Definition
- an inflammation of the mucous membrane lining the nose (usually associated with nasal discharge sneezing, congestion and irritation in the nose, eyes, throat and ears.)
Classification of rhinitis
A. Allergic
Seasonal
Perennial
Occupational
B. Non allergic
Infection
Intrinsic rhinitis
Others.
Allergic Rhinitis-definition:-
Allergic rhinitis is clinically defined as a symptomatic disorder of the nose induced by an IgE-mediated inflammation after allergen exposure of the membranes lining the nose
- an inflammation of the mucous membrane lining the nose (usually associated with nasal discharge sneezing, congestion and irritation in the nose, eyes, throat and ears.)
Classification of rhinitis
A. Allergic
Seasonal
Perennial
Occupational
B. Non allergic
Infection
Intrinsic rhinitis
Others.
Allergic Rhinitis-definition:-
Allergic rhinitis is clinically defined as a symptomatic disorder of the nose induced by an IgE-mediated inflammation after allergen exposure of the membranes lining the nose
ATOPY
Tendency to develop an exagerrated antibody response( IgE) to common aero allergens.
Allergy is its clinical expression.
Genetically inherited.
Elevated IgE OR Exagerrated skin prick test
Tendency to develop an exagerrated antibody response( IgE) to common aero allergens.
Allergy is its clinical expression.
Genetically inherited.
Elevated IgE OR Exagerrated skin prick test
SEASONAL RHINITIS
Allergy to grass pollen,fungal spores
Nasal mucosa may be primed .
A pollen count of more than50/l provokes usually.
More in the evening when pollens settle down.
Allergy to grass pollen,fungal spores
Nasal mucosa may be primed .
A pollen count of more than50/l provokes usually.
More in the evening when pollens settle down.
Evening time is when the pollenssettle down on the ground.
PERENNIAL ALLERGIC RHINITIS
Caused by the digestive enzymes of house dust mite (Dermatophagoides pteronysinnus and D.farinae.
In pillows carpet bedclothes ,curtains ,soft furnishings.
Also cat salivary protien.
Dust Mites (Der p, Der f)
Eight legged arachnids (related to spiders, chiggers and ticks)
Thrive in warm moist micro-environments (inside pillows, cushions, mattresses)
Feed on human and animal dander (dead skin flakes)
Focus on the bedroom
Pillow and mattress covers
Wash bedding in hot water
Damp dust
Cost effective tips
(cheese cloth)
OCCUPATIONAL ALLERGENS
Flour (bakers,grain workers)
Lab animals
Washing powders
Wood dust
Latex-important in surgeons,nurses and other health workers.
Furry and Feathered Friends (Can d1, Fel d1, Mus m)
Dander: proteins in dead skin, urine and saliva
Cats (most common)
Dogs
Birds
Rodents
FOOD AND DRUG INDUCEDRHINITIS
Ig E mediated
Symptoms in mouth tongue and digestive tract.
Sensitivity to preservatives like sulphites,benzoates and tartrazine.
Saint’s or Samter’s triad-Aspirin induced rhinitis,nasal polyposis and late onset asthma.
Allergic rhinits-Aspirin triad:-
Nasal Polyposis
Allergic Sinusitis
Asthma
Natural history of allergic rhinitis:-
onset is common in childhood,adolescence and early adulthood.Symptoms often wane in older adults,but may develop or persist at any age.No apparent gender selectivity orpredisposition for developing allergic rhinitis.May contribute to other conditions such as sleep disorders,fatigue,learning problems.
PERENNIAL ALLERGIC RHINITIS
Caused by the digestive enzymes of house dust mite (Dermatophagoides pteronysinnus and D.farinae.
In pillows carpet bedclothes ,curtains ,soft furnishings.
Also cat salivary protien.
Dust Mites (Der p, Der f)
Eight legged arachnids (related to spiders, chiggers and ticks)
Thrive in warm moist micro-environments (inside pillows, cushions, mattresses)
Feed on human and animal dander (dead skin flakes)
Focus on the bedroom
Pillow and mattress covers
Wash bedding in hot water
Damp dust
Cost effective tips
(cheese cloth)
OCCUPATIONAL ALLERGENS
Flour (bakers,grain workers)
Lab animals
Washing powders
Wood dust
Latex-important in surgeons,nurses and other health workers.
Furry and Feathered Friends (Can d1, Fel d1, Mus m)
Dander: proteins in dead skin, urine and saliva
Cats (most common)
Dogs
Birds
Rodents
FOOD AND DRUG INDUCEDRHINITIS
Ig E mediated
Symptoms in mouth tongue and digestive tract.
Sensitivity to preservatives like sulphites,benzoates and tartrazine.
Saint’s or Samter’s triad-Aspirin induced rhinitis,nasal polyposis and late onset asthma.
Allergic rhinits-Aspirin triad:-
Nasal Polyposis
Allergic Sinusitis
Asthma
Natural history of allergic rhinitis:-
onset is common in childhood,adolescence and early adulthood.Symptoms often wane in older adults,but may develop or persist at any age.No apparent gender selectivity orpredisposition for developing allergic rhinitis.May contribute to other conditions such as sleep disorders,fatigue,learning problems.
MEDIATORS OF ALLERGY
From granules and cellmembrane of basophils and mast cells.
Histamine-itch,sneezing and mucous secretion
LeukotrieneC4-Mucous secretion
LKB4 and PAF-Eosinophil,Neutrophil chemoattractant
From granules and cellmembrane of basophils and mast cells.
Histamine-itch,sneezing and mucous secretion
LeukotrieneC4-Mucous secretion
LKB4 and PAF-Eosinophil,Neutrophil chemoattractant
How are the symptoms caused?
Irritation of freenerve endings---- Itching and sneezing
Increasedmucus production ------ Rhinorrhoea
Vasodilation -------- Congestion
Increasedvascular permeability---- Oedema
Diagnosis of AR
History
Physical / Nasal Examination
Laboratory investigations
-Routine blood;look for eosinophilia
- Skin Prick Test
- RAST
-Nasal lavage for eosinophils
CLINICAL MANIFESTATIONS:-
Repetitive sneezing,watery rhinorrhea,nasal pruritus,nasal congestion
others:-eye symptoms,ear symp,postnasal drainage.
Physical examination:-
nAllergic shiner
nDennie Morgan line(prominent creases below inferior eyelid)
nAllergic crease
nAllergic salute
nNasal mucosa may appear normal or pale bluish, swollen with watery secretions but only if patient is symptomatic
nExclude structural problems (polyps, deflected nasal septum)
Others:
nasal voice, constant mouth breathing, frequent snoring, coughing, repetitive sneezing, chronic open gape of the mouth, weakness, malaise, irritability
Allergic testing-Prick test:-
Patients have to be off of all antihistamines for 4 days. Off of non-sedative antihistamines for up to 6 weeks.
Cannot be on Beta Blockers.
Skin prick testing
It is usually carried out on the inner forearm,but if the patient has bad eczemaon the test can be performed on the back
Ideally the allergens to be selected should be in accordance with the patient’s history
As few as 3 or 4 or up to about 25 allergens can be tested
The arm is coded with a marker pen for the allergens to be tested
A drop of the allergen (extract) solution is placed by each code.
Radio allergosorbent test:-the blood measures of allergy antibody or IgE,produced when your blood is mixed with a series of allegens in a laboratory.
Management of AR:-
Allergen Avoidance
Pharmacotherapy
Immunotherapy
Animal Control Measures:-
The ideal solution:
Remove pets from house
If not possible:
Keep pet out of bedroom
Use HEPA air filtering system
Remove carpet and other reservoirs for allergens in the bedroom
Encasing on mattress, box springs, and pillow
Wash pet weekly.
Outdoor Triggers:-
Pollens: particles released from trees, weeds and grasses
Highest levels at midday (10-2pm)
Use air conditioning, not fans
Visit an air-conditioned mall or movie theater
Not many options (avoidance)
Pharmacotherapy:-
Medications used to treat allergic rhinits:
Antihistamines
Decongestants
AH-D combinations
Corticosteroids
Mast Cell stabilizers
Anticholinergics
Antileukotrienes
Anti-Histamines:-
Act by preventing histamine from binding to the H1-receptors
Primarily helpful in controlling Sneezing, itching & rhinorrhoea; ineffective in releiving nasal blockage
1st generation anti-histamines
- chlorpheniramine
- diphenylhydramine
2nd generation anti-histamines
- cetrizine
- azelastine
- fexofenadine
- loratadine
Intranasal corticosteroid therapy:-
Potent topical activity
Administration of low doses directly at site of action
Considerable efficacy at low doses
High topical: systemic activity ratios
Rapid first-pass hepatic metabolism of any systemically absorbed drug, to compounds with negligible activity
Markedly greater inhibition of EAR than with oral steroids
Immunotherapy:-
Allergy shots (immunotherapy) for allergic rhinitis Treatment Overview
When you get allergy shots (immunotherapy), your allergist or doctor injects small doses of substances that you are allergic to (allergens) under your skin. This helps your body "get used to" the allergen, which can result in fewer or less severe symptoms of allergic rhinitis.
Your allergist will use an extract of grass, weed, or tree pollen; dust mites; molds; or animal dander for allergy shots. You must first have skin testing to find out which allergen you are allergic to.
The "Ideal" Drug For Allergic Rhinitis Should Have The Following Features:
Inhibit both early and late phases
Be an H1 blocker
Counter effects of other mediators
Fast-acting, to control the early phase
Dosing-od or bd for compliance
No side effects
Manage all symptoms
Intranasal administration
The "Ideal" Drugs Are……
"Corticosteroids are undoubtedly the pharmacotherapeutic agents with the broadest application for the treatment of many types of rhinitis"
Irritation of freenerve endings---- Itching and sneezing
Increasedmucus production ------ Rhinorrhoea
Vasodilation -------- Congestion
Increasedvascular permeability---- Oedema
Diagnosis of AR
History
Physical / Nasal Examination
Laboratory investigations
-Routine blood;look for eosinophilia
- Skin Prick Test
- RAST
-Nasal lavage for eosinophils
CLINICAL MANIFESTATIONS:-
Repetitive sneezing,watery rhinorrhea,nasal pruritus,nasal congestion
others:-eye symptoms,ear symp,postnasal drainage.
Physical examination:-
nAllergic shiner
nDennie Morgan line(prominent creases below inferior eyelid)
nAllergic crease
nAllergic salute
nNasal mucosa may appear normal or pale bluish, swollen with watery secretions but only if patient is symptomatic
nExclude structural problems (polyps, deflected nasal septum)
Others:
nasal voice, constant mouth breathing, frequent snoring, coughing, repetitive sneezing, chronic open gape of the mouth, weakness, malaise, irritability
Allergic testing-Prick test:-
Patients have to be off of all antihistamines for 4 days. Off of non-sedative antihistamines for up to 6 weeks.
Cannot be on Beta Blockers.
Skin prick testing
It is usually carried out on the inner forearm,but if the patient has bad eczemaon the test can be performed on the back
Ideally the allergens to be selected should be in accordance with the patient’s history
As few as 3 or 4 or up to about 25 allergens can be tested
The arm is coded with a marker pen for the allergens to be tested
A drop of the allergen (extract) solution is placed by each code.
Radio allergosorbent test:-the blood measures of allergy antibody or IgE,produced when your blood is mixed with a series of allegens in a laboratory.
Management of AR:-
Allergen Avoidance
Pharmacotherapy
Immunotherapy
Animal Control Measures:-
The ideal solution:
Remove pets from house
If not possible:
Keep pet out of bedroom
Use HEPA air filtering system
Remove carpet and other reservoirs for allergens in the bedroom
Encasing on mattress, box springs, and pillow
Wash pet weekly.
Outdoor Triggers:-
Pollens: particles released from trees, weeds and grasses
Highest levels at midday (10-2pm)
Use air conditioning, not fans
Visit an air-conditioned mall or movie theater
Not many options (avoidance)
Pharmacotherapy:-
Medications used to treat allergic rhinits:
Antihistamines
Decongestants
AH-D combinations
Corticosteroids
Mast Cell stabilizers
Anticholinergics
Antileukotrienes
Anti-Histamines:-
Act by preventing histamine from binding to the H1-receptors
Primarily helpful in controlling Sneezing, itching & rhinorrhoea; ineffective in releiving nasal blockage
1st generation anti-histamines
- chlorpheniramine
- diphenylhydramine
2nd generation anti-histamines
- cetrizine
- azelastine
- fexofenadine
- loratadine
Intranasal corticosteroid therapy:-
Potent topical activity
Administration of low doses directly at site of action
Considerable efficacy at low doses
High topical: systemic activity ratios
Rapid first-pass hepatic metabolism of any systemically absorbed drug, to compounds with negligible activity
Markedly greater inhibition of EAR than with oral steroids
Immunotherapy:-
Allergy shots (immunotherapy) for allergic rhinitis Treatment Overview
When you get allergy shots (immunotherapy), your allergist or doctor injects small doses of substances that you are allergic to (allergens) under your skin. This helps your body "get used to" the allergen, which can result in fewer or less severe symptoms of allergic rhinitis.
Your allergist will use an extract of grass, weed, or tree pollen; dust mites; molds; or animal dander for allergy shots. You must first have skin testing to find out which allergen you are allergic to.
The "Ideal" Drug For Allergic Rhinitis Should Have The Following Features:
Inhibit both early and late phases
Be an H1 blocker
Counter effects of other mediators
Fast-acting, to control the early phase
Dosing-od or bd for compliance
No side effects
Manage all symptoms
Intranasal administration
The "Ideal" Drugs Are……
"Corticosteroids are undoubtedly the pharmacotherapeutic agents with the broadest application for the treatment of many types of rhinitis"
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