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Wise et al.

Page 154

The standard recommendation for the treatment of PFAS has been elimination of the offending food. Patients should be counseled on the risk for systemic and anaphylactic reactions. Patients with a history of systemic or anaphylactic reactions should be provided with an epinephrine autoinjector. The proteins responsible for PFAS are often labile and may be denatured by heat. The denatured proteins are typically not cross-reactive with the pollen IgE. Therefore, pollen-associated foods may become edible when heated. In 1 study, food challenges were performed with cooked apple, carrot, or celery in patients with atopic dermatitis and birch pollen allergy who had OAS and dermatologic symptoms upon ingestion of the raw foods. Cooked versions of the offending foods did not cause oral allergy symptoms. 1922 However, some patients did manifest a late eczematous skin reaction, which was likely T-cell–mediated (Table X.E-2). There is also 1 RCT in a group of 30 patients evaluating the use of an antihistamine to reduce PFAS symptoms, which demonstrated a clinically significant reduction in allergy symptoms compared to placebo when ingesting offending foods. 1923 The antihistamine used in this study, astemizole, has been removed from the market due to QT interval prolongation on electrocardiogram. There have been several studies evaluating the effect of targeted immunotherapy for pollen allergy at reducing PFAS symptoms. The results are mixed. Several small cohort studies and RCTs have shown an increased tolerance to the offending food when patients are treated with pollen specific immunotherapy. 1916,1924-1926 However, 1 RCT failed to demonstrate any improved tolerance to apple in birch allergic patients treated with birch specific immunotherapy compared to placebo. 1921 One study evaluating the persistence of tolerance for apple after birch immunotherapy demonstrated that some patients had an increased apple tolerance for up to 30 months after immunotherapy. However, there was no statistically significant difference between the immunotherapy and control groups. 1927 Immunotherapy is not currently recommended for the sole purpose of treating PFAS. Patients receiving immunotherapy for the treatment of pollen allergies should be counseled on the potential but unsubstantiated benefit for improved food tolerance. • Aggregate Grade of Evidence: B (Level 2b: 8 studies; Level 4: 1 study; Table X.E-2). In children, adenoid hypertrophy (AH) and AR may exhibit similar symptoms including nasal obstruction and rhinorrhea. The potential relationship between AR and AH is explored in this section. Adenoid enlargement most commonly begins during infancy; it continues through the first 5 to 6 years of life and involutes with puberty. 1930,1931 Symptomatic AH affects an unknown percentage of children and may contribute to a range of symptoms including nasal obstruction, nasal drainage, sleep disturbance, increased episodes of rhinosinusitis, increased lower respiratory tract infections, worsened asthma, and Eustachian tube dysfunction. 1930,1932

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X.F. Adenoid hypertrophy

Case series evaluating the relationship between AH and allergic sensitization fall into 2 main categories: (1) cohorts of children with allergic conditions assessed for AH; or (2) children

Int Forum Allergy Rhinol . Author manuscript; available in PMC 2020 June 10.