Managing Allergic Fungal Rhinosinusitis

Abstract

Purpose of Review

Management of the patient with allergic fungal rhinosinusitis (AFRS) requires detailed understanding of the pathophysiology and clinical manifestation of the disease. Treatment options and outcomes are evolving and this review enables the otolaryngologist to have a fulsome discussion of the treatment options and expectations of the disease course with the patient.

Recent Findings

Since first described over 30 years ago, no single treatment modality has been found to be curative and managing the disease remains challenging. Ongoing research to improve outcomes with new rinses and light therapy particularly for the recalcitrant patient is described in this review.

Summary

AFRS is a challenging disease to diagnose and treat. A commitment has to be made by both the surgeon and patient for continued follow-up after good surgery. Early recognition of disease relapse and the knowledge of the options available are paramount to reduce the need for multiple surgical intervention and maintenance of a good quality of life.

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Conjunctival provocation tests: prediction of seasonal allergy

Purpose of review The conjunctival provocation test (CPT) is often used to clearly identify the specific allergen causing the symptoms of allergic rhinoconjunctivitis but also to assess the clinical efficacy of an allergen immunotherapy (AIT). As there is no consensus about its predictive value, the aim of this publication is to evaluate under which conditions the CPT can predict the symptom severity during the allergy season after previous AIT. Recent findings Three out of four randomized controlled trials (RCTs) showed a correlation between CPT reactivity and symptoms occurring under natural allergen exposure after previous AIT. Furthermore, one RCT found that performing the CPT 4 weeks after initiating AIT can identify early responders who also show a benefit during the season. Another RCT suggested that conducting the CPT prior to starting AIT can be used to identify patients who may benefit more from treatment than others. Summary The assessment of the reviewed literature led us to the conclusion that the CPT has a predictive value and can consequently be used to assess the efficacy of an administered AIT if performed according to a standardized challenge protocol with high-quality allergen extracts. Correspondence to Ralph Mösges, Institute of Medical Statistics and Computational Biology (IMSB), Faculty of Medicine, University of Cologne, Kerpener Straße 62, 50937 Cologne, Germany. Tel: +49 172 2056230; e-mail: ralph@moesges.de Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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Globalization and anaphylaxis

Purpose of review To understand the impact of globalization in the management of anaphylaxis and identify potential strategies to improve patients' care and prevention. Recent findings Developments in the field of anaphylaxis have been consistently following these globalization trends offering possibilities of collaborations of the allergy community and integrated international initiatives to reach quality care of allergic patients worldwide. Summary Globalization is the process of interaction and integration between people, companies, and governments worldwide. Developments in the field of anaphylaxis have been following these globalization trends offering possibilities of collaborations and integrated international initiatives to reach quality care of allergic patients worldwide. Complex disorders, such as anaphylaxis, have called for complex integrative strategies, leading to a new acceptance of outside traditions. Allergy is encouraging us to accept holistic and integrative medical practices as viable options. With the dissolution of multinational boundaries and the universal free access to information, the notion of holistic and global-based care is emerging as the new reality of the medicine. We strongly believe that the integrated action plan to the management and prevention of anaphylaxis, just possible through the globalization, is a key health, political and economical move that advocates for the best practice of allergology. Correspondence to Luciana Kase Tanno, MD, PhD, Division of Allergy, Department of Pulmonology, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, 371, av. du Doyen Gaston Giraud, 34295 Montpellier Cedex 5, France. Tel: +33 467336107; fax: +33 467633645; e-mail: luciana.tanno@gmail.com Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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Seasonal ocular allergy and pollen counts

Purpose of review The purpose of the article is to provide a historical overview of literature regarding pollen sensitization and ocular allergy with an emphasis on developments that have occurred over the past 5 years. Recent findings Currently, pollen studies have examined the molecular and cellular pathways involved in initiating allergic conjunctivitis to find targets for therapeutics. Studies have also documented the threshold, linear increase and plateau point in the relationship between pollen levels and allergic conjunctivitis symptoms. Summary Traditionally, intact pollen grains are counted as a means of correlating patient symptoms to allergen exposure. However, establishing a dose–response relationship between pollen grain exposure and allergic conjunctivitis has proven to be difficult. It has been observed that ocular allergies induce a two-fold response including early-phase and late-phase IgE-mediated reactions. Sensitization itself is a combination of pollen exposure over time in genetically predisposed individual. However, symptoms appear to reach an asymptotic point at which clinical severity plateaus. More studies are needed to clearly define differences in pollen sensitization by plant species. Correspondence to Leonard Bielory, MD, University Asthma and Allergy Associates, 400 Mountain Ave, Springfield, NJ 07081, USA. Tel: +1 973 912 9817; e-mail: drlbielory@gmail.com Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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Cosmetics and ocular allergy

Purpose of review The purpose of this review was to explore recent developments in the study of ocular cosmetics, as they pertain to adverse reactions that can be attributed to them. Recent findings Immunologically mediated adverse reactions to cosmetics are most commonly the result of sensitization to preservatives, fragrances and dyes used in these products. Metals such as nickel, cobalt, chromium and lead are used in products such as eye shadows and eye liners as well as toy makeup sets in amounts greater than the recommended amount of 1 ppm. Cosmetics make up the majority of fragrance-induced contact dermatitis. Recently, a free smartphone app was developed by American Contact Dermatitis Society that holds promise in better enabling patients to utilize their patch test data while shopping for cosmetics. Summary Both immediate and delayed hypersensitivity reactions linked to cosmetics are often the result of sensitization to preservatives, fragrances and additives in the products themselves. Despite significant advances in our understanding of these reactions, further research will be necessary to elucidate the mechanisms behind these reactions and bring this knowledge to the bedside as to improve patient care with potential cosmetic-based related allergic disorders. Correspondence to Leonard Bielory, MD, University Asthma and Allergy Associates, 400 Mountain Ave, Springfield, NJ 07081, USA. Tel: +1 973 912 9817; e-mail: drlbielory@gmail.com Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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Topical antihistamines, mast cell stabilizers, and dual-action agents in ocular allergy: current trends

Purpose of review To address the current trends of therapeutic mechanisms for treatment of allergic conjunctivitis (AC), based on topical antihistamines and mast cell stabilizers (MCS). Recent findings The antihistamine drug alcaftadine has H4 receptor inverse agonism, anti-inflammatory and MCS activities. The antihistamines levocabastine and azelastine are more effective than placebo in treatment of AC symptoms in randomized controlled trials (RCTs). The topical dual-action antihistamines/MCS olopatadine, azelastine, ketotifen, and epinastine are commonly used in Europe and in the United States for mild subtypes of AC. For the main symptoms of AC, ocular itch and conjunctival hyperemia, epinastine 0.05% was superior to placebo, but equal or more effective than olopatadine 0.1%, while the later was more effective than ketotifen. High concentration olopatadine 0.77% had longer duration of action, better efficacy on ocular itch, and a similar safety profile to low-concentration olopatadine 0.2%. The new formulas of topical dual-action agents present longer duration of action, leading to a decreased frequency of use. Summary The topical dual-action agents are the most effective agents treating signs and symptoms of mild forms of AC. There is superiority to the high-concentration olopatadine drug over other agents on ocular itch, with prolonged effect when used once-daily. Correspondence to Prof. Abraham Solomon, Department of Ophthalmology, Hadassah-Hebrew University Medical Center, Kiryat Hadassah, Ein-Kerem, POB 1200, Jerusalem 91120, Israel. Tel: +972 50 7874664; e-mail: dr.avi.solomon@gmail.com Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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Adults and children with anaphylaxis in the emergency room: why it is not recognized?

Purpose of review Despite many international guidelines have been published in the last 10 years, anaphylaxis continues to be underdiagnosed, undernotified, and undertreated. Anaphylactic reactions in adults and children in emergency departments are frequently not recognized, leading to underutilization of epinephrine, and a higher risk of death. Recent findings A few studies have been recently published showing that educational intervention for both physicians and other healthcare professionals improve diagnosis and treatment of anaphylaxis. Moreover, the new International Classification of Diseases, 11th edition improved classification of anaphylaxis, making it easier to be notified. Summary Anaphylaxis is a life-threatening hypersensitivity reaction that is most frequently seen by emergency physicians and nurses than allergists or immunologists. Education seems to be best strategy to improve management of this severe condition. Correspondence to Marcelo V. Aun, MD, PhD, Faculdade Israelita de Ciências da Saúde (FICS) Albert Einstein, Avenida Brigadeiro Luis Antonio 4267, 01401-002 São Paulo, SP, Brazil. Tel: +55 11 983080404; e-mail: marcelovivoloaun@gmail.com Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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