Download Document

Allergic Rhinitis
Dr. Vishal Sharma
Introduction
 Commonest 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
Aetiology
1. 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
4. DRUG INDUCED: Aspirin, other NSAIDs, antihypertensives, oral contraceptive pills
5. 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 to
allergy. Older child in large family or only child in a
small family  infection is rare so develops allergy.
Grass pollen & dust mite
Pathogenesis
Sensitization & Priming to specific antigen:
Inhaled allergen produces specific IgE antibody
which gets attached to mast cells
Subsequent exposure to same antigen:
Allergen combines with specific IgE antibody 
degranulation of mast cells (even with small
amount of antigen)  chemical mediators released
Acute or Early Phase
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
Late or Delayed Phase
Occurs 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.
Pathogenesis
Pathogenesis
Cardinal Symptoms
1. 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.
Nasal Signs

Repeated lifting of nasal tip (allergic salute) to
relieve itching & open nasal airway  transverse
nasal crease (Darrier’s crease, Hilton’s 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.
Allergic salute
Nasal crease
Pale turbinate, watery
rhinorrhoea
Blue, boggy turbinate
Inferior turbinate appearances
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 lacrimation
Ears: Ear block & ed hearing (due to O.M.E.)
Throat: Chronic pharyngitis, laryngitis
Dennie-Morgan Creases
Allergic Shiners
Allergic conjunctivitis
ARIA Classification
1. Mild intermittent
2. Moderate-severe intermittent
3. Mild persistent
4. Moderate-severe persistent
ARIA = Allergic Rhinitis & its Impact on Asthma
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 +
Investigations
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
Skin prick test
Skin prick test
Skin prick test
Radio-allergo-sorbent test

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 allergenIgE complex.

Amount of radio-labelled anti-IgE antibody on
disc  amount of IgE & is quantified by
counting radioactivity from the disc.
Complications
1. Recurrent sinusitis
2. Nasal polyp
3. Serous otitis media
4. Prolonged mouth breathing
5. Bronchial asthma
6. Atopic dermatitis
7. Conjunctivitis
Differential diagnosis

Vasomotor rhinitis

Rhinitis medicamentosa

Hormonal rhinitis (pregnancy, hypothyroidism,
oral contraceptive use)

Cerebrospinal fluid leak

Ethmoid polyps
Treatment
1. Avoidance of allergens
2. Pharmacotherapy
3. Specific Immunotherapy
4. Surgery: F.E.S.S., Turbinoplasty
Pharmacotherapy
H1-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
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
Antihistamines
Systemic:
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
Nasal Decongestants
Systemic decongestants
 Phenylephrine
 Pseudoephedrine
Topical decongestants
 Xylometazoline
 Oxymetazoline
 Saline
Anti-cold preparations
Name
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
Topical Decongestants

Oxymetazoline 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)
Systemic Antihistamines
Topical Antihistamine spray
Technique of nasal spray
Nasal Decongestants
Sodium Cromoglycate
Ipratropium nasal spray
Corticosteroids
Nasal sprays
Injectable
 Beclomethasone
 Methylprednisolone
 Budesonide
 Fluticasone
Oral
 Mometasone
 Prednisolone
Corticosteroid nasal spray
Methylprednisolone acetate
Montelukast
Drug
Sneeze Rhinor Nasal Nose ed
rhoea block itch smell
Antihistamine
+++
++
+
+++
0
Steroid spray
+++
+++
+++
++
+
Oral steroid
+++
+++
+++
++
++
Cromoglycate
+
+
+
+
0
Topical nasal
decongestant
0
0
++++
0
0
Ipratropium
0
++
0
0
0
Monteleukast
0
+
++
0
0
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
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.
Injectable S.I.T.
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
Treatment protocol
Mild 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
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
Moderate-severe persistent

H1-Antihistamine + Nasal decongestant + double
dose 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
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

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.
Pollen advice

Avoid walking in open grassy spaces during hot, dry
days. 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.
House dust mite advice

Use 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 maintain
the humidity less than 50 %.
Thank You