7/30/2019 1407016_634715615452788750

1/61

Allergic Rhinitis

Dr. Vishal Sharma

7/30/2019 1407016_634715615452788750

2/61

IntroductionCommonest chronic disease of mankind (20%)

Induced after allergen exposure by IgE-mediated

Type 1 hypersensitivity reaction of nasal mucosa

30% pt of allergic rhinitis have bronchial asthma

60-80% pt of asthma also have allergic rhinitis

Prevention of allergen exposure is best treatment

7/30/2019 1407016_634715615452788750

3/61

Aetiology1. ATOPY: genetically inherited ed IgE response 2. ALLERGENS:

* Seasonal (Hay fever): Pollen, Fungus

* Perennial: Dust mite, Domestic pets, Cockroaches

* Occupational (?): Flour, Animal, Wood, Latex, Paint

3. FOOD INDUCED: Nuts, fish, prawns, legumes,

milk, cheese, egg, meat, citrus fruits, wines

7/30/2019 1407016_634715615452788750

4/61

4. DRUG INDUCED: Aspirin, other NSAIDs, anti-

hypertensives, oral contraceptive pills5. POLLUTION (NASAL IRRITANTS): Traffic fumes,

tobacco smoke, mosquito repellents, perfumes,

scented sticks, domestic sprays, bleaches

6. LACK OF INFECTION: Younger child in large

family frequent viral infections & less prone toallergy. Older child in large family or only child in a

small family infection is rare so develops allergy.

7/30/2019 1407016_634715615452788750

5/61

Grass pollen & dust mite

7/30/2019 1407016_634715615452788750

6/61

Sensitization & Priming to specific antigen:

Inhaled allergen produces specific IgE antibody

which gets attached to mast cellsSubsequent exposure to same antigen:

Allergen combines with specific IgE antibody degranulation of mast cells (even with small

amount of antigen) chemical mediators released

Pathogenesis

7/30/2019 1407016_634715615452788750

7/61

Occurs 5 30 min after exposure to antigen due to

release of chemical mediators sneezing, watery

rhinorrhoea, nasal blockage & bronchospasm.

Mucosal edema & Vasodilation nose block

Nerve irritation sneezing & itching ed secretion from nasal gland rhinorrhoea

Smooth muscle contraction bronchospasm

Acute or Early Phase

7/30/2019 1407016_634715615452788750

8/61

Late or Delayed PhaseOccurs 2-8 hours after exposure due to

infiltration by inflammatory cells at site of

antigen deposition edema, congestion & thick

nasal secretion. Sneezing & itching decreases.

Inflammatory cells are eosinophils, neutrophils,

basophils, monocytes & CD4+ T lymphocytes.

7/30/2019 1407016_634715615452788750

9/61

Pathogenesis

7/30/2019 1407016_634715615452788750

10/61

Pathogenesis

7/30/2019 1407016_634715615452788750

11/61

Cardinal Symptoms1. Watery rhinorrhoea

2. Nasal obstruction: bilateral

3. Paroxysmal sneezing: 10-20 at a time

4. Itching in nose, eyes, palate, pharynx

Presence of 2 or more symptoms for > 1 hour on

most days indicates allergic rhinitis.

7/30/2019 1407016_634715615452788750

12/61

Nasal Signs Repeated lifting of nasal tip ( allergic salute ) to

relieve itching & open nasal airway transverse

nasal crease (Darriers crease, Hiltons line ).

Hypertrophied turbinates are covered with pale

or blue, boggy mucosa. Pitting edema seen on

probing ( mulberry turbinates ).

Nasal secretions are watery mucoid.

Nasal polyps with hyposmia / anosmia.

7/30/2019 1407016_634715615452788750

13/61

Allergic salute

7/30/2019 1407016_634715615452788750

14/61

Nasal crease

7/30/2019 1407016_634715615452788750

15/61

Pale turbinate, wateryrhinorrhoea

7/30/2019 1407016_634715615452788750

16/61

Blue, boggy turbinate

7/30/2019 1407016_634715615452788750

17/61

Inferior turbinate appearances

7/30/2019 1407016_634715615452788750

18/61

Other Clinical Signs

Face: Frequent twitching of face ( bunny nose ) Dennie-Morgan creases (in lower eyelid skin)

Allergic shiners (dark discoloration below

lower eyelids) caused by venous stasis

Eyes: Conjunctiva is congested with cobble stone

appearance ; increased lacrimationEars: Ear block & ed hearing (due to O.M.E.)

Throat: Chronic pharyngitis, laryngitis

7/30/2019 1407016_634715615452788750

19/61

Dennie-Morgan Creases

7/30/2019 1407016_634715615452788750

20/61

Allergic Shiners

7/30/2019 1407016_634715615452788750

21/61

Allergic conjunctivitis

7/30/2019 1407016_634715615452788750

22/61

ARIA Classification

1. Mild intermittent

2. Moderate-severe intermittent

3. Mild persistent

4. Moderate-severe persistent

ARIA = A llergic Rhinitis & its Impact on Asthma

7/30/2019 1407016_634715615452788750

23/61

Intermittent symptoms Persistent symptoms

Present for < 4 days / wk Present for > 4 days / wk

Or for < 4 weeks and for > 4 weeks

Mild (presence of all) Moderate-severe (any 1)

Normal sleep Abnormal sleep

Normal daily activities Impaired daily activities

Normal work and school Impaired work & school

Normal sport & leisure Impaired sport & leisure

No troublesome symptom Troublesome symptoms +

7/30/2019 1407016_634715615452788750

24/61

1. Absolute Eosinophil count

2. Nasal smear examination for eosinophils

3. Skin prick test

4. Radio-allergo-sorbent test (R.A.S.T.)

5. Diagnostic Nasal Endoscopy

6. C.T. scan P.N.S.: for sinusitis & nasal polyps

Investigations

7/30/2019 1407016_634715615452788750

25/61

Skin prick test

7/30/2019 1407016_634715615452788750

26/61

Skin prick test

7/30/2019 1407016_634715615452788750

27/61

Skin prick test

7/30/2019 1407016_634715615452788750

28/61

Radio-allergo-sorbent test

7/30/2019 1407016_634715615452788750

29/61

Pt serum is incubated with allergen disc. Only

specific IgE binds with allergen. Rest is washed

away with a buffer.

Disc is incubated with radio-labeled anti - IgE

antibody. Anti-IgE antibody binds with allergen-

IgE complex.

Amount of radio-labelled anti-IgE antibody ondisc amount of IgE & is quantified by

counting radioactivity from the disc.

7/30/2019 1407016_634715615452788750

30/61

Complications1. Recurrent sinusitis

2. Nasal polyp

3. Serous otitis media

4. Prolonged mouth breathing

5. Bronchial asthma6. Atopic dermatitis

7. Conjunctivitis

7/30/2019 1407016_634715615452788750

31/61

Differential diagnosisVasomotor rhinitis

Rhinitis medicamentosa

Hormonal rhinitis (pregnancy, hypothyroidism,

oral contraceptive use)

Cerebrospinal fluid leak

Ethmoid polyps

7/30/2019 1407016_634715615452788750

32/61

1. Avoidance of allergens

2. Pharmacotherapy

3. Specific Immunotherapy

4. Surgery: F.E.S.S., Turbinoplasty

Treatment

7/30/2019 1407016_634715615452788750

33/61

PharmacotherapyH1-Antihistamines: Topical (Azelastine), Systemic

Nasal Decongestants: Topical drops, Systemic

Mast cell stabilizers: Sodium cromoglycate, Ketotifen

Anti-cholinergics: Ipratropium bromide nasal spray

Corticosteroids: Nasal, Oral, Turbinal, Intramuscular Leukotriene receptor antagonists: Montelukast

Newer drugs: RhuMAb-25, Altrakincept

7/30/2019 1407016_634715615452788750

34/61

Antihistamines &Decongestants

Antihistamines Systemic decongestants

Cetirizine (S) Phenylephrine

Fexofenadine (S) Pseudoephedrine

Loratidine (S) Topical decongestants

Levocetrizine (S) Xylometazoline

Desloratidine (S) Oxymetazoline

Azelastine (T) Hypertonic saline

7/30/2019 1407016_634715615452788750

35/61

AntihistaminesSystemic:

Cetirizine: 10 mg OD

Fexofenadine: 120 mg OD Loratidine: 10 mg OD

Levocetrizine: 5 mg OD

Desloratidine: 5 mg OD

Topical: Azelastine spray (0.1%): 1-2 puff BD

7/30/2019 1407016_634715615452788750

36/61

Nasal DecongestantsSystemic decongestants

Phenylephrine

PseudoephedrineTopical decongestants

Xylometazoline

Oxymetazoline

Saline

7/30/2019 1407016_634715615452788750

37/61

Anti-cold preparationsName Chlorpheniramine Decongestant Paracetamol

COLDIN 4 mg PsE 60 mg 500 mg

SINAREST 4 mg PsE 60 mg 500 mg

DECOLD 4 mg PhE 7.5 mg 500 mg

SUPRIN 2 mg PhE 5 mg 500 mg

PsE = Pseudoephedrine; PhE = Phenylephrine

7/30/2019 1407016_634715615452788750

38/61

Topical DecongestantsOxymetazoline 0.05 %: 2-3 drops BD (NASIVION)

Oxymetazoline 0.025 %: 2 drops BD (NASIVION-P)

Xylometazoline 0.1 %: 3 drops TID (OTRIVIN)

Xylometazoline 0.05 %: 2 drops BD (OTRIVIN-P)

Saline 2 %: 3 drops TID

Saline 0.67 %: 2 drops BD (NASIVION-S)

7/30/2019 1407016_634715615452788750

39/61

Systemic Antihistamines

7/30/2019 1407016_634715615452788750

40/61

Topical Antihistamine spray

7/30/2019 1407016_634715615452788750

41/61

Technique of nasal spray

7/30/2019 1407016_634715615452788750

42/61

Nasal Decongestants

7/30/2019 1407016_634715615452788750

43/61

Sodium Cromoglycate

7/30/2019 1407016_634715615452788750

44/61

Ipratropium nasal spray

7/30/2019 1407016_634715615452788750

45/61

Corticosteroids

Nasal sprays Injectable

Beclomethasone Methylprednisolone

Budesonide

Fluticasone Oral

Mometasone Prednisolone

7/30/2019 1407016_634715615452788750

46/61

Corticosteroid nasal spray

7/30/2019 1407016_634715615452788750

47/61

Methylprednisolone acetate

7/30/2019 1407016_634715615452788750

48/61

Montelukast

7/30/2019 1407016_634715615452788750

49/61

Drug Sneeze Rhinor rhoea

Nasalblock

Noseitch

edsmell

Antihistamine +++ ++ + +++ 0Steroid spray +++ +++ +++ ++ +

Oral steroid +++ +++ +++ ++ ++

Cromoglycate + + + + 0

Topical nasal

decongestant

0 0 ++++ 0 0

Ipratropium 0 ++ 0 0 0

Monteleukast 0 + ++ 0 0

7/30/2019 1407016_634715615452788750

50/61

Specific Immunotherapy (SIT)Indications:

1. Insufficient response to conventional drugs

2. Side effects from conventional drugs

3. Rejection of conventional drug treatment.

4. Allergy to one or two allergens only Types:

Systemic injection, intra-nasal, sublingual

7/30/2019 1407016_634715615452788750

51/61

Injectable S.I.T.Serial subcutaneous injections of immunogenic

extracts from relevant allergen in increasing

concentration.

Injections given twice weekly until response is

noticed (6-20 wk) given weekly for 1 year

fortnightly for 1 yr every 3 weeks for 1-3 yr.

7/30/2019 1407016_634715615452788750

52/61

Injectable S.I.T.

7/30/2019 1407016_634715615452788750

53/61

Intranasal & sublingual S.I.T.

Can use 50-100 times greater doses compared to

injection immunotherapy.

Considered in selected patients with:

systemic side effects

refusal to injection treatment

7/30/2019 1407016_634715615452788750

54/61

Treatment protocolMild intermittent

H1-Antihistamine + Nasal decongestant

No Improvement after 1 month

Treat as Moderate-severe Intermittent

In case of improvement: Step down & continue

treatment for 1 month

7/30/2019 1407016_634715615452788750

55/61

Moderate-severe intermittent & Mild persistent

H1-Antihistamine + Nasal decongestant

+ Corticosteroid nasal spray

No Improvement after 1 month Double dose Corticosteroid nasal spray

Ipratropium for rhinorrhoea Cromoglycate

for seasonal cases Montelukast for asthma

No Improvement after 1 month

Specific Immunotherapy + Newer Drugs

7/30/2019 1407016_634715615452788750

56/61

Moderate-severe persistent

H1-Antihistamine + Nasal decongestant + doubledose Corticosteroid nasal spray + Montelukast

No Improvement after 1 month

Add short course of oral corticosteroid

Add Ipratropium spray for rhinorrhoea

Consider surgery for polyps / turbinates No Improvement after 1 month

Specific Immunotherapy + Newer Drugs

G l d i

7/30/2019 1407016_634715615452788750

57/61

General advice Avoid cold drinks, ice cream & very cold air

Avoid cigarette smoke & traffic fumes

Avoid strong perfumes, scented sticks & cosmetics

Avoid head bath with cold water. Use warm water.

Avoid mosquito repellents / bleaches

Have a balanced diet to improve body immunity Sleep with head elevated to se nasal congestion

Adequate fluid intake to loosen nasal secretions

7/30/2019 1407016_634715615452788750

58/61

Exercise regularly

Avoid foods & drugs to which you are allergic

Avoid occupational irritants or change profession

Remove furred animals (cats, dogs) from

bedroom. Wash the pet weekly with warm water Keep bathroom, kitchen, basement + attic clean &

well ventilated. Avoid damp areas. Remove

houseplants & dried flowers.

Use insect repelling chalks. Avoid sprays. Avoid

collection of spilled food material.

7/30/2019 1407016_634715615452788750

59/61

Pollen advice Avoid walking in open grassy spaces during hot, drydays. Move outdoors only on damp days.

Keep windows closed. Move flowering plants away

from doors & windows.

Wear facemask & sunglasses when moving out.

Keep grass & plants trimmed. Get rid of weeds &leaves.

Plant less allergenic flowers & trees.

7/30/2019 1407016_634715615452788750

60/61

House dust mite adviceUse foam pillows & mattresses with dust-proof cover.

Remove carpets, upholstered furniture, stuffed toys,old newspapers & magazines.

Wash bedcovers & clothes in warm water.Damp-wipe house regularly wearing a facemask.

Use vacuum cleaners with high-efficiency particle

arresting (HEPA) filters weekly.

Use air-conditioning (with pollen filters) to maintainthe humidity less than 50 %.

Th k Y

7/30/2019 1407016_634715615452788750

61/61

Thank You