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AAOA SCOPE OF KNOWLEDGE: ALLERGY AND ASTHMA

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I Epidemiology

A. Prevalence

i Regional
ii Change Over Time

B. Populations at risk

i Genetic associations
ii Environmental associations

C. Socioeconomic impact of disease

i Direct cost
ii Indirect costs
iii Quality of life

II Science of the Sites of Allergic Inflammation

A. Anatomy, Histology, physiology, pathophysiology of:

i Nose and paranasal sinuses
ii Pharynx
iii Ear/Eustachian Tubes
iv Larynx/Trachea
v Lungs
vi Eye
vii Skin
viii Gastrointestinal tract

B. Basic physiology, pathophysiology, and principles of:

i Mucociliary function
ii Smell and taste
iii Auditory/vestibular function
iv Voice
v Respiratory function
vi Deglutition
vii Ocular protection mechanisms
- 1 Naso–lacrimal function
- 2 Conjunctival function
viii GI function

III Basic Science

A. Basic components, concepts and applications pertinent to Allergy:

i Immunology
- 1. Function
  - a. General aspects
    - i Recognition
    - ii Surveillance
    - iii Amplification
    - iv Memory
  - b. Triggers of the immune response
    - i Allergens, haptens, epitopes, parasites, macromolecules
  - c. Categories of response
    - i Innate
    - ii Adaptive
- 2. Components
  - a. Inflammatory cells
    - i Macrophages (APC)
    - ii Lymphoid
      - 1 T–cells
      - 2 B–Cells
      - 3 Null cells
    - iii Granulocytes
      - 1 Mast Cells/basophils
      - 2 Eosinophils
      - 3 Neutrophils
      - 4 Platelets
  - b. Immunoglobulins
    - i G
    - ii A
    - iii M
    - iv D
    - v E
  - c. Inflammatory mediators
    - i Cytokines
    - ii Chemokines
    - iii Vasoactive amines
    - iv Leukotrienes
    - v Prostaglandins
    - vi Complement
ii Endocrinology
iii Neurology
iv Molecular cell biology
v Genetics

B. Physiology and pathophysiology

i Immunology
- 1. Cellular communication
  - a. Direct contact
    - i Antigen specific
  - b. Cytokine/Chemokine mediated
    - i Non-antigen specific
- 2. Inflammatory pathways
  - a. Cellular
    - i Microphage
    - ii Granulocyte
      - 1 Mast Cell/Basophils
      - 2 Eosinophil
  - b Non-cellular
    - i Complement
    - ii Arachadonic Acid cascade
    - iii Other
- 3. Immune sensitization
  - a Memory
- 4. Hypersensitivity (Gel and Coombs)
  - a I
  - b II
  - c III
  - d IV
  - e V
  - f VI
ii Allergic response (Type I)
- 1 Allergy sensitization
  - a Antigen processing
  - b T-cell
  - c B-cell
  - d IgE
  - e Mast cell
- 2 Subsequent exposure—trigger
  - a Mast Cell
    - i Antigen crosslinking
    - ii Degranulation
      - 1 Preformed mediators
      - 2 Newly synthesized mediators
      - 3 Cytokines
  - b Early phase response
  - c Late phase response
    - i Cellular Components
  - d Priming
iii Microbiology
- 1 Parasitology
- 2 Bacteriology
- 3 Virology
- 4 Mycology
iv Endocrinology
v Neurology
vi Molecular cell biology
vii Genetics
viii Nutrition

IV Diseases, Disorders, and Conditions

A. Differential diagnosis of inflammatory disease:

i Nose/paranasal sinus
ii Otologic
iii Laryngopharyngeal
iv Tracheobronchial
v Thoracic/Pulmonary
vi Gastrointestinal
vii Ocular
viii Cutaneous

B. Immunologic disorders

i. Allergic diseases
- 1. Allergic Rhinitis
- 2. Allergic conjunctivitis
- 3. Otologic disease
  - a. Otitis media
  - b. Meniere’s
  - c. Otitis externa
  - d. Eustachian tube dysfunction
- 4. Asthma
- 5 Dermatitis
  - a. Eczema
  - b. Contact
  - c. Urticaria/Angioedema
- 6. Allergic laryngitis
- 7. Gastrointestinal
  - a. Eosinophilic esophagitis
ii Co-morbid conditions impacted by allergy
- 1. Rhinosinusitiss
- 2. Otitis media
- 3. Eustachian tube dysfunction
- 4. Disordered sleep
- 5. Laryngeal/pharyngeal/esophageal disorders
  - a. GERD
- 6. Asthma
iii Immunodeficiency
iv Autoimmune diseases

V Diagnostics and Assessment Procedures

A. History

i Symptoms
- 1. Onset, duration, severity
- 2. Triggers
- 3. Exacerbating or ameliorating factors
ii Exposures
- 1. Temporal relationships
  - a. Intermittent
  - b. Persistent
- 2. Identifiable antigen
  - a. Aeroantigens (Inhalants)
  - b. Ingestants
  - c. Contactants
  - d. Injectants
iii Co-morbid conditions
- 1. Rhinosinusitiss
- 2. Otitis media
- 3. Eustachian tube dysfunction
- 4. Disordered sleep
- 5. Laryngeal/pharyngeal/esophageal disorders
  - a. GERD
- 6. Asthma
- 7. Ocular
iv Family/childhood history

B. Physical examination

i Face
ii Ears
iii Nose/Paranasal sinues
iv Oro/Nasopharynx
v Laryngotracheal
vi Pulmonary
vii Skin

C. Adjunctive testing: Indications, limitations, and normal and pathologic findings:

i Ears
- 1. Audiovestibular testing
ii Nose
- 1. Acoustic rhinometry/rhinomanometry
- 2. Nasal cytology/biopsy
- 3. Nasal/paranasal sinus culture
- 4. Nasal endoscopy
- 5. Olfactory testing
- 6. Radiologic testing
iii Larynx
- 1. Laryngoscopy
iv Pulmonary
- 1. Pulmonary function testing
- 2. Radiologic testing
v Sleep
- 1. Polysomnography

D. Allergy testing:

- i Antigen selection
  - 1. Antigen characteristics
    - a. Aeroallergen physical characteristics
    - b. Biologic activity/potency
    - c. Antigen cross reactivity
    - d. Antigen extraction/standardization
  - 2. Aeroallergen distribution
    - a. Principles of distribution
    - b. Local and Regional differences
  - ii Aeroallergen tests
  - - 1. Expanded specific allergen testing
      - a. In vivo
        
        i Principles of in vivo testing
        
        1. Pathophysiology of the skin whealing response
        
        a. Immediate response
        
        b. Delayed response
        
        2. Factors that affect the skin whealing response
        
        ii Specific methodologies
        
        1. Percutaneous (Prick) testing
        
        a. Single percutaneous (prick) testing
        
        b. Multi percutaneous (prick) testing
        
        2. Intradermal testing
        
        a. Single intradermal testing
        
        b. Intradermal dilutional testing
        
        3. Blended techniques of in vivo testing
        
        4. Scratch testing (mentioned only for historical purposes)
        
        5. Provocation
      - b. In vitro
        
        i Principles of in vitro testing
        
        ii Methodologies
- 2. Principles of the allergen screen
  - iii Ingestants (Food Allergy)
    - 1. History
      - a. Food diary
      - b. Anaphylaxis
    - 2. Testing
  - iv Injectants
  - v Contactants
    - 1. Contact tests (patch)

E. Immunologic Evaluation (including rheumatologic)

- - i Humoral
  - ii Cellular

VI Allergy Treatment

A. Environmental control
B. Pharmacotherapy/pharmacology

- - i Antihistamines
  - ii Decongestants
  - iii Mast cell stabilizers
  - iv Mucolytics
  - v Leukotriene modifiers
  - vi Corticosteroids

C. Dietary control

D. Immunotherapy

- i. Desensitization
  - 1. Route of delivery
    - a. Subcutaneous
    - b. Mucosal (e.g., sublingual)
  - 2. Mechanism of action/li>
  - 3. Indications/contraindications
  - 4. Antigen dosing
    - a. Starting dose
    - b. Escalation
    - c. Maintenance
    - d Withdrawal
  - 5. Mixing of treatment vial
  - 6. Duration of therapy
  - 7. Outcomes of immunotherapy
- ii Monoclonal antibody

VII Allergy Emergencies

A. Epidemiology

i Risk factors
ii Recognition
iii Differential diagnosis

B. Management

i High-risk population recognition
ii Preparation
iii Prevention
iii Intervention

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February 22-24 | Dallas, TX
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September 14-16 | Philadelphia, PA
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* Adapted from Marple, BF, et al. “American Academy of Otolaryngic Allergy CME Report: Allergy, Scope of Knowledge.” Otolaryngology—Head and Neck Surgery, 136(1): 8-10, 2007 Jan

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