Important topic for MBBS students from examination point of view

1. Allergic and Intrinsic
Rhinitis
Dr. Krishna Koirala
MBBS,MS
19-11-2019

2. • Definition
– IgE mediated hypersensitivity disease of the mucous
membrane of nasal airways characterized by sneezing ,
itching, watery nasal discharge, sensation of nasal
obstruction, postnasal discharge and hyposmia
• Associations
– Allergic conjunctivitis
– Bronchial asthma
• Prevalence
– Depends on age, gender and geographical locations
– 10-20% with a male predominance
– Peak age - Young adulthood

3. Classification of Allergic Rhinitis
• Old : Seasonal, Perennial, Occupational
• ARIA (Allergic Rhinitis and its impact on Asthma)

4. Etiology
• Atopy (Hereditary)
– Represents a predisposition to develop allergic disease
• Allergens
– Seasonal rhinitis : Grass and tree pollens
– Perennial allergic rhinitis
• House dust mite – Digestive enzymes excreted in faeces
• Domestic pets – Cats, dogs, rabbits, guinea pigs
• Cockroaches
– Occupational Rhinitis : Flours, laboratory animals,
biological washing powders, latex, smokes and fumes

5. • Food and drug induced rhinitis
– More common in children
– Foods
• Milk ,eggs, cheese in children
• Nuts ,fish ,citrus fruits in adults
– Drugs
• Aspirin
• Antihypertensives ( beta blockers, ACE inhibitors )
• Antipsychotic
• Topical nasal decongestants (Rhinitis medicamentosa)
• Pollution
– Perfumes, tobacco smoke, traffic fumes, domestic sprays

8. Diagnosis
• History
– Seasonality, frequency and severity of symptoms
– Patient’s dominant symptoms
– History of potential allergic triggers
– Personal/ family h/o atopic disease
– H/o trauma
– H/o mucopurulent rhinorrhea, facial pain, fever
– Drug allergy and food provoking factors

9. Clinical features
Symptoms
• Seasonal rhinitis
– Sneezing : paroxysmal, frequent
intervals throughout the day,
more in the morning times
– Nasal discharge : watery,
mucoid, yellowish
– Nasal obstruction / blockage
– Itching of nose, eyes, palate
– Tearing/redness of the eyes,
periorbital edema
– Burning/raw sensation of throat
– Wheezing/chest tightness
• Perennial Rhinitis
– Long standing nasal
congestion and PND
– Viscous/ purulent rhinorrhea
– Conjunctivitis less frequent
– Secondary symptoms : loss
of smell and taste, sinusitis,
ETD
– Sneezing less common

10. Signs
• Nose
– Transverse crease at the dorsum of
the nose ( Darrier’s line)
– Allergic salute
– Pale /bluish nasal mucosa
– Boggy and swollen turbinates
– Watery nasal discharge
– Polyps/ hypertrophied turbinates
– Septal deviation
Allergic salute
Darrier’s line

11. • Eyes
– Periorbital edema, conjunctival congestion ,watering
– Marked erythema of palpebral conjunctivae and papillary
hypertrophy of tarsal conjunctivae ( cobblestone)
– Dark circles under the eyes ( allergic shiners)
• Repetitive vigorous rubbing in the peri - orbital region
• Impaired venous return from the
skin and subcutaneous tissues
– Extra skin fold or line under the
lower eyelids ( Denni - Morgan lines)
Denni - Morgan lines

12. • Ear
– Retraced TM, OME
• Pharynx
– Granular pharyngitis,
cobblestone
• Larynx
– Laryngeal edema
• Bronchus
– Bronchospasm

13. Investigations
• Complete Blood Count ,ESR, Absolute Eosinophil Count
• Serum IgE measurements
• Nasal smear for cytology : eosinophils, neutrophils, basophils,
mast cells , epithelial cells and bacteria
• Nasal swabs for bacteriology or viral studies
• Skin prick tests
• RAST (Radioallergosorbent Test)
• ELISA
• Nasal provocation (challenge) test
• Diagnostic Nasal Endoscopy (DNE)
• X-Ray PNS OM view
• CT scan of nose and PNS : coronal/axial /sagittal cut

14. Skin Prick Tests
• Prick or scratch test
– Pricking the skin with a needle or pin containing a small amount of the
allergen
• Patch test
– Applying allergen containing patch to the skin
– If response is seen in the form of a rash, urticaria or
anaphylaxis -- patient has a hypersensitivity to that allergen
• Intradermal test
– A small amount of the allergen solution is injected into the
skin and response is seen

15. • The negative control
– Saline (salt-water) solution
– Response not expected
– If however a patient reacts to a negative control --- the skin
is for whatever reason extremely sensitive
• The positive control
– Histamine, to which everyone is expected to react
– Failure to do so -- medicines the sufferer is taking could
block the response to the histamine and allergens

19. Treatment Modalities
• Allergen avoidance
• Pharmacotherapy
• Immunotherapy
• Treatment of complicating factors

20. 2
1
2

21. • Allergen avoidance
– Useful for a single/ unusual allergen
– Identification of relevant aeroallergens and complete/
partial avoidance of allergens
• Elimination of occupational allergen exposure
• Elimination of pet allergen exposure
• Mite antigen control measures
• Frequent pet washings
• Cockroach control measures
• Closed windows in homes / cars
• Central heating and cooling
• Central air filtering system

22. Pharmacotherapy
• Primary therapy for seasonal / perennial allergic rhinitis
• Corticosteroids
– Topical: Sprays and drops
• Extremely effective for all nasal symptoms of allergy
• Beclomethasone, budesonide, fluticasone, mometasone
– Oral
• Prednisolone 1 mg /kg / day in tapering dose for 2
weeks
– Depot intramuscular route - not recommended

23. • Mast cell stabilizers
– Eg. Sodium chromoglycate drops and sprays
– Less effective than topical corticosteroids
– Treatment of first choice in young children
• Antihistamines
– Eg. Chlorpheniramine, Terfenadine, Astemizole, Loratadine, Cetrizine,
Fexofenadine, Ebastine
– Effective for sneezing, itching, watery rhinorrhea and eye , palate and
throat symptoms
– Less effective in nasal congestion and blockage
– Mainly taken at bedtime
– Newer generations less sedative than older ones

24. • Topical vasoconstrictors
– Xylometazoline, oxymetazoline, ephedrine
– Effective against nasal blockage
– To be used for short period only, prolonged use >2 wks may
lead to Rhinitis medicamentosa (Rebound hyperemia,
nasal congestion and obstruction that occurs following
prolonged and repeated use of topical vasoconstrictors)
• Topical anticholinergics
– Ipratropium Bromide (0.03% nasal spray) for watery
rhinorrhea
• Leucotriene inhibitors
– Montelukast, zafirlukast

25. Allergen Specific Immunotherapy ( SIT)
• Practice of administering gradually increasing quantities of an
allergen extract to an allergic subject to eradicate the allergic
symptoms by subsequent exposure to the causative allergen
• Indications
– Pollen sensitive patients having single allergen, failing to
respond to conventional treatment , having intolerable side
effects of treatment, unable to avoid the allergens
• Contraindications
– Patients with multiple allergies , significant medical illness
and taking drugs likely to impair the treatment of
anaphylaxis

26. • Procedure:
– Allergen injected subcutaneously in increasing doses till
maximum tolerated response is reached
– May also be delivered by the oral, nasal or sublingual routes
– The monoclonal anti - IgE antibody
• Induces the reduction of serum-free IgE levels
• Reduces the symptoms mediated by IgE
• Reduces the severity of the symptoms of seasonal
allergic rhinitis
– Success rates - as high as 80 -90% for certain allergens
– Course : 2 years or more

27. Intrinsic Rhinitis
(Non-allergic Non-infective
rhinitis, Vasomotor rhinitis)

28. Spectrum of Disease
• Vasomotor rhinitis
• Non-Allergic Rhinitis with Eosinophilia Syndrome (NAREs)
• Occupational rhinitis: flour, animal, wood, latex, paint
• Rhinitis medicamentosa: Prolonged use of decongestant
nasal drops
• Drug-induced: propranolol, O.C.P., antidepressants
• Endocrine: hypothyroid, pregnancy, menstruation
• Miscellaneous: honeymoon / emotional/ non airflow /
addiction

30. Vasomotor Rhinitis

31. • Pathogenesis:
– Overactivity of Parasympathetic nervous system of nose
• Nasal congestion (due to nasal vasodilatation)
• Nasal block (due to nasal vasodilatation)
• Watery rhinorrhoea (due to ed nasal glandular
secretions)
• Trigger Factors:
– Emotional stress, sudden change in temperature, humidity ,
blasts of cold air, dust, smoking & traffic fumes

32. Clinical Features
• Symptoms - perennial
– Nasal block (blockers)
– Profuse watery rhinorrhoea (runners)
– Paroxysmal early morning sneezing
– Post nasal drip
• Signs
– Turbinates congested & hypertrophied
• Sequelae
• Nasal polyp, hypertrophic rhinitis, sinusitis

33. ALLERGIC INTRINSIC
Allergen exposure Yes No
Nasal itching +++ Minimal
Sneezing +++ +
Rhinorrhoea ++ +++
Nasal obstruction ++ +
Hyposmia ++ +

34. ALLERGIC INTRINSIC
Nasal mucosa Pale Congested
Nasal polyps ++ Rare
Absolute Eosinophil
Count
ed Normal
Nasal smear
eosinophil
ed Normal
Skin prick test Positive Negative
Treatment Steroid spray, Anti H1,
Nasal decongestant
Ipratropium,
Botulinum

35. Treatment of
Vasomotor Rhinitis

36. General Measures
• Sleep with head end elevated by 30
0
• Sleep + work in a cool environment (not cold)
• Keep body warm
• Regular exercise program to improve vasomotor
tone
• Avoidance of trigger factors

37. Medical Treatment
• Antihistamines:
– Systemic: Cetirizine, fexofenadine, loratadine, levocetrizine,
ebastine
– Topical: Azelastine spray
• Nasal Decongestants
– Systemic: Phenylephrine, pseudoephedrine
– Topical : Xylometazoline, oxymetazoline, saline
• Topical and systemic steroids

39. Drug Sneeze Rhinorrhoea Nasal
block
ed smell
Antihistamine +++ ++ + 0
Steroid spray +++ +++ +++ +
Cromoglycate + + + 0
Topical nasal
decongestant
0 0 ++++ 0
Ipratropium 0 ++ 0 0

40. Steroid sprays Strength /
puff
Acute attack
dose
Maintenance
dose
Beclomethasone 50 g 2 puffs BD 1 puff OD
Budesonide 64 g 2 puffs OD-BD 1 puff OD
Fluticasone 50 g 2 puffs OD-BD 1 puff OD
Mometasone 50 g 2 puffs OD-BD 1 puff OD

41. Surgical Treatment
1. To reduce size of nasal turbinates thus to relieve
nasal obstruction
2. Sectioning parasympathetic secreto - motor fibers of
nose (vidian neurectomy) to relieve excessive
rhinorrhoea

42. Surgeries to reduce the size of turbinate
• For mucosal hypertrophy
– On surface: Electrocautery , Laser
– Submucosal: Electrocautery (Submucosal diathermy),
cryotherapy, radiofrequency ablation
• For bony hypertrophy
– Submucous resection of inferior concha
• For mucosal + bony hypertrophy
– Partial / total turbinectomy

44. Vidian Neurectomy
• Trans - septal approach
• Trans - antral approach (Golding Wood)

45. Rhinitis Medicamentosa
• Rebound nasal congestion due to use of intranasal
decongestants for > 10 -14days
• Prolonged use tachyphylaxis  more frequent dose
• Nasal medications containing benzalkonium chloride cause
more rebound congestion
• Offending drugs : Oxymetazoline , Xylometazoline
– Contract smooth muscle of venous erectile tissue present in
nasal turbinates  mucosal shrinkage and decrease
airway resistance

46. Pathogenesis

47. Clinical Features
• Chronic nasal block requiring increased dose & frequency of topical
decongestants after its prolonged use
• Nasal mucosa appears hyperemic, granular & boggy in early stages and
pale & anemic in later stages
Treatment
• Immediate withdrawal of topical decongestant - Substitute with systemic
nasal decongestants
• Nasal corticosteroid sprays ( Oral corticosteroids for severe cases only)
• Rhinostat system
• Patient Education: Avoid topical decongestant use for > 10 days