Allergic rhinitis: Approach to management and medical treatment

Approach to management of allergic rhinitis

1. Bassel El Baba M.D.
Otolaryngology, Head and Neck Surgery
Head of Division of Otolaryngology, Head and Neck Surgery
Makassed General Hospital

2. Defined as inflammation of the nasal mucosa
characterized by two or more of the following
symptoms:
nasal congestion
anterior/posterior rhinorrhoea
sneezing
itchy nose

3. Prevalence

4. Pathophysiology
Allergic reaction occurs in four phases

8. occurs when these nasal symptoms are the result of
IgE-mediated inflammation following exposure
to an allergen

9. Prevalence
400 million suffers worldwide
> 20% of population in UK
All ages are affected, peaks in teens
Boys more affected than girls but equalizes after
puberty
Most will be managed at Primary Health Care level

10. 30% of patients with AR have asthma
The majority of patients with asthma have AR
AR is a major risk factor for poor asthma control
All patients with AR should be assessed for asthma

11. Up to 80% of patients with bilateral chronic sinusitis
have AR
Otitis media
Conjunctivitis
Lower respiratory tract infections
Dental problems – malocclusion, discoloration
Sleep disorders

12. Subdivided into
intermittent (IAR) .v. persistent (PER)

Severity classified as
mild .v. moderate/severe

15. History and Examination
Skin prick test
Radioallergoabsorbent tests for specific IgE (RAST)
(Nasal allergen challenge)

16. Clinical Manifestations

17. Physical findings
Allergic shiners: Infraorbital edema and
darkening due to subcutaneous
venodilation
Dennie-Morgan lines: Accentuated lines or
folds below the lower lids, suggests
concomitant allergic conjunctivitis
Allergic salute: transverse nasal crease
caused by repeated rubbing and pushing
the tip of the nose up with the hand
Allergic facies: typically seen in children
with early-onset allergic rhinitis, consist
of a highly arched palate, open mouth
due to mouth breathing, and dental
malocclusion

18. SPT(SKIN PRICK TEST)
Allergen introduced into the skin causes degranulation of Ige-sensitized
mast cells with mediator release and
Formation of a wheal and flare.
Simple ,cheap & safe.
Low risk of systemic reactions.
Always undertaken where emergency equipments and resuscitation
capable staff is available.
•Should not be performed in pts on
antihistamines or with severe eczema,
previous anaphylaxis or dermagraphism.
•Positive results- reaction >2mm in under
fives >3mm in adults.
•Positive result should be at least 2mm
greater than the negative control.

19. EDUCATION/ALLERGEN AVOIDANCE
PHARMACOTHERAPY
IMMUNOTHERAPY
Others – Nasal douching
SURGERY

20. General Treatment

21. Explanation of disease, progress (atopic march),
treatments
Genetics
Breastfeeding
Parental smoking
Allergen avoidance – primary/secondary

22. COMMONLY-USED THERAPIES
Nasal saline
Glucocorticoid nasal sprays
Oral antihistamines
Antihistamine nasal sprays
Combination corticosteroid/antihistamine sprays
Oral antihistamine/decongestant combinations

23. Nasal Saline
wash allergens from the nasal passages
used alone for mild symptoms or just before other
topical medications

24. Glucocorticoid nasal sprays
The most effective single therapy for patients with
persistent and significant nasal symptoms is a
glucocorticoid nasal spray
no significant differences in efficacy, no evidence that
doses greater than the recommended maximum for each
preparation provide additional benefit

25. Nasal Corticosteroids
Beclomethasone dipropionate
Budesonide
Ciclesonide
Flunisolide
Fluticasone propionate
Mometasone furoate
Triamcinolone acetonide
First line pharmacotherapy for persistent
allergic rhinitis
Overall safe to use
• Adverse EffectsAdverse Effects
– Nasal irritation; prevented by aiming the
spray slightly away from the nasal septum
– Epistaxis
– Septal perforation (extremely rare)
– Suppressed growth

26. Oral antihistamines
First-generation sedating antihistamines are familiar to patients and available without a
prescription, but they have significant adverse effects, including sedation and impairment of
cognitive function, paradoxical agitation in young children, and anticholinergic side effects
in older adults.
Second-generation agents have few of these problems and are preferred when antihistamine
therapy is desired
Minimally-sedating agentsSedating antihistamines
diphenhydramine
chlorpheniramine
hydroxyzine
brompheniramine
cetirizine
Loratadine
Fexofenadine
Desloratadine
levocetirizine

27. Anti-leukotriene agents
Montelukast
Pranlukast
Zafirlukast
Efficacy
• Equipotent to H1 receptor antagonists
but with
onset of action after 2 days
• Reduce nasal and systemic
eosinophilia
• May be used for simultaneous
treatment of
allergic rhinitis and asthma
Safety
• Dyspepsia (approx. 2%)
Anti-leukotriene agents

28. Involves repeated administration of an allergen extract
to induce a state of immunological tolerance
More effective in limited spectrum of allergies in
particular seasonal pollen allergy
Severe symptoms failing to respond to usual Px
Subcutaneous injection/sublingual route
Studies indicate that 3 years therapy necessary

29. Topical corticosteroids and oral antihistamines (non-
sedating) form the mainstay of treatment
The newer topical steroids e.g. Mometasone furoate and
Fluticasone propionate were highest recommended
Other drugs should only be considered as second-line
treatment
Immunotherapy in selected patients can be highly
effective.

30. ARIA: Allergic Rhinitis and its
Impact on Asthma (2019)
HPF: high power field; IgE: immunoglobulin E; INAH: intranasal
antihistamine; INS: inhaled nasal steroids; LTRA: leukotriene receptor
antagonist

32. Key take-home messages

33. Thank You