Allergy Treatment

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Allergy Treatment

Allergy
Author Credentials 

Cecelia Damask, DO and Matthew Ryan, MD
Education Program Directors
American Academy of Otolaryngic Allergy

Module Summary

Allergy is encountered frequently in the practice of otolaryngology. As a co-morbid condition in relation to many other common ENT diagnoses, understanding and discerning differential diagnosis is key in effective management of patient symptoms. When symptoms occur, consideration through an appropriate history and evaluation, with testing where indicated, should be considered. Environmental and pharmacotherapeutic interventions can reduce or alleviate the symptoms of allergy. Immunotherapy can modify the immune reaction to the offending antigen to result in a cure. The most dramatic complication in diagnosing and managing allergy is anaphylaxis, which must be recognized quickly and treated appropriately (epinephrine, airway support, and circulatory maintenance).

Module Learning Objectives 
  1. Summarize the immunologic factors driving seasonal and perennial allergies and their impact on therapeutic intervention.
  2. Explain role and process of immunotherapy.
  3. Describe role of pharmacotherapy and differential assessment of various products.
  4. Recognize role and effectiveness of environmental control.

Treatment

Learning Objectives 
  1. Understand the treatment options for allergic disease.
  2. Understand how to interpret skin testing results to define therapeutic pathways.
  3. Understand pharmaceutical intervention, mechanisms of action, and management options.
  4. Understand role and value of environmental controls.

Medical Therapies

Learning Objectives 

Understand the role and therapeutic process of immunotherapy; Considering subcutaneous (SCIT) and sublingual (SLIT) delivery options.

References 
  1. IFAR: Allergy Primer: Current Concepts in the Diagnosis and Management of Allergic Rhinitis.
  2. Bousquet J, Locet R, Malling HJ.  Allergen immunotherapy: therapeutic vaccines for allergic diseases. A WHO Position Paper. J Allergy Clin Immunol. 1998 Oct;102(4 Pt 1):558-62.
  3. Gordon BR. Immunotherpay basics. Otolaryngol Head Neck Surg. 1995 Nov;113(5):597-602.

Pharmacology

Learning Objectives 
  • Understand role and process of pharmacotherapy and differential assessment of various products and mechanisms of action:
    • Antihistamines
    • Decongestants
    • Mast cell stabilizers
    • Corticosteroids (systemic and topical)
    • Leukotriene modifiers
    • Biologics
References 
  1. IFAR: Allergy Primer: Current Concepts in the Diagnosis and Management of Allergic Rhinitis.
  2. Ferguson BJ. Environmental controls of allergy. Otolaryngol Clin North Am. 2008 Apr;41(2):411-7.
  3. King HC, Mabry RL, Mabry CS. Pharmacotherapy of allergic rhinitis. in: Allergy in ENT Practice: A Basic Guide. Thieme Publishing Group, New York, NY; 1998:176-199.

Case Studies

  • Uncomplicated seasonal allergic rhinitis: A young male with sneezing, itching membranes, nasal congestion and rhinorrhea each fall, from early October to mid-November. Symptoms are controlled with the use of a topical nasal steroid during this time, with occasional addition of a non-sedating antihistamine and decongestant.
    • Probable single-season (ragweed) allergic rhinitis
    • No requirement for testing, nor for immunotherapy, unless the problem becomes more severe and/or more prolonged, and is uncontrolled by simple therapy.
  • Moderately severe allergic rhinitis: A middle-aged female with chronic nasal congestion, postnasal drainage, and rhinorrhea. Symptoms are perennial, and worse with house-cleaning, gardening, or exposure to dust. No response to conservative medical management.
    • Probably perennial allergic rhinitis (dust mite, mold, possible animal dander)
    • Environmental control should be emphasized. Testing will define the causative allergens, and could allow definitive immunotherapy.
  • There are numerous scenarios other than these involving allergy, and each requires individual attention and careful consideration of diagnostic and treatment options.

Complications

Learning Objectives 
  • Understanding that allergy rarely results in complications, the most dramatic complications is anaphylaxis; Allergy has been shown to impact other otolaryngic disorders such as rhinosinusitis, Meniere’s disease, chronic cough/laryngitis, asthma, and a host of others.
    • Causes of Anaphylaxis
      • Medications
      • Venomous insect stings
      • Food
      • Contrast material
      • Skin Testing
      • Allergy immunotherapy injection
      • Idiopathic or exercise induced
    • Anaphylaxis Sign and Symptoms
      • Tachycardia, hypotension
      • Itching mucous membranes, increased nasal/chest secretions
      • Skin flushed, angioedema
      • Nasal congestion, hoarseness, cough, wheezing/stridor
      • Feeling of impending doom
      • Nausea, vomiting, diarrhea, abdominal cramps, urinary urgency, uterine cramps
    • Management of Anaphylaxis
      • Make diagnosis
      • Slow absorption of offending substance
        • Tourniquet above allergy injection site for example
      • Epinephrine; Repeat 0.3 cc (adults) every 10-15 minutes as needed, to max of 1 cc
      • Airway support
        • Oxygen, delivery method (up to tracheotomy)
        • Inhaled bronchodilator
      • Circulatory support
        • IV line
        • Medications as needed (intropin)
      • Anithistamines, corticosteroids
      • Stabilize, transport, observe, prevent recurrence
References 
  1. IFAR: Allergy Primer: Current Concepts in the Diagnosis and Management of Allergic Rhinitis.
  2. AAOA Anaphylaxis Patient Education tool.
  3. Gordon BR. Prevention and management of office allergy emergencies. Otolaryngol Clin North Am. 1992 Feb;25(1):119-34.

Review

Review Questions 
  1. What are the three methods of treating allergic symptoms?
  2. Discuss the various pharmacotherapy products, mechanisms of action, and use.
  3. Consider dose calculation and its application in initiating immunotherapy.
  4. Describes symptoms characterizing anaphylaxis. List steps in anaphylaxis management.
References 
  1. IFAR: Allergy Primer: Current Concepts in the Diagnosis and Management of Allergic Rhinitis.

NOTE: AAOA is finalizing an new comprehensive review of the allergic rhinitis literature. IFAR: ICAR-Allergic Rhinitis is scheduled to be released in early 2018; That source and the references cited should be used to support these modules.

Resources 

Learner must Sign In to access AAO-HNSF education activities.

  1. Annual Meeting Webcast (AMW):
  2. ENT for the PA-C: