Allergic Rhinitis

Dr. Vishal Sharma

 Introduction
Commonest chronic disease of mankind (20%)

Induced after allergen exposure by IgE-mediated

Type 1 hypersensitivity reaction of nasal mucosa

30% pt of allergic rhinitis have bronchial asthma

60-80% pt of asthma also have allergic rhinitis

Prevention of allergen exposure is best treatment

 Aetiology
1. ATOPY: genetically inherited ed IgE response

2. ALLERGENS:

* Seasonal (Hay fever): Pollen, Fungus

* Perennial: Dust mite, Domestic pets, Cockroaches

* Occupational (?): Flour, Animal, Wood, Latex, Paint

3. FOOD INDUCED: Nuts, fish, prawns, legumes,

milk, cheese, egg, meat, citrus fruits, wines

4. DRUG INDUCED: Aspirin, other NSAIDs, anti-
hypertensives, oral contraceptive pills

5. POLLUTION (NASAL IRRITANTS): Traffic fumes,

tobacco smoke, mosquito repellents, perfumes,
scented sticks, domestic sprays, bleaches

6. LACK OF INFECTION: Younger child in large

family frequent viral infections & less prone to
allergy. Older child in large family or only child in a
small family infection is rare so develops allergy.
Grass pollen & dust mite
 Pathogenesis
Sensitization & Priming to specific antigen:

Inhaled allergen produces specific IgE antibody

which gets attached to mast cells

Subsequent exposure to same antigen:

Allergen combines with specific IgE antibody

degranulation of mast cells (even with small

amount of antigen) chemical mediators released

 Acute or Early Phase
Occurs 530 min after exposure to antigen due to

release of chemical mediators sneezing, watery

rhinorrhoea, nasal blockage & bronchospasm.

Mucosal edema & Vasodilation nose block

Nerve irritation sneezing & itching

ed secretion from nasal gland rhinorrhoea

Smooth muscle contraction bronchospasm

 Late or Delayed Phase
Occurs 2-8 hours after exposure due to

infiltration by inflammatory cells at site of

antigen deposition edema, congestion & thick

nasal secretion. Sneezing & itching decreases.

Inflammatory cells are eosinophils, neutrophils,

basophils, monocytes & CD4+ T lymphocytes.

Pathogenesis
Pathogenesis
 Cardinal Symptoms
1. Watery rhinorrhoea

2. Nasal obstruction: bilateral

3. Paroxysmal sneezing: 10-20 at a time

4. Itching in nose, eyes, palate, pharynx

Presence of 2 or more symptoms for > 1 hour on

most days indicates allergic rhinitis.

 Nasal Signs
Repeated lifting of nasal tip (allergic salute) to
relieve itching & open nasal airway transverse
nasal crease (Darriers crease, Hiltons line).
Hypertrophied turbinates are covered with pale
or blue, boggy mucosa. Pitting edema seen on
probing (mulberry turbinates).
Nasal secretions are watery mucoid.
Nasal polyps with hyposmia / anosmia.
Allergic salute
Nasal crease
Pale turbinate, watery
rhinorrhoea
Blue, boggy turbinate
 Other Clinical Signs
Face: Frequent twitching of face (bunny nose)
Dennie-Morgan creases (in lower eyelid skin)
Allergic shiners (dark discoloration below
lower eyelids) caused by venous stasis
Eyes: Conjunctiva is congested with cobble stone
appearance; increased lacrimation
Ears: Ear block & ed hearing (due to O.M.E.)
Throat: Chronic pharyngitis, laryngitis
Bunny nose
Dennie-Morgan Creases
Allergic Shiners
Itching of eyes
Allergic conjunctivitis
 ARIA Classification
1. Mild intermittent

2. Moderate-severe intermittent

3. Mild persistent

4. Moderate-severe persistent

ARIA = Allergic Rhinitis & its Impact on Asthma

Intermittent symptoms Persistent symptoms
Present for < 4 days / wk Present for > 4 days / wk

Or for < 4 weeks and for > 4 weeks

Mild (presence of all) Moderate-severe (any 1)

Normal sleep Abnormal sleep

Normal daily activities Impaired daily activities

Normal work and school Impaired work & school

Normal sport & leisure Impaired sport & leisure

No troublesome symptom Troublesome symptoms +

 Investigations
1. Absolute Eosinophil count

2. Nasal smear examination for eosinophils

3. Skin prick test

4. Radio-allergo-sorbent test (R.A.S.T.)

5. Diagnostic Nasal Endoscopy

6. C.T. scan P.N.S.: for sinusitis & nasal polyps

Skin prick test
Skin prick test
Skin prick test
Radio-allergo-sorbent test
 Pt serum is incubated with allergen disc. Only
specific IgE binds with allergen. Rest is washed
away with a buffer.
Disc is incubated with radio-labeled anti - IgE
antibody. Anti-IgE antibody binds with allergen-
IgE complex.
Amount of radio-labelled anti-IgE antibody on
disc amount of IgE & is quantified by
counting radioactivity from the disc.
Diagnostic Nasal Endoscopy
 Complications
1. Recurrent sinusitis

2. Nasal polyp

3. Serous otitis media

4. Prolonged mouth breathing

5. Bronchial asthma

6. Atopic dermatitis

7. Conjunctivitis
 Differential diagnosis
Vasomotor rhinitis

Rhinitis medicamentosa

Hormonal rhinitis (pregnancy, hypothyroidism,

oral contraceptive use)

Cerebrospinal fluid leak

Ethmoid polyps
 Treatment
1. Avoidance of allergens

2. Pharmacotherapy

3. Specific Immunotherapy

4. Surgery: F.E.S.S., Turbinoplasty

 Pharmacotherapy
H1-Antihistamines: Topical (Azelastine), Systemic

Nasal Decongestants: Topical drops, Systemic

Mast cell stabilizers: Sodium cromoglycate, Ketotifen

Anti-cholinergics: Ipratropium bromide nasal spray

Corticosteroids: Nasal, Oral, Turbinal, Intramuscular

Leukotriene receptor antagonists: Montelukast

Newer drugs: RhuMAb-25, Altrakincept

 Antihistamines &
Decongestants
Antihistamines Systemic decongestants
Cetirizine (S) Phenylephrine
Fexofenadine (S) Pseudoephedrine
Loratidine (S) Topical decongestants
Levocetrizine (S) Xylometazoline
Desloratidine (S) Oxymetazoline
Azelastine (T) Hypertonic saline
 Antihistamines
Systemic:
Cetirizine: 10 mg OD
Fexofenadine: 120 mg OD
Loratidine: 10 mg OD
Levocetrizine: 5 mg OD
Desloratidine: 5 mg OD

Topical: Azelastine spray (0.1%): 1-2 puff BD

 Nasal Decongestants
Systemic decongestants
Phenylephrine
Pseudoephedrine
Topical decongestants
Xylometazoline
Oxymetazoline
Saline
 Anti-cold preparations
Name Chlorpheniramine Decongestant Paracetamol

COLDIN 4 mg PsE 60 mg 500 mg

SINAREST 4 mg PsE 60 mg 500 mg

DECOLD 4 mg PhE 7.5 mg 500 mg

SUPRIN 2 mg PhE 5 mg 500 mg

PsE = Pseudoephedrine; PhE = Phenylephrine

 Topical Decongestants
Oxymetazoline 0.05 %: 2-3 drops BD (NASIVION)

Oxymetazoline 0.025 %: 2 drops BD (NASIVION-P)

Xylometazoline 0.1 %: 3 drops TID (OTRIVIN)

Xylometazoline 0.05 %: 2 drops BD (OTRIVIN-P)

Saline 2 %: 3 drops TID

Saline 0.67 %: 2 drops BD (NASIVION-S)

Systemic Antihistamines
Topical Antihistamine spray
Technique of nasal spray
Nasal Decongestants
Sodium Cromoglycate
Ipratropium nasal spray
 Corticosteroids
Nasal sprays Injectable

Beclomethasone Methylprednisolone

Budesonide

Fluticasone Oral

Mometasone Prednisolone
Corticosteroid nasal spray
Methylprednisolone acetate
Montelukast
 Drug Sneeze Rhinor Nasal Nose ed
rhoea block itch smell
Antihistamine +++ ++ + +++ 0
Steroid spray +++ +++ +++ ++ +
Oral steroid +++ +++ +++ ++ ++
Cromoglycate + + + + 0
Topical nasal 0 0 ++++ 0 0
decongestant
Ipratropium 0 ++ 0 0 0
Monteleukast 0 + ++ 0 0
Specific Immunotherapy (SIT)
Indications:

1. Insufficient response to conventional drugs

2. Side effects from conventional drugs

3. Rejection of conventional drug treatment.

4. Allergy to one or two allergens only

Types:

Systemic injection, intra-nasal, sublingual

 Injectable S.I.T.
Serial subcutaneous injections of immunogenic

extracts from relevant allergen in increasing

concentration.

Injections given twice weekly until response is

noticed (6-20 wk) given weekly for 1 year

fortnightly for 1 yr every 3 weeks for 1-3 yr.

Injectable S.I.T.
Intranasal & sublingual S.I.T.
Can use 50-100 times greater doses compared to

injection immunotherapy.

Considered in selected patients with:

systemic side effects

refusal to injection treatment

 Treatment protocol
Mild intermittent

H1-Antihistamine + Nasal decongestant
No Improvement after 1 month
Treat as Moderate-severe Intermittent

In case of improvement: Step down & continue

treatment for 1 month
 Moderate-severe intermittent & Mild persistent

H1-Antihistamine + Nasal decongestant
+ Corticosteroid nasal spray
No Improvement after 1 month
Double dose Corticosteroid nasal spray
Ipratropium for rhinorrhoea
Cromoglycate
for seasonal cases Montelukast for asthma
No Improvement after 1 month
Specific Immunotherapy + Newer Drugs
 Moderate-severe persistent

H1-Antihistamine + Nasal decongestant + double
dose Corticosteroid nasal spray + Montelukast
No Improvement after 1 month
Add short course of oral corticosteroid
Add Ipratropium spray for rhinorrhoea
Consider surgery for polyps / turbinates
No Improvement after 1 month
Specific Immunotherapy + Newer Drugs
 General advice
Avoid cold drinks, ice cream & very cold air
Avoid cigarette smoke & traffic fumes
Avoid strong perfumes, scented sticks & cosmetics
Avoid head bath with cold water. Use warm water.
Avoid mosquito repellents / bleaches
Have a balanced diet to improve body immunity
Sleep with head elevated to se nasal congestion
Adequate fluid intake to loosen nasal secretions
 Exercise regularly
Avoid foods & drugs to which you are allergic
Avoid occupational irritants or change profession
Remove furred animals (cats, dogs) from
bedroom. Wash the pet weekly with warm water
Keep bathroom, kitchen, basement + attic clean &
well ventilated. Avoid damp areas. Remove
houseplants & dried flowers.
Use insect repelling chalks. Avoid sprays. Avoid
collection of spilled food material.
 Pollen advice
Avoid walking in open grassy spaces during hot, dry
days. Move outdoors only on damp days.
Keep windows closed. Move flowering plants away
from doors & windows.
Wear facemask & sunglasses when moving out.
Keep grass & plants trimmed. Get rid of weeds &
leaves.
Plant less allergenic flowers & trees.
 House dust mite advice
Use foam pillows & mattresses with dust-proof cover.
Remove carpets, upholstered furniture, stuffed toys,
old newspapers & magazines.
Wash bedcovers & clothes in warm water.
Damp-wipe house regularly wearing a facemask.
Use vacuum cleaners with high-efficiency particle
arresting (HEPA) filters weekly.
Use air-conditioning (with pollen filters) to maintain
the humidity less than 50 %.
Thank You