this lecture demonstrates in details Allergic and Non-allergic rhinitis, the definition, pathophysiology, etiology, presentation, and management.

1. Allergic & Non-Allergic
RhinoSinusitis
Edited and presented by: Khaled Hani Alkhodari
The Islamic university of Gaza, IUGaza

2.  symptomatic inflammation of the paranasal sinuses
and nasal cavity
 Allergic or nonallergic rhinitis leads to sinusitis.
 Nasal discharge and congestion are prominent
symptoms of sinusitis.
 Nasal mucosa and sinus mucosa are similar and are
contiguous.
Definition

3.  One of the top 10 leading diagnoses of office visits in
the United State
 is the second, or may be, the most common chronic
disease in the US.
 Wide range for age among adults, highest in those aged
45 to 74 years
 Female > male
 White > black
 > DM , CLD , Smoker
Epidemiology

4. Some investigators prefer the term "rhinosinusitis" to the
separate terms "rhinitis" and "sinusitis." This is because
the nose and sinus mucosa are contiguous, rhinitis and
sinusitis frequently occur together, rhinitis commonly
leads to sinusitis, and nasal symptoms are common with
sinusitis

6.  Rhinosinusitis task force of the American
academy :
  Acute 7 days – 4 weeks.
  Subacute 4weeks – 12 weeks.
  Recurrent ARS ≥ 4 Episodes of ARS / Y.
  Chronic RS. ≥ 12 weeks .
  Acute exacerbations of CRS.
Classification

8. Allergic rhinitis
 Allergic rhinitis, or allergic rhinosinusitis, is
characterized by paroxysms of sneezing,
rhinorrhea, and nasal obstruction, often
accompanied
◦ by itching of the eyes, nose, and palate.
◦ Postnasal drip, cough, irritability, and fatigue are other
common symptoms [1-3].

10. Allergic Rhinitis

12. Physical findings
 The following physical findings may be present in patients
with active allergic rhinitis [57]:
 ●Infraorbital edema and darkening due to subcutaneous
venodilation, findings that are sometimes referred to as
"allergic shiners"
 ●Accentuated lines or folds below the lower lids (Dennie-
Morgan lines), which suggests concomitant allergic
conjunctivitis
 ●A transverse nasal crease caused by repeated rubbing and
pushing the tip of the nose up with the hand (the "allergic
salute")
 ●"Allergic facies," which are typically seen in children with
early-onset allergic rhinitis, consist of a highly arched palate,
open mouth due to mouth breathing, and dental malocclusion

13. Internal structures of ENT
The internal structures of the nose, oropharynx, and ears should be
examined:
 The nasal mucosa of patients with active allergic rhinitis frequently has
a pale bluish hue or pallor along with turbinate edema
 Clear rhinorrhea may be visible anteriorly, or if the nasal passages are
obstructed, rhinorrhea may be visible dripping down the posterior
pharynx
 Hyperplastic lymphoid tissue lining the posterior pharynx, which
resembles cobblestones (a finding called "cobblestoning")
 Tympanic membranes may retract or serous fluid may accumulate
behind tympanic membranes in patients with significant nasal mucosal
swelling and eustachian tube dysfunction

15. Allergic salute

16. Allergic Rhinitis

17. 2 Types:
 Seasonal (summer, spring, early autumn)
◦ Tree pollens, grass pollens, mold spores
◦ Lasts several weeks
◦ Disappears and recurs following year at the same time
 Perennial
◦ Inhaled: house dust, wool, feathers, foods, tobacco, hair
◦ Ingested: wheat, eggs, milk, nuts
 occurs intermittently for years with no pattern or may
be constantly present
Types

18.  Chronic sinusitis
 Polyps (swollen edematous nasal mucosal
tissue, they can cause complete nasal
obstruction)
 Serous otitis media
Complications

19. Diagnosis
 History (atopy & family history)
 Physical examination:
1. Redness ,swelling of the mucosa
(particularly the turbinates) & mucoid discharge.
2. Check for structural anomalies
(septal deviation or nasl polyps).
 Sensitivity test for specific allergen (skin prick tests)

20. 1. Identification and avoidance of allergen
2. During the acute attack:
1. Antihistamine (systemic or intranasal)
2. Local steroids
3. Decongestant (ephedrine)
3. Sodium cromoglycate (mast cell stabilizer used as
prophyaxis)
4. Desensitization (we keep exposing the body to
gradually increased amounts of allergen until the body
fails to produce IgE as a result to exposure).
Treatment

21. Idiopathic rhinitis
(Nonallergic, noninfectious rhinitis)
(Intrinsic rhinitis)
(Vasomotor rhinitis)
(Nonallergic vasomotor rhinitis)

22. PREVALENCE
 Rhinitis, in both its allergic and nonallergic
forms, affects 10 to 40 percent of the
population in industrialized countries.
 Pure chronic NAR may be responsible for
anywhere from 17 to 52 percent of all cases of
rhinitis in adults.

23. NAR
 DEFINITION — NAR is best defined by the chronic
presence of one or more of the four following cardinal
symptoms of rhinitis, in the absence of a specific etiology
(such as an immunologic, infectious, pharmacologic,
structural, hormonal, vasculitic, metabolic, or atrophic
cause):
◦ Sneezing
◦ Rhinorrhea
◦ Nasal congestion
◦ Postnasal drainage
 Although there is no consensus about how long symptoms
should be present to establish chronicity, some studies
have utilized a minimum duration of over one year

25.  Vasomotor rhinitis is a diagnosis of exclusion
reached after taking a careful history,
performing a physical examination, and, in
select cases, testing the patient with known
allergens.
 2 types ; eosinophilic & non-eosinophilic
(according to the number of eosinophils found
in the nasal secretion)

26. Symptoms:
 Chronic intermittent nasal obstruction
 Rihinorrhea (thin, watery)
Signs:
 Mucosa & turbinates : swollen, pale between
exposure
Clinical features

27. CLINICAL FEATURES
The clinical history is the most important tool used to make
the distinction between NAR and other forms of rhinitis.
NAR Vs. Allergic Rhinitis:
 The most frequent and prominent clinical manifestations of
NAR are nasal blockage and postnasal drip. In contrast,
patients with allergic rhinitis report prominent eye
symptoms, sneezing, and rhinorrhea.
 Patients with NAR often cannot readily identify triggers,
such as times of year when specific pollens are prevalent or
exposure to animals. In contrast, most patients with allergic
rhinitis can identify one or more triggers.

28.  Symptoms most commonly occur throughout the year
(eg, perennial), although the condition may be
exacerbated by weather conditions, particularly during
the spring and fall. Symptoms in those with allergic
disease usually show seasonal patterns, although some
have perennial symptoms.
 Patients with NAR suffer from comorbidities, including
asthma, chronic rhinosinusitis, otitis media, sleep
disturbance, and declines in quality of life, similar to
those with allergic rhinitis.

29.  Temperature change
 Alcohol, dust, smoke
 Stress, anxiety, neurosis
 Endocrine – hypothyroidism,
pregnancy, menopause
 Parasympathomimetic drugs
Triggers

30. Characteristic triggers
 Respiratory irritants (eg, cigarette smoking, strong scents, and
fragrances) are prominent inducers of symptoms, although this
may be true for patients with longstanding allergic rhinitis also.
 Weather changes (eg, fluctuations in temperature, humidity,
and/or barometric pressure) affect many patients with NAR.
 Heated or spicy foods induce watery rhinorrhea in patients with
the syndrome of gustatory rhinitis, which can be considered a
subtype of NAR. Food triggers are more common in older adults,
and gustatory rhinitis and rhinitis of older adults overlap.

31. Relationship with asthma
 NAR, like allergic rhinitis, is associated with asthma and is a
significant risk factor for the development of asthma. Some
studies have found that NAR confers a lower risk of asthma compared with allergic rhinitis
[83], while others have found similar rates of asthma development [84,85].
 There may be subsets of patients with NAR that are at
particularly elevated risk for asthma. Those with
inflammatory NAR with increased nasal eosinophilia appear
to be at greater risk for the development of asthma than
patients with NAR without eosinophilia [13,86,87].
 Those with eosinophilia not only have a comparatively
elevated risk for asthma but also a greater risk for the
development of chronic rhinosinusitis with nasal polyposis
and aspirin sensitivity.  which Syndrome ? (Samter)

32. PHYSICAL EXAM
 The nasal turbinates can appear boggy and edematous
in both allergic rhinitis and NAR.
 The mucosal tissue is more often erythematous in
nonallergic disease as compared with the pale-bluish
hue or pallor seen with allergic rhinitis.
However, none of these findings is diagnostic, and the
mucosa can even appear relatively normal, particularly in
older patients.

34. DIAGNOSIS
 The diagnosis of chronic NAR is based on a characteristic
history and physical examination, combined with the absence
of evidence for clinical allergy to aeroallergens.
 It is therefore a diagnosis of exclusion.
 However, in practical terms, allergy testing is not essential to
making a presumptive initial diagnosis of NAR and beginning
therapy.
 In addition, allergic rhinitis and NAR can coexist, and in such
cases, it may only become clear that the patient has both
disorders in retrospect once an effective combination of
medications is found.

35.  Elimination of irritant factor
 Symptomatic relief with exercise
 Parasympathetic blocker
 Steroids
 Surgery
Treatment

36. Management
 Patients with chronic NAR are generally less responsive
to pharmacologic therapy than those with allergic
rhinitis. Specifically, most find oral antihistamines
unhelpful. However, two classes of medications are
useful in treating the total symptom complex of chronic
NAR:
◦ Topical intranasal glucocorticoids (INGCs)
◦ Topical antihistamine azelastine
◦ In addition to these agents, ipratropium has been approved
specifically to treat the symptom of rhinorrhea in chronic NAR.

37. Primary therapies
 Patients with mild disease may be adequately treated with
either INGC or azelastine.
 If monotherapy is not sufficiently effective, combination
therapy should be the next step.
 Those patients who are very symptomatic tend to respond
better to the combination of an INGC and azelastine.
 We generally use full-strength dosing for both agents and
emphasize to patients that the medications should be used
on a daily basis regardless of the presence or absence of
symptoms.

38. Adjunctive therapies
 Adjunctive therapies that are helpful in some
patients include :
◦ oral decongestants.
◦ nasal saline sprays and irrigations: Daily nasal lavage or
nasal saline sprays can also be useful. These interventions are
particularly helpful for symptoms of postnasal drainage.
◦ oral antihistamines.
◦ Studies of antileukotriene drugs and intranasal
chromones in the treatment of NAR are lacking.

39. Role of surgery
 Several surgical approaches have been used in patients with severe
chronic NAR. These have been reported as uncontrolled case series.
Such interventions may be helpful in patients with difficult symptoms
that are refractory to multiple therapies
 Six to 12 months of medical management should be allowed before
surgical options are considered. Studies of efficacy are lacking.
◦ A turbinectomy can be performed when congestion is predominant.
◦ A number of other surgical procedures have been tried in the past, including
vidian nerve resection, electrocoagulation of anterior ethmoidal nerve,
sphenopalatine ganglion block, and others, None of these techniques have
been shown to have long-term benefits, and the potential risks (eg,
persistent pain) have to be considered carefully, since they may outweigh any
possible benefits.

40. Thank you 