ALLERGIC RHINI

DEFINITION

Allergic rhinitis is clinically de

as a symptomatic
disorder of the nose induced
IgE-mediated inflammation a
allergen exposure of the
 NATURAL HISTORY

•Onset is common in
childhood, adolescence and
early childhood .
• Symptoms often wane in
older adults, but may
develop or persist at any age
 NATURAL HISTORY

•No apparent gender

selectivity or predisposition
to developing AR
• May contribute to a
number of other conditions
 ALLERGIC RHINITIS
• Inflammatory disorder of nasal mucosa,
characterized by pruritus, sneezing,
rhinorrhoea and nasal congestion.
• Adversely affects social life, school
performance, and work productivity;
especially in patients with severe disease
• Loss of productivity, missed school and
work days, and direct costs associated with
treatment create substantial costs to 378: 2112–22
Lancet 2011;
AN ALLERGIC REACTION
 Dendritic
Cells

Moncytes &
Macrophages T- Cells

Inflammatory Cells

B-
Eosinophils Lymphocytes

Mast Cells
 Histamine Chemokines

Chemical Cytokines
Mediators

Leukotrines Prostaglandins
THE ALLERGIC REACTION

Sensitization

Ig E Production

Arming of mast cells

Release of mediators

Clinical effects
INFLAMMATORY CASCADE IN ALLERGIC
RHINITIS

Adapted from Indian J Chest Dis Allied Sci. 2003 Jul-Sep;45(3):179-89

HOW ARE THE SYMPTOMS CAUSED
CLASSICAL SYMPTOMS

Repetitive Nasal Watery

Sneezing Congestion Rhinorrhea P
OTHER MANIFESTATIONS

Eye Symptoms

Ear Symptoms

Post nasal drip

AR

Intermittent Persist
Classification
Moderate
Mild
Sever
INTERMITTENT

<4
days/week < 4 week
PERSISTENT

> 4 days
/week > 4 week
MILD

Normal sleep

No impairment of daily activit

No troublesome Symptoms in untreated

MODERATE TO SEVERE

Abnormal Sleep

Impairement of daily activity

Abnormal work

Troublesome Symptoms
RISK FACTORS FOR ALLERGIC DISEAS

Male G
Season of
Family History dur
Birth
Child

Increase in Dietary
Obe
pollution Changes
ALLERGIC SHINERS
ALLERGIC SALUTE AND CREASE
ALLERGIC CONJUCTIVITIS
AR & CO-MORBIDITIES

Otitis
Media

Asthma URTI

Nasal
Sinusitis
Polyps
ALLERGIC RHINITIS AND DISEASES OF THE UPPER
 AR AND ASTHMA

Approx. 80% of patients

with asthma have
accompanying symptoms
of rhinitis, and up to 60%
of the patients with asthma
have sinusitis
MANAGEMENT OF ALLERGIC RHINITIS

• Allergen Avoidance
• Pharmacotherapy
• Surgery
• Immunotherapy
 ALGORITHM FOR MANAGEMENT OF AR

Intermittent Symptoms Persistent Symptoms

Allergic Rhinitis

Mild Moderate/Severe Mild Moderate/Severe

Intranasal Steroid
• Oral H1 Blocker • Intranasal Steroid
• Intranasal H1 • Oral H1 Blocker
Follow up after 2 wks.
Blocker • Intranasal H1 Blocker
• Leukotrine • Nasal Cromone
modifier • Leukotrine modifier
Improved Failed
In PAR Pt. FU after 2-4 wks.
Review Dx
Step down
If failure step up, if improved continue for one month Compliance

Intranasal Itch/sneeze add Rhinorrhea add Blockage: add oral

Steroid H1 Blocker Ipratropium decongestant/steroid short term
CLINICAL PRACTICE GUIDEL
 ALLERGIC RHINITIS IN ADULTS

Allergic rhinitis (AR) is defined as chronic or recurrent IgE-mediated inflammation of the nasal mucosa. Primary symptoms
include rhinorrhea, sneezing, nasal itching, nasal congestion and postnasal drainage.

• throat clearing

• eye itching

• Tearing

• eye redness

• palatal itching

• impaired sense of smell (and taste),

• fatigue, impaired concentration and reduced productivity

 RECOMMENDATIONS ON THE
DIAGNOSIS OF ALLERGIC RHINITIS IN
ADULTS
The diagnosis of AR is strongly considered in the presence of the following
•
symptoms:
• nasal itching
• sneezing
• rhinorrhea, and/or nasal congestion or obstruction, triggered by allergen exposure.
• Symptoms may be associated with conjunctival redness, itchy and/or teary eyes.

• allergy triggers
• presence of nasal symptoms and watery-itchy eyes
• positive personal history of atopy
• positive family history of atopy
 SUPPORTIVE CLINICAL INFORMATION THAT
• The frequency and duration (intermittent or persistent) and severity of symptoms
BE SOUGHT INCLUDES
Personal history of other manifestations of atopy
THE FOLLOWING:
•
• Family history of atopy
• Identification of possible allergens in the environment: home, workplace, school, etc.
• Absence of symptoms upon change of environment
• Result of previous allergy testing (e.g., skin test, serum specific IgE test, nasal
provocation test)
• The effects of previous allergen avoidance measures

• Response to pharmacological treatment and previous immunotherapy

• A simple Visual Analog Scale (VAS) quantifying the severity of rhinitis symptoms
• Anterior rhinoscopy must be performed to support the diagnosis of AR and other nasal
pathology.
• Pale gray, dull red, or red turbinates
• Boggy turbinates
• Minimal to profuse, watery to mucoid nasal discharge

• Nasal endoscopy is strongly recommended for selected patients.

• A complete Ear, Nose and Throat (ENT) examination must be
performed on all patients with AR.
• high-arched palate
• open-mouth posture
• Denny-Morgan lines
• nasal crease
• Detailed allergic work-up, e.g., skin tests, serum specific IgE tests,
or nasal provocation tests, may be performed for the following:
• Patients with whom a questionable diagnosis exists
• Patients unresponsive or intolerant to pharmacotherapy
• Patients with multiple target organ involvement (i.e., allergic
manifestations in the eyes, nose, throat, skin, lungs, etc.)
• Patients for whom immunotherapy is considered
• Patients with suspected Local AR (LAR
• Local allergic rhinitis (LAR) is a subset of AR wherein
patients have a clinical history and physical examination
findings consistent with AR, but have no evidence of systemic
atopy (i.e., negative skin prick tests, negative serum specific
IgE tests).
RECOMMENDATIONS ON THE
TREATMENT OF ALLERGIC RHINITIS IN
ADULTS
• Patients should be advised to avoid or minimize exposure to allergens

• Multimodal environmental control strategies are better than any single strategy

• Nasal saline irrigation (NSI) or douching is recommended as an adjunctive treatment for

patients with allergic rhinitis.

• Oral antihistamines are strongly recommended in AR with intermittent symptoms and short
term allergen exposure
• Intranasal antihistamines are recommended alternative therapy to oral
antihistamines in AR with intermittent symptoms and short term exposure to
allergens.

• Intranasal corticosteroids (INCS) for at least one month, is strongly

recommended in AR with intermittent moderate-severe symptoms, persistent
symptoms, and long-term exposure to allergens.

• A short course of oral corticosteroids (5 to 7 days) may be recommended in AR

with moderate-severe and persistent symptoms not responsive to INCS.
• Oral anti-leukotriene agents, alone, in combination with antihistamines, or in
combination with INCS, may be recommended in AR especially in the presence
of asthma.

• Intranasal cromolyn sodium may be used in AR, especially because of its

lesser side effects. However, it is less effective than corticosteroids, and has
not been adequately studied in comparison to anti-leukotriene and
antihistamine agents

• Oral and topical decongestants may be used for patients with prominent nasal
obstruction. However, they must be used judiciously and according to
pharmacologic indications
• Combination preparations of pharmacotherapeutic agents may be
patients suffering from AR with inadequate response to monothera

• Allergen specific immunotherapy (SIT) is effective for the treatmen

• VAS scoring should be done periodically to assess symptom sever

response to treatment
THANK YOU