allergic rhinitis

1. Allergic Rhinitis
Dr. Krishna Koirala
MBBS,MS

2. • Definition
– IgE mediated hypersensitivity disease
of the mucous membrane of nasal
airways characterized by sneezing ,
itching, watery nasal discharge,
sensation of nasal obstruction,
postnasal discharge and hyposmia
• Associations
–Allergic conjunctivitis

3. Classification of Allergic
Rhinitis
• Old
–Seasonal
–Perennial
–Occupational

4. ARIA (Allergic Rhinitis and its
impact on Asthma)
classification :
• Intermittent
–Symptoms present <4 days a week
or for <4 consecutive weeks
• Persistent
– Symptoms present >4 days a

5. • Mild
– No Sleep disturbance
– No Impairment of daily activities,
leisure and/or sport
– No Impairment of school or work
– Symptoms present but not troublesome
• Moderate/severe (one or more of the
following items present)
– Sleep disturbance
– Impairment of daily activities, leisure
and/or sport
– Impairment of school or work

6. • Etiology
• Atopy (hereditary)
– Represents a predisposition to develop
allergic disease
• Allergens
– Seasonal rhinitis
• Grass and tree pollens
– Perennial allergic rhinitis
• House dust mite – Digestive enzymes
excreted in faeces
• Domestic pets – Cats, dogs, rabbits,
guinea pigs
• Cockroaches
– Occupational Rhinitis : Flours, laboratory

7. • Food and drug induced rhinitis
– More common in children
,foods/preservatives
– Foods
• Milk ,eggs, cheese in children
• Nuts ,fish ,citrus fruits in adults
– Drugs
• Aspirin
• Antihypertensives ( beta blockers, ACE
inhibitors )
• Antipsychotic
• Topical nasal decongestants (Rhinitis
medicamentosa)

8. Allergen
Mast cells T- lymphocytes
Histamine,
Leukotrienes
prostaglandins
Bradykinin, PAF
Immediate rhinitis symptoms
Itch, sneezing
Watery discharge
Nasal congestion
B -Lymphocytes
Chronic ongoing rhinitis
Nasal blockage
Loss of smell
Nasal hyper reactivity
Eosinophils
Pathogenesis
IgE
IL3,IL5,GM-CSFIL4
Hyperreactivity
Tissue edema

10. Diagnosis
• History
– Seasonality, frequency and severity of
symptoms
– Patient’s dominant symptoms
– History of potential allergic triggers
– Personal/ family h/o atopic disease
– H/o trauma
– H/o mucopurulent rhinorrhea, facial
pain, fever

11. Clinical features
Symptoms
• Seasonal rhinitis
– Sneezing :
paroxysmal, frequent
intervals throughout
the day, more in the
morning times
– Nasal discharge :
watery, mucoid,
yellowish
– Nasal obstruction /
blockage
– Itching of nose, eyes,
palate
– Tearing/redness of
the eyes, periorbital
• Perennial Rhinitis
– Long standing nasal
congestion and PND
– Viscous/ purulent
rhinorrhea
– Conjunctivitis less
frequent
– Secondary symptoms :
loss of smell and
taste, sinusitis, ETD
– Sneezing less common

12. Signs
• Nose
– Transverse crease at the
dorsum of the nose
( Darrier’s line)
– Allergic salute
– Pale /bluish nasal mucosa
– Boggy and swollen
turbinates
– Watery nasal discharge
– Polyps/ hypertrophied
turbinates septal deviation
Allergic saluteDarrier’s line

13. • Eyes
– Periorbital edema, conjunctival congestion
,watering
– Marked erythema of palpebral conjunctivae and
papillary hypertrophy of tarsal conjunctivae
( cobblestone)
– Dark circles under the eyes ( allergic shiners)
• Repetitive vigorous rubbing in the peri -
orbital region
• Impaired venous return from the
skin and subcutaneous tissues
Denni - Morgan lines

14. • Ear
– Retraced TM, OME
• Pharynx
– Granular pharyngitis, cobblestone
• Larynx
– Laryngeal edema
• Bronchus ---bronchospasm

15. Investigations
• Complete Blood Count ,ESR, Absolute
Eosinophil Count
• Serum IgE measurements
• Nasal smear for cytology : eosinophils,
neutrophils, basophils, mast cells ,
epithelial cells and bacteria
• Nasal swabs for bacteriology or viral studies
• Skin prick tests (PRIST)
• RAST
• ELISA
• Nasal provocation (challenge) test
• Diagnostic Nasal Endoscopy (DNE)
• X-Ray PNS OM view

16. Skin Prick Tests
• Prick test or scratch test : Pricking the skin
with a needle or pin containing a small amount
of the allergen
• Patch test
– Applying a patch to the skin, where the
patch contains the allergen
– If an immune - response is seen in the form
of a rash, urticaria or anaphylaxis -- patient
has a hypersensitivity to that allergen
• Intradermal test
– A small amount of the allergen solution is

17. • The negative control
– Saline (salt-water) solution
– Response not expected
– If however a patient reacts to a negative
control --- the skin is for whatever reason
extremely sensitive
• The positive control
– Histamine, to which everyone is expected to
react
– Failure to do so -- medicines the sufferer is
taking could block the response to the
histamine and allergens

23. •An extension of the radioimmunoassay
•Commonly known as "sandwich" technique
•To detect IgE, specific antigens for this antibody are
attached to a matrix particle and Serum suspected to
contain IgE is then added
•Antibody, if present combines on the surface of the
particle
•Now another antibody, one that reacts with human
antibodies, is added which carries a radioactive label
•The entire complex will, therefore, be radioactive if the
antiglobulin antibody combines with the IgE
RAST (Radioallergosorbent test)

24. Treatment Modalities
• Allergen avoidance
• Pharmacotherapy
• Immunotherapy
• Treatment of complicating
factors

25. 2
1
2

26. • Allergen avoidance
• Useful for a single/ unusual allergen
• Identification of relevant aeroallergens ---
Complete/ partial avoidance of allergens
– Elimination of occupational allergen
exposure
– Elimination of pet allergen exposure
– Mite antigen control measures
– Frequent pet washings
– Cockroach control measures
– Closed windows in homes / cars
– Central heating and cooling
– Central air filtering system

27. • Pharmacotherapy
• Primary therapy for seasonal / perennial allergic
rhinitis
• Corticosteroids
– Topical : Sprays and drops
• Extremely effective for all nasal symptoms of
allergy
• Beclomethasone, Budesonide, Fluticasone,
Mometasone spray
• Betamethasone drops
• Sprays better than drops in allergic rhinitis
• Drops better in OMC disease, polyps and
sinusitis
– Oral : Prednisolone 1 mg /kg / day in tapering
dose for 2 weeks

28. Budesonide nasal spray
Beclomethasone nasal
spray
50mcg/dose
Fluticasone nasal spray
50mcg/dose
Fluticasone nasal spray
50mcg/dose

29. • Mast cell stabilizers
–Eg. Sodium chromoglycate drops
and sprays
–Less effective than topical
corticosteroids
–Treatment of first choice in young
children

30. • Antihistamines
– Eg. Chlorpheniramine, Loratadine,
Cetrizine, Fexofenadine, Ebastine
– Effective for sneezing, itching, watery
rhinorrhea and eye , palate and throat
symptoms
– Less effective in nasal congestion
and blockage

31. • Topical vasoconstrictors
– Xylometazoline, oxymetazoline,
ephedrine
– Effective against nasal blockage
– To be used for short period only,
prolonged use >2 wks may lead to
Rhinitis medicamentosa (Rebound
hyperemia, nasal congestion and
obstruction that occurs following

32. • Topical anticholinergics
–Ipratropium Bromide (0.03%
nasal spray) for watery
rhinorrhea
• Leucotriene inhibitors
–Montelukast, zafirlukast

33. • Immunotherapy
• Allergen-specific
immunotherapy (SIT)
– Practice of administering
gradually increasing
quantities of an allergen
extract to an allergic subject
to eradicate the allergic
symptoms by subsequent

34. – Indications
• Pollen sensitive patients having
single allergen, failing to
respond to conventional
treatment ,having intolerable
side effects of treatment, unable
to avoid the allergens
– Contraindications
• Patients with multiple allergies ,

35. • Procedure
– Allergen injected subcutaneously in
increasing doses till maximum
tolerated response is reached
– May also be delivered by the oral, nasal
or sublingual routes
– The monoclonal anti - IgE antibody
• Induces the reduction of serum-free
IgE levels
• Reduces the symptoms mediated by
IgE

36. – Success rates - as high as 80 -90% for
certain allergens
– Course : 2 years or more
• Treatment of complicating factors
–DNS, infection, medications,
Hormonal aberrations