ALLERGIC

RHINITIS
 ALLERGIC RHINITIS
IgE mediated immunologic response to nasal mucosa to air-borne
allergens.
 Symptoms appear in or around a
seasonal particular season.
Pollen grains

Allergic
rhinitis

dust mites,insect
Symptoms are present parts,cockroaches,animal
perennial throughout the year danders
AETIOLOGY :

Inhalant allergens
Seasonal
perennial

Genetic predisposition
pathogenesis
In a genetically predisposed individual

Inhaled allergen

IgE production

IgE binds to basophils & mast cells by its Fc end

On subsequent exposure allergen binds to Fab fragment

Degranulation

Chemical mediators (preformed & newly synthesized)

 Sensitized
Antigen
Mast cell

Release of mediators

Performed Newly synthesized

Histamine Prostaglandins e.g. PGD2
ECF A Leukotrienes e.g. SRS-A
NCF A PAG
Heparin Thromboxane A
Others TNFa
CHEMICAL MEDIATORS

SYMPTOMATOLOGY

VASODILATION
MUCOSAL EDEMA
INFILTRATION WITH E.PHILS
EXCESSIVE SECRETION
SMOOTH MUSCLE CONTRACTION
2 PHASES OF ALLERGIC IMMUNE RESPONSE

Acute or early phase

Within 5-30 min,
Due to release of vasoactive amines like histamine
sneezing, rhinorrhea nasal blockage and/or bronchospasm.

Late or delayed phase

: 2-8 hours after exposure to allergen without additional exposure.
Due to infiltration of inflammatory cells at the site of antigen deposition ( E
phils, N phils, B phil, monocytes and CD4+ T cells)
swelling.,congestion, thick secretion
Clinical features
No age or sex predilection
Symptoms of seasonal nasal allergy.
Paroxysmal sneezing (10-20 sneezes at a time),
nasal obstruction,
watery nasal discharge and
itching in the nose.

Symptoms of perennial allergy.

Frequent colds,
persistently stuffy nose,
loss of sense of smell due to mucosal oedema,
postnasal drip,
chronic cough.
Itching in the nose, eyes, pharynx or larynx.
Signs
Nasal signs :
Transverse nasal crease
Black line in dorsum of nose due to constant upward rubbing
of nose (Allergic salute )
Pale and oedematous nasal mucosa
Swollen turbinates
Thin, watery or mucoid discharge
 Ocular signs
edema of lids
Congestion
Cobble stone appearance of conjunctiva
Dark circles under eyes (allergic shiners)
 Otologic signs
E tube blockage

Retracted T M
&
Serous otitis medis
 Pharyngeal signs
Hyperplasia of submucosal lymphoid tissue

Granular pharyngitis
 Mouth breathing
Ortho dontic changes
 Laryngeal signs
Hoarseness of voice
Edema of vocal cords
Diagnosis :
Detailed history and physical examination.
Investigations :
1. Total and differential count.
Peripheral eosinophilia.
2. Nasal smear
large number of eosinophils.
Also seen in NARES
3. Skin tests.
Prick, scratch and intradermal tests.
4. Radioallergosorbent test (RAST).
Measures specific IgE antibody concentration in the
patients serum.
5. Nasal provocation test.
Complications :
1. Obstruction of sinus ostia Recurrent sinusitis.
2. Nasal polyp
3. Blocking of E tube Serous otitis media
4. Bronchial asthma.
5. Mouth breathing orthodontic changes
Treatment :
1. Avoidance of allergen.
2. Treatment with drugs.
a. Antihistaminics
Decrease rhinorrhea ,sneezing ,nasal itch
A/E :drowsiness
b. Sympathomimetics
a. topically / orally
b. Oral pseudoephedrine & phenylephrine in combn with antihistamines
c. Cause vasoconstriction nasal congestion & edema
d. CNS activation dowsiness due to antihistamines
e. Topical aerosols } phenylephrine , xylometazoline & oxymetazoline
a. nasal obstruction
b. A/E rebound congestion RHINITIS MEDICAMENTOSA

c. Corticosteorids
Oral corticosteorids
acute episodes not relieved by other drugs
Topical steroids } aerosols }beclomethasone budesonide, flunisolide , fluticasone
Inhibit recruitment of inflammatory cells trt of late allergic phase
Trt of RHINITIS MEDICAMENTOSA
 a) Sodium chromoglycate
Stabilizes the mast cells & prevents degraulation.
2% solution for nasal drops or spray or as an aerosol powder
anticholinergics rhinorrhea
Ipratropium bromide
Trt of allergic & nonallergic
leukotriene receptor antagonist
monteleukast
anti ig E igE
omalizumab
3. Immunotherapy
Allergen is given in gradually increasing doses till the
maintenance dose is reached.
formation of IgE & IgG
Upto 3 years