ALLERGIC RHINITIS
Dr Nishikanta Verma
Professor and Head
Department of ENT
Melaka Manipal Medical College
WHAT IS ALLERGIC RHINITIS?
ALLERGENS
IgE mediated hypersensitivity reaction of the
nasal mucosa
Characterized by itchy nose, sneezing, watery
rhinorrhoea and nasal obstruction.
Any proteinaceous material-
inhalant/ ingestant
IgE
PATHOGENESIS
PATHOGENESIS
Allergen deposition- Priming
development of IgE antibodies
Subsequent deposition-
Antigen-antibody complex--
degranulates the mast cells
Release of mediators of allergy
like histamine,leucotrienes
Degranulation processes 1 - antigen; 2 - IgE antibody; 3 - Fc RI receptor;
4 - preformed mediators (histamine, proteases, chemokines, heparin); 5 -
granules; 6 - mast cell; 7 - newly formed mediators (prostaglandins,
leukotrienes, thromboxanes, PAF)
PREDISPOSING FACTORS
Heredity: Family history may be present
Age: more in adults compared to children
Geographical location: Incidence of seasonal rhinitis
differ in different countries
Environmental factors-living conditions
Socio-economic factors
TYPES
Seasonal (Hay fever)
Pollens (spring)
Grasses (summer)
Weeds (Rainy)
Perennial
Round the year
Indoor allergens such as mold, house dust
mite, cockroach and animal dander
Ingestants like sea food, egg, etc.
THE ALLERGIC MARCH
CLINICAL FEATURES- SYMPTOMS
Episodes/bouts of
Sneezing
Watery rhinorrhea
Nasal obstruction
Itching/irritation/burning
sensation in the nose
SIGNS
Reddened nose,
allergic salute, allergic
Generalized pale,
bluish, edematous,
boggy mucosa.
Mulberry turbinate
INVESTIGATIONS
Complete blood picture including TC/DC, absolute
eosinophil count
Nasal smear for eosinophils
X-ray PNS
Allergic skin tests- Prick test, intradermal tests,
invitro tests (ELISA, RAST, PRIST, etc.)
Diagnostic nasal endoscopy
CT scan of OMC
Nasal challenge tests
Subcuticular allergic
test (Prick test)
TREATMENT
Allergen avoidance Avoid pets
Nasal filters/ masks
Air-conditioning
Immunotherapy Room heaters if
Pharmacotherapy (Drugs) humid..prevents fungus
Surgery Vacuum cleaning
Synthetic bed-sheets/
pillows
Change of place/work, etc..
IS IT MILD OR SEVERE?
PHARMACOTHERAPY (DRUGS)
Antihistamines
Decongestants
Steroid sprays
Antibiotics
Mast cell stabilizers
Saline douching
Steam inhalation
NASAL STEROIDS
IMMUNO-THERAPY
Hyposensitization/ desensitization
Choose the antigens (allergens) as per allergic skin
test results
Not more than 5-6 allergens
Repeated intradermal injections (weekly/ monthly)
slowly increase
Terminated if poor response by one year of
treatment
<50% respond
SURGERY
Indicated for obstructive symptoms because of
HYPERTROPHIED TURBINATES
DEVIATED SEPTUM
Submucosal Diathermy
Cryotherapy
Turbinectomy
COMPLICATIONS OF ALLERGIC
RHINITIS
Chronic sinusitis
Ethmoidal polyposis
Exacerbation of bronchial asthma
Emotionally and occupationally affected
Antihistaminic drugs may cause drowsiness-
avoid driving/ machinery
Antihistaminc drugs may increase/ induce
hypertension
Vasomotor rhinitis
Inflammation of the nasal mucosa consequent to
imbalance in the autonomic nerve supply to the
nasal cavity
Parasympathetic overactivity vasodilatation
and engorgement of the turbinates and
increased mucous secretion
Sympathetic opposite response
Nasal cycle
Physiological cyclical events of
Influenced by:
congestion and decongestion
taking place alternating between Climate
the two nasal cavities
Respiration
During quiet respiration we Exercise
breath through one side for Emotions
some time and later through the
other
Posture
Endocrine
Drugs
Controlled by autonomic
nervous system
Clinical features- symptoms and
signs
Nasal symptoms Enlarged reddish
triggered by the factors turbinates especially
that affect the nasal the inferior turbinate
cycle No generalized
Alternating nasal mucosal congestion or
obstruction odema
Watery-mucoid
rhinorrhoea
May be associated with
allergic rhinitis
Treatment
Avoid triggering factors if possible
Nasal decongestants: Topical/ systemic
whenever indicated
Ipratropium Bromide
Vidian neurectomy
Turbinate reducing procedures
ATROPHIC RHINITIS
Chronic inflammation of the nasal mucosa
characterized by atrophy of the mucosa and
the turbinates leading to roomy nasal cavity,
drying of the nasal mucosa and formation of
foul smelling greenish yellow crusts
Syn: Ozaena
Foul smell from the patients nose perceived by
others
Types
Primary: Exact cause is not known
(idiopathic)
Secondary: Secondary to a known cause
SECONDARY ATROPHIC
RHINITIS
Chronic granulomatous infections
Tuberculosis, lupus, sarcoidosis
Syphilis
Leprosy
Rhinoscleroma
Extensive nasal surgeries
Medial maxillectomy
Total maxillectomy
Total inferior turbinectomy
Pathology
Endarteritis/ periarteritis
Atrophy of the nasal mucosa
Roomy nasal cavities and mucociliary dysfunction
Crust formation: Greenish yellow foul smelling crusts
ozaena
SYMPTOMS
Usually bilateral
Nasal discharge and epistaxis
Nasal obstruction
- social
problems
Merciful hyposmia/ anosmia
Signs
Dry mucosa
Atropic turbinates
Roomy nasal cavity
Greenish yellow crusts
Bleeding on attempt to
remove the crusts +/-
Granuloma/ septal
perforation or palatal
perforation +/-
Investigations
To rule out secondary causes
TB: ESR, CXR, Mx, sputum/ nasal secretions for
AFB, etc.
Syphilis: VDRL, TPHA, TPI, etc.
Leprosy: Lepramin test
Rhinoscleroma: Biopsy
Nasal mass/ granuloma: biopsy
Investigations
To rule out secondary chronic sinusitis
X-ray PNS-
Diagnostic nasal endoscopy
CT scan of PNS
Treatment- Medical
Objectives
Removal of foul smelling crusts
Moisturize the nasal mucosa
Increase nasal secretions
Treat secondary infections
Promote formation of normal mucosa- often
difficult
Treatment- Medical
2% Alkaline nasal douching/ lavage: daily probably
life long/ till surgical treatment
25% glucose in glycerine nasal drops: three times a
day
Vitamin and iron supplementation
NO NASAL DECONGESTANTS/ ANTIHISTAMINICS
Surgery
To reduce the roomy nasal cavity
Submucosal implantation of fat/ cartilage/ bone/
synthetic materials
Prognosis
Medically symptoms can be kept under
control
Cure from disease not common even following
surgery