Matt Stumpe, MD Otolaryngologist Mid Kansas Ear, Nose, & Throat

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Leona Blankenship
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1 Matt Stumpe, MD Otolaryngologist Mid Kansas Ear, Nose, & Throat

2 Inflammation of the nasal mucosa secondary to an inappropriate hypersensitivity reaction to an allergen IgE mediated immune response with mast cell activation and release of cytokines

3 Affects up to 1 of every 6 US citizens Significant morbidity Lost work/school days ($2-4 billion/year) 800,000-2 million lost school days Decreased productivity Costs of medical management ($2-5 billion/year)

4 Wichita usually in top 10 USA cities for allergens Studies Allergen density Also takes into account treating Physicians

5 Primary Reaction Phase Type I hypersensitivity Occurs within 5 minutes of allergen exposure Maximum effect in 15 minutes Release of cytokines (histamine, serotonin, leukotrienes, etc.)

6 Secondary (Late) Phase Occurs 4-6 hours after acute phase Leukotrienes (IL-5) and other mediators stimulate: Smooth muscles of airway Proliferation of eosinophils Stimulate airway secretions

7 History Symptoms Physical examination Adjunctive testing Differential Diagnosis

8 Onset, timing, duration, seasonality, severity, associated symptoms, aggravating/alleviating factors Environmental history Family history of atopy Suspected allergens Nasal trauma Anatomy distortion, CSF Rhinorrhea

9 Rhinorrhea Cough/Sneeze Nasal Congestion Post nasal drip Nasal pruritus Watery eyes

10 General appearance Allergic shiners Allergic salute Malaise

11 Nose Septal deviation Polyps Drainage Turbinate hypertrophy Hyponasality Allergic mucosa Normal mucosa

12 Mouth Cobblestoning of oropharynx Ear Middle ear pathology

13 Neck Lymphadenopathy Chest Wheezing Skin Eczema, dermatographism

14 Nasal endoscopy Polyps, ostiomeatal unit obstruction, adenoid hypertrophy Nasal smear Obtained from inferior middle turbinate mucosa >25% eosinophils suggests allergy Total serum IgE Not accurate or cost effective

15 CT scans or other testing is not indicated in workup of Allergic rhinitis

16 Non allergic rhinitis Infectious, NARES, vasomotor rhinitis, atrophic rhinitis, drug induced, hormonally induced, exercise, reflux Anatomic/mechanical factors Septal deviation, turbinate hypertrophy, adenoid hypertrophy, foreign body, neoplasm

17 Immunologic Wegener s, sarcoidosis, midline granuloma, lupus, Sjogren's CSF rhinorrhea

18 Avoidance Symptomatic medication Severe Symptomatic medication Immunotherapy Non pharmacologic therapy

19 Dust - resistant materials on mattress/pillows, low carpet or hardwood floors, frequent dusting/cleaning, place bedding/clothes in dryer Molds disinfect bathrooms, dehumidify basement, clean furnace, avoid gardening Pollens air conditioning, keep windows closed, avoid cutting grass

20 Animals keep out of bedroom/house, special shampoos, remove animal High efficiency particulate air (HEPA) filters Masks may be helpful in unavoidable allergy exposure

21 Nasal Saline 1 st Generation antihistamines Diphenhydramine (Benadryl), chlorpheniramine, promethazine 2 nd Generation antihistamines Loratadine (Claritin), fexofenadine (Allegra), cetirizine (Zyrtec), etc. Topical glucocorticoids Fluticasone (Flonase), mometasone (Nasonex), triamcinolone (Nasacort), etc.

22 Topical Antihistamines Olopatadine (Patanase), azelastine (Astelin/Astepro) Antileukotrienes (2 nd line AR therapy) Montelukast (Singulair), zafirlukast (Accolate) Phenylamines (systemic decongestants) Pseudoephedrine (Sudafed), phenylephrine

23 Mast cell stabilizers not commonly used Cromolyn (NasalCrom, Gastrocrom), nedocromil Imidazolines (topical decongestants) Oxymetazoline (Afrin), phenylephrine (Neo- Synephrine) Are physically addictive Rebound mucosal edema

24 Systemic corticosteroids Most potent medication for symptomatic relief Side effects Prednisone, prednisolone, methylprednisolone, etc. Intraturbinal corticosteroid injection Risk of blindness

25 Turbinate reduction surgery Polypectomy Septoplasty

26 Skin prick, intradermal, in vitro (RAST) Identify antigens to which patient is symptomatically reactive (Go back to avoidance) Antigens chosen to test should be representative of exposure and geography

27 Desensitization to allergens identified Takes years of therapy Changing from TH2 to TH1 immune response Injection immunotherapy Gold Standard Mainstay of treatment in USA Risk of anaphylaxis Sublingual immunotherapy (SLIT) Wide acceptance in Europe and South America, but still gaining acceptance in USA Specific nasal immunotherapy (SNIT) Experimental

28 Sublingual immunotherapy tablets Ragwitek (Merck) Ragweed allergy treatment Grastek (Merck) Timothy grass allergy treatment Oralair (Greer) Multi-grass allergy treatment

29 Acupuncture

30 Any patient you can not manage with these treatment options Suspicion of non allergic nasal pathology Surgical intervention

Allergic Rhinitis: When to Refer to an Allergist

Allergic Rhinitis: When to Refer to an Allergist Kirsten Kloepfer, MD, MS Assistant Professor of Pediatrics Section of Pulmonary, Allergy and Sleep Medicine Disclosures NIH K23 American Academy of Allergy,