Allergic RhinitisDr. Krishna Koirala

MBBS,MS

• Definition

– IgE mediated hypersensitivity disease of the mucous membrane of nasal airways characterized by sneezing , itching, watery nasal discharge, sensation of nasal obstruction, postnasal discharge and hyposmia

• Associations

– Allergic conjunctivitis

– Bronchial asthma

Classification of Allergic Rhinitis

• Old–Seasonal–Perennial–Occupational

ARIA (Allergic Rhinitis and its impact on Asthma) classification :

• Intermittent

–Symptoms present <4 days a week or for <4 consecutive weeks

• Persistent

– Symptoms present >4 days a week and for >4 consecutive weeks

• Mild –No Sleep disturbance–No Impairment of daily activities, leisure

and/or sport–No Impairment of school or work– Symptoms present but not troublesome

• Moderate/severe (one or more of the following items present)– Sleep disturbance– Impairment of daily activities, leisure

and/or sport– Impairment of school or work– Troublesome symptoms

• Etiology• Atopy (hereditary)– Represents a predisposition to develop allergic

disease• Allergens– Seasonal rhinitis

• Grass and tree pollens– Perennial allergic rhinitis

• House dust mite – Digestive enzymes excreted in faeces

• Domestic pets – Cats, dogs, rabbits, guinea pigs • Cockroaches

– Occupational Rhinitis : Flours, laboratory animals, biological washing powders, latex, smokes and fumes

• Food and drug induced rhinitis– More common in children ,foods/preservatives– Foods

• Milk ,eggs, cheese in children• Nuts ,fish ,citrus fruits in adults

– Drugs• Aspirin• Antihypertensives ( beta blockers, ACE

inhibitors )• Antipsychotic• Topical nasal decongestants (Rhinitis

medicamentosa)• Pollution

– Perfumes, tobacco smoke, traffic fumes, domestic sprays, temperature

Allergen

Mast cells T- lymphocytes

Histamine,Leukotrienes

prostaglandinsBradykinin, PAF

Immediate rhinitis symptomsItch, sneezing

Watery dischargeNasal congestion

B -Lymphocytes

Chronic ongoing rhinitis Nasal blockage

Loss of smellNasal hyper reactivity

Eosinophils

Pathogenesis

IgEIL3,IL5,GM-CSFIL4

Hyp

erre

activ

ity

Tissue edema

Diagnosis• History

– Seasonality, frequency and severity of symptoms

– Patient’s dominant symptoms

– History of potential allergic triggers

– Personal/ family h/o atopic disease

– H/o trauma

– H/o mucopurulent rhinorrhea, facial pain, fever

– Drug allergy and food provoking factors

Clinical featuresSymptoms

• Seasonal rhinitis– Sneezing : paroxysmal,

frequent intervals throughout the day, more in the morning times

– Nasal discharge : watery, mucoid, yellowish

– Nasal obstruction / blockage

– Itching of nose, eyes, palate

– Tearing/redness of the eyes, periorbital edema

– Burning/raw sensation of throat

– Wheezing/chest tightness

• Perennial Rhinitis– Long standing nasal

congestion and PND– Viscous/ purulent

rhinorrhea– Conjunctivitis less

frequent– Secondary symptoms :

loss of smell and taste, sinusitis, ETD

– Sneezing less common

Signs• Nose– Transverse crease at the

dorsum of the nose ( Darrier’s line)

– Allergic salute– Pale /bluish nasal mucosa – Boggy and swollen turbinates – Watery nasal discharge– Polyps/ hypertrophied

turbinates septal deviation

Allergic saluteDarrier’s line

• Eyes– Periorbital edema, conjunctival congestion ,watering

– Marked erythema of palpebral conjunctivae and papillary hypertrophy of tarsal conjunctivae ( cobblestone)

– Dark circles under the eyes ( allergic shiners)

• Repetitive vigorous rubbing in the peri - orbital region

• Impaired venous return from the

skin and subcutaneous tissues

– Extra skin fold or line under the

lower eyelids ( Denni - Morgan lines)Denni - Morgan lines

• Ear– Retraced TM, OME

• Pharynx– Granular pharyngitis, cobblestone

• Larynx– Laryngeal edema

• Bronchus ---bronchospasm

Investigations• Complete Blood Count ,ESR, Absolute Eosinophil

Count• Serum IgE measurements• Nasal smear for cytology : eosinophils,

neutrophils, basophils, mast cells , epithelial cells and bacteria

• Nasal swabs for bacteriology or viral studies• Skin prick tests (PRIST)• RAST• ELISA • Nasal provocation (challenge) test• Diagnostic Nasal Endoscopy (DNE)• X-Ray PNS OM view• CT scan of nose and PNS

Skin Prick Tests• Prick test or scratch test : Pricking the skin

with a needle or pin containing a small amount of the allergen

• Patch test

– Applying a patch to the skin, where the patch contains the allergen

– If an immune - response is seen in the form of a rash, urticaria or anaphylaxis -- patient has a hypersensitivity to that allergen

• Intradermal test

– A small amount of the allergen solution is injected into the skin and response is seen

• The negative control – Saline (salt-water) solution– Response not expected – If however a patient reacts to a negative

control --- the skin is for whatever reason extremely sensitive

• The positive control – Histamine, to which everyone is expected to

react– Failure to do so -- medicines the sufferer is

taking could block the response to the histamine and allergens

•An extension of the radioimmunoassay

•Commonly known as "sandwich" technique

•To detect IgE, specific antigens for this antibody are attached to a matrix particle and Serum suspected to contain IgE is then added

•Antibody, if present combines on the surface of the particle

•Now another antibody, one that reacts with human antibodies, is added which carries a radioactive label

•The entire complex will, therefore, be radioactive if the antiglobulin antibody combines with the IgE

•If IgE is not present, the particles will not show radioactivity

RAST (Radioallergosorbent test)

Treatment Modalities

• Allergen avoidance

• Pharmacotherapy

• Immunotherapy

• Treatment of complicating factors

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• Allergen avoidance • Useful for a single/ unusual allergen• Identification of relevant aeroallergens ---

Complete/ partial avoidance of allergens– Elimination of occupational allergen

exposure– Elimination of pet allergen exposure– Mite antigen control measures– Frequent pet washings– Cockroach control measures– Closed windows in homes / cars– Central heating and cooling– Central air filtering system

• Pharmacotherapy • Primary therapy for seasonal / perennial allergic rhinitis• Corticosteroids– Topical : Sprays and drops

• Extremely effective for all nasal symptoms of allergy

• Beclomethasone, Budesonide, Fluticasone, Mometasone spray

• Betamethasone drops• Sprays better than drops in allergic rhinitis• Drops better in OMC disease, polyps and sinusitis

– Oral : Prednisolone 1 mg /kg / day in tapering dose for 2 weeks

– Depot intramuscular route - not recommended

Budesonide nasal sprayBeclomethasone nasal spray50mcg/dose

Fluticasone nasal spray 50mcg/dose

Fluticasone nasal spray 50mcg/dose

• Mast cell stabilizers

–Eg. Sodium chromoglycate drops and sprays

–Less effective than topical corticosteroids

–Treatment of first choice in young children

• Antihistamines

– Eg. Chlorpheniramine, Loratadine, Cetrizine, Fexofenadine, Ebastine

– Effective for sneezing, itching, watery rhinorrhea and eye , palate and throat symptoms

– Less effective in nasal congestion and blockage

– Mainly taken at bedtime

– Newer generations less sedative than older ones

• Topical vasoconstrictors

– Xylometazoline, oxymetazoline, ephedrine

– Effective against nasal blockage

– To be used for short period only, prolonged use >2 wks may lead to Rhinitis medicamentosa (Rebound hyperemia, nasal congestion and obstruction that occurs following prolonged and repeated use of topical vasoconstrictors)

• Topical anticholinergics

– Ipratropium Bromide (0.03% nasal spray) for watery rhinorrhea

• Leucotriene inhibitors

–Montelukast, zafirlukast

• Immunotherapy

• Allergen-specific immunotherapy (SIT)

– Practice of administering gradually increasing quantities of an allergen extract to an allergic subject to eradicate the allergic symptoms by subsequent exposure to the causative allergen

– Indications

• Pollen sensitive patients having single allergen, failing to respond to conventional treatment ,having intolerable side effects of treatment, unable to avoid the allergens

– Contraindications

• Patients with multiple allergies , significant medical illness and taking drugs likely to impair the treatment of anaphylaxis

• Procedure

– Allergen injected subcutaneously in increasing doses till maximum tolerated response is reached

– May also be delivered by the oral, nasal or sublingual routes

– The monoclonal anti - IgE antibody

• Induces the reduction of serum-free IgE levels

• Reduces the symptoms mediated by IgE

• Reduces the severity of the symptoms of seasonal allergic rhinitis

– Success rates - as high as 80 -90% for certain allergens

– Course : 2 years or more

• Treatment of complicating factors

–DNS, infection, medications, Hormonal aberrations