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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 Dr Serge Maurice FRCSE 02 April 2008
Functions of the nose • To smell • To filter, warm and humidify the air we breathe
Allergic Rhinitis Doctère, mo éna ène mari problème ek mo néné
Changes in Terminology • “OLD”: Seasonal & Perennial • “NEW”: Acute or Intermittent and Chronic or Persistent (WHO 2000)
The Symptoms • Seasonal/Acute: Itching, Sneezing, Rhinorrhea. • Perennial/Chronic: The blocked nose
The Acute Symptoms • The tingle • The itchy nose • The volley of sneezes • The flooding rhinorrhea • The ocular symptoms • The itchy palate
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
The Culprits: Pollens • In the Mauritian context, a frequently accused innocent: the sugar cane pollen
The Allergic Reaction • An Idiot’s Guide to the chain of reactions, from the first meeting to the divorce!
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
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
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
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
ImmunoglobulinE(IgE) ALLERGEN Specially in the mastocytes ALLERGIC REACTION Inflammatory Mediators Cytokines The Start
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
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
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
Treatment Principles • Acute/Intermittent/Seasonal Symptoms • Chronic/Persistent/Perennial Symptoms
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
Acute Symptoms • Local and Systemic decongestants • 2nd Generation Antihistamines, systemic and local • Local Steroids
Chronic Symptoms • Local and systemic steroids • 2nd Generation Antihistamines • Other drugs/measures
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)
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
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
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
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…
Some other helpful(?) measures • Saline douches • Petroleum jelly (Vaseline) application • Inhalations • Anti-oxidants (Vit C, E, Beta carotene, zinc, selenium…) • “Muco-regulators” (carbocisteine..)
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.
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