House-Dust Mite Nasal Provocation: A Diagnostic Tool in Perennial Rhinitis
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Background In perennial allergic rhinitis (PAR), the skin-prick test (SPT) is a good diagnostic tool to identify the specific allergens. A nasal provocation test (NPT) is used to identify allergens and to confirm the diagnosis. The aim of this study was to determine the optimal cutoff values of symptom and peak nasal inspiratory flow (PNIF) changes after dust-mite NPT for predicting PAR. We also studied the relationship of the changes of symptoms in NPT and the wheal size of SPT. Methods One hundred five patients with perennial rhinitis underwent the NPT to Dermatophagoides pteronyssinus and the SPT. The NPT was assessed by changes in symptoms and PNIF. The optimal cutoff values of the symptoms score and PNIF changes after the NPT for predicting the SPT were determined using a receiver operating characteristic (ROC) curve. The relationship of the wheal sizes of SPT and the changes from the NPT were analyzed. Results Forty-eight patients had a positive SPT to D. pteronyssinus, of whom 33 patients had a positive NPT by increases of the symptom score. Twenty patients had a positive NPT by decreases of PNIF. The area under the ROC curve was 0.85 for symptom score changes and it was 0.612 for PNIF changes. There was a significant correlation between the wheal size of the SPT and symptom changes in the NPT. Conclusion Nasal provocation is a valuable test to confirm the diagnosis of D. pteronyssinus allergy, especially when the wheal from the SPT is small. The symptom change after the house-dust mite NPT is better than the PNIF change for predicting the PAR.Keywords:
Nasal provocation test
Dust mites
Allergic rhinitis is a frequent immunological disease affecting about 10-25% of the total population. The pathogenesis of allergic rhinitis is presumed to involve an IgE-mediated mechanism. Careful patient history, together with the skin prick test or RAST, usually allows an easy diagnosis of allergic rhinitis. In other cases it may be necessary to confirm diagnosis by the nasal provocation test. Different methods of provocation and measurement of nasal responses have been used in recent years. Scoring of the severity of clinical symptoms is too subjective to be clinically useful and should therefore be supplemented by one of the objective measurement techniques, such as anterior rhinomanometry. Additional analysis of nasal cytologic findings and determination of biomarkers in nasal secretions can be a critical tool in the evaluation of pathophisiology of allergic rhinitis. We critically discuss indications and contraindications for nasal challenges and review current techniques of provocation. We also provide various methods of assessment of nasal responses. The included examples of nasal provocation tests protocols may be helpful in introducing nasal provocation tests into everyday clinical practice.
Nasal provocation test
Rhinomanometry
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Patients affected by cutinegative, RAST negative, chronic hyperreactive rhinitis showed in 15/28 cases positive intradermal tests, nasal provocation test and RAST on nasal fluids. In 13/28 cases high IgE on nasal samples could be observed and seldom were the intradermal tests positive, but in no case were the nasal provocation or nasal RAST positive. Delayed and late positive provocation tests showed different features from early reactions. Criteria of positivity and checks during provocation tests look critical. The occurrence of sinusitis and polyposis can change clinical features. Mediators released from tissues lead to bronchial hyperreactivity.
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Provocation tests with egg or milk antigens were performed on symptomatic patients or those who were skin prick test positive to these antigens. Skin test <i>positive</i> patients responded immediately in 12/13 to nasal, in 7/15 to buccal and in 5/15 to gastric provocation tests. An immediate gastric response was within 1 h. The threshold dose for a positive result showed that tissue sensitivity from greatest to least was in the order: skin, nasal, buccal and gastric. None of the skin test <i>negative</i> group responded to any of the provocation tests. The results, particularly the nasal provocation, validate the skin prick test as a sensitive measure of type I allergy to defined foods. The relative insensitivity of buccal and gastric mucosae may explain positive skin test responses in asymptomatic subjects.
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The aim of the study was to assess the clinical application of the rhinomanometrically controlled nasal provocation tests using allergens according to guidelines given by the German Working Group ‘Nasal and Bronchial Provocation Tests’ in 1990. The study was performed on 24 patients with seasonal allergic rhinitis and 17 patients who were non-allergic volunteers. The results of this method were confronted with a complex allergologic diagnosis based on anamnesis, clinical examination, skin tests and serum IgE. Only a small difference in responses between allergic patients and non-allergic volunteers was observed. The results acquired suggest that the rhinomanometrically controlled nasal provocations with allergens should be used with great care.
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Background Nasal provocation tests (NPTs) are useful for evaluation of patients with allergic rhinitis. The cold dry air (CDA) provocation test is useful for evaluation of patients with nonspecific nasal hyperreactivity (NHR). This study aimed to determine whether the NPT or CDA provocation would be more useful for patients with different clinical pictures. Methods We evaluated changes in nasal symptoms (visual analog scale [VAS]) and acoustic parameters after NPT or CDA provocation in healthy volunteers (group A, n = 27), patients with allergic rhinitis (group B, n = 20), and subjects with nonallergic rhinitis (group C, n = 26). According to their subjective cold hyperresponsiveness (SCH), we compared changes in VAS and acoustic parameters after each protocol. The correlation between results of the skin-prick test (SPT) and changes in VAS after each protocol was analyzed. Finally, we performed an analysis of correlation between NPT and CDA provocation. Results After NPT, group B showed a larger change in VAS for rhinorrhea, sneezing, and itching (p < 0.01). After CDA challenge, the change in VAS for nasal obstruction was larger in group C (p < 0.05). Changes in acoustic parameters were larger in groups B and C after NPT (p < 0.01). After CDA challenge, the SCH + group (n = 49) showed a larger decrease of acoustic parameters than the SCH – group (n = 24; p < 0.01). Significant correlation was observed between the size of SPT and degree of change in VAS after NPT. No significant correlation was observed between NPT and CDA. Conclusion CDA could be an adjunct tool for evaluating NHR in patients with self-reported SCH.
Nasal provocation test
Nonallergic rhinitis
Itching
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We evaluated the effects of histamine and allergen provocations in the nasal mucosa.Nasal provocations were performed with extracts of histamine, Dermatophagoides pteronyssinus (Dp) and mixed grass pollen (Mg) in patients with perennial and seasonal allergic rhinitis and in healthy subjects. Nasal airway resistance (NAR), the amount of secretions, and the number of sneezes were recorded and evaluated.Regarding NAR, histamine provocation resulted in a significant difference compared to Dp provocation, but the difference was not significant when compared to Mg provocation. Only associated antigen provocation caused a significant increase in secretion. No significantly different effect on sneezing was detected between allergens and histamine. Considering total scores, histamine did not cause an increase in nasal reactivity in healthy subjects. A significant but slight difference was found between allergens and histamine in terms of nasal hyperreactivity in patients with allergic rhinitis.As there is a weakly significant difference between allergens and histamine in terms of nasal hyperreactivity in patients with allergic rhinitis, histamine provocation can be used in conditions where allergen provocation is not available.
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Various kinds of diagnostic procedures for allergic rhinitis are available, including careful history taking, physical examination, PNS x-ray, eosinophil in nasal secretion, blood eosinophil count, serum IgE level, skin test, nasal provocation test, RAST and MAST. Among these, careful history taking and skin test have important role in diagnosing the allergic rhinitis. To evaluate the diagnostic significance of nasal provocation test in allergic rhinitis, a clinical study was done in allergic rhinitis patients. The results were as follows; In control group, provocation rate to positive skin allergen was none. House dust and mite revealed the highest provocation rate to positive skin allergen. In the group of positive nasal provocation test, eosinophil in nasal secretion and blood eosinophil count were markedly increased. The positive provocation rate was correlated with degree of positive skin reaction. The provocation reaction after hyposensitization was markedly reduced.
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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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Nasal provocation test
Etiology
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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.
Rhinomanometry
Nasal provocation test
Nasal allergy
Rhinology
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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.
Rhinomanometry
Nasal provocation test
Nasal allergy
Allergic conjunctivitis
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