This presentation discusses the topic Rhinitis

1. Rhinitis Dr T Balasubramanian

2. Definition Rhinitis is defined as inflammation of nasal mucosal lining characterized by one Or more of the following symptoms: 1. Nasal congestion 2. Rhinorrhoea 3. Sneezing 4. Itching

3. Rhinosinusitis Anatomically the lining mucosa is contiguous With that of paranasal sinuses. It goes without Saying that if one is involved the other is also Involved. Hence instead of using the term Rhinitis it would be apt to use the term “ Rhinosinusitis”.

4. Symptom complex Symptom complex of rhinosinusitis include: 1. Nasal congestion 2. Rhinorrhoea 3. Sneezing 4. Itching 5. Hyposmia 6. Anosmia 7. Facial pain 8. Head ache

5. Classification

6. Allergic rhinitis 1. Very common 2. Incidence seems to be increasing 3. Frequently accompanied by asthma 4. Other co existing conditions include: conjunctivitis Sinusitis and otitis media.

7. Symptoms 1. Repeated attacks of sneezing 2. Itiching in the nose 3. Rhinorrhoea 4. Itching of eyes 5. Headache due to congestion of paranasal sinuses 6. These symptoms tend to reduce with age

8. Allergic rhinitis classification 1. Intermittent (Seasonal) 2. Persistent (Perennial) 3. Mild 4. Moderate - severe

9. Seasonal rhinitis 1. Also known as intermittent rhinitis 2. It usually lasts less than 4 days a week 3. The whole disorder lasts for about a month 4. Usually caused due to exposure to seasonal Allergens like pollen 5. Common during spring when flowers bloom

10. Perennial rhinitis 1. Also known as persistent rhinitis 2. Symptoms last for more than 4 days a week 3. Whole disorder lasts for more than a month 4. This is due to continuous exposure to allergen eg. House dust mite

11. Mild allergic rhinitis Allergic rhinitis is considered to be mild if the symptoms Does'nt cause: Sleep disturbance Impairment of daily activity Impairment of work Troublesome symptoms

12. Moderate allergic rhinitis This includes one or more of the following: Sleep disturbance Impairment of daily activity Impairment of work Troublesome symptoms

13. WHO classification of allergic rhinitis WHO has advised abandoning of the terms seasonal and Perennial rhinitis in favour of intermittent and persistent Allergic rhinitis.

14. Why this advise? 1. Pollens and moulds which cause seasonal rhinitis are Perennially present in some areas 2. Symptoms of perennial allergy need not be present Throughout the year 3. Perennial symptoms may present with seasonal exacerbations

15. Allergic rhinitis pathophysiology The reaction occurs in 4 phases 1. Sensitization 2. Subsequent reaction to allergen – early phase 3. Late phase reaction 4. Systemic activation

16. Sensitization Grass pollen / House dust mite / cat dander Harmless in non atopics In atopics gets attached to antigen presenting cells Present in the nasal mucosa These activated APC's stimulate hypersensitivity Mast cells are responsible for sensitization

17. Early phase of allergic rhinitis Histamine is responsible Rhinitis Sneezing Prurutis Mast cell degranulation plays a role Prostaglandin D2 / cytokines may play a role

18. Late phase response This phase is inflammatory in nature Ingress of eosinophils / basophils / mast cells / T lymphocytes / neutrophils / macrophages Eosinophils mature and reside in the nasal mucosa For more than a week Symptoms – Nasal block / hyper reactivity

19. Systemic activation Increased production of eosinophils from bone marrow Bronchial asthma Nasal polyposis

20. Occupational rhinitis 1. Can also be considered as one form of allergic Rhinitis 2. Allergy could be due to exposure to mice / guinea Pig hair in lab 3. Exposure to platinum salts could sensitize a patient

21. Occupational rhinitis Risk factors 1. Smoking 2. Intensity / duration of exposure 3. Atopy

22. NARES Non allergic rhinitis with eosinophilia syndrome Middle aged individuals Nasal eosinophilia Nasal itching Perennial rhinorrhoea Anosmia (rare) Aspirin hypersensitivity + Respond to intranasal topical steroids

23. Endocrine rhinitis Pregnancy rhinitis Puberty rhinitis Menstrual cycle rhinitis Hypothyroidism Acromegaly Emotional rhinitis

24. Drug induced rhinitis Nsaids Beta blockers ACEI Oral contraceptives Rhinitis medicamentosa Cocaine abuse

25. Irritant rhinitis Skier's nose Gustatory rhinitis (due to spicy food) Alcohol rhinitis

26. Vasomotor rhinitis Etiology unknown Sympathetic / parasympathetic imbalance Cold dry air challenge test could help Nasal block & rhinitis predominate

27. Investigations 1. Skin prick tests 2. Radiology 3. Nasal swab 4. Nasal challenge 5. Nasal biopsy for assessing mucociliary function 6. Rhinomanometry 7. Tests for olfaction

28. Thank you