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Home , Allergic rhinitis

Occupational Airways

Volume 7, Issue 1 April 2001

This Issue: Occupational · Occupational Rhinitis By Robert DeBernardo, MD, MBA, MPH · Summary Table of University of Connecticut Health Center, Division of Occupational & Environmental Medicine Number of Reported Cases of Selected Rhinitis may be caused or Respiratory Diseases exacerbated by exposures in the in CT by Year workplace similar to some skin and · Web-Sources lung diseases. In Connecticut, occupational rhinitis accounts for 4% of the respiratory diseases and disorders reported to the Depart- ments of Labor and Public Health.

Workers in service industries account for almost half of these

reports (48%), followed by workers in public administration (29%) and Occupational Airways is 1 produced by the manufacturing (16%). Occupa- Occupational Health & tional rhinitis is generally not less soluble gases such as Special Projects Program, considered a reason for removal ozone.4 , Division of Environmental Epidemiology & from the workplace, and is often , sneezing, itching, and Occupational Health, ignored or overlooked as an sometimes postnasal drainage Connecticut Department of . However, characterize rhinitis.2 Swelling of Public Health, 860/509-7744. the symptoms associated with the nasal turbinates can lead to rhinitis may affect a worker’s quality , obstruction of the sinus Editor/Coordinator: of life, contribute to lost time away ostea with secondary , or Juanita Estrada, Epidemiologist from work and result in decreased obstruction of the eustachian 2,3 productivity. More serious tubes with secondary otitis. Occupational Health Staff: consideration should be given to Obstruction of the nose leads to Carolyn Jean Webb, Director Marian Heyman, this disease condition. mouth breathing, thereby bypass- Epidemiologist/Industrial ing this filtering and humidification Hygienist The nose is the first defense of mechanism and resulting in

Contributor to the . It warms and increased risk of diseases of the this edition: humidifies inhaled air, filters many lower respiratory tract. is Robert DeBernardo, MD, and other large particles, often preceded by rhinitis. 2,3,5 MBA, MPH absorbs water-soluble gases such as sulfur dioxide, and filters some (Continued on page 2) PAGE 2 OCCUPATIONAL AIRWAYS VOLUME 7, ISSUE 1

Table 13,7 the upper and lower respiratory tract to grain 9 Some occupational irritants and allergens that dusts and endotoxin. may induce occupational rhinitis Frequently, chronic or recurrent rhinitis is Irritants Allergens due to or type I response. Occasionally, Ammonia Acid anhydrides a type IV or delayed response can be seen, particularly in association with Benzene Animal proteins sensitizing heavy metals such as chromium and Chlorine Colophony nickel. The type I or allergic response can be sub-classified into acute and late phase Detergents Cotton fibers response. The acute phase begins within 15 Formaldehyde Flour dust minutes of exposure to an allergenic substance. Mediators are released from the mast cells in Ozone Green tea the nasal mucosa giving rise to itching, Paint vapors Latex rhinorrhea and sneezing, mucosal turbinate swelling and congestion. If the exposure Sulfur dioxide Isocyanates ceases, the reaction usually subsides in a few Tobacco dust Permanent wave solution hours. With prolonged or high exposures, a late phase response may ensue. This response is Toluene Psyllium characterized by more marked mucosal edema Xylene Western red cedar and nasal obstruction. This reaction typically begins about 4 hours after the initial exposure and is associated with recruited inflammatory (Continued from page 1) cells () following the acute phase response. This reaction may take 72 hours or Irritant vs. Allergic Rhinitis longer to subside after exposure stops. Thus, in the occupational setting, one may not find the The major occupational risk factors of rhinitis improvement of symptoms on weekends that can be classified as irritant or immunologic one expects with work related conditions. induced (See Table 1). Rhinitis due to irritation Longer time frames such as a week’s vacation tends to clear soon after exposure stops. may be necessary to appreciate the work Symptoms from irritation can be difficult to association. Individuals with allergic rhinitis distinguish from an allergic or immunological usually react to multiple allergens, some at response. Clinically, the symptoms consist of home, some at work and some outdoors. This nasal burning or itching, rhinorrhea, and adds to the difficulty in making a work congestion. The distinction can be made either association. on the basis of identifying the offending agent or obtaining a smear of the nasal secretions, a Pathophysiology nasal mucosal brushing or a biopsy. Polymono- nuclear neutrophils (PMNs) have experimentally Since the epithelia in the nose and lower and clinically been shown to be associated with respiratory tract are similar, the types of irritation, while eosinophils are associated with reactions seen are similar, and rhinitis may be a a type I, allergic response. Lymphocytes are marker of what is occurring in the lower seen with a type IV or delayed hypersensitivity respiratory tract. The size of the particles may response or non-specific conditions. Graham et influence the nature and severity of the reaction al. demonstrated neutrophilia in nasal lavage at each site. Larger particles, those greater from experimental exposure to 0.5 ppm ozone than 5 microns, tend to be trapped in the upper 7 for 4 hours, and Frischer et al. confirmed this in respiratory tract and are more prone to cause 8 children exposed to ambient ozone. Clapp et rhinitis, whereas, smaller particles bypass this al. have shown a similar PMN response in both filtration and tend to trigger more asthma or VOLUME 7, ISSUE 1 OCCUPATIONAL AIRWAYS PAGE 3 hypersensitivity . However, with propensity to cause . high degrees of sensitization and because of are helpful for the sneezing and turbulent air flow, this distinction may become rhinorrhea of allergic rhinitis, but are less blurred. Desrosiers et al. experimentally effective on nasal congestion and will have little exposed eight subjects to a high molecular effect on other types of rhinitis. Because of the weight agent (flour and guar gum) and seven sedative effect, cautions need to be taken in subjects to a low molecular weight substance prescribing them. Even the so-called non- (isocyanate) on two occasions in a random sedating antihistamines can induce some fashion. On one occasion the subjects inhaled slowing of reflexes in certain individuals. through the nose, on the other occasion through Cromolyn is a good the mouth. Inhalation through either the nose or substitute for individuals with the early phase the mouth gave both nasal obstruction and allergic response. nasal sprays are very asthmatic responses.10 Since the nose is effective in decreasing the swollen turbinates exposed at higher concentrations, it is the first from most types of chronic rhinitis with area of the respiratory tract to react. congestion. Individuals with a history of long-term use should be followed carefully with Other nasal effects can occur based on toxic nasal exams since atrophic rhinitis and nasal mechanisms. Nasal septal septal perforation have been ulceration or perforation may be “Treatment of occupational reported. Although other caused by arsenic, calcium rhinitis should be approached steroidal side effects are rare, oxide, chromic acid, or copper similarly to that of other cataracts, glaucoma, and mild dust. Rhinorrhea associated occupational diseases and not adrenal suppression have with miosis, lacrimation and ignored. Chronic rhinitis should been reported with high doses salivation may occur from be considered as a precursor to and prolonged use of inhaled pesticides such as carbaryl, , and also may be malathion, parathion, phosdrin, lower …” associated with intranasal or pyrethrum. A blue-gray steroids. may be caused from silver. Numb mucous membranes may References 6 occur from DDT or rotenone. 1. Connecticut Department of Public Health, Division of Environmental Epidemiology and Occupational Health, Treatment Occupational Disease Surveillance Data, April 2001.

2. Dykewicz, M., et al., Diagnosis and management of Treatment of occupational rhinitis should be rhinitis: Complete guidelines of the joint task force on approached similarly to that of other practice parameters in allergy, asthma and . occupational diseases and not ignored. Chronic Ann Allergy Asthma Immunol, 1998. 81 (5 Pt 2): pp. 478- rhinitis should be considered as a precursor to 518. lower respiratory disease for the reasons 3. Slavin, R., Occupational and allergic rhinitis: Impact on mentioned above. Individuals with this condition worker productivity and safety. Allergy Asthma Proc, 1998. should be evaluated and followed carefully for 19 (5): pp. 277-84. evidence of asthma or hypersensitivity pneumonitis. The precipitating cause should be 4. Bernstein, L., et al., Asthma in the Workplace. 1999, New York - Basel: Marcel Dekker, Inc. p. 742. identified and exposure limited, preferably through engineering or administrative means. 5. Malo, J.L., et al., Prevalence and intensity of rhinocon- Respirators can be helpful, but are seldom junctivitis in subjects with occupational asthma. Eur Respir utilized for rhinitis alone. J, 1997. 10(7): pp. 1513-5.

6. Rosenstock, L. and M. Cullen, Clinical Occupational need to be based on the specific and Environmental Medicine. 1994, Philadelphia: W.B. diagnosis. Nasal should be Saunders Company. avoided in chronic rhinitis because of their (Continued on page 4) Division of Environmental Epidemiology & Occupational Health 410 Capitol Avenue, MS# 11OSP P.O. Box 340308 Hartford, CT 06134-0308

www.state.ct.us./dph John G. Rowland, Governor Joxel Garcia, MD, MBA, Commissioner TO:

(Continued from page 3) Summary of number of reported cases of

7. Graham, D., F. Henderson, and D. House, Neutrophil selected respiratory diseases in CT by year* CT DPH Occupational Disease Surveillance Data influx measured in nasal lavages of humans exposed to ozone. Arch Environ Health, 1988. 43(3): pp. 228-33. 1997 1998 1999 2000 ODSS Total** 8. Frischer, T.M., et al., Ambient ozone causes upper Asthma 27 19 24 27 223 airways in children. Am Rev Respir Dis, RADS*** 4 7 5 9 41 1993. 148(4 Pt 1): pp. 961-4. 1 3 1 0 13 9. Clapp, W.D., et al., The effects of inhalation of grain 3 7 6 7 117 dust extract and endotoxin on upper and lower airways. Asbestos- 2 10 9 4 122 Chest, 1993. 104(3): pp. 825-30. related pleural diseases 10. Desrosiers, M., et al., Nasal response in subjects undergoing challenges by inhaling occupational agents TOTAL 37 46 45 47 516 causing asthma through the nose and mouth. Allergy, * As of May 1, 2001. Data subject to change. ** Occupational Disease Surveillance System (ODSS) total since 1/1990 1998. 53(9): pp. 840-8. *** Reactive Airways Dysfunction Syndrome

Web-Sources

· Environmental Health in Family Medicine · Diagnosis and Management of Rhinitis: Complete Guidelines of the Joint Task A free online curriculum for teaching and learning Force on Practice Parameters in environmental health is available. The target Allergy, Asthma and Immunology audience includes residents in family medicine, pediatrics, and ob/gyn, practicing physicians, and These comprehensive guidelines include informa- other health professionals such as nurses, nurse tion on the clinical characteristics and diagnosis of practitioners and midwives. The case-based the various types of rhinitis, and recommendations modules cover six areas: lead, indoor air quality, on patient evaluation and disease management. outdoor air quality, pesticides, clusters-human health The document also stresses the importance of and water quality, and persistent organic pollutants. managing rhinitis when other disease conditions such as asthma, sinusitis and otitis media are www.ijc.org/boards/hptf/modules/content.html present. www.jcaai.org/Param/Rhinitis/Default.htm

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