Definition Hypersensitivity of the nasal mucosa due to

exposure to allergens

Acute and seasonal or chronic and perennial

What happens in allergic rhinitis?1. Exposure to allergen 2. IgE production by the body3. Formation of allergen IgE complex4. Binding of the complex to mast cells5. Degranulation of the mast cells and

release of inflamatory mediators including histamine.

6. Vasodilation 7. Increase in capillary permability.

Exposure of genetically predisposed individuals to allergens (pollen, animal dander, (pollen, animal dander,

fur)fur)

Activation of T-lymphocytes

Stimulates IgE production by B-lymphocytes

IgE coat mast cells [on re-exposure mast cell degranulation]

1. Mast cells ◦ Contain

Granules (histamine) Other mediators (leukotrienes and PGs)

2. Lymphocytes◦ T cells◦ Increased mobilisation of inflammatory cells

Eosinophils, macrophages, neutrophils

3. Eosinophils◦ Major basic protein, Eosinophilic Cationic

Protein(epithelial injury, nasal block)

Released by inflammatory cells (mast cells, eosinophils, lymphocytes)

1. Leukotrienes◦ hypersecretion of mucus◦ oedema (Increased vascular permeability)

2. Histamine◦ itching, rhinorrhea (Allergic rhinitis)

3. Cytokines◦ Interleukins (IL) ◦ IL-4 (IgE production)◦ IL-3 and IL-5 (eosinophil, mast cell recruitment /

activation)

CLASSIFICATION OF ALLERGIC RHINITIS (AR)

Intermittent AR• < 4 days per week• or < 4 weeks

Mild Intermittent AR Moderate-Severe Intermittent AR

• Normal Sleep • No impairment of daily activities• Normal work and school • No troublesome symptoms

• Abnormal Sleep • Impairment of daily activities• Problem at work and school• Troublesome symptoms

CLASSIFICATION OF ALLERGIC RHINITIS (AR)

Persistent AR• > 4 days per week• or > 4 weeks

Mild Persistent AR Moderate-Severe Persistent AR

• Normal Sleep • No impairment of daily activities• Normal work and school • No troublesome symptoms

• Abnormal Sleep • Impairment of daily activities• Problem at work and school• Troublesome symptoms

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

Clinical features Nasal obstruction with pruritis, sneezing Clear rhinorrhea (containing increased

eosinophils) Itching of eyes with tearing Frontal headache and pressure Mucosa edematous, pale or violet in color Allergic salute transverse nasal skin

crease from rubbing the nose

Diagnosis History (don’t forget to ask about atopy &

family history) Physical examination: 1. look for redness ,swelling of the mucosa

(particularly the turbinates) &mucoid discharge. 2.check for structural anomalies such as

septal deviation or nasl polyps. Sensitivity test for specific allergen ( skin

prick tests)

Treatment 1. identification and avoidance of allergen 2.during the acute attach: -antihistamine (systemic or intranasal) -local steroids -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.

Drug type Itch / sneezing

Discharge Blockage Impaired smell

Nasal preparations

Antihistamines +++ ++ + _

AZELASTINE

Anticholinergics _ +++ _ _ Ipratropium

Decongestants _ + +++ _ Xylometazoline

Oxymetazoline

Mast Cell Stabilizers

+ + + _ Sodium cromoglycate

Topical

Corticosteroids +++ +++ ++ +

Fluticasone

Nometasone

2 sprays/nostril OD

Antihistamines◦ Oral: Most common form of Treatment. (Drowsiness

/ Dryness of mouth / Urinary retention / Blurred vision / appetite +).Cetrizine, Rupatidine

◦ Nasal Spray : Azelastine. Potent H1 blocker with immediate effect / Also blocks other mediators (LT, PAF)

Corticosteroids◦ Nasal Sprays: Most effective treatment of AR /

certain types of perennial rhinitis (Beclomethasone / Budesonide / Fluticasone / Mometasone.

◦ Block both EAR / LAR : Reduce swelling & secretions in nasal mucosa (anti-inflammatory)

◦ Oral Corticosteroids: Short term

Complications - chronic sinositis - polyps( swollen edematous nasal mucosal

tissue , they can cause complete nasal obstruction)

- serous otitis media

- It is a very common type of non-inflammatory, non-allergic rhinitis

-Characterized by a combination of symptoms that includes nasal obstruction and rhinorrhea

-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

Caused by: -temperature change -alcohol, dust, smoke -stress, anxiety, neurosis -endocrine – hypothyroidism, pregnancy,

menopause -parasympathomimetic drugs

Clinical features: -Chronic intermittent nasal obstruction -Rhinorhea (thin, watery) -Mucosa and turbinates : swollen, pale

between exposure

We have 2 types ; eosinophilic & non eosinophilic (according to the number of eosinophils found in the nasal secretion)

TYPES 1.Eosinophilic &

2.Non eosinophilic (according to the number of eosinophils found in the nasal secretion)

Treatment:-Elimination of irritant factor-Parasympathetic blocker-Steroids-Surgery -Symptomatic relief with exercise