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Allergic Rhinitis


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Allergic Rhinitis

  1. 2. Childhood Allergic Rhinitis Difficult To Diagnose Easy To Treat Dr HUSSNI YOUSF QARI PEDIATRIC ALLERGIST IMMUNOLOGIST ALAZIZIAH MCH JEDDAH 27 MAY 2003
  2. 3. DEFINITION <ul><li>An inflammatory disorder of the nasal mucosa initiated by an IgE-mediated hypersensitivity </li></ul><ul><li>characterized by a symptom complex that consists of any combination of the following: sneezing, nasal congestion, nasal itching, and rhinorrhea </li></ul>
  3. 4. EPIDEMIOLOGY <ul><li>incidence: most common chronic disease of the respiratory tract 10% of children and 20% of adolescents and young adults </li></ul><ul><li>Onset under age 30 Peak Incidence in childhood and adolecence </li></ul><ul><li>risk factors: family history of atopy </li></ul>
  4. 5. . <ul><li>Allergic rhinitis affects 20 to 40 million people in the United States annually, including 10% to 30% of adults and up to 40% of children </li></ul><ul><li>Most common chronic disease in United States </li></ul><ul><ul><ul><ul><li>Accounts for two million missed school days </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Accounts for three million missed work days </li></ul></ul></ul></ul><ul><li>Significantly affects quality of life </li></ul>
  5. 6. Prevalence of allergic asthma and rhinitis are increasing Neukirch. Res. Med 1995
  6. 7. <ul><li>Sex: </li></ul><ul><ul><ul><ul><li>Males and females affected in equal proportions. </li></ul></ul></ul></ul><ul><li>Age: </li></ul><ul><ul><ul><ul><li>mainly affect individuals younger than 45 years. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>The condition may begin to appear in patients as young as 2 years and usually reaches a peak in those aged 21-30 years. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>It then tends to remain stable or slowly decrease until patients are aged 60 y, when again the prevalence may increase slightly </li></ul></ul></ul></ul>
  7. 8. Rhinitis is a risk factor for asthma <ul><li>Children whose rhinitis began in the first year of life had more respiratory symptoms at age 6 years and were more likely to have a diagnosis of asthma </li></ul><ul><ul><li>Wright AL. et al. Pediatrics 1994;94:895-01 </li></ul></ul><ul><li>Allergic rhinitis often precedes asthma </li></ul><ul><ul><li>87,5 % of the asthmatic patients had a history of allergic rhinitis </li></ul></ul><ul><ul><li>44.8% experienced the development of seasonal allergic rhinitis first. </li></ul></ul><ul><ul><li>Settipane RJ. et al. Allergy Proc 1994; 15:21-5 </li></ul></ul>
  8. 9. <ul><li>1- Patients with persistent rhinitis should be evaluated for asthma </li></ul><ul><li>2- Patients with persistent asthma should be evaluated for rhinitis </li></ul><ul><li>3- A strategy should combine the treatment of upper and lower airways in terms of efficacy and safety </li></ul>A.R.I.A. Position Paper 2001 Treating the allergic patient : … think globally, treat globally.
  9. 10. Allergy-Asthma Link <ul><li>Treating allergic inflammation in the nose can reduce asthma symptoms and lower airway hyper-responsiveness. 1,2 </li></ul><ul><li>Asthmatic patients with Allergic Rhinitis have higher medical costs </li></ul><ul><li>In a longitudinal study of 783 students: 3 </li></ul><ul><ul><li>Resolution of Allergic Rhinitis symptoms correlated with improvement in asthma (p=.0078) </li></ul></ul><ul><ul><li>Worsening of Allergic Rhinitis was associated with persistence of asthma </li></ul></ul><ul><li>1 Allergy Clin Immonol 1995;95:923-32 </li></ul><ul><li>2 Allergy Clin Immonol 1996;98:274-82 </li></ul><ul><li>3 Allergy Proc 1994;15:21-25 . </li></ul>
  10. 11. Allergies are frequently chronic, complex diseases with Serious Comorbidities <ul><li>Co-morbid conditions associated with allergic rhinitis </li></ul><ul><ul><li>Asthma </li></ul></ul><ul><ul><li>Sinusitis </li></ul></ul><ul><ul><li>Otitis Media </li></ul></ul><ul><ul><li>Allergic Conjunctivitis </li></ul></ul><ul><ul><li>Atopic Dermatitis </li></ul></ul>
  11. 12. <ul><li>Children are seriously affected by allergic rhinitis </li></ul><ul><ul><li>10-40% of school children </li></ul></ul><ul><ul><li>Under treatment is related to learning and behavioral problems </li></ul></ul><ul><li>Allergic rhinitis may contribute to other conditions, such as: </li></ul><ul><li> Sleep disorders </li></ul><ul><li> Fatigue </li></ul>
  12. 13. Natural History of Allergic Rhinitis &Mortality/Morbidity <ul><ul><ul><ul><li>Allergic rhinitis frequently is associated with otitis media, rhinosinusitis, and asthma, either as a precipitating and/or aggravating factor or a symptomatic comorbid condition. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Allergic rhinitis can significantly decrease the quality of life and impair social and work functions, either directly or indirectly , because of the adverse effects of medications taken to relieve the symptoms . </li></ul></ul></ul></ul>
  13. 14. <ul><li>Allergic rhinitis: </li></ul><ul><li> Seasonal allergic rhinitis </li></ul><ul><li> Perennial allergic rhinitis </li></ul><ul><li>Nonallergic rhinitis: </li></ul><ul><li> Infectious rhinitis </li></ul><ul><li> Idiopathic nonallergic or vasomotor rhinitis </li></ul><ul><li> Rhinitis medicamentosa </li></ul><ul><li> Hormonal rhinitis </li></ul><ul><li> Anatomical causes of rhinitis </li></ul><ul><li>The severity of allergic rhinitis ranges from mild to seriously debilitating. </li></ul>Rhinitis Classification
  14. 15. <ul><li>Actual classification: </li></ul><ul><ul><li>Seasonal rhinitis </li></ul></ul><ul><ul><li>Perennial rhinitis </li></ul></ul><ul><ul><li>However this classification is not accurate because : </li></ul></ul><ul><ul><ul><li>Some pollens had perennial pollination ( parietaria ) </li></ul></ul></ul><ul><ul><ul><li>Perennial allergic symptoms are not persistent all over the year </li></ul></ul></ul><ul><ul><ul><li>Polysensitized patients are often symptomatic all over the year </li></ul></ul></ul>Allergic Rhinitis Classification
  15. 16. <ul><li>Moderate-severe rhinitis </li></ul><ul><li>one or more items </li></ul><ul><li>. abnormal sleep </li></ul><ul><li>. impairment of daily activities, sport, leisure </li></ul><ul><li>. abnormal work and school </li></ul><ul><li>. troublesome symptoms </li></ul>Persistent rhinitis . > 4 days per week . and > 4 weeks Mild rhinitis . normal sleep . no impairment of daily activities, sport, leisure . normal work and school . no troublesome symptoms Intermittent rhinitis . Š 4 days per week . or Š 4 weeks A new classification according to ARIA Position Paper
  16. 17. Allergic Rhinitis Mild intermittent Moderate/ severe intermittent Mild persistent Moderate/ severe persistent Quality of life altered Quality of life not altered
  17. 18. Seasonal Allergic Rhinitis <ul><li>Patients experience an IgE-mediated reaction of the </li></ul><ul><li>nasal mucosa to one or more seasonal allergens. </li></ul><ul><li>Symptoms occur, or are increased, during certain seasons. </li></ul><ul><li>Symptoms are periodic, correlating with seasonal </li></ul><ul><li>variation in aeroallergens. </li></ul><ul><li>Characteristic symptoms include: </li></ul><ul><li> Watery rhinorrhea ,Nasal congestion , Repetitive sneezing </li></ul><ul><li> Pruritus of the eyes, nose, ears, and throat </li></ul><ul><li> Watery eyes </li></ul>
  18. 19. <ul><li>Nasal secretions usually contain eosinophils. </li></ul><ul><li> Common allergens causing seasonal allergic rhinitis: </li></ul><ul><li> Grass pollens </li></ul><ul><li> Tree pollens </li></ul><ul><li> Weed pollens </li></ul><ul><li> Fungal (mold) spores </li></ul>
  19. 20. Perennial Allergic Rhinitis <ul><li>Patients have an IgE-mediated reaction to allergens that </li></ul><ul><li>show little or no seasonal variation. </li></ul><ul><li> Symptoms are intermittent or continuous throughout </li></ul><ul><li>the year. </li></ul><ul><li> Characteristic symptoms include: </li></ul><ul><li> Prominent and severe nasal blockage/congestion. </li></ul><ul><li> Postnasal drainage. </li></ul><ul><li> Rhinorrhea and sneezing are less prominent than </li></ul><ul><li>seasonal allergic rhinitis. </li></ul><ul><li>Seasonal pollen sensitivity may contribute to </li></ul><ul><li>exacerbations of rhinitis symptoms in patients with </li></ul><ul><li>perennial allergic rhinitis. </li></ul>
  20. 21. Common allergens causing perennial allergic rhinitis <ul><li>The most important causes of perennial allergic </li></ul><ul><li>rhinitis are indoor inhaled allergens: </li></ul><ul><li> House-dust mite </li></ul><ul><li> Animal dander </li></ul><ul><li> Cockroach </li></ul><ul><li> Mold </li></ul><ul><li> Occupational allergens </li></ul>
  21. 22. Pathophysiology <ul><ul><ul><ul><li>Type I Antibody-Antigen reaction to allergens </li></ul></ul></ul></ul><ul><ul><ul><ul><li>May take 4 years in a given region to be sensitized </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Sequence of events </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>T Lymphocytes and B Lymphocytes release IgE Antibody </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Mast Cells in skin and mucosa with second exposure </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Mast Cells degranulate </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Release of histamine and chemotactic factors </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Release of Prostaglandins and Leukotrienes </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Response of Intravascular Basophils </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Late phase reactants release histamine over 12 hour </li></ul></ul></ul></ul></ul>
  22. 23. Allergy: A Dysregulation of the Immune System APC Th0 Th1 Th2 B lymphocyte Mast cell Eosinophil Allergic Symptoms IFN  IL 4 IL 10 IL 5 IFN  IL 4 IL 13 IL 9 IL 12 IL 18 IL 12 IL 18 IL 4 Allergens IgE Sensitization Phase
  23. 24. Allergy: A Dysregulation of the Immune System Mast cell Basophil Eosinophil Inflammatory Mediators Release Allergens Histamine - Prostaglandins – Leucotriens – Tryptase - ECP Allergic Symptoms Activation Phase
  24. 25. The Natural Course of Allergic Diseases Sensitisation Reversible symptoms Chronic symptoms Airway Remodeling Mites Food Animals Pollens Cockroaches Molds Newborn Childhood / Infancy Adult Atopic dermatitis Rhinitis Rhinitis Food allergy Asthma Asthma Co-factors: Pollutants & Irritants Tobacco smoke, etc…
  25. 26. causes
  26. 27. I ndoor Allergens <ul><ul><ul><ul><li>Perennial allergens of importance are molds, house dust, and animal danders. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Although these allergens are present throughout the year, they tend to be more problematic during the winter, when people spend most of their time indoors. </li></ul></ul></ul></ul>
  27. 31. Outdoor Allergens <ul><ul><ul><ul><li>Seasonal allergens are primarily pollens. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>In general, trees bloom in the spring; </li></ul></ul></ul></ul><ul><ul><ul><ul><li>grasses, in the summer </li></ul></ul></ul></ul><ul><ul><ul><ul><li>weeds, in the fall. </li></ul></ul></ul></ul>
  29. 35. MITES Indoor Allergens COCKROACHES
  30. 36. MESQUITE Pollen Allergens
  31. 37. CHENOPODIUM ALBUM Pollen Allergens
  32. 38. ALFALFA Pollen Allergens FALSE ACACIA
  33. 39. MUGWORT Pollen Allergens TIMOTHY (Grasses)
  34. 40. SORREL Pollen Allergens RUSSIAN THISTLE
  35. 41. BERMUDA GRASS Pollen Allergens
  36. 43. Other Causes <ul><li>I RETANTS : </li></ul><ul><li>URT Infections </li></ul><ul><li>Dusts </li></ul><ul><li>Strong auders </li></ul><ul><li>Change in the weather </li></ul><ul><li>Smoking </li></ul>
  37. 44. CLINICAL FEATURES <ul><li>History: Allergy history </li></ul><ul><li>Details about the presenting symptoms </li></ul><ul><li>Nasal mucous </li></ul><ul><li>Sneezing Rhinorrhea Nasal congestion Pruritus of the nose, palate, pharynx, middle ear , eyes, and throat Eye Tearing and conjunctival discharge (eg, onset, fluctuation, severity) should be obtained. </li></ul>
  38. 45. Other Mucous Membrane Manifestations <ul><li>Eyes </li></ul><ul><li>conjunctival irritation, itching, erythema, & tearing </li></ul><ul><li>Ears </li></ul><ul><li>feeling of fullness in ears with popping </li></ul><ul><li>Sinuses </li></ul><ul><li>pressure and/or pain over cheeks, forehead, or behind eyes </li></ul><ul><li>Systematic Manifestations </li></ul><ul><li>malaise, weakness, fatigue </li></ul>
  39. 46. <ul><li>any recent changes in the patient's Quality of life (eg, at home, in the workplace, in leisure activities, in diet). </li></ul><ul><li>Severity </li></ul><ul><li>does rhinitis interfere with work or school performance or play </li></ul><ul><li>Associated Symptoms </li></ul><ul><li>noisy or oronasal breathing, nasal voice, hyposmia, repeated throat clearing, </li></ul>
  40. 47. . <ul><ul><ul><ul><li>Family history </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>If both parents have allergies, their child has a 50% chance of having the same problem. </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Past medical history </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>In children, a history of recurrent otitis media, upper respiratory tract infection, asthma, chronic rashes, and formula intolerance are suggestive of allergies. </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>identify other atopic conditions - hives, atopic dermatitis, allergic asthma, anaphylactic reactions </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Inquire about the results of previous allergy tests and treatment </li></ul></ul></ul></ul></ul>
  41. 48. <ul><li>Symptoms of Chronic Nasal Obstruction </li></ul><ul><ul><ul><ul><li>Mouth Breathing </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Snoring </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Anosmia </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Cough </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Headache </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Decreased Hearing </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Halitosis </li></ul></ul></ul></ul>
  42. 49. <ul><li>Symptoms associated with chronicity of rhinitis </li></ul><ul><ul><ul><ul><li>Irritability </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Fatigue </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Depression </li></ul></ul></ul></ul>
  43. 50. Physical Examination
  44. 51. Physical Examination <ul><li>Observation </li></ul><ul><li>Patients with allergic rhinitis frequently have a characteristic facial appearance. </li></ul>
  45. 52. Face <ul><li>Facial grimacing and twitching caused by nasal itching in patient with allergic rhinitis. These are frequently repeated and easily noted during patient evaluation. </li></ul>
  46. 53. <ul><li>Characteristic adenoid-type facies in a patient with long-standing allergic rhinitis. Note the open mouth and gaping habitus. </li></ul>
  47. 54. Eyes <ul><li>Allergic shiners, (dark discoloration below the lower eyelids or dark circles beneath the eyes ) caused by venous stasis may be present. </li></ul><ul><li>Patients may have injected conjunctiva; increased lacrimation; and long, silky eyelashes. </li></ul>
  48. 55. <ul><li>Dennie sign originates in the inner canthus and traverses one half to two thirds the length of the lower lid margin in an arc nearly parallel to it. </li></ul><ul><li>Dennie-Morgan lines (creases in the lower eyelid skin) </li></ul>
  49. 56. Nose <ul><li>The allergic salute is characteristic of children with allergic rhinitis and nasal itching and is usually noticed by parents. </li></ul>
  50. 57. <ul><li>The nasal crease across the lower third of the nose results from chronic upward rubbing of the nose with the hand (allergic salute). to relieve itching and open the nasal airway. </li></ul>
  51. 58. Otoscope or Nasal Speculum <ul><li>Pale, edematous inferior nasal turbinate of patient with allergic rhinitis, as seen through a fiberoptic rhinoscope. Even though this tool is not routinely used in evaluations, the physical findings are well illustrated, including watery nasal secretions. . </li></ul>
  52. 59. <ul><li>Nasal secretions can range from clear and profuse to stringy and mucoid. </li></ul>
  53. 60. <ul><li>Nasal Obstruction </li></ul><ul><li>epistaxis in Kisselbach's area </li></ul><ul><li>broadening of body dorsum (due to persistent nasal obstruction) </li></ul>
  54. 61. <ul><li>The presence of polyps does not necessarily indicate that the affected individual has allergic rhinitis. </li></ul>
  55. 62. <ul><li>Chronic Changes </li></ul>
  56. 63. Ears <ul><ul><ul><ul><ul><li>Ears frequently are unremarkable. </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Eczematoid otitis externa and middle ear effusion may be present </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>(Rule out associated Eustachian Tube Dysfunction) </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Dull, imobile Tympanic Membrane </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Conductive Hearing Loss </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>middle ear abnormalities - retracted, scarred ears with serous otitis media </li></ul></ul></ul></ul></ul>
  57. 64. Mouth <ul><ul><ul><ul><ul><li>A high arched palate, narrow premaxilla, and receding chin may be present secondary to long-term mouth breathing. </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>The posterior oropharynx may be granular because of irritation from persistent postnasal discharge. </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Malocclusion from chronic mouth-breathing </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>&quot;Cobblestoning&quot; of adenoids and tonsils </li></ul></ul></ul></ul></ul>
  58. 65. Sinuses <ul><li>(Rule out Sinusitis ) </li></ul><ul><li>Purulent discharge </li></ul><ul><li>Tender </li></ul><ul><li>Impaired transillumination </li></ul>
  59. 66. <ul><li>Chronic Nasal Obstruction </li></ul><ul><li>hypertrophied pharyngeal lymphoid tissue (adenoids and tonsils) </li></ul><ul><li>hypertrophied gingival mucosa and halitosis </li></ul>
  60. 67. INVESTIGATIONS <ul><li>Nasal Secretion </li></ul><ul><li>for eosinophilia (>10-20%) with Wright or Eosin/Methylene Blue stains </li></ul><ul><li>Serum </li></ul><ul><li>eosinophilia </li></ul><ul><li>elevated IgE </li></ul>Eosinophilia on nasal smear from a patient with allergic rhinitis
  61. 68. Allergy Tests <ul><li>Gold standard </li></ul><ul><li>In Vivo - skin tests - immediate, delayed, skin brick test </li></ul><ul><li>In Vitro - Immunoassays – ( Radio-allergo-sorbent ) RAST, CAP, ELISA </li></ul>
  62. 69. Skin Prick Tests Stallerpoint ® plastic lancet Allergen solution The procedure is painless
  63. 70. A specific Battery of Skin Test for Saudi Arabia First Top ten Allergens (covering 90 % of the allergies in the Kingdom) : 1- Dermatophagoides pteronyssinus (mite) 2- Dermatophagoides farinae (mite) 3- Cockroach 4- 12 Grasses 5- Mesquite 6-False Acacia 7-Chenopodium 8-Russian Thistle 9-Histamine 10-Control Negative + six other allergens can be added to cover 99 % of the allergies in the Kingdom
  64. 71. Imaging Studies <ul><li>Sinus Radiograms/CT </li></ul><ul><li>to rule out acute or chronic sinusitis </li></ul>
  65. 72. Differential Diagnosis <ul><li>Nasal Causes of rhinitis </li></ul><ul><ul><ul><ul><li>Nonallergic Rhinitis ( Eosinophilia Syndrome ) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Nasal Polyps </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Vasomotor Rhinitis </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Infectious Rhinitis </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Rhinitis medicamentosa </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Gustatory Rhinitis </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Spicy foods lead to tearing and sweating </li></ul></ul></ul></ul></ul>
  66. 73. MANAGEMENT
  67. 74. Management of Allergic Rhinitis & Asthma Allergen avoidance Pharmacotherapy Allergen Immunotherapy Patient’s education
  68. 75. Avoidance <ul><li>identify allergens and trial of avoidance therapy </li></ul><ul><li>remove offending pets from house </li></ul><ul><li>management of dust mites with plastic covers, rug removal, and washing of stuffed animals </li></ul>
  69. 76. Pharmacologic Treatment of Allergic Rhinitis Mild intermittent rhinitis Moderate/severe intermittent rhinitis Mild Persistent rhinitis Moderate/ severe persistent rhinitis Intranasal corticosteroids Chromone (intranasal) Antihistamines H1 (oral or intranasal) Decongestant (intranasal or oral) (< 10 days)
  70. 77. Prophylactic Therapy <ul><li>Intranasal Corticosteroids </li></ul><ul><li>first line of therapy: </li></ul><ul><li>1. Mechanism of Action </li></ul><ul><li>multifactorial relief of inflammation by decreasing: </li></ul><ul><li>capillary permeability; mucosal edema (vasoconstrictor effect); mucous production; number of mast cells, basophils, eosinophils, and neutrophils; hyperactivity of the nasal mucosa; mediators of inflammation </li></ul><ul><li>2. Action </li></ul><ul><li>useful in the prophylactic management of both seasonal and perennial allergic rhinitis (i.e., begin use 1 week before exposure to allergen - pollens) </li></ul><ul><li>therapeutic effects may not be seen for 5-7 days </li></ul><ul><li>side effects: </li></ul><ul><li>hypothalamic-pituitary axis suppression with long term use, nasal mucosa atrophy, nasal irritation </li></ul>
  71. 78. Sodium Cromoglycate (Rynacrom) <ul><li>second line of therapy: </li></ul><ul><li>1. Mechanism of Action </li></ul><ul><li>stabilizes the mast cell membrane thus inhibiting mediator release </li></ul><ul><li>may block calcium channels in the plasma membrane of the mast cells and prevent calcium transport across the plasma membrane </li></ul><ul><li>prevents both the early and late responses to an allergen </li></ul><ul><li>does not stabilize the basophil membrane and does not inhibit the binding of IgE to mast cells or basophils </li></ul><ul><li>2. Action </li></ul><ul><li>prevents sneezing, rhinorrhea, and nasal itching in patients with seasonal and allergic rhinitis (but not nasal congestion) </li></ul><ul><li>side effects: </li></ul><ul><li>irritability, hypersensitivity </li></ul><ul><li>3. Dose </li></ul><ul><li>initial - 1 spray per nostril 6 times per day </li></ul><ul><li>maintenance - 1 spray per nostril 2-3 times per day </li></ul>
  72. 79. . <ul><li>Beclomethasone (Beconase ® or Beconase AQ ® ) Children 6-12 years: 1 spray (42 mcg) in each nostril twice daily Budesonide (Rhinocort ® or Rhinocort Aqua ® ) Adults and children > 6 years: 2 sprays (32 mcg/spray) in each nostril twice daily or 4 sprays in each nostril once daily </li></ul>
  73. 80. <ul><li>Fluticasone (Flonase ® ) Children 4-12 years: 1 spray (50 mcg) in each nostril once daily Mometasone (Nasonex ® ) Children 3-12 years: 1 spray (50 mcg) in each nostril once daily Triamcinolone (Nasacort ® or Nasacort AQ ® ) Children 6-12 years: 1 spray (55 mcg) in each nostril once daily </li></ul>
  74. 81. . Acute Therapy <ul><li>1. Antihistamines </li></ul><ul><li>1. Mechanism of Action </li></ul><ul><li>Histamine H1-Receptor antogonist </li></ul><ul><li>2. Action </li></ul><ul><li>prevents nasal symptoms (rhinorrhea, nasal itching, sneezing) and conjunctival symptoms (itching, tearing, erythema) </li></ul><ul><li>exerts maximal effect if taken before anticipated exposure (i.e., begin use 2 days before exposure to antigen) </li></ul><ul><li>peak action hours after peak serum concentration achieved </li></ul><ul><li>contraindications </li></ul><ul><li>hypersensitivity reactions </li></ul><ul><li>side effects </li></ul><ul><li>fatigue, dry mouth, somnolence </li></ul>
  75. 82. Doses <ul><li>1. Seldane (Terfenadine) </li></ul><ul><li>2. Hismanal (Astemizole) </li></ul><ul><li>3. Claritin (Loratodine) </li></ul><ul><li>5-10 mg po od (=>2 years of age) </li></ul><ul><li>4. Zyrtic (Cetirizine) </li></ul><ul><li>5-10 mg po od (=>2 years of age) </li></ul>
  76. 83. <ul><li>2.Nasal Decongestant </li></ul><ul><li>Normal saline </li></ul><ul><li>Oral and nasal Decongestant </li></ul>
  77. 84. Others <ul><li>Anticholinergics Ipratropium promide </li></ul><ul><li>Systemic glucocorticosteroids </li></ul><ul><li>Antileukotrienes </li></ul><ul><li>Allergen-specific immunotherapy (vaccination) </li></ul>
  78. 85. <ul><li>_ Subcutaneous immunotherapy : proven efficacy but a risk of severe side-effects. </li></ul><ul><li>- A great need for more safe routes of allergen administration. </li></ul>Subcutaneous Immunotherapy Sublingual Immunotherapy
  79. 86. A.R.I.A. Position Paper 2001 Indication of Allergen Immunotherapy in Allergic Rhinitis mild intermittent mild persistent moderate severe intermittent moderate severe persistent allergen and irritant avoidance Allergen Immunotherapy intra-nasal decongestant (<10 days) or oral decongestant local cromone intra-nasal steroid oral or local non-sedative H1-blocker
  80. 87. <ul><li>Consider immunotherapy for allergic rhinitis when: </li></ul><ul><li> There is a long allergen season. </li></ul><ul><li> The patient has perennial symptoms. </li></ul><ul><li> The patient does not respond to, or does not </li></ul><ul><li>tolerate, medications. </li></ul><ul><li> The patient cannot use, or is unwilling to </li></ul><ul><li>use, medications. </li></ul><ul><li> Developing, or worsening, asthma is possible. </li></ul><ul><li> There is chronic or recurrent rhinosinusitis. </li></ul><ul><li> There is chronic or recurrent middle ear </li></ul><ul><li>disease. </li></ul>
  81. 90. Referral to an allergy/immunology or otolaryngologic allergy specialist forconsultation and/or comanagement is recommended when there is: <ul><li>A pattern of symptoms occurring predominantly in relation to work. </li></ul><ul><li> Consider occupational rhinitis. </li></ul><ul><li> Bilateral chronic nasal congestion with variable sneezing and discharge, but with </li></ul><ul><li>significant olfactory disturbance. </li></ul><ul><li> Consider nasal polyps. </li></ul><ul><li> Persistent rebound congestion resulting from overuse or abuse of intranasal decongestants. </li></ul><ul><li> Consider rhinitis medicamentosa. </li></ul><ul><li> Continuous nasal congestion, particularly if unilateral, with bloodstained secretions. </li></ul><ul><li> Consider malignancy. </li></ul><ul><li> A pattern of persistent symptoms that is not completely responsive to appropriate </li></ul><ul><li>environmental control and medications. </li></ul><ul><li> Consider rhinosinusitis and/or noncompliance with therapeutic regimens . </li></ul>
  82. 92. Take care of my nose keep me happy
  83. 93. THANK YOU