Insha Aleena's document discusses allergic rhinitis (hay fever), including its causes, symptoms, diagnosis, treatment, and complications. Common allergens that can trigger allergic rhinitis include pollen, dust mites, molds, insects, animal dander and house dust. Diagnosis involves taking a medical history, physical examination, and allergy tests such as skin prick tests. Treatment includes avoiding allergens, using antihistamines, decongestants, mast cell stabilizers, corticosteroids, and immunotherapy. Complications can include recurrent sinus infections, nasal polyps, ear infections, and increased risk of asthma if left untreated.

1. Insha Aleena
Allergic Rhinitis
(diagnosis, investigation, treatment and complications)

2. It is an IgE-mediated immunologic response of nasal mucosa to air-borne
allergens and is characterised by watery nasal discharge, nasal obstruction,
sneezing and itchy nose.
Common Allergens
• Pollen
• Dust mites
• Molds
• Insects
• Animal dander
• House dust
• Ingestants
• Drugs

3. Diagnosis
1. History
2. Physical Examination
3. Allergy Diagnosis (investigative tests)
• Skin tests
• Nasal allergen challenge
• Blood test for allergy (IgE)
Presenting Symptoms
• Nasal congestion
• Sneezing
• Clear rhinorrhea
• Itching of nose, eyes, palate
• Post-nasal drip
• Frequent throat clearing
• Cough
• Malaise
• Fatigue

4. History
• Nose complaints and duration: Sneezing/itching/stuffiness/watery discharge/other
-Are the symptoms: Seasonal/perennial
-Severity of symptoms: Mild/moderate/severe
-Other associated complaints: Asthma/eczema/conjunctivitis/others
• Events preceding complaints
-Time and mode of onset
-Event preceding the first attack: Change of occupation/infective illness/change of
home/others

5. • Likely causative allergens
Symptom occur;
All the year round: Yes/No
In the open air/indoors/both
At home/at work/both;
Is the home: In country/in town; old/new/damp
Weather: Dry/humid
During day/at night: In bed on waking/in bedroom/when dust is disturbed/on
bed making
Is the bedroom heavily carpeted/curtained
Does the bed have: An old mattress or pillow/a feather pillow

6. • Past allergic history
• Family history of allergy
• Allergens for which testing is required (suspected allergens from history)
Any contact with animals
Work or hobbies involving: Wood/wool/hay/straw/grain/dust (other than house dust) or
other substances (specify)
Contact with particular plants/detergents etc.
Food consumed before symptoms occurred
Immediate or delayed symptoms
Any known drug allergy
Current medications

7. Examination Findings
• Inferior turbinate hypertrophy
• Pallor of the nasal mucosa
• Oedema of lids, congestion and cobble-stone appearance of the conjunctiva
• Allergic shiners
• Dennie-Morgan lines
• Allergic salute
• Transverse nasal crease across the middle of nasal dorsum
Anterior Rhinoscopy
Ocular Examination
Other Findings

8. Investigation
1. Total and differential count. Peripheral eosinophilia (inconsistent
finding).
2. Nasal smear shows large number of eosinophils.
3. Skin (prick/scratch/intradermal) tests help to identify specific
allergen.
4. Radioallergosorbent test (RAST) is an in vitro test and measures
specific IgE antibody concentration in the patient's serum.
5. Nasal provocation test.
Skin prick test

9. Differential Diagnosis
• Vasomotor rhinitis
• Sinonasal polyposis
• Rhinitis medicamentosa
• CSF rhinorrhoea
Difference between CSF fluid and nasal secretions

10. Complications
• Recurrent sinusitis because of obstruction to the sinus ostia.
• Nasal polypi.
• Serous otitis media.
• Orthodontic problems, adenoid facies and other ill-effects of prolonged mouth breathing
especially in children.
• Bronchial asthma. Patients of nasal allergy have four times more risk of developing bronchial
asthma.

11. Treatment
1. Avoidance of allergen: most successful if the antigen involved is single.
2. Drug therapy:
• Antihistaminics: second generation antihistamines are the drug of choice. To control
rhinorrhoea, sneezing and pruritis. Cause drowsiness.
Topical- Azelastine and Levocabastine
Systemic- Loratidine and Cetrizine

12. Antihistamines
• Second-generation: (Non-sedating
H1 receptor-blocking). They do not
readily cross blood-brain barrier, and
are now the drugs of choice.
• Third-generation: fexofenadine and
levocetrizine.
• Topical: To avoid the systemic side
effects, azelastine and
levocabastine, topical antihistamines
are used intranasally.

13. • Sympathomimetics (Nasal decongestants): constrict blood vessels and reduce nasal
congestion and oedema.
Topical- Oxymetazoline and Xylometazoline
Systemic- Pseudoephedrine and Phenylephrine
• Mast Cell Stabilizers: stabilises the mast cells and prevents them from degranulation despite
the formation of IgE-antigen complex.
Sodium cromoglycate nasal drops.

14. Corticosteroids
A. Oral corticosteroids are very effective in controlling the symptoms of allergic rhinitis but
have several systemic side effects.
Prednisolone
B. Topical steroids inhibit recruitment of inflammatory cells into the nasal mucosa and
suppress late-phase allergic reaction.
• Used as aerosols
• Very effective in the control of symptoms.
• Fewer systemic side effects.
Flunisolide, Beclomethasone, Mometasone, Budesonide, Fluticasone and Triamcinolone

15. • Anticholinergics: inhibits mucous membrane glandular secretion of nose.
Ipratropium bromide nasal spray
• Leukotriene receptor antagonists: act by inhibiting formation of leukotrienes or blocking
their effect.
Montelukast and Zafirlukast
3. Immunotherapy (hyposensitisation): used when drug treatment fails to control symptoms or
produces intolerable side effects. Immunotherapy suppresses the formation of IgE. It also raises
the titre of specific IgG antibody.
Immunotherapy has to be given for a year or so before significant improvement of symptoms can
be noticed.

16. Management
protocol for
allergic
rhinitis

17. Thank You