3. RHINITIS
•Two or more nasal symptoms of:
• Nasal congestion
• Rhinorrhea
• Sneezing/Itching
• Impairment of Smell for
more than 1 hour a day
4. RHINITIS
• Occurs most commonly as allergic rhinitis
• Noninfectious rhinitis has been classified as either
allergic or non-allergic.
• Allergic rhinitis is defined as immunologic nasal
response, primary mediated by immunoglobulin E
(IgE).
• Non-allergic rhinitis is defined as rhinitis symptoms
in the absence of identifiable allergy, structure
abnormality or sinus disease.
5. INTRODUCTION
• Nasal function includes
• Temperature regulation
• Olfaction
• Humidification
• Filtration and Protection
6. INTRODUCTION
• Nasal lining contains secretion of IgA, proteins
and enzymes
• Nasal Cilia propel the matter toward the natural
ostia at frequency of 10-15 beats per minute
• Mucous move at a rate of 2.5-7.5 ml per
minute
7. ALLERGIC RHINITIS
• Defined as an inflammation of the nasal
mucosa, caused by an allergen
• Most common atopic allergic reaction
• Affects 10 to 25% of population
• 50% of rhinitis in ENT is AR
• Most commonly seen in young children and
adolscents
9. PRECIPITATING FACTORS
• Aerobiological flora
• Allergens present in the environment
• House dust and dust mites
• Feathers
• Tobacco smoke
• Industrial chemicals
• Animal dander
• Nasal physiology
• Disturbances in normal nasal cycle
10. PREDISPOSING FACTORS
• Genetic
• Multiple gene interactions are responsible for allergic
phenotype
• Chromosomes 5, 6, 11, 12 & 14 control inflammatory process
in atopy
• 50% of allergic rhinitis patients have a positive family history
of allergic rhiniits
• Endocrine
• Puberty
• Pregnant states and post partum stages
• menopausal
11. PREDISPOSING FACTORS….
• Psychological
• Focal sensitivity states
• Infections: fungal infections nb
• Physical
• Degree of pollution of air
• Humidity and temperature differences
• Temperature changes
• Age & sex
• IgA deificiency
13. PATHOPHYSIOLOGY
• Immunoglobulin (Ig) E mediated type 1
hypersensitivity response to an antigen
(allergen) in a genetically susceptible person
• Type 1 Hypersensitivity causes local
vasodilation and increased capillary
permeability
14. CLASSIFICATON - FORMER
• Seasonal
• Often known by it’s misnomer of Hay fever
• Neither caused by hay or has fever
• Summer cold
• Caused by virus causing URTI (not a true allergic
rhinitis
• Rose fever
• Often cited in indian subcontinent
• Colourful or fragrant flowering plants rarely cause
allergy as their pollens to heavy to be airborne
• Perennial
• Allergens present throughout the year
15. CLASSIFICATION - CURRENT
• Intermittent
• Symptoms present less than 4 days per week and
less than 4 weeks per year
• Persistant
• Symptoms present more than 4 days per week and
more than 4 weeks per year
16. SEVERITY
• Mild
• No interference with daily activity or troublesome
symptoms
• Moderate – severe
• Presence of at least one:
• Impaired sleep, daily activity work or school
• Troublesome symptoms
17. COMPLICATIONS:
• Allergic asthma
• Chronic otitis media
• Hearing loss
• Chronic nasal obstruction
• Sinusitis
• Orthodontic malocclusion in children
18. SIGNS AND SYMPTOMS
• Sneezing
• Itchy nose, ears,
eyes and palate
• Rhinorrhea
• Post nasal drip
• Congestion
• Anosmia
• Headache
• Earache
• Tearing of eyes
• Red eyes
• Swollen eyes
• Fatigue
• Drowsiness
• Malaise
19. PHYSICAL EXAMINATION
• Nasal crease
• Horizontal crease
across the lower half
of the bridge of the
nose
• Rhinorrhoea
• Thin watery secretions
• Deviated or
perforated nasal
septum
20. EXTRA NASAL MANIFESTATIONS
• Retracted and
abnormal flexibility
of TM
• Injection and swelling
of palpebral
conjunctivae with
excess tearing
• Cobblestoning on
oropharynx
21. CLASSICAL SIGNS OF AR
• Over bite
• High arched palate
• Allergic shiners
• Allergic salute
• Transverse crease over
tip of nose and lower
eye lid
• Conjunctival
congestion
• Periorbital oedema
22. INVESTIGATIONS
• FBC
• Histamine test
• Nasal smear
• Intranasal provocation test
• Skin tests
• Subcuticular test
• More accurate with lower incidence of false positive
results
• Contraindicated in case of anti histaminic, anti
inflammatory or decongestant treatment
23. • Intradermal tests
• Be prepared for anaphylaxis
• Skin end point titration test
• Quantitative intradermal test for specific allergen
• Nasal challenge
• Nasal cytology
• Take a sample of nasal cavity without anaesthesia
and send for identificaton of cell types in the nasal
cavity
• Increased number of eosinophils suggests allergic
disease
24. OTHER INVESTIGATIONS
• RAST (radio allergo sorbant test)
• FAST ( fluro allergo sorbant test)
• PRIST (paper immuno allergo sorbant test)
• Xray PNS
• CT PNS (for complicated cases with polyposis)
• Nasal endoscopy ( under local or GA)
• Evaluate for asthma
25. PROGNOSIS
• Treatment is available and patients remain
symptom free only until re exposure to allergic
antigen
• No evidence of mortality from the disease
itself, but high morbidity
• Seasonal allergic Symptoms improve as
patients age
27. AVOIDANCE
• Minimize contact with offending allergens
• Reduce dust mite exposure by encasing bed
pillows and matress in allergen proof covering
• Use of allergen proof bedding…..
28. ACUTE PHASE MEDICATIONS
• Antihistamines effectively block histamine effects
(runny nose and watery eyes)
• Side effects : sedation, dry mouth, nausea, dizziness,
blurred vision, nervousness
• Non sedating antihistamines (cetrizine, loratidine)
• Fewer side effects
• Fexofenadine may be effective
• Carries a lower risk of cardiac arrythmias
• Decongestants
• Shrink nasal mucous membrane by vasoconstriction
• Available OTC and in combination with antihistamines,
analgesics and anti cholinergics
30. • Anticholinergenic agents
• Inhibit mucous secretions, act as drying agent
• Topical eye preparations
• Reduce inflammation and relieve itching and burning
31. MEDICAL: PREVENTIVE THERAPY
• Intranasal corticosteroids
• Reduce inflammation of mucosa
• Prevent mediator release
• Can be used safely daily
• May be given systemically for a short course during a
disabling attack
• Intranasal cromolyn sodium
• Mast cell stabiliser
• Prevents release of chemical mediators
• Oral mast cell stabilizer
• Otpthalmic solution cromolyn
32. • Leukotriene receptor antagonists
• Montelukast (singulair) and Zafirlukast (accolate)
• Systemic agents used for asthma
• Reduce inflammation, edema and mucous sectetions
of allergic rhinitis
35. IMMUNOTHERAPY
• If allergic rhinitis is refractory to
pharmacotherapy or severe
• Helps in reducing the specific serum IgE
level
• decreases the basophil sensitivity
• increases IgG blocking antibody level , thus
preventing allergen from reaching mast
cells and subsequent mast cell
degranulation
36. SURGICAL THERAPY
• Limited
• Submucosal turbinectomy - reduces size of
boggy turbinates
• Septoplasty – correction of deviation of
septum
• Sinus surgery – clearance of sinuses if
sinusitis is present
Caused by repeated upward rubbing of the tip of the nose by the palm of hand
Septal perf may be associated with chronic rhinitis,
Pale bluish oedematous nasal mucosa
Bulky turbinates
Mucosa often coated with clear or mucoid secretions
In advance stage polyp can be seen
Nasal septum may often be thick
Rast positive for offending allergen
Rhinoscopy _ useful to rule out physical obstruction caused by septal deviation, nasal polyps etc
Of the antihistamines, Azelastine intra-nasally has been efficacious for all forms of NAR, including Idiopathic Rhinitis.
It is an H1 receptor antagonist, that also inhibits synthesis of leukotrienes, kinins, cytokines and free radicals.
However, the exact mechanism of action for relief of symptoms is unknown.
Minimize contact with offending allergens, regardless of other treatment
Reduce dust mite exposure by encasing bed pillows and attress in allergen proof coveing