Allergic Rhinitis

I MADE SUDIPTA
Dept of Otorhinolaryngology – Head &
Neck Surgery
INTRODUCTION
AR → Atopic disease which is often found in
clinical practice

It is a manifestation from type I hypersensitivity

based on Gell & Comb classification. IgE
mediated → nasal mucosa as target organ

Affected all age, especially children, teenager

and young adult (productive ages)
Recurrence , disturbed daily activity and
family

Patient has difficulty to concentrate, head

ache, sleep disturbance, emotion
disturbance, frequent sneezing

Decreased productivity in worker, added

expenditure for doctor and medicine
 Definition
Allergic rhinitis is an inflammation process in
mucous membranes of the nose which is
mediated by Ig E. This reaction is due to
abnormal reaction / hypersensitivity of
nasal mucosa to specific allergen.

For normal people this process doesn’t

cause any reaction
 Etiology
Allergen :
1. Inhalant : house dust, pollen, animal
dander, etc
2. Ingestion : Milk, shrimp, egg, peanuts
3. Injection
4. Contact
 Pathophysiology
If someone ingested [ oral, inhalation ] or
injected with allergen, in several minutes
Immune response with production
of antibody or immunoglobulin

Immunoglobulin will react to that allergen

immunity or allergy
[hypersensitivity ]
In Immunity, Immunoglobulin will protect our
body from occurrence of disease.
but
In allergy, Immunoglobulin will cause our
body to suffer from disease.

In mucosa and blood circulation of patient,

there is specific Ig which can only give
reaction to certain allergen
This allergy reaction will degranulate mast cells and/or
basophils releasing of vasoactive amines such
as:
– histamine
– bradykinine
– serotonin etc

Histamine and Serotonin :

– Dilatation & Increase permeability of capillary blood
vessels
– Smooth muscle contraction
– Increase secretion of lacrimal gland, bronchus and
digestive tract
Bradykinine :
– Smooth muscle contraction
– Increase permeability of capillary blood
vessels
– vasodepressor  decrease blood pressure
– Increase secretion of salivary gland and
sweat gland
This process will end if contact with
specific allergen is also discontinued
 Classification
Based on time of exposure and type of
allergen
– Seasonal : present during certain season
– Perennial : present throughout the year and
do not affected by season
New classification of AR by WHO ARIA
( Allergic Rhinitis and Impact on Asthma )
2007
Based on :
1. Intermittent if
* <4 days per week
* or <4 weeks
2. Persistent if
* >4 days/week
* and >4 weeks
Based on severity :
– Mild all of the following
normal sleep
no impairment of daily activities, sport, leisure
no impairment of work and school
no troublesome symptoms

– Moderate-Severe one or more items

abnormal sleep
impairment of daily activities, sport, leisure
impaired work and school
troublesome symptoms
 ARIA Classification
Intermittent Persistent
. < 4 days per week . ≥ 4 days per week
. or < 4 weeks . and ≥ 4 weeks

Mild Moderate-
normal sleep severe
no impairment of daily one or more items
activities, sport,
. abnormal sleep
leisure
. impairment of daily
normal work and activities, sport, leisure
school . abnormal work and school
no troublesome . troublesome symptoms
symptoms
 Sign & Symptoms

- Itchy at the nose, ear and soft palate

- Frequent sneezing
- Nasal blockage
- Clear and watery runny nose
- Nasal mucosa: edema, pale or bluish
• Allergic shiners are the dark discoloration of the
lower eyelids which occurs due to venous stasis
in individuals with chronic nasal congestion

• Allergic salute, due to itching, patient often rubs

his/her nose using the back of the hand

• Allergic crease, a horizontal crease or pale line

that develops across the lower part of the nose
as a consequence of frequent upward wiping of
the nose.
Allergic Salute Allergic Shiner

Allergic Crease Adenoid Facies

 Ancillary procedure

1. Skin test :
Single Intracutan or intradermal or serial [ Skin End-point
Titration ]
Prick Test
Scratch Test
2. Nasal mucous cytology for eosinophilia
3. Ig E specific test [ Radioallergosorbent test /RAST ]
4. Paranasal sinus X-Ray [ Water`s ]
5. Elimination and provocation test [ for food allergy ]
 Management
1. Contact avoidance with allergen
2. Medicine
- anti histamine
- decongestant
- antihistamine + decongestant
- corticosteroid
3. Immunotherapy
4. Increase body resistance with: exercise,
good nutrition and enough rest
ELIMINASI ALERGEN/ AVOIDANCE
Differential diagnose :
1. Acute Rhinitis.
2. Rhinitis medicamentosa.
3. Vasomotor Rhinitis