Allergic rhinitis

Nasal septum bony at back (vomer), front is perpendicular plate of ethmoid

Sometimes can get superior supreme turbinate
Turbinates partly bony and partly tissue venous sinusoids warm the air
Histamine turbinates get hypertrophied
Above inferior meatus = opening for nasolacrimal duct
Anterior ethmoidal cells, maxillary sinus osteomeatal complexes
Sphenoethmoidal recesses opening for sphenoid sinus
Allergy must be something external, younger age group - extrinsic
Vasomotor rhinitis due to autonomic parasympathetic stimulation, drug or partially allergic-induced, older age
group - intrinsic

Other countries allergic rhinitis is seasonal, not in Malaysia all year long
Allergic rhinitis type 1 IgE mediated
Treat with prevention
Pathogenesis mast cells release granules PG, leukotrienes, histamine
Histamine cause inflammation and symptoms
LT inflammatory mediator ati-LT for long term treatment

Clinical features
Not really seasonal in Malaysia
Rhinorrhea, normally there will be mucus discharge secretions are cleared by ciliary function, less dependent on
gravity, tearing etc -> pushed into throat and removed from the airways
Itchiness
FH for allergy eg skin hypersensitivity (allergic dermatitis, eczema), asthma etc -> can co-exist with allergic rhinitis
Ask family if child is presenting with symptoms
Nasal obstruction
Among the 3 turbinates, inferior turbinate is the largest
Sinuses sphenoidal sinus can have 2 septums forming 3 sinuses
Septa can be imbalanced forming sinuses with different sizes

Nasal valve flares up in emotions, heavy breathing etc

If closed can cause breathing difficulty involves inferior turbinate and anterior septum
Deviated septum due to birth trauma
If mild, not pathology
HIT hypertrophied inferior turbinate
Exam with auroscope (largest speculum), headlights and tudicum, endoscope
Turbinates very sensitive painful when poked, fixed, can bleed if traumatized
Nasal polyps mobile, not sensitive, does not bleed

Middle meatus check for pus secretions maxillary sinus most commonly infected
Take cotton ball with adrenalise peck decongest for a while check for anything coming out of the sinus

Investigations
Skin test can cause anaphylaxis done in hospital set up with emergency team ready
Safest one is the skin test
Injection test rarely done blood tests to check level of IgE PRIST or RAST expensive tests
Eosinophilia can be high in allergy. Not very diagnostic
Provocation test spray allergens in the nose check how many times the patient sneezes need to wait for half an
hour before testing the next allergen

Blockage eg severe nasal deviation, hypertrophy of turbinates etc

Allergic rhinitis can become chronic if turbinates does not reduce in size and blockage not cleared

Vasomotor turbinates stays big, does not reduce in size use surgery to reduce size

Treatment avoidance not pets, no carpets, clean fans and air conditioners
Oral antihistamines older ones can be sedative, newer ones not so sedative
Topical steroid sprays older days use oral steroids (S/E severe esp children), but can give for short term
Steroid nasal sprays local effect, rarely cause S/E, occasionally fungal infection
Ephedrine sprays decongestant rapid effect, but long term can cause rebound phenomenon and turbinates
become very thick and does not shrink anymore rhinitis medimentosa have to avoid ephedrine sprays for long
time and use inhaled steroids
Sodium cromoglycate good results but compliance bad as has to use a 4-6 times per day (spray)
Avoid dairy products, seafood
Surgical SMD, TIT, septoplasty only if patient compliant to the above first may not cure only relieve
obstruction, still have to follow above advice
TIT trimming of inferior turbinate cut turbinate, cauterize to prevent beeding can cause lots of crusting -> after
removing turbinate, sometimes may not improve due to lots of crusting -> empty nose syndrome
SMD submucosa diathermy - electric cautery with local anaesthesia (pack) tell patient dont swallow during local
anaesthesia stomach mucosa absorbs much rapidly than nasal mucosa due to large surface area, prepare
emergency team
Cautery if damage mucosa, can cause crusting and bleeding so keep the mucosa intact!
Do turbinoplasty remove part of turbinate but put mucosa back
Septoplasty adjuvant treatment, not curative divide the nasal septum and put it back together relieve
obstruction

Rhinitis sicca
Dryness hot climate, exposure to chemicals
Crusting -> peels off and bleeds
Put petroleum gel, wash regularly

Vasomotor rhinitis
Mainstay is antihistamine and nasal spray
Avoid drugs, stress; exercise more

Allergic rhinitis aka allergic rhinosinusitis