Transcript allergic rhinitis

RHINITIS
Dr. Abdullah Alkhalil
MRCS-ENT(UK), DOHNS(London)
Higher specialty(JUST),
Jordanian Board.
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Definition
• Defined as inflammation of the nasal mucosa
characterized by two or more of the following
symptoms:
nasal congestion
anterior/posterior rhinorrhoea
sneezing
itchy nose
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Classification
• Infective
• Allergic
• Non-infective, Non-allergic
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Infective Rhinitis
• Viral
– Common cold
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Rhinovirus
Parainfluenza
RSV
Adenovirus
– Influenza
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Infective Rhinitis
• Bacterial
– Simple
– Syphilis
– TB
– Atrophic rhinitis
• Fungal ?
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ALLERGIC RHINITIS
• Allergic rhinitis is an IgE-mediated, type 1
hypersensitivity reaction in the mucous
membranes of the nasal airways. The disease
is very common, affecting approximately 30%
of the Westren population. It can be
either seasonal (hayfever) or perennial
(sometimes with seasonal exacerbations).
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ALLERGIC RHINITIS
• Prevalence
400 million suffers worldwide
10 – 30% of population in the world
• All ages are affected, peaks in teens.
• Boys more affected than girls but equalizes
after puberty.
• Most will be managed at Primary Health Care
level.
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Aetiology
• Allergy is a hypersensitivity reaction of tissues
to certain substances called allergens. The
commonest allergens are highly soluble
proteins or glycoproteins. Typical allergens
include pollens, moulds, house dust mite and
animal epithelia.
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Pathophysiology
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ALLERGIC RHINITIS
• Subdivided into
intermittent (IAR) .v. persistent (PER)
• Severity classified as
mild .v. moderate/severe
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Intermittent
symptoms
Persistent
symptoms
< 4 days per week
> 4 days per week
and > 4 weeks
Or < 4 weeks
Moderate-severe
one or more items
Abnormal sleep.
Impairment of daily
activities, sport,
leisure.
Problems caused at
school or work.
Troublesome
symptoms.
Mild
Normal sleep.
Normal daily
activities.
Normal work and
school.
No troublesome
symptoms.
Symptoms
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Rhinorrhea
Cough/sneezing
Nasal congestion
Post nasal drip
Nasal pruritis
Watery eyes
General fatigue
Diminished quality of life
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Symptoms
• Seasonal rhinitis usually occurs any time from
early summer to early autumn depending on
the specific allergen. The patient suffers from
rhinorrhoea, nasal irritation and sneezing,
associated with itchy and watering eyes. Some
individuals (described as atopic) will have a
strong family history of allergy or a previous
history of eczema or asthma.
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Symptoms
• Long-standing cases of perennial allergy may
not display all these features, but they often
have nasal obstruction due to hypertrophy of
the turbinates sometimes associated with
hyposmia. Patients with perennial rhinitis are
almost invariably allergic to house-dust mite
and typically have more than one allergy.
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Physical
• General appearance
– allergic salute, malaise
• Nose
– Watery discharge, turbinate hypertrophy, hyponasality
• Mouth
– Cobblestoning of oropharynx
• Eye
Red eye
• Ear
– Middle ear pathology
• Chest
– wheezing
• Skin
– Eczema
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Allergic salute
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Granular Pharyngitis
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Allergic turbinates
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Investigations
1. Skin tests.
The epidermal prick test and the intradermal injection test use
an allergen placed on the skin of the flexor aspect of the
forearm. If the patient has an allergy to this then a wheal and
flare will come up within 20 minutes. A battery of common
allergens (e.g. pollens, moulds, feathers, house dust mite, animal
epithelia, etc.) are compared with the controls by the wheal they
produce. If the patient is highly sensitive a widespread or even
an anaphylactic reaction may result. Resuscitation equipment
must always be available although the epidermal prick test is
safe if properly performed. If an adverse reaction occurs, a
tourniquet should be placed proximally to contain it and the
patient given intravenous hydrocortisone, chlorpheniramine
(chlorphenamine) and adrenaline (epinephrine).
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Investigations
2. Blood tests. Total plasma IgE levels may be
measured in the plasma radioimmunosorbent test
(PRIST) and IgE to specific allergens in the
radioallergosorbent test (RAST). These tests are
more convenient, do not expose the patient to the
risks of the skin tests and do not rely on the use of a
specific allergen. However, they are more expensive
and have no diagnostic superiority over skin tests.
An eosinophilia may occur in an acute allergic
reaction but is unusual in allergic rhinitis.
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Investigations
3. Nasal smears. An increase in eosinophils in a
nasal smear indicates an allergic rhinitis but is
not diagnostic.
4. Provocation tests. A drop of the suspected
allergen squeezed into the nose may cause
symptoms (rhinorrhoea, sneezing, etc.)- The
effect can be measured objectively by
rhinomanometry.
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Management
1. Avoidance of the precipitating allergen is
obviously helpful, but not always possible.
2. Oral antihistamines. which selectively block
histamine receptors, (e.g. fexofenadine, loratidine).
Some patients still prefer the older antihistamines
which may cause drowsiness (e.g.chlorpheniramine)
and they should be warned of this. Intranasal
antihistamine sprays (e.g. azelastine hydrochloride)
have the advantage of minimal systemic absorption.
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Management
3. Topical steroid sprays and drops are now
considered to be the cornerstone in the
treatment of rhinitis. They are safe and
effective. Crusting and bleeding are the main
side-effects. Systemic absorption is negligible, as
is the chance of promoting fungal infections.
Examples include fluticasone, mometasone, and
triamcinolone sprays.
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Management
4. Topical anticholinergic drugs (e.g. ipratropium
bromide) are useful in the treatment of patients in
whom rhinorrhoea is the predominant symptom.
5. Sodium cromoglycate stabilizes mast-cell
membranes and therefore prevents the release of
the allergic response mediators. It has few sideeffects, but needs to be used five to six times per
day for adequate prophylaxis, so compliance is
poor.
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Management
6. Leukotriene synthesis inhibitors and receptor
antagonists are not marketed for the treatment
of allergic rhinitis, but they show promise for the
future treatment of the disease.
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Management
7. Immunotherapy involves a series of injections of
small amounts of the proven allergens in a purified
form, in the hope that blocking IgG antibodies will
be produced. It is really only of use in patients who
are sensitive to only one or two allergens, in
particular pollen allergy. The main complication of
this treatment is anaphylaxis, and for this reason its
use in the UK has been discouraged. Resuscitation
equipment must always be available where this
therapy is performed, and in case of anaphylaxis
there must be a supply of intravenous
hydrocortisone, chlorpheniramine and adrenaline.
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Non-infective, Non-allergic Rhinitis
• Defined as rhinitis symptoms in the absence of
identifiable allergy, structural abnormalities,
sinus disease or infection.
• Non allergic rhinitis has been described in
many terms including: vasomotor rhinitis,
intrinsic rhinitis, chronic rhinitis and idiopathic
rhinitis.
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Causes of non-allergic rhinitis
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Occuptional
Drug induced
Rhinitis medicamentosa
NARES
Hormonal
Idiopathic or vasomotor
Atmospheric pollution and change in weather
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Clinical features
• NAR accounts for 40–70% of all cases of
perennial rhinitis and becomes more common
with increasing age. All patients exhibit nasal
obstruction and rhinorrhoea or post-nasal
discharge, but itching and sneezing are less
common than in allergic rhinitis. Patients vary
in their degree of nasal obstruction and
discharge. There may be associated nasal
polyps with anosmia.
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Clinical features
• Co-existent sinus pathology is frequently
found (up to 50%) due to the inevitable
compromise of sinus aeration and drainage.
Examination generally reveals a rather red and
angry mucosa, often with copious secretions
and hypertrophy of both middle and inferior
turbinates, causing a consequent reduction in
the airway size.
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Clinical features
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Occupational
• Arises from airborne agents at workplace.
• Agents do not act through immune-mediated
mechanism. They are direct irritants to the
nasal mucosa and cause non-allergic hyperresponsive reactions.
• Over 250 different chemicals identified, like
cigarette smoke, latex, glue, and wood dust.
• Diagnosis ?
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Drug Induced Rhinitis
• Several common medications induce rhinitis
when administered topically or orally.
• Many drugs can cause this type of rhinitis for
example: aspirin, angiotensin converting
enzyme inhibiter, beta blocker, OCP, and
sildenafil.
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Rhinitis Medicamentosa
• It is a drug induced non-allergic rhinitis
associated with prolonged use of topical
nasal decongestant. Also called rebound
or chemical rhinitis.
• Incidence is 1-9%, equal sex distribution
and more common in young to middle
age adults and pregnant women.
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Rhinitis Medicamentosa
• Risk of RM is accepted to be greatest after 10
day use of medication.
• Treatment is gradual stopping of decongestant
with introduction of topical steroids.
• Patient should be warned of temporary
worsening symptoms.
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NARES
• It is characterized on the basis of 20-25% or
greater eosinophils in nasal smears of patient
with rhinitis.
• There is lack of allergy by skin test or IgE
antibodies.
• Prevalence ranges from 13-33% of non-allergic
rhinitis.
• Most common type associated with nasal
polyp and asthma.
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Hormonal Rhinitis
• Defined as rhinitis during periods of known
hormonal imbalance.
• Estrogen are known to affect the autonomic
nervous system by increasing central
parasympathetic activity.
• Therefore, the most common causes are
pregnancy, menstruation, puberty and
exogenous estrogen.
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Hormonal Rhinitis
• Hypothyroidism may also be a known cause of
hormonal rhinitis. In patient with
hypothyroidism, edema increases in the
turbinates as a result of TSH release.
• Nasal congestion and rhinorrhea are the most
common symptoms of hormonal rhinitis.
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Idiopathic rhinitis
• Also known as vasomotor rhinitis is
characterized by nasal blockage and
rhinorrhea, but sneezing and pruritis is lower
than allergic rhinitis.
• Studies have suggested autonomic
dysregulation, neuropeptide or nitric oxide
hyperactivity.
• Diagnosis of exclusion.
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Atrophic Rhinitis
• chronic inflammation of nose characterized
by atrophy of nasal mucosa, including the
glands, turbinate bones and the nerve
elements supplying the nose. Chronic atrophic
rhinitis may be primary and secondary. Special
forms of chronic atrophic rhinitis are rhinitis
sicca anterior and ozaena.
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Clinical Manifestations
• The disease is most commonly seen in females, and
tends to appear during puberty. The nasal cavities
become roomy and are filled with foul smelling crusts
which are black or dark green and dry, making
expiration painful and difficult. Patients usually
complain of nasal obstruction despite the roomy nasal
cavity, which can be caused either by the obstruction
produced by the discharge in the nose, or as a result of
sensory loss due to atrophy of nerves in the nose, so
the patient is unaware of the air flow.
• Permanent loss of smell and impairment of taste may
also be a result of this disease, even after the
symptoms are cured.
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Treatment
• Nasal irrigation using normal saline
• Nasal irrigation and removal of crusts using
alkaline solutions
• 25% glucose in glycerine can be applied to the
nasal mucosa to inhibit the growth of foulsmelling proteolytic organisms
• Young’s operation
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Investigations
• NAR is a diagnosis of exclusion, and the aim of
investigations is to identify other causes of
rhinitis. IgE estimation by PRIST and RAST and
skin testing can be used to indicate allergy.
Radiological examination of the nose and
sinuses with CT scanning may help diagnose
structural abnormalities and any coexistent
sinus infection.
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Management
1. Medical. Antibiotics may be used to treat any co-existent
infective component and a short course of oral steroids is
often helpful to get an initial response. However the
mainstays of maintenance treatment are as follows:
• (a) Intranasal steroids. Many cases respond well to topical
intranasal steroid preparations although in some the
response is disappointing.
• (b) Antihistamines are useful in some cases. Topical
preparations can sometimes have an impressive local
effect.
• (c) Topical ipratropium bromide is useful for its
anticholinergic effect in reducing rhinorrhoea.
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Surgery and Rhinitis
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Surgery and Rhinitis
• Treatment of concomitant problems. Associated
nasal polyps are treated with excision. Correction
of septal deflections and spurs should be
considered to relieve an obstructed airway.
• Turbinate surgery. Most procedures are aimed at
reducing the bulk of the inferior turbinate to
improve the airway. Submucosal diathermy, laser
cautery, and coblation are all successful in the
short term, but obstruction recurs after 1–2
years.
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ARIA
• 1999 – Allergic Rhinitis and its impact on Asthma
(ARIA) WHO workshop setup
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30% of patients with AR have asthma
The majority of patients with asthma have AR
AR is a major risk factor for poor asthma control
All patients with AR should be assessed for
asthma
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