RHINITIS

1. RHINITIS M.Rogha M.D Isfahan university of medical sciences

2. Chronic rhinitis:1-allergic type 2-Non allergic type

3. Chronic rhinitis • 10% of the population suffer from rhinitis • From those with rhinitis symptoms: 43% allergic rhinitis 23% non allergic type 34% mixed allergic & non allergic .

4. Chronic rhinitis can lead to: • sinusitis • nasal polyps • eustachian tube dysfunction • chronic otitis media • disorders of the sense of smell

5. Allergic rhinitis • 40 million Americans may be affected by allergic rhinitis. • Economically, It costs about 2 billion dollars per year. • The patients suffer from its chronicity. • May accompany other aspects of allergy Asthma, urticaria, ….

6. Allergic rhinitis: Seasonal grasses, weeds, trees Perennial dust mite, molds, animal danders, cockroach

7. pathophysiology • Immediate type reaction • Specific IgE synthesis by B-lymphocytes • Sensitized mast cell formation • Bridging one molecule of Ag between two sIgE • Dissolution of mast cells& basophils • Release of inflammatory mediators

10. Pathophysiology contd. So, the main effects are: 1- vasodilation 2-increased permeability of vessels 3-irritation 4-gland stimulation

11. Symptoms & Signs • Itching • Sneezing • Rhinorrhea • Nasal congestion • Allergic salute • Allergic shiners • Dennie-morgan lines • Pale to bluish enlarged turbinates • others

12. Allergic salute

13. Diagnosis • History & physical examination • Skin tests (in vivo) • Serologic tests (in vitro)

14. Skin tests • Epicutaneous scratch test prick puncture test • Intradermal single dilutional multi dilutional

15. Puncture/Prick Testing • 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 should occur • Read positive control in 10 minutes • Read allergens in 15-20 minutes Example of a skin prick/puncture epicutaneous test

16. Multiple Antigen Testing cont’d Example of multiple-puncture device in its loading dock device allowing simultaneous placement of six allergens plus a positive and negative control 2 Example of multiple-puncture

17. Multiple Antigen Testing cont’d Example of positive and negative skin responses to allergens applied with a multiple-puncture device; note the positive and negative control sites Example of application of a multiple-puncture device to the forearm

18. Serologic tests • RAST (Radioallergosorbent test) Ag….sIgE….. Anti IgE* • ELISA (enzyme-linked immunosorbent assay)

19. treatment • Environmental control • Medical antihistamins;3 generation of them are available. corticosteroides; intopical & systemic forms diminish the effects of mediators by decreasing vascular permeability, stabilizing lysosomal membranes,…. alpha adrenergics mast cell stabilizers; chromolyn, olopatadine, quazolast,… leukotrien modifiers; zileuton, montelukast, zafirlukast. human recombinant anti IgE (Omalizumab) • immunotherapy

20. New directions in treatment: Tryptase inhibitors APC-366;  pentamidine-like; BABIM-like; lactoferrin Cytokin modulators Pitrakinra Chemokin inhibitors Cell adhesion blockers neutralizing antibody to lL-5

22. Nonallergic Rhinitis (Vasomotor Rhinitis)

23. Non allergic rhinitis components: Nasal innervation vasculature Mucosal glands

24. pathophysiology • Anatomic effect • Autonomic nervous system effect

25. pathophysiology • Parasympathetic stimulation increased serous glands activity of nasal mucosa Rhinorrhea. • Direct sensory C-fibers stimulation, by histamin, bradykinin & inhaled irritants release of neuropeptides increased vascular permeability& glandular, endothelial & epithelial cell stimulation itching, rhinorrhea, burning sensation. • Hyper responsiveness of afferent sensory nerves exaggerated efferent response over secretion of mucus & increased nasal congestion. • Normal afferent input but hyper reactive efferent arc due to CNS impairment.

26. Diagnostic tests • Methacolin provocative test to evaluate glandular responsiveness. Positive in both allergic & nonallergic rhinitis • Histamin provocative test to evaluate vascular permeability. Positive in both types of rhinitis; mainly in allergic type. • Cold dry air increases mucosal osmolarity C-fiber stimulation, ….. Selective for non allergic rhinitis. • Capsaicin provocative test to evaluate sensory innervation (specific C-fiber stimulant). Selective for non allergic rhinitis.

27. Nonallergic Rhinitis classification • Infectious • Drug-induced • Hormonal • Anatomical • Idiopathic

28. Types of non allergic rhinitis • Drug induced rhinitis • Anti hypertensives • birth control pills • cocaine • nasal drop abuse • NSAID • antipsychotics

29. Causes of vasomotor rhinitis • Pregnancy & premenstrual cold • hypothyroidism • emotional causes • temperature mediated • irritative & environmental rhinitis • gustatory rhinitis • recumbency rhinitis • non airflow rhinitis • compensatory hypertrophic rhinitis • eosinophilic nonallergic rhinitis • Idiopathic rhinitis

30. Treatment of vasomotor rhinitis • Medical avoidance of irritative factors exercises topical nasal steroids decongestants anticholinergic medications (Ipratropium bromide) topical silver nitrate 5-20% • surgical endonasal surgeries vidian neurectomy