Define allergic rhinitis Pathophysiology of allergic rhinitis Signs/symptoms of allergic rhinitis Diagnosis Investigations Complications Treatment Non allergic rhinitis Pathogenesis Signs/symptoms Treatment “It is an IgE-mediated immunologic response of nasal mucosa to airborne allergens and is characterized by watery nasal discharge, nasal obstruction, sneezing and itching in the nose. This may also be associated with symptoms of itching in the eyes, palate and pharynx” . Two clinical types have been recognized: 1. Seasonal. Symptoms appear in or around a particular season when the pollens of a particular plant, to whic the patient is sensitive, are present in the air. 2. Perennial. Symptoms are present throughout the year

1. Allergic/non allergic
rhinitis
DR AWAIS IRSHAD

2. Learning objectives
• Define allergic rhinitis
• Pathophysiology of allergic rhinitis
• Signs/symptoms of allergic rhinitis
• Diagnosis
• Investigations
• Complications
• Treatment
• Non allergic rhinitis
• Pathogenesis
• Signs/symptoms
• Treatment

3. Allergic rhinitis
• “It is an IgE-mediated immunologic response of nasal mucosa to airborne
allergens and is characterized bywatery
• nasal discharge, nasal obstruction, sneezing and itching
• in the nose. This may also be associated with symptoms
• of itching in the eyes, palate andpharynx”
• . Two clinical types have been recognized:
• 1. Seasonal. Symptoms appear in or around a particular
• season when the pollens of a particular plant, to whic
• the patient is sensitive, are present in the air.
• 2. Perennial. Symptoms are present throughout the year

5. Etiology
• Inhalant Allergens. They may be seasonal or perennial. Seasonal allergens include pollens from trees,
grasses
• and weeds. They vary geographically. The knowledge
• of pollen appearing in a particular area and the season in which they occur is important. Their knowledge
• also helps in skin tests. Perennial allergens are present
• throughout the year regardless of the season. They include molds, dust mites, cockroaches and dander
from
• animals. Dust includes dust mite, insect parts, fibres and
• animal danders. Dust mites live on skin scales and other
• debris and are found in the beddings, mattresses,pillows,
• carpets and upholstery.
• Genetic Predisposition. Plays an important part. Chances of children developing allergy are 20 and 47%,
• respectively, if one or both parents suffer from allergic diath

7. Signs/symptoms
• Cardinal symptoms of seasonal nasal allergy include
• paroxysmal sneezing, 10–20 sneezes at a time, nasal obstruction, watery nasal
• discharge and itching in the nose.
• Itching may also involve eyes, palate or pharynx. Some
• may get bronchospasm. The duration and severity of
• symptoms may vary with the season.
• Symptoms of perennial allergy are not so severe as that
• of the seasonal type. They include frequent colds, persistently stuffy nose, loss of
sense of smell due to mucosal
• oedema, postnasal drip, chronic cough and hearing impairment due to eustachian
• tube blockage or fluid in the middle ear.

8. Signs
• Nasal signs include transverse nasal crease—a black
• line across the middle of dorsum of nose due to constant upward rubbing of nose
• simulating a salute (allergic salute), pale and oedematous nasal mucosa which
• may appear bluish. Turbinates are swollen. Thin, watery or mucoid discharge is usually
present.
• Ocular signs include oedema of lids, congestion and
• cobble-stone appearance of the conjunctiva, and dark
• circles under the eyes (allergic shiners).
• Otologic signs include retracted tympanic membrane
• or serous otitis media as a result of eustachian tube
• blockage.

9. • Pharyngeal signs include granular pharyngitis due to
• hyperplasia of submucosal lymphoid tissue. A child
• with perennial allergic rhinitis may show all the features of
prolonged mouth breathing as seen in adenoid
• hyperplasia.
• Laryngeal signs include hoarseness and oedema of
• the vocal cords.

10. •

11. Investigations
1. Total and differential count
2. Nasal smear
3. Skin test
A: Skin prick test
B: specific IgE measurements
4.Radioallergosorbent test
5.Nasal provocation test

12. Complications
• Nasal allergy may cause:
1. Recurrent sinusitis because of obstruction to the sinus ostia.
2. Formation of nasal polyp in about2%.
3. Serous otitis media.
4.Orthodontic problems and other ill-effects of prolonged mouth breathing
especially in children.
5. Bronchial asthma. Patients ofnasal allergy have
four times more risk of developing bronchial asthma.
Twenty to thirty per cent of patients with rhinitis have
asthma

13. Treatment
• Treatment can be divided into:
•
• 1. Avoidance of allergen.
•
• 2. Treatment with drugs.
•
• 3. Immunotherapy

14. Drugs
• Antihistamines
• Sympathomimetic drugs
• Corticosteroids
• Sodium chromoglycate
• Anticholinergics
• Leukotriene receptors antagonist
• Anti IgE

15. Non Allergic rhinitis
• VASOMOTOR RHINITIS (VMR)
• It is nonallergic rhinitis but clinically simulating
nasal allergy with
symptoms of nasal obstruction, rhinorrhoea
• and sneezing. One or the other of these symptoms
may
• predominate. The condition usually persists
throughout
• the year and all the tests of nasal allergy are
negative .

16. PATHOGENESIS
PATHOGENESIS
Nasal mucosa has rich blood supply. Its vasculature is
similar to the erectile tissue in having venous sinusoids
or “lakes” which are surrounded by fibres of smooth
muscle which act as sphincters and control the filling or
emptying of these sinusoids. Sympathetic stimulation
causes vasoconstriction and shrinkage of mucosa, while
parasympathetic stimulation causes vasodilation and engorgement. Overactivity of parasympathetic system also
causes excessive secretion from the nasal glands.
Autonomic nervous system is under the control of hypothalamus and therefore emotions play a great role in
vasomotor rhinitis. Autonomic system is unstable in cases
of vasomotor rhinitis. Nasal mucosa is also hyper-reactive
and responds to several nonspecific stimuli, e.g. change
in temperature, humidity, blasts of air, small amounts of
dust or smoke

17. • SYMPTOMS
• 1. Paroxysmal sneezing. Bouts of sneezing start just after getting out of the bed in the morning.
• 2. Excessive rhinorrhoea. This accompanies sneezing
• or this may be the only predominant symptom. It is
• profuse and watery and may even wet several handkerchiefs. The nose may drip when the patient leans
• forward and this may need to be differentiated from
• CSF rhinorrhoea (see p. 183).
• 3. Nasal obstruction. This alternates from side to side.
• Usually more marked at night. It is the dependent side
• of nose which is often blocked when lying on one side.
• 4. Postnasal drip.
• SIGNS
• Nasal mucosa over the turbinates is generally congested
• and hypertrophic. In some, it may be normal

18. • COMPLICATIONS
•
• Long-standing cases or VMR develop nasal polypi, hypertrophic
rhinitis and sinusitis

19. Other forms of non allergic rhinitis
• Drug induced rhinitis
• Rhinitis medicamentosa
• Rhinitis of pregnancy
• Honeymoon rhinitis
• Emotional rhinitis
• Rhinitis due to hypothyroidism
• Gustatory rhinitis
• Non airflow rhinitis

20. Treatment
Medical
1.Avoidance of physical factors which provoke symptoms, e.g. sudden change in temperature,
humidity,
blasts of air ordust.
2.Antihistaminics and oral nasal decongestants are helpful in relieving nasal obstruction,
sneezing and rhinorrhoea.
3. Topical steroids (e.g. beclomethasone dipropionate,
budesonide or fluticasone), used as spray or aerosol,
are useful tocontrol symptoms.
4.Systemic steroids can be given for a short time in very
severe cases.
5. Psychological factors should be removed. Tranquillizer's may be needed in some patients

21. Surgery
1. Nasal obstruction can be relieved by measures which
reduce the size of nasal turbinates (see hypertrophic
rhinitis). Other associated causes of nasal obstruction,
e.g. polyp, deviated nasal septum, should also be corrected.
2. Excessive rhinorrhoea, not corrected by medical therapy and
bothersome to the patient, can be relieved by
sectioning the parasympathetic secretomotor fibres to
nose (vidian neurectomy

22. Allergic vs non allergic rhinitis

23. CBL 10
THEME: ALLERGIC / NON ALLERGICRHINITIS
10. 20 years old female presented to ENT OPD with the history of bouts of
sneezing specially in the morning with watery nasal discharge, nasal congestion
and teary eyes.
What specific question you would ask in history to elicit the diagnosis?
Give your differential diagnosis.
Give management plan of most probablediagnosis.
Differentiate between Allergic rhinitis, viral/bacterialand vasomotor
1.
2.
3.
4.
rhinitis.
5.
6.
Discuss the complications associated with it.
Write prescription for Allergicrhinitis