Allergic rhinitis

DR. GHULAM SAQULAINENT SURGEON

CDA HOSPITAL, ISLAMABAD

ALLERGIC RHINITISALLERGIC RHINITISDIAGNOSIS AND MANAGEMENTDIAGNOSIS AND MANAGEMENT

04/11/23Capital Hospital Islamabad 3

In a Islamabad based survey conducted by PMRC, out of 2821 households with a total of 16717 individuals were surveyed, 1448 (8.66%) were reported suffering from allergy.

Asthma (n=195), 1.17%

Nasal Allergy (n=360), 2.15%

Skin Allergy (n=290), 1.73%

Conjunctivitis (n=53), 0.32%

Chronic Cough (n=24), 0.14%

Multiple Allergies (n=509), 3.04%

Others (n=17), 0.14%

0.00% 0.50% 1.00% 1.50% 2.00% 2.50% 3.00% 3.50%

Prevalence

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Distribution of Persons with Allergies by Type of Allergy. (n=1448)

Others, 1.20%

Asthma, 13.50%

Multiple allergies, 35.10%

Rhinitis, 24.90%

Urticaria, 20.00%

Conjuctivitis, 3.70%

Chronic Cough, 1.60%


Allergic Rhinitis

Allergic Rhinitis is defined as an inflammation of the

lining of the nose and is characterized by the symptoms

of nasal congestion, rhinorhea, sneezing and itching .

Other symptoms are nasal obstruction, paranasal pain

or headache, pruritis, itchy or watery eyes, anosmia,

dysosmia, chronic pharyngitis, hoarseness and

recurrent inflammation of URT


• Pollens

• Mold.

• Animal dander.

• Dust mites.


Diagnosis

• Careful History

• Physical Examination

• Laboratory Studies for Confirmation


History:The signs and symptoms of Allergic Rhinitis are familiar to many:


History:•Itching/ sneezing,• Nasal pruritis occurs,

particularly in pollen allergy with Itching eyes, nose and throat,

• Sneezing is the most common symptom with pollen allergy,

•Watery Rhinorrhoea,

•Nasal congestion/Obstruction at night causes:

• mouth breathing, • snoring, • restlessness, with

complaints of dry, sore throat in the morning,

• fatique.• anosmia.


Physical ExaminationIntranasal Examination

• Typically, the nasal mucosa is pale pink and swollen.

• Discharge is thin watery, but becomes thick and purulent when secondary infection sets in.

• Oropharyngeal wall may have typical clumps of lymphoid tissue.

• Other associated allergic diseases such as a contact dermatitis or asthma may correlate with flares of allergic symptoms.


•Malocclusion:

•Allergic Shiners: – Dark circles under

the eyes from venous stasis due to engorged nasal membranes

•Rabbit Nose: – The child may wrinkle

the end of the nose constantly,

•Allergic salute – The child may rub the

nose with the palm of the hand in an upward manner


Laboratory Findings:• Peripheral Eosinophilia:• Nasal secretion cytology:

– Presence of 3-10% of eosinophils in nasal secretions is diagnostic of allergic rhinitis except during early infancy.

• Immunoglobulin E– IgE serum levels are elevated in almost half of

cases with allergic rhinitis. However normal IgE does not exclude allergic rhinitis.

• RAST testing – This is a radio-immune assay where a patient's

serum is incubated with different allergens and antigen/antibody complexes are then measured.

– It is a more specific blood test for allergy. – This is not as sensitive as skin testing and more

costly

• Allergy Skin Tests : – Done to identify specific allergens.


COMPLICATIONS OF ALLERGIC RHINITIS

• Recurrent otitis media.

• Hearing loss.

• Sinusitis.

• Nasal or sinus polyps.

• Progression to asthma.

• Anatomical changes in nasal and sinus cavities.


The Basic Pathology

Four types of hypersensitivity reactions

• Type I - IgE mediated reaction

• Type II - IgG/ IgM mediated

• Type III - IgG/ IgM mediated

• Type IV - T cell mediated

(Delayed hypersensivity, Cell-mediated hypersensivity)


PATHOLOGY & PATHOGENESIS

• In allergic rhinitis we see an example of IgE mediated hypersensitivity. In this type with continued exposure atopic individual acquires antibodies of reagin type (IgE Immunoglobulins) from plasma cells.


Allergy Causing Pollen

Excess Mucus Production

Along with submucosa

Mast cells in epithelium

also imprtant

Occurs within 30 Sec. of challenge


HISTAMINEOrigin:• Found in the most tissues of the body.

• Most abundant in mast cells near blood vessels in connective tissue.

• Found in small quantities in basophils(granular part of a cell).

Release:• when an allergen joins an IGE antibody on the surface of

a mast cell or basophil, serine esterase(compound) is activated, and this activation induces the release of histamine.


Effects:• Reactions range from mild itching to shock and

death.

• Response to histamine occurs in one to two minutes.

• Duration of action is about ten minutes.

• Produces effects by acting on H1 receptors.


H1 RECEPTORSStimulation causes:

• constriction of the bronchial smooth muscle.

• Increase mucus secretion in respiratory tract.

• Increased lacrimation.

• Dilation of arterioles and capillaries.

• Weakening of capillary walls.

• Constriction of small veins and venules.

• Dilation of large veins.

• Constriction of smooth muscle of the gut.

• Pain and burning sensations.


Type - I (IgE mediated reaction)

1. Preformed

• Histamines

• NCF (Neutrophil Chemoattractant Factor)

• ECF (Eosinophil Chemoattractant Factor)

• Enzymes

2. Newly formed

• PAF

• Leukotrienes (LTB4)

• Prostaglandin's

• The preformed mediators are responsible for the early phase reaction.

• These mediators are responsible for the commissioning of Eosinophils

• Once the eosinophils are commissioned, the late-phase reaction begins


Type - I (IgE mediated reaction)

Two clinical subgroups

• 1. Atopy

• 2. Anaphylaxis


Atopy

• The term applies to a group of diseases

occurring in individuals with inherited

tendency to develop IgE antibodies

• Allergic Rhinitis serves as an outstanding

example


Anaphylaxis• Certain allergens may induce IgE

mediated response

• Condition is potentially fatal.

• Affect atopic and non-atopic patient.

• Diseases are: Anaphylaxis, Urticaria,

Angioedema etc


ALLERGIC RHINITIS Essentials of Diagnosis

• Nasal pruritis, congestion, rhinorrhea, sneeze attacks, eye irritation. Sometimes eczematous dermatitis

• Environmental allergen exposure

• Confirmed by evidence of specific IgE antibody


TREATMENT

• Avoidance Techniques

• Symptomatic Therapy

• Immunotherapy

The three basic Principles of allergy management are :


Avoidance Therapy

The most effective part of the treatment

• But usually meets failure as the allergens in the

environment often become unavoidable

• Cross-reactivity also plays its part


Health Tips

Pollen grains of trees like paper mulberry can be avoided by

leaving the area densely populated by these plants. Minimize outdoor activity when pollen counts are high. Take medications at least 30 minutes prior to outdoor activity. Shut windows in your house on days pollen counts are high. Wearing face masks Use of air conditioners

Air-filtering devices

Avoiding Irritants. Do a thorough spring cleaning Wash bedding weekly in hot water. Dry laundry indoors. Keep pets off of furniture and out of the bedroom. Keep car windows closed during peak season. When mowing lawn or gardening, wear a filter mask.


Drug Therapy

Three classes of:

• First generation antihistamine have sedating potential.

• Second generation antihistamine having better compliance & lesser sedating potential

• Third generation antihistamine are non- sedating but usually the rescue dose comes with a sedating effect


First Generation Chlorpheniramine

Diphenhydramine

Promathazine etc.

• First Generation have wide pharmacologic profile.

• They easily cross blood brain barrier that is why they cause Sedation

• They are not specific nor selective they cause anticholinergic side effects.

• They have Drug interactions.

• They do not work in late phase of Allergic Reactions.

• They are inconvenient B.I.D and T.I.D Dosage.


Second/ Third Generations Loratadine

Cetirizine

Fexofenadine

Disloratadine

Levocetirizine

Second generation are composed of Relatively Large and less Lipophilic molecules that cross the blood brain barrier less easily

They cause minimal sedation.

They Work in late phase of Allergic Reaction.

Offer convenient once daily Dosage .

They do not have Drug interactions.


But all of them do not have all the Advantages

Some of them cause cardiac side effects

Some of them are not specific and selective

Ant cholinergic side effects.


What is the Right choice

WHICH OFFERS:

• High efficacy

• Fast relief of Allergic Reactions

• Long duration of action

• Minimal sedation

• Low side effects

• Safe in long term use

• Convenient OD dosage


Fast Relief Tandegyl Day provide quick relief of allergic symptoms.

Because it achieves peak plasma concentration with in (0.9 hrs)

Levocetirizine

cetrizine

loratadine

fexofenadine

0

0.5

1

1.5

2

2.5

3

peack plazma concentaration


Slow dissociation Rate

Ensure the strong antagonism of levocetirizine to histamine receptor which resulting in longer duration of action

In symptoms like Sneezing, Rhinorrhoea, Nasal Obstruction, Itch and Flare.


Safety

Tandegyl Day have Minimal Sedation because it does not cross the blood brain barrier.

Tandegyl Day has low side effects because it has 600 folds Higher selectivity towards H1 receptor.

Tandegyl Day has a minimal Risk of Drug interaction because it is poorly metabolized.


Low Volume Of Distribution

Volum ofDistribution

Tand

egyl

Day

Cet

iriz

ine

Fexo

fena

dine

Lora

tidin

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0.4 0.58 5.4

120

020406080

100

120

Tandegyl Day has Low volume of distribution so it is better choice for long term use. Like in Allergic Rhinitis etc.


High compliance

Convenient once daily

Less drowsiness

Low dryness of mouth

Affordable price Rs 5.50

Easily available

A quality product of NOVARTIS


LEVOCETIRIZINE (Tandegyl - Day)

• Potent systemic antihistamine.

• O.D dosage

• Fast onset of action (0.9 Hours).

• Economical (5.50/= per tablet)

• Can be recommended from the age of 2 years

• Has 600 times selectivity with H1 Receptors

• Has 2 fold higher affinity towards H1 Receptors than Citirizine.

• Low drug interactions

• Minimal sedation


Immunotherapy:

• Aim : Increase the patient's tolerance to the particular pollen.

Otolaryngol Clin North Am,7:703-718, October 1874

– Immunotherapy is indicated for those patients who fail environmental controls and medical therapy, or patients with extremely severe allergy.

– Immunotherapy is rarely done in children less than six years of age, as allergic sensitivity is rapidly changing up to that age


Surgical Treatment:• Indicated

– When the turbinates have hypertrophied to a point making breathing difficult.

– Associated structural problems causing obstruction to airway.

– Complications like nasal polypi.


RHINITIS & ASTHMA

Nasal allergy

also seems to be highly correlated with asthma, recurring sinus infection, otitis

media and possibly facial growth abnormalities.


Thank you

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Allergic rhinitis

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