3. DEFINITION AND CLASSIFICATION
EPIDEMIOLOGY
PATHOPHYSIOLOGY AND MECHANISMS
RISK FACTORS
EVALUATION AND DIAGNOSIS
ASSOCIATED CONDITIONS
MANAGEMENT
4. • Rhinitis is defined clinically as having two or more symptoms of
#anterior or posterior rhinorrhoea,
#sneezing
# nasal blockage and/or itching of the nose
during two or more Consecutive days for more than one hour on most days.
• Noninfectious rhinitis has been classified as either Allergic or non-allergic.
• Allergic rhinitis is characterized by inflammatory changes in the nasal mucosa
caused by exposure to inhaled allergen in a sensatised individual resulting in the
above symptoms. It is an IgE mediated reaction.
• The diagnosis of an allergic rhinitis allergic symptoms + history with diagnostic tests
(skin prick testing or by measuring specific IgE levels in the blood (RAST)
6. AETIOLOGY
• Genetic factors (parents if atopic - 3–6 times)( genes involved are 5q, 11q &12q)
• Exposure to an allergen
(SEASONAL : pollen, fungus //// PERENNIAL: dust mite, domestic pets, cockroaches)
• Environmental factors: pollution climate interaction: IRRITANTS (Fumes, tobacco smoke, diesel exhaust, mosquito
repellents, perfumes, scented sticks, domestic sprays, bleaches)
Hygiene hypothesis
• Children who live on farms, contact with livestock, larger family size, more frequent infections and unhygienic
contact less likely to develop
• Possible protective effect of microbial exposure.
• Reduced exposure to infective agents reduces the Th1 Response an overdrive of the Th2 immune
response excessive production of IgE.
• Worms is also protective, possibly because of the production of blocking antibodies (IgG4).Eradication
increases skin allergy to aeroallergen
• Urbanized, western lifestyle promotes AR.
7. The ‘atopic march’ in children refers to the sequential development of allergic diseases,
often starting in infants with Atopic eczema Allergic rhinitis Allergic asthma
8. PREVALENCE
• Prevalence : 0.8% -- 39.7%
• Higher in pediatric age group
• App 80% develop before 20yrs.
9. PATHOPHYSIOLOGY
Sensitization: development of specific IgE
allergens reach antigen-presenting cells (apcs)
APCs promote Th2 polarization
Th2 promotes production of allergen-specific IgE
• inhaled allergen produces specific IgE antibody
which gets attached to mast cells
10. Subsequent response: development of symptoms
• Subsequent exposure to same antigenallergen combines with specific IgE antibody →
degranulation of mast cells → chemical mediators released
11.
12. • ACUTE OR EARLY PHASE RESPONSE
Occurs 5–30 min after antigen exposure
• release of inflammatory mediators
• increased nasal gland secretion → runny nose
• mucosal edema & vasodilation → nose block
• nerve irritation → sneezing & itching
LATE OR DELAYED PHASE RESPONSE
• occurs 2-8 hours after antigen exposure
• infiltration by inflammatory cells (eosinophils, neutrophils, basophils,
monocytes & cd4+ t lymphocytes)
• edema, congestion & thick nasal secretion
• sneezing & itching decreases
13. • IN ATOPIES, ALLERGEN MOLECULES ARE INHALED AND
• PRESUMABLY NOT COMPLETELY CLEARED BY THE MUCOCILIARY
• SYSTEM.
• THEY REACH ANTIGEN PRESENTING CELLS IN THE NOSE, THE
• MOST IMPORTANT OF WHICH ARE DENDRITIC CELLS /
• LANGERHANS CELLS.
• THEY CAPTURE ANTIGEN, PROCESS IT AND PRESENT IT TO NAIVE
• T CELLS IN THE LOCAL LYMPH NODES.
• IF NO ADDITIONAL SIGNAL IS PRESENT THEN A T-CELL RESPONSE
• WILL NOT ENSUE.
• IN ATOPIC INDIVIDUALS, TH2 CELLS PREDOMINATE AT THE
• SITES OF ALLERGIC RESPONSE.
14. SYMPTOMS
SEASONAL ALLERGIC RHINITIS: nasal discharge and conjunctivitis (more
common)
PERENNIAL ALLERGIC RHINITIS: nasal blockage (more common)
less sneezing/nasal discharge /eye symptoms
hyposmia
• RHINORRHEA -CLEAR /MUCOID
• SNEEZING(IN ALLERGIC DISEASE OFTEN
MARKED IS BY EXPLOSIVE PAROXYSMS OF 5
TO 10 SNEEZES OR MORE )
• NASAL BLOCK
• ITCHY NOSE, EARS, EYES AND PALATE
• POST NASAL DRIP
• CONGESTION
• ANOSMIA
• HEADACHE
• EARACHE
• TEARING OF EYES
• RED EYES
• SWOLLEN EYES
• FATIGUE
• DROWSINESS
• MALAISE
15. Seasonal allergic rhinitis
pollen:
Spring (march-june) = tree pollen
Summer (may-august) = grass
Fall (august-october) = weeds
mold:
Spores in outdoors have seasonal
Variation (reduced in winter, increased in
Summer/fall due to humidity)
house dust mites:
Generally “perennial” allergen,
But increased in damp autumn months
16. Perennial allergic rhinitis
fungi/mold:
Exposure peaks accompany activities
Such as harvesting & cutting grass
pet dander (cats, dogs):
Up to 4 months after pet removal
house dust mites:
Live in bedding & carpets
cockroaches:
Respiratory allergy
Important allergen
17. SIGNS
• Crease on tip of nose with crusting – Darrier’s line
• Allergic salute- child pushes tip of nose up with base of palm
as an attempt to control itching
• Allergic gape- mouth breathing from nasal obstruction
18. FACE:
BUNNY NOSE- frequent twitching of face
Periorbital puffiness
Dark circles around eye- ALLERGIC SHINERS(pooling of blood under eyes due to swelling of tissues
in nasal cavity)
Creases in lower eyelids due to spasm of superior tarsal muscle and skin edema to hypoxia DENNIS
MORGAN LINES
• EYE: Conjuctival congestion , Epiphora
• EAR: AURAL FULLNESS(ET DYSFUNCTION)
• THROAT: CHRONIC PHARYNGITIS, LARYNGITIS
19. O/E
ANTERIOR RHINOSCOPY
• ASYMPTOMATIC - NORMAL MUCOSA
• ACTIVE STAGE – PALE , BOGGY, EDEMATOUS NASAL MUCOSA WITH WATERY DISCHARGE
BULKY INFERIOR & MIDDLE TURBINATES, MULBERRY SHAPED
POSTERIOR RHINOSCOPY
• HALITOSIS
• HIGH ARCHED PALATE (CHRONIC MOUTH BREATHING)
• MALOCCLUSION (COMMON)
• TONSILLAR HYPERTROPHY
• COBBLESTONING OF THE OROPHARYNGEAL WALL
• PHARYNGEAL POSTNASAL DISCHARGEPOST NASAL DRIP
20. INFERIOR TURBINATE CLASSIFICATION
SYSTEM
(A) GRADE 1 (0%–25% OF TOTAL AIRWAY SPACE)
(B) GRADE 2 (26%–50% OF TOTAL AIRWAY SPACE)
(C) GRADE 3 (51%–75% OF TOTAL AIRWAY SPACE)
(D) GRADE 4 (76%–100% OF TOTAL AIRWAY SPACE)
24. SKIN TESTS –
Introduce allergen into skin & check the site after 10-15 min for an immediate local
allergic reaction –
wheal and flare
>2mm)
• Method: small lancet to introduce an allergen into the skin. If the patient is
sensitized to the allergen then IgE sensitized mast cells will degranulate and
cause a wheal and flare reaction in the skin.
• Negative (saline) and positive (histamine) controls are also used
• Positive skin tests only give a guide to degree of atopy & not implies nasal allergy
to same allergen
27. BLOOD TESTS FOR ALLERGY
1.TOTAL IGE:
• RARELY HELPFUL AS 50% PTS HAVE IGE LEVELS WITHIN NORMAL RANGE
2.SPECIFIC IGE:
(I) RADIO-ALLERGOSORBENT TEST (RAST) (II)MODIFIED RAST
• THE SAFETY PROFILE OF SERUM SERUM IGE TESTING IS THE BESTS
• NOT INFLUENCED BY DRUGS OR SKIN DISEASE
• LEVELS OF SIGE MAY CORRELATE WITH SEVERITY OF AR SYMPTOMS
28. RAST(Radio allergo sorbent test
Procedure
Specific allergen bound to paper disc
test serum added to it & incubated
specific IgE ab , if present in serum will bind to
allergens & form complexes.
Radioisotope labeled anti-IgE Ab then introduced to Medium
which binds to pre-existing complexes on paper disc
Resultant “ allergen-IgE –anti-IgE” then measured in a γ
counter & the amount of Ab calculated.
29. INDICATIONS:
1. WHEN THERE IS C/I TO SPT
2. WHERE SPT UNAVAILABLE
3. WHEN SPT DIFFICULT TO INTERPRET
DISADVANTAGES:
• MORE EXPENSIVE
• DELAYED(TAKES LONGER)
• NO MORE SENSITIVE OR SPECIFIC TO SPT
Test may give false positive of false negative results.
30. SCALE
THE RAST TEST IS SCORED ON A SCALE FROM 0 TO 6:
RAST rating IgE level (KU/L) comment
• 0< 0.35 ABSENT OR UNDETECTABLE ALLERGEN SPECIFIC IGE
• 0.35 - 0.69 LOW OF ALLERGEN SPECIFIC IGE
• 0.70 - 3.49 MODERATE LEVEL OF ALLERGEN SPECIFIC IGE
• 3.50 - 17.49 HIGH LEVEL OF ALLERGEN SPECIFIC IGE
• 17.50 - 49.99 VERY HIGH LEVEL OF ALLERGEN SPECIFIC IGE
• 55.00 - 100.00 VERY HIGH LEVEL OF ALLERGEN SPECIFIC IGE
• > 100.00 EXTREMELY HIGH LEVEL OF ALLERGEN SPECIFIC
31. PRIST
PAPER RADIO IMMUNOSORBENT TEST
PRINCIPLE
• Incubating the IgE containing serum
with Radioactively labeled anti-IgE
• Total conc of IgE is then proportional
to measured Radioactivity
32. NASAL CHALLENGE TESTS
• Also known as nasal provocative test
• Sniff suspected allergen and the no. & Severity of symptoms noted.
SUBJECTIVE –SYMPTOM SCORES, VAS
OBJECTIVE –SNEEZE COUNT, NASAL INSPIRATORY PEAK FLOW , RHINOMANOMETRY
, ACOUSTIC RHINOMETRY , SPIROMETRY, PULMONARY PEAK FLOW
INDICATION:
- +VE HISTORY & –VE SPT
DISADVANTAGES
1.TIME CONSUMING 2.DIFFICULT 3.EXCESSIVE LAB FACILITIES
4.TRAINED STAFF 5.RESUSCITATION EQUIPMENT
33.
34. ROUTINE RADIOGRAPHIC IMAGING IS NOT RECOMMENDED FOR THE
DIAGNOSIS OF ALLERGIC RHINITIS BUT TO MAY BE NEEDED TO RULE OUT OTHE
DISEASES
XRAY
• LOW DENSITY HAZINESS SEEN IN PNS
• OCCASIONALLY POLYPS
38. COMPLICATIONS:
• ALLERGIC ASTHMA
• CHRONIC OTITIS MEDIA
• HEARING LOSS
• CHRONIC NASAL OBSTRUCTION
• SINUSITIS
• ORTHODONTIC MALOCCLUSION IN
CHILDREN
39. • Nasal symptoms -noted 80% of asthmatics
• Adults-asthma present in 22.5% of adults with AR, vs 7.2% in
general population
• Children-ratio of asthmatics with AR to asthmatics without AR is
even higher
• Effective treatment of allergic rhinitis reduces development of
subsequent asthma
40. MANAGEMENT OF ALLERGIC RHINITIS
1. THE PREVENTION OF ALLERGIC
RHINITIS
2. • METHODS OF REDUCING ALLERGEN
EXPOSURE
3. • PHARMACOLOGICAL TREATMENT OF
ALLERGIC RHINITIS
4. • IMMUNOTHERAPY FOR ALLERGIC
RHINITIS
5. • SURGICAL TREATMENT
6. • COMPLEMENTARY THERAPIES
41. (I) AVOIDANCE OF ALLERGENS
• BEST TREATMENT METHOD
• NOT ALWAYS PRACTICAL
INDOOR ALLERGENS: REMOVING ALLERGEN FROM THE INDOOR ENVIRONMENT
SHOULD BE A PRIMARY STRATEGY FOR THE MANAGEMENT AND TREATMENT OF
ALLERGIC DISEASE
OUTDOOR ALLERGENS:AVOID CONTACT
42. GENERAL ADVICE -- REDUCE ALLERGEN EXPOSURE
• CHIDREN SHOULD BREASTFEED FOR AT LEAST THE FIRST THREE MONTHS
AFTER BIRTH
PARENTS SHOULD NOT SMOKE IN PREGNANCY OR NEAR CHILDREN
AVOID IRRITANTS: SMOKE, DUST, VEHICULAR & OTHER ATMOSPHERIC
POLLUTANTS,
• PHYSICAL FACTORS – EXTREME CHANGES IN TEMPERATURE CAN PRODUCE
SYMPTOMS
LIKE ALLERGIC RHINITIS BUT ARE NON-IGE MEDIATED RESPONSES
• AVOID FOODS & DRUGS TO WHICH YOU ARE ALLERGIC
• AVOID OCCUPATIONAL IRRITANTS OR CHANGE PROFESSION
44. PHARMACOLOGICAL TREATMENT
OF ALLERGIC RHINITIS
• THE MOST WIDELY USED AND EFFECTIVE MEDICATIONS - ORAL OR TOPICAL
ANTIHISTAMINES AND TOPICAL NASAL STEROIDS.
• IT SHOULD BE STRESSED THAT THESE MEDICATIONS AIM TO ACHIEVE
IMPROVED SYMPTOM CONTROL AND ARE NOT A CURE FOR ALLERGY. THEY
GENERALLY NEED TO BE TAKEN FOR AS LONG AS THERE
• IS ALLERGEN EXPOSURE CAUSING SYMPTOMS. SYMPTOM CONTROL IS
BETTER FOR PATIENTS WITH INTERMITTENT ALLERGIC RHINITIS IF THEY START
TREATMENT PRIOR TO EXPOSURE TO THE ALLERGEN TO WHICH THEY ARE
SENSITIZED.
45.
46. ANTIHISTAMINES
• FIRST-LINE TREATMENT -- SYMPTOMS OF RUNNING, SNEEZING AND NASAL AND
EYE ITCHING AND HAVE NO PROBLEM WITH NASAL OBSTRUCTION.
• SECOND GENERATION- LORATADINE AND CETIRIZINE ARE NON-SEDATING,
SAFE FOR LONG-TERM USE-- CAN BE USED FOR CHILDREN.
• THEY HAVE A RAPID ONSET OF ACTION (USUALLY LESS THAN AN HOUR) AND
WILL GIVE SYMPTOM REDUCTION ON A ONCE DAILY DOSING.
• TOPICAL ANTIHISTAMINES (FOR EXAMPLE AZELASTINE)
47. INTRANASAL GLUCOCORTICOSTEROIDS
• INTRANASAL GLUCOCORTICOSTEROIDS-- MOST EFFECTIVE TREATMENT FOR ALLERGIC
RHINOCONJUNCTIVITIS.
• TOPICAL USE IN THE FORM OF A SPRAY OR DROPS IS PREFERRED TO ORAL USE TO REDUCE SIDE
EFFECTS,
• FIRST_X0002_LINE TREATMENT OF CHOICE IN PATIENTS WHO COMPLAIN OF NASAL BLOCK.
• SEVERAL HOURS OR DAYS AND IT CAN TAKE TWO WEEKS FOR FULL BENEFIT TO BE NOTICED
• SIDE EFFECTS OF INTRA-NASAL STEROIDS ARE FEW--EPISTAXIS.( INCORRECT USE)
• MINOR GROWTH RETARDATION HAS BEEN NOTED IN CHILDREN--INTRANASAL BECLOMETASONE
• FLUTICASONE(FROM 4 YEARS) OR MOMETASONEAND TRIAMCINOLONE( FROM 6 YEARS)
48.
49. • ORAL STEROIDS: PREDNISOLONE 20–40MG/DAY
LEUKOTRIENE RECEPTOR ANTAGONISTS (LTRAS)
• CYSTEINYL LEUKOTRIENES ARE A FAMILY OF EICOSANOID INFLAMMATORY MEDIATORS (LTC4, LTD4
AND LTE4) PRODUCED IN LEUKOCYTES, MAST CELLS, EOSINOPHILS, BASOPHILS AND
MACRHPHAGES BY THE OXIDATION OF ARACHIDONIC ACID BY THE ENZYME ARACHIDONATE 5–
LIPOXYGENASE.
• THEIR EFFECTS ARE TO CAUSE BRONCHOCONSTRICTION, INCREASE VASCULAR PERMEABILITY
AND ATTRACT INFLAMMATORY CELLS AND AS SUCH ARE INVOLVED IN THE PROCESSES
UNDERLYING ASTHMA AND ALLERGIC RHINITIS
• SODIUM CROMOGLICATE NASAL SPRAY HAS MODEST EFFECTS ON RHINITIS SYMPTOMS BUT MUST
BE USED FOUR TIMES DAILY, WHICH LIMITS COMPLIANCE.67 IT HAS NO SIDE EFFECTS AND CAN BE
USED ON YOUNG CHILDREN
• CROMOGLICATE EYE DROPS CAN BE EFFECTIVE AGAINST OCULAR ITCHING.
50. DECONGESTANTS
• TOPICAL (E.G. XYLOMETAZOLINE) AND SYSTEMIC DECONGESTANTS (E.G.
PSEUDOEPEDRINE)
• MORE EFFECTIVE, MORE RAPID ONSET OF ACTION.
• THEY REDUCE NASAL OBSTRUCTION , ALLOW ACCESS OF TOPICAL STEROID
INTO AN OTHERWISE OBSTRUCTED NOSE.
• THE DISADVANTAGE IS OF REBOUND VASODILATION WHEN THEIR USE IS
STOPPED( RHINITIS MEDICAMENTOSA)
• A MAXIMUM LENGTH OF TREATMENT OF 7–10 DAYS THEREFORE IS ADVISED.
• SYSTEMIC DECONGESTANTS MAY ALSO HAVE SIDE EFFECTS SUCH AS
INSOMNIA, TACHYCARDIA AND TREMOR
51. • IPRATROPIUM
TOPICAL IPRATROPIUM BROMIDE SPRAY IS EFFECTIVE - WATERY RHINORRHOEA,
USEFUL ADDITION TO A TOPICAL STEROID IF RHINORRHOEA IS NOT BEING WELL
CONTROLLED.
• SIDE EFFECTS ARE INFREQUENT BUT INCLUDE PROSTATIC SYMPTOMS AND
WORSENING OF GLAUCOMA.
NASAL DOUCHING
• SALINE NASAL DOUCHES MAY HELP WITH SYMPTOM CONTROL AND CAN PHYSICALLY
REMOVE AN ALLERGEN FROM THE NASAL MUCOSA.
• IF POLLEN LEVELS ARE HIGH REGULAR DOUCHING MAY BE OF BENEFIT.
52. IMMUNOTHERAPY(DEENSENSITATION)
• IS A METHOD OF INDUCING TOLERANCE TO AN ALLERGEN AND THEREFORE REDUCING
UNWANTED SYMPTOMS.
• IF ALLERGIC RHINITIS IS REFRACTORY TO PHARMACOTHERAPY OR SEVERE
• HELPS IN REDUCING THE SPECIFIC SERUM IGE LEVEL
• DECREASES THE BASOPHIL SENSITIVITY
• INCREASES IGG BLOCKING ANTIBODY LEVEL , THUS PREVENTING ALLERGEN FROM REACHING
MAST CELLS AND SUBSEQUENT MAST CELL DEGRANULATION
• . IT CAN BE GIVEN SUBCUTANEOUSLY BY INJECTION (SCIT) OR SUBLINGUALLY IN DROPS OR
TABLETS (SLIT)
• PATIENTS CONSIDERED ARE THOSE WHO HAVE SEVERE SYMPTOMS BUT WHOSE RESPONSE TO
STANDARD MEDICAL TREATMENT HAS BEEN UNSATISFACTORY, OR THOSE PATIENTS WHO HAVE
UNACCEPTABLE SIDE EFFECTS FROM THEIR MEDICATION.
53. PROCEDURE
• SCIT THERE IS USUALLY AN UPDOSING PHASE OF BETWEEN 2 AND 4 MONTHS WHEN THE DOSE OF ALLERGEN IS
GRADUALLY INCREASED TO THE MAINTENANCE DOSE. THIS MAINTENANCE DOSE IS THEN INJECTED EVERY 4–6
WEEKS FOR A 3-YEAR PERIOD.
• SLIT MAY BE UPDOSED OR, IN SOME TREATMENT PROTOCOLS, THE PATIENT STARTS WITH THE MAXIMUM DOSE
AND CONTINUES WITH THIS DAILY FOR 3 YEARS
• TRANSIENT REDNESS AND ITCHING AROUND AN INJECTION SITE, OR ORAL ITCHING, AND CAN BE REDUCED BY
PRE-TREATMENT WITH AN ORAL ANTIHISTAMINE.
• SIDE EFFECTS: URTICARIA, BRONCHOCONSTRICTION OR ANAPHYLAXIS AND RESUSCITATION FACILITIES WITH
ADRENALINE MUST BE AVAILABLE
• ALMOST ALL REACTIONS WILL OCCUR WITHIN 30 MINUTES OF TREATMENT THEREFORE PATIENTS SHOULD BE
OBSERVED FOR AN HOUR AFTER INJECTION
54. • RECENT EXPOSURE OF THE NOSE TO ALLERGEN MAY LEAD TO
ASYMPTOMATIC EOSINOPHIL INFILTRATION AND A PRO_X0002_INFLAMMATORY
MUCOSAL ENVIRONMENT – A CONCEPT KNOWN AS PRIMING.
55. • ANTI IGE AB- OMALIZUMAB
• RISK OF CAUSING ANAPHYLAXIS AND IS EXPENSIVE.
• IT IS ADMINISTERED BY MONTHLY INJECTION.
• CURRENTLY IT IS RECOMMENDED ONLY FOR PATIENTS WITH SEVERE
ALLERGIC ASTHMA WITH OR WITHOUT RHINITIS SYMPTOMS.
56.
57. SURGICAL THERAPY
• LIMITED
• SUBMUCOSAL TURBINECTOMY - REDUCES SIZE OF BOGGY TURBINATES
• SEPTOPLASTY – CORRECTION OF DEVIATION OF SEPTUM
• SINUS SURGERY – CLEARANCE OF SINUSES IF SINUSITIS IS PRESENT
