Allergic rhinitis and rhinosinusitis

Nanang Mardiraharjo,dr., SpTHT-KL

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• Rhinitis : inflammation of the nasal lining
characterized by nasal congestion, rhinorrhea,
sneezing, and nasal itching.
• Sinusitis : inflammation of the paranasal sinuses.

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• The term rhinosinusitis has been suggested to
replace sinusitis because sinusitis is almost
always accompanied by nasal airway
inflammation.
• Rhinitis and sinusitis frequently occur
together, and the symptoms of nasal discharge
and nasal obstruction are prominent in
sinusitis.

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Major classification of rhinitis and rhinosinusitis based on underlying
pathophysiology.
CSF cerebrospinal fluid; NARES nonallergic rhinitis with eosinophilia syndrome
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 Nasal Anatomy and Function

( a ) Frontal and ( b ) side views of the frontal, ethmoid, sphenoid, and maxillary
sinuses 5
 Allergic Rhinitis
United States :
 Allergic rhinitis : most common atopic disease
 Estimated to affect up to 25% of adults and 40%
of children.
 Approximately 80 million individuals experience
symptoms for >7 days per year.
 Allergic rhinitis accounts for 2 million lost school
days annually, 6 million lost work days, and
medication expenditure of more than $3 billion
annually.
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• The prevalence of allergic rhinitis is lowest
among children younger than 5 years and
peaks in early schoolhood years and early
adult years.
• The onset of allergic rhinitis can occur at any
age, but it is less common in patients older
than 50 years.

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 Pathophysiology
• The symptoms of allergic rhinitis are due to
inflammation induced by an IgE-mediated
immune response to an airborne allergen.
• The complex immune response consists of the
release of inflammatory mediators and the
activation and recruitment of inflammatory
cells to the nasal mucosa

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 sensitizing phenomenon

Allergen presentation of the

exposure allergen by APC

Production of IgE
antibody specific Th2 lymphocytes release
IL-4 and IL-13

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Pathophysiology of allergic rhinitis
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Pathophysiology of allergic rhinitis.
 B-cells produce allergen-specific IgE.
 Allergenspecific IgE binds to mast cells in the nasal
mucosa.
 Inhaled allergens bind to allergen-specific IgE on
mast cells, triggering release of mast cell
mediators.
 These mediators produce:
 (1) early-phase symptoms (rhinorrhea, sneezing,
itching, and nasal obstruction) and
 (2) recruit eosinophils, basophils, and neutrophils for
the late-phase response.

TNF : tumor necrosis factor

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 The early phase, or immediate response

• begins within minutes after exposure

• allergen is inhaled, taken into the mucosa, and
binds to IgE, mast cell degranulation.
• mast cell releases:
– preformed mediators: histamine, tryptase,
chymase, and kininogenase
– newly synthesized mediators: prostaglandin D 2 ,
cytokines, leukotrienes C 4 , D 4 , and E 4

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• mediators  serve to recruit inflammatory
cells into the nasal mucosa, setting up the late
phase response.
• Mucosal glands are stimulated to secrete
conjugates and compounds that dilate the
nasal venous vasculature, leading to sinusoidal
filling and nasal congestion.
• The mediators also stimulate sensory nerves,
producing the symptoms of nasal itch.

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 Late phase response
 nasal congestion  more prominent
 Mast cell-derived mediators act on endothelial cells
the expression of vascular cell adhesion molecules
(VCAM)
adhesion of circulating leukocytes to the endothelial
cells.
 chemoattractants (IL-5) infiltration of eosinophils,
neutrophils, basophils, lymphocytes, and macrophages
 Leukocytes then migrate into the nasal mucosa nasal
inflammatory reaction.

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 Symptoms of allergic rhinitis

 watery rhinorrhea
 paroxysms of sneezing
 nasal congestion
 itchy palate
 itchy, watery eyes.
 These symptoms are reproducible on exposure
to allergens to which the patient has been
sensitized.
 Nasal congestion alone, particularly in children,
may be the sole or major complaint.

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 Allergic rhinitis
Intermittent symptoms Persistent symptoms
• <4 days per week • >4 days/week
• or <4 weeks • and >4 weeks

Mild
Moderate-Severe
all of the following
one or more items
• normal sleep
• abnormal sleep
• no impairment of daily activities,
• impairment of daily activities,
sport, leisure
sport, leisure
• no impairment of work and school
• impaired work and school
• no troublesome symptoms
• troublesome symptoms

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 History
The following questions are helpful in initially
categorizing rhinitis:
1. Are nasal itch or sneezing episodes prominent
symptoms of the rhinitis complex?
2. Are watery, itchy eyes associated with the
rhinitis?
3. Is wheeze associated with the rhinitis?

Positive answers strongly to an allergic origin for

the rhinitis.
These symptoms are not required for the rhinitis to
have an allergic origin.

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 Physical Examination
 classic findings on nasal examination
 pale or bluish, boggy nasal mucosa with a thin, clear, watery
nasal discharge.
 The turbinates are swollen.
 In the setting of obstruction and posterior nasal drainage, the
drainage can cause lymphoid hyperplasia in the posterior
pharynx that resembles cobblestones.
 The allergic shiner : Allergic facies demonstrate dark
infraorbital swollen semicircles.
 The eyes have varying degrees of conjunctival erythema.
 Children may exhibit a transverse nasal crease caused by
constant nose itching or Morgan–Dennie lines,
accentuated horizontal skin folds on the lower lid that are
parallel with the lower lid margin.

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• The physical examination findings can vary
depending on the severity and chronicity of
the allergic rhinitis and the presence of
complicating conditions such as infection and
polyposis.
• No features detected on physical examination
are exclusive to allergic rhinitis.

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 Allergy testing
• most commonly performed
Skin prick • low cost,
• the immediacy of results
testing • higher sensitivity

in vitro tests • radioallergosorbent test

for serum IgE (RAST)
antibody to • enzyme-linked
immunosorbent assay.
allergens
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measurement • not useful in screening for
of total serum allergic rhinitis.
IgE (alone)

• generally not indicated in

this setting
• The finding of osinophils
Nasal smear for on a nasal smear is
suggestive but nonspecific
cytology for allergy.
• A predominance of
neutrophils suggests an
infectious process.

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 ALGORITHM FOR ALLERGIC RHINITIS DIAGNOSIS AND
MANAGEMENT
Check for asthma
especially in
Diagnosis of allergic rhinitis patients with
moderate-severe
and/or persistent
Intermittent symptoms Persistent symptoms
rhinitis

mild Moderate- mild Moderate-

Not in preferred severe severe
order Not in preferred order In preferred order
oral H1- oral H1-antihistamine intranasal CS
antihistamine or intranasal H1-antihistamine or
or intranasal H1-antihistamine LTRA*
H1-antihistamine and/or decongestant
and/or or intranasal CS review the patient
decongestant or LTRA* after 2-4 wks
or LTRA* (or cromone)

improved failure
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 in persistent Step down and review diagnosis
rhinitis continue review compliance
review the patient treatment query infections
after 2-4 weeks for 1 month or other causes

if failure: step-up
if improved:
continue
for 1 month

increase rhinorrhea Itch/sneeze rhinorrhea blockage add

intranasal CS add add H1- add decongestant
ipratropium antihistamine ipratroprium or oral CS
dose (short-term)

failure

*In particular, in patients with surgical referral

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asthma
Mild intermitten Moderate severe Mild Moderate severe
intermitten persistent persistent

Allergen and irritant avoidance may be appropriate

If conjunctivitis add:
oral H1-antihistamine
or intraocular H1-antihistamine
or intraocular cromone
(or saline)

Consider specific immunotherapy

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 RHINOSINUSITIS
Clinical definition
Rhinosinusitis (including nasal polyps) is defined
as:
• inflammation of the nose and the paranasal
sinuses characterised by two or more
symptoms, one of which should be either
nasal blockage/obstruction/congestion or
nasal discharge (anterior/posterior nasal drip):
± facial pain/pressure
± reduction or loss of smell

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and either
 endoscopic signs of:
- polyps and/or
- mucopurulent discharge primarily from middle
meatus and/or
- oedema/mucosal obstruction primarily in
middle meatus
and/or
 CT changes:
 mucosal changes within the ostiomeatal complex
and/or sinuses

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 Duration of the disease

Acute Chronic

• <12 weeks • >12 weeks symptoms

• complete resolution • without complete
of symptoms resolution of
symptoms
• may also be subject
to exacerbations

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• Rhinosinusitis is an inflammatory process
involving the mucosa of the nose and one or
more sinuses.
• The mucosa of the nose and sinuses form a
continuum
sinus are involved in diseases which are
primarily caused by an inflammation of the
nasal mucosa

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• Chronic rhinosinusitis : multifactorial disease.
• Contributing factors :
– mucociliairy impairment ,
– (bacterial) infection,
– allergy,
– swelling of the mucosa for another reason,
– rarely physical obstructions caused by morphological/
anatomical variations in the nasal cavity or paranasal
sinuses.
• Ostiomeatal complex : role in the pathogenesis of
rhinosinusitis

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Pathophysiology Allergy,
rhinosinusitis viral infection

Bacterial Mucosal
growth & inflamation
infection & edema

Mucous
retention -Ostiomeatal complex patency ↓
O₂↓ -viscous of mucous secretion↑
-mucous secretion↑
Ciliary impairment, -movement of cilia ↓
cystic fibrosis
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Viral agents:
• Rhinovirus (24%) and Influenzae (11%)

Bacteria:
• Streptococcus pneumoniae, Haemophilus
influenzae, and Moraxella catarrhalis  most
common bacterial species isolated from the
maxillary sinuses.
• Other streptococcal species, anaerobic
bacteria and Staphylococcus aureus  small
percentage of cases.
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 EVIDENCE-BASED MANAGEMENT SCHEME FOR ADULTS WITH
ACUTE RHINOSINUSITIS FOR PRIMARY CARE AND NON-ENT
SPECIALISTS

Diagnosis
• Symptom-based, no need for imaging (plain x-
ray not recommended)
• Symptoms for less than 12 weeks with
symptom free intervals if the problem is
recurrent

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Common cold/acute viral rhinosinusitis is
defined as:
• duration of symptoms for <10 days

Acute non-viral rhinosinusitis is defined as:

• increase of symptoms after 5 days or
persistent symptoms after 10 days with <12
weeks duration

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Management scheme for primary care for adults with
acute rhinosinusitis

*Fever >38°C, severe pain 35

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EVIDENCE-BASED MANAGEMENT SCHEME FOR ADULTS WITH CRS
WITH OR WITHOUT NP FOR PRIMARY CARE AND NON-ENT
SPECIALISTS

Diagnosis
• Symptoms present longer than 12 weeks
• Plain x-ray or CT scan not recommended

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Chronic rhinosinusitis with or without nasal polyps management
scheme
for primary care and non-ENT specialists (CRS/NP)

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Acute exacerbations of
CRS should be treated
like acute rhinosinusitis

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 Evidence-based surgery for rhinosinusitis

1. In acute rhinosinusitis, surgery is reserved for

the most serious cases and their associated
complications.
2. More than a hundred reviewed case series with
highly consistent results suggesting that patients
with CRS with and without polyps benefit from
sinus surgery.
3. Major complications occur in less than 1%, and
revision surgery is performed in approximately
10% within 3 years.

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4 In the majority of CRS patients, appropriate
medical treatment is as effective as surgery, so
sinus surgery should be reserved for patients
who do not satisfactorily respond to medical
treatment .
5. Functional endoscopic surgery is superior to
minimal conventional procedures including
polypectomy and antral irrigations , but
superiority to inferior meatal antrostomy or
conventional sphenoethmoidectomy is not yet
proven.

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6. In CRS patients not previously operated, extended surgery
does not yield better results than limited surgical
procedures.
Although not evidence-based, the extent of surgery is
frequently tailored to the extent of disease, which appears to
be a reasonable approach.
In primary paranasal surgery, surgical conservatism is
recommended.
7. Revision endonasal sinus surgery is only indicated if medical
treatment is not sufficiently effective.
Substantial symptomatic improvement is generally observed
in both CRS with and without polyps, though the
improvement is somewhat less than after primary surgery.
Complication rates and particularly the risk of disease
recurrence are higher than after primary surgery.

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 EVIDENCE-BASED MANAGEMENT SCHEME FOR CHILDREN
WITH ACUTE RHINOSINUSITIS

Diagnosis
• Symptoms
• Examination (if applicable)
• nasal examination (swelling, redness, pus)
• oral examination: posterior discharge
• exclude dental infection
ENT examination including nasal endoscopy

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Imaging
• (Plain x-ray not recommended)
• CT scan is also not recommended unless
additional problems such as:
• very severe diseases
• immunocompromised patients
• signs of complications

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Management scheme for children with
acute rhinosinusitis

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 EVIDENCE-BASED MANAGEMENT SCHEME
FOR CHILDREN
WITH CHRONIC RHINOSINUSITIS
Diagnosis
 Symptoms present longer than 12 weeks
 Additional diagnostic information
• questions on allergy should be added and, if positive,
allergy testing should be performed.
• other predisposing factors should be considered:
immune deficiency (innate, acquired, GERD)
 Examination (if applicable)
• nasal examination (swelling, redness, pus)
• oral examination: posterior discharge
• exclude dental infection
ENT examination including nasal endoscopy

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Imaging
• (Plain x-ray not recommended)
• CT scan is also not recommended unless
additional problems such as:
• very severe diseases
• immunocompromised patients
• signs of complications

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Chronic rhinosinusitis in children management scheme

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COMPLICATIONS IN SINUS DISEASE

Orbital Complications of Sinusitis

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 Schematic diagram of the five stages of orbital
complication of sinusitis : A, preseptal cellulitis (c); B,
orbital cellulitis (c);
C, subperiosteal abscess (a)
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 D, orbital abscess (a); and
E, cavernous sinus thrombosis (t)

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