ALLARGIC RHINITIS

• Content:
1. Definition
2. Pathogenesis.
3. Diagnosis) sgins&symptoms &other(.
4. Treatment.
5. Monitoring.
ALLERGIC RHINITIS
• Defined as an inflammation of the
nasalmucosa, caused by an allergen
• Most common atopic allergic reaction
• Affects 10 to 259% of population•50% of
rhinitis in ENT is ARMost commonly seen in
young children andadolscents
Classically symptoms of hay fever are more severe in •
themorning and evening this is because pollen rises during the
dayafter being released in the morning and then settled at
[Link] fever symptoms worsen also on windy days.
Whilesymptoms may be reduced after rain and when the
patient stayindoors
lf a first degree relative suffers from atopy then hay fever is•
themost likely cause of rhinitis. (Atopy: A form of
hypersensitivitycharacterized by a familial tendency)
A number of oral medications are implicated in causing •
rhinitisincluding alpha adrenoceptor antagonists
(e.g. .terazosin) (usedfor benign prostate hyperplasia)
SMPTOMS OF ALLERGIC RHINITIS MAY BE CONFUSED WITH
THAT OF COMMON COLD;HE TWO CONDITIONS MAY BE
DISTINGUISHED BY THE FOLLOWING POINTS
Table 2-3: Differential diagnosis of allergic rhinitis and
) the common cold
Common cold Allergic rhinitis
Usually not ocular symptoms Ocular symptoms present
Symptoms lalast for albout 4- Symptoms continue for as
to several days longas the patient is exposed
to theallergens, often for
severalweeks
Can occr at any time of the Symptoms occur at the
year but moresually in the .sametime each year
winter months
Highly contagious (affects Only affect
WHEN DOES ALLERGIC RHINITIS START?

• Outdoor allergens cause seasonal allergicrhinitis (also known

as hay fever), whichtypically occurs during the spring to the
earlysummer, and late summer to early fall. Indoortriggers
include dust mites, pet dander, pestallergens (from rodents,
cockroaches), or moldthat grows in humid indoor places.
 ETIOLOGY: CLASSIFIED AS
• PRECIPITATING FACTORS • PREDISPOSING FACTORS
• • Genetic• Multiple gene interactions are
responsible for allergicphenotype
• • Aerobiological flora • • Chromosomes 5, 6, 11, 12 & 14 control
• Allergens present in the inflammatory processin atopy

environment • • 50% of allergic rhinitis patients have a

positive family historyof allergic rhiniits
• House dust and dust mites
• • Endocrine• PubertyPregnant states and
• Tobacco smoke• Feathers post partum stages• menopausal

• Animal dander • • Psychological. • Focal sensitivity states

• • Infections: fungal infections nb• Physical
• Industrial chemicals
• • Degree of pollution of air• lgA deificiency
• Disturbances in normal nasal cycle • • Age & sex. • Humidity and temperature
• Nasal physiology differences• Temperature changes
PATHOPHYSIOLOG
Y
• • Immunoglobulin (g) E
mediated type
1hypersensitivity response
to an antigen(allergen) in a
genetically susceptible
person• Type 1
Hypersensitivity causes local
vasodilation and increased
capillarypermeability
SIGNS AND SYMPTOMS

1. Sneezing 6•• Earache

2. Post nasal drip 7• Tearing of eyes

3. Rhinorrhea 8• Red eyes

9• Swollen eyes
4. Itchy nose, ears,eyes and
palateCongestionAnosmia 10• Fatigue

5. Headache 11• Drowsiness

•12 Malaise
PHYSICAL EXAMINATION:

• • Nasal crease
• • Horizontal crease across the
lower half of the bridge of the nose
• • Rhinorrhoea
• Thin watery secretions
• • Deviated orperforated
nasalseptum o
INVESTIGATIONS

• FBC. • Nasal smear • • Intradermal tests

• Histamine test. • Intranasal • • Be prepared for anaphylaxis
provocation test • • Skin end point titration test
• • Quantitative intradermal test for
• Şkin tests• Subcuticular test
specific allergen• Nasal challenge
• Contraindicated in case of anti • • Nasal cytology
histaminic, antiinflammatory or • • Take a sample of nasal cavity
decongestant treatment without anaesthesiaand send for
identificaton of cell types in the
• More accurate with lower
nasalcavity
incidence of false positive results
• • Increased number of eosinophils
suggests allergicdisease
 PREVENTION & TREATMENT

- anyway … ......*AVOIDANCE
• Minimize contact with offending allergens
pillows and matress in allergen proof covering
• Reduce dust mite exposure by encasing bed
• One way to prevent allergic rhinitis is to wear a respirator or
mask when near potential allergens

• treatment:
• 1) pharmacotherapy
• 2) immunotherpy
• Pharmacological therapy:
• 1 ) Intranasal Corticosteroids (strong recommendation); 1" line; Moderate-Severe
(Betamethasone)
Oral Antihistamines (strong recommendation); 1t line; Mild-Moderate )2
)loratadine ‫ ـــ‬levocetrizine (
Oral Leukotriene Receptor Antagonists (recommendation); Coexistent asthma )3
(montelukast)
Intranasal Antihistamines (option); If symptoms not improved with oral antihistamine )4
)azelastine(
Decongestants (option); Short term-use if congestion not improved with INCs )5
(phenylepherine)
Intranasal Mast-Cell Stabilizer (option); Before exposure to specific known allergy )6
(cromolyn)
Intranasal Anticholinergics (option); For sever persistent rhinorrhea (ipratropium) )7
Combination Therapy (option); If inadequate response with monotherapy )8
 INTRANASAL CORTICOSTEROIDS
• Intranasal corticosteroids are also first-line therapeutic options
for patients with mild persistent or moderate/severe symptoms
and they can be used alone or in combination with oral
antihistamines. When used regularly and correctly, intranasal
corticosteroids effectively reduce inflammation of the nasal
mucosa and improve mucosal pathology. Studies and meta-
analyses have shown that intranasal corticosteroids are superior
to antihistamines and leukotriene receptor antagonists in
controlling the symptoms of allergic rhinitis, including nasal
congestion, and rhinorrhea. They have also been shown to
improve ocular symptoms and reduce lower airway symptoms in
patients with concurrent asthma and allergic rhinitis
• B-Mast cell stabilizers (Sodium cromoglicate):
• This is available OTC as nasal drop or spray (4%) and as eye drop.
• Like Corticosteroids (CS) , sodium cromoglicate is a prophylactic
agent, but their place in nasal symptoms of allergic rhinitis is
limited because it is less effective than steroids and it need more
frequent administration( 6 times daily)
• It is preferably started 1 week before the hay fever season is likely
to begin and then used continuously
• There are no significant side effects although nasal irritation may
occur ,no drug interactions and can be given to all patient groups.
Clinical experience has shown cromoglicate to be safe in
pregnancy, and sodium cromoglicate safe in breastfeeding
C-Topical Decongestants:
Intranasal OTC decongestants include:
the short acting decongestants naphazoline, phenylephrine,
and tetrahydrozoline
the long-acting decongestants xylometazoline (8-10 hours)
and oxymetazoline (12 hours)
Note : Topical nasal decongestants (sympathomimetics) can
be recommended for those patients in whom systemic (oral)
decongestants are less suitable. (i.e. D.M, Ischemic heart
disease (angina, M.I), hypertension, and hyperthyroidism.
D-Topical antihistamine:
The BNF suggests that treatment should begin 2–3
weeks before the start of the hay fever season. The
dose: apply twice daily; increased if necessary to 4 times
a day, maximum duration of treatment is 6 weeks.
E-Topical ocular preparations:
include sodium cromoglicate and decongestants-
antihistamine (Naphazoline-Antazoline)
Most eye symptoms will be controlled by oraloral
antihistamines, however if symptoms are persistent or
particularly troublesome, topical ocular preparations are
effective
[Link] (oral)
therapy:
A-Systemic (oral) decongestants: like
pseudoephedrine, and phenylephrine which constrict
the dilated blood vessels of the nose
C/I: Systemic (oral) decongestants cause stimulation of
the heart, increase the Bp and may cause
hyperglycemia, Therefore they should avoid in :
Diabetes mellitus.
ischemic heart disease (angina, M.I),
hypertension,
hyperthyroidism.(The hearts of the hyperthyroid
patients are more vulnerable to irregularity, so
stimulation of the heart is particularly undesirable)]
B-Antihistamines:
Note: 1 (important) The maximum effect of
antihistamines is achieved if they are block histamine
release before it occurs. For maximum effectiveness,
therefore, antihistamines should be taken when
symptoms are expected rather than after they have
started.
2-Breakthrough symptoms with one-a-day
antihistamines: Patients who suffer breakthrough
symptoms using a once daily preparation (loratadine,
cetirizine) may benefit from changing to acrivastine,
as three-times-a-day dosing may confer better
symptom control
Antihistamine can be classified into:
A-Sedating Antihistamine:
chlorphenamine (chlorpheniramine)
dexchlorpheniramine
Clemastine
triprolidine
diphenhydramine
Cyproheptadine
Ketotifen
Dimethindene
The major side effect of the older antihistamines is their
potential to cause drowsiness. Their anticholinergic activity
may result in a dry mouth, blurred vision, constipation and
urinary retention. These effects will be increased if the patient
is already taking another drug with anticholinergic effects (e.g.
tricyclic antidepressants, neuroleptics)
Important : Because of their antimuscarinic actions the
sedating antihistamines should be used with care in conditions
such as angle-closure glaucoma, and prostatic hyperplasia;
antimuscarinic adverse effects are not a significant problem
with non-sedating antihistamines
B-Non-Sedating Antihistamine:
loratadine, acrivastine and cetirizine,
levocetirizine ,desloratadine, fexofenadine
Adult dose of Loratadine: 10 mg once daily.
IMMUNOTHERAPY

If allergic rhinitis is refractory to pharmacotherapy or severe• Helps in reducing the

specific serum lgElevel• decreases the basophil sensitivity• increases lgG blocking
antibody level, thus preventing allergen from reaching mastcells and subsequent mast
cell degranulation

SURGICAL THERAPY
• Limited•
• Submucosal turbinectomy - reduces size ofboggy turbinates•
•Septoplasty - correction of deviation ofseptum
•Sinus surgery - clearance of sinuses ifsinusitis is present
 MONITORING

• Confirm the patient's understanding of the disorder.

• Confirm the patient's understanding about allergen avoidancemeasures.
• Assess the patient's symptom response, tolerance, andadherence.
• Assess the patient's administration technique with intranasalproducts..
Recommend second-generation oral antihistamine therapyfor most
patients with mild or intermittent symptoms.
• Consider step-up therapy for exacerbations or incompleteresponse.
• Recommend INCS therapy for moderate-severe or persistentsymptoms.
Suggest additional therapy for those withincomplete control.
• Consider referral to an allergy specialist for patients whorequest
immunotherapy.•).
WHAT SHOULD
BE•MONITORED WHEN TAKING
CETIRIZINEI
ALSO ÂVAILABLE OVER THE
COUNTER,PRESCRIBERS
SHOULD EDUCATE
PATIENTSSDEON THESiDE
POSSIBLE EFFECTS, WHICH
INCLUDE DROWSIAESS,
FATIGUE,AND DRY MOUTH
WHAT TO MONITOR WITH ANTIHISTAMINES?
OEVALUATION OF A PATIENT USING
ANTIHISTAMINESINCLUDE: MONITOR PATIENT
RESPONSE TO THE DRUG
RELIEF OF THE SYMPTOMS OF ALLERGIC(
MONITOR FOR ADVERSE EFFECTS (SKIN.)RHINITIS
DRYNESS, GI UPSET,SEDATION AND DROWSINESS,
URINARY RETENTION,THICKENED SECRETIONS,
GLAUCOMA)

PATIENTS TAKINGLORATADINE
REQUIREMONITORINGREGARDING$YMPTOMATIC
RELIEF,$EDATION, AND
ANYANTICHOLINERGICEFFECTS (SUCH ASDILATED
Use WITH CAUTION IN PATIENTS WITH
ASTHMA,HYPERTHYROIDISM,
CARDIOVASCULARDISEASE,
HYPERTENSION, OR INCREASED OCULAR
PRESSURE
?When to refer
Wheezing and shortness of breath•
Tightness of chest-
Painful sinuses-
Failed medication-
Medicine-induced rhinitis-
Earache and facial pain: As with cold and flu, allergic rhinitis can -
becomplicated by secondary bacterial infections in middle ear
(otitismedia) or the sinuses (sinusitis)
When associated symptoms such as wheezing, tightness of thechest,
shortness- of breath (SOB) are present, immediate referral isadvised.
These symptoms may herald the onset of an asthmaticattack
If no improvement is noted after 5 days of therapy, the patient
shouldbe referred
 ‫اعداد الطالب‬
‫محمد الفداوي‬ ‫زيدان النشيري‬

‫انور مياس‬ ‫بشار الحوثي‬

‫اشراف الدكتوره ايمان الديلمي‬

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