If it isn t allergies what is it?

If it isn t allergies what is it?

How may people in the USA have allergies? Adults 20% Children 30%

Children and food allergies

Allergic reaction

Mast Cells

allergens Pollens ( trees, weeds, and grasses) Dust Dust mites and insects Molds Pets Etc

OAK TREES

Alder pollen grains

Bee

Hornet

Dust Mites

How do you know if that patient is really allergic or not?

Allergic or not? (testing)

Non skin testing related test for allergies RAST IgE specific food, drug, and environmental allergens (valid if medium to high positive) RAST IgG4 for foods (not valid) it will let you know what kinds of food the patient has be eating, or if there is inflammation and large mol. leaking in to the local mucosa, but Not allergic specific.

Were is the IgG4 in this picture?

What % of people in the USA have rhinitis symptom's for any cause?

Answer is: 60%

How many people are using over the counter medications for allergies that do not really work for them, but may give them complications?

What are some of the causes for non-allergic rhinitis?

What types of immune cells are found in the patients nasal secretion's?

Eosinophil-predominant Non-allergic rhinitis with eosinophilia syndrome (NARES) Blood eosinophilia with non-allergic rhinitis Allergic fungal sinusitis Non-allergic fungal sinusitis Churg-Strauss syndrome with granuloma Triad asthma

Neutrophil-predominant Infectious rhinitis Dentogenic sinusitis Nasal polyps in cystic fibrosis HIV/AIDS related infections Humoral Immunodeficiency ( IgG, IgA, IgM, IgE def., IgG subclass def., CVID) Young s syndrome (azoospermia, and nasal polyps) Kartagener s syndrome ( immotile cilia and nasal polyps)

Complex Infiltrates Common cold Basophilic/ metachromatic ( non allergic rhinitis) Wegener s granulomatous vasculitis Sarcoidosis Granulomatous Infections (TB, leprosy, Syphilis) Autoimmune disease s ( RA, SLE, Sjogren s syndrome, autoimmune thyroid disease) Postoperative

CT Wegener s granulomatous

Other causes for nonallergic rhinitis

Normal Sinus X-ray

Deviated Septum Structural anomalies Hypertrophic turbinates Ostiomeatal complex (OMC) anatomic variants Concha bullosa Haller s cells Paradoxical curvature of the middle turbinate

Ostiomeatal complex blockage

Tumors Structural anomalies cont. Mastocytosis (elevated tryptase levels ) Adenoidal hypertrophy Fracture of the facial bones ( testing for spinal fluid) Cribriform plate fx.

Hormonal and drug related Pregnancy ( estrogen and progesterone) Postmenopausal Hypothyroidism Parathyroid Diabetes Acromegaly Adrenergic dysfunction Antihypertensive agents Prostate medications ( Flomax) Rhinitis medicamentosa Glaucoma medications

Neural dysfunction Absent sympathetic function (no vasoconstriction) Horner s syndrome Stellate ganglion resection or block Hyperactive cholinergic parasympathetic function ( excessive mucus exocytosis) Cholinergic rhinitis Trigeminal neuralgia Food / nocifer-activated cholinergic reflex-mediated rhinitis Gustatory rhinitis salsa sniffles Cold dry air-induced rhinorrhea ski bunny rhinitis

Head neuroanatomy C2 Trigeminal nerve C3 C4 Ant. C2 & C3

Horner s syndrome

Neural dysfunction cont. Nociceptive rhinitis/irritant rhinitis increased nociceptive nerve sensitivity to weather changes, perfumes, tobacco smoke, pollution, and other odors. Non-allergic rhinitis of chronic fatigue (CFS). fibromyalgia migraines syndrome

Symptoms Rhinitis Itching Burning pain symptoms Facial and or dental pain Sneezing Purulent nasal symptoms Watery eyes

How do we begin to figure out what they really have? Does the patient have any other comorbid symptoms'? ( arthritis,weight gain or loss, GI pain, skin rash, SOB) Family history: what kinds of problems do the other members have?

What causes the patients their symptoms?

Pollen and non-allergic rhinitis Hyperosmolar The pollen grains cause the local mucosa to lose water therefor the tissue increases nasal secretions in response. Dry and cold air can do the same.

Vanilloid receptor 1 (VR1) Capsaicin stimulate VR1 receptors and nonmyelinated type C trigeminal neurons and leads to pain. Nasal secretions will be increased as well. Substance P also stimulates the C fiber pathways as well ( ex. Diabetic neuropathy pain and migraines).

Cholinergic rhinitis Capsaicin foods Foul smells Perfunes Weather change Bright lights These represent cholinergic forms of rhinitis as a results of afferent limbs of the parasympathetic reflex being over stimulated.

Sympathetic hypofunction Post strokes Horner s syndrome: damage of the sympathetic trunk or superior cervical ganglion ( ex. Anterior surgical cervical discectomy) leading to chronic vasodilation.

Blockade of adrenergic receptors Antihypertensive drugs Flomax

Catecholamine receptor dysfunction Due to thyroxin deficiency in hypothyroidism. others

Hormone effects Acromegaly is felt to be due to abnormal nasal facial bone growth and possible due to excessive growth hormone. Pregnancy : increased mucosal thickness with increasing estrogen and progesterone and the up regulation of H1 receptor expression.

Immunodeficiency The lack of appropriate antibodies in adjacent tissue IgG def. or IgA in secretions can lead to chronic rhinosinusitis as well as gastritis, UTI s and respiratory problems. Neutrophil dysfunctions and or lack of superoxide dismutase is a problem as well. Ciliary dysfunction

How can you treat non-allergic Rule out any allergies rhinitis? Nasal steroids Nasal antihistamines Combinations: Nasal steroids and antihistamines First generation antihistamines ( By the way were did they all go?) don t tell anyone, but you can have them compounded. Decongestant's

How to treat non-allergic rhinitis continued Identify autoimmune diseases based on symptoms and family history. Look for immune problems Check for anatomical problems

How to treat non-allergic rhinitis Eliminate the offending medication if a cause. Dental or ENT consult for mechanical issues. Endocrinologist for hormone dysfunctions if complicated. Orthopedic consult for neck/spinal issues.

How to treat non-allergic rhinitis Hematology oncology consult for the tumors if identified

References Current Allergy and Asthma Reports 5:233-242 2005; M Staevka, J Baraniuk: Persistent Nonallergic Rhinosinusitis. Allergy Asthma Proc 34:328-334, 2013; A Halawi: Chronic rhinosinusitis: Epidemiology and cost. Allergy Asthma Proc 34:132-137, 2013; C Ocampo: Medical therapy as a primary modality for the management of chronic rhinosinusitis.