Incorporating Allergy into the Busy Otolaryngology Practice
With an array of options for allergy testing and treatment, allergy services can be gradually incorporated into what you already offer your patients.
Matthew W. Ryan, MD, Michael P. Platt, MD, and Cecelia Damask, DO
Allergic rhinitis (AR) impacts 60 million Americans, ranking as the nation's sixth most common chronic condition. This upper airway inflammatory disease presents through various symptoms, including sneezing, nasal congestion, and itchy eyes. AR frequently accompanies other conditions that otolaryngologists treat and shares symptoms with numerous sinonasal conditions.
The American Board of Otolaryngology - Head and Neck Surgery includes allergy and immunology within the head and neck in the primary board certification process. Currently, there is a growing need for specialists to treat allergic conditions, and otolaryngologists are uniquely positioned to assess the presence of allergic disease in patients with upper respiratory tract symptoms. Incorporating allergy testing and immunotherapy into your practice allows you to provide comprehensive care to patients and, as an ancillary service, it can help build and expand your practice.
In Vitro Testing vs. Skin Testing
Allergy diagnosis begins with a comprehensive history and physical exam. Diagnostic testing to determine sensitization to allergens is one of the first services you can offer your patients. Allergy testing has several important roles: confirming the clinical diagnosis, identifying the patient’s relevant allergens to implement avoidance measures and selecting appropriate antigens at a safe starting dose for initiation of immunotherapy. The two main testing modalities utilized are allergen-specific Immunoglobulin E (IgE) in the serum (i.e., in vitro testing) and skin testing. An in vitro specific IgE test may be accomplished with a blood draw that is then sent to a laboratory. Some busy practices obtain Clinical Laboratory Improvement Amendments (CLIA) certification to perform their own in vitro specific IgE analysis from patient serum samples. In vitro testing is often used when patients cannot stop medications which block skin reactions (antihistamines), those with sensitive skin (dermatographism), or in younger patients.
Skin testing offers higher sensitivity and immediate results with a simple prick test using select allergen extracts. Plastic disposable multiprick devices are available to efficiently identify allergen-specific IgE causing mast cell degranulation as seen with the classic “wheal and flare” reaction. Intradermal skin testing is another technique which uses a small needle to inject diluted allergen into the dermis (i.e., an intradermal test), looking for a similar reaction.
Some practices may choose to incorporate a blended technique of both prick and intradermal tests, commonly known as “modified quantitative testing.” Allergy diagnostic testing provides the clinician with important information to aid in clinical decision making and is a cornerstone in the management of allergic disease. Most otolaryngology practices should be able to add some form of allergy diagnostic testing with minimal investment.
Immunotherapy for Long-Term Improvement
Patients with AR are treated with allergen avoidance and pharmacotherapy. However, allergen-specific immunotherapy is the only treatment that addresses the underlying immunologic mechanism in allergic disease. Successful immunotherapy decreases symptoms and the need for medications while improving disease-specific quality of life.1 Immunotherapy achieves these benefits via a variety of mechanisms: it reduces mast cell degranulation, induces the production of IgG4 “blocking antibody,” upregulates tolerogenic regulatory T cell populations, and reduces allergen-specific IgE over the long term. Comprehensive allergy care thus includes allergen-specific immunotherapy in addition to testing.
Immunotherapy Options for Your Practice
A variety of immunotherapy options are utilized in practice.1 The simplest method for allergen-specific immunotherapy is sublingual immunotherapy (SLIT) using FDA-approved sublingual tablets. These are currently available for the treatment of grass, ragweed, and dust mite allergy. Another option is SLIT utilizing a customized formulation of aqueous allergen extracts that is based upon clinical determination of a patient’s relevant allergen sensitivities. The advantage of this approach is that allergens other than the FDA-approved grass, ragweed, and dust mite can be treated off-label.
Although SLIT has many advantages, the mainstay of immunotherapy in the U.S. is subcutaneous injection immunotherapy (SCIT). SCIT has the longest track record of clinical use and has been demonstrated to be effective in multiple randomized placebo-controlled trials.2 SCIT is FDA-approved and covered by most health insurance plans. SLIT is utilized by many practices although there are out-of-pocket costs for aqueous SLIT preparation. FDA-approved SLIT tablets often require insurance authorization with possible higher co-pay costs.
Read the AAO-HNSF Clinical Practice Guideline (CPG): Immunotherapy for Inhalant Allergy for trustworthy, evidence-based recommendations regarding the management of inhaled allergies with immunotherapy and visit the Academy for physician and patient handouts, and other resources related to this CPG.
Are Allergy Services Right for Your Practice?
Otolaryngologists have a variety of reasons for incorporating comprehensive allergy care into their practices. Before initiating these services, a practice should consider its goals as well as the requirements for success. Is there a need for allergy services in the area? Will allergy care increase convenience for your patients? Will comprehensive care of nasal disease improve your patients’ outcomes? Do your partners agree about the importance of adding allergy? Will allergy care help build the practice without disrupting current referral patterns in your community?
Like any other decision involving the services offered by your practice, incorporating allergy care should be undertaken with a business plan in mind. The business plan should include tangible metrics of success, including monitoring and analyzing referral trends, financial impact, patient retention rates, and patient outcomes.
Planning for Allergy Care Services as a Business
The primary financial investment when starting an allergy practice is the cost of supplies. These include allergen extracts, syringes, testing devices, and emergency supplies in case of anaphylaxis treatment. Usually, existing personnel in a medical office are able take on the new roles required for allergy care as the practice grows. These roles include performance of allergy skin tests, preparation of testing and immunotherapy vials, and administration of injection immunotherapy. Medical assistants or nurses can perform these duties according to individual state regulations. Having a dedicated allergy staff can be helpful for efficient allergy care.
Office space for the allergy practice must also be considered. A location for the preparation of allergen extracts must comply with USP 797 regulations.3 A shared or dedicated clinical space is needed for skin testing and administering immunotherapy injections. Because SCIT carries with it a risk for anaphylaxis, a monitored location within the office will need to be designated for patient observation after injections are administered. A busy allergy practice may have a dedicated check-in desk for allergy patients, a separate waiting room for observation, an allergenic extract compounding area, and space for testing and treating multiple patients simultaneously.
Building a Suite of Comprehensive, Physician-Led Allergy Services
The physician is the leader of the allergy team and should be the content expert for allergy testing and treatment, management of allergy emergencies, regulatory and compliance statutes, proper billing and coding, and documentation. Allergy-specific CME offerings at the AAO-HNSF Annual Meeting and other societies are helpful to get started and stay current in practice. Allergen supply vendors are a good resource for identifying allergens in your region and purchasing supplies for starting an allergy practice.
With an array of options for allergy testing and treatment, allergy services can be gradually incorporated into what you already offer your patients. Many practitioners start slowly with in vitro testing and sublingual tablet prescriptions. As you and your staff learn more about allergy services and gain comfort in practice, you can expand to include skin testing, injection immunotherapy, and a full spectrum of allergy services.
References
1. Gurgel RK, Baroody FM, Damask CC, Mims J, Ishman SL, Baker DP Jr., Contrera KJ, Farid FS, Fornadley JA, Gardner, DD, Henry LR, Kim J, Levy JM, Reger CM, Ritz HJ, Stachler RJ, Valdez TA, Reyes J, Dhepyasuwan N. (2024), Clinical Practice Guideline: Immunotherapy for Inhalant Allergy. Otolaryngol Head Neck Surg, 2024 Mar; 170: S1-S42. https://doi.org/10.1002/ohn.648
2. Erekosima N, Suarez-Cuervo C, Ramanathan M, et al. Effectiveness of subcutaneous immunotherapy for allergic rhinoconjunctivitis and asthma: a systematic review. Laryngoscope. 2014 Mar;124(3):616-27
3. Lambert, A. “What Is USP 797 and How to Stay Compliant.” Wolters Kluwer Health: Expert Insights, 2020. https://www.wolterskluwer.com/en/expert-insights/what-is-usp-797-and-how-to-stay-compliant