Allergic Rhinitis Kirk H. Waibel CPT, MC Walter Reed Army Medical Center.
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Transcript of Allergic Rhinitis Kirk H. Waibel CPT, MC Walter Reed Army Medical Center.
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Allergic Rhinitis
Kirk H. WaibelCPT, MC
Walter Reed Army Medical Center
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Objectives
• Understand importance of allergic rhinitis
• Recognize variation in allergic symptoms
• Apply appropriate treatment strategies
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My child has allergies!
• Pathophysiology
• History
• Physical Exam
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Allergen
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History
• Onset of symptoms– Infant less than 3 years old– Older child
• Symptoms– Headache - Ocular– Nasal - Oral
• Pruritis
• Sneezing
• Congestion
• Postnasal drip
• Rhinorrhea
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History
• Frequency– Perennial (cat, dog, dust mite, cockroach, molds)
– Seasonal (trees, grass, weeds)
• Severity– School absence
– Loss of smell
– Behavioral changes
– Comorbid conditions
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Physical Exam
• Eyes
• Ears
• Nose
• Oropharynx
• Lungs
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Differential Diagnosis
• Upper respiratory infection
• Chronic sinusitis
• Anatomical nasal obstruction
– Concha bullosa - Nasal polyps
– Deviated nasal septum - Adenoidal hypertrophy
• GERD
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Should you refer for skin testing?
YES• Poor response to
therapeutic trial• Drastic environmental
changes are considered• Strong desire for
immunotherapy
NO• Hx suggestive for AR• Trial of appropriate
therapy successful• Symptoms mild and
easily managed• Mechanical,
anatomical, or infectious causes
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Agent Sneezing Itching Congestion Rhinorrhea Eye
OA +++ +++ +/- ++ ++
NA + + +/- + -
ICS ++ ++ +++ ++ +
OD - - ++ - -
ND - - +++ - -
MCS + + + + -
IND - - - ++ -
Pharmacologic Management
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Antihistamines
• 1st generation: Hydroxyzine (Atarax®)
Diphenhydramine (Benadryl®)
Chlorphenarimine (CTM®)
• 2nd generation: Certirizine (Zyrtec®)
Loratidine (Claritin®)
Fexofenadine (Allergra®)
Desloratadine (Clarinex®)
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Nasal sprays
• Nasal steroids
• Cromolyn (Nasocrom®)
• Oxymetolazone (Afrin®)
• Nasal saline (Ocean®)
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Nasal steroids
• Mometasone (Nasonex®)
• Fluticasone (Flonase®)
• Budesonide (Rhinocort®)
• Vancenase (Beclomethasone®)
• Flunisolide (Nasalide®)0
5
10
15
20
25
Mometa Flutic Budes Beclo Flunisol
% Bioavail
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Immunotherapy
• Rise in IgG “blocking” antibodies
• Reserved for patients who find it difficult to avoid
allergens but do not respond adequately to
pharmacologic therapy
• Children > 7 years old
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Allergist Referral
• Symptoms should exceed 6 weeks and present for at least 2 years in a row
• Inadequate relief after one month of continuous treatment
• Intolerable side effects• Complications of allergy• Patients moving into the area already on
immunotherapy
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Age (yrs)2 18
100
% o
f ad
ult
A
B
C
1. IQ2. Weight3. Lymph nodes 4. OFC5. Length6. Emotional stability
MATCH