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Definition

Rhinitis is defined as the presence of at least one of the


following
Congestion
Rhinorrhea
Snezzing
Nasal itching
Nasal obstruction

Other reported symptoms include


Headache
Facial pain
Ear pain
Itchy throat and palate
Snoring
Sleep disturbance

Definition
Allergic rhinitis is present when hese
symptoms are triggered by an
allergen
Perennial allergic rhinitis
Dust mites
Mold spores
Animal dander

Seasonal allergic rhinitis


pollens

Epidemiology
In US affect 10-30% of adult dan up to 40%
of children
The fifth most common chronic disease in US
Risk factor
Atopic family history
IgE level above 100 IU/ml before age of 6 years
Higher sosioeconomic status
Positive epicutaneous allergen testing

However 44-87% people with rhinitis have


mixed allergic and nonallergic

Epidemiology
Patient downlplay rhinitis symptoms make
the economic burden
The direct costs nearly double from US$6.1
billion in 2000 to US$11.2 billion in 2005
In US there are 3.5 million lost workdays
dan 2 millon lost school days
Estimated productivity decreased US$600
per affected employee per year which is
greater lost than asthma, diabetes an
coronary heart disease

Pathophysiology
Cellular signal
Allergic rhinitis is an IgE-mediated disease resulting
inflammation onf nasal mucosa.
Histamine release from mast cell is a major mediator in
the inflammation
Eosinophilic inflamation also play important role
After allergen exposure, rhinitis can persist for several
weeks
There is an immediate and al late phase
Late phases predominate symptoms is nasal congestion
Eosiniphil releasemediators can induce tissue damage,
pre-treating with topical glucocoticoids reduce eosinophil
infiltration and cytokine release

Pathophysiology
Neuronal aspect
Sensory nerve and the efferent sympathetic
and para sympathetic neurons helps regulate
the mucosal barrier if nasal epithelium
A fibers convey the sensation of pain and cold
to central nervous system
A thick mucosal decrease the ability of these
neurons to sense passing airflow, contibutes to
the sensation of nasal obstruction and dyspnea.
When menthol receptors are stimulated, false
sense of nasal patency and less dyspnea

Pathophysiology
Neuronal aspect
Delayed activation conducting C fibers
C fiber can stimulated by nicotine,cigarette smoke,aldehyde,
formaldehyde,isocyanates,sulfur dioxide
Capsaicin induce sensation of heat and activate trasient
receptor potential and ionchannel protein.
Acetylcholine from parasympathetic innervate glands and
vessel of the airway mucosa.
Eosinophils decrease the negative feedback on acetylcholine
release, resulting increase glandular secretion and
bronchoconstriction
To balance that, sympathetic neuron induce vasoconstriction.
Stimulation of -adrenergic receptors by nasal
decongestantreduce mucosalthickness.

Pathophysiology
Genetics
Monozygotic twins show 45-60%
development of allergic rhinitis
Dizygotic twins have rate 25%

Treatment
Avoidance
Not always possible in case of pollen and mixed
rhinitis
Dust mites
carpet removal,soft toy removal,
allergen impermeable bedding cover,vacuuming
with high-efficiency particulate air (HEPA),
washing with hot water
Animal allergy
removal pet from home
Moisture control can improve mold levels
Pesticide and meticulous control of food debris
can decrease cockroach

Treatment
Antihistamine
Histamines activate H1 receptor to produce sensation of
itching
Leads to sneezing, nose rubbing and allergic salute
First generation controlling rhinorrhea, sneezing
andpruritus. Side effect : sedation
Poor h1 receptor selectivity causing anticholinergic effect :
dry mouth,urinary retention, constipation and tachycardia
Second generation has improved receptor selectivity,
sedation, faster onset and longer duration of action and
fewer adverse effect
Fexofenadine no sedation, loratadine sedation at higher
dose, cetirizine more sedation effect

Treatment
Antihistamine
Topical provide faster onsetand great
efficacy
Improvement of congestion
Require twice daily use
Bitter taste and less effective than
intranasal corticosteroid

Treatment
Steroids
In addition to oral H1-antihistamine
The most effective treatment with onset 2-12
hours
Continual use more effective than needed basis
use
Mild side effect : srusting, dryness, minor epstaxis
Can be added by intranasal antihistamine
Systemic corticosteroid only for severe or
intractable symptoms
5-7 days, not more than 3 weeks

Treatment
Decongestant
Available in oral and topical
Relieving congestion
Studies of H1-antihistamine with oral decongestant
not show benefit
Side effects : insomnia, anorexia, irritability,
elevated blood pressure
Avoidedin children less than 1 year, adult over 60
and patient with cardiac condition
Main side effect for topical is rhinitis medicamentosa
Recommend 10 days of use

Treatment
Cromones
Less efective than topical corticosteroid
Work inhibiting mast cell activation,
neutrophil, eosinophil, monocytes,
macrophages
May be an inhibitory effect on neural
signal

Treatment
Miscellaneous
Anticholinergic, ipratopium bromideavailable in nasal
form
Block parasympathetic which leads to watery
rhinorrhea.
Not decrease sneezing or nasal obstruction
Leukotriene receptor antagonist have been shown to
be effective
After 2 weeks therapy, montelukast decrease
symptoms but lesser than intranasal fluticasone
If intranasal corticosteroid cannot control then
adding montelukast did not give any benefit

Treatment
Taking as a whole, intranasal
corticosteroid be the most effective
The next most effective : oral and
intranasal antihistamine
Different in seasonal and perennial
allergic rhinitis
For some patient with perennial, oral
antihistamine may be as effective as
nasal steroid

Treatment
Immunotherapy
Subcutaneous immunotherapy (SCIT) effective in patient with
identifiable IgE mediated symptom
Has some advantage than other treatment
Effects can be sustained for years, prevent the development of new
allergen sensitivities
Not only control allergyc rhinitis but allergic conjungtivitis and
allergen induced asthma
Large local reaction at injection site are the most common adverse
reaction
Severe systemic reactions are rare
High ambient pollen level and dosing errors were two mainrisk factor
Need staff and equipment that can handle anaphylaxis and patient
observed for 30 minutes
Disadvantage : injection discomfort, frequency of shot and total cost

Treatment
Immunotherapy
Alsocan be given by sublingual
Can cause oral itching and GI side effect
Meta analysis
SLIT less effective in children than adults
SLIT tablet more effective than drops
Effective when given for 12 months or less
compared to over 1 year use
Not effective for rhinitis control in allergyc
asthmatics than subjects without asthma allergy
Beginning at least 3 months before grass season