Intradermal Testing Doubles Identification of Allergy among 110 Immunotherapy-Responsive Patients with Eustachian Tube Dysfunction

Sinonasal Intervention Reduces the Need for Pressure Equalization Tube Placement in Atopic Adults

OBJECTIVES

To determine the impact of management of upper airway atopic disease on middle ear and eustachian tube function in adults.

METHODS

The TriNetX Research Network was queried to construct cohorts of adult patients with atopic disorders of the upper airway (defined by ICD-10 codes for asthma, allergic rhinitis, and chronic rhinosinusitis with nasal polyposis) with concurrent eustachian tube dysfunction (ETD) undergoing medical or surgical intervention for their atopic disease, including monoclonal antibody (mAb) therapy (e.g., dupilumab, mepolizumab, omalizumab), topical nasal steroid spray (fluticasone propionate), functional endoscopic sinus surgery (FESS), septoplasty with inferior turbinate submucosal resection (BITSMR), and allergy immunotherapy. The primary measured outcome was the difference in the rate of pressure equalization tube (PET) placement before and after each intervention.

RESULTS

FESS demonstrated an absolute risk reduction (ARR) of 10.0% (p < 0.05, 95% confidence interval [CI] 8.9%-11.1%), septoplasty/BITSMR 7.5% (p < 0.05, 95% CI 6.3%-8.7%), mAb 5.5% (p < 0.05, 95% CI 4.1%-6.8%), nasal steroid spray (fluticasone proprionate) 0.9% (p < 0.05, 95% CI 0.8%-1.0%), and allergy immunotherapy 2.4% (p < 0.05, 95% CI 1.5%-3.2%). Individually, the three mAb-dupilumab, mepolizumab, and omalizumab-exhibited ARR of 6.5% (p < 0.05%, 95% CI 4.8%-8.3%), 6.8% (p < 0.05, 95% CI 2.6%-11.0%), and 3.4% (p < 0.05, 95% CI 1.4%-5.4%), respectively, without significant differences in rates of PET placement among the three (p = 0.18).

CONCLUSION

Management of upper airway atopic disorders via both medical and surgical intervention is associated with improvement in middle function as measured by the need for PET placement.

LEVEL OF EVIDENCE: 3

Otitis Media With Effusion (OME) and Eustachian Tube Dysfunction: The Role of Allergy and Immunity-An EAACI Position Paper

IgE-mediated allergies play a significant role in respiratory diseases. Given the similar mucosal epithelium of the upper and lower respiratory tracts and their shared (patho)physiological immune responses, the "unified airways" concept views these tracts as a single system. Recently, this model has been extended to include the middle ear, with studies confirming that the Eustachian tube and middle ear are both anatomically and functionally part of the upper airways. However, the relationship between allergies and middle ear disorders remains controversial, with conflicting findings regarding pathogenesis and treatment. The increasing prevalence of allergies highlights the importance of further research. In Germany, the current sensitization rate to aeroallergens is 33.6%, with similar trends across Europe, where rates commonly range up to 30%. This widespread increase underscores the urgent need for a deeper understanding of the correlation between allergies and middle ear disorders across diverse European populations. Ineffective pharmacotherapy or possibly harmful medication for acute and chronic OME, such as systemic steroids, is most likely used globally in an uninformed way, due to a lack of evidence on the connection between allergic inflammation and eustachian tube dysfunction. Further research is essential to clarify the mechanisms linking IgE-mediated allergies to middle ear pathologies and to develop effective treatment strategies. Addressing these knowledge gaps is critical for improving patient outcomes and managing the rising burden of allergic diseases.

Mechanisms and Predictive Biomarkers of Allergen Immunotherapy in the Clinic

Allergen immunotherapy (AIT) remains to be the only disease-modifying treatment for IgE-mediated allergic diseases such as allergic rhinitis. It can provide long-term clinical benefits when given for 3 years or longer. Mechanisms of immune tolerance induction by AIT are underscored by the modulation of several compartments within the immune system. These include repair of disruption in epithelial barrier integrity, modulation of the innate immune compartment that includes regulatory dendritic cells and innate lymphoid cells, and adaptive immune compartments such as induction of regulatory T and B cells. Altogether, these are also associated with the dampening of allergen-specific TH2 and T follicular helper cell responses and subsequent generation of blocking antibodies. Although AIT is effective in modifying the immune response, there is a lack of validated and clinically relevant biomarkers that can be used to monitor desensitization, efficacy, and the likelihood of response, all of which can contribute to accelerating personalized medication and increasing patient care. Candidate biomarkers comprise humoral, cellular, metabolic, and in vivo biomarkers; however, these are primarily studied in small trials and require further validation. In this review, we evaluate the current candidates of biomarkers of AIT and how we can implement changes in future studies to help us identify clinically relevant biomarkers of safety, compliance, and efficacy.

Clinical Relevance and Advantages of Intradermal Test Results in 371 Patients with Allergic Rhinitis, Asthma and/or Otitis Media with Effusion

Background: We evaluated the value of positive intradermal dilution testing (IDT) after negative skin prick tests (SPT) by retrospectively determining allergy immunotherapy (AIT) outcomes. Methods: This private practice, cohort study compared the relative value of SPT vs. IDT in 371 adults and children with suspected manifestations of allergy: chronic allergic rhinitis (AR), asthma and/or chronic otitis media with effusion (OME). The primary outcome measure was symptom resolution following immunotherapy, as determined by symptom severity questionnaires completed by patients before and after AIT. Results: Positive IDT identified 193 (52%) patients who would not otherwise have been diagnosed. IDT detected 3.7-fold more allergens per patient than SPT (8.56 vs. 2.3; p < 0.01). Patients positive only on IDT responded to AIT equally well as those identifiable by SPT, independent of allergen sensitivity (67% by SPT vs. 62% by IDT; p = 0.69, not significantly different). Conclusion: Intradermal titration can identify patients who will benefit from allergy immunotherapy more accurately than SPT. Outcomes analysis in 371 patients shows that IDT doubled their chance of successful treatment with no greater risk of therapeutic failure. Positive IDT, following negative SPT, is clinically relevant and offers superior sensitivity over SPT for detecting allergens clinically relevant to diagnosis of AIT-responsive atopic disease.