allergic rhinitis - definition , classification , etiology , pathophysiology, signs and symptom complications , diagnosis , treatment

1. ALLERGIC RHINITIS

2. DEFINITION : -
It is an IgE mediated immunologic response of
nasal mucosa to airborne allergens.
It is characterized by :-
• Watery nasal discharge
• Sneezing
• Itching in nose
• Nasal obstruction

3. EPIDEMIOLOGY
Distribution : throughout the world approximately 10 to
30% of adults and 40 % of children are affected.
• In childhood it is more common in boys than girls but in
adulthood the prevalence is approximately equal.
• Commonly occours in 2-3rd decade of life.
Mortality and Morbidity : it itself is not life threatning
unless accompanied by severe asthma or anaphylaxis.
• It can frequently lead to significant impairment of quality
of life .
• Symptoms such as fatigue , drowsiness , and malaise can
lead to impaired work and school performance.

4. CLASSIFICATION
Clinically it is of 2 types:-
• Seasonal –symptom appear in and
around a particular season .
• Perennial – symptoms are present
throughout year.

5. CLASSIFICATION (ARIA)
• Allergic rhinitis was reclassified based on the
ARIA guidelines
1) Based on duration of disease :-
INTERMITTENT PERSISTANT
Symptoms are present
- Less than 4 days a
week or
- For less than 4
weeks/year
Symptoms are present
- More than 4 days a
week or
- For more than 4
weeks/year

6. 2) Based on severity of disease:-
MILD MODERATE TO SEVERE
None of the following
symptoms are present:-
-sleep disturbance
-Impairment of daily
activities, leisure and sport
-impairment of school or
work
-Troublesome symptoms
One or more of the above
symptoms are present

7. ETILOGY
1) INHALANT ALLERGENS : they
may be seasonal or perennial .
• Seasonal allergens include
pollens , grasses and weeds
• Perennial allergens include
molds , dust mites,
cockroaches and dander
from animals.

8. 2) GENETIC
PREDISPOSITION : chances
of child developing allergy
are 20 and 47 %
respectively if one or both
parents suffer from allergic
diathesis.

9. PATHOPHYSIOLOGY

10. PATHOPHYSIOLOGY
Leading to congestion , rhinorrhea, itching and sneezing
Increased vascular permeability, glandular hypersecretion ,
afferent nerve stimulation
Increased recruitment of inflammatory cells
Leading to release of various chemical mediators : histamine,
ECF-A, NCF-A , prostaglandins, leukotriene, PAF.
On subsequent exposure degranulation of mast cell occurs

11. CLINICAL FEATURES
SYMPTOMS OF SEASONAL ALLERGIC RHINITIS:-
• Sneezing
• Itching
• Rhinorrhea
• Nasal congestion
• Pharyngeal itching
• Ear popping

12. Symptoms of perennial
allergy :-
• Loss of sense of smell
• Loss of taste
• Persistently stuffy
nose
• Hearing impairment
(due to eustachian
tube blockage )
CLINICAL
FEATURES

13. SIGNS
NASAL SIGNS :-
• Transverse nasal crease : it occours due to constant
upward rubbing of nose simulating a salute
(ALLERGIC SALUTE )
• Bluish oedematous nasal
mucosa
• Swollen tubinates
(mulberry turbinate)
• Thin watery or mucoid
discharge is usually present

14. OCCULAR SIGNS :-
• Oedema of lids
• Congestion
of conjuctiva
• Dark circles around
the eyes
( ALLERGIC SHINERS)
• Dennie-morgan line
(prominent crease below inferior eyelid)
OTOLOGIC SIGNS
• Retracted tympanic membrane or serous
otitis media as a result of eustachian tube
blockage

15. COMPLICATIONS
• Recurrent sinusitis
• Formation of nasal polyp
• Serous otitis media
• Bronchial asthma (4 times more risk )

16. DIAGNOSIS
• It is made mainly on clinical grounds.
INVESTIGATIONS
1)SKIN TEST :these test help to identify specific
allergen.
• Skin prick test : in this a drop of
concentrated allergen solution is placed on
forearm or back and a sharp needle is
pricked into dermis through drop .
Positive reaction : is manifested by formation
of central wheal and a surrounding zone of
erythema.

17. SKIN PRICK TEST

18. 2) RADIOALLERGOSORBENT TEST (RAST ) :- it is an
in vitro test
• It measures specific IgE antibody concentration in
the patients serum
3) TOTAL AND DIFFERENTIAL COUNT :- peripheral
eosionphilia may be seen
4) NASAL SMEARS :- eosinophilia is seen

19. TREATMENT
It can be divided into :-
1. Avoidance of allergen
2. Treatment with drugs
3. Immunotherapy

20. 1)Avoidance of allergen :-
this is the most succesful if the antigen involved is
single

21. 2)Treatment with drugs :-
A.Oral antihistaminics : cetrizine, levocetrizine
• They control rhinorrhoea , sneezing , and nasal
itch
B.Sympathomimetic drugs (oral or topical ) :
epehdrine , phenylephrine
• They constrict blood vessel and reduce nasal
congestion and edema.
• Topical decongestant : oxymetazoline and
xylometazoline

22. C) Corticosteriods : intransal steriods –
budesonide , fluticasone
• Oral steriods : dexamethasone ,
hydrocortisone , methyl prednisolone
• They reduce nasal hyper reactivity and
inflammation and are very effective but
they have several systemic side effects

23. D.Leukotriene receptor antagonist :-
montelukast zafirlukast
• They are well tolerated and have fewer
side effects
E.Mast cell stabilizers: sodium cromoglycate
• They stabilizes the mast cell and prevent
them from degranulation
F.Anticholinergics : ipratropium bromide
• They block rhinorrhoea
G.Anti IgE :- omalizumab
• It reduces IgE levels and has
antiinflammatory effect

24. Immunotherapy : it is used when drug
treatment fails to control symptoms
• In this allergen is given in gradually increasing
dose till the maintenance dose is reached ,
• It suppresses the formation of IgE
• It has to be given for a year or so before
significant improvement of symptoms can be
noticed.