Allergic Disorders Interface with Ear, Nose, and Throat Disorders B.J. Ferguson and Suman Golla

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1 Allergies for the Otolaryngologist Allergic Disorders Interface with Ear, Nose, and Throat Disorders B.J. Ferguson and Suman Golla xv The Evolution of Understanding Inhalant Allergy 519 J. David Osguthorpe This article summarizes the developments that led to the current approach to immunotherapy. These developments were characterized in the early years by empirically derived successive approximations to arrive at effective injection regimens, in the middle years by a sorting through of the wide variations in practice with placebo-controlled clinical trials, and more recently by a closer association of clinical and laboratory measures to better define evidence-based practices. The pace of investigation along with the scientific quality continues to increase. Epidemiology of Allergy 537 Charles S. Ebert Jr and Harold C. Pillsbury III Atopic disease represents a spectrum of disorders characterized by abnormal sensitivity mediated by IgE; approximately 20% of Americans suffer from some form of allergic disease. The sequelae of inhalant and food allergies may present in many organ systems. Manifestations of allergic disease in one site are often associated with symptoms from another site. It is important for clinicians to understand the epidemiology of atopic disease and its causes to facilitate implementation of effective treatment and prevention strategies. This review focuses on the epidemiology of inhalant allergies causing allergic rhinitis and asthma and on IgE-mediated food allergies. Types of Rhinitis 549 Kevin F. Wilson, Matthew E. Spector, and Richard R. Orlandi Rhinitis is a familiar disorder affecting up to 20% of the general population. Chronic rhinitis can be broadly classified into allergic, infectious, or nonallergic or noninfectious, which are distinguished mainly by a careful history and allergy testing. The pathophysiology of nonallergic rhinitis likely involves a combination of inflammatory and neurogenic mechanisms that are poorly understood. Treatment involves avoiding the offending agent, when possible, and using appropriate medications to control the patient s predominant symptoms. Differential Diagnosis in Allergy 561 Robert J. Stachler and Samer Al-khudari The otolaryngic allergist must be able to distinguish between common nonallergic diagnoses that present very similarly to allergic conditions. This article describes a few of the vast myriad of conditions that must be ruled out before a diagnosis of allergy may be made. After reading this article clinicians will be able to identify various conditions, which will enhance

2 viii their ability to appropriately make correct decisions for prompt and efficient management of their patients with allergic or nonallergic diseases of the head and neck. Immunology of Allergy 591 Minka Schofield and Karen H. Calhoun Knowledge of the immune system is advancing rapidly. This review provides an update on the allergy players the cells and major mediators and the form and function of each; discusses how these cells and mediators weave together in the elegant but destructive dance of allergy; and details how specific immunotherapy can cure allergy. Physical Findings in Allergy 603 Kristin Woodbury and Berrilyn J. Ferguson Allergies are typically diagnosed based on detailed history elicited from a patient. Confirmation of the diagnosis by allergy skin or in vitro testing is sometimes also helpful. The authors discuss several physical examination features, specifically in the head and neck region, that are often suggestive of allergy presence. Diagnosis of Inhalant Allergies: Patient History and Testing 611 Christine Franzese In the United States, roughly 20% to 25% of the general adult population is afflicted by some form of chronic allergic respiratory disease, making allergy one of the most commonly diagnosed disorders. Among children, allergic disease is more common, with some sources estimating that it affects up to 40% of children. The focus of this article involves making the diagnosis of the most familiar and best understood of the hypersensitivity reactions, type 1 hypersensitivity, also termed immediate hypersensitivity. Although type 1 hypersensitivity can be caused by ingestion of food antigens or pharmaceuticals, this article focuses on IgE-mediated allergic disease caused primarily by inhalant allergens. Role of Allergy in Sleep-Disordered Breathing 625 Ryan J. Soose Sleep-related symptoms are extremely common in patients with allergic rhinitis. Sleep impairment is likely a major contributor to the overall disease morbidity, direct and indirect health care costs, and the loss of work productivity associated with allergic rhinitis. The association between allergic rhinitis and sleep, and the subsequent impact on disease-specific and general health quality of life measures, is well documented in large epidemiologic studies as well as controlled clinical trials. This article focuses on sleep disruption caused by allergic rhinitis, and the therapeutic and surgical options available to tackle the problem. The Role of Allergy in Otitis Media with Effusion 637 David S. Hurst The role of allergy in chronic otitis media with effusion (OME) is controversial. New evidence from cellular biology and immunology explain the

3 ix basics of allergic reactions and allow more accurate diagnosis of allergies and inflammatory disease throughout the unified airway. This article examines the epidemiologic, methodological, and immunologic studies of allergic causes of OME, including (1) evidence for and against OME as an allergic disease, (2) allergy as a cause for eustachian tube obstruction, (3) examination of the most sensitive diagnostic tests for allergy, and (4) the effect of treatment of underlying allergies in improving and resolving middle ear disease. Allergic and Immunologic Features of Meniere s Disease 655 M. Jennifer Derebery Ménière s disease (MD), which by definition is idiopathic, has been ascribed to various causes, including both inhalant and food allergies. Patients with MD report higher rates of allergy history and positive skin or in vitro tests compared with a control group of patients with other otologic diseases and to the general public. Recent immunologic studies have shown higher rates of circulating immune complexes, CD4, and other immunologic components in patients with MD compared with healthy controls. Published treatment results have shown benefit from immunotherapy and/or dietary restriction for symptoms of MD in those patients who present with both allergy and MD. Asthma 667 Michael J. Parker This article presents the complexity of asthma and its ensuing management. The author details the clinical presentation of asthma, discussing its variability of presentation over time and within and among individuals. Pathophysiology is discussed, including immunohistopathologic features and inflammatory mediators, risk factors, comorbid conditions, natural history, and triggers. Diagnosis is presented in light of the challenging history of patients suspected of the disorder; pulmonary function testing, symptom assessment, impairment assessment, and risk assessment. Categories of asthma severity, controlling triggers, pharmacotherapy, stepwise approaches, and ongoing assessment are discussed, with a review of a clinical trial assessing efficacy of management. Nasal Polyps: Pathogenesis and Treatment Implications 685 Michael A. DeMarcantonio and Joseph K. Han Nasal polyps (NPs) represent a common clinical end point for a myriad of inflammatory disease processes involving the paranasal sinuses. Chronic rhinosinusitis is the most common cause for NPs, but not all NPs are created equally. This article outlines the current understanding of pathogenesis in nasal polyposis and discusses the implications on therapy. Allergic Fungal Rhinosinusitis 697 Matthew W. Ryan Allergic fungal rhinosinusitis is a phenotype of chronic rhinosinusitis with nasal polyposis, characterized by type 1 hypersensitivity to fungi, eosinophilic mucin with fungal hyphae in sinus secretions, and propensity for mucocele

4 x formation and bone erosion. Although its differentiation from other forms of chronic polypoid rhinosinusitis with eosinophilic mucin is sometimes problematic, type 1 hypersensitivity is a component of the disease process. Medical and surgical management can be augmented by immunotherapy directed toward the patient s specific allergen sensitivities. The primary rationale for immunotherapy is to control the allergic diathesis that may be contributing to the patient s chronic sinus inflammation. Allergy Treatment: Environmental Control Strategies 711 William R. Reisacher This article aims to help physicians and allergy care providers understand: the role of environmental control in the treatment of allergic disease; the concept of the inflammatory load ; current published studies on environmental control; factors that influence levels of indoor and outdoor allergens; different methods to decrease patients exposure to indoor and outdoor allergens; problems related to nonallergic symptom triggers; special considerations for school and workplace avoidance; role of environmental control in the prevention of allergic disease; various products available on the market to assist in avoidance; and how to plan with the patient to implement environmental control strategies. Pharmacotherapy for Allergic Rhinitis 727 Thuy-Anh N. Melvin and Alpen A. Patel Allergic rhinitis affects millions of Americans and the numbers continue to increase. Fortunately, there exists a wide array of pharmacotherapeutic options with relatively safe side effect profiles for the management of the varying subtypes. Additionally, there are newer agents on the horizon. The efficacies of intranasal corticosteroids, antihistamines, combination topical therapy, leukotriene inhibitors, mast cell stabilizers, anticholinergics, mucolytics, decongestants, and anti-ige are reviewed. Immunotherapy ^ Traditional 741 Yekaterina A. Koshkareva and John H. Krouse Immunotherapy is an excellent treatment option for a selected subset of patients with inhalant allergies. It consists of intentional serial exposures to allergens, which modulate the immune system and induce immune tolerance through down-regulating the allergic response, resulting in an overall decrease in symptoms. Immunotherapy has been shown to have long-term efficacy in the management of inhalant allergies, as reflected by diminished frequency and duration of symptoms and improved quality of life. The therapy is considered safe, with side effects limited mostly to minor local reactions, and only occasional cases of systemic adverse reactions. Sublingual Immunotherapy 753 Sandra Y. Lin and Bryan Leatherman Sublingual immunotherapy (SLIT) has been shown to be safe and efficacious in treating allergic rhinitis. It has been used in Europe for more

5 xi than 20 years, and interest in the United States is increasing. SLIT has been shown to elicit immunologic changes similar to subcutaneous injection immunotherapy. SLIT may prevent new sensitizations, improve asthma control, and decrease asthma development in allergic individuals. Although differences in antigen quantification and standardization make European dosing schemes difficult to translate in the United States, several new studies suggest the range for effective dosing. Further studies will help clarify optimal dosing. The Allergic March: Can We Prevent Allergies and Asthma? 765 Bruce R. Gordon The allergic march is a progression of atopic disease from eczema to asthma, and then to allergic rhinoconjunctivitis. It appears to be caused by a regional allergic response with breakdown of the local epithelial barrier that initiates systemic allergic inflammation. Genetic and environmental factors predispose to developing the allergic march. There are data to support 4 possible interventions to prevent the allergic march from progressing to asthma: (1) supplements of dietary probiotics, (2) exclusive breast feeding during the first few months of life, or, alternatively (3) use of extensively hydrolyzed infant formulas, (4) treatment with inhalant allergen immunotherapy by either subcutaneous or sublingual methods. The Surgical Management of Allergic Rhinitis 779 Nipun Chhabra and Steven M. Houser In their discussion of the treatment of allergic rhinitis, the authors present key features of the disease and its management, allergen responses, the role of the inferior turbinate, and reviews of outcomes with submucosal resection, total inferior turbinectomy, cryosurgery, laser cautery, radical turbinectomy, submucous turbinectomy, submucous electrocautery, and microdebriber turbinoplasty. The authors discuss radiofrequency ablation and coblation outcomes and complications, along with the role of endoscopic sinus surgery in allergic rhinitis and emphasize the need for Otolaryngologists to be facile with a variety of procedures for best outcomes. Inhalant Allergies in Children 797 James W. Mims and Maria C. Veling Children with chronic or recurrent upper respiratory inflammatory disease (rhinitis) should be considered for inhalant allergies. Risk factors for inhalant allergies in children include a first-degree relative with allergies, food allergy in infancy, and atopic dermatitis. Although inhalant allergies are rare in infancy, inhalant allergies are common in older children and impair quality of life and productivity. Differentiating between viral and allergic rhinitis can be challenging in children, but the child s age, history, and risk factors can provide helpful information. Allergic rhinitis is a risk factor for asthma, and if one is present, medical consideration of the other is warranted.

6 xii Food Allergy in Adults and Children 815 Elizabeth J. Mahoney, Maria C. Veling, and James W. Mims Food allergy is defined as an adverse health effect arising from a specific immune response that occurs reproducibly on exposure to a given food and is distinct from food intolerance. Clinical manifestations of food allergy are varied and involve many systems including respiratory, cutaneous, and gastrointestinal. The double-blinded placebo-controlled oral food challenge remains the gold standard for the diagnosis of IgE-mediated food allergy. Areas of ongoing research include improved understanding of determinants for the development of tolerance versus sensitization for foods, the role of diagnostic testing for specific epitopes for food allergens, and the use of oral immunotherapy for IgE-mediated food allergy. Index 835