Definition, diagnostic criteria and treatment recommendations of allergic pharyngitis
(1) Definition of allergic pharyngitis: there is no universally accepted definition of AP. Drawing on the formulation of the pathogenesis of AP by Jing-Ying Ye et al. and the definition of allergic rhinitis, taking into account the characteristics of submucosal nerve inflammation and increased sensitivity after pharyngeal mucosal injury, combined with preliminary observations. In this paper, we tentatively concluded that AP is a chronic inflammatory reactive disease of the pharyngeal mucosa, mucosal lymphoid tissues and nerve fibers caused by IgE-mediated mediator release after exposure to allergens in atopic individuals, with the participation of multiple immunoreactive cells and cytokines, etc.
(2), clinical features and diagnostic criteria of allergic pharyngitis
Medical history: seasonal rhythms may be present
Allergens: the same as allergic inflammation in other parts of the respiratory tract, allergens mainly include pollen, house dust wax, mold spores, animal dander and other inhalant allergens, chemicals and irritants from the workplace, biological agents (insulin, allergen infused blood products, etc.), drugs, insect storage injuries, animal antiserum, food allergens, etc. can cause allergic reactions.
Course: The course of the disease is related to the time of consultation and the time of misdiagnosis. As in allergic rhinitis, the pathological phase of allergic pharyngitis should also exist with a staging of rapid-onset phase, late-onset phase and the mildest inflammatory persistence. Therefore, the cough in AP should be acute in onset, paroxysmal, and persistent if the allergens persist. In addition, mucosal damage due to allergic inflammation and submucosal neuroinflammation with a lymphoepithelial system response can lead to persistent mucosal inflammation. This cough can therefore manifest itself as acute, subacute and chronic cough.
Secondary symptoms: foreign body sensation in the pharynx, hoarseness, pharyngeal swelling, sore throat; AP is accompanied by a pronounced pharyngeal itch that is often masked by coughing symptoms, which may seem like a brush stroke or anthroposis.
The main signs: pale pharyngeal mucosa; watery and moist surface; light lymphatic follicular hyperplasia in the posterior pharyngeal wall, thickened lateral pharyngeal cords, edema of the uvula, and dental indentation on the lateral edge of the tongue (swelling of the tongue body). Lymphatic follicular hyperplasia of the posterior pharyngeal wall is common to most chronic pharyngitis, but those caused by allergic reactions have widespread swelling of the pharyngeal mucosa, a pale mucosal color, and in most patients, dental indentation on the lateral border of the tongue is evident.
Atopic constitution: concomitant or previous allergic rhinitis, allergic asthma, urticaria, allergic conjunctivitis.
Ancillary tests: skin allergen prick test, serum specific IgE test, pharyngeal mucosal allergen provocation test (there is no reference standard and literature for allergic pharyngitis provocation test, based on bronchial provocation test, nasal mucosal provocation test and conjunctival provocation test, pharyngeal mucosal provocation test is theoretically feasible, but needs to be developed and refined).
With reference to the diagnostic criteria of allergic rhinitis and previous literature reports, this paper summarizes the clinical features of AP as follows: (1) main symptoms: itchy throat, irritating, paroxysmal dry cough; (2) main signs: pale pharyngeal mucosa; sprinkled, moist surface; light lymphatic follicular hyperplasia in the posterior pharyngeal wall, thickened lateral pharyngeal cords, tooth indentation on the lateral edge of the tongue (swelling); (3) laboratory tests: skin prick te test (skin prick teat, SPT) (+) or specific IgE (+).
Diagnostic criteria: For those who meet the above (1)+(3) or (1)+(2)+(3), the diagnosis can be established. If only (1)+(2) are present, the diagnosis is considered to be suspected. The following diseases need to be excluded before the diagnosis can be established.
A, foreign body or tumor in the larynx.
B. Asthma exacerbation in patients with asthma. (Note: Considering that AP and allergic asthma can be co-morbid, those who still have itchy throat and cough after asthma control are considered to be co-morbid with AP)
C. Chest imaging reveals cough-related disease. (Note: routine chest radiographs are required to rule out lower airway disorders).
D. Nasal-sinus patients with existing allergic or non-allergic inflammatory disease (Note: postnasal drip due to rhinosinusitis should be considered and ruled out).
E. Gastro-esophageal-pharyngeal reflux disease (Note: Mostly reflux esophagitis with burning sensation of foreign body in the pharynx and burning sensation behind the sternum requires monitoring of the pH of the esophageal inlet and is treated mainly by acid production in the gastroenterology department).
F. Post-infectious cough (history of upper respiratory tract infection at the beginning of the illness, cough still persists after the symptoms disappear in the acute phase, as a continuation of cough in respiratory tract infection).
(3), Allergic pharyngitis symptom score and grading
Since the main discomfort of AP that affects the quality of life and health is itching and cough, the degree of illness is based on the visual analogue scale (VAS) of the severity of itching and cough.
Itching
Level: 0 1 2 3 4 5 6 7 8 9 10 (0 for the worst 10)
Coughing
Degree: 0 1 2 3 4 5 6 7 8 9 10 (the worst 10 is 0)
Grading: based on the results of a previous clinical observation study [5], the suggested criteria for grading are: mild (VAS: 1-3 points) moderate (VAS: 4-6 points), and severe (VAS: 7-10). In essence, most of those who seek medical attention are moderate to severe patients, and patients tend to tolerate treatment when it reaches mildness and no longer seek medical attention. (Note: The scoring of the gradation is based on the higher of the two symptom scores, for example, if the throat itch is 3 and the cough is 4, it is moderate.)
(4). Principles of treatment and grading of allergic pharyngitis
AP is often misdiagnosed and mistreated in clinical practice. There is a lack of standardized and unified treatment criteria for AP, and the treatment varies between different literatures [. The appropriateness of direct application of nasal hormones (ryanodine or colecalciferol) to the pharynx by Wu et al. is debatable. In this paper, we propose the use of combination medications for AP with stepwise treatment by combining the therapeutic use mentioned in the literature, the pathological mechanism of type I metaplasia, the principles of medication for allergic rhinitis, the treatment plan for Cheng Lei allergic laryngitis and the recommendations for the treatment of post-infectious cough. The drug content is as follows.
A. H1 antihistamines: second-generation oral H1 antihistamines without sedative effects are used. In particular, new H1 antihistamines with strong anti-metabolic effects (levocetirizine, desloratadine, olopatadine, etc.) can be used as the drug of choice for this disease, and the course of treatment is generally ≥ 3 weeks.
B, anti-leukotriene drugs: leukotriene receptor antagonists ( montelukast, pramlintide, etc.) can be the first choice for this disease, the course of treatment is generally ≥ 3 weeks.
C. Glucocorticoids: Glucocorticoids can block the occurrence and development of allergic reactions from multiple links and have strong anti-inflammatory and anti-edema effects. Local (pramipexole) nebulized inhalation therapy is used. Systemic administration is not recommended.
D, honey and coffee: honey and coffee in the appropriate ratio (70g instant coffee to 500g honey) dissolved with 20.8g of honey and 2.9g of coffee each time, drinking, three times a day [18], the literature shows similar effects to glucocorticoids.
E. Mast cell stabilizers: chromogranins prevent mast cell degranulation and reduce the release of inflammatory mediators such as histamine, but have a slow onset of action and are best used as prophylactic therapy.
F, specific immunotherapy: similar to allergic rhinitis, sublingual specific immunotherapy can improve the efficiency of mite allergy pharyngitis treatment.
G. Cough suppressants: The efficacy of central and peripheral cough suppressants on the cough symptoms of this disease needs to be evaluated, and their application is not recommended.
H. Chinese medicine treatment: Treatment was administered according to the theory of Chinese medicine identification, as described in the Chinese medicine literature.
Treatment principles: This paper, combined with the results of previous studies, recommends the use of a combination of drugs in a stepwise treatment.
Mild: simple antihistamine or antileukotriene or honey with coffee.
Moderate: simple antihistamine + antileukotriene; or combined honey plus coffee.
Severe: antihistamine + antileukotriene alone + glucocorticoid (pramipexole) nebulized inhalation, or combined with honey plus coffee.
Note: When montelukast is used in combination with antihistamines, the overall anti-inflammatory effect is superior to that of either class of drugs alone.
Discussion of the clinical management of allergic pharyngitis