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 530 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 (Darriers crease, Hiltons 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
Present for < 4 days / wk Or for < 4 weeks

Persistent symptoms
Present for > 4 days / wk and for > 4 weeks

Mild (presence of all)

Normal sleep Normal daily activities Normal work and school Normal sport & leisure No troublesome symptom

Moderate-severe (any 1)
Abnormal sleep Impaired daily activities Impaired work & school Impaired sport & leisure 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 Phenylephrine Pseudoephedrine Topical decongestants Xylometazoline Oxymetazoline Hypertonic saline

Cetirizine (S) Fexofenadine (S) Loratidine (S) Levocetrizine (S) Desloratidine (S) Azelastine (T)

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 COLDIN SINAREST DECOLD SUPRIN Chlorpheniramine Decongestant Paracetamol 4 mg 4 mg 4 mg 2 mg PsE 60 mg PsE 60 mg PhE 7.5 mg PhE 5 mg 500 mg 500 mg 500 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 Beclomethasone Injectable Methylprednisolone

Budesonide
Fluticasone Mometasone Oral Prednisolone

Corticosteroid nasal spray

Methylprednisolone acetate

Montelukast

Drug
Antihistamine Steroid spray

Sneeze Rhinor Nasal Nose ed rhoea block itch smell

+++ +++ ++ +++ + +++ +++ ++ 0 +

Oral steroid Cromoglycate

Topical nasal decongestant Ipratropium Monteleukast

+++ +
0 0 0

+++ +
0 ++ +

+++ +
++++ 0 ++

++ +
0 0 0

++ 0
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 No Improvement after 1 month

Consider surgery for polyps / turbinates

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