Derriford Hospital. Peninsula Medical School
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1 Asthma and Allergic Rhinitis iti What is the Connection? Hisham Khalil Consultant ENT Surgeon Clinical Senior Lecturer, PMS Clinical Sub-Dean GP Evening 25 June 2008
2 Plymouth Derriford Hospital Peninsula Medical School
3 Allergic Rhinitis and Asthma Definition Pathophysiology Diagnostic Approach Allergic Rhinitis and Asthma Treatment Strategies When is an ENT Referral Required? Discussion
4 Allergic Rhinitis- Definition A symptomatic disorder of the nose, induced after allergen exposure by an IgE- mediated inflammation of the nasal membrane
5 Asthma Asthma is a chronic inflammatory pulmonary disorder that is characterized by reversible obstruction of the airways.
6 Allergic Rhinitis- Epidemiology Affects10-15% 15% UK population Family atopic history common. Can develop at any age but 80% cases appear by age 20 years. Alters social life, affects school performance and work
7 Pathophysiology Allergic Rhinitis Asthma Nasal mucosa Bronchial mucosa Eosinophil infiltration Eos=eosinophils; neut=neutrophils; MC=mast cells; Ly=lymphocytes; MP=macrophages Adapted from Bousquet J et al J Allergy Clin Immunol 2001;108(suppl 5):S148 S149.
8 Arachidonic Acid COX Lipoxygenase Prostaglandins Leukotrienes
9 Allergic Rhinitis Intermittent Persistent < < 4 days/week <4 weeks >4 days/week and > 4 weeks Mild/Moderate-Severe
10 Intermittent t Rhinitis iti Common Allergens Grass pollens Tree pollens Weed pollens Mold spores Symptoms Watery nasal drainage Nasal congestion Repetitive sneezing Itchy eyes, nose, ears, and throat Nose rubbing Allergic salute
11 Persistent Allergic Rhinitis No seasonal variation Symptoms continuous throughout the year Watery nasal drainage and sneezing less prominent Nasal congestion is often the primary symptom
12 Other Symptoms Dry irritated or sore throat Snoring Pain around eye Mouth breathing Orthodontic ti disturbances Frontal headaches/sinusitis Chronic cough
13 Other Symptoms Otitis media/possible hearing loss Altered smell and/or taste Sleep disturbance, with or without daytime fatigue Asthma exacerbation
14 General Symptoms Weakness Discomfort or uneasiness Irritability Fatigue Difficulty concentrating Decreased appetite
15 Diagnostic Approach
16 Diagnostic Approach History Examination Investigations
17 Examination
18 Flexible Nasendoscopy
19 Signs of Allergic Rhinitis iti
20 Signs of Allergic Rhinitis iti
21 Nasal Polyps
22 Rhinosinusitis i iti
23 Allergic Rhinitis and Asthma A One Airway Disease?
24 Allergic Rhinitis and Asthma Frequently overlapping conditions Involvement of the same tissues Common inflammatory processes Common inflammatory cells Common inflammatory mediators
25 Samter s Triad Nasal polyps Asthma Aspirin sensitivity Preponderance of Leukotrienes in the nasal and bronchial mucosa
26 Investigations
27 Skin Tests
28 Other Investigations RAST Nasal Challenge Olfactory test Peak Inspiratory Nasal Air Flow CT Sinuses (d.d rhino-sinusitis)
29 CT Scan Sinuses
30 Treatment
31 Treatment t Strategies t Avoidance of Allergens Medical treatment Immunotherapy Surgery
32 Medical Treatment t Antihistamines Decongestants Steroid nasal sprays Anticholinergic nasal sprays Antileukotrienes
33 H1 Receptor Blockers (A) Prevent t action of histamine i receptors Relieve runny nose,sneezing, itching. Do not control inflammation. Small effect on nasal congestion.
34 Systemic Decongestants Pseudo-ephedrineephedrine Work well for congestion, some for runny nose No effect on itching or sneezing Side effects: insomnia, increased activity, irritability
35 Topical Nasal Corticosteroids Reduce d all nasal symptoms. Use at the lowest effective dose Prolonged use > nasal dryness / epistaxis
36 Anticholinergic i Sprays Ipratropium Effective for rhinorrhoea Mainly used for non-allergic autonomic rhinitis
37 Antileukotrines Montelukast Second line in asthma/rhinitis patients when oral steroids are ineffective Samter s triad Decreased polyp recurrence
38 Stepped Approach
39 Mild Intermittent Symptoms Avoidance of allergens Oral antihistamines +/- decongestants
40 Persistent Mild to Moderate Symptoms Intranasal steroid starting therapy 1-2 weeks prior to season Non-sedating antihistamine and or decongestant as needed Topical ocular (eye) antihistamine i with or without vasonconstrictor or topical eye mast cell stabilizer
41 Severe Symptoms Topical nasal corticosteroids Non-sedating antihistamine Short term burst of oral corticosteroids
42 Severe Symptoms Consider other treatments - Antileukotrienes - Immunotherapy - Surgery
43 Allergic Rhinitis iti Intervention Intermittent Persistent Adults Children Adults Children Oral H1 antihistamines A A A A Intranasal corticosteroids Antileukotrienes Subcutaneous SIT Sublingual SIT Allergen avoidance A A A A A A A A A A A D D D D
44 When Is an ENT Referral Required?
45 ENT Referral Persistent nasal obstruction OSA Associated nasal pathology: *Hypertrophied inferior turbinates *Nasal polyps *Deviated nasal septum
46 Surgical Treatment
47 Turbinate Surgery Diathermy of Inferior turbinates Submucous Diathermy Turbinectomy Submucous conchopexy
48 Turbinate Surgery
49 Nasal Polypectomy
50 Septal Surgery
51 Septoplasty t
52 Septoplasty t
53 Septoplasty t
54 Discussion Presentation on
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