Assoc Prof Ray Sacks Dr Arj Ananda Dr Larry Kalish

Assoc Prof Ray SacksDr Arj AnandaDr Larry Kalish

Assoc Prof Ray SacksDr Arj AnandaDr Larry Kalish

Concord Rhinology, Allergy and Skullbase Surgical Unit Concord Rhinology, Allergy and Skullbase Surgical Unit

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Evening Outline Evening Outline

Dr Arj Ananda Interpreting a CT scan of the sinus

Dr Larry Kalish Allergic rhinitis - Diagnosis and

Management

Assoc Prof Ray Sacks Surgical management of Allergic Rhinitis

Dr Arj Ananda Interpreting a CT scan of the sinus

Dr Larry Kalish Allergic rhinitis - Diagnosis and

Management

Assoc Prof Ray Sacks Surgical management of Allergic Rhinitis

Allergic Rhinitis Diagnosis and Management

Allergic Rhinitis Diagnosis and Management

Dr Larry Kalish

MBBS (Hons I), MS, MMed(Clin Epi), FRACS

Concord Hospital ENT department

Sydney Sinus and Allergy Centre

Dr Larry KalishMBBS (Hons I), MS, MMed(Clin Epi), FRACS

Concord Hospital ENT department

Sydney Sinus and Allergy Centre





Overview Overview

Definitions Epidemiology Unified airway Aetiology Diagnosis Investigations Management

Definitions Epidemiology Unified airway Aetiology Diagnosis Investigations Management

Definitions Definitions

Atopy inherited predisposition to produce IgE to environmental

allergens 40% of Australasian population is atopic All patients with allergic rhinitis are atopic

Allergic reaction exaggerated or inappropriate immune reaction which causes

damage to the host

Rhinitis = inflammation of the nose and sinuses Classified by aetiology

Allergic Non-allergic

Atopy inherited predisposition to produce IgE to environmental

allergens 40% of Australasian population is atopic All patients with allergic rhinitis are atopic

Allergic reaction exaggerated or inappropriate immune reaction which causes

damage to the host

Rhinitis = inflammation of the nose and sinuses Classified by aetiology

Allergic Non-allergic

Rhinitis - classification Rhinitis - classification AllergicNon-allergic

Infectious

Idiopathic or vasomotor Drug-induced (medicomentosa, OCP, cocaine, antihypertensives, NSAIDs etc)

Hormonal rhinitis of pregnancy, menstruation, menapause,

Endocrine Hypothyroidism, diabetes

Rhinitis of no airflowAtrophic - primary vs secondary Eosinophilic rhinitisOther systemic disordersTraumatic - thermal, chemical, physical

AllergicNon-allergic

Infectious

Idiopathic or vasomotor Drug-induced (medicomentosa, OCP, cocaine, antihypertensives, NSAIDs etc)

Hormonal rhinitis of pregnancy, menstruation, menapause,

Endocrine Hypothyroidism, diabetes

Rhinitis of no airflowAtrophic - primary vs secondary Eosinophilic rhinitisOther systemic disordersTraumatic - thermal, chemical, physical

AR - Epidemiology AR - Epidemiology

The prevalence of allergic rhinitis is increasing. Approximately 16% of Australians have allergic

rhinitis, including:

about 19% of working-aged adults about 25% younger adults (25–44 years) about 20% of adolescents (13–14 years) about 12.5% of primary school children (6–7 years)

Approximately 10% of all Australians and 14–16% of Australian children have asthma.

The prevalence of allergic rhinitis is increasing. Approximately 16% of Australians have allergic

rhinitis, including:

about 19% of working-aged adults about 25% younger adults (25–44 years) about 20% of adolescents (13–14 years) about 12.5% of primary school children (6–7 years)

Approximately 10% of all Australians and 14–16% of Australian children have asthma.

Rhinitis occurs in an estimated 75–80% of patients with asthma, with high rates reported in both atopic and non-atopic asthma.

Conversely, 20–30% of patients with known allergic rhinitis also have asthma.

Allergic rhinitis is now a recognised as a risk factor for developing asthma

Rhinitis occurs in an estimated 75–80% of patients with asthma, with high rates reported in both atopic and non-atopic asthma.

Conversely, 20–30% of patients with known allergic rhinitis also have asthma.

Allergic rhinitis is now a recognised as a risk factor for developing asthma

AR - Epidemiology AR - Epidemiology

Hygiene HypothesisHygiene Hypothesis

The most unifying hypothesis

= “Hygiene hypothesis”

Suggests that a Cleaner environment (eg less exposure to bacteria, use of vaccines and antibiotics etc) predisposes to the persistence of an allergic phenotype in early childhood

The most unifying hypothesis

= “Hygiene hypothesis”

Suggests that a Cleaner environment (eg less exposure to bacteria, use of vaccines and antibiotics etc) predisposes to the persistence of an allergic phenotype in early childhood

Unified Airway Theory Unified Airway Theory

The Nasobronchial Reflex, Sino-nasal protection of the lower airway Shared inflammation within a unified

airway

Aspiration of infected or inflammatory sinonasal secretions - UNSUPPORTED

The Nasobronchial Reflex, Sino-nasal protection of the lower airway Shared inflammation within a unified

airway

Aspiration of infected or inflammatory sinonasal secretions - UNSUPPORTED

AR - AetiologyAR - Aetiology

Inhaled AllergensInhaled Allergens

Particles which elicit an allergic response

Identified by their portal of entry via the respiratory tree which is richly supplied with IgE.

Essentially all inhalant allergy is IgE mediated, producing a Type I hypersensitivity reaction.

Particles which elicit an allergic response

Identified by their portal of entry via the respiratory tree which is richly supplied with IgE.

Essentially all inhalant allergy is IgE mediated, producing a Type I hypersensitivity reaction.

HypersensitivityHypersensitivity

Type I- Immediate Hypersensitivity Immediate Allergen binds 2 molecules of IgE Intracellular degranulation and

immediate release of products Ex. Allergic rhinitis, anaphylactic

shock, asthma

Type I- Immediate Hypersensitivity Immediate Allergen binds 2 molecules of IgE Intracellular degranulation and

immediate release of products Ex. Allergic rhinitis, anaphylactic

shock, asthma

From: kay: New England J of Medicine Vol 344(1). Jan 4, 2001. 30-37

Two PhasesTwo Phases

“Early Phase” response 10-30mins after allergen exposure Mast cells degranulate Vascular leakage / interstitial oedema

irritation of sensory nerves - Nasal pruritis, rhinorrhea, nasal congestion and sneezing

“Late Phase” response 4-8 hours later chemotaxis and migration of neutrophils, basophils,

eosinophils, T-lymphocytes, and macrophages across the mucosal endothelium into the nasal submucosa.

“Early Phase” response 10-30mins after allergen exposure Mast cells degranulate Vascular leakage / interstitial oedema

irritation of sensory nerves - Nasal pruritis, rhinorrhea, nasal congestion and sneezing

“Late Phase” response 4-8 hours later chemotaxis and migration of neutrophils, basophils,

eosinophils, T-lymphocytes, and macrophages across the mucosal endothelium into the nasal submucosa.

Allergens Allergens

Seasonals Pollens

Trees - ~ late winter - early spring Grasses - ~ summer Weeds - ~ end of summer / autumn

Perennials Dust mites Moulds - Alternaria, Aspergillus Cockroach allergens Dog and Cat dander

Seasonals Pollens

Trees - ~ late winter - early spring Grasses - ~ summer Weeds - ~ end of summer / autumn

Perennials Dust mites Moulds - Alternaria, Aspergillus Cockroach allergens Dog and Cat dander

AR - HistoryAR - History

If you don’t ask they won’t volunteer Classical Symptoms include

itchy eyes, nose, throat sneezing, BEWARE the reactive NOSE rhinorrhea, congestion,

Other symptoms headache, loss or diminished smell or taste, postnasal

drip, headaches, nocturnal cough, halitosis, mouth breathing, hoarse voice, sore throats and snoring.

Children Throat clearing in kids without nasal symptoms Allergic salute, nasal twitch Nocturnal cough, morning fatigue, “silent sleep apnea”

If you don’t ask they won’t volunteer Classical Symptoms include

itchy eyes, nose, throat sneezing, BEWARE the reactive NOSE rhinorrhea, congestion,

Other symptoms headache, loss or diminished smell or taste, postnasal

drip, headaches, nocturnal cough, halitosis, mouth breathing, hoarse voice, sore throats and snoring.

Children Throat clearing in kids without nasal symptoms Allergic salute, nasal twitch Nocturnal cough, morning fatigue, “silent sleep apnea”

Remember Remember

Patients can mistake symptoms of allergy for asthma

Classical symptoms common BUT not always present Watch out for rhinorrhea and blockage

alone

Patients can mistake symptoms of allergy for asthma

Classical symptoms common BUT not always present Watch out for rhinorrhea and blockage

alone

Onset, duration and pattern of symptoms over the day or year - see table

Family and personal history of allergic conditions, e.g. asthma, atopic dermatitis

Triggering and relieving factors Medications (including alternate

medications) Home, work and leisure environments Systemic symptoms (e.g. daytime fatigue).

Onset, duration and pattern of symptoms over the day or year - see table

Family and personal history of allergic conditions, e.g. asthma, atopic dermatitis

Triggering and relieving factors Medications (including alternate

medications) Home, work and leisure environments Systemic symptoms (e.g. daytime fatigue).

AR - HistoryAR - History

ClassificationClassification

Duration Symptoms

Intermittent

<4days / week OR < 4 weeks

Mild NORMAL SLEEP and minimal impairment of daily activities

Persistent

>4 days / weekOR >4 weeks

Mod-severe

ABNORMAL SLEEP or impairment of sport, leisure, work or troublesome symptoms

AR - Physical ExamAR - Physical Exam Nasal mucosa

pale/bluish, congested, boggy - covered by watery mucosa.

Eyes Dennie Morgan lines (Infraorbital oedema), allergic shiner /

lashes Other

Open mouth breathing, nasal crease, high arch palate, teeth crowding, posterior pharyngeal cobblestoning

Nasal mucosa pale/bluish, congested, boggy - covered by watery

mucosa.

Eyes Dennie Morgan lines (Infraorbital oedema), allergic shiner /

lashes Other

Open mouth breathing, nasal crease, high arch palate, teeth crowding, posterior pharyngeal cobblestoning

Be mindful of Be mindful of Unilateral nasal discharge

Purulent / bloody Foreign body until proven otherwise

Clear / straw colored CSF leak until proven otherwise

Unilateral nasal discharge Purulent / bloody

Foreign body until proven otherwise

Clear / straw colored CSF leak until proven otherwise

Nasal polyps

Difficult to treat eczema, food allergies or poorly controlled asthma

Persistent non-classical symptoms and signs for more than 12 weeks = Chronic CRS

Nasal polyps

Difficult to treat eczema, food allergies or poorly controlled asthma

Persistent non-classical symptoms and signs for more than 12 weeks = Chronic CRS

Be mindful of Be mindful of

AR - InvestigationsAR - Investigations

Allergy testing To confirm diagnosis To give avoidance advice Targeted immunotherapy

Indications Those patients who fail medical trial Identify those patients likely to

benefit from immunotherapy

Allergy testing To confirm diagnosis To give avoidance advice Targeted immunotherapy

Indications Those patients who fail medical trial Identify those patients likely to

benefit from immunotherapy

AR - InvestigationsAR - Investigations

Skin Prick (epicutaneous)RASTnasal provocation test total IgE

Skin Prick (epicutaneous)RASTnasal provocation test total IgE

RememberRemember

“Regardless of diagnostic test the clinical correlation with inhalant trigger is crucial”

Food allergies DO NOT cause allergic rhinitis Nasal sx in reaction to food is NOT allergy but

irritation or chemical intolerance

Rhinitis in response to fumes, temperature or climate change is NON-allergic

“Regardless of diagnostic test the clinical correlation with inhalant trigger is crucial”

Food allergies DO NOT cause allergic rhinitis Nasal sx in reaction to food is NOT allergy but

irritation or chemical intolerance

Rhinitis in response to fumes, temperature or climate change is NON-allergic

Management Management

Hayfever = asthma of the nose Hayfever = asthma of the nose

Patients need to appreciate this Patients need to appreciate this conceptconcept

AR - management AR - management

1. Allergen avoidance

2. Pharmacotherapy

3. Immunotherapy

4. Surgery

1. Allergen avoidance

2. Pharmacotherapy

3. Immunotherapy

4. Surgery

Multimodality treatment Multimodality treatment



The Unified Airway: concepts and management: The Unified Airway: concepts and management: Richard J. Harvey, Janet Rimmer, (in Press)Richard J. Harvey, Janet Rimmer, (in Press)

How can we get rid of Allergens?

How can we get rid of Allergens?

Don’t recommend unless allergen known to be significant contributor to symptoms

And does it work Level 4 evidence for most avoidance

techniques Dehumidifiers, A/C, acaracide sprays - no effect HEPA filter, mattress protectors, removal of carpet

Reduce allergen but NO clinical benefit in adults ONLY kids

Don’t recommend unless allergen known to be significant contributor to symptoms

And does it work Level 4 evidence for most avoidance

techniques Dehumidifiers, A/C, acaracide sprays - no effect HEPA filter, mattress protectors, removal of carpet

Reduce allergen but NO clinical benefit in adults ONLY kids

Allergen Avoidance Allergen Avoidance

Dust mites Encase mattress, box spring, and pillow in allergen impermeable

covers. Wash bed linens weekly in hot water >50oC (caution with potential

scalding in small children) Reduce clutter/toys/collections in bedroom Reduce indoor humidity to <50% Replace carpet with polished floor (ie, wood, vinyl) Replace upholstered furniture with leather, vinyl, wood, or plastic

or wash regularly Vacuum with high efficiency particulate air (HEPA) filters or dust

weekly with mask

Dust mites Encase mattress, box spring, and pillow in allergen impermeable

covers. Wash bed linens weekly in hot water >50oC (caution with potential

scalding in small children) Reduce clutter/toys/collections in bedroom Reduce indoor humidity to <50% Replace carpet with polished floor (ie, wood, vinyl) Replace upholstered furniture with leather, vinyl, wood, or plastic

or wash regularly Vacuum with high efficiency particulate air (HEPA) filters or dust

weekly with mask

Allergen avoidance Allergen avoidance Animal dander

Removal of animal from home If removal is not an option:

Keep animals outside or out of child’s bedroom Change and wash clothes after animal contact Use high-efficiency particulate air filters (eg, HEPA) Bathe animal 2 /week or weekly Wash cages or litter box frequently

Cockroaches Reduce cockroach food supply by encasing food and disposing of garbage

rapidly Restrict access (seal entry sources) Apply insecticides or exterminate professionally

Animal dander Removal of animal from home If removal is not an option:

Keep animals outside or out of child’s bedroom Change and wash clothes after animal contact Use high-efficiency particulate air filters (eg, HEPA) Bathe animal 2 /week or weekly Wash cages or litter box frequently

Cockroaches Reduce cockroach food supply by encasing food and disposing of garbage

rapidly Restrict access (seal entry sources) Apply insecticides or exterminate professionally

Allergen avoidanceAllergen avoidance

Indoor mold Eliminate damp areas and avoid high humidity Repair water leaks Clean moldy areas Limit house plants and exclude from bedroom Avoid humidifiers

ARE THESE MEASURES PRACTICAL ?

Indoor mold Eliminate damp areas and avoid high humidity Repair water leaks Clean moldy areas Limit house plants and exclude from bedroom Avoid humidifiers

ARE THESE MEASURES PRACTICAL ?

Minimize allergen loadMinimize allergen load

Regular nasal irrigation Normal saline irrigation

Aim to physically wash out allergens May improve drug delivery May improve mucociliary clearance

Regular nasal irrigation Normal saline irrigation

Aim to physically wash out allergens May improve drug delivery May improve mucociliary clearance

Drugs Drugs

Inhaled Nasal Corticosteroids

Antihistamines - topical and systemic

Anticholinergic sprays Leukotrienes Inhibitors Alpha-adrenergic agonists - decongestants Mast-cell stabilizer

Systemic and Intraturbinal Corticosteroid injections

Inhaled Nasal Corticosteroids

Antihistamines - topical and systemic

Anticholinergic sprays Leukotrienes Inhibitors Alpha-adrenergic agonists - decongestants Mast-cell stabilizer

Systemic and Intraturbinal Corticosteroid injections

DrugsDrugs

Preventers Inhaled Nasal Corticosteroids Mast-cell stabilizer Leukotrienes Inhibitors

Relievers Antihistamines - topical and systemic Anticholinergic sprays

Emergency Systemic Corticosteroids

Preventers Inhaled Nasal Corticosteroids Mast-cell stabilizer Leukotrienes Inhibitors

Relievers Antihistamines - topical and systemic Anticholinergic sprays

Emergency Systemic Corticosteroids

Drug treatment Drug treatment

Intranasal CorticosteroidsIntranasal Corticosteroids Mometasone (Nasonex) Fluticasone (Avamys, Becanase Allergy, Flixonase)

Bioavailability of <1% Better affinity to glucocorticoid receptor

Budesonide (Rhinocort) Beclomethasone (Becanase)

All no effect on HPA axis

Primarily block the late phase reaction. Only a small fraction is absorbed locally Side effects

Epistaxis 5-8%

Mometasone (Nasonex) Fluticasone (Avamys, Becanase Allergy, Flixonase)

Bioavailability of <1% Better affinity to glucocorticoid receptor

Budesonide (Rhinocort) Beclomethasone (Becanase)

All no effect on HPA axis

Primarily block the late phase reaction. Only a small fraction is absorbed locally Side effects

Epistaxis 5-8%

Antihistamines - oral Antihistamines - oral

Compete with Histamine for the H1 receptor. also change the three dimensional configuration of the receptor, decreasing its affinity

for histamine and down-regulating histamine-driven symptoms

Most effective when taken prophylactically

Non lipophilic second generation - do not cross the blood-brain barrier = minimal sedative effects.

Different classes may be more effective between differing individuals.

Most effective at reducing symptoms of sneezing, nasal itching, and rhinorrhea.

Compete with Histamine for the H1 receptor. also change the three dimensional configuration of the receptor, decreasing its affinity

for histamine and down-regulating histamine-driven symptoms

Most effective when taken prophylactically

Non lipophilic second generation - do not cross the blood-brain barrier = minimal sedative effects.

Different classes may be more effective between differing individuals.

Most effective at reducing symptoms of sneezing, nasal itching, and rhinorrhea.

Antihistamines - topical Antihistamines - topical

Levocabastine (Livositin) Azelastine (Azep)

RAPID onset Symptomatic relief DIAGNOSTIC in my practice

Occular preparations Livsotin / Azep Patanol - antihistamine + mast cell stabilizer

Levocabastine (Livositin) Azelastine (Azep)

RAPID onset Symptomatic relief DIAGNOSTIC in my practice

Occular preparations Livsotin / Azep Patanol - antihistamine + mast cell stabilizer

Other Management Options

Other Management Options

Surgery Turbinoplasty Vidian neurectomy Posterior neurectomy Septoplasty FESS

Immunotherapy Subcutaneous Sublingual

Surgery Turbinoplasty Vidian neurectomy Posterior neurectomy Septoplasty FESS

Immunotherapy Subcutaneous Sublingual

Immunotherapy Immunotherapy

Specific allergen immunotherapy Effective in the Mx of asthma and AR Can achieve durable remission of allergic sx May reduce risk of childhood allergy progressing to

asthma

Best given when there is evidence of AR predominantly due to single allergen

SLIT (sublingual) SCIT (subcutaneous)

Specific allergen immunotherapy Effective in the Mx of asthma and AR Can achieve durable remission of allergic sx May reduce risk of childhood allergy progressing to

asthma

Best given when there is evidence of AR predominantly due to single allergen

SLIT (sublingual) SCIT (subcutaneous)

SCIT SCIT

Subcutaneous injections Weekly to monthly for 2-3 yrs

Adverse effects Injection-site reactions Sneezing Bronchospasms Urticaria Anaphylaxis

Contraindicated Severe or ustable asthma or pts on Beta blockers

Subcutaneous injections Weekly to monthly for 2-3 yrs

Adverse effects Injection-site reactions Sneezing Bronchospasms Urticaria Anaphylaxis

Contraindicated Severe or ustable asthma or pts on Beta blockers

SLITSLIT

Self daily administration Relatively expensive

Limited but improving evidence Probably longer to work 3-5yrs SAFER

Self daily administration Relatively expensive

Limited but improving evidence Probably longer to work 3-5yrs SAFER



The Unified Airway: concepts and management: The Unified Airway: concepts and management: Richard J. Harvey, Janet Rimmer, (in Press)Richard J. Harvey, Janet Rimmer, (in Press)

Documents

Assoc Prof Ray Sacks Dr Arj Ananda Dr Larry Kalish