Non-Infectious Rhinitis PDF

Rhinitis Dr. Luqman A. Mustafa M.B.Ch.B, FKBMS (ORL-HNS) UOD/SCHOOL OF MEDICINE 2022-2023 Defenition : — Inflammation of the mucosal lining of the nose and is defined clinically by a combination of two or more nasal symptoms: rhinorrhea , blocking, itching and sneezing...

Rhinitis Dr. Luqman A. Mustafa M.B.Ch.B, FKBMS (ORL-HNS) UOD/SCHOOL OF MEDICINE 2022-2023 Defenition : — Inflammation of the mucosal lining of the nose and is defined clinically by a combination of two or more nasal symptoms: rhinorrhea , blocking, itching and sneezing Blocked Roundh itors Sherry  exaggested IgE to vespace Atopy is a tendency to develop an exaggerated IgE antibody response 0 Allergy is the clinical presentation of atopic disease in the presence of allergen  Classification of rhinosinusitis 2- Non infectious rhinitis 1- Infectious rhinitis A- Acute : B- B-Non allergic rhinitis: A- Allergic rhinosinusitis 1- Idiopathic rhinitis 1- Chronic nonspecific RS rhinitis ( vasomotor rhinitis) 2- Chronic :specific RS 2- Occupational rhinitis TB, 3- Hormonal rhinitis Syphilis , 4- Drug induced Atrophic rhinitis rhinitis 5- Rhinitis and Rhinoscleroma medicamentosa 6.NonAllergic Rhinitis with Eosinophilia Syndrome (NARES) Allergic rhinitis — Allergic rhinitis occur when the nasal symptoms (rhinorhea ,nasal obstruction ,itching and sneezing ) 0 are the result of IgE mediated inflammation after exposure to allergen. msY  Hyrenensw typed Pathophysiology of Allergic Rhinitis — Allergic rhinitis is a type 1 hypersensitivity reaction mediated via immunoglobulin E which interacts with the allergic molecules and on the other side binds reversibly to mast cells. IDE — this interaction leads to release of cell mediators (like histamine, prostaglandins, and leukotriens )which produce vasodilatation ,increase vascular permeability and plasma exudation.Histamine promotes itching ,sneezing and mucus secretion  leaf The allergic responses can be divided into two phases. -The first is an acute response that occurs immediately after exposure to an allergen. -This phase can either subside or progress into a "late phase reaction" which can substantially prolong the symptoms of a response, and result in tissue damage Aetiology Genetic and family history Environmental factors like exposure to allergen ,air pollution and irritant, occupational allergen like flour, wood dust, latex in surgical gloves,tobacco,detergents and bleach. Food occasionally provoke IgE allergic rhinitis, it may be due to sensitivity to preservatives, some type of food contain histamine like cheese and wine Drugs like penicilline, asprin, antihypertensive, B- blocker, ACE inhibitor Types of allergens: — dust — pollens — feathers — fungal spores — house dust mite Clinical types 0 — Seasonal (like summer hay fever) Caused by seasonal peaks in the airborne load of pollens. — Perennial type (nonseasonal allergic rhinitis; atopic rhinitis): Caused by allergens present throughout the year (e.g., dander). Classification of allergic rhinitis — New classification by ARIA guideline (allergic rhinitis and its impact on asthma) Clinical presentation SLEE — Immediate-type allergic symptoms of sneezing, rhinorrhoea and itch are easily recognized. — However, perennial allergic inflammation is mainly expressed as nasal obstruction, hyper reactivity and often concomitant poor sense of smell feb — Eye symptoms 1 tears pressure  other points in the history Other points in the history — Co morbidities (asthma, sinusitis, ear problem ) 000 — occupational and environmental exposure, — dietary history and drug use all need to be taken into account. — The frequency, severity, duration, persistence, intermittence — or seasonality of symptoms should be asked for Clinical findings Sueley bilateralpale bluish watery secular — A full ENT examination should then be carried out with particular emphasis on the nose. Allergic nasal mucosa is usually bilaterally swollen) pale or bluish in colour, oedematous and covered with watery secretions, — Boggy hypertrophied inferior turbinate Examination of the chest with measurement of pulmonary function should be carried out where there is persistent rhinitis or any suspicion of asthma Laboratory tests Diagnosis of allergic rhinitis is clinical and supported by: cytolooy saewinpm.lk 1-Nasal cytology will show increase eosinophils count in the nasal secretion and nasal mucosa 2-Skin tests (skin prick test SPT) are confirmatory: prick skin test with solution containing various allergens is useful if skillfully done and interpreted with the history skin prick test SPT  1950 3-Blood test will show allergen – specific IgE in the serum by enzyme-linked immunosorbent assays (ELISA), or radioallergosorbant test (RAST) 4-nasal swab for bacterial and viral studies 5- nasal allergen challenge TREATMENT — Management of allergic rhinitis includes allergen — Identification, avoidance, education — pharmacotherapy, — and possibly immunotherapy. identification allergen Avoidance eduction  1-Allergen avoidance Management of patients with allergic rhinitis should always include identification and , where possible avoidance of causal allergens ,but in practice it is often difficult to undertaken. 2- PHARMACOTHERAPY  Topical corticosteroids Topical corticosteroid nasal sprays are extremely effective in controlling nasale symptoms in the majority of patients. Topical corticosteroids are highly effective against all nasal symptoms including nasal congestion and blockage. Example: Mometasone, beclomethasone, budesonide and more recent flutacazone propionate Mometasone not absorbed systematically so can be used in pediatrics > 2 years. Budesonide only one approved for use in pregnancy Monerone in Presence  Antihistamines Antihistamines are particularly effective for symptoms of Sneezing ,itching and watery rhinnorrhea and unlike topical corticosteroids have little effect on nasal congestion and blockage First generation like chlorpheneramine,diphenhydramines should be avoided because of sedation,psychomotor retardation and learning impairment because it cross the BBB and interact with histamine receptors Second generation antihistamine act with an hour topical ones within 15 minutes, eg. Loratidin, cetirizine Third generation, eg. Desloratidine, fexofenadine, levocetirizine Antileukotriens : Leukotriene receptor antagonists have recently been licensed for use in rhinitis. They are effective against congestion and mucus production Sodium cromoglicate Mast cell stabilizer, It is weakly effective against all rhinitis but is safe means it is useful for small children less than four years for whom a topical corticosteroid is not available. 8 Ipratropium bromide Response in patients who do not response to topical corticosteroid alone Nasal douching Systemic corticosteroids These can be used to unblock the nose at the start of treatment or provided for very severe symptoms Depot-injected preparations are not recommended because they are not removable if side effects occur Decongestants Used topically reduce nasal obstruction but increase 0 rhinorrhea,regular use for more than few days result in rhinitis medicamentosa Systemic decongestant are relatively ineffective with side effects like hyperactivity,insomnia in children and hypertension in adult  3-Immunotherapy — Allergen immunotherapy involves the repeated administration of an allergen extract in order to induce a state of immunological tolerance, with a reduction in clinical symptoms and requirements for medication during subsequent natural allergen exposure  Noninfectious nonallergic rhinitis  Noninfectious nonallergic rhinitis typically presents with clear rhinorrhea and nasal obstruction with negative allergic skin test. between provyepatic Gupathbic Interlam Inputs 1- Idiopathic rhinitis (Vasomotor rhinitis ) : Patients with vasomotor rhinitis present with symptoms of nasal obstruction and clear nasal drainage. The symptoms are often associated with changes in temperature, exposure to odours and chemicals, or alcohol use. Some suggest that abnormal autonomic regulation of nasal function leads to vasomotor rhinitis. Noninfectious nonallergic rhinitis 2- Occupational rhinitis : It is caused by exposure to air-born agents present in the work place include dust, sulfur dioxide, garden sprays, and ammonia. This type of rhinitis characterized by sneezing ,nasal discharge and nasal obstruction. It is common in : bakers, farmers, wood workers and workers in detergent industry  Destrosen PHA 3- Hormonal Rhinitis: redeem congestion — The most important example is rhinitis that is associated with pregnancy due to high estrogen level. This rise in estrogen leads to a rise in hyaluronic acid in the nasal tissue, which can result in increasing nasal edema and congestion. 0 Rhinitis is usually most severe during the second and third trimesters of pregnancy 4-Drug induced rhinitis : Many medications may be associated with development of rhinitis.these include: -Aspirin, Trial -NSAIDs -Methyledopa -ACE-I -Beta blockers -Oral contraceptive  Rhinelis Medicalates 5- Rhinitis medicamentosa : It is due to persistent and overuse of topical nasal decongestant. Many times these patients need increasing doses of these sprays as tachyphylaxis occurs. The use of these sprays for prolonged periods leads to rebound rhinitis in which the patient experiences severe obstruction as the effects of the topical agents subside. 0 ↓ the decongestant over a period of one week, and add topical steroid and antihistamines according to the symptoms 6- NONALLERGIC RHINITIS WITH EOSINOPHILIA — Nonallergic rhinitis with eosinophilia (NARES) is a recently described syndrome in which patients present with nasal obstruction and congestion; These patients also display marked eosinophilia on nasal smears but are not allergic to any inhalant allergens by skin o testing or in vitro testing. The cause of NARES remains unknown. NARESQ Noninfectious nonallergic rhinitis Diagnosis : No diagnostic test for diagnosis of noninfective nonallergic rhinitis Diagnosis is by clinical history and exclusion of other cause of rhinitis  Noninfectious nonallergic rhinitis Treatment 1 1- Avoidance of irritating agent (occupational rhinitis ) and using of mask. 2- In drug induced rhinitis : by stopping the offending drug 3-Pharmaclological treatment : A- Intra nasal anticholinergic drug (iprotropium O bromide ) especially when the predominant feature is rhinoorhea B- Topical steroid: Although primarily used for allergic rhinitis, some nonallergic patients respond to topical intranasal steroids C- adrenergic agents : for not more than five days. E D- Saline irrigation: Saline irrigation is an important adjunctive treatment to help avert intranasal stasis and reduce crusting E- intranasal antihistamine sprays have been tried for vasomotor rhinitis 4-Surgical treatment : The surgical treatment for non allergic rhinitis is focused on correcting structural abnormalities that may contribute to patient symptoms A- Septoplasty is used to correct cartilaginous or bony abnormalities of the septum B- Turbinate surgery — Inferior turbinate surgery is also commonly used to counteract non allergic rhinitis Thank you