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Allergic and Nonallergic Rhinitis Dr.Babak Saedi Assistant Professor of Otolaryngology Tehran University of Medical Sciences Types of Rhinitis Pure allergic rhinitis 43% Pure nonallergic rhinitis 23% Mixed 34% 100% 57% Non allergic component National Allergy Advisory Council meeting, The broad spectrum of rhinitis: etiology, diagnosis, and advances in treatment. St. Thomas, US Virgin Islands; 1999. 2 Prevalence of Allergic Rhinitis by Age Group What is Allergic Rhinitis? Inflammation of the nasal mucous membrane An immune response to inhaled allergens Types of Immune Response Immediate Response (minutes) Histamine, tryptase, chymase, kinins, and heparin, leukotrienes, and prostaglanin D2 • Mucous membrane stimulated • Vascular permeability increased • Sensory nerves are stimulated Late Response (4-8 hours) Neutrophils, eosinophils, lymphocytes, and macrophages • Inflammation continues Sources of rhinitus symptoms Symptoms of Allergic Rhinitis Are: Sneezing Nasal Itching Rhinorrhea (running nose) Nasal Congestion May accompany with itching of eye, throat, and ears Systematic effects • Fatigue • Sleepiness Usually not life threatening Symptoms Direct: Nasal congestion Rhinorrhea Pruritis Sneezing Eye tearing & pruritis Ear & palate pruritis Post nasal drip Anosmia Quality-of-Life Issues Fatigue Missing school/work Concentration Halitosis Nuisance Sleep disturbance Decreased daily production Impaired studying Sniffing/snorting Blowing nose Emotional well being Social interactions 8 Physical Changes of Allergic Rhinitis Pale blue, edematous turbinates Clear, watery nasal discharge Crease from nasal salute Lymphoid hyperplasia Watery, itchy eyes 9 Photo Image of Nasal Salute 10 General Approach to Treatment Avoidance Specific immunotherapy Specific allergen Desensitizing Pharmacotherapy Identify type of allergy rhinitis Two Types Seasonal Allergic Rhinitis AKA “hay fever” Caused by seasonal allergens such as pollen from flowers, trees, weeds, etc. Perennial Rhinitis Non-seasonal allergens • Dust mites • Animal dander • Molds http://www.myatmosphere.biz/graphics/Dust_Mites.jpg Diagnosis/Tests Detailed history • Nature,duration, and course of symptoms Physical Facial features, eyes,ears, and nose Tests • Allergy tests • IgE count • Eosinophil count Treatment of Allergic Rhinitis (ARIA) Moderate severe intermittent Mild intermittent < 4 d/wk or < 4 wks < 4 d/wk or < 4 wks Mild persistent > 4 d/wk and > 4 wks Moderate severe persistent > 4 d/wk and > 4 wks Intra-nasal steroid Intra-nasal cromolyn Oral or intra-nasal H1-blocker Intra-nasal decongestant (< 10 days) or oral decongestant Allergen and irritant avoidance Immunotherapy 5/24/2017 Pharmacotherapeutic Options Medication Class Antihistamines Symptoms Controlled Sneezing, rhinorrhea, itching, conjunctivitis 1st generation 2nd generation 3rd generation Comments First line therapeutic For seasonal allergic rhinitis • If sedation is a problem move to non sedative For perennial allergic rhinitis • Use as alternative or combination with intranasal steroid Over the Counter Benadryl, Claritin, ChlorTrimeton, Dimetane, Tavis Prescription Clarinex, Allegra, and Zyrtec Ophthalmic Intranasal Ocular Symptoms Decongestants Nasal Congestion Intranasal Corticosteroids Sneezing, rhinorrhea, itching, nasal congestion Mast Cell Stabilizers Use before allergen’s season Improvements wont be noticed for up to a month in perennial rhinitis Intranasal Anticholinergics Rhinorrhea Excellent choice for perennial rhinitis How Does Antihistamine Work? Competitive antagonists to histamine Example Characteristics of … First Generation Antihistamine Less selective Drowsiness Second and Third Generation Antihistamine Selects for peripheral H1 receptors Little drowsiness Side Effects Side effects through anticholinergic properties α- adrenergic receptors • Norepinephrine • Epinephrine • Dopamine 5-HT receptors • Seratonin Structures of … Dopamine Histamine Norepinephrine Adverse Side Effects 1st Generation Dizziness Tinnitus (ringing in ear) Blurred vision Euphoria Uncoordination Anxiety Insomnia Tremor Nausea Headache Hallucination Psychosis 2nd & 3rd Gen. Fatigue Headache Nausea Dry mouth Structural Examples First Generation H1-receptor Antagonists Ethanolamines Akylamines Chlorpheniramine (Chlor-Trimeton) Piperzamines Diphenydramine (Benadryl) Vistaril (Hydraxyzine) Antivert (Meclizine) www.marvistavet.com/assets/images/Benadryl.gif http://ec3.imagesamazon.com/images/P/B000FKGN38.01._AA280_PIbundle2,TopRight,0,0_AA280_SH20 _SCLZZZZZZZ_V53017918_.jpg Tricyclics Promethazine (Phenergan) http://www.allergizer.com/50226711/images/Phenergan.jpg http://www.petplace.com/articles/images/235906991thm.jpg Second Generation H1-receptor Antagonists Certirizine (Zyrtec) Terfendadine (withdrawn) Loratadine (Claritin) www.fillmyscript.net/images/claritin.gif www.edrugnet.jp/Productphoto/zyrtec.jpg Third Generation H-1 Receptor Antagonists Levocetirizine Desloratadine (Clarinex) Fexofenadine (Allegra) http://www.encolombia.com/images/vademecum/allegra_caja.jpg http://celestinejim.tripod.com/images/Clarinex.jpg What is the role of surgery? •Highly effective •Submucosal resection for good long term results