ALLERGIC RHINITIS

S PANDEY
 OUTLINE

Definition and
Introduction
Etiologies
Presentation
Diagnosis
Prognosis
Management
RHINITIS

Two or more nasal symptoms of:

Nasal congestion
Rhinorrhea
Sneezing/Itching
Impairment of Smell for
more than 1 hour a day
RHINITIS

Occurs most commonly as allergic rhinitis

Noninfectious rhinitis has been classified as either
allergic or non-allergic.
Allergic rhinitis is defined as immunologic nasal
response, primary mediated by immunoglobulin E
(IgE).
Non-allergic rhinitis is defined as rhinitis symptoms
in the absence of identifiable allergy, structure
abnormality or sinus disease.
 INTRODUCTION

Nasal function includes

Temperature regulation
Olfaction
Humidification
Filtration and Protection
 INTRODUCTION
Nasal lining contains secretion of IgA, proteins
and enzymes
Nasal Cilia propel the matter toward the natural
ostia at frequency of 10-15 beats per minute
Mucous move at a rate of 2.5-7.5 ml per
minute
ALLERGIC RHINITIS

Defined as an inflammation of the nasal

mucosa, caused by an allergen
Most common atopic allergic reaction
Affects 10 to 25% of population
50% of rhinitis in ENT is AR
Most commonly seen in young children and
adolscents
ETIOLOGY

Classified as
Precipitating factors
Predisopsing factors
PRECIPITATING FACTORS
Aerobiological flora
Allergens present in the environment
House dust and dust mites
Feathers
Tobacco smoke
Industrial chemicals
Animal dander

Nasal physiology
Disturbances in normal nasal cycle
PREDISPOSING FACTORS

Genetic
Multiple gene interactions are responsible for allergic
phenotype
Chromosomes 5, 6, 11, 12 & 14 control inflammatory process
in atopy
50% of allergic rhinitis patients have a positive family history
of allergic rhiniits

Endocrine
Puberty
Pregnant states and post partum stages
menopausal
PREDISPOSING FACTORS.

Psychological
Focal sensitivity states
Infections: fungal infections nb
Physical
Degree of pollution of air
Humidity and temperature differences
Temperature changes
Age & sex
IgA deificiency
 COMMON ALLERGENS
Pollens
Spring tree pollens(maple alder, birch)
Summet : grass pollent (bluegrass, sheep shorell etc
Autums: weed pollen (ragweed)
Molds
Penicillium, cladosporium etc
Insects
Cockroaches, house flies, fleas, bed bugs
Animals
Cats. Dogs. Horse, monkeys, rats, rabbits etc
Dust mites
dermatophagoides
Ingestants
Nuts, fish, eggs, milk etc
PATHOPHYSIOLOGY

Immunoglobulin (Ig) E mediated type 1

hypersensitivity response to an antigen
(allergen) in a genetically susceptible person
Type 1 Hypersensitivity causes local
vasodilation and increased capillary
permeability
CLASSIFICATON - FORMER
Seasonal
Often known by its misnomer of Hay fever
Neither caused by hay or has fever
Summer cold
Caused by virus causing URTI (not a true allergic
rhinitis
Rose fever
Often cited in indian subcontinent
Colourful or fragrant flowering plants rarely cause
allergy as their pollens to heavy to be airborne
Perennial
Allergens present throughout the year
CLASSIFICATION - CURRENT

Intermittent
Symptoms present less than 4 days per week and
less than 4 weeks per year

Persistant
Symptoms present more than 4 days per week and
more than 4 weeks per year
SEVERITY

Mild
No interference with daily activity or troublesome
symptoms

Moderate severe
Presence of at least one:
Impaired sleep, daily activity work or school
Troublesome symptoms
COMPLICATIONS:

Allergic asthma
Chronic otitis media
Hearing loss
Chronic nasal obstruction
Sinusitis
Orthodontic malocclusion in children
SIGNS AND SYMPTOMS

Sneezing Earache
Itchy nose, ears, Tearing of eyes
eyes and palate Red eyes
Rhinorrhea Swollen eyes
Post nasal drip Fatigue
Congestion Drowsiness
Anosmia Malaise
Headache
PHYSICAL EXAMINATION
Nasal crease
Horizontal crease
across the lower half
of the bridge of the
nose

Rhinorrhoea
Thin watery secretions
Deviated or
perforated nasal
septum
EXTRA NASAL MANIFESTATIONS

Retracted and
abnormal flexibility
of TM
Injection and swelling
of palpebral
conjunctivae with
excess tearing
Cobblestoning on
oropharynx
CLASSICAL SIGNS OF AR

Over bite
High arched palate
Allergic shiners
Allergic salute
Transverse crease over
tip of nose and lower
eye lid
Conjunctival
congestion
Periorbital oedema
INVESTIGATIONS

FBC
Histamine test
Nasal smear
Intranasal provocation test
Skin tests
Subcuticular test
More accurate with lower incidence of false positive
results
Contraindicated in case of anti histaminic, anti
inflammatory or decongestant treatment
 Intradermal tests
Be prepared for anaphylaxis
Skin end point titration test
Quantitative intradermal test for specific allergen
Nasal challenge
Nasal cytology
Take a sample of nasal cavity without anaesthesia
and send for identificaton of cell types in the nasal
cavity
Increased number of eosinophils suggests allergic
disease
OTHER INVESTIGATIONS

RAST (radio allergo sorbant test)

FAST ( fluro allergo sorbant test)
PRIST (paper immuno allergo sorbant test)
Xray PNS
CT PNS (for complicated cases with polyposis)
Nasal endoscopy ( under local or GA)
Evaluate for asthma
PROGNOSIS

Treatment is available and patients remain

symptom free only until re exposure to allergic
antigen
No evidence of mortality from the disease
itself, but high morbidity
Seasonal allergic Symptoms improve as
patients age
 MANAGEMENT:
AVOIDANCE

MEDICAL SURGICAL
AVOIDANCE

Minimize contact with offending allergens

Reduce dust mite exposure by encasing bed
pillows and matress in allergen proof covering
Use of allergen proof bedding..
ACUTE PHASE MEDICATIONS
Antihistamines effectively block histamine effects
(runny nose and watery eyes)
Side effects : sedation, dry mouth, nausea, dizziness,
blurred vision, nervousness
Non sedating antihistamines (cetrizine, loratidine)
Fewer side effects
Fexofenadine may be effective
Carries a lower risk of cardiac arrythmias
Decongestants
Shrink nasal mucous membrane by vasoconstriction
Available OTC and in combination with antihistamines,
analgesics and anti cholinergics
COMMONLY PRESCRIBED
ANTIHISTAMINES
 Anticholinergenic agents
Inhibit mucous secretions, act as drying agent
Topical eye preparations
Reduce inflammation and relieve itching and burning
 MEDICAL: PREVENTIVE THERAPY
Intranasal corticosteroids
Reduce inflammation of mucosa
Prevent mediator release
Can be used safely daily
May be given systemically for a short course during a
disabling attack

Intranasal cromolyn sodium

Mast cell stabiliser
Prevents release of chemical mediators
Oral mast cell stabilizer
Otpthalmic solution cromolyn
 Leukotriene receptor antagonists
Montelukast (singulair) and Zafirlukast (accolate)
Systemic agents used for asthma
Reduce inflammation, edema and mucous sectetions
of allergic rhinitis
TOPICAL NASAL STEROIDS
AMERICAN ALLERGOLOGY
GUIDELINES
IMMUNOTHERAPY
If allergic rhinitis is refractory to
pharmacotherapy or severe
Helps in reducing the specific serum IgE
level
decreases the basophil sensitivity
increases IgG blocking antibody level , thus
preventing allergen from reaching mast
cells and subsequent mast cell
degranulation
SURGICAL THERAPY

Limited
Submucosal turbinectomy - reduces size of
boggy turbinates
Septoplasty correction of deviation of
septum
Sinus surgery clearance of sinuses if
sinusitis is present
 Thank you.