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Objectives
Understanding what allergic rhinitis is
Definition
Allergic rhinitis (AR) = IgE mediated immunologic response of nasal mucosa to air borne allergens,characterised by Nasal congestion
Nasal pruritis
Rhinorrhea
Ages affected
Not seen until after age 4 or 5.
(Takes approx 3 pollen season exposures).
10-15% in adolescents (adolescents and young adults). Peak age 30 (decades 2, 3 and 4).
Predisposition
Genetic:
Positive FHx (polygenic inheritance) Negative FHx does not rule out dx of AR
Atopic dermatitis:
Early sign of predisposition to allergy.
Seasonal Rhinitis
Pollen:
Spring = Trees Summer = Grass Fall = Weeds
Mold:
Spores in outdoors have seasonal variation (reduced #s in winter, increased in summer/fall due to humidity).
Perennial Rhinitis
Fungi/mold:
Exposure peaks accompany activities such as harvesting, cutting grass and leaf raking.
food allergens-
Symptoms
Direct: Nasal congestion Rhinorrhea Pruritis Sneezing Eye tearing & pruritis Ear & palate pruritis Post nasal drip Anosmia
Symptoms
Non-nasal: Sore throat Chronic cough Mouth breathing
Symptoms
Psychosocial/Cognitive: Fatigue Depression Irritability Anxiety Sleep disturbance Poor concentration Impaired learning, decision making and psychomotor speed
Diagnosis
History Physical exam Skin prick testing, Nasal smear,
History
General medical hx Rhinological sx Family Hx
(environmental and/or occupational factors)
Frequency of sx
Duration
Dennie-Morgan line
Eyes
Allergic Shiners Conjunctivitis Tearing
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Ears
Fluid Infection
Lungs
Wheezing Persistent coughing
Other areas
Stigmata of atopic diseases in conjunction with nasal sx:
atopic eczema, asthma
Nasal smears
Eosinophils may help differentiate allergic from infectious rhinitis (neutrophils). Peripheral blood eosinophil counts
does not assist in allergy diagnosis.
Allergic Rhinitis
Therapeutic options
Avoidance Intranasal steroids Antihistamines Decongestants Anticholinergics Cromolyn Leukotriene modifiers Systemic steroids Immunotherapy
Decongestants (oral/topical)
i.e.: Oral Pseudoephedrine Phenylephrine Topical More effective than systemic Oxymetazoline (0.05%) Phenylephrine (1%)
Corticosteroids (intranasal)
i.e: Fluticasone, mometasone Mechanism: Effect: reduce nasal blockage, pruritis, sneezing and rhinorrhea
Corticosteroids (continued)
Note: Fluticasone,mometasone most potent single medication for tx of AR.
Side effects: locally, <10% of pts (sneezing, nasal stinging, burning, irritation).
Ipratropium (intranasal)
i.e.: Atrovent (intransal) Mechanism: inhibits muscarinic cholinergic receptors. Effect: reduces watery rhinorrhea (no effect on nasal itching, sneezing or nasal congestion). Side effects: irritation, crusting, epistaxis.
Leukotrine inhibitors
Monteleukast new medication
Equal in effectiveness to antihistamines Combination of monteleukast and an antihistamine superior to each agent alone
Allergic Rhinitis
Therapeutic options
Immunotherapy
Reserved for unavoidable allergens and inadequate response to standard therapies
NASAL POLYPI
Definition
The term polyp derived from Latin word Polypous Many footed Defined as simple oedematous hypertrophic nasal mucosa Can be unilateral / bilateral
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Classification
1 2 3
Simple nasal polyp Fungal polyp
Malignant polyp
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Aetiology
Chronic rhinosinusitis Asthma Autonomic nervous system dysfunction Genetic predisposition
Aetiology
aspirin intolerance Cystic fibrosis Allergic fungal sinusitis kartageners syndrome Youngs syndrome Nasal mastocytosis
Site of origin
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Examination
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Examination
Smooth glossy multiple mass seen in anterior rhinoscopy Insensitive on probing. Probe can be passed around the polyp Soft and mobile
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Malignant polypi
Also known as sentinel polyp Caused due to mucosal oedema resulting from the malignant tumor All nasal polypoidal mass removed from elderly patients should be subjected to HPE
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Proetz theory
Faulty development of maxillary sinus ostium This is usually large in these pts Hypertrophied mucosa from antral cavity sprouts through this enlarged ostium The growth of polyp is due to impediment to the venous return from the polyp
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Bernoullis phenomenon
Pressure drop occurs next to the constriction. This causes a suction effect pulling the sinus mucosa into the nasal cavity.
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Mucopolysaccharide theory
Proposed by Jakson Changes in the mucopolysaccharide present in the ground substance causes nasal polyposis These changes causes excessive water retention causing swelling of nasal mucosa which appears polypoidal
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Infection / inflammation
Acinous mucous glands inside the antrum gets blocked This forms a cystic lesion within the sinus cavity This cyst gradually enlarges to completely fill the antrum It exits via the accessory ostium to reach the nasal cavity
drtbalu's otolaryngology online 50
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Clinical features
Nasal obstruction Unilateral / bilateral Anosmia Loss of taste Rhinorrhoea watery / mucoid / mucopurulent Head ache Broadening of nose (Frog face)
drtbalu's otolaryngology online 52
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Posterior rhinoscopy
Polyp can be seen at the level of choana Antrochoanal polyp can be seen exiting out of accessory ostium
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Differential diagnosis
Meningocele Angiofibroma Sq cell carcinoma Enlarged turbinates Inverted papilloma
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Radiology
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Medical Management
Antihistamines ? Nasal decongestant Steroids Antibiotics ?
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Treatment
Traditional polypectomy
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