Diagnostic approach to occupational rhinitis: the role of nasal provocation tests

Occupational Rhinitis: An Update

PURPOSE OF REVIEW

Occupational rhinitis is an underdiagnosed disease with significant morbidity and implications in the workplace. Multiple factors associated with this disease continue to pose a challenge to investigators. This review aims to summarize recent literature in occupational rhinitis, including classifications, pathogenesis, diagnosis, and treatment, as well as the impact of occupational rhinitis on individuals. Additionally, it identifies areas in need of further research and investigation.

RECENT FINDINGS

We highlight current research on the association between occupational rhinitis and occupational asthma and the role of immunotherapy in this disease. Discussion includes the impact of social trends on workers and the wider consequences of occupational rhinitis including decreased work productivity, absenteeism, and socioeconomic burden. Occupational rhinitis remains a challenging disease entity due to the numerous potential causative factors, reduced recognition, morbidity in asthma, and therapeutic limitations. Additional research is needed to better identify disease predictors and develop effective management strategies.

International consensus statement on allergy and rhinology: Allergic rhinitis - 2023

BACKGROUND

In the 5 years that have passed since the publication of the 2018 International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis (ICAR-Allergic Rhinitis 2018), the literature has expanded substantially. The ICAR-Allergic Rhinitis 2023 update presents 144 individual topics on allergic rhinitis (AR), expanded by over 40 topics from the 2018 document. Originally presented topics from 2018 have also been reviewed and updated. The executive summary highlights key evidence-based findings and recommendation from the full document.

METHODS

ICAR-Allergic Rhinitis 2023 employed established evidence-based review with recommendation (EBRR) methodology to individually evaluate each topic. Stepwise iterative peer review and consensus was performed for each topic. The final document was then collated and includes the results of this work.

RESULTS

ICAR-Allergic Rhinitis 2023 includes 10 major content areas and 144 individual topics related to AR. For a substantial proportion of topics included, an aggregate grade of evidence is presented, which is determined by collating the levels of evidence for each available study identified in the literature. For topics in which a diagnostic or therapeutic intervention is considered, a recommendation summary is presented, which considers the aggregate grade of evidence, benefit, harm, and cost.

CONCLUSION

The ICAR-Allergic Rhinitis 2023 update provides a comprehensive evaluation of AR and the currently available evidence. It is this evidence that contributes to our current knowledge base and recommendations for patient evaluation and treatment.

Occupational IgE-mediated psyllium allergy in contemporary gluten-free and vegan baking: A case of allergic rhinitis

Psyllium (from Plantago ovata; ispaghula) is used as a dietary supplement and is supplied in the form of husk, granules, capsules, or powder. Consumers using psyllium-containing laxatives, healthcare workers handling these, and pharmaceutical workers in laxative-manufacturing plants are known to be at risk of sensitization and subsequent rhinitis, asthma, contact urticaria, and even anaphylaxis. To our knowledge, the case we present here is the first of baker's immunoglobulin E (IgE)-mediated occupational allergy due to psyllium exposure. Our patient, a 24-year-old female baker with no previous allergies, was referred to our clinic with suspected occupational rhinitis. After 1 year of baking with cereal flour or gluten-free flour-mix, she began to suffer from rhino-conjunctival symptoms during workdays. Skin prick tests with agents from the patient's workplace revealed allergies not only to wheat and rye flours but also to psyllium, with a remarkable 10 mm wheal. Subsequently, nasal provocation tests confirmed occupational allergic rhinitis to psyllium. We also found work-related sensitization to buckwheat, which she used in gluten-free baking. Due to the increased prevalence of celiac disease and the popularity of gluten-free and vegan food, psyllium has recently become a common ingredient in baking, used as a substitute for gluten or eggs. Bakers handle allergens such as these in high concentrations and this may lie behind the emergence of respiratory and dermal symptoms. It is essential to consider new or recenlty introduced materials as possible allergens if it is suspected that a baker has work-related respiratory or allergic symptoms.

Work-Related Upper-Airway Disorders

Work-related rhinitis and laryngeal disorders are common and can significantly contribute to work absences and presenteeism. Each can cause respiratory symptoms that may be misdiagnosed as asthma symptoms, and each may occur as an isolated disorder or may also accompany asthma. Suspicion of these disorders and correct management require a careful medical and occupational history. Investigations for work-related rhinitis include examination of the nose, allergy skin tests, and in some cases, monitoring of peak inspiratory nasal flows at work and off work, or specific challenge tests. Work-related laryngeal disorders require assistance from an otolaryngologist and speech language pathologist.