Occupational Rhinitis

Occupational Rhinitis
Literature Reading
Presentan : Riska Adriana
Pembimbing : dr. Arif Dermawan, Mkes, Sp THT-KL
Dept. of Otorhinolaryngology Head & Neck Surgery

Hasan Sadikin General Hospital
Bandung 2012
Introduction
 Allergies in the workplace are a significant source of illness
 Occupational rhinitis and asthma being the commonest

occupational respiratory diseases in many industrialized
countries
 Allergic rhinitis have an increased risk of developing asthma
Airaksinen L, Tuomi T, Vanhanen M et all. Use of nasal provocation test in the diagnostics of occupational rhinitis.
Rhinology. 45, 40-46. Finland. 2007
 Identifying a workplace-related cause of disease is important
 Work-related rhinitis can be caused by any irritant exposure

at work
 According to the Act on Occupational Diseases in Finland,

occupational rhinitis is defined as work-related rhinitis,
caused by physical, chemical or biological factors
Airaksinen L, Tuomi T, Vanhanen M et all. Use of nasal provocation test in the diagnostics of occupational rhinitis. Rhinology. 45, 40-46.
Finland. 2007
MoscatoVandeplas, Van Wijk, et all. EAACI Taskforce on Occupational Rhinitis.2008. 63 : 969-980
Goal
we reviewed the most recently published rhinitis

guidelines to evaluate whether, and how, they have
considered the relationships between rhinitis and
work and summarized the specific literature on
occupational rhinitis
Moscato G, Siracusa A. Rhinitis Gidelines and Implications for Occupational Rhinitis. Allergy and Clinical
Immunology 2009, 9:110–115
Definition
an inflammatory disease of the nose, which is characterized

by intermittent or persistent symptoms (i.e. nasal congestion,
sneezing, rhinorrhea, and itching), and/or variable nasal
airflow limitation and/or hypersecretion due to causes and
conditions attributable to a particular work environment and
not to stimuli encountered outside the workplace
Immunology 2009, 9:110–115
Occupational rhinitis is defined as the episodic
work-related occurrence of sneezing, nasal
discharge, and nasal obstruction
Exposure to known respiratory irritants at the

workplace can result in increased nasal
hyperreactivity and can predispose the worker to
Castano R, Theriiault, G. Defiining and Classifying Occupational Rhinitis. The Journal of Laryngology & Otology, 1 of 6. 2006
Epidemiology
Surveys of workforces exposed to sensitizing agents indicate that
occupational rhinitis is two to four times more common than
occupational asthma
Occupational allergic diseases are common, and their occurrence

seems to be increasing, with an estimated prevalence of 5% to 15%
The level of exposure is the most important determinant of IgE-

mediated sensitization to occupational agents and occupational rhinitis

classification of rhinitis in the workplace
Occupational Rhinitis Classification
Castano R, Theriiault, G. Defiining and Classifying Occupational Rhinitis. The Journal of Laryngology & Otology, 1
of 6. 2006
Relationships with occupational asthma
 Occupational rhinitis tends to start earlier than occupational

asthma and is considered a marker of the likelihood of
developing occupational asthma
 A longitudinal study of patients seeking compensation for OR

from the Finnish Register of Occupational Diseases showed
an increased risk of asthma
Mechanism
 Occupational allergy can be stratified into high-molecular-weight-

allergen and low-molecular-weight-allergen mediate responses
 Different immunologic mechanisms mediate allergic reactivity to

these occupational allergens as highlighted in this issue by Talini et
al
 High-molecular-weight (HMW) allergens (typically proteins)

induce type I hypersensitivity responses or typical allergies by
inducing IgE antibodies
 Low-molecular-weight allergens (typically chemicals) induce
type 4 hypersensitivity reactions
 Patients with LMW-allergen-induced asthma are more likely

to demonstrate a late-phase airway response
Beezhold D, Sussman G. Occupational Allergies. Journal of Allergy. Volume 2011. Article ID 519329, 2
pages
Causative agents and typical exposures in
Patrick M, Slavin R. Occupational Rhinitis. Immunology and Allergic Clinics of North America. Volume 23. 2003.
• skin prick test Immunological tests
• serum allergen-specific IgE antibodies
assessment
• Nasal Challenge : Rhinomanometry, Nasal Provocation Test Physiological
• anterior rhinoscopy Nasal examination
• nasal endoscopy
• Onset of symptoms at work examination
• Improvement on weekends or vacations
• Recurrence of symptoms on reexposure
physical
• Nasal Symptoms History and
• Compliance with wearing gloves, masks, protective clothing
Diagnosis of occupational rhinitis
Diagnostic
algorithm
Rhinomanometry
Anterior rhinomanometry
 Advantages :
› the technique is easy to perform
› requires little patient
cooperation
› and is convenient for nasal
provocation
 Disadvantages :
› the probes distort the nasal
valves
› tactile sensation may result in
reflex changes
Posterior rhinomanometry
 expensive, and
 the procedure is difficult to
perform for some patients
 Nasal challenge can provide insights into the physical
characteristics of materials that may cause occupational
rhinitis
 Nasal resistance was defined as the ratio between

transnasal pressure and flow when the transnasal pressure
reached 1 cm H2O
 Resistance values were measured on patients who were seated

after a 30 minutes-period of adaptation to the conditions in
the testing room
Lancner Z, Pichon B, Pairon J,, et all. Usefulness of nasal provocation tests in occupational rhinitis. Rhinology, 47, 432-437, 2009
Nasal Provocation Test
• NPT is an fundamental diagnostic approach of

occupational Allergic Rhinitis (Loureiro, 2008)
 The NPT is an “in vivo” diagnostic method that mimics the
allergen natural exposure
 The NPT should only be performed after a pharmacological

washout period, namely H1-antihistamines,corticosteroids
 Most studies it is administered unilaterally by various

methods: spray (without propellant gas), instillation (pipette,
dropper, syringe) or application of small pieces of cotton or
paper discs with impregnated allergen
 Meter-dose pump sprays were used for administration in both sides of the nose
 The choice of the tests material was based on the patient’s history and skin-prick tests
 A patient was seated with a nose-clip during 10 minutes and without nose-clip during 3
minutes
 An isotonic saline solution challenge was realized first
 Dose-response curves were constructed by administering progressive doses of allergens
 Nasal resistances were measured at intervals of 15 minutes
 The ratios of the nasal airway resistances obtained after each dose of allergen over the
NAR obtained after isotonic saline solution ( NAR) were used to quantify the nasal
obstruction
Management
 avoidance of exposure and
 an adequate pharmacotherapy 
pharmacotherapy of occupational
rhinitis is similar to that of other types of
rhinitis
Immunology 2009, 9:110–115
 The second-generation nonsedating antihistamines loratadine,
fexofenadine, and ceterizine are better for treating patients
who need to be awake and alert at work
 Leukotriene modifiers have been shown to decrease nasal

congestion, sneezing, and rhinorrhea
 Saline nasal spray is useful for nonallergic rhinitis
 Topical glucocorticoid nasal sprays are effective for allergic

and nonallergic rhinitis
 Allergen immunotherapy generally is not recommended

Patrick M, Slavin R. Occupational Rhinitis. Immunology and Allergic Clinics of North America. Volume 23. 2003.
Socio-economic Impact
 productivity losses of approximately 1–4% resulting from

missed work time
 rhinitis is associated with substantial impairment in at work

performance, with estimates of lost productivity attributable
to reduced on the job effectiveness ranging from 11 to 40%
Moscato G, Siracusa A. Rhinitis Gidelines and Implications for Occupational Rhinitis. Allergy and Clinical Immunology 2009, 9:110–
115
Prevention
 Primary prevention
› Reducing or eliminating workplace exposure to sensitizing

agents  the most effective approach to minimize the
incidence of the disease
› Controlling exposure at the workplace
› Identification of susceptible workers

 Secondary prevention
› Medical surveillance programs :
 preplacement and periodic administration of a questionnaire

aimed at detecting work-related symptoms
 detection of sensitization to occupational agents
 investigation of possible asthma in all workers with
confirmed occupational rhinitis

Medico-legal aspects
 persistence of exposure to an agent causing allergic OR will

lead to worsening of the disease
 impaired on a permanent basis for the job that caused the

condition as well as for jobs with similar exposures
Policies governing compensation of Occupational

Rhinitis
Conclusion
 People spend more time at work and have greater exposure to

many new, potentially irritative and immunogenic substances,
such as chemicals (soaps, detergents, dyes, paints) and
biologic products (live animals, plants, fungi, pollen)
 The Occupational Safety and Health Administration (OSHA)

documents more than 500,000 potentially hazardous
chemicals in the workplace
 Occupational rhinitis is a frequent disease in many working
groups
 Several recently published rhinitis guidelines have considered

the relationships between rhinitis and work, and or
specifically described occupational rhinitis among the various
forms of rhinitis
TERIMA KASIH

Occupational Rhinitis - Riska

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Presentan : Riska Adriana

Pembimbing : dr. Arif Dermawan, Mkes, Sp THT-KL

Dept. of Otorhinolaryngology Head & Neck Surgery

 Allergies in the workplace are a significant source of illness

 Occupational rhinitis and asthma being the commonest

 Allergic rhinitis have an increased risk of developing asthma

 Work-related rhinitis can be caused by any irritant exposure

 According to the Act on Occupational Diseases in Finland,

we reviewed the most recently published rhinitis

an inflammatory disease of the nose, which is characterized

Exposure to known respiratory irritants at the

Occupational allergic diseases are common, and their occurrence

The level of exposure is the most important determinant of IgE-

MoscatoVandeplas, Van Wijk, et all. EAACI Taskforce on Occupational Rhinitis.2008. 63 : 969-980

 Occupational rhinitis tends to start earlier than occupational

 A longitudinal study of patients seeking compensation for OR

 Occupational allergy can be stratified into high-molecular-weight-

 Different immunologic mechanisms mediate allergic reactivity to

 High-molecular-weight (HMW) allergens (typically proteins)

 Patients with LMW-allergen-induced asthma are more likely

 Nasal resistance was defined as the ratio between

 Resistance values were measured on patients who were seated

• NPT is an fundamental diagnostic approach of

 The NPT should only be performed after a pharmacological

 Most studies it is administered unilaterally by various

 An isotonic saline solution challenge was realized first

 Dose-response curves were constructed by administering progressive doses of allergens

 Nasal resistances were measured at intervals of 15 minutes

 avoidance of exposure and

 Leukotriene modifiers have been shown to decrease nasal

 Saline nasal spray is useful for nonallergic rhinitis

 Topical glucocorticoid nasal sprays are effective for allergic

 Allergen immunotherapy generally is not recommended

 productivity losses of approximately 1–4% resulting from

 rhinitis is associated with substantial impairment in at work

› Reducing or eliminating workplace exposure to sensitizing

› Controlling exposure at the workplace

› Identification of susceptible workers

MoscatoVandeplas, Van Wijk, et all. EAACI Taskforce on Occupational Rhinitis.2008. 63 : 969-980

› Medical surveillance programs :

 preplacement and periodic administration of a questionnaire

MoscatoVandeplas, Van Wijk, et all. EAACI Taskforce on Occupational Rhinitis.2008. 63 : 969-980

 persistence of exposure to an agent causing allergic OR will

 impaired on a permanent basis for the job that caused the

Policies governing compensation of Occupational

 People spend more time at work and have greater exposure to

 The Occupational Safety and Health Administration (OSHA)

 Several recently published rhinitis guidelines have considered

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