Dr.SUDEEP K.C.

IIt is an IgE-mediated immunologic response of nasal mucosa to airbrone allergens. Two types: 11)Seasonal 22) Perennial

AETIOLOGY: Inhalant allergen o Genetic predisposition PATHOGENESIS: Inhaled allergen produce specific IgE antibody in genetic ally predisposed individuals  antibody fixed to tissue mast cells by it Fc end-  on subsequent exposure antigen combines with IgE antibody at its Fab end  degranulation of mast cell  release of mediators which is responsible for all the symptoms.

CLINICAL FEATURES: The cardinal symptoms of seasonal nasal allergy include: Paroxysmal sneezing,10-20 sneezes at a time. Nasal obstruction and watery nasal discharge. Itching in the nose, may involve eyes, palate, or pharynx. Some may get bronchospasm.

Symptoms of perennial allergy:  Frequent colds, persistently stuffy nose, loss of sense of smell due to mucosal edema.  Post nasal drip, chronic cough and hearing impairment due to eustachian tube blockage.  Signs of allergy may be seen in nose, eyes, ears, pharynx or larynx.  Nasal signs include transverse nasal crease, turbinates swollen.

 Ocular signs include oedema of lids, congestion of conjunctiva, dark circles under the eyes.  Otologic signs include retracted TM or serous otitis media.  Pharyngeal signs include granular pharyngitis.  Laryngeal signs include hoarseness of voice and oedema of vocal cords.

Recurrent sinusitis because of obstruction to sinus ostia. Nasal polypi. Serous otitis media. Bronchial asthma. TREATMENT: 1)Avoidance of allergen. 2)Treatment with drugs  antihistamine, corticosteroids, sodium cromoglycate, sympathomimetic drugs 3)Immunotherapy.

 It is non- allergic rhinitis  Clinically simulating with symptoms of nasal obstruction, rhinorrhea and sneezing.  Condition persists whole year  All the tests of nasal allergy are absent.

 Nasal mucosa has rich blood supply.  Sympathetic stimulation causes vasoconstriction and shrinkage of mucosa,  Parasympathetic stimulation causes vasodilation and engorgement, excessive secretion from nasal glands.  ANS is under the control of hypothalamus and emotions play a great role in VMR.  ANS is unstable incases of VMR and nasal mucosa is also hyperactive.

SYMPTOMS (2PEN): Post nasal drip Paroxysmal sneezing Excessive rhinorrhoea Nasal obstruction SIGNS: Nasal mucosa over turbinates is congested and hypertrophic. COMPLICATIONS: long-standing cases of VMR develops nasal polypi, hypertrophic rhinitis and sinusitis.

 Drug-induced rhinitis: several antihypertensives like reserpine, methyldopa, propanolol are sympathetic blocking agent and cause nasal stuffiness. OCP’S also cause nasal obstruction.  Rhinitis medicamentosa: Topical decongestant nasal drops cause rebound phenomenon. Their excessive use causes rhinitis.

 Rhinitis of pregnancy:  Pregnant women may develop persistent rhinitis due to hormonal changes.  Nasal mucosa get edematous and blocks air way.  Honeymoon rhinitis:  follows sexual excitement leading to nasal stuffiness.  Emotional rhinitis:  Nose may react to several emotional stimuli  psychological states like anxiety, tension, humiliation, grief are all known to cause rhinitis  Proper counseling and psychological adjustment should be done.

 Rhinitis due to hypothyroidism  Hypothyroidism leads to hypoactivity of the sympathetic system with predominance of parasympathetic activity causing nasal stuffiness and colds. Replacement of thyroid hormone relievesd the condition.  Non air-flow rhinitis Seen in patients of laryngectomy and tracheostomy. Nose is not used for air flow and the tubinates become swollen due to loss of vasomotor control. Similar changes are also seen in nasopharyngeal obstruction due to choanal atresia or adenoidal hyperplasia, the latter having the additional factor of infection due to stagnation of discharge in the nasal cavity which should otherwise drain freely into the nasopharynx.

A) MEDICAL: AAvoidance of physical factors that provokes the symptoms AAntihistaminic and oral nasal decongestants TTopical steroids SSystemic steroids- short course PPsychological factors should be removed

Adrenergic Agents There are two main families of adrenergic drugs: (1) Phenylamines (eg, ephedrine, pseudoephedrine, phenylephrine, and phenylpropanolamine) and (2) Imidazolines (eg, xylometazoline, oxymetazoline, and naphazoline). Phenylamines are oral agents, whereas imidazolines are topical agents.  The primary role of phenylamines is to decrease mucosal capacitance vessels by agonizing -adrenergic receptors; this leads to a decongestant effect.  Phenylamines can cause dose-related adverse effects such as tremulousness, irritability, tachycardia, hypertension, and urinary retention.  They are contraindicated in patients with hypertension, severe coronary artery disease, and in patients on monoamine oxidase inhibitors.  Topical imidazolines decrease nasal blood flow by affecting 1 - and 2 -adrenergic receptors. Potent vasoconstriction can cause rebound congestion upon withdrawal of the drug (rhinitis medicamentosa) if used for more than 5 days.

Additional Agents  Anticholinergic agents such as ipratropium bromide can be used topically to block parasympathetic input and thereby decrease rhinorrhea. Ipratropium bromide is available in a 0.03% formulation for noninfectious rhinitis and a 0.06% concentration for viral rhinitis.  Anticholinergic agents can be used in combination with intranasal steroids  They should be avoided in patients with narrow- angle glaucoma, prostatic hypertrophy, or bladder neck obstruction.

 Some over-the-counter sprays, such as cromolyn sodium, are safe to be used repetitively. These intranasal sprays act to stabilize mast cell membranes. They must be given prior to mast cell degranulation to be effective and have relatively short half-lives, so their administration must be frequent

Septal Procedures  The surgical treatment for nonallergic rhinitis is focused on correcting structural abnormalities that may contribute to patient symptoms.  Septal deviation is a common defect that can contribute to nasal obstruction.  Septoplasty or nasoseptal reconstruction is used to correct cartilaginous or bony abnormalities of the septum.  Septal perforations can contribute to crusting or epistaxis. The surgical correction of septal perforations may include the placement of septal buttons, advancement flap closures of perforations, and, more recently, free-tissue transfers for large perforations.

 Turbinate Surgery  Inferior turbinate surgery is also commonly used to counteract nonallergic rhinitis.  The type and extent of surgery on the inferior turbinate continues to be a source of debate.  Various techniques for turbinate surgery exist and include outfracture, cauterization, radiofrequency ablation, submucous resection, submucosal reduction via a microdebrider, and partial or complete turbinate resection.  In general, the current trend is to preserve as much turbinate mucosa as possible to allow normal physiologic function to continue.