1. RHINITIS Dr. Abdullah Alkhalil MRCS-ENT(UK), DOHNS(London)
Higher specialty(JUST),
Jordanian Board.

2. Definition
Defined as inflammation of the nasal mucosa characterized by two or more of the following symptoms:
nasal congestion
anterior/posterior rhinorrhoea
sneezing
itchy nose

3. Classification
Infective
Allergic
Non-infective, Non-allergic

4. Infective Rhinitis Viral Common cold Influenza Rhinovirus
Parainfluenza
RSV
Adenovirus
Influenza

5. Infective Rhinitis Bacterial Fungal ? Simple Syphilis TB
Atrophic rhinitis
Fungal ?

6. ALLERGIC RHINITIS
Allergic rhinitis is an IgE-mediated, type 1 hypersensitivity reaction in the mucous membranes of the nasal airways. The disease is very common, affecting approximately 30% of the Westren population. It can be
either seasonal (hayfever) or perennial
(sometimes with seasonal exacerbations).

7. ALLERGIC RHINITIS Prevalence 400 million suffers worldwide
10 – 30% of population in the world
All ages are affected, peaks in teens.
Boys more affected than girls but equalizes after puberty.
Most will be managed at Primary Health Care level.

8. Aetiology
Allergy is a hypersensitivity reaction of tissues to certain substances called allergens. The commonest allergens are highly soluble proteins or glycoproteins. Typical allergens include pollens, moulds, house dust mite and animal epithelia.

10. Pathophysiology

11. ALLERGIC RHINITIS Subdivided into
intermittent (IAR) .v. persistent (PER)
Severity classified as
mild .v. moderate/severe

12. ALLERGIC RHINITIS Moderate-severe one or more items Mild
Intermittent symptoms
< 4 days per week Or < 4 weeks
Moderate-severe one or more items
Abnormal sleep.
Impairment of daily activities, sport, leisure.
Problems caused at school or work.
Troublesome symptoms.
Persistent symptoms
> 4 days per week and > 4 weeks
Mild
Normal sleep.
Normal daily activities.
Normal work and school.
No troublesome symptoms.

13. Symptoms Rhinorrhea Cough/sneezing Nasal congestion Post nasal drip
Nasal pruritis
Watery eyes
General fatigue
Diminished quality of life

14. Symptoms
Seasonal rhinitis usually occurs any time from early summer to early autumn depending on the specific allergen. The patient suffers from rhinorrhoea, nasal irritation and sneezing, associated with itchy and watering eyes. Some individuals (described as atopic) will have a strong family history of allergy or a previous history of eczema or asthma.

15. Symptoms
Long-standing cases of perennial allergy may not display all these features, but they often have nasal obstruction due to hypertrophy of the turbinates sometimes associated with hyposmia. Patients with perennial rhinitis are almost invariably allergic to house-dust mite and typically have more than one allergy.

16. Physical General appearance Nose Mouth Eye Red eye Ear Chest Skin
allergic salute, malaise
Nose
Watery discharge, turbinate hypertrophy, hyponasality
Mouth
Cobblestoning of oropharynx
Eye
Red eye
Ear
Middle ear pathology
Chest
wheezing
Skin
Eczema

17. Allergic salute

18. Granular Pharyngitis

19. Allergic turbinates

20. Investigations 1. Skin tests.
The epidermal prick test and the intradermal injection test use an allergen placed on the skin of the flexor aspect of the forearm. If the patient has an allergy to this then a wheal and flare will come up within 20 minutes. A battery of common allergens (e.g. pollens, moulds, feathers, house dust mite, animal epithelia, etc.) are compared with the controls by the wheal they produce. If the patient is highly sensitive a widespread or even an anaphylactic reaction may result. Resuscitation equipment must always be available although the epidermal prick test is safe if properly performed. If an adverse reaction occurs, a tourniquet should be placed proximally to contain it and the patient given intravenous hydrocortisone, chlorpheniramine (chlorphenamine) and adrenaline (epinephrine).

22. Investigations
2. Blood tests. Total plasma IgE levels may be measured in the plasma radioimmunosorbent test (PRIST) and IgE to specific allergens in the radioallergosorbent test (RAST). These tests are more convenient, do not expose the patient to the risks of the skin tests and do not rely on the use of a specific allergen. However, they are more expensive and have no diagnostic superiority over skin tests. An eosinophilia may occur in an acute allergic reaction but is unusual in allergic rhinitis.

23. Investigations
3. Nasal smears. An increase in eosinophils in a nasal smear indicates an allergic rhinitis but is not diagnostic. 4. Provocation tests. A drop of the suspected allergen squeezed into the nose may cause symptoms (rhinorrhoea, sneezing, etc.)- The effect can be measured objectively by rhinomanometry.

24. Management
Avoidance of the precipitating allergen is obviously helpful, but not always possible.
2. Oral antihistamines. which selectively block histamine receptors, (e.g. fexofenadine, loratidine). Some patients still prefer the older antihistamines which may cause drowsiness (e.g.chlorpheniramine) and they should be warned of this. Intranasal antihistamine sprays (e.g. azelastine hydrochloride) have the advantage of minimal systemic absorption.

25. Management
3. Topical steroid sprays and drops are now considered to be the cornerstone in the treatment of rhinitis. They are safe and effective. Crusting and bleeding are the main side-effects. Systemic absorption is negligible, as is the chance of promoting fungal infections. Examples include fluticasone, mometasone, and triamcinolone sprays.

26. Management
4. Topical anticholinergic drugs (e.g. ipratropium bromide) are useful in the treatment of patients in whom rhinorrhoea is the predominant symptom. 5. Sodium cromoglycate stabilizes mast-cell membranes and therefore prevents the release of the allergic response mediators. It has few side-effects, but needs to be used five to six times per day for adequate prophylaxis, so compliance is poor.

27. Management
6. Leukotriene synthesis inhibitors and receptor antagonists are not marketed for the treatment of allergic rhinitis, but they show promise for the future treatment of the disease.

28. Management
7. Immunotherapy involves a series of injections of small amounts of the proven allergens in a purified form, in the hope that blocking IgG antibodies will be produced. It is really only of use in patients who are sensitive to only one or two allergens, in particular pollen allergy. The main complication of this treatment is anaphylaxis, and for this reason its use in the UK has been discouraged. Resuscitation equipment must always be available where this therapy is performed, and in case of anaphylaxis there must be a supply of intravenous hydrocortisone, chlorpheniramine and adrenaline.

29. Non-infective, Non-allergic Rhinitis
Defined as rhinitis symptoms in the absence of identifiable allergy, structural abnormalities, sinus disease or infection.
Non allergic rhinitis has been described in many terms including: vasomotor rhinitis, intrinsic rhinitis, chronic rhinitis and idiopathic rhinitis.

30. Causes of non-allergic rhinitis
Occuptional
Drug induced
Rhinitis medicamentosa
NARES
Hormonal
Idiopathic or vasomotor
Atmospheric pollution and change in weather

31. Clinical features
NAR accounts for 40–70% of all cases of perennial rhinitis and becomes more common with increasing age. All patients exhibit nasal obstruction and rhinorrhoea or post-nasal discharge, but itching and sneezing are less common than in allergic rhinitis. Patients vary in their degree of nasal obstruction and discharge. There may be associated nasal polyps with anosmia.

32. Clinical features
Co-existent sinus pathology is frequently found (up to 50%) due to the inevitable compromise of sinus aeration and drainage. Examination generally reveals a rather red and angry mucosa, often with copious secretions and hypertrophy of both middle and inferior turbinates, causing a consequent reduction in the airway size.

33. Clinical features

34. Occupational Arises from airborne agents at workplace.
Agents do not act through immune-mediated mechanism. They are direct irritants to the nasal mucosa and cause non-allergic hyper-responsive reactions.
Over 250 different chemicals identified, like cigarette smoke, latex, glue, and wood dust.
Diagnosis ?

35. Drug Induced Rhinitis
Several common medications induce rhinitis when administered topically or orally.
Many drugs can cause this type of rhinitis for example: aspirin, angiotensin converting enzyme inhibiter, beta blocker, OCP, and sildenafil.

36. Rhinitis Medicamentosa
It is a drug induced non-allergic rhinitis associated with prolonged use of topical nasal decongestant. Also called rebound or chemical rhinitis.
Incidence is 1-9%, equal sex distribution and more common in young to middle age adults and pregnant women.

37. Rhinitis Medicamentosa
Risk of RM is accepted to be greatest after 10 day use of medication.
Treatment is gradual stopping of decongestant with introduction of topical steroids.
Patient should be warned of temporary worsening symptoms.

38. NARES
It is characterized on the basis of 20-25% or greater eosinophils in nasal smears of patient with rhinitis.
There is lack of allergy by skin test or IgE antibodies.
Prevalence ranges from 13-33% of non-allergic rhinitis.
Most common type associated with nasal polyp and asthma.

39. Hormonal Rhinitis
Defined as rhinitis during periods of known hormonal imbalance.
Estrogen are known to affect the autonomic nervous system by increasing central parasympathetic activity.
Therefore, the most common causes are pregnancy, menstruation, puberty and exogenous estrogen.

40. Hormonal Rhinitis
Hypothyroidism may also be a known cause of hormonal rhinitis. In patient with hypothyroidism, edema increases in the turbinates as a result of TSH release.
Nasal congestion and rhinorrhea are the most common symptoms of hormonal rhinitis.

41. Idiopathic rhinitis
Also known as vasomotor rhinitis is characterized by nasal blockage and rhinorrhea, but sneezing and pruritis is lower than allergic rhinitis.
Studies have suggested autonomic dysregulation, neuropeptide or nitric oxide hyperactivity.
Diagnosis of exclusion.

42. Atrophic Rhinitis
chronic inflammation of nose characterized by atrophy of nasal mucosa, including the glands, turbinate bones and the nerve elements supplying the nose. Chronic atrophic rhinitis may be primary and secondary. Special forms of chronic atrophic rhinitis are rhinitis sicca anterior and ozaena.

43. Clinical Manifestations
The disease is most commonly seen in females, and tends to appear during puberty. The nasal cavities become roomy and are filled with foul smelling crusts which are black or dark green and dry, making expiration painful and difficult. Patients usually complain of nasal obstruction despite the roomy nasal cavity, which can be caused either by the obstruction produced by the discharge in the nose, or as a result of sensory loss due to atrophy of nerves in the nose, so the patient is unaware of the air flow.
Permanent loss of smell and impairment of taste may also be a result of this disease, even after the symptoms are cured.

45. Treatment Nasal irrigation using normal saline
Nasal irrigation and removal of crusts using alkaline solutions
25% glucose in glycerine can be applied to the nasal mucosa to inhibit the growth of foul-smelling proteolytic organisms
Young’s operation

46. Investigations
NAR is a diagnosis of exclusion, and the aim of investigations is to identify other causes of rhinitis. IgE estimation by PRIST and RAST and skin testing can be used to indicate allergy. Radiological examination of the nose and sinuses with CT scanning may help diagnose structural abnormalities and any coexistent sinus infection.

47. Management
1. Medical. Antibiotics may be used to treat any co-existent infective component and a short course of oral steroids is often helpful to get an initial response. However the mainstays of maintenance treatment are as follows:
(a) Intranasal steroids. Many cases respond well to topical intranasal steroid preparations although in some the response is disappointing.
(b) Antihistamines are useful in some cases. Topical preparations can sometimes have an impressive local effect.
(c) Topical ipratropium bromide is useful for its anticholinergic effect in reducing rhinorrhoea.

48. Surgery and Rhinitis

51. Surgery and Rhinitis
Treatment of concomitant problems. Associated nasal polyps are treated with excision. Correction of septal deflections and spurs should be considered to relieve an obstructed airway.
Turbinate surgery. Most procedures are aimed at reducing the bulk of the inferior turbinate to improve the airway. Submucosal diathermy, laser cautery, and coblation are all successful in the short term, but obstruction recurs after 1–2 years.

52. ARIA
1999 – Allergic Rhinitis and its impact on Asthma (ARIA) WHO workshop setup
30% of patients with AR have asthma
The majority of patients with asthma have AR
AR is a major risk factor for poor asthma control
All patients with AR should be assessed for asthma