1. Allergic and Intrinsic Rhinitis Dr. Krishna Koirala MBBS,MS 19-11-2019

2. Definition – IgE mediated hypersensitivity disease of the mucous membrane of nasal airways characterized by sneezing, itching, watery nasal discharge, sensation of nasal obstruction, postnasal discharge and hyposmia Associations – Allergic conjunctivitis – Bronchial asthma Prevalence – Depends on age, gender and geographical locations – 10-20% with a male predominance – Peak age - Young adulthood

3. Classification of Allergic Rhinitis Old : Seasonal, Perennial, Occupational ARIA (Allergic Rhinitis and its impact on Asthma)

4. Etiology Atopy (Hereditary) – Represents a predisposition to develop allergic disease Allergens – Seasonal rhinitis : Grass and tree pollens – Perennial allergic rhinitis House dust mite – Digestive enzymes excreted in faeces Domestic pets – Cats, dogs, rabbits, guinea pigs Cockroaches – Occupational Rhinitis: Flours, laboratory animals, biological washing powders, latex, smokes and fumes

5. Food and drug induced rhinitis – More common in children – Foods Milk,eggs, cheese in children Nuts,fish,citrus fruits in adults – Drugs Aspirin Antihypertensives ( beta blockers, ACE inhibitors ) Antipsychotic Topical nasal decongestants (Rhinitis medicamentosa) Pollution – Perfumes, tobacco smoke, traffic fumes, domestic sprays

8. Diagnosis History – Seasonality, frequency and severity of symptoms – Patient’s dominant symptoms – History of potential allergic triggers – Personal/ family h/o atopic disease – H/o trauma – H/o mucopurulent rhinorrhea, facial pain, fever – Drug allergy and food provoking factors

9. Clinical features Symptoms Seasonal rhiniti s – Sneezing : paroxysmal, frequent intervals throughout the day, more in the morning times – Nasal discharge : watery, mucoid, yellowish – Nasal obstruction / blockage – Itching of nose, eyes, palate – Tearing/redness of the eyes, periorbital edema – Burning/raw sensation of throat – Wheezing/chest tightness Perennial Rhinitis – Long standing nasal congestion and PND – Viscous/ purulent rhinorrhea – Conjunctivitis less frequent – Secondary symptoms : loss of smell and taste, sinusitis, ETD – Sneezing less common

10. Signs Nose – Transverse crease at the dorsum of the nose ( Darrier’s line) – Allergic salute – Pale /bluish nasal mucosa – Boggy and swollen turbinates – Watery nasal discharge – Polyps/ hypertrophied turbinates – Septal deviation Allergic salute Darrier’s line

11. Eyes – Periorbital edema, conjunctival congestion,watering – Marked erythema of palpebral conjunctivae and papillary hypertrophy of tarsal conjunctivae ( cobblestone) – Dark circles under the eyes ( allergic shiners) Repetitive vigorous rubbing in the peri - orbital region Impaired venous return from the skin and subcutaneous tissues – Extra skin fold or line under the lower eyelids ( Denni - Morgan lines) Denni - Morgan lines

12. Ear – Retraced TM, OME Pharynx – Granular pharyngitis, cobblestone Larynx – Laryngeal edema Bronchus – Bronchospasm

13. Investigations Complete Blood Count,ESR, Absolute Eosinophil Count Serum IgE measurements Nasal smear for cytology : eosinophils, neutrophils, basophils, mast cells, epithelial cells and bacteria Nasal swabs for bacteriology or viral studies Skin prick tests RAST (Radioallergosorbent Test) ELISA Nasal provocation (challenge) test Diagnostic Nasal Endoscopy (DNE) X-Ray PNS OM view CT scan of nose and PNS : coronal/axial /sagittal cut

14. Skin Prick Tests Prick or scratch test – Pricking the skin with a needle or pin containing a small amount of the allergen Patch test – Applying allergen containing patch to the skin – If response is seen in the form of a rash, urticaria or anaphylaxis -- patient has a hypersensitivity to that allergen Intradermal test – A small amount of the allergen solution is injected into the skin and response is seen

15. The negative control – Saline (salt-water) solution – Response not expected – If however a patient reacts to a negative control --- the skin is for whatever reason extremely sensitive The positive control – Histamine, to which everyone is expected to react – Failure to do so -- medicines the sufferer is taking could block the response to the histamine and allergens

19. Treatment Modalities Allergen avoidance Pharmacotherapy Immunotherapy Treatment of complicating factors

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21. Allergen avoidance – Useful for a single/ unusual allergen – Identification of relevant aeroallergens and complete/ partial avoidance of allergens Elimination of occupational allergen exposure Elimination of pet allergen exposure Mite antigen control measures Frequent pet washings Cockroach control measures Closed windows in homes / cars Central heating and cooling Central air filtering system

22. Pharmacotherapy Primary therapy for seasonal / perennial allergic rhinitis Corticosteroids – Topical: Sprays and drops Extremely effective for all nasal symptoms of allergy Beclomethasone, budesonide, fluticasone, mometasone – Oral Prednisolone 1 mg /kg / day in tapering dose for 2 weeks – Depot intramuscular route - not recommended

23. Mast cell stabilizers – Eg. Sodium chromoglycate drops and sprays – Less effective than topical corticosteroids – Treatment of first choice in young children Antihistamines – Eg. Chlorpheniramine, Terfenadine, Astemizole, Loratadine, Cetrizine, Fexofenadine, Ebastine – Effective for sneezing, itching, watery rhinorrhea and eye, palate and throat symptoms – Less effective in nasal congestion and blockage – Mainly taken at bedtime – Newer generations less sedative than older ones

24. Topical vasoconstrictors – Xylometazoline, oxymetazoline, ephedrine – Effective against nasal blockage – To be used for short period only, prolonged use >2 wks may lead to Rhinitis medicamentosa (Rebound hyperemia, nasal congestion and obstruction that occurs following prolonged and repeated use of topical vasoconstrictors) Topical anticholinergics – Ipratropium Bromide (0.03% nasal spray) for watery rhinorrhea Leucotriene inhibitors – Montelukast, zafirlukast

25. Allergen Specific Immunotherapy ( SIT) Practice of administering gradually increasing quantities of an allergen extract to an allergic subject to eradicate the allergic symptoms by subsequent exposure to the causative allergen Indications – Pollen sensitive patients having single allergen, failing to respond to conventional treatment, having intolerable side effects of treatment, unable to avoid the allergens Contraindications – Patients with multiple allergies, significant medical illness and taking drugs likely to impair the treatment of anaphylaxis

26. Procedure: – Allergen injected subcutaneously in increasing doses till maximum tolerated response is reached – May also be delivered by the oral, nasal or sublingual routes – The monoclonal anti - IgE antibody Induces the reduction of serum-free IgE levels Reduces the symptoms mediated by IgE Reduces the severity of the symptoms of seasonal allergic rhinitis – Success rates - as high as 80 -90% for certain allergens – Course : 2 years or more

27. Intrinsic Rhinitis (Non-allergic Non-infective rhinitis, Vasomotor rhinitis)

28. Spectrum of Disease Vasomotor rhinitis Non-Allergic Rhinitis with Eosinophilia Syndrome (NAREs) Occupational rhinitis: flour, animal, wood, latex, paint Rhinitis medicamentosa: Prolonged use of decongestant nasal drops Drug-induced: propranolol, O.C.P., antidepressants Endocrine: hypothyroid, pregnancy, menstruation Miscellaneous: honeymoon / emotional/ non airflow / addiction

30. Vasomotor Rhinitis

31. Pathogenesis: – Overactivity of Parasympathetic nervous system of nose Nasal congestion (due to nasal vasodilatation) Nasal block (due to nasal vasodilatation) Watery rhinorrhoea (due to  ed nasal glandular secretions) Trigger Factors: – Emotional stress, sudden change in temperature, humidity, blasts of cold air, dust, smoking & traffic fumes

32. Clinical Features Symptoms - perennial – Nasal block (blockers) – Profuse watery rhinorrhoea (runners) – Paroxysmal early morning sneezing – Post nasal drip Signs – Turbinates congested & hypertrophied Sequelae Nasal polyp, hypertrophic rhinitis, sinusitis

33. ALLERGICINTRINSIC Allergen exposureYesNo Nasal itching+++Minimal Sneezing++++ Rhinorrhoea+++++ Nasal obstruction+++ Hyposmia+++

34. ALLERGICINTRINSIC Nasal mucosaPaleCongested Nasal polyps++Rare Absolute Eosinophil Count  ed Normal Nasal smear eosinophil  ed Normal Skin prick testPositiveNegative Treatment Steroid spray, Anti H1, Nasal decongestant Ipratropium, Botulinum

35. Treatment of Vasomotor Rhinitis

36. General Measures Sleep with head end elevated by 30 0 Sleep + work in a cool environment (not cold) Keep body warm Regular exercise program to improve vasomotor tone Avoidance of trigger factors

37. Medical Treatment Antihistamines: – Systemic: Cetirizine, fexofenadine, loratadine, levocetrizine, ebastine – Topical: Azelastine spray Nasal Decongestants – Systemic: Phenylephrine, pseudoephedrine – Topical : Xylometazoline, oxymetazoline, saline Topical and systemic steroids

39. DrugSneezeRhinorrhoeaNasal block  ed smell Antihistamine++++++0 Steroid spray+++ + Cromoglycate+++0 Topical nasal decongestant 00++++0 Ipratropium0++00

40. Steroid spraysStrength / puff Acute attack dose Maintenance dose Beclomethasone 50  g 2 puffs BD1 puff OD Budesonide 64  g 2 puffs OD-BD1 puff OD Fluticasone 50  g 2 puffs OD-BD1 puff OD Mometasone 50  g 2 puffs OD-BD1 puff OD

41. Surgical Treatment 1. To reduce size of nasal turbinates thus to relieve nasal obstruction 2. Sectioning parasympathetic secreto - motor fibers of nose (vidian neurectomy) to relieve excessive rhinorrhoea

42. Surgeries to reduce the size of turbinate For mucosal hypertrophy – On surface: Electrocautery, Laser – Submucosal: Electrocautery (Submucosal diathermy), cryotherapy, radiofrequency ablation For bony hypertrophy – Submucous resection of inferior concha For mucosal + bony hypertrophy – Partial / total turbinectomy

44. Vidian Neurectomy Trans - septal approach Trans - antral approach (Golding Wood)

45. Rhinitis Medicamentosa Rebound nasal congestion due to use of intranasal decongestants for > 10 -14days Prolonged use  tachyphylaxis  more frequent dose Nasal medications containing benzalkonium chloride cause more rebound congestion Offending drugs : Oxymetazoline, Xylometazoline – Contract smooth muscle of venous erectile tissue present in nasal turbinates  mucosal shrinkage and decrease airway resistance

46. Pathogenesis

47. Clinical Features Chronic nasal block requiring increased dose & frequency of topical decongestants after its prolonged use Nasal mucosa appears hyperemic, granular & boggy in early stages and pale & anemic in later stages Treatment Immediate withdrawal of topical decongestant - Substitute with systemic nasal decongestants Nasal corticosteroid sprays ( Oral corticosteroids for severe cases only) Rhinostat system Patient Education: Avoid topical decongestant use for > 10 days