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Incorporating Otolaryngic Allergy into Your Practice
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Figure 1.
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The last several decades have seen a rather significant increase in the incidence and prevalence of allergic disorders. There have been several interesting theories put forth to explain this increase, the most popular of which is The Hygiene Hypothesis. This hypothesis supports a gradual shift in the human immune system towards a more Th2 rather than Th1 cell type dominated immunologic response. Some of this shift is thought to have arisen as a result of a steadily decreasing level of exposure to common antigens, parasites and diseases due to "urbanization" and sterilization of our environment.
Perhaps no other medical specialty is better situated to encounter patients with allergic disease than Otolaryngology. Allergic disorders manifest in symptoms affecting multiple organ systems including: eyes, skin, GI tract and the upper and lower respiratory tract from nostrils to alveoli. Furthermore, the Unified Airway Theory has shown us that pathology in one portion of the airway can affect and impact function in separate, sometimes distant areas. Clinical entities as diverse as allergic rhinitis, reactive airway disease, allergic fungal sinusitis, food allergy, chronic rhinosinusitis and nasal polyposis (to name a few) are seen commonly in even the most general, community-based ENT practices.
The immunology of classic inhalant allergy is now quite well understood. (Figure 1) The exposure to, and subsequent modification and presentation of certain environmental antigens by genetically predisposed T-cells culminate in a cellular and chemical cascade that produces allergy symptoms through the actions of chemical mediators such as cytokines, leukotrienes and histamines. This so-called Type I hypersensitivity remains the most common and best understood manifestation of allergic disease. Failure to recognize, identify and treat the allergic component of ENT-related disorders can potentially increase morbidity and negatively impact treatment outcomes, including surgical outcomes. The decision to incorporate otolaryngic allergy into one's practice (at even a simplified level) should realistically be one of necessity rather than choice. We owe it to our patients to treat the entire spectrum of their disease whenever possible. Incorporating allergy into one's practice is a process that can be accomplished incrementally over time until knowledge, skill, demand and resources become such that expansion is possible and desirable. Establishing a good working relationship with a reputable reference laboratory for RAST testing is perhaps the simplest and most cost-effective method to begin assessing the allergic diseases in a patient population. In this manner, one can at least answer the questions "Is my patient allergic and, if so, to what?" This information alone can be quite helpful in planning further management. Expansion to include simple prick testing or "blended" techniques of skin testing such as MQT (modified quantitative testing) requires surprisingly little in additional supplies, personnel and expense to the practicing otolaryngologist. Often, existing ancillary staff can be quickly and easily trained to perform such testing. As the decision to treat naturally evolves from a decision to simply test, more significant resources including equipment, supplies, personnel and dedicated office space become necessary considerations.  | |
Figure 2.
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The traditional algorithm triad for the treatment of allergic disease includes: 1) Avoidance/environmental control measures; 2) pharmacotherapy; 3) immunotherapy. (Figure 2) In order to initiate the first and simplest of these, testing must be performed to identify allergic triggers and plan control measures. The second option for treatment can also easily be initiated following even the simplest of testing. So, it can be said that two of the three options available to treat allergy patients can be initiated with relatively simple testing (such as RAST). Given that the vast majority of patients obtain adequate symptom control without the need for immunotherapy, one can argue that most allergy patients can be helped with information obtained from very limited testing. If you presently are not screening your patients for allergy, I would strongly encourage you to begin doing so. The reasons are many, the opportunities abundant and the rewards great. In the end, you and your patients will be glad you did. If you have any questions or concerns, feel free to contact me directly. The American Academy of Otolaryngic Allergy also serves as an excellent resource for those of us practicing allergy. If you have not already done so, I would encourage you to become a member, attend one of their excellent courses and visit their website at www.aaoaf.org.
Mark J. Hoy, MD
Assistant Professor
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