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Prevalence of autoimmune thyroid disease in chronic rhinitis.



Abstract

A retrospective, controlled study was undertaken to determine the prevalence of autoimmune thyroid disease in 111 adult patients with allergic (77) and nonallergic (34) rhinitis Rhinitis Definition

Rhinitis is inflammation of the mucous lining of the nose.
Description

Rhinitis is a nonspecific term that covers infections, allergies, and other disorders whose common feature is the location of their symptoms.
 seen in a private ENT/allergy practice in the lower Hudson Valley, New York. The control group consisted of 101 patients with no history of chronic rhinitis. Autoimmune thyroid disease was found in 10.4% of the allergic rhinitis group, 14.7% of the nonallergic rhinitis group, and 9.9% of controls, with a trend toward higher prevalence in the nonallergic rhinitis group compared with controls. No statistically significant association was noted between the 3 groups. The female-to-male ratio in the nonallergic rhinitis group was approximately twice as high as in the control group.

Introduction

As early as the 1960s, clinical observation suggested a higher prevalence of thyroid disease in atopic atopic /atop·ic/ (a-top´ik) (ah-top´ik)
1. ectopic.

2. pertaining to atopy; allergic.


atopic

1. displaced; ectopic.

2. pertaining to atopy.
 patients than in the general population. (1,2) Most of the recent work in this area has focused specifically on the relationship between autoimmune thyroid disease (AITD AITD Alone in the Dark (game)
AITD Autoimmune Thyroid Disease
AITD All Inclusive Trust Deed
AITD Australian Institute of Training and Development
) and allergic rhinitis (AR). (3) Amino et al reported that 42% of patients with Graves disease had allergies, compared with 32.6% of the control population. (4) Increased levels of immunoglobulin E and interleukin 13, characteristic of Th2 cell-mediated AR, have been found in patients with Graves disease. (5) Nakamura et al reported a familial, springtime occurrence of silent thyroiditis in only those family members who were allergic to Japanese cedar pollen. (6)

Considering the data linking these two entities, it is reasonable to expect that AITD would be more prevalent in the allergic population than in the nonallergic population. However, a study by Krouse and Krouse found the same prevalence of thyroid disease in allergic patients with positive results on skin testing and in controls with no history of chronic rhinitis (NR). (7) The investigators made no distinction between AITD and non-AITD, and they did not include in the analysis patients with chronic rhinitis of a nonallergic nature. (7)

This study is the first to investigate the association between AITD and chronic rhinitis by comparing the prevalence of AITD in three groups:

* Patients with a history of chronic rhinitis who tested positive for inhalant inhalant /in·hal·ant/ (in-hal´ant)
1. something meant to be inhaled; see inhalation (def. 3).

2. a class of psychoactive substances whose volatile vapors are subject to abuse.
 allergies on skin-prick testing (SPT (Sectors Per Track) The number of sectors in one track. ) or in vitro testing (AR group);

* Patients with chronic rhinitis who tested negative for inhalant allergies (NAR NAR National Association of REALTORS
NAR Nucleic Acids Research (journal)
NAR National Association of Rocketry
NAR Nationale Arbeidsraad (Dutch: National Labor Council; Brussels, Belgium) 
 group); and

* Control patients (NR group).

Patients and methods

A retrospective study was conducted of all patients aged 18 years and older who attended a community-based, private general otolaryngology and otolaryngic allergy practice from October to December 2005. An institutional review board was not available at this study location, but no data were used in the analysis that could be used to identify any individual patient. No procedures were performed unless they were part of the patient's routine care.

Information extracted from patients' charts included laboratory data and/or clinical data for AITD, nasal symptoms (congestion The condition of a network when there is not enough bandwidth to support the current traffic load.

congestion - When the offered load of a data communication path exceeds the capacity.
, rhinorrhea, sneezing To verbally tell somebody about a new and interesting Web site. See viral marketing. , postnasal drip, facial pressure, diminished sense of taste/smell), physical findings on anterior rhinoscopy or nasal endoscopy (pale mucosa, mucosal edema edema (ĭdē`mə), abnormal accumulation of fluid in the body tissues or in the body cavities causing swelling or distention of the affected parts. , thickened thick·en  
tr. & intr.v. thick·ened, thick·en·ing, thick·ens
1. To make or become thick or thicker: Thicken the sauce with cornstarch. The crowd thickened near the doorway.

2.
 mucus, polyps Polyps
A tumor with a small flap that attaches itself to the wall of various vascular organs such as the nose, uterus and rectum. Polyps bleed easily, and if they are suspected to be cancerous they should be surgically removed.
), and any results of allergy testing.

Patients who reported 2 or more nasal symptoms persisting for at least 3 months during the preceding year and who had one positive finding or more on nasal physical examination were included in the chronic rhinitis group. Only those who had undergone allergy testing (the vast majority) were included in the study. On the basis of allergy-testing results, patients were placed in either the AR or the NAR group.

For the purpose of this study, only immunoglobulin E-mediated inhalant allergies were used to differentiate these two groups. An SPT (with Multi-Test II [Lincoln Diagnostics, Inc., Decatur, Ill.]) for 30 allergens (dust, trees, grass, weeds, mold, and epidermals) was used, along with histamine as a positive control and 50% glycerin glycerin /glyc·er·in/ (-in) a clear, colorless, syrupy liquid used as a laxative, an osmotic diuretic to reduce intraocular pressure, a demulcent in cough preparations, and a humectant and solvent for drugs. Cf. glycerol.  as a negative control. Any positive result (wheal wheal (hwel) a localized area of edema on the body surface, often attended with severe itching and usually evanescent; it is the typical lesion of urticaria.

wheal
n.
 greater than 3 mm) placed that patient in the AR group. Patients who could not undergo SPT had in vitro testing (with ImmunoCAP [Phadia AB, Uppsala, Sweden]) for the same antigens. Anypositive results (class 1 or higher) placed the patient in the AR group. Patients who did not have a history of chronicnasal problems were placed in the NR group.

Patient data were stored in a spreadsheet format. Statistical analysis was performed using chi-square tests for association between the AR, NAR, and NR groups and the presence of total AITD. Two-tailed p values were calculated using commercially available software (GraphPad [GraphPad Software, Inc., La Jolla, Calif.]); p [less than or equal to] 0.05 was considered statistically significant.

Results

After a review of 613 charts, 111 patients were placed in the chronic rhinitis (both allergic and nonallergic) group and 101 patients were placed in the control (NR) group (see table 1 for demographic characteristics). Patients in the NR group came to the office for a variety of ear, throat, neck, and facial problems. A few had undergone allergy testing (e.g., for Meniere disease), but even if results were positive, they were not placed in the AR group because they did not have chronic rhinitis.

Of the 111 patients with chronic rhinitis, 77 (69.4%) tested positive for inhalant allergies (AR group) and 34 (30.6%) tested negative (NAR group). Overall, rhinitis symptoms were similar between theAR and NAR groups. Female-to-male ratios were approximately even for the AR and NR groups, but patients in the NAR group were twice as likely to be female compared to controls.

Among all 212 patients, 23 (10.8%) had AITD. Of these 23 patients, 14 (60.9%) had hypothyroidism hypothyroidism: see thyroid gland. , 4 (17.4%) had hyperthyroidism hyperthyroidism: see thyroid gland. , and 5 (21.7%) had euthyroid Euthyroid
Having the right amount of thyroxin stimulation.

Mentioned in: Goiter


euthyroid

having a normally functioning thyroid gland.
 thyroiditis Thyroiditis Definition

Thyroiditis is inflammation of the thyroid gland, a butterfly-shaped organ next to the windpipe.
Description

The thyroid is the largest gland in the neck.
. AITD was found in 8 (10.4%) of the AR group, 5 (14.7%) of the NAR group, and 10 (9.9%) of the NR group. Overall, the mean age for the AITD group was higher than for the AR, NAR, and NR groups by approximately 10 to 15 years, and the female-to-male ratio was 6.67:1.

Table 2 shows results of tests of association and calculation of odds ratios using chi-square analysis with two-by-two boxes. There was no statistically significant association between the presence of AITD and the presence of AR or NAR in the study population or in the control population.

Discussion

As indicated by available evidence, a relationship clearly exists between AITD and AR, but its nature remains unclear. According to the literature, the relationship extends to atopic conditions beyond AR. Using the Oxford database, which covers 2.5 million people, Goldacre et al found a significant association between asthma and both hypothyroidism and thyrotoxicosis thyrotoxicosis /thy·ro·tox·i·co·sis/ (thi?ro-tok?si-ko´sis) a morbid condition due to overactivity of the thyroid gland; see Graves' disease.

thy·ro·tox·i·co·sis
n.
. (8) Verneuil et al demonstrated that the frequency of thyroid autoantibodies was significantly higher in patients with chronic urticaria urticaria /ur·ti·ca·ria/ (ur?ti-kar´e-ah) hives; a vascular reaction of the upper dermis marked by transient appearance of slightly elevated patches (wheals) which are redder or paler than the surrounding skin and often attended by  (26.7%) than in controls (3.3%). (9)

In the current study, findings of clinical manifestations alone indicate that AITD and AR are independent of one another. However, other studies have suggested that an association may be related to subclinical subclinical /sub·clin·i·cal/ (sub-klin´i-k'l) without clinical manifestations.

sub·clin·i·cal
adj.
Not manifesting characteristic clinical symptoms. Used of a disease or condition.
 parameters, such as serum antibodies. Levels of autoantibodies (antithyrotropin-receptor antibodies, antithyroid peroxidase antibodies, and antithyroglobulin antibodies) have been found to increase after seasonal exacerbation of AR, but they might serve as a marker of immune system stimulation rather than clinical exacerbation of thyroid disease. (10) Increases in antibodies alone, secondary to atopic or autoimmune reactions, might not be sufficient to produce clinical changes that would be apparent on routine evaluation. All the patients in the Verneuil study who had urticaria with increased thyroid autoantibodies had normal thyroid hormone levels. (9)

Effects of AITD, AR, and NAR. Further investigation is required to clarify any direct effects that AITD and AR might have on one another. Evidence suggests that AITD and AR might also have indirect effects on each other, through activation of other systemic processes. Up-regulation of Th1-inducing cytokines Cytokines
Chemicals made by the cells that act on other cells to stimulate or inhibit their function. Cytokines that stimulate growth are called "growth factors.
 has been found in association with painless thyroiditis, an active phase of Hashimoto thyroiditis; and Th2 up-regulation has been found in Graves disease. (4,10) Overactivation of the Th2 cytokine Cytokine

Any of a group of soluble proteins that are released by a cell to send messages which are delivered to the same cell (autocrine), an adjacent cell (paracrine), or a distant cell (endocrine).
 pattern is also known to be a dominant feature of AR. Moens et al suggested that a suppressor T-cell defect is responsible for both atopic disease and thyroid autoimmunity. (11)

I believe examining the heterogenous (spelling) heterogenous - It's spelled heterogeneous.  NAR group is important for comparison in evaluating the relationship between AITD and AR. Patients in this group have conditions of varying etiologies, such as vasomotor rhinitis, atrophic rhinitis, rhinitis medicamentosa, nonallergic rhinitis with eosinophilia eosinophilia /eo·sin·o·phil·ia/ (e?o-sin?o-fil´e-ah) abnormally increased eosinophils in the blood.

e·o·sin·o·phil·i·a
n.
An increase in the number of eosinophils in the blood.
, chronic rhinosinusitis, metabolic conditions, structural obstruction, and physical or chemical irritation of the nose. Autoimmune disease might also be a cause. Settipane and Lieberman reported the presence of hypothyroidism in 2% of patients with NAR. (12)

NAR might be a confounding variable in examination of AR in the clinical setting. About half of patients presenting with chronic rhinitis do not have AR, and differentiation between NAR and AR is often based on clinical observation alone, without benefit of formal allergy testing. (13) Symptoms of the two entities overlap extensively, so it is possible that in clinical practice, the diagnosis of "allergies" may be assigned to patients who actually have NAR.

A prevalence of AITD that was almost 50% higher in the NAR group than in the AR group was a surprising finding, although the difference was not statistically significant. In addition, in the AR and NR groups, the female-to-male ratios were approximately even, whereas in the NAR group, the female-to-male ratio was twice that of the control group. This finding is consistent with data from the 1999 National Rhinitis Classification Task Force Survey of Non-allergic Rhinitis. (14) Reports of an even higher female predominance in AITD are consistent with the 6.67:1 female-to-male ratio found in this study. Reasons for the finding are unknown. Drawing conclusions about any linkage between AITD and NAR is difficult on the basis of current data and requires further investigation.

Limitations of the study. The sample was small, particularly for the hyperthyroid Hyperthyroid
Having too much thyroxin stimulation.

Mentioned in: Goiter
 and euthyroid categories. Although in most study patients the diagnosis of AITD was based on laboratory data of thyroid function (thyrotropin thyrotropin (thī'rätrō`pĭn) or thyroid-stimulating hormone (TSH), hormone released by the anterior pituitary gland that stimulates the thyroid gland to release thyroxine. , free [T.sub.4], or autoantibody autoantibody /au·to·an·ti·body/ (-an´ti-bod?e) an antibody formed in response to, and reacting against, an antigenic constituent of one's own tissues.

au·to·an·ti·bod·y
n.
 levels), in a few the diagnosis was based on the patient's history and knowledge of a previously determined diagnosis. Patients were classified as having AR only if the clinical symptom complex of chronic rhinitis coupled with positive inhalant allergy testing was present. It is possible that patients with rhinitis secondary to food allergy were inaccurately categorized as being nonallergic.

Another problem was placement of patients in either the AR or NAR category, because 34% of patients with chronic rhinitis have both allergic and nonallergic features. (14) Also, patients younger than age 18 were excluded from the study because of their low incidence of AITD, but Lindberg et al studied patients in this age group who had various allergic diseases and found elevated levels of thyroid peroxidase autoantibodies, as well as ultrasound evidence of autoimmune thyroiditis, compared with controls. (3)

Clinical implications. Results of this study indicate that no additional workup work·up
n. Abbr. w/u
A thorough medical examination for diagnostic purposes.
 for AITD is necessary based solely on the presence of AR or NAR. It is important, however, to keep in mind the underlying mechanisms of these entities and the associations between them, which might be subclinical. Unexplained or unexpected exacerbations in AR or NAR might warrant further investigation of AITD, and vice versa, as part of the patient's overall management.

This study suggests a linkage between AITD and NAR. These conditions might share immune features or represent coexisting autoimmune disease, and further investigation will proceed in this direction. Studies with larger patient populations and more stringent classification of AITD will also be helpful in determining whether medical and surgical management of chronic rhinitis or AITD will affect the clinical course of the opposite entity.

Acknowledgment

The author had full access to all data in this study and takes responsibility for its integrity and accuracy of data analysis.

References

(1.) Carlston JA. Hypothyroidism in atopy atopy /at·o·py/ (at´ah-pe) a genetic predisposition toward the development of immediate hypersensitivity reactions against common environmental antigens (atopic allergy), most commonly manifested as allergic rhinitis but also as . Ann Allergy 1965;23: 331-4.

(2.) Schwartz HJ. The relationship of thyroid disease and the atopic state. Ann Allergy 1966;24(5):234-7.

(3.) Lindberg B, Ericsson UB, Fredriksson B, et al. The coexistence of thyroid autoimmunity in children and adolescents with various allergic diseases. Acta Paediatr 1998;87(4):371-4.

(4.) Amino N, Hidaka Y, Takano T, et al. Association of seasonal allergic rhinitis seasonal allergic rhinitis,
n See hay fever.

seasonal allergic rhinitis Allergic rhinitis in which Sx wax and wane as a function of environmental pollen. See Allergic rhinitis.
 is high in Graves' disease and low in painless thyroiditis. Thyroid 2003;13(8):811-4.

(5.) Yamada T, Sato A, Komiya I, et al. An elevation of serum immunoglobulin E provides a new aspect of hyperthyroid Graves' disease. J Clin Endocrinol Metab 2000;85(8):2775-8.

(6.) Nakamura S, Isaji M, Ishimori M. Familial occurrence of silent thyroiditis. Endocr J 2005;52(5):617-21.

(7.) Krouse JH, Krouse HJ. Allergic disease and associated concurrent medical illnesses. ORL ORL Oto-Rhino Laryngologie (France)
ORL Orlando Executive Airport (Airport Code)
ORL Optical Return Loss
ORL Journal for Oto-Rhino-Laryngology and its related specialties
 Head Neck Nurs 2002;20(4):10-14.

(8.) Goldacre M, Kurina L, Yeates D, et al. Use of large medical databases to study associations between diseases. QJM QJM Quarterly Journal of Medicine (Association of Physicians)
QJM Quantified Judgement Model
QJM Quantified/Quantitative Judgment Method
 2000;93(10):669-75.

(9.) Verneuil L, Leconte C, Ballet JJ, et al. Association between chronic urticaria and thyroid autoimmunity: A prospective study involving 99 patients. Dermatology 2004;208(2):98-103.

(10.) Takeoka K, Hidaka Y, Hanada H, et al. Increase in serum levels of autoantibodies after attack of seasonal allergic rhinitis in patients with Graves' disease. Int Arch Allergy Immunol 2003; 132(3):268-76.

(11.) Moens HJ, Wiersinga WM, Drexhage HA. Association between autoimmune thyroid disease, atopy, and urticaria? Lancet 1984;2 (8402):582-3.

(12.) Settipane RA, Lieberman P. Update on nonallergic rhinitis. Ann Allergy Asthma Immunol 2001;86(5):494-507.

(13.) Dykewicz MS, Fineman S, Skoner DP, et al. Diagnosis and management of rhinitis: Complete guidelines of the Joint Task Force on Practice Parameters in Allergy, Asthma and Immunology. American Academy of Allergy, Asthma and Immunology. Ann Allergy Asthma Immunol 1998;81(5 Pt 2):478-518.

(14.) National Rhinitis Classification Task Force. The broad spectrum of rhinitis: Etiology, diagnosis, and advances in treatment. Data presented at the National Allergy Advisory Council Meeting; October 16, 1999; St. Thomas, U.S. Virgin Islands.

William R. Reisacher, MD, FACS FACS Fellow of the American College of Surgeons.

FACS
abbr.
Fellow of the American College of Surgeons



FACS

fluorescence-activated cell sorter.
, FAAOA FAAOA Fleet Air Arm Officers Association  

From Rockland Ear, Nose and Throat Associates, PC, West Nyack, New York West Nyack is a hamlet (and census-designated place) in Rockland County, New York, United States. The population was 3,282 at the 2000 census.

The community of West Nyack is in south part of the Town of Clarkstown.
. Dr. Reisacher is now with the Department of Otorhinolaryngology otorhinolaryngology /oto·rhi·no·lar·yn·gol·o·gy/ (-ri?no-lar?ing-gol´ah-je) the branch of medicine dealing with the ear, nose, and throat.

o·to·rhi·no·lar·yn·gol·o·gy
n.
, Weill Medical College of Cornell University, New York City New York City: see New York, city.
New York City

City (pop., 2000: 8,008,278), southeastern New York, at the mouth of the Hudson River. The largest city in the U.S.
.

This article was presented at the American Academy of Otolaryngic Allergy Annual Meeting; September 14-16, 2006; Toronto.

Corresponding author: William R. Reisacher, MD, Weill Medical College of Cornell University, Department of Otorhinolaryngology, 1305 York Ave., 5th Floor, New York, NY 10021. Phone: (646) 962-2093; fax: (646) 962-0030; e-mail: wir2011@med.cornell.edu
Table 1. Patient demographics

                     NR           AR           NAR         AITD
Characteristic    (n = 101)    (n = 77)     (n = 34)     (n = 23)

Mean age (yr)       48.1         41.8         44.9         57.0
Female-to-male     0.91:1       1.03:1       1.82:1       6.67:1
  ratio

NR = no rhinitis; AR =allergic rhinitis; NAR = nonallergic
rhinitis; AITD = autoimmune thyroid disease.

Table 2. Chi-square tests of association

                Chi-square     Odds        p
Comparison        value        ratio     value

AR to AITD         0.03        0.93      0.87
NAR to AITD        0.62        1.53      0.43
N R to AITD        0.18        0.83      0.67

AR = allergic rhinitis; AITD = autoin:mune thyroid disease;
NAR = non-allergic rhinitis; NR = no rhinitis.
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Title Annotation:ORIGINAL ARTICLE
Author:Reisacher, William R.
Publication:Ear, Nose and Throat Journal
Article Type:Clinical report
Geographic Code:1U2NY
Date:Sep 1, 2008
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