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 2 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. 7 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) 8 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 9 Allergic Rhinitis: Pathophysiology 10 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) 11 How are allergies diagnosed? • Allergy Testing – skin prick test • Intradermal testing • Blood test - RAST 12 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 13 Therapeutic Options A multi-factorial approach 15 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 25 Allergic Rhinitis: Medical Treatment Intranasal corticosteroids 26 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 27 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 28 Allergic Rhinitis: Medical Treatment • Nasal Antihistamines Provides lower dose of medication directly to nasal tissue. 29 Allergic Rhinitis: Medical Treatment Intranasal antihistamines and combination sprays Provides 2 medications with different mechanisms in 1 nasal spray. 30 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. 31 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. 33 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/ 35 Sinusitis: Diagnosis 36 Sinusitis: Diagnosis 37 Sinusitis: Diagnosis 38 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 39 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. 43 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 44 Questions?? 45