Allergic Rhinitis 2022 PDF

ALLERGIC RHINITIS Presenters: Dr.Abdallah Bakari ENT Facilitator: Dr Martin (ENT Specialist )  layout Introduction Epidemiology Aetiology and predisposing factors Classification of Allergic Rhinitis Pathophysiology of allergic rhinitis...

ALLERGIC RHINITIS Presenters: Dr.Abdallah Bakari ENT Facilitator: Dr Martin (ENT Specialist )  layout Introduction Epidemiology Aetiology and predisposing factors Classification of Allergic Rhinitis Pathophysiology of allergic rhinitis Clinical presentation Diagnosis and treatment Reference  INTRODUCTION Rhinitis -Inflammation of nasal mucosa Allergic rhinitis ✔is an atopic disease presenting with symptoms of sneezing, nasal congestion, clear rhinorrhea, and nasal itching. ✔It is an IgE mediated immune response that is against inhaled antigen. Allergic rhinitis can be seasonal(20%) ,perennial(40%) or 40% with features of both  Allergens Allergens -Proteinous substance, capable of triggering an IgE-mediated reaction Type of allergens- indoor and outdoor types Outdoor allergens- responsible for seasonal rhinitis. ✔ (pollen-trees, weeds, plants and grasses) ✔ Fungi and mold-spores Indoor allergens- responsible for perennial rhinitis. ✔ Animal danders – from cats, dogs, mice ✔ Dustmites (major allergen in house dust)- sources being from bedding, carpets, stuffed toys, furniture. ✔ Insects-Cockroaches  Common allergens Pollen Fungal spores/ molds - Penicillium Insects - Cockroaches, house flies Animals - Cats, dogs, rats Dust mites - Dermatophagoides Ingestants - Nuts, fish, eggs, milk  Allergic Rhinitis & asthma AR and Asthma frequently co-exist , Allergic rhinitis and asthma are part of the “allergic Allergic rhinitis was detected in 74 to march” 81% of asthmatic subjects, and 40% of allergic rhinitis patients had asthma, suggesting a close link between the two diseases. The children who develop food All patients with AR should be assessed allergy and/or atopic dermatitis often then develop allergic for asthma rhinitis and asthma;  Risk Factors Genetic susceptibility Age and sex Environmental factors: Pollution - suggested to cause an increase in nasal responsiveness to environmental allergens. ✔ Irritants-eg. tobacco smoke, diesel exhaust, mosquito repellents, perfumes. Hormonal: Since it begin in puberty and increases during pregnancy, a hormonal basis is possible.  Classification of AR Previous classification Seasonal Perennial Mixed Phase 1 – Sensitization Antigen- Allerge presentin n g cell Processe d allergen B cell CD4 T cell Plasma IgE cell antibodies.  Phase 2 – Clinical Disease Early Late Phase Phase Allerge n IgE antibodies Resolutio Late-phas n e Cellular reaction Infiltratio Hyper- Mas Complication n responsivenes t s s Mediato cell r Eosinophils release Basophils Blood Nerves Monocytes vessel Lymphocyte s Glands s Sneezing Itching Rhinorrhe a Congestio n  Clinical Presentation.. nasal itching within seconds, which is soon followed by sneezing Systemic Symptoms Rhinorrhea (watery discharge) ✔ Weakness ✔ Discomfort or uneasiness Nasal congestion develops and predominates later ✔ Irritability ✔ Fatigue Others/associated symptoms include: ✔ ocular itching, tearing, eye redness ✔ Difficulty concentrating ✔ throat itching, throat clearing, cough ✔ Decreased appetite ✔ ear itching, pain, ✔ loss of smell (anosmia) or taste ✔ mouth breathing, malocclusion, snoring ✔ fatigue, drowsiness, malaise  SIGNS OF ALLERGIC RHINITIS NASAL SIGNS Allergic Salute-use the palm of their hand to rub and raise the tip of their nose to relieve nasal itching and congestion Nasal crease- line in dorsum of nose result of rubbing the nose (allergic salute)  Cont.… NASAL SIGNS: Hypertrophic inferior turbinate , Figure : View of a left nasal cavity. The nasal cavity is completely blocked (obstructed) due to severe swelling of the inferior turbinate.  FACIAL Dennie-Morgan creases (double skin folds in lower eyelid skin) Allergic shiners (dark discoloration below lower eyelids) caused by venous stasis. OCULAR ✔ Edema of the lids ✔ Conjunctiva is congested with cobble stone appearance of the upper palpebral conjunctiva. ✔ Increased lacrimation.  Otologic signs Presence of higher levels of IgE in the middle ear of allergic children than levels found in the serum at the same time** ✔ E tube dsyfunction  Pharyngeal signs. Cobble stone appearance of the posterior pharyngeal wall (Chronic pharyngitis, laryngitis).  DIAGNOSIS History Physical exam Allergy diagnosis ✔ Skin prick test ✔ Total IgE and specific in vitro testing of serum IgE Antibodies ✔ Nasal smear examination for eosinophils. ✔ Blood Basophil and Histamine release Primary utilized for research ✔ Nasal challenges test purpose Diagnostic Nasal Endoscopy C.T. scan P.N.S: ✔ Radiographic imaging is not routinely recommended for the diagnosis of AR and is primarily used to rule out other conditions such as rhinosinusitis  Cont. Skin prick test (SPT) Rapid, efficient & cost effective. Contain multiple antigens(pollen, mold, dust mite, animal dander) TREATMENT  Avoidance of Triggers Removing allergen from the indoor environment should be a primary strategy for the management and treatment of allergic disease. No carpeting No furry or feathered pets Maintain heating/cooling systems No smoking  Controlling Dust Mites Dust mites are microscopic organisms that feed on dead skin scales Dust mite growth is a function of ✔ Food source (skin scales) ✔ Temperature ✔ Humidity 55 – 73% ✔ Reservoirs -, carpets, mattresses, pillows 29/4/2011 Measures to avoid house mite dust ✔ Mattress covers ✔ Covers for pillows & bedding ✔ Vacuuming ✔ Protein denaturating agents- Tannic acid ✔ Provide adequate ventilation to decrease humidity ✔ Wash bedding regularly with warm water 60°C 29/4/2011 Avoidance of animal allergens Pollen avoidance measures ✔ Remove pet animals (cats, dogs) ✔ Wear facemask & sunglasses from bedroom. when moving out ✔ Wash the pet weekly. ✔ Keep windows closed.  PHARMACOTHERAPY Topical Nasal Treatments Oral Treatments Antihistamines Antihistamines Corticosteroids Corticosteroids Chromones Antileukotrienes Decongestants Decongestants Anticholinergics  SURGERY Usually not indicated Comorbid or complicating conditions ✔ Surgery: F.E.S.S., Turbinoplasty. Surgical treatment is reserved for patients with nasal polyposis, inferior turbinate hypertrophy causing intractable nasal obstruction, or chronic sinus disease refractory to medical treatment.  DIFFERENTIAL DIAGNOSIS Vasomotor rhinitis Rhinitis medicamentosa (Drug induced rhinitis) Hormonal rhinitis (pregnancy, oral contraceptive use) Atrophic rhinitis Environmental rhinitis ( Occupational) Infectious rhinitis Gustatory rhinitis  Key Points Allergic Rhinitis is very common. Thorough history and physical examination including visualization of the nasal anatomy and laboratory investigations. Approach to therapy Environmental control First line pharmacotherapy Nasal Steroids, systemic steroids Immunotherapy Adequate counseling of the patient  References Bailey BJ Head and Neck-otorhinolaryngology 4e 2006 Ballenger 17e NCBI-startpearl-Shweta Akhouri; Steven A. House. Last Update: January 24, 2022 uptodate (Sataloff's comprehensive textbook of otolaryngology head and neck surgery) Marvin P. Fried (editor) Abtin Tabaee (editor) - Rhinology_allergy and immunology (2016).pdf Bluestone and Stools Pediatric Otolaryngology 5th Ed..pdf Prevalence of Allergic Rhinitis among Secondary School Students in Kinondoni District, Dar esSalaam, Tanzania (Zephania Saitabau Abraham1*, Sweety Bindiya Aubroo2, Victor,Mashamba2,Daudi Ntunaguzi3, Kassim Babu Mapondella3 and Enica Richard Massawe3 Mapondella KB, Massawe WA. Prevalence of allergic rhinitis and associated complications among patients receiving ORL services at MNH. Medical journal of Zambia, Vol 45 (2) 72-81 (2018). Prevalence of Allergic Rhinitis among Secondary School Students in Kinondoni District, Dar es Salaam, Tanzania 2019.  References Salo PM, Calatroni A, Gergen PJ, et al. Allergy-related outcomes in relation to serum IgE: results from the National Health and Nutrition Examination Survey 2005-2006. J Allergy Clin Immunol. 2011;127:1226-1235.e7. CDC. Allergies and hay fever. www.cdc.gov/nchs/fastats/allergies.htm. Accessed March 31, 2016. CDC. Allergies. www.cdc.gov/healthcommunication/ToolsTemplates/EntertainmentEd/Tips/Allergies.html. Accessed March 31, 2016. Ballenger’s Otorhinolaryngology Head and Neck Surgery 16th. Cummings Otolaryngology Head and Neck Surgery 7th Ed. Brozek JL, Bousquet J, Baena-Cagnani CE, et al. Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines: 2010 revision. J Allergy Clin Immunol. 2010;126:466-476.