Transcript Allergic Rhinitis

Allergic and
Nonallergic Rhinitis
Dr.Babak Saedi
Assistant Professor of Otolaryngology
Tehran University of Medical Sciences
Types of Rhinitis
Pure allergic rhinitis
43%
Pure nonallergic rhinitis
23%
Mixed
34%
100%
57% Non allergic component
National Allergy Advisory Council meeting, The broad spectrum of rhinitis: etiology,
diagnosis, and advances in treatment. St. Thomas,
US Virgin Islands; 1999.
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Prevalence of Allergic
Rhinitis by Age Group
What is Allergic Rhinitis?
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Inflammation of the nasal mucous
membrane
An immune response to inhaled allergens
Types of Immune Response
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Immediate Response (minutes)
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Histamine, tryptase, chymase, kinins, and
heparin, leukotrienes, and prostaglanin D2
• Mucous membrane stimulated
• Vascular permeability increased
• Sensory nerves are stimulated
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Late Response (4-8 hours)
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Neutrophils, eosinophils, lymphocytes, and
macrophages
• Inflammation continues
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Sources of rhinitus symptoms
Symptoms of Allergic
Rhinitis Are:
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Sneezing
Nasal Itching
Rhinorrhea (running nose)
Nasal Congestion
May accompany with itching of eye,
throat, and ears
Systematic effects
• Fatigue
• Sleepiness
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Usually not life threatening
Symptoms
Direct:
 Nasal congestion
 Rhinorrhea
 Pruritis
 Sneezing
 Eye tearing & pruritis
 Ear & palate pruritis
 Post nasal drip
 Anosmia
Quality-of-Life Issues
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Fatigue
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Missing school/work
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Concentration
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Halitosis
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Nuisance
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Sleep disturbance
Decreased daily
production
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Impaired studying
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Sniffing/snorting
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Blowing nose
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Emotional well being
Social interactions
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Physical Changes of Allergic Rhinitis
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Pale blue, edematous turbinates
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Clear, watery nasal discharge
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Crease from nasal salute
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Lymphoid hyperplasia
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Watery, itchy eyes
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Photo Image of Nasal Salute
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General Approach to
Treatment
Avoidance
 Specific immunotherapy
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Specific allergen
 Desensitizing
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Pharmacotherapy
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Identify type of allergy rhinitis
Two Types
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Seasonal Allergic Rhinitis
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AKA “hay fever”
Caused by seasonal allergens such as pollen
from flowers, trees, weeds, etc.
Perennial Rhinitis
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Non-seasonal allergens
• Dust mites
• Animal dander
• Molds
http://www.myatmosphere.biz/graphics/Dust_Mites.jpg
Diagnosis/Tests
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Detailed history
• Nature,duration, and course of symptoms
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Physical
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Facial features, eyes,ears, and nose
Tests
• Allergy tests
• IgE count
• Eosinophil count
Treatment of Allergic
Rhinitis (ARIA)
Moderate
severe
intermittent
Mild
intermittent
< 4 d/wk or
< 4 wks
< 4 d/wk or
< 4 wks
Mild
persistent
> 4 d/wk and
> 4 wks
Moderate
severe
persistent
> 4 d/wk and
> 4 wks
Intra-nasal steroid
Intra-nasal cromolyn
Oral or intra-nasal H1-blocker
Intra-nasal decongestant (< 10 days) or oral decongestant
Allergen and irritant avoidance
Immunotherapy
4/11/2016
Pharmacotherapeutic Options
Medication Class
Antihistamines
Symptoms Controlled
Sneezing, rhinorrhea, itching,
conjunctivitis
1st generation
2nd generation
3rd generation
Comments
First line therapeutic
For seasonal allergic rhinitis
• If sedation is a problem move
to non sedative
For perennial allergic rhinitis
• Use as alternative or
combination with intranasal
steroid
Over the Counter
Benadryl, Claritin, ChlorTrimeton, Dimetane, Tavis
Prescription
Clarinex, Allegra, and Zyrtec
Ophthalmic Intranasal
Ocular Symptoms
Decongestants
Nasal Congestion
Intranasal Corticosteroids
Sneezing, rhinorrhea, itching, nasal
congestion
Mast Cell Stabilizers
Use before allergen’s season
Improvements wont be noticed for up to a month in perennial rhinitis
Intranasal Anticholinergics
Rhinorrhea
Excellent choice for perennial rhinitis
How Does Antihistamine Work?
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Competitive antagonists to
histamine
Example
Characteristics of …
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First Generation Antihistamine
Less selective
 Drowsiness
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Second and Third Generation
Antihistamine
Selects for peripheral H1 receptors
 Little drowsiness
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Side Effects
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Side effects through anticholinergic
properties
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α- adrenergic receptors
• Norepinephrine
• Epinephrine
• Dopamine
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5-HT receptors
• Seratonin
Structures of …
Dopamine
Histamine
Norepinephrine
Adverse Side Effects
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1st Generation
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Dizziness
Tinnitus (ringing in ear)
Blurred vision
Euphoria
Uncoordination
Anxiety
Insomnia
Tremor
Nausea
Headache
Hallucination
Psychosis
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2nd & 3rd Gen.
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Fatigue
Headache
Nausea
Dry mouth
Structural Examples
First Generation H1-receptor
Antagonists
Ethanolamines
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Akylamines
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Chlorpheniramine
(Chlor-Trimeton)
Piperzamines
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Diphenydramine
(Benadryl)
Vistaril
(Hydraxyzine)
Antivert (Meclizine)
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Tricyclics
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Promethazine
(Phenergan)
http://www.allergizer.com/50226711/images/Phenergan.jpg
http://www.petplace.com/articles/images/235906991thm.jpg
Second Generation H1-receptor
Antagonists
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Certirizine (Zyrtec)
Terfendadine
(withdrawn)
Loratadine
(Claritin)
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www.edrugnet.jp/Productphoto/zyrtec.jpg
Third Generation H-1
Receptor Antagonists
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Levocetirizine
Desloratadine
(Clarinex)
Fexofenadine
(Allegra)
http://www.encolombia.com/images/vademecum/allegra_caja.jpg
http://celestinejim.tripod.com/images/Clarinex.jpg
What is the role of surgery?
•Highly effective
•Submucosal resection for good long term results