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Nasal Provocation Test: How to Maximize Its Clinical Use?

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Nasal Provocation Test: How to Maximize Its Clinical Use? Review article Nasal provocation test: how to maximize its clinical use? Pongsakorn Tantilipikorn1, Pakit Vichyanond2 and Jean Silvain Lacroix3 Summary Introduction In order to diagnose allergic rhinitis (AR), Skin prick tests are recommended as the test of skin prick tests and serum specific IgE level choice for the diagnosis of allergic rhinitis (AR) are the most common used methods. But there due to its simplicity and reproducibility1. In cases are some conditions which the results of both when skin prick testing is not possible, such as methods do not correlate with the clinical inability to discontinue oral antiallergic drug, presentation of AR. Nasal provocation test is responsible practitioners may request for serum specific IgE as an alternative diagnostic test. the method of detecting local IgE at the shock Although skin tests and serum specific IgE organ. There are some variations of NPT in levels are the most reliable method for terms of dosage, allergen administration, determining specific hyperreactivity and evaluation and scoring system. This article sensitization, some discrepancies between serum summarized the usefulness of NPT, its specific IgE and local production specific IgE in indication and contraindication, dosage and the nasal mucosa have been observed2. For instillation techniques for allergens and example, positive skin tests and increased serum evaluation of outcome in the hope that if we level of specific IgE could be present in individuals who do not have any clinical can standardize the procedure and make it manifestations of allergic disease3. In contrast, easier to perform, NPT will be applied more in some patients with symptoms of AR do not have clinical practice. In addition normal values any positive skin tests or serum specific IgE. In among Asian ethnics are presented for such cases, the nasal provocation test (NPT) with appropriate interpretation of the test (Asian specific allergens could help in the establishment Pac J Allergy Immunol 2010;28:225-31) of reliable diagnosis of AR. Upon instilling the culprit allergen into the nasal cavities an allergic Key words: Allergic rhinitis, Diagnosis, Skin prick reaction is produced. Nasal provocation with test, Nasal provocation test, Peak nasal specific allergens is therefore considered the gold inspiratory flow, Acoustic rhinometry, standard for the diagnosis of AR. However, the Rhinomanometry NPT is not popular in clinical practice and is limited to tertiary care centers due to its complexity and inability to test more than one allergen at once. Moreover, results of skin prick tests and serum specific IgE levels could not be From the1Division of Rhinology & Allergy, correlated with NPT response in some Department of Otorhinolaryngology 4-6 2Division of Allergy & Clinical Immunology, investigations . Such drawback could be due to Department of Pediatrics, Faculty of Medicine Siriraj several reasons including the absence of Hospital , Mahidol University, Bangkok, Thailand., universally accepted method for NPT procedures. 3Rhinology-Olfactology Unit, University Hospital, In addition, the dosage of available provocation Geneva, Switzerland Corresponding author: Pongsakorn Tantilipikorn extracts may vary from one manufacturer to Email: [email protected] another. The scoring and recording criteria for Submitted date: 28/10/2010 defining positive NPT reaction are varied as well Accepted date: 17/11/2010 as the objective tools to measure the degree of nasal blockage. Currently, the widely accepted 225 Downloaded from http://apjai.digitaljournals.org. For personal use only. No other uses without permission. Asian Pac J Allergy Immunol 2010;28:225-31 criteria and techniques are adapted from European bronchial provocation test could not be safely Research Centers7. performed7. This article summarized the usefulness of 6. To confirm the role of a specific NPT, its indication and contraindication, dosage occupational agent15,16. and instillation techniques for allergens and 7. To study patho-physiology of allergic evaluation of outcome in the hope that if we can and non allergic reactions. standardize the procedure and make it easier to 8. For allergy research such as the perform, NPT will be applied more in clinical identification of new allergens or in the process practice. In addition normal values among Asian of evaluating new treatments for allergic ethnics are presented for appropriate interpretation conditions. of the test. Nevertheless, NPT is still not used as often as it Application of NPT and its importance could be in clinical practice. Skin Prick testing (SPT) is a standard testing NPT can be carried out safely with only a few for allergy diagnosis. Patients with larger wheal minor side effects. In order to avoid side effects, sizes from SPT are the ones with higher clinical NPT should not be performed during an correlation than those with smaller wheal sizes. exacerbation of the allergic condition or in Some patients with negative SPTs but with patients with a history of severe systemic positive intradermal tests (IDT) do not react to reactions (anaphylactic shock) to the particular allergen challenge. However, this has recently allergen of interest. been questioned by reports from Bodtger in 2006 To minimize false positive results, NPT should and Scadding in 2007. These authors reported that be avoided during an acute episode of rhinitis patients with ab definate allergic history but with since the increase vascular permeability and nasal negative skin tests could later become develop hyper-reactivity could alter the results 17. both positive skin test and NPT results 8,9. Such To minimize false negative results, certain patients with convincing allergic history could medications should be discontinued prior to NPT. make it difficult for clinicians to make a correct These are listed in Table 1. diagnosis during their first encounter with the patient. When there is doubt regarding the Principle of NPT diagnosis of nasal allergy, NPT could be a useful An allergen extract or other provocative agents is procedure for such patients10,11. Moreover, those instilled intranasally and the intensity of nasal with multiple sensitivities, i.e., those who react to symptoms such as itching, sneezing, rhinorrhea several allergens by skin testings, should be and nasal obstruction occurred are recorded. candidates for NPT in order to identify the culprit Distant symptoms, such as ocular and bronchial, allergens. Thus, such patients could be improved can be observed as well. The most important through environmental control measures and the outcome parameter is nasal obstruction which can physician could select appropriate allergens for be assessed by various methods such as peak allergen immunotherapy. nasal inspiratory flow (PNIF), rhinomanometry To date, the indications of NPT are: (RMM) or acoustic rhinometry (ARM) 19,20. 1. To confirm the diagnosis of allergic rhinitis in patients with negative allergy skin tests or without serum specific IgE. Table 1. Medications should be stopped 2. To confirm the clinical relevance of a before nasal provocation test. specific airborn allergen in patients with multiple sensitivities, as determined by skin testings12. Medications Duration to stop before nasal provocation test 3. To confirm nasal reactivity to specific Oral antihistamine 3 days 13 allergen before initiating immunotherapy . Intranasal corticosteroid 1 week7 to 6 weeks18 4. To assess the hyper-reactive state of non- Oral corticosteroid (greater than 2 weeks allergic rhinitis, using capsaicin- or 10 mg/day) 14 Topical nasal decongestant 1 day lipopolysaccharide (LPS)- challenge . Antihypertensive (ACE inhibitors) 3 weeks 5. To confirm the role of a specific allergen in patients with bronchial asthma in which 226 Downloaded from http://apjai.digitaljournals.org. For personal use only. No other uses without permission. Nasal provocation test Figure 1.Nasal provocation test and its response. SP = substance P, CGRP = Calcitonin-gene related peptide, Ach = Acetylcholine, VIP = Vasoactive intestinal peptide, NO = Nitric oxide, LT = Leukotriene. Regarding the immediate allergic response, the patency caused by the nasal cycle23. Nonspecific reactions observed in the ipsilateral nostril are nasal hyper-reactivity can also be investigated by increased nasal secretions (rhinorrhea), nasal challenging the nasal mucosa with isotonic saline blockage, and itching. Rhinorrhea and nasal sprayed into the wider side of the nose7. This obstruction are the main symptoms occurring on should be done as a baseline challenge. the contralateral side. This nasonasal reflex Allergens are available in various forms such involves ipsilateral activation of sensory nerves as solution, powder or pollen grains. Such and a bilateral parasympathetic reflex which can allergen can be administered into the nasal cavity be reduced by atropine-like drugs18,21,22. by several methods i.e. pump spray, paper disc, atomizer, pipettes, or dropper. Important issues Technique which have to be considered before delivering Nasal endoscopy and patient preparation allergen are adverse effects, ease of instillation, Intranasal examination with an endoscope is amount of solution per delivery and distribution the first necessary step to evaluate the pre-existing of mast cell in the nose. NPT can be performed condition or pathology within the nose. Some unilaterally or bilaterally depending on the conditions, such as nasal septal deviation, nasal method of allergen administration. Unilateral polyp or atrophic
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