Po PolskuAllergologic Laboratory Department of Maxillo-Facial Surgery, Military School of Medicine, Lodz, Poland
Published in: R. Spiewak (Editor): "Pollens and Pollinosis: Current Problems". Institute of Agricultural Medicine, Lublin (Poland) 1995, pages 73-77.
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According to the current definition, seasonal rhinitis is diagnosed when a patient has four basic complaints including nasal itch, sneezing - particularly more then five times in series, usually abundant watery or mucous rhinorrhea and periodic nasal blockage. The occurrence of these symptoms is related to the exposure or during provocative tests.
Seasonal rhinitis is synonymously described as hay rhinitis, June rhinitis, pollinosis or hay fever. However, when the problem is considered more extensively than it is enabled by otolaryngologic examination, patients suffering from these symptoms very frequently have complaints concerning many other organs. In addition, these symptoms are not always limited to the period of peak pollination of, for example, grass [3]. Thus, why we don't speak of multiorgan or systemic pollinosis? Or strictly speaking, why do we mention this so rarely or by way of digression? [10, 12] I think that medical education, intentionally limited to the definite organ (either the eye or the skin or the nose), does not befit to the problem created by pollen disease. Thus, although the symptoms of pollinosis create a cohesive multiorgan syndrome well correlating with the extent of the exposure, many textbooks formulate [7, 11, 13] and many specialists treat pollinosis, bronchial asthma or allergic conjunctivitis separately [1]. From the point of view of the "small" specialization, competence become of secondary importance. A pattern of dermatologist, who makes diagnosis of bronchial asthma based on the chest auscultation and spirogram assessment, or of allergologist-laryngologist, who additionally treats the skin and nose, is still disgraceful rather than advisable. It also happens that initially the patient has been treated by ophthalmologist [1] and then by rhinologist [8] exclusively symptomatically, and only following the occurrence of dyspnea the patient lands in pneumonologist in agreement with the typical allergic walk [4]. Natural course of the disease exposing mainly nasal complaints, and above mentioned differences in points of view certainly makes difficult general look or even holistic definition of the disease.
In the consulting room of the allergologist there appear patients hypersensitive to pollens in different stages and forms of the disease, in various seasons of the year and frequently with many problems at the same time. Life itself indicates that past isolationistic approach is archaic. Contemporary internists willingly examine the nose, while laryngologists - the bronchi. Thus, I think that the symptoms of conjunctivitis, air-derived urticaria, serous otitis media or bronchitis are not exactly coexisting with allergic rhinitis, but they constitute the essence of multiorgan ex definitione pollinosis. Werner and Jackson [13] as well as Davies [7] formulate the problem classically, i.e. they treat individual organs separately. However, some more recent reports seem to support my points of view [2, 6, 9, 10, 12].
The following arguments are in favour of the proposed casual approach. Among historical, but coming back again, arguments I would like to indicate tuberculosis. Treatment of tuberculosis pertaining to the throat or bowel is performed by phthisiologists. Next, elimination of pollens reduces all symptoms, while they are enhanced by the exposure to pollens; more and more frequently information on actual pollen grain concentrations put diagnosis on the right track. It should be pointed out that such a self-diagnosis in made more frequently by patients than by their physicians. It is known ex iuvantibus (based on the treatment) that specific immune therapy improves healt state not only in the nose, but also in the throat, eyes or bronchi. It also has well-known prophylactic action. In children specifically desensitized for allergic rhinitis bronchial asthma was found to develop in 1/4 of them only, while it developed in as many as 3/4 of children treated symptomatically only [2]. Symptomatic treatment should be combined with casual one. The former has rather organ-specialistic features, but the latter requires general approach and knowledge crossing the limits of up-to-date fields. Finally, irrespective of the organ stricken with specific or allergic inflammation, the mechanism of the disease is the same. This is supported by the results of skin tests (i.e. provocation of another organ!) in diagnostics of rhinitis. They are still more important than intranasal provocation's with the same allergens.
This discussion is not purely academic. The whole process of diagnostics, treatment and prophylaxis should be awaited to be charged with by the specialist in "the cause" and not by the specialist in "the organ"... The following arguments are in favour of this approach:
Therefore, I think it is time for breaking of barriers of specializations in organs, which are, in fact, fragmentary for the discussed allergic disease induced by exactly determined inflammatory factor in the established concentration and time, with its course according to one pathogenetic pattern, with common diagnostic methods and common casual treatment. As the disease prevalence in increasing, its targeted prophylaxis also necessitates solutions guided from one point of view.
Thus, what are the symptoms of pollinosis as I see them? According to my 25-year personal experience with 2000 consultations a year and base on current literature data, the following organs engaged in pollinosis can be specified:
Searching for these symptoms during history taking and physical examination is important for their finding because the patient yields to the "rule of specialization" as frequently as the physician and adjusts his or her report to physician's education. The presented list of the symptoms of pollinosis does not close the topic of this discussion. As results of up-to-date studies indicate, there still exist difficulties in their assessment.
Difficulties of the evaluation of subjective symptoms usually rely on misdiagnosis of viral and allergic or bacterial and allergic inflammations, which, as a rule, results in useless therapy with antibiotics. It should be hoped that progress in knowledge and education on allergic inflammatory proceses will improve solution of such dilemmas. Difficulties in the evaluation of objective symptoms of the disease are increased even further, because careful examination of the nose or ear on the one hand and completely competent chest auscultation on the other hand are difficult to combine by one person. Thus, it is a need for either formation of teams of specialists in several basic fields of medicine or education targeted to the disease in the aspect of individual organ specialization.
Evaluation of exposure symptoms, when not supported by palynologic data, also leads to errors. For example, May rhinitis is commonly thought to result from grass pollination, and not from birch pollination as it takes place in Poland [3]. Finally, unawareness or even ignorance of so-called cross-symptoms, particularly alimentary ones, is a problem. However, this requires more extensive argumentation. Among incorrectly diagnosed symptoms there is a syndrome of "idiopathic" pharyngitis (instead of throat allergy), psychogenic cough (instead of allergic bronchitis or episodic asthma) and so-called sinobronchial syndrome (instead of extrinsic nasosinobronchial allergy). As erroneous treatment results from incorrect diagnosis, resolved patients are met who have not lost their confidence in physicians saying "this is of nervous origin" or "this is due to dirty city air", and following correct diagnosis of multiorgan pollinosis they have rapidly been cured.
Sometimes incorrect way of medical thinking affects laboratory tests. At time it is not still evident that low total blood serum IgE level or "top" multiallergen tests do not exclude allergy. Finally, even IgE does not correlate well with clinical symptoms. Excessively trustful interpretation of results of so-called skin prick tests can be particularly dangerous. They usually disclose, irrespectively of the intensification of the reaction, mainly atopic diathesis, susceptibility to the disease, and not its existence. Provocative tests are always decisive.
Many persons - both patients and specialists - believe that polinosis appears in the period of exposure only. Meanwhile, in its latent period overt pollinosis can be induced by the contact with hay or pollen, so it permanently exists. Moreover, also in winter remnant symptoms - so-called extraseasonal pollinosis symptoms - can also be disclosed during careful examination. Among seasonal symptoms even episodic dyspnea is of particular importance. After all they always impose immune therapy.
Finally, two groups of patients should be mentioned. I think of small children and old people, who have pollinosis for the first time in their life. Both the groups deserve particular attention due to immunologic and therapeutic differences. During the treatment patients should be strictly observed. We all know the value of diagnosis ex iuvantibus. Even small local exacerbation during immune therapy is the next diagnostic and prognostic test, and each drug used locally is verified by the principle of elimination. Ineffectiveness of the treatment means an error - most frequently erroneous evaluation of disease symptoms. Maybe we were too trustful in computers... May be it is time to come back to old means (today we would say "algorithms") according to Orlowski and other old masters of medical art...
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