Allergic Rhinitis

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one of the commonest ent disease

Transcript of Allergic Rhinitis

    • Definition : IgE mediated hypersensitivity of the mucous membrane of the nose upon exposure to antigenic substance.
  • Incidence : common, 10-20% of population.
  • Types : 1. seasonal2. perennial 3.perennial with seasonal exacerbation.
  • Etiology :
  • Predisposing factors :
  • 1. Genetic predisposition: 50% of cases occur in atopic patient (atopy: tendency to develop an exaggerated Ig E antibody response).
  • 2. Temperature changes.
  • 3. psychgenic.


  • Exciting factors :
  • inhalant: commonest factors e.ghouse dust, tree & grass pollens.
  • Injestant: foods (milk, fish) & drugs ( aspirin, antihypertensive).
  • Injectant: e.g penicillin.
  • Infactant: fungal parasitic & bacterial antigen.
  • Contactant: e.g face powder.


  • Pathogenesis :
  • 1 stexposure :formation of IgE antibodies which bind to specific sites on surface of mast cells.
  • 2nd exposure :+Ag-Ab reaction on surfaces of must cells with degranulation of cells & release of chemical mediators: e.g histamine, bradykinine, serotonine resolution in local inflammatory reaction:
    • Vasodilation: plasma exudate.
    • Increase glandular secretions.
    • Cellular infiltrate (oesinophilis).
    • Smooth muscle contraction.


  • Symptoms :+ve family history in 50%.
  • Itching sensation.
  • Paroxysmal sneezing.
  • Bilateral profuse watery discharge.
  • Bilateral alternating nasal obstruction.
  • Associated allergic symptoms e.g eye, skin or chest.
  • Signs :
  • Pale bluish edematous mucosa.
  • Swollen edematous turbinates.
  • Excessive mucoid secretions.
  • Nasal polyps may be present.


  • Investigations :
  • Skin- prick test: skin of forearm is pricked with a needle passed in extract of different allergens. +ve test is detected by centeral wheel surrounded by erythema.
  • Nasal challenge test: allergen applied inform of spray.
  • Radioallergosrbency test (RAST): incubation of patient serum with specific concentrations of antigens & level of IgE is by radioimmune.
  • High level of IgE by radioimmun.
  • Nasal smear; full of oesinophilis.


  • Treatment:
  • Avoidance of exposure.
  • Immunotherapy: injection of gradually increasing dose of specific antigen over long period of time formation of blocking antibodies.
  • Mast cell stabilizer e.g. sodium chromoglicate.
  • Antihistaminic: systemic & local (spray).
  • Steroids: systemic (short course) &local spray.
  • Surgery:
  • - Reduction of size of turbinate.
  • - Nasal polypectomy

7. Vasomotor rhinitis

  • It is also called intrinsic rhinitis or non allergic perennial rhinitis. It may be related to drugs ( e.g. antihypertensive and contraceptive) or hormonal imbalance at menopause.
  • Clinical picture :
  • Nasal obstruction and watery nasal discharge, which is often precipitated by temperature changes, and dusty atmosphere.
  • Examination; shows swollen, edematous turbinates, with excessive mucoid ecretios.
  • Treatment :
  • It is often unsatisfactory.
  • Topical steroids may be beneficial.
  • If the turbinates are markedly swollen we may do submucous dithermy or submucosal injection of long acting steroids (vidion N1).

8. Nasal polyps

  • Definition :
  • Projections of edematous. Pedunculated mucosa of the nose and/or Paranasal sinuses.
  • Types :
  • Incidence :
  • Common.
  • Age: adult.
  • If occurs in a child 2-10yrs -> cystic fibrosis, should be suspected. There are extensive nasal plyps leading to broadening of the nasal bridge due to distention before fusion of the nasal bones. There is very thick and tenacious nasal discharge (Mucoviscidosis). Sweat test (sodium level) is diagnostic. It has a very high rate of recurrence.
  • - Sex: equal.
  • Uncommon.
  • Age: young adult.
  • Sex: equal

Etiology: 1. Allergy:* Most accepted cause. * 90% of polyps -> oesinophilia. * Allergic rhinitis, Usually present. * 20-40% -> bronchial asthma. 2. Inflammatory, chronic sinusitis.Etiology: Inflammatory or retention cyst: Arise from mucosa of maxillary antrum->directed posteriorly. After passage through sinus ostium->directed towards the choana->nasopharynx.1- Ethmoidal2- Antrochoanal 9.

  • Signs:
  • Allergic:
  • Bilateral, multiple, pale, glistening pedunculated masses (grap-like growth) that fill the nasal bridge in long standing cases (Hypertolirism).
  • Manifestations of allergic rhinitis.
  • Inflammatory:
  • Polyps: usually few pink, soft and arising mainly from the middle meatus.
  • Purulent discharge: mainly from the middle meatus.
  • Anterior rhinoscopy:
  • Swollen inferior turbinate.
  • Accumulated secretions.
  • Sometimes->polyp seen.
  • Posterior rhinoscopy:
  • Single polyp appears in the nasopharynx.
  • Symptoms:
  • Allergic:
  • Bilateral gradual nasal obstruction.
  • Manifestation of allergic rhinitis.
  • Inflammatory:
  • PND: thick and purulent.
  • Unilateral or bilateral nasal obstruction and discharge.
  • Sinus headache.

- Accumulated nasal discharge in the obstructed side. 10. Treatment: Allergic: 1.Medical-> small early polyps. * Systemic steroids. * Topical steroids. * Antibiotics 2ry infection. * Anti allergic treatment. 2.Surgery: * Simple polypectomy. * Intranasal ethmoidectomy (endoscopic or microscopic). - Preoperative & postoperative steroids should be given. - There is high rate recurrence 40% after surgery (9months->2years). Inflammatory : 1.Medical : * Antibiotics. * Decongestant. * Mucolytics. 2.Surgical : Transnasal endoscopic sinus surgery(FESS). Endoscopic removal of nasal, nasopharyngeal, and sinus parts through a wide middle meatal antrostomy. N.B:in recurrent cases -> radical antrum operation was done. N.B: Differential diagnosis of unilateral nasal mass: 1. Benign neoplasm especially inverted, firm papillary polyps.2. Malignant neoplasm: unilateral, bad odor, soft, bleeding on touch mass. 3. Meningocele and encephalocoele: soft, pulsating, reddish, polyp with superior attachment to skull base.

  • Investigations:
  • Culture and sensitivity.
  • Allergic skin test.
  • CT scan nose & paranasal sinuses.
  • Biopsy from the ploys (macrophages or eosinophilia).
  • Sinus view: unilateral maxillary opacity.
  • CT scan.

11. Paranasal sinuses

  • Anatomy paranasal sinuses
  • Air filled spaces , 4 pairs on each side, within skull bones & open in the Latebral wall of nose.
  • Lining:pseudostratified columnar ciliated epithelium which is continuous with that of the nose through their ostia.
  • Arranged in2 groups:
  • *Anterior group:Maxillary, Forntal & Anterior sinuses.
  • *Posterior group:Posterior ethmoid & Sphenoid sinuses.
  • Maxillary sinus:
  • It is contained within the body of maxilla.
  • Development begins in the 3 rdfetal month.
  • Pneumatization starts at bieth, growth continues to 18 years of age.


  • Boundaries:
    • Anteriorly: cheek.
    • Posteriorly: pterygopalaine fossa.
    • Roof: floor or orbit.
    • Floor: palatine and alveolar process of maxilla.
    • Medially: lateral nasal wall.
    • Level of floor of sinus varies with that of nasal floor, before age of 9 years sinus floor is at higher level, after the age of 9 years sinus floor is at lower level.
  • Maxillary sinus ostium :
  • It is made by confluence of maxillary sinus mucosa and nasal mucosa. On looking to the maxillary ostium from inside the sinus it will appear like an ellipse just below the junction of roof and medial wall half way between anterior and posterior walls.
  • Frontal sinus:
  • It is present between outer and inner tables of frontal bone.
  • it begins development after birth.
  • The two frontal sinuses may be of unequal size.
  • The frontal sinus ostium lies in the most dependent area of the sinus.
  • Frontal recess, is the space where frontal sinus opens.