Allergic Rhinitis - srfmr. · PDF fileRhinitis medicamentosa Chronic sinusitis Summary Verify...

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Transcript of Allergic Rhinitis - srfmr. · PDF fileRhinitis medicamentosa Chronic sinusitis Summary Verify...

  • 8/9/2012

    1

    Allergic RhinitisAllergic Rhinitis Christine Hancock, R3Christine Hancock, R3 Cycle 2 Ambulatory Chief TalkCycle 2 Ambulatory Chief Talk Santa Rosa Family Medicine ResidencySanta Rosa Family Medicine Residency August 9, 2012August 9, 2012

    OutlineOutline

    Signs & SymptomsSigns & Symptoms

    �� Paroxysms of sneezing, rhinorrhea, Paroxysms of sneezing, rhinorrhea, nasal obstruction & postnasal nasal obstruction & postnasal drainagedrainage

    �� Periorbital and conjunctival Periorbital and conjunctival erythema, infaorbital cyanosiserythema, infaorbital cyanosis

    �� Swollen, pale nasal turbinates with Swollen, pale nasal turbinates with dimplingdimpling

    �� “Allergic salute”“Allergic salute”

    �� Perennial vs seasonalPerennial vs seasonal

    Differential DiagnosisDifferential Diagnosis

    ��URI (“infectious rhinitis”)URI (“infectious rhinitis”)

    ��Rhinitis 2/2 medsRhinitis 2/2 meds

    ��Rhinitis medicamentosaRhinitis medicamentosa

    ��Vasomotor rhinitis/NARES “nonVasomotor rhinitis/NARES “non-- allergic rhinitis with eosinophilia allergic rhinitis with eosinophilia syndrome”syndrome”

    ��Congenital syphillis, CSF rhinorrhea, Congenital syphillis, CSF rhinorrhea, pregnancy, hypothyroidismpregnancy, hypothyroidism

    ��AspirinAspirin--induced asthmainduced asthma

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    DiagnosisDiagnosis

    �� ClinicalClinical

    �� *Skin testing**Skin testing*

    �� Unclear dxUnclear dx

    �� Poorly controlled Poorly controlled

    symptomssymptoms

    �� Coexisting asthma/Coexisting asthma/

    recurrent sinusitisrecurrent sinusitis

    �� (RAST testing)(RAST testing)

    TreatmentsTreatments

    1. Non1. Non-- pharmacologicpharmacologic

    2. Pharmacologic2. Pharmacologic

    NonNon--pharm: pharm: Allergen AvoidanceAllergen Avoidance

    �� AnimalsAnimals: keep out of pts bedroom, keep in room : keep out of pts bedroom, keep in room w/ HEPA filter, use vacuum w/ HEPA filterw/ HEPA filter, use vacuum w/ HEPA filter

    �� Dust mitesDust mites: mattress, pillow, boxspring covers, : mattress, pillow, boxspring covers, wash bedding weekly (?hot water), reduce indoor wash bedding weekly (?hot water), reduce indoor humidity, remove carpethumidity, remove carpet

    �� CockroachesCockroaches: Exterminate, clean home thoroughly, : Exterminate, clean home thoroughly, encase food fully, fix water leaksencase food fully, fix water leaks

    �� MoldMold: Clean surfaces w/ bleach solution, fix leaks, : Clean surfaces w/ bleach solution, fix leaks, reduce humidityreduce humidity

    Continued…Continued…

    �� Outdoor allergensOutdoor allergens: close windows at home and in : close windows at home and in car, stay indoors, use AC to filter air, shower before car, stay indoors, use AC to filter air, shower before bed, dry laundry inside, wear glasses, rinse contacts, bed, dry laundry inside, wear glasses, rinse contacts, avoid windy days and mornings between 5avoid windy days and mornings between 5--10AM, 10AM, take meds 1 hour before heading outdoorstake meds 1 hour before heading outdoors

    �� Use nasal rinses: make your own normal saline! Use nasal rinses: make your own normal saline! (SOR B)(SOR B)

    �� 4 c (1 qt) of water, boiled for 5 min (?), plus4 c (1 qt) of water, boiled for 5 min (?), plus

    �� 11⁄2 level tsp of table salt 11⁄2 level tsp of table salt -- (Brown & Graham 2004)(Brown & Graham 2004)

    Pharmacologic TxPharmacologic Tx

    1.1. Antihistamines (Antihistamines (diphenhydramine, loratadine, diphenhydramine, loratadine, cetirizine, fexofenadinecetirizine, fexofenadine): Often first line for ): Often first line for mild sxmild sx

    2.2. Intranasal glucocorticoids (budesonide, Intranasal glucocorticoids (budesonide, fluticasone, etc.): Most effective, should be fluticasone, etc.): Most effective, should be first line if moderate to severe sxfirst line if moderate to severe sx

    3.3. Nasal decongestant sprays (topical Nasal decongestant sprays (topical vasoconstrictors vasoconstrictors -- phenylephrine, phenylephrine, oxymetazolineoxymetazoline))

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    Treatment, contd…Treatment, contd…

    �� Mast cell stabilizers Mast cell stabilizers (cromolyn), (cromolyn), leukotriene leukotriene modifiersmodifiers (monteleukast), (monteleukast), ipratropium, ipratropium, ocular ocular preprationspreprations

    �� Systemic glucocorticoidsSystemic glucocorticoids: short course ok if patient : short course ok if patient can’t sleep or work. can’t sleep or work.

    �� Allergen immunotherapyAllergen immunotherapy

    I’m Prego! Now What?I’m Prego! Now What?

    �� NonNon--pharmacologic methodspharmacologic methods

    �� Cromolyn = 1Cromolyn = 1stst line (excellent safety line (excellent safety profile)profile)

    �� Intranasal glucocorticoidsIntranasal glucocorticoids

    �� Antihistamines Antihistamines –– loratadine, loratadine, cetirizine, cholorpheniraminecetirizine, cholorpheniramine

    ComplicationsComplications

    ��Acute bacterial sinusitisAcute bacterial sinusitis

    ��Triggering of other conditions (asthma, eczema)Triggering of other conditions (asthma, eczema)

    ��EpistaxisEpistaxis

    �� InsomniaInsomnia

    ��Rhinitis medicamentosaRhinitis medicamentosa

    ��Chronic sinusitisChronic sinusitis

    SummarySummary

    �� Verify the cause of the allergic sx by history +/Verify the cause of the allergic sx by history +/-- testing.testing.

    �� Reduce allergen exposureReduce allergen exposure

    �� Start an inhaled corticosteroid, a second generation Start an inhaled corticosteroid, a second generation antihistamine, or bothantihistamine, or both

    �� For resistant nasal sx, add a LTRA, for resistant other sx For resistant nasal sx, add a LTRA, for resistant other sx consider cromolyn or an ocular antihistamineconsider cromolyn or an ocular antihistamine

    �� Start allergy shots if inadquate relief with meds or if Start allergy shots if inadquate relief with meds or if allergies are worsening asthma or sinusitis.allergies are worsening asthma or sinusitis.

    ReferencesReferences

    �� Brown, Christopher, and Graham, Scott. Nasal Brown, Christopher, and Graham, Scott. Nasal Rinses: Good or Bad, Curr Opin Otolaryngol Head Rinses: Good or Bad, Curr Opin Otolaryngol Head Neck Surg 12:9Neck Surg 12:9––13. © 200413. © 2004

    �� Plaut, Marshall, and Martin Valentine. 2005. Plaut, Marshall, and Martin Valentine. 2005. Allergic Rhinitis. Allergic Rhinitis. NEJMNEJM 353(18): 1934353(18): 1934--1945.1945.

    �� Saline Nasal Irrigation for Upper Respiratory Saline Nasal Irrigation for Upper Respiratory ConditionsConditions. Am Fam Physician. 2009 November 15; . Am Fam Physician. 2009 November 15; 80(10): 111780(10): 1117––1119 (PDF).1119 (PDF).

    �� UpToDateUpToDate Thanks for listening!