Allergy Testing & Rhinitis

Allergy: Definitions

• Allergy refers to the clinical manifestation of an adverse immune response after repeated contact with a typically harmless substance, regardless of the mechanism. Common substances include pollens, mold spores, animal dander, dust mites, foods, and stinging insects.
• Atopy is the predisposition to an immune response against antigens and allergens, leading to CD4+ Th2 differentiation and overproduction of IgE. This is a Type 1 hypersensitivity reaction.
• Allergic rhinitis is inflammation of the nasal mucous membranes caused by an IgE-mediated response to one or more allergens.
• Allergic rhinitis, along with asthma and eczema, is one of the more common manifestations of atopy.

Allergy: Epidemiology

• Allergic rhinitis has been thought to be a disease process of the nasal airway alone, but is now classified as a component of systemic allergic response with an underlying systemic pathology.
• Prevalence is high, affecting 20-30% of adults and up to 40% of children in the U.S.
• Approximately 40 million individuals are affected in the U.S. alone, with more than 500 million people affected worldwide.
• Allergic rhinitis is the sixth most prevalent chronic illness.
• Treatment costs for allergic rhinitis are at least $1.8 billion annually in the U.S.
• In 1995, the prevalence of self-reported nasal allergies among adult populations was 20.9 % (ranging from 9.5% to 40.9%).
• Rhinitis prevalence has increased in recent decades across almost all geographical regions.
• It is one of the most common chronic pediatric disorders.
• In the 13-14 year age group, 14.6% display symptoms of rhinoconjunctivitis linked to AR, while 8.5% show symptoms in the 6-7 year age group.
• 31.7% self-report current nasal symptoms (ranging from 11.9% to 80.6 %).
• Onset can occur at any age, but the incidence of onset is greatest in adolescence with decreasing incidence with advancing age.
• 80% of people are diagnosed before age 20.
• Symptoms peak during the third and fourth decades of life.
• In a longitudinal study with a 23-year follow-up visit, 54.9% of patients showed improvement in symptoms and 41.6% were symptom-free.
• Patients who had an onset of symptoms at a younger age were more likely to show improvement over time.

Allergy: Risk Factors

• There is an association with genetic predisposition; children have a 30% chance of developing allergic rhinitis if one parent is affected, and a 50% chance of both parents are affected.
• The severity of allergic rhinitis can vary depending on location and season.
• Other risk factors: a family history of atopy, male sex, presence of allergen-specific IgE, a serum IgE greater than 100IU/mL before age 6, and higher socioeconomic status.
• Early introduction of foods or formula and/or heavy exposure to cigarette smoking in the first year of life are risk factors for allergic rhinitis in young children.

Allergy: Protective Factors

• Breastfeeding, early pet exposure, and the "farm effect" are possibly protective factors.
• Meta-analysis of 8 studies suggest there is a 40% lower risk in subjects living on a farm during their first year of life.

Impact of Allergic Rhinitis

• Allergic rhinitis affects school and work performance due to sleep deprivation, fatigue, reduced productivity, and absenteeism.
• There are considerable direct and indirect economic costs from allergy symptoms, prescription and non-prescription medications, and negative side effects from allergy medication.
• Symptomatic effects include diminished quality of life (social and physical functionality, energy and fatigue levels, lack of sleep and mental health).
• Sleep disorders, fatigue, and learning problems may occur with allergic rhinitis.

Allergic Rhinitis: Diagnostic Approach

• The diagnostic approach includes:
• Patient history -Symptoms -Physical examination findings -Allergy testing

Patient History - Intake

• A thorough and comprehensive patient history is an essential element in the evaluation of allergic rhinitis.
• Questions should focus on: symptoms (onset, duration, exposures, magnitude of reaction, patterns, chronicity); exacerbating/alleviating factors; seasonal variation; environmental influences; allergies; medical history; and past and current treatments.
• Patient age at onset of symptoms is helpful to know.
• Constitutional symptoms (headache, malaise, fatigue) are common.
• Personal history of asthma may be relevant.
• Persistent symptoms could be due to exposure to an indoor allergen.
• Seasonal symptoms, or symptoms reproducible from a triggering factor, are highly suggestive of an allergy (ie. environmental allergen exposure with allergen-specific IgE).
• Acute onset (one week or less) usually suggests a viral etiology, acute exacerbation of allergic rhinitis, or, possibly, a foreign body.
• Chronic symptoms with seasonal variations suggest seasonal allergic rhinitis.
• Chronic acute rhinitis can cause may cause postnasal drip, chronic nasal congestion, and obstruction.
• Symptoms improve allergy is probable with use of antihistamines or intranasal corticosteroids.
• Intranasal or oral decongestants can affect both allergic and nonallergic symptoms.
• History of anaphylactic reaction following ingestion of a food or being stung by an insect usually indicates an atopic patient.
• Certain medications can lead to symptom of rhinitis; ie Beta-blockers, acetylsalicylic acid, NSAIDs, ACE inhibitors, and hormone therapy.

Patient History - Environment

• Important to evaluate patient's home, work, and school environments to determine potential triggers.
• Common allergens include pollens, furred animals, textile flooring/upholstery, tobacco smoke, humidity levels at home, and other noxious substances.
• Seasonal allergic rhinitis is most commonly caused by pollens and spores (flowering shrub/tree pollens in spring, flowering plants/grasses in summer, ragweed/molds in the fall).
• Perennial allergic rhinitis may be caused by dust, household mites, air pollution, and pet dander.

Patient History - Family History

• Allergy and atopy tend to be hereditary.
• Genetic factors determine the likelihood of becoming sensitized and producing IgE antibodies.
• Family history of allergies, eczema, or asthma increases this possibility.
• Children with parents with allergies have a >50% chance of becoming allergic themselves.
• Food allergens, dust mites, and inhalant allergens are major causes of alluvial rhinitis and the comorbidities of atopic dermatitis, otitis media with effusion, and asthma in infancy and childhood.
• In older children and adolescents, pollen allergens are more of a causative factor.

Symptomology

• Symptoms include nasal congestion, clear rhinorrhea, sneezing, postnasal drip, and nasal pruritis.
• Allergic conjunctivitis causes eye irritation and excessive tearing, and is commonly associated with animal and outdoor allergens.

Associated Symptoms

• Associated symptoms include chronic sinusitis, nasal polyposis, non-productive cough, bronchospasm, eczematous dermatitis, snoring, sleep apnea, sleep disturbance, headache, difficulty concentrating, low mood, and fatigue.
• In children, malaise or fatigue may be presenting complaints, as well as sinusitis, Eustachian tube dysfunction and otitis media with effusion, asthma, snoring, possible dental overbite, and high-arched palate due to chronic breathing.

Physical Examination

• Examination includes visualization of patient's appearance, the nose, ears, sinuses, and posterior oropharynx.
• Additional: Lymph Nodes, Chest and Skin
• Allergic rhinitis can have the following visualization findings: -conjunctivitis -allergic shiners: blue-grey or purple discoloration under the lower eyelids -Mouth breathing -Frequent sniffling with or without throat clearing.
• Physical exam of the noise may reveal 'nasal salute': transverse nasal crease due to constant rubbing of the nose in an upwards motion.
• An endoscopic nasal exam can assess for structural abnormalities (e.g., septal deviation, nasal ulcerations, and nasal polyps).
• Other findings may include "cobblestoning" of the nasal mucosa, mucosal swelling, discharge, and boggy, pale, or “bluish” (violaceous) nasal turbinates due to venous engorgement
• Assessment before and after decongesting with a topical decongestant is recommended for comparison.
• The incidence of nasal polyposis in the general population is 4%. -It is more common in males. -It is the result of chronic inflammation of the paranasal sinus mucosa. -They are usually bilateral. Unilateral nasal polyps should raise concerns for malignancy. -The polyps are typically benign.
• Generally, ears appear normal; however, assessment for Eustachian tube dysfunction using a pneumatic otoscope should be considered.
• Physical exam of the sinuses may reveal tenderness upon palpation with chronic symptoms or sensitivity detected through tapping maxillary teeth with a tongue depressor.
• Exam of the posterior oropharynx may reveal postnasal drip with mucous accumulation in the back of the nose and throat.
• Note that enlarged tonsils are inversely associated with allergic rhinitis.
• To rule out viral or bacterial causes of rhinitis, an additional lymphadenopathy exam should be performed.
• Additional exams include the chest for concurrent asthma (ie. wheezing) and the skin for dermatitis.
• Physical findings of allergic rhinitis in children may include "shiners", facial grimacing, mouth breathing, a nasal salute, and concomitant otitis media with effusion.

Diagnostic Testing

• Allergy testing typically involves skin testing and/or serum testing (IgE).
• General recommendations for allergy testing will vary, and there are no specific recommendations on when to perform allergy testing for patients with rhinitis
• Tests should be selected that will change outcomes or treatment plans.
• Empiric treatment is appropriate in patients with classic symptoms.
• Diagnostic tests may be appropriate if severe symptoms or an unclear diagnosis is present.
• Diagnostic tests should be considered if the patient is a potential candidate for allergen avoidance treatment or immunotherapy.
• Observation may be appropriate for patients with mild symptoms or an unclear history.
• Types of allergy testing: -Skin Testing through skin prick and intradermal allergen delivery. -Serum Testing (IgE).

Allergy Testing: Skin Testing

• considered the primary method for identifying specific allergic triggers of rhinitis.
• It is a quick in-office procedure with immediate results.
• It has good specificity, with slightly higher sensitivity (verses serum testing).
• It is a relatively more cost effective (verses serum testing).
• Skin testing is a safe procedure which allows for uniformity, but must require a trained technician.
• H2-receptor antagonists, tricyclic antidepressants, and anti-IgE monoclonal antibody omalizumab can interfere with allergy skin test response, and stopping such medication before testing is recommended.
• Contraindications: patients with uncontrolled or severe asthma, unstable cardiovascular disease, pregnancy, concurrent beta-blocker therapy.
• Skin testing detects an immediate allergic response by detecting the release of mast cell or basophil IgE-specific mediators (wheal-and-flare reaction).
• Testing uses allergens relevant to the patient's environment.
• Methods include percutaneous (prick or puncture) and intradermal methods.

Skin Prick Testing

• This test involves a commercial extract of a specific allergen being placed on the skin of the forearms or back.
• The skin has a pricking through the drop to introduce the extract into the epidermis.
• Within 15-20 minutes, a wheal-and-flare response will occur with a positive test.

Intradermal Testing

• More sensitive than the skin prick test and provides more consistent results
• Involves injection of a small amount (max 0.05mL) of the suspected allergen under the surface of skin, in order to raise a bleb 4-6mm in diameter
• Examine the area for a reaction after 15-20 minutes
• A typical reaction looks like a small hive with swelling and redness
• An increase In wheal size of 3mm in diameter beyond the initial bleb is considered positive
• A bleb that has not increased, but has persisted, is itchy and has an associated flare does not meet the criteria for a positive result

Allergy Testing: Serum Testing (IgE)

• Allergen-specific serum IgE testing (e.g., performed by immunosorbent assay) is an allergy testing method.
• Provides an in-vitro measure of a patient's specific IgE levels against particular allergens.
• Serum testing is easy and accurate for atopic allergy, and with newer in-vitro technology, it is equivalent to skin testing in efficacy.
• Though radioallergosorbent (RAST) test is no longer performed, the name is still used to generally describe IgE-specific blood testing.
• Serum Testing is also safe, specific, cost-effective, and reproducible.
• It does not requires trained technicians and the patient does not need to stop taking antihistamines in advance.
• Serum Testing is easy and quick, and therefore preferred especially in children and anxious patients.

Allergy testing in children

• Percutaneous skin testing is appropriate for children 3+ years of age.
• RAST testing is appropriate at any age
• Base testing decisions on clinical history and perform tests only when needed to change therapy or clarify a diagnosis

Nasal Cytology

• Cytology, such as nasal swabs, are typically performed for routine diagnosis, but consider if diagnosis is unclear.
• A sample is taken from both nostrils, from the middle part of the inferior turbinate, and immediately smeared on a glass slide.
• After air-drying, samples are stained and viewed under a microscope.
• The presence of inflammatory cells infiltrating the nasal mucosa and releasing chemical mediators, is likely responsible for symptoms of allergic rhinitis,

Differential Diagnoses for Rhinitis

• Allergic rhinitis
• Nonallergic rhinitis -Viral upper respiratory infections -Vasomotor rhinitis -Rhinitis medicamentosa -Hormonal and drug-induced rhinitis -Nonallergic rhinitis with eosinophilia syndrome
• Common cold
• Sinusites
• Seasonal allergic rhinitis
• Bacterial rhinitis
• Fungal rhinitis
• Rhinitis secondary to a-agonist withdrawl
• Nasal foreign body
• Eosinophilic syndromes
• NARES
• Nasal polyposis
• Atrophic rhinitis
• Gustatory rhinitis

Nonallergic Rhinitis

• Diagnosis is made after the exclusion of is allergic or IgE-mediated causes and is characterized by a negative result on allergy testing
• Most common cause is the acute viral infection
• Other sub types : vasomotor rhinitis, drug-induced rhinitis, rhinitis medicamentosa, hormonal rhinitis, non-allergic rhinitis with eosinophilia syndrome
• Nnonallergic Rhinitis represents at least 23% of rhinitis cases in the U.S. (20-30 million patients); however, pathophysiology is unclear
• The best current evidence supports nociceptor and autonomic nerve dysregulation as components in all forms of nonallergic rhinitis
• More common in women, characterized by Female-to-male ratio of 2:1 to 3:1
• Usually older than 35 years and no family history of allergies

Acute Viral Rhinitis

• Most common cause of an acute viral infection includes: rhinoviruses, respiratory syncytial virus, parainfluenza, influenza, adenoviruses
• Very Common; is assoiciated with other manifestations of vital such as headache, malaives, body aches, coughs
• Nasal drainage is most ofthen clear or white, and can be accompained by nasal congestion and sneexzing
• Is usually self limited and requieres symptamatic trearment such as Streptococcus pneumoniae, group A beta-hemolytic streptococci, Haemophilus influenzae
• Sinusitis is best diagnosed through history, physical examination, and prediction rules

Vasomotor Rhinitis

• "Vasomotor" implies an increased blood supply to the nasal mucosa, although this has not been proven
• Suggested that caused by abnormal autonomic regulation of nasal function, Possible compoundingfactors include previous nasal trauma and extraesophagealanifestations of GERD
• Symptoms mainly consist of congestion, clear nasal drainage, and (less commonly) pruritus and sneezing
• is often associated with temperature, humiity, odours
• Is considered Diagnosis of exclusion should have normal serum IgE levels, negative skin testing or RAST, and no inflammation on nasal cytology

Drug-induced Rhinitis

• Is caued by use of various medications and illicit drugs

Rhinitis Medicamentosa

• Usually patients present with nasal obstruction that has worsened over years, using over the counter topical vasoconstrictive nasal sprays due to increase doses of sprays.
• The use of these sprays leads to rebound rhinitis with severe obstruction during prolonged periods.

Hormonal Rhinitis

• Is cuased by systemic concentration of estrogen rises throut pregnancy the amount of hyaluronic scud in the nasal tissues leads ti further increase in the nasal edema , and leads to further congestion
• Aslo there’s increase in mucous glands, decrease in nasal cilia results in heightened nasal congestion
• Is severe during the second trimester and third trimester

Rhinitis with Nasal Eosinophila Syndrome

• It is a Nonallergic rhinitis with eosinophila. It is an inflmatory type of rhitisis, which leads to increases eosinophilis in secretorys and mast cells degranulation on nasal
• Patients experience nasal destruction, congestion and will further leads to sever exacerbations, including the development of the sinnusts and polypiosis displays maked eosinophilia with skin testing nad in a vitro tesing

Nonallergic Rhinitis

-The patient should have tested secretions testing because testing for eosinphisl does change the allergic frim non causes no not chafe any treamtnet menagetermnrtm , and no other information if the testing. The CAUSE of NARES remains unknown

Non-Allergin Rhinitis

• There is controversy regarding non-allergic rhinitis becausethe epidemiology and diagnostic criteria are confusing : How to differentiate allergy rhinnitis from non alleric rhinitis
• Current research support a third category that includes characteristics of both allergic and non allergic rhinitis
• Prevalence in adults: 43% have a pure allergic rhinnitis, 34 combination and 23% for NON RHINNITIS

Nonallergic Rhinitis

• Is managed slight different that allergic rhinitis, however determine the is important.
• Patient administration system, to help identify patients with a combination rhinitis but the Research is lacking to use beyond gathering demographic data

Subgroups of Allergic Rhinitis

• Seasonal
• Perennial
• Occupational

Subgroups of Allergic Rhinitis: Seasonal

• Approximately 20% of cases or is or are increased during certain seasons
• Trees = spring, grasses = late spring and summer, and weeds and mould is fall
• seems to be more common on the age group

Subgroups of Allergic Rhinitis: Seasonal

Symptoms includes : sneezinge; Watery Rinorrhea; itching for throat area and red watery and nasal congestion

• is usually worst on the windy or morning conditions

Subgroups of Allergic Rhinitis: Perennial

• 40 per cent of cases are symptoms constants with seasonal variation
• more prevalent in adults

Subgroups of Allergic Rhinitis: Perennial

• Symptoms include a nasal construction Blockage and poster nasal drip, and eye symptoms are less common with -Commoner algeries: in door inhalant's Dust minders and more
• Food allergies may also have a trigger

Subgroups of Allergic Rhinitis: Perennial

-Infection is not specific allergens with influences perianal algenious.

• • The higher incidence in the higher incidence of higher respirator tract infection which leads to allergist complication

System Symtoms

Are the seasonal symptoms with allergic rhinitis and can be associated with systematic symtoms Patients may also allerginous, conjuctivililis, asthume, and eczema

the patients do not fit to the to the classification and the triggers is not permanent classification by duration between intermittent and persistent with several mind modern or severe is refer

Occupational Rhinitis

-Is a reaction to occupational exposure and leads to allergy related algenrrelated includes.

• Latex, grains, and more or ittatants such as smoke and hair spary
• Symptoms increase throughout the work week

Occupational Rhinitis

• Symptoms increase include for dryness congestions and runny nose
• Decrease the movement with known exposure

Occupational Rhinitis

• key: The key treamtnebt is determine to advoid the trrigger
• Environmental controls: - Remove alregen, and improve mentillation and

The effect of climate change

• Climate change impact on the occurrence of Allergic rhinitis increase in temperature and carbon monoxide expisure leads to increase pollen production
• Long summer production of the flowering weeds has been shown to increase There is an increase

The change can expoise allergic

Classification of Allergic Rhinits

Allergic rhinitis is characterized by: Duration -Severity

Allergic Rhinits Classification: Duration

It's broken into:

• intermnitent les tha 4 day week or less than 4 weeks
• persistent more then that

Allergic Rhinits Classification: Severity

It’s Broken into:

• Mild: if the symptoms is present but not troubles or the imparnmesnt on the in in Daily activities -Moderate: if the symptoms is present to impair, daily activities

Allergy Testing :Skin Testing

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Asthmas

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Management from the

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Questions cover allergy testing appropriateness, interfering medications, and immunological mechanisms. Also covers conditions unsuitable for testing and interpretation of skin prick test results. Rhinitis symptoms, diagnosis, and differentiation between subtypes are explored.