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Download Upper Respiratory Tract disorder in occupational setting
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Upper Respiratory Tract disorder in occupational setting Causes of Rhinitis • Allergy • Irritants • NARES syndrome • Adverse food reaction • Occupational • Emotional • Hormonal • Atrophic • Drug induced • Ciliary dyskinesia • Anatomic defects • Immunodeficiency diseases Evaluation of Rhinitis • History and physical • Sinus transillumination • Direct visualization with nasal specula • Rhinoscopy • Nasal smear • Allergy screening tests (skin tests or RAST) • Imaging for persistent disease What Do You Need to Know in Addition to Symptoms? • Age at onset • Are sx acute, chronic, recurrent, seasonal or perennial? • What causes the symptoms? • What is the response to antihistamines? • Does patient have any pets Any associated illnesses (asthma, skin rash, otitis media)? • Is there a family history of allergy? Allergic Patients Generally Have • Early onset of symptoms (70% < age 20) • Family history of allergy • Seasonal symptoms • Symptoms with animal exposure • Symptoms worse outdoors • Symptoms worse near fresh-cut grass • Symptoms better in air conditioning • Tobacco and chemicals are not primary excitants • Previous immunotherapy was helpful Nonallergic Patients Generally Have • Later onset of symptoms (70% > age of 20) • No family history of allergy • Tobacco smoke and chemicals primary excitants • Weather changes provoke symptoms • No seasonal aspect to symptoms • No symptoms with exposure to dust • No symptoms with exposure to animals Symptoms of Allergic Rhinitis • Sneezing • Nasal congestion • Watery nasal discharge • Itchy watery eyes • Postnasal drip • Itching Physical Changes of Allergic Rhinitis • Pale blue, edematous turbinates • Clear, watery nasal discharge • Crease from nasal salute • Lymphoid hyperplasia • Watery, itchy eyes Allergic Rhinitis and Concomitant Disease • Management of allergic rhinitis may decrease exacerbations of sinusitis, asthma and otitis media • Early immunotherapy for allergic rhinitis has been shown to decrease the development of asthma Physical Examination • Eyes: conjunctivitis, dark circles, Dennie’s lines • Ears: OM, TM mobility, serous otitis • Mouth: mouth breathing • Lungs: wheezing Nasal Smear • Clear nose of secretions • Gently scrape sample from mucosa of inferior or middle turbinate with plastic ear spatula or cotton swab • Wright’s or Hansel’s stain • Eosinophilia – Allergy (present in 90% of allergic patients) – NARES syndrome – Aspirin sensitivity • Neutrophilia – Infection Sinus X-rays and CT Scans • Sinus x-rays : – Not needed for diagnosis of acute rhinosinusitis – Water’s view for the maxillary sinuses – Town’s view for ethmoid and frontal sinuses – Lateral view for the sphenoid • Limited coronal CT scan – Osteomeatal complex – All sinuses visualized • CT scan gives much better imaging for minimal increased cost Rhinoscopy • Nasal polyps • Septal deviation • Concha bullosa • Eustachian tube dysfunction • Causes of hoarseness • Adenoid tissue • Tumors Treatment of Allergic Rhinitis • Avoidance of identified allergens • Nasal steroids • Antihistamine nasal spray • Antihistamines (sedating and nonsedating) • Decongestants – Nasal sprays (limited 2-3 days) – Oral preferred (limited by side effects) • Nasal irrigation • Leukotrienes General Treatment Modalities • Vigorous exercise • Posture • Avoidance procedures • Saline irrigation Nasal Irrigation • Commercial buffered sprays • Bulb syringe – 1/4 tsp of salt to 7 ounces water • Waterpik with lavage tip – 1 tsp salt to reservoir • Disposable enema bucket – 2 tsp salt, 1 tsp soda per quart of water Treatment of Mild Allergic Rhinitis Step 1 Occasional exposure/symptoms • Environmental control • Saline irrigation • Monotherapy – Nasal steroid or – Nonsedating antihistamine or – Astelazine nasal spray Treatment of Moderate Allergic Rhinitis Step 2 May Last for Months to One Year • Environmental control • Normal saline irrigation • Combination therapy – Nasal steroid and – Nonsedating antihistamine with or without decongestant or – Astelazine • Immunotherapy Treatment of Severe Allergic Rhiniti step 3 Chronic, persistent associated with Sinusitis, Otitis media , asthma • Environmental control • Normal saline irrigation • NSA+/- decongestant • High-dose nasal steroid • Afrin 3 days or fewer • Oral steroid • Immunotherapy Environmental Control/Avoidance • Dust mites – Controls: plastic covers, frequent vacuuming of carpet – Avoid: overstuffed chairs, curtains, stuffed animals, dustcollecting boxes under bed • Cockroaches – Poisoning Environmental Control • Air conditioning • Frequent dusting, cleaning surfaces • Air filters – Hepa filtration • Vacuum cleaners – Dry versus water filtration • Ionizers • Wood burning stoves Pharmacotherapy • Allergic rhinitis – Antihistamines • OTC • Nonsedating • Nonallergic rhinitis – Antihistamines • Drying effect – Decongestants – Nasal steroids – Astelazine – Nasal cromolyn – Ipatropium – Astelazine nasal spray – Nasal steroids – Decongestants • NARES syndrome Nasal Steroids • Flonase • Beconase • Nasonex • Nasacort • Rhinocort • Vancenase • Tri-Nasal Nonsteroid Nasal Sprays • Astelazine • Atrovent • Nasalcrom • Saline Nonallergic Rhinitis As important as allergic rhinitis Present in 57% of patients with rhinitis Nonallergic/Vasomotor Rhinitis • Perennial or episodic symptoms • Chronic, nonpruritic rhinorrhea/congestion • Negative nasal eosinophils • Negative allergy screening • Nonallergic excitants – – – – Viruses Chemicals, tobacco smoke, potpourri Nonallergic foods Weather changes Symptoms of Nonallergic Rhinitis • Nasal congestion is prominent • Sneezing and nasal itching uncommon • Concomitant asthma is less likely • Eye symptoms are fewer • Postnasal drip • Fatigue • Loss of sense of smell and taste Tests Helpful in Diagnosing Nonallergic Rhinitis • Nasal smear will be void of eosinophils – Eosinophils present in 90% of allergic rhinitis – Neutrophils suggest bacterial infection • Skin prick tests or in-vitro testing negative – Negative allergy testing is the best predictor of the nonallergic state Treatment of Nonallergic Rhinitis • • • • • Astelazine nasal spray Steroid nasal spray Nasal irrigation Avoidance Effectiveness of antihistamines questionable Rhinitis — Case Study • 23-year-old has had nasal congestion for the past 23 months. Started as a cold, but symptoms never cleared. “Allergies” several times a year as a child but outgrew them. Never tested. No family hx of allergy. Can’t sleep without his medication. – Is he allergic? – What is your next question? Rhinitis — Case Study • What medication are you using? • Answer: “Afrin, I can’t breath or sleep without it.” Rhinitis Medicamentosa • Rebound congestion from overuse of topical decongestants; oxymetazolone, phenylephrine, cocaine • Erythematous mucosa, congestion, punctate bleeding • Interstitial edema and vasoconstriction • Withdrawal of medication, topical steroids, oral steroids Treatment of Rhinitis Medicamentosa • Initiate topical steroid bilaterally, discontinue decongestant in one nostril, then the second nostril one week later • One-week dose of tapering steroids • Evaluate for the underlying cause of the rhinitis Hormonal Causes of Rhinitis • Pregnancy – Second month to term • Puberty • Oral contraceptives • Hypothyroid state Rhinitis of Pregnancy • Mild symptoms may have been present before (pregnancy aggravated symptoms) • Increase in circulating blood volume • Progesterone induced smooth muscle relaxation • Hormonal effect on nasal mucosa Treatment of Rhinitis in Pregnancy • Caution with medication usage • Nasal saline sprays, steam inhalation • Avoidance of known triggers • Topical medical therapy rather than systemic when possible • Oral pseudoephedrine • Chlorpheniramine Rhinitis — Case Study • 28-year-old with a two-year history of profuse rhinorrhea. No history of rhinitis or asthma as child. Occasional sneezing, little congestion. • Clear nasal discharge on exam, pharynx, tympanic membrane, lungs all normal. • Skin test is negative with good positive control. – What in-office test will make the diagnosis clear? • Nasal smear – revealed marked eosinophilia • Diagnosis: NARES syndrome nonallergic rhinitis with eosinophilia NARES Syndrome • Perennial symptoms – Sneezing – Rhinorrhea – Pruritis • Occasional loss of smell • Nasal smear positive for eosinophils • Allergy screen is negative Nasal Mastocytosis is Rare • Basophilic metachromic nasal disease • Histologic diagnosis • Mast cell infiltration of the mucosa • No eosinophils Atrophic Rhinitis (Ozena) • Found in patients who have had radical nasal tissue removal for congestion – Removal of inferior and or middle turbinates • “Empty nose syndrome” • Excessive drying, crusting and infection • Atrophic changes in the elderly • Klebsiella colonization Treatment of Atrophic Rhinitis Nasal irrigation 3-4 times per day for 2-3 months, then 1-2 times per day indefinitely Rhinitis — Case Study • 45-year-old female with no history of previous symptoms of rhinosinusitis presents with headaches, daily nasal congestion and fatigue for 3-4 months. No hx of viral URI. No family hx of allergy. No changes in cosmetics, no additions to house, no new clothes. No pets. No food reactions known. – What other element of a thorough history might give you a clue as to diagnosis? Rhinitis — Case Study • Where do you work? • How long have you worked there? • Do your symptoms coincide with changing jobs? • Are you more symptomatic at work than at home? • Do your symptoms clear on the weekend or on vacation? Occupational Rhinitis • Patients experience symptoms in workplace • Symptoms improve on weekends/vacation • May be allergic or nonallergic • May coexist with occupational asthma • Treatment is avoidance – Move to another area in the workplace – Move to another job Causes of Occupational Rhinitis • Sick building syndrome – Department of Ecology and Environmental Protection • Gasses from office machines – Inks, paper • Perfumes • Paints, carpet, carpet glue • Laboratory animals Common Workplaces for Occupational Rhinitis • Beauty salons • Tanneries • Clothing stores • Paper industry • Supermarkets • Gardening products • Auto body spraying • Insecticides • Service stations • Food industry • Woodworking • Laboratory animals • Pesticide industry • Office machinery • Plastic manufacturing • Paints, chemicals Common Chemical Exposures Causing Rhinitis • • • • • • • • • • Gasoline/diesel fuels Chlorine Perfumes Cleaning agents Room deodorizers Hair dyes Permanent solutions Paints Auto body paints Herbicides • • • • • • • • • Potpourri Burning candles Petroleum products Formaldehyde New clothing odor Hair spray Toluene Ammonia Acids Mechanical Causes of Rhinitis • Deviated nasal septum • Nasal polyps • Foreign body • Meningocoele • Adenoid hypertrophy • Variants of the osteomeatal complex • Concha bullosa • Tumors of the nose • Congenital atresia Gustatory Rhinitis • Rhinorrhea and/or nasal congestion related to eating • Treatment is identification and elimination • Common causes of gustatory rhinitis – Cheeses – Spicy foods – Wines Food Reactions • Diagnosed by skin prick tests, RAST or elimination diet – Skin prick tests, in-vitro testing will only diagnose IgE-related foods – Elimination diet will diagnose all types adverse food reactions Vasculitides, Autoimmune and Granulomatous Causes • Churg-Strauss Syndrome vasculitis • Systemic lupus erythematosis • Relapsing polychondritis • Sjogren’s syndrome • Sarcoidosis • Wegener’s granulomatosis Nasal Polyps • Grape-like clusters – Maxillary sinus • Inflammatory process • One third associated with asthma – Asthma-aspirin-polyp triad • High rate of recurrence Treatment of Nasal Polyps • Allergy control • Intranasal steroids • Systemic steroids • Avoidance of ASA, NSAIDs • Polypectomy • Ethmoidectomy Importance of Allergy Testing • Distinguishes between allergic, nonallergic and mixed rhinitis • Aids in selecting specific pharmacotherapy • Identifies specific allergens to be avoided and/or treated by immunotherapy when indicated Indications for Allergy Testing • Identification of allergens • Chronic or recurrent symptoms • Symptoms not controlled by avoidance and medication • Medication not tolerated • Decrease cost of medication Contraindications for Allergy Skin Testing • Uncontrolled asthma or recent asthma attack – PEFR must be above 70% personal best effort • Cardiac problems • History of hymenoptera sensitivity • History of anaphylaxis of any kind – Shellfish – Medications Refer to an Allergist • Hymenoptera sensitivities • Antibiotic desensitization • Anesthetic testing • Patients with history of anaphylaxis – Medication – Shellfish – Peanut or other food reactions Instruments Used in Allergy Testing • Invivo tests – Individual skin prick tests • DuoTip • Morrow Brown needle • GreerPick – Multiple antigen applicators • MultiTest • Quintest • Invitro tests – Modified in-vitro testing – CAP system Skin Testing Disadvantages • Affected by medications – Antihistamines – Steroids • Patient discomfort • Rare possibility of anaphylaxis • Dermagraphism • Chronic skin disorders • Very young and atrophic skin Puncture/Prick Testing Figure 1 • Disease-free site • Swipe with alcohol • Apply drop of antigen (1:10 or 1:20 conc.) • Prick skin at 45 to 60 degree angle, or puncture at 90 degrees • Gently lift device, no bleeding Example of a skin prick/puncture should occur epicutaneous test • Read positive control in 10 minutes • Read allergens in 15-20 minutes Multiple Antigen Testing • Alcohol wipe and dry area to be used • Remove device from package • Place in loading dock • Apply to forearm • Read positive control in 10 minutes • Record allergen response in 15-20 minutes Multiple Antigen Testing Figure 2 Example of multiple-puncture device allowing simultaneous placement of six allergens plus a positive and negative control cont’d Figure 3 Example of multiple-puncture device in its loading dock Multiple Antigen Testing Figure 4 Example of application of a multiple-puncture device to the forearm cont’d Figure 5 Example of positive and negative skin responses to allergens applied with a multiple-puncture device; note the positive and negative control sites Skin Testing Precautions • Physician always present • Emergency equipment available and current – Adrenalin and albuterol in testing room • Determine patients’ most recent use of antihistamines, steroids, H2 blockers • Is patient on a beta blocker? – Switch medications or in vitro testing Grading of MultiTest 0 No reaction-1-3 mm wheal 1+ Erythema with 3mm wheal 2+ Erythema with 5 mm wheal 3+ Erythema with 7-10 mm wheal 4+ Erythema with >10 mm wheal 5+ Erythema with >10 mm wheal and pseudopods Reading and Recording Results • Best done by physician scoring and nurse recording • If reaction is borderline, read as the higher class – Example • Difficulty determining if result is #3 or #4 record as #4 Positive and Negative Controls • Imperative to use to validate skin response • Positive negative control = dermagraphism • Negative positive control = medication reaction or hypoactive skin Indications for In-Vitro Testing • Dermatographism • Eczema • Very young skin • Atrophic skin • Long-acting antihistamines • Beta blockers, ACE inhibitors, MAOs • Patients with poorly controlled asthma (70%) • History of anaphylaxis RAST Procedure • Allergen coupled to paper disc • Add patient’s serum • Antigen-antibody complex formed • Radioactive anti IgE added • Anti IgE-antibody-allergen complex formed • Gamma counter scoring RAST Scoring Class 0 200-500 No allergy Class 0/1 500-750 Questionable allergy Class 1 750-1,600 Mild allergy Class 2 1,600-3,600 Moderate allergy Class 3 3,600-8,000 More allergic Class 4 8,000-18,000 More allergic Class 5 Over 18,000 Most allergic Advantages of In-Vitro • Patient safety, no anaphylaxis • Cost-effective screening • Not affected by medication • No irritating skin reactions • Sets safe starting doses for immunotherapy Disadvantages of In-Vitro • Patient does not experience the reaction • Less sensitive than skin tests (?) • Cost per test may be higher • RAST requires 3-14 days to get results RAST Scoring as a Guide to Immunotherapy • The higher the RAST class the more dilute the starting dose of immunotherapy • The lower the RAST class the higher the starting dose of immunotherapy Prescribing Immunotherapy Based on RAST Results • Blood sample is drawn anytime • Serum is removed • Sent to lab and processed • Results correlated with history • Prescription for immunotherapy written • Lab makes up immunotherapy sets Indications for Immunotherapy • Inadequate control with avoidance and pharmacotherapy • Pharmacotherapy for more than 3-4 months per year • Intolerable side effects of medication • Progressive severity of disease • Desire for long-lasting control without Rx Evidence-Based Recommendations • Practice Recommendation: Treat patients diagnosed as having allergic seasonal rhinitis with prophylactic medications (antihistamines and/or intranasal corticosteroids). • Practice Recommendation: Prescribe intranasal corticosteroids to control allergic rhinitis symptoms. • Practice Recommendation: Educate patients with allergic rhinitis about avoidance activities. • Practice Recommendation: Reserve immunotherapy for patients with allergic rhinitis for whom optimal avoidance measures and medication therapy are insufficient to control symptoms.
