Transcript THE NOSE - University of Mauritius

THE NOSE
Dr Serge Maurice FRCSE
02 April 2008
Functions of the nose
 To
 To
smell
filter, warm and humidify the air
we breathe
Some anatomical souvenirs
Noses come in various shapes or sizes
Allergic Rhinitis
Doctère, mo éna ène mari problème ek mo néné
Changes in Terminology
 “OLD”:
 “NEW”:
Seasonal & Perennial
Acute or Intermittent and
Chronic or Persistent (WHO 2000)
The Symptoms
 Seasonal/Acute:
Rhinorrhea.
Itching, Sneezing,
 Perennial/Chronic:
The blocked nose
The Acute Symptoms
 The
 The
 The
 The
 The
 The
tingle
itchy nose
volley of sneezes
flooding rhinorrhea
ocular symptoms
itchy palate
Acute symptoms: Sneezing &
Rhinorrhea
The Chronic Symptoms
A blocked nose, often with hyposmia &
hypoguesia
 Recurrent bouts of AOM in kids
 Otitis Media with effusion in kids and
adults
 The allergic salute
 Recurrent bouts of acute sinusitis in adults
 Chronic sinusitis and nasal polyposis
 A nasal voice
 Snoring and OSA in kids and adults

Chronic Symptom: Blocked nose
The allergic salute
Massive polyposis
The Culprits: Pollens
 In
the
Mauritian
context, a
frequently
accused
innocent:
the sugar
cane pollen
Flowers
Grasses and Trees
Moulds and Mites, Cockroaches
Pet animals
The Allergic Reaction
 An
Idiot’s Guide to the chain of
reactions, from the first meeting to
the divorce!
The first date -1
MACROPHAGE
ANTIGENS
The macrophage ingests the allergens, breaks them up and
presents some of their chemicals to the immune cells, the
lymphocytes
The first date -2
Lymphocyte
Plasmocyte
Antibodies
The lymphocytes send
a message to the
plasmocytes, that
produce the antibodies
Mastocyte
The antibodies attach
themselves firmly to the
mastocytes(containing granules
that intervene in the
inflammatory reaction) and to
basophils
The second date -1
The antigens this time link up to the
antibodies attached to the mastocyte, and
the latter is then activated
The second date -2
The activated mastocyte liberates its
granules, that contain histamine and
other inflammatory chemicals,(triptase,
prostaglandins) responsible for the
allergic reaction
The Start
ImmunoglobulinE (IgE)
Specially in the mastocytes
ALLERGEN
ALLERGIC
REACTION
Inflammatory Mediators
Cytokines
The Progression
Histamine
Leukotrienes
Immediate Reaction:
Acute Inflammation
Vasodilatation,oedema
Mucus++ Itching
Watery Rhinorrhea
Pruritus
Sneezing++++
Early Phase
Cytokines, Interleukins
Neutral proteases
Late Reaction:
Chronic Inflammation
Congested Mucosa
Obstruction, Infection
Blocked nose
Sinusitis
Pharyngitis
Otitis
Late Phase
Diagnosis
HISTORY: ALL IMPORTANT
 Simple Rhinoscopy: Pale, boggy, bluish
mucous membrane
 Sometimes Polyps
 Skin scratch tests and lab tests (RAST,
Phadiatop, Total IgE(inaccurate), nasal
IgE, nasal mucus eosinophils)-test food
allergies in kids
 Imaging NOT necessary for simple AR

Differential Diagnosis
 Chronic
Idiopathic Rhinitis (V.M.R)
 NARES
 Nasal
hypersensitivity, specially to
dust, perfume, tobacco
smoke,SO2,NO2, cold air
 Drug induced- Aspirin (Widal’s), ACE
inhibitors, HRT, Methyl
DOPA,Reserpine
 Last trimester of pregnancy
Treatment Principles
 Acute/Intermittent/Seasonal
Symptoms
 Chronic/Persistent/Perennial
Symptoms
Allergen Avoidance
 If
the allergen has been identified:
 Avoid grass pollens
 Get rid of offending pets
 Treat pillows and mattresses
 Avoid offending foods
 But,
unfortunately, more often than
not, medication needed
Acute Symptoms
 Local
and Systemic decongestants
 2nd
Generation Antihistamines,
systemic and local
 Local
Steroids
Chronic Symptoms
 Local
 2nd
and systemic steroids
Generation Antihistamines
 Other
drugs/measures
Other drugs/measures
 Sodium
Cromoglycate
 Ipatropium Bromide (rhinorrhea)
 SIT & SLIT
 Leukotriene antagonists
(Zafirlukast, Montelukast)
 Empirical dietary exclusion of cow’s
milk and food additives (benzoates,
nitrites, sulphites, colourings)
Specific Immunotherapy
 Sublingual
or injection
 Should be reserved for mono/bi
allergens (e.g. grass pollen & housedust mite)
 NOT as first line, but if other
measures useless
 Injection method should only be
done with resuscitative facilities
available
Side-Effects -1
 Early
2nd G. antiH: (Astemizole,
Terfenadine..) : Liver and cardiac
problems when used in association
with some other drugs
 Newer ones (fexofenadine, cetirizine,
loratidine…):safe, but still cause
drowsyness
 Local acting (levocabastine,
azelastine,): local irritation &
unpleasant taste
Side effects -2
 Local
decongestants – abuse & R.M.
 Systemic decongestants – glaucoma,
prostate, HBP, palpitations, insomnia
 Local Steroids sprays – Great, but
local irritation, epistaxis & no effect
on eye/palate itch
 Cromoglycate – qds, hence poor
compliance
 Ipatropium – only on drip
Systemic Steroids??
 Very
useful in treatment of infective
acute episodes (High Dose Short
Term)
 BE
VERY WARY OF THE DEPOT
STEROID INJECTIONS: Osteoporosis,
muscle damage, diabetes, glaucoma,
cataracts, gastric ulcers…
Some other helpful(?) measures
 Saline
douches
 Petroleum jelly (Vaseline) application
 Inhalations
 Anti-oxidants (Vit C, E, Beta
carotene, zinc, selenium…)
 “Muco-regulators” (carbocisteine..)
To summarise:
 The
problem with allergies such as
Hay fever and Allergic Rhinitis is that
it is considered to be a trivial and
inconsequential disease. Symptoms
such as runny nose, itchy eyes and
nose with sneezing and blockage are
obviously not life threatening, but
affect up to 25% of the population
and are the cause of significant
disability and cost to society…/cont.
To summarise (cont)
Patients may also experience fatigue,
irritability, as well as mood, cognitive and
sleep disturbance in addition to the nasal,
ocular and throat symptoms. Allergic
rhinitis has important co-morbid
associations such as chronic sinusitis, glue
ear, asthma exacerbations, nasal polyps,
sleep apnoea and dental malocclusion.
 Dr A Morris, January 2007, Surrey Allergy
Clinic

 Thank
you for your attention