What Role Does Allergy Play in Chronic Ear Disease and Laryngitis?

IgE-mediated allergy plays a well-established role in both nasal and pulmonary diseases due to the common epithelium and shared mediator responses of the upper and lower airways. This "unified airway" concept has also been described in other sites within the head and neck that contain similar respiratory mucosa: the middle ear and the larynx. This review will highlight the data suggesting a role for IgE-mediated allergic disease in chronic laryngopharyngeal and middle ear disease and the role for allergy testing to aid in diagnosis and treatment of these disorders.

Samter's Triad to Aspirin-Exacerbated Respiratory Disease: Historical Perspective and Current Clinical Practice.

Aspirin-exacerbated respiratory disease (AERD), formerly known as Samter's Triad, is a syndrome of airway inflammation characterized by rhinosinusitis with polyposis, asthma, and nonsteroidal anti-inflammatory drug (NSAID) intolerance. Approximately 7% of patients with asthma will also have AERD making prompt identification, diagnosis, and management of this syndrome important to controlling the disease progression. This paper will provide a brief biographical background on Max Samter, MD, followed by an epidemiologic overview, clinical presentation and diagnosis, and management strategies, which highlight patient counseling and educational needs.

Asthma, rhinitis, and the unified airway.

Patients with rhinitis and rhinosinusitis are commonly treated in otolaryngologists' offices. Many of these patients have concurrent lower respiratory diseases such as asthma. The simultaneous presence of upper and lower airway diseases occurs frequently, and has resulted in the unified airway model, which describes the close relationships between these inflammatory diseases. Understanding the coexistence of respiratory illnesses has implications for the diagnosis and management of both upper and lower airway conditions. It is important for otolaryngologists and otolaryngology nurses to be aware of these common comorbid processes, and to evaluate for the presence of asthma in all patients with upper airway conditions such as rhinitis and rhinosinusitis. This paper will discuss the epidemiology, pathophysiology, mechanisms, and diagnosis and treatment considerations in patients with unified airway diseases.

Impact of COVID-19 on Otolaryngology Literature.

OBJECTIVES/HYPOTHESIS: To understand the effect of the COVID-19 pandemic on the volume, quality, and impact of otolaryngology publications. STUDY DESIGN: Retrospective analysis. METHODS: Fifteen of the top peer-reviewed otolaryngology journals were queried on PubMed for COVID and non-COVID-related articles from April 1, 2020 to March 31, 2021 (pandemic period) and pre-COVID articles from the year prior. Information on total number of submissions and rate of acceptance were collected from seven top-ranked journals. RESULTS: Our PubMed query returned 759 COVID articles, 4,885 non-COVID articles, and 4,200 pre-COVID articles, corresponding to a 34% increase in otolaryngology publications during the pandemic period. Meta-analysis/reviews and miscellaneous publication types made up a larger portion of COVID publications than that of non-COVID and pre-COVID publications. Compared to pre-COVID articles, citations per article 120 days after publication and Altmetric Attention Score were higher in both COVID articles (citations/article: 2.75 ± 0.45, P < .001; Altmetric Attention Score: 2.05 ± 0.60, P = .001) and non-COVID articles (citations/article: 0.03 ± 0.01, P = .002; Altmetric Attention Score: 0.67 ± 0.28, P = .016). COVID manuscripts were associated with a 1.65 times higher acceptance rate compared to non-COVID articles (P < .001). CONCLUSIONS: COVID-19 was associated with an increase in volume, citations, and attention for both COVID and non-COVID articles compared to pre-COVID articles. However, COVID articles were associated with lower evidence levels than non-COVID and pre-COVID articles. LEVEL OF EVIDENCE: 3 Laryngoscope, 132:1364-1373, 2022.

Sublingual immunotherapy for inhalant allergy: cautious optimism.

Sublingual immunotherapy (SLIT) is being utilized with increasing frequency in both Europe and the United States. While the data with commercially-prepared single-antigen SLIT appear promising, there has been an extrapolation of these data beyond the scope of the well-controlled clinical trials that have been published in the literature. In this environment of enthusiasm, it is prudent to examine variables that are relevant in evaluating how SLIT can be incorporated into American allergy practice on a broader scale. This commentary will discuss five areas of potential concern in moving toward wider implementation of SLIT: (1) patient selection for treatment; (2) pattern of sensitization; (3) dosing, preparation, and delivery; (4) safety concerns; and (5) cost of therapy. Additional research is necessary to adequately address these important issues to ensure that SLIT will offer a safe, well-tolerated, and effective treatment for Americans with inhalant allergy.

Effects of mometasone furoate administered via a dry powder inhaler once daily in the evening on nocturnal lung function and sleep parameters in patients with moderate persistent asthma: a randomized, double-blind, placebo-controlled pilot study.

BACKGROUND AND OBJECTIVE: Nocturnal symptoms are common in asthma patients and have the potential for considerable clinical effects due to a lack of sleep and persistent daytime symptoms of somnolence and activity impairment. The primary objective of this investigation was to determine the effect of a 14-day course of once-daily evening administration of mometasone furoate 400 microg administered via a dry powder inhaler (MF-DPI 400 microg qd pm) on the overnight decline in pulmonary function observed in patients with nocturnal asthma. METHODS: Eligible enrollees were between the ages of 18 and 60 years and had established mild to moderate asthma, with an improvement in forced expiratory volume in 1 second (FEV(1)) of >15% after administration of inhaled salbutamol (albuterol) 200 microg. All enrolled patients had a history of nocturnal asthma. Enrollees were randomized to receive MF-DPI 400 microg qd pm or placebo administered between 6 pm and 8 pm for 14 days. The primary outcome evaluated in the study was reduction in nocturnal decline in evening (8 pm) to morning (6 am) FEV(1) values. Secondary outcomes included reduction in nocturnal decline in evening to morning peak expiratory flow rate (PEFR), polysomnographic indices of sleep, and psychometric indices (Nocturnal Rhinoconjunctivitis Quality of Life Questionnaire [NRQLQ], 36-item Short Form of the Medical Outcomes Survey [SF-36], and Asthma Quality of Life Questionnaire [AQLQ]). RESULTS: A total of 20 patients were randomized and completed all phases of the study. No significant differences were observed between treatment groups in the primary outcome of nocturnal decline in FEV(1) from pretreatment to end of treatment. Likewise, there was no significant difference between treatment groups in polysomnographic indices of sleep or quality-of-life assessments. However, there was a trend toward improvement in the activity scale of the AQLQ assessment in the MF-DPI 400 microg qd pm treatment group. CONCLUSION: No significant treatment effect on nocturnal pulmonary function, sleep indices or quality of life was observed with 14-day administration of MF-DPI 400 microg qd pm. These findings are limited by the small sample size and the short treatment period evaluated. Future studies are warranted to study the effects of MF-DPI therapy in patients with nocturnal asthma.

Baseline laryngeal effects among individuals with dust mite allergy.

OBJECTIVE: To examine baseline effects of perennial allergy on laryngeal appearance, laryngeal function, and perceived vocal handicap among individuals without current allergy or voice symptoms. DATA SOURCES: This pilot study included 47 adults: 21 with positive and 26 with negative skin test responses for the dust mite, Dermatophagoides pteronyssinus. METHODS: Subjects were tested for sensitivity to dust mite antigen by prick testing. Laryngeal appearance and function were studied with laryngovideostroboscopy, acoustic and speech aerodynamic analysis, and voice sampling. These parameters were blindly analyzed by three trained examiners. Subjects also completed the Voice Handicap Index (VHI) as a measure of vocal handicap. RESULTS: Subjects allergic to dust mites perceived significantly greater vocal handicap on the VHI than did nonallergic subjects. No significant differences were noted between groups in laryngeal appearance or function. CONCLUSION: These pilot data suggest that, at baseline, allergic individuals perceive greater vocal handicap than their nonallergic counterparts (P = 0.04), even in the absence of current allergy symptoms or observable physical or functional abnormalities. These preliminary observations can serve as an impetus for further research into this important area, including the potential interrelationship between acid reflux disease and allergic laryngeal inflammation.

The unified airway--conceptual framework.

Substantial evidence exists to support the concept that the respiratory system functions as an integrated unit. Pathophysiological processes that involve the upper airway generally occur in conjunction with lower airway diseases, and diffuse inflammation often affects mucosal surfaces of the middle ear, nose, sinuses, and tracheobronchial tree simultaneously. Support for this relationship can be found in epidemiological studies, in shared pathophysiological mechanisms, and in observed interactive treatment effects. This model and its implications are discussed.

Allergic rhinitis--current pharmacotherapy.

The use of pharmacotherapy for allergic rhinitis remains a central strategy in the integrated treatment of the patient. The most appropriate medical therapy depends upon the nature of specific rhinitis symptoms, patient tolerance to and preference for certain classes of medications, and response to treatment. Through an appreciation of these various physiological mechanisms, the physician can select the treatment option or options that will be most likely to effectively manage symptoms.

Asthma: guidelines-based control and management.

Guidelines-based management of the patient with asthma allows maximal levels of function with few adverse effects. A flexible approach to therapy that emphasizes an ongoing partnership between the patient and physician allows optimal communication, facilitating treatment adherence and maximal levels of control. Through assessment of the patient's initial severity of disease and an evaluation of the patient's ongoing level of control, appropriate medical therapy can be initiated and level of therapy can be modified based on the patient's response. Patient education, environmental control strategies, and proper use of medications are vital in achieving maximal benefit in asthma management. Excellent asthma control is possible and should be a goal of both physicians and patients.

Sleep impairment in allergic rhinitis, rhinosinusitis, and nasal polyposis.

Sleep impairment is a significant problem for patients with inflammatory disorders of the upper respiratory tract, such as allergic rhinitis, rhinosinusitis, and nasal polyposis. Nasal congestion, one of the most common and bothersome symptoms of these conditions, is associated with sleep-disordered breathing and is thought to be a key cause of sleep impairment. This review examines sleep impairment associated with allergic rhinitis, rhinosinusitis, and nasal polyposis. It explores the adverse effects of disturbed sleep on patients' quality of life and how these inflammatory nasal conditions can be reduced by therapies that address the underlying problems affecting sleep. Treatment with intranasal corticosteroids has been shown to reduce nasal congestion in inflammatory disorders of the upper respiratory tract. Data on sleep-related end points from clinical trials of intranasal corticosteroids indicate that this reduction is associated with improved sleep, reduced daytime fatigue, and improved quality of life. Further research using measures of sleep as primary end points is warranted, based on the potential of these agents to improve sleep and quality of life in patients with allergic rhinitis, acute rhinosinusitis, and nasal polyposis. Such trials will help to identify the most effective therapies for sleep impairment in these 3 nasal conditions.

Diurnal variability of lung function and its association with sleep among patients with asthma.

This prospective exploratory story examined diurnal variations in pulmonary function and their association with sleep and quality of life (QOL) in 20 adult asthmatics. Peak expiratory flow (PEF) was assessed for 7 days, before bedtime and upon awakening. There was no association between PEF variability and QOL. Six of 13 polysomnographic measures were significantly correlated with overnight decline in PEF. Individuals with greatest decline took longer to fall asleep and enter Stage 1 sleep, spent less time asleep, and experienced poorer sleep efficiency. Diurnal variations in PEF reflect adverse sleep quality, yet impact on QOL is often unnoticed.

Keys to successful management of patients with allergic rhinitis: focus on patient confidence, compliance, and satisfaction.

OBJECTIVE: The American Academy of Otolaryngic Allergy (AAOA) convened an expert, multidisciplinary Working Group on Allergic Rhinitis to discuss patients' self-treatment behaviors and how health care providers approach and treat the condition. PROCEDURES AND DATA SOURCES: Co-moderators, who were chosen by the AAOA Board of Directors, were responsible for initial agenda development and selection of presenters and participants, based on their expertise in diagnosis and treatment of allergic rhinitis. Each presenter performed a literature search from which a presentation was developed, portions of which were utilized in developing this review article. SUMMARY OF FINDINGS: Allergic rhinitis is a common chronic condition that has a significant negative impact on general health, co-morbid illnesses, productivity, and quality of life. Treatment of allergic rhinitis includes avoidance of allergens, immunotherapy, and/or pharmacotherapy (ie, antihistamines, decongestants, corticosteroids, mast cell stabilizers, anti-leukotriene agents, anticholinergics). Despite abundant treatment options, 60% of all allergic rhinitis patients in an Asthma and Allergy Foundation of America survey responded that they are "very interested" in finding a new medication and 25% are "constantly" trying different medications to find one that "works." Those who were dissatisfied also said their health care provider does not understand their allergy treatment needs and does not take their allergy symptoms seriously. Dissatisfaction leads to decreased compliance and an increased reliance on multiple agents and over-the-counter products. Furthermore, a lack of effective communication between health care provider and patient leads to poor disease control, noncompliance, and unhappiness in a significant portion of patients. CONCLUSIONS: Health care providers must gain a greater understanding of patient expectations to increase medication compliance and patient satisfaction and confidence.

Executive summary: asthma and the unified airway.

Asthma is a common comorbid disorder that will be seen by otolaryngologists in their treatment of patients with rhinitis, rhinosinusitis, and otitis media. Among otolaryngologists, however, a diagnosis of asthma is infrequently considered in this patient population. Otolaryngologists, however, may be in an important position to recognize this potential diagnosis and provide treatment or appropriate referral. To further develop this relationship among upper and lower airway inflammation, and to provide important information to otolaryngologists regarding this relationship, a multidisciplinary workgroup was impaneled by the American Academy of Otolaryngologic Allergy in August 2006. The full report of this meeting is published separately as a Supplement to Otolaryngology-Head and Neck Surgery. This Executive Summary provides a brief synopsis of that document, with a focus on comorbid respiratory inflammation for otolaryngologists. In the treatment of their patients with allergic rhinitis and rhinosinusitis, otolaryngologists must be aware of the possible presence of asthma so that appropriate treatment and/or referral can be initiated. The impact of this practice will allow more comprehensive treatment of patients with upper and lower airway disease, and will improve patient symptoms, function, and quality of life.

Asthma and the unified airway.

Inflammatory processes of the upper and lower airway commonly co-exist. Patients with upper respiratory illnesses such as allergic rhinitis and acute and chronic rhinosinusitis often present to both otolaryngologists and primary care physicians for treatment of their symptoms of nasal and sinus disease. These patients often have concurrent lower respiratory illnesses such as asthma that may be contributing to their overall symptoms and quality of life. Unfortunately, asthma frequently remains undiagnosed in this population. It was the objective of this paper to examine the relationship between upper respiratory illnesses such as rhinitis and rhinosinusitis and lower respiratory illnesses such as asthma, and to provide a framework for primary care and specialty physicians to approach these illnesses as a spectrum of inflammatory disease. The present manuscript was developed by a multidisciplinary workgroup sponsored by the American Academy of Otolaryngic Allergy. Health care providers in various specialties contributed to the manuscript through preparation of written materials and through participation in a panel discussion held in August 2006. Each author was tasked with reviewing a specific content area and preparing a written summary for inclusion in this final document. Respiratory inflammation commonly affects both the upper and lower respiratory tracts, often concurrently. Physicians who are treating patients with symptoms of allergic rhinitis and rhinosinusitis must be vigilant to the presence of asthma among these patients. Appropriate diagnostic methods should be used to identify individuals with concurrent respiratory illnesses, and comprehensive treatment should be instituted to reduce symptoms and improve quality of life.

Asthma Management for the Otolaryngologist.

Asthma is a chronic inflammatory disease that will frequently be encountered by otolaryngologists as they manage their patients with upper respiratory diseases. Symptoms such as cough should alert otolaryngologists to consider more broadly the potential role of asthma in the differential diagnosis. It is critical for otolaryngologists to appreciate that patients with allergic rhinitis and chronic rhinosinusitis will often have asthma, and that many of them may not be diagnosed at the time of presentation. Appropriate diagnosis of the patient with asthma, as well as effective treatment for its symptoms, will improve patient function and enhance quality of life.