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THE NOSE

THE NOSE. Dr Serge Maurice FRCSE 02 April 2008. Functions of the nose. To smell To filter, warm and humidify the air we breathe. Some anatomical souvenirs. Noses come in various shapes or sizes. Allergic Rhinitis. Doctère, mo éna ène mari problème ek mo néné. Changes in Terminology.

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THE NOSE

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  1. THE NOSE Dr Serge Maurice FRCSE 02 April 2008

  2. Functions of the nose • To smell • To filter, warm and humidify the air we breathe

  3. Some anatomical souvenirs

  4. Noses come in various shapes or sizes

  5. Allergic Rhinitis Doctère, mo éna ène mari problème ek mo néné

  6. Changes in Terminology • “OLD”: Seasonal & Perennial • “NEW”: Acute or Intermittent and Chronic or Persistent (WHO 2000)

  7. The Symptoms • Seasonal/Acute: Itching, Sneezing, Rhinorrhea. • Perennial/Chronic: The blocked nose

  8. The Acute Symptoms • The tingle • The itchy nose • The volley of sneezes • The flooding rhinorrhea • The ocular symptoms • The itchy palate

  9. Acute symptoms: Sneezing & Rhinorrhea

  10. The Chronic Symptoms • A blocked nose, often with hyposmia & hypoguesia • Recurrent bouts of AOM in kids • Otitis Media with effusion in kids and adults • The allergic salute • Recurrent bouts of acute sinusitis in adults • Chronic sinusitis and nasal polyposis • A nasal voice • Snoring and OSA in kids and adults

  11. Chronic Symptom: Blocked nose

  12. The allergic salute

  13. Massive polyposis

  14. The Culprits: Pollens • In the Mauritian context, a frequently accused innocent: the sugar cane pollen

  15. Flowers

  16. Grasses and Trees

  17. Moulds and Mites, Cockroaches

  18. Pet animals

  19. The Allergic Reaction • An Idiot’s Guide to the chain of reactions, from the first meeting to the divorce!

  20. The first date -1 MACROPHAGE ANTIGENS The macrophage ingests the allergens, breaks them up and presents some of their chemicals to the immune cells, the lymphocytes

  21. Y Y Y Y Y Y The first date -2 Y Y Y Y Y Y Y Y Y Plasmocyte Y Y Lymphocyte Y Mastocyte Antibodies The lymphocytes send a message to the plasmocytes, that produce the antibodies The antibodies attach themselves firmly to the mastocytes(containing granules that intervene in the inflammatory reaction) and to basophils

  22. Y Y Y Y Y Y The second date -1 The antigens this time link up to the antibodies attached to the mastocyte, and the latter is then activated

  23. Y Y Y Y Y Y The second date -2 The activated mastocyte liberates its granules, that contain histamine and other inflammatory chemicals,(triptase, prostaglandins) responsible for the allergic reaction

  24. ImmunoglobulinE(IgE) ALLERGEN Specially in the mastocytes ALLERGIC REACTION Inflammatory Mediators Cytokines The Start

  25. Cytokines, Interleukins Histamine Neutralproteases Leukotrienes Immediate Reaction: Late Reaction: Acute Inflammation Chronic Inflammation Vasodilatation,oedema Congested Mucosa Mucus++ Itching Obstruction, Infection Watery Rhinorrhea Blocked nose Pruritus Sinusitis Sneezing++++ Pharyngitis Otitis The Progression Early Phase Late Phase

  26. Diagnosis • HISTORY: ALL IMPORTANT • Simple Rhinoscopy: Pale, boggy, bluish mucous membrane • Sometimes Polyps • Skin scratch tests and lab tests (RAST, Phadiatop, Total IgE(inaccurate), nasal IgE, nasal mucus eosinophils)-test food allergies in kids • Imaging NOT necessary for simple AR

  27. Differential Diagnosis • Chronic Idiopathic Rhinitis (V.M.R) • NARES • Nasal hypersensitivity, specially to dust, perfume, tobacco smoke,SO2,NO2, cold air • Drug induced- Aspirin (Widal’s), ACE inhibitors, HRT, Methyl DOPA,Reserpine • Last trimester of pregnancy

  28. Treatment Principles • Acute/Intermittent/Seasonal Symptoms • Chronic/Persistent/Perennial Symptoms

  29. Allergen Avoidance • If the allergen has been identified: • Avoid grass pollens • Get rid of offending pets • Treat pillows and mattresses • Avoid offending foods • But, unfortunately, more often than not, medication needed

  30. Acute Symptoms • Local and Systemic decongestants • 2nd Generation Antihistamines, systemic and local • Local Steroids

  31. Chronic Symptoms • Local and systemic steroids • 2nd Generation Antihistamines • Other drugs/measures

  32. Other drugs/measures • Sodium Cromoglycate • Ipatropium Bromide (rhinorrhea) • SIT & SLIT • Leukotriene antagonists (Zafirlukast, Montelukast) • Empirical dietary exclusion of cow’s milk and food additives (benzoates, nitrites, sulphites, colourings)

  33. Specific Immunotherapy • Sublingual or injection • Should be reserved for mono/bi allergens (e.g. grass pollen & house-dust mite) • NOT as first line, but if other measures useless • Injection method should only be done with resuscitative facilities available

  34. Side-Effects -1 • Early 2nd G. antiH: (Astemizole, Terfenadine..) : Liver and cardiac problems when used in association with some other drugs • Newer ones (fexofenadine, cetirizine, loratidine…):safe, but still cause drowsyness • Local acting (levocabastine, azelastine,): local irritation & unpleasant taste

  35. Side effects -2 • Local decongestants – abuse & R.M. • Systemic decongestants – glaucoma, prostate, HBP, palpitations, insomnia • Local Steroids sprays – Great, but local irritation, epistaxis & no effect on eye/palate itch • Cromoglycate – qds, hence poor compliance • Ipatropium – only on drip

  36. Systemic Steroids?? • Very useful in treatment of infective acute episodes (High Dose Short Term) • BE VERY WARY OF THE DEPOT STEROID INJECTIONS: Osteoporosis, muscle damage, diabetes, glaucoma, cataracts, gastric ulcers…

  37. Some other helpful(?) measures • Saline douches • Petroleum jelly (Vaseline) application • Inhalations • Anti-oxidants (Vit C, E, Beta carotene, zinc, selenium…) • “Muco-regulators” (carbocisteine..)

  38. To summarise: • The problem with allergies such as Hay fever and Allergic Rhinitis is that it is considered to be a trivial and inconsequential disease. Symptoms such as runny nose, itchy eyes and nose with sneezing and blockage are obviously not life threatening, but affect up to 25% of the population and are the cause of significant disability and cost to society…/cont.

  39. To summarise (cont) • Patients may also experience fatigue, irritability, as well as mood, cognitive and sleep disturbance in addition to the nasal, ocular and throat symptoms. Allergic rhinitis has important co-morbid associations such as chronic sinusitis, glue ear, asthma exacerbations, nasal polyps, sleep apnoea and dental malocclusion. • Dr A Morris, January 2007, Surrey Allergy Clinic

  40. Thank you for your attention

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