BrazJOtorhinolaryngol.2016;82(6):621---622
www.bjorl.org
Brazilian
Journal
of
OTORHINOLARYNGOLOGY
EDITORIAL
Local
allergic
rhinitis
夽
Rinite
alérgica
local
Allergicrhinitis (AR),by definition, denotes an
inflamma-tionofthenasalmucosa,mediatedbyIgE,accompaniedby
symptomssuchasnasalcongestion,localitching,sneezing
andrhinorrhea.1
Therehave beentwolargestudiesassessingthe preva-lence of AR in Brazil. The first, through questionnaires appliedtochildrenandadolescents,revealedthatnasaland ocularsymptomsduringthepreviousyear,butwithoutthe presenceofanupperrespiratoryinfectionwerepresentin approximately12---15% ofsubjects.The second, alsousing questionnaires,butevaluatingallagerangeswitha diagno-sisofAR,foundaprevalenceof9%.2,3
Interestingly,thesestudiesinferthatthenasalsymptoms areallergicinnature,sincethepresenceofthespecificIgE hasnot beenproven, abasic assumptiontodetermine an allergicetiology(seedefinition).
In1859, CharlesHarrisonBlackleyappliedpollentohis nasalmucosaandthattriggered thesymptomsofrhinitis. Thus,thenasalchallengetest forthediagnosis ofallergic rhinitisappeared.4Othermethodsarealsousedtostudythis
classofantibodiessuchastheskinpricktestingandspecific serummeasurements(immunoenzymaticand immunofluo-rometricassays).2
Oneofthefirststudiestodemonstratetheproductionof specific IgEinnasalsecretiononly waspublishedin1975. Fourteenpatientswithclinicalsymptomssuggestive ofAR causedbydustmites,although withanegative radioaller-gosorbent test (RAST) were submitted to nasal challenge testingwiththisantigen.Allpatientshadnasalsymptoms, whichwereabsentinthecontrolgroup.5
Thisfactdemonstratesthattherearetwophenotypesof AR.Onerepresents‘‘classic’’patients,whoexhibita char-acteristicclinicalpicture,thepresenceofpositivesystemic specific IgE in skin and serumtests, and have a personal andfamilyhistoryofatopy.Theother phenotypecontains individuals who have symptoms only after contact with
夽
Pleasecitethisarticleas:MelloJuniorJF.Localallergicrhinitis.
BrazJOtorhinolaryngol.2016;82:621---2.
allergens,butnofamilyhistoryofatopyandpositivenasal provocationtestonlyfortheantigen.Theseindividualshave whatiscalledLocalAllergicRhinitis(LAR).6
TheprevalenceofLARisnotknown.Somestudiesshow thatover47%ofcasesofnoninfectious,non-allergicrhinitis maybearesultofspecificIgEproductionrestrictedtothe nasalmucosa.7 Being an unknown phenotype, it is
under-diagnosedsoonecanpotentiallyassumethattheprevalence ofanallergicetiologyinnasalsymptomsismuchhigherthan whatiscurrentlyproven.
Thereis verylittlein-depthmedicalliteratureonLAR; however,thequestionsofwhetherLARrepresentsapossible earlyonsetofARhasbeenaddressed.Follow-upofadultand adolescentpatientswithLARfor5yearsdidnotshowany differenceintheonsetofatopyin(6.25%)whencompared tocontrols(5.2%).8
Patients with LAR have the same classic symptoms of those with AR, such as sneezing, itching, nasal obstruc-tion and rhinorrhea.8 A study comparing patients with
AR and LAR also showed that both share a similar clini-calanddemographicphenotype.Theyoccurpreferentially in nonsmokers, female individuals who exhibit a severe persistent clinical picture, often with conjunctival and asthmasymptoms;thehousedustmite(Dermatophagoides pteronyssinus)isthemainassociatedagent.9
Inadditiontothedustmites,otherantigensare associ-atedwithLAR,suchaspollensandfungi,causingsymptoms inbothchildrenandadults.10,11
Froma pathophysiologicalpoint ofview, LARis similar to AR. An inflammatory infiltrate pattern with Th2 (IgE-mediatedclinicalpictures),immediatephasecharacterized bytheactivation andreleaseofbasophil mediatorsanda latephasewitheosinophilattractionandactivationcanbe observed.10
Regarding therapy, LAR patients respond well to both oral and topical medications. Additionally, they also show improvement with allergen-specific subcuta-neous immunotherapy, similarly to patients with AR. A pilot study with 20 patients with LAR sensitive to grasses were submitted to allergen-specific subcutaneous
http://dx.doi.org/10.1016/j.bjorl.2016.09.001
1808-8694/©2016Associac¸˜aoBrasileiradeOtorrinolaringologiaeCirurgiaC´ervico-Facial.PublishedbyElsevierEditoraLtda.Thisisanopen
622 EDITORIAL
immunotherapy. At the end of the study, the authors observed greater tolerance to the allergen and symptom reduction,aswellasdecreaseduseofrescuemedication.12
Currently,double-blindplacebo-controlledstudiesarebeing performedwithgrassandhousedustmiteantigens.7
The diagnosis of LARis corroborated bydemonstrating thepresenceofthenasalspecificIgEthroughnasal provoca-tiontestwithallergensorthelocalsynthesisofIgE,without thepresenceofsystemicatopy.7Thenasalsecretionlavage
is veryuseful toassess cellularity, presence of inflamma-torymediatorsandspecificIgE.7Thenasalchallengetesting
withallergensreproducesthe‘‘natural’’allergicreaction, demonstratingtheimmediateandlatephases,the sensitiza-tiontotheallergenanditsimportanceinsymptomonset.7
Inclinical practice,it is considered the gold standard for thediagnosisofbothARandLAR;however,itisnota rou-tinelyperformedtest,asitistime-consumingandrequires well-trainedstaff.7Therefore,therapiddevelopmentofan
inexpensivemethod for the determination of specific IgE in nasal secretionis important, so we can learn the true prevalenceofthisphenotypeandestablishthecorrectand appropriatediagnosisandtreatmentinourpatients.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
References
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JoãoFerreiradeMelloJunior
