiesfailfail
4atient education and allergen aoidance
Intranasal decongestant (
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2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
$er the &ounter ($T&) Allergy %edicationsBAccessi+le* at modest cost in most cases
%ost current $T& antihistamines* may causedrowsiness* dry mouth* +lurry ision*
constipation 9 urinary retention
$ral decongestants may cause agitation 9sleeplessness* or eleate +lood pressure
Topical decongestants can lead to re+oundcongestion or rhinitis medicamentosa
&romolyn reuires freuent dosing prior to 9during e?posure
Traditional 2rug TherapiesTraditional 2rug Therapies
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2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
Topical 9 $ral 2econgestantsTopical 9 $ral 2econgestants(action per alpha adrenergic receptors* do not reliee(action per alpha adrenergic receptors* do not reliee
rhinitis* pruritis* sneeing)rhinitis* pruritis* sneeing)
Topical 2econgestantsTopical 2econgestants(neosynephrine* o?ymetaoline)(neosynephrine* o?ymetaoline)hrin8 inflamed 9 swollen mucosa through localhrin8 inflamed 9 swollen mucosa through local
asoconstrictionasoconstriction
se no longer than ! days to aoid re+oundse no longer than ! days to aoid re+ound$ral 2econgestants$ral 2econgestants(pseudoephedrine)(pseudoephedrine)
Reduce nasal +lood flow (hence* edema 9Reduce nasal +lood flow (hence* edema 9
hyperemia) 9 may improe sinus ostial patencyhyperemia) 9 may improe sinus ostial patency
%ay +e used indefinitely%ay +e used indefinitely(watch '4* sleep* an?iety* 9 use(watch '4* sleep* an?iety* 9 usewith caution if dia+etes* glaucoma* prostatic hypertrophy*with caution if dia+etes* glaucoma* prostatic hypertrophy*
AD2* etc/)AD2* etc/)
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2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
Reliees rhinitis* e?cess mucous production* as wellas most ocular 9 non!nasal manifestions* +ut notn$s$ .on%es#ionwith short term therapy
%inimal to no sedation (mental alertness 9coordination usually intact)
%ucosal drying aria+ly present (much less amongthan older antihistamines)L consider topicalantihistamine alternatie in those with seere asthmaor +ronchitis
&ostlier than $T& > older generation antihistamines(though most sedate to arying degrees)
4rescription Antihistamines4rescription Antihistamines
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2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
Topically effectie in relieing sneeing* nasalpruritis* rhinorrhea 9 reactie mucosal edema
%inimal systemic a+sorption for most(in youngerchildren* use drugs least a+sor+ed 9 effectie with oncedaily dosing* particularly if also on steroids for asthma)
Effectieness depends on regular use 9 adeuatenasal airway for delieryL reuires at least day or
two +efore clinical onset of action(may need oraldecongestant for first wee8 to aid penetration)Lcan irritate
nasal mucosaL modest effect on ocular symptoms
Topical Nasal teroidsTopical Nasal teroids
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2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
7eu8otriene uppressors7eu8otriene uppressors
7eu8otriene synthesis inhi+itors or receptor7eu8otriene synthesis inhi+itors or receptorantagonists commonly used for asthma (afterantagonists commonly used for asthma (after
therapies with inhaled steroids 9 '!agonists fail)therapies with inhaled steroids 9 '!agonists fail)
&onsider in patients with persisting symptoms&onsider in patients with persisting symptoms
despite topical steroids 9>or antihistamines*despite topical steroids 9>or antihistamines*especially in asthmatics or those with AA triadespecially in asthmatics or those with AA triad
%ay +e useful (aria+le effect) on polyps or%ay +e useful (aria+le effect) on polyps or
hyperplastic nasal > sinus mucosahyperplastic nasal > sinus mucosa
3ew side effects* safe in children G "y>o3ew side effects* safe in children G "y>o
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2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
%ast &ell ta+iliersB%ast &ell ta+iliersBcromolyn ornedocromil in nasal* ophthalmic or inhaledpreparations
AnticholinergicsBAnticholinergicsB topical atropine oripratropium
IgE 'loc8ers > 'indersBIgE 'loc8ers > 'indersBomaliuma+ (as aperiodic shot)* many in pipeline for releasein ne?t few years
alineBalineBsaline sprays* pumped irrigations
$ther Therapies for Inhalant Allergies$ther Therapies for Inhalant Allergies
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2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
Types of 8in TestingTypes of 8in Testing
4atch test4atch test(derm use only)(derm use only)
cratch Testcratch Test
(poor(poorreproduci+ility)reproduci+ility)
Pri.k Tes#Pri.k Tes#
! single pric8 testsingle pric8 test! multi!test deicesmulti!test deices
! Intradermal TestsIntradermal Tests!single intradermal!s8in endpoint
titration (serialdilutions* multipletests to uantitatesensitiity)
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2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
Identify antigens in patient:s enironment(regional* wor8 9 home)
uccessful immunotherapy* 9enironmental modification* depends uponaccurate determination of all (or at least the
maCority) of clinically significant allergens
election of Antigens for 8in orelection of Antigens for 8in or
7a+oratory Testing7a+oratory Testing
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2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
Pri.k Tes#in%Pri.k Tes#in%
trength of antigen predeterminedtrength of antigen predetermined! usually 1B1- or 1B"- antigen weight to olume of liuidusually 1B1- or 1B"- antigen weight to olume of liuid
Antigen placed on s8in (+ac8 or arm) prior toAntigen placed on s8in (+ac8 or arm) prior topric8* s8in is tented up with sharp instrument 9pric8* s8in is tented up with sharp instrument 9then pric8edthen pric8ed
Reactions are determined after "- minutesReactions are determined after "- minutes 5rading system 1Q to Q* measuring +oth wheal5rading system 1Q to Q* measuring +oth wheal
and erythema flare responsesand erythema flare responses
2esigned to detect maCor sensitiities* without2esigned to detect maCor sensitiities* without
uantitation as to degreeL can miss low gradeuantitation as to degreeL can miss low gradesensitiities such as moldssensitiities such as molds
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2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
ingle 4ric8 $ptions
%ulti 4ric8 (arious deices* all of which accomplishsimultaneous punctures with different antigens)
8in 4ric8 Techniues8in 4ric8 Techniues
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2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
Intradermal Testing B ingle AntigenIntradermal Testing B ingle Antigen
&oncentration Tests&oncentration Tests
trength of antigen predeterminedtrength of antigen predetermined! usually -/-1 J -/-cc of 1B0-- to 1B1--- antigen weight tousually -/-1 J -/-cc of 1B0-- to 1B1--- antigen weight to
olume inCected su+cutaneouslyolume inCected su+cutaneously
Reaction read after 1-!"- minutesReaction read after 1-!"- minutes
5rading system 1Q to Q * measure +oth wheal sie5rading system 1Q to Q * measure +oth wheal sie
9 erythema flare responses9 erythema flare responses
2etects maCor sensitiities +ut without uantitatie2etects maCor sensitiities +ut without uantitatie
informationL can detect most low gradeinformationL can detect most low grade
sensitiities if 1B0-- antigen solution utiliedsensitiities if 1B0-- antigen solution utilied
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2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
8in Endpoint (2ilutional) Titration8in Endpoint (2ilutional) Titration
or ETor ET Intradermal inCection of -/-1!-/-" cc of seriallyIntradermal inCection of -/-1!-/-" cc of serially
diluted antigen (usually 1B0* starting with the antigendiluted antigen (usually 1B0* starting with the antigen
concentrate) to produce a mm whealconcentrate) to produce a mm wheal
Reaction read per wheal growth +y 1-!10 minutesReaction read per wheal growth +y 1-!10 minutes If no reaction is detected* progressiely moreIf no reaction is detected* progressiely more
concentrated antigen solutions are inCected until aconcentrated antigen solutions are inCected until a
"mm or more growth in wheal sie occurs or the"mm or more growth in wheal sie occurs or the
highest concentration of antigen (usually 1B1--highest concentration of antigen (usually 1B1--
weight per olume) dilution is reached* signaling noweight per olume) dilution is reached* signaling no
significant sensitiity to the antigensignificant sensitiity to the antigen
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2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
-/-1!/-"cc intradermal testproduces mm wheal
preads to 0mm +y diffusion
If it further enlarges G"mm after1-!10 minutes* test is li8elypositie(i/e/* patient sensitie to the antigen*+ut such must +e confirmed +y yet another "mmwheal growth when the ne?t stronger antigen isinCected)
"
#
$
ET 2iagramET 2iagram
erial Endpoint (2ilutional) 8in Testingerial Endpoint (2ilutional) 8in Testing
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2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
erial Endpoint (2ilutional) 8in Testingerial Endpoint (2ilutional) 8in Testingfor Identification and uantification offor Identification and uantification of
Inhalant ensitiitiesInhalant ensitiities
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2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
Adantages'Dery safe* and can detect low leels of patientsensitiity to an antigen3ew false posities or false negaties
'oth uantitatie and ualitatie (i/e/* identifiesnot only patient sensitiities* +ut magnitude ofthose sensitiities)afe guide to starting therapy
8in Endpoint (2ilutional) Titration8in Endpoint (2ilutional) Titration
- -1 l fAntigen 2oseAntigen 2ose
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2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
-/-1 ml ofarious antigendilutions
deliered +y ET
K; M -/-. g
K0 M -/1; gK M -/=- g
K. M /- g
K" M "- g
K1 M 1-- g
4ric8 1B1- w>M /.- g
-/-"mlingle I2 1B1--- w>M "- g
-/-"mlingle I2 1B0-- w>M- g
Antigen 2oseAntigen 2ose
&omparisons among&omparisons among
8in Testing8in TestingTechniuesTechniues
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2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
Allergen coupled to a solid phase B 4aper dis8(RAT)* &ellulose sponge (Immuno&A4* etc/)
Add patient:s serum
Antigen!Anti+ody comple? formed Anti! IgE added
Anti!IgE Anti+ody!Allergen comple? formed
&omputeried reading of different tags(radioactie* fluorescence* colorimetric*enymatic)
In Ditro Testing 4rocedureIn Ditro Testing 4rocedure
andwich Assay Techniueandwich Assay Techniue
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2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
In Ditro %ethodologyIn Ditro %ethodology
Courtesy cientific American
Allergen coupled to a solid phase B paper dis8 or cellulose spongeAdd patient:s serum* 9IgE Anti+ody!Allergen comple?esformed
(9 possi+ly some Ig5 Anti+ody!Allergen comple?es)Add Anti!IgE* 9Anti!IgE Anti+ody!IgE Anti+ody!Allergen comple?esformed&omputeried reading of different tags (radioactie* fluorescence*colorimetric* enymatic)
% difi d I Di i
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2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
(uantifies patient sensitiity per scale that reflectsamount of specific IgE andcorrelates with ET resultsL
RAT!specific scale shown )
&lass - "0- ! 0-- (Not sensitie)
&lass 1>- 0-1 ! 0- (%arginally sensitie)
&lass 1 01 ! 1;-- (7ow sensitiity)
&lass " 1;-1 ! .;--
&lass . .;-1 ! =---
&lass =--1 ! 1=---
&lass 0 1=--1 ! ---- (Dery sensitie)
%odified In Ditro coring%odified In Ditro coring
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2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
2omparison of2omparison of
0coring0coring0ystems0ystems
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2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
Relatie AdantagesBRelatie AdantagesB
In Dio s/ In Ditro TestingIn Dio s/ In Ditro Testing
In Ditro (immunoassay)In Ditro (immunoassay)
No ris8 of allergic reactionNo ris8 of allergic reaction
Not affected +y drugs orNot affected +y drugs or
s8in conditionss8in conditions4atient conenience4atient conenience
(single enipuncture)(single enipuncture)
Easy to document ualityEasy to document uality
control* reproduci+ilitycontrol* reproduci+ility%ost conenient for allergy%ost conenient for allergy
screenscreen
In Dio (s8in tests)In Dio (s8in tests)
5reater sensitiity (e/g/*5reater sensitiity (e/g/*
molds)molds)
7arger aaila+ility of7arger aaila+ility ofantigensantigens
Immediate test resultsImmediate test results
%oderately less e?pense%oderately less e?pense
No la+oratory certificationNo la+oratory certificationpaperwor8paperwor8
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2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
Testing creens of = ! 1- antigens can precede full +attery
Testing with indiidual antigens rather than antigen mi?es
Treatment 2ecision to treat rests on clinical Cudgement* N$T Cust Q results
EN24$INT* a uantification of patient sensitiity* ia ET or%odified RAT score* indicates safe immunotherapy startingdose
Fhen enough sensitiities necessitate " different treatmentials* high 9 low sensitiities are separated 9 different speedsof dose escalation are possi+le (faster with low sensitiityantigens)
4rinciples &ommon to ET4rinciples &ommon to ET
In Dio 9 In Ditro %ethods of TestingIn Dio 9 In Ditro %ethods of Testing
3ood Allergy3ood Allergy
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2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
3ood Allergy3ood Allergy
(" +asic types B 3i?ed and &yclic)(" +asic types B 3i?ed and &yclic)
%ay cause nasal congestion 9 rhinitis* in%ay cause nasal congestion 9 rhinitis* inaddition to more common food sensitiityaddition to more common food sensitiitymanifestationsB 5I distur+ance* rash*manifestationsB 5I distur+ance* rash*headache* ertigoheadache* ertigo
&onsider ealuation if patient has positie&onsider ealuation if patient has positiehistory for food reactionshistory for food reactions (or colic>ecema(or colic>ecemaas child)*as child)*inhalant allergy wor8up isinhalant allergy wor8up isunimpressie* or therapyunimpressie* or therapy (enironmental(enironmentalmodification* pharmacotherapy*modification* pharmacotherapy*immunotherapy)immunotherapy)fails to +ring e?pected relieffails to +ring e?pected relief
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2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
3ood Reactions3ood Reactions
4realence greatest < . years of age* 9 declines4realence greatest < . years of age* 9 declines
oer ne?t decadeoer ne?t decade
-# of food allergy reactions in children are-# of food allergy reactions in children are
caused +y ; foods B mil8* egg* soy (all of which cancaused +y ; foods B mil8* egg* soy (all of which can
+e outgrown)* 9 wheat* peanut* tree nuts+e outgrown)* 9 wheat* peanut* tree nuts
-# of food allergy reactions in adults are caused-# of food allergy reactions in adults are caused+y foodsB peanut* tree nuts* fish* shellfish+y foodsB peanut* tree nuts* fish* shellfish
&ommon cross reactions +etween inhalants 9&ommon cross reactions +etween inhalants 9
foodsB ragweed 9 melon > +ananaL +irch 9foodsB ragweed 9 melon > +ananaL +irch 9
apple > carrot > potato > haelnut > almondapple > carrot > potato > haelnut > almond
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2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
3i?ed 3ood Allergies3i?ed 3ood Allergies
IgE mediated with immediate clinical reaction toIgE mediated with immediate clinical reaction toingestion* freuentlyingestion* freuently angioedema or anaphyla?isangioedema or anaphyla?is
(most freuently shellfish or peanut)(most freuently shellfish or peanut)
2iagnosis usually made from patient history2iagnosis usually made from patient history
! specific IgE assay will confirm if needed (dospecific IgE assay will confirm if needed (do N$TN$Ts8ins8intest for the food)test for the food)
Treatment is aoidance of offending food*Treatment is aoidance of offending food*
patient should +e instructed in use of selfpatient should +e instructed in use of self
administered* inCecta+le epinephrineadministered* inCecta+le epinephrine
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2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
&yclic 3ood Allergies&yclic 3ood Allergies
%ost common type of food sensitiity* with%ost common type of food sensitiity* withdelayeddelayed onset of symptoms (up to " hours)onset of symptoms (up to " hours)
%ediated +y any of the 5ell 9 &oom+s%ediated +y any of the 5ell 9 &oom+s
reactionsreactions! %ost are immune comple? reactions%ost are immune comple? reactions
2iet and symptom diary identify li8ely offending foods2iet and symptom diary identify li8ely offending foods! day elimination of the particular food* and then a &hallenge day elimination of the particular food* and then a &hallenge
feeding test of that food on 0th dayfeeding test of that food on 0th day
! In itro tests are alternatie in young children (higher freuencyIn itro tests are alternatie in young children (higher freuencyof IgE!mediated food reactions)of IgE!mediated food reactions)
Eli i ti 2i t d &h ll 3 d T tEli i ti 2i t d &h ll 3 d T t
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2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
Elimination 2iet and &hallenge 3ood TestElimination 2iet and &hallenge 3ood Test
Eliminate suspect food* in allproducts* +ased on patient history
4atient improes
Reintroduce suspectfood into diet
ymptoms recur
Eliminate food for !0 days*then &hallenge 3ood Test
4atient unchanged
Ealuate other food(s)*consider other origins tosymptoms
I di ti f I thI di ti f I th
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Indications for ImmunotherapyIndications for Immunotherapy
Aoidance 9 Enironmental %easuresAoidance 9 Enironmental %easuresfail to controlfail to control
symptoms* or are impractical (e/g/* teacher in moldysymptoms* or are impractical (e/g/* teacher in moldyschool +uilding* florist sensitie to plant pollens orschool +uilding* florist sensitie to plant pollens or
eterinarian sensitie to cats)eterinarian sensitie to cats)
4harmacotherapy4harmacotherapyfails to fully control symptoms* orfails to fully control symptoms* or
produces +othersome side!effectsproduces +othersome side!effects %oderate to seere symptoms in " or more seasons* 9%oderate to seere symptoms in " or more seasons* 9
8in or In Ditro tests document IgE mediated8in or In Ditro tests document IgE mediated
sensitiitysensitiity
&ontraindications B&ontraindications B !+loc8er or potential pro+lem with!+loc8er or potential pro+lem withepinephrine* poorly controlled asthma* autoimmune orepinephrine* poorly controlled asthma* autoimmune or
immunodeficiency disease* unrelia+le patientimmunodeficiency disease* unrelia+le patient
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2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
Immunotherapy for Allergic RhinitisImmunotherapy for Allergic Rhinitis
Regular inCections of increasing amounts of AllergenRegular inCections of increasing amounts of Allergenadministered eery 0! days until symptom relieingadministered eery 0! days until symptom relieingdose or ma?imum tolerated dose reached* thendose or ma?imum tolerated dose reached* thenmaintenance dose "! wee8s* +ased on symptomsmaintenance dose "! wee8s* +ased on symptoms
&ontinue maintenance dose until symptoms are&ontinue maintenance dose until symptoms arecontrolled for . !0 years* then can discontinuecontrolled for . !0 years* then can discontinueImmunotherapy in a+out 0#Immunotherapy in a+out 0#
InCections during dose escalation under directInCections during dose escalation under directsuperision of physician trained to managesuperision of physician trained to manage
anaphyla?isanaphyla?is
Immunotherapy 3ailureBImmunotherapy 3ailureB
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2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
Immunotherapy 3ailureBImmunotherapy 3ailureB
&ommon Reasons&ommon Reasons
4atient failure to regularly comply with the4atient failure to regularly comply with theimmunotherapy regimenimmunotherapy regimen
Incorrect antigen dosing 9>or too infreuent shotIncorrect antigen dosing 9>or too infreuent shot
interalsinterals
3ood or chemical sensitiities* or inhalants to3ood or chemical sensitiities* or inhalants towhich patient was not tested or for whichwhich patient was not tested or for which
commercial antigens are unaaila+lecommercial antigens are unaaila+le
Non!allergic rhinitis (asomotor* occupational*Non!allergic rhinitis (asomotor* occupational*
atrophic* medication!induced)atrophic* medication!induced) Rhinosinusitis* Anatomic airway o+structionRhinosinusitis* Anatomic airway o+struction
All i 3 l 4 i itiAllergic 3ungal 4ansinusitis
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Allergic 3ungal 4ansinusitisAllergic 3ungal 4ansinusitis
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2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation2003 The American Academy of Otolaryngology Head and Neck Surgery Foundation
ummary B Allergic Rhinitisummary B Allergic Rhinitis
Affects 1!"0# of populationAffects 1!"0# of population ymptoms > related diseasesymptoms > related diseases eryery releant to thereleant to the
otolaryngologists (e/g/* nasal congestion*otolaryngologists (e/g/* nasal congestion*
rhinitis* rhinosinusitis* otitis media*rhinitis* rhinosinusitis* otitis media*
pharyngitis* laryngitis)pharyngitis* laryngitis)
Initial diagnosis +y , 9 4* with s8in or in itroInitial diagnosis +y , 9 4* with s8in or in itro teststests
as neededas needed
Treatments aaila+le B aoidance 9>or enironmentalTreatments aaila+le B aoidance 9>or enironmental
measuresmeasures* p* patient counseling*atient counseling* physical fitness*physical fitness*
pharmacotherapy*pharmacotherapy*eradicate comor+idity*eradicate comor+idity*immunotherapyimmunotherapy
R f
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ReferencesReferences
3ornadley S* &orey S* $sguthorpe S* et alB Allergic3ornadley S* &orey S* $sguthorpe S* et alB AllergicRhinitisB &linical 4ractice 5uidelines/ $tolaryngolRhinitisB &linical 4ractice 5uidelines/ $tolaryngol
,ead Nec8 urg 110B110* 1;,ead Nec8 urg 110B110* 1;(consensus of American(consensus of AmericanAcademy of $tolaryngology ! ,ead and Nec8 urgery 9 AmericanAcademy of $tolaryngology ! ,ead and Nec8 urgery 9 AmericanAcademy of $tolaryngic Allergy)/Academy of $tolaryngic Allergy)/
$sguthorpe S* 2ere+ery S (guest editors)B$sguthorpe S* 2ere+ery S (guest editors)B$tolaryngic Allergy/ $tolaryngol &lin N Am .;()*$tolaryngic Allergy/ $tolaryngol &lin N Am .;()*"--./"--./
Hrouse S* &hadwic8 * 5ordon '* 2ere+ery SBHrouse S* &hadwic8 * 5ordon '* 2ere+ery SBAllergy and ImmunologyB An $tolaryngicAllergy and ImmunologyB An $tolaryngic
Approach/ 7ippincott Filliams 9 Fil8ins/ 4hil/Approach/ 7ippincott Filliams 9 Fil8ins/ 4hil/"--"/"--"/
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