Overview of Allergic and Vasomotor Rhinitis: Etiopathogenesis, Clinical Features, Complications, and Management

1. DR. SHEETAL RAI ASST. PROFESSOR DEPT OF ENT YENEPOYA MEDICAL COLLEGE

2. SPECIFIC LEARNING OBJECTIVES Describe the etiopathogenesis, clinical features ,complications and management of allergic rhinitis Describe the etiopathogenesis, clinical features ,complications and management of vasomotor rhinitis

3. ALLERGIC RHINITIS Ig E mediated immunologic response of nasal mucosa to air-borne allergens Watery nasal discharge Nasal obstruction Sneezing Itching – nose,eyes,ears and phaynx Seasonal/perennial

4. AETIOLOGY Inhalant allergens -Pollen, mould spores,house dust, insect debris Genetic predisposition

5. PATHOGENESIS 1. Acute /early phase Occurs within half an hour Due to release of histamine like substances Sneezing, rhinorrhea, bronchospasm 2. Late/delayed phase Occurs within 2 – 8 hrs Due to inflammatory cell infiltrate Swelling, congestion, thick secretion

7. CLINICAL FEATURES Nasal signs 1. Transverse nasal crease 2. Allergic salute 3. Pale edematous nasal mucosa Mulberry turbinates

8. CLINICAL FEATURES Ocular signs – lid edema cobblestone appearance of conjunctiva Allergic shiners Otologic signs - retracted TM Secretory Otitis Media Pharyngeal signs – granular posterior pharyngeal wall Laryngeal signs – edema of the vocal cords

9. CLINICAL FEATURES SEASONAL ALLERGY PERENNIAL ALLERGY • Paroxysmal bouts of sneezing • Watery nasal discharge • Itching in the nose,eyes,ears,palate,pharynx • brochospasm • Frequent cold • Persistent stuffy nose • Hyposmia/anosmia • Post nasal drip • Chronic cough • Hearing impairment

10. CLINICAL FEATURES

11. SAMTER’S TRIAD

12. INVESTIGATIONS Total and differential count Nasal smear Skin tests RAST – measures specific IgE antibody in serum Nasal provocation test

13. COMPLICATIONS Recurrent sinusitis Nasal polypi Serous otitis media Prolonged mouth breathing – orthodontic problems Bronchial asthma

14. TREATMENT Avoid the allergen Drug therapy Immunotherapy

15. DRUG THERAPY Antihistaminics – CETRIZINE LEVOCETRIZINE EBASTINE FEXOFENADINE RUPATIDINE LORATIDINE DESLORATIDINE BEPOTASTINE

16. DRUG THERAPY Sympathomimetics ???????????? Relieve nasal obstruction only Oral – PHENYLEPHRINE PSEUDOEPHEDRINE Topical – OXYMETAZOLINE XYLOMETAZOLINE Overuse may lead to Rhinitis medicamentosa

17. DRUG THERAPY Corticosteroids – Suppress late phase allergic reaction Oral – PREDNISOLONE METHYL PREDNISOLONE DEFLAZACORT Topical – BUDESONIDE FLUTICASONE PROPIONATE FLUTICASONE FUROATE MOMETASONE

18. DRUG THERAPY Sodium chromoglycate – Mast cell stabilizer Prevents degranulation Nasal drops/spray/aerosol powder

19. IMMUNOTHERAPY Hyposensitization Allergen given in gradually increasing doses IMMUNOTHERAPY suppresses formation of IgE …… raises the titre of specific IgG antibody

21. TREATMENT ALGORITHM

22. VASOMOTOR RHINITIS Non – allergic rhinitis Symptoms similar to allergic rhinitis Persists throughout the year All tests of nasal allergy - negative

23. PATHOGENESIS Nasal mucosa ---- rich blood supply through VENOUS SINUSOIDS lined by smooth muscle Controlled by autonomic nervous system. Sympathetic stimulation ----------- vasoconstriction & shrinkage of mucosa Parasympathetic stimulation ----------vasodilatation & engorgement of mucosa

24. PATHOGENESIS Problem ??????????? unstable ANS ANS is controlled by Hypothalamus………….hence the role of EMOTIONS Hyperactive nasal mucosa ……… reacts to non specific stimuli.

25. CLINICAL FEATURES Paroxsymal sneezing Excessive rhinorrhea Nasal obstruction Post nasal drip NO ITCHING Congested & hypertrophied turbinates

26. COMPLICATIONS Nasal polyposis Hypertrophic rhinitis Chronic sinusitis

27. TREATMENT MEDICAL – Avoidance Antihistaminics & oral nasal decongestants Topical steroids Psychological help

28. TREATMENT SURGICAL- Relieve nasal obstruction ……septoplasty/polypectomy/FESS VIDIAN NEURECTOMY sectioning of parasympathetic secrotomotor fibres to the nose

29. VIDIAN NERVE

30. VIDIAN NERVE

31. Relationship of vidian nerve to sphenoid sinus and choana

32. THANK YOUAll images have been derived from Google image search

33. SUMMARY • Allergic and Vasomotor rhinitis present with similar features , but have different etiopathogenesis. • The medical treatment for both remains the same. • Vasomotor rhinitis can be corrected surgically by Vidian neurectomy.