Otolaryngic Allergy



FIGURE 8.1 The Development of the Immune Cells.

BFU, Burst-forming unit; BM, basophil mast cell; CFU, colony-forming unit; E, erythroid; Eo, eosinophil; GM, granulocyte-macrophage; Ig, immunoglobulin; MEG, megakaryocyte; NK, natural killer; TCR, T-cell receptor. (From Flint PW, Haughey BH, Lund VJ, et al. Cummings Otolaryngology—Head and Neck Surgery. 6th ed. Philadelphia, PA: Saunders; 2015, fig. 38-1.)



• Class II: immunocompetent antigen-presenting cells



HLA-DR


HLA-DQ


HLA-DP

Major Histocompatibility Complex (Fig. 8.3)



• Class I: all nucleated cells


• Class II: antigen-presenting cells



Macrophage


Dendritic cells


B cells

Complement System (Fig. 8.4)



• Classic pathway


• Lectin pathway


• Alternative pathway

Cytokines (Table 8.1)



• Broad category of small proteins important in cell signaling

Chemokines (Table 8.2)



• Small proteins important in signaling chemotaxis


• Four categories: CXC, CC, CX3C, and CX

Cell Adhesion (Fig. 8.5)



• Intercellular adhesion molecule (ICAM)-1


• ICAM-2


• E-selectin


• P-selectin


• Vascular cellular adhesion molecule (VCAM)

Allergic Triggers: Categories



1. Inhalants


2. Ingestions


3. Injectables


4. Contactants

Stages of Development of an Allergy



• Early response: minutes after exposure antigen



Primary mediator is histamine


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FIGURE 8.2 Domain Structure of Various Antibody Classes.

 (From Krouse JH. Introduction to allergy. In: Krouse JH, Derebery MJ, Chadwick SJ, eds. Managing the Allergic Patient. 1st ed. Philadelphia, PA: Saunders Elsevier; 2008. Originally reproduced from Holgate ST. Allergy. 2nd ed. London: Mosby/Elsevier; 2001:245, fig. 16.4.)

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FIGURE 8.3 Antigen Processing and Presentation.

The antigen undergoes hydrolytic cleavage within antigen-presenting cells, and the resultant oligopeptides are loaded on the antigen-binding grooves of major histocompatibility complex (MHC) molecules and are expressed at the cell surface. (From Flint PW, Haughey BH, Lund VJ, et al. Cummings Otolaryngology—Head and Neck Surgery. 6th ed. Philadelphia, PA: Saunders; 2015, fig. 38-2.)

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FIGURE 8.4 Complement Pathways.

Three pathways of the complement system. B, Factor B; D, factor D; MASP, MBL-associated serine proteases; MBL, mannan-binding lectin. (From Flint PW, Haughey BH, Lund VJ, et al. Cummings Otolaryngology—Head and Neck Surgery. 6th ed. Philadelphia, PA: Saunders; 2015.)


Table 8.1


Cytokines


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BAFF, B-lymphocyte–activating factor belonging to the TNF family; CFU, colony-forming unit; CSF, colony-stimulating factor; DC, dendritic cells; G, granulocyte; GM, granulocyte-macrophage; IFN, interferon; Ig, immunoglobulin; IL, interleukin; LT, lymphotoxin; M, macrophage; MHC, major histocompatibility complex; mRNA, messenger RNA; NK, natural killer; OPGL, osteoprotegerin ligand; SCF, stem cell factor; TGF, transforming growth factor; TH, helper T; TNF, tumor necrosis factor, Treg, regulatory T cells; TSLP, thymic stromal lymphopoietin.



From Flint PW, Haughey BH, Lund VJ, et al. Cummings Otolaryngology—Head and Neck Surgery. 6th ed. Philadelphia, PA: Saunders; 2015, table 38-1.



Table 8.2


Chemokines


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CCL, CC ligand; CK, chemokine; CXCL, CXC ligand; GRO, growth-related oncogene; HCC, human CC chemokine; IFN, interferon; IL, interleukin; MCP, monocyte chemoattractant protein; MGSA, melanoma growth stimulatory activity; MIP, macrophage inflammatory protein; MPIF, myeloid progenitor inhibitory factor; NK, natural killer; SCM, single C motif.


From Flint PW, Haughey BH, Lund VJ, et al. Cummings Otolaryngology—Head and Neck Surgery. 6th ed. Philadelphia, PA: Saunders; 2015, table 38-2.


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FIGURE 8.5 Cellular Adhesion and Recruitment.

GM-CSF, Granulocyte-macrophage colony-stimulating factor; ICAM, intercellular adhesion molecule; IL, interleukin; LTB4, leukotriene B4; PAF, platelet-activating factor; VCAM, vascular cellular adhesion molecule. (From Flint PW, Haughey BH, Lund VJ, et al. Cummings Otolaryngology—Head and Neck Surgery. 6th ed. Philadelphia, PA: Saunders; 2015, fig. 38-4; and Mygind N, Dahl R, Pedersen S, Thestrup-Pedersen K, eds. Essential Allergy. 2nd ed. Oxford: Blackwell Scientific Publications: 1996.)


Symptoms: largely nasal symptoms, including rhinorrhea, sneezing, itching, and congestion, as well as other symptoms, including tearing, wheezing, and, potentially, laryngospasm and bronchospasm


• Late response: hours after exposure to antigen



Mediators: leukotrienes and eosinophils


Symptoms: congestion, increased rhinorrhea, and wheezing

Types of Hypersensitivities (Gell and Coombs Classification)



1. Type I: immediate/anaphylaxis (IgE)


2. Type II: cytotoxic (IgG, IgM)


3. Type III: immune complex (IgG, IgM, IgA)


4. Type IV: cell mediated (T cells)

Type I: Causes of Anaphylaxis



• Inhalants


• Foods


• Drugs


• Insect stings

Type I: Anaphylaxis Symptoms



• Upper respiratory: sneezing, itching, rhinorrhea, and congestion


• Lower respiratory: cough, bronchospasm, and wheezing


• Skin: urticarial, angioedema, itching, and whealing


• Systemic: hypotension, tachycardia, and feelings of impending doom



Type I: Anaphylaxis—Mechanism



• Cross linking of IgE on mast cells


• Degranulation of mast cells


• Release of histamine

Mast Cell Degranulation



• Vasodilation


• Increase capillary permeability


• Bronchoconstriction


• Tissue edema

Type II: Cytotoxic Reaction—Mechanism



• IgG or IgM mediated


• Antibody reaction with antigens on the cell surface


• Activation of complement

Type II: Cytotoxic Reaction—Examples



• Hemolytic anemia


• Transfusion reaction


• Acute graft versus host disease


• Goodpasture syndrome


• Myasthenia gravis

Type III: Immune Complexes—Mechanism



• Immune complexes form (binding of antibody to a soluble antigen)


• Complexes deposit in tissues

Type III: Immune Complexes—Examples



• Serum sickness


• Poststreptococcal glomerulonephritis


• Angioedema


• Gastrointestinal intolerance

Type IV: Cell Mediated—Mechanism



• Direct T-cell activation


• Cell-mediated inflammation

Type IV: Cell Mediated—Examples



• Dermatitis


• Tuberculosis


• Sarcoidosis


• Candidiasis

Allergens


Perennial Allergens



• Mites


• Cockroach


• Cotton particles


• Human skin scales


• Animal dander


• Molds

Seasonal Allergies



• Trees: winter and spring


• Grasses: spring, summer, and fall


• Weeds: summer and fall

Pollen as Allergen



• Windborne


• Lightweight


• Large quantities


• Allergenic in sensitive individuals

History and Physical Exam of Patient with Allergies


History



• Particular emphasis on:



List of medications


Co-morbidities


Previous operations or treatments for allergy


Childhood history


Family history

Physical Exam



• Eyes: allergic “shiners” and long eyelashes


• Ears: erythema, postauricular fissures, desquamation of external auditory canal, tympanosclerosis, tympanic membrane retraction and/or perforation, and serous effusion


• Nose: discharge, edema of turbinates, polyps, and “allergic salute”


• Neck: lymphadenopathy


• Chest: wheezing


• Pharyngeal: high, narrow arched palate; lymphoid hyperplasia; cobblestoning of the posterior pharyngeal wall; hypertrophy of the lateral nasopharyngeal bands; chronic cough, and edema of the uvula and glottis

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Feb 18, 2017 | Posted by in OTOLARYNGOLOGY | Comments Off on Otolaryngic Allergy

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