Allergic rhinitis is a common condition marked by nasal symptoms such as congestion, sneezing, and rhinorrhea, significantly affecting 10-25% of the population, especially children and adolescents. It is triggered by allergens and characterized by an IgE-mediated hypersensitivity response, classified into seasonal and perennial forms. Management includes avoidance of allergens, use of medications like antihistamines and intranasal corticosteroids, and in some cases, immunotherapy.

1. ALLERGIC RHINITIS

2. RHINITIS
Rhinitis is-
two or more nasal symptoms of:
• Nasal congestion
• Rhinorrhea
• Sneezing/Itching
• Impairment of Smell for more than 1 hour a day

3. RHINITIS
• Occurs most commonly as allergic rhinitis
• Non-infectious rhinitis has been classified as either
allergic or non-allergic.
• Non-allergic rhinitis is defined as rhinitis symptoms
in the absence of identifiable allergy, structure
abnormality or sinus disease.

4. EPIDEMIOLOGY
• Global health problem
• Prevalence :10-20%
• Higher in pediatric age group - 42%
• Affecting every 6th person
• Peak age - 13 to 14.
• Approx. 80% - develop symptoms < 20

5. INTRODUCTION
• Nasal function includes
• Temperature regulation
• Olfaction
• Humidification
• Filtration and Protection

6. INTRODUCTION (Cont.)
• 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
• Allergic Rhinitis is clinically defined as a symptomatic disorder of the nose
induced by an IgE-mediated inflammation after allergen exposure of the
membranes lining the nose.
• 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.

8. ETIOLOGY
• Classified as
• Precipitating factors
• Pre-disposing factors

9. PRECIPI ATING 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
rhinitis
• Endocrine
• Puberty
• Pregnant states and post partum stages menopausal

11. PREDISPOSING FACTORS
• Psychological
• Focal sensitivity states
• Infections: fungal infections
• Physical
• Degree of pollution of air
• Humidity and temperature differences
• Temperature changes
• Age & sex
• IgA deficiency

12. COMMON ALLERGENS
Pollen
• Spring tree pollens(maple)
• Summer: grass pollens
• Autums: weed pollens
Molds
• Penicillium, cladosporium etc.
Insects
• Cockroaches, house flies, fleas, bed
bugs
Animals
• Cats, Dogs, Horse, monkeys, rats,
rabbits etc
Dust mites
• Dermatophagoides
Ingestants
• Nuts, fish, eggs, milk etc

14. PATHOPHYSIOLOGY
• Immunoglobulin IgE mediated type1 hypersensitivity response to an
antigen (allergen) in a genetically susceptible person
• Type 1 Hypersensitivity causes local vasodilation and increased
capillary permeability

16. PATHOPHYSIOLOGY (Contd.)
• Sensitization: Development of specific IgE
• Allergens reach Anti-Presenting Cells (APCs)
• APCs promote Th2 polarization
• Th2 promotes production of allergens-specific IgE
• Subsequent response: Development of symptoms
• Nasal symptoms: Early and Late phase response
• Specific and non-specific hyperresponsiveness
• Lower airways symptoms

18. CLASSIFICATON-FORMER
• Seasonal
• Also known as Hay Fever
• Neither caused by hay or fever
• Summer Cold
• Caused by virus causing URTI
• Rose Fever
• Perennial
• Allergens present throughout the year

19. CLASSIFICATION-CURRENT
• Intermittent
• Symptoms present less than 4 days per week and less than 4 weeks per year
• Persistent
• Symptoms present more than 4 days per week and more than 4 weeks per year

20. SEVERITY
• Mild
• No interference with daily activity or troublesome symptoms
• Moderate
• Presence of at least one
• Impaired sleep, daily work, activity.
• Troublesome symptoms

21. ARIA CLASSIFICATION: ALLERGIC RHINITIS
AND ITS IMPACT ON ASHMA

22. COMPLICATIONS
• Allergic asthma
• Chronic otitis media
• Hearing loss
• Chronic nasal obstruction
• Sinusitis
• Orthodontic malocclusion in children

23. 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

24. PHYSICAL EXAMINATION
Nasal crease
• Horizontal crease across the lower half of the bridge of the nose
Rhinorrhea
• Thin watery secretions
• Deviated or perforated nasal septum

25. EXTRA NASAL MANIFESTATIONS
• Retracted and abnormal flexibility of tympanic membrane
• Swelling of palpebral conjunctivae with excess tearing
• Cobble stoning on oropharynx

26. CLASSICAL SIGNS OF ALLERGIC
RHINITIS
• High arched palate
• Allergic shiners
• Allergic salute
• Transverse crease over tip of nose
and lower eye lid
• Conjunctival congestion
• Periorbital oedema

27. INVESTIGATIONS
• FBC (Full blood count)
• Histamine test
• A nasal smear for eosinophil
• Intranasal provocation test
• Skin tests
• Sub-cuticular test
• More accurate with lower incidence of false positive results
• Contraindicated in case of anti histaminic, anti-inflammatory or decongestant
treatment

28. INVESTIGATIONS (Contd.)
• Intradermal tests
• Be prepared for anaphylaxis
• Skin end point titration test
• Quantitative intradermal test for specific allergen
• Nasal challenge (Nasal Provocation)
• Nasal cytology
• Take a sample of nasal cavity without anaesthesia and send for identification
of cell types in the nasal cavity.
• Increased number of eosinophil suggests allergic disease.

30. OTHER INVESTIGATIONS
• RAST (radio allergo sorbant test)
• detect allergen-specific IgE antibodies
• Stablized allergen is incubated with patient’s serum
• Any specific IgE binds to allergen
• Identfied by a second incubation with labelled anti-IgE.
• PRIST (paper radio immuno sorbant test)
• X-ray PNS (Paranasal sinuses)
• CT PNS (for complicated cases with polyposis)
• Nasal endoscopy ( under local or GA)
• Evaluate for asthma

33. MANAGEMENT
Avoidance
• Outdoor exposure
• Stay indoors as much as possible when pollen counts are at their peak.
• Avoid using window fans that can draw pollens and molds into the house.
• Wear glasses or sunglasses when outdoors to minimize the amount of pollen
getting into your eyes.
• Wear a pollen mask (such as a NIOSH-rated 95 filter mask)
• Try not to rub your eyes; doing so will irritate them and could make your
symptoms worse.

34. MANAGEMENT
Avoidance
• Indoor exposure
• Reduce exposure to dust mites, especially in the bedroom. Use “mite-proof”
covers for pillows, comforters and duvets, and mattresses and box springs.
Wash your bedding frequently,
• Clean floors with a damp rag or mop, rather than dry-dusting or sweeping.
• Exposure to pets
• Wash your hands immediately after petting any animals; wash your clothes
after visiting friends with pets.
• If you are allergic to a household pet, keep the animal out of your home as
much as possible

35. MEDICATION
Class Agents Mechanism Symptoms Treated
Antihistamines
Cetirizine
Stabilizes H1 receptor in
inactive conformation
Itching, sneezing, rhinorrhea; not
as effective as nasal congestion
Fexofenadine
Levocetirizine
Loratadine
Desloratadine
Intranasal
antihistamine
Azelastine Stabilizes H1 receptor in
inactive conformation
Itching, sneezing, rhinorrhea,
and nasal congestion
Olopatadine
Leukotriene receptor
antagonist
Montelukast
Leukotriene receptor
antagonist
Reduce inflammation, edema
and mucous secretions
of allergic rhinitis
Anticholinergic
agent
Ipratropium Nasal spray Anticholinergic Rhinorrhea only
Intranasal
Corticosteroid
Fluticasone Propionate
Multiple Anti-
inflammatory effect
Itching, sneezing, rhinorrhea; not
as effective as nasal congestion,
Reduce inflammation of mucosa,
Prevent mediator release.
Fluticasone Furoate
Momotasone
Budesonide
Flunisolide

36. OTHERS
• Decongestants
• Shrink nasal mucous membrane by vasoconstriction
• Available OTC and in combination with antihistamines, analgesics and anti cholinergics
• Relieve the stuffiness and pressure caused by swollen nasal tissue.
• Eg: Oxymetazoline, Phenylephrine, Pseudoephedrine
• Intranasal cromolyn sodium
• Mast cell stabiliser
• Prevents release of chemical mediators
• Oral mast cell stabilizer
• Prevent the release of histamine and other powerful chemical mediators from mast cells
• Eg: Olopatadine, Rupatadine
• Opthalmic solution cromolyn

37. IMMUNOTHERAPY
• Allergy shots:
• A treatment program, which can take three to five years, consists
of injections of a diluted allergy extract, administered frequently in increasing
doses until a maintenance dose is reached.
• Immunotherapy helps the body build resistance to the effects of the allergens.
• Sublingual tablets:
• Placing a tablet containing a mixture of several allergens under your tongue. It
works similarly to allergy shots but without an injection.

38. SURGICAL THERAPY
• It is limited to
• Submucosal turbinectomy - reduces size of boggy turbinates
• Septoplasty - correction of deviation of septum
• Sinus surgery - clearance of sinuses if sinusitis is present

40. Implement appropriate
environmental controls.
If not totally effective, select single-drug treatment based on symptoms:
Antihistamines—sneezing, itching, rhinorrhea, and ocular symptoms
Decongestants (systemic)—nasal congestion
Intranasal steroids—sneezing, itching, rhinorrhea, and nasal congestion
Cromolyn—sneezing, itching, and rhinorrhea
Intranasal antihistamine—rhinorrhea and itching
Intranasal anticholinergic—rhinorrhea
Assess efficacy.
If symptoms controlled but adverse
effects are bothersome or intolerable,
adjust dosage or switch to another
agent within the same therapeutic
category.
If non-adherent, discuss
reasons with patient.
If patient is adherent, adjust dosage or
if necessary, switch to another agent
in a different therapeutic category or
add a second agent from a different
therapeutic category.
If symptoms are not
controlled, assess adherence.
Symptoms controlled.

41. Symptoms controlled.
For perennial disease, once symptoms
are adequately controlled with minimal
adverse effects, continue therapy and
reassess patient in 6 to12 months.
For seasonal disease, once symptoms are
adequately controlled with minimal adverse
effects, continue therapy until end of patient’s
allergy season. Discuss when therapy should
be reinitiated.
If symptoms still not controlled,
consider montelukast.
Additional consideration: Assess patient
for appropriateness of immunotherapy
initially and again if pharmacotherapy
options are not sufficiently effective.
Fig: Treatment algorithm for allergic rhinitis.

42. TREATMENTS THAT ARE NOT
RECOMMENDED FOR ALLERGIC RHINITIS
• Antibiotics
• Effective for the treatment of bacterial infections, antibiotics do not affect the
course of uncomplicated common colds (a viral infection) and are of no
benefit for noninfectious rhinitis, including allergic rhinitis.
• Nasal surgery
• Surgery is not a treatment for allergic rhinitis, but it may help if patients have
nasal polyps or chronic sinusitis that is not responsive to antibiotics or nasal
steroid sprays.