Allergic Rhinitis

Allergic RhinitisAllergic Rhinitis

By AminuddinBy AminuddinAllergy-Immunology Sub Division at ENT Allergy-Immunology Sub Division at ENT

Department,Faculty of Medicine Hasanuddin Department,Faculty of Medicine Hasanuddin UniversityUniversity

Telp (0411)496778Telp (0411)496778Or Hp 081342940514Or Hp 081342940514

Allergic RhinitisAllergic Rhinitis

• Introduce• Definition• Classification• Patomechanism• Symptoms• Diagnosis• Therapy• Complication

• Allergic rhinitis is a global health problem affecting 5 to 50% of the population

• Its prevalence is increasing and probably underestimated

• One of the ten reason for visit in ENT• Although it is not usually a severe disease,

AR alters social life and affects school performance and work productivity

• Costs incurred by rhinitis are substantial

IntroductionIntroduction

Although not fatal,but:Physical functioning Bodily pain Vitality Take a tissueMalaise FatiqueSocial functioning Difficulty concentratingGeneral health/Mental health

Decreasing Quality of Life

Definition Definition • Von Pirquet 1906 Allergy

“ An altered reactivity to foreign substance after prior exposure to the same material “It is not occur of majority of individual.Cause tissue inflamation and organ dysf

• ARIA-WHO 2001 Allergic RhinitisAllergic rhinitis is clinically defined as a symptomatic disorder of the nose,induced after allergen exposure,by an IgE mediated inflamation of the nasal membranes

Target organs of allergy :Target organs of allergy :

Respiratory tract ………………. Asthma

Nose ……………………………. Allergic rhinitis

Eye …………………………….. Allergic conjunctivitis

Skin ……………………………. Urticaria

Digestive tract ………………… Diarrhea

Cardiovascular ………………... Anaphylactic shock

Respiratory tract ………………. Asthma

Nose ……………………………. Allergic rhinitis

Eye …………………………….. Allergic conjunctivitis

Skin ……………………………. Urticaria

Digestive tract ………………… Diarrhea

Cardiovascular ………………... Anaphylactic shock

Organ DiseaseOrgan Disease

PatomechanismPatomechanism

The three steps of AR response :

1. Sensitization phase

2. The Early Phase Reaction

3. The Late Phase Reaction

The Sensitization Phase APC

• Recocnize and process the antigen into antigenic peptides

• Present a peptide portion to T Lymphocyte• Stimulate the secretion of cytokines

Stimulate antigen-specific Ig E production by the B lymphocyte

Secreted Ig E is then bound by high-affinity receptors on mast cell and/or basophil

Allergic InflammationAllergic Inflammation

IgE-bearing B-cellsIgE-bearing B-cells

-

MHC

Fragment

Th2

1. Sensitization Phase1. Sensitization Phase

Adapted from Creticos, 1998

IgE antibody IgE antibody IgE IgE

IgE IgE

Sumarman. Pathophysiology and Diagnostic Procedure of Allergic Rhinitis

The Early Phase Reaction ( EPR ) Reexposure to allergen,mast cell

degranulate,releasing histamine,serotonin,ECF-A,NCF-A,leukotrienes,prostaglandine and cytokines

Histamine is a main effector in EPR producing• Nerve stimulation sneezing and itching• Mucus hypersecretion Nasal discharge• Increasing vascular permeability and v.dilatation

nasal obsruction

-

MHC

Fragment

Th2

Rhinorea

Sneezing

Congestion

Allergic InflammationAllergic Inflammation

2. Early Phase Allergic Reaction2. Early Phase Allergic Reaction (Reaksi alergi fase cepac (RAFC)(Reaksi alergi fase cepac (RAFC)



IgE IgE


Mastosit

IgE IgE

IgE IgE

Sumarman. Pathophysiology and Diagnostic Procedure of Allergic Rhinitis

The Late Phase Reaction ( LPR ) Over the course of several hours The infiltrating inflamatory cell such as

eosinophils,basophils and neutrophil The inflamatory cells release mediators

stimulating and enhancing further inflamatory reaction

Allergic Inflammation

3. Late phase Allergic Reaction3. Late phase Allergic Reaction


-

Rhinorea

Sneezing

Congestion

MHC

Fragment

Th2

Mastosit



IgE IgE

Sumarman. Patophysiology and Diagnostic Procedure of Allergic Rhinitis

Rhinorea

Sneezing

Congestion

CHRONIC

INFLAMMATION

Classification of ARClassification of AR

• Previously AR was sudivided based on the time of exposure into Seaseonal AR ( Out door allergen ) Perennial AR ( Indoor allegen )

• Not satisfactory :• Some places pollen is perennial• Symptoms of Perennial AR not always

present all year round

• This term is still retained to enable

Based on duration of symptoms :

“Intermitten” : the symptoms are present: • < 4 days a week• Or for less than 4 weeks

“Persistent” : the symptoms are present: • > 4 days a week• And for more than 4 weeks

Newer Classification of ARAccording ARIA (Allergic Rhinitis and its Impact on Asthma)-

WHO 2001

Based on severity of simptoms:

“Mild” : that none of the following items are present:• Sleep disturbances• Impairment of daily activity, leisure and/or sport• Impairment of school or work• Trouble some symptoms

“Moderate Severe” : One or more of the following items are present:

•Sleep disturbances• Impairment of daily activity, leisure and/or sport• Impairment of school or work• Trouble some symptoms

New Classification of ARNew Classification of ARAccording to The ARIA (Allergic Rhinitis and its Impact According to The ARIA (Allergic Rhinitis and its Impact

on Asthma)-WHO 2001on Asthma)-WHO 2001

Moderate-severeone or more items

. Abnormal sleep

. Impairment of daily activities, sport, leisure

. Abnormal work and school

. Troublesome symptoms

Persistent . > 4 days per week

. and > 4 weeks

Mild Normal sleep& No impairment of daily

activities, sport, leisure& Normal work and

school& No troublesome

symptoms

Intermittent . < 4 days per week

. or < 4 weeks

Major symptomsMajor symptoms

Repetitive sneezingRhinorroeaNasal obstructionItching of the nose,eyes,ear and throat

Seasonal Allergic rhinitisSeasonal Allergic rhinitis

Symptoms may correlate with the apperarence and intensity of local allergen (Pollens)

Symptoms are periodicCharacteristic symptons :

Watery rhinorroea,profuse and contain eosinophilNasal obstruction:swollen turbinatesSneezing episode Itching of the nose (prominent),ear,eyes,palate or

throatLacrimation

Senses of smell maybe alteredAllergen: Pollen,mould (Out door allergen)

Perennial allergic rhinitisPerennial allergic rhinitis

Symptons are very similar to those of seasonal allergic rhinitis although perennial is persisten,chronic and not severe

The most commom symptoms is nasal obstruction Sneezing,rhinorrhoe and nasopharyngeal and ocular

itching occur less frequently than seasonal AR Post nasal drips ALLERGEN (INDOOR ALLERGEN)

House dust mite Mites Human dander Cockroach Animal dander

DIAGNOSIS ARDIAGNOSIS ARANAMNESIS :

Family allergic history is essentialOnset,progression,severityDurationSeasonsOcular,pharyngeal and systemik symptonsRecurrent sinus or ear infectionsCausal and exacerbating factorsAssociaton with atopic diseaseRelationship to drug use

Physical ExaminationPhysical ExaminationAnterior rhinoscopy with high illumination using

head lamp or endoscop look for :Mucosa can be Inflamed/reddened,pale blue Watery dischargeEnlarge turbinatesNasal polyps can be find : rounded,white,glistening

masses Another symptons :

Mouth breathingAllergic saluteA nasal creaseAllergic shinersFrontal headacheHiposmiaOcular symptons

In Vivo : Anamnesis Examination of the nose

Anterior rhinoscopyNasal endoscopy

Skin test :Prick TestIntra DermalSET

Nasal provocation test

In Vitro : Total Ig E Specific Ig E : RAST & Modifikasi RAST Nasal smear

Diagnosis of AR

Hasil SPTHasil SPT

Therapy of ARTherapy of AR

Four general principles of AR management

1. Avoidance

2. Pharmacologic Therapy

3. Allergen immunotherapy

4. Patient education

5. Surgery for a few highly selected patients

Allergen avoidance House dust mite

• Encase mattress,pillow in an allergen impermeable cover

• Wash bedding weekly in hot water• Reduce indoor humidity• Remove stuffed toys,carpets from bedroom

Animal allergens• Remove the pet from the home

Cockroaches• Keep food or garbage inclosed containers• Use boric acid traps or hydromethanon

Molds/Fungi in home• Clean moldy surfaces• Wash swamp coolers• Fix all water leaks

Outdoor allergens Keep window and doors closed Use air conditioning Refrain from outdoor activities,if

possible,during times of high pollen counts Use a masker/eye glasses Dry clothes in avented dryer,not out side

Pharmacologic TheraphyPharmacologic Theraphy Medications used to treat AR

Antihistamines Decongestanns Antihistamine-decongestant combinations Corticosteroids Mast cell stabilizers Anticholinergics

AntihistaminesAntihistamines The mainstay of pharmacotherapy for AR

is antihistamines Older antihistamines such as

diphenhydramine,prometazine,triprolidine have inherent sedating side effect.

New generation antihistamines such as cetirizine,fexofenadine,loratadine are prefered

Intranasal antihistamines are efective Often combined with oral decongestants

DecongestansDecongestans Simpatomimetic drugs Topical :

Oxymetazoline,Xylometazoline,fenilefrineLong take administration causing rhinitis medicamentosa

Oral : Ephedrine,pseudoephedrine,fenilefrine,phenilpropanolamine.Side effects are tremor,agitation,imsomnia,headache,palpitation,tachycardia and urinary retention

CorticosteroidsCorticosteroids Treat the inflamatory component of AR Intranasal corticosteroids are the first line

of therapy when obstruction is a major problem

Oral corticosteroids : a short (3 – 7 day)course may be appropriate for severe symptoms

Intranasal cromolyn sodium Intranasal cromolyn sodium The mechanism of action remains

uncertain Intraocular chromones are very efective Intranasal chromones are less effective

and their effect is short lasting Minor local side effect

AnticholinergicsAnticholinergics Ipratropium bromide is a generic name Anticholinergic block almost exclusively

rhinorrhea Minor side effects Almost no systemic anticholinergic activity Effective in AR patients with rhinorrhea

Anti LeukotrienesAnti Leukotrienes

Block leukotrienes receptor Well tolerated Promising drugs used alone or

combination with oral antihistamines Effective in AR patients with nasal

obstruction

ImmunotherapyImmunotherapy Allergen specific immunotherapy is the

practice of administering gradually increasing quantities of an allergen to an allergic subject in order to ameliorate symptoms with subsequent exposure to the causative allergen

Its associated with “Blocking” Ig G Administer under the direction of an

allergist or ENT specialist

SurgerySurgery If there are compilcation include :

• Sinusitis• Nasal polyps• Hyperthropy of the nasal turbinates

Complicatins Complicatins Compilcations of AR are :

• Nasal polyposis• Sinusitis• Otitis media

Conclusion

• AR is a major chronic respiratory desease due to :

Prevalence

Impact on quality of life

Economic burden

Links with asthma

• A new classification of AR has been used

• Diagnosis of AR based on in vivo and in vitro

Reference1.Bosquet J, Cauwenberger PV, Kahltaev N. Allergic

Rhinitis and its Impact on Asthma in Collaboration with the WHO, Supplement the Journal of Allergy and Clinical Immunology Vol. 108 Number 5, 2001.

2.Bousquet, Cauwenberger PV, Khaltaev N. Allergic Rhinitis and its Impact on Asthma. Pocket Guide 2001.

4.Naclerio RM, Dirham SR, Mygind N, Rhinitis. Mechanism and Management ; Marcel Dekker inc. 1999.

4.Nelson HS,Rachelefsky GS. Disease of the Atopic Diathesis. Vol 2 , 20005.Holt GR, Mattox DE Gates GA : Decision Making in

Otolaryngology. BC. Dekker inc. 1984..

Vasomotor rhinitisVasomotor rhinitis Definition : Overactive parasympathetic

stimulation of the nasal mucosa producing vasodilatation,edema and hypersecretion of mucus

Factors can causing vasomotor imbalance

Factors can causing vasomotor imbalance• Drugs : Ergotamine,Antihypertensive

(Methyldopa,Reserpine),Chlorpromazine• Physic : Chemical

irritants,humidity,temperature,barometric pressure,strong smells

• Hormonal : Pregnancy,puberty,menses• Psychis : Anxyty,emotional stress

Symptoms are similar to AR but there is :• Nasal obstruction ( alternating )

• No evidence of allergic disease as determined by skin or serum level of Ig E to specific allergens

Vasomotor rhinitisVasomotor rhinitis

Clinical features • Nasal obstruction ( alternating )• Nasal discharge ( often mucous/serous )• Post nasal drips• Sneezing is rare• Not itching• Laboratory measurement :

Normal Ig ESkin test ( - )Eosinophil ( - )

Vasomotor rhinitisVasomotor rhinitis

Rhinitis medicamentosaRhinitis medicamentosa Nasal obstruction caused by prolonged

use of topical decongestant medications is known as rhinitis medicamentosa

Its has been attributed to rebound vasodilatation after prolonged vasoconstriction with topical decongestant

Rebound vasodilatation caused by constrictor mechanism fatique due to hypoxia and by reactive hyperemia

Prolonged use of the topical decongestants diminishes vasoconstriction and increases vasodilatation

All topical decongestanta can produce this phenomeno when used prolonged periods

Symptons:• History use of topical decongestan• Adrenaline/efhedrine topical test no

effect

Rhinitis medicamentosaRhinitis medicamentosa

Therapy : Stop use topical decongestans Decongestant oral Corticosteroid systemic ( Tapering off )

Rhinitis medicamentosaRhinitis medicamentosa

Nasal PolypsNasal Polyps

Definition : Smooth mass,gelatinous,grape-like,pale bags,not easily bleeding,relatively not sensitive,moveable which arise most commonly from the middle meatus extend down into and can lead obstruction of the nasal cavity

Etiology : Allergy Infection Vasomotor imbalance Bernoulli phenomenon

Most polyps are gray or grayish blue but may at times become reddened from local irritations or secindary infection

Most polyps origiginate as an out-pouching of the mucosal covering the maxilary or ethmoid sinuses or osteomeatal complexs.

Antral choanal polyps have a cystic portion within the maxillary sinus and extend into the nose through an accessory osteum in the posterior fontanel


Insidense• Much more often in adult but can occur in

children• Ethmoidal polyps all of age• Antrochoanal polyps young

age,children ( rare )


Location of polyps :• Osteomeatal complexs( anterior ethmoidal

sinuses pre chamber ) in middle meatal• Maxllary sinus usually soliter• Ethmoidal sinuses usually multiple• Middle turbinates• Frontal or sphenoidal sinuses rare


Clinical features• Nasal obtruction• Nasal discharge• Hyposmia • Chefalgia• Deformity of the external nose ( giant polyps )


Diagnosis • Anamnesis• Examination of the nose

Anterior rhinoscopyPosterior rhinoscopyNasal endoscopy

• RadiologicX-Ray sinus paranasalisCT sinus paranasalis


Diffrensial Diagnosis• Inferior nasal turbinates hyperthropy• Benign nasal neoplasm• Malignant nasal neoplasm


Therapy• Medical management

Corticosteroids oral or intra nasalAntibiotics

• Surgical managementSimple intranasal polypectomyEthmoidectomy (intranasal or transantral)Cald-Well-Luc Procedure (CWL)FESS (Functional Endoscopic Sinus Surgery)


Recurence of polyps was caused by• Surgical technic not adequately• Causing of polyps not to control ( Allergy )


Allergic Rhinitis

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