Allergic Rhinitis

Allergic Rhinitis
Allergy
Definition: -
Hypersensitivity to allergens
(pollens, moulds), which
trigger allergic response is
called allergy
If nose is involved :
Nose
Allergic Rhinitis
Allergy
Common aero allergens

* Pollen,
* House dust,
* Mite
Food Allergens
Related Anatomic Structures
Compromised by Allergic Rhinitis
Epidemiology Of Allergic Rhinitis
Respiratory allergy is prevalent among all populations

with increasing trend all over the world.
Epidemiological studies carried out in different countries

indicate the prevalence of respiratory allergy as 1530%*
A recent survey carried out in India shows that 2030%

of the population suffer from allergic rhinitis and that
15% develop asthma.#
# Anonymous: All India Coordinated Project on Aeroallergens and Human Health. Report. Ministry of
Environment and Forests, New Delhi 2000
# Chhabra SK, Gupta CK, Chhabra P, Rajpal S: Prevalence of bronchial asthma in Aeroallergens in clinical practice of allergy in india.an overview,
schoolchildren in Delhi. J Asthma 1998, 35, 291- Anand B. Singh, Pawan Kumar, Ann Agric Environ Med 2003, 10, 131136
296
Sensitization and Immunoglobulin E Production
During the initial stage of the disease, low-dose exposure

leads to the production of specific IgE antibodies.
Antigen that deposited on the nasal mucosa is engulfed
by APCs (macrophages, dendritic cells, Langerhans cells)
and partially degraded
TH2 CD4+ cells are important contributors to allergic
reactions.
On subsequent exposure to the offending allergen, the
IgE antibodies serve as receptors for the antigen
molecules.
Immunology of the Upper Airway and Pathophysiology and Treatment of Allergic Rhinitis, Fuad M. Baroody Robert M. Naclerio, Chapter 40, 597-623
Immunological Mechanisms Underlying Allergic
Rhinitis
Allergic Rhinitis and Rhinosinusitis, Nadir Ahmad, Mark A. Zacharek, Otolaryngol Clin N Am41 (2008) 267281
Early Response to Antigen
Within minutes after exposure of an allergic patient to

antigen, an inflammatory response occurs.
This leads to nasal congestion which will increases in

nasal secretions and nasal airway resistance (NAR).
Several neuropeptidesin addition to sympathetic and

parasympathetic nerves and their transmittersare
found in the nasal mucosa. These play very important
role in the pathogenesis of early response to antigen
Late Response To Antigen
The response to allergen exposure is not limited to the

acute events that occur minutes after exposure.
Hours after antigen challenge, some patients experience

a recurrence of symptoms, most notably nasal
congestion.
This is termed the late response
Both T lymphocytes and mast cells are contributors to

cytokine production during the late allergic reaction.
Early And Late Phase Responses In allergic
rhinitis
Allergic Rhinitis and Rhinosinusitis, Nadir Ahmad, Mark A. Zacharek, Otolaryngol Clin N Am41 (2008) 267281
Pathogenesis Of
Allergic Rhinitis
And
Occurrence Of
Symptoms
Symptoms of Allergic Rhinitis
Recurrent episodes of
sneezing,
Pruritus, rhinorrhea,
Nasal congestion, and
lacrimation
Snorting throat clearing
Postnasal drip.
Nasal obstruction unilateral
or bilateral
Sequelae Of Allergic Rhinitis
Elongated facies, General appearance

Allergic shiners, allergic salute, malaise
Nose
Septal deviation, polyps, drainage, turbinate hypertrophy, hyponasality
Mouth
Cobblestoning of oropharynx
Ear
Middle ear pathology
Neck
Lymphadenopathy, thyroid enlargement
Chest
wheezing
Skin
Eczema, dermatographism
Adenoid Facies
Classification Of Allergic Rhinitis
Seasonal allergic rhinitis is

defined by symptoms that
occur during exposure to
seasonal allergens, such as
ragweed, grasses, outdoor
moulds, and tree pollens.
Perennial allergic rhinitis,

defined as nasal symptoms
for more than 2 hours per
day for more than 9 months
Classification Of Allergic Rhinitis
Thus according to the ARIA

classification,
Intermittent allergic rhinitis :

Symptoms present for less than 4
days a week, or for less than 4
consecutive weeks.
Persistent allergic rhinitis :

Symptoms present for more than
4 days a week and for more than
4 consecutive weeks, with the
realization that patients usually
suffer almost every day.
Severity Of Allergic rhinitis
Physical Examination
Complete ear, nose, and throat examination
Inspect the inner aspect of the nasal cavities
Pale, bluish, and oedematous, and coated with thin, clear

secretions.
It is important to remember that there is no

pathognomonic appearance of the nasal mucosa in
allergic rhinitis
Diagnostic Tests
The 3 most common

tests used to confirm
the diagnosis
Skin testing
Nasal smear
In vitro testing for serum

levels of specific IgE
antibodies.
Nasal Smears
Looks at nasal secretion

component cells
Can help differentiate

allergic rhinitis and
NARES (non allergic
rhinitis with
eosinophilia) from other
forms of rhinitis
Skin Testing
Goal is to identify antigens to which patients are

symptomatically reactive and to quantify the sensitivity if
immunotherapy is planned
There are a variety of acceptable techniques:

Prick testing,
Intradermal testing
In vitro testing
A comparison of skin endpoint titration and skin prick testing iA in the diagnosis of allergic n rhinitis. Rhinitis, Gungor, A et al, ENT Ear, Nose, and Throat Journal (Jan 2004); Vol 83:1, 54 54-60.
Multitest II
Whealing Response
A comparison of skin endpoint titration and skin prick testing iA in the diagnosis of allergic n rhinitis. Rhinitis, Gungor, A et al, ENT Ear, Nose, and Throat Journal (Jan 2004); Vol 83:1, 54 54-60.
Skin Testing : Disadvantages
Affected by previous ingestion of antihistamines or other drugs
Children often do not tolerate multiple skin needle pricks
Prior or coexisting dermatologic conditions, such as eczema or

dermatographism, may preclude the performance of skin tests
The potency of antigen extracts needs to be maintained
Potentially interfering medications must be discontinued prior to

skin
IgE Levels
Raised in 30% to 40% of patients with allergic rhinitis
But can be elevated in patients with nonallergic

conditions and normal subjects
It is of limited use in the diagnosis of allergic rhinitis
The Crux is..
It is always important to remember that a positive

in vitro or skin test result alone does not confirm
the diagnosis of allergic rhinitis in the absence of
supporting clinical history
Allergic Rhinitis And Quality Of Life
Sleep loss or disturbance
Increased daytime
sleepiness
Learning problems in
children
Work absenteeism
Reduction in work
productivity
Immunology of the Upper Airway and Pathophysiology and Treatment of Allergic Rhinitis
Fuad M. Baroody, Robert M. Naclerio
Prevention is better than cure: Avoidance Of
Allergens
It is potentially an effective treatment
Removing a pet from the house,

Covering pillows and mattresses
Washing bedding with hot water
Vacuuming mattresses and pillows.
Pharmacotherapy
Nasal
Drug type Itch / sneezing Discharge Blockage Impaired smell
preparations
Antihistamines +++ ++ + _
AZELASTINE
Anticholinergics _ +++ _ _ Ipratropium
Xylometazoline
Decongestants _ + +++ _
Oxymetazoline
Mast Cell Sodium

+ + + _
Stabilizers cromoglycate
Fluticasone
Topical
Mometasone
Corticosteroids +++ +++ ++ +
Allergic Rhinitis & its Impact on Asthma (ARIA)
Guidelines
Management of Intermittent AR
Avoid Allergens
Mild Intermittent AR Moderate-Severe Intermittent AR
Nasal H1 blocker / Spray Nasal H1 blocker / Spray
Oral H1 blocker Oral H1 blocker
Decongestants Decongestants/LTRA/Chromone
LTRA
Fluticasone - 2 sprays/nostril OD
LTRA= Leukotriene Receptor Antagonists Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines: 2010 Revision ,Broz ek et al
J allergy clin immunol Volume 126, number 3
Allergic Rhinitis & its Impact on Asthma (ARIA)
Guidelines
Management of Persistent AR
Avoid Allergens
Nasal H1 blocker
Oral H1 blocker / LTRA
Decongestants / Chromone
Intranasal CS / Mometasone/ /Fluticasone
Review patients after 2-4 weeks
Step up if no improvement Continue: 1 month if improvement

Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines: 2010 Revision ,Broz ek et al J allergy clin immunol Volume 126, number 3
Leukotriene Receptor Antagonists
Food and Drug Administration approved the leukotriene

receptor antagonists for asthma initially, but the latter
has been approved for treatment of allergic rhinitis
therapy also. *
The recent ARAI (2010) recommends to use oral

leukotriene receptor antagonists (monteleukast) in adults
and children with seasonal AR and in preschool children
with persistent AR**
**Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines: 2010 Revision , *Allergic Rhinitis Current Pharmacotherapy ,John H. Krouse, Otolaryngol Clin N Am 41 (2008) 347358
Broz ek et al J allergy clin immunol Volume 126, number 3
Montelukast
Montelukast is effective in the treatment of both upper-

and lower-airway inflammation.
It is an ideal medication to consider in the treatment of

patients with concurrent allergic rhinitis and asthma.
It can be used alone or in combination with other

medications for both diseases
Allergic Rhinitis Current Pharmacotherapy ,John H. Krouse, Otolaryngol Clin N Am 41 (2008) 347358
ARAI-2010 Use Of Newer Antihistaminics
New-generation oral H1-antihistamines (fexofenadine)

that do not cause sedation and do not interact with
cytochrome P450 are recommended over the old
generation H1 blockers.
In vivo and in vitro studies have demonstrated that

second-generation antihistamines decrease both phases
of the allergic response, possessing both antiallergic and
anti-inflammatory properties
Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines: 2010 Revision ,Broz ek et al J allergy clin immunol Volume 126, number 3
Fexofenadine
Improves symptoms of allergy like nasal itching,

rhinorrhea, and sneezing as well as conjunctival
symptoms
Several studies have demonstrated an improvement in

QOL for subjects treated with fexofenadine compared
with placebo or other antihistamines.
It does not penetrate the CNS translating clinically into

less sedation
Allergic Rhinitis Current Pharmacotherapy ,John H. Krouse, Otolaryngol Clin N Am 41 (2008) 347358
Summary
Allergic rhinitis is a common problem practice
Diagnosis is usually clinical supported by various tests
The most appropriate medical therapy depends upon the

nature of each patients symptoms, his or her tolerance
to and preference for certain classes of medications, and
the response to treatment
Montelukast and fexofenadine are effective drugs to treat

mild to moderate allergic rhinitis
Thank you

Allergic Rhinitis

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Allergic Rhinitis

Common aero allergens

Respiratory allergy is prevalent among all populations

Epidemiological studies carried out in different countries

A recent survey carried out in India shows that 2030%

During the initial stage of the disease, low-dose exposure

Within minutes after exposure of an allergic patient to

This leads to nasal congestion which will increases in

Several neuropeptidesin addition to sympathetic and

The response to allergen exposure is not limited to the

Hours after antigen challenge, some patients experience

This is termed the late response

Both T lymphocytes and mast cells are contributors to

Elongated facies, General appearance

Seasonal allergic rhinitis is

Perennial allergic rhinitis,

Thus according to the ARIA

Intermittent allergic rhinitis :

Persistent allergic rhinitis :

Complete ear, nose, and throat examination

Inspect the inner aspect of the nasal cavities

Pale, bluish, and oedematous, and coated with thin, clear

It is important to remember that there is no

The 3 most common

In vitro testing for serum

Looks at nasal secretion

Can help differentiate

Goal is to identify antigens to which patients are

There are a variety of acceptable techniques:

Affected by previous ingestion of antihistamines or other drugs

Children often do not tolerate multiple skin needle pricks

Prior or coexisting dermatologic conditions, such as eczema or

The potency of antigen extracts needs to be maintained

Potentially interfering medications must be discontinued prior to

Raised in 30% to 40% of patients with allergic rhinitis

But can be elevated in patients with nonallergic

It is of limited use in the diagnosis of allergic rhinitis

It is always important to remember that a positive

Sleep loss or disturbance

Removing a pet from the house,

Anticholinergics _ +++ _ _ Ipratropium

Mast Cell Sodium

Mild Intermittent AR Moderate-Severe Intermittent AR

Nasal H1 blocker / Spray Nasal H1 blocker / Spray

Oral H1 blocker Oral H1 blocker

Review patients after 2-4 weeks

Step up if no improvement Continue: 1 month if improvement

Food and Drug Administration approved the leukotriene

The recent ARAI (2010) recommends to use oral

Montelukast is effective in the treatment of both upper-

It is an ideal medication to consider in the treatment of

It can be used alone or in combination with other

New-generation oral H1-antihistamines (fexofenadine)

In vivo and in vitro studies have demonstrated that

Improves symptoms of allergy like nasal itching,

Several studies have demonstrated an improvement in

It does not penetrate the CNS translating clinically into

Allergic rhinitis is a common problem practice

Diagnosis is usually clinical supported by various tests

The most appropriate medical therapy depends upon the

Montelukast and fexofenadine are effective drugs to treat

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