Franzese / Damask / Wise Handbook of Otolaryngic Allergy

1. Auflage 2019
ISBN: 978-1-63853-574-4
Verlag: Thieme
Format: EPUB
Kopierschutz: 6 - ePub Watermark

E-Book, Englisch, 304 Seiten, ePub

While encyclopedic tomes on the treatment of allergies have a place on the library shelves of otolaryngologists, provides a user-friendly office resource clinicians can consult on a daily basis. Written by Christine Franzese, Cecelia Damask, Sarah Wise, and Matthew Ryan, the book encompasses the basic science of allergies, essential knowledge, and how to perform each procedure.

Part one starts with basic immunology and allergic rhinitis definition and classifications, followed by discussion of sensitivities vs. clinical allergies, the unified airway concept, and different classes of inhalant allergens. Parts two and three detail all aspects of diagnosis and diverse skin testing methods such as Specific IgE testing. Subsequent parts discuss current treatment methods, allergy emergencies such as anaphylaxis, atopic disorders, and professional issues clinicians must tackle to successfully incorporate allergy treatment into practice.

Key Highlights

• The use of diverse types of pharmacotherapy including decongestants, anti-cholinergics, and antihistamines, as well as biologics, alternative medicines, and monosensitization vs. polysensitization
• Discussion of immunotherapy approaches including subcutaneous, sublingual, sublingual tablets, and oral mucosal
• Managing associated atopic disorders such as penicillin allergy, asthma, food allergies, eosinophilic esophagitis, and atopic dermatitis
• Worksheets with correct answers enable self-testing and accurate vial mixing/preparation

This user-friendly reference is a must-have companion for otorhinolaryngology residents and practitioners at any stage of their careers who treat patients with allergies.

This book includes complimentary access to a digital copy on

Autoren/Hrsg.

Franzese, Christine B.

Damask, Cecelia C.

Wise, Sarah K.

Ryan, Matthew W.

Fachgebiete

• Medizin | Veterinärmedizin Medizin | Public Health | Pharmazie | Zahnmedizin Klinische und Innere Medizin HNO-Heilkunde, Phoniatrie, Audiologie
• Medizin | Veterinärmedizin Medizin | Public Health | Pharmazie | Zahnmedizin Klinische und Innere Medizin Allergologie
• Medizin | Veterinärmedizin Medizin | Public Health | Pharmazie | Zahnmedizin Klinische und Innere Medizin Immunologie

Inhaltsverzeichnis

Part 1: The Basics
1 Basics of Immunology
2 Allergic Rhinitis: Definition and Classifications
3 Sensitization versus Allergy
4 Unified Airway Concept
5 Inhalant Allergens: Grasses
6 Inhalant Allergens: Trees
7 Inhalant Allergens: Molds
8 Inhalant Allergens: Epidermals and Danders
9 Inhalant Allergens: Weeds
Part 2: Diagnosis of Allergy
10 History
11 Patient Surveys and Questionnaires
12 Physical Examination
13 Differential Diagnosis
Part 3: Testing Methods
14 Conditions That Can Impact Skin Testing
15 Skin Testing: Prick
16 Skin Testing: Intradermal
17 Skin Testing: Blended Techniques
18 Specific Immunoglobin E Testing for Inhalant Allergy
Part 4: Treatment
19 Environmental Avoidance
20 Pharmacotherapy: Decongestants
21 Anticholinergics
22 Antihistamines
23 Corticosteriods
24 Leukotriene Receptor Antagonists
25 Mast Cell Stabilizers
26 Combination Therapies
27 Biologics
28 Alternative Remedies
29 Immunotherapy: Subcutaneous Immunotherapy
30 Immunotherapy: Sublingual Immunotherapy
31 Sublingual Tablets
32 Oral Mucosal Immunotherapy
33 Treatment: Monosensitization Versus Polysensitization
Part 5: Allergy Emergencies
34 Anaphylaxis
35 Other Urgencies and Emergencies
Part 6: Associated Atopic Disorders
36 Penicillin Allergy
37 Asthma
38 Food Allergy
39 Eosinophilic Esophagitis (EoE)
40 Atopic Dermatitis
Part 7: Practice Makes Perfect
41 Worksheets on Allergy Testing with Answers
42 Worksheets on Vial Mixing/Preparation with Answers
Part 8: Adding Allergy to Your Practice
43 USP and Compounding
44 Office Set-up
45 Patient Selection
46 Nurse Selection and Training
47 Billing and Coding

Leseproben

5 Inhalant Allergens: Grasses

5.1 When Summer Isn’t Something to Look Forward To

Grass pollen can be a potent allergen for sensitized individuals and is typically present during the summer months, especially early summer. There are three subfamilies of grasses that are most common in the United States: Pooideae, Cloridodeae, and Panicoideae. Cross-reactivity among grasses is high within subfamilies. It is important to understand allergen cross-reactivity and standardization in order to provide excellent care for the allergy patient.

5.2 Serious Stuff

5.2.1 Quick Review… What Is an Antigen? And What Is an Allergen?

An is a substance, most commonly a protein or polysaccharide, that causes the body to produce an antibody. The part of the antigen that is recognized by the body’s immune system is the . The is the part of the antibody that recognizes the antigen epitope. The epitope-paratope configuration that occurs upon antigen-antibody recognition is a unique three-dimensional lock-and-key formation. Of note, some epitopes from different antigens may be sufficiently similar in structure to bind the same antibody paratope; this results in . An is antigen that specifically triggers the allergic cascade; an allergen epitope binds paratopes on immunoglobulin E (IgE) molecules.

5.2.2 Tell Me a Bit More About Allergens… Please?

Substances containing allergenic proteins and polysaccharides are frequently complex biological constructs (e.g., pollen spores), and they often contain multiple proteins with varied epitopes. Certain allergens are identified as more important than the others. A is an antigenic fraction to which at least 50% of patients are sensitive per in vitro or in vivo testing. A minor allergen causes less than 50% of patients to react. For example, the major allergen in cat dander extract is Fel d 1, but the extract can contain multiple minor allergens as well. Understandably, patients will vary in their reactivity to major and minor allergens. Multiple major allergens have been identified and are noted throughout this and other inhalant allergen chapters.

A vial of allergen extract contains multiple components including the major and minor allergens themselves, as well as inert proteins and extract solution. Most nonstandardized extracts are preserved in a 50% glycerin solution ± 0.4% phenol. Extracts will deteriorate over time with a typical shelf life of = 3 years at 4 °C.

5.2.3 What Are Standardized and Nonstandardized Allergen Extracts?

For the most part, allergy extracts have been only roughly quantified, although more strict standardization is evolving. Nonstandardized quantification schemes include allergen units (Noon units, 1 unit of pollen toxin from 1,000th part of 1 mg Phleum pollen), protein nitrogen units (PNU, 0.01 µg of phosphotungstic acid-precipitable protein nitrogen), and weight per volume (W/V). The last method is the most commonly used method: the weight (grams) of dry allergen in a volume (100 mL) of solution. Bioequivalence will be roughly maintained within a company through consistent manufacturing, but significant variation will exist between manufacturers.

Standardized extracts date back to 1981 and are extracts which have been tested to be equivalent to a recognized reference. The Food and Drug Administration (FDA) produces a reference standard and manufacturers compare their product lot with this standard. If a sample’s activity is between 70% and 140% of the reference standard then the lot passes and is designated the same bioequivalent allergy unit (BAU) concentration as the standard. Multiple standardization methods exist. Grass allergens are standardized via radioallergosorbent (RAST) or enzyme-linked immunosorbent assay (ELISA) inhibition. Standards for dust mite are referenced using three fold dilutions, similar to the five-fold dilutions used for intradermal dilutional testing, although erythema size, not wheal, is measured. Cat is standardized by assaying major allergen content (Fel d 1). If a standardized allergen exists, then it is best to use the standardized allergen instead of its W/V quantified option; the bioactivity across lots and manufacturers is more consistent and hence safer. Standardized extracts are quantified in allergy units (AU) for dust mites, BAUs for some allergens (e.g., cat, grasses), or major allergen content in micrograms (e.g., short ragweed Amb a1). Some of the current standardized allergens licensed within the United States are discussed throughout this and other inhalant allergen chapters.

5.2.4 What Is Cross-Reactivity?

Cross-reactivity is a concept that must be understood to fully appreciate the complexities of allergy management. As many plants share a common evolutionary history, their allergens (and epitopes) will be conserved or minimally changed between species. Cross-reactivity increases with the closeness of the biologic relationship: order ? family ? (tribe within a family) ? genus ? species (the latter are most closely related). Cross-reactivity between intimately related species is common. Hence the body may react to two different pollinating species of plant interchangeably as the “lock and key” of antigen to IgE (epitope to paratope) molecule is similar. When an individual reacts similarly to different species, these species are described as being cross-reactive. In general, grasses tend to have the most cross-reactivity, weeds to a lesser degree, and trees possess the least cross-reactivity. Cross-reactivity can also occur between unrelated inhalants, and between foods and inhalants, if they happen to contain similar epitopes. An example is orally ingested apples and inhaled birch pollen that contain similar epitopes; a birch-sensitive patient can develop oral itching/swelling (oral allergy syndrome) from eating apples.

5.2.5 What Are Thommen’s Postulates?

Plant-derived allergens differ geographically, depending upon the prevalent species in a particular area and the local climate (?Fig. 5.1). In 1931, Thommen’s postulates were proposed. These are helpful to explain what constitutes an allergenic plant. These rules include:

1. The pollen must be wind-borne, or . Insect-pollinated plants are termed . Pollens from entomophilus plants tend to be heavy and sticky; these pollens do not trigger allergic responses unless present in overwhelming concentrations. plants combine the two strategies discussed and use both wind and insects for pollination.

2. The pollen must be produced in large quantities.

3. The pollen must be light enough to travel a long distance on the wind currents.

4. The plant must be broadly distributed within the environment.

5. The pollen must contain allergens capable of causing an allergic response.

Fig. 5.1 Pollen grains seen under scanning electron microscopy.

5.2.6 What Exactly Is Pollen?

A pollen particle is the male germinal cell (gametophyte) used for plant reproduction. Most aeroallergen pollen grains are 15 to 50 µm in diameter (?Fig. 5.1). The germinal center is surrounded by a vaguely spherical rigid wall of polysaccharide material termed Pollen grains are produced in the microsporangium of the plant and released passively into the environment to reach the receptive female stigma. A pollen allergen is typically a low-molecular-weight molecule (5–60 kDa) carried on a pollen particle that diffuses rapidly into an aqueous solution upon contact. For example, when a pollen grain strikes the nasal membrane, allergens diffuse away from the firm structure to be encountered by IgE molecules on the surface of mast cells. Pollen and/or its allergenic particles may also be aerosolized in smaller fragments allowing the material to bypass nasal filtering and reach the lungs. Pollens are typically released during the morning, and patients may experience aggravation of symptoms at that time. Dry, windy days will elevate pollen counts while damp, rainy weather will temporarily reduce the counts.

5.2.7 What Types of Plants Produce Allergenic Pollens?

The two major categories of pollen-producing plants are and . Gymnosperms carry their ovules “naked” on the scales of a cone or on the end of short stalks. Examples of gymnosperms include nonflowering trees (e.g., ginkgo) and conifers. The majority of pollen-producing plants are angiosperms; their sex organs are within flowers and their seeds are usually located within a fruit. The term angiosperm encompasses flowering trees, grasses, and weeds. The United States is divided into 11 zones based upon the climate and flora in these regions. As pollens are geography-specific, it is imperative that one identifies the species in their area to guide allergy testing and treatment.

5.2.8 What Are Some Highlights About Grass Allergens?

Grass pollens are among the most potent allergens produced in nature and have been reported to be the most prevalent cause of allergic rhinitis worldwide. However, of approximately 4,500 grass species worldwide, only a small number are of allergenic importance. Up to 50 antigens have been identified in grass pollens, including 10...