Allergic Rhinitis Ebook
Allergic fungal rhinosinusitis (AFRS or AFS in the literature) is a hypersensitivity disease of the paranasal sinuses afflicting patients who are immunocompetent albeit with a history of atopy and allergic rhinitis to fungi. The disease process begins as the fungi become entrapped within the nasal cavity, presumably because of ostium obstruction or mucociliary disorder, and initiate a hypersensitive immune response. Just as with the other forms of fungal sinusitis, A. fumigatus is the most common etiological agent associated with AFRS (Table 1.1).
Mast cells participate both in acquired (e.g., IgE-dependent) and innate immune responses and tend to be present in tissues that interface between the organism and its environment (e.g., skin, respiratory tract, gastrointestinal tract) (121,122). The IgE-dependent roles of mast cells in allergic reactions, hay fever, and asthma are well established (121-123). Allergens and Ags recognize and crosslink specific IgE bound to the cell surface high-affinity IgE receptor, FceRI, to trigger acute hypersensitivity reactions, late-phase reactions, and chronic inflammatory reactions by release of preformed mediators present in the cytoplasmic granules (biogenic amines, proteoglycans, neutral proteases, TNF-a) and de novo synthesized mediators (leukotrienes, prostaglandins, cytokines).
Also Lactobacillus strains have been shown to confer differential effects on cytokine production and expression of surface markers on murine dendritic cells (85). Furthermore, lactobacilli induced in vitro, in a strain dependent manner, Treg-like low proliferating Th population producing TGF-b and IL-10 (86). TGF-b is the key cytokine in induction of T-cell differentiation towards Tregs (Fig. 2) (87). In a clinical study, improvement in atopic eczema symptoms following oral administration of lactobacilli was accompanied by increased serum concentrations of TGF-b (17). Interestingly, oral supplementation of lactobacilli in breast-feeding mothers was followed by increased TGF-b concentrations in breast-milk (88). This increase may have contributed to subsequently lower prevalence of atopic eczema in children. It should be noted, however, that allergic sensitization was not affected and allergic rhinitis and asthma may have increased in frequency (89). Nevertheless, these studies are not...
Patients with this syndrome, pansinusitis is common. Although nasal polyps may complicate ordinary allergic rhinitis (approximately 1-2 in some studies) and are a common manifestation of cystic fibrosis (up to 50 of such patients), the highest incidence of nasal polyps occurs in the patients with NSAID hypersensitivity (up to 90 ). Such polyps often respond to systemic steroid treatment but may recur within days of its cessation.
Immediate hypersensitivity can produce allergic rhinitis (chronic runny or stuffy nose) conjunctivitis (red eyes) allergic asthma atopic dermatitis (urticaria, or hives) and other symptoms. These symptoms result from the immune response to the allergen. In people who are not allergic, the allergen stimulates one type of helper T lymphocyte, the TH1 cells, to secrete interferon-y and inter-leukin-2. In people who are allergic, dendritic cells stimulate the other type of helper T lymphocytes, the TH2 cells, to secrete other lymphokines, including interleukin-4 and interleukin-13. These, in Hay fever, asthma, and most other allergic conditions The symptoms of hay fever (itching, sneezing, tearing, runny nose) are produced largely by histamine and can be treated effectively by antihistamine drugs that block the H1-histamine receptor. In asthma, the difficulty in breathing is caused by inflammation and smooth muscle constriction in the bronchioles as a result of chemicals released by mast...
Clinical diagnosis is straightforward when otological examination shows a fluid level (Fig. 20.2) or bubbles behind the eardrum. In more subtle cases, tympanometric studies may be required. The finding of a flat (type b) tympanogram is diagnostic. Initial treatment of OME should be conservative. Coexisting allergic rhinitis, URTI should be adequately treated. The use of antibiotics is controversial. However if there is any evidence of acute otitis media, a course of antibiotics is advisable. Persistent OME is more effectively treated with myringotomy and insertion of a grommet (Fig. 20.3). In infants and young children, adenoidectomy
Atopic dermatitis (AD) is a clinical syndrome characterized by an itchy rash with a variety of morphological cutaneous features that change with age, in association with a positive family history and concomitant presence of other atopic diseases (atopic asthma, hay fever, and occasionally urticaria) (Williams, 1997). The atopic immunological state is characterized by a propensity to develop type 1 IgE mediated responses in response to certain antigens, but the cutaneous immuno-pathology of atopic dermatitis is characterized by the presence of a T cell and inflammatory cell infiltrate resembling the pattern seen in type IV hypersensitivity reactions (rather than the type 1-like response seen in urticaria). The onset of the rash is typically in early life, peaking at age four years and tending to improve with age, although a large proportion of subjects may develop other forms of eczema later in life (Williams, 1997). Drawing the boundary between mild atopic dermatitis and normality is...
A more effective approach to nasal congestion and inflammation is the use of a topical nasal corticosteroid spray. This class of agent is the most potent and effective modality for the treatment of allergic rhinitis and is effective against all of the manifestations of this disorder (8). Common side effects include local nasal irritation and occasional thrush. Less common, but possibly important in the case of long-term use, are an increase in incidence of glaucoma, cataracts, and osteoporosis. These drugs diminish the inflammatory influx of cells into the nasal mucosa and diminish the strength of the local allergic response.
There is clear evidence that otitis media with effusion is highly related to an allergic diathesis. When this converts to chronic draining otitis media, the allergic component would seem to still be relevant, although direct evidence is scant (17-19). Therefore, the surgeon must consider allergy evaluation, based on a patient history of other allergic diatheses, especially of the unified respiratory epithelium. Patients with chronic draining ear and allergic rhinitis, chronic rhinosinusitis, and asthma are strong candidates for allergy workup before contemplating surgical treatment.
For a long time, allergic rhinitis is classified as seasonal or perennial. More recently, it is being reclassified as intermittent or persistent depending on the total duration of the symptomatic period. Management of rhinitis is dependent on the underlying cause. Superimposed infection is not uncommon and should be treated accordingly.
The majority of studies that have evaluated subjective sleep quality and indicators of health have been cross-sectional. For example, patients with hypertension, diabetes, kidney disease, polycys-tic ovary syndrome, and cancer report greater subjective sleep quality complaints than do age- and sex-matched healthy controls (e.g., Alebiosu et al, 2009 Haseli-Mashhadi et al, 2009 Knutson et al, 2006 Liu et al, 2009 Sabbatini et al, 2008 Tasali et al, 2006). In a community-based study of mid-life adults without clinical cardiovascular disease, Jennings and colleagues reported that higher PSQI-assessed sleep quality complaints were associated with increased prevalence of the metabolic syndrome (Jennings et al, 2007). Although these data preclude attributions of causality, sleep quality is likely related to health in complex and sometimes indirect ways. For example, evidence that sleep quality improves with treatment of the primary medical disease (e.g., allergic rhinitis, hypertension,...
(British Thoracic Society Scottish Intercollegiate Guidelines Network, 2003). Asthma is strongly associated with atopy as demonstrated by the link with eczema and hay fever and the detection of IgE, or a positive skin prick test, to a specific allergen (Witt et al., 1986 Woolcock et al., 1987). Asthma is termed extrinsic if it is associated with atopy and intrinsic if it occurs in the absence of atopy.
Allergic rhinitis is highly prevalent and one identified study examined how relevant medications may affect neurophysiological functioning, particularly sleepiness and alertness. Ng and colleagues (2004) failed to find any differences between first and second generation antihistamines in a study of children using a cross-over design that also included a placebo condition. The latency of the P300 in an oddball task was increased by both antihistamines relative to placebo although sleepiness alertness ratings were unaltered. The authors suggest that the electrophysiology measures were more sensitive than ratings and should be used to determine the effects on alertness of antihistamines.