Allergic RhinitisAllergic Rhinitis
By AminuddinBy AminuddinAllergy-Immunology Sub Division at ENT Allergy-Immunology Sub Division at ENT
Department,Faculty of Medicine Hasanuddin Department,Faculty of Medicine Hasanuddin UniversityUniversity
Telp (0411)496778Telp (0411)496778Or Hp 081342940514Or Hp 081342940514
Allergic RhinitisAllergic Rhinitis
• Introduce• Definition• Classification• Patomechanism• Symptoms• Diagnosis• Therapy• Complication
• Allergic rhinitis is a global health problem affecting 5 to 50% of the population
• Its prevalence is increasing and probably underestimated
• One of the ten reason for visit in ENT• Although it is not usually a severe disease,
AR alters social life and affects school performance and work productivity
• Costs incurred by rhinitis are substantial
IntroductionIntroduction
Although not fatal,but:Physical functioning Bodily pain Vitality Take a tissueMalaise FatiqueSocial functioning Difficulty concentratingGeneral health/Mental health
Decreasing Quality of Life
Definition Definition • Von Pirquet 1906 Allergy
“ An altered reactivity to foreign substance after prior exposure to the same material “It is not occur of majority of individual.Cause tissue inflamation and organ dysf
• ARIA-WHO 2001 Allergic RhinitisAllergic rhinitis is clinically defined as a symptomatic disorder of the nose,induced after allergen exposure,by an IgE mediated inflamation of the nasal membranes
Target organs of allergy :Target organs of allergy :
Respiratory tract ………………. Asthma
Nose ……………………………. Allergic rhinitis
Eye …………………………….. Allergic conjunctivitis
Skin ……………………………. Urticaria
Digestive tract ………………… Diarrhea
Cardiovascular ………………... Anaphylactic shock
Respiratory tract ………………. Asthma
Nose ……………………………. Allergic rhinitis
Eye …………………………….. Allergic conjunctivitis
Skin ……………………………. Urticaria
Digestive tract ………………… Diarrhea
Cardiovascular ………………... Anaphylactic shock
Organ DiseaseOrgan Disease
PatomechanismPatomechanism
The three steps of AR response :
1. Sensitization phase
2. The Early Phase Reaction
3. The Late Phase Reaction
The Sensitization Phase APC
• Recocnize and process the antigen into antigenic peptides
• Present a peptide portion to T Lymphocyte• Stimulate the secretion of cytokines
Stimulate antigen-specific Ig E production by the B lymphocyte
Secreted Ig E is then bound by high-affinity receptors on mast cell and/or basophil
Allergic InflammationAllergic Inflammation
IgE-bearing B-cellsIgE-bearing B-cells
-
MHC
Fragment
Th2
1. Sensitization Phase1. Sensitization Phase
Adapted from Creticos, 1998
IgE antibody IgE antibody IgE IgE
IgE IgE
Sumarman. Pathophysiology and Diagnostic Procedure of Allergic Rhinitis
The Early Phase Reaction ( EPR ) Reexposure to allergen,mast cell
degranulate,releasing histamine,serotonin,ECF-A,NCF-A,leukotrienes,prostaglandine and cytokines
Histamine is a main effector in EPR producing• Nerve stimulation sneezing and itching• Mucus hypersecretion Nasal discharge• Increasing vascular permeability and v.dilatation
nasal obsruction
-
MHC
Fragment
Th2
Rhinorea
Sneezing
Congestion
Allergic InflammationAllergic Inflammation
2. Early Phase Allergic Reaction2. Early Phase Allergic Reaction (Reaksi alergi fase cepac (RAFC)(Reaksi alergi fase cepac (RAFC)
Adapted from Creticos, 1998
IgE antibody IgE antibody IgE IgE
IgE IgE
IgE-bearing B-cellsIgE-bearing B-cells
Mastosit
IgE IgE
IgE IgE
Sumarman. Pathophysiology and Diagnostic Procedure of Allergic Rhinitis
The Late Phase Reaction ( LPR ) Over the course of several hours The infiltrating inflamatory cell such as
eosinophils,basophils and neutrophil The inflamatory cells release mediators
stimulating and enhancing further inflamatory reaction
Allergic Inflammation
3. Late phase Allergic Reaction3. Late phase Allergic Reaction
Adapted from Creticos, 1998
-
Rhinorea
Sneezing
Congestion
MHC
Fragment
Th2
Mastosit
IgE-bearing B-cellsIgE-bearing B-cells
IgE antibody IgE antibody IgE IgE
IgE IgE
Sumarman. Patophysiology and Diagnostic Procedure of Allergic Rhinitis
Rhinorea
Sneezing
Congestion
CHRONIC
INFLAMMATION
Classification of ARClassification of AR
• Previously AR was sudivided based on the time of exposure into Seaseonal AR ( Out door allergen ) Perennial AR ( Indoor allegen )
• Not satisfactory :• Some places pollen is perennial• Symptoms of Perennial AR not always
present all year round
• This term is still retained to enable
Based on duration of symptoms :
“Intermitten” : the symptoms are present: • < 4 days a week• Or for less than 4 weeks
“Persistent” : the symptoms are present: • > 4 days a week• And for more than 4 weeks
Newer Classification of ARAccording ARIA (Allergic Rhinitis and its Impact on Asthma)-
WHO 2001
Based on severity of simptoms:
“Mild” : that none of the following items are present:• Sleep disturbances• Impairment of daily activity, leisure and/or sport• Impairment of school or work• Trouble some symptoms
“Moderate Severe” : One or more of the following items are present:
•Sleep disturbances• Impairment of daily activity, leisure and/or sport• Impairment of school or work• Trouble some symptoms
New Classification of ARNew Classification of ARAccording to The ARIA (Allergic Rhinitis and its Impact According to The ARIA (Allergic Rhinitis and its Impact
on Asthma)-WHO 2001on Asthma)-WHO 2001
Moderate-severeone or more items
. Abnormal sleep
. Impairment of daily activities, sport, leisure
. Abnormal work and school
. Troublesome symptoms
Persistent . > 4 days per week
. and > 4 weeks
Mild Normal sleep& No impairment of daily
activities, sport, leisure& Normal work and
school& No troublesome
symptoms
Intermittent . < 4 days per week
. or < 4 weeks
Major symptomsMajor symptoms
Repetitive sneezingRhinorroeaNasal obstructionItching of the nose,eyes,ear and throat
Seasonal Allergic rhinitisSeasonal Allergic rhinitis
Symptoms may correlate with the apperarence and intensity of local allergen (Pollens)
Symptoms are periodicCharacteristic symptons :
Watery rhinorroea,profuse and contain eosinophilNasal obstruction:swollen turbinatesSneezing episode Itching of the nose (prominent),ear,eyes,palate or
throatLacrimation
Senses of smell maybe alteredAllergen: Pollen,mould (Out door allergen)
Perennial allergic rhinitisPerennial allergic rhinitis
Symptons are very similar to those of seasonal allergic rhinitis although perennial is persisten,chronic and not severe
The most commom symptoms is nasal obstruction Sneezing,rhinorrhoe and nasopharyngeal and ocular
itching occur less frequently than seasonal AR Post nasal drips ALLERGEN (INDOOR ALLERGEN)
House dust mite Mites Human dander Cockroach Animal dander
DIAGNOSIS ARDIAGNOSIS ARANAMNESIS :
Family allergic history is essentialOnset,progression,severityDurationSeasonsOcular,pharyngeal and systemik symptonsRecurrent sinus or ear infectionsCausal and exacerbating factorsAssociaton with atopic diseaseRelationship to drug use
Physical ExaminationPhysical ExaminationAnterior rhinoscopy with high illumination using
head lamp or endoscop look for :Mucosa can be Inflamed/reddened,pale blue Watery dischargeEnlarge turbinatesNasal polyps can be find : rounded,white,glistening
masses Another symptons :
Mouth breathingAllergic saluteA nasal creaseAllergic shinersFrontal headacheHiposmiaOcular symptons
In Vivo : Anamnesis Examination of the nose
Anterior rhinoscopyNasal endoscopy
Skin test :Prick TestIntra DermalSET
Nasal provocation test
In Vitro : Total Ig E Specific Ig E : RAST & Modifikasi RAST Nasal smear
Diagnosis of AR
Hasil SPTHasil SPT
Therapy of ARTherapy of AR
Four general principles of AR management
1. Avoidance
2. Pharmacologic Therapy
3. Allergen immunotherapy
4. Patient education
5. Surgery for a few highly selected patients
Allergen avoidance House dust mite
• Encase mattress,pillow in an allergen impermeable cover
• Wash bedding weekly in hot water• Reduce indoor humidity• Remove stuffed toys,carpets from bedroom
Animal allergens• Remove the pet from the home
Cockroaches• Keep food or garbage inclosed containers• Use boric acid traps or hydromethanon
Molds/Fungi in home• Clean moldy surfaces• Wash swamp coolers• Fix all water leaks
Outdoor allergens Keep window and doors closed Use air conditioning Refrain from outdoor activities,if
possible,during times of high pollen counts Use a masker/eye glasses Dry clothes in avented dryer,not out side
Pharmacologic TheraphyPharmacologic Theraphy Medications used to treat AR
Antihistamines Decongestanns Antihistamine-decongestant combinations Corticosteroids Mast cell stabilizers Anticholinergics
AntihistaminesAntihistamines The mainstay of pharmacotherapy for AR
is antihistamines Older antihistamines such as
diphenhydramine,prometazine,triprolidine have inherent sedating side effect.
New generation antihistamines such as cetirizine,fexofenadine,loratadine are prefered
Intranasal antihistamines are efective Often combined with oral decongestants
DecongestansDecongestans Simpatomimetic drugs Topical :
Oxymetazoline,Xylometazoline,fenilefrineLong take administration causing rhinitis medicamentosa
Oral : Ephedrine,pseudoephedrine,fenilefrine,phenilpropanolamine.Side effects are tremor,agitation,imsomnia,headache,palpitation,tachycardia and urinary retention
CorticosteroidsCorticosteroids Treat the inflamatory component of AR Intranasal corticosteroids are the first line
of therapy when obstruction is a major problem
Oral corticosteroids : a short (3 – 7 day)course may be appropriate for severe symptoms
Intranasal cromolyn sodium Intranasal cromolyn sodium The mechanism of action remains
uncertain Intraocular chromones are very efective Intranasal chromones are less effective
and their effect is short lasting Minor local side effect
AnticholinergicsAnticholinergics Ipratropium bromide is a generic name Anticholinergic block almost exclusively
rhinorrhea Minor side effects Almost no systemic anticholinergic activity Effective in AR patients with rhinorrhea
Anti LeukotrienesAnti Leukotrienes
Block leukotrienes receptor Well tolerated Promising drugs used alone or
combination with oral antihistamines Effective in AR patients with nasal
obstruction
ImmunotherapyImmunotherapy Allergen specific immunotherapy is the
practice of administering gradually increasing quantities of an allergen to an allergic subject in order to ameliorate symptoms with subsequent exposure to the causative allergen
Its associated with “Blocking” Ig G Administer under the direction of an
allergist or ENT specialist
SurgerySurgery If there are compilcation include :
• Sinusitis• Nasal polyps• Hyperthropy of the nasal turbinates
Complicatins Complicatins Compilcations of AR are :
• Nasal polyposis• Sinusitis• Otitis media
Conclusion
• AR is a major chronic respiratory desease due to :
Prevalence
Impact on quality of life
Economic burden
Links with asthma
• A new classification of AR has been used
• Diagnosis of AR based on in vivo and in vitro
Reference1.Bosquet J, Cauwenberger PV, Kahltaev N. Allergic
Rhinitis and its Impact on Asthma in Collaboration with the WHO, Supplement the Journal of Allergy and Clinical Immunology Vol. 108 Number 5, 2001.
2.Bousquet, Cauwenberger PV, Khaltaev N. Allergic Rhinitis and its Impact on Asthma. Pocket Guide 2001.
4.Naclerio RM, Dirham SR, Mygind N, Rhinitis. Mechanism and Management ; Marcel Dekker inc. 1999.
4.Nelson HS,Rachelefsky GS. Disease of the Atopic Diathesis. Vol 2 , 20005.Holt GR, Mattox DE Gates GA : Decision Making in
Otolaryngology. BC. Dekker inc. 1984..
Vasomotor rhinitisVasomotor rhinitis Definition : Overactive parasympathetic
stimulation of the nasal mucosa producing vasodilatation,edema and hypersecretion of mucus
Factors can causing vasomotor imbalance
Factors can causing vasomotor imbalance• Drugs : Ergotamine,Antihypertensive
(Methyldopa,Reserpine),Chlorpromazine• Physic : Chemical
irritants,humidity,temperature,barometric pressure,strong smells
• Hormonal : Pregnancy,puberty,menses• Psychis : Anxyty,emotional stress
Symptoms are similar to AR but there is :• Nasal obstruction ( alternating )
• No evidence of allergic disease as determined by skin or serum level of Ig E to specific allergens
Vasomotor rhinitisVasomotor rhinitis
Clinical features • Nasal obstruction ( alternating )• Nasal discharge ( often mucous/serous )• Post nasal drips• Sneezing is rare• Not itching• Laboratory measurement :
Normal Ig ESkin test ( - )Eosinophil ( - )
Vasomotor rhinitisVasomotor rhinitis
Rhinitis medicamentosaRhinitis medicamentosa Nasal obstruction caused by prolonged
use of topical decongestant medications is known as rhinitis medicamentosa
Its has been attributed to rebound vasodilatation after prolonged vasoconstriction with topical decongestant
Rebound vasodilatation caused by constrictor mechanism fatique due to hypoxia and by reactive hyperemia
Prolonged use of the topical decongestants diminishes vasoconstriction and increases vasodilatation
All topical decongestanta can produce this phenomeno when used prolonged periods
Symptons:• History use of topical decongestan• Adrenaline/efhedrine topical test no
effect
Rhinitis medicamentosaRhinitis medicamentosa
Therapy : Stop use topical decongestans Decongestant oral Corticosteroid systemic ( Tapering off )
Rhinitis medicamentosaRhinitis medicamentosa
Nasal PolypsNasal Polyps
Definition : Smooth mass,gelatinous,grape-like,pale bags,not easily bleeding,relatively not sensitive,moveable which arise most commonly from the middle meatus extend down into and can lead obstruction of the nasal cavity
Etiology : Allergy Infection Vasomotor imbalance Bernoulli phenomenon
Most polyps are gray or grayish blue but may at times become reddened from local irritations or secindary infection
Most polyps origiginate as an out-pouching of the mucosal covering the maxilary or ethmoid sinuses or osteomeatal complexs.
Antral choanal polyps have a cystic portion within the maxillary sinus and extend into the nose through an accessory osteum in the posterior fontanel
Nasal PolypsNasal Polyps
Insidense• Much more often in adult but can occur in
children• Ethmoidal polyps all of age• Antrochoanal polyps young
age,children ( rare )
Nasal PolypsNasal Polyps
Location of polyps :• Osteomeatal complexs( anterior ethmoidal
sinuses pre chamber ) in middle meatal• Maxllary sinus usually soliter• Ethmoidal sinuses usually multiple• Middle turbinates• Frontal or sphenoidal sinuses rare
Nasal PolypsNasal Polyps
Clinical features• Nasal obtruction• Nasal discharge• Hyposmia • Chefalgia• Deformity of the external nose ( giant polyps )
Nasal PolypsNasal Polyps
Diagnosis • Anamnesis• Examination of the nose
Anterior rhinoscopyPosterior rhinoscopyNasal endoscopy
• RadiologicX-Ray sinus paranasalisCT sinus paranasalis
Nasal PolypsNasal Polyps
Diffrensial Diagnosis• Inferior nasal turbinates hyperthropy• Benign nasal neoplasm• Malignant nasal neoplasm
Nasal PolypsNasal Polyps
Therapy• Medical management
Corticosteroids oral or intra nasalAntibiotics
• Surgical managementSimple intranasal polypectomyEthmoidectomy (intranasal or transantral)Cald-Well-Luc Procedure (CWL)FESS (Functional Endoscopic Sinus Surgery)
Nasal PolypsNasal Polyps
Recurence of polyps was caused by• Surgical technic not adequately• Causing of polyps not to control ( Allergy )
Nasal PolypsNasal Polyps