Transcript Upper Respiratory Tract disorder in occupational setting

Upper Respiratory Tract
disorder
in occupational setting
Causes of Rhinitis
• Allergy
• Irritants
• NARES syndrome
• Adverse food reaction
• Occupational
• Emotional
• Hormonal
• Atrophic
• Drug induced
• Ciliary dyskinesia
• Anatomic defects
• Immunodeficiency
diseases
Evaluation of Rhinitis
• History and physical
• Sinus transillumination
• Direct visualization with nasal specula
• Rhinoscopy
• Nasal smear
• Allergy screening tests (skin tests or RAST)
• Imaging for persistent disease
What Do You Need to Know in
Addition
to Symptoms?
• Age at onset
• Are sx acute, chronic, recurrent, seasonal or
perennial?
• What causes the symptoms?
• What is the response to antihistamines?
• Does patient have any pets Any associated illnesses
(asthma, skin rash, otitis media)?
• Is there a family history of allergy?
Allergic Patients Generally
Have
• Early onset of symptoms (70% < age 20)
• Family history of allergy
• Seasonal symptoms
• Symptoms with animal exposure
• Symptoms worse outdoors
• Symptoms worse near fresh-cut grass
• Symptoms better in air conditioning
• Tobacco and chemicals are not primary excitants
• Previous immunotherapy was helpful
Nonallergic Patients
Generally Have
• Later onset of symptoms (70% > age of 20)
• No family history of allergy
• Tobacco smoke and chemicals primary excitants
• Weather changes provoke symptoms
• No seasonal aspect to symptoms
• No symptoms with exposure to dust
• No symptoms with exposure to animals
Symptoms of Allergic Rhinitis
• Sneezing
• Nasal congestion
• Watery nasal discharge
• Itchy watery eyes
• Postnasal drip
• Itching
Physical Changes of Allergic
Rhinitis
• Pale blue, edematous turbinates
• Clear, watery nasal discharge
• Crease from nasal salute
• Lymphoid hyperplasia
• Watery, itchy eyes
Allergic Rhinitis and Concomitant
Disease
• Management of allergic rhinitis may decrease
exacerbations of sinusitis, asthma and otitis media
• Early immunotherapy for allergic rhinitis has been
shown to decrease the development of asthma
Physical Examination
• Eyes: conjunctivitis, dark circles, Dennie’s lines
• Ears: OM, TM mobility, serous otitis
• Mouth: mouth breathing
• Lungs: wheezing
Nasal Smear
• Clear nose of secretions
• Gently scrape sample from mucosa of inferior or
middle turbinate with plastic ear spatula or cotton
swab
• Wright’s or Hansel’s stain
• Eosinophilia
– Allergy (present in 90% of allergic patients)
– NARES syndrome
– Aspirin sensitivity
• Neutrophilia
– Infection
Sinus X-rays and CT Scans
• Sinus x-rays :
– Not needed for diagnosis of acute rhinosinusitis
– Water’s view for the maxillary sinuses
– Town’s view for ethmoid and frontal sinuses
– Lateral view for the sphenoid
• Limited coronal CT scan
– Osteomeatal complex
– All sinuses visualized
• CT scan gives much better imaging for minimal increased cost
Rhinoscopy
• Nasal polyps
• Septal deviation
• Concha bullosa
• Eustachian tube dysfunction
• Causes of hoarseness
• Adenoid tissue
• Tumors
Treatment of Allergic Rhinitis
• Avoidance of identified allergens
• Nasal steroids
• Antihistamine nasal spray
• Antihistamines (sedating and nonsedating)
• Decongestants
– Nasal sprays (limited 2-3 days)
– Oral preferred (limited by side effects)
• Nasal irrigation
• Leukotrienes
General Treatment Modalities
• Vigorous exercise
• Posture
• Avoidance procedures
• Saline irrigation
Nasal Irrigation
• Commercial buffered sprays
• Bulb syringe
– 1/4 tsp of salt to 7 ounces water
• Waterpik with lavage tip
– 1 tsp salt to reservoir
• Disposable enema bucket
– 2 tsp salt, 1 tsp soda per quart of water
Treatment of Mild Allergic Rhinitis
Step 1
Occasional exposure/symptoms
• Environmental control
• Saline irrigation
• Monotherapy
– Nasal steroid or
– Nonsedating antihistamine or
– Astelazine nasal spray
Treatment of Moderate Allergic Rhinitis
Step 2
May Last for Months to One Year
• Environmental control
• Normal saline irrigation
• Combination therapy
– Nasal steroid and
– Nonsedating antihistamine with or without decongestant
or
– Astelazine
• Immunotherapy
Treatment of Severe Allergic Rhiniti
step 3
Chronic, persistent associated with Sinusitis, Otitis media , asthma
• Environmental control
• Normal saline irrigation
• NSA+/- decongestant
• High-dose nasal steroid
• Afrin 3 days or fewer
• Oral steroid
• Immunotherapy
Environmental Control/Avoidance
• Dust mites
– Controls: plastic covers, frequent vacuuming of carpet
– Avoid: overstuffed chairs, curtains, stuffed animals, dustcollecting boxes under bed
• Cockroaches
– Poisoning
Environmental Control
• Air conditioning
• Frequent dusting, cleaning surfaces
• Air filters
– Hepa filtration
• Vacuum cleaners
– Dry versus water filtration
• Ionizers
• Wood burning stoves
Pharmacotherapy
• Allergic rhinitis
– Antihistamines
• OTC
• Nonsedating
• Nonallergic rhinitis
– Antihistamines
• Drying effect
– Decongestants
– Nasal steroids
– Astelazine
– Nasal cromolyn
– Ipatropium
– Astelazine nasal spray
– Nasal steroids
– Decongestants
• NARES syndrome
Nasal Steroids
• Flonase
• Beconase
• Nasonex
• Nasacort
• Rhinocort
• Vancenase
• Tri-Nasal
Nonsteroid Nasal Sprays
• Astelazine
• Atrovent
• Nasalcrom
• Saline
Nonallergic Rhinitis
As important as allergic rhinitis
Present in 57% of patients with
rhinitis
Nonallergic/Vasomotor Rhinitis
• Perennial or episodic symptoms
• Chronic, nonpruritic rhinorrhea/congestion
• Negative nasal eosinophils
• Negative allergy screening
• Nonallergic excitants
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Viruses
Chemicals, tobacco smoke, potpourri
Nonallergic foods
Weather changes
Symptoms of Nonallergic
Rhinitis
• Nasal congestion is prominent
• Sneezing and nasal itching uncommon
• Concomitant asthma is less likely
• Eye symptoms are fewer
• Postnasal drip
• Fatigue
• Loss of sense of smell and taste
Tests Helpful in Diagnosing
Nonallergic Rhinitis
• Nasal smear will be void of eosinophils
– Eosinophils present in 90% of allergic
rhinitis
– Neutrophils suggest bacterial infection
• Skin prick tests or in-vitro testing negative
– Negative allergy testing is the best
predictor of the nonallergic state
Treatment of Nonallergic
Rhinitis
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Astelazine nasal spray
Steroid nasal spray
Nasal irrigation
Avoidance
Effectiveness of antihistamines questionable
Rhinitis — Case Study
• 23-year-old has had nasal congestion for the past
23 months. Started as a cold, but symptoms
never cleared. “Allergies” several times a year as
a child but outgrew them. Never tested. No family
hx of allergy. Can’t sleep without his medication.
– Is he allergic?
– What is your next question?
Rhinitis — Case Study
• What medication are you using?
• Answer: “Afrin, I can’t breath or sleep without it.”
Rhinitis Medicamentosa
• Rebound congestion from overuse of
topical decongestants; oxymetazolone,
phenylephrine, cocaine
• Erythematous mucosa, congestion,
punctate bleeding
• Interstitial edema and vasoconstriction
• Withdrawal of medication, topical steroids,
oral steroids
Treatment of Rhinitis
Medicamentosa
• Initiate topical steroid bilaterally, discontinue
decongestant in one nostril, then the second
nostril one week later
• One-week dose of tapering steroids
• Evaluate for the underlying cause of the rhinitis
Hormonal Causes of Rhinitis
• Pregnancy
– Second month to term
• Puberty
• Oral contraceptives
• Hypothyroid state
Rhinitis of Pregnancy
• Mild symptoms may have been present before
(pregnancy aggravated symptoms)
• Increase in circulating blood volume
• Progesterone induced smooth muscle relaxation
• Hormonal effect on nasal mucosa
Treatment of Rhinitis in
Pregnancy
• Caution with medication usage
• Nasal saline sprays, steam inhalation
• Avoidance of known triggers
• Topical medical therapy rather than systemic
when possible
• Oral pseudoephedrine
• Chlorpheniramine
Rhinitis — Case Study
• 28-year-old with a two-year history of profuse rhinorrhea. No
history of rhinitis or asthma as child. Occasional sneezing,
little congestion.
• Clear nasal discharge on exam, pharynx, tympanic
membrane, lungs all normal.
• Skin test is negative with good positive control.
– What in-office test will make the diagnosis clear?
• Nasal smear
– revealed marked eosinophilia
• Diagnosis: NARES syndrome nonallergic rhinitis with
eosinophilia
NARES Syndrome
• Perennial symptoms
– Sneezing
– Rhinorrhea
– Pruritis
• Occasional loss of smell
• Nasal smear positive for eosinophils
• Allergy screen is negative
Nasal Mastocytosis is Rare
• Basophilic metachromic nasal disease
• Histologic diagnosis
• Mast cell infiltration of the mucosa
• No eosinophils
Atrophic Rhinitis (Ozena)
• Found in patients who have had radical nasal
tissue removal for congestion
– Removal of inferior and or middle turbinates
• “Empty nose syndrome”
• Excessive drying, crusting and infection
• Atrophic changes in the elderly
• Klebsiella colonization
Treatment of Atrophic
Rhinitis
Nasal irrigation 3-4 times per day for 2-3 months,
then 1-2 times per day indefinitely
Rhinitis — Case Study
• 45-year-old female with no history of previous
symptoms of rhinosinusitis presents with
headaches, daily nasal congestion and fatigue for
3-4 months. No hx of viral URI. No family hx of
allergy. No changes in cosmetics, no additions to
house, no new clothes. No pets. No food reactions
known.
– What other element of a thorough history might
give you a clue as to diagnosis?
Rhinitis — Case Study
• Where do you work?
• How long have you worked there?
• Do your symptoms coincide with changing jobs?
• Are you more symptomatic at work than at home?
• Do your symptoms clear on the weekend or on
vacation?
Occupational Rhinitis
• Patients experience symptoms in workplace
• Symptoms improve on weekends/vacation
• May be allergic or nonallergic
• May coexist with occupational asthma
• Treatment is avoidance
– Move to another area in the workplace
– Move to another job
Causes of Occupational
Rhinitis
• Sick building syndrome
– Department of Ecology and Environmental
Protection
• Gasses from office machines
– Inks, paper
• Perfumes
• Paints, carpet, carpet glue
• Laboratory animals
Common Workplaces for
Occupational Rhinitis
• Beauty salons
• Tanneries
• Clothing stores
• Paper industry
• Supermarkets
• Gardening products
• Auto body spraying
• Insecticides
• Service stations
• Food industry
• Woodworking
• Laboratory animals
• Pesticide industry
• Office machinery
• Plastic manufacturing
• Paints, chemicals
Common Chemical Exposures
Causing Rhinitis
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Gasoline/diesel fuels
Chlorine
Perfumes
Cleaning agents
Room deodorizers
Hair dyes
Permanent solutions
Paints
Auto body paints
Herbicides
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Potpourri
Burning candles
Petroleum products
Formaldehyde
New clothing odor
Hair spray
Toluene
Ammonia
Acids
Mechanical Causes of Rhinitis
• Deviated nasal
septum
• Nasal polyps
• Foreign body
• Meningocoele
• Adenoid hypertrophy
• Variants of the osteomeatal
complex
• Concha bullosa
• Tumors of the nose
• Congenital atresia
Gustatory Rhinitis
• Rhinorrhea and/or nasal congestion related to
eating
• Treatment is identification and elimination
• Common causes of gustatory rhinitis
– Cheeses
– Spicy foods
– Wines
Food Reactions
• Diagnosed by skin prick tests, RAST or elimination diet
– Skin prick tests, in-vitro testing will only diagnose
IgE-related foods
– Elimination diet will diagnose all types adverse food reactions
Vasculitides, Autoimmune and
Granulomatous Causes
• Churg-Strauss Syndrome vasculitis
• Systemic lupus erythematosis
• Relapsing polychondritis
• Sjogren’s syndrome
• Sarcoidosis
• Wegener’s granulomatosis
Nasal Polyps
• Grape-like clusters
– Maxillary sinus
• Inflammatory process
• One third associated with asthma
– Asthma-aspirin-polyp triad
• High rate of recurrence
Treatment of Nasal Polyps
• Allergy control
• Intranasal steroids
• Systemic steroids
• Avoidance of ASA, NSAIDs
• Polypectomy
• Ethmoidectomy
Importance of Allergy Testing
• Distinguishes between allergic, nonallergic and mixed
rhinitis
• Aids in selecting specific pharmacotherapy
• Identifies specific allergens to be avoided and/or treated
by immunotherapy when indicated
Indications for Allergy Testing
• Identification of allergens
• Chronic or recurrent symptoms
• Symptoms not controlled by avoidance and
medication
• Medication not tolerated
• Decrease cost of medication
Contraindications for
Allergy Skin Testing
• Uncontrolled asthma or recent asthma attack
– PEFR must be above 70% personal best effort
• Cardiac problems
• History of hymenoptera sensitivity
• History of anaphylaxis of any kind
– Shellfish
– Medications
Refer to an Allergist
• Hymenoptera sensitivities
• Antibiotic desensitization
• Anesthetic testing
• Patients with history of anaphylaxis
– Medication
– Shellfish
– Peanut or other food reactions
Instruments Used in Allergy
Testing
• Invivo tests
– Individual skin prick tests
• DuoTip
• Morrow Brown needle
• GreerPick
– Multiple antigen applicators
• MultiTest
• Quintest
• Invitro tests
– Modified in-vitro testing
– CAP system
Skin Testing Disadvantages
• Affected by medications
– Antihistamines
– Steroids
• Patient discomfort
• Rare possibility of anaphylaxis
• Dermagraphism
• Chronic skin disorders
• Very young and atrophic skin
Puncture/Prick Testing
Figure 1
• Disease-free site
• Swipe with alcohol
• Apply drop of antigen
(1:10 or 1:20 conc.)
• Prick skin at 45 to 60 degree
angle, or puncture at 90 degrees
• Gently lift device, no bleeding
Example of a skin prick/puncture
should occur
epicutaneous test
• Read positive control in
10 minutes
• Read allergens in 15-20 minutes
Multiple Antigen Testing
• Alcohol wipe and dry area to be used
• Remove device from package
• Place in loading dock
• Apply to forearm
• Read positive control in 10 minutes
• Record allergen response in 15-20 minutes
Multiple Antigen Testing
Figure 2
Example of multiple-puncture
device allowing simultaneous
placement of six allergens plus a
positive and negative control
cont’d
Figure 3
Example of multiple-puncture
device in its loading dock
Multiple Antigen Testing
Figure 4
Example of application of a
multiple-puncture
device to the forearm
cont’d
Figure 5
Example of positive and negative skin
responses to allergens applied with a
multiple-puncture device; note the
positive and negative control sites
Skin Testing Precautions
• Physician always present
• Emergency equipment available and current
– Adrenalin and albuterol in testing room
• Determine patients’ most recent use of
antihistamines, steroids, H2 blockers
• Is patient on a beta blocker?
– Switch medications or in vitro testing
Grading of MultiTest
0
No reaction-1-3 mm wheal
1+
Erythema with 3mm wheal
2+
Erythema with 5 mm wheal
3+
Erythema with 7-10 mm wheal
4+
Erythema with >10 mm wheal
5+
Erythema with >10 mm wheal
and pseudopods
Reading and Recording
Results
• Best done by physician scoring and nurse
recording
• If reaction is borderline, read as the higher class
– Example
• Difficulty determining if result is #3 or #4 record as #4
Positive and Negative Controls
• Imperative to use to validate skin response
• Positive negative control = dermagraphism
• Negative positive control = medication reaction or
hypoactive skin
Indications for In-Vitro
Testing
• Dermatographism
• Eczema
• Very young skin
• Atrophic skin
• Long-acting antihistamines
• Beta blockers, ACE inhibitors, MAOs
• Patients with poorly controlled asthma (70%)
• History of anaphylaxis
RAST Procedure
• Allergen coupled to paper disc
• Add patient’s serum
• Antigen-antibody complex formed
• Radioactive anti IgE added
• Anti IgE-antibody-allergen complex formed
• Gamma counter scoring
RAST Scoring
Class 0
200-500
No allergy
Class 0/1
500-750
Questionable allergy
Class 1
750-1,600
Mild allergy
Class 2
1,600-3,600
Moderate allergy
Class 3
3,600-8,000
More allergic
Class 4
8,000-18,000
More allergic
Class 5
Over 18,000
Most allergic
Advantages of In-Vitro
• Patient safety, no anaphylaxis
• Cost-effective screening
• Not affected by medication
• No irritating skin reactions
• Sets safe starting doses for immunotherapy
Disadvantages of In-Vitro
• Patient does not experience the reaction
• Less sensitive than skin tests (?)
• Cost per test may be higher
• RAST requires 3-14 days to get results
RAST Scoring as a Guide to
Immunotherapy
• The higher the RAST class the more dilute the
starting dose of immunotherapy
• The lower the RAST class the higher the starting
dose of immunotherapy
Prescribing
Immunotherapy Based
on RAST Results
• Blood sample is drawn anytime
• Serum is removed
• Sent to lab and processed
• Results correlated with history
• Prescription for immunotherapy written
• Lab makes up immunotherapy sets
Indications for
Immunotherapy
• Inadequate control with avoidance and
pharmacotherapy
• Pharmacotherapy for more than 3-4
months per year
• Intolerable side effects of medication
• Progressive severity of disease
• Desire for long-lasting control without Rx
Evidence-Based Recommendations
• Practice Recommendation: Treat patients diagnosed as having allergic
seasonal rhinitis with prophylactic medications (antihistamines and/or
intranasal corticosteroids).
• Practice Recommendation: Prescribe intranasal corticosteroids to
control allergic rhinitis symptoms.
• Practice Recommendation: Educate patients with allergic rhinitis about
avoidance activities.
• Practice Recommendation: Reserve immunotherapy for patients with
allergic rhinitis for whom optimal avoidance measures and medication
therapy are insufficient to control symptoms.