Allergic Rhinitis Dr. Shishir Modak Past President – IAP Pune Master trainer in ATM, RTI – GEM,...

Allergic RhinitisAllergic Rhinitis

• Dr. Shishir Modak• Past President – IAP Pune• Master trainer in ATM , RTI – GEM, PSPID• RAP , Nutrition , TB Modules


• Case 1

• Varshini 11 yr old girl

• H/o Recurrent cold since 6 months. Paroxysmal sneezing , Sneezing more than 50 times in few minutes.

• Symptoms worsen in August/ September

• ? Seasonal Allergic Rhinitis , ? Viral


• Case 2

• Shourya 5 yr old boy

• H/ o Cough , cold off & on for last 3 months. H/ o Fever & Earache 2 months back . Subsided with a course of antibiotic.

• However Cold & Cough Don’t go away. It is always there. No Breathlessness.

• Could it be Allergic ?


• Case 3• Salil, 5 yr old boy Cough, Cold , Sneezing - 15 days No Fever , No chest signs Recurrent since 4 months. GP gave

Antibiotic , Nebulization & Cough Syrup but cough, cold persists. Now he has started Aerocort inhaler since 5 days & patient has come for a second opinion.


• Patients come to us with common symptoms of Recurrent Cough & Cold with few additional points which are different in each patient.

• These confusing symptoms should be dissected out & Analyzed.

• Careful History & Examination is a must.


• Need to differentiate between

• Allergic Rhinitis & Infectious Rhinitis (Cold) Sinusitis – Allergic/ Viral/ Bacterial

• Adenoid Hyperplasia & Otitis Media –

• ? Infectious with ? Underlying allergy

• Allergic Rhinitis alone Or As a Co morbid with Asthma

• Tratment Plan changes accordingly.


• Symptoms suggestive of AR

• 2 or more of the following symptoms for >1 hr on most days

• Watery Rhinorrhea

• Sneezing, esp. paroxysmal

• Nasal Itching

• Nasal Obstruction


• Symptoms usually NOT associated with AR• Unilateral symptoms ++++• Only Nasal obstruction • Mucopurulent Rhinorrhea-Posterior Rhinorrhea

(post nasal drip)-With thick mucus-& no anterior Rhinorrhea-

• Pain, Recurrent Epistaxis & Anosmia• Refer patient to an ENT


• Common Cold Allergic Rhinitis• Cold lasts for a week Cold lasts > 10 days• Usually Fever + Fever absent• Constitutional sympt. Allergic Signs• Nasal mucosa Red Nasal mucosa pale

?Response to Antihist Good response to Antihist

Family members affected Not affected at a time


• Symptom Clues beyond nose• Ocular Allergy –• Watering , Itching & Redness of eyes• ( Allergic Conjunctivitis )• Eczemas – Atopic Dermatitis• Ear Fullnss• Palatal Pruritus

•


• Symptomps of Co morbidities & Complications

• Sinusitis – Headache , Bad Breath, Cough in Lying down posn.

• OSA – Snoring , Mouth Breathing, Hyper Nasality of Voice

• Otitis Media with Effusion ( OME )

• Asthma – Uncontrolled Asthma


• 4 major cardinal symptoms of AR are• –Sneezing• –Itching (Nasal) • –Rhinorrhoea• –Congestion• Allergic Rhinitis (AR) is a chronic inflammatory

disease of the nose induced by an IgE mediated inflammation, after allergen exposure of mucus membrane of nose

• Children affected with AR – 5 – 25 %


• History• Ask for• Running Nose – Clear Watery Discharge• Paroxysmal Sneezing• Nasal itching• Associated Nasal Block• Watering of Eyes, Itching, redness• Atopic Eczemas, Asthma like Symptoms• Family H/o Allergy


• Examination • Allergic Signs –• Allergic Shiners – Dark Circles below eyes• Allergic Salute – Rubbing nose in upward

direction• Darrier Line – Horizontal crease above tip of

the nose• Allergic Gape – Mouth Breathing , Snoring


• Itching of Nose with Rhinorrhea


• Allergic Shiners


• Transverse Crease


• Allergic Salute


• Grouping of Nasal Symptoms

• Sneezers & Runners

• Paroxysmal Sneezing, Watery Ant. Rhinorrhea, Nasal itching , conjunctivitis,

• Worse during day , Improves at night

• Blockers –

• Little Sneezing, Thick mucus, Severe congestion, worse at night

Management of Allergic RhinitisManagement of Allergic Rhinitis

• Drugs• Stepwise Approach• Mild Intermittant• Second Generation H1 Antihistaminics• Or LTRA

Management of Allergic RhinitisManagement of Allergic Rhinitis

• Mild Persistent• Second Generation H1 Antihistamines +

LTRA + INS• Allergen Avoidance• Severe Persistent• SGH1A + LTRA + INS• Allergen Avoidance• Allergen Specific Immunotherapy


• Oral H1 Antihistamines• First Generation –• CPM , Diphenhydramine, Promethazine,

Triprolidine• Drying of Secretions , Drowsiness ,• Anti Cholinergic Side Effects• Cognitive impairment• Should not be used


• Second Generation Antihistaminics –

• Preferred Drugs

• No or little drowsiness, Minimal side effects, Safe for long term use.

• Cetrizine , Levocetrizine

• Fexofenadine

• Loratadine


• Topical Antihistaminics

• Delivered by Nasal Spray

• Quick action in minutes.

• Side Effects – Bitter taste, some irritation, Drowsiness. Can be used above 5 yrs.

• Azelastine spray – 1 – 2 sprays o.d.


• Montelukast• LTRA• Recommended for all severities of AR.• Useful for AR with Asthma • Safe for long term use• Dose 4mg upto – 5 yrs• 5 mg – 5 to 10 yrs• 10 mg – above 10 yrs• Fixed dose combi with H1 Antihist.= avoid


• Intra Nasal Steroids

• First line therapy for moderate-severe AR

• Effective against all symptoms of AR incl. Congestion, Sneezing, Itching (nasal), Rhinorrhea, & Eye symptoms

• Most efficacious medication available for Allergic Rhinitis



• Onset of action - 5-7 hours of dosing Up to 2 weeks required for optimum

effect• Very useful for nasal blockers• Quality of life score improvement with

INSs better than oral & topical H1 antihistamines


• Intra Nasal Steroids• Choose INS with low systemic bio availability• Mometasone Furoate,• Fluticasone Furoate• Fluticasone Propionate• Avoid – Beclomethasone, Triamcinolone• Negligible side effects even after long term use• Compliance & Technique should be checked



• Technique –

• Clear the nose of the secretions

• Insert the nozzle into the nostril

• Direct the spray laterally away from the septum - towards the ear

• Use right hand to spray left nostril & left hand to spray right nostril


• Intra Nasal Decongestants• Xylometazoline, Oxymetazoline• Effective in nasal obstruction. • To be used only for short term = 5 – 7 days• Do not improve nasal itching, rhinorrhea &

sneezing• Prolonged use results in Tachyphylaxis &

rebound congestion• Oral Decongestants – Not Recommended• Phenylephrine, Pseudoephedrine,


• Environmental Control• Triggers – • Outdoor – Allergens -Pollens – Tree, Grass,

Weeds

• Indoor – House Dust Mite, Fungal Molds, Pets, Cockroaches

• Irritants – Cigarette Smoke, Mosquito Coil, • Cooking fuels, Air Pollution• Avoidance of Environmental Triggers important


• ImmunoTherapy• Indications• Moderate / Severe Persistent AR• Inadequate response to Pharmacotherapy• Unsatisfactory Compliance• Inadequate response to Environmental

Control• Specific 2- 3 Allergens


• ImmunoTherapy -• Called as ‘Allergy Vaccines’• Modifies underlying cause of Allergy• Short term & long term benefits• Sustained effect even after treatment

withdrawal• Useful in Allergic Rhinitis & Asthma• Allergy Skin Test a Prerequizite


• Subcutaneous Immunotherapy

• Very Effective , Side effects – Urticarias, Severe Systemic Reactions , Clinic visits reqd.

• Sublingual Immunotherapy -

• Effective, Less side effects, Systemic reactions rare, Can be given at home.


• AR & its impact on Asthma

• 30% of AR patients have Asthma,

• 80% asthmatics have AR

• AR is a risk factor for Asthma

• AR & Asthma share common allergens

• Proper treatment of AR improves Asthma Control & PFT


• Take Home Messages• Look for Cardinal Symptoms – Rhinorrhea,

Itching, Sneezing,Nasal Block• Watch for CoMorbids – Asthma, Occular Allergy,

Adenoid Hypertrophy• Rule out or treat Infections• SGH1A, LTRA, INS depending on severity• Treatment of AR improves Asthma control.• Specific Immunothrapy in rare cases


• THANK YOU !

Date post:	25-Dec-2015
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Allergic Rhinitis Dr. Shishir Modak Past President – IAP Pune Master trainer in ATM, RTI – GEM,...

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