Positive allergen reaction in allergic and nonallergic rhinitis: a systematic review

Abstract

Background:The diagnosis of allergic rhinitis (AR) is based on cutaneous and serological assessment to determine immunoglobulin E (IgE)-mediated disease. However, discrepancies between these tests and nasal provocation exist. Patients diagnosed as non-allergic rhinitis (NAR) but with positive nasal allergen provocation test (NAPT) may represent a local allergic condition or entopy, still suitable to allergy interventions. The objective of this study was to determine the frequency of nasal reactivity toward allergens among AR and NAR patients, and to describe the diagnostic characteristics of NAPT methodologies.Methods: EMBASE (1947-) and Medline (1946-) were searched until December 8, 2015. A search strategy was used to identify studies on AR or NAR patients subjected to diagnostic local nasal provocation. All studies providing original NAPT data among the AR or NAR population were included. Meta-analysis of proportion data was presented as a weighted probability % (95% confidence interval [CI]). Results:The search yielded 4504 studies and 46 were included. The probability of nasal allergen reactivity for the AR population was 86.3% (95% CI, 84.4 to 88.1) and in NAR was 24.7% (95% CI, 22.3 to 27.2). Reactivity was high with pollen for both AR 97.1% (95% CI, 94.2 to 99.2) and NAR 47.5% (95% CI, 34.8 to 60.4), and lowest with dust for both AR 79.1% (95% CI, 76.4 to 81.6) and NAR 12.2% (95% CI, 9.9 to 14.7). NAPT yielded high positivity when defined by subjective end-points: AR 91.0% (95% CI, 86.6 to 94.8) and NAR 30.2% (95% CI, 22.9 to 37.9); and lower with objective endpoints: AR 80.8% (95% CI, 76.8 to 84.5) and NAR 14.1% (95% CI, 11.2 to 17.2). Conclusion:Local allergen reactivity is demonstrated in 26.5% of patients previously considered non-allergic. Similarly, AR, when defined by skin-prick test (SPT) or serum specific IgE (sIgE), may lead to 13.7% of patients with inaccurate allergen sensitization or non-allergic etiologies. C 2017 ARS-AAOA, LLC. How to Cite this Article: Hamizan AW, Rimmer J, Alvarado R, et al. Positive allergen reaction in allergic and nonallergic rhinitis: a systematic review. Int Forum Allergy Rhinol. 2017;7:868-877.

Central compartment atopic disease: prevalence of allergy and asthma compared with other subtypes of chronic rhinosinusitis with nasal polyps

“…Given the retrospective nature of this study, allergy testing was not available for all patients. However, not all patients with classic AR symptoms and inhalant triggers will have positive allergy testing . Patients with CRSwNP NOS were the least likely of the CRSwNP subtypes to have allergy testing performed (75 of 132, 56.8%).…”

Local allergic rhinitis: Implications for management

“…In the past years several publications have highlighted the importance of considering LAR as a major differential diagnosis in children, and the importance of evaluating the target organ by means of NAPT to rule out or confirm the diagnosis. In the systematic review mentioned above, nasal allergen reactivity in children under 16 years old with NAR was 16.1% (95% CI, 9.5‐24.0) …”

“…The mite D. pteronyssinus , has been identified as the main individual allergen inducing nasal allergic reactivity in both young adults and elderly patients with AR or LAR. Interestingly, allergic reactivity to the mould Alternaria alternata is more frequent in LAR subjects, whereas allergy to pollen and animal dander is more typical of AR individuals …”

“…NAPT is currently the gold standard for LAR diagnosis, along with the detection of sIgE in the nasal secretions or a positive basophil activation test (BAT) . NAPT has the capability of differentiate between allergic (AR and LAR) and non‐allergic individuals (healthy controls and NAR), as well as between relevant and no‐relevant allergen sensitisation in atopic subjects . Previous to NAPT a nasal challenge with saline is recommended to rule out non‐specific nasal hyperreactivity …”

The relationship between allergy and chronic rhinosinusitis

“…Furthermore, there is evidence that systemic allergy testing may not always reflect nasal pathophysiology. In a subset of patients, systemic allergy testing may be negative but locally‐present IgE in the sinonasal cavity may be present, a condition that has been referred to as local allergic rhinitis or “entopy.” To illustrate this concept, a systematic review by Hamizan et al compared local nasal allergen reactivity with systemic reactivity in rhinitis patients. They found local reactivity in 26.5% of patients previously considered non‐allergic.…”