Download allergic rhinitis and the ent practice

Review Article
ALLERGIC RHINITIS
AND THE ENT PRACTICE
RL Friedman | MBBCh, FCS(SA) ORL
M Hockman | MBBCh, FCS(SA) ORL
ENT Surgeons, Mediclinic Sandton, Johannesburg
Email | [email protected]
ABSTRACT
The term allergic rhinitis implies nasal inflammation with a specific allergic cause. Despite excellent clinical guidelines for the management of this condition, therapy is often unsatisfactory in many patients. A number of reasons
for this phenomenon are possible, including the presence of local disease, ongoing and unrecognised allergic
triggers, but also comorbid or unrelated pathologies in the nose and sinuses. Careful nasal and facial examination
is mandatory in patients, but especially those who fail first line therapy for allergic rhinitis.
INTRODUCTION
Allergic rhinitis (AR) refers to two significant clinical areas:
1. Rhinitis – inflammation of the nasal mucous
membranes;
2. Allergy - the specific cause of the rhinitis.
The literature, including Allergic Rhinitis in Asthma
(ARIA),1,2 reviewing and researching into clinical allergic
rhinitis, has focused extensively on these two factors. In
doing this, the underlying pathophysiology, the diagnosis and the management have been extensively covered
– arguably with good controlled clinical trial outcomes.
Excellent practical guidelines have flowed from this. Good
medical advice, following extensive continuing medical
professional development programs, has been at hand
and the correct treatment products have readily been
available and reasonably priced.
AR is the most common presenting allergic disease. In
one study, it was shown that at a particular time, up to
40% of patients will demonstrate a positive skin prick test
to one of the common aeroallergens, while 30% of this
randomly tested population exhibit a clinical diagnosis of
allergic rhinitis.3 AR is also stated currently to be the most
common of all chronic conditions in children.4 AR has a
significant effect on quality of life (QOL) with a host of consequences if left untreated. The disease burden includes
the obvious physical and social functional impairment but
also a very significant financial burden.5,6 This is important, especially when considering the host of comorbid
conditions associated and probably caused by AR. In the
context of this paper, failed AR management must add to
this burden considerably.6
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Current Allergy & Clinical Immunology | March 2015 | Vol 28, No 1
Clinically the disease is said to be categorised by very
specific symptoms - nasal obstruction, nasal itch, sneeze
and rhinorrhoea and a positive allergy test. Some authors
now include specific eye symptoms. In this context, two
specific issues need to be addressed:
1. Local allergic rhinitis: Patients with non-allergic
rhinitis might have local nasal specific IgE antibo­­dies
in the absence of systemic specific IgE. In suggestive cases with negative conventional test results,
local nasal allergen provocation should be consi­
dered as the management and clinical outcomes, in
the various non-allergic rhinitides and AR, may differ
considerably.7
2. Geographic importance of allergy test panels: The
importance of identifying the aero-allergen distribution within specific geographical distributions cannot
be overstated when attempting to diagnose allergy
and specifically AR. In South Africa, the South African
Allergic Rhinitis Working Group, in association with
the Allergy Society of South Africa and in collaboration with major laboratories within the country, have
developed a test panel of allergens more specific to
the various biomes within the country. These will be
updated as the needs arise to increase local spe­
cificity within South Africa. Specific allergen extracts
for our modified test panel are being negotiated with
the manufacturers. This particularly applies to the tree
pollen extracts.8
Unfortunately though, despite this, there is a consistently
worrying statistic that an unsatisfactory number of “well
diagnosed”, “well managed” and “compliant” patients do
not achieve the real satisfaction that studies predict, and
REVIEW ARTICLE
we believe, should be achieved. In some circumstances
up to 20% of patients manage very unsatisfactory results
and remain highly symptomatic,9 significantly more have
only a partial response. In children, health related quality
of life (HRQOL) has been shown to overestimate patients’
and parents’ satisfaction with disease management and
the benefit of treatment.10
Amongst the reasons previously given for this are poor
management choices as well as inadequate compliance.
Personal practical clinical experience has suggested additional issues relating to this.
One very common practical issue noted by the authors is the
confusion in the choice between intranasal corticosteroids
(INCS) and antihistamines as primary treatment protocol
after avoidance measures – especially in children. This
despite the literature concurrence that INCS are the drug
of choice where persistence or significant symptoms
are the rule.2,9 This is especially practical where nasal
obstruction is the predominant symptom.11
This paper however would like to review the issue of this
unsatisfactory response to adequate diagnostics and
availability of adequate management from an otorhinolo­
gic point of view.
ALLERGIC RHINITIS – DIAGNOSTIC AND
THERAPEUTIC CONSIDERATIONS
The outcome issue that ENT practices are faced with re­
gularly seem to be consistent - inadequate diagnosis of
treatment failure in allergic rhinitis patients. An example is
provided in Figure 1.
In this example (Figure 1), failed allergic rhinitis treatment
should have been a diagnostic issue. Due to the prevalence of AR, and the fact that presentation of AR presents
primarily to the non-rhinologist, the diagnostic science
may require re-evaluation especially where the patient
response to management was inadequate.
Dealing with the above two facts, AR diagnostic features
seem to be an issue. Allergy and rhinitis are the two
basic features of the pathology but not the total clinical
phenotype. More appropriately, the problem exists in an
exceptionally complex and variable organ, both in form
and function – the nose.
Nasal anatomy and airflow dynamics, non-allergic nasal
inflammatory diseases, muco-ciliary dynamics, the “nasal
cycle” including temperature regulation and humidity
control issues, exercise, age and external pollutants
and toxins have a significant impact on the nose and its
response to AR treatment.
Even without the use of available rhinologic examination technology such as a nasal endoscope and modern
Figure 1: Vague nasal “discomfort”; severe anterior & posterior rhinorrhoea; multiple failed AR and “sinus” treatments. Many years duration.
(Note: “hyperteliorism”, expansion of ethmoids into orbits, severe frontal
sinus bone destruction into anterior cranial fossa.)
radio­logy, a routine general nasal examination can be extremely useful. Unfortunately this is a seldom performed
ritual in routine cases. Training for this skill is also generally very limited. The authors have reviewed these practical
problems and attempted to categorise general clinical observations that are clinically very recognisable and quite
specific for physical nasal pathology, especially where
nasal obstruction is the dominant symptom.
It must be emphasised, and not ignored, that although the
cardinal symptoms mentioned above are the more specific
and diagnostic symptoms of AR,1 they are definitely not exclusive. At the coal face, many other signs and symptoms
present and some of the failures in AR management
outcomes must relate to co-morbidities, complications and
other nasal conditions that commonly are not diagnosed.
Itching of the ears, palate, or throat (not just nose),
sleep disturbance, anosmia, parosmia, mouth breathing,
snoring, dry mouth and throat (may be sore), behavioural
changes (especially in children), concentration issues,
cough (commonly non-productive), headache, blocked
ears, and facial fullness, are all relatively common
symptoms in AR. These symptoms, as with the cardinal
symptoms mentioned above, are not specific for AR and
are commonly associated with non-AR causes. Nasal
A
B
C
A. Nasal fracture at age 4 years significant nasal airway obstruction
B. Untreated fracture at age 14 years
C. CT scan age 14 years
Figure 2: Years of unsuccessful AR treatment for nasal obstruction
Current Allergy & Clinical Immunology | March 2015 | Vol 28, No 1
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A
Figure 3: Lip retraction and tongue thrust with nasal obstruction and obstructed nasal airway in a deviated nose
itch, sneeze, rhinorrhoea and nasal obstruction in clinical
studies, however, have shown better specificity and sensitivity for AR. There is also a major difference in non-verbal
paediatric, verbal paediatric and adult presentations,4 especially with regard nasal obstruction.
PROBLEMS RELATING TO NASAL OBSTRUCTION
(CONGESTION) AS A SYMPTOM:
1. In adults, chronicity and persistence of the symptom
and compensatory mouth breathing, often lead to “normalisation” of the nasal obstruction symptom. Often
during an acute allergy attack these patients refer the
nasal obstruction to their “better” nose as this is the
side that they relate to with their breathing. Adults with
long standing symptoms, relatively frequently are only
aware of their obstruction when it is finally relieved.
2. One common adult symptom, more related to the mouth
breathing aspect of nasal obstruction, is the fear of
“facial proximity”. These patients avoid close personal
contact, are uncomfortable in crowds and large queues
and have many avoidance measures and manoeuvers
such as hand to face protective actions in these situations. Air hunger is a relatively common symptom in
these situations. When questioned appropriately, these
patients often unburden themselves of multiple efforts to
get to the root of these issues.
3. In young children, nasal obstruction (congestion), is a
relatively late sign in AR.12
4. Nasal obstruction is an early predominant sign in rhinosinusitis, as well as in adenoidal hypertrophy (with
or without tonsil hypertrophy) and less frequently, in
tumours of the nose and post-nasal space.
5. Obstruction may be a significant symptom in internal
and external nasal deformities.
Rhinorrhoea may also be multifactorial in origin. AR
comorbidities and complications, physical nasal issues and
non-allergic rhinitides are all commonly present with anterior
and/or posterior nasal discharge. In this vein, it should be
emphasised that “post-nasal discharge” is not a diagnosis
but a symptom of many nasal conditions.
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Current Allergy & Clinical Immunology | March 2015 | Vol 28, No 1
B
C
A. “Inverted V” deformity
B. Nasal valve collapse
C. Nasal ptosis
Figure 4: Important signs in nasal obstruction
Important further questioning regarding family history,
seasonality, obvious allergen causes, surgery and injuries
to face and nose, as well as questioning about other potential allergic organ systems and comorbid conditions,
are vital.
Exclusion criteria, necessary in clinical studies, ensure that
the quoted results relate to the treatment protocol and the
disease itself. Unfortunately these “clinically pure patients”
are rarely seen in practice with the consequent divergent
outcome issues possibly resulting.13 Treating physicians
must be aware of these possible outcome shortfalls.
Specific to this paper is nasal obstruction as a symptom
in AR.
In the diagnosed AR patient where, despite all the above
as well as compliant adequate guideline based treatment,
management shortfalls are experienced, follow up must
be active both in the short and medium term. Further
clinical evaluation at the primary level or ORL referral
must be undertaken at this point prior to more extensive,
often costly and time consuming allergy workup or costly
polypharmacy.
IMPORTANT EXAMINATION IN THE MANAGEMENT
OF AR:
1. Non-Specific
• Adenoid face/long face – in children: It appears to develop
with any long term pre-pubertal nasal obstruction.
• Allergic shiners: This may be present with any long term
nasal congestion. Looser skin in the older patient tends
to lead to discoloured bagginess below the eyes.
• Allergic line: A skin crease just above the nasal tip
area, results from continuous upward rubbing of the
nose –“allergic salute”. It occurs mainly in allergic
patients, probably related to itch.
• Facial eczema: Especially in children.
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•
Lip retraction: The “cupids lip” usually starts in childhood and often persists to adulthood. It appears to be
a permanent adaptation to long term nasal obstruction
– maintains an open oral airway even when the jaws
are closed. There is some experimental evidence that
forced oral breathing may lead to long term muscle
changes in oral and diaphragmatic musculature.14
All the above have been referred to as the so-called
“allergy face” in children but they really indicate persistent
and long term nasal obstruction. In adults especially, but in
children on occasion, the shape and form of the outside of
the nose may also be indicative of more permanent nasal
obstruction.
A narrow or pinched middle third of the nose may suggest
middle third of the nose cartilage collapse, sometimes exhibiting the “inverted V” sign. Similarly, over prominent nasal
dimples are suggestive of nasal inlet obstruction, (nasal
valve area). This area is responsible for 50% of total airway
resistance. In health it is the rate limiting step of airflow to
the lungs. These nasal valves may only collapse on inspiration and may be unilateral. Narrowing here increases airway
resistance according to Poiseuille’s Law; “The effective resistance in a tube is inversely proportional to the fourth power of
the radius change.” Halving the radius of the tube effectively
increases the resistance by a factor of 16.
A deviated external nose may be suggestive of a deviated
nasal septum which may be complex and obstructive. A
nasal ptosis (overhanging tip) often accompanies this with
a caudal nasal septal deformity or shortening. Caudal
nasal septal deformities are especially important as they
effect the nasal valve areas. More importantly they are
easily seen without any special instrumentation.
When examining airway competence the physician should
place a finger below each nostril delicately on alternate
sides, so as not to distort the nose and assess the airway
Figure 5: Unilateral nasal “valve” collapse on sniffing
with gentle diaphragmatic breathing as well as with a deep
sniff. Sometimes these lateral walls may only collapse on
deep inspiration. These patients may complain of nasal
obstruction with exercise.
The “Cottle” sign, gently drawing the sidewall of the nose
away from the midline, will give information relating to the
nasal inlet – internal nasal valve area.
In patients with nasal obstruction, a good nonspecific
examination, such as the above, is quick and within the
capabilities of all physicians and might alert the physician prior to AR treatment failure or if after treatment
failure, prevent unnecessary additional medication and
investigation.
2. Specific examination
Should the above red-flag a patient prior to or after
treatment failure, then referral for a more thorough nasal
examination including nasal endoscopy and CT scan
evaluation is indicated. Basic geographic and personal
specific allergy testing at primary care and specialist level
is mandatory. Total IgE testing value is limited.
Figure 6: Illustrative example: 32 yr. old male. “Sinus” diagnosis for years, in reality actual relevant symptom was a persistent blocked nose. Post nasal
discharge, asthmatic. Family history of proven allergy. Total IgE 250 Ku/l. Phadiotop positive. Multiple skin prick test positive. Repeated poor response to
all “medicines and sprays”, multiple combination of medicines including asthma medicines and oral steroids. Multiple over-the-counter (OTC)
medications.
Note: Severe nasal septal deformity + severe and complex aeration of left lateral nasal wall structures + chronic rhinosinusitis. No previous trauma.
RED FLAG: Complex deviation of the external nose should be very suggestive of internal nasal structure problems.
Current Allergy & Clinical Immunology | March 2015 | Vol 28, No 1
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CONCLUSION
Despite significant increased current literature and continuing professional development training, the required
response to adequate guideline based compliant diagnosis and treatment is inadequate for patients with nasal
disease. Many postulates have been advanced, but from
a practical and rhinologic point of view, nasal diagnostic
issues have been understated. Ethically, this may be a
problem from an “evidentiary uncertainty”15 point of view, if
not on a personal level, likely from a group level.
Finally, a significant issue directly related to this, relates
to the poor outcomes in nasal surgery where nasal allergy
has not been diagnosed and or treated.
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Berger WE. Ciclesonide: a novel inhaled corticosteroid for the treatment of persistent asthma – a pharmacologic and clinical profile.
Therapy 2005; 2(2):167-178.
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