1. M.Rogha M.D Isfahan university of medical sciences
RHINITIS
M.Rogha M.D
Isfahan university of medical sciences

2. Chronic rhinitis: 1-allergic type 2-Non allergic type

3. Chronic rhinitis 10% of the population suffer from rhinitis
From those with rhinitis symptoms:
43% allergic rhinitis
23% non allergic type
34% mixed allergic & non allergic .

4. Chronic rhinitis can lead to:
sinusitis
nasal polyps
eustachian tube dysfunction
chronic otitis media
disorders of the sense of smell

5. Allergic rhinitis
40 million Americans may be affected by allergic rhinitis.
Economically, It costs about 2 billion dollars per year.
The patients suffer from its chronicity.
May accompany other aspects of allergy Asthma, urticaria, ….

6. Allergic rhinitis: Seasonal grasses, weeds, trees Perennial
dust mite, molds, animal danders, cockroach

7. pathophysiology Immediate type reaction
Specific IgE synthesis by B-lymphocytes
Sensitized mast cell formation
Bridging one molecule of Ag between two sIgE
Dissolution of mast cells& basophils
Release of inflammatory mediators

10. Pathophysiology contd.
So, the main effects are:
1- vasodilation
2-increased permeability of vessels
3-irritation
4-gland stimulation

11. Symptoms & Signs Itching Sneezing Rhinorrhea Nasal congestion
Allergic salute
Allergic shiners
Dennie-morgan lines
Pale to bluish enlarged turbinates
others

12. Allergic salute

13. Diagnosis History & physical examination Skin tests (in vivo)
Serologic tests (in vitro)

14. Skin tests Epicutaneous Intradermal prick puncture test
scratch test
prick puncture test
Intradermal
single dilutional
multi dilutional

15. Puncture/Prick Testing
Disease-free site
Swipe with alcohol
Apply drop of antigen (1:10 or 1:20 conc.)
Prick skin at 45 to 60 degree angle, or puncture at 90 degrees
Gently lift device, no bleeding should occur
Read positive control in 10 minutes
Read allergens in minutes
Example of a skin prick/puncture epicutaneous test

16. Multiple Antigen Testing cont’d
Using multiple applicators, either MultiTest or Quintest, allows simple, easily applied allergens with reproducible results. By limiting testing to patients with rhinitis and no history of asthma decreases the chances of allergic reactions. Reading the tests is best done with the physician reading the test and the nurse recording the results. There is more uniformity in scoring than if one is scoring the test, looking away to record, then back again at the next reaction. Any patient with a history of previous anaphylaxis of any kind, patients with unstable asthma should be referred to an allergist.
SMP – my vote is to keep this one but I bow to Harold’s suggestion since he knows which slides communicate the information most easily.
Example of multiple-puncture device in its loading dock
device allowing simultaneous placement of six allergens plus a positive and negative control
2 Example of multiple-puncture

17. Multiple Antigen Testing cont’d
Using multiple applicators, either MultiTest or Quintest, allows simple, easily applied allergens with reproducible results. By limiting testing to patients with rhinitis and no history of asthma decreases the chances of allergic reactions. Reading the tests is best done with the physician reading the test and the nurse recording the results. There is more uniformity in scoring than if one is scoring the test, looking away to record, then back again at the next reaction. Any patient with a history of previous anaphylaxis of any kind, patients with unstable asthma should be referred to an allergist.
SMP – my vote is to keep this one but I bow to Harold’s suggestion since he knows which slides communicate the information most easily.
Example of positive and negative skin responses to allergens applied with a multiple-puncture device; note the positive and negative control sites
Example of application of a multiple-puncture device to the forearm

18. Serologic tests RAST ELISA (Radioallergosorbent test)
Ag….sIgE….. Anti IgE*
ELISA
(enzyme-linked immunosorbent assay)

19. treatment Environmental control Medical
antihistamins; 3 generation of them are available.
corticosteroides; in topical & systemic forms
diminish the effects of mediators by decreasing vascular permeability, stabilizing lysosomal membranes,….
alpha adrenergics
mast cell stabilizers; chromolyn, olopatadine, quazolast,…
leukotrien modifiers; zileuton, montelukast, zafirlukast.
human recombinant anti IgE (Omalizumab)
immunotherapy

20. New directions in treatment:
Tryptase inhibitors
APC-366;  pentamidine-like; BABIM-like; lactoferrin
Cytokin modulators
Pitrakinra
Chemokin inhibitors
Cell adhesion blockers
neutralizing antibody to lL-5

22. Nonallergic Rhinitis
(Vasomotor Rhinitis)

23. Non allergic rhinitis components:
Nasal innervation
vasculature
Mucosal glands

24. pathophysiology
Anatomic effect
Autonomic nervous system effect

25. pathophysiology
Parasympathetic stimulation increased serous glands activity of nasal mucosa Rhinorrhea.
Direct sensory C-fibers stimulation, by histamin, bradykinin & inhaled irritants release of neuropeptides increased vascular permeability& glandular, endothelial & epithelial cell stimulation itching, rhinorrhea, burning sensation.
Hyper responsiveness of afferent sensory nerves exaggerated efferent response over secretion of mucus & increased nasal congestion.
Normal afferent input but hyper reactive efferent arc due to CNS impairment.

26. Diagnostic tests Methacolin provocative test Histamin provocative test
to evaluate glandular responsiveness. Positive in both allergic & nonallergic rhinitis
Histamin provocative test
to evaluate vascular permeability. Positive in both types of rhinitis; mainly in allergic type.
Cold dry air
increases mucosal osmolarity C-fiber stimulation, …..
Selective for non allergic rhinitis.
Capsaicin provocative test
to evaluate sensory innervation (specific C-fiber stimulant). Selective for non allergic rhinitis.

27. Nonallergic Rhinitis classification
Infectious
Drug-induced
Hormonal
Anatomical
Idiopathic

28. Types of non allergic rhinitis
Drug induced rhinitis
Anti hypertensives
birth control pills
cocaine
nasal drop abuse
NSAID
antipsychotics

29. Causes of vasomotor rhinitis
Pregnancy & premenstrual cold
hypothyroidism
emotional causes
temperature mediated
irritative & environmental rhinitis
gustatory rhinitis
recumbency rhinitis
non airflow rhinitis
compensatory hypertrophic rhinitis
eosinophilic nonallergic rhinitis
Idiopathic rhinitis

30. Treatment of vasomotor rhinitis
Medical
avoidance of irritative factors
exercises
topical nasal steroids
decongestants
anticholinergic medications (Ipratropium bromide)
topical silver nitrate 5-20%
surgical
endonasal surgeries
vidian neurectomy