ALLERGIC RHINITISPembimbing : dr Daniel Widjaja, Sp.THT-KL Penyaji : Aditya Purwaka

Introduction Rhinitis : inflammation of the lining of the nose Nasal symptoms : - anterior/posterior rhinorrhoea - sneezing - nasal blockage - and/or itching of the nose

Introduction Symptoms : during 2 or more consecutive days > 1 hour on most days. Allergic rhinitis is the most common form of non-infectious rhinitis. Several non allergic: infections, hormonal imbalance, physical agents, anatomical anomalies, the use of certain drugs.

Allergic Rhinitis Allergic rhinitis is clinically defined as a symptomatic disorder of the nose induced by an IgE-mediated inflammation after allergen exposure of the membranes of the nose. Global Health problem:10-25% worldwide

Allergic Rhinitis Post nasal drip with profuse anterior rhinorrhoea mainly occured Chronic Rhinosinusitis : PND without significant anterior rhinorrhoea

Allergic Rhinitis Pre-school children may just have nasal obstruction Nasal obstruction is the only symptom, rarely associated with allergy Non allergic may have a similar symptoms

Classification Time of exposure - Seasonal:outdoor allergen - Perennial: indoor allergen - Occupational

New Classification is based on duration, and is subdivided into intermittent or persistent disease is based on severity, and is subdivided into mild or moderatesevere,depending on symptoms and quality of life

Risk Factors Genetics and familial history Early life : young maternal age, multiple gestation, prematurity, low birth, hormones during pregnancy. Ethnic groups: England native lower, maori suffered more. Allergen exposure: animals, insects, plants, fungi, or occupational sources.

Risk Factors Food allergens Pollutants : - automobile pollution(CO, NO, CO2, lead, diesel exhaust) - indoor pollution(tobacco smoke) Social Class: role of social class change over time, increase in low socio economic status.

Mechanisms IgE dependent mechanisms Allergy is generally caused by sustained overproduction of IgE in response to common enviromental antigens. IgE production: complex interaction from B-cell, T-cell, mast cell, and basophils, involving the presence cytokines interleukin(IL)-4, IL-13, and IL-18

Mechanism Allergen-specific IgE becomes fixed to FceRI on the membranes of mast cell and basophils. Mast cells accumulation in the airway mucosa is an important pathophysiologic event in allergic rhinitis, as inhalled allergens impact the mucosal of nose.

Mechanisms Agregation of receptor-bound IgE mediators(histamine, leukotriene) produce allergy response Immediate response: itching, sneezing, blockage of the nose, and rhinorrhoea.

Mechanisms Non IgE dependent mechanisms Allergen, on account of their enzymatic proteolytic activity, directly activate epithelial cells and eventually lead to a Th2-immune responce,inducing cytokine and chemokine release airway inflammation

CO-MORBIDITIESAsthma The nasal and bronchial mucosa have many similarities. Asthma and rhinitis often co-exist in the same patients: Asthma-Rhinitis Rhinitis-Asthma AR risk factor for asthma AR increased nonspecific bronchial hyperreactivity

CO-MORBIDITIESAllergic diseases may be systemic bronchial-nasal inflamation When considering a diagnosis of rhinitis or asthma, an evaluation of both the lower and upper airways should be made.

CO-MORBIDITIESOther co-morbidities sinusitis and conjunctivitis. The associations between allergic rhinitis, nasal polyposis and otitis media are less well understood

Diagnosis

SYMPTOMS OF ALLERGIC RHINITIS Clinical history is essential for an accurate diagnosis of rhinitis, assessment of its severity, and likely response to treatment. In patients with mild intermittent allergic rhinitis, a nasal examination is optimal.

SYMPTOMS OF ALLERGIC RHINITIS All patients with persistent allergic rhinitis need a nasal examination. Anterior rhinoscopy Nasal endoscopy : posterior nasal cavity and middle meatus.

Diagnosis Skin test - Scratch test : possible systemic reaction - Prick and puncture test : recommended, high degree correlation between symptoms and provocative challenge - Intradermal skin test : for allergy diagnosis in some instances(weak allergen sollution).If standardized extract available, not required.

Diagnosis- Prick-prick test : with fresh foods, reduce poor standardization of food extract commercially available. WHO, European Academy of Allergology and Clinical Immunology (EAACI), US Joint council of Allergy Asthma and Immunology reccomend the use of Skin-Prick puncture test as a major test.

Diagnosis In Vitro Test - Serum total IgE: should no longer used - Serum specific IgE : first used radioallergosorbent(RAST), now radiolabeled or enzyme-labeled. Nasal challenge test : used in research Important in the diagnosis of occupational rhinitis

Diagnosis Imaging : - plain sinus radiograph are not indicated. - CT Scan :limited use, to eliminate others. Mucolciliary function: little relevance in AR, relevant in the DD chronic rhinorrhoea in children.

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The management of allergic rhinitis The management of allergic rhinitis includes: allergen avoidance: - most allergen avoidance studies have dealt with asthma symptoms and very few have studied rhinitis symptoms.

The management of allergic rhinitis medications (pharmacological treatment) - Oral H1-antihistamines (second generation recommended): cetirizine, loratadine, desloratadine, chlorpheniramine(1st) - Local H1-antihistamines (Intranasal,intraocular) : azelastine, levocabastine

The management of allergic rhinitis- Intranasal corticosteroids(most effective drugs for AR): mometasone, triamcinolone - Oral/IM corticosteroids:dexa,methyl - Local Chromones (intranasal,intraocular) - Oral decongestant :ephedrine, pseudoephedrine

The management of allergic rhinitis Intranasal decongestant : oxymetazoline Intranasal anticholinergic (block almost exclusively rhinorrhoea) :ipratropium

The management of allergic rhinitis Specific immunotherapy : therapeutic vaccines for allergy diseases Traditionally subcutaneous, now available local routes. Need precise diagnosis of IgE mediated allergy Sublingual:recommended for pollen allergy, maybe used for mite Intranasal:maybe used for pollen Appears to reduce the development of Asthma

CONSIDER IMMUNOTHERAPY Subcutaneous specific immunotherapy is indicated In patients insufficiently controlled by conventional pharmacotherapy. In patients in whom oral H1-antihistamines and intranasal pharmacotherapy insufficiently control symptoms. In patients who do not wish to be on pharmacotherapy. In patients in whom pharmacotherapy produces undesirable side effects. In patients who do not want to receive longterm pharmacological treatment.

CONSIDER IMMUNOTHERAPY High dose nasal and sublingualswallow specific immunotherapy In children, specific immunotherapy is effective.

The management of allergic rhinitis education surgery may be used as an adjunctive intervention in a few highly selected patients - Follow-up is required in patients with persistent rhinitis and severe intermittent rhinitis.

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