International consensus statement on allergy and rhinology: Allergic rhinitis - 2023

BACKGROUND

In the 5 years that have passed since the publication of the 2018 International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis (ICAR-Allergic Rhinitis 2018), the literature has expanded substantially. The ICAR-Allergic Rhinitis 2023 update presents 144 individual topics on allergic rhinitis (AR), expanded by over 40 topics from the 2018 document. Originally presented topics from 2018 have also been reviewed and updated. The executive summary highlights key evidence-based findings and recommendation from the full document.

METHODS

ICAR-Allergic Rhinitis 2023 employed established evidence-based review with recommendation (EBRR) methodology to individually evaluate each topic. Stepwise iterative peer review and consensus was performed for each topic. The final document was then collated and includes the results of this work.

RESULTS

ICAR-Allergic Rhinitis 2023 includes 10 major content areas and 144 individual topics related to AR. For a substantial proportion of topics included, an aggregate grade of evidence is presented, which is determined by collating the levels of evidence for each available study identified in the literature. For topics in which a diagnostic or therapeutic intervention is considered, a recommendation summary is presented, which considers the aggregate grade of evidence, benefit, harm, and cost.

CONCLUSION

The ICAR-Allergic Rhinitis 2023 update provides a comprehensive evaluation of AR and the currently available evidence. It is this evidence that contributes to our current knowledge base and recommendations for patient evaluation and treatment.

International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis

BACKGROUND

Critical examination of the quality and validity of available allergic rhinitis (AR) literature is necessary to improve understanding and to appropriately translate this knowledge to clinical care of the AR patient. To evaluate the existing AR literature, international multidisciplinary experts with an interest in AR have produced the International Consensus statement on Allergy and Rhinology: Allergic Rhinitis (ICAR:AR).

METHODS

Using previously described methodology, specific topics were developed relating to AR. Each topic was assigned a literature review, evidence-based review (EBR), or evidence-based review with recommendations (EBRR) format as dictated by available evidence and purpose within the ICAR:AR document. Following iterative reviews of each topic, the ICAR:AR document was synthesized and reviewed by all authors for consensus.

RESULTS

The ICAR:AR document addresses over 100 individual topics related to AR, including diagnosis, pathophysiology, epidemiology, disease burden, risk factors for the development of AR, allergy testing modalities, treatment, and other conditions/comorbidities associated with AR.

CONCLUSION

This critical review of the AR literature has identified several strengths; providers can be confident that treatment decisions are supported by rigorous studies. However, there are also substantial gaps in the AR literature. These knowledge gaps should be viewed as opportunities for improvement, as often the things that we teach and the medicine that we practice are not based on the best quality evidence. This document aims to highlight the strengths and weaknesses of the AR literature to identify areas for future AR research and improved understanding.

Food Allergy 2014: State of the Science

Program Description:

This miniseminar includes 3 didactic lectures, an audience-interactive section, and Q&A. The lectures will focus on why food allergies develop by taking a critical look at the latest scientific evidence available in the literature, the role of oral tolerance in human evolution, and the relationship of failure to achieve oral tolerance on the health of the individual, relevant immunology, nonimmunologic food reactions versus immunologic reactions, both IgE-mediated and non–IgE-mediated, current methods of diagnosing food allergies, cutting-edge strategies such as component-resolved testing, skin and in vitro methods versus double-blind, placebo-controlled food challenge. Treatment options for food allergy will also be discussed.

Educational Objectives:

(1) Evaluate the scientific basis of IgE- and non–IgE-mediated food allergy. (2) Describe the manifestations of food allergy in the head and neck region. (3) Use the currently available treatments for food allergy as well as future directions.

Food Allergy 2013: State of the Science

Program Description:

This miniseminar includes didactic lectures, an audience-interactive section, and Q&A. The lectures will focus on why food allergies develop by taking a critical look at the latest scientific evidence available in the literature, the role of oral tolerance in human evolution, and the relationship of failure to achieve oral tolerance on the health of the individual, relevant immunology, non-immunologic food reactions versus immunologic reactions, both immunoglobulin E (IgE)-mediated and non-IgE-mediated, current methods of diagnosing food allergies, cutting-edge strategies such as component-resolved testing, skin and in vitro methods versus double-blind, placebo-controlled food challenge.

Educational Objectives:

1) Analyze the literature comparing different methods for diagnosing food allergy. 2) Evaluate the scientific basis of IgE and non-IgE mediated food allergy. 3) Describe the currently available treatments for food allergy as well as future directions.

Food Allergy 2011: State of the Science

Program Description: Food allergies are difficult for the patient to understand and challenging for the clinician to treat. The CDC has recently reported that the prevalence of reported food allergies increased 18% over the past 10 years in children under 18. In addition, children with food allergies are 2 to 4 times more likely to suffer from asthma and other allergies. Allergic reactions to foods can produce life-threatening anaphylaxis, but have also been associated with other head and neck problems such as Meniere’s disease, migraine headache, chronic rhinitis, and chronic serous otitis media. There is a wide range of symptoms attributed to food allergies, such as nausea, cramping, diarrhea, dermatitis, urticaria, asthma, and joint pain. However, despite the fact that otolaryngologists see a large number of patients with food allergies, diagnosis and treatment strategies still remain controversial. The first part of the miniseminar will focus on the scientific basis of food allergies by taking a critical look at the latest scientific evidence available in the literature. A basic review of the relevant immunology will be provided along with a comparison of IgE-mediated food reactions versus non-IgE-mediated food reactions. The impact that food preparation and food spoiling has on allergic pathways will also be examined. In the second part of the miniseminar, the manifestations of food allergies will be discussed. The recent literature concerning the rise in prevalence of food allergies will be analyzed and the impact of food allergies on the head and neck and airway will be reviewed. We will examine the role of oral tolerance in human evolution and the relationship of failure to achieve oral tolerance on the health of the individual. The next section will be devoted to the current diagnostic modalities available for the diagnosis of food allergies. The use of structured patient-completed surveys to maximize thoroughness and efficiency will be discussed. We will compare the performance and accuracy of the different methods of food allergy testing, including skin and in vitro methods vs. the traditional gold standard of double-blind, placebo-controlled food challenge. The final part of the presentation will be devoted to treatment strategies for food allergies. Traditional methods, such as elimination diets and recognizing emergencies will be reviewed, as well as more cutting-edge techniques, such as oral and sublingual desensitization and genetically modified foods, will also be discussed. Audio-visual materials will be used to help present this information to the audience.

Educational Objectives: 1) Analyze the literature comparing different methods for diagnosing food allergy. 2) Evaluate the scientific basis of IgE and non-IgE mediated food allergy. 3) Understand the currently available treatments for food allergy as well as future directions.

Neurotrophins and tonsillar hypertrophy in children with obstructive sleep apnea

Enlarged adenotonsillar tissue (AT) is a major determinant of obstructive sleep apnea (OSA) severity in children; however, mechanisms of AT proliferation are poorly understood. We hypothesized that early exposure to respiratory syncytial virus (RSV) may modify AT proliferation through up-regulation of nerve growth factor (NGF)-neurokinin 1 (NK1) receptor dependent pathways. AT harvested from 34 children with OSA and 25 children with recurrent tonsillitis (RI) were examined for mRNA expression of multiple growth factors and their receptors. In addition, NK1 receptor expression and location, and substance P tissue concentrations were compared in AT from OSA and RI children. NGF mRNA and its high-affinity tyrosine kinase receptor (trkA) expression were selectively increased in OSA (p<0.001). NK1 receptor mRNA and protein expression were also enhanced in OSA (p<0.01), and substance P concentrations in OSA patients were higher than in RI (p<0.0001). AT from OSA children exhibit distinct differences in the expression of NGF and trkA receptors, NK1 receptors, and substance P. The homology between these changes and those observed in the lower airways following RSV infection suggests that RSV may have induced neuro-immunomodulatory changes within AT, predisposing them to increased proliferation, and ultimately contribute to emergence of OSA.

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.

Leukotriene modifier therapy for mild sleep-disordered breathing in children

BACKGROUND

Children with mild sleep-disordered breathing (SDB), who may not be recommended for adenotonsillectomy, frequently exhibit neurocognitive and behavioral morbidity, and may benefit from alternative therapeutic interventions, such as leukotriene modifier therapy.

METHODS

Twenty-four children with SDB completed an open-label intervention study for 16 weeks with daily montelukast therapy. Sleep studies and adenoid size estimates from lateral X-ray films of the neck were obtained before and after treatment. In a parallel study, adenoid and tonsillar tissues from children with obstructive sleep apnea or recurrent throat infections were subjected to quantitative polymerase chain reaction, immunohistochemistry, and Western blotting for gene and protein expression of leukotriene receptors LT1-R and LT2-R, and for concentrations of LTB4 and LTC4/D4/E4.

RESULTS

Montelukast treatment induced significant reductions in adenoid size and respiratory-related sleep disturbances, which were absent in 16 children with SDB who did not receive treatment. LT1-R and LT2-R mRNA was similarly abundant in adenoid tissues, but increased LT1-R and LT2-R protein expression and higher levels of LTB4 and LTC4/D4/E4 emerged in children with obstructive sleep apnea.

CONCLUSIONS

Oral therapy with a leukotriene modifier appears to be associated with improved breathing during sleep. Double-blind, placebo-controlled trials will be needed to corroborate current findings and solidly establish antiinflammatory strategies, such as leukotriene modifiers, as therapeutic alternatives in children with SDB too mild to justify referral for adenotonsillectomy.

Glucocorticoid receptor subunit expression in adenotonsillar tissue of children with obstructive sleep apnea

Tonsillectomy and adenoidectomy (T&A) is a frequent surgical procedure in children with obstructive sleep apnea (OSA). Many symptomatic children who do not fulfill the currently recommended criteria for T&A may benefit from topical intranasal steroid therapy. However, the expression of glucocorticoid receptor (GCR) expression in adenoid and tonsillar tissue is currently unknown. The objective of this study was to assess and compare expression patterns of the human GCR in children who undergo T&A for either recurrent throat infections (RI) or OSA. Adenotonsillar tissues from 36 children with OSA or RI were subjected to quantitative PCR using specific primers for GCR-alpha and GCR-beta and to immunohistochemistry and Western blotting for protein expression of GCR isoforms. mRNA encoding for expression of both GCR-alpha and GCR-beta was detected in the tonsils and adenoids of all children, with markedly higher relative abundance of the GCR-alpha. Furthermore, GCR-alpha mRNA expression was increased in OSA-derived adenoid and tonsil tissues compared with RI, whereas no differences emerged for GCR-beta. Immunoblots confirmed these findings for the protein transcripts of these genes, and immunohistochemistry showed a specific topographic pattern of distribution for both receptors in tonsillar tissue. GCR-alpha and GCR-beta are expressed in pediatric adenotonsillar tissue, are more abundant in OSA patients, and demonstrate a specific topographic pattern of expression. These findings along with the high GCR-alpha:GCR-beta ratio suggest a favorable profile for topical steroid therapy in snoring children with adenotonsillar hypertrophy.

The Treatment of Allergic Rhinitis with Immunotherapy: A Review of 1,000 Cases

We conducted a 10-year retrospective chart review of 1,000 immunotherapy-treated patients to evaluate the efficacy and safety of serial dilution quantitative intradermal testing in the management of allergic rhinitis. Three months after the initiation of immunotherapy, these patients had been assessed to ascertain whether or not they had experienced any overall improvement in their initial symptoms. Also included in this evaluation were determinations of each patient's use of medications as well as the incidence of adverse reactions to treatment and recurrent sinus infections. We found that 860 patients had achieved complete relief of their symptoms and required no other treatment; the remaining 140 patients experienced a partial improvement and continued to use pharmacotherapy to control breakthrough symptoms. During skin testing, only one patient experienced a systemic reaction, which responded to subcutaneous epinephrine. There were no deaths. We conclude that serial dilution quantitative intradermal testing is safe and that quantification of skin reactivity in evaluating and treating allergic rhinitis with immunotherapy is completely effective in the vast majority of patients.

The treatment of allergic rhinitis with immunotherapy: a review of 1,000 cases

We conducted a 10-year retrospective chart review of 1,000 immunotherapy-treated patients to evaluate the efficacy and safety of serial dilution quantitative intradermal testing in the management of allergic rhinitis. Three months after the initiation of immunotherapy, these patients had been assessed to ascertain whether or not they had experienced any overall improvement in their initial symptoms. Also included in this evaluation were determinations of each patient's use of medications as well as the incidence of adverse reactions to treatment and recurrent sinus infections. We found that 860 patients had achieved complete relief of their symptoms and required no other treatment; the remaining 140 patients experienced a partial improvement and continued to use pharmacotherapy to control breakthrough symptoms. During skin testing, only one patient experienced a systemic reaction, which responded to subcutaneous epinephrine. There were no deaths. We conclude that serial dilution quantitative intradermal testing is safe and that quantification of skin reactivity in evaluating and treating allergic rhinitis with immunotherapy is completely effective in the vast majority of patients.

The Importance of Quantifying Skin Reactivity in Treating Allergic Rhinitis with Immunotherapy

Therapeutic options for the treatment of allergic rhinitis include environmental modifications to decrease exposure to allergens, pharmacotherapy, and immunotherapy for those patients who do not experience satisfactory relief of their symptoms with medical management. Skin testing is the best established and most sensitive indicator of allergic disease. Several techniques are currently in use to identify pertinent antigens in the treatment of inhalant allergies. We describe the various skin testing techniques that are associated with such inhalant allergies. Quantification of skin reactivity to formulate a successful antigen vial for effective immunotherapy is necessary in the management of allergic disease.

The importance of quantifying skin reactivity in treating allergic rhinitis with immunotherapy

Therapeutic options for the treatment of allergic rhinitis include environmental modifications to decrease exposure to allergens, pharmacotherapy, and immunotherapy for those patients who do not experience satisfactory relief of their symptoms with medical management. Skin testing is the best established and most sensitive indicator of allergic disease. Several techniques are currently in use to identify pertinent antigens in the treatment of inhalant allergies. We describe the various skin testing techniques that are associated with such inhalant allergies. Quantification of skin reactivity to formulate a successful antigen vial for effective immunotherapy is necessary in the management of allergic disease.