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Rhinitis
- 2. Inflammation ofnasal mucosa INFECTIVE Acute – common cold (non specific), diptheria (specific) Chronic (non specific) – simple chronic rhinitis, hypertrophic rhinitis, rhinitis sicca, rhinitis caseosa, granuloma, sarcoidosis, atrophic rhinitis Chronic (specific) – rhinosporodiosis, rhinoscleroma, TB, leprosy, syphilis, lupus, fungal NON INFECTIVE Allergic rhinitis, VMR
- 3. Common cold/Coryza Non specific rhinitis Any sex any age Etiology – rhinovirus (mc), influenza (Severe form), parainfluenza, adenovirus, ECHO viruses Secondary infection – bacterial – streptococci, pneumococci, H. influenzae, staphylococci Predisposing factors – change of climate, cold and wet climate, low immunity, vitamin and nutritional deficiency, diabetes, TB, thyroid disorders Transmission – airborne – sneezing , coughing, talking, contact - kissing
- 4. C/F –lasts for 2 – 3 weeks Burning sensation of back of nose, nasopharynx, throat dryness – initial symptom Sore throat, fever low grade, bodyache, nasal stuffiness, rhinorrhoea, sneezing, post nasal discharge, dry cough Influenza – malaise, joint pain, acute respiratory obstruction – children Secondary bacterial infection – mucopurulent discharge Self limiting disease, influenza – high morbidity, mortality
- 5. Complications –pharyngitis, tonsillitis, lymphadenitis, sinusitis, otitis media, LRTI, GI infection, laryngitis D/D – Allergic rhinitis, VMR, Chronic rhinitis Treatment – Bed rest/ Isolation Plenty of fluids/ nutritious diet Steam inhalation with inhalant capsules Decongestants, nasal drops, analgesics, antipyretics, Vitamin C, antibiotics (if mucopurulent discharge ), NSAID NO ASPIRIN – INCREASED SHEDDING OF VIRUS Avoid smoking, alcohol, dirty and crowded places Influenza vaccine
- 6. Acute specificrhinitis Etiology – Corynebacterium diptheriae Age – children (carriers) C/F – fever, malaise, joint pain, nasal obstruction, blood stained discharge from nose Signs – purulent nasal discharge, foul smelling Excoriation of nasal skin Greyish white pseudomembrane over nasal floor, inferior turbinate and septum , loosely attached, rarely bleeds on removal Less toxic, loose membrane – due to mucous blanket covering the mucosa
- 7. D/D –chronic rhinitis, atrophic rhinitis, influenza, F/B (but U/L) Investigations – X Ray PNS, Nasal swab c/s Treatment – Isolation Anti diptheria serum/ antitoxin Pencillin/ Erythromycin PRIMARY BACTERIAL RHINITIS - Pneumococci, streptococci, staphylococci – more common in children RHINITIS WITH EXANTHEMAS – Measles, Rubella, Chicken pox
- 8. Predisposing factors– recurrent attacks of acute rhinitis, infections in sinuses, pharynx, chronic irritation due to dust, smoke, smoking, alcohol, pollution, DNS, Allergic rhinitis, VMR, hypothyroidism, lack of exercise, nasal drops overuse Types Initial stage – chronic simple rhinitis - reversible Advanced stage – chronic hypertrophic rhinitis - irreversible
- 9. CHRONIC SIMPLERHINITIS C/F – Nasal obstruction – worst on lying at night Nasal discharge – mucoid/ mucopurulent Post nasal discharge Headache – enlarged turbinates touch septum Loss of smell Signs – secretions present, enlarged turbinates which pit on pressure and shrink on applying vasoconstrictor
- 10. CHRONIC HYPERTROPHICRHINITIS Advanced stage Irreversible mucosal thickening, no pitting on pressure or no shrinkage of turbinates due to fibrosis – permanent hypertrophied turbinates Persistent severe nasal obstruction at night Mouth breathing, hawking, thick voice Diffuse hypertrophy mainly of inferior turbinate – papillary hypertrophy anterior end, mulberry hypertrophy posterior end (pinkish)
- 11. Diagnosis –DNE, X Ray PNS Treatment Treat the cause Antibiotics for acute exacerbations Alkaline nasal douching For early stage – topical steroids, nasal decongestants For advanced stage – turbinoplasty – turbinectomy, SMR, diathermy, electrocautery, LASER COMPENSATORY HYPERTROPHY RHINITIS – due to marked DNS on opposite side
- 12. Due toprolonged use of local nasal decongestant drops – oxymetazoline, xylometazoline – more than 1 week Rebound congestion C/F Nasal obstruction worst at night, headache due to blockage ostia Bloody red nasal mucosa with granulations, turbinate hypertrophy Treatment – stop nasal drops, oral/systemic steroids, intranasal steroids, turbinate reduction
- 13. Cocaine Antihypertensives– ACE inhibitors, beta blockers Aspirin, NSAID OCP, estrogens Gabapentin, methyldopa HORMONAL RHINITIS – puberty, menstruation, pregnancy , sex (honeymoon rhinitis) EMOTION INDUCED RHINITIS – stress, anxiety, tension, grief, emotions FOOD INDUCED RHINITIS – hot spicy food, alcohol IRRITATIONAL RHINTIS – dust, smoke, ammonia, acid fumes, formalin, FB
- 14. Atrophic changesaffecting the anterior nasal cavity due to dry and dusty enviroment Etiology – farmers, miners, bakers, iron and goldsmith, alcoholics, nutritional deficiency, post nasal surgery Pathology – respiratory epithelium changes to squamous, atrophy of seromucinous glands C/F – dirty black crusts in anterior 1/3rd of nasal cavity which on removal can cause ulceration, nasal bleed, perforation, dry mucosa Non foul smelling nasal discharge Nasal obstruction, Epistaxis
- 15. Treatment Changeof place of work, lifestyle Avoid nose picking, removal of crusts Use masks and filters at work Lubrication with antibiotic steroid ointment 25% glucose in glycerine nasal drops – 3 drops TDS for 2-3 months Alkaline nasal douching
- 16. NASAL CHOLESTEATOMA Chronic inflammation of nose due to formation of granulations and foul smelling offensive cheesy material in nasal cavity Affects nose and PNS (mainly maxillary sinus) Etiology – nasal stenosis, adhesions, synechiae, sinusitis, FB Nose, rhinolith, fungal infections Pathology – stagnation of secretions, accumulated discharge, caseous material formation, destruction of bony walls, on microscopy – cholesterol crystals Males (mc), any age (3rd and 4th decade mc)
- 17. C/F –foul smelling nasal discharge, nasal obstruction, loss of smell, headache, halitosis, defective taste Signs – cheesy material (white debris) in nasal cavity, ulceration of nasal mucosa, perforation and destruction of walls, external deformity Investigations DNE, CT PNS, X Rays Biposy Fungal culture D/D – Malignancy, Fungal sinusitis
- 18. Complications –Intracranial spread, orbital complications (rare) Prognosis - good Treatment Oral Pencillin thrice a day for 7 days Endoscopic removal of cause Removal of debris and granulation tissue FESS – for restoration of sinus drainage
- 19. Chronic inflammatorycondition of nose associated with progressive atrophy of nasal mucosa and turbinate bones charaacterised by greenish yellow crusts (posterior part), foul smell (OZAENA) Types Primary Idiopathic Endocrinal imbalance – more common in females during menstrual age (puberty to menopause), aggravated during menstruation and pregnancy Nutritional deficiency – Vitamin A, D, Iron – more in poor socio economic group, malnourished Racial – more in whites and yellow races Hereditary – AD Climate - Common in tropical countries like India
- 20. Secondary infection– Klebsiella ozaenae (perez bacilli), Diptheroids, Proteus, E coli Autoimmune disorder Broad nose Secondary – DNS (U/L) TB, syphilis, leprosy, lupus, rhinoscleroma Trauma Excessive turbinatectomy RT Chronic rhinosinusitis
- 21. Pathology Respiratory-> squmaous epithelium – stagnated mucous – crusts – secondary infection Gland atrophy – dryness Nerves atrophy – nasal blockage, anosmia (I) Periarteritis and endarteritis – diminished blood supply to mucosa Symptoms Foul offensive smell – perceived by others Anosmia/ hyposmia (merciful) B/L Nasal Obstruction – crusts, nerve atrophy Greenish yellow crusts – posterior part Epistaxis – dislodgement of crusts Headache
- 22. Signs Depressionof bridge of nose, broadened nose Nasal vestibulitis Fetor Roomy nasal cavities, turbinate atrophy Pale dry mucosa Nasopharynx visible on ant rhinoscopy Septal perforation Complications – atrophic pharyngitis (dry throat, irritation, atrophic laryngitis (cough, hoarseness), Sinusitis with small PNS, middle ear infection (Eustachian tube obstruction), Maggots in nose (foul smell, nerve atrophy)
- 23. Investigations CBC– Hb Serum Iron and proteins VDRL C/S of Nasal swab X Ray PNS, CT PNS – hypoplasia, opacity, thickened walls of maxillary sinus, erosion of lateral wall Chest X Ray – TB Nasal smear/biopsy D/D – Rhinitis sicca, Syphilis, leprosy, rhinoscleroma, rhinoloith, FB, Sinusitis (no crusts) Prognosis – life long , regress after middle age
- 24. Treatment Purpose– restore hydration, minimize crusting Medical Alkaline nasal douching – 56.8 g (2 parts) Sodium chloride/ salt, 28.4 g (1 part) of Sodium bicarbonate/baking soda (loosen crusts), 28.4 g (1 part) of Sodium biborate/washing soda (anti septic) in 280 ml (2 glasses) of warm water irrigation using 20 ml syringe , 2-3 times a day for life long 25% glucose in glycerine nasal drops/ paint after crust removal – inhibit proteolytic organisms/ foul smell Gauze pack soaked in liquid paraffin – lubricate nose, loosen crusts Kemicetene anti ozaenae solution Potassium iodide orally – loosens secretions
- 25. Placental extractinjections submucosally Estrogen/ Estradiol nasal spray – increase vascularity of nasal mucosa Vitamin A, D, E, Iron Chloramphenicol nasal drops Streptomycin/ Rifampicin Surgical Young’s operation- both nasal apertures completely closed for upto 2 years anteriorly Modified young’s operation – a 3 mm opening left for breathing Submucosal injection of teflon paste, fat, cartilage Section and medial displacement of lateral wall Transfer of stenson’s duct to maxillary sinus
- 26. Mikulicz disease Chronic granulomatous disease characterised by sclerosis and stenosis of nasal passages can also effect pharynx, larynx, trachea Etiology Klebsiella rhinoscleromatis Young age – 2nd or 3rd decade Females Rural areas Poor socio economic status, poor nutrition and hygiene North India, East Europe, Middle East, South America, Africa
- 27. Pathogenesis Airborne – droplet/ contamination material Pathology Begins in vestibule of nose, then spread to nose, pharynx, larynx, trachea, bronchi Histopathology Mikulicz cells – large foam cells containing bacilli Russell bodies- homogenous eosinophilic inclusion bodies C/F Prodromal/catarrhal stage – nasal mucosa congested, foul smelling purulent yellowish nasal discharge, sneezing Atrophic stage – atrophy but pink mucosa, nasal obstruction, crusting, headache, epistaxis Granulomatous stage – multiple painless rubbery nodule, non ulcerative, enlarge to form hard pale granulomas
- 28. Broadening, thickeningand woody feel of nose (Hebra nose) Dyspnoea and stridor (if larynx affected) Cicatrization stage Fibrosis of external nose (Tapir nose) Stenosis of vestibule, nasopharynx, larynx with adhesions leading to respiratory distress Diagnosis – biopsy D/D – Atrophic rhinitis (pale mucosa), tertiary syphilis
- 29. Treatment Prolongedantibiotics for 4-6 weeks Streptomycin – DOC Tetracycline Amoxycillin, ciprofloxacin, rifampicin, ampicillin, doxycycline Steroids – to reduce fibrosis Nasal reconstruction – to establish airway RT – not effective
- 30. Chronic granulomatousdisease affecting the mucous membrane of nose, nasopharynx manifesting as vascular polyps Can also affect larynx, bronchi, conjuctiva, skin, genitals, lip and palate and spread to liver and spleen through blood Endemic in coastal areas- india, srilanka, africa, south america Young age – 15 to 40 years M:F 4:1 Etiology – Rhinosporidium seeberi (aquatic protozoa)/ Kinealyi water borne – contaminated water of ponds with animal dung – cattle, horses, mules Air borne – dust mixed with animal dung Trauma is a predisposing factor
- 31. Pathology Sporangia– chitinous cyst containing spores Symptoms Nasal obstruction U/L Epistaxis Blood tinged nasal discharge Post nasal discharge, hyposmia Signs U/L leafy pink to purple granular polypoidal mass with black spots bleeds on touch, pedunculated and friable attached to nasal septum or lateral wall or nasopharynx Avoid probe test Biopsy – avoided as bleed, sporangia, can do DNE D/D – Nasal growth
- 32. Treatment Completeexcision of mass by diathermy knife or LASER and cauterization of base Endoscopic examination – to identify pedicle For larger mass – lateral rhinotomy approach Dapsone Amphotericin B
- 33. Mycobacterium tuberculosis Secondary to pulmonary TB Affects anterior part of nasal cavity (cartilaginous septum), ant end of inferior turbinate Stages Catarrhal – inflammation and congestion Nodular – tuberculoma formation Ulcerative – septal perforation Cicatrization – fibrosis, stenosis, adhesions Pathology – acid fast bacilli, epitheloid cells, langheran giant cells
- 34. C/F Serosanginousnasal discharge, later stage – blood stained Nasal obstruction Pain – due to exposed nerve endings Signs – bright nodular thickening of septum with perforation, adhesions, stenosis Investigations – chest x ray, swab c/s, biopsy , sputum for AFB, biopsy, x ray pns Treatment – ATT, surgical reconstruction
- 35. Indolent andchronic form of TB F:M 2:1 Early adult age Nasal vestibule (mc), skin of nose and face Pathology – granuloma formation, fibrosis, stenosis C/F Foul smelling nasal discharge, crusting, nasal obstruction, epistaxis Butterfly appearance of nasal skin Reddish brown APPLE JELLY NODULES – become prominent on pressing by a glass slide Chronic vestibulitis, septal perforation
- 36. Diagnosis –biopsy, c/s, mantoux test, chest x ray Complications – atrophic rhinitis, chronic dacrocystitis Treatment ATT Reconstructive surgery
- 37. Hansen’s disease Lepromatous leprosy – nose involved in all cases Tropical/subtropical warm/wet climate Anterior end of inferior turbinate (mc), septum Mycobacterium leprae Mode of transmission – prolonged contact, droplet infection C/F Catarrhal stage – coryza with bacterial infiltration following nose picking Nodular stage – thickening of affected part, secondary atrophic rhinitis Ulcerative stage – septal perforation, nasal destruction Cicatrization stage – fibrosis, stenosis of vestibule Saddle nose deformity, columellar retraction, AR
- 38. Diagnosis –biopsy Treatment Dapsone – DOC for 2 months Rifampicin, clofazimine, isoniazid Surgical reconstruction – after disease free
- 39. Treponema Pallidium– spirochete ACQUIRED SYPHILIS Primary CHANCRE – hard, non painful, ulcerated papule most commonly involves nasal vestibule with enlarged rubbery LN – rare Secondary Simple catarrhal rhinitis- skin rash, rhinitis, fever, crusting Tertiary – MC Gumma – affects bony part of septum (mc), cartilage part (rare) – swelling seen, ulcerates, scarring Septal perforation, palatal perforation, collapse of nasal bridge, pain, headache worst at night, crusts, bleeding, offensive nasal discharge , vestibular stenosis
- 40. Congenital Birth– 1st three months of life Snuffles – excoriation of nasal vestibule or skin of upper lip, features of simple catarrhal rhinitis Delayed – puberty – Gumma formation Diagnosis – biopsy, VDRL test Treatment Pencillin – DOC Doxycycline, amoxycillin Alkaline nasal douching Surgical reconstruction when disease cured/free
- 41. Granulomatous diseaseassociated with abnormality of cell mediated and humoral immunity Resembles TB but Non caseating Females , 3rd to 5th decade Involves almost all organs – nose, lungs, eyes, salivary glands, tonsils, larynx, skin, ears Nasal features – submucosal bluish red nodules on septum and inferior turbinate, vestibule Crusts with nasal obstruction, pain, epistaxis Also cause – lymphadenopathy, facial nerve palsy, sudden deafness
- 42. Diagnosis Biopsy– non caseating granuloma without myc. Tuberculosis Chest X Ray – diffuse pulmonary infiltrates with hilar adenopathy Bronchopulmonary lavage Gallium 67 scan Kveim test – positive Increased serum and urinary calcium, ESR, Alkaline phosphatase Treatment – topical steroid nasal spray, oral steroids Methotrexate – for refractory cases
- 43. Autoimmune conditionassociated with necrotizing granulomas and vasculitis of upper and lower respiratory tract 1st site affected – nasal cavity Also involves kidneys and skin M=F, 40-50 years of age Very rapid destruction but less severe Type 1 – limited to nose C/F – ulceration of nose with very large crusts, blood stained nasal discharge, pain over dorsum of nose, doesn’t respond to medical treatment Can lead to septal perforation, saddle nose Associated with weakness, fatigue, night sweats, arthralgia
- 44. Type 2– with pulmonary symptoms like cough, hemoptysis, pleuritic pain and cavity in lung Type 3 – multi organ involvement Eyes – NLD obstruction, proptosis Ear – serous otitis media, profound SNHL Oropharynx – ulcers, gingival lesions Subglottis and trachea - stenosis Kidneys – renal failure – cause of death Skin Prognosis – high chances of recurrence
- 45. Diagnosis CBC– anaemia, raised ESR, eosinophilia Raised RFT Urine – red cells, casts and albumin X Ray chest – cavity Biopsy (from turbinates) – vasculitis, granuloma Anti Neutrophilic Cytoplasmic Antibody (ANCA) C ANCA (cytoplasmic) – more specific than p ANCA (perinuclear) More sensitive for type 3 disease D/D – Sinonasal lymphoma
- 46. Treatment Immunosuppressive therapy – Oral Cyclophosphamide/Azathioprine – cytotoxic drugs Wysolone Cotrimoxazole – for early limited type 1 IV Ig Plasma exchange Nasal douching for crusts Surgery – reconstruction when disease inactive
- 47. Malignant granuloma/midline lymphoma/ stewart’s granuloma/ peripheral T cell neoplasm Slow destruction but very severe No pulmonary/renal involvement No vasculitis Autoimmune disease leading to destruction of midline of face Nasal – ulceration of cartilage and bone, serosanguinous discharge, swelling of nose Can involve upper lip, maxillary sinus, oral cavity Can be secondary infected by bacteria Destruction of nose and PNS
- 48. Diagnosis Biopsy Immunohistochemical studies EBV – RNA Treatment Curative RT Surgical debridement No role of steroids or cytotoxic drugs
- 49. MC –children, mental retarded adults Can enter through anterior and posterior nares Accidental – children – ant nares Food particles, vomitus while coughing, regurgitation – post nares, due to nasopharyngeal isthmus incompetency Iatrogenic – sponge, cotton swabs Bullets – penetrating FB Infection – atrophic rhinitis - maggots
- 50. Types Living– maggots, leech Non living – organic (seeds, grams), inorganic (paper, button, pebble, rubber, chalk, beads, cell battery) C/F h/o FB Sneezing, u/l nasal blockage, u/l bleeding u/l foul smelling nasal discharge purulent and may be blood stained Pain FB seen – mc site is lower part of nasal cavity Oedematous mucosa with granulations
- 51. Complications Emergency– risk of inhalation into lower respiratory tract Rhinolith – long term FB with deposition of calcium and magnesium salts Nasal infection, sinusitis Swallowed in oesophagus Diagnosis X ray PNS, Lateral view Neck – radio opaque FB DNE
- 52. Treatment FBremoval Forceps/hook/ ET catheter – pass behind the FB to pull it Children – under GA Leech – removed by putting pinch of salt/ hypertonic saline/ oxalic acid on body
- 53. Calculus/concretions Nose Stone formation in nasal cavity Formed around FB, blood clot, secretions – long standing, thick mucus Due to deposition of carbonates and phosphates of calcium and magnesium C/F Large hard irregular but friable mass – greyish brown or greenish black in colour, stony hard on probing near floor of nasal cavity U/L Nasal obstruction u/l foul smelling blood stained nasal discharge Head ache, epistaxis
- 54. Ulceration ofmucosa and granulations MC – adults Diagnosis – X Ray PNS, DNE Complications – Oroantral fistula Treatment Endoscopic removal under GA Break the rhinolith into small pieces Large rhinolith – lateral rhinotomy
- 55. Maggots innose Larvae of house fly – genus chrysomyia Tropics – hot and humid climate Months of August to November Infest nose, nasopharynx, PNS Also ear, tracheostoma and neck flaps Etiology Poor hygiene Foul smelling nasal discharge seen in atrophic rhintis, syphilis, leprosy, wegner’s granulomatosis, suppurative sinusitis, malignancy of maxilla Immunocompromised patients - DM
- 56. Osteoradionecrosis afterRT Comatosed patients Pathogenesis – foul smell attracts flies which lay eggs, develop into larva in 24 hours (maggots) Larva secrete proteolytic enzymes which cause extensive destruction C/F Tickling sensation in nose leading to irritation Sneezing Lacrimation Blood stained nasal discharge, foul smelling Nasal obstruction Crusting and loss of sensation
- 57. Headache, fever,toxemia Cellulitis of face and nose, diffuse swelling Pain over root of nose Congestion, oedema and ulceration of nasal mucosa Complications Intracranial complications like meningitis Septicaemia/ infection Destruction of nose and PNS Palatal perforation and fistulae, septal perforation Psychological effect
- 58. Treatment Isolatethe patient – with mosquito net to avoid contact with flies, hospitalization Nasal hygiene to prevent recurrence Inj TT Broad spectrum antibiotics for secondary infection Irritate the maggots and plug the nasal cavity by using cotton pledgets soaked in liquid paraffin, chloroform, turpentine oil, ether Topical oil, liquid paraffin drops Nasal douching Forceps removal
- 59. Acute IgEmediated immunological (type I hypersensitivity) response of nasal mucosa to a allergen (antigen) associated with atleast 2 of the following symptoms – nasal discharge, nasal blockage, itching and watering from the nose Co exists with asthma in 45% patients, allergic dermatitis Allergens Inhaled – house dust mite, pollens, moulds, animal dander, insects Food – eggs, sea food, pea nut, milk, wheat Drugs – aspirin, hypotensive drugs, iodide TYPES Seasonal – HAY FEVER – more severe, pollens – tree/grass/weeds Perennial – less severe – dust mite, mould, animal dander
- 60. Precipitating factors Age – younger age – 15-40 years Sex – slightly in males Flora – geography, climate, season Pollutants and smoke – industrialization, urbanization Genetics – family history 50% positive Infection – effects on tissue Endocrine – increased in pregnancy, menstruation, menopause Psychological Work place and living conditions – crowded, dirty, dusty, damp, less sunlight Deficiency of Vitamin C,D,Calcium and IgA Trauma
- 61. Pathophysiology Mucosaalready sensitized to a allergen (priming) Second exposure -> antibody produced against antigen -> fixes to mast cells ->degranulation of mast cells -> release of mediators – IMMEDIATE RESPONSE – within 5-30 minutes of exposure Histamine – sneezing, itching, watery discharge PG – nasal blockage, Leukotriens – sinusitis, cold, polyp LATE RESPONSE – after 2-8 hours – eosinophils, neutrophils, basophils, CD4 T cells – swelling, thick secretions, nasal congestion
- 62. C/F 10-20bouts of sneezing at a time B/L Nasal obstruction Watering and itching of nose Watering and itching of eyes Itching of palate, skin Decreased sensation of smell Bronchospasm Recurrent cold in perennial AR Signs – oedematous nasal mucosa pale blue, oedematous turbinates pale blue, clear/mucoid secretions, polypoidal mucosa, thickened septum, high arched palate
- 63. Allergic shiners– dark circles around eyes due to venous stasis Allergic salute – rubs nose with the palm Dennie Morgan/Darrier’s line – transverse nasal crease along middle of nasal dorsum Complications Recurrent Sinusitis, nasal polyp Eyes – conjuctivitis and oedema Ears – SOM, ET blockage, retracted TM, CHL Pharynx – granular pharyngitis, adenoid facies Larynx – vc oedema, hoarseness of voice
- 64. Intermittent AR– symptoms less than 4 weeks or less than 4 days per week Persistant AR – symptoms more than 4 weeks or more than 4 days per week Diagnosis Nasal smear – nasal cytology for eosinophilia (>10%) CBC – TLC/DLC, AEC DNE X Ray PNS/ CT PNS – sinusitis/polyp
- 65. IN VIVOTESTS Subcuticular test/ skin prick test/ scratch test Preferred, reproducible, more accurate, less false positive Wheal more than 3 mm than negative control 10 min for histamine, 20 min for allergens C/I – extensive dermatitis, dermatographism, on antihistamines Intradermal tests High risk of anaphylaxis Nasal provocation/ challenge test – small amount of allergen is sniffed by the patient, applied to mucosa, through nebulizer – anaphylaxis risk
- 66. IN VITROTESTS RAST – Radio Allergo Sorbent Test FAST – Fluoro Allergo Sorbent Test PRIST – Paper Immuno Allergo Sorbent Test Specific IgE Total IgE No risk of systemic reaction No affect of dermatitis, dermatographism, antihistamines Less sensitive More false negative results
- 67. TREATMENT Avoidanceof allergen Avoid early morning outdoors for pollen Keep pets away for animal dander Change bedsheets and pillow covers twice a week, encass the mattresses, vacuum cleaner/wet mopping, avoid carpets – dust mite Repair leaks, damp walls – indoor moulds Change of place, work, enviroment, AC closed rooms, less articles in room, avoid food and drugs causing allergy
- 68. DRUGS Antihistamines 1st gen – CPM – sedation 2nd gen – cetrizine, loratidine – less sedation 3rd gen – levocetrizine, fexofenadine – minimal sedation Relieves itching, watering and sneezing No effect on nasal obstruction Azelastin nasal spray – no long term sedation, safe Steroids Intranasal steroids – DOC , less side effects, can be used for longer periods – fluticasone, mometasone, budesonide, beclomethasone – rarely long term lead to fungal infection and crusting Oral steroids – in severe cases, for shorter periods
- 69. Mast cellstabilizers Sodium chromoglycate nasal drops/spray For prophylaxis Decongestants For nasal obstruction and mucosal oedema Oral – phenylephrine, pseudoephedrine Topical – xylometazoline, oxymetazoline, ephidrine – use less than 7 days – Rhinitis medicamentosa Anticholinergic drugs Ipratropium bromide – topical For watery rhinorrhoea, post nasal discharge Not for sneezing, nasal obstruction, pruritus
- 70. Antileukotriens Monteleukast,zafirleukast, pratileukast For nasal obstruction, mucous secretions Anti IgE antibody Omalizumab Above age of 12 years For AR associated with moderate to severe asthma Saline irrigation Surgical – septoplasty, turbinate reduction, FESS Immunotherapy – SCIT, SLIT – suppresses IgE, raise IgG, for severe AR not responding to medical and avoidance therapy, more effective when single or fewer allergens Desensitization – for specific allergens, drug allergy
- 71. PROTOCOL MILD– oral antihistaminics MODERATE/PERSISTANT – INS SEVERE – oral antihistaminics and INS VERY SEVERE – Oral steroids and immunotherapy If nasal obstructions – topic nasal decongestants For prophylaxis – intra nasal sodium chromoglycate
- 72. Chronic conditionof nasal cavity associated with nasal blockage and rhinorrhoea due to imbalance in autonomic nervous system with parasympathetic overactivity and sympathetic underactivity Parasympathetic leads to vasodilation and congestion Etiology Younger age, females, anxiety and depression, psychological Precipitated by dust, fumes, climate changes, irritants, alcohol, exercise Endocrinal/ hormonal causes No cause identified - idiopathic
- 73. C/F Profuseexcessive rhinorrhoea, more early morning – runners B/L alternating nasal obstruction, more at night – blockers Post nasal discharge Sneezing, itching - rare Less oedematous pale mucosa Turbinate hypertrophy Mulberry inferior turbinate – posterior end Complications Polyps, sinusitis D/D – Allergic rhinitis, infective rhinitis
- 74. Diagnosis CBC,Nasal smear, Allergy tests CT/MRI Treatment Antihistamines Oral decongestants Ipratropium bromide nasal spray – for nasal secretions Topical decongestants – not effective Exercise – adjuvant role Alprazolam – tranquillizer Avoid precipitating factors
- 75. Surgery Turbinatereduction Vidian neurectomy – for refractory cases with excessive rhinorrhoea – section of the ps fibres NARES Non Allergic Rhinitis with Eosinophilia Perennial Negative SPT/ IN VITRO TESTS Aggravated by weather changes, chemical irritants Watery discharge, itching, sneezing, epiphora Nasal smear - eosinophilia