ALLERGIC RHINITIS

Dr Ravikumar MS(ENT) Assoc Prof Raichur Institute Of Medical Sciences

Objectives
Understanding what allergic rhinitis is

How to recognize allergic rhinitis

Treatment

Definition
Allergic rhinitis (AR) = IgE mediated immunologic response of nasal mucosa to air borne allergens,characterised by Nasal congestion

Nasal pruritis
Rhinorrhea

Sneezing Nasal sx lasting > 1 hr on most days.

Ages affected
Not seen until after age 4 or 5.
(Takes approx 3 pollen season exposures).

10-15% in adolescents (adolescents and young adults). Peak age 30 (decades 2, 3 and 4).

Predisposition
Genetic:
Positive FHx (polygenic inheritance) Negative FHx does not rule out dx of AR

Atopic dermatitis:
Early sign of predisposition to allergy.

Previous exposure/environmental factors

Comorbidities assd with AR

Asthma Sinusitis Otitis Media (with effusion) (AR occurs frequently in pts with asthma and atopic dermatitis.)

Types of Allergic Rhinitis

Seasonal (intermittent sx) Perennial (chronic & persistent sx)

Seasonal Rhinitis
Pollen:
Spring = Trees Summer = Grass Fall = Weeds

Mold:
Spores in outdoors have seasonal variation (reduced #s in winter, increased in summer/fall due to humidity).

House dust mites:

Generally a perennial allergen, but may be increased in damp autumn months.

Perennial Rhinitis
Fungi/mold:
Exposure peaks accompany activities such as harvesting, cutting grass and leaf raking.

Pet Dander (cats, dogs):

Can linger up to 4 months after pet removal.

House dust mites:

Cockroaches:
Respiratory allergy

food allergens-

Pathophysiology of Allergic Rhinitis

Source: Cummings Otolaryngology: Head & Neck Surgery

Symptoms
Direct: Nasal congestion Rhinorrhea Pruritis Sneezing Eye tearing & pruritis Ear & palate pruritis Post nasal drip Anosmia

Symptoms
Non-nasal: Sore throat Chronic cough Mouth breathing

Symptoms
Psychosocial/Cognitive: Fatigue Depression Irritability Anxiety Sleep disturbance Poor concentration Impaired learning, decision making and psychomotor speed

Diagnosis
History Physical exam Skin prick testing, Nasal smear,

History
General medical hx Rhinological sx Family Hx
(environmental and/or occupational factors)

Frequency of sx
Duration

(daily, episodic, seasonal, perennial)

Severity (increased, decreased or same) Qualitate nasal discharge:

AR: clear and watery

Physical exam Nose

Nasal mucosa classically pale blue, but not diagnostic (60%). Thick yellowish secretions suggest infection. Structural deformities that may impede air flow (deviated nasal septum, nasal polypys, hypertrophied turbinates). Allergic Salute

Dennie-Morgan line

Eyes
Allergic Shiners Conjunctivitis Tearing

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Ears
Fluid Infection

Lungs
Wheezing Persistent coughing

Other areas
Stigmata of atopic diseases in conjunction with nasal sx:
atopic eczema, asthma

Skin Prick Testing

IgE-mediated rxn (Type I). Small, but significant potentail for anaphylactic rxn. Wheal & flare response (15-20 minutes)

Includes a positive and control soln.

Positive rxn = over 3cm wheal with assd flare and pruritis (no rxn to neg control).

In vitro serum test (RAST)

Radioallergosorbent test Serum levels of specific IgE antibodies. No longer performed IMMUNOCAP newer technology widely performed

Nasal smears
Eosinophils may help differentiate allergic from infectious rhinitis (neutrophils). Peripheral blood eosinophil counts
does not assist in allergy diagnosis.

Allergic Rhinitis
Therapeutic options
Avoidance Intranasal steroids Antihistamines Decongestants Anticholinergics Cromolyn Leukotriene modifiers Systemic steroids Immunotherapy

Antihistamines First Generation

diphenhydramine Mechanism: inhibition of histamine (H1) receptors. Effect: reduce sneezing, nasal pruritis and rhinorrhea, but not congestion. Side Effects: anticholinergic activity --> adverse CNS effects.

Antihistamines Second Generation

cetirizine, loratadine, fexofenadine Mechanism: inhibit histamine (H1) receptors. Effect: same as First generation. Note:
Nonsedating

Topical preparation available Azelastine

Decongestants (oral/topical)
i.e.: Oral Pseudoephedrine Phenylephrine Topical More effective than systemic Oxymetazoline (0.05%) Phenylephrine (1%)

Mechanism: alpha-adrenergic agonist. Effect: vasoconstriction Side effects:

Oral: HA, nervousness, irritability, tachycardia, palpitations, insomnia. Topical(nasal): prolonged use (>5-7 days) leads to rhinitis medicamentosa

Corticosteroids (intranasal)
i.e: Fluticasone, mometasone Mechanism: Effect: reduce nasal blockage, pruritis, sneezing and rhinorrhea

Corticosteroids (continued)
Note: Fluticasone,mometasone most potent single medication for tx of AR.

intanasal: acts locally.

goal: control sx with lowest possible dose. >90% achieve symptomatic relief.

Side effects: nasal irritation, bleeding (nasal septal perforation).

Cromolyn Sodium (intranasal)

Mechanism: mast cell stabilizing agent --> reduces release of histamine and other mediators. Effects: reduces nasal pruritis, sneezing, rhinorrhea and congestion. Note:
prophylactic use: start before pollinosis sx or unavoidable/predictable exposures.

Side effects: locally, <10% of pts (sneezing, nasal stinging, burning, irritation).

Ipratropium (intranasal)
i.e.: Atrovent (intransal) Mechanism: inhibits muscarinic cholinergic receptors. Effect: reduces watery rhinorrhea (no effect on nasal itching, sneezing or nasal congestion). Side effects: irritation, crusting, epistaxis.

Leukotrine inhibitors
Monteleukast new medication
Equal in effectiveness to antihistamines Combination of monteleukast and an antihistamine superior to each agent alone

Allergic Rhinitis
Therapeutic options
Immunotherapy
Reserved for unavoidable allergens and inadequate response to standard therapies

Effects- Rise in serum-specific IgG

Suppression of IgE Shift from TH2 to TH1 profile Reduction of inflammatory cells in the nasal mucosa and secretions Onset of action 12 weeks after starting therapy, increases slowly over 1-2 years Subcutaneous (SCIT) Antigen extract is injected into the skin Sublingual (SLIT) Antigen is applied under the tongue Widely used in Europe

NASAL POLYPI

Definition
The term polyp derived from Latin word Polypous Many footed Defined as simple oedematous hypertrophic nasal mucosa Can be unilateral / bilateral

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Classification
1 2 3
Simple nasal polyp Fungal polyp

Malignant polyp

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Simple nasal polypi

Also known as inflammatory polyp Ethmoidal polyp Antrochoanal polyp

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Aetiology
Chronic rhinosinusitis Asthma Autonomic nervous system dysfunction Genetic predisposition

Aetiology
aspirin intolerance Cystic fibrosis Allergic fungal sinusitis kartageners syndrome Youngs syndrome Nasal mastocytosis

Site of origin

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Examination

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Examination
Smooth glossy multiple mass seen in anterior rhinoscopy Insensitive on probing. Probe can be passed around the polyp Soft and mobile

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Malignant polypi
Also known as sentinel polyp Caused due to mucosal oedema resulting from the malignant tumor All nasal polypoidal mass removed from elderly patients should be subjected to HPE

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A/C polyp theories of etiopathogenesis

Proetz theory Bernoullis phenomenon Mucopolysaccharide changes Infections

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Proetz theory
Faulty development of maxillary sinus ostium This is usually large in these pts Hypertrophied mucosa from antral cavity sprouts through this enlarged ostium The growth of polyp is due to impediment to the venous return from the polyp

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Bernoullis phenomenon
Pressure drop occurs next to the constriction. This causes a suction effect pulling the sinus mucosa into the nasal cavity.

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Mucopolysaccharide theory
Proposed by Jakson Changes in the mucopolysaccharide present in the ground substance causes nasal polyposis These changes causes excessive water retention causing swelling of nasal mucosa which appears polypoidal

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Infection / inflammation
Acinous mucous glands inside the antrum gets blocked This forms a cystic lesion within the sinus cavity This cyst gradually enlarges to completely fill the antrum It exits via the accessory ostium to reach the nasal cavity
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Reasons for posterior migration of AC polyp

The accessory ostium is present posteriorly Inspiratory air current is more powerful than expiratory current there by pushing the polyp posteriorly The natural slope of nasal cavity is directed posteriorly Cilia beats towards the choana

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Clinical features
Nasal obstruction Unilateral / bilateral Anosmia Loss of taste Rhinorrhoea watery / mucoid / mucopurulent Head ache Broadening of nose (Frog face)
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Posterior rhinoscopy
Polyp can be seen at the level of choana Antrochoanal polyp can be seen exiting out of accessory ostium

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Parts of antrochoanal polyp

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Differential diagnosis
Meningocele Angiofibroma Sq cell carcinoma Enlarged turbinates Inverted papilloma

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Radiology

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Medical Management
Antihistamines ? Nasal decongestant Steroids Antibiotics ?

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Treatment
Traditional polypectomy

Caldwel Luc procedure

Microdebrider Endoscopic sinus surgery Recurrence
Multiple small polyps common Large and antro-coanal less so

AC polyp / Ethmoidal polypi

Ethmoidal polypi Seen in adults Allergy is the common cause Multiple (bunch of grapes) Arises from ethmoidal labyrinth Seen easily on anterior rhinoscopy X ray PNS may show hazy ethmoids and normal maxillary sinuses Mostly bilateral Recurrence is common Polypectomy Antrochoanal polyp Seen in children and adolescents Infection is the common cause Unilateral Arises from maxillary antrum Seen commonly in post nasal exam X ray PNS shows hazy maxillary antrum

Usually unilateral Recurrence is uncommon Caldwel luc surgery in recurrent cases

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