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Allergic Rhinitis

Allergic Rhinitis. Dr. Vishal Sharma. Introduction.  C ommonest chronic disease of mankind (20%)  Induced after allergen exposure by IgE-mediated Type 1 hypersensitivity reaction of nasal mucosa  30% pt of allergic rhinitis have bronchial asthma

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Allergic Rhinitis

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  1. Allergic Rhinitis Dr. Vishal Sharma

  2. Introduction  Commonest chronic disease of mankind (20%) Induced after allergen exposure by IgE-mediated Type 1 hypersensitivity reaction of nasal mucosa  30% pt of allergic rhinitis have bronchial asthma  60-80% pt of asthma also have allergic rhinitis  Prevention of allergen exposure is best treatment

  3. Aetiology 1. ATOPY:genetically inherited ed IgE response 2. ALLERGENS: * Seasonal (Hay fever):Pollen, Fungus * Perennial:Dust mite, Domestic pets, Cockroaches * Occupational (?):Flour, Animal, Wood, Latex, Paint 3. FOOD INDUCED:Nuts, fish, prawns, legumes, milk, cheese, egg, meat, citrus fruits, wines

  4. 4. DRUG INDUCED:Aspirin, other NSAIDs, anti-hypertensives, oral contraceptive pills 5. POLLUTION (NASAL IRRITANTS):Traffic fumes, tobacco smoke, mosquito repellents, perfumes, scented sticks, domestic sprays, bleaches 6. LACK OF INFECTION:Younger child in large family  frequent viral infections & less prone to allergy. Older child in large family or only child in a small family  infection is rare so develops allergy.

  5. Grass pollen & dust mite

  6. Pathogenesis Sensitization & Priming to specific antigen: Inhaled allergen produces specific IgE antibody which gets attached to mast cells Subsequent exposure to same antigen: Allergen combines with specific IgE antibody  degranulation of mast cells (even with small amount of antigen)  chemical mediators released

  7. Acute or Early Phase Occurs 5–30 min after exposure to antigen due to release of chemical mediators sneezing, watery rhinorrhoea, nasal blockage & bronchospasm.  Mucosal edema&Vasodilation nose block  Nerve irritation sneezing & itching  ed secretion from nasal gland rhinorrhoea  Smooth muscle contraction bronchospasm

  8. Late or Delayed Phase Occurs 2-8 hours after exposure due to infiltration by inflammatory cells at site of antigen deposition  edema, congestion & thick nasal secretion. Sneezing & itching decreases. Inflammatory cells are eosinophils, neutrophils, basophils, monocytes & CD4+ T lymphocytes.

  9. Pathogenesis

  10. Pathogenesis

  11. Cardinal Symptoms 1.Watery rhinorrhoea 2.Nasal obstruction: bilateral 3.Paroxysmal sneezing: 10-20 at a time 4.Itching in nose, eyes, palate, pharynx Presence of 2 or more symptoms for > 1 hour on most days indicates allergic rhinitis.

  12. Nasal Signs • Repeated lifting of nasal tip (allergic salute) to relieve itching & open nasal airway transverse nasal crease (Darrier’s crease, Hilton’s line). • Hypertrophied turbinates are covered with pale or blue, boggy mucosa. Pitting edema seen on probing (mulberry turbinates). • Nasal secretions are watery  mucoid. • Nasal polyps with hyposmia / anosmia.

  13. Allergic salute

  14. Nasal crease

  15. Pale turbinate, watery rhinorrhoea

  16. Blue, boggy turbinate

  17. Inferior turbinate appearances

  18. Other Clinical Signs Face: Frequent twitching of face (bunny nose)  Dennie-Morgan creases (in lower eyelid skin)  Allergic shiners (dark discoloration below lower eyelids) caused by venous stasis Eyes: Conjunctiva is congested with cobble stone appearance; increased lacrimation Ears: Ear block & ed hearing (due to O.M.E.) Throat: Chronic pharyngitis, laryngitis

  19. Dennie-Morgan Creases

  20. Allergic Shiners

  21. Allergic conjunctivitis

  22. ARIA Classification 1. Mild intermittent 2. Moderate-severe intermittent 3. Mild persistent 4. Moderate-severe persistent ARIA = Allergic Rhinitis & its Impact on Asthma

  23. Intermittent symptoms Persistent symptoms Present for < 4 days / wk Present for > 4 days / wk Or for < 4 weeks and for > 4 weeks Mild (presence of all) Moderate-severe (any 1)  Normal sleep  Abnormal sleep  Normal daily activities  Impaired daily activities  Normal work and school  Impaired work & school  Normal sport & leisure  Impaired sport & leisure  No troublesome symptom  Troublesome symptoms +

  24. Investigations • Absolute Eosinophil count • Nasal smear examination for eosinophils • Skin prick test • Radio-allergo-sorbent test (R.A.S.T.) • Diagnostic Nasal Endoscopy • C.T. scan P.N.S.:for sinusitis & nasal polyps

  25. Skin prick test

  26. Skin prick test

  27. Skin prick test

  28. Radio-allergo-sorbent test

  29. Pt serum is incubated with allergen disc. Only specific IgE binds with allergen. Rest is washed away with a buffer. • Disc is incubated with radio-labeled anti - IgE antibody. Anti-IgE antibody binds with allergen-IgE complex. • Amount of radio-labelled anti-IgE antibody on disc  amount of IgE & is quantified by counting radioactivity from the disc.

  30. Complications • Recurrent sinusitis • Nasal polyp • Serous otitis media • Prolonged mouth breathing • Bronchial asthma • Atopic dermatitis • Conjunctivitis

  31. Differential diagnosis • Vasomotor rhinitis • Rhinitis medicamentosa • Hormonal rhinitis (pregnancy, hypothyroidism, oral contraceptive use) • Cerebrospinal fluid leak • Ethmoid polyps

  32. Treatment • Avoidance of allergens • Pharmacotherapy • Specific Immunotherapy • Surgery: F.E.S.S., Turbinoplasty

  33. Pharmacotherapy H1-Antihistamines: Topical (Azelastine), Systemic Nasal Decongestants:Topical drops, Systemic Mast cell stabilizers: Sodium cromoglycate, Ketotifen Anti-cholinergics:Ipratropium bromide nasal spray Corticosteroids: Nasal, Oral, Turbinal, Intramuscular Leukotriene receptor antagonists:Montelukast Newer drugs: RhuMAb-25, Altrakincept

  34. Antihistamines & Decongestants AntihistaminesSystemic decongestants • Cetirizine (S)  Phenylephrine • Fexofenadine (S)  Pseudoephedrine • Loratidine (S) Topical decongestants • Levocetrizine (S)  Xylometazoline • Desloratidine (S)  Oxymetazoline • Azelastine (T)  Hypertonic saline

  35. Antihistamines Systemic: Cetirizine: 10 mg OD Fexofenadine: 120 mg OD Loratidine: 10 mg OD Levocetrizine: 5 mg OD Desloratidine: 5 mg OD Topical:Azelastine spray (0.1%): 1-2 puff BD

  36. Nasal Decongestants Systemic decongestants  Phenylephrine  Pseudoephedrine Topical decongestants  Xylometazoline  Oxymetazoline  Saline

  37. Anti-cold preparations PsE = Pseudoephedrine; PhE = Phenylephrine

  38. Topical Decongestants • Oxymetazoline 0.05 %: 2-3 drops BD (NASIVION) • Oxymetazoline 0.025 %: 2 drops BD (NASIVION-P) • Xylometazoline 0.1 %: 3 drops TID (OTRIVIN) • Xylometazoline 0.05 %: 2 drops BD (OTRIVIN-P) • Saline 2 %: 3 drops TID • Saline 0.67 %: 2 drops BD (NASIVION-S)

  39. Systemic Antihistamines

  40. Topical Antihistamine spray

  41. Technique of nasal spray

  42. Nasal Decongestants

  43. Sodium Cromoglycate

  44. Ipratropium nasal spray

  45. Corticosteroids Nasal sprays Injectable  Beclomethasone  Methylprednisolone  Budesonide  Fluticasone Oral  Mometasone  Prednisolone

  46. Corticosteroid nasal spray

  47. Methylprednisolone acetate

  48. Montelukast

  49. Specific Immunotherapy (SIT) Indications: 1. Insufficient response to conventional drugs 2. Side effects from conventional drugs 3. Rejection of conventional drug treatment. 4. Allergy to one or two allergens only Types: Systemic injection, intra-nasal, sublingual

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