Transcript Document
Allergic Rhinitis
Dr. Vishal Sharma
Introduction
Commonest chronic disease of mankind (20%)
Induced after allergen exposure by IgE-mediated
Type 1 hypersensitivity reaction of nasal mucosa
30% pt of allergic rhinitis have bronchial asthma
60-80% pt of asthma also have allergic rhinitis
Prevention of allergen exposure is best treatment
Aetiology
1. ATOPY: genetically inherited ed IgE response
2. ALLERGENS:
* Seasonal (Hay fever): Pollen, Fungus
* Perennial: Dust mite, Domestic pets, Cockroaches
* Occupational (?): Flour, Animal, Wood, Latex, Paint
3. FOOD INDUCED: Nuts, fish, prawns, legumes,
milk, cheese, egg, meat, citrus fruits, wines
4. DRUG INDUCED: Aspirin, other NSAIDs, antihypertensives, oral contraceptive pills
5. POLLUTION (NASAL IRRITANTS): Traffic fumes,
tobacco smoke, mosquito repellents, perfumes,
scented sticks, domestic sprays, bleaches
6. LACK OF INFECTION: Younger child in large
family frequent viral infections & less prone to
allergy. Older child in large family or only child in a
small family infection is rare so develops allergy.
Grass pollen & dust mite
Pathogenesis
Sensitization & Priming to specific antigen:
Inhaled allergen produces specific IgE antibody
which gets attached to mast cells
Subsequent exposure to same antigen:
Allergen combines with specific IgE antibody
degranulation of mast cells (even with small
amount of antigen) chemical mediators released
Acute or Early Phase
Occurs 5–30 min after exposure to antigen due to
release of chemical mediators sneezing, watery
rhinorrhoea, nasal blockage & bronchospasm.
Mucosal edema & Vasodilation nose block
Nerve irritation sneezing & itching
ed secretion from nasal gland rhinorrhoea
Smooth muscle contraction bronchospasm
Late or Delayed Phase
Occurs 2-8 hours after exposure due to
infiltration by inflammatory cells at site of
antigen deposition edema, congestion & thick
nasal secretion. Sneezing & itching decreases.
Inflammatory cells are eosinophils, neutrophils,
basophils, monocytes & CD4+ T lymphocytes.
Pathogenesis
Pathogenesis
Cardinal Symptoms
1. Watery rhinorrhoea
2. Nasal obstruction: bilateral
3. Paroxysmal sneezing: 10-20 at a time
4. Itching in nose, eyes, palate, pharynx
Presence of 2 or more symptoms for > 1 hour on
most days indicates allergic rhinitis.
Nasal Signs
Repeated lifting of nasal tip (allergic salute) to
relieve itching & open nasal airway transverse
nasal crease (Darrier’s crease, Hilton’s line).
Hypertrophied turbinates are covered with pale
or blue, boggy mucosa. Pitting edema seen on
probing (mulberry turbinates).
Nasal secretions are watery mucoid.
Nasal polyps with hyposmia / anosmia.
Allergic salute
Nasal crease
Pale turbinate, watery
rhinorrhoea
Blue, boggy turbinate
Inferior turbinate appearances
Other Clinical Signs
Face: Frequent twitching of face (bunny nose)
Dennie-Morgan creases (in lower eyelid skin)
Allergic shiners (dark discoloration below
lower eyelids) caused by venous stasis
Eyes: Conjunctiva is congested with cobble stone
appearance; increased lacrimation
Ears: Ear block & ed hearing (due to O.M.E.)
Throat: Chronic pharyngitis, laryngitis
Dennie-Morgan Creases
Allergic Shiners
Allergic conjunctivitis
ARIA Classification
1. Mild intermittent
2. Moderate-severe intermittent
3. Mild persistent
4. Moderate-severe persistent
ARIA = Allergic Rhinitis & its Impact on Asthma
Intermittent symptoms
Persistent symptoms
Present for < 4 days / wk
Present for > 4 days / wk
Or for < 4 weeks
and for > 4 weeks
Mild (presence of all)
Moderate-severe (any 1)
Normal sleep
Abnormal sleep
Normal daily activities
Impaired daily activities
Normal work and school
Impaired work & school
Normal sport & leisure
Impaired sport & leisure
No troublesome symptom
Troublesome symptoms +
Investigations
1. Absolute Eosinophil count
2. Nasal smear examination for eosinophils
3. Skin prick test
4. Radio-allergo-sorbent test (R.A.S.T.)
5. Diagnostic Nasal Endoscopy
6. C.T. scan P.N.S.: for sinusitis & nasal polyps
Skin prick test
Skin prick test
Skin prick test
Radio-allergo-sorbent test
Pt serum is incubated with allergen disc. Only
specific IgE binds with allergen. Rest is washed
away with a buffer.
Disc is incubated with radio-labeled anti - IgE
antibody. Anti-IgE antibody binds with allergenIgE complex.
Amount of radio-labelled anti-IgE antibody on
disc amount of IgE & is quantified by
counting radioactivity from the disc.
Complications
1. Recurrent sinusitis
2. Nasal polyp
3. Serous otitis media
4. Prolonged mouth breathing
5. Bronchial asthma
6. Atopic dermatitis
7. Conjunctivitis
Differential diagnosis
Vasomotor rhinitis
Rhinitis medicamentosa
Hormonal rhinitis (pregnancy, hypothyroidism,
oral contraceptive use)
Cerebrospinal fluid leak
Ethmoid polyps
Treatment
1. Avoidance of allergens
2. Pharmacotherapy
3. Specific Immunotherapy
4. Surgery: F.E.S.S., Turbinoplasty
Pharmacotherapy
H1-Antihistamines: Topical (Azelastine), Systemic
Nasal Decongestants: Topical drops, Systemic
Mast cell stabilizers: Sodium cromoglycate, Ketotifen
Anti-cholinergics: Ipratropium bromide nasal spray
Corticosteroids: Nasal, Oral, Turbinal, Intramuscular
Leukotriene receptor antagonists: Montelukast
Newer drugs: RhuMAb-25, Altrakincept
Antihistamines &
Decongestants
Antihistamines
Systemic decongestants
Cetirizine (S)
Phenylephrine
Fexofenadine (S)
Pseudoephedrine
Loratidine (S)
Topical decongestants
Levocetrizine (S)
Xylometazoline
Desloratidine (S)
Oxymetazoline
Azelastine (T)
Hypertonic saline
Antihistamines
Systemic:
Cetirizine: 10 mg OD
Fexofenadine: 120 mg OD
Loratidine: 10 mg OD
Levocetrizine: 5 mg OD
Desloratidine: 5 mg OD
Topical: Azelastine spray (0.1%): 1-2 puff BD
Nasal Decongestants
Systemic decongestants
Phenylephrine
Pseudoephedrine
Topical decongestants
Xylometazoline
Oxymetazoline
Saline
Anti-cold preparations
Name
Chlorpheniramine Decongestant Paracetamol
COLDIN
4 mg
PsE 60 mg
500 mg
SINAREST
4 mg
PsE 60 mg
500 mg
DECOLD
4 mg
PhE 7.5 mg
500 mg
SUPRIN
2 mg
PhE 5 mg
500 mg
PsE = Pseudoephedrine;
PhE = Phenylephrine
Topical Decongestants
Oxymetazoline 0.05 %: 2-3 drops BD (NASIVION)
Oxymetazoline 0.025 %: 2 drops BD (NASIVION-P)
Xylometazoline 0.1 %: 3 drops TID (OTRIVIN)
Xylometazoline 0.05 %: 2 drops BD (OTRIVIN-P)
Saline 2 %: 3 drops TID
Saline 0.67 %: 2 drops BD (NASIVION-S)
Systemic Antihistamines
Topical Antihistamine spray
Technique of nasal spray
Nasal Decongestants
Sodium Cromoglycate
Ipratropium nasal spray
Corticosteroids
Nasal sprays
Injectable
Beclomethasone
Methylprednisolone
Budesonide
Fluticasone
Oral
Mometasone
Prednisolone
Corticosteroid nasal spray
Methylprednisolone acetate
Montelukast
Drug
Sneeze Rhinor Nasal Nose ed
rhoea block itch smell
Antihistamine
+++
++
+
+++
0
Steroid spray
+++
+++
+++
++
+
Oral steroid
+++
+++
+++
++
++
Cromoglycate
+
+
+
+
0
Topical nasal
decongestant
0
0
++++
0
0
Ipratropium
0
++
0
0
0
Monteleukast
0
+
++
0
0
Specific Immunotherapy (SIT)
Indications:
1. Insufficient response to conventional drugs
2. Side effects from conventional drugs
3. Rejection of conventional drug treatment.
4. Allergy to one or two allergens only
Types:
Systemic injection, intra-nasal, sublingual
Injectable S.I.T.
Serial subcutaneous injections of immunogenic
extracts from relevant allergen in increasing
concentration.
Injections given twice weekly until response is
noticed (6-20 wk) given weekly for 1 year
fortnightly for 1 yr every 3 weeks for 1-3 yr.
Injectable S.I.T.
Intranasal & sublingual S.I.T.
Can use 50-100 times greater doses compared to
injection immunotherapy.
Considered in selected patients with:
systemic side effects
refusal to injection treatment
Treatment protocol
Mild intermittent
H1-Antihistamine + Nasal decongestant
No Improvement after 1 month
Treat as Moderate-severe Intermittent
In case of improvement: Step down & continue
treatment for 1 month
Moderate-severe intermittent & Mild persistent
H1-Antihistamine + Nasal decongestant
+ Corticosteroid nasal spray
No Improvement after 1 month
Double dose Corticosteroid nasal spray
Ipratropium for rhinorrhoea Cromoglycate
for seasonal cases Montelukast for asthma
No Improvement after 1 month
Specific Immunotherapy + Newer Drugs
Moderate-severe persistent
H1-Antihistamine + Nasal decongestant + double
dose Corticosteroid nasal spray + Montelukast
No Improvement after 1 month
Add short course of oral corticosteroid
Add Ipratropium spray for rhinorrhoea
Consider surgery for polyps / turbinates
No Improvement after 1 month
Specific Immunotherapy + Newer Drugs
General advice
Avoid cold drinks, ice cream & very cold air
Avoid cigarette smoke & traffic fumes
Avoid strong perfumes, scented sticks & cosmetics
Avoid head bath with cold water. Use warm water.
Avoid mosquito repellents / bleaches
Have a balanced diet to improve body immunity
Sleep with head elevated to se nasal congestion
Adequate fluid intake to loosen nasal secretions
Exercise regularly
Avoid foods & drugs to which you are allergic
Avoid occupational irritants or change profession
Remove furred animals (cats, dogs) from
bedroom. Wash the pet weekly with warm water
Keep bathroom, kitchen, basement + attic clean &
well ventilated. Avoid damp areas. Remove
houseplants & dried flowers.
Use insect repelling chalks. Avoid sprays. Avoid
collection of spilled food material.
Pollen advice
Avoid walking in open grassy spaces during hot, dry
days. Move outdoors only on damp days.
Keep windows closed. Move flowering plants away
from doors & windows.
Wear facemask & sunglasses when moving out.
Keep grass & plants trimmed. Get rid of weeds &
leaves.
Plant less allergenic flowers & trees.
House dust mite advice
Use foam pillows & mattresses with dust-proof cover.
Remove carpets, upholstered furniture, stuffed toys,
old newspapers & magazines.
Wash bedcovers & clothes in warm water.
Damp-wipe house regularly wearing a facemask.
Use vacuum cleaners with high-efficiency particle
arresting (HEPA) filters weekly.
Use air-conditioning (with pollen filters) to maintain
the humidity less than 50 %.
Thank You