allergic rhinitis

Allergic Rhinitis

Allergy

• Definition: -

Hypersensitivity to allergens

(pollens, moulds), which

trigger allergic response is

called allergy

• If nose is involved :

Nose

– Allergic Rhinitis

AllergyAllergy

Common aero allergens

* Pollen,

* House dust,

* Mite

Food Allergens

Related Anatomic StructuresCompromised by Allergic Rhinitis

Epidemiology Of Allergic Rhinitis

• Respiratory allergy is prevalent among all populationswith increasing trend all over the world.

• Epidemiological studies carried out in different countriesindicate the prevalence of respiratory allergy as 15–30%*

• A recent survey carried out in India shows that 20–30%of the population suffer from allergic rhinitis and that15% develop asthma.#

# Anonymous: All India Coordinated Project on Aeroallergens and Human Health. Report. Ministry ofEnvironment and Forests, New Delhi 2000

# Chhabra SK, Gupta CK, Chhabra P, Rajpal S: Prevalence of bronchial asthma inschoolchildren in Delhi. J Asthma 1998, 35, 291-296

Aeroallergens in clinical practice of allergy in india.an overview,Anand B. Singh, Pawan Kumar, Ann Agric Environ Med 2003, 10, 131–136

Sensitization and Immunoglobulin E Production

• During the initial stage of the disease, low-dose exposureleads to the production of specific IgE antibodies.

• Antigen that deposited on the nasal mucosa is engulfedby APCs (macrophages, dendritic cells, Langerhans cells)and partially degraded

• TH2 CD4+ cells are important contributors to allergicreactions.

• On subsequent exposure to the offending allergen, theIgE antibodies serve as receptors for the antigenmolecules.

Immunology of the Upper Airway and Pathophysiology and Treatment of Allergic Rhinitis, Fuad M. Baroody Robert M. Naclerio, Chapter 40, 597-623

Immunological Mechanisms Underlying Allergic Rhinitis

Allergic Rhinitis and Rhinosinusitis, Nadir Ahmad, Mark A. Zacharek, Otolaryngol Clin N Am41 (2008) 267–281

Early Response to Antigen

• Within minutes after exposure of an allergic patient toantigen, an inflammatory response occurs.

• This leads to nasal congestion which will increases innasal secretions and nasal airway resistance (NAR).

• Several neuropeptides—in addition to sympathetic andparasympathetic nerves and their transmitters—arefound in the nasal mucosa. These play very importantrole in the pathogenesis of early response to antigen


Late Response To Antigen

• The response to allergen exposure is not limited to theacute events that occur minutes after exposure.

• Hours after antigen challenge, some patients experiencea recurrence of symptoms, most notably nasalcongestion.

• This is termed the late response

• Both T lymphocytes and mast cells are contributors tocytokine production during the late allergic reaction.


Early And Late Phase Responses In allergic rhinitis

Allergic Rhinitis and Rhinosinusitis, Nadir Ahmad, Mark A. Zacharek, Otolaryngol Clin N Am41 (2008) 267–281

Pathogenesis Of Allergic Rhinitis

And

Occurrence Of Symptoms

Symptoms of Allergic Rhinitis

• Recurrent episodes ofsneezing,

• Pruritus, rhinorrhea,

• Nasal congestion, andlacrimation

• Snorting throat clearing

• Postnasal drip.

• Nasal obstruction unilateralor bilateral


Sequelae Of Allergic Rhinitis

• Elongated facies, General appearance– Allergic shiners, allergic salute, malaise

• Nose– Septal deviation, polyps, drainage, turbinate hypertrophy, hyponasality

• Mouth– Cobblestoning of oropharynx

• Ear– Middle ear pathology

• Neck– Lymphadenopathy, thyroid enlargement

• Chest– wheezing

• Skin– Eczema, dermatographism


Adenoid Facies

Classification Of Allergic Rhinitis

• Seasonal allergic rhinitis isdefined by symptoms that

occur during exposure toseasonal allergens, such asragweed, grasses, outdoormoulds, and tree pollens.

• Perennial allergic rhinitis,defined as nasal symptomsfor more than 2 hours perday for more than 9 months


Classification Of Allergic Rhinitis

• Thus according to the ARIAclassification,

• Intermittent allergic rhinitis :Symptoms present for less than 4days a week, or for less than 4consecutive weeks.

• Persistent allergic rhinitis :Symptoms present for more than4 days a week and for more than4 consecutive weeks, with therealization that patients usuallysuffer almost every day.


Severity Of Allergic rhinitis


Physical Examination

• Complete ear, nose, and throat examination

• Inspect the inner aspect of the nasal cavities

• Pale, bluish, and oedematous, and coated with thin, clear secretions.

• It is important to remember that there is no pathognomonic appearance of the nasal mucosa in allergic rhinitis


Diagnostic Tests

The 3 most common tests used to confirm the diagnosis

• Skin testing

• Nasal smear

• In vitro testing for serumlevels of specific IgE

antibodies.


Nasal Smears

• Looks at nasal secretion component cells

• Can help differentiate allergic rhinitis and NARES (non allergic rhinitis with eosinophilia) from other forms of rhinitis


Skin Testing

• Goal is to identify antigens to which patients are symptomatically reactive and to quantify the sensitivity if immunotherapy is planned

• There are a variety of acceptable techniques:– Prick testing,

– Intradermal testing

– In vitro testing

A comparison of skin endpoint titration and skin prick testing iA in the diagnosis of allergic n rhinitis. Rhinitis, Gungor, A et al, ENT – Ear, Nose, and Throat Journal (Jan 2004); Vol 83:1, 54 54-60.

Multitest II

Whealing Response

A comparison of skin endpoint titration and skin prick testing iA in the diagnosis of allergic n rhinitis. Rhinitis, Gungor, A et al, ENT – Ear, Nose, and Throat Journal (Jan 2004); Vol 83:1, 54 54-60.

Skin Testing : Disadvantages

• Affected by previous ingestion of antihistamines or other drugs

• Children often do not tolerate multiple skin needle pricks

• Prior or coexisting dermatologic conditions, such as eczema ordermatographism, may preclude the performance of skin tests

• The potency of antigen extracts needs to be maintained

• Potentially interfering medications must be discontinued prior toskin


IgE Levels

• Raised in 30% to 40% of patients with allergic rhinitis

• But can be elevated in patients with nonallergicconditions and normal subjects

• It is of limited use in the diagnosis of allergic rhinitis


The Crux is..

It is always important to remember that a positive in vitro or skin test result alone does not confirm the diagnosis of allergic rhinitis in the absence of supporting clinical history


Allergic Rhinitis And Quality Of Life

• Sleep loss or disturbance

• Increased daytime sleepiness

• Learning problems in children

• Work absenteeism

• Reduction in work productivity

Immunology of the Upper Airway and Pathophysiology and Treatment of Allergic RhinitisFuad M. Baroody, Robert M. Naclerio

Prevention is better than cure: Avoidance Of Allergens

It is potentially an effective treatment

• Removing a pet from the house,

• Covering pillows and mattresses

• Washing bedding with hot water

• Vacuuming mattresses and pillows.


Pharmacotherapy

Drug type Itch / sneezing Discharge Blockage Impaired smell Nasal

preparations

Antihistamines +++ ++ + _AZELASTINE

Anticholinergics _ +++ _ _ Ipratropium

Decongestants _ + +++ _Xylometazoline

Oxymetazoline

Mast Cell Stabilizers

+ + + _Sodium

cromoglycate

Topical

Corticosteroids +++ +++ ++ +

Fluticasone

Mometasone

Management of Intermittent AR

Avoid Allergens

Mild Intermittent AR Moderate-Severe Intermittent AR

Nasal H1 blocker / Spray

Oral H1 blocker

Decongestants

LTRA

Nasal H1 blocker / Spray

Oral H1 blocker

Decongestants/LTRA/Chromone

Fluticasone - 2 sprays/nostril OD

LTRA= Leukotriene Receptor Antagonists

Allergic Rhinitis & its Impact on Asthma (ARIA) Guidelines

Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines: 2010 Revision ,Broz ek et alJ allergy clin immunol Volume 126, number 3

Allergic Rhinitis & its Impact on Asthma (ARIA) Guidelines

Management of Persistent AR

Avoid Allergens

Nasal H1 blocker

Oral H1 blocker / LTRA

Decongestants / Chromone

Intranasal CS / Mometasone/ /Fluticasone

Review patients after 2-4 weeks

Step up if no improvement Continue: 1 month if improvement

Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines: 2010 Revision ,Broz ek et al J allergy clin immunol Volume 126, number 3

Leukotriene Receptor Antagonists

• Food and Drug Administration approved the leukotrienereceptor antagonists for asthma initially, but the latterhas been approved for treatment of allergic rhinitistherapy also. *

• The recent ARAI (2010) recommends to use oralleukotriene receptor antagonists (monteleukast) in adultsand children with seasonal AR and in preschool childrenwith persistent AR**

**Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines: 2010 Revision ,Broz ek et al J allergy clin immunol Volume 126, number 3

*Allergic Rhinitis Current Pharmacotherapy ,John H. Krouse, Otolaryngol Clin N Am 41 (2008) 347–358

Montelukast

• Montelukast is effective in the treatment of both upper-and lower-airway inflammation.

• It is an ideal medication to consider in the treatment ofpatients with concurrent allergic rhinitis and asthma.

• It can be used alone or in combination with othermedications for both diseases

Allergic Rhinitis Current Pharmacotherapy ,John H. Krouse, Otolaryngol Clin N Am 41 (2008) 347–358

ARAI-2010 –Use Of Newer Antihistaminics

• New-generation oral H1-antihistamines (fexofenadine)that do not cause sedation and do not interact withcytochrome P450 are recommended over the oldgeneration H1 blockers.

• In vivo and in vitro studies have demonstrated thatsecond-generation antihistamines decrease both phasesof the allergic response, possessing both antiallergic and

anti-inflammatory properties

Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines: 2010 Revision ,Broz ek et al J allergy clin immunol Volume 126, number 3

Fexofenadine

• Improves symptoms of allergy like nasal itching,rhinorrhea, and sneezing as well as conjunctivalsymptoms

• Several studies have demonstrated an improvement inQOL for subjects treated with fexofenadine comparedwith placebo or other antihistamines.

• It does not penetrate the CNS translating clinically intoless sedation

Allergic Rhinitis Current Pharmacotherapy ,John H. Krouse, Otolaryngol Clin N Am 41 (2008) 347–358

Summary

• Allergic rhinitis is a common problem practice

• Diagnosis is usually clinical supported by various tests

• The most appropriate medical therapy depends upon thenature of each patient’s symptoms, his or her toleranceto and preference for certain classes of medications, andthe response to treatment

• Montelukast and fexofenadine are effective drugs to treatmild to moderate allergic rhinitis

Thank you

allergic rhinitis

Health & Medicine

treatment of allergic

late response

late allergic reaction

allergic patient toantigen

inflammatory response

pathogenesis of early

upper airway

baroody robert