Allergic rhinitis - presentation
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Allergic rhinitis - presentation
- 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
- 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
- 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
- 35. 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
- 36. 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
- 37. • Thank you….
Editor's Notes
- Characterized by sneezing nasal blockage,
- Caused by repeated upward rubbing of the tip of the nose by the palm of hand Septal perf may be associated with chronic rhinitis,
- Pale bluish oedematous nasal mucosa Bulky turbinates Mucosa often coated with clear or mucoid secretions In advance stage polyp can be seen Nasal septum may often be thick
- Eosinophils, mast cells, epithelial cells, lymphocytes, neutrophils, goblet cells…
- Rast positive for offending allergen Rhinoscopy _ useful to rule out physical obstruction caused by septal deviation, nasal polyps etc
- Of the antihistamines, Azelastine intra-nasally has been efficacious for all forms of NAR, including Idiopathic Rhinitis. It is an H1 receptor antagonist, that also inhibits synthesis of leukotrienes, kinins, cytokines and free radicals. However, the exact mechanism of action for relief of symptoms is unknown.
- Minimize contact with offending allergens, regardless of other treatment Reduce dust mite exposure by encasing bed pillows and attress in allergen proof coveing