Diagnostic evaluation of food-related allergic diseases

John Eckman1, Sarbjit S Saini1 and Robert G Hamilton

Abstract
Food allergy is a serious and potentially life-threatening problem for an estimated 6% of children and 3.7% of adults. This review examines the diagnostic process that begins with a patient's history and physical examination. If the suspicion of IgE-mediated food allergy is compelling based on the history, skin and serology tests are routinely performed to provide confirmation for the presence of food-specific IgE antibody. In selected cases, a provocation challenge may be required as a definitive or gold standard reference test for confirmation of IgE mediated reactions to food. Variables that influence the accuracy of each of the diagnostic algorithm phases are discussed. The clinical significance of food allergen-specific IgE antibody cross-reactivity and IgE antibody epitope mapping of food allergens is overviewed. The advantages and limitations of the various diagnostic procedures are examined with an emphasis on future trends in technology and reagents.

Introduction
Approximately 6% of children and 3.7% of adults experience IgE-mediated allergic symptoms following the ingestion of food. This contrasts with approximately 20% of the population that alters their diet for a perceived adverse reaction to food. The allergist has the challenge of accurately identifying immunologically and non-immunologically-mediated reactions in the setting of this perception using information provided by the patient's history, skin and serology testing for food-specific IgE and food challenges.

A number of general issues must be considered when reviewing studies on the diagnosis of food allergy. These considerations include the characteristics of the patientpopulation in individual studies, the instrumentation and interpretation of allergen-specific IgE skin and serology testing and variations in food challenge protocols. This review examines the diagnostic process that begins with a patient's history and physical examination. We will overview considerations involved in skin testing and then focus on specific IgE testing, which has become of paramount importance in both diagnosing and following the natural history of food allergy. We highlight potential problems with the "gold standard" of food allergy diagnosis, the double-blinded, placebo-controlled food challenge.

We then review the importance of considering cross-reactivity in the interpretation of skin testing and specific-IgE testing while discussing new technologies that may help decipher the degree of cross-reactivity. Finally, we mention the experimental studies of food-allergen epitope mapping in predicting the natural history of milk and egg allergy.

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Diseases of the salivary glands in infants and adolescents

Maik Ellies, Rainer Laskawi

Abstract
Background: Diseases of the salivary glands are rare in infants and children (with the exception of diseases such as parotitis epidemica and cytomegaly) and the therapeutic regimen differs from that in adults. It is therefore all the more important to gain exact and extensive insight into general and special aspects of pathological changes of the salivary glands in these age groups. Etiology and pathogenesis of these entities is still not yet fully known for the age group in question so that general rules for treatment, based on clinical experience, cannot be given, particularly in view of the small number of cases of the different diseases. Swellings of the salivary glands may be caused by acute and chronic inflammatory processes, by autoimmune diseases, by duct translocation due to sialolithiasis, and by tumors of varying dignity. Clinical examination and diagnosis has also to differentiate between salivary gland cysts and inflammation or tumors.

Conclusion: Salivary gland diseases are rare in childhood and adolescence. Their pattern of incidence differs very much from that of adults. Acute and chronic sialadenitis not responding to conservative treatment requires an appropriate surgical approach. The rareness of salivary gland tumors is particularly true for the malignant parotid tumors which are more frequent in juvenile patients, a fact that has to be considered in diagnosis and therapy.

Introduction
Diseases of the salivary glands are rare in infants and children (with the exception of diseases such as parotitis epidemica and cytomegaly) and the therapeutic regimen differs from that in adults. It is therefore all the more important to gain exact and extensive insight into general and special aspects of pathological changes of the salivary glands in these age groups. Previous studies have dealt with the clinical distribution pattern of the various pathological entities in infants and older children.

According to these studies, important pathologies in these age groups are acute and chronic sialadenitis (with special regard to chronic recurrent parotitis) and secondary inflammation associated with sialolithiasis. The etiology and pathogenesis of these entities in young patients, however, are still not yet sufficiently understood, so that therapeutic strategies based on extensive clinical experience cannot be defined, particularly in view of the small number of patients in the relevant age groups. The acute forms of sialadenitis are mainly caused by viral or bacterial infections. The predominant cause of parotid swelling in infancy is parotitis epidemica.

This disease has its peak incidence between the ages of 2 and 14. Acute inflammation of the parotid gland, with evidence of Staphylococcus aureus, is often seen in neonates and in children with an underlying systemic disease accompanied by fever, dehydration, immunosuppression and general morbidity. Acute inflammation of the submandibular gland, as opposed to that of the parotid is usually due to a congenital anomaly of a salivary duct or an excretory duct obstruction. Reports on sialolithiasis in infants and adolescents, however, are very scarce and are mostly presented as rarities in clinical case reports. For chronic sialadenitis the predominant etiological factors are secretion disorders and immunological reactions. The pathogenesis of chronic recurrent parotitis has still not been completely elucidated and is, next to mumps, the most frequent sialadenitis in infancy.

Neoplastic changes are very rare in children and adolescents, compared to salivary gland inflammations. Their annual incidence in all juvenile age groups is 1 to 2 tumor cases in 100,000 persons. According to Eneroth salivary gland tumors make up 0.3% of all human tumors, and less than 10% of all juvenile head and neck tumors are located in the salivary glands. Only 1% of all head and neck tumors originate in the salivary glands, regardless of patient age. Not only makes this low incidence the establishment of a generally applicable therapeutic regime difficult; this task is not made easier by the circumstance that not more than 5% of all salivary gland tumors are found in the age group of up to 16 years. As a consequence therapies very often lean on experience gained in the last decades from long-term studies for the treatment of adult patients. Primary dysgenetic, and secondary, acquired salivary gland cysts, and other malformations of the salivary glands have to be distinguished early and without doubt from specific benign and, above all, malignant lesions by pathohistological examination.

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Non-allergic rhinitis: a case report and review

Cyrus H Nozad, L Madison Michael, D Betty Lew, Christie F Michael

Abstract
Rhinitis is characterized by rhinorrhea, sneezing, nasal congestion, nasal itch and/or postnasal drip. Often the first step in arriving at a diagnosis is to exclude or diagnose sensitivity to inhalant allergens. Non-allergic rhinitis (NAR) comprises multiple distinct conditions that may even co-exist with allergic rhinitis (AR). They may differ in their presentation and treatment. As well, the pathogenesis of NAR is not clearly elucidated and likely varied. There are many conditions that can have similar presentations to NAR or AR, including nasal polyps, anatomical/mechanical factors, autoimmune diseases, metabolic conditions, genetic conditions and immunodeficiency.

Here we present a case of a rare condition initially diagnosed and treated as typical allergic rhinitis vs. vasomotor rhinitis, but found to be something much more serious. This case illustrates the importance of maintaining an appropriate differential diagnosis for a complaint routinely seen as mundane. The case presentation is followed by a review of the potential causes and pathogenesis of NAR.

Introduction
The term rhinitis can be used to describe many distinct entities with varying pathogeneses, despite similar presentations. Generally, rhinitis is considered allergic if significant inhalant allergy is diagnosed and is considered non-allergic when symptomatology is perennial or periodic and not IgE mediated. Thus non-allergic rhinitis (NAR) comprises a mixed bag of conditions ranging from vasomotor rhinitis (VMR) to hormonally induced rhinitis.

Overall, rhinitis results in significant cost to the world population. In 2002, the direct and indirect costs for allergic rhinitis (AR) were estimated to be $7.3 billion and $4.28 billion, respectively. Given that an estimated 1 in 3 patients with rhinitis are diagnosed with NAR, with 19 million people in the United States alone, it is reasonable to conclude that NAR also results in a significant economic burden.

NAR is a condition primarily seen in adulthood with 70% of cases developing after the age of 20. There is a greater prevalence among females compared to males, and the overall prevalence of NAR in industrialized countries has ranged from 20-40%. The following case presentation is an example of a patient with typical NAR symptoms who fits the epidemiological profile, but who presented atypically, failed to respond to standard therapy and was subsequently found to have a much more serious underlying condition.

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Acute mastoiditis: A one year study in the pediatric hospital of Cairo university

Mosaad Abdel-Aziz, Hassan El-Hoshy

Abstract
Background: Acute mastoiditis is a serious complication of acute otitis media especially in the pediatric age group. This study reports the authors experience in the treatment of children admitted with acute mastoiditis to the Pediatric Hospital of Cairo University throughout the year 2007, also we aimed to evaluate our current management of this serious disease.

Methods: Nineteen children were included in this study, 11 females and 8 males, their ages ranged from 9 months to 11 years. All children were treated with intravenous antibiotic on initial admission, myringotomy was considered for cases that did not respond to medical treatment for 48 hours, while cortical mastoidectomy (with myringotomy) was reserved for cases that presented initially with subperiosteal abscess with or without postauricular fistula, cases with intracranial complications and for cases that showed no response to myringotomy (after 48 hours). Follow up of the patients was carried out for at least 1 year.

Results: Medical management alone was enough in 5 cases (26%); all of them had erythematous tender mastoid on first presentation. Seven cases (37%) needed myringotomy; 2 of them showed no response and they needed cortical mastoidectomy and the other 5 cases responded well except for 1 case that developed post-auricular subperiosteal abscess 2 months later necessitating cortical mastoidectomy with no evidence of recurrence till the end of the follow-up period. Seven cases (37%) presented with subperiosteal abscess and they needed cortical mastoidectomy with myringotomy; they showed no recurrence till the end of the study.

Conclusion: Conservative management is an effective method in the treatment of non-complicated acute mastoiditis, but myringotomy should be considered if there is no response within 48 hours. Cortical mastoidectomy should be used in conjunction with the medical management in the treatment of complicated cases.

Background
Acute mastoiditis is a serious complication of acute otitis media (AOM). It is more common in the pediatric age group as most patients are younger than 4 years, this higher incidence in younger age group reflects the peak age for AOM, however its incidence has been decreased since the revolution of antibiotic therapy. Some recent literature indicated an increase of the disease incidence in last years especially in countries with less antibiotic prescription, while others reported that no increased incidence despite the national restriction guidelines of antibiotics prescription. The disease my cause significant and even life-threatening complications beyond the tympanomastoid system; including subperiosteal abscess, Bezolds abscess, facial paralysis, suppurative labyrinthitis, meningitis, epidural and subdural abscess, brain abscess, lateral sinus thrombophlebitis, and otitic hydrocephalus.

The treatment of acute mastoiditis is variable, ranging from conservative management in the form of parenteral antibiotic therapy to myringotomy (with or without ventilation tube placement) to a more aggressive intervention in the form of mastoidectomy. This study reports the authors experience in the treatment of children admitted with acute mastoiditis to the Pediatric Hospital of Cairo University throughout the year 2007, also we aimed to evaluate our current management of this serious disease in the pediatric population.

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Evaluation of young smokers and non-smokers with Electrogustometry and Contact Endoscopy
Pavlidis Pavlos, Nikolaidis Vasilios, Anogeianaki Antonia, Koutsonikolas Dimitrios, Kekes Georgios and Anogianakis Georgios

Abstract
Background: Smoking is the cause of inducing changes in taste functionality under conditions of chronic exposure. The objective of this study was to evaluate taste sensitivity in young smokers and non-smokers and identify any differences in the shape, density and vascularisation of the fungiform papillae (fPap) of their tongue.

Methods: Sixty-two male subjects who served in the Greek military forces were randomly chosen for this study. Thirty-four were non-smokers and 28 smokers. Smokers were chosen on the basis of their habit to hold the cigarette at the centre of their lips. Taste thresholds were measured with Electrogustometry (EGM). The morphology and density of the fungiform papillae (fPap) at the tip of the tongue were examined with Contact Endoscopy (CE).

Results: There was found statistically important difference (p < 0.05) between the taste thresholds of the two groups although not all smokers presented with elevated taste thresholds: Six of them (21%) had taste thresholds similar to those of non-smokers. Differences concerning the shape and the vessels of the fungiform papillae between the groups were also detected. Fewer and flatter fPap were found in 22 smokers (79%). Conclusion: The majority of smokers shown elevated taste thresholds in comparison to nonsmokers. Smoking is an important factor which can lead to decreased taste sensitivity. The combination of methods, such as EGM and CE, can provide useful information about the vascularisation of taste buds and their functional ability.

Background
Complete loss of taste is rather uncommon because the presence of four major afferent routes for taste provides substantial redundancy to the sensory communication for taste and a substantial back-up system in case of failure of any single nerve. There are two categories of taste measurement, whole mouth and regional tests. A preliminary evaluation of a patient suffering from taste disorders can be performed with the use of colourless solutions of sweet, bitter, sour and salt. More sophisticated is regional chemogustometry whereby chemicals are applied to part of the tongue usinga piece of filter paper or a cotton swab. Regional chemogustometry can also be performed using closed chambers cemented to the tongue.

The simplest regional test for evaluation of taste is EGM. EGM was introduced in the clinical assessment of taste sensitivity during the 1950s. Compared to tests based on chemical solutions, EGM is an efficient clinical tool, used in the evaluation of taste disorders caused by different factors such as middle-ear surgery, Bell's palsy, tumors, and tonsillectomy. Increased application of this method is due to its easiness, the short time required and its quantitative character. CE is a diagnostic technique suitable for head and neck screening. It was developed for observing cell construction in the epithelial surface. The first application of CE was in gynecology. The quality of the images and magnifications obtained with endoscopes, led to the application ofCE in otolaryngology. CE allows for both in vivo and in situ observations of pathology in the superficial layer of the tongue, nasal mucosa, vocal cords in laryngomicrosurgery and nasopharynx.

The effects of smoking on taste sensitivity and olfaction have been studied since the early 60's. However, up to day, only few experimental studies provide histological data about the effects of smoke on the size and shape of the tongue papillae. The aim of this study is to investigate if smokers and non-smokers differ in EGM thresholds on the anterior and posterior tongue and soft palate and if any observed difference, in EGM thresholds on the anterior tongue of smokers vs. non-smokers, can be attributed to a difference in the density or morphology of fungiform papillae at that site.

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