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Allergic rhinitis

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Allergic rhinitis

  1. 1. ALLERGIC RHINITIS DIAGNOSIS AND MANAGEMENTDR. GHULAM SAQULAINENT SURGEONCDA HOSPITAL, ISLAMABAD
  2. 2. In a Islamabad based survey conducted by PMRC, out of2821 households with a total of 16717 individuals weresurveyed, 1448 (8.66%) were reported suffering from allergy. Others (n=17), 0.14% Multiple Allergies (n=509), 3.04% Chronic Cough (n=24), Types of Allergies 0.14% Conjunctivitis (n=53), 1 0.32% Skin Allergy (n=290), 1.73% Nasal Allergy (n=360), 2.15% Asthma (n=195), 1.17% 0.00% 0.50% 1.00% 1.50% 2.00% 2.50% 3.00% 3.50% Prevalence 03/13/13 Capital Hospital Islamabad 3
  3. 3. Distribution of Persons with Allergies byType of Allergy. (n=1448) Urticaria, Asthma, 20.00% 13.50% Conjuctivitis, Rhinitis, 3.70% 24.90% Chronic Cough, 1.60% Others, 1.20% Multiple allergies, 35.10% 03/13/13 Capital Hospital Islamabad 4
  4. 4. Allergic Rhinitis Allergic Rhinitis is defined as an inflammation of the lining of the nose and is characterized by the symptoms of nasal congestion, rhinorhea, sneezing and itching . Other symptoms are nasal obstruction, paranasal pain or headache, pruritis, itchy or watery eyes, anosmia, dysosmia, chronic pharyngitis, hoarseness and recurrent inflammation of URT 03/13/13 Capital Hospital Islamabad 5
  5. 5. • Pollens • Mold. • Animal dander. • Dust mites. 03/13/13Capital Hospital Islamabad 6
  6. 6. Diagnosis • Careful History • Physical Examination • Laboratory Studies for Confirmation 03/13/13 Capital Hospital Islamabad 7
  7. 7. History:The signs and symptoms of Allergic Rhinitis arefamiliar to many: 03/13/13 Capital Hospital Islamabad 8
  8. 8. •Itching/ sneezing, • Nasal pruritis occurs, History: particularly in pollen allergy with Itching eyes, nose and throat, • Sneezing is the most common symptom with pollen allergy,•Watery Rhinorrhoea,•Nasal congestion/Obstructionat night causes: • mouth breathing, • snoring, • restlessness, with complaints of dry, sore throat in the morning, 03/13/13 Capital Hospital Islamabad • fatique. 9
  9. 9. Physical ExaminationIntranasal Examination• Typically, the nasal mucosa is pale pink and swollen.• Discharge is thin watery, but becomes thick and purulent when secondary infection sets in.• Oropharyngeal wall may have typical clumps of lymphoid tissue.• Other associated allergic diseases such as a contact dermatitis or asthma may correlate with flares of allergic symptoms. 03/13/13 Capital Hospital Islamabad 10
  10. 10. •Malocclusion:•Allergic Shiners: – Dark circles under the eyes from venous stasis due to engorged nasal membranes•Rabbit Nose: – The child may wrinkle the end of the nose constantly,•Allergic salute – The child may rub the nose with the palm of the hand in an upward manner 03/13/13 Capital Hospital Islamabad 11
  11. 11. Laboratory Findings:• Peripheral Eosinophilia:• Nasal secretion cytology: – Presence of 3-10% of eosinophils in nasal secretions is diagnostic of allergic rhinitis except during early infancy.• Immunoglobulin E – IgE serum levels are elevated in almost half of cases with allergic rhinitis. However normal IgE does not exclude allergic rhinitis.• RAST testing – This is a radio-immune assay where a patients serum is incubated with different allergens and antigen/antibody complexes are then measured. – It is a more specific blood test for allergy. – This is not as sensitive as skin testing and more costly• Allergy Skin Tests : – Done to identify specific allergens. 03/13/13 Capital Hospital Islamabad 12
  12. 12. COMPLICATIONSOF ALLERGIC RHINITIS • Recurrent otitis media. • Hearing loss. • Sinusitis. • Nasal or sinus polyps. • Progression to asthma. • Anatomical changes in nasal and sinus cavities. 03/13/13 Capital Hospital Islamabad 13
  13. 13. The Basic Pathology Four types of hypersensitivity reactions • Type I - IgE mediated reaction • Type II - IgG/ IgM mediated • Type III - IgG/ IgM mediated • Type IV - T cell mediated (Delayed hypersensivity, Cell-mediated hypersensivity) 03/13/13 Capital Hospital Islamabad 14
  14. 14. PATHOLOGY & PATHOGENESIS• In allergic rhinitis we see an example of IgE mediated hypersensitivity. In this type with continued exposure atopic individual acquires antibodies of reagin type (IgE Immunoglobulins) from plasma cells. 03/13/13 Capital Hospital Islamabad 15
  15. 15. Along with submucosa Mast cells in epithelium Occurs withinAllergy Causing Pollen also imprtant 30 Sec. of challenge Excess Mucus Production 03/13/13 Capital Hospital Islamabad 16
  16. 16. HISTAMINEOrigin:• Found in the most tissues of the body.• Most abundant in mast cells near blood vessels in connective tissue.• Found in small quantities in basophils(granular part of a cell).Release:• when an allergen joins an IGE antibody on the surface of a mast cell or basophil, serine esterase(compound) is activated, and this activation induces the release of histamine. 03/13/13 Capital Hospital Islamabad 17
  17. 17. Effects:• Reactions range from mild itching to shock and death.• Response to histamine occurs in one to two minutes.• Duration of action is about ten minutes.• Produces effects by acting on H1 receptors. 03/13/13 Capital Hospital Islamabad 18
  18. 18. H1 RECEPTORS Stimulation causes: • constriction of the bronchial smooth muscle. • Increase mucus secretion in respiratory tract. • Increased lacrimation. • Dilation of arterioles and capillaries. • Weakening of capillary walls. • Constriction of small veins and venules. • Dilation of large veins. • Constriction of smooth muscle of the gut. • Pain and burning sensations. 03/13/13 Capital Hospital Islamabad 19
  19. 19. Type - I (IgE mediated reaction) 1. Preformed 2. Newly formed • Histamines • PAF • NCF (Neutrophil • Leukotrienes (LTB4) Chemoattractant Factor) • • ECF (Eosinophil Chemoattractant Factor) Prostaglandins • The preformed mediators are responsible for the early phase reaction. • These mediators are responsible for the commissioning of Eosinophils • Once the eosinophils are commissioned, the late-phase reaction begins • Enzymes 03/13/13 Capital Hospital Islamabad 20
  20. 20. Type - I (IgE mediated reaction) Two clinical subgroups • 1. Atopy • 2. Anaphylaxis 03/13/13 Capital Hospital Islamabad 21
  21. 21. Atopy • The term applies to a group of diseases occurring in individuals with inherited tendency to develop IgE antibodies • Allergic Rhinitis serves as an outstanding example 03/13/13 Capital Hospital Islamabad 22
  22. 22. Anaphylaxis • Certain allergens may induce IgE mediated response • Condition is potentially fatal. • Affect atopic and non-atopic patient. • Diseases are: Anaphylaxis, Urticaria, Angioedema etc 03/13/13 Capital Hospital Islamabad 23
  23. 23. ALLERGIC RHINITISEssentials of Diagnosis • Nasal pruritis, congestion, rhinorrhea, sneeze attacks, eye irritation. Sometimes eczematous dermatitis • Environmental allergen exposure • Confirmed by evidence of specific IgE antibody 03/13/13 Capital Hospital Islamabad 24
  24. 24. TREATMENTThe three basic Principles of allergy management are : • Avoidance Techniques • Symptomatic Therapy • Immunotherapy 03/13/13 Capital Hospital Islamabad 25
  25. 25. Avoidance Therapy The most effective part of the treatment • But usually meets failure as the allergens in the environment often become unavoidable • Cross-reactivity also plays its part 03/13/13 Capital Hospital Islamabad 26
  26. 26. Health Tips Pollen grains of trees like paper mulberry can be avoided by  leaving the area densely populated by these plants.  Minimize outdoor activity when pollen counts are high.  Take medications at least 30 minutes prior to outdoor activity.  Shut windows in your house on days pollen counts are high.  Wearing face masks  Use of air conditioners  Air-filtering devices Avoiding Irritants.  Do a thorough spring cleaning  Wash bedding weekly in hot water.  Dry laundry indoors.  Keep pets off of furniture and out of the bedroom.  Keep car windows closed during peak season. 03/13/13  When mowing lawn Islamabad wear a filter mask. Capital Hospital or gardening, 27
  27. 27. Drug Therapy Three classes of: • First generation antihistamine have sedating potential. • Second generation antihistamine having better compliance & lesser sedating potential • Third generation antihistamine are non- sedating but usually the rescue dose comes with a sedating effect 03/13/13 Capital Hospital Islamabad 28
  28. 28. First Generation  Chlorpheniramine  Diphenhydramine  Promathazine etc. • First Generation have wide pharmacologic profile. • They easily cross blood brain barrier that is why they cause Sedation • They are not specific nor selective they cause anticholinergic side effects. • They have Drug interactions. • They do not work in late phase of Allergic Reactions. • They are inconvenient B.I.D and T.I.D Dosage. 03/13/13 Capital Hospital Islamabad 29
  29. 29. Second/ Third Generations  Loratadine  Cetirizine  Fexofenadine  Disloratadine  Levocetirizine  Second generation are composed of Relatively Large and less Lipophilic molecules that cross the blood brain barrier less easily  They cause minimal sedation.  They Work in late phase of Allergic Reaction.  Offer convenient once daily Dosage .  03/13/13 They do not have Drug interactions. Capital Hospital Islamabad 30
  30. 30. But all of them do not have all the Advantages  Some of them cause cardiac side effects  Some of them are not specific and selective  Ant cholinergic side effects. 03/13/13 Capital Hospital Islamabad 31
  31. 31. What is the Right choice WHICH OFFERS: • High efficacy • Fast relief of Allergic Reactions • Long duration of action • Minimal sedation • Low side effects • Safe in long term use • Convenient OD dosage 03/13/13 Capital Hospital Islamabad 32
  32. 32. Fast Relief Tandegyl Day provide quick relief of allergic symptoms. Because it achieves peak plasma concentration with in (0.9 hrs) 3 fexofenad ine 2.5 2 loratadine 1.5 cetrizine Levocetiri 1 zine 0.5 0 peack plazma concentaration 03/13/13 Capital Hospital Islamabad 33
  33. 33. Slow dissociation Rate  Ensure the strong antagonism of levocetirizine to histamine receptor which resulting in longer duration of action  In symptoms like Sneezing, Rhinorrhoea, Nasal Obstruction, Itch and Flare. 03/13/13 Capital Hospital Islamabad 34
  34. 34. Safety  Tandegyl Day have Minimal Sedation because it does not cross the blood brain barrier.  Tandegyl Day has low side effects because it has 600 folds Higher selectivity towards H1 receptor.  Tandegyl Day has a minimal Risk of Drug interaction because it is poorly metabolized. 03/13/13 Capital Hospital Islamabad 35
  35. 35. Low Volume Of Distribution Tandegyl Day has Low volume of distribution so it is better choice for long term use. Like in Allergic Rhinitis etc. 120 100 120 80 60 40 0.4 0.58 5.4 Volum of 20 Distribution 0 Tandegyl Day Cetirizine Fexofenadine Loratidine 03/13/13 Capital Hospital Islamabad 36
  36. 36. High compliance  Convenient once daily  Less drowsiness  Low dryness of mouth  Affordable price Rs 5.50  Easily available 03/13/13  ACapital Hospital Islamabad of NOVARTIS quality product 37
  37. 37. LEVOCETIRIZINE (Tandegyl - Day)• Potent systemic antihistamine.• O.D dosage• Fast onset of action (0.9 Hours).• Economical (5.50/= per tablet)• Can be recommended from the age of 2 years• Has 600 times selectivity with H1 Receptors• Has 2 fold higher affinity towards H1 Receptors than Citirizine.• Low drug interactions• Minimal sedation 03/13/13 Capital Hospital Islamabad 38
  38. 38. Immunotherapy:• Aim : Increase the patients tolerance to the particular pollen. Otolaryngol Clin North Am,7:703-718, October 1874 – Immunotherapy is indicated for those patients who fail environmental controls and medical therapy, or patients with extremely severe allergy. – Immunotherapy is rarely done in children less than six years of age, as allergic sensitivity is rapidly changing up to that age 03/13/13 Capital Hospital Islamabad 39
  39. 39. Surgical Treatment:• Indicated – When the turbinates have hypertrophied to a point making breathing difficult. – Associated structural problems causing obstruction to airway. – Complications like nasal polypi. 03/13/13 Capital Hospital Islamabad 40
  40. 40. RHINITIS & ASTHMA Nasal allergyalso seems to be highly correlated with asthma, recurring sinus infection, otitis media and possibly facial growth abnormalities. 03/13/13 Capital Hospital Islamabad 41
  41. 41. 03/13/13Capital Hospital Islamabad 42
  42. 42. Thank you AnswersQuestions? 03/13/13 Capital Hospital Islamabad 43

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