1.
ALLERGIC RHINITIS
S PANDEY

2.
OUTLINE
•Definition and
Introduction
•Etiologies
•Presentation
•Diagnosis
•Prognosis
•Management

3.
RHINITIS
•Two or more nasal symptoms of:
• Nasal congestion
• Rhinorrhea
• Sneezing/Itching
• Impairment of Smell for
more than 1 hour a day

4.
RHINITIS
• Occurs most commonly as allergic rhinitis
• Noninfectious rhinitis has been classified as either
allergic or non-allergic.
• Allergic rhinitis is defined as immunologic nasal
response, primary mediated by immunoglobulin E
(IgE).
• Non-allergic rhinitis is defined as rhinitis symptoms
in the absence of identifiable allergy, structure
abnormality or sinus disease.

5.
INTRODUCTION
• Nasal function includes
• Temperature regulation
• Olfaction
• Humidification
• Filtration and Protection

6.
INTRODUCTION
• Nasal lining contains secretion of IgA, proteins
and enzymes
• Nasal Cilia propel the matter toward the natural
ostia at frequency of 10-15 beats per minute
• Mucous move at a rate of 2.5-7.5 ml per
minute

7.
ALLERGIC RHINITIS
• Defined as an inflammation of the nasal
mucosa, caused by an allergen
• Most common atopic allergic reaction
• Affects 10 to 25% of population
• 50% of rhinitis in ENT is AR
• Most commonly seen in young children and
adolscents

8.
ETIOLOGY
• Classified as
• Precipitating factors
• Predisopsing factors

9.
PRECIPITATING FACTORS
• Aerobiological flora
• Allergens present in the environment
• House dust and dust mites
• Feathers
• Tobacco smoke
• Industrial chemicals
• Animal dander
• Nasal physiology
• Disturbances in normal nasal cycle

10.
PREDISPOSING FACTORS
• Genetic
• Multiple gene interactions are responsible for allergic
phenotype
• Chromosomes 5, 6, 11, 12 & 14 control inflammatory process
in atopy
• 50% of allergic rhinitis patients have a positive family history
of allergic rhiniits
• Endocrine
• Puberty
• Pregnant states and post partum stages
• menopausal

11.
PREDISPOSING FACTORS….
• Psychological
• Focal sensitivity states
• Infections: fungal infections nb
• Physical
• Degree of pollution of air
• Humidity and temperature differences
• Temperature changes
• Age & sex
• IgA deificiency

12.
COMMON ALLERGENS
• Pollens
• Spring tree pollens(maple alder, birch)
• Summet : grass pollent (bluegrass, sheep shorell etc
• Autums: weed pollen (ragweed)
• Molds
• Penicillium, cladosporium etc
• Insects
• Cockroaches, house flies, fleas, bed bugs
• Animals
• Cats. Dogs. Horse, monkeys, rats, rabbits etc
• Dust mites
• dermatophagoides
• Ingestants
• Nuts, fish, eggs, milk etc

13.
PATHOPHYSIOLOGY
• Immunoglobulin (Ig) E mediated type 1
hypersensitivity response to an antigen
(allergen) in a genetically susceptible person
• Type 1 Hypersensitivity causes local
vasodilation and increased capillary
permeability

14.
CLASSIFICATON - FORMER
• Seasonal
• Often known by it’s misnomer of Hay fever
• Neither caused by hay or has fever
• Summer cold
• Caused by virus causing URTI (not a true allergic
rhinitis
• Rose fever
• Often cited in indian subcontinent
• Colourful or fragrant flowering plants rarely cause
allergy as their pollens to heavy to be airborne
• Perennial
• Allergens present throughout the year

15.
CLASSIFICATION - CURRENT
• Intermittent
• Symptoms present less than 4 days per week and
less than 4 weeks per year
• Persistant
• Symptoms present more than 4 days per week and
more than 4 weeks per year

16.
SEVERITY
• Mild
• No interference with daily activity or troublesome
symptoms
• Moderate – severe
• Presence of at least one:
• Impaired sleep, daily activity work or school
• Troublesome symptoms

17.
COMPLICATIONS:
• Allergic asthma
• Chronic otitis media
• Hearing loss
• Chronic nasal obstruction
• Sinusitis
• Orthodontic malocclusion in children

18.
SIGNS AND SYMPTOMS
• Sneezing
• Itchy nose, ears,
eyes and palate
• Rhinorrhea
• Post nasal drip
• Congestion
• Anosmia
• Headache
• Earache
• Tearing of eyes
• Red eyes
• Swollen eyes
• Fatigue
• Drowsiness
• Malaise

19.
PHYSICAL EXAMINATION
• Nasal crease
• Horizontal crease
across the lower half
of the bridge of the
nose
• Rhinorrhoea
• Thin watery secretions
• Deviated or
perforated nasal
septum

20.
EXTRA NASAL MANIFESTATIONS
• Retracted and
abnormal flexibility
of TM
• Injection and swelling
of palpebral
conjunctivae with
excess tearing
• Cobblestoning on
oropharynx

21.
CLASSICAL SIGNS OF AR
• Over bite
• High arched palate
• Allergic shiners
• Allergic salute
• Transverse crease over
tip of nose and lower
eye lid
• Conjunctival
congestion
• Periorbital oedema

22.
INVESTIGATIONS
• FBC
• Histamine test
• Nasal smear
• Intranasal provocation test
• Skin tests
• Subcuticular test
• More accurate with lower incidence of false positive
results
• Contraindicated in case of anti histaminic, anti
inflammatory or decongestant treatment

23.
• Intradermal tests
• Be prepared for anaphylaxis
• Skin end point titration test
• Quantitative intradermal test for specific allergen
• Nasal challenge
• Nasal cytology
• Take a sample of nasal cavity without anaesthesia
and send for identificaton of cell types in the nasal
cavity
• Increased number of eosinophils suggests allergic
disease

24.
OTHER INVESTIGATIONS
• RAST (radio allergo sorbant test)
• FAST ( fluro allergo sorbant test)
• PRIST (paper immuno allergo sorbant test)
• Xray PNS
• CT PNS (for complicated cases with polyposis)
• Nasal endoscopy ( under local or GA)
• Evaluate for asthma

25.
PROGNOSIS
• Treatment is available and patients remain
symptom free only until re exposure to allergic
antigen
• No evidence of mortality from the disease
itself, but high morbidity
• Seasonal allergic Symptoms improve as
patients age

26.
MANAGEMENT:
MEDICAL SURGICAL
AVOIDANCE

27.
AVOIDANCE
• Minimize contact with offending allergens
• Reduce dust mite exposure by encasing bed
pillows and matress in allergen proof covering
• Use of allergen proof bedding…..

28.
ACUTE PHASE MEDICATIONS
• Antihistamines effectively block histamine effects
(runny nose and watery eyes)
• Side effects : sedation, dry mouth, nausea, dizziness,
blurred vision, nervousness
• Non sedating antihistamines (cetrizine, loratidine)
• Fewer side effects
• Fexofenadine may be effective
• Carries a lower risk of cardiac arrythmias
• Decongestants
• Shrink nasal mucous membrane by vasoconstriction
• Available OTC and in combination with antihistamines,
analgesics and anti cholinergics

29.
COMMONLY PRESCRIBED
ANTIHISTAMINES

30.
• Anticholinergenic agents
• Inhibit mucous secretions, act as drying agent
• Topical eye preparations
• Reduce inflammation and relieve itching and burning

31.
MEDICAL: PREVENTIVE THERAPY
• Intranasal corticosteroids
• Reduce inflammation of mucosa
• Prevent mediator release
• Can be used safely daily
• May be given systemically for a short course during a
disabling attack
• Intranasal cromolyn sodium
• Mast cell stabiliser
• Prevents release of chemical mediators
• Oral mast cell stabilizer
• Otpthalmic solution cromolyn

32.
• Leukotriene receptor antagonists
• Montelukast (singulair) and Zafirlukast (accolate)
• Systemic agents used for asthma
• Reduce inflammation, edema and mucous sectetions
of allergic rhinitis

33.
TOPICAL NASAL STEROIDS

34.
AMERICAN ALLERGOLOGY
GUIDELINES

35.
IMMUNOTHERAPY
• If allergic rhinitis is refractory to
pharmacotherapy or severe
• Helps in reducing the specific serum IgE
level
• decreases the basophil sensitivity
• increases IgG blocking antibody level , thus
preventing allergen from reaching mast
cells and subsequent mast cell
degranulation

36.
SURGICAL THERAPY
• Limited
• Submucosal turbinectomy - reduces size of
boggy turbinates
• Septoplasty – correction of deviation of
septum
• Sinus surgery – clearance of sinuses if
sinusitis is present

37.
• Thank you….