Memorandum by the Royal National Throat
Nose and Ear Hospital (RNTNE)
The RNTNE hospital is the national centre for
ENT, treating annually some 60,000 patients, referred locally
and from all over the UK. It is recognised internationally as
a centre of excellence.
Allergy is a form of dysregulated immunity such
that antibodies of the IgE class are formed against harmless molecules
(allergens) eg house dust mite faecal proteins, grass pollen and
cat dander. Subsequent allergen contact causes a reaction involving
mast cell degranulation and release of powerful mediators resulting
in eosinophilic inflammation.
Several thousand allergic individuals are seen
at RNTNE, predominantly with rhinitis, ie inflammation of the
nasal lining. The prevalence of allergic rhinitis has quadrupled
since the mid 20th century and now affects one in four persons
in the UK. The prevalence is continuing to increase in many parts
of the world. The reasons for this are uncertain—the hygiene
hypothesis may explain early onset rhinitis, but is unlikely to
account for its later development. Other possible factors include
pollution, diet and persistent infection and need investigation.
Rhinitis, which can be allergic or non-allergic,
ranges in severity from mild intermittent symptoms of rhinorrhoea,
itch, sneeze and nasal blocking to severe, persistent problems
with marked effects on quality of life, greater than those attributable
to mild or moderate asthma. Secondary effects of rhinitis include
development or exacerbation of asthma, sinusitis, otitis media
with effusion, pharyngitis, sleep problems, and vocal dysfunction.
At RNTNE these severe forms of rhinitis form the major part of
those seen by the Allergy service led by Dr Glenis Scadding.
Using medical treatment, including allergen
avoidance, the need for surgery in conditions such as rhinosinusitis,
nasal polyposis and otitis media with effusion has been considerably
decreased and quality of life has been improved for sufferers.
A beneficial effect of upper respiratory tract therapy upon concomitant
asthma has been noted.
If it were possible to improve diagnosis
and treatment of rhinitis in its early stages the need for these
patients to be seen in secondary care could probably be reduced.
GOVERNMENT ADVICE
The setting up of asthma clinics with standardised
management in primary care is an undoubted success but does not
include allergen recognition nor rhinitis management. Unfortunately
rhinitis is often trivialised or overlooked, misdiagnosed and
mistreated. Rhinitis is present in about 80 per cent of asthmatics
and contributes to airways hyper-reactivity, with retrospective
studies demonstrating significant benefit such as reduced A&E
visits and hospitalisation from rhinitis therapy. A recent survey
of General Practitioners with an interest in airways diseases
(General Practitioners in Airways Group, GPIAG members) showed
that few knew the symptoms of rhinitis, very few were aware of
tests to substantiate a diagnosis of allergic rhinitis or were
capable of treating it adequately. GPs should have the recognition
and therapy of rhinitis added to their supervision of asthma patients.
Another reason to improve allergic rhinitis
care is the possibility of its progression to asthma. This is
preventable in children by appropriate specific subcutaneous immunotherapy
(SCIT). Recently sublingual immunotherapy (SLIT) has been shown
to be of proven benefit for rhinitis in a Cochrane meta-analysis.
Preliminary results suggest that this form of treatment may also
prevent disease progression as well as reducing symptoms and the
need for other medication. There is an urgent need for large well-controlled
studies to validate this, to examine the doses of allergen needed
and to look at pharmaco-economic implications since this form
of immunotherapy is safer and more convenient—it can be
carried out by the patient at home after initial dosing in a setting
with resuscitatory facilities.
A further area of interest and promise is the
interaction of infection, particularly with rhinoviruses, and
allergy. The combination of allergic sensitisation, allergen exposure
plus a rhinoviral cold result in a twenty fold risk of a child
being hospitalised for asthma. Similar disease exacerbation of
nasal polyposis occurs with viral colds suggesting synergy between
two different inflammatory processes which requires further study.
REFERENCES [NOT
PRINTED].
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