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Allergic Rhinitis : Its Impact

on Sinonasal Problems
Dr. A B John, MBBS (S pore), FRCS
(Glasg), FAMS (S pore)
Snr. Consultant ENT Surgeon
Mount Elizabeth Medical Centre & Visiting
Rhinologist, Alexander Hospital, Singapore.

Rhinology
I.

II.

Allergic Rhinitis

How Sinonasal problems/ Rhinology


overlaps or impacts with Allergy
How Allergy is managed in
comprehensive Sinonasal Care

What is Allergy ?
C Von Pirquet 1906, fist coined the term
allergy to designate a changed reaction or
altered sensitivity
It indicated a hypersensitivity reaction to
otherwise innocuous foreign materials which
results in harm to the host
It involves a Type 1 Hypersensitivity reaction
Mast cells play a significant initiating role

What is rhinitis ?
Is local inflammation
of the lining of the
nose
Demonstration of
local inflammation is
often not possible,
therefore we
clinicians often look
at symptoms of
itching, sneezing,
discharge & blockage

What is rhinitis ?
SAR -- symptoms brought about by seasonal
allergens, such as pollens and some molds; and
PAR -- symptoms brought about by year-round
environmental allergens, such as dust mites, pet
dander, and certain molds and pollens.
As a consequence of these symptoms, patients
often experience fatigue, irritability, and
mood/cognitive disturbances.
The buzz word - presenteeism: people going to
work/ physically there but not productive.
Symptom of AR Decrease of productivity @
work place

NEW CLASSIFICATION OF RHINITIS - ARIA

Intermittent
. Less than 4 days per
week and less than 4
weeks

Persistent
. More than 4 days per
week and more than 4
weeks

Mild

Moderate-severe

normal sleep
& no impairment of daily
activities, sport, leisure
& normal work and
school
& no troublesome
symptoms

one or more items


. abnormal sleep
. impairment of daily
activities, sport, leisure
. abnormal work and
school
. troublesome symptoms

Allergic Rhinitis : Health &


Economic Impact.
10 -40 % of population in
industrialized nations
- US prevalence 17 22 %
Low mortality rate, but QOL
issues
- Direct costs (US)
1995- $ 2.4 billion
2001-$ 8 billion (Meltzer)
- Indirect costs
Time of work -10 million man
days per year
Time off school average 2
days/year

In 11 Asian countries. The


prevalence of allergic rhinitis in
Asia was found to range from 10
to 30% in adults and 10 to 46%
in children.
The most common age group
of patients with allergic rhinitis
was 10-30 years. In adults, AR
more common in women, in
children it was more common in
boys
Allergic Rhinitis and Asthma: The Link, The

New ARIA Classification and Global


Approaches to Treatment 2004 . R Pawanker, et.
al

Impact of AR in Singapore

As part of an international effort the international study of


asthma and allergies in childhood (ISAAC) written questionnaire
was administered to 6238 schoolchildren. Rhinitis was
reported by 44% in 1996. The analysis showed a higher
prevalence of wheezing and rhinitis was associated with males,
and subjects of higher socioeconomic status (based on type of
housing and total family income).

Prevalence & severity of asthma, rhinitis & eczema in Singapore schoolchildren. Arch Dis Child
1996, 74, Goh DYT; Chew FT; Quek SC; Lee BW Department of Pediatrics, National University
of Singapore .

In Singapore the prevalence in adults it is estimated has


between 4.5% to 25%, dependent on the diagnostic criteria.

A prevalence study of chronic rhinitis among residents in Telok Blangah Town, Singapore, Ann
Acad Med Singapore 1994;23, Chia SE, et al
Epidemiology of chronic rhinitis in Singapore: prevalence estimates, demographic variation&
clinical allergic presentation. Ann Acad Med Singapore 1994;23, Ng TP, Tan WC.
Rhinitis do diagnostic criteria affect the prevalence & treatment Allergy 2002- Wang DY

Diagnosis of ALLERGY :
Skin prick test
Reliable, sensitive
and reproducible

Pricking device

Immediate results
(20 min)

Cheap

Painless

Drops of allergen
extracts
for diagnostic use

Allergen Skin Test & Total IgE in


Adults with Rhinitis in Singapore
Study was done to determine the allergen skin
test positivity and total serum IgE of adult
patients in Singapore with clinical features of
allergic rhinitis
The most common allergen noted was to D.
farinae, tested positive in 76.5 % of patients.
Serum IgE levels were also noted to be
significantly higher in this group compared to
controls.

Allergen Skin Test & Total IgE in Adults with Rhinitis in Singapore. A B John,

Lee H S, Lee YW, Chng HH ; Asian Pacific Journal of Allergy & Immunology (1996).

What are the allergens ?

The prevalence and distribution of six indoor allergens


in 956 dust samples obtained from homes, childcare
centers, schools, and a hospital in Singapore was
studied. The results indicate that compared with public
places, the home constitutes a major reservoir of indoor
allergens. House dust mites formed the most important
indoor allergens locally, with storage mite, B. tropaclis,
constituting one of the major allergenic components of
dust in Singapore.
The home should be the target for allergen avoidance
measures.

Prevalence and distribution of indoor allergens in Singapore. Clin Exp Allergy :1997
Aug;27, Zhang L; Chew FT; Soh SY; Yi FC; Law SY; Goh DY; Lee BW .

House-dust Mite Allergy

Keeping a Pet

Airborne pollen & spores allergens ?

Among patients with allergic


disease, oil-palm pollen were
observed to have the highest
frequency of positive
reactions(40%), then resam-fern
spores & sea-teak pollen. Among
Fungal spores Curvularia spp &
Drechslera like spores, were
tested highest +.

Evaluation of the allergenicity of tropical


pollen & airborne spores in Singapore.
Allergy 2000:55:340-347, FT Chew, SH Lim,
HS Shang, MD Siti Dahlia, DYT Goh, BW
Lee.

Major environmental aeroallergens in


Singapore
I.
II.
III.
IV.

V.

House dust mite: Der P, Der F & Blomia T


Cockroach
Cat & Dog Dander
Grass & tree pollen: the common allergens
are oil palm & resam fern spore, present year
round
Moulds: less of a problem locally

Dust Control in the Bedroom

Counseling on Allergen
Avoidance

http--www.copeson.org.mx-medicos-asma-Prevencion_alergia_WAO_Guidelines_cond-ACII.pdf.url

http--www.copeson.org.mx-medicos-asma-Prevencion_alergia_WAO_Guidelines_cond-ACII.pdf.url

Sly RM. Changing prevalence of allergic rhinitis and asthma.


Ann Allergy Asthma Immunol. 1999;82:233-248

Indoor Air
Pollution

Nasal mucosa is contiguous with that of the


paranasal mucosa : to differentiate between
rhinitis & sinusitis is essentially artificial !

Pathophysiology of chronic &


persistent allergic inflammation

There is eosinophilic predominance, with edema,


inflammation, increased vascular permeability, mucous
hypersecretion & impaired ciliary function
There is an inflammatory cellular activation &
mucosal reactivity to wide range of other challenges :
priming
Finally chronic & persistent allergy stimulation results
in turbinate hypertrophy, polypoidal mucosal
degeneration or polyps with compromise of sinus ostia.

Is it Rhinitis or

Rhinosinusitis ?
Mucosal Thickening,
Opacification of
Frontal, Ethmoidal,
and Maxillary
Sinuses

Obstructed
Middle Meatus

Congested Middle
and Inferior
Turbinates

Overlap of Allergy/Rhinology what is the evidence that allergy


predisposes to sinus problems
Rhinology

Allergy

Epidemiological studies showing


associations with ABRS
Furukawa (1992)- Concordance between ABRS
& AR between 25-70 % (higher than the general
population) JACI 1992
Savolailen(1989)- 224 Army recruits with ABRS
compared to 102 controls. Allergy 1989
-Allergy symptoms failed to vary between the two
groups
-skin testing reveled increased allergy among those
recruits with ABRS (p<0.05)

Epidemiological studies showing


associations with CRS
Rachelefsky(1991)- 90 children with CRS
Skin test positive- 51%(p<0.05). JACI 1991;87:210
Furukawa(1992)-Reviwed results from two antibiotic
studies. JACI 1992;89:332
More infections among population of patients with allergy
by skin test (p<0.012)
Walner(1998)-147 pediatric patients undergoing ESS
Allergies- 56%
Asthma-19%
Immunodeficiencies-8.8%. ArchOto;124:425.
Conclusion = Evaluate CRS patients for allergies.

Epidemiological studies showing


associations with AR on CT scan
Krouse CT findings
correlate with degree of
inhalant sensitivities
OTO-HNS 2000;123:389
Ramandan-CT findings
with degree of inhalant
sensitivities
AJR;1999;13:345.

Epidemiological studies showing impact


upon surgical outcome.
Osgulthorpe

(1999)- Reviewed
world literature
1985 1998
Long term success
in uncomplicated
sinusitis: 90-93%
Long term success
in allergic rhinitis:
78-85%

Effect of Allergy Treatment showing


impact upon surgical outcome

Nishioka Patients with inhalant allergies undergoing


surgery experienced improved outcomes if treatment
coupled with immunotherapy
Nishioka OTO-HNS 1994;110:406-12

Folker AFS treated postoperatively with


immunotherapy
in mucosal recurrence of inflammation
in revision surgery
in systemic steroid usage
Quality of Life measure
Folker. Laryngoscope 1998;108:1623.

Comprehensive rhinologic
or sinonasal care should
account for the impact of
allergic rhinitis

Rhinitis do diagnostic criteria affect the prevalence & treatment Allergy 2002- Wang

Rhinitis do diagnostic criteria affect the prevalence & treatment Allergy 2002- Wang

Treatment of allergic rhinitis (ARIA)


Allergic Rhinitis and its Impact on Asthma

moderate
severe
intermittent

mild
persistent

moderate
severe
persistent

mild
intermittent intra-nasal steroid
local cromone

oral or local non-sedative H1-blocker


intra-nasal decongestant (<10 days) or oral decongestant

allergen and irritant avoidance


immunotherapy

TREATMENT BASED ON EVIDENCE - ARIA

allergen
allergen
avoidance
avoidance

indicated
indicated
when
whenpossible
possible

pharmacotherapy
pharmacotherapy
safety
safety
effectiveness
effectiveness
easy
easyto
tobe
beadministered
administered

immunotherapy
immunotherapy

costs

effectiveness
effectiveness
specialist
specialistprescription
prescription
may
mayalter
alterthe
thenatural
natural
course
courseof
ofthe
thedisease
disease

patient's
patient's
education
education

always
alwaysindicated
indicated

Addressing Allergic InflammationImmunotherapy


TH1- protect
against infection
TH2-promote
allergic humoral
response
Goal can be based
upon
-Suppression of TH2
cytokine activity
-Redirecting aberrant
TH2responses to
TH1

SIT: anti-inflammatory and immunomodulatory


effects
SIT
+
IL 5

Th2
IL 10/TGF
IL 4

+
IFN

IL 4
IL 13

Eosinophils

Th1

Treg

B Lymphocytes
Mast cells

---Inflammatory mediators

SIT
Riad FADEL, MD

Clinically documented Sublingual


Immunotherapy demonstrated:
An improvement in rhinitis and conjunctivitis symptoms

induced by pollen or mite allergens.


An improvement in asthma control in adults and children.
A decrease in the use of the most widely prescribed

antiallergic medications.
An optimal safety profile in children and adults.
That its the chosen therapy by children and parents,

compared to subcutaneous immunotherapy.

Take- Home Message

The prevalence of allergic rhinitis seems to be on the


rise, in post industrialized countries (like Singapore).
Whether this trend is due to greater exposure to indoor
allergens, more urban living & more air pollution (the
haze), greater awareness of allergic disease or better
data collection we do not know for sure.
Primary care clinicians can expect to see more patients
with allergic rhinitis with persistent/chronic symptoms
& by implication more chronic sinusitis
These patients are prime candidates for aggressive
allergic treatment

Take- Home Message


Recent Singapore community health survey
showed alarming finding of patients poor
understanding of allergic rhinitis & comorbidities & poor efficacy of the treatments
prescribed by physicians.
The very low use of nasal steroids & secondgeneration anti-histamines, both widely
recognized as the treatment of choice for rhinitis
needs to changed.

Thank-you

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