Allergic rhinitis - presentation

brief summary of Allergic rhinitis and its management

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1. ALLERGIC RHINITIS S PANDEY

2. Outline Definition and Introduction Etiologies Presentation Diagnosis Prognosis Management

3. RHINITIS Two or more nasal symptoms of: Nasal congestion Rhinorrhea Sneezing/Itching Impairment of Smell for more than 1 hour a day

4. 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 .

5. Introduction Nasal function includes Temperature regulation Olfaction Humidification Filtration and Protection

6. 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

7. 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

8. etiology Classified as Precipitating factors Predisopsing factors

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. Complications: Allergic asthma Chronic otitis media Hearing loss Chronic nasal obstruction Sinusitis Orthodontic malocclusion in children

18. 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

19. 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

20. Extra nasal manifestations Retracted and abnormal flexibility of TM Injection and swelling of palpebral conjunctivae with excess tearing Cobblestoning on oropharynx

21. 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

22. 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

23. 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

24. 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

25. 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

26. MANAGEMENT: MEDICAL SURGICAL AVOIDANCE

27. 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…..

28. 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

29. Commonly Prescribed Antihistamines

30. Anticholinergenic agents Inhibit mucous secretions, act as drying agent Topical eye preparations Reduce inflammation and relieve itching and burning

31. 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

32. Leukotriene receptor antagonists Montelukast ( singulair ) and Zafirlukast ( accolate ) Systemic agents used for asthma Reduce inflammation, edema and mucous sectetions of allergic rhinitis

33. Topical Nasal Steroids

34. MEDICAL TREATMENT Avoid the allergen Lifestyle changes Career changes Pharmacotherapy Antihistaminic drugs Steroids Sodium chromoglycate Stabilises mast cell and prevents degranulation of mast cells thus reduces symptomatic manifestations Decongestants Saline irrigation of nasal cavity

35. AMERICAN ALLERGOLOGY GUIDELINES

36. 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

37. 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