Allergic Rhinitis 2024 PDF

Rhinitis 2024 Rhinitis: classification Rhinitis: classification Rhinitis: classification  Questions for diagnostic rhinitis 1. Are nasal itch or sneezing episodes prominent symptoms of the rhinitis complex? 2. Are watery, itchy eyes associated with the rhinitis? 3. Is wheeze associated wi...

Rhinitis 2024 Rhinitis: classification Rhinitis: classification Rhinitis: classification  Questions for diagnostic rhinitis 1. Are nasal itch or sneezing episodes prominent symptoms of the rhinitis complex? 2. Are watery, itchy eyes associated with the rhinitis? 3. Is wheeze associated with the rhinitis? 4. Are the symptoms prominent year-round or are they present only at certain times of the? If present only during certain months of the year, which months? 5. Age, location, and type of home 6. History of dampness or water problems in the home 7. Type of heating and air-conditioning system 8. Presence or absence of smoking in the home 9. All indoor and outdoor pets 10. Occupational exposure 11. Are the nasal symptoms exclusively one sided? 12. Is there purulent nasal discharge? 13. Is facial or teeth pain associated with this? Allergic rhinitis is an IgE‐mediated inflammation of the naso‐ocular region. Caused by seasonal and/or perennial aeroallergens, common symptoms include nasal congestion, rhinorrhea, sneezing and itching of the nose, palate, and eyes. Allergic rhinitis - 3D Medical Animation Atopic rhinitis  Atopic rhinitis Take a history of environmental exposures such as parenteral smoking, pets, dust mites, toys, carpet, bedding etc. Presentation  Breathing problem through nose  Postnasal drip  Cough  Nose rubbing  Suborbital venous congestion  Watery-red eyes  Pale or bluish, boggy nasal mucosa with a thin, clear, watery nasal discharge Allergic shiners Dennie–Morgan lines  Atopic rhinitis -Investigations  Skin tests for specific antigens  Total serum IgE  Specific serum IgE measurements  Nasal smear for cytology  A sinus CT scan may be considered for a patient with persistent symptoms refractory to therapy ARIA - guideline Visual analogue scale in allergic rhinitis Visual-analogue scale used for nasal obstruction Rhinitis: classification Noninfectious Structural Rhinosinusitis- Nasal polyps  Smooth, pale, gelatinous outgrowths of the nasal mucosa that resemble a peeled grape  Most polyps are located in the middle meatus and originate from the ethmoid sinuses  Long history of symptoms of perennial rhinitis  Nasal obstruction and congestion, and most have a decrease in or absence of the sense of smell  The major complication of nasal polyps is infectious sinusitis  Polyps are only minimally vascular and, thus, do not tend to bleed  Noninfectious Structural Rhinosinusitis- Polyposis with Aspirin Sensitivity Asthma + nasal or sinus polyps + aspirin sensitivity Noninfectious Structural Rhinosinusitis- tumor  Most common presenting symptoms: unilateral nasal stuffiness and discharge  Approximately one-fourth of patients have eyelid swelling, unilateral tearing, diplopia  Furniture and nickel workers have a higher incidence of sinus carcinoma than the general population  Noninfectious Structural Rhinosinusitis- Foreign body  Most common in young children, psychiatric patients  Common presenting symptoms include unilateral nasal blockage with nasal bleed or purulent discharge  The foreign object usually can be detected on nasal examination or with a radiographic study  Noninfectious Structural Rhinosinusitis- Adenoidal Hypertrophy  Adenoids typically stop enlarging between ages 4 and 7 years and then start decreasing in size, so they are hardly present during the teen years  Adenoidal hypertrophy is seen primarily in young children and presents with any combination of mouth breathing, halitosis, persistent runny nose or nasal congestion, ear infections, and snoring  After age 1 year, the adenoids are not an important part of the immune system and removal is not associated with an increase in upper respiratory tract infections  Noninfectious Structural Rhinosinusitis- Septal Deviation 1. Deviation of the septum to one side can be congenital or induced by trauma 2. Septal deviation can be corrected surgically when the deviation is thought to significantly obstruct drainage Rhinitis: classification Noninfectious Nonstructural Rhinitis and Rhinosinusitis- Vasomotor Rhinitis  Vasomotor rhinitis is characterized by the presence of nasal symptoms for ≥ 9 months each year  The condition is often exacerbated by exposure to irritants such as smoke or dust, wind, rapid changes in temperature or atmospheric pressure, and smells  On physical examination, the nasal turbinates are often erythematous and boggy in appearance as opposed to a pale or bluish found in allergic rhinitis  To diagnose vasomotor rhinitis, allergic rhinitis should be ruled out with allergy skin prick testing or in vitro allergy testing Noninfectious Nonstructural Rhinitis and Rhinosinusitis- Vasomotor Rhinitis Noninfectious Nonstructural Rhinitis and Rhinosinusitis- Nonallergic Rhinitis with Eosinophilia Syndrome  Paroxysms of sneezing, profuse watery rhinorrhea, and occasional loss of the sense of smell  Nasal cytology or smear, however, shows significant eosinophilia  It is generally accepted that nasal scrapings from the nasal turbinate that show 5–25 eosinophils per high-power field is compatible with the diagnosis  Despite the eosinophilia, neither skin prick testing to allergens nor in vitro allergy testing is positive  Intranasal corticosteroids are considered standard treatment Noninfectious Nonstructural Rhinitis and Rhinosinusitis- Atrophic Rhinitis  Atrophic rhinitis is a syndrome of progressive atrophy of the nasal mucosa in elderly patients  The primary symptoms are chronic nasal congestion and the sensation of an unpleasant odor  Physical examination shows crusting and loss of nasal mucosa  There is no effective treatment, but supportive treatment with nasal humidification may decrease symptoms Noninfectious Nonstructural Rhinitis and Rhinosinusitis- Hormonal Rhinitis Pregnancy Oral contraceptives, conjugated estrogens Hypothyroidism  During pregnancy, rhinitis symptoms, primarily congestion, begin in the second month and continue to term  Rhinitis of pregnancy abates soon after delivery  Hypothyroidism has been associated with increased nasal secretions and nasal congestion, but the evidence for an association is limited Noninfectious Nonstructural Rhinitis and Rhinosinusitis- Medication-Induced Rhinitis  The nasal mucosa appears inflamed and erythematous intranasal  Decongestant products containing α-adrenergic agonists (i.e., oxymetazoline or phenylephrine) using more than 4-5 days  β-blockers, angiotensin-converting enzyme inhibitors, and α-receptor antagonists, chlorpromazine, aspirin, and nonsteroidal anti-inflammatory agents  Topical intranasal corticosteroids appear to help relieve symptoms until the patient’s normal nasal cycle returns. Normal function returns in 7–28 days Noninfectious Nonstructural Rhinitis and Rhinosinusitis- Rhinitis from Food Ingestion  Gustatory rhinitis refers to watery rhinorrhea that occurs immediately after the ingestion of foods, particularly spicy foods  This is vagally mediated and responds to treatment with intranasal ipratroprium Treatment Treatment  The Main Immunological Mechanism Immune reaction of Adults : Th1/Th2 balance Protect Th 1 Th 2 Allergy The difference between a normal infectious immune response and a type 1 hypersensitivity response is that in type 1 hypersensitivity, the antibody is IgE instead of IgA, IgG, or IgM The Main Immunological Mechanism Protect Th 1 Th 2 allergy Th2-assimetry Allergen immunotherapy Corrects immune Answer  Allergen immunotherapy Allergen immunotherapy consists of injections of allergen extracts to which the patient is allergic to induce an immunologic tolerance 1. Immunotherapy increases IL-10, which serves as a regulatory cytokine and dampens the inflammatory response 2. Allergen immunotherapy increases allergen-specific IgG 3. It also decreases allergen-specific IgE and allergen-induced mediator release and shifts the cytokine release profile of T-cells from a Th2 pattern to a Th1 pattern 4. The shift in cytokine release decreases the levels of IL-4 and IL-5 and decreases activation of eosinophils and mast cells 5. A typical course of immunotherapy is 3–5 years  Allergen immunotherapy Build up phase Maintenance phase 1. The main risk of allergen immunotherapy is the development of a severe allergic reaction or asthma exacerbation to the immunotherapy injection 2. Patients who have unstable asthma or a baseline FEV 1 < 70% are at increased risk for reaction and should be excluded from immunotherapy  Allergen immunotherapy Build up phase Maintenance phase 1. The main risk of allergen immunotherapy is the development of a severe allergic reaction or asthma exacerbation to the immunotherapy injection 2. Patients who have unstable asthma or a baseline FEV 1 < 70% are at increased risk for reaction and should be excluded from immunotherapy Mandatory literature: Clinical Allergy: Diagnosis and Management Gerald W. Volcheck; USA – 2009pp.117-163 Oxford Handbook of Clinical Immunology and Allergy 3rd edition, 2013, G. Spickettpp.139-142ARIA guideline Allergy and Clinical immunology Hugh A. Sampson, Scott L. Friedman-2015 pp.36-52