This document discusses allergic rhinitis, including its diagnosis and management. It provides details on:
- A survey that found 8.66% of people suffered from some form of allergy. Rhinitis was the most common at 24.9%.
- The symptoms, signs, and complications of allergic rhinitis. It is an IgE-mediated inflammatory response in the nose to allergens like pollen, mold, dander and dust mites.
- Diagnosis involves taking a careful history, physical exam, and potential laboratory tests like IgE levels, skin prick tests and RAST to identify specific allergens.
- Management includes avoidance of triggers,
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Allergic rhinitis
2. ALLERGIC RHINITIS
DIAGNOSIS AND MANAGEMENT
DR. GHULAM SAQULAIN
ENT SURGEON
CDA HOSPITAL, ISLAMABAD
3. In a Islamabad based survey conducted by PMRC, out of
2821 households with a total of 16717 individuals were
surveyed, 1448 (8.66%) were reported suffering from allergy.
Others (n=17), 0.14%
Multiple Allergies
(n=509), 3.04%
Chronic Cough (n=24),
Types of Allergies
0.14%
Conjunctivitis (n=53),
1 0.32%
Skin Allergy (n=290),
1.73%
Nasal Allergy (n=360),
2.15%
Asthma (n=195), 1.17%
0.00% 0.50% 1.00% 1.50% 2.00% 2.50% 3.00% 3.50%
Prevalence
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4. Distribution of Persons with Allergies by
Type of Allergy. (n=1448)
Urticaria, Asthma,
20.00% 13.50%
Conjuctivitis, Rhinitis,
3.70% 24.90%
Chronic Cough,
1.60%
Others, 1.20%
Multiple
allergies,
35.10%
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5. Allergic Rhinitis
Allergic Rhinitis is defined as an inflammation of the
lining of the nose and is characterized by the symptoms
of nasal congestion, rhinorhea, sneezing and itching .
Other symptoms are nasal obstruction, paranasal pain
or headache, pruritis, itchy or watery eyes, anosmia,
dysosmia, chronic pharyngitis, hoarseness and
recurrent inflammation of URT
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7. Diagnosis
• Careful History
• Physical Examination
• Laboratory Studies for
Confirmation
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8. History:
The signs and symptoms of Allergic Rhinitis are
familiar to many:
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9. •Itching/ sneezing,
• Nasal pruritis occurs, History:
particularly in pollen
allergy with Itching eyes,
nose and throat,
• Sneezing is the most
common symptom with
pollen allergy,
•Watery Rhinorrhoea,
•Nasal congestion/Obstruction
at night causes:
• mouth breathing,
• snoring,
• restlessness, with
complaints of dry, sore
throat in the morning, 03/13/13
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• fatique. 9
10. Physical Examination
Intranasal Examination
• Typically, the nasal mucosa is
pale pink and swollen.
• Discharge is thin watery, but
becomes thick and purulent
when secondary infection sets
in.
• Oropharyngeal wall may have
typical clumps of lymphoid
tissue.
• Other associated allergic
diseases such as a contact
dermatitis or asthma may
correlate with flares of allergic
symptoms.
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11. •Malocclusion:
•Allergic Shiners:
– Dark circles
under the eyes
from venous
stasis due to
engorged nasal
membranes
•Rabbit Nose:
– The child may
wrinkle the end of
the nose constantly,
•Allergic salute
– The child may rub
the nose with the
palm of the hand in
an upward manner
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12. Laboratory Findings:
• Peripheral Eosinophilia:
• Nasal secretion cytology:
– Presence of 3-10% of eosinophils in nasal
secretions is diagnostic of allergic rhinitis
except during early infancy.
• Immunoglobulin E
– IgE serum levels are elevated in almost half of
cases with allergic rhinitis. However normal
IgE does not exclude allergic rhinitis.
• RAST testing
– This is a radio-immune assay where a
patient's serum is incubated with different
allergens and antigen/antibody complexes are
then measured.
– It is a more specific blood test for allergy.
– This is not as sensitive as skin testing and
more costly
• Allergy Skin Tests :
– Done to identify specific allergens.
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13. COMPLICATIONS
OF ALLERGIC RHINITIS
• Recurrent otitis media.
• Hearing loss.
• Sinusitis.
• Nasal or sinus polyps.
• Progression to asthma.
• Anatomical changes in nasal and
sinus cavities.
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14. The Basic Pathology
Four types of hypersensitivity reactions
• Type I - IgE mediated reaction
• Type II - IgG/ IgM mediated
• Type III - IgG/ IgM mediated
• Type IV - T cell mediated
(Delayed hypersensivity, Cell-mediated
hypersensivity)
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15. PATHOLOGY & PATHOGENESIS
• In allergic rhinitis we see an
example of IgE mediated
hypersensitivity. In this type
with continued exposure
atopic individual acquires
antibodies of reagin type
(IgE Immunoglobulins) from
plasma cells.
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16. Along with
submucosa
Mast cells in
epithelium Occurs within
Allergy Causing Pollen also imprtant 30 Sec. of
challenge
Excess Mucus
Production
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17. HISTAMINE
Origin:
• Found in the most tissues of the body.
• Most abundant in mast cells near blood vessels in
connective tissue.
• Found in small quantities in basophils(granular part of a
cell).
Release:
• when an allergen joins an IGE antibody on the surface of
a mast cell or basophil, serine esterase(compound) is
activated, and this activation induces the release of
histamine.
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18. Effects:
• Reactions range from mild itching to shock and
death.
• Response to histamine occurs in one to two
minutes.
• Duration of action is about ten minutes.
• Produces effects by acting on H1 receptors.
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19. H1 RECEPTORS
Stimulation causes:
• constriction of the bronchial smooth muscle.
• Increase mucus secretion in respiratory tract.
• Increased lacrimation.
• Dilation of arterioles and capillaries.
• Weakening of capillary walls.
• Constriction of small veins and venules.
• Dilation of large veins.
• Constriction of smooth muscle of the gut.
• Pain and burning sensations. 03/13/13
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20. Type - I (IgE mediated reaction)
1. Preformed 2. Newly formed
• Histamines • PAF
• NCF (Neutrophil • Leukotrienes (LTB4)
Chemoattractant Factor)
•
• ECF (Eosinophil
Chemoattractant Factor)
Prostaglandin's
• The preformed mediators are responsible for the early phase reaction.
• These mediators are responsible for the commissioning of Eosinophils
• Once the eosinophils are commissioned, the late-phase reaction begins
• Enzymes
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21. Type - I (IgE mediated reaction)
Two clinical subgroups
• 1. Atopy
• 2. Anaphylaxis
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22. Atopy
• The term applies to a group of diseases
occurring in individuals with inherited
tendency to develop IgE antibodies
• Allergic Rhinitis serves as an outstanding
example
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23. Anaphylaxis
• Certain allergens may induce IgE
mediated response
• Condition is potentially fatal.
• Affect atopic and non-atopic patient.
• Diseases are: Anaphylaxis, Urticaria,
Angioedema etc
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24. ALLERGIC RHINITIS
Essentials of Diagnosis
• Nasal pruritis, congestion, rhinorrhea, sneeze
attacks, eye irritation. Sometimes eczematous
dermatitis
• Environmental allergen exposure
• Confirmed by evidence of specific IgE antibody
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25. TREATMENT
The three basic Principles of
allergy management are :
• Avoidance Techniques
• Symptomatic Therapy
• Immunotherapy
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26. Avoidance Therapy
The most effective part of the treatment
• But usually meets failure as the allergens in the
environment often become unavoidable
• Cross-reactivity also plays its part
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27. Health Tips
Pollen grains of trees like paper mulberry can be
avoided by
leaving the area densely populated by these plants.
Minimize outdoor activity when pollen counts are high.
Take medications at least 30 minutes prior to outdoor activity.
Shut windows in your house on days pollen counts are high.
Wearing face masks
Use of air conditioners
Air-filtering devices
Avoiding Irritants.
Do a thorough spring cleaning
Wash bedding weekly in hot water.
Dry laundry indoors.
Keep pets off of furniture and out of the bedroom.
Keep car windows closed during peak season. 03/13/13
When mowing lawn Islamabad wear a filter mask.
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28. Drug Therapy
Three classes of:
• First generation antihistamine have sedating
potential.
• Second generation antihistamine having better
compliance & lesser sedating potential
• Third generation antihistamine are non- sedating
but usually the rescue dose comes with a sedating
effect
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29. First Generation
Chlorpheniramine
Diphenhydramine
Promathazine etc.
• First Generation have wide pharmacologic profile.
• They easily cross blood brain barrier that is why they
cause Sedation
• They are not specific nor selective they cause
anticholinergic side effects.
• They have Drug interactions.
• They do not work in late phase of Allergic Reactions.
• They are inconvenient B.I.D and T.I.D Dosage.
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30. Second/ Third Generations
Loratadine
Cetirizine
Fexofenadine
Disloratadine
Levocetirizine
Second generation are composed of Relatively Large and less
Lipophilic molecules that cross the blood brain barrier less easily
They cause minimal sedation.
They Work in late phase of Allergic Reaction.
Offer convenient once daily Dosage .
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They do not have Drug interactions.
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31. But all of them do not have all the
Advantages
Some of them cause cardiac side
effects
Some of them are not specific and
selective
Ant cholinergic side effects.
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32. What is the Right choice
WHICH OFFERS:
• High efficacy
• Fast relief of Allergic Reactions
• Long duration of action
• Minimal sedation
• Low side effects
• Safe in long term use
• Convenient OD dosage 03/13/13
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33. Fast Relief
Tandegyl Day provide quick relief of allergic symptoms.
Because it achieves peak plasma concentration with in (0.9 hrs)
3 fexofenad
ine
2.5
2 loratadine
1.5 cetrizine
Levocetiri
1 zine
0.5
0
peack plazma concentaration 03/13/13
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34. Slow dissociation Rate
Ensure the strong antagonism of
levocetirizine to histamine receptor
which resulting in longer duration of
action
In symptoms like Sneezing,
Rhinorrhoea, Nasal Obstruction, Itch
and Flare.
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35. Safety
Tandegyl Day have Minimal Sedation
because it does not cross the blood brain
barrier.
Tandegyl Day has low side effects
because it has 600 folds Higher selectivity
towards H1 receptor.
Tandegyl Day has a minimal Risk of Drug
interaction because it is poorly
metabolized. 03/13/13
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36. Low Volume Of Distribution
Tandegyl Day has Low volume of distribution so it is better choice
for long term use. Like in Allergic Rhinitis etc.
120
100
120
80
60
40 0.4 0.58 5.4 Volum of
20 Distribution
0
Tandegyl Day
Cetirizine
Fexofenadine
Loratidine
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37. High compliance
Convenient once daily
Less drowsiness
Low dryness of mouth
Affordable price Rs 5.50
Easily available
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quality product 37
38. LEVOCETIRIZINE (Tandegyl - Day)
• Potent systemic antihistamine.
• O.D dosage
• Fast onset of action (0.9 Hours).
• Economical (5.50/= per tablet)
• Can be recommended from the age of 2 years
• Has 600 times selectivity with H1 Receptors
• Has 2 fold higher affinity towards H1 Receptors
than Citirizine.
• Low drug interactions
• Minimal sedation 03/13/13
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39. Immunotherapy:
• Aim : Increase the patient's tolerance to the particular pollen.
Otolaryngol Clin North Am,7:703-718, October 1874
– Immunotherapy is indicated for those patients who fail
environmental controls and medical therapy, or patients
with extremely severe allergy.
– Immunotherapy is rarely done in children less than six
years of age, as allergic sensitivity is rapidly changing up
to that age
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40. Surgical Treatment:
• Indicated
– When the turbinates
have hypertrophied to
a point making
breathing difficult.
– Associated structural
problems causing
obstruction to airway.
– Complications like
nasal polypi.
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41. RHINITIS & ASTHMA
Nasal allergy
also seems to be highly correlated with
asthma, recurring sinus infection, otitis
media and possibly facial growth
abnormalities.
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