Allergic

Rhinosinusitis
Literature Reading

Budhy P.K.

Department of Otorhinolaryngology-HNS
Padjadjaran University School of Medicine
Bandung
2 0 0 4
Allergic rhinosinusitis = Allergic rhinitis

Allergic rhinosinusitis (AR)

a symptomatic disorder of the nose,
induced after allergen exposure, by
an IgE-mediated inflammation of the
nasal membranes

2
INTRODUCTION
Allergy accounts partly or entirely for the chief
complaints of an estimated 50% of new patients
seen in a general otolaryngology practice
Expertise in managing allergic problems of the
upper respiratory tract is of great practical value
for the otolaryngologist.

3
THE ALLERGIC REACTION
Gell and Coombs type I immediate (anaphylactic)
hypersensitivity reaction
Allergen-specific IgE is bound to mast cells or
basophils
Reacts cause mast cell degranulation and the
release of histamine and other mediators of
inflammation (e.g., prostaglandins, leukotrienes)
begins within 2 to 5 min of such an antigen-
antibody reaction, peak after about 15 min.

4
 THE ALLERGIC REACTION

Second (late) phase result of mediator release

from cells (neutrophils, eosinophils) and occurs
about 4 to 6 hr after the acute phase
reactions under influence mediators called
cytokines
Understanding this prototypical allergic reaction
and effect on the upper respiratory tract
consider therapeutic either preventing or
alleviating the results of the allergic event
(Fig. 28-1)

5
DIAGNOSIS OF ALLERGY
Signs and Symptoms of Allergic Rhinitis
Inhalant upper respiratory allergy suspected
basis of typical historical points and physical
stigmata
Symptoms
nasal itching
Sneezing
Rhinorrhea
postnasal drainage
Complaints may be seasonal or perennial, and a
linkage with known exposure to allergens
(especially dust and animal danders) is often noted
Symptoms may begin at any age

6
 DIAGNOSIS OF ALLERGY

Signs of allergic rhinitis airway obstruction

open-mouthed adenoid facies
Itching membranes involuntary grimacing, repetitive
upward wiping of tip nose with the hand (allergic
salute)
visible transverse crease across the nasal tip
Infraorbital tissue congestion allergic shiners and
puffiness around the eyes
Allergic nasal mucosa appears pale during rhinoscopy,
with clear rhinorrhea (in the absence of secondary
infection)
Polyps may be present, although not all polyps are
allergic in origin patients should be evaluated for
contributory allergy
high arched palate (part of the nonadenoidal adenoid
facies) prominent pharyngeal lymphoid follicles and
lateral bands are seen commonly in patients with allergy

7
 DIAGNOSIS OF ALLERGY

Adjunctive Tests
Anterior rhinoscopy often suggests allergic
rhinitis
Fiberoptic endoscopy small polyps, indicative of
concomitant sinus disease sinus computed
tomography scans
Allergic rhinitis is suggested by the presence of
eosinophils in stained smears of nasal secretions
The clinician must be aware,
prolonged use of topical nasal corticosteroids
syndrome of nonallergic rhinitis with eosinophilia (NARES)
nasal smears may be considered to be helpful but not
definitively diagnostic
Assay of total IgE

8
 DIAGNOSIS OF ALLERGY

Definitive Testing for Atopy

Proof that upper respiratory allergy is present
demonstrating allergen-specific IgE in the patient
Introducing suspected allergen under the skin and
allowing it to react with IgE bound to mast cells
confirmed by wheal and flare
Early skin tests were conducted by abrading or
scratching the skin soon replaced by the prick test
multiple tests can be done easily at one sitting with
relatively little discomfort, prick testing is popular for
screening
Low degrees of atopy Intradermal tests although
slightly more painful and much more time-consuming
injected intradermally Measurement of the wheal that
forms provides a quantitative dimension not found in
prick testing.

9
 DIAGNOSIS OF ALLERGY

Beginning with a weak and anticipated nonreacting

dilution, progressively stronger antigen concentrations are
intradermally injected
The end point marks the concentration at which
immunotherapy can safely be initiated
the end point first positive wheal that initiates progressive
positive whealing (concentration producing the 7-mm wheal)
confirming wheal (concentration producing 9-mm wheal)
Variants in positive whealing
positive wheals
plateau
flash response
Skin tests benchmark for confirming IgE-mediated inhalant
allergy in addition to discomfort and the risk of producing
an anaphylactic reaction, other disadvantages including
multiple factors affect skin test results other testing
methods have been developed

10
 DIAGNOSIS OF ALLERGY

Direct measurement of allergen-specific IgE in patient

serum
patient serum is allowed to react with known antigens
(Marker) radioactive substance, the test is called a
radioallergosorbent test (RAST)
(Marker) fluorescing agents are used in ELISA (enzyme-linked
immunosorbent assay) tests
considered more specific (but less sensitive) than skin tests
easier on the patient (one venipuncture rather than many
skin pricks) and carry no risk of systemic anaphylaxis
in vitro testing requires from 1 (ELISA) to 3 (RAST) days
outlines appropriate and inappropriate uses of in vitro tests
Dipstick tests based on ELISA technology
semiquantitative tests useful for screening

11
 DIAGNOSIS OF ALLERGY

species cross-reactivity plus a knowledge of antigens

most likely to have clinical importance in a given region
allows testing for only a few representative grasses,
weeds, and trees
Cross-reactivity among trees is unfortunately less
marked, and these must be treated individually,
depending on local prevalence
Adding the most important molds plus house dust mite
and relevant animal danders brings the number of
inhalant antigens in the basic screening test to about 15
Others can be added if positive results are obtained on
initial skin or in vitro testing, but if testing for the
screening panel is negative, the likelihood of significant
inhalant allergy to other antigens is less than 5%.
Table 28-3 shows antigens in a typical screening panel

12
MANAGEMENT OF
ALLERGIC RHINITIS
After a working diagnosis of allergic Rhinosinusitis
is established by a history, physical examination,
and adjunctive tests, a number of agents can be
used to treat the condition
Allergy testingeither in vivo or in vitromust
precede immunotherapy also confirms
offenders and facilitates more appropriate
allergen avoidance
Management of nasal allergy proceeds in a
stepwise fashion

13
 MANAGEMENT OF
ALLERGIC RHINITIS

Level I: Prevention and Simple Control

Measures of Symptoms

Best treatment for allergic rhinosinusitis

avoidance of inciting allergens
Complete avoidance of all allergens rarely
practical, but the allergy patient should practice
the best environmental control possible

14
 MANAGEMENT OF
ALLERGIC RHINITIS

Environmental Control
Animal Danders,
Animal danders should be completely avoided
cannot be avoided should at least be kept out of primary
living and sleeping areas Reservoirs cleaned frequently
with a high-efficiency particle arresting (HEPA)filter
vacuum
Dust,
House dust as a unique antigen contains antigens such as
animal danders, molds, cockroach, and house dust mite
Major species of house dust mite are
Dermatophagoides farinae
Dermatophagoides pteronyssinus
Antigens from cockroach bodies thorough environmental
control

15
 MANAGEMENT OF
ALLERGIC RHINITIS
Molds,
Both outdoor and indoor sources of antigen
Houseplant major source (dried flowers)

Pollen,
Avoidance is almost impossible short of giving up all
outside activities
Minimize nonspecific irritation of the nasal mucosa
Saline nasal spray clean nasal passage

16
 MANAGEMENT OF
ALLERGIC RHINITIS

First-line Pharmacotherapy
Total avoidance of inciting allergens is not
practical Offer medications to relieve
symptoms
first-generation antihistamines
Decongestants
Pseudoephedrine
Phenylpropanolamine
phenylephrine
All systemic decongestants exert an a-adrenergic effect,
which can cause central nervous system stimulation,
hypertension, and similar undesirable effects

17
 MANAGEMENT OF
ALLERGIC RHINITIS
Cromolyn
cromolyn nasal spray
stabilizes and protects mast cells from degranulation
nasal spray prevents or lessens symptoms when applied
before an anticipated allergen exposure
most effective in patients with mild to moderate symptoms
not be effective in those whose allergic symptoms are severe
or perennial
Antihistamines often combined with decongestants to treat
allergic rhinitis
Second- and Third-generation Antihistamines
nonsedating antihistamines
relatively lipid insoluble and cross the bloodbrain barrier
poorly
free of undesirable anticholinergic effects, relatively
nonsedating preparations, safer congeners of existing
antihistamines, and topical forms

18
 MANAGEMENT OF
ALLERGIC RHINITIS

Level II: Recognition and Management of

Complicating Factors
Clinician must constantly assess the clinical status
and adjust therapy accordingly
If allergic patient who has done well on a regimen
develops problems consider presence other
types of rhinitis before changing therapy
Typical patient with vasomotor rhinitis
experiences rhinorrhea as a result of temperature
extremes, eating, stress, or exposure to irritants
Treatment avoidance and primarily
symptomatic.
Nasal and sinus infections may occur
underlying nasal allergy

19
 MANAGEMENT OF
ALLERGIC RHINITIS
Such problems must be recognized not only to
institute appropriate antibiotic therapy but because
infection often alters the patients response to
allergen immunotherapy unacceptable local skin
reactions to injections
Allergy injections should be omitted until antibiotics
have become effective, especially if the patient is
febrile
Excessive use of decongesting nose drops or sprays
may complicate rhinitis, causing a rebound rhinitis
In addition, a number of medications, especially a-
adrenergic blocking agents and some
antihypertensives, may produce nasal congestion
as a side effect

20
 MANAGEMENT OF
ALLERGIC RHINITIS
Physician must establish that this has occurred
and then withdraw the offending medication for
relief.
When a female patient becomes pregnant, nasal
congestion may complicate the clinical picture
Numerous causes may account for rhinitis of
pregnancy, more properly called rhinitis during
pregnancy.
Although therapy of allergic rhinitis during
pregnancy demands careful attention by the
physician, the problem can be controlled without
compromising the health of the mother or fetus
general principles for managing nasal allergy duri
ng pregnancy
.
21
 MANAGEMENT OF
ALLERGIC RHINITIS

Level III: Corticosteroids for Control of Severe

or Chronic Symptoms
Adrenocorticosteroids
most potent agents available not first-line
pharmacotherapy
effects decreasing capillary permeability
stabilizing lysosomal membranes
blocking migratory inhibitory factor
by inhibiting arachidonic acid metabolism
action of other mechanisms that are not fully understood
Systemic corticosteroid administration undesirable
side effects and consequences.
Treatment with larger doses or treatment for longer than
1 month terminated by gradual dosage tapering
corticosteroid supplementation may be needed by these
patients if they are subjected to stress, including surgery,
before adrenal recovery occurs

22
 MANAGEMENT OF
ALLERGIC RHINITIS
General rules use corticosteroids :
Establish an accurate diagnosis
Use other, less potentially hazardous measures first
Limit dosage to the smallest effective amount for the shortest
time necessary to relieve symptoms or control the problem
Use corticosteroids locally, where possible, to concentrate the
therapeutic effect and limit the likelihood of systemic
complications.
Nasal corticosteroid aerosols have generally
replaced systemic therapy severe symptoms
allergic rhinosinusitis
Large polyps prevent proper mucosal contact, as do
large septal deviations, decreasing effectiveness
Use corticosteroid nasal sprays regularly stop
therapy if side effects occur
Long-term administration of nasal corticosteroids
requires regular intranasal examinations

23
 MANAGEMENT OF
ALLERGIC RHINITIS
First nasal corticosteroid Dexamethasone
delivered by a fluorocarbon propellant
Onset of effect is rapid, but duration is brief
The initial adult dosage is two sprays in each nostril t.i.d.
(equivalent to 1.0 mg daily)
limited to 21 days.
Beclomethasone
available as a suspension delivered by a propellant and as an
aqueous pump spray preparation
Each puff delivers approximately 42 mg of beclomethasone
(total daily dose of 336 mg)
improvement is noted dosage is reduced to the lowest
effective maintenance level
Effects may last for several days after the spray is
discontinued.

24
 MANAGEMENT OF
ALLERGIC RHINITIS
Flunisolide
nasal spray is contained in a polyethylene glycol base and is
delivered by a pump spray
Each spray delivers about 25 mg of flunisolide (total daily dose
of 200 mg)
flunisolide is changed to a less active metabolite in the first
pass through the liver
Triamcinolone
propellant or as a pump spray, in an initial dosage of two puffs
per nostril qd, providing a total dose of 220 mg
Budesonide
pressurized spray but may soon be available in an aqueous
form
once daily dosing, four puffs in each nostril (total dose of 256
mg

25
 MANAGEMENT OF
ALLERGIC RHINITIS
Fluticasone
topically active corticosteroid with poor gastrointestinal
absorption plus extensive first-pass hepatic metabolism
delivered as a pump spray, two sprays in each nostril qd, for a
dose of 200 mg
Mometasone furoate
aqueous pump spray once daily (total daily dose of 200 mg)
Dose-ranging, effectiveness, and safety studies are ongoing.
Despite apparently improving margins of safety of
topical nasal corticosteroids, some studies are
suggesting that significant absorption from the
nose can occur and that systemic effects may be
occurring even at therapeutic doses with some of
these preparations.

26
 MANAGEMENT OF
ALLERGIC RHINITIS
An additional means of administering
corticosteroids to relieve symptoms while
minimizing systemic effects is by intraturbinal
injection of a repository form (1951)
Its use was questioned in the 1960s reports of
associated visual loss
In 1981, a thorough review of 11 cases indicated
reflex vasospasm or retrograde embolization
into the retinal circulation
Suggestions for preventing these events have
been widely published, and when the proper
technique is followed, the procedure has proved
safe and effective

27
 MANAGEMENT OF
ALLERGIC RHINITIS
Safe intraturbinal corticosteroid injection involves
the following:
1. Pretreatment of the mucosa with a topical
vasoconstrictor
2. Use of a repository corticosteroid with small particle size
such as triamcinolone acetonide or prednisone tebutate
3. Placement of the injection just beneath the mucosa of
the anterior tip of the inferior turbinate
4. Gentle injection, avoiding undue pressure
Patients who require two or more intraturbinal
steroid injections per year are candidates for
definitive allergic rhinitis treatment
(immunotherapy).

28
 MANAGEMENT OF
ALLERGIC RHINITIS

Level IV: Immunotherapy

offers a possible cure for allergy is immunotherapy
should not be considered a last resort
advantages may be evident at any point in the
course of management
In general, criteria candidates for immunotherapy :
symptoms are not easily controlled with pharmacotherapy
sensitive to allergens that cannot be readily avoided
symptoms span two or more allergy seasons or are severe
willing to cooperate in a program of immunotherapy

29
 MANAGEMENT OF
ALLERGIC RHINITIS
large doses of antigen administered parenterally
shown to suppress IgE formation and produce IgG
:
small initial doses of immunotherapy may (and typically
do) cause an initial rise in IgE
continued therapy at appropriate doses causes IgE
production to decrease and IgG (blocking antibody)
production to increase
parenteral therapy is necessary to deliver high enough
doses to stimulate formation of blocking antibody
chronic therapy with very low antigen doses may worsen
rather than improve the patients status.

30
 MANAGEMENT OF
ALLERGIC RHINITIS
immunotherapy produces cellular changes that
include decreased reactivity of basophils and
lymphocytes.
Immunotherapy should be prescribed and
administered under the supervision of an
appropriately trained physician who is prepared
to manage anaphylaxis

31
DISORDERS ASSOCIATED WITH
ALLERGIC RHINOSINUSITIS
Allergic rhinosinusitis may be complicated by
or associated with other processes
Polyps
Isolated antrochoanal polyps are usually caused
by infection
1/3 can be expected to display inhalant allergy
should at least be screened for allergy
Although pharmacotherapy and immunotherapy
may not produce total resolution of manifest
polyps in allergic patients, such treatment begun
before definitive nasal and sinus surgery and
continued afterward appears to make polyp
recurrence less likely.
32
 DISORDERS ASSOCIATED WITH
ALLERGIC RHINOSINUSITIS

Sinusitis
Recurrent sinusitis associated with obstruction
of the ostiomeatal complex
Chronic hyperplastic rhinosinusitis may arise from
repeated allergic reactions involving these target
organs
Contributory allergic condition must be
considered
Surgery failed trial of medical management
Immunotherapy when appropriate, started
prior to surgery and continued afterward,
enhances end results.

33
 DISORDERS ASSOCIATED WITH
ALLERGIC RHINOSINUSITIS

Asthma
Improvement in asthma often follows surgery for
chronic sinusitis
Connection between hyperreactive lower airway
disease and allergic rhinosinusitis has been
postulated
Improvement in asthma following
pharmacotherapy of allergic rhinosinusitis has not
been conclusively demonstrated
Many patients with nasal allergy also suffer from
asthma, and the treatment of the two disorders
requires close cooperation between the various
specialists involved.

34
 DISORDERS ASSOCIATED WITH
ALLERGIC RHINOSINUSITIS

Otitis Media
Multiple risk factors appears to be involved in
recurrent otitis media and persistent effusion,
including functional Eustachian tube obstruction
by infection or allergy

35
 DISORDERS ASSOCIATED WITH
ALLERGIC RHINOSINUSITIS

Upper Respiratory Infections

No causal relationship between upper respiratory
allergy and frequent upper respiratory infections
has been established
Patients find the initial symptoms of a rhinovirus
infection (sneezing, rhinorrhea, nasal congestion)
mimic those of allergic rhinitis
Any relief from frequent infections following
allergy immunotherapy constitutes a welcome but
unpromised benefit.

36
COMPLICATIONS OF
TREATMENT
Treatment may cause complications some with
significant potential risk
Complications
Pharmacotherapy
immunotherapy

37
 COMPLICATIONS OF TREATMENT

Pharmacotherapy
Undesirable effects occur from drug treatment for
nasal allergy change in therapeutic agent
normally alleviates the problem
More serious potential cardiac arrhythmias that
can follow coadministration of terfenadine or
astemizole with macrolide antibiotics or systemic
antifungals
Need for physicians remain educated about
interactions and side effects of all new (and
existing) drugs.

38
 COMPLICATIONS OF TREATMENT

Immunotherapy
immunotherapy for inhalant allergy involves
the parenteral introduction of a foreign protein
to which the patient possesses allergen-
specific IgE every allergy injection carries
the potential for an allergic emergency!
Guidelines minimize possibility disastrous
consequence :
Use intradermal titration methods of skin testing to
determine a safe starting dose.
Use in vitro tests for labile patients and for antigens that
can produce especially severe reactions.
Confirm in vitro results with a vial test on the skin before
instituting immunotherapy.
Exercise great care in the preparation and administration
of antigenic extracts.
Advance treatment doses carefully and thoughtfully rather
than by a set schedule.
39
 COMPLICATIONS OF TREATMENT

Management of Allergic Emergencies

Knowing how to manage anaphylaxis

important for physicians
Must
differentiate early anaphylaxis from vasovagal syn
cope or needle reaction
Syncope patient in a recumbent position and
administering an ammonia ampule usually suffice,
although oxygen inhalation may afford both physical and
psychological benefit
The use of a
flow sheet helps to speed proper treatment and
makes omission of important steps less likely
40
 COMPLICATIONS OF TREATMENT

For personnel likely to be involved in assisting

with an allergic emergency, drills and training in
cardiopulmonary resuscitation are recommended
Expiration dates of drugs and availability of
properly operating equipment must be checked
regularly
More anaphylactic fatalities result from airway
obstruction than from cardiovascular collapse

41
 COMPLICATIONS OF TREATMENT

After the diagnosis is established, help is

summoned, and epinephrine (the mainstay of
treatment of anaphylaxis) is administered,
priorities are
establishing and protecting an airway
establishing an intravenous lifeline
administering more epinephrine if needed, followed by
an antihistamine, a corticosteroid, and possibly an H2
blocker
Heparin has a marked capacity to bind histamine
and has been shown to have a life-preserving
effect in animals

42
ADVANCES IN
ALLERGIC RHINOSINUSITIS
Diagnosis
New developments are making the diagnosis of
allergic rhinosinusitis easier, but proper physician
judgment remains critical
Computer-assisted history taking may save time
and ensure that no important questions are
inadvertently omitted, an ongoing evaluation of
the patients symptoms and response to
treatment is the responsibility of the allergy team
In vitro testing methods are being improved
continually to provide more accurate results
rapidly, but a knowledge of skin test mechanisms
and interpretation remains essential.

43
 ADVANCES IN
ALLERGIC RHINOSINUSITIS

Treatment
Second- and third-generation antihistamines
relieve symptoms without many of the side
effects associated with older preparations;
however, the cost is greater
Standardization of extracts used in
immunotherapy one allergy unit (AU) of any
pollen is biologically equivalent to dust mite or
mold contribute to the safety of the procedure
The ability to measure mediator substances in
nasal secretions has provided a giant stride in
studies of the allergic reaction and its proper
therapy.

44
AREAS OF CONTROVERSY AND
CONTINUING INVESTIGATION
Food Hypersensitivity
Little disagreement exists that IgE-mediated acute
allergic reactions to food occur (e.g., hives after
eating shrimp)
Acute hypersensitivity suspected on the basis of
history and confirmed by in vitro specific IgE assay
Controversy still exists regarding delayed or
cyclic food allergy, involving mechanisms other
than a Gell and Coombs type I reaction
Cyclic food allergy is best diagnosed by a careful
analysis of dietary habits and symptom production,
followed by a challenge refeeding test in which
omission of the suspected food
Diagnosis is further confirmed by skin responses to
intradermal testing

45
 AREAS OF CONTROVERSY AND
CONTINUING INVESTIGATION

Fungal Hypersensitivity and Yeast Problems

Opinion is divided about the existence of
hypersensitivity in nonimmunocompromised
patients with fungal sinusitis, and the benefit of
allergen-specific immunotherapy remains in
question.
Both diagnosis and treatment of this syndrome
remain controversia
Although some persons undoubtedly benefit from
the dietary restrictions that are advocated as
treatment, the benefits of systemic antifungal
therapy have not been proved in controlled studies

46
 AREAS OF CONTROVERSY AND
CONTINUING INVESTIGATION

Chemical Hypersensitivity
Exposure to chemicals may cause respiratory
symptoms, and chemicals may act as haptens to
produce true hypersensitivity reaction
The premise that maladaptation to chemical
exposure results in chronic fatigue, malaise, and
many chronic ear, nose, and throat complaints
remains controversial
Although numerous anecdotal reports of patient
improvement offer support, appropriate studies
are necessary to clarify this controversial subject

47
HIGHLIGHTS
The best management of allergic rhinitis is to
avoid the triggering antigen, if possible.
The best pharmacotherapy of allergic rhinitis is
that which prevents the allergic event rather than
that which treats the aftereffects.
The safest way to administer corticosteroids for
allergic rhinitis is topical, to concentrate effect
and lessen systemic effects, but even this route
carries potential risks.
Immunotherapy offers the only possible means of
cure for inhalant allergy and is indicated for
patients who are unresponsive to simple
pharmacotherapy, whose symptoms span more
than one season or are severe, and who are
willing to cooperate in a program of injections.

48
 HIGHLIGHTS

Allergy management in patients who are

candidates for nasal or sinus surgery is best
begun before surgerynot to avoid the surgery
but to ensure better results (at surgery and in the
long term)
Patients with negative skin tests (tested for
appropriate allergens with potent extracts
properly applied) are not candidates for repeat
testing with in vitro allergy tests
Skin tests are positive more often than in vitro
tests for specific allergens; this may represent a
greater sensitivity in the former or greater
specificity in the latter.

49
 HIGHLIGHTS

If management that has been helpful suddenly

becomes ineffective in an allergy patient, look for
a change in allergen exposure or for a
complication such as infection or rebound rhinitis.
Allergic rhinosinusitis is found often among
patients seen in a general otolaryngology
practice; its management should not tax the
capabilities of a properly trained otolaryngologist.

50
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BIBLIOGRAPHY
Bennett JE. Searching for the yeast connection. N Engl J Med
1990;322:1766.
Boyles JH Jr. Chemical sensitivity: diagnosis and treatment.
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Fornadley JA, Corey JP, Osguthorpe JD, et al. Allergic rhinitis:
clinical practice guideline Otolaryngol Head Neck Surg
1996;115:115.
Gordon BR. Allergy skin tests and immunotherapy:
comparison of methods in common use. Ear Nose Throat J
1990;69:47.
Hurst DS. Association of otitis media with effusion and
allergy as demonstrated by intradermal skin testing and
eosinophil cationic protein levels in both middle ear effusions
and mucosal biopsies. Laryngoscope 1996;106:1128.
King WP. Efficacy of a screening radioallergosorbent test.
Arch Otolaryngol 1982;108:781.

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 BIBLIOGRAPHY

King WP, Rubin W, Fadal R, et al. Efficacy of alternative tests for

delayed-cyclic food hypersensitivity. Otolaryngol Head Neck Surg
1989;101:385.
Nalebuff DJ. In vitro testing methodologies: evolution and current
status. Otolaryngol Clin North Am 1992;25:27.
Mabry RL. Pharmacotherapy with immunotherapy for the
treatment of otolaryngologic allergy. Ear Nose Throat J 1990;69:63.
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Otolaryngol Head Neck Surg 1995;113:120.
Mabry RL. Management of allergic emergencies. In: Krause HF, ed.
Otolaryngologic allergy and immunology. Philadelphia: WB
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F28-1

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F28-2

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T28-2

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T28-3

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T28-5

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T28-6

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 The complexity of pathophysiology of allergic inflammation
Allergen
Mastosit
A
C
U IgE
IgE
T
Rhinorea E
Histamine
S
Sneezing Y
Tryptase IgE
M PGD2 LTs Antibody
P Cytokines
Congestion T
O
M
S
CD4+
IgE
CD25+
Allergen Class II MHC
Th2 EOS C
H
T cell r R
Basic proteins O I
N
LTs Cytokines N
I F Rhinorea
IF C L
Fragment A
S M Sneezing
Histamine Y A
M T
IL-1 CD4+ LTs P I Congestion
Th1 Cytokines T O
ANTIGEN O N
M
S
PRESENTING Baso
CELLS
Early- and late-phase allergic reactions
(APC)
Sumarman. The rational manag of AR & its impact on asthma. WHO-ARIA 2001 12
Pathophysiology of Allergic Inflammation
 Treat AR in a Stepwise Approach (adolescent and adults)
Diagnosis of allergic rhinitis (history + skin prick tests or serum specific IgE)

Allergen avoidance

Intermittent symptoms Persistent symptoms

Mild Moderate-severe Mild Moderate-severe

Not in preferred order

Intranasal CS
Oral H-1-blocker Not in preferred order
Intranasal-H1-blocker Oral H-1-blocker
and/or decongestant Intranasal-H1-blocker Review the patient after 2-4 weeks
and/or decongestant
Intranasal CS
If + Conjunctivitis add: (Chromone)
Oral H-1-blocker Improved Failure
or Intraocular H1-blocker
or Intraocular Chromone
In persistent rhinitis review Step-down and Review diagnosis
(or saline) continue treatment
the patient after 2-4 weeks Review compliance
for 1 month Query infections or other causes

If improved: continue for 1 month If failure: step-

and/or up Increase Rhinorrhea: Blockage: add
and/or intranasal add ipratropium decongestant, or oral
CS dose and/or CS (short term)
and/or
Itch sneeze: Failure:
add H1 blocker Surgical refferal

(ARIA WHO Consensus 2002) Consider Specific Immunotherapy

 Treatment of Allergic Rhinitis
Allergic Rhinitis and its Impact on Asthma

moderate
moderate mild severe
severe persistent persistent
intermittent
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
27
 Stepwise treatment proposed

moderate moderate
mild mild
severe severe
intermittent persistent
intermittent persistent

Oral H1- AH Nasal Oral H1-AH Nasal

Beclomethasone Beclomethasone
high dose or high dose
(300-400 g /daily) (300-400 g /daily)
Nasal
If needed after Beclomethasone
Severe
1 week treat low dose symptoms
add (100-200 g /daily) add
Oral H1-AH Oral H1-AH
and / or and / or
Oral CS Oral CS