The Truth about Allergies: Severe Allergies and Sinus Problems Phillip LoSavio, MD

The Truth about Allergies:
Severe Allergies and Sinus
Problems
Phillip LoSavio, MD
Sindhura Bandi, MD
Christopher D. Codispoti, MD, PhD
Outline
I.
II.
III.
IV.
V.
What is an allergy
Allergy Statistics
Allergy triggers
Allergy and Sinus disease
Treatments
A. Medical
B. Surgical
VI. Conclusions
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I. What is an Allergy?
• From the Greek word “asthma” meaning “panting”.
• An allergic reaction is an immune reaction consisting
of the development of a type of antibody called
immunoglobulin E (IgE) against a specific foreign
substance (the antigen or allergen).
• IgE are attached to immune cells called mast cells
and basophils.
• On recognition of antigen, the mast cells and
basophils release histamine and other mediators
3
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001076/
4
Allergic Diseases
• Worldwide, the rise in prevalence of allergic
diseases has continued in the industrialized
world for more than 50 years.1
• Worldwide, sensitization rates to one or more
common allergens among school children are
currently approaching 40%-50%.1
1.
World Health Organization. White Book on Allergy 2011-2012 Executive Summary. By Prof. Ruby
Pawankar, MD, PhD, Prof. Giorgio Walkter Canonica, MD, Prof. Stephen T. Holgate, BSc, MD, DSc,
FMed Sci and Prof. Richard F. Lockey, MD.
6
Allergic Rhinitis & Sinusitis:
Statistics
• Roughly 7.8% of people age 18 and over in the U.S. have hay fever.3
• In 2010, 10% of U.S. children aged 17 years and under have suffered from
hay fever over the course of 12 months.1
• In 2010, white children in the U.S. were more likely to have had hay fever
(10%) than black children (7%).1
• Worldwide, allergic rhinitis affects between 10% and 30 % of the
population.2
• Worldwide, sensitization (IgE antibodies) to foreign proteins in the
environment is present in up to 40% of the population.2
• Roughly 13% of people age 18 and over in the U.S. have sinusitis.3
1. Bloom B, Cohen RA, Freeman G. Summary health statistics for U.S. children: National Health Interview Survey, 2010.
National Center for Health Statistics. Vital Health Stat 10(250). 2011.
2. World Health Organization. White Book on Allergy 2011-2012 Executive Summary. By Prof. Ruby Pawankar, MD, PhD, Prof.
Giorgio Walkter Canonica, MD, Prof. Stephen T. Holgate, BSc, MD, DSc, FMed Sci and Prof. Richard F. Lockey, MD.
3. Summary Health Statistics for U.S. Adults: National Health Interview Survey, 2010. By Jeannine S. Schiller, M.P.H.,
Jacqueline W. Lucas, M.P.H., Brian W. Ward, PhD and Jennifer A. Peregory, M.P.H., Division of Health Interview Statistics.
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Allergic rhinitis:
Risk Factors
• Family history of atopy
– Greater chance of a child developing allergic
rhinitis if both parents have a history of atopy
compared to if only 1 parent has a history of atopy
• Serum total IgE > 100 IU/ml before age 6 years
• Presence of an additional atopic disorder (ie:
asthma, eczema, food allergy)
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Allergic Rhinitis:
Signs and symptoms
• Rhinitis is characterized
by 1 or more of the
following symptoms:1
– Nasal congestion
– Runny nose (anterior
rhinorrhea)
– Post-nasal drip
(posterior rhinorrhea)
– Sneezing
– Itching
1.
Wallace D, et al J Allergy Clin Immunol 2008 Aug; 122 (2 Suppl): S1-84
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Allergic Rhinitis:
Pathophysiology
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Allergic Rhinitis:
Diagnosis
• A careful history
• Exam findings supportive of allergic etiology
– Dennie Morgan lines (prominent folds of lower
eyelid)
– Allergic shiners
– Nasal crease
• Detection of allergen specific IgE
– Skin testing
– Blood test (in vitro allergen specific IgE, aka RAST)
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How are allergies diagnosed?
• Allergy Testing – skin prick test
• Intradermal testing
• Blood test - RAST
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How skin testing works
• The skin of the forearm is poked with the
testing device with the liquid allergen on the
tip – usually made of plastic
• Allergens stay on the skin for
15-20 minutes
• Testing is interpreted
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Therapeutic Options
A multi-factorial approach
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Environmental Interventions
General principles:
• Should advise patients with symptoms to
implement environmental controls
appropriate to their documented allergen
sensitivities.
– Personalized to their symptoms
– Give specific advice, not generalities.
Environmental Interventions
Dust mite avoidance:
• Humidity control
– Mites require humidity, reason for absence at high
altitudes
– Reduce humidity to < 50%, a level which can cause
uncomfortable nasal dryness
– Use saline spray to moisturize, do NOT use
humidifiers
• Allergen reduction
Environmental Interventions
Dust mite avoidance:
• Allergen reduction
– Wash sheets, pillow cases, mattress covers, and
blankets weekly in hot water with detergent.
– Removal of carpet (especially in the bedroom) and
plush toys.
– Weekly vacuuming.
• Sustained effort for 3 to 6 months necessary
for clinical benefits.
Environmental Interventions
Dust mite avoidance:
• Physical barriers
– Dust mite-impermeable
mattress and pillow covers
– Plastic covers block
everything, but are
uncomfortable
– Woven fabrics with pore size
<2 mm can block passage of
immature & adult mites, have
smooth texture, and resilient
to repeated washings
(Preferred barrier method).
High efficiency Particulate Air (HEPA) filter
Environmental Interventions
Pet avoidance:
• Ideally, removal of pet from the home.
• Compromise is to keep pet outdoors.
• Air filters (HEPA) are effective if pet is
removed.
Environmental Interventions
Rodent (mouse, rats) avoidance:
• Professional extermination is recommended if
animals or droppings are visualized.
Cockroach avoidance:
• Removing food sources.
• Placing baited traps.
• Removing reservoirs of cockroach debris.
• Sealing wall cracks.
Environmental Interventions
Pollen avoidance:
• Closing windows during at risk season
• Running air conditioner as a filter
• Staying indoors when possible
• Showering before bed or after returning from
indoors
Environmental Interventions
Mold avoidance:
• Reducing humidity
• Fixing any structural damage (ex. fixing leaky
roofs, basement water damage)
• Mold remediation
Medications
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Allergic Rhinitis:
Medical Treatment
Intranasal corticosteroids
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Allergic Rhinitis:
Medical Treatment
Intranasal corticosteroids:
• Work by decreasing inflammation by:
– Reducing inflammatory chemical messengers (cytokines
such as interleukin-1 ).
– Reducing expression of inflammatory enzymes
(cyclooxygenase-2)
• All formulations are efficacious.
• Can have local irritation to some products, that can
be solved by switching to another product
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Allergic Rhinitis:
Medical Treatment
Oral Antihistamines
-Claritin (loratadine)
-Zyrtec (cetirizine)
-Allegra (fexofenadine)
-Benadryl (diphenhydramine)
-Atarax (hydroxyzine)
-Xyzal (levocetirizine)
-Clarinex (desloratadine)
-Chlortrimeton (chlorpheniramine)
-Sinequan (doxepin)
• All reduce inflammation by reducing inflammatory cytokines.
• Older antihistamines may sedation
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Allergic Rhinitis:
Medical Treatment
• Nasal Antihistamines
Provides lower dose of medication directly to nasal tissue.
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Allergic Rhinitis:
Medical Treatment
Intranasal antihistamines and combination sprays
Provides 2 medications with different mechanisms in 1 nasal spray.
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Allergic Rhinitis:
Medical Treatment
Leukotriene Receptor Antagonist
• Leukotrienes are generated
from arachidonic acid and
involved in asthma and allergic
rhinitis.
• Are oral medications effective in
treating asthma and allergic
rhinitis.
• An alternative or add-on
therapy.
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Allergic Rhinitis:
Medical Treatment
Allergy Shots (Allergy Immunotherapy)
•
•
•
•
•
•
•
Immunotherapy is a preventive treatment for allergic reactions to substances such as
grass pollens, house dust mites and pet dander.
Immunotherapy involves giving gradually increasing doses of the substance, or allergen,
to which the person is allergic.
An extract of a small amount of the allergen is injected into the skin of the arm. An
injection may be given once a week (sometimes more often) for about 30 weeks, after
which injections can usually be administered every two weeks.
Eventually, injections can be given every four weeks.
The duration of therapy may be three to five years, sometimes longer.
The incremental increases of the allergen cause the immune system to become less
sensitive to the substance, probably by causing production of a "blocking" antibody,
which reduces the symptoms of allergy when the substances is encountered in the
future.
Immunotherapy also reduces the inflammation that characterizes rhinitis and asthma.32
Allergic Rhinitis:
Complications & association with sinusitis
• Allergic rhinitis is a risk factor for chronic sinusitis.
• Inflammation can limit mucous drainage leading
to sinus inflammation (sinusitis)
• Other risk factors associated with sinusitis:
– Asthma (found in 20% of patients)
– Aspirin-exacerbated respiratory disease
– Tobacco smoking
– Noxious pollutants and irritants that may decrease
mucous clearance.
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Sinus anatomy:
Coronal view
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001670/
34
Sinus anatomy:
Sagittal view
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002607/
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Sinusitis:
Diagnosis
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Sinusitis:
Diagnosis
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Sinusitis:
Diagnosis
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Sinusitis:
Medical Management
Nasal saline irrigation:
• Reduces post-nasal drainage
• Removes mucous secretions
• Removes allergens and irritants caught in the
mucous
Intranasal corticosteroids:
• Reviewed earlier
Leukotriene receptor antagonists:
• Reviewed earlier
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Sinusitis:
Medical Management
Oral corticosteroids (ex. prednisone):
• Reduce inflammation of the nasal lining
• Reduce nasal polyp size
• Try to limit due to systemic side effects
40
Sinusitis:
Surgical Management
Functional Endoscopic Sinus Surgery (FESS):
• Attempts to restore physiologic sinus function.
• As does not address underlying inflammation,
FESS requires intense medical therapy postoperatively.
41
Sinusitis:
Surgical Management
Indications for FESS:
• Removal of material from opacified sinuses
• Re-opening of sinus ostia
• Removal of severe nasal polyps
• Failure of intense medical therapy
42
Summary
• Allergic rhinitis and sinusitis are common
• Exposure to allergens results in inflammation
of nasal and sinus lining (epithelium).
• Avoidance can be effective.
• There are multiple medical therapies that are
effective.
• Surgical therapy are safe and effective.
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Acknowledgements
• Amber Raza and members of Rush University
Department of Public relations.
• Members of Comprehensive Allergy, Asthma
and Sinus Center here at Rush University
Medical Center.
• Faculty of the departments of:
– Immunology, microbiology and allergy,
– Otolaryngology,
– Pulmonary
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Questions??
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