Internal Medcine II – Allergy / Immunology

Allergic Rhinitis


Ma. Fredelita C. Asuncion, MD, FPCP, FPSAAI

July 2017

E P I D E M I C A L E R T A N D R E S P O N S E
 Learning objectives – Allergic Rhinitis
Following this presentation you should be able
to:
•  Differentiate allergic from non-allergic rhinitis
•  Define the pathophysiology of allergic rhinitis
•  Define diagnostic and therapeutic approach to
allergic rhinitis 

Internal Medicine II – Allergy/Immunology

E P I D E M I C A L E R T A N D R E S P O N S E
 Allergic Rhinitis

•  Inflammation to the mucosal lining of the nose

caused by inappropriate hypersensitivity reaction
to an aeroallergen.

•  IgE mediated immune response, with mast cell

activation and release of cytokines

Internal Medicine II – Allergy/Immunology

E P I D E M I C A L E R T A N D R E S P O N S E
“Allergic Salute”

- describes the way that many children use the palm of

their hand to rub and raise the tip of their nose to relieve
nasal itching and congestion (and possibly to wipe away
some mucus).

Internal Medicine II – Allergy/Immunology

E P I D E M I C A L E R T A N D R E S P O N S E
Case
•  A 22 yr old male presents with runny nose, nasal
congestion, constantly clearing his throat, sniffing,
snorting, disruptive to fellow students. He
experiences most esp when entering the school
library.
•  What do you need to know in addition
to symptoms?
•  What physical signs can help you?
•  What quick tests can help you with the
diagnosis?

Internal Medicine II – Allergy/Immunology

E P I D E M I C A L E R T A N D R E S P O N S E
 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 (cats, dogs, animals with
hair)?
•  Any associated illnesses (asthma, skin rash, otitis
media)?
•  Is there a family history of allergy?

Internal Medicine II – Allergy/Immunology

E P I D E M I C A L E R T A N D R E S P O N S E
E P I D E M I C A L E R T A N D R E S P O N S E
 Allergic Patients Generally Have :
•  Early onset of symptoms (70% < age 20)
•  sneezing; rhinorrhea; obstruction of the nasal
passages; conjunctival, nasal, and pharyngeal
itching; and lacrimation
•  Occurs after temporal exposure to allergens
•  Family history of allergy
•  Seasonal symptoms
•  Symptoms with animal exposure
•  Symptoms worse outdoor
•  Tobacco and chemicals are not primary excitants
•  Previous immunotherapy was helpful

Internal Medicine II – Allergy/Immunology

E P I D E M I C A L E R T A N D R E S P O N S E
 Allergic Rhinitis
SYMPTOMS: SIGNS:
•  Episodic watery •  conjunctiva congested and
rhinorrhea and edematous
sneezing •  Swelling of the turbinates
and mucous membranes
•  obstruction of the with obstruction of the
nasal passages with sinus ostia and eustachian
lacrimation tubes precipitates infection
•  Clear, watery nasal
•  pruritus of the discharge
conjunctiva, nasal
mucosa, and •  Crease from nasal salute
oropharynx •  Lymphoid hyperplasia

Internal Medicine II – Allergy/Immunology

E P I D E M I C A L E R T A N D R E S P O N S E
 Physical Examination
•  External appearance, evidence of trauma
•  Color, consistency of nasal discharge

•  Mucosal swelling
•  Presence of odor

•  Polyps, septal deviation, concha bullosa

•  Tenderness over sinuses

Internal Medicine II – Allergy/Immunology

E P I D E M I C A L E R T A N D R E S P O N S E
 Physical Examination

•  Eyes: conjunctivitis, dark circles, Dennie’s lines

•  Ears: OM, TM mobility, serous otitis

•  Mouth: mouth breathing

•  Lungs: wheezing

Internal Medicine II – Allergy/Immunology

E P I D E M I C A L E R T A N D R E S P O N S E
 Nasal Crease

- a line across the bridge of the nose usually the result - particularly
in children - of rubbing the nose (allergic salute) to relieve nasal
congestion and itching

Internal Medicine II – Allergy/Immunology

E P I D E M I C A L E R T A N D R E S P O N S E
 “Allergic Shiners”
- Dark circles around the eyes caused by stasis of blood
secondary to pressure on the veins from edema of the mucous
membranes of the nasal and paranasal cavities

Internal Medicine II – Allergy/Immunology

E P I D E M I C A L E R T A N D R E S P O N S E
 Allergic Cobblestoning of
Conjunctiva

- Due to edema and hyperplasia of the papillae,

seen in chronic allergic conjunctivae

Internal Medicine II – Allergy/Immunology

E P I D E M I C A L E R T A N D R E S P O N S E
 AR in children
Nasal congestion can result in chronic mouth breathing,
associated with the development of a high, arched
palate, an elevated upper lip, and an overbite

Internal Medicine II – Allergy/Immunology

E P I D E M I C A L E R T A N D R E S P O N S E
 Postnasal drip

postnasal drip
and repeated
sore throats
from allergic
mucus building
up and being
discharged into
the throat

Internal Medicine II – Allergy/Immunology

E P I D E M I C A L E R T A N D R E S P O N S E
 Pathophysiology

Internal Medicine II – Allergy/Immunology

E P I D E M I C A L E R T A N D R E S P O N S E
 Non Allergic Rhinitis

•  Etiology – strong odors, irritants, change in

temperature (vasomotor), Non Allergic
Rhinitis with Eosinophlia Syndrome
(NARES), infection (common cold)
•  Nasal Discharge – yellowish/green, thick
•  Symptoms - same

Internal Medicine II – Allergy/Immunology

E P I D E M I C A L E R T A N D R E S P O N S E
 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
•  Not triggered with exposure to dust or animal

Internal Medicine II – Allergy/Immunology

E P I D E M I C A L E R T A N D R E S P O N S E
 Diagnosis
•  Accurate history and physical examination
•  Nasal smear
•  Skin test by intracutaneous route (puncture or prick)
with the allergens

Internal Medicine II – Allergy/Immunology

E P I D E M I C A L E R T A N D R E S P O N S E
 Allergic Rhinitis: Classification
Intermittent Persistent
•  < 4 days per week •  > 4 days per week
•  or < 4 weeks •  and > 4 weeks

Mild Moderate-Severe
one or more items
•  Normal sleep
•  Abnormal sleep
•  No impairment of
daily •  Impairment of daily
activities, sport, activities, sport,
leisure
leisure
•  Abnormal work and
•  Normal work & school
school •  Troublesome
•  No troublesome symptoms
symptoms in
untreated patients

Internal Medicine II – Allergy/Immunology

E P I D E M I C A L E R T A N D J Allergy
R E S P O N S E Clin Immunol 2001;108:S147-336.
 AR, Sinusitis, Asthma: The link
Common Triggers and Pathophysiology
Same mediators
Anatomy/ Physiology
•  IgE
•  Upper and lower airways are contiguous •  Histamine
•  Functional linkage – nose vs mouth breathing •  Cytokines
•  Similar histology(epithelial, neural, vascular) •  Leukotrienes
Same triggers
•  dust mite, pollen, pet dander, Same drugs
moulds, fungi •  Anti IgE
Allergic
Same cells •  Steroids(ICS/ INS)
Rhinitis
•  Mast cells •  Antihistamines
•  Eosinophils •  Antileukotrienes
Asthma Sinusitis

Internal Medicine II – Allergy/Immunology

E P I D E M I C A L E R T A N D J Allergy
R E S P O N S E Clin Immunol 2001;108:S147-336.
 What is the most effective
means of controlling allergic
rhinitis?

a)  Avoidance of allergens

b)  Antihistamine
c)  Steroids
d)  immunotherpahy

Internal Medicine II – Allergy/Immunology

E P I D E M I C A L E R T A N D R E S P O N S E
 ARIA workshop: Therapeutic options

Allergen avoidance
indicated when possible

Pharmacotherapy Immunotherapy
Safety, effectiveness
easy to be administered costs Specialist Rx, may alter the natural
course of the disease

Patient's education
always indicated

Internal Medicine II – Allergy/Immunology

E P I D E M I C A L E R T A N D R E S P O N S E
 Step ladder treatment of AR: ARIA

moderate
severe
mild persistent
moderate persistent
severe
intermittent
mild
intermittent
Intra-nasal steroid
Local cromone

Oral or local non-sedative H1 blocker

Intra-nasal decongestant (<10 days) or oral decongestant
Allergen and irritant avoidance

Immunotherapy

Internal Medicine II – Allergy/Immunology

E P I D E M I C A L E R T A N D J Allergy
R E S P O N S E Clin Immunol 2001;108:S147-336.
 Treatment and Prevention
•  Avoidance of exposure to the offending
allergen- most effective means of controlling allergic
diseases

•  Oral antihistamines of the H1 class- effective

for nasopharyngeal itching, sneezing, and watery
rhinorrhea and for such ocular manifestations as
itching, tearing, and erythema, but they are not
efficacious for the nasal congestion
•  fexofenadine, loratadine, desloradine, cetirizine,
levocetirizine, olopatadine, bilastine, and azelastine

Internal Medicine II – Allergy/Immunology

E P I D E M I C A L E R T A N D R E S P O N S E
 Treatment and Prevention
•  Intranasal Corticosteroids – use in persistent
cases, control of nasal congestion
- beclomethasone, flunisolide, triamcinolone,
budesonide, fluticasone propionate, fluticasone
furoate, ciclesonide, and mometasone furoate
•  Topical antihistamines

Internal Medicine II – Allergy/Immunology

E P I D E M I C A L E R T A N D R E S P O N S E
 Treatment and Prevention
•  Oral - adrenergic agonist decongestants
(Phenylephrine)- standard for the management of
nasal congestion, generally in combination with an
antihistamine.

•  CysLeukotriene1 blocker (Montelukast)-

approved for treatment of both seasonal and
perennial rhinitis, reduces both nasal and ocular
symptoms

Internal Medicine II – Allergy/Immunology

E P I D E M I C A L E R T A N D R E S P O N S E