Nasal Allergy and Allied Conditions

2. Dr Asmatullah Achakzai
Associate Professor ENT Head and
neck surgery
FCPS, MCPS, DLO, MBBS
Nasal Allergy and Allied Conditions

3. CHRONIC ALLERGIC RHINITIS
 What is Allergy?
 It was Clemens Von Pirquet, a Viennese
pediatrician, who used the term allergy in 1906
denoting an altered state of reactivity to an organic
substance, i.e. allergen.
 It is an immunoglobulin E (IgE)-mediated
immunological response of nasal mucosa.
 Atopy means a tendency to develop allergic
diseases.

4. Types of Allergic Response
 Type I or atopic hypersensitivity: Atopic hypersensitivity occurs in
those persons who form reaginic antibodies when exposed to
certain antigens. It is mediated by IgE antibodies, levels of which
increase to more than 100 units/mL. This type of reaction is seen
in allergic rhinitis, bronchial asthma, hay fever and eczema.
 Anaphylactic reaction: Anaphylactic reaction is a severe form of
allergic reaction, which occurs immediately after exposure to the
antigen, e.g. injecting horse serum and it can be fatal.

 Delayed hypersensitivity (Type IV): Unlike the above two types, it
does not depend upon antibodies, but on sensitized T-
lymphocytes.

5. Classification
 Allergic rhinitis and its impact on asthma (ARIA)
panel in association with World Health
Organization (WHO) recommended a revised
classification in 2001, which aims at better
management of allergic patients. It classifies it
into:
 Mild
 Moderate to severe
 Intermediate
 Persistent type

6. Mechanism of Allergy (Pathogenesis)
 The mechanism of allergy
(pathogenesis) are as
follows:
 Reaginic antibodies also
called IgE combine with cells
such as circulating basophils
or tissue mast cells.
 Later on, whenever there is
provocation allergens
combine with cell bound
reaginic antibodies.

7. Predisposing Factors
 Following factors predispose the tissues to allergy
 Heredity
 Infection
 Endocrine Factors
 Nutritional Factors
 Geographical Factors
 PH
 Trauma
 Meteorological and Seasonal Conditions
 Psychological Factors

8. Types of Nasal Allergy
 Seasonal Allergic Rhinitis (Hay Fever)
 Hay fever is season specific because of prevalence of
pollens of grasses, flowers, trees or shrubs. It starts in
March to May or August to September. It may affect the
nasal, pharyngeal or bronchial mucous membrane.
 Perennial Allergic Rhinitis
 Perennial allergic rhinitis is due to exogenous allergens
such as inhalants, i.e. house dust, mattress, furniture,
soaps, creams, perfumes, odors of fish, egg and coffee.
House dust contains feces of mites Dermatophagoides
pteronyssinus.

9. Clinical Features of Nasal Allergy
 Symptoms
 Irritation and itching of eyes and palate .
 Sneezing, 10 to 15 at a time .
 Nasal obstruction .
 Rhinorrhea .
 Increased lacrimation .
 Decreased or loss of sense of smell .
 Signs
 Chronic cough .
 Impairment of hearing .
 Congestion and edema of mucous membrane .
 Color of mucous membrane over turbinates may from pale to
bluish or dull red .
 Mucous membrane becomes very sensitive and touching may
initiate sneezing and rhinorrhea.
 Conjunctival congestion .

10. Investigations
• Blood for total leukocyte count (TLC)
or
differential leukocyte count (DLC)
• Nasal smear for eosinophils
• X-ray paranasal sinus (PNS)
• Special tests for allergy - Diagnostic
nasal
endoscopy - Saccharin test to test
nasociliary
function of nasal mucosa (normal
duration is
30 minute).

11. Nasal Provocation Test
 Application of allergens to skin, nasal mucous
membrane, bronchial mucous membrane or
conjunctiva by simple application or scratch test
(prick test).
 Intra cutaneous or intra mucosal injection, scratch
or prick test are more specific and safer for
inhalants, but intra dermai method is 100 times
more sensitive than prick test.

12. Elimination of Allergies
 Such as foods likely to cause allergy or allergen
free chamber may be used to see the effect.
Leukopenic Index
 A drop of 2,000 in white blood cell (VVBC)/ml
after ingestion of allergens indicates
hypersensitivity.
Radioallergosorbent Test
 Radioallergosorbent test (RAST) measures IgE
level. It uses an enzymes instead of iostopes to
label anti-IgG, which is measured in
spectrometery.

13. Treatment
 Treatment can be discussed under the following
subheads
 Avoiding the possibly known factor of allergy
 If the patient can find out the causative agent and
avoids the contact, which may be any food article,
any pet or other agent. It might need a change of
job or place.
 Use of nasal filters or dust masks may help to some extent.

14. Role of Drugs
 Antihistamines
 Sympathomimetic drugs
 Role of steroids
 Topical nasal Sprays
 Submucosal corticosteroids and steroid depot
therapy
 Sodium chromoglycate nasal spray

15. Non-Allergic Rhinitis
 Vasomotor rhinitis
 Rhinitis medicamentosa
 Endocrinal rhinitis:
 Drug-induced rhinitis such as contraceptive pills,
antihypertensive and neostigmine.

16. Vasomotor Rhinitis
 Vasomotor rhinitis occurs more in emotionally
unstable persons, especially in women of 20 to
40 years. It is because of over activity of para
sysmpathesis due to imbalance of autonomic
nervous systems (ANS) which is under the effects
of hypothalamus.

17. Factors which disturb vasomotor
balance
 Psychogenic factors
 Endocrine factors
 Physical agents
 Drugs

18.  Pathology
 Nasal mucosa shows evidence of edema, vascular
dilatation, round cell infiltration and increased
glandular activity.
 Clinical Features
 Nasal obstruction and rhinorrhea are more
pronounced than sneezing.
 Conjunctival symptoms not present
 Other symptoms such as postnasal drip, headache,
fatigue and migraine, may be seen.

19. On Examination
 Enlargement or hypertrophy of turbinates
 Mucosa of turbinate may give mulberry-like
appearance and is pale to dusky red in color
treatment.
 Conservative treatment
 Physical exercise, cool baths and avoiding those
factors, which initiate the symptoms.
 Tranquilizers such as alprazolam may also help
 Phenylpropanolamine 25 to 50 mg/day alone or in
combination with antihistamines.

20.  Surgical Treatment
 Cauterisation of turbinates helps in reduction of size
 Submucosal diathermy of the turbinates
 Cryosurgery is also helpful
 Vidian neurectomy

21. Other forms of Rhinitis
 There may be
 Rhinits of pregnancy.
 Drug induced rhinitis.
 Honeymoon rhinits.
 Endocrinal disorders as seen in hypothyroidism,
 Gustatory rhinitis as after a spicy food.

22. ANY QUESTIONS ??

23. THANK YOU