Allergy Samples in a Lab

Allergic otitis should be approached the same as any other allergic disease using aggressive allergy therapy just as is done for allergic asthma and allergic rhinitis. Specifically, the allergy literature states that: “allergen specific immunotherapy and allergen reduction (avoidance) are the only interventions in allergic disease with the potential to reduce symptoms in the long term.” It should be noted that allergic medications including short term steroids and antihistamines have failed to cure OME patients as they seem to only help allergic rhinitis or acute asthma or dermatitis episodes. (See Conventional allergy treatment)

Current efforts to manage patients with chronic OME or to prevent the reccurrence through the use of medication has been a dismal failure. Both the American Academy of Pediatrics and American Academy of Otolaryngology (ENT) -Head and Neck Surgery recognize that prophylactic antibiotics are not effective. The use of antibiotics themselves to treat OME have been found to be no more effective than placebo. Certainly the placement of tympanostomy tubes is effective, although opposed on emotional grounds by the parents who raise legitimate concerns regarding anesthesia risks and cost. It should be recognized that published guidelines both in the United States and Europe state that it is essential to remove the fluid from the middle ear and return the hearing back to normal as soon as possible in a child who has had unilateral effusion for six months or bilateral effusion for more than three months.

The patient with allergic otitis i.e.; chronic effusion greater than two months, a chronically draining tube or perforation or mastoid cavity, or the patient who presents with conductive hearing loss, effusion and no history of otitis media after a school screening hearing test all should be considered as possibly having allergic otitis. Diagnosis is best done using intradermal testing. Prick testing will pick up only 43% of atopics as it is done at such low concentrations so as to function only as a screening test. RAST test has been found to identify 30-60% of atopics when dealing with allergic rhinitis which is a low level allergic disease. Allergic otitis similarly is a low level disease in that most of these patients have IgE’s below 100 (Hurst, Allergy 2000). Therefore if allergy is suspected and RAST is negative, intradermal testing must be pursued.

The majority of OME patients have been found to be positive to common inhalants including: dust and molds regardless of climate, time of year or country. These are best managed by appropriate immunotherapy as would be used for patients with allergic rhinitis or allergic asthma. Recurrence rates for OME using conventional tympanostomy tube treatment runs at 25% and recurrence rates using allergy immunotherapy has been less than 5%.

If the child has allergies to foods, as is often the case (Nsouli, 1986) (Hurst, Laryngoscope, 1996) then a 7 day elimination followed by a one day challenge diet should confirm that food and the food avoided. Dairy products, orange juice, eggs are the most frequent among infants.

Once the diagnosis of OME has been made it is essential to remove the fluid and place tympanostomy tubes when appropriate and accepted indicators have been met. Once that is done the tubes will provide 6-12 months of time before they are extruded and the fluid may recur. During this time appropriate allergy diagnosis can be made using intradermal testing according to AAOA guidelines and appropriate allergen avoidance, food elimination, and/or allergy immunotherapy can be instituted.

Successful management chronic otitis media with effusion depends upon physicians recognizing 1) that OME is a physical sign of allergy, 2) that it is predominantly the atopic patient who develops OME because of the unique response of the cells in their middle ear, and 3) understand that like any other allergic disease – only until the host child is identified and treated aggressively for his allergies will the disease resolve.

Successful management chronic otitis media with effusion depends upon physicians recognizing 1) that OME is a physical sign of allergy, 2) that it is predominantly the atopic patient who develops OME because of the unique response of the cells in their middle ear, and 3) understand that like any other allergic disease – only until the host child is identified and treated aggressively for his allergies will the disease resolve.

So exactly how do I diagnose and treat a patient?

1) Determine if the child is having episodes of recurrent acute otitis media.

This is usually an infant or toddler with one infection after another every 4 to 6 weeks but usually clears in between. Follow the guidelines of the American Academy of Otolaryngology – get hearing tested and a tympanogram. If frequency warrants – that is 6-10 infections in a year or persistant hearing loss than placement of tubes will reduce the number of infections by 80% and MOST IMPORTANTLY, restore hearing immediately.

2) Determine if the child is having chronic otitis media with effusion – OME

This is the child who has only occasional infectiols but in between the fluid in one or both ears does not clear. Tympanograms are FLAT and hearing loss is present. This child needs tubes first to MOST IMPORTANTLY, restore hearing immediately. Then you have time while the tubes stay in for a year to do the appropriate allergy testing and start allergy treatment.

  • Antihistamines, nasal steroid sprays, prednisone rarely work.
  • Before you can treat with allergy shots, you must be tested.

There are 3 ways to test for allergy: Prick tests, Blood test, and Skin tests.

Allergy Testing.

Demonstration of any relationship of otitis or sinusitis to allergy depends first on determining if the patient is “atopic” – the medical word for allergic. A clinical diagnosis of Type I hypersensitivity, or atopy, specifically requires the detection of allergen specific IgE antibodies by means of skin testing and/or in-vitro testing. The patient may or may not be symptomatic or allergic.[129] Intradermal tests use various delivery systems (scratch, prick, IDT) to introduce antigen into the skin. The resulting wheal or bump is assumed to represent the response of the patient to specific IgE.

The last 25 years have seen the advent of increasing standardization and quantification of allergy diagnostic testing based on the original works of Noon’s prick test[116] as described in 1910. Although prick test results correlate well with symptoms, it is recognized to be highly subjective, non-standardized and has low reproducibility.[113],[25] For patients with a low sensitivity disease like sinusitis or ear disease, intradermal skin tests may have the only positive results.[36]

Serial endpoint titration as used by Ear Nose and Throat Allergists has become the standard by which all new allergens are quantified at the National Institute of Health.[114] This form of Intradermal testing(IDT) is now the approved standard for diagnosing allergy as endorsed by the American Academy of Otolaryngologic Allergy and the American Academy of Otolaryngology Head and Neck Surgery. The validity of IDT and RAST/ELISA are is also certified by the American Medical Association, and the American Academy of Allergy, Asthma and Immunology.[7],[48] Thus both the definition of atopy as “the propensity of an individual to develop IgE antibodies” and the means of testing for allergy using either clinical or biologic measures have been refined to allow a more accurate diagnosis of the atopic patient. Reliable allergy evaluations can now be performed with established testing methods and materials offering high specificity and sensitivity in both clinical and histopathology studies.

During the past 60 years sixteen investigators have used intradermal skin testing (IDT) to evaluate their entire patient populations. They have demonstrated that allergy testing and treatment are very successful (70-100%) in treating children with chronic OME. In fact, there is not a single published paper which demonstrates anything to the contrary.

Summary: OME is clinically and immunologically a separate entity from acute OM. Conventional therapy with antibiotics has proven ineffective, yet is still maintained in the current management plan of most pediatricians.[166] Eventual treatment of persistent OME with myringotomy and placement of tympanostomy tubes, although required to return the ear to normal function, is fraught with complications and only temporarily resolves the problem in a significant percentage of patients. Conventional allergists do not appreciate the fact that the middle ear is an extension of the upper respiratory system and therefore have ignored this disease. Interdermal testing is the most accurate way to diagnose allergies in these children. Skin testing is necessary before treatment by allergy shots can be individualized. Allergy shots – immunotherapy – is the most effective long term treatment for chronic ear disease.

Successful management of chronic otitis media with effusion depends on physicians being willing to recognize that OME is a sign of allergy. They must recognize that in OME it is predominantly the allergic patient who develops OME because of the unique response of the cells in their middle ear to the stimulus of viral or bacterial infections. Like any other allergic disease, only until the host is identified as being atopic and treated aggressively for his/her allergies will the disease will resolve.