ALLERGIC

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EPIDEMIOLOGY
▸ AR is a widespread and disabling inflammatory disease,
affecting 10 to 25% of the population worldwide.

▸ o 20 – 30% of Europeans
▸ o 10 – 30% of adults in United States
▸ o up to 50% in some age groups (adolescents)
▸ o In the Philippines, from 18% in the urban areas to 22.1% in
rural areas and from 26% in young children to 32% in
adolescent
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PATHOPHYSIOLOGY
▸ Symptomatic disorder of the nose induced by an IgE- mediated inflammation
after allergen exposure of the membrane lining of the nose.

▸ Allergens are always proteins. You cannot be sensitized to non-protein

objects.

▸ Primary symptoms:
▸ o Rhinorrhea
▸ o Sneezing
▸ o Nasal Itching
▸ o Nasal Obstruction
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EARLY PHASE RESPONSE

▸ Allergen-specific IgE antibodies bind to high affinity Fc

receptors on the surface of mast cells and basophils. On re-
exposure, the Fc receptors are cross-linked, causing the
activation of the mast cells in the nasal mucosa with the
subsequent release of histamine, leukotrienes, and various
cytokines and chemokines.
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EARLY PHASE RESPONSE

▸ Mast Cells and Basophils release
▸ Histamine- Sneezing, Pruritus, Rhinorrhea
▸ Leukotriene- Congestion, Bronchospasms
▸ Cytokines- Cell activation, Cell recruitment
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LATE PHASE RESPONSE

▸ The response is not limited to the acute events that occur
minutes after exposure

▸ Hours after antigen challenge, some patients experience

recurrence of symptoms, most notably nasal congestions

▸ Elevations of nasal airway resistance 4 to 10 hours after

antigen challenge, peak around 6 hours, resolution by 24
hours
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LATE PHASE RESPONSE

▸ cytokines (with its cell activation and cell recruitment effect)
will attract adhesion molecules that will be attached to your
endothelial cell.

▸ It will come out to the submucosa and away from the

vascular structures.

▸ There is transendothelial migration to the soft tissue,

causing more congestion.
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CLASSIFICATION
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DIAGNOSIS
▸ The diagnosis of AR is strongly considered in the presence of the following
symptoms: nasal itching, sneezing, rhinorrhea, and/or nasal congestion or
obstruction, triggered by allergen exposure.
▸ Supportive clinical information that must be sought:
▸ o Frequency and duration
▸ o Other manifestations of atopy (skin, asthma)
▸ o Family history of atopy
▸ Identification of possible allergens in the environment
▸ o Absence of symptoms upon change of environment
▸ o Result of previous allergy testing
▸ o The effects of previous allergen avoidance measures
▸ o Response to treatment and previous immunotherapy
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ANTERIOR
RHINOSCOPY
▸ Anterior rhinoscopy must be performed to
support the diagnosis of AR and other
nasal pathology.

▸ The following findings may be observed:

▸ o Pale gray, dull red, or red turbinates

▸ o Boggy turbinates (very pathognomonic;

looks edematous, full, wet, about to
explode)

▸ o Minimal to profuse, watery to mucoid

nasal discharge
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NASAL ENDOSCOPY
▸ Nasal endoscopy is strongly recommended for selected
patients. It provides valuable information especially in cases
with atypical symptoms, complications, treatment failures, or
when other pathology is suspected.
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DIAGNOSIS
▸ A complete Ear, Nose, and Throat (ENT) examination must be performed on all
patients with AR. The presence of other associated conditions, such as otitis
media with effusion, may also be uncovered.

▸ Detailed allergic work-up, e.g. skin tests, serum specific IgE tests, or nasal
provocation tests, may be performed for the following patients:

▸ Questionable diagnosis exists

▸ Unresponsive or intolerant to pharmacotherapy
▸ Multiple target organ involvement (allergic manifestations in the eyes, nose,
throat, skin, lungs,etc.)

▸ Immunotherapy is considered
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TREATMENT
▸ Avoid or minimize exposure to allergens. Foremost
treatment

▸ Limit outdoors exposure when pollen counts are high.

▸ Indoor allergen avoidance:
▸ Dust mite (most prevalent allergen), Remove
animal/cockroach (pet/pest), Pollen
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TREATMENT
Nasal Saline Irrigation (NSI) or douching

Recommended as an adjunctive treatment for patients with

allergic rhinitis.

▸ Economical
▸ Safe
▸ Effective
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ORAL ANTIHISTAMINES

▸ Strongly recommended in AR with:

Intermittent symptoms

Short term allergen exposure.

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INTRANASAL ANTIHISTAMINES
▸ Recommended alternative therapy to oral antihistamines in
AR with:

Intermittent symptoms

Short term exposure to allergens

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INTRANASAL CORTICOSTEROIDS
▸ For at least one month
▸ Strongly recommended in AR with:
Intermittent moderate-severe symptoms

Persistent symptoms

Long-term exposure to allergens.

▸ Duration of therapy can be individualized based on patient follow-up findings

▸ Most effective medication class in controlling symptoms of allergic rhinitis
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ORAL CORTICOSTEROIDS
▸ Oral Corticosteroids
▸ Short course (5 to 7 days)
▸ Recommended in AR with:
▸ o Moderate-severe symptoms
▸ o Persistent symptoms not responsive to INCS
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OTHER TREATMENTS
1. Allergen Specific Immunotherapy (SIT)- Only treatment that
can alter the natural history of AR

2. Oral and Topical Decongestants

3. Oral anti-leukotriene agents

4. Intranasal cromolyn sodium

5. Novel extracts- Anti-IgE