Allergic Rhinitis

Definition AR: symptomatic disorder of the nose induced after allergen exposure by an IgEmediated inflammation of the membranes lining the nose. Patophysiology

Etiology 1. Infectious rhinitis: rhinosinusitis 2. Work-related rhinitis: 3. Drug-induced rhinitis: Aspirin, NSAIDs Inhibit the COX1 and COX2 enzymes and precipitate asthma attack and naso-ocular reaction It cause intense eosinophilic inflammation on nasal and bronchial tissue and combined with cysteinyl leukotrienes (CysLT) and prostaroid overproduction Reaction usually is within 3 hours Symptoms: rhinorrhoea, conjunctival injection, periorbital edema, scarlet clushing on head and neck sometimes Eosinophil on nasal mucosa and bronchial airway Example: methyldopa, ACE inhibitor, oral contraceptive, etc

4. Hormonal rhinitis: Menstrual cycle, puberty, pregnancy (3rd semester, because of estrogen), hypothyroid

5. Physical and chemical rhinitis Sudden temperature change Swimmer: inhale much chlorine or hypochloride Runner: start to decongestion soon until 30 minutes after

6. Smoke Tobacco smoke alter the mucocilliary clearance and cause the eosinophillic and allergic like inflammation on nasal mucosa on non-atopic children Symptoms: rhinorrhoea, nasal congestion, PND, sneezing

7. Food Food induced anaphylaxis gustatory rhinitis (hot and spicy food) rhinorrhoea Capsalcin: stimulate the sensory nerve fibers induced the release tachykinins and other neuropeptide

Symptoms 3 cardinal symptoms: sneezing, nasal obstruction, mucous discharge Other symptoms: Anterior or posterior rhinorrhoea Itching of the nose

Classification Based on the severity of symptoms and quality of life outcomes: Mild Moderate-severe: sleep disturbance, impairment of daily activities, impairment of school/work, symptoms present and troublesome

Based on the onset: IAR (Intermittent Allergic Rhinitis): symptoms are present <4 days a week or for <4 consecutive weeks PER (Persistent Allergic Rhinitis): symptoms are present more than 4 days a week and for more than 4 consecutive weeks

Examination Differential Diagnosis Rhinosinusitis with/without nasal polyps Mechanical factors: deviated septum, foreign bodies, choanal atresia, etc

Tumors: benign, malignant Granulomas: wageners granulomatosis, infectious, etc Cilliary defects Cerebrospinal rhinorrhea

Diagnosis Scoring based: Features of allergic rhinitis: clinical symptoms, season of the year, triggers, parental history, individual medical history, and perceived allergy Doctors diagnosis: anamnesis, examination, skin test to common aeroallergens

Management