defination,pathophysiology,classification, ARIA guidelines, treatment options of allergic rhinitis

1. ALLERGIC RHINITIS
DR MANUPRITA SHARMA
M.S ENT
ALLERGOLOGIST.

2. INTRODUCTION
 RHINITIS also known as coryza ,is
irritation and inflammation of the
mucous membrane inside the nose.
 Common symptoms are a stuffy nose,
runny nose, sneezing, and
post-nasal drip.

3. CLINICAL SyMPTOMS
Excessive mucus production
Congestion
Sneezing paroxysm
Watery eyes
Nasal and ocular pruritus

4. In rhinitis, the inflammation of the mucous
membrane is caused by viruses, bacteria,
irritants or allergens. The most common kind
of rhinitis is allergic rhinitis , which is usually
triggered by airborne allergens such as
pollen and dander.

5. ALLERGIC RHINITIS
 Allergic rhinitis is an immunoglobulin E–mediated
disease, thought to occur after exposure to indoor and
outdoor allergens such as dust mites, insects, animal
danders, molds, and pollens.
 Allergic rhinitis involves inflammation of the mucous
membranes of the nose, eyes, eustachian tubes, middle
ear, sinuses, and pharynx

6. EPIDEMIOLOGy
 Allergic rhinitis is the most common cause of rhinitis. It is an
extremely common condition, affecting approximately 20% of the
population.
 Rhinitis is very common. Allergic rhinitis is more common in
some countries than others; in the United States, about 10%–
30% of adults are affected annually
 Although allergic rhinitis is not a life-threatening condition,
complications can occur and the condition can significantly
impair quality of life

7. PATHOPHySIOLOGy
 Inflammation of the mucous membranes is characterized by a complex
interaction of inflammatory mediators but ultimately is triggered by an
immunoglobulin E (IgE)–mediated response to an extrinsic protein
 When the specific protein is inhaled into the nose, it can bind to the IgE on the
mast cells, leading to immediate and delayed release of a number of mediators
 The mediators that are immediately released include histamine, tryptase,
chymase, kinins, and heparin

8.  The mast cells quickly synthesize other mediators, including leukotrienes
and prostaglandin D2
 Over 4-8 hours, these mediators, through a complex interplay of events,
lead to the recruitment of other inflammatory cells to the mucosa, such as
neutrophils, eosinophils, lymphocytes, and macrophages
 This results in continued inflammation, termed the late-phase response
 Systemic effects, including fatigue, sleepiness, and malaise, can occur
from the inflammatory response

9. THE NERVOUS SySTEM IN AR
 The nose provides defensive and homeostatic functions requiring rapid responses to physical and
chemical stimuli. Sensory nerves transmit signals from the mucosa, generating sensations, such as
pruritus; motor reflexes, such as sneezing; and parasympathetic and sympathetic reflexes that affect
the glandular and vascular nasal apparatuses.
 Neural function can be chronically up regulated in the presence of mucosal inflammation
 Up regulation of the nasal nervous system can occur at various levels of the reflex pathways, resulting
in exaggerated responses (neural hyper responsiveness).
 NEUROTROPHINS, such as the nerve growth factor, are prime candidates as mediators of neural
hyper responsiveness.

10. ARIA: CLASSIFICATION OF ALLERGIC RHINITIS
INTERMITTENT
< 4 days per week
or < 4 weeks
PERSISTENT
> 4 days per week
and > 4 weeks
MILD
• normal sleep
• no impairment of daily
activities, sport, leisure
• normal work and school
• no troublesome smptoms
MODERATE TO
SEVERE (one or more
items)• Abnormal sleep
• Impairment of daily
activities, sport, leisure
• Abnormal work and
school
• Troublesome symptomsSYMPTOMS IN UNTREATED PATIENTS

12. THE ARIA NOMENCLATURE
 Replaces the current nomenclature of seasonal and
perennial rhinitis
 The number "4" is key to an understanding of this
classification strategy
 Allergic rhinitis is divided into 2 areas (intermittent and
persistent disease)

13. THE “ NUMBER 4” IN ARIA
 Patients with intermittent disease
Have symptoms for less than 4 days/week and less than 4
weeks/year,
 Patients with persistent disease
Have symptoms for more than 4 days/week for more than 4
weeks/year.

14. SIGNS AND SYMPTOMS
 SNEEZING
 ITCHING: NOSE, EYES,
EARS, PALATE
 RHINORRHEA
 POSTNASAL DRIP
 CONGESTION
 ANOSMIA
 HEADACHE
EARACHE
TEARING
RED EYES
EYE SWELLING
FATIGUE
DROWSINESS
MALAISE

15. NASAL FEATURES
 NASAL CREASE: A horizontal crease across the lower half of the
bridge of the nose; caused by repeated upward rubbing of the tip of
the nose by the palm of the hand
 Thin, watery nasal secretions
 DEVIATION OR PERFORATION OF THE NASAL
SEPTUM: May be associated with chronic rhinitis, although there
can be other, unrelated causes

16. EARS, EYES, AND OROPHARYNX
Manifestations of allergic rhinitis affecting the ears, eyes, and oropharynx include the
following:
 EARS: Retraction and abnormal flexibility of the tympanic membrane
 EYES: Injection and swelling of the palpebral conjunctivae, with excess tear
production; Dennie-Morgan lines (prominent creases below the inferior eyelid); and
dark circles around the eyes (“allergic shiners”), which are related to vasodilation or
nasal congestion
 OROPHARYNX: "Cobblestoning," that is, streaks of lymphoid tissue on the posterior
pharynx; tonsillar hypertrophy; and malocclusion (overbite) and a high-arched palate

17. COMPLICATIONS
 ACUTE OR CHRONIC SINUSITIS
 OTITIS MEDIA
 SLEEP DISTURBANCE OR APNEA
 DENTAL PROBLEMS (OVERBITE): CAUSED BY
EXCESSIVE BREATHING THROUGH THE MOUTH
 PALATAL ABNORMALITIES
 EUSTACHIAN TUBE DYSFUNCTION

18. DIAGNOSTIC TOOLS
MOST COMMON
 Skin prick test – GOLD STANDARD
 Radioallergosorbent test (RAST)
LESS COMMON
 Total serum IgE: Neither sensitive nor specific for allergic rhinitis, but the results can be
helpful in some cases when combined with other factors
 Total blood eosinophil count: Neither sensitive nor specific for the diagnosis, but, as with total
serum IgE, can sometimes be helpful when combined with other factors

19. IMAGING STUDIES
Imaging studies used in the diagnosis and evaluation of allergic rhinitis include the
following:
 RADIOGRAPHY: Can be helpful for evaluating possible structural abnormalities or
to help detect complications or comorbid conditions, such as sinusitis or adenoid
hypertrophy
 COMPUTED TOMOGRAPHY SCANNING: Can be very helpful for evaluating
acute or chronic sinusitis
 MAGNETIC RESONANCE IMAGING: Also can be helpful for evaluating sinusitis

20. SKIN TESTING
 Skin testing involves introducing controlled amounts of allergen and control substances into
the skin
 It is convenient, safe, and widely accepted
 Allergic rhinitis can have an immediate or delayed response
 Primary goal of skin testing - detect the immediate allergic response caused by the release
of mast cell or basophil IgE-specific mediators - create the classic wheal and flare reaction
after 15 mins
 The delayed response occurs four to eight hours after exposure to the sensitizing allergen
and is less useful in clinical diagnosis.

21. RADIOALLERGOSORBENT TEST
(RAST)
 Indirectly measures the quantity of immunoglobulin E (IgE) serving
as an antibody to a particular antigen
 Allergen-specific IgE antibody testing is particularly useful in
primary care if percutaneous testing is not practical (e.g., problems
with reagent storage, expertise, frequency of use, staff training) or if
a patient is taking a medication that interferes with skin testing (e.g.,
tricyclic antidepressants, antihistamines)
 RAST is highly specific but generally not as sensitive as skin testing

22. NEW DIAGNOSTIC METHODS
Exhaled nitric oxide (eNO)
 Similar to eNO in asthma, nNO is a noninvasive marker
 Potentially suitable to monitor upper airway inflammation following allergen-induced late response.
 Exhaled nitric oxide (eNO) is a validated noninvasive marker of airway inflammation in asthma. In
patients with allergic rhinitis (AR), increased levels of nasal nitric oxide (nNO) have also been
measured. However, the applicability of nNO as a marker of upper airway inflammation awaits
validation.
 Exhaled nitric oxide (NO) is currently the MOST RELIABLE MARKER of rhinobronchial
inflammation, but its routine assessment is difficult as the test is available only in highly specialized
centers

23. TREATMENT STRATEGIES
ENVIRONMENTAL CONTROL MEASURES AND
ALLERGEN AVOIDANCE
PHARMACOLOGIC MANAGEMENT
IMMUNOTHERAPY
SURGERY

24. ENVIRONMENTAL CONTROL MEASURES
AND ALLERGEN AVOIDANCE
RY Seedat, Current Allergy & Clinical Immunology,
March 2013Vol 26, No.1

25. PHARMACOTHERAPY
FACTORS :
 Efficacy
Safety
Cost-effectiveness of medications
Patient preference
Objective of the treatment
Likely adherence to recommendations
Severity and control of the disease
The presence of comorbidities

26. Treatment type Ocular symptoms
Nasopharyngeal
itching Sneezing Rhinorrhea
Intranasal
corticosteroids
✓ ✓ ✓ ✓
Oral
antihistamines
✓ ✓ ✓ ✓
Intranasal
antihistamines
— ✓ ✓ ✓
Decongestants ✓ — — ✓
Intranasal
cromolyn
(Nasalcrom)
— ✓ ✓ ✓
Intranasal
anticholinergics
— — — ✓
Leukotriene
receptor
antagonists
✓ — — ✓
Nasal saline
irrigation
— — — ✓
Immunotherapy ✓ — ✓ ✓

27. CORTICOSTEROIDS
Intranasal corticosteroids
 Treatment of AR include beclomethasone
dipropionate, budesonide, triamcinolone
acetonide, fluticasone propionate,
mometasone furoate, fluticasone furoate
and ciclesonide
 INCSs are the single most effective class of
medications for AR
 They are effective against all the symptoms
of AR, with a low incidence of adverse
effects
Systemic corticosteroids
 Oral glucocorticosteroids SHOULD NOT
be considered as a first line of treatment
but a short course can be used in patients
with moderate-severe nasal symptoms not
controlled with other treatments
 Oral corticosteroids should be avoided in
children, pregnant women, and patients
with known contraindications

28. ANTIHISTAMINES
ORAL ANTIHISTAMINES
 Antihistamines are inverse agonists at H1-receptors
 Oral antihistamines are equal or superior to INCSs for ocular
symptom relief but less effective than intra-ocular antihistamines and
mast cell stabilisers
 The first-generation (old) antihistamines are poorly selective for the
H1 receptor
 Second-generation (new) oral antihistamines include cetirizine,
ebastine, loratadine, mizolastine, desloratadine, fexofenadine and
levocetirizine are highly selective

29. ANTIHISTAMINES
Intranasal
antihistamines
 They have a rapid (less than
15 minutes) onset of action
 Adverse effects are rare and
mild, and include unpleasant
taste and increased risk of
somnolence
Leukotriene receptor
antagonists
 LTRAs are as effective as
antihistamines, but less
effective than INCSs in
improving symptoms

30. ANTIHISTAMINES
Cromones
 Sodium cromoglycate has
been shown to be
effective for the treatment
of AR but it is less
effective that INCSs and
antihistamines
Decongestants
 Intranasal decongestants
are very effective in the
treatment of nasal
obstruction but do not
improve other symptoms

31. ANTIHISTAMINES
Anticholinergic compounds - Ipratropium bromide
is effective in controlling rhinorrhoea but is ineffective
against the other symptoms of AR
Nasal irrigation - Buffered hypertonic saline may be
superior to buffered normal saline for nasal
symptoms

32. SPECIFIC IMMUNOTHERAPY
 Allergen specific immunotherapy (SIT), administered as SUBCUTANEOUS
IMMUNOTHERAPY (SCIT) or as SUBLINGUAL IMMUNOTHERAPY (SLIT),
is an important form of treatment for AR
 SIT is the only treatment that may alter the natural course of the disease as it
can prevent the development of new sensitisations and can prevent the
development of asthma when introduced to patients with only allergic
rhinoconjunctivitis
 SIT is indicated in patients with proven IgE-mediated allergy to a single
allergen whose symptoms are insufficiently controlled with pharmacotherapy

33. SURGERY
The goal of surgery of the inferior turbinate is to
minimise allergen effects by reducing bulky
inflammatory tissue or inducing scar formation,
while enhancing patency of the nasal fossa
The vidian neurectomy is now seldom performed
because of the development of effective medical
treatments

34. HOW ALLERGIC RHINITIS MANAGEMENT IS
CHANGING
1990 . . .
 1st generation antihistamines
 Poor awareness of allergic rhinitis
 Few diagnostic tests
 Frequent lost days at school and work
 Little emphasis on seriousness of disease
2007
 2nd generation antihistamines
 Intranasal steroids
 Better control, less lost days
 Topical antihistamines
 ARIA guidelines
 Asthma and rhinitis concept –
one disease
 Better quality of life for people
with ‘frequent colds

35. NEW RECOMMENDATIONS FOR TREATMENT
 Intranasal steroids and oral antihistamines are recommended as first
lines of treatment. Oral leukotriene receptor antagonists are not.
 Sublingual or subcutaneous immunotherapy should be offered to patients
who do not respond to pharmacologic therapy.
 Acupuncture is an option for patients who do not wish to take meds.

36. SUMMARY
Rhinitis is an inflammation of the nasal mucosa
Associated clinical symptoms include excessive mucus production, congestion,
sneezing paroxysm, watery eyes, and nasal and ocular pruritus
 Most Common are Percutaneous skin test and Radioallergosorbent test (RAST)
 Management methods are pharmacotherapy, immunotherapy and avoidance of
allergens

37. THANK YOU