Nasal allergen provocation test in nasal polyposis with and without allergy
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CRSwNP is characterised by eosinophilic inflammation and local IgE production. The amount of local tissue IgE in CRSwNP is independent of the atopic status and serum IgE of the patient. Moreover patients with CRSwNP and pollen allergy do not show prominent symptoms during season. Four groups of patients (n=48) underwent nasal allergen provocation test for grass pollen. We included 12 patients with allergic rhinitis based on grass allergy, 12 patients with CRSwNP without grass allergy, 12 patients with CRSwNP with grass allergy, and 12 control patients. The diagnosis of grass allergy was based on skin prick test and RAST. The test was positive based on change in nasal airflow measured by active anterior rhinomanometry and symptoms. In annex, VAS scores were performed before and after NAPT. The nasal allergen provocation test was positive in 19 % of the patients with CRSwNP without allergy and in 54% of the patients with CRSwNP with allergy. In contrast 100% of the patients with allergic rhinitis developed a positive provocation test, whereas in the control group 8% of the patients developed a positive provocation test. CRSwNP without allergy did not show a significant increase in VAS scores of complaints. In contrast, allergic rhinitis patients and CRSwNP patients with grass allergy developed a significant increase in nasal obstruction and nasal drip. However, in allergic CRSwNP patient the symptoms after provocation were significantly lower compared to AR patients. This suggests that local IgE present in these patients are functional after allergen provocation with grass pollen. However there is a reduced reactivity after grass pollen stimulation in CRSwNP compared to allergic rhinitis. This reduced reactivity is most likely due to the polyclonality of local IgE or IgG4 blocking activity in CRSwNP.Keywords:
Nasal provocation test
Allergic conjunctivitis
Rhinomanometry
Reported here are the results of a large‐scale trial conducted under the guidance of Prof Giovanni Motta, which I coordinated. A total of 656 patients with nasal hyperreactivity were recruited in 51 Italian centres (18 in the north of Italy, 20 in central Italy and 13 in the south). The trial's results were as follows. 1) A clear clinical prevalence of sensitization to different allergens in the different areas of Italy, which could be roughly classified thus: a) in Northern Italy birch and grasses were the main species; b) in Central Italy mites prevailed but oleaceae were also sigmficant; c) in Southern Italy panetaria and oleaceae were the prevailing species. 2) Most cases were sensitive to several allergens, although a considerable proportion (22%) actually presented reactions only to one, the main allergen. 3) Taking account of the patients sensitive to only one allergen and those responding to a main allergen, the proportion of patients reacting clinically to only one allergen rises to 64%. 4) The specific nasal provocation test (sNFT) offers specificity comparable. to in vivo diagnostic methods such as the prick test, and in vitro methods such as RAST, but is much more sensitive. 5) The sNPT can be done in any season. 6) The sNPT is highly specific below a threshold value of nasal reactivity, which can be identified for each allergen studied and expressed in Allergenic Units. 7) In patients in whom the prick test shows multiple sensitivity, the specific NPT identifies the allergen presumably responsible for the nasal reactions (main allergen). In the light of these findings double‐blind specific immunotherapy was started, to last 1 year, in 107 patients (49 given placebo and 58 active treatment), with nasal allergy to grasses, parietaria and mites. The results of this treatment were as follows: 74.1% of patients presented a reduction in nasal resistance, measured by dynamic anterior rhinomanometry, indicating relief of nasal obstruction; mucociliary transport time became normal in 81% of patients, meaning that rhinorrhoea had become less marked; there was a significant rise in the nasal reactivity threshold in 74.1% of patients, illustrating the degree of desensitization achieved; nasal IgA increased in 62.5% of patients and IgG in 55.2% indicating improvement in the local immunological picture. No such improvements were detectable in the patients given placebo. In conclusion, therefore, the findings of this trial in allergic rhinitis underline that the specific NPT proved more sensitive than other in vivo and in vitro diagnostic methods and is unquestionably a fundamental investigational approach for assessing nasal allergies, identlfying the allergens causing the symptoms and setting up rational local immunotherapy. The sNPT also showed the efficacy of specific intranasal immunotherapy.
Nasal provocation test
Rhinomanometry
Oleaceae
Hay fever
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ENWEndNote BIBJabRef, Mendeley RISPapers, Reference Manager, RefWorks, Zotero AMA Krzych-Fałta E. The conjunctival allergen provocation test and the nasal allergen provocation test as specific alternatives to the oral food challenge. Advances in Dermatology and Allergology/Postępy Dermatologii i Alergologii. 2022;39(2):245-250. doi:10.5114/ada.2021.105362. APA Krzych-Fałta, E. (2022). The conjunctival allergen provocation test and the nasal allergen provocation test as specific alternatives to the oral food challenge. Advances in Dermatology and Allergology/Postępy Dermatologii i Alergologii, 39(2), 245-250. https://doi.org/10.5114/ada.2021.105362 Chicago Krzych-Fałta, Edyta. 2022. "The conjunctival allergen provocation test and the nasal allergen provocation test as specific alternatives to the oral food challenge". Advances in Dermatology and Allergology/Postępy Dermatologii i Alergologii 39 (2): 245-250. doi:10.5114/ada.2021.105362. Harvard Krzych-Fałta, E. (2022). The conjunctival allergen provocation test and the nasal allergen provocation test as specific alternatives to the oral food challenge. Advances in Dermatology and Allergology/Postępy Dermatologii i Alergologii, 39(2), pp.245-250. https://doi.org/10.5114/ada.2021.105362 MLA Krzych-Fałta, Edyta. "The conjunctival allergen provocation test and the nasal allergen provocation test as specific alternatives to the oral food challenge." Advances in Dermatology and Allergology/Postępy Dermatologii i Alergologii, vol. 39, no. 2, 2022, pp. 245-250. doi:10.5114/ada.2021.105362. Vancouver Krzych-Fałta E. The conjunctival allergen provocation test and the nasal allergen provocation test as specific alternatives to the oral food challenge. Advances in Dermatology and Allergology/Postępy Dermatologii i Alergologii. 2022;39(2):245-250. doi:10.5114/ada.2021.105362.
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Summary A rapid and convenient method of nasal provocation (aerosol provocation combined with passive anterior rhinomanometry) is described. A comparative study between skin tests, bronchial provocations and nasal provocations highlights the usefulness of this method.
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Optical rhinometry is a new method that allows the direct, real time measurement of changes in swelling of the nasal mucosa by external measurement. The measurement is carried out with monochromatic near‐infrared light. The change of intensity of the swelling is displayed and recorded. Different preceding studies on adults already showed the reliability and absence of side effects of the measuring method. With the help of a prototype of an optical rhinometer specially developed for children, 65 measurements were performed on a total of 13 children and adolescents having one‐sided nasal provocation tests with histamine and allergens, negative provocation tests with control solution and decongestion with xylometazoline. The nasal provocation tests were implemented by optical rhinometry while simultaneously using the established method of active anterior rhinomanometry. We found significant differences between positive and negative provocation tests in both methods (p < 0.01). Decongestion was different from all other groups in both methods (p < 0.01). No clear connection could be made between the percentage increase of rhinometric extinction and the percentage increase of obstruction measured by anterior rhinomanometry. The evaluation of the nasal provocation test via continuous direct measurement of swelling of the nasal mucosa membrane seems feasible in children. Data which so far could not be measured, such as the beginning of swelling and the time of the maximum state of swelling, might increase the diagnostic validity of provocation tests.
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Acoustic Rhinometry
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We studied a group of allergic patients by active anterior rhinomanometry. We performed the nasal provocation test (NPT) and we observed two kinds of responses. The Type I pattern consists of an increase in delta P and an increase in resistance. The type II pattern consists of an increase in the flow value (V) and an increase in resistance. There are significant differences in the frequency of the two patterns among the allergens.
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The diagnosis of occupational rhinitis (OR) must be better confirmed than in allergic rhinitis of other aetiology. A provocation test is required to confirm the causality between the disease and the work exposure. The purpose of this study has been to examine the feasibility of active anterior rhinomanometry and visual analogue scale in the diagnostics of OR, and to compare the results of these measurements to a nasal status change score. The study subjects have been 50 consecutive patients suspected of having OR. Altogether 148 bilateral nasal provocation tests (NPTs), 55 placebo- and 93 allergen-NPTs, have been done. Based on the change in the nasal status and change in the nasal airway resistance (NAR), there are 42 positive NPTs. Although overlapping between placebo and allergen provocations exists, an increase of > 50% in NAR is recommended to regard the result as positive in NPT. The evaluation of the nasal reaction in the NPT is mainly based on anterior rhinoscopy and the change in the status score, but OR diagnostics should also include some physiological measurement.
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A nasal provocation test was carried out in two groups of adults: patients with birch pollen allergy (n = 25) and a group of healthy volunteers with no nasal allergy (n = 25). An endonasal provocation test was performed using increasing concentrations of birch pollen extract. The maximal duration of the test was 1 hour. The physiologic changes in the nasal patency in both groups were studied at a separate session at 10-minute intervals during 1 hour. The nasal patency was recorded with a computerized rhinomanometer using the anterior active method. The statistical analysis of the results shows that modern rhinomanometry is a reliable method of objectively evaluating the alternations in nasal obstruction during a nasal provocation test. The rhinomanometric findings correlate well with the rhinoscopic findings and the subjective symptoms of the patients. The changes in the nasal resistance values during the provocation were significantly larger than the physiologic ones. The individual biologic rhythmicity of nasal airway patency cannot hide the real positive result of a rhinomanometric provocation test, but it must be considered as an important factor in interpreting the results in nasal challenge.
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Methods Four groups of patients (n=48) underwent nasal allergen provocation test for grass pollen. We included 12 patients with allergic rhinitis based on grass allergy, 12 patients with CRSwNP without grass allergy, 12 patients with CRSwNP with grass allergy, and 12 control patients. The diagnosis of grass allergy was based on skin prick test and RAST. The test was positive based on change in nasal airflow measured by active anterior rhinomanometry and symptoms. In annex, VAS scores were performed before and after NAPT.
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Allergic conjunctivitis
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Even simple and relatively safe provocation procedures like nasal allergen challenges, should aim to allow detection of positivity with the less possible discomfort to the patient. The objective of this work was to evaluate if the use of rhinomanometric measurements during nasal provocation procedures could allow a decrease in the total administered allergen dose, causing less symptoms to the patients but without increasing the number of false-negatives, comparatively to clinical scores or nasal peak-flow measurements. Our results showed that performing rhinomanometric measurements during nasal HDM challenge procedures can lead in many patients to a reduction in the total dose of allergen administered during the challenge, without loss of sensitivity or specificity. This allergen dose reduction translates in less time consumed during the provocation and less patients' discomfort.
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In 17 cases of nasal allergy (8 cases untreated, 9 cases receiving specific hyposensitization) nasal resistance was measured by rhinomanometry (16 cases by the anterior method, one case by the oscillation method).Nasal resistance was measured before, at the end of and 60 min. after nasal provocation. During provocation resistance was also determined before and after nose, blowing if the patient complained of nasal obstruction.Serous nasal secretion due to provocation was found to be an important factor in the increased resistance and a sensation of nasal obstruction based on reactive swelling of the turbinates. In unilateral provocation (10 cases), serous nasal discharge and increased nasal resistance appeared on the opposite side. In bilateral provocation (6 cases), a significant increase in nasal resistance was recognized on the narrower side.
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