ALLERGIC RHINITIS

S PANDEY

OUTLINE

•Definition and Introduction

•Etiologies

•Presentation

•Diagnosis

•Prognosis

•Management

RHINITIS

•Two or more nasal symptoms of:

• Nasal congestion

• Rhinorrhea

• Sneezing/Itching

• Impairment of Smell for more

than 1 hour a day

RHINITIS

• Occurs most commonly as allergic rhinitis

• Noninfectious rhinitis has been classified as either

allergic or non-allergic.

• Allergic rhinitis is defined as immunologic nasal

response, primary mediated by immunoglobulin E (IgE).

• Non-allergic rhinitis is defined as rhinitis symptoms in

the absence of identifiable allergy, structure abnormality

or sinus disease.

INTRODUCTION

• Nasal function includes

• Temperature regulation

• Olfaction

• Humidification

• Filtration and Protection

INTRODUCTION

• Nasal lining contains secretion of IgA, proteins and enzymes

• Nasal Cilia propel the matter toward the natural ostia at frequency of 10-15 beats per minute

• Mucous move at a rate of 2.5-7.5 ml per minute

ALLERGIC RHINITIS

• Defined as an inflammation of the nasal mucosa, caused by an allergen

• Most common atopic allergic reaction

• Affects 10 to 25% of population

• 50% of rhinitis in ENT is AR

• Most commonly seen in young children and adolscents

ETIOLOGY

• Classified as

• Precipitating factors

• Predisopsing factors

PRECIPITATING FACTORS• Aerobiological flora

• Allergens present in the environment

• House dust and dust mites

• Feathers

• Tobacco smoke

• Industrial chemicals

• Animal dander

• Nasal physiology

• Disturbances in normal nasal cycle

PREDISPOSING FACTORS

• Genetic

• Multiple gene interactions are responsible for allergic phenotype

• Chromosomes 5, 6, 11, 12 & 14 control inflammatory process in atopy

• 50% of allergic rhinitis patients have a positive family history of allergic rhiniits

• Endocrine

• Puberty

• Pregnant states and post partum stages

• menopausal

PREDISPOSING FACTORS….

• Psychological

• Focal sensitivity states

• Infections: fungal infections nb

• Physical

• Degree of pollution of air

• Humidity and temperature differences

• Temperature changes

• Age & sex

• IgA deificiency

COMMON ALLERGENS• Pollens

• Spring tree pollens(maple alder, birch)

• Summet : grass pollent (bluegrass, sheep shorell etc

• Autums: weed pollen (ragweed)

• Molds

• Penicillium, cladosporium etc

• Insects

• Cockroaches, house flies, fleas, bed bugs

• Animals

• Cats. Dogs. Horse, monkeys, rats, rabbits etc

• Dust mites

• dermatophagoides

• Ingestants

• Nuts, fish, eggs, milk etc

PATHOPHYSIOLOGY

• Immunoglobulin (Ig) E mediated type 1 hypersensitivity response to an antigen (allergen) in a genetically susceptible person

• Type 1 Hypersensitivity causes local vasodilation and increased capillary permeability

CLASSIFICATON - FORMER

• Seasonal

• Often known by it’s misnomer of Hay fever

• Neither caused by hay or has fever

• Summer cold

• Caused by virus causing URTI (not a true allergic rhinitis

• Rose fever

• Often cited in indian subcontinent

• Colourful or fragrant flowering plants rarely cause allergy as their pollens to heavy to be airborne

• Perennial

• Allergens present throughout the year

CLASSIFICATION - CURRENT

• Intermittent

• Symptoms present less than 4 days per week and less than 4 weeks per year

• Persistant

• Symptoms present more than 4 days per week and more than 4 weeks per year

SEVERITY

• Mild

• No interference with daily activity or troublesome symptoms

• Moderate – severe

• Presence of at least one:

• Impaired sleep, daily activity work or school

• Troublesome symptoms

COMPLICATIONS:

• Allergic asthma

• Chronic otitis media

• Hearing loss

• Chronic nasal obstruction

• Sinusitis

• Orthodontic malocclusion in children

SIGNS AND SYMPTOMS

• Sneezing

• Itchy nose, ears, eyes and palate

• Rhinorrhea

• Post nasal drip

• Congestion

• Anosmia

• Headache

• Earache

• Tearing of eyes

• Red eyes

• Swollen eyes

• Fatigue

• Drowsiness

• Malaise

PHYSICAL EXAMINATION• Nasal crease

• Horizontal crease across the lower half of the bridge of the nose

• Rhinorrhoea

• Thin watery secretions

• Deviated or perforated nasal septum

EXTRA NASAL MANIFESTATIONS

• Retracted and abnormal flexibility of TM

• Injection and swelling of palpebral conjunctivae with excess tearing

• Cobblestoning on oropharynx

CLASSICAL SIGNS OF AR

• Over bite

• High arched palate

• Allergic shiners

• Allergic salute

• Transverse crease over tip of nose and lower eye lid

• Conjunctival congestion

• Periorbital oedema

INVESTIGATIONS

• FBC

• Histamine test

• Nasal smear

• Intranasal provocation test

• Skin tests

• Subcuticular test

• More accurate with lower incidence of false positive results

• Contraindicated in case of anti histaminic, anti inflammatory or decongestant treatment

• Intradermal tests

• Be prepared for anaphylaxis

• Skin end point titration test

• Quantitative intradermal test for specific allergen

• Nasal challenge

• Nasal cytology

• Take a sample of nasal cavity without anaesthesia and send for identificaton of cell types in the nasal cavity

• Increased number of eosinophils suggests allergic disease

OTHER INVESTIGATIONS

• RAST (radio allergo sorbant test)

• FAST ( fluro allergo sorbant test)

• PRIST (paper immuno allergo sorbant test)

• Xray PNS

• CT PNS (for complicated cases with polyposis)

• Nasal endoscopy ( under local or GA)

• Evaluate for asthma

PROGNOSIS

• Treatment is available and patients remain symptom free only until re exposure to allergic antigen

• No evidence of mortality from the disease itself, but high morbidity

• Seasonal allergic Symptoms improve as patients age

MANAGEMENT:

MEDICAL SURGICAL

AVOIDANCE

AVOIDANCE

• Minimize contact with offending allergens

• Reduce dust mite exposure by encasing bed pillows and matress in allergen proof covering

• Use of allergen proof bedding…..

ACUTE PHASE MEDICATIONS

• Antihistamines effectively block histamine effects (runny nose and watery eyes)

• Side effects : sedation, dry mouth, nausea, dizziness, blurred vision, nervousness

• Non sedating antihistamines (cetrizine, loratidine)

• Fewer side effects

• Fexofenadine may be effective

• Carries a lower risk of cardiac arrythmias

• Decongestants

• Shrink nasal mucous membrane by vasoconstriction

• Available OTC and in combination with antihistamines, analgesics and anti cholinergics

COMMONLY PRESCRIBED ANTIHISTAMINES

• Anticholinergenic agents

• Inhibit mucous secretions, act as drying agent

• Topical eye preparations

• Reduce inflammation and relieve itching and burning

MEDICAL: PREVENTIVE THERAPY

• Intranasal corticosteroids

• Reduce inflammation of mucosa

• Prevent mediator release

• Can be used safely daily

• May be given systemically for a short course during a disabling attack

• Intranasal cromolyn sodium

• Mast cell stabiliser

• Prevents release of chemical mediators

• Oral mast cell stabilizer

• Otpthalmic solution cromolyn

• Leukotriene receptor antagonists

• Montelukast (singulair) and Zafirlukast (accolate)

• Systemic agents used for asthma

• Reduce inflammation, edema and mucous sectetions of allergic rhinitis

TOPICAL NASAL STEROIDS

AMERICAN ALLERGOLOGY GUIDELINES

IMMUNOTHERAPY• If allergic rhinitis is refractory to

pharmacotherapy or severe

• Helps in reducing the specific serum IgE level

• decreases the basophil sensitivity

• increases IgG blocking antibody level , thus preventing allergen from reaching mast cells and subsequent mast cell degranulation

SURGICAL THERAPY

• Limited

• Submucosal turbinectomy - reduces size of boggy turbinates

• Septoplasty – correction of deviation of septum

• Sinus surgery – clearance of sinuses if sinusitis is present

• Thank you….