ALLERGIC RHINITIS
Dr. LOKNATH SAHOO
Associate Professor, Dept. of E.N.T
I.M.S. & SUM Hospital Bhubaneswar
Definition
◦ Clinical hypersensitivity of nasal mucosa to foreign substances mediated through IgE
antibodies.
◦ Rhinitis any 2 of the symptoms of Running nose, Itching, Blockade, Sneezing.
◦ ARIA (Allergic Rhinitis and its Impact on Asthma) GUIDELINES
◦ Based On Duration:
◦ Intermittent symptoms - < 4 days per week, < 4 weeks
◦ Persistent symptoms - > 4 days per week, > 4 weeks
◦ Based on Severity:
◦ Mild – Normal sleep, Normal daily activity, Normal work and school, No troublesome
◦ Symptoms.
◦ Moderate – severe – vice versa
Risk factors
1. Adolescent males
2. IgA deficiency state
3. Family history of allergy (Allergic rhinitis).
Seasonal allergy indicates risk of Asthma
4. Environmental factors
◦ Hygiene hypothesis – lifestyle changes, increased exposure to allergens, pollution, irritants, and
dietary modifications that decreases TH1 type immune response.
5. Common allergens
◦ Seasonal Allergens (Seasonal Allergic Rhinitis aka Hay fever): Tree, Grass,Weed Pollens.
◦ Perennial Allergens: Dust, Dander, Mites
◦ Occupational allergens: Latex, Flour, Washing Powders, Lab Animals
◦ Food And Drug Allergens – peanuts, egg, meat, fish etc.
◦ Comorbidities: Asthma, otitis media, sinusitis, LRTI, dental occlusion.
◦ Smoking increases IgE but DECREASES incidence of Allergic Rhinitis
Pathophysiology
There are 4 phases
◦ Sensitization
◦ Early phase reaction
◦ Late phase reaction
◦ Systemic Activation
Clinical presentation
Symptoms
◦ Runny nose
◦ Itching
◦ Nasal blockade
◦ Sneezing
◦ Otological Signs and Pharyngeal signs (granular Pharyngitis), vocal cord
oedema leading to laryngeal signs (hoarseness)
Signs
Mostly found in paediatric population
◦ Darriers Line – crease in tip of nose with crusting
◦ Periorbital oedema
◦ Dark circles around eyes – Allergic Shiners
◦ Transverse Crease on lower eyelid – Dennie Morgan
Folds (Muller Muscle Spasm)
◦ Conjunctival congestion
◦ Epiphora
◦ Allergic salute
◦ Allergic Facies – High Arched Palate, Narrow Chin,
Elongated Maxilla.
Nasal Examination
◦ Anterior Rhinoscopy:
Normal mucosa in asymptomatic patients.
Pale, Boggy, Bluish oedematous nasal mucosa.
Bulky turbinates with coating of clear or mucoid secretions.
Mulberry shaped turbinates.
Note – always look for ethmoidal polyps.
Investigations
◦ Blood Picture
Especially Eosinophil counts, Ig E level, IgA levels
◦ Skin prick test(SPT)
Fast, Cheap & more sensitive than RAST,altered by therapy & less reliable for Food allergen.
For SPT test positivity it should be 2 mm more than the negative (mean wheal diameter at 15min)
SPT for food allergen is less reliable and less safe than for inhaled allergen
So not applied for patients on antihistaminics, severe eczema, previous life threatening
anaphylaxis or dermagraphism.
◦ RAST (Radio Allergo Absorbant Test) :Doesn’t alter with therapy
◦ RAST, FAST, MAST, PRIST, Total IgE, ELISA all are less sensitive than Skin Prick Test.
Nasal Allergen Challenge testing
Treatment
Medical
◦ Avoidance of allergens
◦ Antihistamines
◦ Steroids-local & systemic (R/o diabetes and hypertension before starting steroids)
◦ Immunotherapy
◦ Immunoglobulins injection histoglobulins S/C or [Link] inj x 10 weeks
◦ Sodium cromoglycate spray
◦ Tab Ketotifen-1-1-1 x month
◦ Anticholinergic nasal spray
◦ Antihistamine nasal spray
◦ Silver nitrate cauterization 15%
◦ Local application of hydrocortisone in inferior turbinate and nasal septum
◦ ANTIHISTAMINICS
1st gen – Chlorpheniramine
2nd generation – Terfinadine, Ebastine, Loratidine.
Antihistaminics are more effective if used regularly than intermittently.
◦ NASAL DECONGESTANTS
Reduce nasal obstruction but increase rhinorrhoea so give accordingly.
◦ Systemic decongestants are ineffective
◦ MAST CELL STABILISERs
1. Sodium Chromoglycolate 2. Nedocromil 3. Ketotifen 4. Methyl Xanthines like
theophylline 5. Quercetin 6. Omalizumab
◦ ANTICHOLINERGICS
For excessive rhinorrhoea Ipratropium bromide can be used
◦ ANTI LEUKOTRIENES
Monteleukast
Zafirleukast
Mainly effective for nasal polyposis
◦ STEROIDS
Nasal steroids reduce inflammation and consequent hyper reactivity, reduce nasal symptoms, eye
symptoms and improve the sense of smell.
Fluticasone propionate is licensed for children from four years onwards.
Rhinitis of pregnancy often resistant to treatment.
◦ IMMUNOTHERAPY (Allergy Vaccine Therapy)
◦ Generally, 'updosing' phase involves weekly dosing for 8 –16 weeks, followed by 'maintenance'
◦ injections at 4 – 8 weekly intervals for 3 – 5 years.
Immunotherapy
INDICATIONS
IgE mediated disease
1. Inability to avoid allergen 2. Limited spectrum of disease (1 or 2 allergens) 3. Inadequacy or
unresponsiveness to drug treatment
CONTRAINDICATIONS
1. Coexistent Asthma 2. Patients on β blockers 3. Other immunological diseases 4. < 5yrs age
5. Pregnancy (maintenance therapy can be continued)
◦ SIDE EFFECTS
◦ Local reaction (minimal), Systemic reaction rare (rhinitis, asthma very rarely severe like
anaphylaxis)
◦ Urticaria usually occur in updosing phase and within 30 min from injection
◦ These effects usually are seen with subcutaneous dose.
◦ Sublingual route application as drops or tablets are better.
Complications !!
◦ Sinusitis
◦ Nasal Polyposis
◦ Eustachian tube dysfunction
◦ Otitis Media With Effusion
◦ Chronic Pharyngitis
◦ Chronic Bronchitis
◦ Triggers attack of chronic bronchitis
There is treatments