In the name of God
Dr. Sasan Dabiri Otorhinolaryngologist Head & Neck Surgeon January 2011 Imam Hospital complex - Tehran
Rhinitis Allergic Rhinitis Infectious Rhinitis Nonallergic Rhinitis Neoplastic Rhinitis References Atrophic Rhinitis Granulomatous Rhinitis
Clinical Hypersensitivity of Nasal Mucosa to Foreign Substances mediated through IgE Antibodies
The Unified Airway
Prevalence : 10-20% Most patients have symptoms before age 20 Severity of disease remains constant throughout childhood and early adulthood ( usually improves in middle age )
Increasing Risk Good hygiene ( lower infection, antibiotic ) Poor sun exposure ( vitamin D ) Personal or family History
Seasonal recurrent episodes of symptoms after exposure to allergens or symptoms occur during exposure to seasonal allergens Perennial symptoms for more than 2 hours per day for more than 9 months of the year Episodic symptoms on exposure to allergens that are not normally present in the environment ( cat )
ARIA classification is used to suggest a treatment algorithm Intermittent symptoms present for less than 4 days a week or for less than 4 consecutive weeks Persistent symptoms present for more than 4 days a week and for more than 4 consecutive weeks
ARIA classification is used to suggest a treatment algorithm Mild No troublesome symptoms No sleep disturbance No impairment of daily leisure/sport/school/work Moderate to Severe one or more of the items mentioned above
Itching : most suggestive of allergic etiology involves not only the nose but also the palate, throat, eyes, and ears Rhinorrhea : usually clear Anterior: sniffing and nose blowing Posterior: snorting, throat clearing, and PND Sneezing (with tingling ) Nasal obstruction ( due to congestion)
Loss of smell (loss of taste) Exaggeration of nasal cycle Sleep disturbance & snoring Learning problems during school Exacerbation of symptoms by irritants (strong odors or perfumes, tobacco, air pollutants)
Ear popping and clicking (Eustachian tube dysfunction) Ocular symptoms : itching, tearing, conjunctival injection Systemic symptoms : general malaise, fatigue, irritability
Allergic shiners : puffiness of the eyelids and periorbital cyanosis Adenoid facies : elongated facies - open mouth - pinched nostrils - flattened malar eminences - raised upper lips - high arched palate - retracted jaws Allergic salute : supra tip crease at the junction of ULC & LLC
References no pathognomonic appearance of nasal mucosa in allergic rhinitis topical decongestant exam nasal endoscopy
Clinical History + Diagnostic Tests Skin Test Epicutaneous (prick / puncture) Intradermal In vitro serum IgE antibodies
Avoidance potentially effective treatment indoor Limited evidence about effectiveness Outdoor lack of effectiveness of avoidance measures
Antihistamines Oral :All symptoms unless nasal congestion Safe for long term treatment First generation Second generation (safe in pregnancy) Topical : reduces nasal congestion
References Steroids Intranasal The most potent group The First line in Rx Useful for prevention & treatment Useful for ocular symptoms Systemic For complete obstruction in pollen season Reducing obstruction in rhinitis medicamentosa
Decongestant (Topical) Risk of seizure in children Risk of Rhinitis medicamentosa specific indications Ipratropium (Topical) Reduces rhinorrhea Cromolyn (Topical) Useful in prevention Reduces sneezing, itching, rhinorrhea Needs a good compliance (4 6 times /day)
Leukotriene modifiers (Systemic) Reduces all symptoms Immunotherapy The last line in Rx Subcutaneous Sublingual Recombinant DNA allergens
Mild : PRN intranasal steroid Moderate to severe : Regular intranasal steroid (if can t use, Rx with antihistamines) complete Continue Rx Evaluate response after 2 weeks
Mild : PRN intranasal steroid Moderate to severe : Regular intranasal steroid (if can t use, Rx with antihistamines) complete Evaluate response after 2 weeks incomplete eye rhinorrhea +Intraocular antihistamine / mast cell stabilizer + ipratropium congestion + antihistamine decong. / montelukast
Mild : PRN intranasal steroid Moderate to severe : Regular intranasal steroid (if can t use, Rx with antihistamines) Evaluate response after 2 weeks complete incomplete refractory Consider Dx after max. Rx Immunotherapy