Question of the Month

Test your knowledge with our Question of the Month, organized by our Patient & Professional Relations (PPR) Committee! These allergy trivia questions and answers are a fun way to learn fun ENT facts while keeping your knowledge sharp.

Question: Early-Life Environmental Risk and Immune Programming

A prospective birth cohort study evaluates environmental exposures and subsequent development of atopic disease by age 10.

Which of the following exposures is most strongly associated with increased risk of allergic sensitization through impaired early immune tolerance?

A. High endotoxin exposure in early infancy
B. Cesarean section delivery without labor
C. Early daycare attendance
D. Exposure to older siblings
E. Residence in a rural farming environment

Correct Answer: B

Explanation:
Cesarean delivery—especially without labor—alters neonatal microbial colonization, leading to reduced gut microbial diversity and impaired immune tolerance development, increasing risk of atopy.

• A, C, D, E: Generally protective via the “hygiene hypothesis” and microbial diversity exposure

Key Sources

• AAP policy statements on early-life allergy prevention
• NIH allergy and asthma research summaries
• EAACI prevention guidelines
• Dominguez-Bello MG et al.
  “Delivery mode shapes the acquisition and structure of the initial microbiota.”
  PNAS, 2010
• Stokholm J et al.
  “Cesarean section and risk of allergic disease.”
  JACI
• Ege MJ et al.
  “Exposure to environmental microorganisms and childhood asthma.”
  New England Journal of Medicine, 2011

Question: Advanced Biomarkers of Type 2 Inflammation in CRSwNP

A 52-year-old with refractory chronic rhinosinusitis with nasal polyps is being evaluated for biologic therapy. Nasal biopsy shows eosinophilic inflammation.

Which of the following combinations most strongly predicts a favorable response to type 2 biologic therapy?

A. Low serum IgE, neutrophilic infiltrate, elevated IL-17
B. Elevated blood eosinophils, high total IgE, and comorbid asthma
C. Normal eosinophil count, elevated CRP, and bacterial biofilm presence
D. Elevated IFN-γ expression and Th1 predominance
E. Isolated nasal obstruction without olfactory dysfunction

Correct Answer: B

Explanation:
Type 2 inflammation is characterized by eosinophilia, elevated IgE, and Th2 cytokine signaling (IL-4, IL-5, IL-13). Comorbid asthma and anosmia further strengthen the phenotype predictive of response to biologics such as dupilumab, mepolizumab, or omalizumab.

• A & D: Reflect non–type 2 (Th17/Th1) inflammation
• C: Suggests infection-driven disease
• E: Lacks hallmark clinical features (e.g., anosmia)

Key Sources

• EPOS 2020 (EPOS 2020)
• AAO-HNS clinical practice guidelines
• AAAAI biologics guidance
• Bachert C et al.
  “Biologics in chronic rhinosinusitis with nasal polyps.”
  JACI, 2020
• Han JK et al.
  “Biologics for CRS: patient selection and biomarkers.”
  Otolaryngologic Clinics of North America

Question: Anti-IgE Therapy Nuance in Food Allergy

A 16-year-old with severe peanut allergy is undergoing oral immunotherapy (OIT). Due to frequent dose-limiting reactions, adjunctive therapy with Omalizumab is initiated.

Which of the following best explains how omalizumab improves tolerability during OIT?

A. It irreversibly depletes mast cells in gastrointestinal mucosa
B. It reduces FcεRI receptor expression on mast cells and basophils over time
C. It blocks IL-4 and IL-13 signaling pathways
D. It increases allergen-specific IgG4 production directly
E. It inhibits eosinophil trafficking into the lamina propria

Correct Answer: B

Explanation:
Beyond binding free IgE, omalizumab leads to downregulation of FcεRI receptors on mast cells and basophils, decreasing cellular sensitivity to allergen exposure. This is key in improving safety during OIT.

• A: No mast cell depletion
• C: That’s more consistent with dupilumab
• D: IgG4 changes occur indirectly with OIT, not directly via omalizumab
• E: More related to IL-5–targeted therapies

Key Sources

• FDA approval and mechanism summary for Omalizumab (updated for food allergy indication, 2024)
• AAAAI practice updates on biologics in food allergy
• EAACI Food Allergy Guidelines
• Wood RA et al.
  “A randomized, double-blind, placebo-controlled study of omalizumab combined with oral immunotherapy for multiple food allergies.”
  The Lancet Gastroenterology & Hepatology, 2016
• Sampson HA et al.
  “Mechanisms of action of anti-IgE therapy.”
  Journal of Allergy and Clinical Immunology (JACI)