THE NOSETHE NOSE

Dr Serge Maurice FRCSEDr Serge Maurice FRCSE

02 April 200802 April 2008

Functions of the noseFunctions of the nose

To smellTo smell

To filter, warm and humidify the air To filter, warm and humidify the air we breathewe breathe

Some anatomical souvenirsSome anatomical souvenirs

Noses come in various shapes or sizesNoses come in various shapes or sizes

Allergic RhinitisAllergic Rhinitis

Doctère, mo éna ène mari problème ek mo néné

Changes in TerminologyChanges in Terminology

““OLD”: Seasonal & PerennialOLD”: Seasonal & Perennial

““NEW”: Acute or Intermittent and NEW”: Acute or Intermittent and Chronic or Persistent (WHO 2000)Chronic or Persistent (WHO 2000)

The SymptomsThe Symptoms

Seasonal/Acute: Itching, Sneezing, Seasonal/Acute: Itching, Sneezing, Rhinorrhea.Rhinorrhea.

Perennial/Chronic: The blocked nosePerennial/Chronic: The blocked nose

The Acute SymptomsThe Acute Symptoms

The tingleThe tingle The itchy noseThe itchy nose The volley of sneezesThe volley of sneezes The flooding rhinorrheaThe flooding rhinorrhea The ocular symptomsThe ocular symptoms The itchy palateThe itchy palate

Acute symptoms: Sneezing & Acute symptoms: Sneezing & RhinorrheaRhinorrhea

The Chronic SymptomsThe Chronic Symptoms

A blocked nose, often with hyposmia & A blocked nose, often with hyposmia & hypoguesiahypoguesia

Recurrent bouts of AOM in kidsRecurrent bouts of AOM in kids Otitis Media with effusion in kids and adultsOtitis Media with effusion in kids and adults The allergic saluteThe allergic salute Recurrent bouts of acute sinusitis in adultsRecurrent bouts of acute sinusitis in adults Chronic sinusitis and nasal polyposisChronic sinusitis and nasal polyposis A nasal voiceA nasal voice Snoring and OSA in kids and adultsSnoring and OSA in kids and adults

Chronic Symptom: Blocked noseChronic Symptom: Blocked nose

The allergic saluteThe allergic salute

Massive polyposisMassive polyposis

The Culprits: PollensThe Culprits: Pollens

In the In the Mauritian Mauritian context, a context, a frequently frequently accused accused innocent: innocent: the sugar the sugar cane pollencane pollen

FlowersFlowers

Grasses and TreesGrasses and Trees

Moulds and Mites, CockroachesMoulds and Mites, Cockroaches

Pet animalsPet animals

The Allergic ReactionThe Allergic Reaction

An Idiot’s Guide to the chain of An Idiot’s Guide to the chain of reactions, from the first meeting to reactions, from the first meeting to the divorce!the divorce!

The first date -1The first date -1

ANTIGENS

MACROPHAGE

The macrophage ingests the allergens, breaks them up and presents some of their chemicals to the immune cells, the lymphocytes

The first date -2The first date -2

Lymphocyte Plasmocyte

Antibodies Mastocyte

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

The second date -1The second date -1

The antigens this time link up to the antibodies attached to the mastocyte, and the latter is then activated

The second date -2The second date -2

The activated mastocyte liberates its granules, that contain histamine and other inflammatory chemicals,(triptase, prostaglandins) responsible for the allergic reaction

The StartThe Start

ALLERGEN ImmunoglobulinE (IgE)Specially in the mastocytes

Inflammatory Mediators Cytokines

ALLERGICREACTION

The ProgressionThe Progression

Watery RhinorrheaPruritus

Sneezing++++

Immediate Reaction:Acute Inflammation

Vasodilatation,oedemaMucus++ Itching

HistamineLeukotrienes

Blocked noseSinusitis

PharyngitisOtitis

Late Reaction:Chronic Inflammation

Congested MucosaObstruction, Infection

Neutral proteases

Cytokines, Interleukins

Early Phase Late Phase

DiagnosisDiagnosis HISTORY: ALL IMPORTANTHISTORY: ALL IMPORTANT Simple Rhinoscopy: Pale, boggy, bluish Simple Rhinoscopy: Pale, boggy, bluish

mucous membranemucous membrane Sometimes PolypsSometimes Polyps Skin scratch tests and lab tests (RAST, Skin scratch tests and lab tests (RAST,

Phadiatop, Total IgE(inaccurate), nasal IgE, Phadiatop, Total IgE(inaccurate), nasal IgE, nasal mucus eosinophils)-test food nasal mucus eosinophils)-test food allergies in kidsallergies in kids

Imaging NOT necessary for simple ARImaging NOT necessary for simple AR

Differential DiagnosisDifferential Diagnosis Chronic Idiopathic Rhinitis (V.M.R)Chronic Idiopathic Rhinitis (V.M.R) NARESNARES Nasal hypersensitivity, specially to Nasal hypersensitivity, specially to

dust, perfume, tobacco dust, perfume, tobacco smoke,SO2,NO2, cold airsmoke,SO2,NO2, cold air

Drug induced- Aspirin (Widal’s), ACE Drug induced- Aspirin (Widal’s), ACE inhibitors, HRT, Methyl inhibitors, HRT, Methyl DOPA,ReserpineDOPA,Reserpine

Last trimester of pregnancyLast trimester of pregnancy

Treatment PrinciplesTreatment Principles

Acute/Intermittent/Seasonal Acute/Intermittent/Seasonal SymptomsSymptoms

Chronic/Persistent/Perennial Chronic/Persistent/Perennial SymptomsSymptoms

Allergen AvoidanceAllergen Avoidance

If the allergen has been identified:If the allergen has been identified: Avoid grass pollensAvoid grass pollens Get rid of offending petsGet rid of offending pets Treat pillows and mattressesTreat pillows and mattresses Avoid offending foodsAvoid offending foods

But, unfortunately, more often than But, unfortunately, more often than not, medication needednot, medication needed

Acute SymptomsAcute Symptoms

Local and Systemic decongestantsLocal and Systemic decongestants

22ndnd Generation Antihistamines, Generation Antihistamines, systemic and localsystemic and local

Local SteroidsLocal Steroids

Chronic SymptomsChronic Symptoms

Local and systemic steroidsLocal and systemic steroids

22ndnd Generation Antihistamines Generation Antihistamines

Other drugs/measuresOther drugs/measures

Other drugs/measuresOther drugs/measures Sodium CromoglycateSodium Cromoglycate Ipatropium Bromide (rhinorrhea)Ipatropium Bromide (rhinorrhea) SIT & SLITSIT & SLIT Leukotriene antagonists (Zafirlukast, Leukotriene antagonists (Zafirlukast,

Montelukast)Montelukast) Empirical dietary exclusion of cow’s Empirical dietary exclusion of cow’s

milk and food additives (benzoates, milk and food additives (benzoates, nitrites, sulphites, colourings)nitrites, sulphites, colourings)

Specific ImmunotherapySpecific Immunotherapy Sublingual or injectionSublingual or injection Should be reserved for mono/bi Should be reserved for mono/bi

allergens (e.g. grass pollen & house-allergens (e.g. grass pollen & house-dust mite)dust mite)

NOT as first line, but if other NOT as first line, but if other measures uselessmeasures useless

Injection method should only be done Injection method should only be done with resuscitative facilities available with resuscitative facilities available

Side-Effects -1Side-Effects -1 Early 2Early 2ndnd G. antiH: (Astemizole, G. antiH: (Astemizole,

Terfenadine..) : Liver and cardiac Terfenadine..) : Liver and cardiac problems when used in association problems when used in association with some other drugswith some other drugs

Newer ones (fexofenadine, cetirizine, Newer ones (fexofenadine, cetirizine, loratidine…):safe, but still cause loratidine…):safe, but still cause drowsynessdrowsyness

Local acting (levocabastine, Local acting (levocabastine, azelastine,): local irritation & azelastine,): local irritation & unpleasant tasteunpleasant taste

Side effects -2Side effects -2 Local decongestants – abuse & R.M.Local decongestants – abuse & R.M. Systemic decongestants – glaucoma, Systemic decongestants – glaucoma,

prostate, HBP, palpitations, insomniaprostate, HBP, palpitations, insomnia Local Steroids sprays – Great, but Local Steroids sprays – Great, but

local irritation, epistaxis & no effect local irritation, epistaxis & no effect on eye/palate itchon eye/palate itch

Cromoglycate – qds, hence poor Cromoglycate – qds, hence poor compliance compliance

Ipatropium – only on dripIpatropium – only on drip

Systemic Steroids??Systemic Steroids??

Very useful in treatment of infective Very useful in treatment of infective acute episodes (High Dose Short acute episodes (High Dose Short Term)Term)

BE VERY WARY OF THE DEPOT BE VERY WARY OF THE DEPOT STEROID INJECTIONS: Osteoporosis, STEROID INJECTIONS: Osteoporosis, muscle damage, diabetes, glaucoma, muscle damage, diabetes, glaucoma, cataracts, gastric ulcers…cataracts, gastric ulcers…

Some other helpful(?) measuresSome other helpful(?) measures

Saline douchesSaline douches Petroleum jelly (Vaseline) applicationPetroleum jelly (Vaseline) application InhalationsInhalations Anti-oxidants (Vit C, E, Beta Anti-oxidants (Vit C, E, Beta

carotene, zinc, selenium…)carotene, zinc, selenium…) ““Muco-regulators” (carbocisteine..)Muco-regulators” (carbocisteine..)

To summarise:To summarise: The problem with allergies such as The problem with allergies such as

Hay fever and Allergic Rhinitis is that Hay fever and Allergic Rhinitis is that it is considered to be a trivial and it is considered to be a trivial and inconsequential disease. Symptoms inconsequential disease. Symptoms such as runny nose, itchy eyes and such as runny nose, itchy eyes and nose with sneezing and blockage are nose with sneezing and blockage are obviously not life threatening, but obviously not life threatening, but affect up to 25% of the population affect up to 25% of the population and are the cause of significant and are the cause of significant disability and cost to society…/cont.disability and cost to society…/cont.

To summarise (cont)To summarise (cont)

Patients may also experience fatigue, Patients may also experience fatigue, irritability, as well as mood, cognitive and irritability, as well as mood, cognitive and sleep disturbance in addition to the nasal, sleep disturbance in addition to the nasal, ocular and throat symptoms. Allergic ocular and throat symptoms. Allergic rhinitis has important co-morbid rhinitis has important co-morbid associations such as chronic sinusitis, glue associations such as chronic sinusitis, glue ear, asthma exacerbations, nasal polyps, ear, asthma exacerbations, nasal polyps, sleep apnoea and dental malocclusionsleep apnoea and dental malocclusion..

Dr A Morris, January 2007, Surrey Allergy Dr A Morris, January 2007, Surrey Allergy ClinicClinic

Thank you for your attentionThank you for your attention