1. Rhinitis

2. What is Rhinitis?
The nasal passages are lined with a membrane that produces mucus
Mucus is one of the body's defense systems:
Thin clear liquid, traps small particles and bacteria
The trapped bacteria usually remain harmless in healthy individuals
Even under normal circumstances, this produces a cycle of congestion and decongestion that occurs continuously throughout the day
When one side of the nose is congested, air passes through the open, or decongested, side. The sides alternate between being wide open and being narrowed

3. Allergic Rhinitis, Facts
More than 50 million Americans suffer from allergies
Sixth leading chronic disease in U.S.
4.5 billion dollars in health care costs annually
3.8 million days lost yearly (from work and school)

4. Allergic Rhinitis: Effect On Quality of Life
People with perennial allergic rhinitis, may experience sleep disorders and daytime fatigue.
Often they attribute this to medication, but studies suggest congestion may be the culprit in these symptoms.
Patients with seasonal allergies experience hundreds of brief, subtle awakenings, called "microarousals", each night. In such cases, people are not aware that they wake up, but such events can cause fatigue the next day.

5. Allergic Rhinitis: Effect On Quality of Life
Children with severe allergies may have a higher risk for behavioral problems than those without allergies
There have been reports that 30% to 45% of people with allergic rhinitis also suffer from ear infections (otitis media)
Chronic nasal obstruction can affect a child's appearance. If a child can only breathe through the mouth, this might lead to an elongated face and an overbite from teeth coming in at an abnormal angle
Chronic rhinitis can cause headaches and also affect a child's sleep, concentration, hearing, appetite, and growth

6. Allergic Rhinitis: Risk Factors
Increasing age, atopy, and high socioeconomic status
Parental history is also positively associated with development of allergic rhinitis. A maternal history of allergy was significantly associated with a diagnosis of rhinitis by age 6 years
Other risk factors include indoor and outdoor air pollution

7. Sagittal view of the inside of the nasal cavity

8. Allergic Rhinitis: Mechanism

9. Allergic Rhinitis: Symptoms
Rhinitis develops when congestion becomes severe or other changes occur that irritate the nasal passage
Patient must experience at least two of the following symptoms for an hour or more on most days:
Runny nose
Obstruction in the nasal passage
Nasal itching
Sneezing
These symptoms may occur as a result of colds or environmental irritants, such as allergens, cigarette smoke, chemicals, changes in temperature, stress, exercise, or other factors

10. The Allergic Appearance: Allergic shiners related to chronic nasal congestion Mouth breathing and a gaping mouth

11. Chronic Rhinitis
When rhinitis lasts for a long period, it is most often caused by allergies but can also be caused by structural problems or chronic infections.

12. Chronic Rhinitis Not Related to Allergies
Aging Process
Mucous membranes become dry with age
Cartilage supporting the nasal passages weakens, causing changes in airflow
Therapy:
Avoid possible allergens and airborne irritants and keep the nasal passages moist. Decongestants would not be appropriate

13. Vasomotor Rhinitis: Chronic Rhinitis Not Related to Allergies
Increased parasympathetic stimulation
Overreaction to irritants, cigarette smoke, air pollutants, strong odors, alcoholic beverages, stress, and exposure to cold
Gustatory rhinitis
Not the same as allergic reaction

14. Chronic Rhinitis Not Related to Allergies
Foreign Objects
Blockage in young children is very often caused by foreign objects
If left in place, they may eventually cause infection and nasal discharge, usually in one side of the nose, which may be yellow or green and foul smelling (very)

15. Rhinitis of Pregnancy
One in five pregnant women will experience rhinitis symptoms (2nd or 3rd trimester)
Hormonally induced
Spontaneously resolves within few weeks after delivery
Limited therapeutic options

16. Drug-Induced Rhinitis Chronic Rhinitis Not Related to Allergies
Medications and Illegal Drugs
overuse of decongestant sprays can, over time (three to five days), cause inflammation in the nasal passages and worsen rhinitis, Rhinitis Medicamentosa
Aspirin, Ibuprofen, and Naproxen
Oral contraceptives, hormone replacement therapy, anti-anxiety agents, some antidepressants, and some blood pressure medications, including beta-blockers and vasodilators
Sniffing cocaine damages nasal passages and can cause chronic rhinitis

17. Local Allergic Rhinitis
Patients demonstrate Allergic Rhinitis symptoms but without other systemic manifestations
Negative SPT and negative RAST
Diagnosis: Nasal provocation and detection of specific IgE in nasal mucosa

18. Conditions that mimic rhinitis
Cystic fibrosis
Mucociliary defects
Cerebrospinal rhinorrhoea
Anatomic abnormalities
Foreign bodies
Tumors
Granulomas: Sarcoid, Wegener’s, Midline Granuloma

19. Chronic Rhinitis Not Related to Allergies
Polyps
soft, fluid-filled sacs
impede mucus drainage and restrict airflow
develop from sinus infections, do not regress on their own and may multiply and cause considerable obstruction
Deviated Septum
A common structural abnormality that causes rhinitis When deviated, it is not straight but shifted to one side, usually the left

20. Nasal Polyps
Protrude from the sinuses into the nasal cavities, usually from the middle meatus
Can be unilateral, or bilateral
Anosmia, most common presentation
Very common in CF
50% of children (4-16 y/o) w/ nasal polyps have CF

22. Looking for asthma…

23. In Patients with Rhinitis:
Routinely ask for symptoms suggestive of asthma
Perform chest examination
Consider lung function testing
Consider tests for bronchial hyperresponsiveness in selected cases

24. AR Classification Intermittent Persistent
. < 4 days per week
. or < 4 weeks
Persistent
. > 4 days per week
. and > 4 weeks
Mild
normal sleep
& no impairment of daily activities, sport, leisure
& normal work and school
& no troublesome symptoms
Moderate-severe
one or more items
. abnormal sleep
. impairment of daily activities, sport, leisure
. abnormal work and school
. troublesome symptoms
in untreated patients

25. Allergic Rhinitis: Diagnosis
Diagnosis is clinical Allergy Testing Skin testing and in-vitro blood testing
Testing is important to institute specific avoidance measures
Skin testing is slightly more sensitive
Common allergens
Outdoors: tree, grass, weed pollens, and mold
Indoors: dust mites, pet dander, cockroaches and mold

26. Allergy skin prick testing
Skin prick test / positive result

27. Other diagnostic tests
Nasal secretion / scraping cytology
Nasal allergen challenge
Nasal endoscopy
CT scan
anatomic abnormalities
concomitant presence of sinusitis

28. Immunoassay vs skin test for diagnosis of allergy
Not influenced by medication
Not influenced by skin disease
Does not require expertise
Quality control possible
Expensive
Skin test
Higher sensitivity
Immediate results
Requires expertise
Cheaper

29. Allergic Rhinitis: Diagnosis
Imaging studies
X-rays have a limited value
CT scans are preferred for evaluation of sinusitis
Endoscopy
Usually performed by an ENT physician, allows easy evaluation of the nose, and throat areas

30. Management of allergic rhinitis
The management of allergic rhinitis involves the following
components:
Allergen avoidance
Pharmacotherapy.
Allergen immunotherapy. Of note, immunotherapy helps prevent the development of asthma in children with allergic rhinitis, and thus should be given special consideration in the pediatric population.

31. Environmental control
The most logical strategy for disease that relates to the indoor environment
Effectiveness requires comprehensive and multifaceted measures
More studies are needed to also address the role of indoor pollutants (e.g. NO2, tobacco smoke, …)

32. Allergic Rhinitis: Treatment Avoidance/Indoor Protection
Pets:
If patient is allergic to pets, they should be given away or kept outside
If this isn't possible, they should at least be confined to carpet- free areas outside the bedroom
Cats harbor significant allergens, which can even be carried on clothing; dogs usually present fewer problems
Washing animals once a week can reduce allergens. Dry shampoos, such as Allerpet, are now available for pets that remove allergens from skin and fur and are easier to administer than wet shampoos.

33. Allergic Rhinitis: Treatment Avoidance/Indoor Protection
Dust Control
simply using a spray furniture polish is very effective for reducing both dust and allergens
Air cleaners, filters for air conditioners, and vacuum cleaners with HEPA filters can help remove particles and small allergens found indoors
Neither vacuuming nor the use of anti-mite carpet shampoo, however, is effective in removing mites in house dust. In fact, vacuuming stirs up both mites and cat allergens
Carpets and rugs should be avoided if possible

34. Allergic Rhinitis: Treatment Avoidance/Indoor Protection
Bedding and Curtains
Using semipermeable coverings to fully encase mattresses, and pillows is the most proven effective step in reducing dust mite levels
Curtains should be replaced with shades or blinds
Bedding should be washed using the highest temperature setting

35. Allergic Rhinitis: Treatment Avoidance/Indoor Protection
Reducing Humidity in the House
Dust mites thrive in humidity and damp houses increase the risk for mold
On-going humidifiers, then, can be counterproductive. If they are used, humidity levels should not exceed 40% and they should be cleaned daily with a vinegar solution

36. Allergic Rhinitis: Medical Treatment

38. Allergic Rhinitis: Second-Generation (Nonsedating) Antihistamines
The newer second-generation antihistamines do not usually cause drowsiness to the extent that the first generation antihistamines do.
Brand Names.
Loratadine is approved for children age two and over.
Cetirizine is the only antihistamine to date approved for infants as young as six months.
Fexofenadine (Allegra)
Studies suggest that cetirizine is more effective than either of these other agents in improving symptoms, including in children, although cetirizine causes more drowsiness at higher doses.

39. Allergic Rhinitis: Oral Decongestants
Oral decongestants come in many brands, which mainly differ in their ingredients.
The most common active ingredient is pseudoephedrine.

40. Allergic Rhinitis: Oral Decongestants
Side Effects of Decongestants
Agitation and nervousness.
Drowsiness (particularly with oral decongestants and in combination with alcohol).
Changes in heart rate and blood pressure.
Avoid combinations of oral decongestants with alcohol or sedatives.

41. Nasal corticosteroids
reduction of
mucosal inflammation
late phase reactions
priming
nasal hyperresponsiveness 1
reduction of
mucosal mast cells
acute allergic reactions 2
suppression of
glandular activity
and vascular leakage
induction of
vasoconstriction 3
reduction of
symptoms and exacerbations

42. Allergic Rhinitis: Corticosteroid Nasal Sprays
Benefits:
The most effective agents currently available for treating allergic rhinitis.
Blocks the inflammatory response that triggers an allergic attack. They do not relieve symptoms immediately but may take several hours before their effects are felt.
They reduce inflammation and mucus production.
They improve night sleep and daytime alertness in patients with perennial allergic rhinitis.
Beneficial in treating polyps in the nasal passages.

43. Nasal corticosteroids
Overall safe to use
Adverse Effects
Nasal irritation
Epistaxis
Septal perforation (extremely rare)
HPA axis suppression (inconsistent and not clinically
significant)
Suppressed growth (only in one study with beclomethasone)

44. Allergic Rhinitis: Corticosteroid Nasal Sprays
Corticosteroids available in nasal spray form include the following:
Beclometazone (Beconaze). Approved for children over six
Mometasone furoate (Nasonex). Approved for use in patients as young as three.
Fluticasone (Flonase). Approved for children over four.
Budesonide (Rhinocort). Approved for children over six.

45. Medications for Allergic Rhinitis - ARIA
sneezing rhinorrhea nasal nasal eye obstruction itch symptoms
H1-antihistamines
oral to
intranasal
intraocular
Corticosteroids
Cromones
intranasal
intraocular
Decongestants
intranasal
oral
Anti-cholinergics
Anti-leukotrienes
Management combines allergen avoidance and pharmacologic therapy, with allergen immunotherapy added for refractory or severe cases.
Intranasal glucocorticoids (INGCs) are the most effective single therapy for allergic rhinitis in most patients with significant or persistent symptoms.
With this in mind, we favor the following approaches for specific patient groups:
Children <3 years — For children <3 years, initial treatment depends upon both of the child's symptoms and the concerns of the parents/caregivers.
For children <3 years with mild symptoms, we suggest a second generation antihistamines (Grade 2B). Cetirizine (approved for children ≥6 months), loratadine, and fexofenadine (both approved for children ≥2 years) are similarly efficacious and are available in syrups.
If this is not effective or the child has prominent congestion, we suggest changing to an INGC with minimal systemic bioavailability and once-daily dosing (Grade 2B). Mometasone furoate and fluticasone furoate are approved for children ≥2 years of age.
Intranasal cromolyn may be helpful for children with mild or episodic symptoms, whose parents are especially concerned about possible side effects, although the need for frequent dosing (one to two sprays three to four times daily) limits compliance.

46. Nasal Antihistamines
Efficacious and equal to or superior to oral antihistamines for treatment of SAR
Clinically significant effect on nasal congestion
Improved nasal symptoms in patients who failed oral antihistamines
Onset of action: 30 vs minutes for oral antihistamine
Side effects: Sedation, bitter taste

47. Nasal Antihistamines Azelastine Olopatadine (Patanase)
Azelastine/Fluticasone (Dymista)

48. Anticholinergic treatment: ipratropium bromide
Nasal glands are activated by muscarinic, cholinergic receptors
Ipratropium bromide is a nonselective muscarinic receptor antagonist
Ipratropium bromide applied intranasally blocks rhinorrhea induced by
cholinergic stimulation
Ipratropium bromide has negligent systemic anticholinergic activity
Topical adverse effects: excessive dryness, epistaxis

49. Anti-leukotriene agents
CysLT1 Receptor
Antagonists
Montelukast *
Pranlukast *
Zafirlukast
5-Lipoxygenase
Inhibitors
Zileuton
* Approved for allergic rhinitis

50. Anti-leukotriene treatment in allergic rhinitis
Efficacy
Equipotent to H1 receptor antagonists but with onset of action after 2 days
Reduce nasal and systemic eosinophilia
May be used for simultaneous treatment of allergic rhinitis and asthma
Safety
Dyspepsia (approx. 2%)

51. Allergen Immunotherapy
Criteria for Allergen Immunotherapy
Severity of rhinitis symptoms
Duration of rhinitis symptoms
Progression of rhinitis
Failure to respond to medical treatment

52. Allergic Rhinitis: Allergen Immunotherapy
Administering Therapy
Immunotherapy requires a prolonged course of weekly injections ("allergy shots"). The process generally follows this course:
Injections of diluted extracts of the allergen are given on a regular schedule, usually weekly at first, then in increasing doses until a maintenance dose has been reached. It usually takes several months to reach a maintenance dose.
At that time, intervals between shots can be two to four weeks, and the treatment is continued for up to three to five years.
Patients can experience some relief within three to six months; if there is no benefit within months, the shots should be discontinued.

53. Anti IgE - omalizumab Not licensed to treat allergic rhinitis
Could be considered in severe cases unresponsive to conventional treatment
Could be an adjunct to immunotherapy in severe cases

54. SPECIAL CASES PAEDIATRIC PATIENTS
>4 years should be treated as for adults
Children (>4) with AR and Asthma can be treated with combination of newer topical and inhaled corticosteroids
Diagnosis in smaller children is difficult as can have up to 6 to 8 colds per year
Small children – oral antihistamines, saline sprays and corticosteroids if symptoms severe
<2 years fortunately rare

55. ALLERGIC RHINITIS IN PREGNANCY
FDA considers no drugs are considered completely safe
FDA RISK Categories for drugs in pregnancy (based on good studies in pregnant women)
A – safe to baby in 1st trimester
B – safe in pregnant animals, no human studies
C – drugs show foetal problems in animal studies
but benefits may outweigh the potential risks
D – clear risk to foetus but there may be instances
X – should not be used in pregnancy

56. ALLERGIC RHINITIS IN PREGNANCY
Nasal Saline
Nasal corticosteroids – all Category C except Budesonide which was recently reassigned B – nasal steroid of choice
Antihistamines – usually not very effective but older antihistamine chlorpheniramine, loratadineand cetrizine are B
Oral steroids C
Decongestants - C

57. Capsaicin
Capsaicin has been shown to be of benefit to Idiopathic Rhinitis.
Nasal Capsaicin, results in rhinorrhea, nasal blockage and sneezing through c-fibers (pain receptors).
Repeated application of capsaicin, however, lead to desensitization and degeneration of C-fibers.

58. Treatment
Dosage is five high dose treatments of intranasal capsaisin over 1 day at 1 hr intervals after local anesthesia or five treatments spread out over 2 wks.
Up to 75% of patients will show long lasting (from 4 month to over 1 yr.) relief of symptoms.
Even after symptom free period is over, a repeat dose of capsaisin will most likely repeat itself.

59. Treatment Surgery is reserved for failed medical therapy only.
Nasal polyps, inferior turbinate hypertrophy and septal spurs may obstruct nasal cavity and block the action of topical medications.

60. What is the role of surgery?
Sometimes effective
Submucosal resection for good long term results

61. Surgery is reserved for failed medical therapy only.
Nasal polyps, inferior turbinate hypertrophy and septal spurs may obstruct nasal cavity and block the action of topical medications.

62. Allergic Rhinitis: Conclusions
Allergic disorders are on the rise and have a significant impact on the quality of life
Allergic rhinitis can lead to other comorbidities such as asthma and sinusitis
Treatment should focus on trigger identification and avoidance, medications and allergen immunotherapy

63. References
Dykewicz MS, et al. Ann Allergy Asthma Immunol 1998;81(5 Pt 2):
Rondon et al. J Investig Allergol Clin Immunol 2010; 20(5):
Wallace et al. J Allergy Asthma Clin Immunol 2008; 122: S1-84
M. Varghese, M. C. Glaum and R. F. Lockey, Clinical & Experimental Allergy, 2010 (40) 381–384